Heartland Hospice

“Upon patient record review 1 of 19 (Patient #10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 10: SC did not perform comprehensive assessment as they were not able to get in touch with patient. There was no mini spiritual assessment completed and the RN did not complete the assessment in the comprehensive assessment. The SC did not see the patient.”

“Upon patient record review and home visits, 6 of 19 (Patient #1,2,3,4,12,14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: Triple ATB ointment remains on the hospice medication profile for care of staples that have been removed and the wound is healed. Corrected on site, order discontinued. In addition, the Hospice medication profile contains orders for Lidocaine patches to be applied to back and shoulder areas daily. The Facility MAR has instructions to apply only to the lower back daily. The Hospice medication profile contains orders for Lorazepam 0.5mg every 4 hours prn the facility has Lorazepam 0.5 every 6 hours prn. The Hospice medication profile contains order for Lasix 20mg ½ tab every other day and the facility MAR has daily. The Hospice medication profile contains Oxybutynin Chloride ER 10mg at bedtime. This was not on the facility MAR. The hospice medication profile contains Vitamin D3 daily, this is not on the facility MAR. Corrected on site, orders updated. Patient 2: Hospice medication profile has buspirone 5mg twice daily and facility MAR has 1 time daily. The hospice medication profile has Levsin ordered, this was not included on the facility MAR. The Hospice medication profile has fesoterodine ordered this is not on the facility MAR. The hospice medication profile contains Valproic acid ordered this was not on the facility MAR. The facility MAR has Depakote Sprinkles. The Hospice medication profile does not have this order. The facility does not have Oxygen orders, the hospice medication profile contains orders for Oxygen 2L PRN. Corrected on site, orders updated. Patient 3: Upon home visit finding, the patient is still taking Seroquel 25mg at HS this medication was discontinued. Furosemide was lowered to ½ tab daily on 8/7/25 but still remains on the medication profile as 1 tab daily. POC has Senna lax 8.6mg patient has Senna S 50-8.6 in home. The SN documented on 7/24/25 “Daughter reports giving Tylenol and Tramadol daily with positive results. There is no Tylenol on the medication profile. Corrected on site, orders updated. Patient 4: Per home visit finding, the spouse states patient has not taken his dorzolamide or latanoprost in months and has been taking Visine red eye 1 drop to each eye twice daily instead. Medication profile contains order for Senna S 8.6-50 daily. In home patient has Senna 8.6mg daily ordered 7/31/25. Corrected on site, medication profile updated. Corrected on site, orders updated. Patient 12: The medication profile added 8/5/25 contains an order for triple antibiotic ointment to apply thin layer to wound bed every 72 hours though does not state where the wound is. The POC does have the site noted. Corrected on site, med profile updated. Patient 14: The medication profile has Ascorbic acid powder ordered 1.1 grams/scoop by mouth daily. There is no diluent ordered. Corrected on site order updated.”

“Upon patient record review, 2 of 19 (Patient #9,12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 9: Patient is being seen once weekly by SN. Pt has a right calf wound that was not measured on visit 8/5/25 it was last measured 7/31/25. Right calf wound not measured or assessed at 8/8/25 visit. Per wound care policy wounds are to be measured weekly. Patient 12: The SN documented on 7/7/25 patient has boggy heels and SN to bring booties at next visit. Next visit 7/14/25 there were no booties documented being given or assessment of the heels noted. No further follow up to bilateral heels as of current.”

“Upon patient record review, 1 of 19 (Patient #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 14: Pt is on ASA daily and has wounds. There is no risk for bleeding care plan initiated with goals and interventions. Corrected on site, care plan updated.”

“Upon patient record review, 5 of 19 (Patient #1,2,3,4,14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The current POC contains orders for Lidocaine patches to be applied to back and shoulder areas daily. The Facility MAR has instructions to apply only to the lower back daily. The current Hospice POC contains orders for Lorazepam 0.5mg every 4 hours prn the facility has Lorazepam 0.5 every 6 hours prn. The current Hospice POC contains order for Lasix 20mg ½ tab every other day and the facility MAR has daily. The current Hospice POC contains Oxybutynin Chloride ER 10mg at bedtime. This was not on the facility MAR. The current hospice POC contains Vitamin D3 daily, this is not on the facility MAR. Corrected on site, orders updated. Patient 2: The Facility MAR shows patient taking Prosource 30cc daily. This is not on the hospice plan of care. Hospice POC has buspirone 5mg twice daily and facility MAR has 1 time daily. The HSP POC has Levsin ordered, this was not included on the facility MAR. The Hospice POC has fesoterodine ordered this is not on the facility MAR. The hospice POC contains Valproic acid ordered this was not on the facility MAR. The facility MAR has Depakote Sprinkles. The Hospice POC does not have this order it had been discontinued. The facility does not have Oxygen orders, the hospice POC contains orders for Oxygen 2L PRN. Corrected on site, orders updated. Patient 3: Per home visit finding, Pt is still taking Seroquel 25mg at HS this medication was discontinued on the POC. Furosemide was lowered to ½ tab daily on 8/7/25 but still remains on POC as 1 tab daily. POC has Senna lax 8.6mg patient has Senna S 50-8.6 in home. The SN documented on 7/24/25 “Daughter reports giving Tylenol and Tramadol daily with positive results. There is no Tylenol on the POC. Corrected on site, all meds orders updated. Patient 4: Per home visit finding spouse states patient has not taken his dorzolamide or latanoprost in months and has been taking Visine red eye 1 drop to each eye twice daily instead. POC contains order for Senna S 8.6-50 daily. In home patient has Senna 8.6mg daily ordered 7/31/25. Corrected on site, medication updated. Corrected on site, orders updated. Patient 14: The POC has Ascorbic acid powder ordered 1.1 grams/scoop by mouth daily. There is no diluent ordered. The POC has an order on 7/4/25 to drain Pleuryx drain 2x per week on Mondays and Fridays. Notify physician if output greater than 1,000ml. Dressing to be changed after each drain. There is no evidence of what type of dressing is to be applied, what technique is to be used. Both corrected on site, orders updated.”

“Upon patient record review, 3 of 19 (Patient #1,2,10) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 1: The patient is having episodes now of incontinence requiring wearing briefs. Was noted to be moderate risk for skin breakdown on recertification 7/7/25. There was no high risk for skin breakdown added to the care plan. Corrected on site, care plan updated. Patient 2: Upon home visit finding, patient wearing Geri sleeves. There is no order for Geri sleeves, corrected on site, order added. The facility had an order for “US of the left lower leg to R/O DVT, Pain and swelling on 7/15/25 and an order for a chest x-ray on 7/16/25. There were no orders on the hospice POC for either of these tests the SN did not update the POC. Corrected on site, care plan updated Patient 10: The patient remains a full code. Pt is non verbal, confused and is on her 3rd certification period. There are no care planning goals and interventions for end of life choices or update in the progress toward the patients continued decline in the record. Corrected on site, care plan updated to work toward obtaining advance directives. Corrected on site, care plan updated”

“Upon patient record review, 3 of 19 (Patient #8,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: Foley order 7/26/25 is for 16fr 5ml balloon. The SN documented inserting a 16fr 10ml balloon catheter on 8/3/25. Volunteer orders on POC 7/12/25 contain orders for volunteer twice a month. The volunteer saw the patient four times in June- 6/22, 6/23 two visits, 6/30. There is no evidence of an order to increase visits. Patient 13: POC order from 4/25/25 to current is for Oxygen 2L per nasal cannula. At 8/1/25 visit chaplain documented calling nurse due to patient anxiety and chaplain instructed family to place oxygen on at 2.5 liters. There is no order to increase the oxygen. The SN documented 8/1/25 that she educated family to add Thickener to fluids due to her choking when drinking fluids and eating. There was no order added for thickener. On 8/5 the SN reports patient is eating well and on a regular diet. The POC has soft diet ordered. Corrected on site, orders and care plan updated. Patient 14: The POC contains an order for Pleuryx to be drained twice weekly and a dressing applied. On 7/7/25, 7/14 , 7/18, 7/21, 8/1, 8/5, 8/8, 8/11 the SN documented draining the fluids but no documentation that a dressing was applied or that sterile technique was used.”

“Upon patient record review, 2 of 19 (Patient #1,2) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: Patient had a fall on 7/6/25 with trip to ER to get stiches to his head. There is no direction to the aide on the aide POC to alert aide regarding the wound. Shampooing and hair care is ordered. Patient 2: Aide tasks are marked “N, task already completed and RN Betce notified” for all visits from 6/30/25 until current. Many hospice aide visits being completed in later afternoon, patient is in a SNF. There was no evidence the RN updated the POC after multiple attempts when aide tasks where unable to be completed. Corrected on site. Care plan updated for just companionship.”

“Upon patient record review 5 of 19 (Patient #1,7,9,10,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: The aide POC has directive to shave patient the first visit of the week. The aide shaved the patient on 6/30/25, 7/2/25,7/3/25. Shower is ordered on Wednesday and Friday. The aide showered the patient on 7/3/25 (Thursday) and 6/30/25 which is a Monday, 7/10 (Thursday) and 7/14 (Monday). The aide bathed the patient on 7/8/25 which is a Tuesday (ordered Wed, Fri). There is an order on Aide POC to wash eye glasses and electric scooter weekly on aide POC 5/30/25. There is no directive for the aide to do this on their aide task documentation forms so these tasks have never been completed. Patient 7: On the Aide POC shampoo is ordered weekly. The aide shampooed patient 7/21, 7/22, 7/14 and 7/17,7/18, 6/30, 7/1. There is no evidence the aide called he nurse to get orders to shampoo the patient extra days. The aide did not complete feeding and bathing 7/25/25 due to already being done by facility. Patient 9: Shampoo not completed 7/18, 7/22, 7/24 aide documented not needed this visit it is ordered every visit. Patient 10: On 7/9/25 the aide documented “no” to tasks assist with feeding, hair care documented “already completed”. On 7/21 the aide marked “no” and already completed to all tasks. On 8/1/25 the aide documented in assist with feeding “No feed, left out for her at the time”. Pt is a total feed per aide plan of care. There is no evidence the RN notified of these tasks left uncompleted and to leave food out for the patient who is total feed. Patient 12: Aide POC update 7/25/25 the nurse instructs the patient has a hoyer lift in home do not use patient is bedbound. Visits 7/24-8/12 the hoyer lift is marked “yes” by the aide.”

“Upon patient record review, 4 of 19 (Patient #2,4,9,14) did not have evidence that each patient record contains responses to medications, symptom management, treatments, and services. Patient 2: Wound care performed on 8/12/25 and 7/7/25 by SN does not state how patient tolerated the wound care. Patient 4: Wound care completed on 7/9/25 by the SN, does not state how the care was tolerated. Patient 9: Wound care performed by SN with no documentation on how patient tolerated the wound care 7/31/25. Patient 14: Pt has Pleuryx drain on 7/18, 7/21, 7/25 8/1, 8/5, 8/8, 8/11 visits the SN did not document how the procedure was tolerated.”

“Upon patient record review, 10 of 19 (Patient #1,2,4,5,8,9,10,11,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: 7/9/25 the SN documented “Administered Ativan during visit”, no evidence of what dose was administered and wound care documented in wound by restating order on 7/9,7/1,7/14 unclear if the details of order were followed. On 7/14 the SN documented: PVT, MTG, AAOx4. 7/15/25 ADM coord. These are not approved abbreviations. Patient 2: The POC 4/15/25 contains an order “Wound care to reopened right elbow, ST 2 daily and PRN.”This is not an approved abbreviation. Patient 4: POC 6/24/25 “Hospice nurse/facility nurse to place indwelling catheter”. Pt in a home. SN documented 7/9/25 “STG2 to sacrum with TX in place”. STG2 not approved. In wound assessment the order is written and then the nurse documented after the order “Cleansed, Zinc, CDD”. There are no details of the wound care provided. The SN on 7/15/25 documented the foley catheter size as “161” it is a 16 french”. On 7/15/25 the SN documented “ASP precautions”, “sleing 18+H daily”, 7/29/25 “PTS DGHT”. ASP, sleing, and PTS DGHT are not approved abbreviations. 7/18/25 patient sleeping “Approx 20H daily”, Approx is not an approved abbreviation. Wound care documented by SN by restating order and then “Cleansed, Zinc, protective dressing.” No details of the care provided. 7/22/25 SN documented “NT with B+BS4Q, m3dication. Not approved abbreviations. The SN documented 8/1/25 the order then “cleansed, zinc to perimeter, and medihoney to open area, CDD,PLCD” no details of what the wound was cleansed with, CDD & PLCD not approved abbreviations. SN documented 8/5/25 “foley 16F 10cc exchanged today without difficulties.” No evidence of sterile technique used. Patient 5: The SN documented on 7/17/25 wound care in wound assessment the order and then added “cleansed and barrier cream applied” care details are unclear of wound care provided. SN documented 7/21/25 the order then added “cleansed, Zinc”. SN documented 7/31/25 and 8/11/25 in wound assessment the order and “cleansed, applied,CDD”. The details of the wound care provided are unclear. Patient 8: The SN documented 7/25/25 “instructed on morphine use with extreme dyspnea and set 5 syringes up for pt for ease of administration.”the dose of morphine is not documented. 7/16/25 the SN documented “16 Fr foley placed with out difficulty” no balloon size or technique used. Patient 9: SN documented 7/2/25 “AAOx1, BL lower extremity edema, +BS. Not approved abbreviations. Patient 10: MSW documented 7/15/25 “patient’s Fatgeris still in the nursing home thanks to Fayes multiple appeals.” Patient 11: SN documented “PT” in the narrative on 7/15/25. There is nothing else in the narrative. SN documented AAOx2 on 8/1/25. This is not an approved abbreviation. On 8/5/25 SN documented “PERVDIL no concerns at this time.” Patient 13: Chaplain documented 8/1/25 “called OCM”. Not an approved abbreviation. Patient 14: SN documented 7/11/25, wound care as order and not in past tense and applied dressing to Pleuryx site does not state what type of dressing. Drained Pleuryx, no evidence sterile technique used. 7/18,7/21,7/25 wound care documented not in past tense to indicate care was completed. 7/25 the SN documented applying a dressing after Pleuryx drain does not state type of dressing. On 8/1,8/5,8/8,8/11 SN documented drained pleuryx drain, wound care completed according to orders. Unclear what wound care was provided.”

“Upon patient record review, 3 of 19 (Patient #1,2,7) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 1: The POC contains an order for volunteers to start 7/1/25 for 12 visits per month. There is evidence the volunteer made a visit on 6/19/25, 6/20/25, 6/24/25, 6/26/25. SN instructed patient to use zinc paste to his burning rectum on 7/14/25, there is no order for barrier cream on the POC. On 7/16/25 the SN documented cleansed wound with betadine prior to removing staples. There was no order for betadine. On 7/28/25 the SN documented “Facility ask to check patient for possible C diff due to mucus in stool and foul odor” There was no order to check for C diff. Patient 2: Patient is in a facility, the nursing care plan has risk for bleeding due to patient being on a blood thinner. There is no evidence patient is on a blood thinner. Corrected on site, care plan updated. Patient 7: Patient is in a facility and is on ASA daily, there is no bleeding risk care plan with goals and interventions initiated on the nursing care plan. Corrected on site, care plan added.”