Heartland Hospice

“Upon patient record review, 1 of 5 records (Patient #4) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family’s needs and coordinated 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 #4: The record indicated pressure wound care orders to the sacrum dated 9/27/24. There was not evidence of wound care or assessments regarding this wound. For the dates of 10/3/24, 10/10/24, and 10/16/24, documentation revealed, skin not assessed, ‘patient in common room.’ For the date of 10/24/24, documentation revealed skin not assessed, deferred. Agency policy indicates wounds are to be assessed weekly.”

“Upon patient record review, 1 of 5 records (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects 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 #3: The record indicated that the patient is admitted with COPD and wears oxygen continuously. She also continues to smoke 1/2 to 1 pack of cigarettes/day. There was not evidence of specific goals and interventions based on the safety issues in regards to smoking and oxygen safety.”

“Upon patient client record review, 2 of 5 records (Patient #1,#3) 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. . Patient #1: The record indicated an order dated 10/23/24, HS 1W1, 2W8, effective 10/23/24. Leadership confirmed that this was most likely an aide frequency. There was not evidence that HS is an acceptable abbreviation for the aide. Patient #3: Documentation in an IDG dated 10/31/24, regarding the question in the narrative section asking if the patient was a full code, and the social worker responded, “yes.” The record indicated that the patient has an Advance Directive indicating a DNR which is a part of the record.”

“Upon patient record review, 6 of 19 (Patient #3,5,6,7,12,16) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3 Antibiotic ordered on 8/23/24 for 7 days, no evidence of an end date on medication profile. Patient #5 SN note on 9/6/24 states patient with oxygen in place, no evidence on medication profile Patient #6 SN note on 9/11/24 states the patient using oxygen via NC @ 6LPM, order on 5/12/24 states Oxygen administration via NC at 3-5LPM and via non-rebreather mask at 6-8LPM. Patient #7 SN note on 8/20/24, 8/27/24, 9/1024 and 9/13/24 state the patient is using oxygen at 4LPN via NC continuously, no evidence of oxygen on medication profile Patient #12 SN note on 7/25/24 state patient utilizing oxygen @ 32LPM, 8/5/24 @ 4LPM, 8/15/24 @ 3-4LPM, 8/21/24 and 8/26/24 @ 2LPM, however order in place on 4/1/24 for oxygen administration @ 3LPM continuous, no evidence on medication profile Patient #16 SN note on 8/2/24 states the patient is using oxygen 2-4lpm and order is for oxygen 2lpm QHS however, there is not evidence of oxygen order on medication profile.”

“Upon patient record review, 1 of 19 (Patient #16) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #16 had a nurse visit with comprehensive assessment on 8/2/24 and did not receive the next one until 8/19/24.”

“Upon patient record review, 2 of 19 (Patient #3,8) 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 #3 Plan of Care does not include Bleeding Precautions Patient #8 Plan of Care does not include Oxygen Precautions”

“Upon patient record review, 6 of 19 (Patient #3,7,8,12,16,17) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3 Order on 7/5/24 state Chaplain frequency of 1PRN and MSW of 1PRN. Patient #7 Order on 8/16/24 for Chaplain frequency of 1PRN EVAL and MSW 1PRN EVAL. On 8/20/24 the Chaplain Add-on visit order states frequency of 1MO3, effective 8/16/24 and on 8/20/24 the MSW add on visit order states frequency of 1MO3 effective 8/20/24. Patient #8 Order on 6/10/24 for MSW visit frequency of 1PRN Patient #12 Order on 4/9/24 MSW visit frequency 1PRN, Chaplain frequency 1PRN Patient #16 Order on 6/11/24 MSW visit frequency 1PRN and on 6/17/24 MSW visit frequency order for MSW 3PRN effective 6/11/24 1MO4, 4 PRN. On 6/11/24 Chaplain visit frequency 1PRN and on 6/17/24 has 2 different orders for Chaplain frequency, one is written by MSW with frequency of 1MO3 and an additional order written by the Chaplain with frequency of 3 PRN effective 6/11/24 1EVERY2M2, 1M1 Patient #17 Order on 4/25/24 state Chaplain frequency of 1PRN and MSW 1PRN”

“Upon patient record review, 6 of 19 (Patient #3,5,6,7,12,16) 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 #3 Antibiotic ordered on 8/23/24 for 7 days, no evidence of an end date on order. Patient #5 SN note on 9/6/24 states patient with oxygen in place, no evidence of an order. Patient #6 SN note on 9/11/24 states the patient using oxygen via NC @ 6LPM, order on 5/12/24 states Oxygen administration via NC at 3-5LPM and via non-rebreather mask at 6-8LPM. Patient #7 SN note on 8/20/24, 8/27/24, 9/1024 and 9/13/24 state the patient is using oxygen at 4LPN via NC continuously, no evidence of oxygen order in place. Patient #12 SN note on 7/25/24 state patient utilizing oxygen @ 32LPM, 8/5/24 @ 4LPM, 8/15/24 @ 3-4LPM, 8/21/24 and 8/26/24 @ 2LPM, however order in place on 4/1/24 for oxygen administration @ 3LPM continuous. Patient #16 SN note on 8/2/24 states the patient is using oxygen 2-4LPM, however order in place for oxygen 2LPM QHS.”

“Upon client record review, 6 of 19 (Patient #3,4,6,8,15,16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 MSW note on 8/13/24 states patient frequency of 2x/month and order in place is for 2M1, MSW visit made 8/13/24 with no evidence of a 2nd visit made per order. Patient #4 Order on 8/5/24 states MSW frequency is 1M1, 2M2 with effective date of 8/1/24 in addition to an order on 8/1/24 for MSW x1 EVAL, however MSW visits made on 8/5/24 and 8/20/24 with no evidence of an order for an additional visit. Patient #6 SN note on 8/15/24 states wound care completed to skin tear, no evidence of wound care orders in place. Patient #8 Order on 6/10/24 states SN visit frequency is 1WK9. SN visits were made 8/8/24, 8/22/24 and 9/5/24. No evidence of visit made or evidence of missed visits the week of 8/11/24 and 8/25/24. Patient #15 Order on 6/20/24 with effective date of 6/29/24 states MSW 1 visit every month. No evidence of visits made or missed visit documentation for June, July and August. Patient #16 Order on 6/11/24 states MSW visit frequency is 1M4, however the patient received MSW visits on 6/17/24 and 6/24/24.”

“Upon patient record review 3 of 19 (Patient #3,8,12) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3 Aide care plan states patient to utilize walker at every visit however, Aide documented on 9/9/24, “Patient does not walk”, 9/12/24 “Not needed” and on 9/16/24 “Patient uses wheelchair” Aide care plan included bathing the patient at every visit. On 8/30/24, 9/4/24, 9/9/24 and 9/11/24, aide documented she did a bed bath. Aide care plan includes use of bed side commode. On 9/9/24 aide documented “Pt does not use BSC” and 9/12/24, aide documented bed side commode “Not needed”. Patient #8 Aide care plan includes obtaining weight on the 1st visit of every month. Aide documented “per visit frequency, not needed this visit” on 8/1/24 and 9/5/24, which were the 1st visits of the month. Patient #12 Aide care plan included shaving to be completed at every visit. Aide documented “Shaving not needed” on 7/18/24 and 8/22/24”

“Upon patient client record review, 1 of 19 (Patient #5) 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 #5 SN note on 8/6/24 and 8/13/24 state “Wound care completed as ordered” which did not include clear, complete details of care provided or how the patient tolerated the care.”

“Upon patient record review, 2 of 19 (Patient #12, 13) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice’s 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient #12, 13 There was no documentation in the clinical record that the SNF received the update on the most recent hospice plan of care.”