Heartland Hospice

“Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 4: The medical record contained nursing documentation and a physician order for DME upon admission 2/13/25 identifying an oxygen concentrator was ordered. There was no evidence of oxygen rate, frequency, and delivery method included on the medication profile. After agency investigation, leadership reported that the patient did not have an oxygen concentrator. Corrected on site with an order to discontinue equipment and note entered to clarify the patient did not have oxygen.”

“Upon patient record review, 1 of 5 (Patient #5) 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 5: The medical record contained the last plan of care update order 2/19/25 identifying social work and spiritual care frequencies as 1 PRN each discipline. The patient had declined both services.”

“Upon patient record review, 1 of 5 (Patient #4) 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 4: The medical record contained nursing documentation and a physician order for DME upon admission 2/13/25 identifying an oxygen concentrator was ordered. There was no evidence of an order for oxygen rate, frequency, and delivery method. After agency investigation, leadership reported that the patient did not have an oxygen concentrator. Corrected on site with an order to discontinue equipment and note entered to clarify the patient did not have oxygen.”

“Upon patient record review, 7 of 23 records (Patient #2,#4,#5,#7,#8,#10,#18) 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 #2: The medication profile contained Amoxicillin 500 mg 3x/day, dated 9/18/24. The order indicated that this medication was to be for 7 days. This remained on the medication profile. Corrected on site. Patient #4: Upon home visit, Clopidogrel, Furosemide, IBU, Miralax Potassium Chloride were on the hospice medication profile but not the facility MAR. Corrected on site. Patient #5: Upon home visit, the hospice record contained Tylenol 500mg, 2 caps q6h prn and the facility MAR contained Tylenol 500mg, 1 tab q6h prn. Corrected on site. Also the hospice record contained Potassium liquid 20 mEq/15ml and the facility MAR contained Klor Con 10 mEQ, 2 tabs. Corrected on site. In addition, Zofran, Preparation H, Loperamide and Hydroxyzine were on the hospice medication profile but not on the facility MAR. Corrected on site. Patient #7: The medication profile contained oxygen 2L/min continuous without evidence of a route. Corrected on site. Upon home visit, ASA was included on the hospice medication profile but was not on the facility MAR. Corrected on site. Patient #8: The medication profile contained Hydrocortisone 1% topical cream to affected areas. There was not evidence of a specific location or a specific frequency. Corrected on site. Upon home visit, Robitussin was on the hospice Medication profile but was not on the facility MAR. Duo-nebs, Vistaril and joint supplement were on the facility MAR but were not included on the hospice medical record. Corrected on site. In addition, Nystatin 100,000/Gm topical powder to affected area without evidence of a specific location. Corrected on site. Patient #10: The medication record contained Acetaminophen 325mg 2 caps q4h prn pain or fever and Acetaminophen 650mg rectal suppository 1 q4h prn fever. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #18: The medication profile contained Latanoprost eye drops, 1 drop at bedtime without evidence of which eye.”

“Upon patient record review, 4 of 23 records (Patient #4,#12,#15,#17) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4,#12: There was not evidence of a bereavement assessment. Patient #15: The patient was admitted on 11/7/24. The bereavement assessment was completed on 11/19/24. Patient #17: The patient was admitted on 8/15/24. The bereavement assessment was completed on 8/22/24”

“Upon patient record review, 2 of 23 records (Patient #12,#18) 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 #12: Nurse documentation dated 12/27/24 indicated that the patient had a deep tissue injury on both heels. There was not evidence of an assessment or dressing change since this date. Patient #18: On 10/12/24, the record contained orders for wound care to a coccyx wound. On 10/28/24, the record indicated a skin tear. There was not evidence of assessments, measurements, or wound care, or if the wound was still present or was healed.”

“Upon patient record review, 6 of 23 records (Patient #1,#6,#8,#10,#12,#15) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient 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 #1: The record indicated that the patient resided at home. The plan of care had goals and interventions for facility coordination. Corrected on site. Patient #6: The record indicated that the patient was on Eliquis. There was not evidence of bleeding precautions on the plan of care. Corrected on site. In addition, The patient was admitted with a diagnosis of cerebral atherosclerosis. The record indicated that the patient was confused, dependent for bathing, dressing, grooming and toileting. She also had decreased muscle coordination, balance problems and was disoriented X3. There was not evidence that the plan of care reflected patient/family goals and interventions based on the neurological problems. Corrected on site. Patient #8: The record indicated that the patient was on Xarelto daily. There was not evidence of bleeding precautions on the plan of care. Corrected on site. Patient #10: The patient was admitted with a diagnosis of malignant neoplasm of the esophagus. The patient was only able to eat small bites and a small amount of food. Eating would lead to vomiting. He had dysphasia when eating solids. He had Barrett’s esophagus and weight loss. There was not evidence of nutritional needs in the plan of care. Corrected on site. In addition, GI listed only assess for signs and symptoms of impaired GI system without addressing the issues that the patient had. Corrected on site. Patient #12: The plan of care contained problems with goals and interventions for assessing and managing a gastrostomy tube and a tracheostomy. There was not evidence that the patient had either of these devices. Corrected on site. Patient #15: The record indicated that the patient had a history of bladder cancer. His primary hospice diagnosis was end stage renal, and he was having hematuria with clots. There was not evidence that the plan of care reflected patient/family goals and interventions based on this problem. Corrected on site.”

“Upon patient record review, 4 of 23 records (Patient #1,#7,#10,#11) 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 #1: The visit frequency for the social worker was for an evaluation. The evaluation was conducted on 8/26/24. After the evaluation, the visit frequency for the social worker was for 2 prn. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #7: The initial visit frequency upon admission for the social worker and the spiritual care counselor was 2 prn. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #10: The visit frequency for the spiritual care counselor dated 11/19/24 was 2 prn effective 2/1/25. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #11: The visit frequency for the social worker and the spiritual care counselor at admission was 1 prn for an evaluation. This is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.”

“Upon patient record review, 5 of 23 records (Patient #5,#7,#8,#10,#18) 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 #5: Vistaril was included on the facility MAR There was not evidence of an order in the hospice record. Corrected on site. Patient #7: The record contained an order for oxygen 2L/min continuous without evidence of a route. Corrected on site. Patient #8: The record contained an order for Hydrocortisone 1% topical cream to affected areas. There was not evidence of a specific location or a specific frequency. Corrected on site. Also, Duo-nebs, Vistaril and joint supplement were on the facility MAR but there was not an order in the hospice record. Corrected on site. In addition, Nystatin 100,000/Gm topical powder to affected area without evidence of a specific location. Corrected on site. Patient #10: The record contained an order for Acetaminophen 325mg 2 caps q4h prn pain or fever and Acetaminophen 650mg rectal suppository 1 q4h prn fever. There was not evidence of a maximum allowable dose for 24h or a parameter for fever. Corrected on site. Patient #18: The record contained an order for Latanoprost eye drops, 1 drop at bedtime without evidence of which eye.”

“Upon patient record review, 3 of 23 records (Patient #11,#12,#18) 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 #11: The record indicated that a Foley catheter was inserted on 11/21/24. There was not evidence that the revised plan of care included information from the patient’s updated comprehensive assessment. Patient #12: Nurse documentation dated 12/27/24 indicated that the patient had a deep tissue injury on both heels. There was not evidence that wounds were a part of the care plan. Patient #18: On 10/12/24, the record contained orders for wound care to a coccyx wound. On 10/28/24, the record indicated a skin tear. There was not evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment.”

“Upon client record review, 8 of 23 records (Patient #1,#8,#10,#11,#14,#15,#17,#18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: The visit frequency for the social worker for the benefit period beginning 11/21/24 was 1m4. There was not evidence of a visit by the social worker for this benefit period. Patient #8: The frequency for the volunteer was 1x/month to start 12/4/24. The record indicated visits were conducted on 12/11/24 and 12/17/24. Patient #10: The visit frequency for the social worker for the benefit period beginning 11/19/24 was 1m3. There was not evidence of a visit by the social worker. In addition, the visit frequency for the spiritual care counselor was 1m3. There was not evidence of a visit in December. Patient #11: The record indicated an order dated 11/21/24 to insert a 16F Foley catheter with a 10cc Balloon, with no order to change or irrigate the catheter. Documentation revealed that the catheter was changed on 12/24/24 due to a triage call stating that the catheter was leaking. (There was not evidence of an order). Corrected on site. Patient #14:The visit frequency for the social worker for the benefit period beginning on 12/11/24 was 1m3. There was not evidence of a visit by the social worker for this certification period. Patient #15: The visit frequency for the spiritual care counselor was 1m1, 2m2 effective 11/11/24. The record indicated only 1 visit for month 2 (December). Patient #17: The social work frequency for the benefit period beginning on 11/13/24 was 2m3, 1m1. The record indicated only 1 missed visit document in November and 1 visit in December. Patient #18: The visit frequency for the spiritual care counselor effective 11/1/24 was 1x/week until 1/10/25 when they were decreased to 1x/month. Visits were conducted only on 11/22/24, 11/29/24, 12/9/24, 12/27/24 and 1/3/25. In addition, the social work visit frequency for the benefit period beginning 10/10/24 was 1m3. There was not evidence of a visit in October.”

“Upon patient record review 2 of 23 records (Patient #1,#16) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1: The visit narrative by the social worker dated 8/26/24 indicated that the patient/family was interested in meals on wheels. There was not evidence of follow-up. Patient #16: The record indicated that the patient was interested in updating his POA to make his x-wife his MPOA. The social worker note from admission dated 11/21/24 revealed that the SW would help to coordinate this. There was not evidence of follow-up.”

“Upon patient record review, 4 of 23 records (Patient #1,#5,#7,#11) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions including alerts and precautions, for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide plan of care indicated to change linens on Monday, Wednesday and Friday. The aide visit frequency was 2x/week. Corrected on site. Patient #5: The record indicated that the patient had a fall on 11/10/24. The recertification visit conducted by the nurse indicated that the patient was a fall risk and had sustained falls within the past 3 months. There was not evidence of fall precautions on the aide plan of care. Corrected on site. Patient #7: The patient was on Plavix 75 mg daily. On 1/7/25, she had an episode of blood in her urine. There was not evidence that bleeding precautions were on the aide plan of care. Corrected on site. Patient #11: The aide plan of care indicated to provide a shower every visit and to provide a bed bath every visit. Corrected on site.”

“Upon patient record review 4 of 23 records (Patient #4,#7,#11,#17) 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 Patient #4: The aide plan of care indicated to provide nail care weekly. The aide visit frequency was 2x/week. The record indicated that nail care was provided at most visits. Patient #7: The aide plan of care indicated to provide a shower, haircare, shampoo, and linen change 1x/week. The aide visit frequency was 2x/week. For the week of 1/12/25-1/18/25, these tasks were conducted at both visits. Patient #11: The visit frequency for the aide was increased on 1/6/25 to 2x/week on Mondays and Thursdays. For the week of 1/5/25-1/11/25, the record indicated only 1 visit (On a Wednesday). For the week of 1/12/25-1/18/25, visits were conducted on Monday and Wednesday. In addition, the tasks of check for emesis, date of last BM and weight were all ordered every visit. For many visits, the documentation by the aide indicated, ‘per frequency not needed.’ There was also documentation stating, ‘completed by other assigned HHA.’ There was not evidence that another aide was assigned to provide care. Patient #17: The aide plan of care indicated to provide a shower weekly. The aide visit frequency was 2x/week. The aide documentation revealed that a shower was provided at all visits.”

“Upon client record review, 2 of 23 records (Patient #5,#11) 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 #5: The visit frequency for the social worker for the benefit period beginning on 12/10/24 was 2m1, 3m1,1m1. There was not evidence of 2 visits for month 1 (December). Patient #11: Upon admission, the record indicated that a volunteer was accepted. There was not evidence of follow-up. Corrected on site.”

“Upon patient record review, 1 of 6 (Patient #1) 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 1: The medical record contained nursing documentation since admission identifying patient has wounds to bilateral dorsum. There was no evidence of wound measurements between 12/3/23 and 12/16/24 as required per agency policy for weekly measurements.”

“Upon patient record review, 2 of 6 (Patients #1,#2) 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 equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of oxygen, a nebulizer, and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon recertification assessment 11/22/24 identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care.”

“Upon patient record review, 4 of 6 (Patients #2,#3,#4,#5) 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 2: There was no evidence the revised plan of care 10/24/24, 11/21/24, and 12/5/24 included clinical updates on patient progress towards goals. There was no evidence of a revised plan of care on 11/7/24. Patient 3: There was no evidence the revised plan of care 10/30/24, 11/13/24, ang 11/27/24 included clinical updates on patient progress towards goals. Corrected on site with late data entry. Patient 4: There was no evidence the revised plan of care 10/24/24 and 11/7/24 included clinical updates on patient progress towards goals and plan to discharge patient due to extended prognosis. Patient was discharged 11/11/24. Patient 5: There was no evidence the revised plan of care 10/17/24 and 10/31/24 included the plan to discharge patient due to extended prognosis. Patient was discharged 11/2/24.”