Heartland Hospice (York)

“Upon patient record review, 5 of 19 (Patients #3,#5,#6,#7,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medication profile contained duplicative listing of cholestyramine scheduled doses. Corrected on site with removal of one listing. Patient 5: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site with order received and medication profile updated. Patient 6: The medication profile contained diclofenac topical gel with no area defined for administration. Corrected on site with order clarification and medication profile updated. Patient 7: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The profile also contained instructions for oxycodone tablets with a route in the vein. Corrected on site with orders received and medication profile updated. Patient 9: The medical record contained care planning regarding use of oxygen and orders for oxygen equipment. There was no evidence of oxygen listed on the medication profile. Corrected on site with order received and medication profile updated.”

“Upon patient record review, 2 of 19 (Patients #7,#10) 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 7: The medical record contained an initial bereavement assessment 6/18/25. Start of care occurred 6/9/25. Patient 10: The medical record contained an initial bereavement assessment 7/30/25. Start of care occurred 7/23/25.”

“Upon patient record review, 4 of 19 (Patients #2,#7,#11,#13) 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 2: The medical record contained nursing documentation since admission identifying patient issues with dyspnea, pitting edema, and a peritoneal dialysis catheter in place. The CTI for benefit period starting 7/13/25 also indicated the patient has diagnosis of heart failure. There was no evidence of problems, goals, and interventions related to the dialysis catheter or respiratory and cardiovascular dysfunction. Plan of care updated for addition of respiratory and cardiovascular. Corrected on site with plan of care update. Patient 7,11: The medical record contained an order for Eliquis. There was no evidence of problems, goals, and interventions related to the risk for bleeding. Corrected Patient 13: The medical record contained nursing documentation since admission identifying patient issues with alcohol dependence and depression. There was no evidence of problems, goals, and interventions related to chemical dependency and depression. Corrected on site with plan of care update.”

“Upon patient record review, 4 of 19 (Patients #5,#6,#7,#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 5: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency and delivery method. Corrected on site with order received. Patient 6: The medication profile contained diclofenac topical gel with no area defined for administration. Corrected on site with order clarification. Patient 7: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The profile also contained instructions for oxycodone tablets with a route in the vein. Corrected on site with orders received and medication profile updated. Patient 14: The medical record contained nursing documentation since admission identifying patient use of a CPAP. There was no evidence of an order for CPAP parameters.”

“Upon patient record review, 4 of 19 (Patients #1,#2,#5,#13) 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 1,13: The medical record contained an order for a nebulized medication. There was no evidence of an order for a nebulizer included in the plan of care. Corrected on site with order received. Patient 2: The medical record contained nursing documentation 7/2/25 identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a walker and nebulizer. There was no evidence of orders for the walker and nebulizer included in the plan of care. Corrected on site with orders received.”

“Upon patient record review, 2 of 19 (Patients #3,#19) 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 3: The medical record contained a CTI for benefit period starting 6/30/25 identifying patient diagnosis of chronic proctitis with diarrhea. There was no evidence the plan of care was updated to include problems, goals, and interventions related to gastrointestinal dysfunction. Corrected on site with plan of care update. Patient 19: There was no evidence the plan of care was updated to include plan to discharge.”

“Upon personnel record review, 1 of 16 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 8: The skills competency did not observe temp, pulse, respiration, tub bath, and shower. Required vitals corrected on site with skills competency completed.”

“Upon patient record review, 3 of 19 (Patients #4,#9,#14) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 4: The aide care plan included instructions for the aide to leave a wound dressing in place. There was no evidence the patient had a wound. Corrected on site with aide care plan update. Patient 9: The medical record contained nursing documentation 5/29/25 identifying patient is a 2 person max assist with transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site with aide care plan update. Patient 14: The medical record contained nursing documentation upon admission identifying patient need for moderate assist with transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site with aide care plan update.”

“Upon patient record review 2 of 19 (Patients #11,#14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 11: There was no evidence of an aide supervisory visit documented from 5/15/25 to 7/28/25. Patient 14: There was no evidence of an aide supervisory visit documented from 6/19/25 to 7/10/25.”

“Upon patient client record review, 1 of 19 (Patient #11) 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 11: The medical record contained nursing documentation identifying patient use of a walker upon admission and a hospital bed 5/12/25. After agency investigation, the patient does not have this equipment and the documentation was inaccurate. Corrected on site with documentation clarification.”

“Based on review of medical records and interviews with staff the agency failed to ensure staff followed the visit schedule as ordered for by the physician on the plan of care for two (2) of three (3) records reviewed. MR #1-2. findings include: A review of medical records completed May 14, 2024, between approximately 11:30AM and 2:30PM revealed the following: MR#1, SOC: 6/30/2023, Certification period: 4/25/2024-6/23/2024, Physician Orders dated 4/29/24: “Frequency changes HHA reduce from 5x weekly to 3x weekly M/W/F not enough aide support to justify 5x weekly event though patient has minimal other supports and is showing declines and needs assistance. MSW visit needed to manage patient needs.” Documentation showed home health aide visits made: M 4/29, W 5/1, Th 5/2, W 5/8, Th 5/9 and M 5/13. No documentation to show the physician was notified of the missed visits or the change to ordered schedule. MR #2, SOC:10/26/2023; certification period: 4/23/24-6/21/24: Physician Orders dated 4/9/24: “Calendar frequency HHA 2wk1, 3wk8”. Documentation showed the home health aide made visits 4/29, and 5/1. No other visits were documented for the Month of May. No documentation to show the physician was notified of the missed visits. Interview with EMP#2 at approximately 12:30PM confirmed the above findings.”

“Based on review of policies and procedures, medical records and interviews with staff the agency failed to ensure wound care was performed as ordered for one (1) of three (3) records reviewed. MR #2. findings include: A review of policies/procedures completed 5/14/2024 between approximately 5:00PM and 7:00PM revealed the following: Wound assessment, Documentation and Clinical Oversight: CLIN.14; Role of the LPN/LVN in wound care; 1. “The RN retains the overall responsibility for patient care.” 3. The LPN/LVN will execute interventions in accordance with the Plan of Care, collect data on wound status, document the patient record, and contribute to the evaluation of individualized interventions related to the Plan of Care”. A review of medical records completed May 14, 2024, between approximately 11:30AM and 2:30PM revealed the following: MR #2, SOC:10/26/2023; certification period: 4/23/24-6/21/24: Physician Orders: Right side of stump Stage II diabetic ulcer cleanse with Normal sterile saline, pat dry with gauze, use skin prep on surrounding skin place square of aquacel with silver on open area of wound cover with optifoam dressing. Change daily by caregivers and nurse during visits”. Visit note: 5/8/24 did not contain any documentation showing the nurse followed the above order. Interview with EMP#2 at approximately 12:30PM confirmed the above findings.”

“Based on review of policy/procedures, review of volunteer services documentation and interview with the agency administrator, the agency failed to ensure documentation showed volunteers services equaled, at a minimum, five (5)% of the total patient care hours of all paid hospice employees and contract staff for one (1) of one (1) year reviewed. 2023. Review of policy 4-007 on 6/20/24 between approximately 11:00 AM through 1:30 PM revealed: Policy: Volunteer Services; “Gentiva, Hospice division (the hospice) will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers. Section: Procedure 1. “The Volunteer Coordinator will develop, implement and evaluate the volunteer services program on an ongoing basis but at least annually”. 7. “The Volunteer Coordinator will ensure that volunteers provide a minimum of 5% of the total number of patient care hours of paid and contracted hospice personnel... The volunteer coordinator will maintain records of cost savings achieved through the use of volunteers”. Review of agency documentation completed on 6/20/24 between approximately 10:00 AM and 12:00 PM revealed the following: Volunteer cost savings report for 2023 broke down as follows: January total patient care hours was = 2% February was = 2% March was = 2% April was = 2% May was =4% June was = 2% July was = 2% August was = 2% September was = 4% October was = 3% November was = 4% December was = 4% An interview with the agency administrator completed on 6/20/24 between approximately 2:00PM and 3:00PM confirmed the above findings.”