Heartland Hospice Services - Greenville

“Upon patient record review, 2 of 14 (Patient #3,6) 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 3: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 05/10/2024, assessment completed on 07/24/2024. Patient 6: No evidence that the bereavement risk assessment was completed within 5 days of the election of hospice. Patient admitted on 10/1/2024, assessment completed on 12/21/2024.”

“Upon patient record review, 1 of 14 (Patient #7) 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 #7: The record indicated that the RN conducted a visit on 06/10/24 and the next visit by the RN was not conducted until 07/01/24, which is 21 days.”

“Upon patient record review, 7 of 14 (Patient #1,2,3,4,5,8,10) 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 1: Patient has a diagnosis of Dysphagia and difficulty swallowing related to Alzheimer’s. No evidence of problems, goals, and interventions related to risk for aspiration included in the plan of care. Corrected on site Patient 2: RN visit narratives indicate that the patient has a stage 2 wound to the left heel. No evidence of problems, goals, and interventions related to altered skin integrity included in the plan of care. Corrected on site Patient 3: Patient has diagnosis of depression and currently prescribed 2 medications for depression. The record also indicates that the patient has a sacral and coccyx DTI wound. No evidence of problems, goals, and interventions related to depression or altered skin integrity included in the plan of care. Corrected on site Patient 4: Patient has a suprapubic cath and a history of UTIs. No evidence of problems, goals, and interventions related to risk for infection included in the plan of care. Corrected on site Patient 5: Patient has diagnosis of depression and currently prescribed 2 medications for depression. No evidence of problems, goals, and interventions related to depression included in the plan of care. Corrected on site Patient 8: Patient has diagnosis of depression and dysphagia. No evidence of problems, goals, and interventions related to risk for aspiration or depression included in the plan of care. Corrected on site. Corrected on site Patient 10: Patients record showed documentation of heart failure on RN assessment. No evidence of problems, goals, and interventions related to cardiac included in the plan of care. Corrected on site. Corrected on site”

“Upon patient record review, 3 of 14 (Patient #3,5,9) 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,#5,#9: The initial visit frequency for the social worker and the spiritual care counselor was 1 prn.”

“Upon patient record review, 3 of 14 (Patient #6,9,10) 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 6: The record indicated wound care supplies listed on the active supply list. No evidence that the patient has had a wound during time on service. Corrected on site Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an orders for the equipment included in the plan of care. Corrected on site. Patient 10: The record indicated wound care supplies listed on the active supply list. No evidence that the patient has had a wound during time on service. Corrected on site”

“Upon patient record review 2 of 14 (Patient #3,7) 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: There was no evidence the aide completed all the assigned tasks during visits completed on 06/03/2024 and 06/04/2024. Task not completed were: transfer the patient from the bed to the chair, transfer the patient from the chair to the bed, and transfer the patient to the wheelchair. no evidence of communication with the nurse or supervisor explaining why the tasks were unable to be completed. Patient 7: There was no evidence the aide completed all the assigned tasks during visits completed on 06/18/2024 to 7/23/2024. Task not completed were: transfer the patient from the bed to the chair, transfer the patient from the chair to the bed, and transfer the patient to the wheelchair. Aide documented “per frequency task not needed” the record shows that the task frequency was daily. No evidence of communication with the nurse or supervisor explaining why the tasks were unable to be completed.”

“Upon patient record review 4 of 14 (Patient #1,2,5) 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 1: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 05/13/24-06/13/24 (31 days), 06/13/24- the start of survey (40 days). Patient 2: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 06/25/24-7/23/24 (29 days). Patient 5: No evidence that a registered nurse made supervised visits every 14 days between 07/01/24-07/18/24 (16 days).”

“Upon patient client record review, 1 of 14 (Patient #2) 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 2: The record indicated that the RN copied her same narrative for her visits that occurred on 06/21/2024, 06/28/2024, 07/02/2024. Aide documented a missed visit note for 06/26/24 that doesn’t state the name of the casemanager that was notified of the missed visit inside the template of the note.”