Heart and Soul Hospice LLC

“Based on policy review, medical record review and interview, the agency failed to assess and document patient’s ability to safely self-administer medications correctly per policy for 1 of 3 (Patient #1) sampled patients. The findings included: Review of the agency’s “Patient Self-Administration of Medication” policy revised October 2019 revealed, “...The hospice Case Manger will provide an opportunity for the patient to administer his/her own medications...The Case Manager will...Assess the patient’s ability to self-administer medications correctly and document the patient’s response and understanding to teaching...” Medical record review for Patient #1 revealed a Start of Care date of 2/28/2026 with diagnoses which included Amyotrophic Lateral Sclerosis, Epilepsy, Hypertension, and Chronic Pain. The Visit Note Report, Hospice Admission assessment completed on 2/28/2026, revealed no documentation Patient #1 was assessed for his ability to safely administer medications to himself and no documentation the Patient was instructed how to safely administer his medications. Review of the Plan of Care dated 2/28/2026 through 5/28/2026 revealed Patient #1 was taking hydromorphone, (Dilaudid) a semi-synthetic opioid analgesic used to manage moderate to severe pain, 1 milligram/milliliter (mg/ml) via injection every hour as needed for severe pain or shortness of breath, Lorazepam, (Ativan), a medication used to treat anxiety, insomnia, and seizure disorders, 2 mg/ml via injection every 8 hours for anxiety, and Lorazepam 2 mg/ml concentrate by mouth every 4 hours as needed for anxiety. The combined use of hydromorphone and Lorazepam can cause severe, life-threatening breathing problems, coma, or death. During an interview on 7/21/2026 at 3:41 PM, the Executive Director stated nursing staff could have done better documenting.”

“Based on policy review, medical record review and interview, the agency failed to ensure patients were provided written policies and procedures for managing controlled drugs for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of the agency’s “Home Use and Disposal of Controlled Substances” policy revised October 2019 revealed, “...The Admitting Nurse/Case Manager will provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient/representative and family. The Admitting Nurse/Case Manger will verbally discuss the policy in a language and manner that they understand to ensure the safe use and disposal of controlled drugs. The Admitting Nurse/Case manager will document in the clinical record that the patient/representative and family have received a copy of the policies and procedures...” 2. Medical record review for Patient #1 revealed a Start of Care date of 2/28/2026 with diagnoses which included Amyotrophic Lateral Sclerosis, Epilepsy, Hypertension, and Chronic Pain.Review of the Plan of Care dated 2/28/2026 through 5/28/2026 revealed Patient #1 was taking controlled substances which included hydromorphone for severe to moderate pain, and Lorazepam for anxiety, insomnia, and epilepsy.Review of the Visit Note Report, Hospice Admission assessment completed on 2/28/2026, revealed no documentation Patient #1 and/or his family or caregivers were provided copies of the agency’s policies and procedures on the management and disposal of controlled drugs. 3. During an interview on 7/21/2026 at 3:41 PM, the Executive Director verified staff should have documented better regarding controlled substances.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the hospice did not ensure the medication profile was updated when new medication was added, or changes were made to existing medication. Clinical Record 1: The patient elected the hospice benefit on 12/08/2023 and resided in an Assisted Living Facility (ALF). During the home visit observation with the Registered Nurse (RN) [Staff 5], the patient’s medications were reviewed by comparing the hospice medication profile to the patient’s ALF medication administration record (MAR)/medication list. The hospice medication profile dated 04/04/2024 documented, “Senna with Docusate 8.6mg-50mg, take one tablet daily (order date 12/08/2023). Fluticasone Propionate 50mcg/actuation nasal spray, spray one spray each nostril daily (order date 12/08/2023).” The ALF MAR revealed Senna with Docusate was discontinued on 12/12/2023, and Fluticasone Propionate was discontinued on 02/08/2024. The ALF staff confirmed the patient had not been taking the Senna and Fluticasone Propionate since discontinued. The RN present for the visit confirmed an update of the hospice medication profile was needed. Clinical Record 3: The patient elected the hospice benefit on 03/22/2024 and resided at home. During the home visit observation with the Social Worker [Staff 6], a medication review was completed by comparing the hospice medication profile to the patient’s current medication regimen. The patient was alert and oriented and confirmed his/her current medications. The medications presented by the patient revealed the patient was receiving Tamsulosin 0.4mg capsule, take one capsule daily (bottle dated 03/21/2024), Furosemide 20mg, take one tablet daily (bottle dated 02/29/2024), Ondansetron 4mg, take one twice daily as needed for nausea (patient reports taking at least twice weekly starting before hospice election), Ipratropium Bromide 0.5mg/Albuterol Sulfate 3mg inhalation solution, Use one 3ml vial in the nebulizer every 4 hours as needed for shortness of breath (dated 03/22/2024). The patient confirmed during the home visit that these medications are part of his medication regimen. The Tamsulosin, Furosemide, Ondansetron, and Ipratropium Bromide/Albuterol Sulfate were not documented on the hospice medication profile. During a joint record review and interview on 04/05/2024, the Executive Director agreed medication profiles were not updated with the patient’s current medication regimen.”

“It is required that hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients receiving wound care by the hospice, the hospice did not ensure that wound care was provided as ordered on the plan of care. Clinical Record 1: The patient elected the hospice benefit on 12/08/2023. The plan of care dated 12/08/2023 included an order that stated, wound care assess, and cleanse left heel wound with normal saline or wound cleanser, pat dry, apply a small padded or island dressing two times week. Clinical record review revealed during the week of 12/17/2023 to 12/23/2023, the Skilled Nurse documented wound care was provided on 12/18/2023. There was no documented evidence in the clinical record of a second visit to provide wound care as ordered on the plan of care and no evidence that a reason for the missed wound care was documented. During a joint record review and interview on 04/05/2024, the Executive Director agreed there was no documented evidence the wound care was completed as ordered. The Executive Director stated, it looks like the Registered Nurse did not update the frequency, so it wasn’t scheduled.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) clinical records reviewed of patients receiving wound care by the hospice, the hospice did not ensure that physician orders were in place before providing wound care. Clinical Record 1: The patient elected hospice care on 12/08/2023. The Registered Nurse documentation on 12/11/2023 revealed wound care was provided to a stage 2 wound on the left outer ankle. The clinical record contained no documented evidence of a physician’s order for wound care to the left outer ankle. During a joint record review and interview on 04/05/2024, the Executive Director agreed there was no documented evidence of a physician’s order for wound care to the left outer ankle in the clinical record.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed with patient live discharge, the hospice did not ensure that the discharge summary was forwarded to the patient’s attending physician. Clinical Record 18: The patient elected the hospice benefit on 12/07/2023 and revoked the hospice benefit on 12/15/2023. The clinical record contained no documented evidence that a copy of the discharge summary was sent to the patient’s attending physician. Clinical Record 19: The patient elected the hospice benefit on 04/27/2023 and revoked the hospice benefit on 09/10/2023. The clinical record contained no documented evidence that a copy of the discharge summary was sent to the patient’s attending physician. During a joint record review and interview on 04/05/2024, the Executive Director agreed there was no documented evidence that the discharge summaries were sent to the patient’s attending physicians.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the most recent hospice plan of care, hospice election form and any advance directives, physician certification and recertification of the terminal illness, names and contact information for hospice staff involved in the patient’s care, instructions on how to access the hospice’s 24-hour on-call system, hospice medication information, and hospice physician and attending physician (if any) orders. This standard was not met as evidenced by observation and interview. In 1 of 1 (100%) home visit observation where the patient received hospice services at a nursing facility, the hospice did not ensure the Nursing Facility (NF) received a copy of the patient’s most recent hospice plan of care. Home Visit 2: The patient elected hospice care on 04/26/2023 and resided in a Nursing Facility (NF). During the home visit observation with the Hospice Aide (HA) [Staff 8], review of hospice binder with the patient’s hospice documents provided to the nursing facility revealed the most recent hospice plan of care was dated 06/03/2023 to 08/01/2023. The HA present at the visit confirmed there was no other hospice plan of care in the binder. The facility nurse confirmed the hospice binder was where the hospice documentation was kept. During an interview on 04/05/2024, the Executive Director agreed there was no documented evidence that the nursing facility was provided with the most recent hospice plan of care.”