Heart N Soul Hospice Memphis LLC

“Based on policy review, medical record review, and interview, the agency failed to update the medication profile for 1 of 2 (Patient #2) patients reviewed.The findings included:1. Review of the agency’s “Monitoring List and Monitoring” policy, revised on 9/1/2024, revealed, “...The Hospice Registered Nurse (RN) will be responsible for coordinating the effort of monitoring the medication regimen by compiling assessment data through a collaborative effort of all hospice staff involved in the patient’s care, including the pharmacist. A medication/drug profile will be maintained on all patients…The Hospice will review, monitor and maintain a current, accurate list of all prescription and over the counter (OTC) medications, herbal remedies and other alternative treatments that could affect drug therapy by the patient…” 2. Review of the medical record revealed Patient #2 was admitted on 3/28/2025 with diagnoses that included Alzheimer’s Disease with Late Effect, Drug-Induced Adrenocortical Insufficiency, Depression, and Presence of Right Artificial Hip Joint. Review of the “HOSPICE CERTFICATION AND PLAN OF CARE” dated 3/28/2025, revealed orders for treatment and a home medication list. Observations in Patient #2’s home on 4/8/2025 at 3:45 PM, revealed the following the home medications:Rivastigmine (treats memory loss) 9.5 milligrams (mg)/24-hour patchFludrocortisone (used to help control the amount of sodium and fluids in the body) 0.1 mg orally every dayOTC Aspirin (acts as a blood thinner) 81 mg orally every dayOTC Melatonin (hormone which helps regulate sleep cycles) orally every night for sleepOTC D3 (Vitamin D) 5,000 IU (international units)OTC Vitamin C 500 mg orally every dayOTC Gummies 500 micrograms (mcg) with D3 and Zinc orally every dayFluticasone Propionate nasal spray (used to treat inflammation and allergies) 50 mcg as neededBetamethasone dipropionate spray 0.05% topical for EczemaTriamcinolone acetonide 0.1% topical for Eczema The medications listed above were not included on the medication list from the Plan of Care. During an interview on 4/8/2025 at 9:45 AM, the Clinical Manager stated “that’s all that [Family Friend #1] showed me when we admitted the patient…” The Clinical Manager confirmed that Patient #2’s medications needed to be reconciled.”

“Based on policy review, medical record review, and interview, the agency failed to follow the plan of care and notify the responsible physician for missed visits for 1 of 5 (Patient #1) sampled patients. The findings included: Review of the agency’s “Plan of Care Process,” policy dated 9/1/2024, revealed “…To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient’s…specific needs...in collaboration with the Attending Physician…” Review of the medical record revealed Patient #1 was admitted to the agency on 2/24/2025 with diagnoses that included Cerebral Infarction, Aphasia, Hepatic Encephalopathy, Cirrhosis of Liver, Hypertension, and Hemiplegia. Review of the physician’s order dated 2/24/2025, revealed Home Health Aide (HHA) to see the patient 2 times per week for 13 weeks Review of the physician’s order dated 3/17/2025, revealed “…HHA visits D/C’d [discontinued] per family request. Review of the Calendar Worksheet revealed HHA services were provided on 3/21/2025. There was no physician order to continue the HHA visits after the visits had been discontinued on 3/17/2025. During an interview on 4/8/2025 at 1:40 PM, the Clinical Manager stated “…We didn’t have orders for the patient to be seen by the aide [on 3/21/2025]…””

“Based on policy review, medical record review, and interview, the agency failed to maintain a system of communication and integration in accordance with the hospice’s own policies and procedures by failing to ensure clinical notes were documented in a timely manner for 4 of 8 (Patient #1, #3, #4, and #5) patients reviewed. The findings included: 1. Review of the agency’s “…Clinical Documentation Policy,” last revised 9/2024, revealed, “…All clinical documentation should be completed during or shortly after the patient encounter. All documentation must be finalized and synced into the EHR [Electronic Health Record] by 9:00 a.m. local time the following day…” 2. Review of the medical record revealed Patient #1 was admitted to the agency on 2/24/2025 with diagnoses that included Cerebral Infarction, Aphasia, Hepatic Encephalopathy, Cirrhosis of Liver, Hypertension, and Hemiplegia. Review of the Visit Note Report revealed a Registered Nurse (RN) admission visit was made on 2/24/2025 at 3:43 PM. The documentation for the visit was completed on 2/25/2025 at 11:33 AM. Review of the Visit Note Report revealed a Skilled Nurse Focus Assessment visit was made on 2/25/2025 at 2:18 PM. The documentation for the visit was completed on 2/26/2025 at 1:20 PM. Review of the Visit Note Report revealed a RN Comprehensive Assessment visit was made on 4/4/2025 at 3:00 PM. The documentation for the visit was completed on 4/6/2025 at 5:55 PM. 3. Review of the medical record revealed Patient #3 was admitted to the agency on 12/14/2024 with diagnoses that included Malignant Neoplasm of Prostate and Secondary Malignant Neoplasm of Bone, and Lymph Node. Review of the Visit Note Report revealed a Skilled Nurse Focus Assessment visit was made on 3/21/2025 at 10:27 AM. The documentation for the visit was completed on 3/22/2025 at 4:27 PM. Review of the Visit Note Report revealed a Social Worker Initial Evaluation visit was made on 3/24/2025 at 9:25 AM. The documentation for the visit was completed on 3/27/2025 at 2:28 PM.Review of the Visit Note Report revealed an Aide visit was made on 4/1/2025 at 11:45 AM. The documentation for the visit was completed on 4/2/2025 at 12:15 PM. Review of the Visit Note Report revealed a Skilled Nurse Focus Assessment visit was made on 4/4/2025 at 10:37 AM. The documentation for the visit was completed on 4/5/2025 at 3:15 PM. 4. Review of the medical record revealed Patient #4 was admitted to the agency on 1/23/2025 with diagnoses that included End Stage Renal Disease, and Alzheimer’s Disease. Review of the Visit Note Report revealed a Social Worker Initial Evaluation visit was made on 1/25/2025 at 12:23 PM. The documentation for the visit was completed on 1/28/2025 at 8:57 AM. 5. Review of the medical record revealed Patient #5 was admitted to the agency on 1/9/2025 with diagnoses that included Malignant Neoplasm of Cervix, Diabetes, and Drug-Induced Polyneuropathy. Review of the Visit Note Report revealed an Aide visit was made on 1/13/2025 at 10:26 AM. The documentation for the visit was completed on 1/18/2025 at 8:25 PM. Review of the Visit Note Report revealed a Social Worker visit was made on 1/24/2025 at 1:27 PM. The documentation for the visit was completed on 1/27/2025 at 3:00 PM. 6. During an interview on 4/8/2025 at 1:57 PM, the Executive Director (ED) confirmed the time frame for documentation of visits was to be completed by the 9:00 the next morning following the visit. The ED confirmed visits notes for Patient #1, #3, #4, and #5 were not completed timely.”

“Based on medical record review and interview, the facility failed to provide supervisory visits for 1 of 3 (Patient #1) patients reviewed. The findings included: Review of the medical record revealed Patient #1 was admitted to the agency on 2/24/2025 with diagnoses that included Cerebral Infarction, Aphasia, Hepatic Encephalopathy, Cirrhosis of Liver, Hypertension, and Hemiplegia. Review of the physician order dated 2/24/2025, revealed “…HHA [Home Health Aide] 2 wk [week] 13 [2 times a week for 13 weeks]…” There was no documentation that a supervisory visit was performed 2 weeks after the patient’s admission. During an interview on 4/8/2025 at 1:45 PM, the Clinical Manager confirmed a supervisory visit of the HHA was not performed 2 weeks after Patient #1’s admission.”