Heart to Heart Hospice of Texas Ltd

“Based on record review and interview, the agency failed to provide care and services according to the Interdisciplinary Groups written plan of care (hospice aide services) for 1 (#3) of 6 records reviewed where the patients received hospice aide services. The failure placed the patients at risk for inappropriate care that could result in a negative outcome. Patient #3: Record review of Patient #3s clinical record revealed a Plan of Care dated11/18/2022 to 2/11/2023. The Plan of Care indicated that Patient #3 started on the agencys services on 11/18/2022. The Plan of Care listed Malignant Neoplasm of Prostate (Prostate cancer) as the primary diagnosis. The Plan of Care contained an order for the hospice aide to provide services 5 times each week. The week of 12/4/2022 Patient #3 did not receive 5 hospice aide visits as ordered in the Plan of Care. Patient #3 received 4 hospice aide visits – 12/5/2022, 12/7/2022, 12/8/2022, and 12/9/2022. The week of 12/11/2022 Patient #3 did not receive 5 hospice aide visits. Patient #3 received 2 hospice aide visits 12/14/2022 and 12/15/2024. Patient #3s record contained documentation of a missed visit for 12/16/2022. Patient #3s clinical record did not contain physician orders that decreased the frequency of hospice aide visits to less than 5 times each week. The clinical record did not contain evidence that Patient #3 or Patient #3s caregiver had refused hospice aide visits for 12/6/2022, 12/12/2022, and 12/13/2022. During an interview on 7/8/2024 at 11:04 a.m. with the Alternate Administrator, the Alternate Supervising Nurse, and the Regional Vice President of Operations, the surveyor discussed Patient #3 hospice aide services. Patient #3 had an order for hospice aide services 5 times a week. Patient #3 did not receive hospice aide services 5 times each week. Patient #3 received hospice aide services 4 times the week of 12/4/2022 and two times the week of 12/11/2022 along with documentation of one missed hospice aide visit. The Alternate Supervising Nurse informed the surveyor that usually a reason for missed visits would be if another hospice aide was going to provide services and they would refuse the other aide. The surveyor asked how the refusal for a hospice aide visit would be documented. The Alternate Supervising Nurse informed the surveyor that the aide would document the missed visit. The surveyor asked why Patient #3 did not receive hospice aide visits 5 times for the weeks of 12/4/2022 and 12/11/2022. The Alternate Supervising Nurse stated, “;I wasnt here when [Patient #3] was on service. I can follow up with the aide scheduler.” The agency did not present further information to the surveyor prior to the surveyor exiting the agency.”

“Based on record review and interview, the hospice failed to maintain a system of communication that ensured the ongoing sharing of information between all disciplines providing services, directly or under arrangement, in 1 (#4) of 6 patient records reviewed in that, Registered Nurse F failed to notify the physician of Patient #4s decreased oxygen saturation level (percentage of oxygen in the blood). The failure placed the patients at risk that changes in health status would not be addressed by the physician. Patient #4: Record review of Patient #4s clinical record revealed a Plan of Care dated 9/8/2023 to 12/6/2023. The Plan of Care indicated that Patient #4 started on the agencys services on 9/8/2023. The Plan of Care listed Senile Degeneration of the Brain (mental deterioration associated with aging) as the primary diagnosis. Patient #4s clinical record contained a 3-page document titled “;Hospice Informed Consent/Election of Hospice Benefits.” The form was signed by Patient #4s legal representative on 9/8/2023. The document indicated that an attending physician could be chose. The legal representative chose “;I do not wish to choose an attending physician. The hospice physician will oversee my medical care in hospice.” Registered Nurse F conducted a skilled nurse visit on 9/11/2023. Registered Nurse F documented that Patient #4s oxygen saturation level was 98%. Registered Nurse F conducted a skilled nurse visit on 9/15/2023. Registered Nurse F documented that Patient #4s oxygen saturation level was 86%. Patient #4s clinical record did not contain evidence that the hospice physician had been notified of the decrease in Patient #4s oxygen saturation level. Licensed Vocational Nurse G conducted an as-needed skilled nurse visit on 9/17/2023. Licensed Vocational Nurse G documented that Patient #4 was lethargic, oxygen saturation level in the low 90s. Hospice Physician H was notified and laboratory testing for a urinalysis with a culture and sensitivity was ordered along with a chest x-ray (noninvasive high-energy radiation imaging of the inside of the chest that can help detect problems with the heart and lungs). The chest x-ray was performed on 9/17/2023. The impression of the chest x-ray was a slight lower lobe and modest left lower lobe infiltrates. The finds were new since 12/20/2022. The report was electronically signed on 9/17/2023 at 22:36 (10:30 p.m.) Patient #4s clinical record contained documentation by Hospital W that Patient #4 was admitted to the hospital on 9/18/2023 at 5:50 a.m. Patient #4 was admitted to Hospital W with the diagnoses of Pneumonia (lung infection), Pleural Effusion (fluid buildup between the layers of tissue lining the lungs and chest cavity), Chronic Obstructive Pulmonary Exacerbation (sudden or sustained worsening of a chronic inflammatory lung disease which causes difficulty breathing) and a urinary tract infection (bacterial infection of urinary tract). During an interview on 7/8/2024 at 9:39 a.m. with Registered Nurse F, the surveyor discussed Patient #4. Patient #4 had low oxygen saturation levels. Registered Nurse F was asked if the hospice physician had been notified. Registered Nurse F stated, “;I dont remember.” During an interview on 7/8/2024 at 11:04 a.m. with the Alternate Administrator, Alternate Supervising Nurse, and Regional Vice President of Operations, the surveyor discussed Patient #4 and the process of reporting to the hospice physician. The Alternate Supervising Nurse informed the surveyor that the staff report changes to the physician and the physician would give orders for interventions. The Alternate Supervising Nurse informed the surveyor that the hospice physician wouldnt know about changes if staff did not notify the hospice physician or if it was not discussed at the Interdisciplinary Team meeting. The agency had a policy titled “;Interdisciplinary Group Roles and Responsibilities,” labeled TX.08, and dated 2/26/2021. The policy read in part; “;Purpose To identify the roles and responsibilities of the Interdisciplinary Group (IDG) for a parent or Multi-site program. Policy I. The Agency will designate and IDG, who, in consultation with the patients attending physician, will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members...Procedure...II. The Agency will designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patients and familys needs...VII...The Agency will develop a system to communicate among all persons involved in the patients care, which included an opportunity to ask and respond to questions (e.g.- reporting, updating and/or handing off communications) ...””

“Based on record review and interview, the Registered Nurse that supervised the hospice aides failed to prepare specific written patient care instructions for the hospice aides regarding the use of a shower chair or specific written patient care instructions regarding a splint/plaster cast for 2 (#5, #6) of 6 patient records reviewed that received hospice aide services The failure placed patients at risk of injury or negative outcomes as a result of not providing specific written instructions for a splint/sling/plaster cast, and a shower chair. The agency utilized an electronic medical record system. Patient #5: Record review of Patient #5s clinical record revealed Hospice Interdisciplinary Comprehensive Assessment and Plan of Care Update Reports that were dated 5/30/2023, 6/13/2023, 6/27/2023, and 7/11/2023. The Plan of Care Update Reports indicated that Patient #5 started on the agencys services on 5/18/2023. The Plan of Care Update Reports listed Malignant Neoplasm of the Rectum (Rectal Cancer) as the primary diagnosis. The Plan of Care Update Report dated 5/30/2023 contained an order for hospice aide services once for the first week, then 5 times a week. The Plan of Care Update Reports dated 6/13/2023, 6/27/2023, and 7/11/2023 contained orders for hospice aide services 5 times each week. Registered Nurse C documented a phone call on 7/3/2023, that Patient #5 had a left Ulna (bone in the forearm) fracture (a partial or complete break in the bone), and that Patient #5 was going to be evaluated for a splint or cast. Registered Nurse D documented on 7/3/2024 that a nurse practitioner notified Registered Nurse D that Patient #5 had a left Ulnar fracture and that the Facility Medical Doctor wanted to send Patient #5 to the hospital. Registered Nurse D conducted a skilled nurse visit on 7/4/2023. Registered Nurse D documented that Patient #5 had a splint to the left arm and a sling; and that Patient #5 was to follow up with an Orthopedic physician (physician that specializes in injuries of muscles, bones, joints, ligaments, and tendons) regarding the fracture. Registered Nurse D conducted a visit on 7/10/2023. Registered Nurse D documented that Patient #5 had a plaster cast to the left arm. Patient #5s clinical record contained a hospice aide care plan with an effective date of 5/18/2023. The aide care plan did not include written instructions regarding Patient #5s splint or plaster cast to the left forearm. The aide care plan listed that the hospice aide was to provide the task of showering Patient #5 on Mondays, Wednesdays, and Fridays. Patient #5s clinical record did not contain any other aide care plans. During an interview on 7-8-2024 at 11:04 a.m. with the Alternate Administrator, Alternate Director of Nursing, and the Regional Vice President of Operations, the surveyor discussed that Patient #5 had a splint and then a plaster cast due to a fracture of the left Ulna in July 2023. The hospice aide care plan did not indicate that Patient #5 had a splint and later a plastered cast. The surveyor asked what the aide would need to know when a patient had a splint or a plastered cast. The Alternate Director of Nursing stated the aide would need to know about “;keeping it dry, let the nurse know of redness, swelling, or odors.” The Alternate Director of Nursing informed the surveyor that the Alternate Director of Nursing was not in this position at that time and did not know why it wasnt included in the hospice aide care plan. Patient #6: Record review of Patient #6s clinical record revealed a Recertification Plan of Care Update that was dated 5/22/23 to 7/20/2023. The Plan of Care did not list the primary diagnosis. The Plan of Care contained an order for Patient #6 to receive hospice aide visits 5 times a week. Hospice Aide E conducted a visit on 6/14/2023. Hospice Aide E documented that Patient #6 was receiving a shower and was sliding on the shower chair. Hospice Aide E documented holding onto Patient #6s left arm to avoid Patient #6 falling “;over the hole.” Hospice Aide E documented that Patient #6s arm was red. Hospice Aide E notified the nurse and showed the nurse so “;they will know what happened to [Patient #6s] arm.” Patient #6s clinical record contained a hospice aide care plan that was effective 1/13/2023. The hospice aide care plan listed that Patient #6 was to receive a shower on Mondays, Wednesdays, and Fridays. The hospice aide care plan did not include written instructions that a shower chair was to be used. Patient #6s clinical record did not contain any other hospice aide care plans. During an interview on 7/8/2024 at 11:04 a.m. with the Alternate Administrator, Alternate Supervising Nurse, and the Regional Vice President of Operations, the surveyor discussed the incident with Patient #6, Hospice Aide E, and the shower chair. The hospice aide care plan did not contain written instructions to use a shower chair. The Alternate Director of Nursing did not know why the shower chair was not included in the hospice aide care plan, “;I was not in this position at that time.” The agency had a policy titled “;Implementing Care and Treatment,” labeled TX.07, and dated 1/1/2020. The policy read in part; “;Purpose To ensure patient care and treatment are provided as identified in the care planning process. Policy...Procedure...III. The Agency RN (Registered Nurse) who is a member of the IDG (Interdisciplinary Group) will oversee the assignment of a hospice aide to a particular patient...IV. The aide will be provided with written instructions for patient care prepared by an RN...””

“Based on record review and interview, the hospice aides provided services that were not included in the plan of care and failed to provide services ordered by the Interdisciplinary group for 3 (#4, #5, #6) of 3 patients that received hospice aide services from contracted hospice aides. The failure placed the patients at risk of receiving inappropriate care, or the omission of care, that could result in a negative outcome. Patient #4: Record review of Patient #4s clinical record revealed a Plan of Care dated 10/2/2023 to 11/1/2023, second admission to the agency. The Plan of Care indicated that Patient #4 started on the agencys services on 10/2/2023. The Plan of Care listed Senile Degeneration of the Brain (mental deterioration associated with aging) as the primary diagnosis. The Plan of Care contained an order for Patient #4 to receive hospice aide services 5 times a week. The surveyor was given an “;Aide Care Plan History Report” that enabled the surveyor to review the Aide Care Plan and any changes to the Aide Care Plan since Patient #4s admission. The Aide Care Plan History Report listed the following tasks for the hospice aides to perform effective 10/23/2023: Bathing – bed bath every visit. Dressing every visit. Foot Care every visit. Hair Care every visit. Nail Care every visit. Oral Care every visit. Perineal Care every visit. Skin Care every visit. Contract Hospice Aide V provided hospice aide services on 10/24/2023, 10/26/2023, 10/27/2023, 10/30/2023, and 10/31/2023. On 10/24/2023 Provided Shower (bed bath ordered), shampoo, ambulation, transfer/mobility assist, light housekeeping, linen change, tasks not included in the Aide Care Plan. On 10/25/2023 (visit conducted by Contract Aide U) Provided Ambulation, Mobility/Transfer, and light housekeeping, tasks not included in the Aide Care Plan. Did not provide a bed bath which was ordered to be every visit. On 10/26/2023 Provided shampoo, ambulation, mobility/transfer assist, linen change, and light housekeeping, tasks not included in the Aide Care Plan. On 10/27/2023 Provided shower (bed bath ordered), shampoo, ambulation, mobility/transfer, linen change, and light housekeeping, tasks not included in the Aide Care Plan. Did not provide dressing which was ordered every visit. On 10/30/2023 Provided mobility/transfer, linen change, and light housekeeping, tasks not included in the Aide Care Plan. On 10/31/2023 Provided ambulation, mobility/transfer, linen change, and light housekeeping, tasks not included in the Aide Care Plan. Patient #5: Record review of Patient #5s clinical record revealed Hospice Interdisciplinary Comprehensive Assessment and Plan of Care Update Reports that were dated 5/30/2023, 6/13/2023, 6/27/2023, and 7/11/2023. The Plan of Care Update Reports indicated that Patient #5 started on the agencys services on 5/18/2023. The Plan of Care Update Reports listed Malignant Neoplasm of the Rectum (Rectal Cancer) as the primary diagnosis. The Plan of Care Update Report dated 5/30/2023 contained an order for hospice aide services once for the first week, then 5 times a week. The Plan of Care Update Reports dated 6/13/2023, 6/27/2023, and 7/11/2023 contained orders for hospice aide services 5 times each week. Patient #5s clinical record contained a “;Aide Care Plan Report” that indicated that it was the current Aide Care Plan and was effective 5/18/2023. The Aide Care Plan included the following tasks to be performed by the hospice aide: Transfer client from bed/chair every visit. Bathing – partial sponge bath on Tuesdays and Thursdays. Bathing – Shower on Mondays, Wednesdays, and Fridays. Hair Care (did not include shampooing) every visit. Skin Care every visit. Perineal Care every visit. Foot Care every visit. Oral Care every visit. Nail Care every visit. Dressing every visit. Empty trash every visit. Change Linens on Mondays, Wednesdays, and Fridays. Precautions- Standard precautions every visit. Bleeding every visit. Mobility- Wheelchair bound every visit. Other Services- RN notified of changes every visit. Patient #5 received hospice aide services by contracted hospice aides from Contract Agency X on 7/3/2023, 7/4/2023, 7/5/2023, 7/6/2023, and 7/7/2023. Contract Aide Y provided the hospice aide visits on 7/3/2023, 7/4/2023, 7/5/2023, 7/6/2023, and 7/7/2023. On visit 7/3/2023 (Monday) (Was advised by facility nurse not to move the patient too much by giving a bed bath or shower due to fracture to their left hand). Did not provide foot care, nail care, or dressing for Patient #5 which was ordered to be performed every visit. On visit 7/4/2023 (Tuesday) Provided a shower but a partial bed bath was ordered on Tuesdays. Provided shampoo and ambulation which were not tasks included in the Aide Care Plan. Changed Linens which was ordered to be done on Mondays, Wednesdays, and Fridays. On visit 7/5/2023 (Wednesday) Provided ambulation which was not a task included in the Aide Care Plan. Did not provide Nail care which was ordered to be performed every visit. On 7/6/2023 (Thursday) Provided ambulation which was not a task included in the Aide Care Plan. Did not provide nail care which was ordered to be performed every visit. Provided Linen change which was ordered to be done on Mondays, Wednesdays, and Fridays. On 7/7/2023 (Friday) Provided a bed bath (shower was ordered on Mondays, Wednesdays, and Fridays). Did not provide nail care or transfer to bed/ chair which were ordered to be performed every visit. The clinical record did not indicate a refusal of care by the patient. Patient #6: Record review of Patient #6s clinical record revealed a Recertification Plan of Care Update that was dated 5/22/23 to 7/20/2023. The Plan of Care did not list the primary diagnosis. The Plan of Care contained an order for Patient #6 to receive hospice aide visits 5 times a week. Patient #6s clinical record contained a “;Aide Care Plan Report” that indicated that it was the current Aide Care Plan and was effective 1/13/2023. The Aide Care Plan included the following tasks to be performed by the hospice aide: Transfer Client from bed/chair every visit. Bathing – partial sponge bath on Tuesdays and Thursdays. Bathing – shower on Mondays, Wednesdays, and Fridays. Hair Care (does not include shampooing) every visit. Skin Care every visit. Perineal Care every visit. Precautions- Standard Precautions every visit. Mobility- One-person transfer every visit. Wheelchair bound every visit. Walker every visit. Intake/Output- Output – Date of Last BM (bowel movement). Other Services – RN (registered nurse) notified of changes every visit. COVID-19 Screening completed prior to visit. All potential risk reported to RN every visit. Contract Aide Z provided a hospice aide visit on 6/5/2023. On visit 6/5/2023 Monday) Provided a bed bath (shower ordered on Mondays, Wednesdays, and Fridays). Provided ambulation and linen change which were not included in the Aide Care Plan. The clinical record did not indicate a refusal of care by the patient. During an interview on 7/8/2024 at 9:39 a.m. with Registered Nurse F, the surveyor asked Registered Nurse F how you would know if the contract hospice aides were following the Aide Care Plan. Registered Nurse F stated, “;I would have to take their word for it and their documentation.” Registered Nurse F informed the surveyor that Registered Nurse F did know how the contract hospice aide notes get to the office or chart. Register Nurse F informed the surveyor if Registered Nurse F was not able to review the contracted aides paper notes, Registered Nurse F would talk to the patient or family. During an interview on 7/8/2024 at 11:04 a.m. with the Alternate Administrator, Alternate Supervising Nurse, and the Regional Vice President of Operations, the surveyor discussed that the contract hospice aides were providing tasks that were not included in the Aide Care Plans and were not providing some tasks that were included in the Aide Care Plans. The surveyor asked what the task Hair Care meant. The Alternate Supervising Nurse informed the surveyor that the Hair Care task did not include shampooing. The surveyor asked how the contract aides would receive the agencys Aide Care Plans and how the registered nurse would be able to review the contract aide paper documentation. The Alternate Supervising Nurse stated, “;We fax the Aide Care Plans” to the contract agency. The Alternating Supervising Nurse informed the surveyor that the contract hospice aides would document their visits on paper notes. The contract agency would send the paper notes to the agency and once received, the notes would be uploaded to the patient records and the patient care managers reviewed them. The agency had a policy titled “;Interdisciplinary Group Roles and Responsibilities,” labeled TX.08, and dated 2/26/2021. The policy read in part; “;Purpose To identify the roles and responsibilities of the Interdisciplinary Group (IDG0 for a parent or Multi-site program. Policy. I. The Agency will designate and IDG, who, in consultation with the patients attending physician, will work together to provide for the physical, medical, psychosocial, emotional, and spiritual needs of the terminally ill patient and/or family members as delineated in a patient specific plan of care. II. The IDG must include, but not limited to...A. A doctor of medicine or osteopathy (who is an employee or under contract with the hospice) B. A registered nurse...Procedure I. The IDG, in collaboration with the attending physician (if any), will prepare a written plan of care for each patient/family-specific needs...The IDG, in its entirety, will supervise the care and services including...E. Hospice Aides and Homemakers...””