Tender Heart Hospice Care

“Based on record review and interview, the hospice interdisciplinary group failed to review, revise, and document the individualized plan as frequently as the patient’s condition required, but no less frequently than every 15 calendar days, in that the agency failed to revise the plan of care for the frequency of staff visits for 5 (#6, #7, #8, #9, #13) of 10 active patient records reviewed. The failure placed the patients at risk of poor symptom control. Patient #6:Record review Patient #6’s clinical record revealed an Initial Plan of Care dated 1/18/2025. The Plan of Care indicated that Patient #6 started on the agency’s services on 1/18/2025. The Plan of Care listed Congestive Heart Failure (condition of a weakened heart muscle unable to pump blood effectively throughout the body) as the terminal diagnosis. The Initial Plan of Care contained an order for skilled nurse visits 3 times each week. Patient #6’s clinical record contained a document titled “IDG (Interdisciplinary Group Meeting) dated 2/4/2025. The documentation in the narrative portion of the document indicated that Interdisciplinary Team Meeting occurred on 1/30/2025. The signatures of staff that attended the Interdisciplinary Team Meeting were dated 1/30/2025. The Interdisciplinary Group documentation indicated that Patient #6 was to receive 3 skilled nurse visits each week. Patient #6’s clinical record contained a Plan of Care order dated 2/13/2025. The Plan of Care contained an order for Patient #6 to receive 3 skilled nurse visits each week. Patient #6’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 2/27/2025. The Interdisciplinary Group documentation indicated that Patient #6 was to receive 3 skilled nurse visits each week. Patient #6’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 3/13/2025. The Interdisciplinary Group documentation indicated that Patient #6 was to receive 3 skilled nurse visits each week. Registered Nurse D conducted skilled nurse visits on 2/5/2025, 2/12/2025, 2/19/2025, and 3/5/2025. Licensed Vocational Nurse G conducted skilled nurse visits on 1/29/2025 and 2/26/2025. The plan of care was not revised for the skilled nursing visit frequency. Patient #6’s clinical record indicated that Patient #6 received one skilled nurse visit the weeks of 1/26/2025, 2/2/20205, 2/9/20205, 2/16/20205, 2/23/2025, and a missed visit the week of 3/9/2025 instead of 3 skilled nurse visits each week. Patient #7:Record review of Patient #7’s clinical record revealed an Initial Plan of Care dated 5/21/2024. The Plan of Care indicated that Patient #7 started on the agency’s services on 5/21/2024. The Plan of Care listed Colon Cancer as the terminal diagnosis. The Plan of Care contained an order for Patient #7 to receive 3 skilled nurse visits for the first week. Patient #7’s record contained a Plan of Care order dated 1/16/2025. The Plan of Care contained an order for Patient #7 to receive skilled nurse visits 2 times each week. Patient #7’s clinical record contained a Plan of Care order dated 1/31/2025. The Plan of Care contained an order for Patient #7 to receive skilled nurse visits 2 times each week. Patient #7’s clinical record contained a Plan of Care order dated 2/13/2025. The Plan of Care contained an order for Patient #7 to receive skilled nurse visits 2 times each week. Patient #7’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 1/7/2025. The Interdisciplinary Group documentation indicated that Patient #7 was to receive 2 skilled nurse visits each week. Patient #7’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 1/162025. The Interdisciplinary Group documentation indicated that Patient #7 was to receive 2 skilled nurse visits each week. Patient #7’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 2/13/2025. The Interdisciplinary Group documentation indicated that Patient #7 was to receive 2 skilled nurse visits each week. Registered Nurse C conducted skilled nurse visits on 1/17/2025 and 1/21/2025. Licensed Vocational Nurse G conducted skilled nurse visits on 1/27/2025 and 2/23/2025. The Supervising Nurse conducted skilled nurse visits on 2/4/2025 and 2/12/2025. The plan of care was not revised for the skilled nursing visit frequency. Patient #7’s clinical record indicated that Patient #7 received one skilled nurse visit the weeks of 1/19/2025, 1/26/2005, 2/2/2025, and 2/9/20205 instead of 2 skilled nurse visits each week. Patient #8:Record review of Patient #8’s clinical record revealed an Initial Plan of Care dated 2/12/2025. The Plan of Care indicated that Patient #8 started on the agency’s services on 2/12/2025. The Plan of Care listed Acute Chronic Combined Systolic and Diastolic Heart Failure (condition where the heart’s ability to pump blood and relax/fil is impaired) as the terminal diagnosis. The Plan of Care contained an order for Patient #8 to receive to have as needed visits from the Social Worker and Chaplain. Patient #8’s clinical record contained a Plan of Care dated 2/13/20205. The Plan of Care contained orders for Patient #8 to receive a visit from the Social Worker and from the Chaplain one time a week. Patient #8’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 2/13/2025. The Interdisciplinary Group documentation indicated that Patient #8 was to receive Social Worker and Chaplain visits one time a week. Patient #8’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 2/27/2025. The Interdisciplinary Group documentation indicated that Patient #8 was to receive Social Worker and Chaplain visits one time a week. Patient #8’s clinical record contained documentation of an Interdisciplinary Group Meeting dated 3/13/2025. The Interdisciplinary Group documentation indicated that Patient #8 was to receive Social Worker and Chaplain visits one time a week. Social Worker F conducted visits on 2/13/2025 and 3/12/2025. Chaplain E conducted visits on 2/13/20205 and 3/6/2025. The plan of care was not revised for the social worker and chaplain visits. Patient #8’s clinical record indicated that Patient #8 received Social Worker and Chaplain visits one time a month instead of one time each week. Patient #9:Record review of Patient #9’s clinical record revealed an Initial Plan of Care dated 10/14/2024. The Plan of Care indicated that Patient #9 started on the agency’s services on 10/14/20204. The Plan of Care listed Senile Degeneration of the Brain (disorders characterized by a progressive decline in mental processes involved in acquiring, processing, and using information, impacting memory, reasoning, and the ability to perform everyday activities) as the terminal diagnosis. The Plan of Care contained an order for skilled nurse visits 3 times each week. Patient #9’s clinical record contained Plans of Care dated 1/16/2025, 1/30/2025, 2/13/2025, and 2/27/2025. The Plans of Care contained orders for Patient #9 to receive skilled nurse visits 3 times each week. Patient #9’s clinical record contained documentation of an Interdisciplinary Group Meetings dated 1/16/2025. The Interdisciplinary Group documentation indicated that Patient #9 was to receive skilled nurses visits 3 times each week. Patient #9’s clinical record contained a document titled “IDG (Interdisciplinary Group Meeting) dated 2/4/2025. The documentation in the narrative portion of the document indicated that Interdisciplinary Team Meeting occurred on 1/30/2025. The signatures of staff that attended the Interdisciplinary Team Meeting were dated 1/30/2025. The Interdisciplinary Group documentation indicated that Patient #9 was to receive skilled nurse visits 3 times each week. Patient #9’s clinical record contained documentation of an Interdisciplinary Group Meetings dated 2/13/2025. The Interdisciplinary Group documentation indicated that Patient #9 was to receive skilled nurses visits 3 times each week. Patient #9’s clinical record contained documentation of an Interdisciplinary Group Meetings dated 2/27/2025. The Interdisciplinary Group documentation indicated that Patient #9 was to receive skilled nurses visits 3 times each week. Registered Nurse C conducted skilled nurse visits 1/17/2025 and 1/21/2025.Registered Nurse D conducted skilled nurse visits on 1/28/20205, 2/11/20205, 2/20/2025, and 3/4/2025.The Supervising Nurse conducted skilled nurse visits on 2/4/2025 and 2/25/2025. The plan of care was not revised for the skilled nursing visit frequency. Patient #9’s clinical record indicated that Patient #9 received one skilled nurse visit the weeks of 1/12/2025, 1/19/2025, 1/26/2005, 2/2/2025, 2/9/20205, 2/16/2025, 2/23/2025, and 3/2/20205 instead of 3 skilled nurse visits each week. Patient #13:Record review of Patient #13’s clinical record revealed an Initial Plan of Care dated 12/1/20203. The Plan of Care indicated that Patient #13 started on the agency’s services on 12/1/20203. The Plan of Care listed Colon Cancer as the terminal diagnosis. The Plan of Care contained an order for skilled Nurse visits one time each week. Patient #13’s clinical record contained a Plan of Care dated 2/27/2025. The Plan of Care contained an order for Patient #13 to receive skilled nursing visits one time each week. Patient #13’s clinical record contained documentation of an Interdisciplinary Group Meetings dated 2/27/2025. The Interdisciplinary Group documentation indicated that Patient #13 was to receive skilled nurses visits one time each week. Registered Nurse D conducted skilled nurse visits on 3/3/2025, 3/5/2025, and 3/7/2025. Registered Nurse D conducted 3 skilled nurse visits the week of 3/2/2025. Patient #13’s Plan of Care did not contain an order for Patient #13 to receive skilled nurse visits the week of 3/2/2025. The plan of care was not revised for the skilled nursing visit frequency. Patient #13’s clinical record indicated that Patient #13 was to receive one skilled nurse visit the week of 3/2/20205 instead of 3 skilled nurse visits. During an interview on 3/20/20205 at 12:45 p.m. with the Administrator and Supervising Nurse, the survey discussed that Plans of Care and Interdisciplinary Meeting documentation of staff frequency differed from the visit frequencies provided by staff. The surveyor asked who was responsible to ensure the staff’s frequency on the Plans of Care and the Interdisciplinary Team documentation. The Supervising Nurse informed the surveyor that it would be the nurse case manager for nursing services and the social worker and chaplain for their frequencies. The surveyor asked why the visits frequency differed from the frequencies on the Plan of Care and Interdisciplinary Team documentation. The Supervising Nurse stated, “I think it was picked in error.” The surveyor asked what the process for interdisciplinary team meeting was. The Supervising Nurse informed the surveyor that the nurse would report on patient for the last 14 days, any changes or any new orders. Each nurse was supposed to be documenting any new issues and frequency. The surveyor asked how does the frequency get changed on the schedules. The Supervising Nurse informed the surveyor that the scheduler attends the interdisciplinary team meetings and would be directed at the meeting, the frequency to schedule visits by the Interdisciplinary Team. Registered Nurse C was no longer employed at the agency and was not available for an interview. During an interview on 3/24/2025 at 3:08 p.m. with Chaplain E, the surveyor discussed the frequency of visits conducted differed from the frequency of visits on the Plans of Care and Interdisciplinary Team documentation. The surveyor asked Chaplain E who was responsible for inputting the frequency of chaplain visits on the Plans of Care and Interdisciplinary Team documentation. Chaplain E informed the surveyor that Chaplain E did the schedule and was responsible to put the frequency of chaplain visits on the Interdisciplinary Team documentation and Plans of Care. The surveyor asked why the Plans of Care and Interdisciplinary Team documentation indicated that chaplain visits were to be made weekly. Chaplain E stated, “I don’t know why it was put that way.” Chaplain E informed the surveyor that the frequency of the visits of one time a month was the correct frequency for chaplain visits. During an interview on 3/24/2025 at 3:15 p.m. with Social Worker F, the surveyor discussed the frequency of visits conducted differed from the frequency of visits on the Plans of Care and Interdisciplinary Team documentation. The surveyor asked Social Worker F who was responsible for inputting the frequency of social work visits on the Plans of Care and the Interdisciplinary Team documentation. Social Worker F informed the surveyor that the frequency of visits was supposed to be one time each month and that Social Worker F was responsible to put the frequency of social work visits on the Plans of Care and Interdisciplinary Team documentation. The surveyor asked why the Plans of Care and Interdisciplinary Team documentation indicated that social work visits were to be one time a week. Social Worker F stated, “Maybe I put it in wrong.” During an interview on 3/24/20205 at 3:20 p.m. with Registered Nurse D, the surveyor discussed the frequency of visits conducted differed from the frequency of visits on the Plans of Care and Interdisciplinary Team documentation. The surveyor asked Registered Nurse D who was responsible for inputting the frequency of skilled nursing visits on the Plans of Care and the Interdisciplinary Team documentation. Registered Nurse D informed the surveyor that the nurse would put in the frequencies. Registered Nurse D informed the surveyor that the previous Case manager left and Registered Nurse D was helping out. Registered Nurse D informed the surveyor that the visits that were conducted was the correct frequencies for the visits. Registered Nurse D instructed the surveyor that regarding Patient #13, the frequency was supposed to be 3 times that week due to multiple teeth were extracted. Registered Nurse D stated, “I forgot to put it in.” During an interview on 3/24/2025 at 4:15 p.m. with the Administrator and Supervising Nurse, the Administrator and Supervising Nurse did not dispute the finding and did not present evidence that changed the finding. The surveyor asked how this could affect the agency’s patients. The Administrator and Supervising Nurse informed the surveyor that it could have a negative effect. Review of the agency’s policy titled “Care Planning Process,” labeled TX.6, and dated 3/1/2025 read in part; “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient/family’s specific needs and problems. Policy...The Interdisciplinary Team Plan of Care, based upon the initial/comprehensive health assessment will be developed within fifteen (15) days of the start of care. Procedure...2. Updated Interdisciplinary Team Plan of Care...2.3 Content of the IDT (Interdisciplinary Team) Plan of Care will include...A detailed statement of the scope and frequency of services and interventions planned to meet identified patient/family need...4. The IDT Plan of Care will be updated during the Interdisciplinary Team Meetings at a minimum of every fifteen (15) days or more often as needed, based on...””

“Based on record review and interview, the agency failed to have a discharge summary that included treatments, symptoms, pain management, the current plan of care, the latest physician orders and any other documentation that would assist in post-discharge continuity of care in 1 (#4) of 2 patients discharged in accordance with the Code of Federal Regulations 418.26. The failure placed the patients at risk for a negative outcome when post agency discharge continuity of care was not coordinated. The Code of Federal Regulations 418.26 read in part; ...”Reasons for Discharge. A hospice may discharge a patient if (1) The patient moves out of the hospice’s service area or transfers to another hospice; (2) The hospice determines that the patient is no longer terminally ill...” Patient #4:Record review of Patient #4’s clinical record revealed an Initial Plan of Care that was dated 6/19/2023. The Plan of Care indicated that Patient #4 started services on 6/19/2023. The Plan of Care listed Congestive Heart Failure (condition where a weakened heart muscle cannot pump blood effectively throughout the body) as the terminal diagnosis. Patient #4’s record contained a physician order dated 8/8/2024. The physician order read to discharge Patient #4 from hospice services due to extended prognosis. Patient #4’s record contained a document titled “Discharge Live” that was dated 8/8/2024 and signed by Registered Nurse C. Registered Nurse C documented the reason for Patient #4’s discharge was “Patient no longer terminally ill. Patient seen for live discharge visit for extended prognosis. Patient and family informed of this 2 weeks prior. Patient was referred to [visiting provider agency] and will be evaluated by that team on 8/11/24.” Patient #4’s clinical record did not contain a discharge summary that included treatments, symptoms, pain management, the current plan of care, the latest physician orders, and any other documentation that would assist in post-discharge continuity of care Registered Nurse C was no longer employed at the agency. During an interview on 3/20/2025 at 12:45 p.m. with the Administrator and Supervising Nurse, the surveyor discussed that Patient #4’s record did not contain a discharge summary that included treatments, symptoms, pain management, the current plan of care, the latest physician orders and any other documentation that would assist in post-discharge continuity of care. The surveyor asked who would be responsible for documenting the discharge summary. The Supervising Nurse stated, “The nurse, the Case manager.” The agency did not provide any evidence that changed the finding by the time the surveyor exited the agency on 3/24/2025. During an interview on 3/24/2025 at 4:15 p.m. with the Administrator and Supervising Nurse, the surveyor asked how this could affect the agency’s patients. The Administrator and Supervising Nurse informed the surveyor that it could have a negative effect. A review of the agency’s policy titled “Patient Transfer/Agency Dissolution,” labeled PE. 5, and dated 11/1/2008. The policy read in part; “Purpose To ensure appropriate, timely, and coordinated patient transfers. Policy...2. Agency will consider the following when initiating transfer plans: The reason for the transfer or transfer/discharge...Procedure...10. The Discharge Summary will include - Summary of the patient’s stay including treatments, symptoms, and pain management, Patient’s current POC (plan of care), Patient’s latest physician orders, and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility...””