Heart to Heart Hospice of San Antonio, LLC

“It is required that each Patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #(TX.06 “Plan of Care Process” (revised 01/01/20), stated in part, “Information will be gathered from the initial assessment and be used by the agency to develop the Initial Plan of Care/Physician’s Orders and to provide care and services to treat a patient’s and patient’s family’s immediate care and support needs ... A revised POC will include information from the patient’s updated comprehensive assessment and will note the patient’s progress toward outcomes and goals specified in the plan of care ...” Agency policy #TX.16 “Medication Administration and Management” (08/21/15) stated in part, “The patient’s physician and Agency Nursing Management will be notified if the patient is not taking or receiving medication as prescribed...” In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the Patient’s plan of care identified planned interventions and reflected patient and family goals for problems identified in the comprehensive assessments. Clinical Record 5: The Patient elected the hospice benefit on 10/02/2024 with a diagnosis of acute diastolic and systolic congestive heart failure. The Patient resided in a nursing facility. An as-needed (PRN) visit note completed by the Registered Nurse (RN) on 10/11/2024 documented, “A call by the facility had been made because Family reported Patient not having a bowel movement since day admitted to facility 10/02/2024. The patient was also complaining of a stomachache. The patient was given a Bisacodyl 10mg suppository...” On 10/30/2024, the RN comprehensive assessment documented, “Family had been changing the Patient, but no one was tracking when or if the Patient was voiding or stooling ... I asked the facility nurse to give the patient a suppository since the family stated there had not been stool in the last 4 days.” On 11/18/2024, the nurse documented that the Patient was having issues with nausea and vomiting due to the Patient’s persistent problem with constipation. The nurse requested that the facility nurse administer the PRN Ondansetron for nausea and assess the Patient for impacted stool. The Patient’s medication profile documented bisacodyl, a 10 mg suppository to be administered rectally every day, and ondansetron HCL, 4 mg every six hours by mouth as needed for nausea and vomiting. Both medications were dated 10/03/2024. On 10/25/2024, during the Interdisciplinary Group (IDG) meeting, the nurse documented, “Patient has complained of stomach pain ... “On 11/08/2024, during the IDG, the RN documented, “SN plan, progress toward measurable goals ... for the next 2 weeks: comfort and safety ...” The RN left the section blank for changes since the last IDG. The plan of care dated 10/02/204 to 12/30/2024 did not include documentation of interventions or patient and family goals to address the Patient’s identified problems with nausea, vomiting, and constipation. Clinical Record 7: The Patient elected the hospice benefit on 07/22/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). On 08/11/2024 at 1535, the nurse documented a call with the Patient and Caregiver, “Reports they are completely out of Fentanyl patches ... would like Valium instead of Lorazepam. Action taken: Contact (pharmacy name) states that a refill order was placed, but it was too early at that time - they will fill it out and deliver it today. Pt has Lorazepam 0.5mg Q4H. States it is ineffective and that he has taken two at a time, and they do nothing for me. Pt states that he has used Valium in the past ...” On 08/16/2024 at 0422, the Patient called after hours with the “request for a sleeping pill... Valium ...” Another call on 08/21/2024 at 2112 documented that the Patient was “calling to request a refill on his morphine. States he is completely out ... Action taken on-call physician approved emergency refill of pts morphine. (Pharmacy name) to fill medication and deliver STAT to pt tonight ...” On 09/13/2024 at 2030, the nurse documented, “Spoke with Triage (name). Nurse visits are to be made prior to ordering any medications. To do med reconciliation, the patient/family requests via triage Combivent and Fentanyl. Earlier today, the Family called requesting a different type of medication for anxiety, and there was no mention of any other medications needed when asked. Patient/family have a history of calling after hours asking for different medications...” During the IDG on 08/30/2024, the RN documented, “Pt keeps reporting that temazepam/lorazepam is not effective for anxiety. He states they gave him Valium in the hospital, and it relaxed him and made him feel much better...Pt hasn’t been taking his routine medications. He has self-diagnosed and decided what he needed and what he didn’t... The Caregiver, prior to going outside... stated that he was going to ask about controlling his medications and that he won’t take them as ordered and takes more than what is ordered and more often. She keeps all narcotics locked in her bedroom inside ... She stated he had a history of drug abuse, and she didn’t trust him to medicate himself.) He became upset again when told his Caregiver had to control his medications ...” Additionally, during the IDG meeting on 08/30/2024, the nurse also documented changes since the last IDG, “Pts has had Fentanyl 12mcg patch added to MAR, and morphine increased from 0.25ml to 0.5ml. Pt still states not effective, only pain complaints sciatica and migraines. Refused to try gabapentin. Muscle relaxer Robaxin ordered ...” During the IDG on 09/13/2024, the nurse documented, “request made for sleep aide awaiting response ... high anxiety and restlessness...Social Worker ... next 2 weeks: SW will continue to advocate for pt at facility. SW will ensure pt safety and will assist with EOL planning ... changes since the last IDG ... pt resides with roommates in a small apt in the back yard of a friend’s home. ... He has a history of substance abuse, and there are concerns about his drug seeking as he continues to ask for different pain medications... “Then, on 09/13/2024 at 0934, a call was documented by the nurse that the patient was “requesting refill - almost out of Combivent and no more Fentanyl patches available.” A call was documented on 09/17/2024 at 1718, “per (name), pt has not slept for 3-4 days, and is upset as she sees this as suffering and pt has requested specific medications the reports work for his body, but hospice physician has not ordered it...visit made...” Then at 1952 on 09/17/2024, the nurse documented the Patient stated, “missed the nurse when she came for a visit ... states want a nurse back at home tonight and again voiced frustration over not getting meds changed for symptom management. Action taken: called and spoke with RNCM, who reports drug-seeking behavior for specific meds and will not allow new PRN meds time to become effective before requesting other interventions with a focus on Valium. Per RMCM, Dr. (name) is aware of this and is not ordering this medication for the patient now...” The nurse documented during IDG on 09/27/2024, “Patient-reported having pain to neck, shoulders, and chest ... SN plan, progress toward measurable goals and frequency for the next 2 weeks: comfort and safety ... changes since the last IDG ... very anxious. The patient reports an increase in pain in the chest, neck, and head.... Social Worker ... plan, progress toward measurable goals and frequency for the next 2 weeks: continue to assess for community resources and will assist with EOL planning... changes since last IDG: ... high risk for falls and has chronic pain ... he is a full code per choice ... will continue to visit with pt 1 x monthly ...” A call received on 09/27/2024 at 1732 documented that the caller wanted to “follow up on the delivery of the Patient’s lorazepam 0.5mg tablets. She reports she spoke with staff 3 days ago regarding this, and they have still not received anything. The patient has been out of the lorazepam for 3 days ...” The same day, at 1843, another call was documented, “Pt calling in following up on refill for Lorazepam that he requested 3 days ago.” Minutes later, at 1845, another call from the Patient was documented as “(name) calling requesting lorazepam refill - pt is completely out.” The nurse documented on 09/28/2024, “Caregiver declined morning visit. I called the Patient again late afternoon and tried to arrange a visit, but he refused.” The next day, 09/29/2024, the nurse documented, “called after 1300 to arrange a visit... The Caregiver and the Patient declined today’s visit. The Caregiver stated he didn’t want a visit today and didn’t need anything.” Then, on 09/30/2024 at 1655, the Patient called and stated, “needs morphine liquid refill asap. He is completely out and gets ill when he doesn’t have it ... Upon investigation, med was filled about an hour before this call ... Call placed to (pharmacy name), who reports med has been filled and is awaiting transport...(patient name) updated of ETA of incoming medication delivery....” The Social Worker documented during the IDG meeting on 10/11/2024 that the Patient had a “limited support system and has a history (Hx) of substance abuse ... high risk for rehospitalization ...” A physician’s order for a urine drug analysis was documented on 10/28/2024. The lab report scanned into the record documented, ‘We cannot ascertain the test(s) you desire from the written order.’ No other test order was documented.” On 11/20/2024, a problem was added to the Patient’s care plan for medication management with the intervention for the nurse to provide resources for the Patient and Caregiver to maintain medication compliance, including a medication planner, printed medication list, and assistance filling the medication box. The goal was for the Patient and Caregiver to administer the Patient’s medication according to the ordered regimen. The Patient’s plans of care dated 07/22/2024 to 10/19/2024 and 10/20/2024 to 01/17/2024 did not include documentation of planned interventions or goals to address the Patient’s repeated calls after hours attempting to obtain early refills and medication changes. There were no identified interventions or patient-specific goals for the Patient’s identified problem of insomnia. with related interventions or patient-specific goals related to his sleeping issues. Clinical Record 8: The Patient elected the hospice benefit on 03/08/2024 with a diagnosis of interstitial pulmonary disease. On 09/16/2024 at 1207, the Social Worker (SW) documented, “SW completed a PRN visit...Extended Family is threatening to take the patient out of the facility. They do not have medical power of attorney (MPOA)... In the past, they had an open adult protective services (APS) referral and were placed in their niece’s care. The family wants this to be changed so they can take the home. A new APS referral was opened for guidance as APS was involved with placement issues in the past ...” During the IDG meeting on 09/18/2024, the nurse documented, “Pt is unhappy and tearful, asking to leave the facility. She was always taken care of by Family at home and given homemade meals. She does not sleep well. SN plan, progress toward measurable goals, frequency the next 2 weeks: weekly...” The Social Worker documented that the Patient did not utilize social services. In a care coordination note dated 10/04/2024, the Social worker documented, “SW contacted APS worker ... to check the open case status. I left a message (L/M) and will attempt again later. The patient’s family continues to attempt to change the patient’s MPOA/power of attorney (POA), but it is unclear if there is an A&O to change advance directives. Pt had a previous APS case where she was removed from this Family into niece’s home. It is unclear if pt can return to this home after removal ...” A Social Worker visit note dated 10/10/2024 documented, “Pt’s daughter and grandchildren were at the facility. They changed advance directives to include the patient’s daughter as the primary agent to help with decisions. The family spoke with the facility’s business office as they questioned the status of Medicaid benefits to cover the cost of the patient staying at the facility. SW revised hospice benefits and guidelines for the family. Updated copies were provided to the Family and facility ...” During the IDG on 10/11/2024, the Registered Nurse (RN) documented, “SN plan, progress toward measurable goals, frequency for the next 2 weeks: weekly...” The social worker documented that “SW will continue to ensure the patient’s safety and comfort. SW will assist with EOL planning, including DNR and funeral arrangements. There have been changes since the last IDT. The patient resides in a 24-hour facility and needs assistance with some ADLs. The patient is Spanish speaking.” The care coordination note completed by the SW on 10/15/2024 documented, “received a phone call that pt grandson was discharging the Patient from the facility and taking to daughter’s home. The hospice team was notified ...” On 11/13/2024, the SW documented that the patient/family needed providers, which she had in place before the move to the facility. The plan of care included the Social Work goal for community resources dated 07/23/2024 with no active interventions. The goal was for the Patient and caregivers to know and access appropriate community resources to provide additional care. The plan of care dated 07/30/2024 to 09/27/2024 and 09/28/2024 to 11/26/2024 did not include documentation of planned interventions or goals for the identified problems with the problematic and changing family dynamics, the Patient’s and Family’s history of involvement with APS, the participation of multiple family members in the Patient’s care, or the Patient and Family’s need for Spanish translation services. Clinical Record 10: The Patient transferred to this hospice and signed the benefit election on 09/10/2024 with a diagnosis of acute leukemia of unspecified cell type. The RN admission assessment dated 09/10/2024 documented that the Patient-reported vertigo and dizziness. A physician’s order dated 09/10/2024 ordered ondansetron HCL 4 mg by mouth every six hours as needed for nausea and vomiting. On 09/19/2024, the nurse visit note documented, “Pt reports feeling nauseated only after consuming a heavy meal last night which consisted of meat and potatoes... pt took Zofran...she is tired due to getting up early this morning from nausea/vomiting ... she reports N/V episode at 4 AM today ... “On 10/24/2024, the RN visit note documented, “Pt reports dizziness due to hx of vertigo. Awaiting new orders ...” On 10/31/2024, the nurse visit note documented dizziness and vertigo. The RN comprehensive assessment dated 11/07/2024 documented, “PT reported abdominal discomfort due to overeating last night. She believes it’s gas and has already taken OTX GasX ...” On 11/14/2024, the nurse visit note was documented: “Pt states that she took 1/4 Meclizine tablet, and it made her sleep for 1 1/2 days, so she refuses to retake it for vertigo ...” In the IDG dated 09/25/2024, the nurse noted changes since the last IDG, including decreasing appetite and increasing nausea that the Patient was controlling with Zofran. The plan, progress, and frequency noted in the IDG Meeting on 10/09/2024 were to visit the Patient weekly and continue to follow the prescribed plan of care for the Patient to maintain her current level of independence. Changes noted were a decreased appetite, with only one full meal eaten daily, and random snacks. On 11/19/2024, the physician ordered: “Meclizine 25 mg by mouth daily as needed for dizziness.” The plans of care dated 09/15/2024 to 11/13/2024 and 11/14/2024 to 01/12/2025 did not include documentation of interventions or patient goals to address the identified problems with dizziness, nausea, and vomiting. During a joint record review and an interview on 11/22/2024, the Administrator (RN)/Executive Director/Area Vice President of Clinical Operations confirmed that there was no documented evidence that the plans of care included problems, goals, and interventions for the problems identified in the assessments.”

“It is required that each patient’s individualized written plan of care: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.5 “Orders for Care” (revised on 04/05/22) stated in part, “Agency will obtain orders and provide care in accordance with physician’s orders which are established prior to initiating patient care ...” In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatments necessary to meet the patient’s needs. Clinical Record 10: The patient elected the hospice benefit on 09/10/2024 with the diagnosis of acute leukemia of unspecified cell type. The Registered Nurse (RN) comprehensive assessment dated 11/07/2024 documented, “PT reports abdominal discomfort due to eating too much last night. She believes it’s gas and has already taken OTX GasX ...” The plans of care dated 09/15/2024 to 11/13/2024 and 11/14/2024 to 01/12/2025 did not document GasX. Clinical Record 18: The patient elected the hospice benefit on 04/20/2024 with the diagnosis of malignant neoplasm of the pancreas. The patient resided in a nursing facility. The RN’s initial assessment dated 04/20/2024 documented, “ currently has a peripherally inserted central catheter (PICC) line and is getting Cefepime due to leukocytosis, has three (3) more days being provided by facility ...” The nurse visit note dated 04/21/2024 documented that the patient had a PICC line and had two more days left on the antibiotic (ABT) to be administered by the facility staff. A physician’s order was documented on 04/20/2024 for Cefepime two grams/50 ml dextrose 5% to be administered via intravenous piggyback every eight hours. The end date was documented as 04/23/2024. In the Interdisciplinary Group Meeting (IDG) note for 04/26/2024, the RN documented that “currently has a PICC line and getting Cefepime due to leukocytosis ... currently being treated for leukocytosis with IV abt ... SNF staff to continue PICC line maintenance for ABT therapy and continue to monitor for any adverse reactions ...” The IDG on 05/10/2024 did not include documentation related to the PICC line or the IV antibiotics. There were no coordination notes related to the PICC line, and no orders were scanned into the medical record. The patient’s plan of care for 04/20/2024 to 07/18/2024 included intravenous (IV) supplies and IV dressing change supplies under the supplies section, but the dressing change frequency was not documented. There were no plan of care orders to discontinue the PICC line after the completion of the course of IV antibiotics. During a joint clinical record review and interview on 11/22/2024, the Administrator (RN)/Executive Director/Area Vice President of Clinical Operations confirmed that the plan of care did not include orders for the patient’s PICC line and Gas-X, which the nurse noted the patient was taking.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review and observation. Agency policy #IC.3 “Hand Hygiene “ (revised 09/15/22) stated in part, “Hand Hygiene with an alcohol-based hand rub - staff will apply product to the palm of one hand. Staff will rub hands together, covering all surfaces of hands and fingers, until hands are dry. This should take around 20 seconds...” In 1 of 4 (25%) home visit observations, the agency did not ensure that hand hygiene was performed correctly when indicated per agency policy. Home Visit 4: During the home visit with the Registered Nurse (RN) [Personnel Record 5] on 11/21/2024, the RN applied alcohol-based hand sanitizer three times after touching the patient before reaching into the clean compartment of the nursing bag. The RN rubbed their hands each time for approximately 4-8 seconds and did not rub their hands until dry, as per agency policy.”

“It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.7 “Implementing Care and Treatment” (revised 01/01/2020) stated in part, “The Agency RN ... will oversee the assignment of a hospice aide ... to meet identified patient needs ...The aide will be provided with written instructions for patient care ... “ In 1 of 15 (7%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 5: The patient elected the hospice benefit on 10/02/2024 with the diagnosis of acute diastolic and systolic congestive heart failure. The patient resided in a nursing facility. The plan of care dated 10/02/2024 to 12/30/2024 ordered HA services three (3) times a week. The HA care plan dated 10/29/2024 assigned the HA the relevant task: document the date of the patient’s last bowel movement every visit. The HA documented that this task was “not completed,” “Not required,” and no date of the last bowel movement was documented on the HA visit notes dated 11/11/2024, 11/13/2024, 11/18/2024, and 11/20/2024. During a joint record review and interview on 11/21/2024, the Administrator (RN)/Executive Director/Area Vice President of Clinical Operations confirmed that the HA did not complete the task on the care plan as written.”