Heart to Heart Hospice of North Texas LLC

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] includes identified 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 “Plan of Care Process” (dated 01/01/2020) stated in part, “The POC includes ... interventions to manage pain and symptoms and identified issues/problems ... measurable outcomes anticipated from implementing and coordinating the POC ... 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 “Medical Record Content” (dated 03/06/2020) stated in part, “To ensure each medical record ... contains information which describes problems and needs of the patient ... and accurately describes care provided, and results ....Each medical record will contain ...identification of problems, needs, actions, and goals.” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included patient-specific interventions based on newly identified problems derived from data obtained from the patient’s updated comprehensive assessments. Clinical Record 5: The patient elected the hospice benefit on 09/20/2022 with the diagnosis of cerebral atherosclerosis. The comprehensive assessment completed by the Registered Nurse (RN) dated 03/12/2024 documented the patient’s “edema and redness noted to both lower extremities (BLE) ... pt with redness to right lower extremity (RLE) with 1+ pitting edema noted to BLE ...” On 03/15/2024, the physician ordered: “Doxycycline 100mg by mouth twice daily for seven days for cellulitis.” The comprehensive assessment completed by the RN on 03/21/2024 documented, “edema and redness noted to BLE ... “ The patient’s plan of care (POC) dated 03/13/2024 to 05/11/2024 did not document identified planned interventions based on problems identified in the comprehensive assessments related to the patient’s cellulitis. Clinical Record 7: The patient elected the hospice benefit on 05/29/2024 with the diagnosis of malignant neoplasm sigmoid colon. The admission assessment completed by the RN dated 05/29/2024 documented, “Patient has a suprapubic 16 Fr urinary catheter and an ostomy bag ...” The patient’s POC dated 05/29/2024 to 08/26/2024 did not document identified planned interventions based on problems identified in the comprehensive assessments related to the patient’s colostomy bag placement or for the 16 Fr suprapubic urinary catheter. Clinical Record 10: The patient elected the hospice benefit on 03/15/2024 with the diagnosis of senile degeneration of the brain. The comprehensive assessment completed by the RN dated 06/24/2024 documented that the patient “refuses personal care as well as meals. Patient very resistant to personal care and showers ...” On 06/07/2024, the recertification comprehensive assessment completed by the RN documented that the patient was “easily confused and forgetful ... refuses to get out of bed ... Patient frequently refuses a bed bath and shower. She will only allow the aide to change her. She often refuses meals. Patient refuses for someone to assist her with eating ... Patient occasionally does have behaviors with staff; however, redirection is most of the time effective ...” The Licensed Vocational Nurse (LVN) visit note dated 07/01/2024 documented, “Pt in bed, irritable and agitated with this nurse. Facility staff report pt has been refusing care and meals more frequently. Pt confusion continues worsening...” The patient’s medication profile documented Remeron 15 mg daily, dated 03/16/2024, and Memantine 5 mg by mouth at bedtime, dated 06/23/2024. The patient’s POC dated 06/13/2024 to 09/10/2024 did not document identified planned interventions based on problems identified in the comprehensive assessments related to the patient’s increased agitation and refusal of care. Clinical Record 11: The patient elected the hospice benefit on 06/19/2023 with the diagnosis of senile degeneration of the brain. The admission assessment completed by the RN dated 06/19/2023 documented, “Facility nurse reports occasional behavioral outbursts with pt ‘ransacking’ room ....” The behavioral problems continued, as documented by the RN in the comprehensive assessment dated 05/16/2024, “Symptoms to be addressed through medication management this visit - behaviors - facility requesting Xanax as needed (PRN) .... staff nurse asked for PRN anxiety medication due to patient having behaviors. Dr. ... was contacted by this nurse, and MD ordered Xanax three times a day PRN .” A physician’s order dated 05/16/2024 was written for Xanax 0.5mg by mouth three times daily as needed. On 05/30/2024, the recertification comprehensive assessment completed by the RN documented, “Facility reports pt having behaviors recently, but is managed with medication PRN ...” On 06/18/2024, the skilled nurse documented, “Staff report patient has been having increase in behaviors in the evenings ... patient has been rummaging through bedroom and has been more anxious ...” On 07/01/2024, the physician ordered the patient’s Xanax to be changed from an “as needed” medication to a scheduled medication, “0.25mg by mouth twice a day.” On 07/02/2024, the LVN visit note documented, “patient slightly agitated at time of visit ...” The patient’s plans of care dated 04/14/2024 to 06/12/2024 and 06/13/2024 to 08/11/2024 did not document identified planned interventions based on problems identified in the comprehensive assessments related to the patient’s increased agitation, ongoing need for observation, and medication management with multiple medications. Clinical Record 12: The patient elected the hospice benefit on 02/01/2024 with the diagnosis of Alzheimer’s Disease. On 05/22/2024, the recertification comprehensive assessment completed by the RN documented that the patient “requires total care with all ADS ...Pt continues to be at risk for aspiration due to dysphagia, continues on pureed diet with honey thick liquids ....” The Certification of Terminal Illness (CTI) for the benefit period dated 06/11/2024 to 08/09/2024, signed by the physician on 05/29/2024, documented in the physician’s narrative that patient had “dysphagia ... has history of aspiration ... difficulty eating and swallowing pills ...” The patient’s plans of care dated 04/12/2024 to 06/10/2024 and 06/11/2024 to 08/09/2024 did not document identified planned interventions based on problems identified in the comprehensive assessments related to the patient’s documented dysphagia, honey-thickened liquids, pureed diet, and history of aspiration. Clinical Record 18: The patient elected the hospice benefit on 01/07/2022 with the diagnosis of senile degeneration of the brain. The LVN PRN visit note dated 12/08/2024 documented, “PRN visit made today at request of daughter due to continued edema to both lower extremities (BLE) patient continues to have swelling to BLE more pronounced to left lower extremity (LLE) ... patient unable to be educated ... due to cognition ... patient was previously on Lasix 40 mg and Potassium Chloride 20 meq daily ... daughter stated medications were somewhat effective; approval received from MD to restart medications. Patient also reported patient has been rocking in chair and drawing in stomach. Patient recently treated for UTI. Suspect possibility of bladder spasms. New order received for Flavoxate 100mg PO TID...” The physician order dated 12/08/2023 ordered: “Lasix 40 mg by mouth daily, Potassium Chloride 20 meq by mouth daily, and Flavoxate 100mg by mouth three times daily.” The patient’s POC dated 10/29/2023 to 12/27/2023 did not document identified planned interventions based on problems identified in the assessments related to the patient’s edema to bilateral lower extremity and bladder spasms. During the joint clinical record reviews and interviews on 07/09/2024, 07/10/2024, and 07/11/2024, the Area Quality Manager confirmed the findings presented in the clinical record evidence.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Implementing Care and Treatment” (dated 01/01/2020) read in part, “The agency RN ... will oversee the assignment of a hospice aide to a particular patient ... The aide will be provided with written instructions for patient care prepared by an RN ...” In 3 of 18 (17%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure that the Registered Nurse (RN) provided patient-specific written instructions for the Hospice Aide (HA). Clinical Record 1: The patient elected the hospice benefit on 05/10/2023. The plans of care for the benefit periods 03/05/2024 to 05/03/2024 and 05/04/2024 to 07/02/2024 ordered HA services five (5) times a week. The recertification assessment completed by the RN dated 04/16/2024 documented “has continued to develop red raised areas to right leg, skin cancer per daughter ... worsening areas of lesion with drainage requiring dressing changes 3x weekly and as soiled...” Additionally, the RN documented instructions to use aseptic technique to clean the left lower leg with wound cleanser, apply calcium alginate to open draining areas, and cover with a non-adhesive dressing and wrap with an Ace wrap three times weekly and when soiled. An intervention was added to the patient’s plan of care on 04/16/2024, to perform aseptic dressing changes three times weekly and as needed for soiled dressings. The intervention included cleaning the wound with wound cleanser, applying petroleum gauze, covering it with a non-adhesive dressing, and wrapping it with a softball and ace wrap. On 06/05/2024, the RN noted during the Interdisciplinary Group Meeting (IDG) that the areas of lesions on the patient’s left lower leg were increasing in size and had progressed to lesions on the sole. Dressing changes continued three times weekly and as needed. The HA Care Plan dated 03/05/2024 to 05/03/2024 and 05/04/2024 to 7/02/2024 assigned the HA the relevant tasks to perform either a partial sponge bath or shower per patient/daughter preference at each visit and perform hair, skin, perineal, foot, and oral care and dress the patient during each visit. Standard precautions, fall precautions, and skin integrity inspections were also included. No specific instructions were provided to the HA regarding the wound/dressing during the patient’s showers and personal care. Clinical Record 7: The patient elected the hospice benefit on 05/2/2024. The plan of care for the benefit period 05/29/2024 to 08/26/2024 ordered HA services five (5) times a week. The admission assessment completed by the RN dated 05/29/2024, documented that the patient was being admitted to hospice with the diagnosis of colon cancer and “Patient has a suprapubic 16 French (Fr) urinary catheter and an ostomy bag ...” The HA Care Plan dated 05/30/2024 to 08/26/2024 assigned the HA the relevant tasks: partial sponge bath on Tuesday and Thursday, and a shower on Monday, Wednesday, and Friday, and perform hair, skin, perineal, and foot care and dress the patient at each visit. Weekly, the aide assisted with nail care. Standard, bleeding, fall, and diabetic precautions were also included. No specific instructions or precautions were included for the suprapubic catheter or the colostomy bag care during personal care. Clinical Record 17: The patient elected the hospice benefit on 10/17/2023. The plan of care for the benefit period dated 01/15/2024 to 04/13/2024 ordered HA services five (5) times a week. The comprehensive assessment completed by the RN dated 03/13/2024 documented that the patient had a stage three pressure ulcer to the mid-back measuring 3.5 x 1 x 0 with scant serous drainage. On 03/13/2024, the physician ordered wound daily by applying 0.1% Gentamicin ointment to the wound bed, placing a collagen pad, and covering it with a foam bandage. The Hospice Aide Care Plan dated 01/12/2024 to 04/16/2024 assigned the HA the relevant tasks: a partial sponge bath on Tuesday and Thursday and a shower on Monday, Wednesday, and Friday, and turn/reposition in bed, transfer from bed/chair, perform hair care, skin care, perineal care, oral care, nail care, and dress the patient at each visit. Standard precautions, oxygen precautions, fall precautions, and skin integrity checks during each visit were also included. No specific instructions were provided to the HA regarding the wound/dressing during the patient’s showers and personal care. During joint clinical record reviews and interviews on 07/09/2024 and 07/10/2024, the Area Quality Manager confirmed the findings.”