Heart to Heart Hospice of West Houston

“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” (last revised 01/01/2020) stated in part, “Information will be gathered from the initial assessment and 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 the patient’s family’s immediate care and support needs ...The update of the comprehensive assessment will be accomplished by the hospice Interdisciplinary Group ... and will evaluate changes that have taken place since the initial assessment ... Measureable outcomes anticipated from implementing and coordinating the POC...” In 2 of 19 (11%) clinical records reviewed, that agency did not ensure that the plan of care identified planned interventions based on the comprehensive assessment. Clinical Record 5: The patient elected the hospice benefit on 11/21/2024 with the diagnosis of chronic obstructive pulmonary disease. The plan of care dated 11/21/2024 to 02/18/2024 was reviewed. Chaplain and Social Work services were declined at admission. The Physician’s Certification of Terminal Illness documented, “ Husband overwhelmed with caring for patient ...” The RN visit note dated 11/25/2024 documented, “Patient is very forgetful, asking the same questions multiple times in the course of a single conversation. The spouse at the bedside was getting very frustrated with her ...hard to take care of her when she’s like this...” On 12/09/2024, the RN documented, “Spouse was emotional/tearful on visit stated he felt overwhelmed but that he also wanted to continue caring for her. Refusing respite services at this time ... educated spouse on hypoxia in COPD patient leading to confusion/forgetfulness, specific decline noted in patient ...RN visits increased to 2x weekly...” During the Interdisciplinary Group Meeting (IDG) dated 12/10/2024, the Hospice Physician documented, “Husband burned out and declines respite ...” The RN reported during IDG that “spouse reports she is still very forgetful...She displays tachypnea with mildly labored breathing at rest. She is on continuous oxygen currently 7L NC ... Restlessness is better controlled with use of PRN Morphine ... Skilled Nurse (SN) plan, goals ... for the next 2 weeks: Patient will report well controlled anxiety by 12/24/24... Changes ... ER visits ... Hospital visit 11/27/2024, not admitted, and family did not notify hospice ... “ The plan of care dated 11/21/2024 to 02/18/2024 did not include documentation of planned interventions or patient/family goals for the husband’s identified problem with anxiety, frustration, and burnout. Clinical Record 10: The patient elected the hospice benefit on 08/23/2024 with the diagnosis of acute combined systolic and diastolic congestive heart failure. The patient resided in a nursing facility/long-term care. During the Interdisciplinary Group Meeting (IDG) on 10/15/2024, the nurse documented, “No recent use of oxygen; breathing unlabored, room air, edema noted BLE 2+ ... Skilled Nurse (SN) plan, progress... frequency for the next 2 weeks: Patient will display less agitation with use of scheduled Zoloft for anxiety/agitation ....” During the 10/29/2024 Interdisciplinary Group Meeting, the Registered Nurse (RN) documented, “Patient is now on oxygen, satting 79% or less without oxygen. Edema noted BLE 1-2+... SN plan, progress... frequency for the next 2 weeks: Patient will display less agitation with use of scheduled Zoloft for anxiety/agitation ....” The Registered Nurse (RN) recertification assessment dated 11/06/2024 documented, “Respirations are even but with crackles to mid and lower aspects of bilateral lungs... Edema 1+ noted to BLE. BLE noted tender to the touch ... “ The Skilled Nursing (SN) visit note dated 11/12/2024 documented, “pt continues to have a chronic cough likely r/t prior pneumonia and fluid overload. RN witnessed ongoing productive cough with course expiratory wheezing ... “ On 11/26/2024, the SN documented the patient was taking “DuoNeb treatments at least once daily.” During the IDG Meeting on 11/26/2024, the SN documented, “The patient is now on oxygen, satting 79% or less without oxygen. Edema noted BLE 1-2+... SN plan, progress... frequency for the next 2 weeks: Patient will display less agitation with use of scheduled Zoloft for anxiety/agitation...” The plans of care dated 08/23/2024 to 11/20/2024 and 11/21/2024 to 02/18/2025 documented an intervention for the patient’s identified cardiopulmonary issues dated 08/23/2024. The intervention documented that the SN was to obtain and record the patient’s pulse oximetry reading, with a documented goal that the hospice nurse would obtain and monitor the patient’s oxygen saturation readings. Beyond the orders for oxygen and DuoNeb medications, the plans of care dated 08/23/2024 to 11/20/2024 and 11/21/2024 to 02/18/2025 did not document interventions or related patient/family-identified goals of care for the patient’s identified problem with dyspnea and edema. The plan of care findings were confirmed during a joint clinical record review and interview with both Patient Care Managers on 12/13/2024.”

“It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: 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.06 “Plan of Care Process” (last revised 01/01/2020) stated in part, “The Plan of Care (POC) will include all services necessary for the palliation and management of the terminal illness and related conditions...Information will be gathered from the initial assessment and 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 the patient’s family’s immediate care and support needs...” In 1 of 19 (5%) clinical records reviewed, that agency did not ensure that the patient’s plan of care included drugs and treatment necessary to meet the patient’s needs. Clinical Record 3: The patient elected the hospice benefit on 08/26/2024 with the diagnosis of other sequelae of cerebral infarction with a secondary diagnosis of Parkinson’s disease. were reviewed. The start of care assessment completed by the Registered Nurse (RN) dated 08/26/2024 documented the presence of a Foley catheter. The next day, the RN assessment documented, “Foley catheter with urine output ... F/C change today, 18Fr 30ml ...” The Licensed Vocational Nurse (LVN) visit note dated 09/27/2024 documented, “The patient has a foley catheter in place with approximately 440ml of amber cloudy urine noted to GU bag ...” The (PRN) as needed RN visit note dated 09/29/2024 documented, “per daughter, pt complains of pain to Foley catheter site...Daughter states the Foley catheter was meant to be changed on Friday but this did not occur...Foley catheter changed per order using clean technique ...” A physician’s order to change the patient’s 22 (Fr) French Foley catheter using a sterile technique was documented on 11/17/2024. In the Interdisciplinary Group Meeting (IDG) dated 09/03/2024, the Hospice Physician documented that the patient had a history of urinary retention, but the nurse documented only the presence of a Foley catheter. On 09/17/2024, during IDG, the nurse documented the presence of a Foley catheter. During the IDG Meeting on 10/01/2024, the nurse documented, “She is incontinent of bladder and has a Foley catheter in place ..” The IDG Meetings dated 10/15/2024, 10/29/2024, 11/12/2024, and 11/26/2024 documented, “She is incontinent of bladder and has a Foley catheter in place.” On 12/10/2024, the nurse documented in the IDG Meeting notes that the patient had a Foley catheter in place to aid in the healing of the patient’s wound and that an unscheduled visit was performed on 11/17/2024 due to a Foley catheter malfunction. The plans of care dated 08/26/2024 to 10/24/2024 and 10/25/2024 to 12/23/2024 did not include an order for the Foley catheter to include the size of the catheter and the specified balloon size and frequency of catheter changes except for the order on 11/17/2024. The plan of care findings were confirmed during a joint clinical record review and interview with both Patient Care Managers on 12/13/2024.”

“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; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment; [and] other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review and observation. Agency policy #IC.3 “Hand Hygiene” (last revised on 09/15/2022) stated in part, “Hand Hygiene with Soap and Water: Staff will identify and gather appropriate supplies... Staff will apply the amount of soap recommended by the manufacturer to hands and rub hands together vigorously for at least 15 seconds .. Staff will rinse hands and wrists thoroughly with water. With hands held upright, staff will dry hands and wrists thoroughly with a clean paper towel. They will use a paper towel to turn off the faucet ... Staff may use an alcohol-based hand rub for routinely decontaminating hands in clinical situations ... Prior to entry into the supply bag ... After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient ... After removing gloves..” In 1 of 4 (25%) home visits observed, the agency did not ensure hand hygiene was performed when indicated per the agency’s policy. Home Visit 3: The patient elected the hospice benefit on 10/01/2024 and resided in a nursing/long-term care facility. During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 12/12/2024, the RN attempted to clean their hands with soap and water, but no paper towels were available. They dabbed their hands on their scrub top to dry them, donned clean gloves, and removed the thermometer, blood pressure cuff, pulse oximeter, and stethoscope from their bag. After the vitals were obtained, without changing gloves or washing their hands, the RN reached into the clean section of the bag to get a measuring tape. After completing the assessment, the RN removed their gloves and utilized hand sanitizer. New gloves were donned. The patient requested assistance to reposition himself in the bed. The RN raised the head of the electronic hospital bed, held the patient’s head, removed a pillow, and straightened the towel beneath the patient’s head. After repositioning the patient, the RN reentered the bag without changing gloves and cleansing hands.”

“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. In 1 of 18 (6%) clinical records reviewed of patients that accepted Hospice Aide (HHA) services, the agency did not ensure that the Hospice Aide provided services included in the plan of care. Clinical Record 2: The patient elected the hospice benefit on 10/01/2024 with a diagnosis of senile degeneration of the brain. The plan of care dated 10/01/2024 to 12/24/2024 ordered HHA services three (3) times a week. The HHA care plan dated 10/23/2024 and 10/31/2024 assigned the HHA the relevant tasks: bedbath every Monday and Friday and a shower each Wednesday. The HHA visit notes dated 11/01/2024, 11/04/2024, 11/08/2024, 11/11/2024, 11/13/2024, 11/15/2024, 11/18/2024, 11/20/2024, 11/22/2024, 11/25/2024, 11/27/2024, and 11/29/2024, documented the bedbath and shower were performed during each visit. During an interview and a joint clinical record review and interview on 12/10/2024, the Area Clinical Manager confirmed that the aide did not document the tasks performed as assigned in the HHA care plan. The Area Clinical Manager stated that this aide was no longer employed by the agency.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HR.10 “Staff Competency” (dated 10/01/2021) stated in part, “The hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including paraprofessionals and professionals...” Agency policy #HR.8 “Hospice Aide/Homemaker Competency Evaluation” (last revised 10/28/2021) stated in part, “The Hospice will select a written competency evaluation and a skills checklist ...The competency evaluation and skills checklist will be administered by a Registered Nurse ... The RN will document observation of skills as required ... The following subject areas must be evaluated by observing an aide’s performance of the task with a patient ... Appropriate and safe techniques in performing personal hygiene ... Bed Bath; Sponge, tub, and shower bath; Hair shampooing in skin, tub, and bed...” In 1 of 9 (11%) personnel records reviewed of individuals providing care, the agency did not ensure that skills and competencies were assessed. Personnel Record 10: The Hospice Aide was hired on 08/21/2023. The initial Hospice Aide Competency Checklist included a date indicating that the skill was performed satisfactorily for sponge bath and shampoo in the bed only. The skill for a patient shower and sink shampoo had no date documented and did not specify the evaluation of the skill as satisfactory or unsatisfactory. During a joint personnel record review and interview on 12/13/2024, the Executive Director confirmed that the skills for a shower bath, tub bath, and shampoo in the tub and sink did not include an evaluation of the skill as satisfactory or unsatisfactory.”