Heart to Heart Hospice of Sugar Land

“It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient’s attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review, document review, and interviews with the Patient Care Manager, which revealed the hospice: Failed to ensure that the Registered Nurse (RN) provided continuous assessment of the patient’s needs in 1 of 14 (7%) clinical records reviewed [HCPC.19.I/L540]; Failed to ensure that each patient’s written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments in 5 of 14 (36%) clinical records reviewed [HCPC.21.I/L545]; and Failed to ensure that that each patient’s written plan of care included planned Interventions to manage pain and symptoms based on problems identified in the comprehensive assessments in 1 of 14 (7%) clinical records reviewed [HCPC.21.I/L546]. The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.56: Interdisciplinary group, care planning, and coordination of service. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the hospice agency.”

“It is required that the hospice develops and maintains an emergency preparedness (EP) plan that is reviewed and updated at least every two(2) years. This standard was not met as evidenced by document review and interview. The agency did not ensure that the emergency preparedness plan was reviewed and updated every two (2) years. A review of the agency’s EP plan for 2022, 2023, and 2024 revealed that the agency did not document a review of the agency’s EP plan for 2022 and 2023. There was documentation that the EP plan was reviewed and updated on 06/25/2024. During an interview on 10/22/2024, the Executive Director/Disaster Coordinator confirmed that no such documentation was found. A review of the hospice’s emergency plan for the years 2022, 2023, and 2024 revealed that the agency did not document a review of the agency’s plan for 2022 and 2023. There was documentation that the emergency plan was reviewed and updated on 06/25/2024. An interview with the Executive Director/Disaster Coordinator (Personnel Record 2) on 10/22/2024 confirmed that no such documentation was able to be found. The agency’s leadership, including the Executive Director/Disaster Coordinator, hired on 11/21/2023, and the Patient Care Manager/Alternate Disaster Coordinator hired on 03/21/2023, signed job descriptions for Disaster Coordinator and Alternate Disaster Coordinator on 05/24/2024 and 06/24/2024, respectively and did not have any further documentation to provide.”

“It is required that the hospice providing care in the patient’s home conducts exercises to test the emergency preparedness plan annually, including participation in a full-scale exercise that is community-based every two (2) years or when a community-based exercise is not accessible. Testing includes participation in an individual, facility-based functional exercise every two (2) years. Or if the organization experiences a natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. Conducting an additional exercise every two (2) years – opposite the year that a full-scale exercise or functional exercise is conducted. This exercise may include but is not limited to a second full-scale exercise that is community-based or a facility-based functional exercise, a mock disaster drill, or a tabletop exercise or workshop that is led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario and a set of problem statements, directed messages, or prepared questions designed to challenge the emergency plan. This standard was not met as evidenced by document review and interview. The agency did not ensure that exercises were conducted annually to test the emergency preparedness plan. A review of the agency’s emergency preparedness plan (EPP) for 2022, 2023, and 2024 revealed that the agency documented a fire drill conducted on 08/19/2024 and activation of the EPP on 02/22/2024 and 07/07/2024. There was no documentation of testing or natural/manmade disasters for 2022 and 2023. During an interview on 10/22/2024, the Executive Director/Disaster Coordinator confirmed the finding. The agency’s leadership, including the Executive Director/Disaster Coordinator, hired on 11/21/2023, and the Patient Care Manager/Alternate Disaster Coordinator hired on 03/21/2023, did not provide further documentation. A review of the hospice’s emergency plan for the years 2022, 2023, and 2024 revealed that the agency had an agency fire drill documented on 08/19/2024 and two events during which the emergency plan was activated on 02/22/2024 and 07/07/2024. However, there was no documentation of any testing or natural/manmade disasters for 2022 and 2023. An interview with the Executive Director/Disaster Coordinator (Personnel Record 2) on 10/22/2024 confirmed that no such documentation was able to be found. The agency’s leadership, including the Executive Director/Disaster Coordinator, hired on 11/21/2023, and the Patient Care Manager/Alternate Disaster Coordinator hired on 03/21/2023, signed job descriptions for Disaster Coordinator and Alternate Disaster Coordinator on 05/24/2024 and 06/24/2024, respectively and did not have any further documentation to provide.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PE.1 “Patient Assessments” (01/01/2020) stated in part, “Updates to the comprehensive assessment will be accomplished by the IDG ...to include ... reassessing a patient’s needs when there is a significant health status change in the client’s condition...” In 1 of 14 (7%) clinical records reviewed, the agency did not ensure continuous assessment of the patient’s needs when there was a significant change in the patient’s condition. Clinical Record 13: The patient elected the hospice benefit on 03/26/2024 with the diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility. The Registered Nurse (RN) PRN (as needed/pro re nata) visit note dated 08/13/2024 documented, “Received pt laying in recliner chair pt appeared to be in and out of sleep, responsive to verbal stimuli, facility staff stated pt was unresponsive prior to visit, sternum rub performed, pt alert and oriented x1, poor PO intake noted today per FSN ....” On 08/14/2024, the PRN visit note documented, “Awakens easily but says he feels lousy but is unable to say how, med tech states she had to give Zofran this morning because he was feeling nauseous ... had episode of unresponsiveness yesterday where staff couldn’t awaken him but by time (hospice) nurse got to facility, pt was responsive but lethargic, unknown cause of unresponsiveness so discussed with Dr... who recommends decreasing Seroquel back down to 25mg BID and decreasing Norco to 5/325 BID. Updated family and staff on new orders. Will continue to monitor.” On 08/14/2024, the physician ordered the Seroquel to be reduced to 25mg by mouth twice daily (from 50mg twice daily) and the Norco 5/325mg by mouth twice daily (from three times a day). A clinical record review revealed no other phone call or nursing visit documented to reassess the patient after the changes in the patient’s level of consciousness and medication changes until 08/21/2024, when the hospice nurse pronounced the patient. During a joint clinical record review and interview on 10/23/2024, the Patient Care Manager confirmed that there was no additional documentation of any visits or phone calls made to follow up with the patient after the change in condition and medication order changes until 08/21/2024 to pronounce the patient.”

“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 #PE.1 “Patient Assessments” (01/01/2020) stated in part, “Updates to the comprehensive assessment will be accomplished by the IDG ... to include ... changes that have taken place since the initial assessment or last comprehensive assessment, including the patient’s progress toward desired outcome, as well as the patient’s response to care ... Information from the updated comprehensive assessment will be used by the IDG to update the patient/family POC ...” Agency policy #TX.06 “Plan of Care Process” (01/01/2020) stated in part, “To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patient and family’s needs ... individualized written POC established by the hospice interdisciplinary group in collaboration with ... the patient or representative, and the primary caregiver ... and in accordance with the patient’s needs...A revised POC ... will note the patient’s progress toward outcomes and goals specified in the plan of care ...” In 5 of 14 (36%) clinical records reviewed, the agency did not ensure that each patient’s written plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected the hospice benefit on 03/10/2024 with the diagnosis of secondary neoplasm to the retroperitoneum and peritoneum. The RN Hospice comprehensive assessment dated 06/27/2024 documented, “wife stated yesterday was a severe pain and nausea episode due to being constipated... Yesterday’s episode was also caused by constipation, and received orders for Lactulose BID ... Pt and wife state that nausea meds are still effective ... “ A physician’s order was documented on 06/27/2024 for Lactulose two tablespoons by mouth twice daily as needed for constipation. The RN comprehensive assessment dated 08/08/2024 documented, “pt complained of flu-like symptoms, complained of night sweats and difficulty urinating, notified attending physician with new orders...” A physician’s order for Cipro 250mg by mouth twice daily for seven days for a urinary tract infection was documented. The Interdisciplinary Group Meeting (IDG) on 08/21/2024 included a nurse note that updated that the patient had recently been placed on Cipro for signs and symptoms of a urinary tract infection. The plan of care dated 06/08/2024 to 09/05/2024 did not include documentation of patient/family goals for the treatment. The plan of care did not include documentation of interventions or goals for the patient’s identified problem with symptomatic nausea requiring the use of nausea medications as needed. Clinical Record 10: The patient elected the hospice benefit on 03/11/2024 with a diagnosis of Alzheimer’s disease. A physician’s order was documented on 07/09/2024 for the patient to transfer to respite care. A review of the patient’s plans of care dated 05/10/2024 to 07/08/2024 and 07/09/2024 to 09/06/2024 revealed no documented problem, intervention, or goal for the patient’s respite stay. Clinical Record 12: The patient elected the hospice benefit on 09/18/2023 with a diagnosis of unspecified cirrhosis of the liver. On 09/23/2023, a coordination note documented that the patient was “asking for a nurse visit tomorrow to get a sleeping pill...” On 09/24/2023, the physician ordered, “Trazodone 25mg by mouth at bedtime for insomnia.” The RN comprehensive assessment dated 10/02/2023 documented that the patient was requesting a paracentesis and that the order for the procedure had been faxed. A physician’s order to schedule a paracentesis for the patient’s ascites was documented on 10/02/2023. The clinical record review revealed the patient’s plan of care, dated 09/18/2023 to 12/16/2023, did not include documentation of interventions or goals related to the patient’s identified problems of insomnia or for the ordered paracentesis. Clinical Record 13: The patient elected the hospice benefit on 03/26/2024 with a diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The physician’s certification of terminal illness (CTI) for the benefit period dated 06/24/2024 to 09/21/204 documented the patient’s “Cognitive decline evidenced by increased combativeness and need to increase Seroquel. Patient with increased Ativan PRN doses, oriented x1, increased confusion, and combative with staff ...” The RN assessment dated 06/28/2024 documented, “Pt found lying in bed with eyes closed in no apparent distress but appears to not be feeling well. Med tech states she had to give a dose of Zofran this morning due to pt having one episode of vomiting ... pt became resistant and aggressive when trying to clean and give meds. Med tech unable to give oral meds and says she will reattempt later...” On 07/31/2024, the RN comprehensive assessment documented, “also discussed with staff with providing care to pt due to his aggression toward them. Discussed this with daughter who says she is aware he can become aggressive with staff especially during bathing and she is agreeable to changing aide care plan to include sponge baths instead to see if that is an easier for pt to complete, aide care plan changed...” The PRN nursing visit note dated 08/12/2024 documented, “Received pt laying in recliner chair pt appeared to be in and out of sleep, responsive to verbal stimuli, facility staff stated pt was unresponsive prior to visit, sternum rub performed, pt alert and oriented x1, poor PO intake noted today per FSN ....” The follow-up PRN visit by the RN on 08/14/2024 documented, “Awakens easily but says he feels lousy but is unable to say how, med tech states she had to give Zofran this morning because he was feeling nauseous ... had episode of unresponsiveness yesterday where staff couldn’t awaken him but by time (hospice) nurse got to facility, pt was responsive but lethargic, unknown cause of unresponsiveness so discussed with Dr... who recommends decreasing Seroquel back down to 25mg BID and decreasing Norco to 5/325 BID. Updated family and staff on new orders. Will continue to monitor.” The patient’s medication profile documented Seroquel 25mg by mouth twice daily effective 05/03/2024; on 08/01/2024, the dose was increased to 50mg twice daily, and on 08/14/2024, the dose was decreased back to the original dose. The plan of care dated 06/24/2024 to 09/21/2024 did not include documentation of interventions or goals related to the aggressive behavior of the patient. The patient’s unresponsive episode was not documented in the plan of care. Clinical Record 14: The patient elected the hospice benefit on 08/29/2023 with a diagnosis of senile degeneration of the brain. The RN comprehensive assessment visit note dated 04/15/2024 documented, “Received call from PCH caregiver ... pt has been having increased wheezing and SOB with exertion during transfers at nighttime... caregiver stated the wheezing often flares at nighttime, notified attending physician, received new orders ...Educated PCH caregiver on SOB signs and symptoms and interventions to prevent wheezing by administering medications as ordered ....” On 04/15/2024, the physician ordered “Ipratropium 0.5mg - albuterol 3mg (2.5mg base)/3ml nebulized every six hours as needed for SOB/wheezing.” On 06/05/2024, the skilled nurse (SN) PRN visit note documented, “Received report pt noted with change in condition, pt appeared lethargic, pt was noted with SOB placed on 2L O2 ... notified patient’s daughter on pt status ...” The SN visit note dated 06/07/2024 documented, “Received patient ... alert and oriented time 1... pt noted with worsening dysphagia...” The IDG on 04/17/2024 documented the physician’s order for the “Duo Neb” needed for shortness of breath and wheezing. The plans of care dated 03/26/2024 to 05/24/2024 and 05/25/2024 to 07/23/2024 did not include documentation of interventions or goals to address the patient’s identified respiratory problem, lethargy, and dysphagia. During an interview and a joint clinical record review on 10/23/2024, the Patient Care Manager confirmed that the patients’ plans of care did not include all identified problems, with planned interventions and patient/family goals of care provided.”

“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; includes all services necessary for the palliation and management of the terminal illness, including the following: intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #PE.1 “Patient Assessments” (01/01/2020) stated in part, “Information from the updated comprehensive assessment will be used by the IDG to update the patient/family POC ...” In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that each patient’s written plan of care included planned Interventions to manage pain and symptoms based on problems identified in the comprehensive assessments. Clinical Record 10: The patient elected the hospice benefit on 03/11/2024 with a diagnosis of Alzheimer’s disease. On 06/27/2024, the RN (as needed/pro re nata) PRN visit note documented, “received call ... pt noted with swollen left chest ... noted with facial grimacing, pt noted with 4x4 raised abscess with bruising... notified attending physician with new orders for Clindamycin and Tramadol...” A physician’s order was documented on 06/28/2024 for “Tramadol 50mg by mouth every four hours as needed for pain” and “Clindamycin 300mg by mouth four times a day for seven days.” During the Interdisciplinary Group Meeting (IDG) on 07/11/2024, the nurse noted that the patient had been placed on an antibiotic for an abscess on the patient’s chest and required an order for Tramadol for pain. A review of the patient’s plans of care dated 05/10/2024 to 07/08/2024 and 07/09/2024 to 09/06/2024 revealed no documented patient/family goals related to the treatment of the chest abscess or interventions and goals for the patient’s identified problem with pain. During an interview and a joint clinical record review on 10/23/2024, the Patient Care Manager confirmed that there was no documentation that the patients’ plans of care included newly identified problems, with planned interventions, or patient/family goals of care provided.”