Heart to Heart Hospice of Decatur

“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 and interview. In 5 of 15 (33%) clinical records reviewed, the agency did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1: The patient elected hospice care on 8/17/2023. The primary diagnosis was a malignant neoplasm of unspecified part of right bronchus or lung. The initial Registered Nurse (RN) assessment dated 8/17/2023 documented a “5” on the (Missouri Alliance for Home Care) MAHC-10 fall assessment scale, at risk for falling, stated “2 falls in last week.” The POC effective 8/17/2023 through 11/15/2023 did not include documentation of interventions and goals for the fall risk. Clinical Record 3: The patient elected hospice care on 4/6/2023. The primary diagnosis was atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. The RN assessments dated 4/6/2023, 4/7/2023, and 4/12/2023 documented “bilateral lower extremity chronically edematous 2+ and recent multiple falls.” The POC effective 4/6/2023 through 4/28/2023 did not include documentation of interventions and goals for the fall risk. Clinical Record 4: The patient elected hospice care on 12/24/2022. The primary diagnosis was malignant neoplasm of overlapping sites of colon. The initial RN assessment dated 12/24/2022 documented a “6” on the MAHC-10 fall assessment scale, at risk for falling. The POC effective 12/24/2022 through 1/24/2023 did not include documentation of interventions and goals for the fall risk. Clinical Record 7: The patient elected hospice care on 7/14/2022. The primary diagnosis was senile degeneration of the brain. The initial RN assessment on 7/14/2022 documented a “5” on the MAHC-10 fall assessment scale, at risk for falling. The POC effective 7/14/2022 through 10/6/2022 did not include documentation of interventions and goals for the fall risk. Clinical Record 8: The patient elected hospice care on 5/5/2023. The primary diagnosis was senile degeneration of the brain. The initial RN assessment on 5/5/2023 documented wounds to the coccyx pressure ulcer stage III, left heel pressure ulcer stage III, right heel pressure ulcer stage III, 3+ edema to the left leg, and a “10” on the MAHC-10 fall assessment scale, at risk for falling. The POC effective 5/5/2023 through 5/31/2023 did not include documentation of interventions and goals for the fall risk. During a joint record review and interview on 11/17/2023, the Area Clinical Manager agreed there was no documented evidence that the patient’s written POC included interventions and goals for the identified problems.”

“It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure that hospice aide services were provided as ordered. Clinical Record 3: The patient elected hospice care on 4/6/2023. The plan of care dated 4/6/2023 through 4/28/2023 ordered hospice aide services one (1) visit per one (1) week, then five (5) visits per week. A review of the hospice aide visit notes dated 4/9/2023 through 4/15/2023 revealed hospice aide visits were completed 4/11/2023, 4/12/2023, 4/13/2023, and 4/14/2023. The actual frequency for the week of 4/9/2023 through 4/15/2023 was four (4) times one week. There was no documented evidence that a fifth hospice aide visit was made or reason for the missed visit. Clinical Record 5: The patient elected hospice care on 9/27/2022. On 9/30/2022, the physician ordered hospice aide services one (1) visit per one (1) week, then five (5) visits per week. There was no documented evidence that hospice aide visits were made during the weeks of 10/2/2022 through 10/8/2022, 10/9/2022 through 10/15/2022, and 10/16/2022 through 10/22/2022. There was no evidence of documented missed visits or communication with the physician to change the plan of care. On 10/30/2022, the physician ordered hospice aide services for two (2) visits per week. There was no documented evidence that hospice aide visits were made during the weeks of 10/30/2022 through 11/5/2022. There was no evidence of documented missed visits or communication with the physician to change the plan of care. On 12/4/2022, the physician ordered hospice aide services five (5) visits per week. There was no documented evidence that hospice aide visits were made the week of 12/4/2022 through 12/10/2022. There was no evidence of documented missed visits or communication with the physician to change the plan of care. During a joint review of the record and an interview on 11/16/2023, the Area Clinical Manager agreed there was no documented evidence that hospice aide services were provided as ordered.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients that received hospice aide (HA) services, the agency did not ensure that the hospice aide reported changes in the patient’s medical and nursing needs to the registered nurse (RN) as the changes relate to the plan of care. Clinical Record 11: The hospice aide visit note dated 10/25/2022 documented that the patient reported feeling nauseated. There was no documented evidence that the HA notified the RN of the patient’s nausea. During a joint review of the record and an interview on 11/17/2023, the Area Clinical Manager agreed there was no documented evidence that the hospice aide reported the changes to a registered nurse.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy, “Patient Transfer PE.3,” stated in part, “If the care of a patient is transferred to another Medicare/Medicaid-certified facility, the Agency will forward copies of the following to the receiving facility, the hospice discharge summary which includes but is not limited to, a summary of the patient’s care (pain management, symptoms, and treatments), the patient’s current plan of care, including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patient’s post-discharge continuity of care.” In 1 of 4 (25%) clinical records reviewed of patients transferred to another hospice, the agency did not ensure that the discharge summary was sent to the receiving hospice. Clinical Record 7: The patient elected hospice care on 7/14/2022. A review of the agency’s unattended live discharge visit documentation dated 10/6/2022 revealed the patient transferred to another hospice per patient/family request. There was no documented evidence that the discharge summary was sent to the receiving hospice. During a joint review of the record and an interview on 11/17/2023, the Area Clinical Manager agreed there was no documented evidence that the agency forwarded a copy of the hospice discharge summary to the receiving hospice.”