Heartland Hospice (Roanoke)

“Upon patient record review, 3 of 5 (Patients #1,#3,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: The medication profile contained multiple oral medication tablets and capsules with inappropriate secondary routes of under the tongue including loperamide, aspirin, docusate sodium, esomeprazole magnesium, famotidine, glimepiride, haloperidol, melatonin, mirtazapine, sertraline, and miralax oral powder. Corrected on site with order clarifications and medication profile update. Patient 3: The medication profile contained multiple oral medication tablets and capsules with inappropriate secondary routes of under the tongue including acetaminophen, duloxetine, methadone, olanzapine, pantoprazole, pepcid, reglan, senna plus, and simethicone. Corrected on site with order clarifications and medication profile update. Patient 4: The medication profile contained instructions for nitroglycerin administration every five minutes as needed. There was no evidence instructions regarding maximum dose.”

“Upon patient record review, 4 of 5 (Patients #1,#2,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained multiple medication orders for oral tablets and capsules with inappropriate secondary routes of under the tongue including loperamide, aspirin, docusate sodium, esomeprazole magnesium, famotidine, glimepiride, haloperidol, melatonin, mirtazapine, sertraline, and miralax oral powder. Corrected on site with order clarifications. Patient 2: The medical record contained nursing documentation 8/20/25 identifying patient continued use of condom catheters at night. There was no evidence of a treatment order for catheter use. Corrected on site with order received. Patient 3: The medical record contained multiple medication orders for oral tablets and capsules with inappropriate secondary routes of under the tongue including acetaminophen, duloxetine, methadone, olanzapine, pantoprazole, pepcid, reglan, senna plus, and simethicone. Corrected on site with order clarifications. Patient 4: The medical record contained an order for nitroglycerin administration every five minutes as needed. There was no evidence instructions regarding maximum dose.”

“Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice’s care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4) There was not evidence of a current patient list with general condition and location in the Emergency ‘Grab and Go’ binder. Corrected on site.”

“Upon patient record review, 7 of 19 records (Patient #1,#3,#5,#8,#10,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medication profile contained Nystatin topical powder dated 4/17/25, 3 times/day for 21 days. This remained on the medication profile. Corrected on site. In addition, dated 3/7/25, Questran 4 Gm powder. Mix 1 packet with a drink 1x/day until stools are formed. There was not evidence of an amount of diluent, and this remained on the medication profile with no evidence to give prn. Corrected on site. Patient #3: The medication profile contained Creon 24000-76000-120000 cap, delay release 3x/day as needed for pancreatic insufficiency. There is not evidence of a clear reason of when to administer the medication, and it is an unclear dosage. Also this medication is not used for dosing ‘as needed’. Corrected on site. In addition, the record indicated that the patient was on oxygen 2-4L/min prn. There was not evidence that this was included on the medication profile. Corrected on site. Patient #5: The record indicated that the patient was on intermittent oxygen at 2L/min. There was not evidence that this was in the medication profile. Corrected on site. Patient #8: The medication profile listed Tylenol 325 mg 2 tabs q6h prn. The medication in the home was Tylenol 500mg and the caregiver indicated that she was administering 1 tablet. Corrected on site. Patient #10: The medication profile dated 4/22/25 contained Lidocaine 4% patch. Apply 1 patch to right side daily x 7 days. There was not evidence of a specific location and the medication remained on the medication profile. Corrected on site. In addition, nurse documentation from admission indicated the patient was on oxygen at 4L/min via mask and at the time of recertification on 6/27/25 was on C-Pap. There was no evidence that this was in the medication profile. Corrected on site. Patient #12: The hospice medication profile had 2 orders for Seroquel: 25 mg daily and 25 mg 3x/day. The MAR at the facility had only 1: 25 mg 3x/day. The hospice medication profile had Escitalopram 20 mg and the facility MAR had to administer 15 mg. Also, the hospice medication profile contained Memantine and Diclofenac. This was not on the facility MAR. The facility MAR contained Fosamax 70 mg and this was not on the hospice medication profile. Corrected on site. Patient #13: An order dated 5/31/25 indicated to d/c oxygen, patient not using. Also, a note indicating for DME to pick up the oxygen. This remained on the medication profile. Corrected on site.”

“Upon patient record review, 1 of 19 records (Patient #9) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family’s needs and coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #9: The patient had a diagnosis of unspecified cirrhosis of the liver. The record indicated that this patient was going for paracenteses weekly. There was not evidence of assessments by the nurse related to pre and post care for the paracentesis, including abdominal measurements, (pre and post treatment).”

“Upon patient record review, 8 of 19 records (Patient #1,#2,#4,#6,#8,#9,#10,#12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: The record on admission indicated that the patient had a history of frequent falls. Documentation included that he had frequent falls and a problem with balance. Documentation from the NP during face to face exams on 3/21/25 and 5/27/25 indicated that he was a high risk for falls. The nurse documentation from 6/24/25 indicated that there was teaching regarding fall precautions. There was not evidence that fall precautions and safety were a part of the plan of care. Corrected on site. Patient #2: The patient was admitted with Alzheimer’s Disease, late onset. The record indicated that the patient was disoriented, and forgetful, had fecal and urinary incontinence, was unable to ambulate and was bed-bound. She required total care and was dependent for all activities, and her nutritional status was poor. There was not evidence that neurological or Alzheimer’s reflected patient/family goals and interventions. Corrected on site. Patient #4: The record indicated that the patient had a urostomy. There was not evidence that the plan of care included goals and interventions related to the urostomy. Corrected on site. Patient #6: The patient was admitted with central cord syndrome at level of cervical spine. He was paralyzed, had multiple wounds and was total care. There was not evidence that his neurological problems reflected patient/family goals and interventions. Corrected on site. Patient #8: Documentation and observed home visit reveals keloid wounds on the patient’s upper right arm and upper left arm with orders for dressing changes. There was not evidence that the plan of care reflects patient/family goals and interventions related to the wounds. Corrected on site. Patient #9: The patient had a diagnosis of unspecified cirrhosis of the liver, had ascites and was going for paracenteses weekly. There was not evidence of ascites, or paracentesis with goals and interventions regarding these problems and treatments. Corrected on site. Patient #10: Nurse documentation from admission indicated the patient was on oxygen at 4L/min via mask and at the time of recertification on 6/27/25 was on C-Pap. There was no evidence that oxygen or C-Pap was in the plan of care. Corrected on site. Patient #12: The patient was admitted with a diagnosis of traumatic sub-dural hematoma. There was not evidence that plan of care included goals and interventions related to the neurological issues. Corrected on site.”

“Upon patient record review, 6 of 19 records (Patient #2,#4,#5,#6,#11,#12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #2,#4,#5,#6,#12: The initial visit frequency for social worker and the spiritual care counselor was 1 prn. No evidence of scope and frequency. Patient #11: The initial visit frequency for social worker was 1 prn. No evidence of scope and frequency.”

“Upon patient record review, 8 of 19 records (Patient #1,#3,#5,#8,#9,#10,#11,#12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record contained Questran 4 Gm powder, dated 3/7/25. Mix 1 packet with a drink 1x/day until stools are formed. There was not evidence of an order for the amount of diluent. There was no evidence to continue to give prn. Corrected on site. Patient #3: The record contained an order for Creon 24000-76000-120000 cap, delay release 3x/day as needed for pancreatic insufficiency. There is not evidence of a clear reason of when to administer the medication, and it is an unclear dosage. Also this medication is not used ‘as needed’. Corrected on site. In addition, the record indicated that the patient was on oxygen 2-4L/min prn. There was not evidence of an order. Corrected on site. Patient #5: The record indicated that the patient was on intermittent oxygen at 2L/min. There was not evidence of an order. Corrected on site. Patient #8: The medication profile listed Tylenol 325 mg 2 tabs q6h prn. The medication in the home was Tylenol 500mg and the caregiver indicated that she was administering 1 tablet. There was not evidence of an order for the 500mg. Corrected on site. Patient #9: The record indicated that this patient was going for paracenteses weekly. There was not evidence of an order. The patient had a diagnosis of unspecified cirrhosis of the liver. Corrected on site. Patient #10: The record contained an order for Lidocaine 4% patch. Apply 1 patch to right side daily x 7 days. There was not evidence of a specific location. Corrected on site In addition, nurse documentation from admission indicated the patient was on oxygen at 4L/min via mask and at the time of recertification on 6/27/25 was on C-Pap. There was no evidence of an order for oxygen or C-Pap. Corrected on site. Patient #11: The record indicated an order dated 6/2/25 for wound care to a stage I pressure ulcer to cleanse the area with wound cleanser, pat dry, apply zinc. Cover with bordered gauze for comfort. There was not a location of the wound. Corrected on site. Patient #12: The facility MAR contained Fosamax 70 mg There was not an order in the hospice record. Corrected on site.”

“Upon patient record review, 4 of 19 records (Patient #1,#3,#4,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The record indicated that the patient was using a nebulizer and a walker. There was not evidence that these pieces of equipment were included in the plan of care. Corrected on site. Patient #3: The record indicated that the patient had a nebulizer and also used oxygen at 2-4L/min. There was not evidence that these pieces of equipment was listed on the plan of care. Corrected on site. Patient #4: The record indicated that the patient had a urostomy. There was not evidence of any supplies related to the urostomy in the plan of care. Corrected on site. Patient #5: The record indicated that the patient had a bed, overbed table, alternating pressure pad, wheelchair and oxygen. There was not evidence the equipment was listed on the plan of care. Corrected on site.”

“Upon patient record review, 5 of 19 records (Patient #1,#2,#6,#11,#14) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #1: The record dated 6/24/25 indicated that the patient was short of breath and had +3 pitting edema and mottling to the LLE. An order was obtained for Lasix 40mg BID X 5 days. On 6/30/25, the patient’s lungs were described as having crackles and Lasix was now ordered for 20 mg daily. The patient was admitted with a diagnosis of right heart failure. There was not evidence that the cardiac goals and interventions were updated since admission, 12/19/24. Corrected on site. Patient #2: The record indicated that the patient was started on antibiotics, date 5/2/25 for a cellulitis of the right AKA, and again on 5/30/25 for a yeast infection. There was not evidence that the care plan was revised to reflect these infections. Corrected on site. In addition, The patient had a wound of her right AKA. The last documented wound care order was dated 6/16/25 with subsequent documentation of dressing changes. The plan of care indicated that the goals and interventions for this wound had ended on 6/4/25, but the documentation in the visits indicated the wound and care was still on-going. Corrected on site. Patient #6: The record indicated on 5/1/25 that the patient was started on Keflex for a UTI, and then on Augmentin, dated 6/20/25 for a wound infection. There was not evidence that the plan of care was revised to reflect these infections. In addition, the patient had multiple wounds including a sacral wound, left tibia, right tibia, right heel, iliac crest, left elbow, right flank. The documentation indicates that the wounds were changing and orders were being revised frequently. The last noted update to the care plan for these wounds was recorded on 4/27/25. Corrected on site. Patient #11: The nurse visits were increased to daily on 7/8/25 due to imminence of death. There was not evidence that the plan of care was revised to reflect this change. Corrected on site. In addition, the patient developed a skin tear to the right upper arm on 5/15/25 and a skin tear to the left hand on 7/6/25. There was not evidence that the care plan reflected these changes. Corrected on site. Patient #14: The social worker visits were discontinued on 5/29/25 and the spiritual care counselor visits were discontinued on 5/28/25. Care plans for both the social worker and the spiritual care counselor with goals and interventions remained active on the care plan. Corrected on site.”

“Upon patient record review, 3 of 19 records (Patient #5,#9,#10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The visit frequency for the social worker was 2m2 and 2 prn effective 6/1/25. There was not evidence of 2 visits for the month of June. Patient #9: The record indicated a visit by a volunteer on 6/23/25. There was not evidence of an order. Patient #10: The visit frequency for the social worker was 2 every 2m2, 2m1,1m1, and 3 prn effective 4/17/25. The record indicated that an evaluation was conducted on 4/17/25 with subsequent routine visits on 5/13/25, 5/30/25, and 6/17/25.”

“Upon patient record review, 3 of 19 records (Patient #17,#18,#19) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery, as well as following the plan of care Patient #17: The 1 month letter was due to be sent on 11/28/24 but was not sent until 12/16/24. The 6 month letter was due to be sent on 4/27/25 but was not sent until 6/17/25. Patient #18: The 2 week card was due to be sent on 3/17/25 but was not sent until 5/19/25. The 3 month letter was due to be sent on 6/1/25 but was not sent until 6/17/25. Patient #19: The 3 month letter was due to be sent on 2/24/25 but was not sent until 4/3/25. The 6 month letter was due to be sent on 5/25/25 but was not sent until 6/18/25.”

“Upon patient record review, 2 of 19 records (Patient #1,#5) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The aide plan of care indicated for the task of light housekeeping without evidence of what specifically was to be completed. Corrected on site Patient #5: The aide plan of care indicated to provide nail care as needed. Corrected on site”

“Upon patient record review, 1 of 19 records (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #9: The election of benefit indicated that the patient did not choose an attending physician. However, the record contained an order on Heartland letterhead indicating a physicians order from a community physician. The order was for an admission to Heartland Hospice as well as a check box that stated, ‘In consultation with the patient, I prefer to remain the attending and will sign all physician orders and remain in open communication with the hospice team (signed by the community physician and dated 4/28/25). This also accompanied 38 pages of H&P faxed from this physicians office per Heartland request. There was not evidence of any other correspondence to or from this physician.”

“Upon patient record review, 3 of 19 records (Patient #2,#6,#12) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: The visit frequency for the social worker was 2 every 2m2, 2m2 and 2 prn effective 4/27/25. The record indicated an evaluation was conducted on 4/30/25 followed by routine visits on 5/14/25, 5/30/25, 6/12/25 and 6/25/25. The visit frequency for the spiritual care counselor was 3 every 2m2, 3m1, 1m1 and 3 prn effective 4/27/25. The record indicated that an evaluation was conducted on 4/28/25 followed by routine visits on 5/5/25, 5/12/25, 5/19/25, 6/2/25, 6/9/25, 6/27/25 and 7/7/25. Patient #6: The visit frequency for the spiritual care counselor was 3 every 2m2, 2m2, 3 prn. The record indicated that an evaluation was conducted on 4/28/25 followed by routine visits on 5/5/25, 5/12/25, 5/19/25, 6/2/25 and 6/9/25. Patient #12: The visit frequency for the social worker was 2 every 2m2, 2m1,1m1, and 3 prn effective 4/24/25. The record indicated that an evaluation was conducted on 4/28/25 with subsequent routine visits on 5/9/25, 5/30/25, and 6/18/25.”