Heartland Hospice Madison

“Upon patient record review, 2 of 5 (Patient #1,2) 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: During home visit medication reconciliation, there was a medication bottle for Morphine 15mg. The nurse indicated that the medication was being used as backup in the event that the patient needed an acute increase of her pain medications. No evidence that Morphine 15mg IR PRN was included on the current medication profile. Patient 2: The plan of care indicated that the patient was receiving a monthly medication injection from a community mental health clinic and that the patient was being seen by the community psychiatrist. The RN documented that the patient reported he was started on Vyvanse by the community psychiatrist. No evidence that the medication profile included orders for the monthly injections or Vyvanse.”

“Upon patient record review, 1 of 5 (Patient #3) 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 3: MSW and SC frequency on the initial plan of care (06/18/2026) is ordered as one PRN. No evidence that routine visits were included on the initial plan of care.”

“Upon patient record review, 2 of 5 (Patient #1,2) 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: During home visit medication reconciliation, there was a medication bottle for Morphine IR 15mg Q4 PRN. The nurse indicated that the medication was being as backup in the event that the patient needed an acute increase of her pain medications. No evidence that an order was received from the hospice MD to use Morphine IR 15mg prn. The medical record had an order for Morphine IR 30mg to be used PRN. Patient 2: The plan of care indicated that the patient was receiving a monthly medication injection and RN documentation indicated that the patient was recently prescribed Vyvanse from a community mental health psychiatrist. No evidence that an order was received from the hospice MD for either of those medications.”

“Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 2: The medical record indicated that the patient was being seen by a community psychiatrist at the time of admission and has continued to be seen by the provider during his time on service. The medical record indicated that the community psychiatrist is also prescribing medications for this patient. No evidence of coordination or collaboration of care with the community psychiatrist.”

“Upon patient record review, 7 of 14 (Patient #3,#4,#5,#6,#7,#8,#9) 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#3: The medication profile indicates acetaminophen is a scheduled medication to be taken every 4 hours for a temperature greater than 100.5. This medication was intended to be PRN as patient is not being treated for an ongoing fever. In addition, the medication profile also indicates hydroxyzine HCL 25mg as a no for not having reviewed directions for use. During the home visit it was noted that the clonazepam 0.5mg instructions read that this is an as needed medication. However, the medication profile states clonazepam 0.5mg is a scheduled medication to be given twice a day. Patient#4: The medication profile indicates ondansetron 4mg is marked as a no for reviewed side effects/interactions. Also hyoscyamine 0.125mg is marked as a no for reviewed purpose of medication. The medication profile also list patient as using diclofenac 1% gel. However, there is no amount to apply topically noted on the medication profile. Senna 1-2 tabs PRN every 12 hours for constipation is also noted on the medication profile. However, there are no instructions on when patient should take one tab or 2 tabs. Patient#5: The medication profile indicates that lactulose, MiraLAX, pantoprazole, and senna plus are all marked as no for reviewed purpose of medication, reviewed directions for use, and reviewed side effects/interactions. Patient#6: The medication profile indicates that PRN albuterol inhaler is marked no for reviewed side effects/interactions. Also, acetaminophen is ordered for pain and fever. However, there is no parameter for fever. Patient#7: The medication profile indicates that MiraLAX, oxygen, and senna plus are all marked as no for reviewed purpose of medication, reviewed directions for use, and reviewed side effects/interactions. It is also noted that oxygen is listed at 2-4 lpm at bedtime via nasal cannula. However, the nurse documents on 4/9/26 and 4/27/26 that patient is using oxygen 50% of the time. The nurse also documents on 4/13 that patient was at 88% SPO2 during visit. Nurse applied oxygen and patient SPO2 went up to 94%. Patient#8: The medication profile indicates furosemide 20mg is marked a no for reviewed side effects/interactions. Pantoprazole 40mg is marked no for reviewed purpose of medication, reviewed directions for use, and reviewed side effects/interactions. Patient#9: The medication profile indicates senna plus is marked no for reviewed side effects and interactions.”

“Upon patient record review, 3 of 14 (Patient #3,#6,#9) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate 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#3: Upon review of the record, MSW documents during visit on 4/8/26 that patient is having light chest pain and throat discomfort. MSW documents notifying the RN. However, there is no evidence of the RN following up with this patient. Patient#6: The record indicates the patient had a wound to the left upper extremity with a partial skin flap. Documentation indicates patient refused measurements on 2/21/26. The is no evidence of measurements being completed on this wound for the week of 2/22/26, week of 3/1/26, or the week of 3/8/26. Patient#9: There is no evidence of measurements for week of 5/3/26 for wound #1 to left ankle, wound #3 to the right ankle, or wound #6 to the right buttock.”

“Upon patient record review, 1 of 14 (Patient #5) 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#5: The record indicates per nurse documentation on multiple visits that patient keeps a bottle of vodka next to him and is noted to take drinks of the vodka during visits. The patient is admitted to hospice services with a terminal diagnosis of alcoholic cirrhosis of the liver. The plan of care did not contain problems, goals, or interventions of the terminal diagnosis.”

“Upon patient record review, 4 of 14 (Patient #2,#3,#4,#7) 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#2: Record indicates patient requires use of thickener. There is no evidence of thickener ordered on the plan of care. Patient#3: The record indicates acetaminophen is ordered as scheduled for fever. However, this is suppose to be a PRN medication as patient is not being treated for fever. Patient#4: The record indicates senna is ordered as take 1-2 tabs prn for constipation. However, there are no clear instructions on when to take 1 or take 2 tabs. Also, diclofenac 1% topical gel is also ordered to apply per instructions every 6 hours bilaterally to knees PRN pain. However, there is no amount indicated. Patient#7: The order for oxygen states 2-4 lpm at bedtime vis nasal cannula. The nurse documents on 4/9/26 and 4/27/26 that patient is using oxygen 50% of the time. The nurse also documents on 4/13 that patient was at 88% SPO2 during visit. Nurse applied oxygen and patient SPO2 went up to 94%.”

“Upon patient record review, 3 of 14 (Patient #1,#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 equipment and supply needs. Patient#1: The chart indicates a pump was ordered as DME on the plan of care. However, there is no evidence of a DME pump being used by this patient. Patient #3: The nurse documents patient uses a transport wheelchair. There is no evidence of a wheelchair listed on the plan of care. Patient #4: The record indicates a gait belt is listed to be used for transfers on the aide plan of care. However, there is no gait belt listed on the plan of care.”

“Upon patient record review, 3 of 14 (Patient #1,#4,#6) 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 indicates that the plan of care list the foley catheter is a 16 Fr. However, this order changed to an 18fr foley on 4/28/26 and was not updated on the plan of care. Patient#4: Nursing documentation on 4/22/26 indicates patient is having increase in swallow time with the ensure and increase in difficulty swallowing and swallow time with crushed medications. However, there is no evidence of updated goals or interventions to include aspiration precautions or education on plan of care. Patient#6: The nurse documents patient has had multiple wounds/skin tears to left elbow and bruises to hand in February of 2026. She also documents patient having thin skin. There is no evidence of updated interventions on plan of care to include skin integrity education or precautions.”

“Upon patient client record review, 2 of 14 (Patient #3,#7) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient#3: On 4/17/26 the nurse documents the Vyvanse medication planner was filled. However, this patient is not taking Vyvanse. Patient#7: Nurse documentation 4/4/26 - 4/13/26 states patient wound is stage 2 on the wound care page. However, in the previous narrative the wound is documented as stage 1.”