Every finding on record at Care From the Heart Hospice LLC

Based on interview and record review, the agency failed to complete home visits per the plan of care for two of 14 sampled patients (6, 7). As a result, patients did not receive the care and services ordered by the physician. --- Findings: 1. Per the agency’s Plan of Care, dated 5/1/25, for the certification period of 9/30/24 through 11/28/24, Patient 6 had a start of care date of 9/3/24, and had orders for the Hospice Aide (HA) to visit three times per week. On 4/29/25 a review was conducted of Patient 6’s medical record. There were two HA visits documented on the week of 9/3/24, and there were no communication notes to explain the missed visit. On 4/30/25 at 10:20 A.M., an interview and record review was conducted with the Director of Patient Care Services (DPCS) of Patient 6’s medical record. The DPCS stated, Patient 6 should have had an order for 2 HA visits on the first week of service, and 3 HA visits per week starting the following week. 2. Per the agency’s Plan of Care, dated 5/1/25, for the certification period of 5/14/24 through 7/12/24, Patient 7 had a start of care date of 5/20/23, and had orders for the HA to visit two times per week. On 4/29/25 a review was conducted of Patient 7’s medical record. There were no HA visits documented on the weeks of 6/23/24 or 6/30/24, and there were no communication notes to explain the missed visits. On 4/30/25 at 10:20 A.M., an interview and record review was conducted with the DPCS of Patient 7’s medical record. The DPCS stated, the HA should have documented if the visits happened or why the visits were missed. Per the agency’s policy, titled Missed Visits, revised April 2020, “…If a visit is missed and not rescheduled the clinician will…Notify the IDG (Interdisciplinary group) and clinical supervisor of the missed visit and reason for missed visit…”

Based on interview and record review, the agency failed to document notes in a timely manner for two of 14 sampled patients (1, 3). As a result, the notes were not available to review. --- Findings: 1. Per the agency’s Plan of Care, dated 5/1/25, for the certification period of 3/6/25 through 5/4/25, Patient 1 had orders for the Skilled Nurse (SN) to visit one time per week. On 4/29/25 a review was conducted of Patient 1’s medical record. There were no SN visits documented on the weeks of 3/30/25 or 4/20/25. On 4/29/25 at 2:23 P.M., an interview was conducted with the Director of Patient Care Services (DPCS) of Patient 1’s medical record. The DPCS stated, SN visits were conducted for Patient 1 on 4/2/25 and 4/23/25, but the SN had not yet entered the documentation for the visits. The DPCS further stated, the SN should have documented her visit notes within 72 hours of the visit. 2 . Per the agency’s Plan of Care, dated 5/1/25, for the certification period of 3/26/25 through 5/24/25, Patient 3 had orders for the Skilled Nurse (SN) to visit two times per week. On 4/29/25 a review was conducted of Patient 3’s medical record. A SN visit note was started on 4/22/25, but the note was incomplete and was not signed. There were no other SN visit notes on the week of 4/22/25. On 4/29/25 at 2:23 P.M., an interview was conducted with the DPCS of Patient 3’s medical record. The DPCS stated the SN note for Patient 3 on 4/22/25 should have been completed within 72 hours of the visit. Per the agency’s policy, titled Contents of Clinical record, revised April 2020, “…Each entry will be dated and signed…”

Based on interview and record review, the agency failed to ensure that patient clinical records contained signed documents for patient recertification for five of fourteen sampled patients (Patients 8, 10, 11, 13, 14). This failure had the potential for residents to be improperly recertified. --- Per the Agency’s admission record, Patient 8 was admitted on 10/23/24 with a diagnosis of Hypertensive (High Blood Pressure) heart disease.Per the Agency’s admission record, Patient 11 was admitted on 5/13/24 with a diagnosis of Acute Kidney failure.Per the Agency’s admission record, Patient 10 was admitted on 7/9/24 with a diagnosis of Cerebrovascular Disease (decreased blood flow in the brain).Per the Agency’s admission record, Patient 13 was admitted on 2/10/24 with a diagnosis of Chronic systolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).Per the Agency’s admission record, Patient 14 was admitted on 10/29/24 with a diagnosis of Alzheimer’s Disease (a disease characterized by a progressive decline in mental abilities). During a record review of Patient 8’s Electronic Medical Record (EMR), the Interdisciplinary Group (IDG) note dated 3/31/25 was not signed by the Physician, the face to face (F2F) visit on 4/3/25 was not completed, and the Physician’s Certification of Terminal Illness (CTI) for Certification Period 3 was incomplete because it referenced the missing F2F note. During a record review of Patient 10’s Electronic Medical Record (EMR) the face to face (F2F) visit on 4/18/25 was not completed, and the Physician’s Certification of Terminal Illness (CTI) for Certification Period 5 was incomplete because it referenced the missing F2F note. During a record review of Patient 11’s Electronic Medical Record (EMR), the Interdisciplinary Group (IDG) notes dated 10/28/24, 11/11/24, 11/25/24, and 12/9/24 were not signed by the Physician, the face to face (F2F) visit on 10/23/24 was not completed, and the Physician’s Certification of Terminal Illness (CTI) for Certification Period 3 was incomplete because it referenced the missing F2F note. During a record review of Patient 13’s Electronic Medical Record (EMR), the Interdisciplinary Group (IDG) note dated 3/31/25 was not signed by the Physician, the face to face (F2F) visit on 3/18/25 was not completed, and the Physician’s Certification of Terminal Illness (CTI) for Certification Period 25 was incomplete because it referenced the missing F2F note.During a record review of Patient 14’s Electronic Medical Record (EMR), the Interdisciplinary Group (IDG) notes dated 3/31/25 and 4/12/25 were not signed by the Physician, the face to face (F2F) visit on 4/9/25 was not completed, and the Physician’s Certification of Terminal Illness (CTI) for Certification Period 6 was incomplete because it referenced the missing F2F note.During an Interview with the Director of Patient Care Services (DPCS) on 4/30/25 at 10:35 A.M., the DPCS stated the IDG note is a plan of care it includes any updates or changes to the plan of care. It also contains physician orders recertification, medication changes, and visit frequencies. The DPCS further stated “…because it is an MD order, it needs to be signed by the physician. It should be signed on the day of the IDG meeting...”The DPCS continued stating That to recertify a patient, we need a Physician’s Certification of Terminal Illness (CTI). It is a general assessment and validates the need for continued care. If a patient is in their 3rd benefit period or beyond, they need a Face to Face visit. If the CTI indicates a Face to Face is needed but there is no Face to Face note, the CTI may not be valid. The DPCS concluded “…we are missing the completed Face to Face notes so we are not in compliance, and we should be in compliance…” Because of this “…there is the possibility that the patient is not receiving the care the physician ordered or receiving care without a physician’s order…”During a review of the agency’s policy and procedure titled The Plan of Care, Policy No. 4-027.1 revised April 2020, indicated “…6… The hospice Medical Director will need to review the patient’s history and physical…to be able to sign the certification of terminal illness section of the plan of care…”During a review of the agency’s policy and procedure titled Contents of Clinical Record No. 4-078.1 revised April 2020, indicated “…2…X. Certification and recertification(s) of terminal illness including physician narrative and face-to-face encounters as needed…3. Each entry will be dated and signed…”