Every finding on record at Caring & Helping Hearts Hospice

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 3: There is no evidence in the patient record that the patient received a copy of the Patient's Rights and Responsibilities. There are no forms or evidence in the EMR.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon client record review, 1 of 7 (Patient #3) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed, or that the a health care provider was chosen.

Upon patient record review, 1 of 7(Patient #3) did not have evidence of the appropriate documentation for release of confidential information. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient 3: On 3/14/24 the patient was admitted to hospice and consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why the consents were not reviewed and signed.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon patient record review, 5 of 7 (Patient #1,4,5,6,7) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,4,5,6,7: On the RN comprehensive assessment the RN did not take into consideration the imminence of death.

Upon patient record review, 1 of 7 (Patient #7) 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 7: There are no goals or interventions included in the POC for spiritual care.

Upon client record review, 1 of 7 (Patient #7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #7: On the IDG note for 5/13/25 the chaplain did not sign the IDG note to evidence collaboration with IDG to review and revise patient plan of care.

Upon patient record review, 2 of 7 (Patient #4,7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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; 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 4: On the aide plan of care there is an order for "feeding assistance, encourage fluids as tolerated if not contradicted", there is not a frequency included in this order. Patient 7: On the aide plan of care there is an order “ Record bowel movements, encourage fluids as tolerated, if not contraindicated ” there is not a frequency included in this order.

Upon patient client record review, 1 of 7 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 3: There is no evidence in the patient record that there is signed copies of the notice of patient rights, signed election statement, information on individual cost sharing for hospice services, notification of the individual's right to receive an election statement addendum, information on the BFCC_QIO. The patient was admitted to hospice without consents signed.

Upon patient client record review, 1 of 7 (Patient #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 7: On the RN comprehensive assessment the RN documented, “During the hospital stay he was found to have hemoglobin”. This entry is not clear or complete. On the RN assessment 5/9/25, the entry is not complete and authenticated the document is not signed by the RN completing the visit. On the initial POC there are orders, "Admit to Hope Springs Hospice", this is the incorrect admitting hospice agency.

Upon observation, there was no evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time.

Upon client record review, 2 of 7 (Patient #5,6) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 5: On 9/9/24 the patient was transferred, there is no record of a copy of the patient clinical record or discharge summary being available to the attending physician. Patient 6: On 9/9/24 the patient was transferred, there is no record of a copy of the patient clinical record or discharge summary being available to the attending physician.

Upon patient record review, 1 of 7 (Patient #3) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 3: On the 3/14/24 there is a telephone order for medications and GT wound dressing. These orders are not signed by the physician.

Upon client record review, 1 of 7 (Patient #3) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 3: On 3/14/24 the patient was admitted to hospice, consents were not signed with caregiver/family members. Pt. was unresponsive at the time of admission, there is no evidence of documentation about why consents were not reviewed and signed.

Upon client record review, 1 of 7 (Patient #4) 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 4: On 4/22/23 the SN visited the patient, "facility stating the patient had pulled out his catheter” RN documented “deflated balloon, sterilized catheter, and readjusted length, then reinflated balloon with 10cc sterile water. Catheter care was provided”. There are no orders for a foley catheter on the POC or orders to care for the catheter.

Upon patient record review, 1 of 5 (Patient #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 Patient 2: There was no evidence of the patient's PRN oxygen present on the medication list. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #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 equipment and supply needs. Patient 2: There was no evidence of the patient's required medical equipment listed in the plan of care. Per the initial comprehensive assessment and treatment orders, the patient utilizes oxygen PRN for comfort; however the oxygen equipment was not included on the plan of care. (corrected onsite)