Every finding on record at Heart 2 Heart Hospice Care LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visits observed, it was revealed that the agency did not ensure the staff followed the hand hygiene policy. Agency Policy: 5.7, Standard Precautions for all Health Care Workers (no date), stated in part, "2. Wash Hands - Hands must be washed before and after contact with each patient, if hands become soiled with body fluids, before the donning (putting on) of sterile gloves, after the removal of all gloves, after contact with non-intact skin and wound dressings and if moving from a contaminated area to a clean area... 4. Gloves should be changed after each patient contact. When gloves are removed, thorough hand washing is required. Gloves do not take the place of hand washing." Agency Policy: PC.I10, Infection Control - Hand Hygiene and Bag Technique (no date), stated in part, "1. Use of alcohol-based hand sanitizer is preferred (until dry) ... a. Before and after caring for patients, or when coming in contact with inanimate objects/equipment in the immediate vicinity of the patient. b. Between tasks on the same patient and particularly when there is prolonged or intense contact with the patient; i.e. bathing. c. After removing gloves. d. After touching objects that are potentially contaminated." HOME VISIT 4: During the home visit (Clinical Record 11) on 08/21/2025 with the Registered Nurse (RN) (Personnel Record 5), the RN was observed to use alcohol hand gel and then donned multiple sets of gloves (at the same time). The RN assessed the patient's vital signs, removed the linens, and assessed the skin. The patient was turned to the side with the help of a facility nurse, and the coccyx was observed. The RN removed one pair of gloves. The RN cleaned the wound with wound cleanser and measured the wound. Skin prep was applied to the surrounding skin, and the RN removed another pair of gloves and then calcium alginate and a foam dressing were applied. The RN used wipes to clean the perineal and buttocks, used barrier cream, put a new brief on the patient, and removed another pair of gloves. The RN used alcohol hand gel and then again donned multiple sets of gloves. The RN cleaned the assessment equipment and removed one set of gloves. The RN applied medication to the patient's back and removed another set of gloves. The RN covered the patient with bedding, removed another set of gloves, and then used alcohol hand gel. The RN used multiple sets of gloves at a time, which was not in the hand hygiene policy. The RN did not decontaminate the hands when gloves were removed. During a joint document review and interview on 08/22/2025, the Director of Clinical Services agreed the staff did not follow the Standard Precautions for all Health Care Workers and Infection Control - Hand Hygiene and Bag Technique policies.

It is required that a hospice aide provide services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that a hospice aide provided services included in the plan of care. CLINICAL RECORD 5: The Hospice Aide plan of care, dated 10/01/2024, included an aide visit frequency of twice per week with the following tasks: Pain Management: Notify nurse if patient exhibits any verbal or non-verbal signs of pain or symptoms; Bathing: Assist to dress, Shower; Hair Care: Shampoo/style; Skin Care: Inspect skin; check pressure areas; Call nurse if new skin problems are noted; Shave; Trim nails - fingers (weekly) , toes (biweekly); Oral care Assist with brushing teeth; Home Management: Bed linen change; Miscellaneous: Complete/update resident status sheet; Safety Precautions: Safety precautions assigned. The Hospice Aide Visit Notes dated 05/27/2025, 05/30/2025, and 06/03/2025 lacked documentation that the patient had been shaved. There was no documented reason for not completing the task. CLINICAL RECORD 15: The Hospice Aide plan of care dated 11/06/2024 included the aide visit frequency of once weekly with the following tasks: Pain Management: Notify nurse if patient exhibits any verbal or non-verbal signs of pain or symptoms; Bathing: Assist to dress, Shower; Hair Care: Comb/brush, Shampoo/style; Skin Care: Inspect skin; check pressure areas; Call nurse if new skin problems are noted; Trim nails - fingers (weekly), toes (biweekly); Oral care Assist with brushing teeth; Home Management: Bed linen change; Miscellaneous: Complete/update resident status sheet; Safety Precautions: Safety precautions assigned. The Hospice Aide Visit Note dated 11/20/2024 lacked documentation the following tasks were completed: shower; hair care: comb/brush, shampoo/style; and oral care: assisted with brushing teeth. There was no documented reason for not completing the tasks. During a joint clinical record review and interview on 08/22/2025, the Director of Clinical Services confirmed that the Hospice Aide had not provided services nor documented a reason for not providing services as included in the plan of care.

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 4 of 15 (27%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/01/2024 with a diagnosis of congestive heart failure. The Hospice Aide Care Plan dated 10/01/2024 included aide visits ordered twice a week with the following tasks: Pain Management: Notify nurse if patient exhibits any verbal or non-verbal signs of pain or symptoms; Bathing: Assist to dress, Shower; Hair Care: Shampoo/style; Skin Care: Inspect skin; check pressure areas; Call nurse if new skin problems are noted, Shave, Trim nails - fingers (weekly) , toes (biweekly); Oral care Assist with brushing teeth; Home Management: Bed linen change; Miscellaneous: Complete/update resident status sheet; Safety Precautions: Safety precautions assigned. The Hospice Aide Visit Notes dated 05/27/2025, 05/30/2025, and 06/03/2025 lacked documentation that the patient was shaved. The Hospice Aide Visit Note dated 06/06/2025 documented "refused" with no interventions selected. The record lacked additional documentation if all tasks were refused, if this was a ‘missed visit’ or which specific tasks were refused. The record lacked documented evidence the RN was notified for any of these visits related to changes in the plan of care. CLINICAL RECORD 6: The patient elected the hospice benefit on 05/21/2025 with a diagnosis of Multiple Sclerosis. The Hospice Aide Care Plan dated 07/22/2025 included a visit frequency of once per week with the following relevant tasks: Notify nurse if patient exhibits any verbal or non-verbal signs of pain or symptoms; Bathing: Assist to dress, Shower; Hair Care: Shampoo/style; Skin Care: Inspect skin; check pressure areas; Call nurse if new skin problems are noted, Shave, Trim nails - fingers (weekly) , toes (biweekly); Oral care Assist with brushing teeth; Home Management: Bed linen change; Miscellaneous: Complete/update resident status sheet; Safety Precautions: Safety precautions assigned. The Hospice Aide Visit Note dated 07/23/2025 documented, "Pain Management: No evidence of pain; Skin Care: Trimmed fingernails, trimmed toenails; Miscellaneous: Completed/updated resident status sheet; Safety Precautions: Safety precautions followed; Communication: Homeowner gave pt [patient] a shower yesterday because he forgot I was coming to shower him. Pt did not want a shave today will bring electric razor to shave him next week." The Aide Missed Visit note dated 07/30/2025 documented "Reason for missed visit: Called Foster home approximately 1 hour before I was set to arrive. Let them know I’d be coming out to give pt (patient) a shower. They informed me they had already showered him yesterday. I let them know that last visit they did not need to shower him on Tuesday as I would be there on Wednesdays to shower him. Caregiver told me she did not see a reason for me to come out as he already had a shower. Will call at beginning of week to remind them I’ll be out on Wednesdays and not to shower pt Tuesday.” The documentation lacked notification to the registered nurse of changes to the plan of care. CLINICAL RECORD 13: The patient elected the hospice benefit on 01/22/2025 with a diagnosis of senile degeneration of the brain. The Hospice Aide Care Plan dated 01/22/2025 included an aide visit frequency of twice a week with the following relevant tasks: Bathing: Assist to dress, Shower; Hair Care: Shampoo/style; Skin Care: Inspect skin; check pressure areas; Call nurse if new skin problems are noted, Trim nails - fingers (weekly) , toes (biweekly); Bed linen change. The Hospice Aide Visit Note dated 08/11/2025 documented, "Patient refused shower. Painted and clipped and cleaned fingernails. Provided hair comb and style." The Hospice Aide Visit Note dated 08/18/2025 documented, "Nails and toenails still turned down. Patient refused shower. I comb the brush and styled patient's hair and did bed linen." The documentation lacked notification to the RN of changes to the plan of care. CLINICAL RECORD 15: The patient transferred to the agency on 11/22/2024 with a diagnosis of malignant neoplasm of pleura. The Hospice Aide Care Plan dated 11/06/2024 included an aide visit frequency of once weekly with the following relevant tasks: Shower; Hair Care: Comb/brush, Shampoo/style; Oral care Assist with brushing teeth. The Hospice Aide Visit Note dated 11/20/2024 lacked documentation the following tasks were provided: shower; Hair Care: Comb/brush, shampoo/style; and Oral Care: Assisted with brushing teeth. The documentation lacked notification to the RN of changes to the plan of care. During a joint clinical record review and interview on 08/22/2025, the Director of Clinical Services confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed it was revealed that the agency did not ensure the discharge summary was sent to the receiving Medicare/Medicaid certified facility. CLINICAL RECORD 15: The patient's care was transferred to another hospice provider on 12/01/2023. The record lacked evidence that a discharge summary was created and forwarded to the receiving hospice. During a joint record review and interview on 08/22/2025, the Director of Clinical Services confirmed that the record lacked evidence that the discharge summary was sent to the receiving Medicare/Medicaid-certified facility. The Director of Clinical Services stated that they were told that they did not have to send a discharge summary if someone was transferring or revoking.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records for discharged patients reviewed revealed that the agency did not ensure the discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 16: The patient discharged (revocation) from services on 04/22/2025. The record lacked documentation that a discharge summary was created and forwarded to the patient's attending physician. During a joint record review and interview on 08/22/2025, the Director of Clinical Services confirmed that the record lacked evidence that the discharge summary was forwarded to the patient’s attending physician. The Director of Clinical Services stated that they were told that they did not have to send a discharge summary if someone was transferring or revoking.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following a summary of the patient’s hospice stay, including treatments, symptoms, and pain management; the patient’s current plan of care; the patient’s latest physician orders; and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed, in which a discharge summary was required, it was revealed that the agency did not ensure the discharge summary was created and provided to a facility receiving a hospice patient for care, or to the patient’s community attending physician upon hospice discharge. CLINICAL RECORD 15: The date of the transfer was 11/22/2024, the record lacked evidence of a discharge summary document. CLINICAL RECORD 16: The date of the revocation was 04/22/2025, the record lacked evidence of a discharge summary document. During a joint record review and interview on 08/22/2025, the Director of Clinical Services confirmed that the record lacked evidence of a discharge summary and stated that they were told that they did not have to create a discharge summary for transfers and revocations.

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. The hospice has a means to authenticate entries or to identify the author of each entry. This standard was not met as evidenced by a review of clinical records and interviews. 7 of 8 (88%) clinical records reviewed revealed that credentials for the RN were not included with the RN signature on the hospice benefit election form. Clinical Record 1: Election of hospice benefit dated 10/18/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 2: Election of hospice benefit dated 10/28/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 3: Election of hospice benefit dated 10/13/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 5: Election of hospice benefit dated 6/20/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 6: Election of hospice benefit dated 10/4/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 7: Election of hospice benefit dated 9/16/22 did not identify credentials for the RN signature on the hospice benefit election form. Clinical Record 8: Election of hospice benefit dated 10/30/22 did not identify credentials for the RN signature on the hospice benefit election form. Interview and record review with the Administrator, alternate administrator and director of clinical services on 11/02/2022 confirmed this finding.