Every finding on record at Heart of Hospice, LLC

Based on record review and interview, the agency failed to ensure an initial bereavement assessment was completed with a patients family and/or other individuals for 1 (Patient #4) of 19 (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, and Patient #19) sampled patients reviewed for initial bereavement requirements. Findings: --- Review of Patient #4s hospice plan of care for the certification period of 08/31/2024 through 11/28/2024 revealed there was no documented evidence, and the agency presented no documented evidence, an initial bereavement assessment had been completed since admission on 08/31/2024. In an interview on 10/28/2024 at 11:47 a.m., S1Executive Director indicated S3Master Social Worker (MSW) had not completed an initial bereavement assessment for Patient #4 as required.

Based on record reviews and interviews, the agency failed to ensure the nurse assessed wounds weekly for 2 (Patient #1 and Patient #15) of 6 (Patient #1, Patient #7, Patient #9, Patient #12, Patient #13, and Patient #15) sampled patients reviewed for weekly wound care measurements. Findings: --- Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed, in part, assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information can be used to track the progress of wound healing. Review of the agencys Wound Assessment, Documentation and Photography policy and procedure revised on 03/01/2021 revealed, in part, wound measurements were to be documented in the medical record weekly. Patient #1 Review of Patient #1s Wound Record Report revealed Patient #1 had a right lower buttock stage II pressure ulcer (open wound caused by pressure). Further review revealed the week of 09/08/2024 through 09/14/2024 no wound care measurements were obtained. Further review revealed Patient #1s wound care measurements were not obtained for the week of 09/08/2024 through 09/14/2024 or for the week of 09/15/2024 through 09/21/2024. There was no documented evidence, and the agency presented no documented evidence, Patient #1s wound was measured weekly for the above mentioned time period as required. In an interview on 10/29/2024 at 10:47 a.m., S1Executive Director (ED) indicated wounds were expected to be measured weekly. Patient #15 Review of Patient #15s Wound Record Report revealed Patient #15 had a right lower buttock stage II pressure ulcer. Further review revealed no wound care measurements were obtained for Patient #15s wound for the week of 03/24/2024 through 03/30/2024 There was no documented evidence, and the agency presented no documented evidence, Patient #15s wound was measured weekly for the above mentioned time period. In an interview on 10/29/2024 at 10:27 a.m., S1ED indicated no wound care measurements were obtained of Patient #15s right lower buttock wound the week of 03/24/2024 through 03/30/2024 as required.

Based on record review and interview, the agency failed to ensure the contract with a patients nursing facility contained a provision which required hospice to report all alleged violations of mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property for 1 (Patient #1) of 1 (Patient #1) sampled patient contracts reviewed for contract requirements. Findings: --- Review of Patient #1s Hospice Agreement between the agency and Patient #1s nursing facility dated 07/16/2024 revealed, in part, there was no documented evidence, and the agency presented no documented evidence, that the contract contained a provision which required hospice staff to report to the nursing facility administrator any alleged violations of mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property. In an interview on 10/28/2024 at 3:24 p.m., S2Business Office Manager indicated Patient #1s contract between the agency and Patient #1s nursing facility did not have provisions for reporting abuse, neglect, and misappropriation of property as required.

Based on record review and interview, the agency failed to ensure a statewide criminal background check was completed as required for a registered nurse for the state of Louisiana for 1 (S1Executive Director) of 5 (S1Executive Director, S3Master Social Worker, S4Medical Director, S5Alternate Executive Director, and S6Registered Nurse) sampled licensed employees reviewed for criminal background checks requirements. Findings: --- Review of S1Executive Directors (ED) personnel file revealed a date of hire as executive director of 03/10/2024. Review further revealed S1EDs criminal background check was completed on 10/08/2019. Further review revealed S1EDs criminal background check revealed it only included three parishes, and did not include a statewide check. There was no documented evidence, and the agency presented no documented evidence, S1ED had a criminal background check completed for the entire state of Louisiana. In an interview on 10/29/2024 at 11:15 a.m., S1ED indicated the agency was unable to locate any documentation a statewide criminal background check had been completed for herself, S1ED, since date of hire.

Based on record review and interview the agency failed to ensure staff monitored wound healing by assessing and documenting wound status weekly per professional standards for 1 of 1 sampled patients (Patient #9) reviewed for wound care in a total sample of 15. Findings: Review of the Wound Ostomy and Continence Nurses Society's Guidelines revealed, in part, assessment and documentation of wound status, which includes comprehensive clinical data demonstrating evidence of progress in healing or failure to heal. Comprehensive wound assessment includes: dimensions and depth; presence, location and depth of any sinus tracts or undermining areas; status and characteristics of the wound bed; volume, color, and odor of exudates; evidence of infection in surrounding tissues. Further review revealed when recorded over time this information should be used to track the progress of wound healing. Review of Patient #9's Physician Order dated 11/02/2021 revealed an order for wound care to the left greater trochanter stage IV (four- wound with bone exposed) clean with wound cleanser and apply anasept gel to wound bed, pack with dry dressing and cover with an ABD pad (large absorbent dressing) daily. Review of Patient #9's record revealed no evidence and the agency did not present any documented evidence of the agency having obtained wound care measurements on the following weeks: the week of 11/21/2021 to 11/27/2021; the week of 11/29/2021 to 12/04/2021; and the week of 12/05/2021 to 12/11/2021. In an interview on 12/15/2021 at 2:29pm, S2PCM (Patient Care Manager) stated wound care measurements should be obtained weekly.