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 no later than 5 days after the date of hospice election as part of the patient’s comprehensive assessment for 3 (#7, #9, #11) out of 19 sampled patients. --- Findings:Review of the agency’s policy and procedure titled, Bereavement Assessment with a revised date of 03/01/2021 revealed, “Purpose: To ensure appropriate and coordinated bereavement services are provided to families and caregivers of hospice patients. Procedure: 1. The Social Worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice…” Review of patient #7’s electronic clinical record revealed the start of care date and election date for hospice services was 02/17/2026.  Review of patient #9’s electronic clinical record revealed the start of care date and election date for hospice services was 2/22/2026.Review of patient #11’s electronic clinical record revealed the start of care of date and election date for hospice services was 02/14/2026. There was no evidence patient #7, #9, and #11’s Bereavement Risk Assessments were completed within 5 days of admission.On 03/10/2026 at 11:00 a.m., an interview and record review was conducted with S1ED (Executive Director).  She confirmed the initial Bereavement Risk Assessments for Patient #7, Patient #9, and Patient #11 were not completed within 5 days of admission.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure the HA (Hospice Aide), SN (Skilled Nurse), MSW (Medical Social Worker), and CH (Chaplain) followed the POC for visits as ordered for 5 (#4, #5, #8, #12, and #14) out of 19 sampled patients. --- Findings: 1. Patient #4.  Review of the patient’s electronic clinical record revealed the start of care date was 07/18/2025.  The patient’s admitting diagnosis was Alzheimer’s disease.  The benefit period reviewed was 01/14/2026 to 03/14/2026.   Review of the patient's POC for benefit period 01/14/2026 to 03/14/2026 revealed an order for HA effective 01/14/2026 2wk1, 3wk8 (Hospice Aide visits two times a week for one week, three visits a week for eight weeks). The POC revealed an order for MSW effective 01/14/2026 1M1, 2M1, 1M1, 4 prn for urgent psychosocial needs/interventions (Medical Social Worker visit effective the week of 01/14/2026 one visit a month for one month, two visits a month for one month, one visit a month for one month, four visits as needed…).  Further review of the POC revealed an order for CH effective 01/14/2026 2M2, 1M1, 3 prn for urgent spiritual care needs/interventions (Chaplain visits effective 01/14/2026 two visits a month for two months, one visit a month for one month, three visits as needed…). Review of the patient’s HA visit notes for the week of 01/18/2026 revealed no evidence that 3 HA visits were made for that week as ordered.   Review of the patient’s MSW visit notes for the time from 01/14/2026 to 01/31/2026 revealed no evidence that a visit was made as ordered. Review of the patient’s CH visit notes for the time from 01/14/2026 to 01/31/2026 revealed no evidence that 2 visits were made as ordered.  On 03/10/2026 at 10:20 a.m., an interview was conducted with S1ED (Executive Director) after she reviewed the patient’s electronic clinical record.  S1ED confirmed that the HA, MSW, and CH visits were not made as ordered per the patient’s benefit period POC dated 01/14/2026 to 03/14/2026.   2. Patient #5. Review of the patient’s electronic clinical record revealed the start of care date was 01/04/2026.  The patient’s admitting diagnoses included heart disease, Alzheimer’s disease and cerebral infarction.  The benefit period reviewed was 01/04/2026 to 04/03/2026.   Review of the patient's POC for benefit period 01/04/2026 to 04/03/2026 revealed an order for HA 2wk13, (Hospice Aide two visits a week for thirteen weeks).   Review of the patient’s HA visit notes for the weeks of 01/04/2026 and 01/18/2026 revealed no evidence that 2 HA visits were made for those weeks as ordered.   On 03/10/2026 at 1:10 p.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record.  S1ED confirmed that the HA visits were not made as ordered per the patient’s benefit period POC for the weeks of 01/04/2026 and 01/18/2026.   3. Patient #8. Review of the patient’s electronic clinical record revealed the start of care date was 02/13/2026.  The patient’s admitting diagnosis included liver cell carcinoma.  The benefit period reviewed was 02/13/2026 to 05/13/2026.   Review of the patient's POC for benefit period 02/13/2026 to 05/13/2026 revealed an order for SN effective 02/15/2026 5wk1, 4wk1, 2wk10, 12SN prn visits for urgent symptom management (skilled nurse visits effective the week of 02/15/2026 five visits a week for one week, four visits a week for one week, two visits a week for ten weeks, and twelve skilled nurse visits as needed for urgent symptom management).  Further review of the POC revealed an order for HA effective 02/15/2026 3wk12, 1wk1 (Hospice Aide effective 02/15/2026 two visits a week for twelve weeks, one visit a week for one week).   Review of the patient’s SN visit notes for the week of 02/22/2026 revealed no evidence that 4 skilled nurse visits were made for that week as ordered.   Review of the patient’s HA visit notes for the week of 02/15/2026 revealed no evidence that 3 HA visits were made for that week as ordered.   On 03/10/2026 at 3:25 p.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record.  S1ED confirmed that the SN and HA visits were not made as ordered per the patient’s benefit period POC dated 02/13/2026 to 05/13/2026.   4. Patient #12. Review of the patient’s electronic clinical record revealed the start of care date was 02/21/2026.  The patient’s admitting diagnosis included dysphagia following cerebral infarction.  The benefit period reviewed was 02/21/2026 to 05/21/2026.   Review of the patient's POC for benefit period 02/21/2026 to 05/21/2026 revealed an order for SN 1wk1, 4wk1, 3wk11, 2wk1, 12SN prn visits for urgent symptom management (skilled nurse visits one time a week for one week, four visits a week for one week, three visits a week for eleven weeks, two visits a week for one week, and twelve skilled nurse visits as needed for urgent symptom management).   Review of the patient’s SN visit notes for the week of 02/22/2026 revealed no evidence that 4 skilled nurse visits were made for that week as ordered.    On 03/11/2026 at 4:05 p.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record.  S1ED confirmed that the SN visits were not made as ordered per the patient’s benefit period POC dated 02/21/2026 to 05/21/2026.   5. Patient #14.  Review of the patient’s electronic clinical record revealed the start of care date was 09/02/2022.  The patient’s admitting diagnosis included malignant neoplasm of bladder.  The benefit period reviewed was 02/13/2026 to 04/13/2026.   Review of the patient's POC for benefit period 02/13/2026 to 04/13/2026 revealed an order for SN 2every2wk2, 2wk7, 1wk1, 18SN prn visits for urgent symptom management (skilled nurse visits two visits every two weeks for two weeks, two visits a week for seven weeks, one visit a week for one week, eighteen skilled nurse visits as needed for urgent symptom management).   Review of the patient’s SN visit notes for the week of 02/22/2026 revealed that 2 skilled nurse visits were made for that week and there were no orders for visits that week.   On 03/11/2026 at 4:05 p.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record.  S1ED confirmed that the SN visits were not made as ordered per the patient’s benefit period POC dated 02/13/2026 to 04/13/2026.

Based on record review and interview, the hospice agency failed to ensure the patients rights to receive effective pain management and symptom control for conditions related to the terminal illness as evidenced by the SN (Skilled Nurse) failing to reconcile the patients (#1) medication in his EKIT (Emergency Medication Kit) to ensure the patients Morphine (pain medication) was in the home during a skilled nurse visit made on 09/14/2024 for 1 (#1) out of 3 (#1, #2, and #3) sampled patients. --- Review of the agencys policy titled, Emergency Medication Kit Usage-Hospice with an effective date of 09/25/2008 and a last revision date of 10/25/2010. The policy read in part, Purpose: to identify a uniform methodology in the utilization of emergency medication kits in the Hospice patients home used to provide timely access to medications needed for urgent symptom control. Policy: Emergency medication kits (comfort packs) can be utilized for emergency use and management of comfort-related symptoms. Procedure: 1. A complete list of all drugs contained within the emergency medication kit and information on each drug will be included in each kit... 4. A nurse will assess the contents of the emergency medication kit at every visit as part of the medication reconciliation process. Review of Patient #1s electronic clinical record revealed the start of care and election date for hospice services was 09/13/2024. The patients admitting diagnosis included in part the following diagnoses: Hypertensive Heart Disease Without Heart Failure, Hemothorax and Multiple Fractured Ribs. The benefit period reviewed was 09/13/2024 to 12/11/2024. Review of the patients POC (Plan of Care) for benefit period 09/13/2024 to 12/11/2024 revealed under Goals—Patient pain will be reduced (as evidenced by reduction in pain score) within 24 hours. Further review of the POC revealed under Medications an order for Morphine Concentrate 100mg (milligram) /5ml (milliliter)(20mg/ml) oral solution oral every 4 hours as needed for pain, EKIT(indicating that this medication was in the patients emergency medication kit) Review of the SN visit note dated 09/13/2024 revealed that an EKIT for Patient #1 was sent to the pharmacy for the family pick up. Review of the SN visit note dated 09/14/2024 revealed under Medications, the SN documented that the comfort pack (EKIT) was present and intact. Further review revealed the SN indicated that a medication reconciliation was performed during the visit. A review of the agencys call log revealed a call was received on 09/15/2024 at 11:55 a.m. from the Patient #1s daughter. She stated the patient had a change in condition. He was wheezing, confused, agitated and was in pain and very uncomfortable. Further review revealed that S3RN (Registered Nurse) responded at 12:13 p.m. S3RN stated that she would follow-up and address the patients needs. Review of the SN visit note dated 09/15/2024 revealed that S3RN arrived at Patient #1s home at 1:21 p.m. Further review of the visit note revealed, ";Pt is visibly in pain, complaining of rib discomfort. Observed moaning, facial grimacing, shuffling of feet and signs of terminal agitation. Pt appeared restless and uncomfortable. Family reports these symptoms started yesterday unresolved." On 10/21/2024 at 4:30 p.m., a phone interview was conducted with Patient #1s daughter. Patient #1s daughter stated she picked up the patients emergency medication kit from the pharmacy. She was told that the kit was supposed to have Morphine, which was for the patients pain. On 09/15/2024, she called the agency because her father was complaining of pain and was very anxious. She was told by the person on the phone to give him Morphine. When she went to look for the Morphine in the emergency medication kit, there was no Morphine. On 10/22/2024 at 12:55 p.m., a phone interview was conducted with S3RN. She stated that on 09/15/2024, when she arrived at the patients home, there was no Morphine in the home. On 10/22/2024 at 12:25 p.m., a phone interview was conducted with S3RN. She stated when she arrived at the patients home on 09/15/2024, she checked the comfort kit and discovered that there was no Morphine in the kit. She stated a family member had went to the pharmacy to pick it up. On 10/22/2024 at 3:54 p.m., a phone interview was conducted with S4RN. He stated that when he went to the patients home on 09/14/2024, the EKIT had not been opened yet. When asked if he opened the EKIT to check the medications, he stated that he could not recall if he opened the EKIT. When asked how he conducted a medication reconciliation during the visit, he stated that he reconciled the medications that were presented to him. When asked if there was Morphine in the home, he stated that he did not recall Morphine being in the home at the time he reconciled the medications. He confirmed that he did not reconcile the EKIT medications. On 10/22/2024 at 4:15 p.m., an interview was conducted with S1ED (Executive Director). S1ED was asked should the nurse who made the visit on 09/14/2024 have checked the comfort pack (EKIT) to make sure that the patient had received all the necessary medications. She confirmed that the nurses should conducted a medication reconciliation of the patients emergency medication kit every visit.

Based on record review and interview, the agency failed to ensure the individualized written POC (plan of care) included all services necessary for the palliation and management of the terminal illness and related conditions as evidenced by failing to include orders for medication to manage the patients (#2) symptoms for 1 (#2) out of 3 (#1, #2, #3) sampled patients. --- Review of the agencys Policy and Procedure titled Initial & Comprehensive Admission Assessment & Plan of Care with a revised date of 04/01/2022 read: ";...4. All treatments, medications, and services provided must be on the... plan of care..." Review of Patient #2s electronic clinical record revealed the patients start of care date was 09/13/2024. The patients admitting diagnoses included Cerebrovascular Disease with Multi-Infarct Dementia, Cerebral Infarction, Hypertension, and Atrial Fibrillation. The patients benefit period reviewed was 09/13/2024 to 12/11/2024. Review of the patients SN (Skilled Nurse) visit narrative note dated 09/17/2024 revealed, ";Late entry for 09/16/2024.... Family states they were told they were going to get something stronger than Imodium for pt (patient) as well as antibiotics but have not received anything. SN VU (verbalized understanding) and apologized for this issue. SN recommended Lomotil and family is willing to try it... Family in agreeance and okay with just receiving Lomotil to slow down diarrhea for pt... Lomotil sent in to local pharmacy... for family to pick up..." On 10/22/2024 at 10:22 a.m., a telephone interview was conducted with S2RN (Registered Nurse). S2RN stated the family was complaining about the patient having diarrhea and not getting any medications to resolve it. S2RN stated she informed the family she would get an order for Lomotil to address the patients diarrhea and she sent the order to the patients pharmacy. Review of the patients electronic clinical record, which included the medication list, revealed there was no order for Lomotil. On 10/22/2024 at 4:15 p.m., an interview was conducted with S1ED (Executive Director). She reviewed the patients electronic clinical record and confirmed the patient had diarrhea and that there was no order for Lomotil to manage the diarrhea.

The facility failed to meet the Condition of Participation: Drugs Biologicals Medical Supplies & DME. Based on record review and interview, the agencys SN (Skilled Nurse) failed to ensure the patient (#1) and the patients caregiver received adequate education and training to determine the ability of the patient and/or caregiver to safely administer the medications in the patients emergency medication kit (EKIT) in the home as per the patients POC (Plan of Care) for 1 (#1) out of 3 (#1, #2, and #3) sampled patients. (L0692) Based on record review and interview, the hospice agency failed to ensure its policies and procedures were followed as evidenced by the SN failing to reconcile the patients emergency medication kit (EKIT) in the home for 1 (#1) out of 3 (#1, #2, and #3) sampled patients. (L0696) --- See findings at L0692 and L0696.

Based on record review and interview, the agencys SN (Skilled Nurse) failed to ensure the patient (#1) and the patients caregiver received adequate education and training to determine the ability of the patient and/or caregiver to safely administer the medications in the patients emergency medication kit (EKIT) in the home as per the patients POC (Plan of Care) for 1(#1) out of 3 (#1, #2, and #3) sampled patients. This deficient practice resulted in delay of management of the patient's increased level of pain. --- Review of Patient #1s electronic clinical record revealed the start of care and election date for hospice services was 09/13/2024. The patients admitting diagnosis included in part the following diagnoses: Hypertensive Heart Disease Without Heart Failure, Hemothorax and Multiple Fractured Ribs. The benefit period reviewed was 09/13/2024 to 12/11/2024. Review of the patients POC (Plan of Care) for benefit period 09/13/2024 to 12/11/2024 revealed an order to provide education to patient/caregiver regarding current medication regimen, instruction include: medication name, purpose, dosing, schedule, side effects, effectiveness and potential medication interactions. Review of the SN (Skilled Nurse) visit dated 10/14/2024 revealed the SN documented that education was provided to the patients caregiver on medication regimen, managing dyspnea, and pain management. On 10/21/2024 at 4:30 p.m., a phone interview was conducted with Patient #1s daughter who stated that she picked up the patients emergency medication kit from the pharmacy on 09/14/2024. She stated that a nurse made a visit that day and had not discussed how to give the medications. She stated they had to call a friend who was a hospice nurse to help them to administer the patient some of his medications. She stated that on 09/15/2024, the patient was complaining with increased pain and was very agitated. She had to call the agency because she had no idea on how to give the medications. On 10/22/2024 at 3:54 p.m., a phone interview was conducted with S4RN (Registered Nurse). S4RN was asked if he educated the patient and/or the patients caregiver on the emergency medication kit (EKIT) medications. He stated that he had discussed with the patients daughter the patients medication regimen. S4RN was asked if he educated her specifically on how to administer the emergency kit medications. S4RN stated that he felt that he didnt need to because there was a pharmacist in the family. On 10/22/2024 at 4:15 p.m., an interview was conducted with S1ED (Executive Director). She stated that the nurses should be educating the patient and/or caregiver on the side effects, usage, purpose and administration of the patients emergency medications every visit. She stated that nurse should have ensured that the patient and/or caregiver were able to give the medication safely by observing them.

Based on record review and interview, the hospice agency failed to ensure its policies and procedures were followed as evidenced by the SN failing to reconcile the patients emergency medication kit (EKIT) in the home for 1 (#1) out of 3 (#1, #2, and #) sampled patients. This deficient practice resulted in a delay of timely management of the patient's increased level of pain due to failure to have Morphine readily available in the patient's EKIT. --- Review of the agencys policy titled, Emergency Medication Kit Usage-Hospice with an effective date of 09/25/2008 and a last revision date of 10/25/2010. The policy read in part,...1. A complete list of all drugs contained within the emergency medication kit and information on each drug will be included in each kit... 4. A nurse will assess the contents of the emergency medication kit at every visit as part of the medication reconciliation process. Review of Patient #1s electronic clinical record revealed the start of care and election date for hospice services was 09/13/2024. The patients admitting diagnosis included in part the following diagnoses: Hypertensive Heart Disease Without Heart Failure, Hemothorax and Multiple Fractured Ribs. The benefit period reviewed was 09/13/2024 to 12/11/2024. Review of the SN visit dated 09/13/2024 revealed that an EKIT (emergency medication kit) for Patient #1 was sent to the pharmacy and the family would pick up. Review of the SN visit dated 09/14/2024 revealed under Medications, the SN documented that the comfort pack (EKIT) was present and intact. Further review revealed that the SN indicated that a medication reconciliation was performed during the visit. On 10/21/2024 at 4:30 p.m., a telephone interview was conducted with Patient#1s daughter who stated that on 09/14/2024, she picked up the patients emergency medication kit from the pharmacy. She was told that the kit was supposed to have Morphine, which was for the patients pain. On 09/15/2024, she called the agency because the patient was complaining of pain and was very anxious. She was told by the person on the phone to give him Morphine. There was no Morphine when she went to look for the Morphine in the emergency medication kit. On 10/22/2024 at 12:25 p.m., a telephone interview was conducted with S3RN (Registered Nurse). She stated when she arrived at the patients home on 09/15/2024, she checked the comfort kit/EKIT and discovered that there was no Morphine in the kit. On 10/22/2024 at 3:54 p.m., a telephone interview was conducted with S4RN. He stated that when he went to the patients home on 09/14/2024, the EKIT had not been opened yet. When asked if he opened the EKIT to check the medications, he stated that he could not recall if he opened the EKIT. When asked how he conducted a medication reconciliation during the visit, he stated that he reconciled the medications that were presented to him. When asked if there was Morphine in the home, he stated that he did not recall Morphine being in the home at the time he reconciled the medications. He confirmed that he did not reconcile the EKIT medications. On 10/22/2024 at 4:15 p.m., an interview was conducted with S1ED (Executive Director). S1ED was asked should the nurse who made the visit on 09/14/2024 have checked the comfort pack (EKIT) to make sure the patient had received all the necessary medications. She confirmed that the nurses should have conducted a medication reconciliation of the patients emergency medication kit on every visit.

Based on record review and interview, the agency failed to provide evidence that it conducted exercises to test the emergency preparedness plan at least annually as evidenced by not having a mock disaster drill for the year 2022. --- Review of the agencys emergency preparedness plan binder that was provided by S1ED (Executive Director) failed to contain evidence that a mock disaster drill was conducted for the year 2022. On 4/26/2023 at 12:30 p.m., an interview was conducted with S1ED. He confirmed that a mock disaster drill was not conducted for the year 2022.

Based on observation, record review and interview, the agency's staff failed to review all medications that Patient #3 was currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, and duplicate drug therapy as evidenced by an observation made on 4/24/2023 with S3RN (Registered Nurse) during the home visit at the facility where Patient #3 resided for 1 (#3) out of 3 (#1, #2, #3) patients in which home visits were made. --- Patient #3. Review of the agencys Monitoring Medications policy and procedure revealed, ";Purpose: To provide a process to ensure continuous monitoring of medications in patients home. Policy: A drug regimen will be performed on all patients... Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period... Procedure: 1. A Comprehensive Medication Review will be completed on admit and at every Interdisciplinary Group (IDG) meeting, in conjunction with all comprehensive assessments... 3. All nurses participating in the patients care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care..." Review of Patient #3s electronic clinical records revealed the start of care date was 3/31/2023. The patients diagnoses included Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The benefit period reviewed was 3/31/2023 to 6/28/2023. Review of the patient's POC (Plan of Care) for benefit period 3/31/2023 to 6/28/2023 revealed the following order, SN 2wk13, 1wk1 (skilled nurse visit two times a week for thirteen weeks, skilled nurse visit one time a week for one week). On 4/24/2023 at 1:45 p.m., a home visit, at the facility where Patient #3 resided, was conducted with the patient and S3RN (Registered Nurse). S3RN was observed reviewing/reconciling the patients medications with the facility nurse. During this observation, S3RN discovered that Docusate Sodium 50mg (milligrams)/5ml (milliliters) ordered on 4/3/2023, Hydralazine 25 mg tablet ordered on 3/31/2023, Isosorbide Dinitrate 30 mg tablet ordered on 4/4/2023, Lasix 40 mg tablet ordered on 4/4/2023, Melatonin 5 mg chewable tablet ordered on 4/5/2023, Metformin 500 mg tablet ordered on 3/31/2023, Vitamin D2 1,250 mcg (micrograms) 50,000 units ordered on 3/31/2023, Aspirin 81 mg chewable tablet ordered on 3/31/2023, and Coreg 6.25 mg tablet ordered on 3/31/2023 were not documented on the patients current medication profile. On 4/24/2023 during the home visit that began at 1:45 p.m., an interview was conducted with S3RN. S3RN stated the patients medication profile should have been current and updated during the previous skilled nurse visits that were made on 4/4/2023, 4/6/2023, 4/11/2023, 4/13/2023, 4/18/2023, and on 4/20/2023 before the visit she made on 4/24/2023. On 4/25/2023 at 11:55 a.m., an interview was conducted with S2DOCO (Director of Clinical Operations). S2DOCO confirmed the patients medication profile should have been current and updated prior to the skilled nurse visit that was made by S3RN on 4/24/2023.

Based on record review and interview, the agency failed to ensure the patient's written individualized POC (plan of care) was followed as evidenced by the agency failing to ensure HA (hospice aide) visits were made as ordered per the POC for 1 (#1) out of 13 sampled patients. --- Patient #1. Review of the patient's electronic clinical record revealed a start of care date 3/31/2023. The patient's admitting diagnosis was Malignant Neoplasm of Lower Lobe Left Bronchus or Lung. The benefit period reviewed was 3/31/2023 to 6/28/2023. Review of the patient's POC for the benefit period 3/31/2023 to 6/28/2023 revealed an order for HA visits 1wk1, 3wk12, 2wk1 (hospice aide visits one time a week for one week, three times a week for twelve weeks, two times a week for one week). Review of the patient's HA visit notes revealed no evidence that 3 HA visits were made for the weeks of 4/2/2023, 4/9/2023, and for the week of 4/16/2023 as ordered per the patients POC. On 4/25/2023 at 11:45 a.m., S2DOCO (Director of Clinical Operations) reviewed the patient's electronic clinical records and confirmed that there was no evidence that 3 HA visits were made for the weeks of 4/2/2023, 4/9/2023, and for the week of 4/16/2023 as ordered per the patients POC.