Every finding on record at Heart of Hospice, LLC

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 SN (Skilled Nurse) followed the POC for visits as ordered for 3 (#5, #9, and #14) out of 19 sampled patients. --- 3. Patient #14Review of the patient’s electronic clinical records revealed the start of care date was 4/06/2026.  The patient’s admitting diagnosis included Malignant Neoplasm of Unspecified main Bronchus. The benefit period reviewed was 06/05/2026 to 08/03/2026.Review of the patient's POC for benefit period for 06/05/2026 to 08/03/2026 revealed an order for SN effective 06/05/2026 2every2wk2, 2wk7, 7 prn visits for urgent symptom management (skilled nurse visits effective 06/05/2026 two visits every two weeks for two weeks, two visits a week for seven weeks, seven skilled nurse visits as needed for urgent symptom management).  Review of the patient’s SN visit notes for the week of 06/05/2026 revealed no SN visits. Review of the patient’s SN visit notes for the week of 06/07/2026 revealed 1 SN visit was made. Review of the patient’s SN visit notes for the week of 06/14/2026 revealed 1 SN visit was made.  On 06/24/2026 at 10:30 a.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record. She confirmed that the SN visit orders were not followed per the patient’s POC for the benefit period dated 06/05/2026 to 08/03/2026.  Findings: 1. Patient #5. Review of the patient’s electronic clinical record revealed the start of care date was 10/18/2024.  The patient’s admitting diagnoses included chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia.  The benefit period reviewed was 06/10/2026 to 08/08/2026.   Review of the patient's POC for benefit period 06/10/2026 to 08/08/2026 revealed an order for SN effective 06/10/2026 1wk9, 4 prn visits for urgent symptom management (skilled nurse visits effective 06/10/2026 one time a week for nine weeks, and four skilled nurse visits as needed for urgent symptom management).   Review of the patient’s SN visit notes for the week of 06/10/2026 revealed no evidence that a skilled nurse visit was made for that week as ordered.   On 06/23/2026 at 10:30 a.m., an interview was conducted with S1ED (Executive Director) after she reviewed the patient’s electronic clinical record.  Also, at this time, a telephone interview was conducted with S2QC (Quality Coordinator).  Both confirmed that a SN visit was not made as ordered for the week of 06/10/2026 per the patient’s POC for the benefit period dated 06/10/2026 to 08/08/2026.   2. Patient #9.  Review of the patient’s electronic clinical record revealed the start of care date was 09/09/2025.  The patient’s admitting diagnosis included congestive heart failure.  The benefit period reviewed was 06/06/2026 to 08/04/2026.   Review of the patient's POC for benefit period 06/06/2026 to 08/04/2026 revealed an order for SN effective 06/06/2026 2every2wk2, 2wk7, 1wk1, 3 prn visits for urgent symptom management (skilled nurse visits effective 06/06/2026 two visits every two weeks for two weeks, two visits a week for seven weeks, one visit a week for one week, three skilled nurse visits as needed for urgent symptom management).   Review of the patient’s SN visit notes for the week of 06/07/2026 and 06/14/2026 revealed that 2 skilled nurse visits were made for those weeks. There were no orders for SN visits for the week of 06/14/2026.   On 06/23/2026 at 10:50 a.m., an interview was conducted with S1ED after she reviewed the patient’s electronic clinical record. Also, at this time, a telephone interview was conducted with S2QC (Quality Coordinator).  Both confirmed that the SN visit orders were not followed per the patient’s POC for the benefit period dated 06/06/2026 to 08/04/2026.

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 SN (skilled nurse) and HA (Hospice Aide) followed the POC as ordered for 1 (#15) out of 19 sampled patients. --- Patient #15. Review of the patients electronic clinical record revealed a start of care date 2/1/2023. The patients admitting diagnosis was Pulmonary Hypertension and Congestive Heart Failure. The benefit period reviewed was 7/31/2023 to 9/28/2023. Review of the patient's POC for benefit period 7/31/2023 to 9/28/2023 revealed an order for SN effective 7/31/2023 2wk9, 6 prn for urgent symptom management needs/change in condition (skilled nurse visits two times a week for nine weeks, six visits as needed for urgent symptom management needs/change in condition). The POC revealed an order for HA visits effective 7/31/2023 3wk8, 2wk1 (hospice aide visits three times a week for eight weeks, two visits a week for one week). Review of the patients electronic clinical record for the week of 7/31/2023 and 8/6/2023 revealed that 2 SN visits and 3 HA visits were not made for those weeks as ordered per the benefit period POC. On 8/16/2023 at 11:45 a.m., an interview was conducted with S1ED (Executive Director). She reviewed the patients electronic clinical record and confirmed the SN and the HA did not make the visits as ordered per the POC for the weeks of 7/31/2023 and 8/6/2023.

Based on record and policy and procedure review and interview, the agency failed to ensure patient (#2) received nursing services that ensured the patient needs were met to relieve severe pain after a fall for 1 (#2) out of 19 sampled patients. --- Review of the agencys On-Call & Back-Up Services policy and procedure revealed, ";Purpose: To ensure that essential services will be available to all hospice patients at all times, 24 hours, 7 days a week. Policy: The agency will make all attempts to provide full services at the times, frequencies and level of care specified in the patients plan of care... Procedure: 5. Hospice patient/representatives calls are handled in the following manner: a. The initial responder or RN on-call nurse will decide, according to information received on the call, if the problem can be resolved on the phone or if a staff member needs to be sent to the home. The on-call nurse will be responsible for contacting the appropriate on-call staff member or making the visit themselves if a visit is appropriate. If the patient/representative requests a visit, a visit should be made..." Patient #2. Review of the patients electronic clinical record revealed SOC (start of care) date was 10/5/2022 and the admitting diagnosis was Atherosclerotic Heart Disease. The benefit period reviewed was 6/2/2023 to 7/31/2023 and 8/1/2023 to 9/29/2023. Review of the patient's POC for benefit period 6/2/2023 to 7/31/2023 revealed an order for SN visits 1wk1, 3wk8, 1wk1, 4 prn for urgent symptom management needs/change in condition (skilled nurse visit one time a week for one week, three visits a week for eight weeks, one visit one time a week for one week and four visits as needed for urgent symptom management needs/change in condition ). Review of the agencys complaint log revealed a complaint made by the patients family. The Complaint Report dated 7/15/2023 at 11:04 a.m. revealed, ";Description: I received a phone call from triage reporting the family (the patients son) is very upset because the facility called this morning at 6 reporting the patient was in pain. (S2RN-Registered Nurse) was notified and she spoke with the facility (staff). (S2RN) said she did not feel the patient needed morphine and since that was the only medication she had access to that the facility will need to call their on call nurse. The family is very upset because the nurse did not make a visit to assess the patient and he was able to drive all the way from (out of state) and no nurse had showed up. (Another nurse) was sent to make a visit once MOC (Manager on Call) was notified of situation and the patient was given Morphine and Tramadol with no relief. Her level of pain required new orders from hospice which were delayed due to no visit being made by (S2RN)..." Review of the patients SN visit note dated 7/15/2023 at 10:20 a.m. revealed, ";Narrative: PRN visit made to assess patient due to pain/fall. Pt had a fall last night. Pt complained of pain to right rib cage. SN assessed pain. Pt complained 5/10... administered Roxanol 0.25 mg prior to SN arrival. Along with Tramadol. After an hour pt still complained of pain. New orders obtained for Oxycodone 10 mg and Ibuprofen 800 mg..." On 8/15/2023 at 11:08 am, an interview was conducted with S1ED (Executive Director). She reviewed the patients Complaint Report and the SN visit note dated 7/15/2023. She confirmed that (S2RN) was the on call nurse and confirmed that she did not make a visit. S1ED stated that (S2RN) should have made the visit to assess the patient because the patient was in pain. She stated that there was no reason why (S2RN) did not make the visit to assess the patient.

Based on record review and interview, the agency failed to ensure the RN (Registered Nurse) made an on-site visit to patient #15's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide as evidenced by no documentation found in Patient #15's electronic clinical record of the RN making a supervisory visit no less frequently than every 14 days for 1 (#15) out of a sample of 19 patients. --- Patient #15. Review of the patients electronic clinical record revealed a start of care date 2/1/2023. The patients admitting diagnosis was Pulmonary Hypertension and Congestive Heart Failure. The benefit period reviewed was 7/31/2023 to 9/28/2023. Review of the patient's POC for benefit period 7/31/2023 to 9/28/2023 revealed an order for SN effective 7/31/2023 2wk9, 6 prn for urgent symptom management needs/change in condition (skilled nurse visits two times a week for nine weeks, six visits as needed for urgent symptom management needs/change in condition). The POC revealed an order for HA visits effective 7/31/2023 3wk8, 2wk1 (hospice aide visits three times a week for eight weeks, two visits a week for one week). The patient's HA visit notes were reviewed and revealed the visits started on 8/1/2023 for the benefit period 7/31/2023 to 9/28/2023. There was no evidence found from 8/2/2022 to 8/15/2022, (14 days) that the RN made a supervised visit for the hospice aide between this time frame. On 8/16/2023 at 11:45 am, an interview was conducted with S1ED (Executive Director). S1ED reviewed the patient's electronic clinical records and she verified that the RN did not make a supervisory visit for the HA no less frequently than every 14 days.