Every finding on record at Heart to Heart Hospice Corp

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, it was revealed that the hospice did not ensure the Interdisciplinary Group (IDG) completed an initial spiritual and psychosocial assessment no later than five calendar days after the election of hospice care. Clinical Record 1: The hospice benefit date of election was 4/25/23. The chaplain documented the initial spiritual assessment on 5/2/23 (7 days). The social worker documented the initial psychosocial assessment on 5/1/23 (6 days). There was no documented evidence that the initial spiritual and psychosocial assessments were completed no later than five calendar days after the election of hospice care. There was no documented reason for the delay. Clinical Record 5: The hospice benefit date of election was 8/18/23. The chaplain documented the initial spiritual assessment on 8/24/23 (6 days). The social worker documented the initial psychosocial assessment on 8/24/23 (6 days). There was no documented evidence that the initial spiritual and psychosocial assessments were completed no later than five calendar days after the election of hospice care. There was no documented reason for the delay. During a joint record review and interview on 11/8/23, the Alternate Administrator confirmed the finding.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 4 of 6 (67%) clinical records reviewed, it was revealed that the hospice did not ensure the drug profile was updated. Clinical Record 1 / Home Visit 3: The hospice benefit date of election was 4/25/23. The medication profile dated 4/25/23 - 11/8/23, documented the following: "Acetaminophen/Codeine #3 oral tablet 300-30, take 1 tablet every 4 hours as needed for moderate pain, effective 6/15/23." During the home visit on 11/8/23, the assisted living facility (ALF) medication profile documented, "APAP with Codeine 300-30mg, take 2 tablets every 4 hours, as needed for pain, effective 8/21/23, and Quetiapine 25mg take 1 tab daily at bedtime, effective 4/3/23." The hospice medication profile did not include Quetiapine, or APAP with Codeine 300-30mg, two tablets every 4 hours, as needed for pain. There was no documented evidence that the medications were reconciled, and the hospice medication profile updated. Clinical Record 2 / Home Visit 4: The hospice benefit date of election was 9/29/23. The medication profile dated 9/29/23 - 11/8/23, documented the following: "Atorvastatin 40mg, 1 time a day, effective 9/29/23; and Furosemide 40mg, 1 time a day, effective 9/29/23. During the home visit on 11/8/23, a review of the medications revealed the patient was taking the following: Atorvastatin 20mg every day, last filled 10/11/23; and Furosemide 20mg every day, last filled 10/11/23. The patient’s daughter confirmed the current medications. The hospice medication profile did not include Atorvastatin 20mg or Furosemide 20mg. There was no documented evidence that the medications were reconciled, and the hospice medication profile updated. Clinical Record 3 / Home Visit 2: The hospice benefit date of election was 9/7/23. The medication profile dated 9/7/23 - 11/8/23, revealed the following: Trazodone 100mg tab, at bedtime, effective 9/7/23. During the home visit on 11/8/23, the ALF medication profile listed the following: "Quetiapine 12.5mg in AM, 25mg at bedtime, effective 10/2/23; and Trazodone 150mg, give one half tablet (75mg) at bedtime, effective 3/13/23. The hospice medication profile did not include Quetiapine or Trazodone 75mg. There was no documented evidence that the medications were reconciled, and the hospice medication profile updated. Clinical Record 5: The hospice benefit date of election was 8/18/23. The medication profile dated 8/18/23 - 9/27/23, revealed no medications. The plan of care (POC) dated 8/18/23, included the following: Metoprolol Succinate 25mg ER, 1 tab daily; Refresh Tear Drops 0.5% ophthalmic; and Acetaminophen 500mg, every 6 hours, as needed for pain. The hospice medication profile did not include Metoprolol Succinate, Refresh Tear Drops or Acetaminophen. There was no documented evidence that the medications were reconciled, and the hospice medication profile updated. During a joint record review and interview on 11/8/23, the Alternate Administrator confirmed the finding.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, it was revealed that the hospice did not ensure the plan of care (POC) included planned interventions and goals based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The hospice benefit date of election was 9/29/23. The Registered Nurse (RN) assessment dated 10/3/23, documented 1+ bilateral lower extremity (BLE) edema. The RN assessment dated 10/12/23, documented 1+ BLE edema. The RN assessment dated 10/19/23, documented 2+ BLE edema. However, the POC dated 9/29/23 - 12/27/23, did not include interventions and goals for edema. During a joint record review and interview on 11/8/23, the Alternate Administrator confirmed the finding.

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 observation, document review, and interview. In 1 of 4 (25%) observed home visits, it was revealed that the hospice did not ensure the staff followed the hand hygiene policy. Agency policy, Hand Hygiene and Compliance Program, stated in part, “The proper procedure for handwashing when using soap and water is as follows: Turn water to a comfortable warm temperature. Hold hands under running water so they get completely wet. Lather hands well with liquid, antimicrobial soap: use frictions; wash between fingers, wash area around and under nails. Using a clean paper towel, dry hands thoroughly. Turn off water faucet using towel. Discard paper towels in a disposable bag or waste can.” Home Visit 3 / Clinical Record 1 / Staff 1: During the home visit on 11/8/23, the Registered Nurse (RN) was observed as follows: placed a paper towel to the left of the sink; placed a bottle of soap on the towel; wet the hands and opened the bottle of soap; poured soap on the hands; washed and rinsed hands; turned off the sink with the paper towel on which the bottle of soap was sitting; with wet hands, picked up a plastic bag with more paper towels inside; removed paper towels; separated the towels; place one paper towel on top of the plastic bag; and dried hands with the paper towel. During an interview on 11/8/23, the Administrator confirmed that the RN did not follow the hand hygiene policy.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 3 (100%) records reviewed of patients that were discharged due to death, it was revealed that the hospice did not ensure that bereavement services that were provided to the bereaved were documented in the clinical record. Document 3: Agency policy, "Bereavement Policy," stated in part, "The hospice has a plan for providing regular and ongoing supervision of bereavement staff and volunteers. The hospice documents bereavement services provided. The Agency's bereavement services will be available to the patient's family members for thirteen (13) months from the date of patient's death." Clinical Record 4: The patient's date of election was 4/21/2023. The patient's date of death was 6/5/2023. The bereavement plan of care revealed sympathy card due same day 6/5/2023, bereavement informational booklet given or sent due same day 6/5/2023, family made aware of bereavement services within 2 days due 6/7/2023, healing forms will be sent at 3 months due 9/5/2023, There was no documented evidence that the sympathy card, informational booklet, and healing forms were sent. Clinical Record 5: The patient's date of election was 8/18/2023. The patient's date of death was 9/27/2023. The bereavement plan of care revealed sympathy card due same day 9/27/2023, bereavement informational booklet given or sent due same day 9/27/2023, family made aware of bereavement services within 2 days due 9/29/2023. There was no documented evidence that the sympathy card and informational booklet were sent. Clinical Record 6: The patient's date of election was 6/8/2023. The patient's date of death was 8/28/2023. The bereavement plan of care revealed sympathy card due same 8/28/2023, bereavement informational booklet given or sent due same day 8/28/2023, family made aware of bereavement services within 2 days due 8/30/2023. There was no documented evidence that the sympathy card and informational booklet were sent. During a joint record review and interview on 11/9/2023, the Alternate Administrator agreed there was no documented evidence of the bereavement services that were provided. The Alternate Administrator stated, I know we are doing it, but agree there is nothing documented to show we are. During a joint record review and interview on 11/9/2023, the Bereavement Coordinator agreed there was no documented evidence bereavement services were provided. The Bereavement Coordinator stated, I don’t see any documentation to show it was done.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed, of patients receiving hospice aide services, it was revealed that the hospice did not ensure that the hospice aides were assigned written patient care instructions. Clinical Record 1: The hospice benefit date of election was 4/25/23. The primary hospice diagnosis was dementia. The hospice aide plan of care (POC) effective 7/24/23, included: shampoo weekly only when needed and desired by patient; and apply barrier cream each visit only when needed and desired by patient. The POC did not provide patient care instructions that specified when a shampoo and/or barrier cream were needed. Clinical Record 5: The hospice benefit date of election was 8/18/23. The primary hospice diagnosis was Alzheimer's disease with late onset. The hospice aide POC effective 8/18/23, included: hair care each visit only per patient's wishes; shampoo weekly only per patient's wishes; mouth/denture care each visit only per patient's wishes; and nail care each visit only per patient's wishes. The POC did not provide patient care instructions that specified when hair care, shampoo, mouth/denture care, and nail care were needed. During a joint record review and interview on 11/8/23, the Alternate Administrator confirmed the findings.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) records reviewed it was revealed that the hospice did not ensure the clinical record included the clinical notes including the care and services provided. Clinical Record 5: The hospice benefit date of election was 8/18/23. The patient's date of death was 9/27/23. The discharge summary revealed that on 9/27/23, the hospice received a call that the patient was turning purple while sitting in wheelchair, and the registered nurse (RN) went to the facility where the resident resided. However, there was no documentation of an RN death visit. Clinical Record 6: The hospice benefit date of election was 6/8/23. The patient's date of death was 8/28/23. The discharge summary revealed that on 8/28/23, the hospice received a call that the patient stopped breathing, and the case manager was notified. However, there was no documentation of an RN death visit. During a joint record review and interview on 11/9/23, the Alternate Administrator confirmed the finding and stated, "I know we did the death visits, but do not see the documentation. We are still learning the charting."

It is required that the hospice medical director or physician-designee provides written and signed recertification of the terminal illness to meet the hospice care benefit requirement. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins. This standard was not met as evidenced by clinical record review and interview. In 1 of 6 (17%) clinical records reviewed, it was revealed that the hospice did not ensure that the medical director or physician-designee, provided written and signed recertification of the terminal illness. Clinical Record 1: The hospice benefit date of election was 4/25/23. There was no evidence that a recertification was completed for the second benefit period dated 7/24/23-10/21/23. During an interview on 11/9/23, the Hospice Medical Director stated, "I depend on the agency to help with that. There are so many dates to remember. I wish I could remember them all." During a joint record review and interview on 11/8/23, the Alternate Administrator confirmed the finding and stated that, there was no documentation that the recertification was completed.