Every finding on record at Heart to Heart Hospice of Austin, Ltd

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; [and] 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; [and] 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 measures 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, document review, and interview. Agency policy #PC.85 "Medication List and Monitoring" (dated 09/01/2024) stated in part, "Medication monitoring will include appropriate data/information to develop ...a current, complete medication profile..." In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the patient's medication profile was updated with medication changes. Clinical Record 1: The patient elected the hospice benefit on 12/10/2024. The Registered Nurse (RN) visit note dated 05/21/2025, documented that the patient "demonstrates increased abdominal discomfort, Bentyl effective BID ..." The patient's medication profile for the benefit period dated 03/10/2025 to 06/07/2025 did not document Bentyl. During an interview and a joint clinical record review on 06/04/2025, the Area Vice President of Operations/RN confirmed Bentyl was not included in the patient’s medication profile.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care This standard was not met as evidenced by clinical record review, document review, interview, and observation. Agency policy #PC.30 "Plan of Care Process " (dated 09/01/2024) stated in part, "the comprehensive assessment will identify... physical...needs related to the terminal illness that will be addressed to promote the Hospice patient's...comfort...Data elements that allow for measurement of outcomes...The data elements for each patient will be used in individual patient care planning..." Agency policy #IM.30 "Medical Record Content " (dated 09/01/2024) stated in part, "The comprehensive assessment will include data elements that allow for measurement of outcomes to be used in individual patient care planning, coordination of services..." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 5/Home Visit 2: The patient elected the hospice benefit on 08/16/2022. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 7] on 06/05/2025, the RN [Personnel Record 7] discussed the patient's ongoing issues with constipation with the patient's spouse and the facility nurse. The facility nurse informed the RN [Personnel Record 7] that the patient was requiring almost weekly suppositories to have a bowel movement successfully. The RN [Personnel Record 7] informed the facility nurse and the patient's spouse that the patient's nurse practitioner would be consulted regarding a potential need to change the bowel regimen. The skilled nurse (SN) visit note dated 06/05/2025 documented, "Pt required Dulcolax supp today, which was effective, due to no BM x 3 days. BS hypoactive x4 quads. New order for Biscodyl 5mg at HS in addition to Senna-S 2 tabs BID..." The patient's medication profile documented the following medications documented as ordered 08/16/2022: bisacodyl 10mg rectal suppository, daily as needed for constipation, MiraLAX 17 g/dose oral powder, 17 g daily by mouth as needed for constipation, and Milk of Magnesia 400 mg/5ml, 15- 30ml daily by mouth as needed for constipation. On 01/15/2025, Senna Laxative 8/6mg tablet, two (2) tablets twice a day, was added to the patient's medication profile. The SN did not address the patient's constipation during the Interdisciplinary Group Meetings dated 05/01/2025, 05/15/2025, and 05/30/2025. The plans of care dated 04/02/2025 through 05/31/2025 and 06/01/2025 through 07/30/2025 identified the patient's problem with their gastrointestinal system and documented the intervention to educate the patient's spouse and facility staff about the patient's bowel regimen. The plans of care documented the patient's goal: the patient will follow an effective bowel program to prevent/relieve constipation, and constipation will be managed. The goals to "prevent and/or relieve" and manage the patient's constipation do not include measurable outcomes specific to the patient. During a joint clinical record review and interview on 06/06/2025, the Area Vice President of Operations/RN confirmed that the patient's plan of care did not include measurable outcomes for the ongoing constipation problem.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 19 (5%) clinical records reviewed, the hospice did not ensure that the patient's written plan of care included all medications. Clinical Record 1: The patient elected the hospice benefit on 12/10/2024. The patient resided at home. The Registered Nurse (RN) visit note dated 05/21/2025 documented that the patient "demonstrates increased abdominal discomfort, Bentyl effective BID ..." The plans of care for the benefit period dated 03/10/2025 to 06/07/2025 did not document Bentyl. During a joint clinical record review and an interview on 06/04/2025, the Area Vice President of Operations/RN confirmed that the plan of care did not include Bentyl. An order was documented on 06/04/2025 to bring the medical record into compliance.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group and 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, document review, and interview. Agency policy,#PC.35 "Implementing Care and Treatment (PC.35)," stated in part, "The hospice aide (HA) will be provided with written instructions for patient care prepared by a Registered Nurse (RN) ..." In 2 of 18 (11%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. Clinical Record 7: The patient elected the hospice benefit on 01/17/2025. The plan of care for the benefit period dated 05/12/2025 to 07/10/2025 ordered Hospice Aide services five times a week. The Hospice Aide care plan dated 01/17/2025, active at the time of review, assigned the HA the relevant tasks of providing a bed bath, perineal care, and skin care at each visit. The skilled nurse (SN) visit note dated 05/12/2025 documented a stage three pressure ulcer to the patient's coccyx measuring 2.1 cm x 0.9 cm x 0.2 cm. On 05/15/2025, the physician ordered to "cleanse the wound daily, pat dry, apply calcium alginate to the wound bed, and cover with a foam border dressing." The HA care plan did not provide instructions for the HA regarding the patient's wounds and the wound dressings, should they become wet, soiled, or dislodged during the bed bath and personal care. Clinical Record 18: The patient elected the hospice benefit on 11/20/2024 and died on hospice services on 12/24/2024. The plan of care for the benefit period dated 11/20/2024 to 12/24/2024 ordered HA services three times weekly until 12/04/2024, when the frequency of visits was increased to five times a week. At admission, the SN documented that the patient had a stage four pressure ulcer to the right and left hip, left shoulder, right scapula, and upper right buttocks. Physician orders were documented at admission to "cleanse the wound with normal saline, pat dry, apply calcium alginate to the wound bed, and cover with foam dressing three times a week and as needed when soiled." On 11/21/2024, the Social Worker documented that the patient was deaf. The patient's mother reported that the patient reads lips but is not as good at signing anymore. During the Interdisciplinary Group Meeting on 11/27/2024, the SN documented that the patient was deaf and mute but could communicate with some sign language and a whiteboard. The HA care plan dated 11/26/2024 assigned the HA the relevant tasks of providing a bed bath and perineal care at each visit. On 12/05/2024, the frequency of wound dressing changes was increased to five times a week. The HA care plan did not provide instructions for the HA regarding the patient's wounds and the wound dressings, should they become wet, soiled, or dislodged during the bed bath and personal care, or provide information about the patient's communication challenges and needs. During a joint clinical record review and interview on 06/05/2025, the Area Vice President of Operations/RN confirmed the lack of instructions to the aide for the patients' wounds, wound dressings, and communication needs.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide was supervised by the Registered Nurse, no less frequently than every 14 days. Clinical Record 14: The patient elected the hospice benefit on 12/02/2024. The plan of care for the benefit period dated 03/02/2025 to 05/30/2025 ordered Hospice Aide services twice a week. The RN documented HA supervisory visits on 03/06/2025 and 03/21/2025, with 15 days outstanding, and 04/22/2025, with 32 days outstanding, and 05/09/2025, with 17 days outstanding. During a joint clinical record review and interview on 06/05/2025, the Area Vice President of Operations/RN confirmed the gaps in aide supervision and explained that the RN had documented missed visits, which caused the gaps in supervision. A Licensed Vocational/Practical Nurse performed nursing visits, but they could not perform aide supervision.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment, and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records, review of policy, and interview. In 3 of 13 (23%) clinical records reviewed it was revealed the agency did not ensure the plans of care were revised to include updates from comprehensive assessments with patient progress towards outcomes and goals.. The agency policy titled "Review and Revision of Patient Care " (revised 8/1/2004) states, in relevant parts, "Agency will review and revise patient care in accordance with changes in the patient's condition; spiritual status, psychosocial status, residential environment; patient's response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations." And, "Upon identifying that patient care needs have changed, adjustments to the care planning documents will be made." Clinical Record 5: The record evidenced the patient elected hospice care on 3/5/2022. On 7/14/2022 the RN documented in the comprehensive assessment that the patient had a UTI (urinary tract infection). The RN received orders for Cephalexin 500MG tablet to be administered PO 1 tablet 3 times a day for 7 days. The plans of care, updated by the Interdisciplinary Group on 7/21/2022, 8/4/2022, and 8/18/2022, were not updated to include the UTI as a problem with Cephalexin as an intervention with goals. Clinical Record 1: The record evidenced the patient elected hospice care on 8/4/2022 with a primary diagnosis of COPD. On 8/23/2022 the RN documented in the comprehensive assessment that the patient "had a change from the day before." Continuing to document new findings that the "patient was lethargic and minimally responsive." The RN received and documented "orders for daily visits for management of EOL (end-of-life) symptoms." The plan of care reviewed and updated by the Interdisciplinary Group on 8/30/2022 was not updated to include end-of-life symptoms as a problem and daily RN visits as an intervention with goals. Clinical Record 8: The record evidenced the patient elected hospice care on 5/10/2022. On 5/30/2022 the RN documented in the comprehensive assessment that the patient had +4 edema to the right hand and +3 edema to the left hand. The RN documented receipt of an order for Lasix 20mg PO daily. The plan of care, reviewed and updated by the Interdisciplinary Group on 6/9/2022, 6/23/2022, 7/7/2022, 7/21/2022, 8/4/2022, and 8/18/2022, was not updated to include edema as a problem and the medication, Lasix, as an intervention with goals. During an interview on 8/31/2022 the Administrator confirmed these findings. Agency Policy titled "Review and Revision of Patient Care " (revised 8/1/2004) states, in part, "Agency will review and revise patient care in accordance with changes in the patient's condition; spiritual status, psychosocial status, residential environment; patient's response to care; and changes that have occurred regarding diagnosis, treatment, medications, precautions and limitations." And, "Upon identifying that patient care needs have changed, adjustments to the care planning documents will be made."