Every finding on record at Heart to Heart Hospice of Detroit, LLC

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 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. In 1 of 10 (10%) clinical records reviewed of patients with oxygen ordered, the agency did not ensure that the comprehensive assessment included a review of the patient's current medications. Clinical Record 7: The patient elected hospice care on 05/24/2023 with a diagnosis of senile degeneration. The nursing assessment dated 11/01/2023 documented that the patient was short of breath and starting on oxygen per nasal via cannula. On 11/01/2023, the physician ordered 2 liters/minute per nasal cannula for shortness of breath and a low oxygen saturation of peripheral oxygen (SPO2). The medication profile did not document oxygen.

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and] ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure the IDG designated Registered Nurse (RN) coordinated care and implemented the plan of care. Clinical Record 7: The patient elected hospice care on 05/24/2023 with a diagnosis of senile degeneration. On 08/17/2023, the physician ordered the skilled nurse (SN) to obtain a low oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit. The nursing assessment dated 11/01/2023 documented that the patient was short of breath and starting on oxygen per nasal via cannula. On 11/01/2023, the physician ordered 2 liters/minute per nasal cannula for shortness of breath and a low oxygen saturation of peripheral oxygen (SPO2). The plan of care and updated plans, which were reviewed every two weeks, did not include interventions for oxygen, and oxygen was not added to the plan of care. The SN visit frequency was two (2) times a week. The nursing assessments visit notes dated 09/29/2023, 10/02/2023, 10/04/2023, and 10/12/2023 documented vital signs but no SPO2. Clinical Record 10: The patient elected hospice care on 11/22/2023 with a diagnosis of senile degeneration. The plan of care from 11/22/2024 through 12/20/2024 documented goals and interventions for a pet therapy evaluation to meet the patient's needs and promote emotional support. The skilled nurse comprehensive assessment documented a need for the patient to be evaluated for pet therapy services to provide comfort and emotional support. The interdisciplinary group meetings (IDG) on 11/26/2024, 12/11/2024, and 12/24/2024 did not address the pet therapy evaluation that had not occurred. There was no documentation of notification of pet therapy or updates to the plan of care. During an interview on 03/18/2025, the Regional Quality Manager/Administrator stated that pet therapy had not been started and that the new staff member had documented this in error, as pet therapy was unavailable. They stated that regarding clinical record 7, the pulse oxygen level had not been documented every visit as ordered.

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 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure that the plan of care documented all interventions for the patient's care based on problems identified in the comprehensive assessments. Clinical Record 2: The patient elected the hospice benefit on 12/19/2022 with a primary diagnosis of senile degeneration of the brain and secondary anxiety disorder. The certificate of terminal illness (CTI) dated 12/19/2022 documented, "assisted with controlling and helping a patient with agitation and anxiety as clinically warranted." The initial and updated plan of care dated 12/28/2022, 01/11/2023, 01/25/2023, 02/08/2023, and 02/22/2023 did not document interventions to address the patient's identified problem with anxiety and agitation. Clinical Record 7: The patient elected the hospice benefit on 05/24/2023 with the diagnosis of senile degeneration. On 08/17/2023, the physician ordered to "obtain an oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit, then on 11/01/2023, the physician ordered oxygen at 2 liters per nasal cannula for shortness of breath and low SPO2. The patient's plan of care did not include documentation of interventions to address the patient's identified problems with shortness of breath and low SPO2 as of this review on 03/18/2025. During an interview and joint record review on 03/18/2025, the Regional Quality Manager/Administrator stated that the interventions were not updated and complete.

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 and interview. In 2 of 23 (9%) clinical records reviewed of community hospice patients, the agency did not ensure that the plan of care included all medications and treatments. Clinical Record 7: The patient elected hospice care on 05/24/2023 with the diagnosis of senile degeneration. On 08/17/2023, the physician ordered to "obtain an oxygen saturation of peripheral oxygen (SPO2) (pulse oximetry) with vital signs every visit, then on 11/01/2023, a physician ordered oxygen at 2 liters per nasal cannula for shortness of breath and low SPO2. The oxygen was not documented in the patient's plan of care as of the review on 03/18/2025. Clinical Record 22: The patient elected the hospice benefit on 08/23/2024 with a diagnosis of skin cancer and died on 10/13/2024. The patient had a Foley catheter in place at admission. The initial and updated plans of care documented the intervention, "Educate on maintenance of Foley." The plans of care did not include documentation of the care and maintenance of the Foley catheter, including the size, the frequency for changing and flushing the Foley catheter. During an interview and a joint record review on 03/18/2025, the Regional Quality Manager/Administrator confirmed that the plans of care did not include all medications and treatments the patient received.

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, interview, and observation. In 3 of 21 (14%) clinical records reviewed of community and Inpatient Unit (IPU) hospice patients who received Hospice Aide services, the agency did not ensure that the HA received written patient care instructions from the Registered Nurse (RN) to meet the patient's care needs. Clinical Record 1: The patient elected the hospice benefit on 08/24/2022 with a diagnosis of coronary heart disease (CAD). The patient was admitted with COVID-19. The HA care plan dated 08/25/2022 assigned the HA the relevant task: "Shower every visit, but the patient may need to medicate prior to showering." The HA care plan included the assigned task of assessing for infection. The HA care plan was updated on 01/13/2023, 11/16/2023, and 12/05/2024 (the last update). The updated care plans continued to document that the patient had COVID-19. The patient did not have COVID-19 during the subsequent benefit periods. Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 06/27/2024 with a diagnosis of degeneration of the brain. The plan of care ordered HA services two (2) times a week. The patient was admitted with a Foley catheter that was discontinued on 08/04/2024. The HA care plan dated 06/27/2024 and updated on 06/28/2024 assigned the HA the relevant tasks: shower and perineal care every visit. The HA care plan did not document instructions for the HA regarding the care of the Foley catheter during the shower and pericare. The skilled nursing (SN) assessment visit note dated 06/28/2024 documented that the patient was wearing a brace on the right lower leg and heel protectors. There were no instructions for the HA regarding the brace and heel protectors. The patient continued with heel protectors, which were observed during the home visit with the Social Worker (SN) [Personnel Record 3] on 03/19/2025. Additionally, the SN assessment visit note dated 08/12/2024 documented a right heel wound with a foam dressing. The wound was dressed with a foam dressing through 09/17/2024. The HA care plan was updated on 08/20/2024 and 09/14/2024, continuing the assigned task for a shower every visit but not documenting that there was a dressing or what to do during the shower if the dressing was saturated or fell off. The HA care plan was updated on 10/03/2024, changing the shower to a bed bath. Clinical Record 17: The patient elected the hospice benefit on 12/19/2024 with a primary diagnosis of Alzheimer's Disease, a recent fall, and a fractured left arm. The skilled nursing comprehensive assessment dated 12/19/2024 documented the patient's use of a left arm sling 24 hours a day, 7 days a week. The HA care plan documented on 12/19/2024 assigned the HA the tasks of bed bath and shampoo every visit with a visit frequency of 2 times a week. The HA care plan was updated on 01/14/2025 and assigned the task of showering and shampooing every visit. The HA care plan did not provide the HA with instructions regarding using the sling during showers. During an interview and a joint record review on 03/18/2025, the Regional Director of Compliance/Administrator confirmed that the detail was not documented in the care plans.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure interventions for all problems identified in the updated comprehensive assessment were documented in the plan of care. Clinical Record 4: The patient elected hospice care on 04/14/2023 with the diagnoses of Lupus and declining physical status. On 06/01/2023, the physician ordered "Fleets enema daily as needed for constipation and Senna Plus BID." The comprehensive assessments dated 05/22/2023 and 06/05/2023 documented the patient's increased difficulty taking fluids related to difficulty eating and increased discomfort and problems with constipation. The plan of care was not updated with interventions and goals for constipation. During an interview and a joint record review on 07/19/2023, the Clinical Director agreed that the documentation of the updated care plan was not in place.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed with documented orders, the agency did not ensure all wound orders included the location of the wound. Clinical Record 1: The patient elected hospice care on 03/25/2023 with the diagnosis of CVA (cerebral vascular accident). On 04/10/2023, the physician ordered, "Cleanse stage 1 pressure injury daily with wound cleanser, and prn if soiled. Apply Medihoney to non-adhesive 4x4, and cover with waterproof foam dressing.” The physician’s order did not include the locations of the wounds identified in the comprehensive assessment as the coccyx and anterior and mid-left buttocks. On 04/17/2023, the physician ordered, "Cleanse wound with wound cleanser and apply Medihoney cover with waterproof foam dressing changes daily and prn soiled.” The physician’s order did not include the locations of the wounds identified in the comprehensive assessment as the coccyx and anterior and lower left buttocks. On 04/21/2023, the physician ordered, "Apply Dakin’s to a 4x4 gauze and pack stage III pressure injury cover with waterproof border gauze or foam dressing change daily. The physician’s order did not include the location of the wound identified in the comprehensive assessment as the coccyx. On 04/25/2023, the physician ordered, "Cleanse abrasions with wound cleanser, pat dry, apply Medihoney daily and open to air." The physician’s order did not include the locations of the abrasions identified in the comprehensive assessment and the Interdisciplinary Group notes as the forehead, elbows, and shin. The physicians' orders were incomplete and did not include documentation of the locations of the wounds. During an interview on 07/19/2023, the Clinical Director and the Nursing Supervisor stated that the location was documented on the clinical notes. They agreed that the orders did not include the location of the wounds.

It is required that the hospice designates a registered nurse member of the IDG to: ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: 1. The hospice IDG in collaboration with the attending physician (if any); 2. The patient or patient representative; 3. The primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by review of clinical records, document review and interview. 6 of 16 (38%) records failed to evidence that the registered nurse ensured the implementation of the plan of care for disciplines to follow required frequencies or ordered care, or to provide ordered care in the timeframe ordered. Agency Policy TX.06 "Plan of Care Process" [reviewed 01/01/202] states in part, "...ensures that the care provided is in accordance with the written plan of care, appropriately planned, and delivered in a timely manner to meet the patient and family's specific needs." The following records failed to evidence that Chaplain services were provided according to the visit frequencies ordered on the plans of care: Record #53467: the patient's date of benefit election was 04/22/2022. A chaplain order was written for visit frequencies of 3 week 1, then 1 every 2 weeks. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. The frequency, the week of 05/15/2022 (visit frequency of 1 every 2 weeks) no visit was made; there was no reason documented for the missed visit. Record #82429: the patient's date of benefit election was 04/06/2022. A chaplain visit frequency order was written for 3 week 1 then 1 every week 4. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. The week of 05/01/2022 (every week 4 visit frequency) no visit was made and no reason documented for the missed visit. Record #41798: the patient's date of benefit election was 05/05/2022. A chaplain visit frequency order was written for 3 week 1. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. Record #33655: the patient's date of benefit election was 01/04/2022. A chaplain visit frequency order was written for 3 week 1 and 1 every 2 weeks. The first week only 1 visit was documented: there was no reason documented for not providing the other 2 visits. The following records failed to evidence medical social worker services were provided according to the visit frequencies ordered on the plans of care: Record #53467: the patient's date of benefit election was 04/22/2022. A social work visit frequency order was written for 3 week 1 then 1 every week 4. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. Record #33655: the patient's date of benefit election was 01/04/2022. A social work visit frequency order was written for 3 week1. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. Record #41758: the patient's date of benefit election was 05/05/2022. A social work visit frequency order was written for 3 week 1. The first week only 1 visit was documented; there was no reason documented for not providing the other 2 visits. The following records evidenced nursing interventions were provided without orders and/or failed to evidence that nursing interventions were provided according to the plans of care: Record #82430: a patient with a Foley catheter that was reported as pulled out on 05/14/2022. The on-call nurse made the as-needed visit and replaced the catheter. The plan of care did not document any evidence of an order or intervention for the replacement of the catheter. Record #74260: the plan of care documented a written intervention on 04/13/2022 to insert a Foley catheter every 30 days and may irrigate for patency. There was no documentation of the catheter being changed until 06/02/2022 (day 53, 23 days late and almost time for the second scheduled catheter change). The Regional Vice President of Clinical Operations, Chaplain and Clinical Manager, on interview, stated that the visit frequencies not followed were related to a software issue that populated the orders with prn [as needed] visits and that the summary written on all of the assessments did document the intended frequency of 1 week 1 and then follow up visits. They agreed that the order was not correct and that they will investigate with the software vendor how to correct this. They also stated that the documentation lacked orders and following specific catheter care orders written on the plan of care.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records, document review and interview. 5 of 16 (31%) records failed to document interventions and goals for all problems identified in the initial comprehensive assessments or updated comprehensive assessments as required by agency policy. Agency Policy TX.06 "Plan of Care Process" [reviewed 01/10/2020] states in part, "The hospice will develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments." Record #82430: the patient was admitted on 04/06/2022 with a Foley Catheter and a significant abdominal ascites. During the benefit period, constipation was noted on the updated comprehensive assessment and there were multiple medication changes to control the problem. On 05/19/2022 an updated comprehensive assessment noted much increased edema and a medication intervention of Bumex [used to reduce extra fluid]. The plan of care reviewed 06/21/2022 failed to evidence interventions or goals for the catheter, constipation or the edema/cardiac symptoms documented on the initial and updated comprehensive assessments. Record #33655: the patient was admitted on 01/22/2022. An updated comprehensive assessment on 03/26/2022 identified a potential urinary tract infection treated with antibiotics; there were no interventions or goals documented on the updated plan of care as of the date of review, 06/21/2022. The patient revoked the hospice benefit on 04/16/2022. Record #41758: the patient was admitted on 04/02/2022 with an initial comprehensive assessment that documented a port in the left chest. There were no documented interventions or goals for the port management as of the date of review, 06/20/2022. Additionally, a dietician was consulted related to nutrition concerns, a new ostomy and output concerns on the updated comprehensive assessment dated 04/14/2022 but there were no documented interventions or goals for the nutrition concerns as of the date of review, 06/20/2022. Record #39263: the patient was admitted on 04/06/2022 with an initial comprehensive assessment that documented a port in the right chest. There were no documented interventions or goals for the port management as of the date of review, 06/20/2022. NOTE: The patient revoked the hospice benefit on 05/11/2022 to move to another state. Record #29428: the patient was admitted on 05/06/2022 with an initial comprehensive assessment that documented a Foley catheter and a new ileostomy. There were no documented interventions or goals for the Foley catheter or the care of the ileostomy. The Clinical Manager and the Regional Vice President of Clinical Operations, on interview, stated that the interventions and goals were not documented in the plan but that care was documented in nursing assessments for all of the identified areas and no infections or adverse events occurred.

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 during home visits, document review and interview. 1 of 4 (25%) visits revealed the agency policy for hand hygiene/bag technique was not followed. Agency Policy IC.12 [review date 01/01/202] states in part, "When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed and equipment and supplies are returned to the bag." Record #41798: during the observed home visit with staff member #71888 (a registered nurse) on 06/21/2022, the nurse conducted a complete physical assessment which included blood pressure, pulse oxygenation, temperature, and assessment of lung sounds and bowel sounds. The nurse cleaned the thermometer, pulse ox machine, stethoscope and blood pressure cuff with an antimicrobial wipe and dropped each piece of equipment into the nursing bag without washing hands. The observed nurse, on interview, stated that the equipment had just been cleaned.

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 review of clinical records, document review and interview. 3 of 14 (21%) records in which a hospice aide was accepted for care, revealed a lack of clear and specific written instructions for the aide assignments, thus leaving the aide to potentially make decisions outside of the aide's scope of practice. The agency's Job Description for Hospice Aide [revised February 2020] states, in part, "Essential duties provide direct patient care to patient under direction of the RN and according to the Hospice Aide Plan of Care." Record #82430: The hospice aide plan, documented 04/06/2022, failed to include Foley catheter care for a patient receiving a bed bath and assist of 2 to move. The patient was admitted with the catheter on 04/06/2022 and continued with the catheter through the date of record review, 06/21/2022, There was no task assigned for the aide to perform catheter care. Record #29428: The hospice aide plan, documented 05/06/2022, failed to include Foley catheter care or ileostomy care for a patient receiving a bed bath each visit. The patient was admitted with the catheter on 05/06/2022 and continued with the catheter through the date of record review, 06/21/2022. Record #74260: The hospice aide plan, documented 04/13/2022, failed to include Foley catheter care for a patient receiving a bed bath every visit. The patient was admitted with the catheter on 04/13/2022, was confused and was a full transfer by the aide; the catheter continued through the date of record review, 06/21/2022. The Clinical Manager and Regional Vice President of Clinical Operations, on interview reviewed the records and stated that the Foley catheter was not on the plans and that the aide would be washing around it during the baths.

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: physician orders. This standard was not met as evidenced by review of clinical records, document review and interview. 5 of 16 (32%) records revealed physician orders were either absent for care that required orders or incomplete for information required in a physician order. Agency Policy "TX.5 Orders for Care" [reviewed 10/01/2015] states in part, "Agency will obtain orders and provide care in accordance with physicians orders which are established prior to initiating patient care and reviewed/revised by the physician as needed or at least at the end of each benefit period." Record #82430: the patient was admitted on 04/06/2022 with a 16 French/10cc Foley catheter. On 05/14/2022 the patient pulled out the catheter and a nursing visit was made to replace the catheter. There was no evidence of a physician order for the Foley catheter as of the date of review, 06/21/2022. Record #29428: the patient was admitted on 05/06/2022 with a Foley catheter and a new ileostomy. There was no evidence of a physician order for the Foley catheter or care of the new ileostomy as of the date of review, 06/21/2022. Record #74260: the patient had an updated plan of care on 04/13/2022 to insert a Foley catheter and change every 30 days and may irrigate for patency. There was no evidence of a physician order for what to irrigate the catheter with or how frequently it could be irrigated. Record #41758: a written physician order on 05/19/2022 stated to flush the chest port every 6 weeks with 300 units of heparin. There was no evidence of additional direction on the order for the length or gauge of the Huber needle required to access the port. Record #39263: the patient had an identified port in the right chest on admission 04/26/0222. There were no physician orders for care of this port inclusive of flushes or maintenance, or documentation if the port is not to be maintained as of the date of record review, 06/20/2022. NOTE: This patient revoked the Medicare hospice benefit on 05/11/2022. The Clinical Manager and Regional Vice President of Clinical Operations, on interview, stated that the orders were not found in the records. NOTE: No adverse events, or port problems were documented for this agency.

It is required that the hospice inpatient facility provides meals to each patient that are: obtained, stored, prepared, distributed, and served under sanitary conditions. Food is available 24/7 to respond to patient’s needs or requests. The Interdisciplinary Group (IDG) is kept informed of the patient’s response to their prescribed diet. This standard was not met as evidenced by observation during the agency-owned in-patient unit, toured on 06/21/2022. The in-patient unit had food in the patient/family area refrigerator and cupboard with open bottles and packages with no markings or label of the date opened. The patient/family refrigerator had 2 sixteen ounce bottles of dressing and one eight ounce package of cream cheese that were all opened with no date label of when they had been opened. The cupboard with dry goods for patients and families had a half-bag of animal crackers that was opened with no date label of when it had been opened. The charge nurse, on interview, stated that the dressing bottles had been opened on 06/20/2022 and agreed that they should have been labeled It was unclear when the crackers and cream cheese had been opened. NOTE: All opened items were disposed of.