Every finding on record at Heart to Heart Hospice of East Texas, LLC

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 1 of 23 (4%) clinical records reviewed revealed the agency did not ensure that the hospice interdisciplinary group completed a comprehensive assessment within 5 days of the election of the hospice care benefit. CLINICAL RECORD 9: The patient elected the hospice benefit on 01/09/2025 with a diagnosis of diffuse large B-Cell lymphoma. The social worker completed a comprehensive visit on 01/15/2025, which is six (6) days after the election of the hospice benefit. The record lacked evidence as to why the visit was not scheduled within the five (5) day timeframe. In a joint record review and interview on 10/02/2025 with the administrator (Personnel Record 7), she agreed that the social worker did not see the patient within 5 days of the election of the hospice benefit, and the record lacked evidence as to why the social worker did not see the patient within the timeframe.

It is required that each patient’s individualized written plan of care include all medical supplies and appliances 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 revealed the agency did not ensure all medical supplies and appliances were included in the patient's individualized plan of care. CLINICAL RECORD 10: The patient elected the hospice benefit dated 08/09/2025, with a terminal diagnosis of progressive supranuclear ophthalmoplegia. The interdisciplinary plan of care dated 08/09/2025-10/07/2025 did not include any equipment or supplies. The Registered Nurse documented in the comprehensive start of care visit dated 08/09/2025, an oxygen concentrator and bedside table were given to the patient by hospice. CLINICAL RECORD 18: The patient elected the hospice benefit dated 09/10/2025, with a terminal diagnosis of ALS. The interdisciplinary plan of care dated 09/10/2025 - 12/08/2025 did not include any equipment or supplies. The Registered Nurse documented in the comprehensive start of care visit dated 09/10/2025, a hospital bed, gel overlay, wheelchair, and oxygen concentrator were given to the patient by hospice. In an interview with the DON (Personnel Record 8) and Administrator (Personnel Record 7) on 10/02/2025, they agreed that "the hospice plans of care for both patients did not include any equipment to be used by hospice staff in the care of the patient".

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review conducted with the Administrator (Personnel Record 7) and Volunteer Coordinator on 10/03/2025 revealed that the volunteer percentage for the past year (January 2024 to December 2024) was below five percent (5%) of the total patient care hours of all paid hospice employees and contract staff and calculated at 2.33%. The percentage for the period from January 2025 to September 2025 is 3.60%. The volunteer coordinator stated, "I hope to be at the 5% mark by the end of the year." The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review conducted with the Administrator and Volunteer Coordinator on 10/03/2025 revealed that the volunteer percentage for the past year (January 2024 to December 2024) was below five percent (5%) of the total patient care hours of all paid hospice employees and contract staff, and calculated at 2.33%. The percentage for the period from January 2025 to September 2025 is 3.60%. The volunteer coordinator stated, "I hope to be at the 5% mark by the end of the year."

It is required that the written Patient Bill of Rights includes the right to: be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by a review of clinical records, document review, and interviews. Agency policy PE.4 revised 6/20/2022 titled Patient Discharge stated in part under the subtitled section, "Procedure... (II) the hospice will provide the Notice of Medicare Non-Coverage to the Medicare patient, no later than two days before the effective date of the end of the coverage that their Medicare coverage will be ending." 1 of 4 (25%) clinical records reviewed where the patients were live discharges from the agency, revealed the agency failed to provide the Notice of Medicare Non-Coverage document and the explanation of the patient’s right to appeal the discharge. Clinical Record 11: The patient elected the Hospice Benefit on 12/29/2020. The patient's payor source was Medicare. The agency 5-day discharge notice form was signed on 10/17/2022 by the patient with an effective discharge date of 10/21/2022. The State Medicaid hospice program discharge form was signed on 10/17/2022 with an effective date of discharge of 10/21/2022. There was no documented evidence that the patient was provided a Notice of Medicare Non-Coverage (NOMNC) form providing the patient notice of the right to appeal the discharge due to no longer meeting criteria for terminally ill. An interview with Area Clinical Manager on 11/4/2022 confirmed the Notice of Medicare Non-Coverage (NOMNC) was missing from the record during the joint record review and the agency could not provide evidence that it was provided to the patient.

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 medical supplies and appliances necessary to meet the needs of the patient and the documentation in the patient’s record is in accordance with the hospice’s policies and procedure. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 16 (25%) clinical records reviewed revealed the agency failed to document the supplies and/or DME provided to the patient in the written plan of care. Clinical Record 2: The patient with an election of Hospice benefit dated 1/20/2022 The following four (4) plans of care: 1st benefit period dated 1/20/2022-4/19/2022; 2nd benefit period dated 4/20/2022-7/18/2022; 3rd benefit period dated 7/19/2022-9/16/2022 and 4th benefit period dated 9/17/2022-11/15/2022, documented "none" for supplies and DME Due to an internal audit, the following supplies, and DME were documented on 9/6/2022: oxygen concentrator, oxygen supplies, wheelchair, briefs, and wipes, however not all the DME provided by the agency were documented. A shower chair, suction machine setup, nebulizer setup, and hospital bed setup were missing from the current plan of care. Clinical Record 7: The patient with an election of Hospice benefit dated 11/3/2020 had documented "none" for supplies and DME on the following twelve (12) plans of care: 1st benefit period dated 11/3/2020-1/31/2021; 2nd benefit period dated 2/1/2021-5/1/2021; 3rd benefit period dated 5/2/2021-6/30/2021; 4th benefit period 7/1/2021-8/29/2021; 5th benefit period dated 8/30/2021-10/28/2021; 6th benefit period dated 10/29/2021-12/27/2021; 7th benefit period dated 12/28/2021-2/25/2022; 8th benefit period dated 2/26/2022-4/26/2022; 9th benefit period dated 4/27/2022-6/25/2022; 10th benefit period dated 6/26/2022-8/24/2022; 11th benefit period dated 8/25/2022-10/23/2022 and the current 12th benefit period dated 10/24/2022-12/22/2022. The patient received the following DME: oxygen concentrator with the regulator, rollator wheelchair, nebulizer setup, quad cane, beside commode, O2 M6 with carry bag. The patient did not receive or need any supplies per the assigned Registered Nurse. Clinical Record 8: Patient with the election of benefit dated 5/6/2022 had documented supplies and DME as none on the following three (3) plans of care: 1st benefit period dated 5/6/2022-8/3/2022; 2nd benefit period dated 8/4/2022-11/1/2022 and current 3rd benefit period dated 11/2/2022-12/31/2022. The patient received the following items from the hospice: an oxygen concentrator, O2 backup cylinder, over-bed table, suction machine setup, nebulizer setup, wheelchair with cushion, walker, and shower chair. Clinical Record 14: The patient with election of benefit dated 6/25/2022 had no documentation of DME, only the supplies that were provided by the agency on the plan of care dated 6/25/2022-8/16/2022. The supplies were documented on the plan of care: chux, wipes, brief/bladder control pads, and gloves. The following DME was not documented on the plan of care: hospital bed, beside commode, over bed table, shower chair, and wheelchair. An interview with the Area Clinical Manager confirmed the supplies and/or DME were missing from the plans of care during a joint record review for record 2, record 7, record 8, and record 14. The agency conducted an internal audit in September 2022 and was working with the nurses to ensure documentation of all supplies and DME on plans of care.

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 a review of clinical records, observation, and interviews. 2 of 11 (18%) clinical records reviewed where Hospice Aide services were accepted, the agency did not document detailed instructions for the hospice aide to follow and update the Hospice Aide Care Plan to reflect the current patient status. Clinical Record 3: The patient with the election of benefit dated 7/2/2022 had a Hospice Aide care plan dated 7/2/2022 and updated 7/7/2022 and 9/13/2022. The Hospice Aide care plan documented an assigned task of "reviewed patient diet" to be completed at every visit and no details were documented to provide further instruction or explanation of the task. Hospice aide visits dated 10/24/2022, 10/21/2022, 10/20/2022, 10/19/2022, and 10/18/2022 documented the assigned task of "reviewed patient diet" as not completed and not applicable. Interviewed Hospice aide (Staff 1) on 11/3/2022 to obtain clarification of the meaning of the task. The Hospice aide was not aware of the meaning of the task and stated that would document was not applicable (NA) and not completed because the family and the private sitter would feed and provide the patient's meal. Clinical Record 1: The patient with the election of benefit dated 4/10/2021 had an aide care plan updated on 6/30/2022. The aide care plan had a documented assigned task of "emptying urinary drainage bag" every visit. Hospice Aide frequency was 3xweek with a second Hospice Aide to assist 3xweek. The patient did not have a catheter (Home Visit 2) and the aide care plan was not updated to reflect the patient's current status. Home Visit 2: During the observation visit on 11/2/2022 with RN, it was observed that the patient did not have a urinary catheter as RN completed the nursing assessment. Interview with the Area Clinical Manager on 11/3/2022 agreed the Hospice Aide care plan needed clearer instructions for the Hospice Aide to follow the expected patient care.

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 physician orders. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 4 of 16 (25%) clinical records reviewed revealed the agency failed to document physician orders for treatments performed. Clinical Record 1: The patient elected Hospice benefits on 4/10/2021. The plan of care order dated 4/10/2021 states, "insert/maintain indwelling catheter 16FR/30 CC balloon, may irrigate with 60CC sterile water PRN. Change catheter every 30 days or as needed." Observation during Home visit 2 on 11/2/2022, the patient did not have a urinary catheter. There was no physician order documented for the discontinuation of the Foley catheter. Clinical Record 12: The patient elected Hospice benefits on 10/12/2021 with documented diagnoses of esophageal cancer and difficulty swallowing (dysphagia). The patient had a date of death of 5/13/2022. A Physician order dated 10/12/2021 documented "ensure continuous tube feedings @ 60cc/hr," with no route of feedings included in the order. Plans of care revealed no physician orders for water administration or flushing or checking residual or peg tube skin care cleaning and maintenance. The RN visit dated 1/11/2022 documented "patient has peg tube noted to left upper quadrant with boost running per feeding pump at 70ML/HR continuously. Patient tolerates well without signs or symptoms of nausea or discomfort." No physician order was documented for the changes in tube feedings in the written plans of care. The Physician orders dated 12/15/2021 0928 documented "Place Foley catheter" without catheter size, balloon size or amount or type of fluid to inflate the balloon or connection of gravity bag or when how often to change the catheter. Coordination note dated 12/15/2022 documented "RN placed 18FR Foley catheter inpatient, balloon inflated with 30ML." The Area Clinical Manager confirmed during a joint record review on 11/42022 that the peg tube feedings and Foley catheter orders were not accurate and missing elements. Clinical Record 14: The patient was readmitted for hospice services, and signed the Election of Hospice Benefit Form dated 9/13/2022 with documented diagnoses of bone and cervical, and kidney failure. The Skilled Nurse (SN) visit dated 9/15/2022 documented "SN reprimed fresh tubing and restarted the pump. SN changed out the adapter piece at end of the peg tube. The new adapter is connected to the kangaroo pump and does not leak. Tube flushes easily. 10 CC dark gastric fluid residual noted. The skin around tube has no s/s of infection. The patient has bilateral nephrostomy tubes with clear yellow urine." There were no physician orders documented for nephrostomy tube or peg tube maintenance or tube feedings in the written plan of care. The Area Clinical Manager confirmed on 11/4/2022 during a joint record review that the physician orders were missing. Clinical Record 2: The patient with the election of benefit dated 1/20/2022 had a documented IDT meeting dated 3/18/2022 that documented the patient fell on 3/10/2022 requiring a trip to the emergency room and receiving six staples to the forehead due to a laceration. PRN RN visits status post fall and returns from hospital dated 3/10/2022 documented patient fell first and hit the floor and received six staples. RN Visit dated 3/18/2022 documented stitches to the right forehead that needed to be removed however nurse brought incorrect materials. Documented removed dressing over the staples and cleansed area. No physician order for wound care of the laceration or removal of the staples is documented in the written plan of care. An interview with Area Clinical Manager on 11/3/2022 confirmed the physician order was missing. The agency later on the same day requested and received the written discharge order from the hospital dated 3/10/2022.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40. I and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) discharge records reviewed where the patients were live discharges from the agency, revealed the agency did not provide the receiving facility a discharge summary for coordination and continuity of patient care. Clinical Record 14: The patient chose revocation of agency services effective 9/17/2022 to seek treatment at a local hospital. RN visit note dated 9/17/2022 documented that "patient and family wishes were for the patient to be sent to ER for treatment. The patient admitted to the non-contracted facility from ER. The patient transported to the facility. CM gave report to EMS and facility nurse." There was no documented evidence of a discharge summary provided to the receiving hospital for coordination of care. Interview with Area Clinical Manager on 11/4/2022 confirmed discharge summary and/or patient clinical record was not sent to the receiving hospital to ensure coordination of care.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. Criminal background checks are obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three (3) months of the date of employment for all states in which the individual has lived or worked during the past three (3) years. This standard was not met as evidenced by document review and interview. 1 of 12 (8%) agency contracts reviewed revealed the agency failed to include the clause in the contract that all contracted employees who have direct patient contact or access to patient records obtained criminal background checks. Contract 11: Agency's hospital contract for General Inpatient Care (GIP) and outpatient services with an effective date of June 14, 2019, did not have documented requirement clause of criminal background checks for contracted personnel with direct access to hospice patients or their records. Interview with the Area Clinical Manager on 11/4/2022 confirmed the criminal background clause was missing from the contract during a joint contract review.