Every finding on record at Heart to Heart Hospice of Flint, 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 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 #TX.17 stated in part, "The hospice will maintain a current, accurate Medication Profile of all prescription and over-the-counter medications taken by the patient." In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the medication profile was updated with changes made to the patient's medications. Clinical Record 5: The patient elected hospice care on 07/06/2023 with a primary diagnosis of lung cancer. The Skilled Nursing (SN) visit notes dated 08/01/2023 and 08/11/2023 documented the patient's oxygen liter flow as 5 liters per minute and 8 liters per minute, respectively. The initial and updated medication profiles documented the oxygen liter flow as 2–4 liters per minute. The medication profile was not updated to include documentation of the correct liter flow. During the interview, the Area Clinical Manager and the Patient Care Manager stated that the oxygen liter flow was not updated.

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 clinical record review, document review, and interview. Agency policy #TX.06 “Plan of Care Progress” stated in part, “The hospice will develop an individualized written POC for each patient The POC must reflect patient and family goals and interventions based on the problem identified in the initial, comprehensive, and updated comprehensive assessments.” In 6 of 19 (32%) clinical records reviewed, the agency did not ensure that the plan of care (POC) identified planned interventions for all problems identified in the initial and updated comprehensive assessment. Clinical Record 2: The patient elected hospice care on 06/27/2024 with a diagnosis of congestive heart failure (CHF). The initial comprehensive assessment dated 06/27/2023 documented the patient had a stage IV sacral wound, a colostomy, and a Foley catheter in place. The initial plan of care dated 06/27/2023 did not identify an intervention for the Foley catheter or the colostomy that required care. The plans of care were updated every two weeks until the patient’s revocation on 7/17/2024, and interventions for the colostomy and Foley catheter were not documented. Clinical Record 5: The patient elected hospice care on 07/26/2023 with a diagnosis of lung cancer. The Initial comprehensive assessment dated 07/26/2023 documented the patient’s 3+ edema in both lower extremities. The edema with increasing redness was documented in the skilled nursing (SN) visit notes dated 8/01/2023,08/02/2023, and 08/11/2023. The plan of care did not include documentation of interventions to address the patient’s problems with skin integrity or edema. Clinical Record 8: The patient elected hospice care on 05/01/2024 with a diagnosis of cerebral vascular accident (CVA). The initial comprehensive assessment dated 05/01/2024 documented the patient had “itchy skin” and reassessments documented weekly documented itchy skin and the use of an anti-itch cream. The SN visit note dated 05/28/2024 documented an opening on the patient’s left hand with an intact dressing. The SN visit note dated 06/05/2024 documented that the patient’s left hand continued to be “red” but was open to air. The POC documented the intervention “Educate staff on reporting changes in patient skin breakdown/condition” for the identified problems with skin integrity. The intervention did not document the sleeve the patient wore on each arm to protect their skin and prevent further breakdown, as documented in the SN visit notes dated 05/28/2024 through 06/05/2024. The recertification assessment dated 07/12/2024 documented that the patient had frequent skin tears. The POC interventions did not address the patient’s frequent skin tears. Clinical Record 9: The patient elected hospice care on 02/22/2024 with a diagnosis of CVA. The Initial comprehensive assessment dated 02/22/2024 documented the patient’s poor turgor. The updated assessment dated 04/29/2024 through the present documented a right foot dressing and abdominal rash requiring cream. The POC interventions were not updated to address the problems with skin integrity as of 08/06/2024. Clinical Record 10: The patient elected hospice care on 03/01/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The Initial comprehensive assessment dated 03/01/2024 and updated assessments identified the patient’s forgetfulness. The updated assessment completed on 06/07/2024 identified the patient’s increased anxiety and confusion, requiring Ativan twice a day and as needed. The POC interventions did not address the patient’s anxiety. Clinical Record 12: The patient elected hospice care on 11/16/2023 with the diagnoses of Alzheimer’s Disease and anxiety. The certificate of terminal illness (CTI) dated 04/14/2024 documented “terminal decline behavior of confusion, anxiety, agitation.” There were adjustments to the patient’s Seroquel on 01/03/2024, 03/14/2024, and 03/18/2024. The patient’s Ativan was changed on 11/17/2023, 03/19/2024, and 04/02 /2024, and Haldol was added on 04/23/2024. The plan of care did not include interventions related to the patient’s anxiety and confusion as of the review on 08/06/2024. During an interview, the Area Clinical Manager and the Patient Care Manager confirmed the findings and stated that the interventions were not documented.

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: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.06, “Plan of Care Progress,” stated in part, “A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care documented the scope and frequency of services. Clinical Record 14: The patient elected hospice care on 04/09/2024 with a diagnosis of esophageal cancer. The initial plan of care dated 04/09/2024 through 06/07/204 documented an email address and no discipline frequency or duration in the section labeled “Frequency/Duration of Visits.” Skilled Nursing, Hospice Aide, and Chaplain were the disciplines providing care and services. During an interview, the Area Clinical Manager and Patient Care Manager confirmed the finding and stated that the email should not have been there and that they would look into it.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #IC.3 "Hand Hygiene" stated in part, "Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below... Before having direct contact with patients. After contact with inanimate objects in the immediate vicinity of the patient." In 1 of 4 (25%) home visits observed, the agency did not ensure that hand hygiene was performed as indicated per the agency's policy. Home Visit 4/Clinical Record 19: During the home visit with the Chaplain (CH) [Personnel Record 7] on 08/06/2024, the CH did not use an alcohol-based hand rub before patient contact occurred. The Chaplain gave the patient a tissue for a runny nose, took the tissue after the patient used it, and touched the patient's back, wheelchair, and documentation device. The CH provided a prayer with the patient and ended the visit. The CH did not perform hand hygiene during the patient visit. The Patient Care Manager, who observed the visit, agreed during an interview that hand hygiene was not followed.

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 17 (12%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA received clear and specific instructions from the Registered Nurse for all care that the patient required. Clinical Record 14: The patient elected hospice care on 04/09/2024 with a diagnosis of esophageal cancer. The initial comprehensive assessment documented that the patient had a PEG (percutaneous endoscopic gastrostomy) tube. The HA care plan documented on 04/09/2024 and updated on 05/21/2024 and 07/03/2024 did not provide the HA with instructions for care of the PEG tube during the shower: should it be covered or plugged and what to do should the dressing become wet. Clinical Record 16: The patient elected hospice care on 03/05/2024 with a diagnosis of Alzheimer's Disease. The patient had a Foley catheter. The HA care plan documented on 03/05/2024 assigned the HA the relevant tasks: shower and empty drainage bag every visit. The nursing visit note dated 03/26/2024 documented that the catheter was removed per the physician's order. The HA care plan updated on 04/052024 and 05/08/2024 continued to include emptying the drainage bag even though the Foley had been removed. During an interview, the Area Clinical Manager and Patient Care Manager stated that the care plans were not updated with all the details.

It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed that included additional physician orders, the agency did not ensure all required physician orders were documented. Clinical Record 5: The patient elected hospice care on 07/06/2023 with a primary diagnosis of lung cancer. The Skilled Nursing (SN) visit notes dated 08/01/2023 and 08/11/2023 documented the patient's oxygen liter flow as 5 liters per minute and 8 liters per minute, respectively. The plan of care ordered oxygen at 2–4 liters per minute. The initial and updated medication profiles documented the oxygen at 2–4 liters per minute. A clinical record review revealed no documented physician order to increase the flow rate of oxygen from 2–4 liters per minute (LPM) to 5–8 LPM. Clinical Record 8: The patient elected hospice care on 05/01/2024 with a diagnosis of cerebral vascular accident (CVA). The initial comprehensive assessment dated 05/01/2024 documented the patient had "itchy skin." The weekly reassessments documented the patient's itchy skin and the use of an anti-itch cream. A clinical record review revealed no evidence of a physician's order for an "anti-itch cream." During the interview with the area clinical manager and patient care manager they stated that the physician orders were not documented.