Every finding on record at Heart to Heart Hospice of Fort Worth, 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 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, observation, and interview. In 4 of 23 (67%) clinical record reviews and home visits observed, the agency did not ensure the drug profile contained the patient’s current medications to identify actual or potential drug interactions. Clinical Record 1/Home Visit 1: The patient elected hospice care on 12/27/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in an adult living facility (ALF). During the home visit with the Hospice Aide [Personnel Record 7] on 09/24/2024, the hospice medication profile was compared to the ALF medication list. The ALF medication list documented the following medications that were not documented on the agency’s medications profile: MiraLAX 17 grams, one (1) packet daily as needed for constipation, effective 12/27/2023; (Ativan, Benadryl, and Haldol) ABH gel 1/25/1, every six (6) hours as needed for agitation, effective 02/01/2024; ABH gel 1/25/1... before showers Monday/Wednesday/Friday, effective 03/11/2024; and Mighty shake two (2) times a day for supplement, effective 06/05/2024. The hospice medication profile documented the following medication not listed on the ALF medication list: Vitamin D3 daily, effective 12/28/2023. The agency medication profile documented Trazadone 50 mg, 1/2 tab nightly, effective 12/28/2023. The ALF medication list documented Trazadone 50 mg, give one (1) tab nightly as needed, effective 02/17/2022, and Trazadone 50 mg, give one (1) tab nightly scheduled, effective 01/01/2024. There was no evidence that the ABH and MiraLAX were reviewed with the patient’s medication regimen. Clinical Record 2/Home Visit 2: The patient elected hospice care on 05/08/2023 with a diagnosis of senile degeneration of the brain. The patient resided in an ALF. During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 09/24/2024, the hospice medication profile was compared to the ALF medication list. The ALF medication list documented the following medication(s) not listed on the hospice medication profile: Docusate 100 mg one (1) cap as needed, effective 02/02/2023; (Dextromethorphan) DM Oral chest congestion cough syrup 10-100mg/5ml as needed, effective 11/21/2023; Senna Plus 8.6/50 mg two (2) tabs as needed, effective 06/12/2024. The hospice medication profile documented the following medication(s) not listed on the ALF medication list: Permethrin Topical Cream as directed for scabies, effective 06/20/2023; DM cough syrup 10-100mg/5ml four (4) times daily, effective 11/15/2023; Robitussin DM 10-100 mg/5ml four (4) times daily, effective 08/26/2024. There was no evidence that Docusate and Senna Plus were reviewed with the patient’s current medication regimen. Clinical Record 4/Home Visit 4: The patient elected hospice care on 04/25/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA) [Personnel Record 11] on 09/25/2024, the hospice medication profile was compared to the SNF medication administration record (MAR). The SNF MAR documented the following medication(s) not listed on the hospice medication profile: Acetaminophen 325 mg, two (2) tablets every 6 hours as needed, effective 11/09/2023; Vibegron 75 mg one (1) tab daily, effective 11/10/2023; Hyoscyamine 0.125 every 4 hours as needed, effective 04/30/3034; and Midodrine 2.5 mg every 6 hours as needed, effective 07/10/2024. The hospice medication profile documented the following medications not listed on the SNF MAR: Atropine eye drops every 4 hours as needed, effective 04/26/2024. In addition, the hospice medication profile documented the acetaminophen as a suppository and not an oral tablet as per the SNF MAR. There was no evidence that Vibegron, Hyoscyamine, and Midodrine were reviewed as part of the patient’s medication regimen. Clinical Record 6/Home Visit 6: The patient elected hospice care on 12/13/2023 with a diagnosis of malignant neoplasm of the colon. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 12], the hospice medication profile was compared to the SNF medication administration record (MAR). The hospice medication profile documented the following medications not listed on the SNF MAR: Advair inhaler, one (1) puff twice daily, effective 12/14/2023; Ativan 0.5 mg every 4 hours as needed, effective 12/14/2023; and Nystatin powder twice daily. The SNF MAR documented 187.5 mg daily (updated 07/19/2024), and the hospice medication profile documented 75 mg daily. The Executive Director printed the hospice medication profiles for the visits on 09/25/2024. Upon returning to the agency, the Executive Director confirmed the discrepancies during an interview and a joint review of the records.

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] 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 23 (4%) clinical records reviewed, the agency did not ensure the patient's plan of care reflected goals and identified planned interventions based on problems identified in the comprehensive assessments. Clinical Record 15: The patient elected hospice care on 05/14/2024 with a diagnosis of malignant neoplasm of the lung. The skilled nursing (SN) visit note dated 05/18/2024 documented an "as-needed visit for inability to urinate." The SN visit note dated 05/22/2024 documented that the patient was tested and had a "urinary tract infection (UTI)." The SN visit note dated 06/12/2024 documented the patient had "pain with urination." The SN visit note dated 06/19/2024 documented "obtaining a urine specimen and sent off for urine culture." The SN assessment dated 07/05/2024 documented that the physician ordered "antibiotic Cipro for another UTI." The SN visit note dated 08/23/2024 documented the physician ordered Flomax. The plan of care was not updated to include interventions and goals for the patient's identified genitourinary problem. During an interview on 09/26/2024, the Executive Director agreed the patient's plan of care should have included interventions and goals to address the patient's genitourinary 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, observation, and interview. In 4 of 23 (67%) clinical record reviews and home visits observed, the agency did not ensure the plan of care included drugs necessary to meet the patient's needs. Clinical Record 1/Home Visit 1: The patient elected hospice care on 12/27/2023 with a diagnosis of Alzheimer’s Disease. The patient resided in an adult living facility (ALF). During the home visit with the Hospice Aide [Personnel Record 7] on 09/24/2024, the hospice medication profile was compared to the ALF medication list. The ALF medication list documented the following medications that were not documented on the patient's current plan of care MiraLAX 17 grams, one (1) packet daily as needed for constipation, effective 12/27/2023; (Ativan, Benadryl, and Haldol) ABH gel 1/25/1, every six (6) hours as needed for agitation, effective 02/01/2024; and ABH gel 1/25/1... before showers Monday/Wednesday/Friday, effective 03/11/2024. Clinical Record 2/Home Visit 2: The patient elected hospice care on 05/08/2023 with a diagnosis of senile degeneration of the brain. The patient resided in an ALF. During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 09/24/2024, the hospice medication profile was compared to the ALF medication list. The ALF medication list documented the following medication(s) not listed on the patient's current plan of care: Docusate 100 mg one (1) cap as needed, effective 02/02/2023; and Senna Plus 8.6/50 mg two (2) tabs as needed, effective 06/12/2024. Clinical Record 4/Home Visit 4: The patient elected hospice care on 04/25/2024 with a diagnosis of congestive heart failure (CHF). The patient resided in a skilled nursing facility (SNF). During the home visit with the Hospice Aide (HA) [Personnel Record 11] on 09/25/2024, the hospice medication profile was compared to the SNF medication administration record (MAR). The SNF MAR documented the following medication(s) not listed on the patient's current plan of care: Vibegron 75 mg, one (1) tab daily, effective 11/10/2023; Hyoscyamine 0.125 every 4 hours as needed, effective 04/30/3034; and Midodrine 2.5 mg every 6 hours as needed, effective 07/10/2024. The Executive Director printed the hospice medication profiles for the visits on 09/25/2024. Upon returning to the agency, the Executive Director confirmed the discrepancies during an interview and a joint review of the records.

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 3 of 21 (14%) clinical records reviewed in which Hospice Aide services were accepted, the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the Hospice Aide (HA). Clinical Record 16: The patient elected the hospice benefit on 09/11/2024 with a diagnosis of congestive heart failure (CHF). The plan of care ordered HA services five (5) times a week. The HA care plan documented by the RN dated 09/11/2024 assigned the HA the relevant tasks: foot care, applying lotion, notify the RN of skin changes every visit. The initial nursing assessment dated 09/11/2024 documented that the patient had "wounds to bilateral heels covered with dressings." The HA documented foot care, applied lotion, and notified the RN of skin changes during every visit. The HA did not address the wound dressing in the visit note. The HA care plan did not include documentation of instructions addressing the management of the wound dressing should the dressing become soiled, dislodged, or wet during care. Clinical Record 20: The patient elected the hospice benefit on 04/13/2024 with a diagnosis of malignant neoplasm of the left lung. The plan of care ordered HA services five (5) times a week. The HA care plan documented by the RN dated 04/13/2024 assigned the HA the relevant tasks: perineal and incontinent care every visit. The initial nursing assessment dated 04/13/2024 documented that the patient had a Foley catheter. The HA care plan did not include documentation of instructions addressing the Foley catheter care during the perineal and incontinence care. During an interview, the Executive Director stated, "Foley should have been on the care plan as the aide is doing care while doing incontinent care." Clinical Record 22: The patient elected the hospice benefit on 09/16/2023 with a diagnosis of senile degeneration of the brain. The plan of care ordered HA services five (5) times a week. The HA care plan documented by the RN dated 09/16/2023 assigned the HA the relevant tasks: incontinent care every visit and a bed bath three (3) times a week (M-W-F). The skilled nursing visit dated 09/17/2023 documented a "pressure ulcer stage IV to the coccyx covered with dressing." The HA care plan did not include documentation of instructions addressing the management of the wound dressing should the dressing become soiled, dislodged, or wet during care. During an interview and a joint record review on 09/25/2024, the Executive Director confirmed the HA care plans did not contain specific written instructions for the aide regarding the wounds or the Foley.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met, as evidenced by clinical record review, interview, and observation. In 2 of 21 (10%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 4/Home Visit 4: The patient elected hospice care on 04/25/2024. The plan of care ordered HA services five (5) times a week. During the home visit with the Hospice Aide (HA)[Personnel Record 11] on 09/25/2024, the HA provided oral care, shampoo, and changed the linens. The HA care plan dated 07/24/2024 assigned the HA the relevant tasks: bed bath three (3) times a week, dress patient, apply lotion, and provide peri care every visit. Clinical Record 16: The patient elected hospice care on 09/11/2024. The HA care plan dated 09/11/2024 assigned the HA the relevant task of a shower every visit. The HA visit note dated 09/20/2024 documented the shower as "not required this visit." There was no evidence that the HA care plan was changed or the reason the shower was not required. During an interview and joint record review on 09/25/2024, the Executive Director confirmed the HA care plans had not been followed.

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 clinical record review and interview. In 6 of 23 (26%) clinical records reviewed, the agency did not ensure the patient's clinical record contained complete physician orders. Clinical Record 2: The patient elected hospice care on 05/08/2023. The physician's order dated 04/14/2024 ordered: "SN (skilled nurse) PRN (as needed)." The physician's order did not include documentation of indications or instructions for the PRN visit. Clinical Record 15: The patient elected hospice care on 05/14/2024. The physician's order dated 06/28/2024 ordered: "SN PRN." The physician's order did not include documentation of indications or instructions for the PRN visit. Clinical Record 17: The patient elected hospice care on 08/26/2024. The physician's order dated 09/01/2024 ordered: "SN PRN." The physician's order did not include documentation of indications or instructions for the PRN visit. Clinical Record 18: The patient elected hospice care on 11/16/2023. On 02/23/2024, the physician ordered: "Clean with wound spray and pat dry. Apply TAO and cover with padded bordered dressing." The physician's order did not include documentation of the wound's location, who would perform the wound care or the frequency of the wound care. Clinical Record 21: The patient elected hospice care on 06/27/2024. The physician's orders dated 07/30/2024 and 08/03/2024 ordered: "SN PRN." The physician's order did not include documentation of indications or instructions for the PRN visit. Clinical Record 22: The patient elected hospice care on 09/16/2023. The physician's order dated 11/04/2023 ordered: "SN PRN." The physician's order did not include documentation of indications or instructions for the PRN visit. During a joint clinical record review and an interview on 09/26/2024, the Executive Director agreed the "PRN" orders needed to include a reason for the visit and were incomplete as written. The wound orders "also needed to be clarified."

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 3 of 16 (19%) records reviewed, the agency failed to complete the initial comprehensive assessment in 5 days as required. Record #75739: The patient's start of care (SOC) was 11/11/2021. A Chaplain missed visit note dated 11/21/2021 stated, "Date of visit 11/18/2021; Describe efforts made to avoid missed visit: phone calls" (7 days post election of the hospice benefit). There was no documentation of attempts to reach the patient/caregiver during the initial 5 days after the election date. Record #98765: The patient's SOC was 11/23/2021. The initial Chaplain visit was performed on 11/29/2021 (6 days post election of the hospice benefit). There was no documentation justifying the assessment being performed later than the required 5 days. Record #52232: The patient's SOC was 12/18/2020. The initial Chaplain evaluation was performed on 12/24/2021 (6 days post election of the hospice benefit). There was no documentation in the record to justify the late assessment. In an interview with the Executive Director, it was confirmed that the assessments were not completed in the required 5 calendar days after the election of hospice care.

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: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by record review and interview. In 8 of 16 (50%) records reviewed the agency RNs failed to ensure that care was provided following the Plans of Care (POC) ordered visit frequencies. Record #26648: The patient's start of care (SOC) was 9/22/2021. The initial POC dated 9/22/2021 stated, "SN 4wk1". The week of 9/22/2021, 2 SN visits were performed. There were no documented reasons for the missed visits. Record #86832: The patient's SOC was 9/9/2021. The initial POC dated 9/9/2021 was established on 9/9/2021. The RN visit frequency ordered on 9/9/2021 was RN 4w1, 2w1. The week of 9/9/2021, 2 SN visits were performed on 9/9 and 9/10/21. There were no documented reasons for the missed visits. Record #75739: The patient's SOC was 11/11/2021. The initial POC dated 11/11/2021 stated, "RN 4w1 and 4 prn". Two SN visits were performed. There were no documented reasons for the missed visits. Record #28456: The patient's SOC was 11/19/2021. The initial POC dated 11/19/2021 stated, "SN 3wk1, 1wk12 and 4 prn". One visit was performed on 11/19 (Friday). There were no documented reasons for the missed visits. Record #98765: The patient's SOC was 11/23/2021. The initial POC dated 11/23/2021 stated, "SN 4wk1 and 4 prn". Two SN visits were performed the week of 11/23. There were no documented reasons for the missed visits. Record #64868: The patient's SOC was 12/10/2021. The initial POC dated 12/10/2021 stated, "SN 5w1". The week of 12/10/2021, 4 SN visits were performed - 2 visits on 12/10/2021 and 2 visits performed on 12/11/2021. There was no documented reason for the missed 5th visit for that week. Record #11694: The patient's SOC was 9/16/2021. An order dated 9/20/2021 stated, "order clarification 1x/weekly SNV per hospice POC". The week of 11/28/2021, two SN visits were performed. There was no order for the second visit. Record #52232: The patient's SOC was 12/18/2020. An order dated 10/14/2021 stated, "SW 1x/month and 2 prn" and "CH 1x/month and 2 prn". There were no documented SW (social work) or Chaplain visits in November 2021 and no documented reasons for the missed visits. In an interview with the Executive Director, it was confirmed that the care was not provided in accordance with the ordered visit frequencies.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by record review and interview. In 9 of 15 (60%) records of patients receiving aide services, the agency failed to provide care in accordance with the ordered aide visit frequencies. Record #68925: The patient's start of care (SOC) was 5/10/2021. The initial order dated 5/10/2021 stated, "Aide 1w1, 2w11". One aide visit was performed the week of 6/27/2021. There was no documented reason for the missed visit. Record #26648: The patient's SOC was 9/22/2021. The initial order dated 9/22/2021 stated, "aide to start 3x/week on 9/26/2021" A missed visit note on 9/26/2021 stated family declined aide due to not being vaccinated". There were no aide visits performed, no order to discontinue aide services and no documentation of the reasons for the missed visits. Record #86832: The patient's SOC was 9/9/2021. The initial order dated 9/9/2021 stated, "HHA 1wk1, 7wk1, 6wk 11, 2wk11". A missed visit note dated 9/10/2021 stated, "patient is on COVID hall. Physician notified Y/N - (response) N". The week of 9/12/2021, 1 aide visit was performed on 9/17/2021. There were no documented reasons for the missed visits. The week of 9/19/2021, 5 aide visits were performed. There was no documented reason for the missed visit. The week of 9/26/2021, the aide visit frequency was 2w1. Three visits were performed on 9/27, 9/29 and 9/30/2021. There was no order for the extra visit. Record #69913: The patient's SOC was 8/30/2021. The initial order dated 8/31/2021 stated, "aide 2wk1, 3wk12". The week of 9/12/2021, 2 aide visits were performed. There was no documented reason for the missed visit. The week of 9/19/2021, there were no aide visits performed and no documented missed visit reasons. Record #11694: The patient's SOC was 9/16/2021. The initial order dated 9/16/2021 stated, "aide 1w1, 5w12". The week of 11/21/2021, 4 aide visits were performed. There was no documented reason for the missed visit. Record #91495: The patient's SOC was 3/26/2021. The recertification order dated 9/15/2021 stated, "aide 5x/week". The week of 11/21/2021, 4 aide visits were performed. There was no documented reason for the missed visit. Record #12015: The patient's SOC was 10/11/2021. The initial aide order dated 10/12/2021 stated, "aide 5x/week". On 11/1/2021, a missed visit note was created in the EMR, but included no information regarding the missed visit. The week of 10/31/2021, 3 aide visits were performed and1 justified missed visit was documented. There was no documented reason for the fifth visit (missed). The week of 11/21/2021, 4 aide visits were performed, there was no documented reason for the missed visit. The week of 11/21/2021, 2 aide visits were performed and 2 justified missed visits were documented. There was no documented reason for the missed fifth visit for that week. There was an order, dated 10/12/2021, for aide 5x/week. Record #98765: The patient's SOC was 11/23/2021. The initial aide order dated 11/23/2021 stated, "aide 2wk1, 3wk12". The week of 11/23/21, 1 aide visit was performed. There was no documented reason for the missed visit. Record #83525: The patient's SOC was 10/11/2021. The initial aide order dated 10/11/2021 stated, "aide 5x/week". The week of 10/31/2021, 4 aide visits were performed. There was no documented reason for the missed visit. In an interview with the Executive Director, it was confirmed that the care was not provided following the ordered aide visit frequencies.