Every finding on record at Heart to Heart Hospice of Houston LLC

It is required that each patient in the hospice inpatient facility always has an adequate supply of hot water and has plumbing fixtures with control valves that automatically regulate the temperature of the hot water used by patients. This standard was not met as evidenced by interview and observation. The agency did not ensure that the inpatient unit plumbing fixtures with control valves automatically regulated the temperature of the hot water used by patients. During a tour of the inpatient unit (IPU) on 6/17/2025, the water temperature tested in room 218 was noted at 129°F. During an interview on 06/17/2025, the Vice President of Operations (VPO) for the IPU agreed with the observed temperature and asked the facilities staff, who were present for the tour and interview, to turn down the water heater temperature, which was immediately done. During an interview on 06/17/2025, the Vice President of Operations (VPO) for the IPU agreed with the observed temperature. Observation: During tour of IPU on 6/17/2025, the agency failed to ensure regulation of hot water in the IPU. Water temperature tested in room 218 was noted at 129'. Interview with VP of Operations over IPUs on 6/17/2025 where she agreed with the observed temperature; she asked facilities staff who were present to turn down the water heater temperature which was immediately done.

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. 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). This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 13 (16%) clinical records reviewed, the hospice did not ensure that spiritual counselor and social worker visits were completed as ordered on the plans of care. Clinical Record 5 was reviewed and revealed that the social worker visit frequency was "monthly," as documented in the IDG Comprehensive Assessment Plan of Care Review 6/14/22 in the social worker summary section. The record was missing a social worker visit note in July 2022. Additionally, the spiritual counselor visit frequency was "3 week 1" on a physician's order dated 6/14/22. The record revealed two missing spiritual counselor visits during the week of 6/14/22. Clinical Record 7 was reviewed and revealed the patient was admitted to the hospice inpatient facility on general inpatient level of care (GIP) on 5/18/22. The social worker's visit frequency on a physician's order dated 5/19/22 was "3 week 1". The record revealed two missing social worker visits during the week of 5/19/22. Additionally, the spiritual counselor visit frequency on a physician's order dated 5/18/22 was "4 week 1". The record revealed two missing spiritual counselor visits during the week of 5/18/22. During an interview on 8/19/22, the Regional Director of Clinical Operations stated she could not locate the missing visit notes, coordination notes, physician's orders, and/or Interdisciplinary Group discussion notes regarding the missing visit notes.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 8 (13%) applicable clinical records reviewed, of patients receiving hospice aide services revealed the hospice did not ensure hospice aide visits were completed as assigned on the plan of care. Clinical Record 6 was reviewed and revealed that the frequency of hospice aide visits was three times a week. The clinical record was missing hospice aide visit notes from 1/9/22 through 2/5/22, thus compliance with the ordered visit frequency could not be validated. During an interview on 8/19/22, the Regional Director of Clinical Operations stated she could not locate the missing aide visit visits, coordination notes, physician's orders, and/or Interdisciplinary group discussion notes for the missing hospice aide visits. Additionally, the Regional Director of Clinical Operations stated the hospice aide services were provided under contract and would have been on paper and not documented directly into the electronic medical record (EMR).

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 a review of clinical records and interviews. In 5 of 13 (38%) clinical records reviewed, the hospice did not ensure timely wound care physician orders, as well as physician's orders including the specific dosage of the medication to be administered or a lack of physician orders for medications administered. Clinical Record 4: The clinical record, on review, was missing physician order for wound care that was provided from 6/2/22 to 6/7/22. The patient was readmitted to hospice on 6/1/22. The nursing visit documentation on 6/2/22 included "stage 3 sacral wound, client change dressing, provided wound care supplies and dressing supplies." The nursing visit note dated 6/8/22 included a wound assessment and wound care dressing change. NOTE: Physician's orders were obtained on 6/8/22 for wound care. During an interview on 8/19/22, the Regional Director of Clinical Operations stated she could not locate the wound care orders in the plan of care or physician's orders until the orders were documented on 6/8/22. During the exit conference, it was revealed that the nursing note on 6/2/22 included the patient had a stage 3 wound and a stage I wound. However, the nurse documented in the 6/2/22 nursing visit note, "client changed the wound dressing, and wound care dressing supplies were provided." The clinical record revealed no orders for wound care dressing changes until 6/8/22. Clinical Record 2: The patient was on General Inpatient Care (GIP) from 5/18/22 through 5/20/22 at the hospice inpatient facility. The patient expired on 5/20/22. The clinical record, on review, revealed missing physician's orders for Morphine and Ativan documented on the Medication Administration Record (MAR). The MAR documented "Order date 5/18/22 Dilaudid 1 mg IV/SQ every 2 hours PRN pain/dyspnea" and "Order date 5/18/22 Ativan 1 mg IV/SQ every 2 hours PRN agitation/restlessness" however, no physician's orders were located. During the interview on 8/19/22, the Regional Director of Clinical Operations, who the Executive Director designated, stated she could not find the missing physician's orders for the Morphine and Ativan documented on the MAR for 5/18/22. The MAR recorded Dilaudid was administered SQ without a physician order on 5/18/22 at 2215 and 5/19/22 at 0035, and Ativan was administered SQ without a physician order on 5/18/22 at 2215 and 5/19/22 at 0035. The physician wrote orders on a physician visit note on 5/19/22 (the day after the Ativan and Dilaudid were administered) for Dilaudid and Ativan "IV" (not SQ as administered), "every 4 hours" (not every two hours as documented on the MAR) and "scheduled" (not PRN as documented on the MAR). Clinical Record 3: The patient was on GIP at the hospice inpatient facility from 6/24/22 through 7/6/22 and expired on 7/6/22. On 6/25/22, the MAR documented "discontinued date 6/25/22 morphine 4 mg IV PRN" and "discontinued date 6/25/22 Ativan 2 mg IV every 4 hours". The clinical record, on review, revealed no physician's order to discontinue the morphine and Ativan on 6/25/22. The order was obtained on 6/26/22 at 1228pm to discontinue the Morphine and Ativan. Clinical Record 8: The patient transferred to the general inpatient level of care (GIP) at the hospice inpatient facility on 8/16/22. A physician's order 8/16/22 included "Morphine 20 mg/5 ml oral solution, 0.5 ml every two hours PRN" did not have the milligram dosage of Morphine to be administered, only "0.5 ml". Additionally, the order was not transcribed correctly onto the medication administration record (MAR) used to document medications administered at the inpatient facility. The MAR included "Roxanol 20 mg/ml, 0.5 ml, PO/SL every 2 hours prn", which was not the morphine concentration ordered. Based on the concentration of the Roxanol ordered, "20 mg/5 ml", and the amount to be administered, "0.5 ml", the morphine dosage calculates to "2 mg," and the Roxanol transcribed onto the MAR documented as "20 mg/ml, 0.5 ml" which calculates to "10 mg". The dosage of Roxanol administered to the patient, "10 mg", did not match the dosage amount ordered by the physician, "2 mg". The MAR documented that 10 mg Roxanol (not 2 mg as ordered) was administered to the patient on 8/16/22 at 355pm, 8/17/22 at 8 am, 1120am, and 1600, and 8/18/22 at 830am. A subsequent order 8/17/22 included "Morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution, 0.5 ml every two hours PRN". This order was not transcribed onto the MAR 8/17/22 and was documented as administered on the MAR 8/16/22 without an order. The physician's order form at the top included "Date of order 8/17/22", the order was signed by the receiving nurse and dated "8/17/22", and included "start date of 8/16/22", which was the day before the order was documented. An additional order on 8/18/22 included "discontinue morphine sulfate 20 mg/ml, give 0.5 ml (10 mg) PO/SL every two hours prn", begin morphine sulfate 20 mg/ml, give 1 ml (20 mg) SL every two hours scheduled for pain/SOB". This order was not correctly transcribed onto the MAR. The MAR documented "order date 8/17/22, morphine sulfate 20 mg/ml, give 1 ml (20 mg) SL every two hours scheduled for pain/SOB", which is the day before the medication was ordered. Additionally, the MAR documented a 20 mg dose was administered to the patient on 8/17/22 at 10 am without an order. During an interview on 8/18/22 with the LVN who transcribed the order and administered the medication, the LVN stated, "I transcribed the wrong order date and documented the wrong date that I administered the medication on 8/17/22, but I meant the order was 8/18/22 and that I administered the medication on 8/18/22". During an interview on 8/18/22, the Inpatient Patient Care Manager stated they only had one concentration of morphine at the inpatient facility, 20 mg/ml, and that several different types of morphine concentrations are available in the electronic medical record (EMR) to select when entering the concentration of the morphine ordered. During an interview on 8/19/22, the Regional Director of Clinical Operations confirmed the morphine order did not include the milligram dosage to be administered. Additionally, the Director of Clinical Operations confirmed that the morphine dosage documented as administered to the patient did not match the dosage amount of morphine ordered by the physician based on the morphine concentration ordered. Clinical Record 7: The patient was on Respite level of care at the hospice inpatient facility from 5/18/22 through 5/22/22. The MAR included "order date 5/18/22 Senna 8.6 mg PO BID". Clinical record review revealed no physician's orders for the Senna on 5/18/22; a physician's order for the Senna was documented on 5/19/22. The physician's order form was written "Order date 5/19/22," and the bottom of the form was signed by the nurse electronically on 5/19/22 at 543am. An additional order on 5/19/22 at 548am included "Clobetasol, Magnesium Oxide, Mirtazapine, Multivitamins, Nitroglycerin, and Toprol," which were not transcribed onto the MAR for 5/19/22. These medications were documented on the MAR 5/18/22 without an order. During the interview on 8/19/22, the Regional Director of Clinical Operations stated she could not locate the missing physician's orders and confirmed physician's orders were not correctly transcribed onto the MAR.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are: Identified in the plan of care and provided to a patient while under the care of the hospice. THIS IS A CMS CONDITION-LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of clinical records and interviews with agency leadership which revealed significant issues in the inpatient hospice facility with ensuring that controlled drugs and biologicals related to the palliation and management of the terminal illness and related conditions were identified in the plan of care and provided to a patient while under the care of the hospice [HCDT.29.I/L687]. Additionally, the inpatient hospice facility failed to ensure physician orders were present in the patient clinical record [HSIM3.I/L678/418.104(a)(7)]. The cumulative effect of this systemic practice could negatively impact all patients and could contribute to the inability of the hospice to provide effective ongoing care and services during the end-stage of life.

It is required that drugs and biologicals related to the palliation and management of the terminal illness and related conditions are: identified in the plan of care and provided to a patient while under the care of the hospice. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 13 (23%) clinical records reviewed Skilled Nursing administered drugs and biologicals related to palliation and management of terminal illness and related conditions that were not included as part of the patients' plans of care. Clinical Record 3: The patient was on General Inpatient Care (GIP) at the hospice inpatient facility from 6/24/22 through 7/6/22 and expired on 7/6/22. The physician's order on 6/25/22 for "Morphine 4 mg IV every 4 hours ATC" was not transcribed onto MAR and not documented as administered to the patient as ordered. During an interview on 8/18/22, the Regional Director of Clinical Operations stated that "ATC" was "around the clock." The physician's order on 6/25/22 also included "Morphine 4 mg IV every 2 hours PRN", which was not transcribed onto the MAR for 6/25/22 and was documented as administered on the MAR on 6/24/22, the day before the order. The physician's order 6/25/22 included "Ativan 2 mg IV every 4 hours ATC", which was not transcribed onto MAR and not documented as administered to the patient as ordered. The physician's order on 6/25/22 also included "Ativan 2 mg IV every 2 hours PRN", which was not transcribed to the MAR on 6/25/22 and was documented as administered on the MAR on 6/24/22, the day before the order. Clinical Record 8: The patient transferred to the general inpatient level of care (GIP) at the hospice inpatient facility on 8/16/22. The physician's order 8/16/22 included "Morphine 20 mg/5 ml oral solution, 0.5 ml every two hours PRN" did not have the milligram dosage of Morphine to be administered, only "0.5 ml". Additionally, the order was not transcribed correctly onto the medication administration record (MAR) used to document medications administered at the inpatient facility. The MAR included "Roxanol 20 mg/ml, 0.5 ml, PO/SL every 2 hours prn", which was not the morphine concentration ordered. Based on the concentration of the Roxanol ordered, "20 mg/5 ml", and the amount to be administered, "0.5 ml", the morphine dosage calculates to "2 mg," and the Roxanol transcribed onto the MAR documented as "20 mg/ml, 0.5 ml" which calculates to "10 mg". The dosage of Roxanol administered to the patient, "10 mg", did not match the dosage amount ordered by the physician, "2 mg". The MAR documented that 10 mg Roxanol (not 2 mg as ordered) was administered to the patient on 8/16/22 at 355pm, 8/17/22 at 8 am, 1120am, and 1600, and 8/18/22 at 830am. A subsequent order 8/17/22 included "Morphine concentrate 100 mg/5 ml (20 mg/ml) oral solution, 0.5 ml every two hours PRN". This order was not transcribed onto the MAR 8/17/22 and was documented as administered on the MAR 8/16/22 without an order. The physician's order form at the top included "Date of order 8/17/22", the order was signed by the receiving nurse and dated 8/17/22, and included "start date of 8/16/22", which was the day before the order was documented. An additional order on 8/18/22 included "discontinue morphine sulfate 20 mg/ml, give 0.5 ml (10 mg) PO/SL every two hours prn", begin morphine sulfate 20 mg/ml, give 1 ml (20 mg) SL every two hours scheduled for pain/SOB". This order was not correctly transcribed onto the MAR. The MAR documented "order date 8/17/22, morphine sulfate 20 mg/ml, give 1 ml (20 mg) SL every two hours scheduled for pain/SOB", which is the day before the medication was ordered. Additionally, the MAR documented a 20 mg dose was administered to the patient on 8/17/22 at 10 am without an order. During an interview on 8/18/22 with the LVN who transcribed the order and administered the medication, the LVN stated, "I transcribed the wrong order date and documented the wrong date that I administered the medication on 8/17/22, but I meant the order was 8/18/22 and that I administered the medication on 8/18/22". During an interview on 8/18/22, the Inpatient Patient Care Manager stated they only had one concentration of morphine at the inpatient facility, 20 mg/ml, and that several different types of morphine concentrations are available in the electronic medical record (EMR) as a download to select when entering the concentration of the morphine ordered. During an interview on 8/19/22, the Regional Director of Clinical Operations confirmed the morphine order did not include the milligram dosage to be administered. Additionally, the Director of Clinical Operations confirmed that the morphine dosage documented as administered to the patient did not match the dosage amount of morphine ordered by the physician based on the morphine concentration ordered. Clinical Record 7: The patient was on Respite level of care at the hospice inpatient facility from 5/18/22 through 5/22/22. The MAR included "order date 5/18/22 Senna 8.6 mg PO BID". A clinical record review revealed no physician's orders for the Senna on 5/18/22; a physician's order for the Senna was documented on 5/19/22. The physician's order form was written "Order date 5/19/22", and the bottom of the form was signed by the nurse electronically on 5/19/22 at 543am. An additional order on 5/19/22 at 548am included "Clobetasol, Magnesium Oxide, Mirtazapine, Multivitamins, Nitroglycerin, and Toprol," which were not transcribed onto the MAR for 5/19/22. These medications were documented on the MAR 5/18/22 without an order.