Every finding on record at Heart to Heart Hospice of San Marcos LLC

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 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care included interventions and family goals based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 12: The patient elected the hospice benefit on 08/25/2025. On 08/31/2025, an on-call coordination note by the RN documented that the patient’s niece reported the patient was “drug-seeking” and required supervision of narcotics to prevent misuse or diversion. The niece also reported that the patient had invited “known drug users” to her home and accused the family of “holding her hostage.” During the RN visit on 09/07/2025, the patient stated she was now staying with a friend in another town because her home lacked running water. She complained that her niece had mistreated her, withheld medications, lied about her, and “kept her heavily medicated.” On 10/03/2025, the patient called the on-call nurse, stating she had left her oxycodone in an Uber and requested an early refill. The nurse informed her that the medication could only be refilled when due. That same day, the Social Worker attempted a home visit but found the patient absent. The patient’s brother reported that she had gone walking with a friend who “uses drugs” and would not comment on whether the patient was also using. Later that day, the RN documented that the residence was cluttered with trash, dirty clothing, and soaked briefs, with a strong odor of urine. The patient was lying on a bed without sheets and reported pain. The nurse noted the oxycodone could not be refilled until the following Monday and reinforced medication safety. The plan of care for the benefit period dated 08/25/2025 through 11/22/2025 did not identify problems related to the patient’s frequent moves, medication safety, home environment, or drug-seeking behaviors, nor did it include interventions addressing these issues. During a joint clinical record review and interview on 10/09/2025, the Vice President of Clinical Operations confirmed the finding.

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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's plan of care included drugs and treatments to meet the patient's needs.. CLINICAL RECORD 17: The patient elected the hospice benefit on 08/18/2025 and died under hospice care on 08/26/2025. The plan of care for the benefit period dated 08/18/2025 through 11/15/2025 ordered continuous oxygen at 6 liters per minute via nasal cannula. During the Registered Nurse’s (RN) visit on 08/24/2025, the patient’s oxygen saturation was documented at 68% while receiving 8 liters per minute via nasal cannula. On 08/25/2025, documentation indicated the patient’s oxygen saturation was 84% on 10 liters per minute. At the post-death Interdisciplinary Group (IDG) meeting on 09/04/2025, the physician’s note documented that the patient was on 8 liters per minute of continuous oxygen. However, the plan of care was not updated to reflect the increase to 10 liters per minute as documented prior to the patient’s death. During a joint clinical record review and interview on 10/09/2025, the Vice President of Clinical Operations confirmed the finding.

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 1 of 15 (7%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions from the Registered Nurse (RN) to meet the needs of a patient with a wound. CLINICAL RECORD 13: The patient elected hospice care on 6/11/2025 with diagnoses of Parkinson's disease and dementia, unspecified. The plans of care for the benefit periods dated 06/11/2025 to 09/08/2025 and from 09/09/2025 to 12/07/2025 ordered Hospice Aide (HA) services three times a week. The active Hospice Aide care plan, dated 08/22/2025, assigned the HA the relevant tasks: assisting with showering, shampooing the patient's hair, skin care, foot care, and shaving at each visit. On 09/05/2025, the Registered Nurse (RN) documented an unstageable wound on the patient's left iliac crest measuring 1.2 cm x 1.9 cm x 0.2 cm. A physician's order was also documented on the same day for wound care, which involved cleansing the wound with wound cleanser, patting it dry with gauze, applying Medi-Honey to the wound bed, and covering it with a dry dressing daily, six times per week by the facility nurse and once per week by the hospice nurse. During the visit on 09/12/2025, the RN documented that the wound had increased in size to 1.3 cm x 2 cm x 0.3 cm. New wound care orders were received to cleanse the wound with wound cleanser, pat it dry, apply calcium alginate to the wound bed, and then cover it with a dry dressing. The care was to be performed daily, six times per week by the facility nurse and once per week by the hospice nurse. The wound was documented as healed as of 10/08/2025, and the HA plan of care was updated 10/09/2025 to provide an intervention should the wound recur. "If the wound presents, do not remove the dressing. Notify the facility nurse and hospice nurse immediately if the dressing comes off, becomes soiled, or requires attention. Keep dressing dry/cover during shower." The HA plan of care developed by the RN did not include instructions regarding the wound or any specific interventions to notify the RN of any changes while the wound was active. The finding was confirmed following a joint clinical record review and an interview with the Vice President of Clinical Operations on 10/09/2025.

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 assessment, and measurable outcomes anticipated from implementing and coordinating the plan of care. 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, document reviews and interviews. Policy # TX.06 titled PLAN OF CARE PROCESS, revised 01/01/2020, states in part, "The plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care." 13 of 13 (100%) clinical records reviewed revealed that the hospice plans of care were not individualized to include measurable outcomes anticipated from implementing and coordinating the plan of care in accordance with the hospice's policies and procedures. Clinical Record 13: The patient was admitted 08/30/2022. The plan of care identified "need for medication management" as a problem on 08/30/2022 with the goal of "patient/caregiver verbalize/demonstrate understanding of the importance of medication management." Clinical Record 6: The patient was admitted 10/28/2022. The plan of care identified "altered home safety" as a problem on 10/28/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 11: The patient was admitted 02/05/2020. The plan of care identified "patient/caregiver knowledge deficit related to oxygen therapy management" as a problem on 02/05/2020 with the goal of "patient/caregiver verbalize understanding for oxygen management." Clinical Record 8: The patient was admitted 11/12/2022. The plan of care identified "altered home safety" as a problem on 11/12/022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 12: The patient was admitted 07/27/2022. The plan of care identified "need for medication management" as a problem on 07/27/2022 with the goal of "patient/caregiver verbalize/demonstrate understanding of the importance of medication management." Clinical Record 10: The patient was admitted 09/23/2022. The plan of care identified "altered home safety" as a problem on 09/23/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 9: The patient was admitted 09/13/2022. The plan of care identified "altered home safety" as a problem on 09/13/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 7: The patient was admitted 10/27/2021. The plan of care identified "altered urinary status" as a problem on 10/27/2021 with the goal of "patient/caregiver verbalize measures to protect skin." Clinical Record 3: The patient was admitted 11/03/2022. The plan of care identified "patient/caregiver knowledge deficit related to oxygen therapy management" as a problem on 11/03/2022 with the goal of "patient/caregiver verbalize understanding for oxygen management." Clinical Record 2: The patient was admitted 11/23/2022. The plan of care identified "altered home safety" as a problem on 11/23/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 4: The patient was admitted 09/29/2022. The plan of care identified "altered home safety" as a problem on 09/22/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." Clinical Record 5: The patient was admitted 01/13/2022. The plan of care identified "patient/caregiver knowledge deficit related to oxygen therapy management" as a problem on 01/13/2022 with the goal of "patient/caregiver verbalize understanding for oxygen management." Clinical Record 1: The patient was admitted 12/07/2022. The plan of care identified "altered home safety" as a problem on 12/07/2022 with the goal of "patient/caregiver verbalizes/demonstrates proper safety measures related to fall prevention." The Area Clinical Manager was interviewed on 12/15/2022 during a joint review of clinical records. She stated that the plans of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care in accordance with the hospice's policies and procedures. She stated that these findings were self-identified, and they have a performance improvement project that will be implemented in January 2023. No further information was provided.