Every finding on record at Heart to Heart Hospice of the Brazos, LLC

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), the patient or patient representative, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with active wounds, the agency did not ensure hospice care and services provided to the patient followed the individualized plan of care established by the hospice interdisciplinary group (IDG). Clinical Record 12: The patient elected hospice services on 8/9/2023 with a diagnosis of osteomyelitis of vertebra, sacral and sacrococcygeal region. The initial assessment completed by the registered nurse (RN) dated 8/9/2023 documented the patient's stage II pressure ulcer on the coccyx area and bilateral heels. On 8/14/2023, the physician ordered: "cleanse wound on coccyx with normal saline, pat dry, pack with calcium alginate and cover with foam dressing. RN to change weekly and wife to change every other day and as needed for soilage." On 8/14/2023, 8/23/2023, and 9/6/2023 the RN visit notes documented "wound care done, packed with wet to dry dressing until calcium alginate is available. Covered with dry dressing." On 9/11/2023 and 9/26/2023 the RN visit notes did not include documentation of wound care or an assessment of the wound. On 10/3/2024, 10/10/2023 and 10/17/2023 the RN documented "cleanse wound with normal saline, patted dry, packed with wet to dry dressing until calcium alginate is available." On 10/24/2023, the physician ordered: "cleanse wound to left ankle and heel with normal saline, pat dry, apply calcium alginate to wound bed and cover with a dry dressing. Change every other day." On 10/24/2023 the RN documented that the coccyx wound was "cleaned with normal saline, patted dry, packed with wet to dry dressing until calcium alginate is available and that the left ankle was cleansed with normal saline patted dry, applied alginate to wound bed and covered with dry dressing." On 11/7/2023, the physician ordered: "cleanse coccyx wound with normal saline, pat dry, pack with calcium alginate to wound bed and cover with foam dressing. RN to assess weekly and wife to change as needed." On 11/7/2023, 11/21/2023, 12/12/2023, and 12/19/2023, the RN visit notes did not include documentation of wound care or an assessment of the wound. During an interview, the Area Clinical Manager agreed that the RN did not follow the plan of care developed by the interdisciplinary team.

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: medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by document review, clinical record review, and interview. In 18 of 19 (95%) clinical records reviewed, the agency did not ensure that the plan of care included medical supplies and appliances necessary to meet the patient's needs. Clinical Record 1: The patient elected hospice care on 1/27/2023. The patient required wound care supplies: non-adherent dressing, kerlex, and normal saline. These medical supplies were not documented in the patient's plan of care. Clinical Record 2: The patient elected hospice care on 11/17/2023. The patient required wound care supplies for a pressure ulcer on the left heel, including calcium alginate and foam dressing. The patient required a wheelchair. These medical supplies and the wheelchair were not documented in the patient's plan of care. Clinical Record 3: The patient elected hospice care on 11/12/2023. The patient required a hospital bed and oxygen concentrator. The hospital bed and oxygen concentrator were not documented in the patient's plan of care. Clinical Record 4: The patient elected hospice care on 11/21/2023. The registered nurse (RN) visit note dated 11/21/2023 documented the patient's wheelchair use. The wheelchair was not documented on the patient's plan of care. Clinical Record 5: The patient elected hospice care on 9/20/2023. The patient required an oxygen concentrator and oxygen supplies. The oxygen supplies and the oxygen concentrator were not documented in the patient's plan of care. Clinical Record 7: The patient elected hospice care on 10/26/2023.The patient required an oxygen concentrator and oxygen supplies. The oxygen supplies and the oxygen concentrator were not documented in the patient's plan of care. Clinical Record 8: The patient elected hospice care on 9/25/2023. The patient required a hospital bed and an oxygen concentrator. The hospital bed and the oxygen concentrator were not documented in the patient's plan of care. Clinical Record 9: The patient elected hospice care on 9/10/2023. The patient required a hospital bed and oxygen concentrator. The hospital bed and the oxygen concentrator were not documented in the patient's plan of care. Clinical Record 11: The patient elected hospice care on 6/8/2023. The RN's initial assessment dated 6/8/2023 documented that the patient required briefs. The RN visit note dated 6/12/2023 documented that the patient had oxygen and oxygen supplies in the home. The oxygen supplies and the oxygen were not documented in the patient's plan of care. Clinical Record 12: The patient elected hospice care on 8/9/2023. The patient required wound supplies. The RN's initial assessment documented the patient required a Hoyer lift, shower bench, and catheter supplies. The Hoyer lift, shower bench, and catheter supplies were not documented on the patient's plan of care. Clinical Record 13: The patient elected hospice care on 10/9/2023. The patient required oxygen supplies and a nebulizer. The oxygen supplies and the nebulizer were not documented in the patient's plan of care. Clinical Record 14: The patient elected hospice care on 9/15/2023. The patient required oxygen and oxygen supplies. The oxygen supplies and the oxygen were not documented in the patient's plan of care. Clinical Record 15: The patient elected hospice care on 5/31/2023 and died on 7/11/2023. The patient required a hospital bed, over bed table, foley catheter supplies, and oxygen supplies. The patient's plan of care did not document the oxygen supplies, hospital bed, over-bed table, or Foley catheter supplies. Clinical Record 16: The patient elected hospice care on 10/27/2023 and was discharged on 11/10/2023. The patient required a shower chair. The shower chair was not documented on the patient's plan of care. Clinical Record 17: The patient elected hospice care on 1/11/2023 and was discharged on 10/16/2023. The patient required an oxygen concentrator and an oxygen cylinder. The oxygen concentrator and the oxygen cylinder were not documented in the patient's plan of care. Clinical Record 18: The patient elected hospice care on 4/18/2022 and died on 7/18/2023. The patient required an oxygen concentrator and an oxygen cylinder. The oxygen concentrator and the oxygen cylinder were not documented in the patient's plan of care. Clinical Record 19: The patient elected hospice care on 9/23/2022 and died on 10/6/2023.The patient required an oxygen concentrator and an oxygen cylinder. The oxygen concentrator and the oxygen cylinder were not documented in the patient's plan of care. During an interview, the Executive Director and Area Clinical Manager stated that this issue was recently identified, and they were working on changes to the process of placing supplies and DME on the patient plans of care. They have a performance improvement plan in place that was dated 12/20/2023.

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 16 (6%) clinical records reviewed of patients who received hospice aide (HHA) services, the agency did not ensure that the hospice aide plan of care was updated. Clinical Record 6: The patient elected hospice care on 6/13/2023. For the certification period dated 10/9/2023 through 12/7/2023, the hospice aide plan of care ordered: "HHA 3xwk1, then 5xwk," and the hospice aide was assigned the tasks: sponge baths on Tuesday and Friday and showers on Monday, Wednesday, and Friday. On the recertification plan of care dated 12/8/2023, hospice aide services were ordered "3xwk." The hospice aide plan of care assigned the tasks: sponge baths on Tuesday and Friday and showers on Monday, Wednesday, and Friday. During a joint review of the clinical record and interview, the Executive Director confirmed that the hospice aide plan of care was not updated for the certification period starting on 12/8/2023.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are: noted in the plan of care; [and] documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients that accepted volunteer services, the agency did not ensure that followed up by the agency. Clinical Record 3: The patient elected hospice care on 11/12/2023. The Volunteer Coordinator coordination note dated 11/14/2023 documented that the patient had accepted volunteers. A joint review of the clinical record with the Executive Director revealed no documented evidence that the agency followed up on the patient's acceptance of volunteer services. The Interdisciplinary Group (IDG) meeting note dated 11/28/2023 documented no mention of volunteer services or follow-up. The IDG meeting notes dated 11/28/2023 and 12/12/2023 documented the problem of "Volunteer/companionship, a Goal of patient need for companionship supported throughout the dying process." The Volunteer Coordinator did not document, and there was no evidence of follow-up for the volunteer request for the patient.

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 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record included physician orders for wound care. Clinical Record 12: The patient elected hospice services on 8/9/2023 with a diagnosis of osteomyelitis of vertebra, sacral and sacrococcygeal region. The initial assessment completed by the registered nurse (RN) dated 8/9/2023 documented the patient's stage II pressure ulcer on the coccyx area and bilateral heels. On 8/14/2023 ordered "cleanse wound on coccyx with normal saline, pat dry, pack with calcium alginate and cover with foam dressing. RN to change weekly and wife to change every other day and as needed for soilage." The RN documented that a wet-to-dry dressing was performed on the patient for the visits dated 8/14/2023, 8/23/2023, 9/6/2023, 10/3/2023, 10/10/2023, 10/17/2023, and 10/24/2023. During a joint review of the clinical record and interview, the Area Clinical Manager confirmed that the RN used a wet-to-dry dressing without a physician's order.