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

It is required that each patient’s individualized written plan of care include measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 4 of 19 (21%) clinical records reviewed revealed the agency did not ensure that the patient's plans of care included goals that were individualized and measurable. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/03/2024 with the diagnosis of hypertensive heart disease with heart failure. The plans of care for the benefit periods 04/01/2025 to 05/30/2025 and 01/01/2025 to 03/31/2025 were reviewed. During the Registered Nurse's (RN) visit on 03/10/2025, it was noted on the Edmonton Symptom Assessment Scale (ESAS) that the patient's shortness of breath was rated a three. Also included was that the patient's lung sounds were diminished in all lobes, and the patient was short of breath at rest with a productive cough. The patient's medication list included DuoNeb four times a day and oxygen at two to five liters per minute by nasal cannula as needed. During the nurse's visit on 04/14/2025, the documentation included a respiratory rate of twenty with an ESAS shortness of breath score of four. It was noted that the patient was short of breath after getting out of the shower. The patient's plan of care identified dyspnea as a problem and included interventions to administer supplemental oxygen as ordered, assess oxygen saturation levels, and educate the patient and caregivers on oxygen safety and equipment maintenance. The identified goal was that the patient would voice or show signs of decreased episodes of shortness of breath. The goal of decrease is not measurable. CLINICAL RECORD 7: The patient elected the hospice benefit on 06/27/2024 with the diagnosis of Alzheimer's disease, with the comorbid condition of severe dementia with psychotic disturbance. The plans of care for the benefit periods 02/22/2025 to 04/22/2025 and 12/24/2024 to 02/21/2025 were reviewed. During the nurse's visit on 01/28/2025, the nurse documented that the "...Patient's spouse reported he started giving the Seroquel 50mg twice daily over the weekend to help control the patient's agitation and behaviors. Changes were discussed with (hospice NP), and an order was given to increase Seroquel to BID..." The original order dated 07/16/2024 was for Seroquel, fifty milligrams by mouth at bedtime for sundowning behaviors. On 01/28/2025, the Seroquel dose was increased to fifty milligrams by mouth twice daily. On 03/05/2025, the nurse noted that the "patient was uncooperative and did not allow vital signs for this visit...Medication changes... to help control the patient's dementia behaviors..." A physician's order documented the same date increased the patient's Seroquel to 150 milligrams, an extended twenty-four-hour tablet by mouth at bedtime, and the addition of Depakote, 250 milligrams, a delayed-release tablet by mouth twice a day for behaviors. The plan of care included the identified problem of sundowning behaviors with interventions to assess for causes of altered mental status (infection, pain, urinary retention, constipation), educate on anticipated decline in neurological status as the disease progresses, and assess the effectiveness of neurological medications. The goal identified was that the patient's self-care needs would be met by the caregiver and hospice staff while maintaining dignity and maximum autonomy and personal independence. The goal of dignity and maximum autonomy is not measurable. CLINICAL RECORD 8: The patient elected the hospice benefit on 03/08/2025 with the diagnosis of cerebral palsy and the comorbid condition of anxiety disorder. The plan of care for the benefit period 03/08/2025 to 06/05/2025 was reviewed. During the Registered Nurse's admission visit on 03/08/2025, the patient's anxiety was rated a seven on the Edmonton Symptom Assessment Scale. In the psychological assessment section of the note, the nurse noted that the patient was alert but agitated and combative. A physician's order for the same date included Lorazepam, one milligram per gastric tube every six hours as needed for anxiety and/or agitation. The patient's plan of care identified the problem of anxiety and agitation with interventions to administer medications for anxiety/agitation as ordered, evaluate the effectiveness of the antianxiety medication, and assess for signs and/or symptoms of anxiety/agitation. The goal was for effective symptom management. Effective symptom management is not a measurable goal. CLINICAL RECORD 14: The patient elected the hospice benefit on 04/09/2024. The patient's plans of care for the benefit periods 04/04/2025 to 06/02/2025 and 02/03/2025 to 04/03/2025 were reviewed. During the Registered Nurses (RN) visit on 03/31/2025, she documented that the patient had left-sided weakness, a shuffling gait, stooped posture, generalized weakness, poor endurance, and fatigued easily. The patient utilized the assistive devices of a cane and a rollator. On 04/22/2025, the nurse documented increased weakness and poor balance. The plan of care included identifying an increased risk for falls. The intervention was to educate the patient and/or caregiver on ways to reduce fall risk, identify safety issues, educate on safety precautions, and assess for weakness and/or fatigue. The goal was for the patient to have decreased falls, and decreased is not measurable. During a joint clinical record review and interview with the Executive Director/RN (Personnel Record 2) on 04/23/2025, she confirmed that the goals presented in evidence were not individualized or measurable.

It is required that all hospice aide services must be provided by an individual who has successfully completed a training and competency evaluation program described below. The competency evaluation addresses each of the following subject areas, and they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including reading and recording temperature, pulse, and respiration. The appropriate and safe techniques in performing personal hygiene and grooming tasks, including bed bath, hair shampoo (sink, tub, and bed), toileting and elimination, and safe transfer techniques and ambulation. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record reviewed of hospice aides revealed the agency did not ensure that all required personal hygiene and safety transfer techniques were documented as observed by the Registered Nurse on the Initial Competency form in accordance with agency policy. AGENCY POLICY: The hospice's policy dated 09/01/2024 entitled "Hospice Aide/Homemaker Competency Evaluation (HR.45)" read in part that "...The hospice will ensure that each hospice aide successfully completes a hospice aide skills competency evaluation in accordance with federal and state laws and regulations prior to the aide performing care independently...Documentation of successful completion is required, whether the training was provided by the hospice or by another training facility...The competency evaluation and skills checklist will be administered by an RN...and will be scheduled during the orientation period. The RN will document observation of skills as required and will sign and date the completed checklist...The following subject areas must be evaluated by observing an aide's performance with a patient or pseudo-patient ...bed bath ... hair shampooing in skin, tub, and bed ... toileting and elimination... safe transfer techniques..." PERSONNEL RECORD 10: The Hospice Aide was hired on 01/25/2023, and the "Initial Competency Assessment Skills Checklist—Hospice Aide" form was documented and signed by the Registered Nurse and the Hospice Aide on 02/07/2023. The following tasks were not documented as observed on the Competency Skills Checklist form. These task were just verbalized and not observed: reading and recording pulse and respirations, bed bath, hair shampoo (sink, tub, and bed), toileting and elimination (urinal and bedpan), and safe transfer techniques (Hoyer lift). There was no documented evidence that the aide was observed reading and recording pulse and respirations, sink and tub bath, toileting (urinal) and safe transfer techniques (Hoyer Lift) in accordance with agency policy. During a joint personnel record review and interview with the Executive Director/RN (Personnel Record 2) on 04/24/2025, she confirmed that the skills in evidence were not observed. She explained that a new graduate nurse completed the Skills Checkoff, and the Business Office Manager, who was in charge of personnel records, was also new to her position. The form used then made it optional for the RN to document a task as either observed or verbalized. Additionally, the Executive Director/RN could locate the in-person supervisory visit performed by the RN on 02/07/2023 in a visit note in the patient's medical record, noted in the evidence. The Hospice Aide's plan of care that the aide performed included a bed bath, hair shampoo, and elimination with a bedpan. The Executive Director/RN (Personnel Record 2) inquired about the Public Health Emergency Waivers and if they were applicable in this circumstance. Upon review, the only applicable waiver for initial competency assessment was introducing a trained person to role-play as a patient or a computer-based mannequin device, which does not impact the evidence.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the Volunteer Department and QAPI documents on 04/21/2025 revealed that the average percentage of volunteer hours for 2024 was 0.26%. For the first quarter of 2025, the average was 1.68%. There was no documented evidence that the hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff for 2024. The volunteer hours for 2024 were 0.26%. In addition, there was no documented evidence that Volunteer QAPI Performance Improvement Project (PIP) was identified. Monthly initiatives to recruit new volunteers through flyers, colleges, churches, etc., were documented. The Volunteer Coordinator was recently hired on 02/04/2025. Additionally, retention activities were recorded monthly by the new Volunteer Coordinator to show how the volunteer coordinator is working to keep the current volunteers engaged. Since she started with the hospice, the Volunteer Coordinator had onboarded two new volunteers, had two more about to begin training, and two more submitted for background checks. During an interview with the Executive Director (Personnel Record 2) and the Volunteer Coordinator (Personnel Record 5) on 04/24/2025 the volunteer hour percentage from 2024 was confirmed. A review of the Volunteer Department and QAPI documents on 04/21/2025 revealed that the average percentage of volunteer hours for 2024 was 0.26%. For the first quarter of 2025, the average was 1.68%, which is an improvement but still under the 5% requirement. No Volunteer QAPI Performance Improvement Project (PIP) was identified. The volunteer hour percentage from 2024 was confirmed during an interview with the Executive Director (Personnel Record 2) and the Volunteer Coordinator (Personnel Record 5) on 04/24/2025. Monthly initiatives to recruit new volunteers through flyers, colleges, churches, etc., were documented. The Volunteer Coordinator was recently hired on 02/04/2025. Additionally, retention activities were recorded monthly by the new Volunteer Coordinator to show how the volunteer coordinator is working to keep the current volunteers engaged. Since she started with the hospice, the Volunteer Coordinator had onboarded two new volunteers, had two more about to begin training, and two more submitted for background checks.

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. The medication review process includes the identification of the following: the effectiveness of drug therapy and the drug's side effects. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements 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 when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (07%) clinical records reviewed did not include a review of a new medication that was added. Clinical Record 1: Election of hospice care occurred on 3/1/22. The RN documented in the progress note dated 6/20/2022. a "new order for Doxycycline 100 mg twice a day by mouth for ten days for possible infection due to high blood sugars." RN visit dated 6/27/2022, no update on effectiveness or side effects from new antibiotic ordered. IDG note dated 7/7/2022, " patient is on an antibiotic for possible infection." Medication Profile was reviewed on 7/20/22, this was not updated on the drug profile or the plan of care. During an interview with the Alternate Director of Nursing on 7/20/22, she confirmed “that the antibiotic was ordered and they forgot to add it to the drug profile on the plan of care.” In Clinical Record 1, elected hospice care 3/1/22, the RN documented in the progress note dated 6/20/2022: "new order for Doxycycline 100 mg twice a day by mouth for 10 days for possible infection due to high blood sugars". RN visit dated 6/27/2022, no update on effectiveness or side effects from new antibiotic ordered. IDG note dated 7/7/2022, " patient is on an anitbiotic for possible infection". Medication Profile reviewed on 7/20/22, this was not updated on the drug profile or the plan of care. During an interview with the Alternate Director of Nursing on 7/20/22, she confirmed “that the Antibiotic was ordered and they forgot to add it to the drug profile on the plan of care”.

It is required that the hospice designates an Interdisciplinary Group or groups that, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 13 (08%) clinical records reviewed did not meet the specific patient needs identified in the comprehensive assessment. Record 1: The start of care was 3/1/22, on admission, the RN documented in the comprehensive assessment that the patient was at high risk for falls as evidenced by "shortness of breath at rest, limited mobility, and increased weakness." On 7/20/22, the Plan of Care did not include interventions or goals for fall prevention. In the IDT note written by the Chaplain on 3/10/22, "patient is unable to ambulate and should be assisted when walking to avoid a fall." The Alternate Director of Nursing reviewed the care plan on 7/20/22 and confirmed during an interview that the high risk for falls was not addressed in the care plan. Record 1 , start of care 3/1/22, on admission it was documented that the patient was a high risk for falls as evidenced by "shotness of breath at rest, limited mobility, and increased weakness". On 7/20/22 there was not a written plan of care for falls. In the IDT note written by the Chaplain, 3/10/22, "patient is unable to ambulate and should be assisted when walking to avoid a fall". Current care plan effective 7/20/22 did not address a care plan for the high risk for falls. The alternate director of nursing reviewed the care plan, 7/20/22, and confirmed during an interview on 7/20/22 that the high risk for falls was not addressed in the care plan.