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

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: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. Agency policy TX.06 "Plan Of Care Process" (reviewed 01/01/2020) stated in part, "The plan of care includes, but is not limited to, measurable outcomes anticipated from implementing and coordinating the plan of care." In 6 of 16 (38%) clinical records reviewed, the agency did not ensure that each patient's plan of Care (POC) included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected the hospice benefit on 06/27/2024 with the diagnosis of acute respiratory failure. The initial comprehensive assessment identified the problem of "alteration in comfort." The POC dated 06/27/2024 documented the patient's goal: "Pt/caregiver understand the cause of pain." The goal statement did not include a measurable outcome. Clinical Record 3: The patient elected the hospice benefit on 05/31/2024 with a diagnosis of malignant neoplasm of the left bronchus. The initial comprehensive assessment identified the problem of "alteration in comfort." The POC dated 05/31/2024 documented the patient's goal: "Pain will be managed." The goal statement did not include a measurable outcome. Clinical Record 7: The patient elected the hospice benefit on 07/27/2024 with a diagnosis of acute respiratory failure. The initial comprehensive assessment identified the problem of "alteration in comfort." The POC dated 07/07/2024 documented the patient's goal: "Pt's pain will be managed with current medication." The goal statement did not include a measurable outcome. Clinical Record 10: The patient elected the hospice benefit on 09/09/2022 with a diagnosis of malignant neoplasm of the head, face, and neck. The initial comprehensive assessment identified the problem of "alteration in comfort pain." The POC dated 09/09/2022 documented the patient's goal: "Pt exhibits reduction/relief of any pain symptoms." The goal statement did not include a measurable outcome. Clinical Record 15: The patient elected the hospice benefit on 01/01/2022 with a diagnosis of malignant neoplasm unspecified female breast. The initial comprehensive assessment identified the problem of "alteration in comfort." The POC dated 01/01/2022 documented the patient's goal "Pt/caregiver understand the cause of pain." The goal statement did not include a measurable outcome. Clinical Record 16: The patient elected the hospice benefit on 07/12/2022 with a diagnosis of malignant neoplasm pancreas unspecified. The initial comprehensive assessment identified the problem of "alteration in comfort." The POC dated 07/12/2022 documented the patient's goal: "Pt's pain will be managed." The goal statement did not include a measurable outcome. During an interview and a joint record review on 08/27/2024, the Area Clinical Manager confirmed that the Plans of Care did not include measurable outcomes.

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. Agency policy #TX.07 "Implementing Care and Treatment." stated in part, "The aide will be provided with written instructions for patient care by an RN." In 1 of 11 (9%) clinical records reviewed of patients receiving Hospice Aide (HA) services, the agency did not ensure the HA received written patient care instructions specific to the patient's care needs. Clinical Record 13: The patient elected hospice care on 05/04/2022 with a diagnosis of end-stage renal disease. The HA care plan dated 05/04/2022 assigned the HA the relevant task: shave the patient as requested. The HA did not receive instructions regarding the frequency of shaving the patient. During an interview and a joint clinical record review, the Area Clinical Manager confirmed that the aide care plan written by the RN did contain specific instructions for the aide to follow.

It is required that If a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy # PE.3 "Patient Transfer" stated in part, "If the care of a patient is transferred to another Medicare/Medicaid-certified facility, (the agency) will forward to the receiving facility a copy of the hospice discharge summary; and the patient's clinical record if requested." In 1 of 2 (50%) clinical records reviewed of patients transferred to another facility, the agency did not ensure that a discharge summary was forwarded to the receiving facility. Clinical Record 6: The patient elected hospice care on 08/22/2023 and transferred to a hospital on 09/07/2023 to seek aggressive treatment. A clinical record review revealed no evidence that the Transfer/Discharge Summary was forwarded to the receiving hospital. During an interview and a joint clinical record review on 08/27/2024, the Area Clinical Manager confirmed that a discharge summary was not forwarded to the receiving hospital.