Every finding on record at Hearth Hospice of Tennessee, LLC

Upon patient record review, 3 of 27 (Patient #6,7,13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 6: The medical record contained nursing documentation upon admission and continuous RN routine assessments that indicated the patient uses BiPap at night. There was no evidence that BiPap oxygen orders were added to the current medication list. Corrected on site. Patient 7: The nursing documentation indicated that patient had Miralax in the home and it was being used to help treat constipation. No evidence that Miralax was added to current medication list. Corrected on site Patient 13: The medication list contains 2 entries for Lorazepam. The first entry is for Lorazepam every 4 hours via J-tube. The second entry is for Lorazepam every 6 hours applied topically. No evidence that instructions were given on when to use which form of Lorazepam. Corrected on site.

Upon patient record review, 7 of 27 (Patient #8,9,11,12,13,15,19) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Admitted on 01/01/2025, completed during the survey, 05/20/2025 Patient 9: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Admitted on 12/09/2024, completed during the survey, 05/20/2025 Patient 11: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Admitted on 06/26/2024, completed during the survey, 05/20/2025. Patient 12: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Patient admitted on 11/18/2024, completed during the survey, 05/20/2025. Patient 13: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Patient admitted on 10/04/2024, completed on 05/15/2025 Patient 15: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Patient admitted on 01/09/2025, completed on 05/13/2025. Patient 19: No evidence that the bereavement risk assessment was completed within 5 days of election of benefits. Patient admitted on 10/27/2024 completed on 11/12/2024

Upon patient record review, 4 of 27 (Patient #6,7,9,13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The medical record contained nursing documentation upon admission and continuous RN routine assessments that indicated the patient uses BiPap at night. There was no evidence of an order for BiPap on the current plan of care. Corrected on site. Patient 7: The nursing documentation indicated that patient had Miralax in the home and was being used to help treat constipation. No evidence of an order for Miralax was received. Corrected on site. Patient 9: The current plan of care contains wound care orders for barrier cream to be applied the area of sheering on the inner thighs. No evidence that a frequency was included with the order. Corrected on site Patient 13: The medication list contains 2 entries for Lorazepam. The first entry is for Lorazepam every 4 hours via J-tube. The second entry is for Lorazepam every 6 hours applied topically. No evidence that instructions were given on when to use which form of Lorazepam. Corrected on site.

Upon patient record review, 3 of 27 (Patient #1,17,19) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record indicated that the patient uses a Hoyer lift daily for mobility. No evidence that the Hoyer lift was listed on the current DME list. Corrected on site. Patient 17: The medical record indicated that the patient uses a Hoyer lift with transfers. Aide plan of care contains instructions for a Hoyer lift to be used when transferring. No evidence that the Hoyer lift was listed on the current DME list. Corrected on site. Patient 19: The medical record indicated that agency was providing wound care supplies for the patient. No evidence that the wound care supplies was included on the current supply list. Corrected on site.

Upon patient record review, 2 of 27 (Patient #15,20) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 15: The aide plan of care has orders for the aide to shower the patient at the request of the pt/caregiver as needed. No evidence that a frequency was assigned. Corrected on site. Patient 20: The aide plan of care has orders for the aide to shower and shampoo as needed. No evidence that a frequency was assigned to either task. Corrected on site.

Upon patient record review 2 of 27 (Patient #9, 17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 9: The medical records has missed visit notes for the aide visit on 01/23//2025 for aide missed visit due to "CNA called in", missed aide visit on 03/04/24 due to "staff illness", missed aide visit on 04/29/25 due to "staff illness". No evidence that CG/patient refused the visit or an order was received to decrease frequency for those weeks. Patient 17: The aide plan of care has orders for the aide and to perform a complete bed bath every Thursday and to perform a shower on every Tuesday. The documentation indicated that the aide completed both task on 01/09/25, 01/14, 01/16, 01/28, 01/30, 02/04, 02/06, 02/11, 02/20, 2/25, 03/04, 03/06, 03/11, 03/13, 03/18, 03/20, 03/25, 03/27, 04/01, 04/03, 04/08, 04/10, 04/15, 04/17, 04/22, 04/24, 04/29, 05/01, 05/06, 05/08.

Upon patient record review 1 of 27 (Patient #19) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 19: No evidence that an RN completed an on-site visit every 14 days between 03/17/2025 and 04/09/2025, 23 days between supervised visits.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The documentation indicated that the volunteer percentage for the provider number 2024 was 3.41%.

Upon patient record review, 1 of 27 (Patient #10) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 10: The medical record contained nursing clinical notes that were copied and pasted to several nursing assessments. The nursing notes written on 04/03/25, 04/08, 04/11, and 04/15 were the same note.

Upon patient record review, 1 of 27 (Patient #19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 19: The plan of care has RN visits ordered as one visit a week. No evidence that a SN visit occurred during the week 0f 03/23/25. No evidence that the visit was missed at the request of the patient/caregiver or that the MD ordered a change in frequency for the week.

Upon patient record review, 2 of 27 (Patient #9,19) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 9: The current plan of care contains wound care orders for barrier cream to be applied to the area of sheering on the inner thighs. No evidence that those orders identified who is responsible performing the wound care, hospice staff or facility staff. Corrected on site Patient 19: Wound care orders on the plan care. No evidence that the order included who is responsible for performing the wound care, hospice staff or facility staff. Corrected on site