Every finding on record at Heartland Hospice Inc.

Upon patient record review 1 of 14 (Patient #7) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #7 The patient elected the hospice benefit on 2/27/25. The EMR showed a start of care date for 03/13/25. The initial nursing comprehensive assessment was not completed until 03/13/25.

Upon patient record review 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #7 The patient elected the hospice benefit on 2/27/25. The EMR showed a start of care date for 03/13/25. The comprehensive assessment by all disciplines was not completed until 03/13/25.

Upon patient record review, 2 of 14 (Patient #3,10) 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 #3 The nursing comprehensive assessment dated 04/01/25 showed evidence that patient is receiving continuous oxygen at 2LPM as documented in the nursing narrative as well as in the respiratory assessment area. This is not listed on the medication profile. Patient #10 The nursing comprehensive assessment dated 02/27/25 showed that the nurse documented in the narrative that the patient is a diabetic and that diabetes was being controlled with an oral diabetes medication. This is not listed on the medication profile.

Upon patient record review, 1 of 14 (Patient #7) 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 #7 The patient elected the hospice benefit on 2/27/25. The EMR showed a start of care date for 03/13/25. The initial bereavement assessment was not completed until 03/13/25.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #9 The medical record shows patient primary diagnosis is COPD and patient is utilizing an Albuterol inhaler for symptom management. There is no evidence that training on proper usage of the inhaler was provided to patient/caregiver.

Upon patient record review, 5 of 14 (Patient #1,3,5,6,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1 The nursing comprehensive had documentation which showed patient was a diabetic and had listed this as a related diagnosis. There was no evidence of problems, goals or interventions related to the endocrine system. Patient #3 The nursing comprehensive had documentation which showed patient was assessed to be at high risk for skin breakdown as evidenced by a documented 11 on the Braden Risk Assessment. There was no evidence of problems, goals or interventions related to the integumentary system. In addition, the social worker comprehensive assessment was completed on 04/03/25 and reviewed plan of care however did not document that coping strategies was a goal of care. Patient #5 The patient medication list showed evidence that patient was taking Bisacodyl daily for constipation. There was no evidence of problems, goals or interventions related to constipation. Patient #6 The social worker comprehensive assessment was completed on 03/17/25 and reviewed plan of care however did not document that coping strategies was a goal of care. Patient #10 The nursing comprehensive showed evidence that the patient is a diabetic and is taking an oral anti-diabetic medication. There was no evidence of problems, goals, or interventions related to the Endocrine system.

Upon patient record review, 2 of 14 (Patient #3,10) 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 #3 The nursing comprehensive assessment dated 04/01/25 showed evidence that patient is receiving continuous oxygen at 2LPM as documented in the nursing narrative as well as in the respiratory assessment area. There is no evidence that a physician order for the oxygen was received or documented. Patient #10 The nursing comprehensive assessment dated 02/27/25 showed that the nurse documented in the narrative that the patient is a diabetic and that diabetes was being controlled with an oral diabetes medication. There is no evidence that a physician order for that oral diabetes agent was received or documented.

Upon patient record review, 3 of 14 (Patient #1,3,4) 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 Documentation on the nursing comprehensive assessment dated 04/14/25, noted patient was using a hospital bed and shower chair for their DME needs. There was no evidence that this equipment was listed on the plan of care. Patient #3 Upon completed home visit, the patient mentioned that the nebulizer treatment is effective for symptoms of shortness of breath. The medication list also included an order for nebulized medication. There was no evidence that the nebulizer was listed on the plan of care. Patient #4 Documentation on the nursing comprehensive assessment dated 03/18/25, noted patient had the following equipment: hospital bed, cane, walker, wheelchair and shower chair. There was no evidence that the equipment was listed on the plan of care.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 12 The IDG notes did not validate MSW involvement with signatures on the IDG's on 1/8/25, 1/16, 1/30, 2/13, 2/27, 3/13, 3/27, 4/10, 4/24, and 5/22. These patients were receiving MSW visits. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 There was evidence of an order for MSW visits for "1 time every certification period to provide support to the family." Neither the order or comprehensive assessment outlined coping strategies as a goal of care. There were no other visit notes from the MSW subsequent to the comprehensive assessment.

Upon patient record review 2 of 14 (Patient #3,6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #3 The medical record showed the MSW documented on the IDG's for 04/10/25, 04/24/25, 05/08/25, and 05/22/25 "social worker will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family". Neither the order or comprehensive assessment outlined coping strategies and there were no other visit notes from the MSW subsequent to the comprehensive assessment. There was not evidence that care and services were not provided based on the assessment and patient and family needs. Patient #6 The medical record showed the MSW documented on the IDG's for 03/27/25; 04/10/25, 04/24/25, 05/08/25, and 05/22/25 "social worker will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family". Neither the order or comprehensive assessment outlined coping strategies as a goal of care and there were no other visit notes from the MSW subsequent to the comprehensive assessment. There was not evidence that care and services were not provided based on the assessment and patient and family needs.

Upon patient record review, 2 of 14 (Patient #5,7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5 The Hospice Medicare Election statement does not clearly identify the effective date for which patient chose to initiate hospice. The documents were signed on 03/15/25. On page 2 of 5, the section for which the patient/family was to document the start of care date was left blank. Patient #7 On page 2 of 5 on the Hospice Medicare Election statement, the date the patient elected the hospice benefit was written at 2/27/25. The EMR showed a start of care date for 03/13/25. The nursing comprehensive assessment was also completed on 03/13/25.

Upon patient record review, 2 of 14 (Patient #3,6) 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 #3 The medical record showed the MSW documented on the IDG's for 04/10/25; 04/24/25; 05/08/25 and 05/22/25 "social worker will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family". This same exact documentation was presented on each IDG note. Patient #6 The medical record showed the MSW documented on the IDG's for 03/27/25; 04/10/25; 04/24/25; 05/08/25 and 05/22/25 "social worker will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family". This same exact documentation was presented on each IDG note.

Upon patient record review, 2 of 5 records (Patient #1, #4 ) 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. Patient 1: Medication profile dated 3/1/2022 included Diclofenac Sodium 1% topical gel 2 g gel apply to painful area 4x daily for pain. There was no evidence of a site. Corrected on site. Patient 4: 1/12/2022 Med profile included O2 2L/M via nc as needed for SOB/Wheeze. Physician order dated 1/12/2022 0900 included same verbiage as med profile. A second Dr order dated 1/12/2022 0900 included Oxygen 2-5 L/M via nc for SOB. Missing evidence of Oxygen at 2-5LPM on the med profile.

Upon patient record review, 2 of 5 records (Patient #1, #4) 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 1: Order dated 3/1/2022 included Diclofenac Sodium 1% topical gel apply to painful area 4x daily for pain. There was no evidence of a site. Corrected on site. Patient 4: Physician order dated 1/12/2022 0900 for O2 2L/M via nc as needed for SOB/Wheeze. A second physician order dated 1/12/2022 0900 included Oxygen 2-5 L/M via nc for SOB. On Care plan dated 1/12/2022 there are two separate entries, one states O2 2L via nc 2 hours a day as needed. The second entry same day states O2 2L/min via nc as needed. There was no evidence of a clear order or direction on the care plan for the O2.

Upon client record review, 1 of 5 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: In patient nurses notes dated 4/4/2022 and 4/18/2022 documented give 2 LPM O2 via NC, O2 concentrator next to bed. There are no orders for the O2.