Every finding on record at Heaven and Earth Hospice, LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #1-036, "Interdisciplinary Group Coordination of Care," stated in part, "The type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions... " In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care reflected the patient and family's goals of care. Clinical Record 1: The patient elected the hospice benefit on 08/12/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided in an assisted living facility (ALF). The Registered Nurse (RN) visit note dated 08/19/2024 documented, "Pt COVID positive, increased coughing, has guafenesin, was started on Levaquin 500mg x7d, productive cough ...lung sounds diminished bilaterally, patient congested with rhonchi, on 3L 02 NC continuously, O2 sats 96% ... keeps rubbing eyes, eyes are irritated, c/o a stye ... started on gentamycin eye drops ..." On 08/19/2024, the physician ordered "Levaquin 500mg by mouth daily for seven days" and Gentamycin Eye Drops 0.3%: one (1) drop each eye four times a day for seven days." The Interdisciplinary Group Meeting dated 08/23/2024 documented the order dated 08/19/2024 for Levaquin and Gentamycin and the nurse note documented "Pt COVID positive, increased coughing, has guaifenesin, was started on Levaquin 500mg x7d, productive cough ...lung sounds diminished bilaterally, patient congested with rhonchi, on 3L 02 NC continuously, O2 sats 96% ... keeps rubbing eyes, eyes are irritated, c/o a stye ... started on gentamycin eye drops ... and the goal for next two weeks was to continue to monitor the patient and adjust care as needed." The patient's plan of care did not reflect the patient's or family's goals related to the treatment with Levaquin and Gentamycin eye drops. Clinical Record 6: The patient elected the hospice benefit on 11/30/2023 with a diagnosis of COPD. The patient resided in a nursing facility (NF). The coordination note dated 09/06/2024 documented, "(nurse) from (facility) called and stated that (patient) choked this am and she thinks he may have aspirated. Wanted to know if he may need an antibiotic...." On 09/06/2024, the physician ordered "Rocephin 1GM intramuscular injection every twenty-four hours for three days for possible aspiration pneumonia. The IDG meeting dated 09/11/2024 documented "had an episode of choking leading to aspiration... lung file revealed crackles and wheezing in trachea ... Rocephin 1GM was ordered IM x3 days.... crackles were resolved... He has a pureed diet and is at a higher risk for aspiration ...goals for next two weeks - monitor comfort." The patient's plan of care did not identify the patient's or family's goals for the patient's risk for aspiration or treating a potential aspiration pneumonia with an antibiotic. Clinical Record 12: The patient elected the hospice benefit on 08/27/2024 with a diagnosis of COPD. The Interdisciplinary Group Meeting (IDG) dated 09/06/2024 included documentation of the physician order dated 08/29/2024 for Trazadone 150mg: two tablets by mouth at bedtime, and the RN note documenting "Goal for the next two weeks: continue to monitor and adjust care. RN: ...takes Trazodone for sleep..." The IDG meeting dated 09/20/2024 included documentation of the physician order dated 09/16/2024 for Robitussin Cough and Cold: 5ml by mouth three times a day as needed for coughing, and the RN note documenting, "Goal for next two weeks: continue to monitor and adjust care. RN: ...Pt has a cough and is taking cough syrup... gout in hands bilat takes allopurinol ... uses 2.5L NC 02 PRN and at night, uses albuterol nebs BID, productive cough ... 1+ edema BLE ... still has a productive cough, taking Robitussin DM x5 days. Pt stated he walked down to the end of the hall with physical therapy ...." The IDG meeting dated 10/04/2024 included documentation that the dose for Trazodone was changed in an order dated 10/04/2024 to Trazodone 150mg by mouth at bedtime and the RN note documenting "Goal for next two weeks: continue to monitor and adjust care. RN: "... has a productive cough, diminished breath sounds ... 2+ edema BLE ... " The patient's plan of care did not reflect the patient's or family's goals related to using Trazodone for sleep or the new onset of coughing requiring cough medicine. During an interview and a joint record review on 10/09/2024, the Area Manager of Accreditation and Regulation confirmed the findings. No further documentation of patient or family goals for the care was presented before the exit conference.

It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan: information from the patient’s updated comprehensive assessment; [and] record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met, as evidenced by clinical record review, document review, and interview. Agency policy #1-037 “Interdisciplinary Group Meetings” stated in part, “... The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care ... A plan of care update will be completed or updated for each patient and family/caregiver no less frequently than every fifteen (15) days ... Such updates will include progress toward targeted outcomes...” In 15 of 19 (79%) clinical records reviewed, the agency did not ensure that there was documentation of how the patient was progressing toward established goals noted in the plan of care. Clinical Record 1: The patient elected the hospice benefit on 08/12/2024. The Interdisciplinary Group Meetings dated 08/23/2024, 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 08/12/2024 through 11/09/2024. Clinical Record 2: The patient elected the hospice benefit on 06/12/2024. The Interdisciplinary Group Meetings dated 06/14/2024, 06/28/2024, 07/11/2024, 07/26/2024, 08/09/2924, 08/23/2024, 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 06/12/2024 through 07/07/2024 and 07/08/2024 through 09/05/2024. Clinical Record 3: The patient elected the hospice benefit on 09/05/2024. The Interdisciplinary Group Meetings dated 09/18/2024 and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 09/05/2024 through 10/12/2024. Clinical Record 5: The patient elected the hospice benefit on 11/28/2023. The Interdisciplinary Group Meetings dated 07/03/2024, 07/17/2024, 07/31/2024, 08/14/2024, 08/28/2024, 09/11/2024, 09/25/2024, and 10/09/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 05/12/2024 through 07/10/2024, 07/11/2024 through 09/08/2024, and 09/09/2024 through 11/07/202. Clinical Record 6: The patient elected the hospice benefit on 11/30/2023. The Interdisciplinary Group Meetings dated 08/14/2024, 08/28/2024, 09/11/2024, 09/25/2024, and 10/09/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 07/27/2024 through 09/24/2024 and 09/25/2024 through 11/23/2024. Clinical Record 7: The patient elected the hospice benefit on 04/25/2024. The Interdisciplinary Group Meetings dated 08/14/2024, 08/28/2024, 09/11/2024, 09/25/2024, and 10/09/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 07/24/2024 through 09/21/2024 and 09/22/2024 through 11/20/2024. Clinical Record 8: The patient elected the hospice benefit on 03/16/2024. The Interdisciplinary Group Meetings dated 08/23/2024, 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 06/14/2024 through 09/11/2024 and 09/12/2024 through 11/10/2024. Clinical Record 11: The patient elected the hospice benefit on 05/17/2024. The Interdisciplinary Group Meetings dated 07/11/2024, 07/26/2024, 08/09/2924, 08/23/2024, 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 05/31/2024 through 08/28/2024 and 08/29/2024 through 11/26/2024. Clinical Record 12: The patient elected the hospice benefit on 08/27/2024. The Interdisciplinary Group Meetings dated 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 08/27/2024 through 11/24/2024. Clinical Record 13: The patient elected the hospice benefit on 07/11/2024. The Interdisciplinary Group Meetings dated 07/26/2024, 08/09/2924, 08/23/2024, 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 07/11/2024 through 09/08/2024 and 09/09/2024 through 11/07/2024. Clinical Record 14: The patient elected the hospice benefit on 09/05/2024. The Interdisciplinary Group Meetings dated 09/18/2024 and 10/02/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 09/05/2024 through 10/07/2024. Clinical Record 15: The patient elected the hospice benefit on 11/30/2023 and revoked the hospice benefit on 07/15/2024. The Interdisciplinary Group Meetings dated 05/08/2024, 05/22/2024, 06/05/2024, 06/19/2024, 07/03/2024, and 07/17/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care 04/28/2024 through 06/26/2024 and 06/27/2024 through 08/25/2024. Clinical Record 16: The patient elected the hospice benefit on 09/13/2024 and revoked the hospice benefit on 10/01/2024. The Interdisciplinary Group Meetings dated 09/20/2024 and 10/03/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 09/13/2024 through 12/11/2024. Clinical Record 18: The patient elected the hospice benefit on 08/24/2024 and died on hospice services on 09/22/2024. The Interdisciplinary Group Meetings dated 09/06/2024, 09/20/2024, and 10/04/2024 did not include documentation of progress toward the outcomes and goals specified in the plan of care dated 08/24/2024 through 11/21/2024. Clinical Record 19: The patient elected the hospice benefit on 12/06/2023 and died on hospice services on 03/07/2024. The Interdisciplinary Group Meetings dated 01/03/2024, 01/17/2024, 01/31/2024, 02/14/2024, 02/28/2024, and 03/13/2024 did not include documentation of progress toward the outcomes and goals specified in the plans of care dated 12/06/2023 through 02/03/2024 and 02/04/2024 through 04/03/2024 During a joint record review and interview on 10/09/2024, the Area Manager of Accreditation and Regulation confirmed no progress toward goals was identified for each patient in their care plan. The evidence in the clinical record was the date the goal was identified only. Some goals were completed/removed, and that date was noted, but there was no evidence between the initiation of the goal and the completion of the goal documented.

It is required that the hospice’s policies and procedures define a system of communication and integration that sustains coordination of services and provides documentation of exchange of information. The policies and procedures ensure that the Interdisciplinary Group maintains responsibility for directing, coordinating, and supervising the care and services provided. Sharing of information occurs and is ongoing with other non-hospice healthcare providers providing services unrelated to the terminal illness and related conditions. This standard was not met as evidenced by clinical record review, observation, document review, and interview. Agency policy #1-006, "Care/Service Coordination," stated in part, "Care coordination will include, but not be limited to ... Timely documentation of coordination of care activities ... Integration of services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect the patient safety and treatment effectiveness and the coordination of care provided by all disciplines ... Documentation of communications will be included in the medical record on a communication note, case conference summary, or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. Written evidence of care coordination may be found in the plan of care/service, discipline-specific notes in the patient's medical record, or the interdisciplinary group meeting notes. Personnel involved in patient care/service, including those providing contracted services, will have access to the plan of care and other relevant patient information to ensure coordination and continuity. Personnel will be knowledgeable regarding patient needs, goals of care, and service. Contract personnel will provide all services according to the patient's plan of care; submit documentation of services provided including clinical notes, schedule of visits, and patient evaluations/assessments ..." In 1 of 1 (100%) clinical records reviewed of patients who received non-hospice healthcare services, the agency did not ensure that sharing of information occurred with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Clinical Record 12/Home Visit 3: The patient elected hospice care on 08/27/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The patient resided at an assisted living facility (ALF). The physician's certification of terminal illness for the benefit period dated 08/27/2024 through 11/24/2024 documented: "Getting physical therapy ..." The Skilled Nurse (SN) documented for the Interdisciplinary Group Meeting (IDG) dated 09/06/2024, "Pt stated he walked down to the end of the hall with physical therapy ...." The Registered Nurse (RN) visit note dated 09/10/2024 documented that the patient received "physical therapy 3x WK..." During the home visit with the RN [Personnel Record 7] on 10/08/2024, the patient's brother stated that the patient was receiving physical therapy services. A clinical record review revealed no evidence of communication, sharing of information, or coordination of care with the physical therapist. During a joint clinical record review and interview on 10/10/2024, the Area Manager of Accreditation and Regulation confirmed there was no evidence of coordination between the Interdisciplinary Group and the physical therapist regarding the patient's physical therapy visits.

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, observation, and interview. In 1 of 18 (6%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure HA received written patient care instructions to meet the patient's needs. Clinical Record 19: The patient elected the hospice benefit on 12/06/2023 with a diagnosis of Alzheimer's disease. The patient resided in a nursing facility. The plan of care for the benefit period 02/04/2024 to 04/03/2024 ordered HA services five (5) times a week. The HA care plan dated 12/06/2024, with no updates, assigned the HA the relevant tasks of a shower with a shower chair and a bed bath every visit. The HA visit notes dated 03/04/2024 and 03/05/2024 documented, "Bathing completed - N...note: bed bath." The HA was not provided with specific instructions on the type of bath to provide, leaving the HA to make decisions outside their scope of practice. The Area Manager of Accreditation and Regulations confirmed the findings during a joint clinical record review and interview on 10/10/2024. The Director of Operations updated/corrected both HA care plans before the end of the site visit.

It is required that a hospice aide provides services: included in the plan of care. This standard was not met, as evidenced by clinical record review, observation, and interview. In 2 of 18 (11%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure HA provided in the plan of care. Clinical Record 13/Home Visit 1: The patient elected the hospice benefit on 07/11/2024 with the diagnosis of senile degeneration of the brain. The patient resided in a nursing facility. A review of the plans of care for the benefit periods 07/11/2024 to 09/08/2024 and 09/09/2024 to 11/07/2024 revealed that on 07/17/2024, the physician ordered an increase in the frequency of HA services from twice (2) a week to five (5) times a week, effective 07/22/2024. The HA care plan dated 08/27/2024 documented the HA frequency as twice (2) a week and assigned the HA the relevant tasks of a bed bath every visit. During the home visit with the Hospice Aide (HA) [Personnel Record 12] on 10/08/2024, the HA stated they performed care on Tuesdays and Thursdays, and the other three days were "social visits." The HA visit notes dated 09/09/2024, 09/11/2024, 09/12/2024, 09/16/2024, 09/18/2024, 09/19/2024, 09/23/2024, 09/25/2024, 09/27/2024, 09/30/2024, 10/04/2024, and 10/08/2024 documented "social visit" for all interventions. The HA did not provide the bed bath every visit as assigned in the plan of care. Clinical Record 19: The patient elected the hospice benefit on 12/06/2023 with a diagnosis of Alzheimer's disease. The patient resided in a nursing facility. The plan of care for the benefit period 02/04/2024 to 04/03/2024 ordered HA services five (5) times a week. The HA care plan dated 12/06/2024, with no updates, assigned the HA the relevant tasks of a shower with a shower chair and a bed bath every visit. The HA visit notes dated 03/04/2024 and 03/05/2024 documented, "Bathing completed - N...note: bed bath." The HA did not provide the shower with a shower chair and bed bath every visit as assigned in the plan of care. During a joint clinical record review and interview on 10/10/2024, the Area Manager of Accreditation and Regulations confirmed the findings. The Director of Operations updated/corrected both HA care plans before the end of the site visit.

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 #1-027, "Discharge Summary," stated in part, "A copy of the discharge summary will be provided to the patient's Attending Physician..." In 2 of 2 (100%) clinical records reviewed of patients with a live discharge, the agency did not ensure that the discharge summary was sent to the attending physician. Clinical Record 15: The patient elected hospice care on 11/30/2023 with a diagnosis of chronic kidney disease stage 3B and revoked the election of hospice care on 07/15/2024 to pursue rehabilitative physical, occupational, and speech therapy. The patient resided in a nursing facility. A clinical record review revealed no documentation that the patient's discharge summary or clinical information was forwarded to the attending physician upon discharge. Clinical Record 16: The patient elected hospice care on 09/13/2024 with a diagnosis of chronic diastolic congestive heart failure and revoked the election of hospice care on 10/01/2024 to pursue aggressive treatment. A clinical record review revealed no documentation that the patient's discharge summary or clinical information was forwarded to the attending physician upon discharge. During a joint record review and interview on 10/10/2024, the Area Manager of Accreditation and Regulation confirmed no discharge summary or clinical information was forwarded to either patient's attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, and the patient’s latest physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #1-027 "Discharge Summary" stated in part, "Hospice will have a discharge summary completed and maintained in the medical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include as appropriate: The date of discharge, the date the Physician and the patient informed of discharge; The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable; The status of problems identified at admission and during the provision of care ... Continuing symptom management needs ... A summary of the care or service provided; The patient's current plan of care; The patient's latest physician orders. The discharge summary will be completed within 72 hours of discharge ... " In 2 of 2 (100%) clinical records reviewed of patients with a live discharge, the agency did not ensure that a summary of the patient's hospice stay was documented in the patient's clinical record upon hospice discharge. Clinical Record 15: The patient elected hospice care on 11/30/2023 with a diagnosis of chronic kidney disease stage 3B and revoked the election of hospice care on 07/15/2024 to pursue rehabilitative physical, occupational, and speech therapy. The patient resided in a nursing facility. A clinical record review revealed no evidence that a discharge summary, including a summary of the patient’s hospice stay, was documented. Clinical Record 16: The patient elected hospice care on 09/13/2024 with a diagnosis of chronic diastolic congestive heart failure and revoked the election of hospice care on 10/01/2024 to pursue aggressive treatment. A clinical record review revealed no evidence that a discharge summary, including a summary of the patient’s hospice stay, was documented. During a joint record review and interview on 10/10/2024, the Area Manager of Accreditation and Regulation confirmed that neither patient's clinical record included a discharge summary that included a summary of the hospice stay and symptom management, plan of care, or physician orders. Additionally, there was no evidence that any clinical information was forwarded to the attending physicians upon discharge to assist with continuity of care.

Based on record review and interview, the hospice failed to ensure imminence of death was assessed during the comprehensive assessment for six (Patients #1, 3, 7, 9, 10 and 11 ) of eleven patients. Findings: Patient #1 A review of the Initial Assessment dated 01/14/22 showed no assessment of imminence of death. Patient #3 A review of the Initial Assessment dated 01/04/22 showed no assessment of imminence of death. Patient #7 A review of the Initial Assessment dated 04/07/22 showed no assessment of imminence of death. Patient #9 A review of the Initial Assessment dated 03/31/22 showed no assessment of imminence of death. Patient #10 A review of the Initial Assessment dated 03/31/22 showed no assessment of imminence of death. Patient #11 A review of the Initial Assessment dated 03/17/22 showed no assessment of imminence of death. On 04/14/22 at 1:26 pm, Staff B stated imminence of death was not assessed on the comprehensive assessment for Patients #1, 3, 7, 9, 10 and 11.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eight (Patients #1, 3, 4, 5, 6, 9, 10 and 11) of eleven patients reviewed. Findings: Patient #1 A review of the plan of care dated 01/14/22 to 04/13/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A plan of care dated 01/04/22 to 04/03/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A plan of care dated 12/30/21 to 03/29/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 12/02/21 to 03/01/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 01/31/22 to 03/31/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 03/31/22 to 06/28/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 03/31/22 to 06/28/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 03/17/22 to 06/14/22 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 04/14/22 at 1:26 pm, Staff B stated the plans of care for Patients #1, 3, 4, 5, 6, 9, 10 and 11 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure implementation of PIPs for all employees and all patients on service from April 8th, 2021 to April 14th, 2022. Findings. A review of agency records for 2021 showed one PIP closed on 04/08/21. A review of agency records documented no implementation or review of PIPs from 04/08/21 to 04/14/22. On 04/14/22 at 1:15 pm, Staff B stated there were no PIPs implemented for the hospice from April 8th, 2021 to April 14th, 2022.

Based on a record review and interview, the governing body failed to ensure an agency specific QAPI program was evaluated annually for all 35 patients on hospice services and all agency staff for 2020 and 2021. A review of administrative records showed no governing body review of the agency specific QAPI program for 2020 and 2021. On 04/14/22 at 1:55 pm, Staff B stated the governing body minutes did not show review of the agency specific QAPI for the hospice in 2020 and 2021.

Based on record review and interview, the hospice failed to ensure governing body oversight of ongoing operations of the patient care delivery systems for calendar years 2020 and 2021 effecting all 35 patients and staff. Findings: A review of administrative records showed no governing body oversight of ongoing operations of the patient care delivery systems specific to the hospice in the calendar years of 2020 and 2021. On 04/14/22 at 1:55 p.m., Staff B stated there was no documentation which showed evidence of governing body oversight of ongoing operations of the patient care delivery systems specific to the hospice in calendar years 2020 and 2021.