Every finding on record at Heavenly Healthcare LLC

Observed in Environment of Care Session. During the Emergency Management session for the Hospice program, it was noted that the organization did not activate its Emergency Operations plan during the year 2024 in response to either an actual emergency or as a planned exercise. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 1 of 2 discharged records reviewed, it was noted that the patient’s right to be notified when Medicare covered services were ending and the right to appeal the decision was not implemented. For example, a review of the medical record for HosRRDC#2, revealed no documented evidence that a Notice of Medicare Non-Coverage form was completed prior to the patient being discharged from Hospice services. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 4 of 10 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record(s) for HosRRHV#3, HosRRNHV#2, HosRRNHV#3, and HosRRNHV#4, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 6 of 10 patient records reviewed, it was noted that the organization did not ensure medication orders were clear and accurate. For example, during a review of the medical record(s) for HosRRHV#1, HosRRHV#2, HosRRHV#3, and HosRRNHV#4, HosRRNHV#5, and HosRRNHV#6, the following order was noted: Oxygen, 2-5 lpm Inhale prn, daily as needed, shortness of breath, O2 below 90%. The order did not include the device for oxygen administration. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the Certification of Terminal Illness statement(s) for benefit period #1, for HosRRNHV#2, and HosRRNHV#4, and HosRRNHV#7, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for certification of hospice services. This area of the document was left blank. Example #2: A review of the Certification of Terminal Illness statement(s) for benefit period #1, and benefit period #2, for HosRRNHV#3, and HosRRNHV#6, revealed that the Certifying Physician Summary did not document clinical information to support the medical prognosis and support for certification of hospice services. This area of the document was left blank. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not implement its policy related to entries in the medical record. For example, during the review of the medical record for HosRRHV#2, it was noted that 9 weeks after the start of care date the Physician’s signature line on the Certification of Terminal Illness statement for benefit period #1, did not include a signature and date. This observation was reviewed with the agency leadership team.

Observed in Record Review. In 4 of 4 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable. For example, “Symptoms of disease process will be managed” and “Patient will be free of injury.” Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility, or safety, none of the goals had a timeframe for completion. Findings were verified by the Administrator/COO and Hospice Nurse.

Observed in Patient Home. In 2 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy IC.15”. For example, during RRHV#1 the hospice aide did not hand sanitize/change her gloves after touching the patient then touching the surrounding area, then touching the patient again. During RRHV#3 the skilled nurse, did not hand sanitize after cleaning her equipment. Findings were verified by the Administrator/COO who was present during the home visits. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Bag Technique Policy IC.60”. During RRHV#3, the skilled nurse set her bag down on a barrier on the patient’s bedroom floor. Additionally, she went in and out of her bag to get hand sanitizer and clean gloves prior. Finding was verified by the Administrator/COO who was present during the home visit. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per the “Bag Technique Policy IC.60”. During RRHV#3 the skilled nurse put a barrier down on the patient’s bed. She then laid out her equipment and proceeded to clean the equipment prior to use and then placed them back on the same barrier. After using the equipment on the patient, she cleaned them again and put them right into her nursing bag without allowing for drying. Finding was verified by the Administrator/COO who was present during the home visit.

Observed in Record Review. In 1 of 4 patient records reviewed, for active patients, it was noted by the nurse surveyor that hospice aide supervisory visits had not been made withing the required 14 days. For RRNHV#1, a Hospice Aide Supervisory visit has not been made since the hospice aide started seeing the patient 23 days ago., not the required 14 days. Finding was verified by the Administrator/COO and Hospice Nurse.