Every finding on record at Lion Heart Hospice Inc

Upon patient record review, 5 of 14 (Patients # 6, 7, 8, 9, 10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #6) The comprehensive assessment dated 7/3/25, there was no evidence of documentation regarding imminence of death. Patient #7) The comprehensive assessment dated 6/14/25, there was no evidence of documentation regarding imminence of death. Patient #8) The comprehensive assessment dated 1/26/24, there was no evidence of documentation regarding imminence of death. Patient #9) The comprehensive assessment dated 4/20/24, there was no evidence of documentation regarding imminence of death. Patient #10) The comprehensive assessment dated 12/5/24, there was no evidence of documentation regarding imminence of death.

Upon patient record review, 2 of 14 (Patient #1,2) 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 #1) The patient's current medication profile listed dulcolax 10 mg rectal suppository, daily if needed if no bowel movement in three days. The patient did not have this medication in their possession or in their medication box. Patient #2) The patient's current medication profile listed albuterol 90mcg/actuation, inhalation aerosol. The patient did not have this medication in their possession or in their medication box.

Upon patient record review, 2 of 14 (Patients # 2, 3) 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 #2) During home visit, patient's supplies included body wash, adult diapers, wipes, gloves, barrier pads, chucks and lotion. The latest plan of care dated 7/3/25 did not contain evidence of these supplies. COS by updating plan of care. Patient #3) During home visit, patient's supplies included body wash, adult diapers, wipes, gloves, barrier pads, chucks, shampoo and lotion. The latest plan of care dated 7/3/25 did not contain evidence of these supplies. COS by updating plan of care.

Upon personnel record review, 1 of 11 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 6) Upon review of the aide competencies completed on 6/10/23 and 6/13/24, they did not contain evidence that the following skills where verified: a) Shampoo-sink, tub, and bed, b) Bath-sponge, tub, and shower, c) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. COS by updating competency skills completed.

Upon patient record review, 3 of 14 (Patients # 1, 2, 9) 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 # 1) The hospice aide plan of care dated 4/11/25, the tasks of turn and position, record bowel movement and change linens did not contain frequencies. COS by updating aide plan of care. Patient # 2) The hospice aide plan of care dated 6/16/25, the tasks of turn and position, record bowel movement and change linens did not contain frequencies. COS by updating aide plan of care. Patient # 9) The hospice aide plan of care dated 4/20/24, the task of change linens did not contain a frequency. COS.

Upon patient record review 1 of 14 (Patient # 2) 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 # 2) The hospice aide plan of care 6/16/25, recording bowel movements was an assigned task. There was no evidence of this documentation on the hospice aide notes dated 6/20, 6/24, 6/27, and 7/8/2025.

Upon client record review, 3 of 5 (Patients #1, 2, 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 SN frequency 1x every 2 weeks. SN visits weekly on 7/7/22 and 7/14/22. Patient #2 SN frequency 1x every 2 weeks. SN visits weekly on 6/2/22, 6/10/22, 6/16/22, 6/24/22, 6/30/22, 7/8/22, 7/14/22. Patient #5 RN frequency 1x every 2 weeks. RN visits 4/1/22 and 4/2/22.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patients #1 and 3, LVN donned gloves and went in and out of nursing bag without washing hands. LVN did not wash hands after removing gloves. Patient #2, LVN donned gloves and went in and out of nursing bag without washing hands.

Upon patient record review 1 of 1 applicable (Patient #5) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care. Patient #5 Care plan dated on 4/1/22 states facial hair- safety razor. Aide documentation on 4/2/22 did not complete this task as directed on plan of care. HHA frequency 2x/week, only one HHA visit week of 4/1/22.