Every finding on record at Loving Hearts Hospice and Palliative Care,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 and interview. In 1 of 19 (5%) clinical records reviews it was revealed that the agency did not ensure that the patient's written plan of care identified interventions based on the problems identified in the comprehensive assessments. CLINICAL RECORD 1: The hospice benefit was elected on 01/24/2025. During the initial nursing assessment, documentation indicated that the patient was receiving continuous feedings through a feeding tube and had a Foley catheter in place. The initial plan of care and subsequent plans of care did not include goals or interventions related to this care assessment or documentation of monitoring for potential problems related to them. During an interview with the Director of Nurses on 05/23/2025, she stated that they have been really focusing on plans of care through their education and will continue to focus on this area.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed it was revealed that the agency did not ensure the clinical record contained physician's orders. CLINICAL RECORD 1: The hospice benefit was elected on 01/24/2025. Review of admission orders included "catheter care catheter care frequency ___ for standing orders catheter care frequency___, enteral feeding enteral feeding ___(amount) ___ ml/day pump type:___ for standing orders enteral feeding ___(amount)___ ml/day pump type___, foley irrigation foley irrigation ___ solution ___ ml ___ frequency ___ for standing orders foley irrigation ___ solution ___ ml ___ frequency ___" The clinical record lacked orders with complete information CLINICAL RECORD 8: The hospice benefit was elected on 03/23/2025. . Nursing documentation on 04/10/2025 indicated that a Foley catheter was inserted, and documentation on 04/11/2025 stated that the Foley was discontinued due to patient discomfort. However, the clinical record did not reflect a physician's order to insert the Foley catheter on 04/10/2025 or to remove the Foley catheter on 04/11/2025. CLINICAL RECORD 12: The hospice benefit was elected on 10/14/2024. The admission orders included "catheter care catheter care frequency ___ for standing orders catheter care frequency___, foley irrigation foley irrigation ___ solution ___ ml ___ frequency ___ for standing orders foley irrigation ___ solution ___ ml ___ frequency ___, catheter change (catheter change q___ with ___ FR ___ ___ ml balloon catheter.) for standing orders related catheter change q ___ with ___ FR ___ ___ ml balloon catheter, dressing change ( change ___ dressing q ___. ___ and PRN using sterile techniques with alcohol/betadine.) for standing orders related Change ____ dressing q ___. ___ and PRN using sterile techniques with alcohol/betadine". The orders were not completed with the required information. During an interview with the Director of Nurses and the Administrator on 05/23/2025 they stated that they were working on the orders section of the electronic medical record as well as putting together education for the clinical staff.

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 and interview. In 2 of 2 (100%) clinical records reviewed of live discharged patients it was revealed that the agency did not ensure that a discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 18: The hospice benefit was elected on 03/29/2024. The patient moved out of service area on 07/01/2024. The clinical record lacked evidence that the discharge summary was sent to the attending physician. CLINICAL RECORD 19: The hospice benefit was elected on 07/11/2024 and services were revoked on 09/10/2024. The clinical record lacked evidence that the discharge summary was sent to the attending physician. During an interview with the Director of Nurses on 05/23/2025, she stated they have identified the break in the discharge process and are having education in the next couple of weeks.

It is required that the patient’s pain is assessed as part of a comprehensive assessment. The documented assessment of the patient’s pain includes: the patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (7%) records reviewed revealed that the agency did not ensure the pain assessment included the patient's/family's goals for pain management. Clinical Record 8 - In the recertification assessment, on 7/12/2022, the RN answered "yes" for the question, "Is pain an active problem for the patient?" The question, "What is an acceptable pain level for you?", was left blank and no answer was provided anywhere else in the assessment. The care plan, effective 7/12/22 to present, did not state the patient's or family's goals for pain management. During interview with the clinical manager (Staff 9) conducted on 8/17/2022, they confirmed that the pain assessment did not include the patient's goal and there was no other place in the record it would be documented.

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 10 (10%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure the hospice aide provided services according to the plan of care visit frequency orders. Clinical Record 3 - During the benefit period beginning 12/29/2021 and ending 2/3/2022, with the patient's death, hospice aide visits were ordered to be provided as two (2) times per week. During the week of 1/16/2022, only one visit was documented as completed on 1/20/2022. There was no evidence of a missed visit note or description of why the second visit was not provided. During an interview with the clinical manager (Staff 9), on 8/18/2022, it was confirmed that there was only one visit documented for the week of 1/16/2022 and the agency was unable to provide documentation for the missed visit.