Every finding on record at Affinity Care of Indiana LLC

It is required that licensed professional services provided directly or under arrangement are supervised only by appropriately qualified health care professionals who meet the appropriate qualifications specified under §418.114 and who practice under the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #7044 "Supervision" (effective 03/01/2019) stated in part, "Medical social services must be provided by a qualified social worker, under the direction of a physician." In 2 of 2 (100%) personnel records reviewed of Social Workers, the agency did not ensure that all Social Workers were supervised by appropriately qualified health care professionals who meet the appropriate qualifications per state regulation and specified under §418.114. The agency job description for "Medical Social Worker" stated in part, "A graduate of a Master's program in social work accredited by the Council of Social Work Education, or a Bachelor's degree in an accredited program." State Regulation: The state requires specific qualifications to practice as a licensed social worker. You can choose from three licensing levels: Licensed Bachelor Social Worker (LBSW), Licensed Social Worker (LSW), and Licensed Clinical Social Worker (LCSW). "Title Protection in Law...Effective January 1, 2017 pursuant to (state code), if you have an MSW degree and are working in a behavioral health and human services position (regardless of job title) you must be licensed. Beginning January 1, 2017, you MUST either hold an active social work license, or apply for a clinical social work license and be approved by the Board to take the ASWB Clinical Examination prior to January 1, 2017 for any accrued clinical experience hours and supervision hours to count towards your clinical social work licensure. On January 1, 2017 if you do not have an active social work license and have been working towards accruing your clinical experience hours and supervision hours for clinical social work licensure, the hours you have accrued will not count toward the clinical social work license requirement and you will be required to obtain the social work license and begin accruing clinical hours and supervision hours toward the clinical social work license according to Ind. (state code) There are no exceptions to the licensure requirement except as outlined in (state code). Previous exceptions regarding date of graduation will no longer apply effective January 1, 2017." Personnel Record 1: The Social Worker with a bachelor's degree in social work (BSW) was hired on 07/02/2023. The supervision of the BSW for 2023 and 2024 was documented with oversight from a Social Worker with a Master's degree in Social Work (MSW) who was licensed in the state. The MSW left the organization on 12/24/2024. In January, February, and March of 2025, oversight for the BSW for completion of admissions, discharges, interdisciplinary conferences, and change-in-condition hospice visits was provided by the hospice Medical Director, licensed in this state, and an MSW licensed in a different state. Personnel Record 2: The Social Worker with the Master's degree in social work (MSW) was hired on 01/02/2025. The MSW was a recent graduate and had taken their boards for state licensure. However, at this time, the MSW has not passed the state board and remains unlicensed. In January, February, and March of 2025, oversight for the MSW for completion of admissions, discharges, interdisciplinary conferences, and change-in-condition hospice visits was provided by the hospice Medical Director, licensed in this state, and an MSW licensed in a different state. During an interview, the Executive Director, who had been in communication with the corporate office, had documented active recruitment for social work positions but was not able to hire a candidate and stated that the physician oversight and social work oversight were thought to meet the regulation.

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, interview, and observation. In 1 of 6 (17%) clinical records reviewed of patients receiving Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) provided services included in the plan of care. Clinical Record 6/Home Visit 1: The patient was elected hospice care on 02/19/2025 with a diagnosis of congestive heart failure (CHF). The plan of care ordered Hospice Aide (HA) services two (2) times a week. The initial and updated HA care plans dated 02/18/2025 and 02/28/2025, respectively, assigned the HA the tasks of bed bath and turn in bed each visit. The HA visit notes dated 03/14/2025, 03/18/2025, and 03/21/2025 documented that a shower was provided. The RN assessment dated 03/18/2025 (completed by a different RN) documented that the patient would be approached about showering as the RN felt the patient was ready to participate. There was no documented evidence that the RN and HA communicated, and the care plan was changed to a shower. During the home visit with a Registered Nurse and Hospice Aide on 03/25/2025, the HA provided a shower to the patient. During an interview on 03/25/2025, the Hospice Aide (who provided the care) stated that the Registered Nurse (RN) told her the patient was ready for a shower. During an interview on 03/25/2025, the Executive Director stated that this problem was identified during the renewal site visit in February and that there is a process improvement plan in place.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 6 (17%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA reported changes in the patient's needs related to the care plan to the Registered Nurse (RN). Clinical Record 6/Home Visit 1: The patient was elected hospice care on 02/19/2025 with a diagnosis of congestive heart failure (CHF). The plan of care ordered Hospice Aide (HA) services two (2) times a week. The initial and updated HA care plans dated 02/18/2025 and 02/28/2025, respectively, assigned the HA the tasks of bed bath and turn in bed each visit. The HA visit notes dated 03/14/2025, 03/18/2025, and 03/21/2025 documented that a shower was provided. The RN assessment dated 03/18/2025 (completed by a different RN) documented that the patient would be approached about showering as the RN felt the patient was ready to participate. There was no documented evidence that the RN and HA communicated, and the care plan was changed to a shower. There was no documentation that the RN was notified and approved the bath change. During the home visit with a Registered Nurse and Hospice Aide on 03/25/2025, the HA provided a shower to the patient. During an interview, the HA stated that the nurse had told her she could provide a shower and that she had been doing that. During an interview and joint record review on 03/25/2025, the Executive Director agreed that the HA care plan was not updated with the shower task and that a shower could be provided as of the review on 03/25/2025.

It is required that a social worker who holds a bachelor’s degree is supervised by a CMS-qualified MSW who has a degree from a school of social work accredited by the Council on Social Work Education and has one (1) year of experience in a health care setting. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #7044 "Supervision" (effective 03/01/2019) stated in part, "Medical social services must be provided by a qualified social worker, under the direction of a physician." In 2 of 2 (100%) personnel records reviewed of social workers, the agency did not ensure that the social worker who holds a bachelor’s degree was supervised by a CMS-qualified Medical Social Worker (MSW) per the state regulation. The agency job description for "Medical Social Worker" stated in part, "A graduate of a Master's program in social work accredited by the Council of Social Work Education, or a Bachelor's degree in an accredited program." State Regulation: The state requires specific qualifications to practice as a licensed social worker. You can choose from three licensing levels: Licensed Bachelor Social Worker (LBSW), Licensed Social Worker (LSW), and Licensed Clinical Social Worker (LCSW). "Title Protection in Law...Effective January 1, 2017 pursuant to (state code), if you have an MSW degree and are working in a behavioral health and human services position (regardless of job title) you must be licensed. Beginning January 1, 2017, you MUST either hold an active social work license, or apply for a clinical social work license and be approved by the Board to take the ASWB Clinical Examination prior to January 1, 2017 for any accrued clinical experience hours and supervision hours to count towards your clinical social work licensure. On January 1, 2017 if you do not have an active social work license and have been working towards accruing your clinical experience hours and supervision hours for clinical social work licensure, the hours you have accrued will not count toward the clinical social work license requirement and you will be required to obtain the social work license and begin accruing clinical hours and supervision hours toward the clinical social work license according to Ind. (state code) There are no exceptions to the licensure requirement except as outlined in (state code). Previous exceptions regarding date of graduation will no longer apply effective January 1, 2017." Personnel Record 1: The Social Worker with a bachelor's degree in social work (BSW) was hired on 07/02/2023. The supervision of the BSW for 2023 and 2024 was documented with oversight from a Social Worker with a Master's degree in Social Work (MSW) who was licensed in the state. The MSW left the organization on 12/24/2024. In January, February, and March of 2025, oversight for the BSW for completion of admissions, discharges, interdisciplinary conferences, and change-in-condition hospice visits was provided by the hospice Medical Director, licensed in this state, and an MSW licensed in a different state. Personnel Record 2: The Social Worker with the Master's degree in social work (MSW) was hired on 01/02/2025. The MSW was a recent graduate and had taken their boards for state licensure. However, at this time, the MSW has not passed the state board and remains unlicensed. In January, February, and March of 2025, oversight for the MSW for completion of admissions, discharges, interdisciplinary conferences, and change-in-condition hospice visits was provided by the hospice Medical Director, licensed in this state, and an MSW licensed in a different state. During an interview, the Executive Director, who had been in communication with the corporate office, had documented active recruitment for social work positions but was not able to hire a candidate and stated that the physician oversight and social work oversight were thought to meet the regulation. My thought is that they do not meet the requirements for HSRM 23.I/L787 because the state regulation requires licensure for the Medical Social Worker. The Corporate Medical Social Worker does not have a current state of Indiana license.

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, document review, and interview. Agency policy #7016, "Hospice Aide Supervisory Visits " (03/01/2019), stated in part, "A registered nurse will be responsible for providing written instructions via the Hospice Aide plan of care …" In 1 of 18 (6%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse (RN) provided the HA with written patient care instructions to meet the patient's needs. Clinical Record 3: The patient elected the hospice benefit on 04/11/2024 with the diagnosis of nutritional marasmus. The patient resided in an assisted living facility (ALF). The plan of care for the benefit period 12/07/2024 to 02/04/2025 ordered HA services twice weekly. The skilled nursing (SN) visit note dated 12/06/2025 documented a right proximal thigh surgical site with a permanent surgical drain. On 10/11/2024, the physician ordered wound care three times a week and as needed if the dressing became soiled or dislodged. On 12/11/2024, the physician updated the wound care order to "cleanse the wound with wound cleanser or normal saline, pat dry, apply Skin Prep to the peri-wound area, cover with adhesive foam dressing three times a week, and as needed, should the dressing become soiled or dislodged." The wound and wound care were documented in the SN visit notes dated 12/13/2024,12/27/2024, 01/17/2025, and 01/29/2025 and continued as of 02/12/2025. The active HA care plan dated 04/11/2024 assigned the HA the relevant task of a shower every visit. The HA care plan did not provide the HA with instructions for managing the patient's wound dressing should it become soiled or dislodged during the shower. During a joint clinical record review and interview on 02/12/2024, the Executive Director/RN and the Clinical Director confirmed that the aide's care plan did not include instructions to the HA about the patient's wound.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #6020, "Provision of Care to Residents of SNF/NF or ALF" (effective 03/01/2019), stated in part, "The plan of care must identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions; reflect the participation of (hospice), the SNF/NF… " In 1 of 8 (12%) clinical records reviewed of patients who resided in a nursing facility (NF), the agency did not ensure that the patient's plan of care delineated which provider, the hospice or the facility, was responsible for performing the functions that were agreed upon and included in the plan of care. Clinical Record 19: The patient elected the hospice benefit on 08/12/2024 with the diagnosis of malignant neoplasm of the larynx. The patient resided in a NF. The plans of care for benefit periods 08/12/2024 to 11/09/2024 and 11/10/2024 to 02/07/2025 did not include documentation of the delineation of duties regarding the patient's wound care and management between the hospice and the nursing facility. During a joint clinical record review and interview, the Executive Director/RN and the Clinical Director confirmed that the patient's plan of care did not delineate care and services between the hospice and the nursing facility.