Every finding on record at Deaconess VNA Plus, LLC

Based on record review and interview, the agency failed to ensure an RN completed on-site supervisory visits for hospice aides every 14 days for 3 of 11 active records reviewed. (Patients #3, #4, and #6) Findings include: --- 1.     Review of a revised 01/27/2025 policy titled 33.08, Nursing Service indicated, but was not limited to, "…Procedure: …1. Duties and Responsibilities: Registered Nurse…Prepares written instructions and provides supervision for home health aides (HHAs)…". 2.     Review of a revised 04/17/2023 policy titled 33.16, Supervision of Paraprofessionals indicated, but was not limited to, "…Policy: …2. Per the Condition of Participation Interpretive Guidelines G-228: If the patient receives skilled nursing care, the Registered Nurse (RN) must perform the supervisory visit…Associated Documents and Resources:…Indiana Medicare-Home Health Aide with a Skill Every 14 days, Aide may or may not be present…" 3.     The Clinical Record for Patient #3, benefit period 02/17/2025 - 04/17/2025 evidenced an order on the POC for aide services two (2) time a week to provide assistance with direct and indirect activities of daily living. The aide visited Patient #3 on 02/17/2025, 02/21/2025, 02/24/2025, 02/28/2025, 03/03/2025, 03/07/2025, 03/10/2025, 03/14/2025, 03/14/2025, 03/17/2025, 03/21/2025, 03/24/2025, 03/28/2025, 03/31/2025, 04/04/2025, 04/07/2025, 04/11/2025, and  04/14/2025. The RN failed to complete an on-site supervisory visit between 03/11/2025-04/01/2025, which did not adhere to every 14 days as required. 4.     The Clinical Record for Patient #4, benefit period 02/02/2025 - 05/22/2025 evidenced an order on the POC for aide services two (2) time a week to provide assistance with direct and indirect activities of daily living. The aide visited Patient #4 on 02/25/2025, 02/27/2025, 03/03/2025, 03/06/2025, 03/10/2025, 03/13/2025, 03/17/2025, 03/20/2025, 03/24/2025, 03/27/2025, 03/31/2025, 04/03/2025, 04/07/2025, 04/10/2025, 04/15/2025 and 04/19/2025. A supervisory visit was only completed on 04/09/2025 and 04/16/2025. The RN failed to complete supervisory visits every 14 days between 02/02/2025 - 04/08/2025 required to maintain compliance and in line with agency policy. 5.     The Clinical Record for Patient #6, benefit period 02/24/2025 - 05/24/2025 evidenced an order on the POC for aide services two (2) times a week for the first week and three (3) time a week thereafter to provide assistance with direct and indirect activities of daily living. The aide visited Patient #6 on 02/26/2025, 02/28/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/14/2025, 03/17/2025, 03/19/2025, 03/21/2025, 03/24/2025, 03/26/2025, 03/28/2025, 03/31/2025, 04/02/2025, 04 04/04/2025, 04/07/2025, 04/09/2025, 04/11/2025, 04/14/2025, 04/16/2025, and 04/18/2025.  The RN failed to complete an on-site supervisory visit between 03/19/2025-04/10/2025, which did not adhere to every 14 days as required. 6.     During an interview on 04/22/2025 at 4:10 PM, the Director of Nursing (Administrator) indicated supervisory visits for aide services should occur every 14 days. The administrator could provide no reason why supervisory visits were not completed and he/she has educated on this regularly.

Based on policy review and interview, the agency failed to assure hospice staff furnished orientation on hospice philosophy, policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying at all facilities that provide care to hospice patients for 4 of 4 active contracted facilities housing hospice patients, with the potential to affect all contracted facilities housing hospice patients. (Entities #1, 2, 3, and 4) Findings include: --- 1.     Review of a revised 01/02/2025 policy titled 83.06, Hospice Care for Nursing Facility Residents - Written Agreements indicated, but was not limited to, "…Procedure: …3. Provisions in the written agreement include but are not limited to: Hospice employees ensure that facility staff providing care to Hospice patients is oriented to the Hospice philosophy of care, pain control, symptom management, principles of death and dying, patients right and documentation of requirements…". 2.     Review of a signed contract dated 07/28/2024 with Entity 1 indicated, but was not limited to, "…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice's symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility's policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…" 3.     Review of a signed contract dated June 19, 2024 with Entity 2 indicated, but was not limited to, "…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice's symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility's policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…" 4.     Review of a signed contract dated 04/08/2025 with Entity 3 indicated, but was not limited to, "…2. DUTIES AND OBLIGATIONS OF HOSPICE…2.10. Orientation, and Education. Hospice agrees to provide orientation and in-service education to personnel at Facility, to acquaint them with the Hospice philosophy of care and service and Hospice's symptom management protocols. Hospice agrees to provide information to Hospice employees, contractors, agents and volunteers concerning Facility's policies and procedures, as provided to Hospice by Facility. Hospice shall assess the skills and competence of all individuals furnishing care to Hospice Patient, and shall maintain (a) written policies and procedures describing its method(s) of assessment of competency and (b) a written description of the in-service training provided during the previous twelve (12) months…" 5.     Review of a signed contract dated June 19, 2024, with Entity 2 indicated, but was not limited to, "…IV. HOSPICE SERVICES AND RESPONSIBILITIES…4.16. Orientation and Education. Both parties shall provide sufficient orientation and in-service education to personnel to acquaint them with the Hospice's and the Facility's philosophy of care and services.  The parties agree to each provide orientation to the other party's employees, contractors agents, and volunteers regarding their respective  policies, procedures, and services that will be provided.  The Hospice will offer in-services at a variety of times so as to accommodate the Facility's employees on all shifts. In addition to the Hospice's philosophy, content will include discussion of the Hospice IDG and its role in care planning, palliative care and symptom control practices, as well as the responsibilities of both the Hospice and Facility…" 6.     During an interview on 04/23/2025 at 2:00 PM, the Director of Nursing (Administrator) was asked if there was any documentation that assured the education sent to facilities was completed and by who as written in the contracts signed by the facilities and the hospice? The administrator could not provide any evidence of completed training by the facility staff, in-services provided by either entity, and/or who provided it and how often to allow for staff turnover within facilities. The administrator indicated that sending the training to the facilities did not comply with the written contracts for the facilities and did not assure the hospice in any way the facility did provide the training for their staff.

Based on record review and interview, the agency failed to demonstrate knowledge of advance directive changes based on current state laws for 1 of 1 hospice agency admission packet review. Findings include: On 5/5/2022 at 2:42 p.m. AS-2 provided the 2022 admission packet book that included Advanced Directives dated 2018 for review. During an interview on 5/12/2022 at 10:55 a.m. CS-5 reviewed the 2022 admission packet book that contained the 2018 Advanced Directives and confirmed the information was current. The CS-5 indicated if the Advanced Directives were updated there would be an updated sticker placed over the 2018 date. CS-5 indicated, Consolidated Health Services (contracted management services) corporate compliance CS-10, would be responsible for any updated Indiana laws regarding Advanced Directives. CS-5 was unaware of the July 2021 update to the Advanced Directives.

Based on observation, record review, and interview, the agency failed to ensure personnel records were complete and accurate with administrative control that was clearly delineated in the hospice's organizational structure for 1 of 1 hospice agency. Findings include: 1. An undated Deaconess Health System, INC Policy &Procedure No. 45-05 S policy titled Personnel Record Administration was provided by the Regional Vice President of Clinical Services (AS-5) on 5/11/2022 at 3:40 p.m. The policy indicated, but was not limited to, "I. SCOPE: This policy and procedure applies to the system entities in which Deaconess has least 50% or greater ownership including but not limited to ..." 2. A list of Personnel Records was provided on 5/9/2022 during the daily exit conference. All requested Personnel Records were not received until 3:00 p.m. on 5/10/2022 due to the Employee Health (Comp Center) not available due to TB vaccination update administrations with staff. During personnel record review on 5/10/22 at 3:00 p.m. in collaboration with CS-5, all required documentation was not contained within the complete file and no one at the hospice had direct access to any of the employee files needed to complete the review. 3. During an interview on 5/5/2022 at 11:27 a.m., the Manager of Clinical Services (AS-2) indicated the medical file for personnel records are kept and maintained at the Deaconess Employee COMP center. This entity is responsible for ensuring all medical requirements by employees are current and communicate this information with the hospitals and joint ventures of Deaconess Health Systems. 4. On 5/5/2022 at 11:27 a.m. the AS-2 was asked to provide vaccination /exemption status on all direct and contracted staff for review. On 5/6/2022 at 12:40 p.m. asked AS-2 again for vaccinated exempted employee list and review of medical / religious exemptions to evidence compliance with the vaccination mandate for Covid-19. On 5/6/2022 at 2:25 p.m. AS-2 and CS-1 indicated Deaconess Hospital (owner of the hospice agency) would not give the state agency access to view the vaccination exemptions for hospice personnel to evidence compliance with the vaccination mandate for Covid-19. The hospice agency failed to demonstrate stewardship and control over the hospice agencies personnel /medical files in order to evidence compliance without impeding the survey process. 5. During an interview on 5/6/2022 at 2:25 p.m. AS-2 indicated that Deaconess personnel would not give the agency the hospice staff Covid vaccination exempt statements to determine compliance with the vaccine mandate without the surveyor signing a form. Requested the vaccination exemptions and covid vaccination cards a second and final time from the MCS.

Based on record review and interview, the agency failed to ensure the most stringent requirement of disposal of in-patient unit controlled substances (drugs with a high potential for abuse) were performed by licensed personnel for 1 of 1 in-patient hospice agency. Findings include: 1. An undated policy titled Deaconess VNA Plus, LLC Hospice Center Medications, Narcotic Orders was provided by the AS-2 on 5/12/2022 at 8:45 a.m. The policy indicated, but was not limited to, "All narcotic medications utilized by patients in the Hospice Center will be ordered and managed in accordance with Federal and State laws. ... 2. Nursing personnel will maintain narcotic administration and documentation ... 3. All Schedule II narcotic medications will be kept in a locked drawer/cabinet. Only Hospice Center RNs, pharmacists or physicians will have access to the keys for this drawer/cabinet. ... 5. If for any reason the entire order is not administered to the patient, the remaining Schedule II narcotic will be destroyed according to the Disposal of Narcotics Policy. All other Controlled Substances ... 2. Disposition of any unused controlled substance will follow normal procedures for all medication: Complete MAR. Witnessed and signed by RN/RN or RN/Hospice Aide. Dispose of medication as per facility policy." 2. A 2018 NAHC Resource: Hospice Disposal of Controlled Substances: Public Law 115-271 - Support for Patients and Communities Act -- Opens Door for Hospice Disposal of Controlled Substances indicated, but was not limited to, "Section 3222 of the Support for Patients and Communities Act authorizes specific hospice staff employed by or working under arrangement for qualified hospices to dispose of controlled substances ... Hospices must observe the most stringent requirement. ... a. ... Types of staff that can dispose of the controlled substances. The Act allows only nurses (RN, LPN, NP), physicians, and physicians assistants. ... 3. The Act requires the hospice to train any nurses, physicians or physician assistants disposing of controlled substances in the disposal of controlled substances in a secure and responsible manner so as to discourage abuse, misuse, or diversion so this may require modifications to existing training or additional training topics. Also, evidence of this training should be maintained." 3. Review of the Diversion Control Division website at https://www.deadiversion.usdoj.gov/schedules/ indicated Schedule II Controlled Substances have a high potential for abuse which may lead to severe psychological or physical dependence. Examples of Schedule II narcotics (pain medications) include: hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®). Other Schedule II narcotics include: morphine, opium, codeine, and hydrocodone. . 4. During an interview on 5/5/2022 at 1:30 p.m. in-patient center RN-3 and Certified Nursing Assistant (CNA)-4 indicated CNA's are allowed to waste narcotics (Dilaudid and morphine) along with the RN on night shift. 5. During an interview on 5/12/2022 at 8:45 a.m. AS-2 indicated in-patient center RN's along with CNA's are allowed to waste narcotics on night shift because the agency does not have the luxury of staffing 2 (two) RN's on night shift.

Based on record review and interview, the agency failed to ensure hospice staff furnished orientation on hospice philosophy, policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying all skilled nursing licensed facilities that provide care to hospice patients for 6 of 6 active skilled nursing facilities, with the potential to affect all contracted skilled nursing facilities. (Entities #1,#2,#3,#4,#5,#6) Findings include: 1. An 11/2019 contract titled Hospice-Skilled Nursing Facility Agreement was provided by CS-5 on 5/11/2022 at 4:45 p.m. The contract indicated, but was not limited to, "2.11 Training, Education and Assessment. Hospice shall provide orientation and training for all Personnel, including but not limited to the staff's specific job duties, and Hospice's philosophy, policies and procedures regarding methods of comfort, pain control, and symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. ... provide in-service training and education programs where required. Hospice shall have written policies and procedures describing its method(s) of assessment of competency and maintain a written description of the in-service training provided during the previous 12-month period." 2. Review of the Active Clients in Facilities Report provided by AS-2 on 5/5/2022 at 2:22 p.m. indicated 8 active hospice patients reside in skilled nursing facilities for Entities #1,#2,#3, #4, #5, #6. 3. During an interview on 5/11/2022 at 2:30 p.m. AS-2 and CS-5 were asked how the agency ensures orientation and training on hospice occurred for all skilled nursing facilities based on agency contract. Neither AS-2 or CS-5 knew who provided orientation and training for skilled nursing facilities. 4. During an interview on 5/11/2022 at 3:30 p.m. AS-2 and CS-5 were unable to provide evidence that orientation and training on hospice occurred for all skilled nursing facilities for the years 2022, 2021, and 2020. 5. During an interview on 5/11/2022 at 4:20 p.m. Volunteer Coordinator (VC)-1 indicated past employee #7 and him/herself conducted in-services to skilled nursing facilities but stopped in 2017 and was taken over by another personnel who was longer with the agency. VC-1 indicated archived files would be stored at Deaconess Hospital and was unsure who to reach to retrieve files but would try. The agency was not able to provide any further documents by exit date.

Based on record review and interview, the agency failed to ensure direct care staff and contracted staff qualifications that provide services were kept current for 6 of 28 personnel records reviewed, with the potential to affect all hospice personnel. (RN#5, RN#7, RN#8, CNA#5, CNA#6, MT#1) Findings include: 1. A 5/25/2021 revised CHI policy, titled Administrative Control, was provided by CS-5 on 5/9/2022 at 11:50 a.m. The policy indicated, but was not limited to, "The Administrative Staff maintains administrative control and establishes lines of authority for the delegation of responsibility. ... 1. The Company/Agency is defined as: ... Deaconess VNA Plus, LLC ... 2. The Governing Body is responsible for : Overseeing compliance ... Establishing or approving written policies and procedures governing all operations. ... Human resource management ... Employee qualifications ... 3. All care services not directly provided by the Company are monitored and controlled by the Company ... A written contract is developed and implemented ..." 2. An undated policy titled, Deaconess Health System, INC Personnel Records Administration was provided by CS-5 on 5/11/2022 at 3:40 p.m. The policy indicated, but was not limited to, "Scope: This policy and procedure applies to the system entities in which Deaconess has at least 50% or greater ownership ... Deaconess VNA Plus, LLC ... IV. Policy: It is the policy of Deaconess to: ... B. Verify the background, licensure and/or licensure of all employees filing positions where such is required ... V. ... A. The Human Resources Department is responsible for: 1. ... maintaining personnel records. ... 4. Making personnel records available ... 5. ... provide accurate employment information ... B. The COMP Center is responsible for maintaining records ... establish all Deaconess employees are ...free of active communicable diseases. C. Department Directors/Managers are responsible for generating and maintaining up-to-date employee competency files and able to furnish them upon request by HR, a regulatory credentialing agency, or other local/state/federal agency." 3. An undated job description titled DVNA Director of Clinical [Services] was provided by CS-5 on 5/12/2022 at 10:45 a.m. The job description indicated, but was not limited to, "is responsible for the day-to-day operational responsibilities and oversight of all personnel ... services provided by the Hospice Agency ... overall management ...". 4. On 5/11/2022 at 10:15 a.m. reviewed personnel files along with AS-2 . The agency failed to ensure the following personnel files included orientation to hospice: RN-5, RN-7, RN-8, CNA-5, CNA-6. During the review, the agency failed to ensure a current contract and criminal background check were available for review for Music Therapist (MT)-1. At that time, AS-2 was unsure why the personnel files did not include hospice orientation and a background check for MT-1. The AS-2 indicated in 2018 the Foundation started funding for MT-1's services, but was unsure of the names of the people who made up the Foundation.

Based on record review and interview, the agency failed to ensure a criminal background check was obtained for 1 of 1 contracted music therapy record review. (MT-1) Findings include: A 5/25/2021 revised CHI policy, titled Administrative Control, was provided by CS-5 on 5/9/2022 at 11:50 a.m. The policy indicated, but was not limited to, "The Administrative Staff maintains administrative control and establishes lines of authority for the delegation of responsibility. ... 1. The Company/Agency is defined as: ... Deaconess VNA Plus, LLC ... 2. The Governing Body is responsible for : Overseeing compliance ... Establishing or approving written policies and procedures governing all operations. ... Human resource management ... Employee qualifications ... 3. All care services not directly provided by the Company are monitored and controlled by the Company ... A written contract is developed and implemented ..." An undated job description titled DVNA Director of Clinical [Services] was provided by CS-5 on 5/12/2022 at 10:45 a.m. The job description indicated, but was not limited to, "is responsible for the day-to-day operational responsibilities and oversight of all personnel ... services provided by the Hospice Agency ... overall management ...". On 5/5/2022 at 11:27 a.m. AS-2 indicated the hospice agency contracts Music Therapy (MT). On 5/9/2022 at 4:20 p.m. AS-2 and CS-5 was asked to provide MT-1's personnel file and contract for review. Both AS-2 and CS-5 were unsure if the contract was current given the MT was funding by the Foundation. On 5/11/2022 at 10:15 a.m. reviewed personnel files along with AS-2 . The agency failed to ensure a current contract and a criminal background check were available for review for MT-1.

Based on record review and interview, the agency failed to ensure the contracted music therapist vaccination status was made available for review for 1 of 1 music therapy personnel record review. (MT-1) Findings include: 1. An undated policy titled, Deaconess Health System, INC Personnel Records Administration was provided by CS-5 on 5/11/2022 at 3:40 p.m. The policy indicated, but was not limited to, "A. The Human Resources Department is responsible for: 1. ... maintaining personnel records. ... 4. Making personnel records available ... 5. ... provide accurate employment information ... B. The COMP Center is responsible for maintaining records ... establish all Deaconess employees are ... free of active communicable diseases. 2. The complete clinical record for patient 2, start of care date 4/13/21, was reviewed on 5/6/22. The plan of care for the 1st benefit period 4/13/21-7/11/21 included an order for Music Therapy as needed. Orders of Discipline and Treatments indicated Music Therapy will be provided. The agency failed to ensure the music therapist was vaccinated per federal/state regulations or agency policy, and contracted with the agency to provide direct patient services. 3. The complete clinical record for patient 6, start of care date 5/4/22, was reviewed on 5/10/22. The plan of care for the 1st benefit period 5/4/22-8/1/22 included an order for Music Therapy as needed upon request of the patient. The agency failed to ensure the music therapist was vaccinated per federal/state regulations or agency policy, and contracted with the agency to provide direct patient services. 4. The complete clinical record for patient 7, start of care date 5/2/22, was reviewed on 5/10/22. The plan of care for the 1st benefit period 5/2/22-7/30/22 included an order for Music Therapy as needed upon request of the patient. The agency failed to ensure the music therapist was vaccinated per federal/state regulations or agency policy, and contracted with the agency to provide direct patient services. 5. On 5/11/2022 at 10:15 a.m. reviewed personnel files along with AS-2 . The agency failed to ensure the Covid vaccination status or exemption was kept within the medical personnel file for Music Therapist #1.