Every finding on record at Heart to Heart Hospice of Eastern Indiana, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.17 "Medication List and Monitoring" dated 01/10/2021 read in part, "A Hospice Registered Nurse will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all Hospice staff involved in the patient's care, including the pharmacist. A medication profile/list will be maintained on all patients. Medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile." In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that all current medications were included in the patient's drug profile. Clinical Record 4: The patient elected hospice care on 09/27/2024. The initial nursing assessment dated 09/27/2024 documented, "The patient was on 4 liters of oxygen while in the emergency room and is now on 3 liters." A clinical record review revealed the patient's medication profile dated 09/27/2024 did not document oxygen. Clinical Record 6: The patient elected hospice care on 08/01/2024. The initial nursing assessment dated 08/01/2024 documented, "The patient is on supplemental oxygen at 2 liters." A clinical record review revealed the patient's medication profile dated 08/01/2024 did not document oxygen. Clinical Record 7: The patient elected hospice care on 08/29/2024. On 08/29/2024, the physician ordered: "Oxygen via nasal cannula at 2 liters as needed for shortness of breath or comfort." A clinical record review revealed the patient's medication profile dated 08/29/2024 did not document oxygen. Clinical Record 8: The patient elected hospice care on 06/25/2024. The initial plan of care dated 06/25/2025 through 09/22/2024 documented, "Administer oxygen as required." A clinical record review revealed the patient's medication profile dated 06/25/2024 did not document oxygen. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, "Oxygen is not listed on these patients' medication profiles."

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 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 10/16/2024 with a diagnosis of multiple sclerosis. The patient resided in a skilled nursing facility (SNF). The initial nursing assessment dated 10/16/2024 documented, “Patient has dysphagia.” The POC dated 10/16/2024 through 01/13/2025 did not include documentation of planned interventions related to the patient’s dysphagia. Clinical Record 3: The patient elected hospice care on 05/21/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a SNF. The initial nursing assessment dated 05/21/2024 documented, “Patient has dysphagia.” The POC dated 05/21/2024 through 08/18/2024 did not include documentation of planned interventions related to the patient’s dysphagia. Clinical Record 10: The patient elected hospice care on 02/06/2024 with a diagnosis of pulmonary fibrosis. On 02/06/2024, the physician ordered: “Warfarin (anticoagulant) 5mg tablet by mouth daily.” The POC dated 02/06/2024 through 05/05/2024 did not include documentation of planned interventions related to the patient’s risk for bleeding. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, “There are no interventions in the plan of care for these patients regarding dysphagia or bleeding risk.”

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient's plan of care included drugs and treatments necessary to meet the patient's needs. Clinical Record 7: The patient elected hospice care on 08/29/2024 with a diagnosis of multiple myeloma. The plan of care for the certification period dated 08/29/2024 through 10/27/2024 ordered, "Maintain indwelling foley catheter. Flush with 30 ml normal saline as needed for patency. Replace foley catheter Q4 weeks or PRN if dislodged or occluded." The plan of care orders did not document the size of the Foley catheter to be used. Clinical Record 8: The patient elected hospice care on 06/25/2024 with a diagnosis of end-stage heart failure. The initial plan of care dated 06/25/2024 through 09/22/2024 ordered: "Administer oxygen as required." The plan of care orders did not include documentation of the route of oxygen administration, the flow rate of the oxygen, or the frequency of oxygen administration until 07/29/2024. Clinical Record 14: The patient elected hospice care on 06/17/2024 with diagnoses of diffuse traumatic brain injury and chronic respiratory failure. The initial plan of care dated 06/17/2024 through 07/22/2024 ordered: "Change trach inner cannula and trach sponge daily." The plan of care orders did not include documentation of the size of the tracheostomy tube. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, "There are no orders for oxygen, Foley, and tracheostomy size in these patient charts.

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 and interview. In 3 of 15 (20%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that all written patient care instructions were included in the HA care plan. Clinical Record 14: The patient elected hospice care on 06/17/2024 with diagnoses of diffuse traumatic brain injury and chronic respiratory failure. On 06/17/2024, the physician ordered wound care with dressings to wounds on the patient's coccyx and ankles. The plan of care (POC) dated 06/17/2024 through 07/22/2024 ordered "Aide 3x per week." The HA care plan dated 06/17/2024 assigned the HA the relevant task of a "Bed bath at every visit." The HA care plan did not provide the HA with instructions addressing the coccyx and ankle dressings during the bed bath should the dressing become wet or dislodged. Clinical Record 18: The patient elected hospice care on 05/31/2024 with a diagnosis of malignant neoplasm of the lung. On 06/01/2024, the physician ordered wound care with a dressing to a wound on the patient's coccyx. The plan of care dated 05/31/2024 through 06/18/2024 ordered "Aide 3x per week." The aide care plan dated 05/31/2024 assigned the HA the relevant task of a "Bed bath at every visit." The HA care plan did not provide the HA with instructions addressing the coccyx dressing during the bed bath should the dressing become wet or dislodged. Clinical Record 19: The patient elected hospice care on 04/09/2024 with a diagnosis of senile degeneration of the brain. On 05/30/2024, the physician ordered wound care with dressings to wounds on the patient's coccyx and ankles. The plan of care dated 04/09/2024 through 06/28/2024 ordered "Aide 4x per week." The HA care plan dated 04/09/2024 assigned the HA the relevant task of a "Shower at every visit." The HA care plan did not provide the HA with instructions addressing the coccyx dressing during the shower should the dressing become wet or dislodged. During an interview and a joint record review on 10/30/2024, the Executive Director confirmed the findings, stating, "There are no wound dressing instructions on these aide care plans."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 1: The patient elected hospice care on 07/02/2024 with the diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The plans of care dated 08/03/2024 through 10/01/2024 and 10/02/2024 through 12/01/2024 ordered “Aide 2x per week.” Hospice Aide supervisory visits were documented as completed on 08/13/2024 and 08/29/2024, with sixteen (16) days outstanding, and 09/25/2024 and 10/14/2024, with nineteen (19) days outstanding. Clinical Record 13: The patient elected hospice care on 05/30/2024 with a diagnosis of end-stage renal disease. The patient resided in a skilled nursing facility (SNF). The plans of care dated 05/30/2024 through 08/27/2024 and 08/28/2024 through 11/25/2024 ordered “Aide 3x per week.” Hospice Aide supervisory visits were documented as completed on 06/11/2024 and 06/28/2024, with seventeen (17) days outstanding; on 07/16/2024, with nineteen (19) days outstanding; and on 07/31/2024, with fifteen days outstanding. Hospice Aide supervisory visits were documented as completed on 09/18/2024 and 10/03/2024, with fifteen (15) days outstanding. During an interview and a joint record review on 10/30/2024, the Executive Director confirmed the findings, stating, “There are no other aide supervisory visits in these records.”.

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, the agency did not ensure that the patient's clinical record contained physician orders for all care and services. Clinical Record 4: The patient elected hospice care on 09/27/2024 with a diagnosis of congestive heart failure. The initial nursing assessment dated 09/27/2024 documented, "The patient was on 4 liters of oxygen while in the emergency room and is now on 3 liters." A clinical record review revealed no documentation of a physician's order for oxygen. Clinical Record 6: The patient elected hospice care on 08/01/2024 with a diagnosis of malignant neoplasm of the lung. The initial nursing assessment dated 08/01/2024 documented, "The patient is on supplemental oxygen at 2 liters." A clinical record review revealed no documentation of a physician's order for oxygen. Clinical Record 16: The patient elected hospice care on 10/31/2023 with a diagnosis of senile degeneration of the brain. The hospice discharge visit note dated 06/19/2024 documented, "Patient is being discharged due to no longer being terminally ill." A clinical record review revealed no documentation of a physician's order for discharge. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the finding, stating, "There are no orders for oxygen in these patient charts. There is not an order for discharge in the discharged patient's chart."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy OX.17 Medication List and Monitoring (revised 010121) stated in part, "The Hospice will maintain a current, accurate medication profile of all prescription and over the counter medications taken by the patient." 2 of 12 (16%) records in which medication changes were required failed to document an updated medication profile with a full review of all medications. Record #27815: Nursing visit note 11/26/2021 documented an upper respiratory infection with orders for Doxycycline [a medicine that fights bacterial infections] and Mucinex [relieves coughing]. Then, on nursing visit note 11/30/2021, the Doxycycline was discontinued, and Azithromycin [ a medicine that fights bacterial infections] 500mg started for the patient. On nursing visit note 12/07/2021, the patient is taking Robitussin for his harsh cough. Azithromycin and Robitussin are not documented on the medication profile as of review 12/28/2021. Record #66344: Admitted 03/20/2021 with Oxygen [a medication to help with breathing] at 3-5 liters. On 05/01/2021, the physician ordered Phenergan [a medication for upset stomach], and on 05/12/2021, the physician ordered Meclizine [for dizziness]. None of these medications were documented on the medication profile as of review 12/27/2021. Interview with the Area Vice President of Operations and the Patient Care Manager who stated that in September of 2021, a process improvement project started to assure that all medications are included on the medication profile and completely reviewed with the physician and pharmacist.

In collaboration with the individual's attending physician (if any), it is required that the Interdisciplinary Group reviews, revises, and documents the individualized care plan: as frequently as the patient's condition requires but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy TX.06 Plan of Care Process (revised 010120) stated in part, "A revised plan of care will include information from the patients updated comprehensive assessment and will note the patient progress toward outcomes and goals specified in the plan of care." 2 of 12 (16%) records in which the patient was provided hospice services long enough for changes in care documented, lacked revised plan of care from the patient's updated comprehensive assessment. Record #27815: Admitted 08/10/2021. The nursing assessment completed 11/26/2021 documented increased respiratory distress with orders for antibiotics and cough relief for an upper respiratory infection. Nursing assessment 12/07/2021 documented continued difficulty with cough relief. The updated plan of care 12/02/2021 and 12/16/2021 failed to update the plan for any respiratory interventions or goals. The plan of care was not updated as of review 12/28/2021. Record #44363: Admitted 08/02/2021. Nursing assessment completed 11/26/2021 stated Macrobid [medication for treating bacterial infection] started for urinary tract infection. The updated plan of care on 12/02/2021 documented no infections and resolved urinary infection on 11/05/2021. The paper plan of care documented 12/02/2021 was also not updated with the current urinary tract infection review 12/28/2021. Interview with the Area Vice President of Operations and Patient Care Manager stated that the plans of care had been a focus of the agency, but the two records were not fully updated for all care.

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 a clinical record review, document review, and interview. Agency Policy TX.07 (revised 1.1.2020) Implementing care and Treatment, stated in part, "The aide will be provided with written instructions for patient care prepared by an RN which may include but not be limited to Personal care." 1 of 13 (08%) records in which a hospice aide was accepted revealed a lack of clear and updated specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide's scope of practice. Record #80158: Aide written instructions documented 03/26/2021 with the duty of a shower for a bath. Patient status was documented as declining, and on 04/02/2021, the aide called the nurse to confirm a bed bath was allowed; care was documented on 04/02/2021 aide note. Registered Nurse visit note on 04/03/2021 documented patient declining and bedbound. Registered Nurse visit note 04/07/2021 documented patient transitioning to imminent death. Hospice Aide written instructions continued to document a shower for this patient who died 04/12/2021. No update was documented on the aide's written instructions to change the duty of bath from shower to bed bath for two weeks of care and visits, leaving the aide to decide on the task of bath. Interview with the Area Vice President of Operations and Patient Care Manager stated that the instructions should have been updated and that a process improvement initiated in September of 2021 was placed to assure updates of instructions as well as aide education to notify the nurse if instructions are not accurate to the care required.

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: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, including the care and services provided. This standard was not met as evidenced by a review of clinical records, document review, and interview. Agency Policy IM.7 (revised 1.1.2020) Medical Record Format stated in part, "Active Medical Record: Nursing, communication notes." 1 of 14 (07%) records failed to include all communication notes for the care provided to the patient. Record #66344: Nursing communication note on 04/27/2021 documented that orders were obtained from a physician for a potassium lab draw. Nursing visit note 05/03/2021 documented attempted lab draw with three unsuccessful attempts. Documentation on nursing visit note stated that caregiver stated that the patient is a very difficult draw and requires vascular to draw blood. The record failed to document a communication note of how the lab was drawn and follow up for the lab draw prior to the revocation on 05/16/2021. Interview with the Area Vice President of Operations and the Patient Care Manager stated that the communication note should have documented the access to vascular for the lab draw and follow-through for the lab draw.

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 a review of clinical records, document review, and interview. Agency Policy TX.16 Medication Administration and Management (Revised 082115) stated in part, "Agency nurse will obtain physician orders...A written physician order is obtained for medication...." 1 of 12 (16%) records in which additional physician orders were required failed to document a physician order for medications. Record #27815: Nursing visit note 11/20/2021 documented Doxycycline [medication to treat a bacterial infection] was discontinued and started Azithromycin [medication to treat a bacterial infection] 250mg orally two tablets then one tablet daily for four days, no physician order as of review 12/28/2021. Nursing visit note 12/07/2021 documented Robitussin [medication to decrease cough] started for patient cough. No physician order was documented as of review 12/28/2021. Interview with the Area Vice President of Operations and Patient Care Manager stated that they agreed, physician orders were not documented correctly for a patient in a skilled facility.