Every finding on record at Heart to Heart Hospice of Evansville, 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 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 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 and interview. In 3 of 4 (75%) clinical records in which the patient had an infusion, the agency did not ensure that saline and heparin flushes were documented on the medication profile for review of all medications. CLINICAL RECORD 10: The patient elected hospice care on 09/09/2025 with a diagnosis of breast cancer. The initial comprehensive assessment documented that the patient, with a (general inpatient) GIP level of care, received an infusion through a right chest port. The medication profile did not include the normal saline and the 100-unit heparin required to maintain the port in the right chest. The nursing assessment dated 09/16/2025 documented that the port was flushed with saline and heparin. The medication profile did not document heparin and normal saline. There was no evidence that the heparin was reviewed with the patient's medication regimen. CLINICAL RECORD 17: The patient elected hospice care on 09/19/2025 with a diagnosis of esophageal cancer. The initial comprehensive assessment dated 09/19/2025 documented that the patient had a port in the right chest that was not accessed. The updated nursing assessment dated 10/21/2025 documented that the facility was doing the monthly flush on the right upper chest port. The saline and heparin that would be used for this flush were not documented on the medication profile for a full review of medications. CLINICAL RECORD 21: The patient elected hospice care on 02/14/2025 with a diagnosis of vulva cancer. The initial comprehensive assessment dated 02/14/2025 documented that the patient, with a GIP level of care, had a port that was accessed with orders to flush with saline before and after medication administration, and monthly with heparin. The normal saline and heparin (should be 100 unit) were not documented on the medication profile and consequently not reviewed for all interactions. During an interview on 11/14/2025, the Director of the Inpatient Unit and the Administrator stated that the saline and heparin were not on the medication profiles. During an interview, the Vice President confirmed that the medications were ordered, but they were not on the medication profile, where they would have been reviewed for potential interactions.

It is required that each patient’s individualized written plan of care: 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, document review, and interview. In 3 of 27 (11%) clinical records reviewed for the community program, the agency did not ensure that the patient's plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 6: The patient elected hospice care on 10/10/2025 with a diagnosis of idiopathic pulmonary fibrosis. The updated comprehensive assessments completed by the Registered Nurse (RN) dated 10/22/2025 documented the patient's anxiety, and on 10/26/2025, the patient's urinary retention. The plan of care (POC) did not document interventions for the patient's anxiety. The POC interventions documented for genitourinary were not specific to the patient's urinary retention or the two urinary tract infections (UTI) treated on 10/27/2025 and 11/12/2025. CLINICAL RECORD 11: The patient elected hospice care on 10/04/2025 with a diagnosis of breast cancer. The updated comprehensive assessment completed by the RN dated 10/22/2025 and 10/24/2025 documented the patient's respiratory distress. A physician's order dated 10/23/2025 ordered doxycycline for infection. The updated nursing assessment dated 10/28/2025 documented that the patient had not yet started doxycycline for pneumonia related to family visiting. The updated plan of care did not document interventions for the patient's identified respiratory distress. The plan of care documented an intervention for cardiopulmonary monitoring of pulse oximetry, but it was not specific to measures related to respiratory distress. CLINICAL RECORD 15: The patient elected hospice care on 11/09/2025 with a diagnosis of esophageal cancer with a comorbidity of diabetes. The initial comprehensive assessment completed by the RN dated 11/09/2025 identified that the patient had a gastrostomy tube (G-tube) and was not tolerating Jevity feedings. The Hospice Aide assigned tasks included notifying the nurse of any signs of hypo or hyperglycemia, as the patient was at risk. The initial POC and the POCs updated every two weeks did not document interventions for the patient's diabetes. During an interview and joint review of the records, the Administrator confirmed that they did not find the specific and individualized interventions.

It is required that each patient’s individualized written plan of care: 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, document review, and interview. Agency policy #PC.135 "Pain and Symptom Management" stated in part, "When pain is assessed to be at a level greater than the patient's goal, the patient will be reassessed within a timely manner following this pain intervention. The IDG will consider personal, physical, cultural, psychosocial, spiritual, and/or ethnic beliefs in the education of patients regarding pain and symptom management." In 1 of 27 (4%) clinical records reviewed for the community program, the agency did not ensure that the patient's plan of care (POC) included interventions to manage pain and symptoms. CLINICAL RECORD 6: The patient elected hospice care on 10/10/2025 with a diagnosis of idiopathic pulmonary fibrosis. The updated comprehensive assessment dated 10/22/2025 documented the patient's increased pain. The plan of care documented the intervention for pain: "educate patient /facility of different rated of onset duration. Roxanol (narcotic pain medication) every 15 min." The plan of care intervention was not specific to other measures to control the patient's pain. The POC did not document interventions for the patient's pain that were individualized. During an interview and joint review of the records, the IPU Director and the Administrator confirmed that they did not find the specific and individualized interventions.

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, document review, and interview. In 4 of 27 (15%) clinical records reviewed for the community program, the agency did not ensure that the patient's plan of care included the drugs and treatments necessary to meet the patient's needs. CLINICAL RECORD 8: The patient elected hospice care on 09/09/2025 with a diagnosis of lung cancer. The initial comprehensive assessment dated 09/09/2025 documented an old gastrostomy tube (G-tube) site that required a dressing. The plan of care dated 09/09/2025 documented interventions to educate the caregiver on reporting changes in skin breakdown/condition. The updated assessments documented that the dressing was clean, dry, and intact, and that the skin at the dressing site was evaluated. The POC interventions did not document the type of individualized dressing. CLINICAL RECORD 10: The patient elected hospice care on 09/09/2025 with a diagnosis of breast cancer. The initial comprehensive assessment dated 9/09/2025 documented that the patient was admitted at the GIP (general inpatient) level of care for pain and nausea and received an infusion through a right chest port. Orders were written for the infusion line to be dressed per the physician's order and changed every 7 days per sterile technique. The plan of care interventions were non-specific for access to the port (the infusion device) (which would be with a Huber needle of a specific length), and the frequency of change of PCA (pain control anesthesia) lines. CLINICAL RECORD 17: The patient elected hospice care on 09/19/2025 with a diagnosis of esophageal cancer. The initial comprehensive assessment dated 09/19/2025 documented that the patient had a port in the right chest that was not accessed. The updated nursing assessment dated 10/21/2025 documented that the facility was doing the monthly flush on the right upper chest port. The initial plan of care, dated 09/19/2025 and updated every two weeks, did not document interventions for maintaining the port, including monthly access and flushes to maintain patency. CLINICAL RECORD 21: The patient elected hospice care on 02/14/2025 with a diagnosis of vulva cancer. The initial comprehensive assessment dated 02/14/2025 documented that a port was identified. Orders were written to flush the port with 10 mL of normal saline before and after medication administration. The initial plan of care (POC), updated every two weeks, included documentation of interventions to access the port with sterile technique, flush with 10 ml of normal saline, administer heparin, and cover with a preferred dressing, on or around the first of the month. The plan of care intervention did not document the type of needle (Huber), its length, or the Huber needle's gauge. There were physician orders for a sterile dressing change, but the plan of care interventions did not document that the change was to be completed weekly. Additionally, the initial comprehensive assessment identified that the patient had a suprapubic catheter, to be evaluated and flushed with normal saline as needed (prn). The plan of care interventions did not include documentation of the amount of normal saline to be used for the flush. During an interview on 11/14/2025, the Inpatient Unit Director stated that the patient wanted specific items for their dressing, and that this sometimes changed, which was why it was written as preferred. The Director also stated that the patient's preferred items may have been more specific.

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, observation, and interview. In 6 of 26 (23%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient's needs. CLINICAL RECORD 14: The patient elected hospice care on 08/20/2025 with a diagnosis of cerebral ischemia. The initial comprehensive assessment dated 08/20/2025 documented that the patient has a urostomy/colostomy. The HA care plan dated 08/20/2025, with no updates as of 11/12/2025, assigned the HA the tasks: shower and perineal care. The HA care plan did not assign the HA tasks related to the colostomy or pouch, if they become soiled, dislodged, or wet during care. CLINICAL RECORD 16: The patient elected hospice care on 11/03/2025 with a diagnosis of multiple sclerosis. The updated nursing comprehensive assessment dated 11/04/2025 documented that the patient had air boots bilaterally due to their feet being turned in. The air boots were to remain on the patient. The HA care plan dated 11/04/2025, with no updates as of 11/13/2025, did not document that the air boots were to be on the patient. CLINICAL RECORD 20: The patient elected hospice care on 04/17/2025 with a diagnosis of pulmonary disease. The updated nursing assessment on 04/23/2025 documented a wound on the patient's left upper buttock with wound care orders. The HA care plan dated 05/27/2025 and updated 07/17/2025 assigned the HA the tasks: bed bath/partial bed bath. The HA care plan did not document the presence of a wound dressing until 07/17/2025, 54 days after the dressing was initiated. The wound was treated until 09/29/2025. CLINICAL RECORD 25: The patient elected hospice care on 03/09/2025 with a diagnosis of breast cancer. A clinical record review revealed that the patient had a PleurX drain and a coccyx wound as of 03/09/2025 and a Foley catheter as of 03/11/2025. The HA care plan dated 03/12/2025 assigned the HA the tasks: bed bath and perineal care. The HA care plan did not identify that the patient had a PleurX, a wound dressing, or a Foley catheter, and did not provide the HA with instructions regarding emptying the Foley drainage bag, what to do should the wound dressing become soiled, wet, or dislodged during care, or that a drain was placed in the patient's abdomen. CLINICAL RECORD 28/HOME VISIT 5: The patient elected hospice care on 11/09/2025 with a diagnosis of hemiplegia. The HA care plan dated 11/09/2025 assigned the HA the tasks: bed bath and perineal care. A physician's order dated 11/12/2025 ordered a Foley catheter to be inserted. During the home visit with the Inpatient Unit Nurse (IPU) [Personnel Record 12] on 11/12/2025, the patient had a Foley catheter with dependent drainage. The HA care plan was not updated to include a task for Foley care. CLINICAL RECORD 29/HOME VISIT 6: The patient elected hospice care on 11/06/2025 with a diagnosis of breast cancer. The HA care plans updated on 11/07/2025 and 11/12/2025 assigned the HA the tasks of bed bath and perineal care. A physician's order dated 11/07/2025 ordered a Foley catheter to be inserted. During the home visit with the Inpatient Unit Nurse (IPU) [Personnel Record 12] on 11/12/2025, the patient had a Foley catheter with dependent drainage. The HA care plan was not updated to include a task for Foley care. Additionally, the patient had a protective dressing on the coccyx (11/12/2025), a gauze dressing on the bilateral shins, and an extensive dressing on the left breast since admission on 11/06/2025. The HA care plan did not include a task for Foley care, did not identify the different wounds or wound dressings, and did not provide the HA with instructions for emptying the Foley drainage bag or what to do should any of the wound dressings become soiled, wet, or dislodged during care. During an interview and joint record review on 11/14/2025, the Director of the IPU, the Vice President of the IPU, the Administrator, and the Area Vice President of Clinical Services stated that the identified care was not documented on the HA care plan. During an interview on 11/14/2025, the IPU Manager provided a sheet with documentation that included identification of the catheter and wounds but was not specific about who was providing or had provided the care. It was a task list used by all staff, but it documented no dates, signatures, or times for when tasks were completed. The IPU Manager stated that these guides were not being scanned into the clinical records but were used by staff.

It is required that drugs and biologicals are labeled and stored in accordance with state law and regulation, as well as accepted standards of practice. At a minimum, labels include: the patient’s full name; generic, trade, or brand name of the medication, as well as amount dispensed; directions for use, including route, rate, frequency, and method of administration; prescriber’s name; expiration date; [and] cautionary instructions. This standard was not met as evidenced by interview and observation. The agency did not ensure that drug and biological labels included the date opened and the expiration date. The multi-dose medications utilized in the inpatient setting were not correctly labeled for the date opened and the date of expiration. During a tour of the IPU medication room on 11/12/2025, a multi-dose vial of lidocaine was stored in a cabinet with over-the-counter medications. The multi-dose vial was unsealed. There was no date for when the vial had been accessed. The Inpatient Unit Director was not sure when it was used. An interview with the staff on 11/12/2025 revealed that they had not accessed the vial and were unclear about when it had been opened. DOCUMENTS: Guidance for Multi-Dose Vials: "Discard 28 days unless manufacturer specifies a different, shorter, or longer beyond use date in the package insert. " The online package insert was reviewed with no clear direction for disposal date after opening. Consequently, the 28-day rule would apply, but the vial was unlabeled, making this date unavailable. During an interview on 11/12/2025, the Inpatient Unit Director stated I will discard this as we do not know when it was opened. The Inpatient Unit Director destroyed the vial. Multi Dose medications utilized in the inpatient setting, the agency did not ensure that the multi dose opened container was correctly labeled for date open and date for expiration. During Tour of the IPU medication room on 11/12/2025; a multi dose vial of lidocaine was in a cabinet with over the counter medications stored. The multi dose vial was unsealed. There was no date of when the vial had been accessed. The IPU director was not sure when it had been used. Interview with the staff revealed they had not accessed the vial and were unclear as to when it had been opened. The vial was destroyed by the director.

It is required that the inpatient hospice facility physical plant has procedures for controlling the reliability and quality of: the scheduled and emergency maintenance and repair of all equipment. This standard was not met as evidenced by interview and observation. A tour of the Inpatient Unit (IPU) revealed that the agency did not ensure proper clothes dryer maintenance was conducted. A tour on 11/13/12025 of the agency's Inpatient Unit (IPU) linen storage area included an inspection of a domestic clothes washer and dryer. Inspection of the clothes dryer revealed that the lint trap was not clean, and lint was present on the filter screen. An additional inspection of the IPU exterior did not reveal the location of the domestic dryer vent to the outside. During an interview on 11/13/2025, the IPU's Director of Maintenance, who was present for the IPU tour, stated that they were unaware of where the dryer vent to the outside was and had not been cleaning the dryer vent duct. During an interview on 11/13/2025, the Vice President of Inpatient Units stated that there was no instruction on the dryer regarding cleaning the lint filter before and/or after each use. A tour of the Inpatient Unit (IPU) revealed that the agency did not ensure that proper clothes dryer maintenance was performed.

It is required that the hospice inpatient facility provides meals to each patient that are: palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by interview and observation. A tour of the agency's Inpatient Unit (IPU) kitchen revealed that the agency did not ensure that food served to patients was at the proper temperature when it was served. During a tour of the IPU's kitchen on 11/13/2025, the following appliances were observed to be used for the preparation of patient food: a microwave, a two-burner hot plate, and a toaster oven. There was no evidence of a food temperature log. During an interview with an IPU nurse who prepares food for patients in the IPU's kitchen, the IPU nurse described the process of meal preparation, including heating frozen prepared meals in the microwave and cooking eggs on the hot plate, but did not mention testing the food for temperature. When asked how they would know that the food was at the proper temperature, the IPU nurse said they test it with a thermometer. When asked where that thermometer was, the IPU nurse retrieved it from a drawer where it was under multiple utensils and other items. When asked whether they record the food's temperature, the IPU nurse stated that recording it is not part of the process and is not done. During an interview on 11/13/2025, the IPU Director, who was present for part of the IPU kitchen tour, confirmed that the temperature of food being served to patients is not logged and that there was no method to confirm that proper temperatures were achieved before serving the food to patients. A tour of the agency's Inpatient Unit's (IPU) kitchen revealed that the agency did not ensure that food served to patients was at the proper temperature when it was served.

It is required that the hospice inpatient facility provides meals to each patient that are: obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by interview and observation. A tour of the agency's Inpatient Unit (IPU) kitchen revealed that the agency did not ensure that the food available for patient service was not expired and was stored at the proper temperature. During a tour of the IPU's kitchen on 11/13/2025, the following items were found in the kitchen and were expired: flavored butter was in the refrigerator and had an expiration date in 10/2025; an unsealed and opened bag containing a tray of frozen biscuits was in the freezer and was marked with an open date in 08/2025; and seven (7) individual jello containers were in the cabinet and marked with expiration dates in 08/2025. Over a dozen individual servings of vegetables in sealed, plastic cups were stored in the cabinet outside of their original container and did not have their expiration dates marked. Two (2) opened, partially used bags of bread were in the cabinet, and were past their expiration date of earlier in 11/2025. A partially used stick of butter was found on the counter at room temperature. During an interview on 11/13/2025, the Vice President of the Inpatient Units, who was present for the IPU tour, including the kitchen tour, confirmed that the identified items were expired, that the vegetables lacked marked expiration dates, and that the butter was found on the counter. A tour of the agency's Inpatient Unit's (IPU) kitchen revealed that the agency did not ensure that food that was available to be served to patients was not expired and was stored at the proper temperature.

It is required that the hospice inpatient facility documents the training and demonstration of competency in restraint or seclusion in each designated employee’s personnel record. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 2 (100%) personnel records reviewed for the inpatient unit (IPU) clinical staff, the agency did not ensure that training on restraints and seclusion was provided for IPU staff per agency policy. Agency policy IPU #1131, "Restraint and Seclusion" (dated 02/09/2023), stated in part, "All staff will be aware of the restraint and seclusion free philosophy and annual training on this philosophy will be provided to all staff." A review of the agency's "2025 Annual Hospice House HHA Specific Training Calendar", "2025 Annual Hospice House Nurse Specific Training Calendar", "2025 Annual Hospice House Executive Director Specific Training Calendar", and "2025 Annual Hospice House Patient Care Manager Specific Training Calendar" revealed that the calendars did not include training specific to the agency's restraint and seclusion philosophy and/or policy. PERSONNEL RECORD 10: The personnel record for this IPU Director, hired on 10/04/2022, contained no documented evidence of training on the agency's restraint and seclusion philosophy. PERSONNEL RECORD 12: The personnel record for this Inpatient Unit (IPU) Registered Nurse (RN), hired on 03/28/2022, contained no documented evidence of training on the agency's restraint and seclusion philosophy. During an interview on 11/13/2025, the IPU Director stated that they could not produce any documentation showing that training had been done with IPU staff on the agency's restraint and seclusion philosophy.

Based on record review and interview, the agency failed to ensure staffing for all services reflects patient acuity levels, which was needed to ensure potential negative outcomes are avoided for 1 of 3 closed record reviews. (Patient #1) Finding include: --- An undated and untitled inpatient guideline for staffing was provided by Licensed Practical Nurse (LPN) 3 on 08/31/2023 at 10:25 AM that indicated how the agency staffs the inpatient unit based on the number of patients. LPN 3 stated when the inpatient unit has 8 or more patients staffing needs go up. A review of the inpatient guideline indicated, but was not limited to the following: 1-3 patients on census – 2 staff (RN, HHA) on day shift (12 hours) and 2 staff (RN, HHA) on night shift (12 hours) 4-7 patients on census – 3 staff (RN, LPN, HHA) on day shift and 2 staff (RN, HHA) on night shift 8- 12 patients on census – 4 staff (RN, RN, LPN, HHA) on day shift and 3 staff (RN, RN, HHA) on night shift Review of the Manual Daily Census Report for 06/16/2023 to 06/21/2023 indicated the inpatient census was 8 to 10 during that time frame. The Census Report indicated the level of care as General Inpatient (GIP), Respite (provides temporary relief for a primary caregiver) and Routine Care (focused on providing physical, spiritual, and emotional support to patients and families) for the following days: 06/16/2023- General Inpatient (GIP) 6; Respite patients 2 06/17/2023- General Inpatient (GIP) 6; Respite patients 3 06/18/2023- General Inpatient (GIP) 5; Respite patients 4 06/19/2023- General Inpatient (GIP) 6; Respite patients 3 06/20/2023- General Inpatient (GIP) 6; Respite patients 4 06/21/2023- General Inpatient (GIP) 8; Respite patients 2 On 08/31/2023 at 10:30 AM the June 2023 staffing schedule, Administrator notes, and staffing guidelines were reviewed along with the Administrator which revealed the inpatient unit was short-staffed by 1 on night shift 06/16/2023 and short staff by 1 on day shift for 06/17/2023, 06/18/2023, 06/19/2023, 06/20/2023, and 06/21/2023. The Administrator stated they were unable to find replacement staff for the shifts, but indicated the Director of Nursing was to count as additional staff even though it was not documented on the schedule, as he/she was on duty as a floor nurse providing direct patient care. During an interview on 08/31/2023 at 10:30 AM the Administrator was asked how the inpatient unit staffs based on the acuity level (levels to accurately staff a person's care plan and treatments) for each shift. The Administrator stated the agency uses its judgment regarding how to staff based on the acuity level and the agency does not have a specific policy on staffing. The agency follows a guideline that was developed by the former Administrator. The agency was unable to demonstrate the ability to staff by acuity. During an interview on 08/31/2023 at 12:00 PM the Director of Nursing was asked how the inpatient unit staff based on the acuity level as indicated in §418.110(a). The DON stated it was based on staff judgment. The DON was unable to provide additional information that indicated he/she was on duty providing direct patient care from 06/16/2023 to 06/21/2023 time frame.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (15%) records reviewed revealed the agency did not ensure that the plans of care specified the specific safety and wound care needs of the patients as identified in the comprehensive nursing assessments. Clinical Record 1: The patient elected the hospice benefit on 1/1/23 with a diagnosis of malignant neoplasm of the bone. the initial nursing comprehensive assessment documented a fall risk assessment score of "8" which indicated "at risk for falling". In the admission narrative note the RN also documented a hospitalization from 11/20 to 11/22/22 as a result of a fall. The fall resulted in fractures at T10, L4, and pelvis; the patient has been wearing a back brace ever since. The POC effective from 1/1/23 to current did not list any problems, goals or interventions related to safety or falls nor did it include specifics related to the patient wearing the back brace. Clinical Record 5: The patient elected the hospice benefit on 2/24/22 with a diagnosis of breast cancer. The nursing comprehensive assessment dated, 1/17/2023, documented that the wound under right breast reopened with bloody drainage noted. On 2/9/23 the RN documented, "wound care provided to cancer lesion under right breast". The plan of care effective for the benefit period, 12/21/22 to current, did not include any orders or specific interventions related to the wound care for the breast lesion, it stated "hospice nurse to observe and assess skin integrity and to notify hospice physician of any observed potential complications. Hospice team to develop additional skin integrity care plan items if necessary." In interviews conducted on 2/9/23 and 2/10/23, the Area Clinical Manager and the Patient Care Manager (Staff 8) reviewed the records and identified that the safety needs, and wound care needs were addressed within the clinical assessments but agreed that this information was missing from the patient plans of care.

It is required that Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) records reviewed revealed that the agency did not ensure that the nursing visits met the ordered visit frequency in the plan of care. Clinical Record 4: The election of benefit was 12/31/21. A physician order, dated 1/9/23, changed the skilled nurse visit frequency to "every other day". Nursing visits were documented as made on 1/9/23, 1/10/23, 1/11/23 and 1/13/23. In an interview with the Patient Care Manager on 2/9/23 she stated that the patient was visited an extra day and that they did not follow the physician-ordered visit frequency. She confirmed that there were no PRN (as needed) skilled nurse visit orders available to cover the additional visit.

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 review of clinical records and interview. In 1 of 10 (10%) records reviewed in which hospice aide services were accepted, the agency did not ensure that the RN provided specific instructions for the aide to complete the personal care tasks. Clinical Record 1: Election of benefit was 1/1/23. The initial nursing assessment documented that the patient "wears back brace at all times since fall in November." The physician certification of terminal illness dated 1/4/23 reported the patient had been hospitalized from 11/20/22 to 11/22/22 after a fall that resulted in fractures of T10, L4, and pelvis. The hospice aide care plan, effective 1/1/23 to current, assigned the task "shower every visit" with an ordered visit frequency of 3 times per week. The aide care plan did not provide instructions regarding the back brace. In an interview with the Patient Care Manager, conducted on 2/8/23, it was confirmed that the patient was to wear the back brace and the aide care plan did not provide instructions for the aide regarding if the back brace could or could not be removed during showers.

It is required that the hospice designates that inpatient staff who have direct patient care responsibility are trained and demonstrate competency in: applying restraints; implementing seclusion; monitoring, assessment, and care of a patient in restraint or seclusion. The hospice inpatient staff training is documented and occurs as part of the hospice inpatient facility orientation; and subsequently, on a periodic basis consistent with hospice policy and in consideration of the competency of the staff and the needs of the patient population served. This standard was not met as evidenced by document reviews, interviews and review of personnel records. IPU Policy # 1133 Restraint and Seclusion Training Requirements dated 5/3/2020 states in part, "All Staff designated by the hospice as having direct patient care responsibilities including contract or agency personnel, must demonstrate the competency in the application of restraints, implementation of seclusion, monitoring, assessment and providing care for a patient in restraints. a) before performing any restraint procedures b) as part of orientation c) annually as part of the IPU patient care staff competency program." 5 of 5 (100%) personnel records reviewed, of Inpatient Unit (IPU) direct care employees or contracted staff, revealed that the agency did not ensure that restraint or seclusion competency was demonstrated and documented in the employee's personnel records upon orientation. Staff 12- Hospice Aide; Date of Hire (DOH) 4/13/22: The personnel record did not contain documented evidence of restraint or seclusion competency. Staff 13- RN; DOH 3/28/22: The personnel record did not contain documented evidence of restraint or seclusion competency. Staff 14- IPU Unit Director; DOH 12/13/21: The personnel record did not contain documented evidence of restraint or seclusion competency. Staff 15- Medical Director; contract effective: 3/21/17: Personnel file did not contain documented evidence of restraint or seclusion competency. Staff 17-RN; DOH 8/15/22: The personnel record did not contain documented evidence of restraint or seclusion competency. In an interview with the Administrator on 2/8/23, she stated that they completed the training on the policy but had not included competency for restraints or seclusion because, "we don't use any restraints." This was confirmed by the Medical Director (Staff 15) in an interview on 2/9/23 when he stated, "there have not been any restraints ordered the entire time the unit has been open." The IPU opened in May 2022. The Administrator reported that the policy was being revised to acknowledge they are "restraint-free" but confirmed that they did not follow the current policy.