Every finding on record at Heart to Heart Hospice of Indianapolis, 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 observation, clinical record review, and interview. In 3 of 4 (75%) home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current medications. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 12/16/2024 with a diagnosis of chronic systolic heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the ALF medication profile (printed on 09/23/2025). The following medications were documented on the ALF medication profile and not on the hospice medication profile: ferrous sulfate 325 mg, one (1) tablet daily (ordered 03/20/2025). The last comprehensive nursing visit was dated 09/18/2025. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 11/21/2023 with a diagnosis of Alzheimer's disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the SNF medication profile (printed on 09/23/2025). The following medications were documented on the SNF medication profile and not on the hospice medication profile: artificial tears, one (1) drop in the left eye four times daily (ordered 08/15/2025); and bisacodyl 10 mg suppository, one (1) every 24 hours as needed (ordered 11/22/2024). The last comprehensive nursing visit was dated 09/20/2025. Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 08/09/2025 for a diagnosis of intrahepatic bile duct carcinoma. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the SNF medication profile (printed on 09/23/2025). The following medications were listed on the SNF medication profile and not on the hospice medication profile: nitroglycerin, one (1) tablet every 5 minutes as needed for chest pain (ordered 09/13/2025); oxycodone 10 mg, one (1) tablet every 4 hours as needed (ordered 08/09/2025); polyethylene glycol, 17 grams by mouth as needed (ordered 08/09/2025); and Senna S 8.6-50 mg, two (2) tablets twice daily (ordered 08/12/2025). The last comprehensive nursing visit was dated 09/16/2025. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings, stating, "The nurses should be doing medication reconciliations with every visit."

It is required that each patient’s individualized written plan of care: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by observation. clinical record review, and interview. In 1 of 4 (25%) home visits observed, the agency did not ensure that the patient’s written plan of care included the necessary drugs and treatments to meet the patient's needs. Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 08/09/2025 for a diagnosis of intrahepatic bile duct carcinoma. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 09/23/2025, the following medications were listed on the SNF medication profile and not on the patient's plan of care: nitroglycerin, one (1) tablet every 5 minutes as needed for chest pain (ordered 09/13/2025); oxycodone 10 mg, one (1) tablet every 4 hours as needed (ordered 08/09/2025); polyethylene glycol, 17 grams by mouth as needed (ordered 08/09/2025), and Senna S 8.6-50 mg, two (2) tablets twice daily (ordered 08/12/2025). The last comprehensive nursing visit was dated 09/16/2025. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings, stating, "These medications were not included in the hospice list."

It is required that 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 16 (19%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient's needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/16/2024 with a diagnosis of chronic systolic heart failure. The patient resided in an assisted living facility (ALF). The HA care plan dated 07/30/2025 assigned the HA the relevant tasks: "Bathing-shower, foot care, hair care, nail care-clean and filing, perineal care, shampoo (weekly) skin care, skin care-lotion, transfer client from bed/chair, transfer client from chair to bed, offer fluids, wheelchair bound, RN notified of changes, diabetic precautions, fall precautions, standard precautions." All tasks were to be completed on every visit, except shampoo. The HA services were ordered twice weekly. The skilled nursing (SN) visit note dated 08/24/2025 documented a "new wound to right leg." The physician's order dated 09/09/2025 ordered: "Mid back wound. Cleanse with wound cleanser twice weekly, pat dry, and place a 4 x 4 foam dressing. Measure weekly." The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the shower. CLINICAL RECORD 5: The patient elected hospice care on 03/24/2025 with a diagnosis of sarcopenia. The patient resided in an ALF. The HA care plan revision dated 08/08/2025 assigned the HA the relevant tasks: "Bathing-bed bath, dressing-apply compression stockings, glasses, hair care, nail care-clean, oral care-brush, perineal care, skin care-lotion, review patient diet, two person transfer, wheelchair bound, companionship (three times a week), narrative, RN notified of changes, bleeding, fall precautions, take patient's weight (monthly)." A revision on 08/11/2025 included "assist with feeding." All tasks were to be completed on every visit unless otherwise specified. HA services were ordered seven (7) times weekly. The physician's order dated 08/11/2025 ordered: "Wound care to BLE (bilateral lower extremity). Clean the wound with wound cleanser or normal saline (NS). Pat dry, cover open areas with non-adherent dressing, wrap with kerlix, secure with tape, and apply Tubigrip." The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the bed bath. CLINICAL RECORD 6: The patient elected hospice care on 04/20/2024 with a diagnosis of end-stage heart failure. The patient resided in a skilled nursing facility (SNF). The HA care plan revision dated 08/04/2025 assigned the HA the relevant tasks: "Bathing-bed bath, shampoo, hair care, skin care-deodorant, lotion, perineal care, oral care, nail care-clean, dressing, hearing aides, change linens, tidy patient area." All tasks were to be completed on every visit. HA services were ordered twice weekly. The physician's order dated 08/29/2025 ordered: "Right calf skin tear. Apply Xero foam and wrap with kerlix." The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the bed bath. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings. He agreed that the HA care plans should provide "specific instructions for the wound dressings."

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.60 "Employee Supervision" (revised 12/06/2024) stated in relevant part: "A RN must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care." In 1 of 1 (100%) personnel records reviewed for a Hospice Aide (HA), the agency did not ensure that a Registered Nurse (RN) made an annual on-site visit to the location where a patient was receiving care, to observe and assess each HA while they were performing care. Personnel Record 7: The Hospice Aide was hired on 03/30/2017. A personnel record review revealed that no documented annual on-site supervisory visit was conducted in 2024. During a joint personnel record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the finding and stated that the "previous Administrator/Executive Director had not documented the completion of many items in 2024."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.10 "Staff Competency" (revised 11/15/2024) stated in relevant part: "The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff's basic skill levels for all staff providing care, including volunteers (if applicable), contracted staff, paraprofessionals, and professionals." In 3 of 9 (33%) personnel records reviewed of individuals providing care, the agency did not ensure that the skills and competencies of all individuals providing care, including volunteers, were assessed.   Personnel Record 3: The Registered Nurse was hired on 08/12/2024. A personnel record review revealed that no initial skills competencies were documented at the time of hire. Personnel Record 5: The Social Worker was hired on 05/26/2021. A personnel record review revealed that no annual skills competency was completed in 2024. Personnel Record 8: The Social Worker/Bereavement Coordinator was hired on 05/31/2008. It was confirmed with the Administrator that this employee "sometimes functions as a social worker." A personnel record review revealed that no annual skills competency was completed in 2024. During a joint personnel record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the finding, stating that the "previous Administrator/Executive Director had not documented the completion of many items in 2024."

Based on record review and interview, the agency failed to document and investigate an injury of unknown origin as required by hospice policy in 1 of 5 patients reviewed. (Patient #1) Findings include: --- On 5/17/23 at 9:55 AM, a review of an undated agency's policy 'ABUSE, NEGLECT AND EXPLOITATION (ANE) RI.5 IN,' revealed "...Injuries of unknown source ... 1. The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and 2. The injury is suspicious because of the extent of the injury or the location of the injury...PROCEDURE ...The hospice agency ... will investigate immediately, resolve, take corrective action..." On 5/17/23 at 10:15 AM, a review of an undated agency's policy 'PATIENT RIGHTS AND RESPONSIBILITIES RI.1 IN,' revealed "...17. To be assured that the hospice will ensure...injuries of unknown source ... are reported ... to the hospice administrator. The hospice will immediately investigate ... and will immediately take action to prevent further potential violations while the alleged is being investigated ..." A review of Clinical Record #1 on 5/15/23 revealed a Skilled Nursing visit note dated 4/4/23 and signed by RN 2, which indicated bruising identified in the narrative note, "as evidenced by patient having bruises on forehead from bumping head on bedrails, as verbalized by FSN [facility staff nurse] ... Patient's resolving bruise was reported to PCM [Primary Care Manager] for further questioning. FSN was unable to find [sic a] record relating to incident at this time". A review of the agency's incident logs failed to identify an incident report, investigation, and actions taken to prevent further injuries of unknown origin for Patient #1 related to their bruised forehead. During an interview on 5/17/23 at 11:13 AM with Person 1, a family member of Patient #1, they indicated they had noticed the bruising either on 4/5/23 or 4/6/23, and had taken pictures and indicated they talked to the facility Administrator at Entity 2, they were told that Entity 2 and the hospice agency would be investigating the bruising, later Person 1 indicated they were informed by the agency the bed rails caused the bruising, and the rails would be removed. During an interview on 5/17/23 at 2:11 PM with RN 3, they indicated an incident report should have been written.

Based on record review and interview, the agency failed to update the comprehensive assessment and the plan of care so that accurate care planning decisions could take place in 1 of 5 clinical records. (Patient #1) Findings include: --- 3. On 5-17-2023 at 2:58 PM, when queried as to whether he had been made aware in early April 2023 of Patient #1's reported facial bruising of unknown origin, the Medical Director indicated that if he was made aware of the bruising, this would have been documented in IDT notes. When queried further as to what action would be taken in a case with bruising of unknown origin, indicated that an inquiry would follow to include the patient's fall risk, whether the patient was taking a blood thinner, where the patient was rated on the PPS scale, whether neuro checks were done and had the patient deteriorated any since then. He further indicated the agency would soon be discussing this case at length. 1. A review of Clinical Record #1 on 5/15/23 revealed a Skilled Nursing visit note dated 4/4/23 and signed by RN 2 indicated bruising identified in the narrative note, "as evidenced by patient having bruises on forehead from bumping head on bedrails, as verbalized by FSN [facility staff nurse]...Patient's resolving bruise was reported to PCM [Primary Care Manager] for further questioning. FSN was unable to find record relating to incident at this time" . A review on 5/15/23 of Clinical Record #1 revealed an IDG (Interdisciplinary Discipline Group) meeting on 4/5/23 that failed to identify bruising or new orders. 2. During an interview on 5/17/23 at 2:08 PM, RN 3 indicated Patient #1 bruised forehead was discussed at the IDG meeting 0n 4/5/23, but further indicated they didnt see documentation of the discussion in the IDG meeting report.

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, and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by a review of clinical records, observation, and interviews. 5 of 13 (38%) clinical records reviewed revealed that the agency did not ensure that drug profiles contain a complete list of patients' prescription drugs and supplements. Clinical Record 11: The Skilled Nursing (SN) assessment at the start of care on 10/4/2022 notes that the patient is short of breath at times as he has lung cancer and is requesting oxygen PRN. Oxygen is not included on the medication list. The SN visit note documented on 10/18/2022 reveals that oxygen is in the home. SN start of care assessment on 10/4/2022 revealed that patient suffers from oropharyngeal cancer. "Patient has a peg tube and can take nothing by mouth due to nausea." Medication profile includes gabapentin oral solution, levsin tablet, morphine concentrate, lorazepam concentrate, ondansetron dissolving tablet but does not include directions for use and need to be administered via peg tube. Clinical Record 10: The SN assessment at the start of care on 11/26/2022 reveals that the patient is using oxygen at 4L/M per NC. The medication profile does not include Oxygen. During a home visit on 11/30/2022, Site visitor observed the patient wearing oxygen per nasal cannula. Clinical Record 12: The SN assessment on admission on 7/8/2022 reads in part, "Dysphagia has worsened requiring meds to be crushed." There are no instructions on medication profile to crush medications. Clinical Record 5: The SN assessment on the start of care on 11/22/2022 reveals that the patient is on oxygen and very short of breath. Oxygen is not included in the medication profile. Clinical Record 4: The SN assessment on SOC 9/14/2022 reveals that the patient utilizes oxygen and is extremely short of breath even with talking. The Plan of Care includes oxygen precautions under safety measures and includes an intervention to instruct in the safe use of oxygen, however, oxygen is not included on the medication list. In an interview with the leadership team on 11/29/2022, Administrator stated in part, "I understand and we updated them today." 4 of 13 (30%) of clinical records reviewed revealed that the agency did not ensure that drug profiles contain a complete list of patients prescription drugs and supplements.

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. 3 of 13 (23%) clinical records reviewed revealed that the agency did not ensure that the plan of care specified the care and services needed to meet the specific needs of the patient. Clinical Record 5: The Plan of Care (POC) dated 11/22/2022 includes a template that reads, "Hospice nurse to insert /maintain indwelling catheter FR/CC, may irrigate with change catheter every or as needed." Specifics related to the size of the catheter, balloon, and frequency of change are not included in the care plan. Further, the start of care Skilled Nursing (SN) assessment dated 11/22/2022 documents that the patient is on oxygen. The POC dated 11/22/2022 includes a template statement that reads, "Hospice nurse to instruct in the safe use of oxygen and monitor effectiveness." The POC does not include orders related to dose, route, and frequency of oxygen. Clinical Record 11: The SN Assessment at the start of care on 10/04/2022 notes that the patient is short of breath and requesting oxygen PRN. The same RN assessment notes that the patient had a peg tube placed as a result of oropharyngeal cancer leaving the patient unable to swallow. The POC dated 10/4/2022 does not include orders for oxygen and does not include interventions for the peg tube. The peg tube is listed on the plan of care under nutritional requirements "2 cal 2.0 peg tube" but there is nothing included in interventions related to care of the peg tube, frequency of feedings, etc. Clinical Record 13: The SN assessment on admission on 8/31/2022 revealed that the patient had an Aspira drain placed prior to admission for treatment of symptoms related to ascites. The POC dated 8/31/2022 does not include interventions related to the Aspira drain. In an interview with the Administrator and Patient Care Managers on 12/1/2022, Administrator stated in part, " We have updated the care plans that we could but the system does not allow us to enter interventions related to the Aspira drain and we just document it in IDT. We are working with the vendor to allow us to add information that is not on a template." 3 of 13 (23%) of clinical records reviewed revealed that the agency did not ensure that the plan of care specified the care and services needed to meet the specific needs of the patient.

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 interviews. In 2 of 11( 18%) records reviewed with aide services revealed that the agency did not ensure that the aide care plan provided written instructions specific to allow the aide to practice within the scope of services for an aide. Clinical Record 2: Skilled Nursing (SN) Assessment upon admission on 2/11/2022 notes that the patient is on Oxygen at 4L per nasal cannula. Note also indicates that the patient is a fall risk and encouraged to use a walker when the patient is up. Aide care plan dated 2/11/22 lists "Mobility - Independent" there is no indication to the aide that the patient should use a walker or is a fall risk. There is no indication to the aide that the patient is on oxygen. Clinical Record 5: Aide care plan dated 11/22/2022 includes aide tasks - Bathing - Bed Bath every visit and Bathing-Shower Weekly. Instructions are not clear to the aide which type of "Bathing" should be performed every visit. In an interview with the leadership team and Administrator on 11/29/2022, Administrator stated in part, " Ok, that makes sense, they have to narrow it down." In 2 of 11( 18%) records reviewed with aide services revealed that the agency did not ensure that the aide care plan provided written instructions specific to allow the aide to practice within the scope of service for an aide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 in 11 (9%) clinical records reviewed with aide services revealed that the agency did not ensure that the aide provided services as ordered on the aide care plan. Clinical Record 4: Aide care plan dated 9/14/2022 includes shower and hair care every visit. The aide visit note on 11/22/22 reveals that the aide did not provide a shower. Aide visit note dated 11/25/2022 reveals that the aide did not perform shower, hair care, or skin care with no explanation. The aide visit note on 11/28/2022 revealed that the aide did not provide shower or hair care with no documentation of patient refusal. In an interview with the leadership team on 11/29/2022, Administrator stated in part, "That makes sense. We will have to teach them to document refused instead of not completed." 1 in 11 (9%) of clinical records with aide services revealed that the agency did not ensure that the aide provided services as ordered on the aide care plan.

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 a review of clinical records and interviews. 1 in 11 (9%) of clinical records with aide services revealed that the agency did not ensure that the aide reported changes in the patient's needs that impacted the aide's plan of care. Clinical Record 4: Aide care plan dated 9/14/2022 includes Shower and Hair Care every visit. The aide visit note on 11/22/22 reveals that the aide did not provide a shower and there is no indication of notification to the RN. Aide visit note dated 11/25/2022 reveals that the aide did not perform shower, hair care, or skin care with no explanation and no indication that RN was notified. The aide visit note on 11/28/2022 revealed that the aide did not provide a shower, or hair care with no documentation of patient refusal or notification to the RN. Interview: In an interview with the leadership team on 11/29/2022, Administrator stated in part, "That makes sense. We will have to teach them to document refused instead of not completed."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum, Physician orders. This standard was not met as evidenced by a review of clinical records, interviews, and observations. 4 of 13 (30%) clinical records reviewed revealed that the agency did not ensure that physician orders were included in the clinical record for all services. Clinical Record 4: Skilled Nursing (SN) assessment on Start of Care (SOC) 9/14/2022 reveals that the patient utilizes oxygen and is extremely short of breath even with talking. The plan of care included oxygen precautions under safety measures and included an intervention to instruct in the safe use of oxygen, however, there are no orders for oxygen on the plan of care or medication list. Clinical Record 5: SN assessment on Start of Care 11/22/2022 reveals that the patient is on oxygen and very short of breath. The clinical record does not contain physician orders for the administration of oxygen. Clinical Record 10: The patient was admitted on 11/26/2022 with a primary diagnosis of Lung Cancer. The SN assessment upon admission reveals that the patient is using Oxygen at 4L/M per nasal cannula. Observation during the home visit on 11/30/2022 confirmed that the patient is using continuous oxygen. There are no orders for oxygen dose, frequency, or route. Oxygen is not included on the med list on the Plan of Care. Clinical Record 11: SN assessment on Start of Care 10/4/2022 reveals that the patient has secondary Lung Cancer, is short of breath, and is requesting oxygen PRN. SN visit note on 10/18/2022 reveals that oxygen is in the home. The clinical record does not include specific orders for oxygen use, rate, or frequency. The Patient Care Manager stated in part in an interview on 11/30/22, " So, we write PRN oxygen orders from the beginning if we order oxygen." In an interview with the Administrator and Patient Care Managers on 12/1/2022, stated in part, "We have updated the clinical record with late entries." 4 of 13 (30%) clinical records reviewed revealed that the agency did not ensure that physician orders were included in the clinical record for all services.