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

It is required that each patient’s individualized written plan of care include all services necessary for the palliation and management of the terminal illness, including 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient's individualized plan of care included all treatments necessary to meet the patient’s needs. CLINICAL RECORD 11: The patient elected the hospice benefit on 12/30/2025. Review of the clinical record revealed the initial comprehensive assessment and skilled nursing documentation identified the patient had a Mickey button feeding tube in place for medication administration and gravity feedings twice daily. The plan of care dated 12/30/2026 did not include specific interventions for management of the feeding tube, including administration of tube feedings, flushes, or site care. During joint clinical record review and interview with the Patient Care Manager on 02/13/2026, confirmed that the patient’s plan of care did not include individualized interventions addressing feeding tube management.

It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident which includes the hospice election form and the physician's certification of the terminal illness. This standard was not met as evidenced by interview and observation. In 1 of 1 (100%) home visits to a skilled nursing facility, it was revealed that the agency did not ensure that the required information was provided to the skilled nursing facility. HOME VISIT 2 / CLINICAL RECORD 2: During the home visit observation with the Registered Nurse [Personnel record #2] on 02/11/2026, a review of the agency’s hospice binder, revealed the binder did not contain the hospice election form dated 01/06/2026 and the certification of terminal illness. This finding was reviewed with the Patient Care Manager, present at home visit, confirmed that the hospice binder did not contain all required information.

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; other alternative treatments that could affect drug therapy. 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, interview, and observation. 2 of 3 (67%) home visits observed where medication reconciliations were performed revealed the hospice medication profiles were inaccurate. Clinical Record 12: The patient, with an election of hospice benefit dated 1/13/2023, had a primary diagnosis of COPD and was receiving hospice services at a skilled nursing facility. The agency provided the requested documentation, including a medication profile dated 3/22/2023 with active and discontinued medications. There was evidence of multiple medication reviews with the date range of 1/13/2023 through 3/22/2023, performed by the hospice physician and several Registered Nurses. Home Visit 2: During the visit with the hospice Chaplain on 3/23/2023 at the skilled nursing facility (SNF) where the patient (Record 12) resided, a medication reconciliation was performed, comparing the hospice medication profile to the SNF physician order report. The reconciliation revealed two medications were listed on the hospice medication profile as scheduled compared to as needed (PRN) on the facility physician's orders. Loperamide 2mg as needed (PRN), an antidiarrheal medication, was ordered on 11/4/2022 per the SNF physician report, with instructions to give 4mg by mouth after the first loose stool, then 2mg after each additional loose stool with a maximum of 16mg per day. The hospice medication profile had the medication dated 2/15/2023 with the same dosage and instructions; however, it did not document the medication as needed (PRN). Cyclobenzaprine 10 mg, a muscle relaxant, was ordered on 12/28/2019 per the SNF physician order report, to take by mouth once a day as needed (PRN) for muscle spasms. The hospice medication profile had the medication dated 1/13/2023, cyclobenzaprine 10mg by mouth daily. Clinical Record 13: The patient, with an election of hospice benefit dated 10/7/2022, had a primary diagnosis of cerebral atherosclerosis and was receiving hospice services at an assisted living facility. The agency provided the requested documentation, including a medication profile dated 3/22/2023 with active and discontinued medications. There was evidence of multiple medication reviews with the date range of 1/11/2023 through 3/8/2023, performed by the hospice physician only and none by the Registered Nurse. Home Visit 3: During the home visit with the hospice aide on 3/23/2023 at an assisted living facility where the patient (Record 13) resided, a medication reconciliation was performed by comparing the hospice medication profile to the assisted living facility's current physician orders for the patient for the time frame of 3/1/2023 through 3/31/2023 and last reviewed on 2/24/2023 by the skilled facility nurse. The reconciliation revealed the hospice medication profile had inaccurate warfarin dosages and frequencies. Warfarin, a blood thinner or anticoagulant, was documented with two different orders on the hospice medication profile: dated 10/7/2022, warfarin 2.5mg by mouth with no specific frequency but instructions of Sunday, Tuesday, Wednesday, Friday, and Saturday. The second warfarin of 5mg by mouth had no specific frequency but instructions for Monday and Thursday. The ALF physician order dated 12/27/2022 documented warfarin 3mg, one tablet by mouth once a day, and recheck PT/INR in one week. A physician order was dated 2/3/2023 to continue the current coumadin dose and PT/INR in two weeks. An interview on 3/24/2023 with the Area Clinical Manager confirmed the medication profiles were inaccurate for Record 12 and Record 13 after reviewing the findings of the home visits.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. 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, and the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by clinical record review and interview. 1 of 6 (17%) records reviewed where the patients had wound care treatment orders revealed the agency did not follow the wound care orders per the plan of care. Clinical Record 7: The patient with an election of hospice benefit dated 1/7/2023, had a primary diagnosis of gangrene and received hospice services at a skilled nursing facility. The Hospice Plan of Care order dated 1/7/2023 documented "wound care location right lower extremity (RLE) calf, hospice nurse to administer venous stasis care one (1) times per week; facility/caregiver to perform dressing change daily and/or on alternate days as needed for displacement or soilage. Wound to be cleansed with Hibiclans, patted dry, soak Kerlix in Gentamicin with Dakins 0.25% solution, pack wound bed and undermining at proximal end of wound, cover with ABD, and wrap with Kerlix using aseptic technique." The wound care and assessments were not completed for two weeks, from 1/8/2023 through 1/23/2023. The wound was assessed, and wound care was performed on the admission dated 1/7/2023 and then later at the nursing visit on 1/26/2023. The hospice nursing visits dated 1/8/2023, 1/9/2023, 1/13/2023, 1/16/2023, 1/18/2023, and 1/23/2023 documented wound was not assessed, and the caregiver completed care, not following the hospice plan of care. An interview with the Area Clinical Manager during a joint record review confirmed that the wound care orders were not followed per the hospice plan of 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 clinical record review and interview. In 1 of 13 (8%) clinical records reviewed where hospice aide services were accepted, the agency's hospice aide care plan was inaccurate and did not provide patient specific written instructions for a hospice aide assistant. Clinical Record 10: The patient with an election of hospice benefit dated 8/22/2022 received hospice aide services at a skilled nursing facility. The Aide Care Plan dated 11/9/2022 documented assigned tasks of a bed bath twice weekly and shower once weekly. The frequency entered was three times per week (HHA 3xweekly). However, the hospice aide was only going twice weekly (2xweekly), with one of those days with a hospice aide assistant for assistance with the shower. The hospice aide care plan did not document the need for such assistance or detail the assignment of the second hospice aide. The agency captured the hospice aide assistant visit as a billable visit who documented against the care plan. During the joint record review on 3/24/2023, the Area Clinical Manager stated that the agency had been cited in the past for not entering a frequency for the hospice aide assistant, which provided the rationale for the three times a week frequency, but the twice a week visits. However, it was confirmed that the hospice aide care plan was inaccurate with the current frequency of the two bath types and should have been documented bed bath weekly and shower weekly with a hospice aide assistant.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a Registered Nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed where hospice aide services were accepted, the Registered Nurse was not notified by the aide of completed tasks that were not assigned on the aide care plan. Clinical Record 5: The patient, with an election of hospice benefit dated 11/7/2022, received hospice aide services at an assisted living facility. The Aide Care Plan dated 12/5/2022 documented the assigned task of a shower weekly. The aide frequency was increased from twice weekly (2xweekly) to five times per week (5xweekly), effective 1/11/2023. The hospice aide visit note dated 1/19/2023 documented not completing the assigned shower task "due to frequency not require this visit," however, the aide documented in the narrative note assisting the patient with a bed bath. The aide documented "N" as not notifying the RN of changes. The hospice aide visit note dated 1/23/2023 documented "Y" as completing a shower and then documented in the narrative note assisted the patient with a bed bath, and RN was documented as not being notified. The hospice aide visit note dated 1/30/2023 documented "N" as not completing a shower due to not being required at the visit; however, the aide documented in the narrative note assisting the patient with a bed bath and tidying up the room. The aide documented not notifying the RN of changes. An interview with the Area Clinical Manager on 3/24/2023 during a joint record review confirmed the hospice aide should have notified the Registered Nurse of completing the unassigned task of a bed bath so the care plan could be updated accurately and the follow-up with any changes in the patient's condition.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and document review. In 2 of 2 (100%) clinical records reviewed where the patients were live discharged from the agency and transferred to a local hospital, the agency did not forward a copy of the hospice discharge summary to the receiving hospitals. Clinical Record 3: The patient, with an election of hospice benefit dated 11/19/2021, received hospice services at a skilled nursing facility. The Hospice Unattended Live Discharge note dated 6/29/2022 documented that the patient elected revocation to seek treatment at a local hospital due to an increased abdominal girth, and the agency revocation form was signed and effective 6/29/2022. The patient was admitted to the hospital with a bowel obstruction. The Discharge-Transfer Summary Report dated 6/30/2022 did not document being sent to the hospital. The IDT meeting dated 7/6/2022 documented by the RN that a copy of the discharge summary was sent to the attending physician, but no documentation of it being sent to the local hospital. The agency provided no other evidence that the discharge summary was sent to the hospital. Clinical Record 5: The patient with an election of hospice benefit dated 11/7/2022 received hospice services at an assisted living facility (ALF). Discharge-Transfer Summary Report dated 2/11/2023 was not sent to receiving hospital, where the patient was transferred per the daughter's request after suffering from a fall with injury at the ALF. The IDT meeting documentation dated 2/22/2023 stated the patient was admitted to the hospital with a T7 compression fracture and later admitted to the general inpatient unit with another hospice agency for pain management. There was no documentation or evidence of the discharge summary or information being sent to the hospital or the other hospice agency. An interview with the Area Clinical Manager on 3/24/2023 during the joint record review and a follow-up with the agency's medical records confirmed that the discharge summaries for both live discharges of Record 3 and Record 5 were not forwarded to the receiving hospitals.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 4 of 6 (67%) clinical records reviewed where patients received hospice services at skilled nursing facilities (SNF), the agency did not have a written plan of care established in consultation with the SNF representatives that specified which provider was responsible for performing the functions that were agreed upon and included in the plan of care. The agency utilized the agency form titled Facility and Hospice Delineation of Duties to document the care of the hospice patient/resident that was needed and specified which provider was responsible for performing the functions agreed upon and included in the plan of care. In addition, on the bottom of the form were two signature/date lines for each provider, the hospice agency representative, and the facility representative, to document the acknowledgment and agreement of the delineation of duties. Clinical Record 3: The patient with an election of hospice benefit dated 7/3/2022 had a primary diagnosis of COPD and received hospice services at a skilled nursing facility. There was no evidence or documentation of the agency form titled Facility and Hospice Delineation of Duties in the record. Clinical Record 9: The patient, with an election of hospice benefit dated 6/25/2022, received hospice services at a skilled nursing facility and was later transferred to a different skilled nursing facility on 3/14/2023. The agency form titled Facility and Hospice Delineation of Duties was completed at the start of care for the first skilled nursing facility. The physician order dated 3/13/2023 documented the patient transferred to another contracted skilled facility effective 3/14/2023. The agency form titled Facility and Hospice Delineation of Duties dated 3/10/2023 was completed and signed by the hospice RN. However, it was missing the facility representative's signature and the date that acknowledged the agreement on the delineation of duties. Clinical Record 10: The patient with an election of hospice benefit dated 8/26/2022 received hospice services at a skilled nursing facility. There was no evidence or documentation of the agency form titled Facility and Hospice Delineation of Duties in the record. Additionally, the agency form titled Facility Notification dated 8/26/2022 was not signed by a facility representative. Clinical Record 12: The patient with an election of hospice benefit dated 1/13/2023 received hospice services at a skilled nursing facility. There was no evidence or documentation of the agency form titled Facility and Hospice Delineation of Duties in the record. Additionally, the agency form titled Facility Notification dated 1/13/2023 was not signed by a facility representative. During the joint record reviews on 3/24/2023, the Area Clinical Manager confirmed the agency did not follow the facility process of completing the delineation form.