Every finding on record at Heart to Heart Hospice of Northern 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 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 clinical record review, document review, and interview. Agency policy #TX17 "Medication list and Monitoring" (dated 01/10/2021) stated in part, "The hospice will maintain a current, accurate Medication profile of all prescription and over- the counter (OTC) medications taken by the patient." In 2 of 6 (33%) clinical records reviewed of patients receiving oxygen, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient's current prescription and over-the-counter (OTC) drugs. Clinical Record 11: The patient elected the hospice benefit on 05/09/2024. A physician's order for oxygen 2 liters per minute (LPM) by nasal cannula (NC) was documented on admission. The patient's medication profile did not include documentation of oxygen. Clinical Record 16: The patient elected the hospice benefit on 11/19/2023. A physician's order for oxygen was documented on admission. The patient's medication profile did not include documentation of oxygen. During interviews on 07/16/2024 and 07/17/2024, the Patient Care Manager (PCM) confirmed that oxygen was not included in the patient's medication profile. Agency Policy TX.17 dated 01/10/2021 titled "Medication list and Monitoring." Stated "The hospice will maintain a current, accurate Medication profile of all prescription and over- the counter (OTC) medications taken by the patient."

It is required that the comprehensive assessment includes the patient’s or family’s need for referrals and further evaluation by appropriate health professionals. This standard was not met as evidenced by clinical record review and interview. Agency policy #LD.2 " Scope of Services" stated in part, "Hospice will provide care that optimizes comfort and dignity, and is consistent with a patient and family needs and goals, with patient needs and goals as priority. Agency will offer the following services: Speech language Pathology Services Evaluation." In 1 of 1 (100%) clinical records reviewed of a patient needing further evaluation by an appropriate health professional, the agency did not ensure that the patient was evaluated by an appropriate health care professional as ordered. Clinical Record 1: The patient elected the hospice benefit on 06/28/2024. On 07/05/2024, the physician ordered a speech evaluation for diet modification. There was no evidence of a speech evaluation as of the clinical record review on 07/16/2024, 11 days after the order was written. A clinical record review revealed no evidence that the patient's speech therapy evaluation was completed or that speech therapy was consulted regarding the evaluation order. During an interview and a joint review of clinical records on 07/16/2024, the Patient Care Manager (PCM) confirmed that the speech evaluation was not done. Policy LD.2 tiltled " Scope of Services stated in part "Hospice will provide care that optimizes comfort and dignity, and is consistent with a patient and family needs and goals, with patient needs and goals as priority. Agency will offer the following services: Speech language Pathology Services Evaluation.

It is required that each patient’s individualized written plan of care: measurable outcomes anticipated from implementing and coordinating the plan of care. 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) included measurable outcomes anticipated from the implementing and coordinating the plan of care. Clinical Record 7: The patient elected hospice care on 02/20/2024 with the diagnosis of cerebral vascular accident (CVA). On admission, the nursing comprehensive assessment documented the patient's "coping/depression." The POC documented the patient goal: "Patient will verbalize acceptance and satisfaction with current plan of care." The goal did not include a measurable outcome. Clinical Record 13: The patient elected hospice care on 01/24/2023 with the diagnosis of malignant neoplasm of prostate. On admission, the nursing comprehensive assessment documented the patient's "coping/depression." The POC documented the patient goal: "Patient will verbalize acceptance and satisfaction with current plan of care." The goal did not include a measurable outcome. Clinical Record 19: The patient was admitted on 03/30/2024 with the diagnosis of malignant neoplasm of gallbladder. On admission, the nursing comprehensive assessment documented the patient's "alteration in comfort." The POC documented the patient goal: "pt's pain will be controlled with present pain medication." The goal did not include a measurable outcome. During an interview and a joint record review on 07/16/2024 and 07/17/2024, the Patient Care Manager (PCM) confirmed that the records did not include goals with measurable outcomes. No additional information or documentation was provided. Agency Policy TX.06 titled "Plan of Care Process dated 01/01/2020 indicated the hospice would develop individualized plan of care (POC) for each patient, which include measuable outcomes anticipated from implementing and coordinating the plan of care."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.07 "Implementing Care," stated in part, "The aide will be provided with written instructions for patient care prepared by an RN...aide will provide direct patient care under the direction of the RN and according to the Hospice Aide Plan of Care." In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 4: The patient elected the hospice benefit on 02/27/2024. The initial Hospice Aide care plan dated 02/27/2024 assigned the HA the relevant task of a bedbath. The HA visit notes dated 02/29/2024 and 03/07/2024 documented that the HA gave the patient a partial bath instead of a bed bath. The HA did not follow the HA care plan. Clinical Record 10: The patient elected the hospice benefit on 02/15/2024. The initial Hospice Aide care plan dated 02/15/2024 assigned the HA the relevant task of a shower. The HA visit notes dated 02/26/2024 documented that the HA gave the patient a bed bath. The HA did not follow the HA care plan. During an interview and a joint review of clinical records on 07/16/2024, the Patient Care Manager (PCM) confirmed that the Hospice Aides did not follow the HA care plans. Agency policy TX.07 titled " implementing Care indicated " The aide will be provided with written instructions for patient care prepared by an RN." The Aide position desciption essential duties indicated " aide will provide direct patient care under the direction of the RN and according to the Hospice Aide Plan of Care."

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. 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 the HA reported changes related to the plan of care to the Registered Nurse (RN). Clinical Record 4: The patient elected the hospice benefit on 02/27/2024. The initial Hospice Aide care plan dated 02/27/2024 assigned the HA the relevant task of a bedbath. The HA visit notes dated 02/29/2024 documented that the HA gave the patient a partial bath instead of a bed bath. The HA did not notify the Registered Nurse (RN) of the change to the HA care plan. Clinical Record 10: The patient elected the hospice benefit on 02/15/2024. The initial Hospice Aide care plan dated 02/15/2024 assigned the HA the relevant task of a shower. The HA visit notes dated 02/26/2024 documented that the HA gave the patient a bed bath. The HA did not notify the RN of the change to the HA care plan. During an interview and a joint review of clinical records on 07/16/2024, the Patient Care Manager (PCM) confirmed that the Hospice Aides did not inform the RN of changes in the patient's care plan. Agency Policy TX.07 Indicated "Reporting changes in the patient's medical, nuring, rehailitative, and social condition/needs to a registered nurse as the changes relate to the POC and QAPI activities.

Based on record review and interview, the hospice failed to ensure it monitored and analyzed patient falls to ensure patient safety and quality of care and failed to utilize the falls information obtained to initiate a performance improvement plan to mitigate/eliminate patient falls for 1 of 1 QAPI program reviewed. Findings include: --- 1. A review of a "QI [Quality Improvement] Event Report" evidenced there were 71 unattended falls and 15 attended falls reported from 01/01/23 - 09/11/23. 2. A review of the agency's QAPI (Quality Assessment Performance Improvement) program evidenced the number of falls in the 4th quarter of 2022 was 35 and the number of falls in the first quarter of 2023 was 47. The program failed to evidence initiatives or performance improvement plans (PIP) were in place to monitor, analyze, and mitigate falls as patients declined. 3. On 09/13/23 at 10:33 AM, the Executive Director indicated she was aware of the falls but no PIP was in place at this time to manage and mitigate falls.