Every finding on record at Heart to Heart Hospice of Northwest 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; 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; 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, interview and observation. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the patient's current medications were included in the drug profile. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 11/17/2025. During a home visit with the Registered Nurse (RN) [Personnel Record Review 7] on 02/18/2026, a review of the patient's medication revealed a prescription bottle labeled "Metformin 1,000mg tablets, take half a tablet two times daily." The patient produced over-the-counter medications labeled "Fish Oil 1,200mg capsules," "Vitamin D3 25mcg capsules," and "Immodium 2mg tablets." In an interview, the patient stated, "I have been taking those medications for a long time." The caregiver in the home stated, "I know he has been taking all of those medications for at least three years." The agency's medication profile dated 02/17/2026 did not include documentation of metformin, fish oil, vitamin D, or Immodium. There was no evidence that the comprehensive assessment included a review of metformin, fish oil, vitamin D, or Immodium with the patient's current medication regimen. CLINICAL RECORD 3/HOME VISIT 3: The patient elected the hospice benefit on 07/17/2022. The patient resided in an assisted living facility (ALF). During a home visit with the Chaplain (Personnel Record Review #4) on 02/19/2026, the patient's ALF medication list was reviewed with the facility's RN. The ALF medication list documented "Date: 09/25/2024 nystatin cream 100,000 units per gram, apply topically daily as needed for redness to abdominal skin folds; Date: 09/26/2025 guaifenesin 10mg/5ml, give 10ml by mouth every 6 hours as needed for cough." The agency's medication profile dated 02/18/2026 did not document the use of nystatin cream or guaifenesin. There was no evidence that the comprehensive assessment included a review of nystatin cream or guaifenesin CLINICAL RECORD 11: The patient elected the hospice benefit on 09/22/2025. A physician's order dated 09/22/2025 ordered "Oxygen 3 liters per nasal cannula continuously." The medication profile dated 09/22/2025 did not document oxygen. During joint record reviews and interviews on 02/18/2026 and 02/19/2026, the Area Clinical Manager confirmed the above findings that oxygen, nystatin cream, guaifenesin, metformin, fish oil, vitamin D, and Imodium were not included in the patients' medication profiles.

It is required that each patient’s individualized written plan of care: 1. Reflects patient and family goals; identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; 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, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the plan of care included the drugs and treatments necessary to meet the patient's needs. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 11/17/2025. During a home visit with the Registered Nurse [Personnel Record 7] on 02/18/2026, the patient's prescription bottle was labeled "Metformin 1,000mg tablets, take half a tablet two times daily" and the over-the-counter medications with the labels reading "Fish Oil 1,200mg capsules," "Vitamin D3 25mcg capsules," and "Imodium 2mg tablets" were provided. During an interview, the patient stated, "I have been taking those medications for a long time." The caregiver in the home stated, "I know he has been taking those medications for at least three years." The POC did not include documentation of metformin, fish oil, vitamin D, or Imodium. CLINICAL RECORD 15: The patient elected the hospice benefit on 09/03/2025. The Skilled Nursing note dated 11/11/2025 documented "18Fr coude foley catheter changed." A review of the clinical record revealed that the plan of care did not include the size or maintenance of the Foley catheter. During joint record reviews and interviews on 02/18/2026 and 02/20/2026, the Area Clinical Manager confirmed the above findings that the plan of care did not include all orders for the Foley catheter, metformin, fish oil, vitamin D, or Imodium.

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 2 of 15 (13%) clinical records reviewed, in which Hospice Aide (HA) services were provided, the agency did not ensure that all written patient care instructions were included in the Hospice Aide care plan. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/11/2026. A physician's order dated 02/04/2026 included orders for wound care with a wound dressing to a wound on the patient's right buttock. The plan of care dated 01/11/2026 through 03/11/2026 ordered "HA 2 times weekly." The Hospice Aide care plan dated 01/26/2026 assigned the HA the relevant task of "Bed bath every visit." The HA care plan was not updated to include instructions regarding the wound dressing on the right buttock if it became wet or dislodged during the bed bath. CLINICAL RECORD 11: The patient elected the hospice benefit on 09/22/2025. A physician's order dated 09/22/2025 included orders for "Oxygen 3 liters via nasal cannula continuously." The plans of care dated 09/22/2025 through 12/20/2025 and 12/21/2025 through 03/20/2026 ordered "HA 2 times weekly". The Hospice Aide care plan dated 09/22/2025 assigned the HA the relevant task of "Shower every visit." The Hospice Aide care plan did not include instructions on how the Hospice Aide should use the oxygen during the shower. During joint record reviews and interviews on 02/18/2026 and 02/19/2026, the Area Clinical Manager confirmed the above findings, stating, "There are no wound dressing or oxygen instructions included in the care plans for the aide."

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide; and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 7 of 15 (47%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed by a Registered Nurse at least every 14 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/17/2025. The plan of care dated 11/17/2025 through 02/14/2026 ordered "HA 2 times weekly." The first Hospice Aide visit was dated 11/21/2025. Hospice Aide supervisory visits were dated 12/03/2025, 12/11/2025, and 12/19/2025. The next Hospice Aide supervisory visit was dated 01/16/2026, with 28 days outstanding. CLINICAL RECORD 2: The patient elected the hospice benefit on 01/11/2026. The plan of care dated 01/11/2026 through 03/11/2026 ordered "HA 2 times weekly." The first Hospice Aide visit was dated 01/13/2026. Hospice Aide supervisory visits were documented as completed on 01/22/2026 and 02/06/2026, with 15 days outstanding. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/12/2025. The plan of care dated 11/12/2025 through 02/09/2026 ordered "HA 2 times weekly starting week of 11/17/2025." The first Hospice Aide visit was dated 11/21/2025. Hospice Aide supervisory visits were documented as completed on 12/02/2025, 12/10/2025, 12/20/2025, and 12/31/2025. The next Hospice Aide supervisory visit was dated 01/19/2026, with 19 days outstanding. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/30/2025. The plans of care dated 10/30/2025 through 01/27/2026 and 01/28/2026 through 04/27/2026 ordered "HA 2 times weekly starting week of 11/06/2025." The first Hospice Aide visit was dated 11/07/2025. The first Hospice Aide supervisory visit was dated 01/29/2026, with 83 days outstanding. CLINICAL RECORD 9: The patient elected the hospice benefit on 08/22/2025. The plans of care dated 08/22/2025 through 10/20/2025, 10/21/2025 through 12/19/2025, and 12/20/2025 through 02/17/2026 ordered "HA 2 times weekly." The first HA visit was dated 08/25/2025. Hospice Aide supervisory visits were documented as completed on 08/26/2025, 08/30/2025, 09/02/2025, 09/10/2025, and 09/23/2025. The next HA supervisory visit was dated 10/15/2025, with 22 days outstanding. HA supervisory visits were documented on 10/28/2025 and 11/04/2025. Hospice Aide supervisory visits were documented as completed on 11/23/2025 (19 days outstanding), 12/09/2025 (12 days outstanding), 12/30/2025 (21 days outstanding), and 01/21/2026 (22 days outstanding). CLINICAL RECORD 11: The patient elected the hospice benefit on 09/22/2025. The plans of care dated 09/22/2025 through 12/20/2025 and 12/21/2025 through 03/20/2026 ordered "HA 2 times weekly." The first Hospice Aide visit was dated 09/25/2025. Hospice Aide supervisory visits were dated 09/30/2025 (5 days outstanding, 10/10/2025 (10 days outstanding), and 12/22/2025 (73 days outstanding). CLINICAL RECORD 18: The patient elected the hospice benefit on 09/01/2025. The plan of care dated 09/01/2025 through 11/29/2025 ordered "HA 4 times weekly." The first Hospice Aide visit was dated 09/03/2025. Hospice Aide supervisory visits were dated 09/09/2025 (6 days outstanding), 09/17/2025 (8 days outstanding), and 10/02/2025 (15 days outstanding). During joint record reviews and interviews on 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026, the Area Clinical Manager confirmed the above findings, stating, "We will be completing re-education with all nursing staff regarding completing and documenting aide supervisory visits every 14 days."

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 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 IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all medications were updated on the medication profile and reviewed for all potential interactions. Document 1: TX.17 Medication List and Monitoring [reviewed 01/01/2021] stated in part, "The hospice will maintain a current, accurate Medication profile of all prescription and over-the-counter medications taken by the patient." Clinical Record 2: Nursing comprehensive visit 8/14/2023 documented Lasix (a medication to clear extra fluid) to start daily for increased lower extremity edema. A nursing visit on 8/17/2023 documented that Lasix had arrived and was started. The medication profile was not updated to include Lasix. An interview with the Executive Director, who reviewed the record and agreed that the medication profile was not updated with the changed medication.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. (L625) 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 5 (20%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure that the aide plan documented specific written instruction for safety and the aide assignment, thus leaving the aide to make decisions outside the aide's scope of practice. Clinical Record 5: The aide plan of care documented 06/16/2023 an assigned task of showering every visit and activity of stand-by assist with a walker. A Skilled Nursing visit on 07/10/2023 documented a fall and several falls after this date. A wheelchair was obtained on 07/10/2023 with instructions to be used with assistance and for the patient not to transfer alone. The patient had several falls after this, but the facility used a wheelchair. This was an observed visit on 09/08/2023 with the nurse. The patient stated that she could stand to transfer but used only the wheelchair, which she can propel with her feet, but that she does not transfer without assistance. The aide plan continued to direct a walker and was not updated for the safety of using the wheelchair. An interview with the Executive Director on 09/08/2023 revealed that the Registered Nurse should have updated the aide plan to add a wheelchair for more specific safety precautions while providing personnel care.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) supplements, and 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 a 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. In 4 of 13 (31%) clinical records reviewed, the agency did not ensure that initial and subsequent comprehensive assessments included updated drug profile that contained the patient's current over the counter (OTC) medications and other treatments that could affect drug therapy. Clinical Record 2: The patient election of the hospice benefit was signed on 01/05/2023 with a primary diagnosis of Hepatic Failure. During a home visit on 03/14/23, the caregiver verbalized that the patient took two ibuprofen tablets by mouth as instructed by the RN when the patient fell two weeks ago. The patient's medication profile was not updated to include the new order. Clinical Record 3: The patient election of the hospice benefit was signed on 02/25/2023. On 03/06/23, the hospice RN wrote an order to "start antidiarrhea medication every four hours prn diarrhea." The patient's medication profile still needs to be updated to include the new order. Clinical Record 1: The patient election of the hospice benefit was signed on 12/15/2022. The initial comprehensive assessment was completed 12/15/2022. The facility medication profile documented the patient was receiving Zofran 4mg q 8 hours prn nausea and vomiting on 01/28/2022. Zofran was not listed on the hospice medication profile on 03/15/23. Clinical Record 6: The patient was admitted for hospice services on 07/26/2022 with a primary diagnosis of Congestive Heart Failure. The patient was started on nebulizer treatment every six hours prn. There was no documentation of the reason for the prn medication. During an interview on 03/15/2023, the Executive Director stated the medications were not present on the drug profiles at the time of the clinical record review.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, the agency did not provide evidence that the initial bereavement assessment was completed. Clinical Record 13: The patient was admitted for Hospice services on 09/27/2022. The primary diagnosis was Senile Degeneration of the Brain. The Registered Nurse and Social Worker’s notes were reviewed between 09/27/2022 and 10/03/2022, and there was no documented evidence that an initial bereavement assessment was completed. During an interview with the Executive Director on 04/03/2023, it was confirmed that the bereavement assessment was not completed during the initial assessment.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness, intervention to manage pain and symptoms, measurable outcomes anticipated from implementing and coordinating the plan of care, drugs, and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 9 of 13 (69%) clinical records reviewed, the hospice did not ensure the plan of care was individualized to include problems identified during the initial assessment and measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2: The patient elected hospice care on 01/05/2023. The initial assessment completed on 01/05/23 identified patient was a fall risk. The plan of care did not include documentation of a measurable outcome. Clinical Record 1: The patient elected hospice care on 12/15/2022. During the home visit on 03/15/23, a review of the plan of care identified an outcome as "pain alteration in comfort." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 3: The patient elected hospice care on 02/25/2023. The initial assessment identified a "risk for fall." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 4: The patient elected hospice care on 03/30/22. The initial assessment identified "pain/comfort." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 5: The patient elected hospice care on 06/09/2022. The initial assessment identified "Altered Cardiopulmonary Status." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 7: The patient elected hospice on 09/27/2022. The initial assessment identified "Altered home safety." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 6: The patient elected hospice on 07/26/2022. The initial assessment identified a "need for skilled teaching regarding pain/altered comfort." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 8: The patient elected hospice on 08/16/2022. The initial assessment identified the "need for medication management." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. Clinical Record 9: The patient elected hospice on 06/18/2022. The plan of care identified "altered skin integrity." The plan of care did not include documentation of a measurable outcome anticipated from implementing and coordinating the plan of care. The Executive Director was interviewed on 03/15/2023 and agreed the plan of care was not individualized to include problems identified in the initial assessment and did not include measurable outcomes to manage the patient's symptoms.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, and observation. Agency policy [review date 01/01/2020] states in part, "When the visit is completed, reusable equipment is cleaned using alcohol, disinfectant wipe and/or antimicrobial soap and water as appropriate, hands are washed, and equipment and supplies are returned to the bag." 3 of 3 (100%) observed home visits revealed the clinicians did not follow acceptable standards of practice or agency policy to prevent the transmission of infections and communicable disease. Home Visit 2 (Clinical Record 2): The patient was admitted to services on 01/05/2023 with a diagnosis of Hepatic Failure. During the observed home visit conducted on 03/14/23, the Registered Nurse (RN) donned exam gloves, performed vital signs, and cleaned the equipment used to perform vital signs. Hand hygiene was not completed before returning the equipment to the visit bag. Home Visit 1 (Clinical Record 1): The patient was admitted to Hospice services on 12/15/2022 with a primary diagnosis of Senile Degeneration of the Brain. During the observed home visit on 03/15/2023, the RN obtained the patient's vital signs, cleaned the equipment, and returned them to her bag. Hand hygiene was not completed after cleaning the equipment used to assess the patient's vital signs. Home Visit 3 (Clinical Record 3): The patient was admitted to Hospice services on 02/25/2023 with a primary diagnosis of Senile Degeneration of the Brain. During the observed home visit on 03/14/23, the hospice aide washed her hands, closed the faucet, and used the same paper towel to dry her hands. During an interview conducted on 03/14/2023, the Executive Director confirmed that the clinicians did not follow the agency's policy.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed on 04/03/2023, the agency did not ensure that the hospice notice of election form documented the start of care date as it was blank. CLINICAL RECORD 12: The hospice election form was signed on 01/28/2023 with a primary diagnosis of End-Stage Heart Disease and lacked documentation of a different start of care date (It was blank). The start of care date was 01/27/2023, one day before the date the hospice benefits election was signed. During an interview with the Area Executive Director, it was confirmed that the signed notice of election of Hospice benefit form did not document the start of care date.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper and contains, Physician Orders. This standard was not met as evidenced by clinical record review. In 1 of 1 (100%) clinical record review of a patient with an indwelling urinary catheter, the agency did not provide evidence that a physician order to place an indwelling catheter was obtained on admission. CLINICAL RECORD 12: The patient was admitted for Hospice services on 01/28/2023 with a primary diagnosis of Senile Degeneration of the Brain. The RN documented on the initial assessment that the patient had an indwelling urinary catheter. No physician order specified the catheter size, balloon size, or what must be changed written on admission. A new physician order was written on 03/22/2033 fifty-three (53) days after the admission.

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 and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and document review. 1 of 1 (100%) discharge record reviewed did not include documentation that the discharge summary was sent to the receiving facility within the required timeframe. Clinical Record 11: The patient elected hospice care on 12/19/2022. The discharge was reviewed and revealed the patient was discharged due to revocation on 02/08/2023. The RN completed a discharge summary. There was no evidence that the discharge summary was sent to the receiving hospital for continuity of care. The Executive Director was interviewed on 03/16/2023 and confirmed that the discharge summary and/or patient clinical record was not sent to the receiving hospital to ensure continuity of care.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident: the most recent hospice plan of care. This standard was not met as evidenced by clinical record review, document review, interviews, and observation. 1 of 1 (100%) clinical record and facility binder of a patient residing in a Skilled Nursing Facility (SNF) revealed the hospice did not ensure the most current updated plan of care was provided to the SNF. Home Visit 1 (Clinical Record 1): The patient elected hospice care on 12/15/2022 and was admitted with a diagnosis of Senile Degeneration of the Brain. During the observed visit on 03/15/23, the hospice binder at the SNF was reviewed with the Hospice Registered Nurse (RN). The plan of care located in the binder was the start of the care plan of care. There was no evidence the SNF had a current plan of care for the patient. The RN, during an interview following the visit, stated, "Looks like the only items here are from the beginning of care, I have not updated the plan of care." The Area Clinical Manager was interviewed on 03/15/23 and confirmed the plan of care was not updated and was not sent to the SNF.

Based on observation, record review and interview, the hospice agency failed to provide effective pain management related to the terminal illness in 1 of 2 residential home visits. (Patient #1) Findings include: --- Record review evidenced an agency policy dated 03/28/2022, titled, ";Patient Rights And Responsibilities," stated, ";... To receive effective pain management and symptom control from the hospice for the conditions related to the terminal illness ...." Record review of an agency policy dated 01/01/2020, titled, ";Pain Management," stated, ";... The Agency will educate direct patient care staff and patient regarding pain assessment and management ... Pain intensity rating will be recorded utilizing a pain scale as determined by Agency ... Pain will be assessed as part of every patient contact if patient reports pain or is at risk of pain...." Clinical record review on 3/13/2023, for patient #1, start of care 09/27/2022, evidenced an agency document dated 03/01/2023, titled, ";Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report," which stated, ";... Hospice Primary Diagnosis ... Senile Degeneration of the Brain [mental deterioration with memory loss] ... Patient is having increased hallucinations. Patient has had a fall and developed a new wound from the fall ...." Clinical record review of an agency document dated 03/10/2023, titled, ";Visit Note Report," indicated the patient reported a wound pain level of 8 ( 0=no pain, and 10=worst pain possible). The visit note indicated the pain frequency was daily, pain quality was tender, throbbing and pain interventions were medication, rest. Review of an agency document titled, ";Wound Record Report," for 02/27/2023, indicated the left tibial wound pain level at 8, 03/03/2023, the wound report indicated the pain level at 1, at 03/05/2023, the report indicated the patient had no pain, and 03/10/2023, the wound report indicated the pain level at 8. During an observation of a home visit on 03/10/2023, at 10:30 AM, the patient indicated the left leg wound was at a pain level of 8 prior to the wound care. The wound care was performed by LPN (licensed practical nurse) #1, and no medication was given prior to wound care. During an interview on 03/10/2023, at 10:45 AM, after wound care, LPN #1 indicated the patient had Alzheimers and could not answer pain level correctly. LPN #1 asked patient again regarding pain level and patient indicated pain remained to left leg wound site after wound care. During an interview on 03/13/2023, at 3:30 PM, the administrator indicated pain assessment should indicate describing pain on a pain scale, document pain medications given last 24 hours, document if onset of pain was new, and education. The administrator indicated they would expect pain medications to be given prior to wound care for a patient complaint of pain at a level of 8.

Based on observation, record review and interview, the hospice agency failed to review all of the patients prescriptions and over-the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy in 1 of 2 residential home visits. (Patient #1) Findings include: --- Record review of an agency policy dated 01/01/2021, 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 ... Changes in the medication regimen will be documented in the medical record either on the medication profile, on a verbal order and in Plan of Care, as well as communicated to the patient and/or caregiver. Changes in medication regimen will be updated as frequently as necessary to keep the profile accurate...." Clinical record review on 03/10/2023, for patient #1, start of care 09/27/2022, evidenced an agency document titled, ";Hospice Recertification Plan of Care Update," for certification 12/26/2022-03/25/2023. This document indicated the patient was on medications including but not limited to, Atropine (for secretions), Lorazepam (antianxiety) , Morphine (pain reliever), Furosemide (diuretic) and Metoprolol (blood pressure medication) 25 mg (milligrams) one tablet twice a day. Review of the patients home medications during the 03/10/2023, home visit, included but was not limited to Atorvastatin (cholesterol medication), Fish Oil, Loperamide (diarrhea medication), Metoprolol 25mg ½ tablet twice a day, and Vitamin B. Review failed to evidence the plan of care medication included all the patients home medications to include Atorvastatin, Fish Oil, Loperamide, vitamin B and the current dose of Metoprolol. Review failed to evidence the patients home medication list included Lorazepam, Morphine, and Furosemide. Review of the patients home hospice binder failed to evidence a medication list provided by the hospice agency. During an observation of a home visit on 03/10/2023, from 9:45 AM-11:50 AM, LPN (licensed practical nurse) #1 failed to be observed reviewing the patients medications. During an interview on 03/13/2023, at 3:45 PM, the administrator indicated the nurse should reconcile the medications at each nurses visit and at recertification. The administrator indicated an updated medication list should be in the patients home hospice binder.

Based on record review and interview, the hospice agency failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings for 3 of 5 active patient clinical records reviewed. (Patient #1, #5, #8) Findings include: --- Clinical record review on 3/13/2023, for Patient #8, evidenced an agency document titled ";Client Coordination Note Report" dated 1/19/2023, which indicated the patient fell resulting in an abrasion to the left side of the head. Review failed to evidence the agency notified the primary care physician of the patients fall prior to 1/25/2023. During an interview on 3/14/2023, at 12:50 PM, the administrator indicated the physician was not notified of the patients fall prior to 1/25/2023 and indicated the nurse should notify the physician of the fall at the fall follow-up visit that is to be conducted within 24 hours of notification of the fall. Record review evidenced an agency policy reviewed on 04/05/2022, titled, ";Orders for Care," stated, ";... The licensed or professional staff contacts the physician for input and possible orders: ... A change in patients condition occurs ...." Record review evidenced an agency policy reviewed on 11/01/2010, titled, ";Physician Services," stated, ";... The Agency Medical Director, physician employees, and contracted physicians of the agency, in conjunction with the patients attending physician, are responsible for the palliation and management of the terminal illness and conditions related to the terminal illness ... Agency responsibilities are to assist in the provision of patient care and include, but not be limited to, the following: ... To communicate changes in the patients condition in a timely ... manner ...." Record review evidenced an agency policy reviewed on 02/26/2021, titled, ";Interdisciplinary Group Roles and Responsibilities," stated, ";The IDG (interdisciplinary group) ... will supervise the care and services including: Drugs, biologicals and treatments ... Record review on evidenced an undated agency policy received on 03/14/2023, titled, ";Dermatologic and Wound Care," stated, ";... Document the following on the visit report: The procedure and patient toleration, Condition of the patients skin, Any patient/caregiver instructions and response to teaching, including adherence to recommendations, Physician notification, if applicable ...." Clinical record review on 03/13/2023, for patient #1, start of care 09/27/2022, evidenced an agency document dated 03/05/2023, titled, ";Wound Record Report," indicated the left pretibial wound measured 0.4 centimeters (length), 0.7 centimeters (width), 0.2 centimeters (depth), had normal skin color surrounding wound, had no peripheral tissue edema, and no pain associated with the wound. Review of the Wound Record Report for date 03/10/2023, indicated the left pretibial wound measured 1 centimeter (length), 3.5 centimeters (width), 0.02 centimeters (depth), had bright red skin color surrounding wound, peripheral tissue edema of less than 4 centimeters, and pain level of 8 (0=no pain, 10=worst possible pain). Review failed to evidence the physician was notified regarding the increase in wound size, surrounding skin color bright red, and peripheral tissue edema change in wound condition from 03/05/2023 to 03/10/2023. During an interview on 03/13/2023, at 3:27 PM, the administrator indicated the nurse should have notified the physician regarding the wound change in condition.

Based on record review and interview, the hospice agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infections and communicable disease in 2 of 4 clinical records reviewed with an infection. (Patient #3, #6) Findings include: --- 1. Record review of an agency policy dated 01/01/2020, titled, ";Quality Assessment Performance Improvement Program," stated, ";... Areas for improvement will be identified through the collection of data for Analysis of Agency services. Systems that measure significant outcomes for optimal care include: ... Infection control activities ... The Agency will strive to improve operational and patient health and safety outcomes by implementing a performance improvement plan that incorporates the following essential processes: ... Monitoring performance through data collection ... When planning for performance improvement, Agency leaders will consider the following: ... Identifying the data collection methodology (i.e. how and by whom data will be collected and what process will be used to analyze data) ...." 2. Record review of an agency policy dated 01/01/2020, titled, ";Performance Improvement Process: Data Collection," stated, ";... Performance Improvement measurements may include: ... Infections ...." 3. Record review of an agency policy dated 11/01/2020, titled, ";Infection Control Program," stated, ";... The Infection Control Program will include: ... A system that coordinates: Surveillance for the occurrence of an infection, Identification of the occurrence ... Documentation completed by all staff will include at a minimum: Date the infection was detected ... Type of Infection ... Process for Reporting Patient Infections The Agency will track all infections ... Every patient infection will be reported as soon as any Agency staff member is aware of it. All Reported infections will be documented on the appropriate Agency form for monthly review, analysis, trending, and initiation of performance improvement activities if deemed necessary ...." 4. Record review of an agency policy dated 07/01/2016, titled, ";Occurrence/Incident Reporting," stated, ";Agency will document and report all occurrences/incidents ... that deviate from routine Agency operations and might results in potential harm to a patient/caregiver ...." 5. Clinical record review on 03/14/2023, for patient #3, start of care 01/23/2023, evidenced an agency document dated 02/21/2023, titled, ";Visit Note Report," which indicated the patient was seen for inflammation, pain and swelling to the right eye. The visit note report indicated the right eye was swollen shut, the eye was bright red and irritated, the eye was weeping tears and had green matter that morning. The visit note report indicated Maxitrol eye drops were ordered which contained two antibiotics and a steroid. Review failed to evidence an infection occurrence report was completed. During an interview on 03/14/2023, at 1:06 PM, registered nurse #1 indicated new infections should be documented in the electronic medical record and there was a check box to indicate new infections to be reported. During an interview on 03/14/2023, at 2:38 PM, the administrator indicated an occurrence report was not completed for the patients new eye infection. 6. Clinical record review for patient #6, start of care 01/05/2023, evidenced an agency document dated 01/19/2023, titled, ";Visit Note Report," which indicated the patient had a foley catheter (tube into the bladder to drain urine), had completed antibiotic on Sunday 01/15/2023, for a urinary tract infection. Review failed to evidence an infection occurrence report was completed. During an interview on 03/13/2023, at 4:20 PM, the administrator indicated no occurrence report had been completed regarding the urinary tract infection.

Based on record review and interview, the administrator failed to provide oversight of the day-to-day operations by ensuring the agency followed its policy on completing incident reports in 1 of 3 active clinical records reviewed with falls. (Patient #8) The findings include: --- Record review of an agency policy dated 07/01/2016, titled, ";Occurrence/Incident Reporting," stated, ";... Agency will document and report all occurrences/incidents ... that deviate from routine Agency operations and might results in injury or potential harm to a patient/caregiver ... Adverse events include, but are not limited to: ... Provision of care errors, i.e., procedures error which results in trauma and/or injury, falls ... An Occurrence/Incident Report will be completed on all occurrences or incidents, as defined in policy, by the staff member involved or the first person to become aware of the incident...." Clinical record review on 3/13/2023, for Patient #8, evidenced an agency document titled ";Client Coordination Note Report" dated 1/19/2023, which indicated the patient fell resulting in an abrasion to the left side of the head. Review failed to evidence the agency completed an occurrence report regarding the patients fall. During an interview on 3/14/2023, at 12:47 PM, the administrator indicated there was not an occurrence report completed for the patients fall reported on 1/19/2023. The administrator indicated the nurse on-call who was notified of the fall or the nurse who completed the fall follow-up visit should complete the occurrence report.

Based on observation, record review and interview, the hospice agency failed to include policies and procedures to ensure the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated; and failed to include policies and procedures that were implemented to ensure tracking of all staff vaccination status including contracted staff. Findings include: --- During an interview on 3/13/2023, at 2:28 PM, the administrator indicated she was unaware of the vaccination status for the alternate administrator, Corporate Staff #1, and Corporate Staff #3. The administrator indicated she was unaware of how the vaccination status was tracked for the corporate staff. Record review of an agency policy, reviewed on 01/14/2022, titled, ";Infection Control & Prevention: Mandatory COVID-19 Vaccination Policy," stated, ";... Effective March 15, 2022, all applicable employees, to include new hire, will be fully vaccinated for COVID-19, except for those employees who have been granted exemptions from COVID-19 vaccination ... Regardless of clinical responsibility or patient contact, the policies and procedures apply to the following hospice employees, who provide any care, treatment, or other services for the hospice and/or its patients: Hospice employees ... and Individuals who provide care, treatment, or other services for the hospice and/or its patients, under contract or by other arrangement. The policies and procedures of this section do not apply to the following hospice employees: ... (ii) Employees who provide support services for the hospice that are performed exclusively outside of the settings where hospice services are provided to patients and who do not have any direct contact with patients, patient families and caregivers, and other employees ...." Review of the agency policy failed to evidence the agencys COVID-19 specific mitigating intervention for unvaccinated staff. During the entrance interview on 03/09/2023, at 9:49 AM, the administrator indicated the hospice agency is contracted for physical therapy, occupational therapy, speech therapy and dietary consultation. Review of an agency document dated 07/16/2019, evidenced a contract agreement between entity #2 and the hospice agency for physical therapy, occupational therapy, and speech therapy. Review failed to evidence documentation and tracking for contracted staff at entity #2 of the COVID-19 vaccine. During an interview on 03/10/2023, at 4:30 PM, corporate employee #3 indicated a letter was sent to contractors to request a letter from contracting companies to provide information regarding the COVID-19 vaccination status of employees. Review of an agency document received on 03/10/2023, dated, 02/01/2022, identified as the contract letter request regarding COVID-19 vaccination status, requested information regarding employee COVID-19 vaccination status. Review failed to evidence documentation was received from entity #2 regarding the employee vaccination status. Review of an agency document titled, ";COVID-19 Vaccine Mandate Accommodation Approval or Denial," indicated the staff requesting medical or religious accommodation regarding the COVID-19 vaccine was required to wear an N-95/KN-95 mask, face shield, gloves and while in the office or healthcare setting are required to wear a N95/KN-95 and face shield at all times. During an observation of an assisted living visit on 03/13/2023, from 11:30 AM-12:34 PM, unvaccinated registered nurse #2 failed to evidence use of a face shield during patient care. During an observation on 03/09/2023, at 11:45 AM, corporate staff #1 and #4 arrived at the hospice office. During the entrance interview on 03/09/2023, at 9:49 AM, corporate staff #4 was also identified as the hospice agencys alternate administrator. Corporate staff #4 was not identified on the employee list provided. The vaccine status of corporate staff #4 was not provided by exit. During an observation of a home visit on 03/10/2023, the administrator was in attendance in the patients home. During an observation on 03/09/2023, the administrator was in contact with corporate staff #1, and #4 in the agency office; on 03/10/2023, the administrator was in contact with corporate staff #1 in the agency office; on 03/13/2023 the administrator was in contact with corporate staff #1, #3, #4 in the agency office; and on 03/14/2023 the administrator was in contact with corporate staff #1, #3, and #4 in the agency office. Review failed to evidence the COVID-19 vaccination status of corporate staff #1, #3, and #4 were provided by exit. During an interview on 03/10/2023, at 4:30 PM, the administrator indicated the hospice agency was not tracking or documenting corporate office staff or contracted staff vaccine status, only the direct employees' vaccine status was being tracked and documented.