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

It is required that each patient’s individualized written plan of care reflects the patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met, as evidenced by clinical record review, document review, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's individualized written plan of care reflected the patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Agency policy #TX.06 "Plan of Care Process" (revision date 01/01/2020) stated in part, "The hospice will develop an individualized written plan of care (POC) for each patient. The POC must reflect patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments." Clinical Record 12: The patient elected hospice care on 04/17/2024. The on-call clinical note documented "Wheezing and fighting for air. Started wheezing this evening and has periods of shortness of breath (SOB). Instructed if patient becomes SOB to give morphine." An as-needed (prn) visit was completed on 07/21/2024 to follow up on symptoms, and a physician order was obtained for DuoNeb's every four hours. A clinical record review revealed no evidence that the patient's plan of care was updated to document the patient's and family's respiratory goals and planned interventions to address the patient's identified problems of wheezing and shortness of breath. Clinical Record 17: The patient elected hospice care on 04/26/2023. A skilled nursing visit was completed on 10/23/2023 at the request of the patient's wife due to the patient's decline in condition over the weekend. The wife requested for the patient's defibrillator to be deactivated. A physician order was obtained on 10/23/2023 to increase skilled nursing visits to daily, implement Hospice Aide (HA) visits five (5) times a week, deactivate the defibrillator, and turn off the tachycardia therapy. A clinical record review revealed no evidence that the patient's plan of care was updated to document the patient's and family's goals for comfort and planned interventions addressing the patient's change in condition. The Area Clinical Manager confirmed the findings in a joint record review and interview on 08/14/2024.

It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.06 “Plan of Care Process” (revision date 01/01/2020) stated in part, “The Plan of Care includes but is not limited to...Measurable outcomes anticipated from implementing and coordinating the plan of care.” In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that the patient’s written plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 10: The patient elected hospice care on 05/15/2024. The Chaplain completed a spiritual evaluation on 05/17/2024 and updated the plan of care to include the intervention “Chaplain to treat, listen with concern in the moment and provide caring, compassionate resources” with the patient’s goal “Patient and her caregiver will experience spiritual uplift and increased peace.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the Chaplain services. Clinical Record 11: The patient elected hospice care on 05/29/2024. The Chaplain updated the plan of care on 06/10/2024 to include the intervention “Family will experience spiritual support throughout their loved one’s end of life journey through sharing and updates by this Chaplain” with the patient’s goal “Chaplain to treat, provide active listening, counsel, emotional support, care coordination and/or end-of-life education.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the Chaplain services. Clinical Record 12: The patient elected hospice care on 04/17/2024. The Social Worker (SW) updated the plan of care on 06/17/2024 to include the intervention “Social Worker to provide companionship with the patient through physical presence” with the patient’s goal “Patient’s need for companionship will be supported throughout the dying process.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the SW plan of care. Clinical Record 13: The patient elected hospice care on 05/24/2024. The Chaplain completed a spiritual evaluation on 05/28/2024 and updated the plan of care to include the intervention “Chaplain to treat, listen with concerns in the moment and provide caring, compassionate response” with the patient’s goal “Patient will experience spiritual uplift and increased peace through sharing his fears and experiences.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the Chaplain services. Clinical Record 14: The patient elected hospice care on 04/26/2024. The SW completed a psychosocial evaluation on 04/29/2024 and updated the plan of care to include the intervention “Social worker to evaluate caregiver’s ability to verbalize resources and support” with the patient’s goal “Patient will manage and normalize grief/complications of grief.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the SW plan of care. Clinical Record 16: The patient elected hospice care on 09/30/2023. The Chaplain completed a spiritual evaluation on 10/02/2023 and updated the plan of care to include the intervention “Chaplain to treat, listen with concern in the moment and provide caring, compassionate response” with the patient’s goal “Patient/caregiver will experience spiritual uplift and increased peace.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the Chaplain services. Clinical Record 18: The patient elected the hospice benefit on 01/19/2023. The Social Worker (SW) updated the plan of care on 07/12/2023 to include the intervention “Social worker to treat, provide patient and family with emotional comfort and support” with the patient’s goal “Patient and family have decreased fear/anxiety regarding the death and dying process.” The plan of care did not include a goal with measurable outcomes anticipated from implementing the SW plan of care. The Area Clinical Manager confirmed the findings during a joint record review and interview on 08/14/2024.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; 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; and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by document review, interview, clinical record review, and observation. Agency policy #IC.3 “Hand Hygiene” (revision date 09/15/2022) stated in part, “Staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below...After removing gloves.” In 1 of 4 (25%) home visits observed, the agency did not ensure that the hospice followed accepted standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions such as hand hygiene. Home Visit 3/Clinical Record 3: The patient elected hospice care on 01/26/2024. The wound care orders were revised on 08/08/2024 to include: “Cleanse abdomen with wound cleanser, pat dry with gauze, apply collagen to the wound bed, and apply bordered foam dressing.” During the home visit with the Licensed Practical Nurse (LPN) [Personnel Record 10] on 08/14/2024, the LPN cleaned their hands with hand sanitizer, retrieved the needed supplies, and placed them on the barrier. The LPN sanitized their hands, donned gloves, and removed the patient’s abdominal dressing. The LPN changed gloves and proceeded with wound care as ordered. According to the agency policy, the LPN did not clean their hands between glove changes during the wound care. The Executive Director was present during the home visit observation on 08/14/2024. In an interview on 08/14/2024, the Executive Director confirmed the findings and stated, “Yes, I saw that she didn’t cleanse her hands between glove changes.”

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: the initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #IM.10 “Timelines” (revision date 06/2022) stated in part, “All clinical and progress notes will be written the day service is rendered. Devices will be synced daily.” In 7 of 19 (37%) clinical records reviewed, the agency did not ensure that the patient’s clinical record included clinical notes documenting the care and service provided in alignment with agency policy. Clinical Record 1: The patient elected hospice care on 06/20/2024. Skilled nursing visits were ordered and provided two times weekly beginning 07/31/2024. The Skilled Nursing (SN) visit notes dated 07/31/2024 and 08/06/2024 were completed and submitted on 08/01/2024 (one day after the visit) and 08/08/2024 (two days after the visit), respectively. The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 2: The patient elected hospice care on 04/24/2024. The recertification plan of care, effective 07/23/2023, ordered weekly SN visits. The SN visit note dated 07/31/2024 was completed and submitted on 08/04/2024 (four days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 4: The patient elected hospice care on 03/08/2023. The recertification plan of care, effective 06/30/2024, ordered weekly SN visits. The SN visit note dated 07/05/2024 was completed and submitted on 07/08/2024 (three days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 7: The patient elected hospice care on 06/14/2024. The plan of care, effective 06/14/2024, ordered SN visits two times a week. The SN visit note dated 08/02/2024 was completed and submitted on 08/05/2024 (three days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 10: The patient elected hospice care on 05/15/2024. The plan of care, effective 05/15/2024, ordered SN visits two times a week. The SN visit note dated 08/06/2024 was completed and submitted on 08/08/2024 (two days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 13: The patient elected hospice care on 05/24/2024. A physician order dated 07/16/2024 ordered SN visits two times a week beginning 07/16/2024. The SN visit dated 08/09/2024 was completed and submitted on 08/11/2024 (two days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. Clinical Record 14: The patient elected hospice care on 04/26/2024. The recertification plan of care, effective 07/25/2024, ordered SN visits two times a week. The SN visit note dated 07/27/2024 was completed and submitted on 08/01/2024 (five days after the visit). The clinical record lacked evidence that the documentation was completed as services are rendered per the agency policy. During a joint record review and interview on 08/14/2024, the Area Clinical Manager confirmed the findings, stating, “Our policy is that documentation is submitted the day services are rendered.”