Every finding on record at Indiana University Health, Inc.

Observed in Record Review. In 2 of 3 patient records reviewed, of patients with wounds the surveyor observed that the organization had not measured wounds weekly as required by HCO policy. For example the wound was identified and then no evidence of wound measure for over one month and this occurred twice since wound identified . In a second record the surveyor observed over 3 month time period that the wound was not measured for over 3 weeks repeatedly . The issue was observed, discussed and confirmed with hospice leadership. Observed in Patient Home. In 1 of 6 home visits conducted, The hospice surveyor observed that the SN had not completed the assessment of patient according to organization policy. The surveyor observed the SN only assess front of chair/bed bound patient. The SN did not look at any part of back of patient to include coccyx. The SN stated to hospice surveyor that she received this assessment from home health aide or nursing facility staff. This was observed and confirmed by organization leadership.

Observed in Document Review. In 1 of 4 bereavement records reviewed, the organization had not completed an initial bereavement assessment. The organization developed a care plan, but there was no documented initial bereavement assessment. The care plan was not based on the caregiver's assessed needs. This finding was discussed with hospice leadership.

Observed in Tracer Activities. In 1 of 6 home visits conducted, The hospice surveyor observed during hospice home visit 1 that the patient caregiver complained that on admit the RN had not provided education on ostomy care. The patient was new to the caregiver sisters home and sister caregiver stated she had never cared for his ostomy previous. The caregiver stated she informed the admitting RN that patients ostomy was problematic and she needed education on care. The caregiver claimed that she received no education and soon after admit nurse left ostomy came off and they had to call a relative for help and supplies . The caregiver claimed after calling office she received a nurse and some education. The issue was observed by, discussed with and confirmed by hospice leadership.

Observed in Individual Tracer. In 8 of 20 patient records reviewed, The hospice surveyor observed that all timeframes associated with goals for nursing, social worker and chaplain on care plans had not contained individualized timeframes with short and long term goals. The surveyor observed that timeframes associated with goals on care plan stated throughout care for timeframe. The issue was observed with, discussed and confirmed with hospice leadership.

Observed in Document Review. In 1of 4 bereavement records reviewed, the organization had not created a bereavement care plan based on the assessed needs of the caregiver. The organization completed an initial bereavement assessment but no plan of care was created. The organization did not provide bereavement services to the caregiver and there was no record of declination. This finding was discussed with hospice leadership. Observed in Document Review. In 1of 4 bereavement records reviewed, the organization had not created a bereavement care plan based on the assessed needs of the caregivers. The organization had completed a care plan, but the information gathered from an initial assessment was not incorporated into the care plan. The organization had not completed an initial bereavement assessment. This finding was discussed with hospice leadership.

Observed in Tracer Visit. The hospice surveyor observed that the organization did not have a written policy that was provided to patients and family at the time of survey. In discussion with hospice leadership it was confirmed that the organization had not been providing written policy to any of their hospice patients.

Observed in Tracer Activities. In 1/6 home visits the hospice surveyor found no evidence the patient or family was educated on the organization's policy for managing and disposing of scheduled drugs. The caregiver stated she had not been educated on this and SN on visit could not locate a policy left in home, further SN on visit stated he was not aware of policy to be left in home. The SN was well aware of his process related to destruction of controlled substances, but not about educating patient and family on policy. This issue was observed, discussed and confirmed with organization leadership.

Observed in Individual Tracer. The hospice surveyor observed during hospice tracer #4 at SNF that the hospice had not provided a copy of the patients CTI to the nursing facility. This issue was discussed and confirmed with both RN on visit andhospice leadership.

Observed in Individual Tracer. The hospice observed in 1/5 home visits that the financial responsibilities of patient/family for hospice services had not been filled in on the form left in the patients home. This issue was discussed and confirmed with hospice leadership.

Observed in Record Review. In 9 of 15 patient records reviewed, the hospice surveyor observed that the plan of care had not included measurable outcomes anticipated from implementing and coordinating the plan of care. This issue was discussed and confirmed with organization leaders.

Observed in Individual Tracer. The hospice surveyor observed that on home visit that a recent admitted patient had foley changed due to leaking around foley catheter , but there had been no order to change foley cath for leaking. The only order had stated to change catheter monthly. This issue was discussed and confirmed with hospice leadership.

Observed in Document Review. In 3 of 3 tracers conducted, on bereavement records the surveyor observed that the bereavement care plans had not included specific, individualized interventions, and the timing and frequency were the same exactly for all levels of bereavement risk. The surveyor observed that while the hospice had been doing bereavement for all bereaved , but had not developed a care plan for said bereavement.

Observed in Building Tour. The hospice surveyor observed during hospice house tour that on one smoke door (one side) that the door had not latched. This issue was observed and confirmed with hospice leadership. Issue fixed while surveyor on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

This condition is not met as evidenced by: Based on record review and interview, the hospice agency failed to implement its abuse and neglect policy about an allegation of sexual abuse by having failed to ensure the allegation was immediately reported to the hospice administrator (See L 0508); failed to fully investigate the alleged abuse; failed to conduct an assessment of patient #13 to identify the presence or absence of physical findings; failed to conduct their investigation in accordance with the policy requirement of reporting cases of suspected abuse as required by state statutes, appropriate protection organizations including law enforcement, Adult Protective Services, and the Indiana Department of Health (See L 0509.) These failures had the potential effect to place and/or leave patient #13 in an unsafe environment. The failure to implement agency policy had the potential to affect all 192 agency patients. An immediate jeopardy related to the failure of staff and personnel contracted with the hospice to immediately report patient #13's allegation of sexual abuse to the administrator, and failure to implement the investigation and reporting requirements of their policy was identified and announced to the administrator on 2-15-22. The immediate jeopardy remained unremoved upon the survey exit on 2-15-22, at approximately 5:40 PM, due to the failure to submit an acceptable Immediacy Removal Plan. The administrator was notified the Immediate Jeopardy was unremoved at 5:16 PM. The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of quality of care in a safe environment for the Condition of Participation 418.52, Patient's Rights.

Based on record review and interview, the agency failed to ensure all patients and/or patient representatives were provided with written notice of the patient's rights and responsibilities in a language they understood during the initial assessment, and in advance of providing care, for 1 (Patient #8) of 1 record reviewed for clients and/or patient representatives with limited English proficiency, out of a sample of 16 patients. Findings include: 1. A review of agency policy #6410313, titled "Sensory Impaired/Limited English Proficient Clients", last revised 5/21/19, indicated "D. Clients who have visual impairment or who are otherwise unable to read English, must have all consents, waivers and agreements communicated to them in their customary language prior to signing any material." The policy also indicated "All materials requiring the client's signature must be translated for the client, verbally or in writing." The policy failed to evidence patients and/or patient representatives would be provided written notice of patient's rights and responsibilities in a language they understood. 2. A review of the clinical record for patient #8 evidenced a "Clinical Note", effective date 2/4/22, which indicated a telephone call was placed to the patient's father to discuss scheduling the initial/start of care visit, and stated, "[Name of Person QQQ] (an interpreter provided via IU Health Hospice) will be available for interpreting services via telephone. Further review of the "Clinical Note" evidenced a second entry identified as the admission alert/IDG (interdisciplinary group) notification, effective date 2/5/22, which indicated "Patient consents completed with patient's father, [Name of Person RRR]. Family only speaks Spanish; will need interpreter; [Name of Person QQQ] assisted via telephone for Admission." 3. During an interview on 02-15-2022 at 3:39 PM, the Administrator verified the family of patient #8 did not understand English and a written notice of their patient rights had not been provided in a language the family could understand.

Based on record review and interview, the hospice agency failed to ensure an allegation of sexual abuse (Patient #13) was reported immediately by the hospice Employee and contracted staff to the hospice administrator, as required by hospice policy, for 1 of 1 active patients whose clinical record documented an allegation of sexual abuse, out of a total sample of 16 active patients. The failure to implement this requirement of the hospice policy had the potential of Patient #13 remaining/being in a potentially unsafe environment and had the potential to affect all 192 hospice patients. The findings include: 1. An agency policy received from the administrator on 2-11-22 at 1:25 PM titled, "Abuse and Neglect," last revised 6-14-19 ID 654806, stated " ... I. Purpose ... A. To communicate the guidelines to identify and report suspected abuse and neglect ... Scope... A. Applies to all Hospice team members... G. Examples that may warrant referral ... 5. Sexual abuse/Molestation/Rape," 8. Adults ... a. Behavioral Changes-uncharacteristic signs of fear or anxiety, isolation ...Tearfulness. Section V. Policy Statements ... B. Indiana University Health Hospice reports all suspected cases of abuse ... in compliance with appropriate state statutes to appropriate protection organizations including law enforcement. VI. Procedures ... Hospice Administrator will be made aware of all cases of suspected and confirmed abuse ... B. If any of above abuse activities are suspected ... the Hospice Administrator will be notified, and a report will be called to the Adult Protective Services Hotline ... G. Hospice personnel will observe all Patients for unexplained...evidence of sexual abuse..." 2. The clinical record of Patient #13 was reviewed on 2-11-22. The record indicated an election of benefit date of 11-28-21, and a principal diagnosis of biventricular heart failure (both sides of the heart are affected,) other pertinent diagnoses included, but were not limited to (if there are more) : hepatic failure (liver) without coma, and Tetralogy of Fallot (condition at birth involving abnormalities of the heart). A document dated 11-28-21, titled "Type of Visit: Comprehensive," indicated in "Medical History... Other: TBI (traumatic brain injury) 2005." Patient #13 was in a contracted Medicare facility (entity X) for general in-Patient care as a hospice patient. 3. In a clinical note dated 12-20-21, written by Employee Z, Medical Social Worker (MSW), reported person K, of entity X, phoned to report having observed Patient #13 crying and Patient #13 reported "My mom's boyfriend molested me." 4. On 12-20-21, Employee Z phoned Employee T, a registered nurse supervisor at Indiana University Health Hospice (IU) to report Patient #13's allegation of sexual abuse. 5. On 12-20-21, Employee Z phoned Patient #13's mother/primary caregiver (PCG)/Health Care Representative (HCR,) person L, to discuss the allegation and told the mother the Hospice would share the mother's response to the hospice team and entity X. Patient #13's mother denied the allegation. Employee Z phoned Employee T, with an update and reported the Hospice was calling the mother again "to further explore ..." Employee Z reported the follow-up call to Employee T and wrote "Both thsi (sic: this) writer and Employee T agreed that this situation did not merit an Adult Protective Services (APS report based on the information provided by pt's (sic Patient's) mother." Employee Z reported the information to the hospice care team via email. 6. A review of the email dated 12-20-21, at 5:26 PM, sent by Employee Z to the hospice care team failed to include IU Hospice administrator, Employee A, as an addressee. 7. On 2-7-2022, the hospice census was 192 Patients, which included Patients with developmental delays, physical limitations, dementia, or other cognitive impairments, who remained at risk because the hospice failed to notify the administrator as required in their Abuse and Neglect policy. 8. During an interview on 2-11-22 at 3:20 PM, Employee A, administrator, confirmed not having been included in the email above, nor having been informed of Patient #13's allegation of sexual abuse. Employee A confirmed he/she was supposed to be notified immediately. 9. During an interview on 2-11-22 at 4:44 PM, Employee A, administrator, confirmed Employee T "did not notify me [sic the administrator]." 10. During an interview with Employee Z (MSW) on 2-14-22 at 10:42 AM, he/she verified not having notified the administrator of Patient 13's sexual abuse allegation. 11. During an interview on 2-14-22 at 11:00 AM, Employee T, when queried if the administrator was notified, responded, "I don't think we did, we sent an email to the care team." Employee T also stated, "we should have included [sic the administrator] in the communication." 12. During an interview on 2-14-22 at 11:37 AM, with Employee AA, IU Hospice Medical Director, he/she stated, "Our process clearly is to report to (name of administrator), we did not." 13. During an interview on 2-15-22 at 9:21 AM, Person L recalled having received a call from the hospice agency regarding the allegation of sexual abuse. The mother reported sharing Patient #13 had a history of reporting this accusation in the past and a history of this being investigated.

Based on record review and interview, the agency failed to immediately investigate Patient's (Patient #13) allegation of sexual abuse, to include having conducted an assessment; failed to report a basis to believe sexual harm to an endangered adult as required by their policy and Indiana Code 12-10-3-9; and failed to take actions in accordance with agency policy to prevent further violations while the alleged sexual abuse was investigated to determine if it was verified for 1 of 1 patients whose clinical record evidenced an allegation of sexual abuse (Patient #13) of a total sample of 16 active patients, with the potential to affect all 192 hospice patients. Findings include: 1. An agency policy received from the administrator on 2-11-22 at 1:25 PM titled, "Abuse and Neglect," last revised 6-14-19, ID 654806, stated " ... I. Purpose ... A. To communicate the guidelines to identify and report suspected abuse and neglect ... Scope ... A. Applies to all Hospice team members ... G. Examples that may warrant referral ... 5. Sexual abuse/Molestation/Rape," 8. Adults ... a. Behavioral Changes-uncharacteristic signs of fear or anxiety, isolation ... Tearfulness. Section V. Policy Statements ... B. Indiana University Health Hospice reports all suspected cases of abuse ... in compliance with appropriate state statutes to appropriate protection organizations including law enforcement. VI. Procedures ... Hospice Administrator will be made aware of all cases of suspected and confirmed abuse ... B. If any of above abuse activities are suspected, ... the Hospice Administrator will be notified, and a report will be called to the Adult Protective Services Hotline ... G. Hospice personnel will observe all Patients for unexplained...evidence of sexual abuse..." 2. A review of an Indiana statute, IC 12-10-3-9, revealed a "Duty to report endangered adult Sec. 9. (a) An individual who believes or has reason to believe that another individual is an endangered adult shall make a report under this chapter. (b) If an individual is required to make a report under this chapter in the individual's capacity as a member of the staff of a medical or other public or private institution, school, hospital, facility, or agency, the individual shall immediately notify the individual in charge of the institution, school, hospital, facility, or agency, or the individual's designated agent, who also becomes responsible to report or cause a report to be made." 3. A review of the clinical record for Patient #13, evidenced an election of benefit date of 11-28-21, and a principal diagnosis of biventricular heart failure (both sides of the heart are affected,) other pertinent diagnoses included: hepatic failure (liver) without coma, and Tetralogy of Fallot (condition at birth involving abnormalities of the heart). A document dated 11-28-21, titled "Type of Visit: Comprehensive," indicated in "Medical History... Other: TBI (traumatic brain injury) 2005." Patient #13 was in a contracted Medicare facility (entity X) for general in-Patient care as a hospice patient. 4. A review of a clinical note dated 12-20-21, written by Employee Z, Medical Social Worker, evidenced (MSW, Employee K, of entity X, phoned to report having observed Patient #13 crying and Patient #13 stated, "My mom's boyfriend molested me." Employee K indicated being aware Patient #13' was "delayed" (cognitively) so he/she was not sure of the accuracy of the statement. Employee Z wrote he/she placed a call to the "Hospice Supervisor," Employee T, a Hospice Registered Nurse Supervisor and "reported the aforementioned information; writer (Employee Z) stated that I plan to call the pts (Patient's) mother/PCG (primary caregiver) and discuss the report with her directly; (name of Employee T) verbalized agreement with this plan." 5. A review of a clinical note dated 12-20-21, evidenced Employee Z phoned the Patient's mother and informed her of Patient #13's allegation of sexual abuse. Employee Z's note stated, "(Name of Mother) responded by chuckling (in a manner in which someone does when they have heard something before and shared with writer that 'this is part of (name of Patient 13) cycling' (Mother's statement) ... making "delusional statements." Employee Z informed the mother the hospice would share her response with the hospice team and Entity X. 6. A review of a clinical note dated 12-20-21, evidenced Employee Z noted he/she reported the telephone call with Patient #13's mother to Employee T and planned to call Patient 13's mother again "to conduct further exploration into pts [sic Patient's] possible motives." Employee T agreed to this plan. 7. A review of a clinical note dated 12-20-21, evidenced Employee Z phoned Patient 13's mother and the mother indicated not having had a boyfriend in 15 years. 8. A review of a clinical note dated 12-20-21, evidenced Employee Z phoned Employee T and reported the information from the call. Employee T instructed Employee Z to make a clinical note and update the care team. "Both thsi (sic: this) writer and (name of Employee T) agreed that this situation did not merit an APS report based on the information provided by the pts (sic Patient's) mother." 9. During an interview with the administrator on 2-11-22 at 3:20 PM, the administrator indicated not being aware of Patient #13's allegation of sexual abuse and stated had he/she been informed, would have sent an RN immediately to assess Patient #13. 10. Review of the hospice census report evidenced on 2-7-2022, the hospice census was 192 Patients, which included Patients with developmental delays, physical limitations, dementia, or other cognitive impairments, who remained at risk because the hospice failed to notify the administrator as required in their Abuse and Neglect policy. 11. On 2/14/2022 at 11:00 AM., when queried if anyone did an assessment of Patient #13 following the allegation of sexual abuse, Employee T stated, "I'm not sure." A review of the clinical record failed to evidence a comprehensive assessment for Patient #13 on or about 12-20-21. 12. During an interview on 2-15-22 at 9:21 AM, Person L, recalled having received a call from the hospice agency regarding the allegation of sexual abuse [could not recall how long ago.] The mother, person L, reported Patient #13 had a history of reporting this accusation in the past and a history of this being investigated. The mother indicated Patient #13's guardian was Patient #13's father. 13. During an interview on 2-11-22 at 3:20 PM, Employee A, administrator, confirmed not having notified the medical director, not having ensured a comprehensive assessment of Patient #13 was conducted at the time of the allegation of sexual abuse, not having notified Adult Protective Services and the Indiana Department of Health as required by their policy, not having implemented precautions for the safety of Patient #13 and other hospice Patients, and not having educated hospice staff and Medicare contracted providers of respite and/or general in-patient care in December 2021, in relation to the hospice's abuse and neglect policy. The administrator indicated Patient #13's guardian was his/her father and the father had not been contacted by the hospice on or about 12-20-2021.

Based on record review and interview, the agency failed to ensure all patients received a patient-specific comprehensive assessment that included the patient's need for physical, psychosocial, emotional, and spiritual care, and accurately included all areas of hospice care related to the palliation and management of the patient's terminal illness and related conditions (L 521 and L 524.) The cumulative effect of these systemic problems resulted in the agency's inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with 42 CFR 418.54 Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Based on record review and interview, the agency failed to ensure all patients received a patient specific comprehensive assessment which accurately reflected the patient's current health status and accurately included the patient's need for physical, psychosocial, emotional, and spiritual care; and included all areas of hospice care related to the palliation and management of the terminal illness and related conditions for 2 (Patients #8, 12) of 16 active records reviewed. Findings include: 1. A review of the clinical record for patient #8, start of care date 2/5/22, revealed a history and physical dated 2/1/22, which evidenced the patient was a minor in the care of both non-English speaking parents. Patient #8 had a history of metastatic bilateral stage 4b retinoblastoma of the left eye, diagnosed outside the United States, in the family's country of origin. The patient underwent bilateral enucleation on an unknown date and had bilateral prosthetic eyes. The patient's father was working in the United States (USA) at the time of the diagnosis and the patient, patient's mother and 11-year-old sibling subsequently came to the USA for treatment, leaving the patient's 13-year-old sibling remained in their country of origin. Patient #8 was admitted to the hospital on 1/5/22 for uncontrolled pain, nausea, and vomiting, with a weight loss of >10% over the last 6 months. The patient tested positive for COVID 19 at the time of this hospital admission. The pain and nausea/vomiting were controlled after the hospital admission but remained ongoing issues. The document evidenced both parents had a good understanding of the patient's prognosis but spoke no English. Patient #8 was independently ambulatory, had a right port, diminished lung sounds, and an irregular heartbeat. Patient #8 was on several medications, including multiple eye drops and evidenced periorbital swelling of the left eye. The patient's VCTI (Verbal Certification of Terminal Illness) indicated a malignant neoplasm of the left eye. A review of a document titled "Initial Visit", dated 2/5/22, indicated the type of visit was "comprehensive." The patient was a toddler under the age of 3 years, was totally blind. The patient cried throughout the assessment and was assessed as both a #0 and a #3 on the "Face Scale", with normal behavior and affect, and was assessed as low risk for suicide. The patient's breathing was normal on room air, with diminished breath sounds. The heart rhythm was irregular. The patient was dependent in bathing, dressing, feeding, transfers, bowel/bladder continence, and ambulation to the bathroom, had a communication deficit, poor nutrition, and had a right chest port. The assessment failed to evidence the patient received an age appropriate and comprehensive physical, psychosocial, and emotional assessment, including but not limited to nutritional, all body systems, and developmental status, including but not limited to, methods to self soothe, ability to express or tolerate pain, functional status, ability to make needs known, ability to communicate in a language the patient understood, presence of prosthetic eyes and impact of blindness; and age appropriate preparation and understanding of imminent death. The assessment evidenced the "patient/responsible party" and "patient/family/caregiver" provided assessment input but failed to evidence the identity and/or role of "responsible party, family, or caregiver" and failed to indicate the patient was a toddler, and developmentally unable to answer questions or participate in collective group. The assessment evidenced the family had a faith, a spiritual community, and a priest that visited; had low risk for bereavement; had financial concerns and income source of "unknown." The assessment indicated the patient's father had cognitive disabilities and spoke no English. The assessment failed to evidence both parents were accurately assessed for emotional, psychosocial, and spiritual status, including but not limited to, religious denomination and practices, type of support provided by the spiritual community, adjustment deficits related to recent arrival in the United States, literacy, language and/or cultural barriers, separation from another child, isolation from known supports and traditions; and failed to evidence the work status of either caregiver, whether caregiver employment was impacted, if all immediate needs were met, including housing, utilities, food, and medications, and if resources/referrals were needed in advance of the medical social work assessment in 5 days. The assessment also failed to evidence the family was accurately assessed as to preparedness for imminent death of a toddler/sibling, impact of the loss of other immediate family members within the previous 6 months, and the impact of COVID-19 diagnosis and quarantine. On 2/10/21 at 3:22 PM, employee Q, a registered nurse, was interviewed about the admission visit for Patient #8. When queried as to whether a specific assessment was available for pediatric patients, employee Q stated the same adult assessment is used on all patients. When queried as to whether employee Q could free-type when documenting the comprehensive assessments, employee Q stated they must choose from pre-loaded options for all assessment questions and there were no specific options for pediatric patients, and no options to identify the "responsible party". When queried as to how employee Q separated the patient's assessment and each caregiver assessment, employee Q stated there was not a way to do that in the agency EMR (Electronic Medical Record). When queried as to why the patient's bereavement risk was low, employee Q stated, "They seemed fine. The mom had just experienced the death of both her parents within the last 6 months and they seemed fine." When queried as to whether the loss of one's parents, the separation from a teenage daughter, presence in an unfamiliar country, inability to understand English, and imminent death of a toddler would likely increase the probability of grief or depression, employee Q repeated that they seemed fine. When queried as to previous pediatric nursing and/or pediatric hospice experience, Employee Q stated not having had previous pediatric experience and indicated no specific pediatric hospice training was provided at orientation, but the clinician's attended a presentation on pediatric hospice provided by the agency's medical director. Employee Q stated the agency's pediatric patients are also seen via the palliative care team at entity TTT, who specialize in pediatrics, so they manage the patient's non-hospice related medical needs. 2. A review of the clinical record for patient #12, start of care date 1/26/22, evidenced a history and physical dated 1/23/22 which indicated patient #12 had a pre-natal diagnosis of Trisomy 13 (a genetic abnormality with multiple congenital anomalies affecting neurological development and incompatible with life). Post-natal diagnoses included Trisomy 13, small chin with abnormal profile, polydactyly (extra fingers), absent CSP (Cavum Septum Pellucidum - an abnormality of the brain), abnormal cardiac anatomy, including a possible Atrioventricular canal defect (AV Canal - a serious and life-threatening defect), congenital vertical talus deformity of the left foot, and ankyloglossia (tongue tied, or restricted frenulum causing potential oral feeding difficulty) which was treated with a frenectomy (a procedure where the frenulum is clipped to allow increased tongue movement) prior to discharge from the hospital. Patient #12 was breastfed on demand but evidenced weight loss. Patient #12 lived with mother and father and no siblings were identified. A review of a document titled "Initial Visit", dated 1/26/22, evidenced the type of visit was "comprehensive." The patient was a 3-day old newborn with a medical history of Trisomy 13 and a surgical history of tongue clip. Review of the patient's spiritual/religious concerns indicated "Per agency policy Social Worker or Chaplain will discuss with patient/responsible party" The assessment indicated the social worker would visit in 5 days; the patient declined a visit from the chaplain; had no manifestations of grief; and had learning barriers of "infant." The patient was evaluated for hospice criteria and indicated dependence in bathing, dressing, feeding, transfers, and bowel/bladder continence. Continued review of the patient's physical, emotional, psychosocial, and spiritual status indicated patient #12 was well groomed, breathed normally, had abnormal heart sounds, present bowel sounds, 2 unidentified incision/surgical sites, was confined to bed, had occasionally moist skin, and responded to verbal commands but could not always communicate discomfort or need to be turned or had a sensory impairment which limited ability to feel pain or discomfort in 1 or 2 extremities. The assessment failed to evidence an age appropriate and patient specific physical assessment, including but not limited to the patient's status as a newborn, significant cardiac anomalies, and their potential to rapidly affect death and dying, the potential of mosaic Trisomy 13 (a type of Trisomy 13 that could extend the patient's life), and the ability to effectively breastfeed for comfort and hunger. The assessment also failed to indicate the identity or role of the "responsible party"; and failed to evidence the patient's parents received an accurate emotional, psychosocial, and spiritual assessment that included assessment of bonding, expectation of grief, ability to provide newborn care, risk of post-partum depression, and understanding of comorbidities including, but not limited to, AV Canal, small chin, and ankyloglossia,and as the primary caregivers for an infant with terminal illness.

Based on record review and interview, the agency failed to ensure all patients received an accurate and age-appropriate comprehensive assessment that identified the physical, psychosocial, emotional, and spiritual needs related to the patient's terminal illness, comfort, and dignity throughout the dying process for 2 (Patients 8 and 12) of 2 active pediatric records reviewed in a total sample of 16 active records. Findings include: 1. A review of the clinical record for patient #8, start of care date of 2/5/22, revealed a history and physical dated 2/1/22, which evidenced the patient was a minor in the care of both non-English speaking parents. Patient #8 had a history of metastatic bilateral stage 4b retinoblastoma of the left eye, diagnosed outside the United States, in the family's country of origin. The patient underwent bilateral enucleation on an unknown date and had bilateral prosthetic eyes. The patient's father was working in the United States (USA) at the time of the diagnosis and the patient, patient's mother and 11-year-old sibling subsequently came to the USA for treatment, leaving the patient's 13-year-old sibling remained in their country of origin. Patient #8 was admitted to the hospital on 1/5/22 for uncontrolled pain, nausea, and vomiting, with a weight loss of >10% over the last 6 months. The patient tested positive for COVID-19 at the time of this hospital admission. The pain and nausea/vomiting were controlled after the hospital admission but remained an ongoing concern. The document evidenced both parents had a good understanding of the patient's prognosis but spoke no English. Patient #8 was independently ambulatory, had a right port, diminished lung sounds, and an irregular heartbeat. Patient #8 was on several medications, including multiple eye drops and evidenced periorbital swelling of the left eye. The patient's VCTI (Verbal Certification of Terminal Illness) indicated a malignant neoplasm of the left eye. A review of a document titled "Initial Visit", dated 2/5/22, indicated the type of visit was "comprehensive." The patient was a toddler under the age of 3 years, was totally blind. The patient cried throughout the assessment and was assessed as both a #0 and a #3 on the "Face Scale", with normal behavior and affect, and was assessed as low risk for suicide. The patient's breathing was normal on room air, with diminished breath sounds. The heart rhythm was irregular. The patient was dependent in bathing, dressing, feeding, transfers, bowel/bladder continence, and ambulation to the bathroom, had a communication deficit, poor nutrition, and had a right chest port. The assessment failed to evidence the patient received an age appropriate and comprehensive physical, psychosocial, and emotional assessment, including but not limited to nutritional, all body systems, and developmental status, including but not limited to, methods to self soothe, ability to express or tolerate pain, functional status, ability to make needs known, ability to communicate in a language the patient understood, presence of prosthetic eyes and impact of blindness; and age appropriate preparation and understanding of imminent death. The assessment evidenced the "patient/responsible party" and "patient/family/caregiver" provided assessment input but failed to evidence the identity and/or role of "responsible party, family, or caregiver" and failed to indicate the patient was a toddler, and developmentally unable to answer questions or participate in collective group. The assessment evidenced the family had a faith, a spiritual community, and a priest that visited; had low risk for bereavement; had financial concerns and income source of "unknown." The assessment indicated the patient's parents spoke no English, and the father had cognitive disabilities. The comprehensive assessment failed to be accurate and age-specific by having failed to evidence both parents were assessed for emotional, psychosocial, and spiritual status, including but not limited to, religious denomination and practices, type of support provided by the spiritual community. The comprehensive assessment failed to be accurate and age-specific because it failed to identify Patient #8 was blind because of removal of both eyes and then prosthetic replacements, failed to document Patient #8's port with location and purpose, failed to evidence Patient #8's COVID-19 positive status, failed to include the work status and availability of parent caregivers, failed to assess the impact of the family's recent move to a new country and the loss of family/community support during the death journey of their toddler, failed to assess immediate care needs to include ongoing housing, need for assistance with utilities--heat, water, sanitary sewer, etc. due to no identifiable source of income, failed to assess whether the family members had healthy coping mechanisms and support in place in relation to the parents and siblings of the child whose death was impending. On 2/10/21 at 3:22 PM, employee Q, a registered nurse, was interviewed concerning the admission visit for patient #8. When queried as to whether a pediatric-specific assessment was available for pediatric patients, employee Q stated the same adult assessment is used on all patients. When queried as to whether employee Q could free-type when documenting the comprehensive assessments, employee Q stated clinicians must choose from pre-loaded options for all assessment questions and there were no specific options for pediatric patients. 2. A review of the clinical record for patient #12, start of care date 1/26/22, age of 3 days old, and evidenced a history and physical dated 1/23/22, which indicated patient #12 had Trisomy 13 (a genetic abnormality with multiple congenital anomalies affecting neurological development and incompatible with life) and also a small chin with abnormal profile, polydactyly (extra fingers,) absent CSP (Cavum Septum Pellucidum - an abnormality of the brain), abnormal cardiac anatomy, including a possible Atrioventricular Canal Defect (AV Canal - a serious and life-threatening defect,) congenital vertical talus deformity of the left foot, and ankyloglossia (tongue tied, or restricted frenulum causing potential oral feeding difficulty) which had been treated with a frenectomy (a procedure where the frenulum is clipped to allow increased tongue movement) prior to discharge from the hospital. Patient #12 evidenced weight loss. Patient #12 lived with mother and father. A review of a document titled "Initial Visit," dated 1/26/22, evidenced the type of visit was "comprehensive." Review of the patient's spiritual/religious concerns indicated Patient #12 the learning barriers of "infant." A review of the patient's physical, emotional, psychosocial, and spiritual status indicated patient #12 was well groomed, breathed normally, had abnormal heart sounds, present bowel sounds, had 2 incision/surgical sites which failed to be identified as to type and location, responded to verbal commands but had a sensory impairment which limited ability to feel pain or discomfort in 1 or 2 extremities. The assessment failed to evidence an age appropriate and patient specific physical assessment, including but not limited to the patient's status as a newborn, significant cardiac anomalies with their potential to rapidly affect the rate of the death and dying process, failed to assess Patient #12's ability to effectively breastfeed for comfort and sustenance. The comprehensive assessment failed to evidence Patient #12 received an age-appropriate functional assessment to include muscle tone and reflexes. The assessment failed to evidence the patient's parents received an complete and accurate emotional, psychosocial, and spiritual assessment that included assessment of bonding, expectation of grief, ability to provide newborn care, coping strategies, the risk of post-partum depression, and understanding of their baby's terminal and associated conditions which contributed to feeding difficulties and the increased the risk of an obstructed airway.

Based on record review and interview, the agency failed to ensure all hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs as they desire, for 1 (Patient 8) of 2 pediatric patients in a sample of 16 active patients. Findings include: 1. A review of the plan of care for patient #8, for the benefit period or 2/5/22 - 5/5/22, evidenced a primary diagnosis of malignant neoplasm of left retina. The plan of care failed to evidence secondary diagnoses that included blindness, pain, nausea, vomiting, or anorexia/weight loss, presence of a chest port (implanted access device for intravenous therapy), and failed to evidence a surgical history of bilateral enucleation and prosthetic eyes. The plan of care indicated the patient consumed a regular diet but failed to evidence dietary and needs and/or specialties appropriate for the growth and development of a toddler with nausea, vomiting, and >10% weight loss in the past 6 months. Safety measures included COVID-19 precautions and Basic Home Safety but failed to evidence safety needs for a toddler with no vision, infection control needs related to a compromised immune system and presence of a port, medication safety related to use of narcotics and children in the home, use of a car seat/safety belt when traveling, safety with sleep, including use of a crib/bed with rails. The plan of care evidenced a physician's order "SN (skilled nurse)/patient/parents/caregivers to flush before each use with 1 ml (milliliter) normal saline and 1 ml heparin (10 units/ml) using SASH method ..." but failed to indicate what was flushed, the type of access and bodily location, and failed to be patient specific and individualized, with consideration the patient, parents, and caregivers did not participate in flushing a port. The plan of care also failed to include age-appropriate patient specific and measurable goals that reflected the needs, progress, and outcomes for a toddler under 3-years old with terminal metastatic retinoblastoma 4b and no vision, with non-English speaking family with bereavement, financial, and separation needs. 2. On 2/10/21 at 3:22 PM, employee Q, a registered nurse, was interviewed about the admission visit for Patient #8. When queried as to whether a specific assessment was available for pediatric patients, employee Q stated the same adult assessment is used on all patients. When queried as to why the patient's bereavement risk was low, employee Q stated, "They seemed fine." The mom had just experienced the death of both her parents within the last 6 months and they seemed fine." When queried as to whether the loss of one's parents, the separation from a teenage daughter, presence in an unfamiliar country, inability to understand English, and imminent death of a toddler would likely increase the probability of grief or depression, should be addressed in care planning, employee Q repeated that the parents seemed fine.

Based on record review and interview, the agency failed to ensure that all patients, their families, and/or representatives received education and training related the specific and age-appropriate needs for 1 (Patient #8) of 2 active pediatric patients whose clinical record was reviewed, out of a sample of 16 active patients. Findings include: 1. A review of the clinical record for patient #8, start of care date 2/5/22, revealed a history and physical dated 2/1/22, which evidenced the patient was a minor in the care of both non-English speaking parents. Patient #8 had a history of metastatic bilateral stage 4b retinoblastoma of the left eye, diagnosed outside the United States, in the family's country of origin. The patient underwent bilateral enucleation on an unknown date and had bilateral prosthetic eyes. The patient's father was working in the United States (USA) at the time of the diagnosis and the patient, patient's mother and 11-year-old sibling subsequently came to the USA for treatment, leaving the patient's 13-year-old sibling remained in their country of origin. Patient #8 was admitted to the hospital on 1/5/22 for uncontrolled pain, nausea, and vomiting, with a weight loss of >10% over the last 6 months. The patient tested positive for COVID 19 at the time of this hospital admission. The pain and nausea/vomiting were controlled after the hospital admission but remained ongoing issues. The document evidenced both parents had a good understanding of the patient's prognosis but spoke no English. Patient #8 was independently ambulatory, had a right port, diminished lung sounds, and an irregular heartbeat. Patient #8 was on several medications, including multiple eye drops and evidenced periorbital swelling of the left eye. The patient's VCTI (Verbal Certification of Terminal Illness) indicated a malignant neoplasm of the left eye. A review of a document titled "Initial Visit", dated 2/5/22, indicated the type of visit was "comprehensive." The patient was a toddler under the age of 3 years, was totally blind, and was assessed with the help of "patient/responsible party" and "patient/family/caregiver" The assessment failed to include a patient specific and age appropriate comprehensive assessment that reflected the patient's age and development related to terminal illness and imminent death; failed to appropriately assess the emotional status, psychosocial status, medical status, cognitive status, health status, spiritual/religious status, support systems, development, safety, medication effectiveness/side effect, language and ability to express needs, nutritional status, functional ability related to a toddler with terminal illness; and failed to appropriately include and assess the patient's parent/primary caregivers and siblings, including but not limited to, ability to communicate, ability to cope, emotional status, health status related to COVID-19 exposure, spiritual status, and risk for bereavement related to loss of a toddler/sibling, separation from other family and culture, and inability to communicate in a language they understood. A review of the plan of care for patient #8, for the benefit period or 2/5/22 - 5/5/22 evidenced a primary diagnosis of malignant neoplasm of left retina. The plan of care failed to evidence secondary diagnoses that included blindness, pain, nausea, vomiting, or anorexia/weight loss, presence of a chest port (implanted access device for intravenous therapy), and failed to evidence a surgical history of bilateral enucleation and prosthetic eyes. The plan of care indicated the patient consumed a regular diet but failed to evidence dietary and needs and/or specialties appropriate for the growth and development of a toddler with nausea, vomiting, and >10% weight loss in the past 6 months. Safety measures included COVID-19 precautions and Basic Home Safety but failed to evidence safety needs for a toddler with no vision, infection control needs related to a compromised immune system and presence of a port, medication safety related to use of narcotics and children in the home, use of a car seat/safety belt when traveling, safety with sleep, including use of a crib/bed with rails. The plan of care evidenced "SN (skilled nurse)/patient/parents/caregivers to flush before each use with 1 ml (milliliter) normal saline and 1 ml heparin (10 units/ml) using SASH method ..." but failed to indicate what was flushed, the type of access, the bodily location of the access, and failed to be patient specific and individualized, with consideration the patient, parents, and caregivers did not participate in flushing a port. The plan of care also failed to include age-appropriate patient specific and measurable goals that reflected the needs, progress, and outcomes for a toddler under 3-years old with terminal metastatic retinoblastoma 4b and no vision; and non-English speaking family with bereavement, financial, and separation needs. The record failed to evidence the patient's parents received teaching or education, including but not limited to the patient's port; failed to receive teaching or education concerning medication, including dose, side effects, interactions, reason for use, and accurate delivery; failed to receive education related to the patient's bowel regimen, including how to mix and administer MiraLAX, signs and symptoms of impaction, and ways to mitigate constipation; failed to receive education related to nutrition, types of food, and the patient's desire to eat during hospice journey; and failed to receive education related to uncontrolled pain, nausea, and vomiting. During an interview on 02-15-2022 at 3:39 PM, the administrator verified the clinical record failed to evidence patient #8's family had received appropriate education.

Based on record review and interview, the Interdisciplinary Team failed to ensure a plan of care included services being provided by an outside home health provider and the delineation of duties between the hospice and home health agency in 2 (Patients 1 and 10) of 2 record reviewed patients receiving services from home health or attendant care providers in a total sample of 20 patients. Findings Include: 1. Review of an Indiana University Health policy stat id: 7365079, with a revision date of 05-14-2020, titled, "Hospice Coordination of Care" was provided by Registered Nurse (RN) Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...the facility and hospice are to communicate with each other and document such communication to ensure the needs of the patients are being addressed and met 24 hours a day ..." 2. Review of an Indiana University Health policy stat id:6532489, with a revision date of 06-13-2019, titled, "Plan of Care" was provided by the RN, Director of QAPI, Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...A Hospice RN will coordinate with contracted care givers including but not limited to nursing facility staff and in home private care givers to ensure appropriate information is reported to the Interdisciplinary Group (IDG) so that Plan of Care can be updated appropriately ..." 3. During a home visit at patient #1's home on 2-10-2022, at 11:20 AM, observed Person N, a family member, coming from patient #1's room. Person M, patient #1's family member, confirmed that Person N is a paid attendant, works for Entity O (a home health agency), which assists in hands-on care for patient #1. 4. The clinical record of an active patient #1 was reviewed on 2-10-2022, and indicted an election date of 6-14-2021. The record contained a plan of care for the benefit period of 2-07-22 to 4/07/22. Patient diagnosis included: Amyotrophic lateral sclerosis, Motor neuron disease unspecified, Other specified anxiety disorders, Amyloidosis, unspecified, and Other chronic pain. The plan of care indicated orders for Skilled Nursing (SN) 2 times a week for 9 weeks and 2 as needed (PRN) visits for pain/anxiety/ Short of Breath (SOB). The plan of care failed to indicate coordination of care, type of services, and responsibilities with Entity O, for attendant care services patient #1 was receiving. The plan of care failed to evidence delineation of duties between both providers. A review of an agency's documents titled, "Charts/Clinical Notes" IDG and coordination of care notes for the last 5 weeks (01-11-2022 to 02-08-2022) failed to evidence that any collaboration/coordination took place between Entity O, a home health agency, and the RN occurred. A review of a SN Discipline Note dated 01-18-2022, indicated in the narrative that the patient is now receiving a Home Health Aide (HHA) one time a week and the patient's family member is to be the paid caregiver 20 hours a week. The SN Note failed to evidence any collaboration of care with Entity O. Interdisciplinary Team notes for from 01-11-2022 to 02-08-2022, failed to evidence any collaboration the hospice agency may have made with Entity O. A review of a document received from Entity O, dated 01-06-2022, titled "Service Plan" evidenced patient #1 was receiving personal care and homemaking services. The service plan indicated the patient was to receive care on Tuesdays from 2:00 PM to 8:00 PM, Wednesdays at 10:00 AM, Thursdays at 10:00 AM, and Friday from 9:00 AM to 12:00 PM. The service plan indicated the care to be provided included the following: light housekeeping, clean kitchen, clean bathroom, clean living room, clean dining room, clean bedroom, empty trash, laundry, change bed linens, companionship, dress/undress, steady ambulation, toilet, change protective briefs, and assistive devices. During a phone interview on 02-14-2022 at 11:29 AM, the Business Office Manager, for Entity O, Person P, confirmed patient #1 was receiving services from Entity O. Person P confirmed patient #1 had started receiving home health aide services on 01-11-2022. Person P further confirmed there was no documentation of collaboration of care with Indiana University Health Hospice. 5. The clinical record of patient #10 was reviewed on 02-15-2022, with an election date of 01-13-2022. The record contained a plan of care for the benefit period of 01-13-22 to 04-12-22. The plan of care indicated patient #10 was receiving care services Entity RR (a home health agency), but failed to evidence any delineation of duties between both providers. A review of an agency document titled, "Routine Visit" dated 01-13-2022, indicated visit type was a Skilled Nursing comprehensive Assessment. The initial comprehensive assessment contained a section titled "Care Management/Care Coordination" that failed to evidence collaboration/coordination with any other outside health services patient was receiving. Interdisciplinary Team notes for from 01-13-2022 to 02-08-2022, failed to evidence any collaboration the hospice agency may have made with Entity RR and TT. A review of the agency document titled, "Team Care Plans" dated 02-08-22, failed to evidence any collaboration the hospice agency may have made with Entity RR and TT. A review of a document received from Entity RR (an attendant care agency), a document titled, "Service Plan" dated 11-17-202, indicated patient #10 was receiving 4 hours a day for 5 days a week of homemaking/companion care and personal care. The service plan indicated the care to be provided included the following: companionship, medication reminders, meal preparation, toileting assistance, and fall precautions. A review of a document received from Entity TT (a structured family care agency), a document titled, "Structured Family Care Service Plan" dated 11-10-2021, indicated patient #10 was receiving homemaking/companion care, and activities of daily living. The service plan indicated the care to be provided included the following: housekeeping, medication reminders, meal preparation, bathing assistance, skin hygiene, hair assistance, oral hygiene, dressing, nail care, shaving assistance, toileting, changing briefs, and transfer assistance with an assistive device. During a phone interview on 02-15-2022 at 1:20 PM, the Director of Client Services, Person SS, of Entity RR (a home health agency), indicated patient #10 had been receiving 20 hours of care a week starting 12-07-2021. When queried about coordination of care with the hospice agency, Person SS confirmed the family member told the agency patient #10 had a hospice provider and had passed away on 02-07-2022. During a phone interview on 02-15-2022 at 1:46 PM, the Director, Person UU, of Entity TT (a structured family care agency), confirmed the family member was employed to care for patient #10 for 24 hours a day 7 days a week since 11-10-2021.

Based on record review and interview, the agency failed to ensure all plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care for 1 (Patient #8) of 2 pediatric patients in a sample of 16 active clinical records. Findings include: 1. Review of a policy, "Plan of Care," last reviewed/revised 6/13/2019, stated, " ... The Plan of Care will be based on patient goals and will include appropriate time frames, settings, and services required to meet those goals ..." 2. A review of the plan of care for patient #8, for the benefit period or 2/5/22 - 5/5/22 evidenced a primary diagnosis of malignant neoplasm of left retina. The plan of care failed to include age-appropriate patient-specific and measurable goals that reflected the needs, progress, and outcomes for a toddler under 3-years old with terminal metastatic retinoblastoma 4b, no vision, with non-English speaking family experiencing bereavement, financial, and separation needs. 3. During an interview on 02-15-2022 at 4:50 PM, the administrator verified the plan of care for patient #8 failed to contain individualized and measurable/objective goals.

Based on record review, the agency failed to implement drugs and treatment necessary to meet the needs of the patient for 1 (Patient #2) of 20 clinical records reviewed . Findings Include: 1. Review of an Indiana University Health policy stat id: 7773633, with a revision date of 03-11-2020, titled, "Medication Management" was provided by Registered Nurse (RN) Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-15-2022, at 4:55 PM. The policy indicated but was not limited to, " ... Medications are available to hospice patients on a 24 hour a day basis..." 2. The clinical record of patient #2 was reviewed on 02-15-2022 and indicted an election date of 12-31-2019. The record contained an agency document titled, "Team Care Plan" effective date 02-09-2022. The team care plan indicated the following medications: Docusate Sodium 100 milligrams (mg)1 capsule twice a day by mouth (PO), Acetaminophen 1 tablet 500 mg 1 tablet every 2 hours as needed PO, Ativan 0.5 mg 1 tablet every 2 hours PO as needed for agitation/anxiety, may give 2 tabs for severe anxiety, Ciprofloxacin HCI 500 mg 1 tablet three times a week Monday, Wednesday, and Friday, PO (start date 01-17-2022), Ducal rectal suppository 10 mg 1 suppository daily as needed (PRN) constipation, Hyoscyamine Sulfate 0.125 mg 1 tablet every 4 hours as needed PO for secretions, Ibuprofen 800 mg 1 tablet every 6 hours PO PRN pain moderate(4-6), Middies HCI 5 mg 1 tablet every evening PO, Middies HCI 5 mg 2 tablets every morning PO, Mucinex Extended-Release 12 hour 600 mg 1 tablet twice a day PO, Normal Saline Flush Intravenous Solution 0.9% 20-30 milliliters (ml) daily irrigation PRN for suprapubic catheter occlusion, Oxybutynin Chloride 5 mg 1 tablet three times a day PO, Oxygen 2-10 liters/minute as needed for shortness of breath nasal cannula, Pepto-Bismol Chewable 262 mg 2 tablets every hour PRN PO heart burn, do not exceed 16 tablets in 24 hours. A review of an agency document titled, "IDG Physician Note" dated 01-13-2022 at 8:09 AM, indicated patient #2 as having ongoing Urinary tract infections and starting the patient on a prophylactic antibiotic (antibiotics that are taken to prevent infection). A review of an agency document titled, "Statewide Triage Call: Medication Location" dated 01-26-2022 at 7:56 AM, indicated a call from patient #2's family member, asking where the antibiotic is that was ordered. It had not been received. During a telephone interview with Patient #2 on 02-07-2022 at 12:33 PM, after introducing self the other party disconnected the call. Attempted to call back at 12:35 PM, and left a message for a return call. Calls were placed to the family member on 02/07, 02/14, and 02/15/2022, with no return calls. During an interview on 02/15/2022 at 5:00 PM, the Administrator, Employee A, when queried about the hospice providing medications, supplements and supplies, confirmed the Hospice was responsible to provide the medications, supplements, and supplies.

Based on record review, observation, and interview, the agency failed to include all durable medical equipment (DME) and medical supplies necessary to meet the patient's needs in the plan of care (POC) in 7 (Patients # 2, 5, 6, 7, 10, 14, and 16) of 20 clinical records reviewed. Findings Include: 1. Review of an Indiana University Health policy stat id:6532489, with a revision date of 06-13-2019, titled, "Plan of Care" was provided by the Registered Nurse (RN), Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...Indiana University Health Hospice plans the care, treatment, and services provided to hospice patients in order to meet the patient's and his or her care giver's unique needs ..." 2. The clinical record of an active patient #2 was reviewed on 02-15-2022, and indicted an election date of 12-31-2019. The record contained an agency document titled, "Routine Visit" with a date of 12-17-2021. The document indicated the visit type was a "Comprehensive Nursing Assessment." The recertification comprehensive assessment contained a section titled, "Genitourinary" suprapubic catheter failing to indicate the size of catheter and inflation or the catheter bulb. A review of an agency document titled, "Team Care Plan" with a date as of 02-07-2022, contained a section titled, "DME/Supplies." The section "DME/Supplies" indicated but was not limited to, " ... leg drainage bag 600 ml, large catheter adapter ..." The care plan failed to indicate the suprapubic catheter and size. 3. During observation of a Home Health Aide (HHA) visit, Employee P, on 02-10-2022, at 10:50 AM, at Entity E (a skilled nursing facility), providing care to patient #5. The home health aide adjusted the four side rails on the hospital bed to remove the soiled brief, perform incontinence care, apply a new brief, straighten the bed pad, and reposition patient #5. In the bathroom of patient #5, there was a bedside toilet, shower chair, and a raised toilet chair on the toilet. The clinical record of active patient #5 was reviewed on 02-10-2022, and indicated an election date of 07-24-2021. The record contained an agency document titled, "Routine Visit" with a date of 01-18-2022. The document indicated the visit type was a "Comprehensive Nursing Assessment." The recertification comprehensive assessment contained a section titled, "Genitourinary" that indicated the patient was incontinent and wore briefs. A review of the plan of care for a benefit period of 01-20-22 to 03-20-22, indicated a section titled, "DME and Supplies" which indicated "CPAP, Overbed table." The plan of care failed to list briefs and pads as Patient #5 used for incontinent issues per the comprehensive assessment dated 01-18-2022. The plan of care failed to indicate a bedside toilet, shower chair, and a raised toilet chair on the toilet as equipment in the home. During an interview on 02-10-2022 at 11:10 AM, the Certified Nursing Assistant, Person I, confirmed the patient was incontinent and used briefs and pads. 4. The clinical record of an active patient #6 was reviewed on 02-11-2022, and indicted an election date of 04-25-2021. The record contained an agency document titled, "Routine Visit" with a date of 12-15-2021. The document indicated the visit type was a "Comprehensive Nursing Assessment." The recertification comprehensive assessment contained a section titled, "Genitourinary" that indicated the patient was incontinent and wore briefs. A review of the plan of care for the benefit period of 12-21-21 to 02-18-22, indicated a section titled, "DME and Supplies" which indicated "Broda Chair." The plan of care failed to list briefs,and pads as Patient #6 used for incontinence per the comprehensive assessment dated 12-15-2021. 5. The clinical record of an active patient #7 was reviewed on 02-14-2022, and indicated an election date of 10-14-2021. The record contained an agency document titled, "Initial Visit" with a date of 10-06-2021. The document indicated the visit type was a "Comprehensive Nursing Assessment." The initial comprehensive nursing assessment indicated patient #7 was incontinent and used briefs. A review of an agency document titled, "Skilled Nurse Routine Visit" with a date of 12-29-2021, indicated patient ##7 was finishing a nebulizer treatment before the nurse assessment. A review of the plan of care with the benefit period 01-04-22 to 04-03-22, indicated a section titled, "DME/Supplies." The section "DME/Supplies" indicated but was not limited to, " Low Air Loss (LAL) mattress, hospital bed, bedside table, oxygen concentrator, bumper pads for rails, 2 sets of half rails, face masks, and bedside commode." The plan of care failed to indicate the briefs and a nebulizer. 6. The clinical record of an active patient #10 was reviewed on 02-15-2022, and indicated an election date of 01-13-2022. The record contained an agency document titled, "Routine Visit" with a date of 01-13-2022. The document indicated the visit type was a "Comprehensive Nursing Assessment." The initial comprehensive nursing assessment indicated patient #10 had a port left upper chest. A review of an agency document titled, "Home Health Aide Assignments" dated 01-13-2022 to 02-08-2022 indicated the home health aide was to change soiled/wet briefs each visit. A review of an agency document titled, "Physical Therapy with Treatment Initial Visit" dated 01-25-2022. The initial visit contained a section titled, "Devices and Equipment" that indicated the following but not limited to, " ... Patient Equipment: electric hospital bed, bed rails, commode, wide-based quad cane, tub transfer bench, tub seat chair, urinal, front wheeled walker, bedside commode, and low air loss mattress ..." A review of the plan of care with the benefit period 01-13-22 to 04-12-22, indicated a section titled, "DME/Supplies." The section "DME/Supplies" indicated but was not limited to, " ... bed, half rails, low airflow mattress, bedside commode, bedside table, tub transfer, raised toilet seat, walker, cane, shower chair, and bedside commode..." The plan of care failed to indicate the urinal, briefs, port flush syringes, Huber needle (a specially designed hollow needle used to go through the skin as well as the silicone septum of an implanted port), and the size of the Huber needle. 7. The clinical record of an active patient #14 was reviewed on 02-14-2022, and indicated an election date of 02-06-2022. The record contained an agency document titled, "Initial Visit" with a date of 02-06-2022. The initial assessment indicated patient #14 was an inpatient at the hospital and the section titled, "Admission Information" indicated patient #14 was in a hospital bed. The section titled, "Safety Precautions" indicated but was not limited to, " ...Call light within reach, patient instructed in use. Assesses for safest bed rail position...items in reach (e.g. water, urinal, telephone) ..." The section titled "Physical/Intravenous (IV) Access/ Infusion" indicated the patient had a peripheral IV (a way of giving a drug or other substance through a needle inserted into a vein) in the left lower arm to administer continuous pain medication. The initial assessment further indicated patient #14 was on oxygen at 40% high flow. A review of the plan of care with the benefit period 02-06-22 to 05-06-22, indicated a section titled, "DME/Supplies." The section "DME/Supplies" indicated, "Not Applicable (N/A)." The plan of care failed to indicate patient #10's hospital bed, side rails, oxygen and oxygen supplies, urinal, IV needle, and IV supplies. During an interview on 02-14-2022 at 4:32 PM, the administrator, Employee A confirmed all DME/supplies should be listed on the plan of care and updated as needed. 8. During a home visit on 2-10-22 at 9:30 AM, Patient #16 was observed working with therapy personnel, Employees U and V. Patient 16's primary caregiver (PCG) reported they were utilizing a wedge cushion and a Boppy (pillow used for therapeutic positioning) to position Patient #16. PCG reported patient able to maintain better head control utilizing the Boppy. Employee V instructed PC on use of the wedge cushion and Boppy to relieve pressure on Patient #16's head. The clinical record for patient #16 was reviewed on 2-09-22 and indicated an election of benefit as 1-12-22. The plan of care indicated a primary diagnosis of epilepsy (excessive and abnormal brain cell activity causing seizures) and other diagnoses of encephalopathy (brain disease that alters brain function or structure), congenital hypotonia (abnormal low muscle tone present from birth), and torticollis (condition in which the head becomes persistently to turned to one side) The plan of care contained a Physical Therapy goal of "pt (patient) to tolerate tummy time with the support of a boppy pillow for three minutes ..." The plan of care indicated the PCG manages episodes of incontinence of urine and stool with diapers. The plan of care failed to include DME/medical supplies including Boppy pillow, wedge cushion, and briefs for incontinence/diapers. During an interview on 2-11-22 at 9:18 AM. Employee A confirmed that DME are a to be recorded on the plan of care and updated as needed.

Based on record review and interview, the agency failed to ensure the Interdisciplinary Team updated the plan of care when there were changes in a patient's diet, medications, and failed to ensure goals were updated, measurable, and pertinent/specific to the patient's ongoing care needs in 2 (Patients #5 and 7) of 14 active records reviewed in a sample of 20. Findings Include: 1. Review of an Indiana University Health policy stat id:6439152, with a revision date of 05-23-2019, titled, "Interdisciplinary Group (IDG)" was provided by the Registered Nurse (RN), Administrator, Employee A, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...The IDG is responsible for: 1. establishing, implementing, reviewing, and revising the patient's plan of care ...3. documenting all care and services provided in a timely manner ..." 2. Review of an Indiana University Health policy stat id: 6532489, with a revision date of 06-13-2019, titled, "Plan of Care" was provided by the RN, Director of Quality, Employee E, on 02-08-2022 at 1:50 PM. The policy indicated but was not limited to, " ...The plan of care will be modified based on patient changes, or patient response to care, or patient achievement of goals which are identified during ongoing assessment, and ongoing collaboration with patient ..." 3. The clinical record of patient #5 was reviewed on 02-10-2022, and indicted an election date of 07-24-2021. The record contained an agency document titled, "Team Care Plan" effective date 02-09-2022, which included orders for Medications: Benadryl 25 milligrams (mg) 1 tablet every 4 hours PO (by mouth) as needed for itching, Hyoscyamine Sulfate 0.125 mg 1 tablet every 4 hours PO as needed for excess secretions, Hydrocodone-Acetaminophen 5-325 mg 1 tablet PO every 4 hours, Morphine Sulfate 20 mg/milliliter (ml) 0.25 ml every 2 hours PO as needed for mild pain or dyspnea, Morphine Sulfate 0.5 ml PO of sublingual (SL) every 2 hours as needed for moderate pain, Nystatin External Powder 100000 units/gram (GM) 1 application every 12 hours as needed for irritation external abdominal folds, Ondansetron HCI 4 mg 1 tablet PO every 6 hours as needed nausea/vomiting, Oxygen 2 liters/minute as needed for shortness of breath via nasal cannula, Vanicream External Cream 1 application twice a day external. The orders for safety measures were listed as fall precautions and standard/infection control precautions. The Interdisciplinary Team failed to update the plan of care as evidenced by the following: A review of a document titled, "Medications" with a date of 02-10-2022, was provided by Entity E's (skilled nursing facility) Director of Nursing, Person G, on 02-10-2022 at 10:20 AM. The Medications indicated the following medications were ordered: Benadryl 25 milligrams (mg) 1 tablet every 4 hours oral as needed for itching, Bisacodyl 10 mg suppository once a day as needed (PRN) rectal, Hydrocodone-acetaminophen 5-325 mg four times a day, Hyoscyamine Sulfate 0.125 mg 1 tablet every 4 hours oral as needed for excess secretions, Morphine Sulfate 100 mg/5 ml give 0.25 ml every 2 hours oral as needed for mild pain or dyspnea, Morphine Sulfate 100 mg/5 ml give 0.5 ml oral every 2 hours as needed for moderate pain, Morphine Sulfate 100 mg/5 ml give 0.25 ml at bedtime oral, Nystatin External Powder 100000 units/gram (GM) 1 application every 12 hours as needed for irritation external abdominal folds. The care plan and medication list were not reconciled. A review of a Skilled Nursing note dated 02-08-2022 at 9:35 PM indicated the facility, Entity E, made the nurse aware of the family member, Person SSS testing positive for COVID 19. The nurse further documented speaking to Person SSS and advising them to stay at home and rest. During the observation 02-10-2022 at 10:50, the home health aide, donned gloves, gown, mask, and shield before entering patient #5's room to provide care. During an interview on 02-10-2022 at 10:15 AM, the Executive Director, Person F, of Entity E (the skilled nursing facility), indicated that a message had been given to discontinuing medications and that the patient was on droplet precautions due to patient #5's family member, Person SSS, tested positive for COVID 19. Person F confirmed Entity E, allows Person SSS to visit patient #7 by using the back door to enter and exit by the patient's room. The IDG team failed to take action to ensure the the isolation precautions were maintained. 4. The clinical record of patient #7 was reviewed on 02-14-2022 and indicted an election date of 10-06-2021. The record contained a plan of care for the benefit period of 01-04-22 to 04-03-22 which included orders for a regular diet. The Interdisciplinary Team failed to update the plan of care as evidenced by the following: A review of an agency document titled, "Recertification Statement for second 90 day period" dated 01-04-2022, indicated the patient able to take soft foods and evidenced diagnosis of aspiration pneumonia. A review of a clinical note dated 02-09-2022 at 7:78 PM, indicated the RN ordered supplies to include 45- thickened liquid packets. During an interview on 02-14-22 at 3:42 PM, the family member, Person Y indicated Patient #7 was fed 6-7 times a day with food processed in a blender and thickener added to all foods due to the patient's poor suck and swallow response. Person Y further confirmed the patient had choked and aspirated before while being fed. During an interview on 02-14-22 at 4:32 PM, the administrator confirmed the plan of care should have been updated and reflected the patient's current nutrition, DME/Supplies, medications, interventions, outcomes, and goals.

Based on record review and interview, the Interdisciplinary Team failed to ensure all collaboration with outside home health providers was documented in 2 (Patients #1 and 10) of 3 records reviewed of patients who received services from home health and attendant care providers, in a sample of 20. Findings Include: 1. Review of an Indiana University Health policy stat id: 7365079, with a revision date of 05-14-2020, titled, "Hospice Coordination of Care" was provided by Registered Nurse (RN) Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...the facility and hospice are to communicate with each other and document such communication to ensure the needs of the patients are being addressed and met 24 hours a day ..." 2. Review of an Indiana University Health policy stat id:6532489, with a revision date of 06-13-2019, titled, "Plan of Care" was provided by the RN, Director of QAPI, Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...A Hospice RN will coordinate with contracted care givers including but not limited to nursing facility staff and in home private care givers to ensure appropriate information is reported to the Interdisciplinary Group (IDG) so that Plan of Care can be updated appropriately ..." 3. During a home visit at patient #1's home on 2-10-2022, at 11:20 AM, observed Person N, a family member, coming from patient #1's room. Person M, patient #1's family member, confirmed that Person N is a paid attendant, worked for Entity O (a home health agency), which assisted in hands-on care for patient #1. 4. The active clinical record of Patient #1 was reviewed on 2-10-2022, and indicted an election date of 6-14-2021. On 02-11-2022, the agency was provided a list of documents to provide, which included, but not limited to, skilled (SN) visit notes, any coordination notes, plans of care, and IDG notes from 01-05-22 to 02-10-22. A review of an agency's documents titled, "Charts/Clinical Notes" IDG and coordination of care notes for the last 5 weeks (01-11-2022 to 02-08-2022) failed to evidence documentation of collaboration/coordination having taken place between Entity O, a home health agency, and the RN occurred. A review of a SN Discipline Note dated 01-18-2022, indicated in the narrative that the patient was now receiving a Home Health Aide (HHA) one time a week and the patient's family member is to be the paid caregiver 20 hours a week. The SN Note failed to evidence any collaboration of care with Entity O. Interdisciplinary Team notes for from 01-11-2022 to 02-08-2022, failed to evidence any documentation of collaboration between the hospice agency and Entity O. A review of a document received from Entity O, dated 01-06-2022, titled "Service Plan" evidenced patient #1 was receiving personal care and homemaking services. The service plan indicated the patient was to receive care on Tuesdays from 2:00 PM to 8:00 PM, Wednesdays at 10:00 AM, Thursdays at 10:00 AM, and Friday from 9:00 AM to 12:00 PM. The service plan indicated the care to be provided included the following: light housekeeping, clean kitchen, clean bathroom, clean living room, clean dining room, clean bedroom, empty trash, laundry, change bed linens, companionship, dress/undress, steady ambulation, toilet, change protective briefs, and assistive devices. During a phone interview on 02-14-2022 at 11:29 AM, the Business Office Manager, for Entity O, Person P, confirmed patient #1 was receiving services from Entity O. Person P confirmed patient #1 had started receiving home health aide services on 01-11-2022. Person P further confirmed there was no documentation of collaboration of care with Indiana University Health Hospice. 4. The clinical record of patient #10 was reviewed on 02-15-2022, and evidenced an election date of 01-13-2022. The record contained a plan of care for the benefit period of 01-13-22 to 04-12-22. The plan of care indicated patient#10 was receiving care services Entity RR (a home health agency) but failed to evidence collaboration of care between the home health agency and the hospice agency. A review of an agency document titled, "Routine Visit" dated 01-13-2022, indicated visit type was a Skilled Nursing comprehensive Assessment. The initial comprehensive assessment contained a section titled "Care Management/Care Coordination" failed to evidence documentation of collaboration/coordination with any other outside health services patient was receiving. Interdisciplinary Team notes for from 01-13-2022 to 02-08-2022, failed to evidence any documentation of collaboration of care between the hospice agency and Entity RR and TT. A review of the agency document titled, "Team Care Plans" dated 02-08-22, failed to evidence documentation of collaboration of care between the hospice agency and the Entity RR and TT. A review of a document received from Entity RR (an attendant care agency), titled, "Service Plan" dated 11-17-202, indicated patient #10 was receiving 4 hours a day for 5 days a week of homemaking/companion care and personal care. The service plan indicated the care to be provided included the following: companionship, medication reminders, meal preparation, toileting assistance, and fall precautions. A review of a document received from Entity TT (a structured family care agency), a document titled, "Structured Family Care Service Plan" dated 11-10-2021, indicated patient #10 was receiving homemaking/companion care, and activities of daily living. The service plan indicated the care to be provided included the following: housekeeping, medication reminders, meal preparation, bathing assistance, skin hygiene, hair assistance, oral hygiene, dressing, nail care, shaving assistance, toileting, changing briefs, and transfer assistance with an assistive device. During a phone interview on 02-15-2022 at 1:20 PM, the Director of Client Services, Person SS, of Entity RR (a home health agency), indicated patient #10 had been receiving 20 hours of care a week starting 12-07-2021. When queried about coordination of care with the hospice agency, Person SS indicated the family member told the agency patient #10 had hospice and passed away on 02-07-2022. During a phone interview on 02-15-2022 at 1:46 PM, the Director, Person UU, of Entity TT (a structured family care agency), confirmed the family member was employed to care for patient #10 for 24 hours a day 7 days a week since 11-10-2021. During an interview on 02-15-2022 at 3:39 PM, the Director of QAPI, Employee E, when queried where to find documentation of collaboration/coordination of care with other agencies in the patient's home, confirmed the location should be in the IDG notes, clinical notes, or on the admission summary on the plan of care, and were not documented for Patients 1 and 10.

Based on record review and interview, the agency failed to ensure governing body oversight to ensure the hospice maintained an effective QAPI(Quality Improvement and Performance Improvement) program to document improvement in Hospice performance for 1 of 1 Hospice provider. The cumulative effect of this systemic problem resulted in the agency's inability to ensure patients received appropriate services which could result in the agency not providing quality health care, thus resulting in non-compliance with 42 CFR 418.58 Condition of Participation: Quality Assessment/Performance Improvement. Findings include: A review of an agency policy titled "Quality Assessment and Performance Improvement" (QAPI), last revised 1/12/22, indicated the QAPI program "included an established, data-driven quality assessment and performance improvement program; monitored all operations and services; took action to attain and sustain improvements; and provided standards and guidance for identifying opportunities and priorities for improvement, developing, maintaining, and analyzing data to improve services." The policy indicated the Home Care and Hospice QAPI committee was responsible for identification and evaluation of actual and potentially problematic clinical issues, defining targeted areas of study, the review and analysis of incident reports, customer complaints, perception of care surveys, and clinical record review results. QAPI plans included quality control, risk management findings and areas of concern in safety, review and analysis of infection control, adverse events outcome reports/audits, and significant event review. The policy indicated the program should include high risk, high volume, problem prone areas including, but not limited to, patient/family instruction prior to discharge, therapeutic drug monitoring, and appropriate supplies and equipment delivered in a timely fashion. Data sources utilized included risk management, utilization management, quality control, outcomes of processes, performance measures, infection-control surveillance and reporting, pain management, and customer feedback reports. The policy indicated "The data is utilized to compare its performance over time ... the care provided shall be evaluated to determine whether an opportunity for improvement exists ... Indiana University Health Home Care and Hospice always evaluates undesirable patterns of trends in performance and significant events. When an opportunity for improvement is identified, the appropriate leader or designee develops a plan of action ... The organization uses criteria to define their own performance measures or to select performance measures ...." The policy indicated the minutes of the QAPI Committee must be submitted to the Board Committee on Quality and Patient Safety, and the care would be evaluated to determine whether an opportunity for improvement exists. On 1/31/21 at 1:30 PM, the agency administrator was asked for the complete agency QAPI program, including all performance improvement plans, committee meeting minutes, and all governing body meeting minutes related to QAPI within the last 12 months. The administrator provided a document titled "Pain Assessment" and a document titled "Bowel Regimen with Opioid," which each included an unlabeled graph representing the parent and 3 branches, and evidenced categories titled agency, state, and national statistical percentages, with the agency goals in percentages for January - December of 2021. No further documentation was provided documenting the analysis, need for action, action taken/performance improvement plan(s), identified opportunities for improvement, or any sustained improvement. On 2/7/22 at 2:48 PM, the agency's incident and complaint logs for the previous 12 months were reviewed. The incident log evidenced 135 falls, 21 Care Delivery events, 9 Skin Pressure or Accidental Injury events, 19 Medication/Adverse Drug events, 8 Medical Device/Supply events, 4 Resource Allocation events, 4 Behavior/Unauthorized Discharge events, and 4 Other events. The complaint log evidenced 20 Communication issues, 28 Patient Care and Treatment issues, 1 Access issue, 1 Behavior issue, 1 Physical Environment issue, 1 System Devices issue, 1 ADA (American's with Disabilities) issue, 1 Billing issue, and 1 Item Lost/Damaged issue. Review of the QAPI program failed to evidence analysis and/or implementation of interventions to reduce the risk of harm to patients. Review of a document titled "Board of Directors Meeting," dated 2/25/21, evidenced a review of 2021 Safety, Quality, Patient Experience Plans, review and approval of Home Care and Hospice 2020 Performance and 2021 Plan Action, and an Audit and Compliance Committee Update. The document failed to evidence QAPI information for 2021, to include governing body oversight and the identification of indicators and measures to track high risk, high volume, problem prone areas, education, identified areas for improvement, any performance improvement activities. On 2/8/22 at 2:26 PM, the QAPI documents were reviewed with the administrator. The administrator was queried as to whether all QAPI documentation demonstrated an effective program which demonstrated analysis and appropriate tracking/trending and responses to QAPI data, and the administrator answered "No."

Based on record review and interview, the agency failed to ensure documentation of coordination of care activities with the patient's skilled nursing facility for 1 (Patient #5) of 2 records reviewed of hospice patients who received care in a skilled nursing facility (SNF) in a sample of 20. Findings Include: 1. Review of an Indiana University Health policy stat id: 7365079, with a revision date of 05-14-2020, titled, "Hospice Coordination of Care" was provided by Registered Nurse (RN) Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ...the facility and hospice are to communicate with each other and document such communication to ensure the needs of the patients are being addressed and met 24 hours a day ..." 2. The clinical record of patient #5 was reviewed on 02-10-2022 and indicted an election date of 07-24-2021. The record contained an agency document titled, "Team Care Plan" effective date 02-09-2022, which included orders for Medications: Benadryl 25 milligrams (mg) 1 tablet every 4 hours PO (by mouth) as needed for itching, Hyoscyamine Sulfate 0.125 mg 1 tablet every 4 hours PO as needed for excess secretions, Hydrocodone-Acetaminophen 5-325 mg 1 tablet PO every 4 hours, Morphine Sulfate 20 mg/milliliter (ml) 0.25 ml every 2 hours PO as needed for mild pain or dyspnea, Morphine Sulfate 0.5 ml PO of sublingual (SL) every 2 hours as needed for moderate pain, Nystatin External Powder 100000 units/gram (GM) 1 application every 12 hours as needed for irritation external abdominal folds, Ondansetron HCI 4 mg 1 tablet PO every 6 hours as needed nausea/vomiting, Oxygen 2 liters/minute as needed for shortness of breath nasal cannula, Vanicream External Cream 1 application twice a day external. A review of a document titled, "Medications" with a date of 02-10-2022, was provided by Entity E's (skilled nursing facility) Director of Nursing, Person G, on 02-10-2022 at 10:20 AM. The Medications indicated the following medications were ordered: Benadryl 25 milligrams (mg) 1 tablet every 4 hours oral as needed for itching, Bisacodyl 10 mg suppository once a day as needed (PRN) rectal, Hydrocodone-acetaminophen 5-325 mg four times a day, Hyoscyamine Sulfate 0.125 mg 1 tablet every 4 hours oral as needed for excess secretions, Morphine Sulfate 100 mg/5 ml give 0.25 ml every 2 hours oral as needed for mild pain or dyspnea, Morphine Sulfate 100 mg/5 ml give 0.5 ml oral every 2 hours as needed for moderate pain, Morphine Sulfate 100 mg/5 ml give 0.25 ml at bedtime oral, Nystatin External Powder 100000 units/gram (GM) 1 application every 12 hours as needed for irritation external abdominal folds. The hospice and nursing home lists of medications were not congruent and failed to evidence collaboration between the hospice and the SNF. During an interview on 02-10-2022 at 10:15 AM, the Executive Director, Person F, of Entity E (the skilled nursing facility), indicated Person F received a message that had been given to the facility from the hospice that they were discontinuing medications, as patient #5 had entered the active dying phase. The agency failed to update the facility staff on all changes with the patient's medications. During an interview on 02-11-2022 at 9:10 AM, the Administrator, Employee A, confirmed the skilled nursing facilities were to be updated with any changes to their shared patient by the hospice staff. The administrator indicated the hospice agency left a binder at each facility that contained the plan of care, updates, communication notes, and education for facility staff.

Based on record review, and interview the agency failed to ensure it had provided and documented orientation and training of Skilled Nursing Facilities (SNF) staff who were furnishing care to hospice patients in this hospice's philosophy, this hospice's policies and procedures regarding comfort in pain control, symptom management, principles about death and dying and the individuals' responses to death, and patient rights in 19 of 21 skilled nursing facilities (SNFs) who were contracted to provide services to hospice patients. (Entity E, T, U, Z, CC, EE, HH, JJ, LL, NN, VV, XX, BBB, DDD, GGG, III, KKK, LLL, OOO) Findings Include: 1. Review of an Indiana University Health policy stat id: 7365079, with a revision date of 05-14-2020, titled, "Hospice Coordination of Care" was provided by Registered Nurse (RN) Director of Quality Assurance Process Improvement (QAPI), Employee E, on 02-08-2022, at 1:50 PM. The policy indicated but was not limited to, " ... Procedures: A. The hospice provides services to patients who reside in facilities ...G. Hospice staff assures that facility staff providing care to hospice patients is oriented to the hospice philosophy of care, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, principles about death and dying, patients response to death, patients' rights and documentation requirements ..." 2. During a facility visit to Entity E the care location of patient #5, on 2-10-2022, at 10:10 AM, the Facility Executive Director, Person F, when queried about Indiana University Health Hospice providing the facility staff with orientation and in-services regarding the hospice philosophy and policies and procedures, stated, "It has never happened." During an interview on 2-10-2022, at 10:10 AM, the Facility Interim Director of Nursing, Person G, for Entity E, confirmed that Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. During an interview on 2-10-2022, at 10:30 AM, the Facility Licensed Practical Nurse (LPN), Person H, for Entity E and Patient #5, confirmed that Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. During an interview on 2-10-2022, at 11:10 AM, the Certified Nursing Assistant (CNA), Person I, for Entity E and Patient #5, confirmed their employment with Entity E for over 5 years and in that time Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 3. During an interview on 2-10-2022, at 12:50 PM, the RN Supervisor, Employee R, confirmed Indiana University Health Hospice does not provide the facility staff with orientation and in-services regarding the hospice philosophy and policies and procedures. Employee R further indicated thy provide patient binders left at the nurse's station, for communication and documentation. 4. During a phone interview on 2-14-2022, at 11:58 AM, the Director of Health Services, Person S, for Entity T, confirmed that in their 9 years of employment with Entity T, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 5. During a phone interview on 2-14-2022, at 12:10 PM, the Director of Nursing, Person W, for Entity U, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 6. During a phone interview on 2-14-2022, at 12:15 PM, the Social Worker/Admissions Director, Person V, for Entity U, confirmed that in their 6 years of employment with Entity U, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 7. During a phone interview on 2-14-2022, at 4:07 PM, the Director of Nursing, Person AA, for Entity Z, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 8. During a phone interview on 2-14-2022, at 4:21 PM, the Director of Nursing, Person DD, for Entity CC, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 9. During a phone interview on 2-14-2022, at 4:07 PM, the Assistant Director of Nursing, Person BB, for Entity Z, confirmed that in their 8 years of employment with Entity Z, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 10. During a phone interview on 2-15-2022, at 10:05 AM, the Director of Nursing, Person FF, for Entity EE, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 11. During a phone interview on 2-15-2022, at 10:10 AM, the Assistant Director of Nursing, Person GG, for Entity EE, confirmed that in their 14 years of employment with Entity EE, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 12. During a phone interview on 2-15-2022, at 10:49 AM, the Director of Nursing, Person PPP, for Entity OOO, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 13. During a phone interview on 2-15-2022, at 10:52 AM, the Director of Nursing, Person II, for Entity HH, confirmed that in their 9 ½ years of employment with Entity HH, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 14. During a phone interview on 2-15-2022, at 11:05 AM, the Executive Director, Person KK, for Entity JJ, confirmed in their 10 years of employment with Entity JJ, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 15. During a phone interview on 2-15-2022, at 11:13 AM, the Administrator Assistant, Person MM, for Entity LL, confirmed in their 6 years of employment with Entity LL, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 16. During a phone interview on 2-15-2022, at 11:35 AM, the Director of Nursing, Person OO, for Entity NN, confirmed that in their 12 years of employment with Entity NN, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 17. During a phone interview on 2-15-2022, at 1:58 PM, the LPN, Person WW, for Entity VV, confirmed that in their 16 years of employment with Entity VV, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 18. During a phone interview on 2-15-2022, at 2:23 PM, the Administrator, Person ZZ, for Entity LLL, confirmed that in their 3 years of employment with Entity CC, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 19. During a phone interview on 2-15-2022, at 2:29 PM, the Administrator, Person HHH, for Entity GGG, confirmed that in their 6 years of employment with Entity GGG, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 20. During a phone interview on 2-15-2022, at 2:38 PM, the Director of Nursing, Person YY, for Entity XX, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 21. During a phone interview on 2-15-2022, at 2:41 PM, the Administrator, Person AAA, for Entity CC, confirmed that in their 3 years of employment with Entity CC, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 22. During a phone interview on 2-15-2022, at 2:51 PM, the Director of Nursing, Person CCC, for Entity BBB, confirmed that in their 6 years of employment with Entity BBB, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 23. During a phone interview on 2-15-2022, at 2:56 PM, the Director of Nursing, Person EEE, for Entity DDD, confirmed that in their 11 years of employment with Entity DDD, Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 24. During a phone interview on 2-15-2022, at 4:46 PM, the Director of Nursing, Person JJJ, for Entity III, confirmed Indiana University Health Hospice had not provided the staff at the facility with orientation and in-services regarding the hospice philosophy and policies and procedures. 25. During an interview on 2-11-2022 at 9:10 AM, the Administrator, Employee A, when queried about facility in-services regarding the hospice philosophy and policies confirmed the agency was to provide those to facilities. During an interview on 2-11-22 at 9:09 AM, with the Administrator, employee A, the administrator confirmed no education had been provided in the skilled nursing facilities with respite and general in patient care contracts with IU Health Hospice. The administrator explained a binder was present in the patient's room with the hospice philosophy and who to call at the hospice. She stated " ... scheduling the facilities (in references to the provision of required hospice education) has been challenging."