Every finding on record at Intrepid of Northern Indiana, Inc

Upon patient record review, 1 of 14 (Patient 10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 10: The medical record did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 1 of 14 (Patient 2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 2: HSP medication profile 12/6/23 has Ondansetron PRN with no frequency, The HSP medication profile has an order for Acetaminophen 1 tab 3 times daily, the facility MAR has 2 tabs daily. The facility MAR has pt taking Anusol and Hydralazine these medications are not on the HSP medication profile and no evidence of an interim order for these meds.

Upon patient record review, 2 of 14 (Patient 8,10) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: The Bereavement assessment was completed 11/8/23 which is not with in 5 days of the initial assessment. Patient 10: The medical record does not contain a bereavement assessment by the MSW,SC, or RN.

Upon patient record review, 4 of 14 (Patient 2,3,4,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: Hospice medication order 12/6/23 has Ondansetron PRN with no frequency, The Hospice POC has an order for Acetaminophen 1 tab 3 times daily, the facility MAR has 2 tabs daily. The facility MAR has patient taking Anusol and Hydralazine these medications are not on the Hospice POC and no evidence of an interim order for these meds. Patient 3: The medication order 12/6/23 contains orders for Prinivil 10mg daily, the facility MAR has 20mg daily, O2 orders on HSP POC are for 3 liters and the facility MAR has O2 2 liters. In addition, the LPN documented 11/17/23 "patient on 2 liters of oxygen". The POC contains an order for patient to be on 3 liters on oxygen. Patient 4: The POC 11/22/23 did not include the following: visit frequencies for all disciplines, nursing care plans, allergies. Patient 11: The POC order 4/4/22 contains a Foley order to change every 30 days and prn with no reason.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 8: The nurse documented on 11/8/23 "Pt now using Broda chair in facility". There was no evidence of an order for a Broda chair. Corrected on site.

Upon client record review, 9 of 14 (Patient 2,4,6,7,8,9,10,11,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The nurse documented on 12/5/23 wound cleansed with betadine. There is no evidence of an order for betadine. Corrected on site. Patient 4: The POC 11/22/23 contains an order for MSW to visit once a week. There is only evidence of 1 visit being made on 11/27/23. The nurse documented on 12/6/23 "oxygen turned up to 10 liters". There is no evidence of an order for oxygen at 10 liters. Corrected on site. Patient 6: The POC 10/20/23 contains an order for 2 prn Nursing visits. There is evidence the nurse made 3 prn visits to the patient on 10/24/23, 10/29/23, 11/22/23 there is no evidence of an order for the 3rd prn visit to be completed. Patient 7: The POC 10/20/23 contains an order for MSW 2 times per month, there are only 2 visits documented in the chart on 10/23/23 and 11/10/23 there were no second visits completed those months. The SC has POC orders 10/20/23 for 2 times per month and the patient was seen 10/24/23 and 11/16/23 there were no second visits those months. The RN POC orders for 0 visits week 1, patient was admitted by RN with initial assessment completed on 10/20/23 this is week one. Patient 8: The POC 11/1/23 contains an order for MSW 1 time per month. The MSW saw the patient and documented visits on 11/3/23,11/8/23 and 11/27/23 there is no evidence of an order for the extra visits. Corrected on site. Patient 9: The POC 10/25/23 contains an order for SN 1 time a week for week 1. There is evidence the SN saw the patient on 10/25/23 and 10/27/23. The second visit was not PRN and there was no order for the second visit. Patient 10: The POC 11/1/23 contains an order for 0 SN visits week one. The patient's RN initial assessment was completed week one on 11/1/23. Patient 11: The POC 8-2-23 contains an order for SN 1x a week. The medical record contains documented visits by the nurse twice weekly the weeks of 8/2/23-9/25/23. Patient 13: The POC contains an evaluation order with in 5 days of admission for SC visit, this visit was completed timely. The SC saw the patient again on 11/29/22 and there is no evidence of an order for future visits.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patients 1 and 2: The RN did not clean stethoscope after using on patient and prior to use on the next patient.

Upon patient client record review, 2 of 14 (Patient 5,12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 5: The nurse signs her name as RNCM as the authentication on 5/27/22. This was a paper document used in place of the psychosocial assessment. Patient 12: The POC is dated and signed by the physician on 11/24/21. The patient was not admitted until 11/26/21 according to the EOB and RN initial assessment.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient 11: Pt was discharged for cause and there was no evidence of patient understanding, response, receipt of prior notice or resolutions attempts by agency. The agency did not follow Guidelines §418.104(e) regarding revocation or termination of hospice services Chapter 2, §2082 and their policy Discharge 6.26 which states the clinical record must reflect the discharge planning activities, coordination with other care providers, the patient's response and understanding of these activities, patient care instructions and reasonable notice prior to discharge whenever possible.

Upon client record review, 1 of 14 (Patient 2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The medical record contains an order for wound care to the foot and does not state who will perform the wound care.