Every finding on record at Luminary Hospice of Indiana, LLC

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 17 (6%) clinical records reviewed of hospice patients who elected hospice aide services it was revealed that the agency did not ensure that hospice aides were supervised by a registered nurse who made an on-site visit to the patient’s home no less frequently than every 14 days. CLINICAL RECORD 1: Review of the documentation for the benefit period dated 01/26/2026 to 03/26/2026, revealed the hospice aide visit frequency was ordered four times per week, and aide visits were completed as ordered. The hospice aide supervisory visits by the registered nurse were documented as completed on 01/29/2026, 02/03/2026, 02/13/2026, 02/18/2026, 02/24/2026, 03/13/2026 (17 days), 03/19/2026, and 03/26/2026. During an interview with the Executive Director (Personnel Record 5) and the Director of Clinical Services (Personnel Record 6) on 04/07/2026 they stated they would be providing education to the clinical staff.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The review of the documented volunteer hours did not provide evidence that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The volunteer percentage for the last 12 months from April 2025 to March 2026, averaged 0.81%. During an interview with the volunteer coordinator (Personnel Record 8) on 04/10/2026, she stated that she had recently taken over the role and was aware that the hours were not meeting the requirement, but they were working on increasing the volunteer percentage. Since becoming the volunteer coordinator, she has reached out to current volunteers and strengthened recruitment and retention efforts, resulting in greater engagement. The document review of the volunteer hours lacked evidence that hospice volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This was evidenced by the volunteer percentage for the last 12 months as follows: April 2025 1.03%, May 2025 0.56%, June 2025 1.33%, July 2025 0.23%, August 2025 0.42%, September 2025 0.52%, October 2025 0.25%, November 2025 0.42%%, December 2025 2.40%, January 2026 0.67%, February 2026 0.5%, and March 2026 1.41% this is an average of 0.81% for the last 12 months.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record review of a patient that was discharged from hospice services due to admission to facility revealed the agency did not provide the facility with the discharge summary. CLINICAL RECORD 19: The clinical record review revealed there was no documented evidence that the patient's discharged summary was sent to the facility. The documentation dated 03/06/2026, stated, "Admitted inpatient effective 03/06/2026 to a non-contracted facility. Husband/pt aware of discharge from hospice." During an interview with the Executive Director (Personnel Record 5) and the Director of Clinical Services (Personnel Record 6) on 04/10/2026, they stated they were sure that the discharge summary, as well as the medication list and plan of care, were faxed to the hospital, but that they were unable to locate the fax cover sheet at this time.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, and interview. In 8 of 14 (57%) clinical records reviewed, it was revealed that the agency did not ensure the plan of care included patient and family goals with measurable outcomes and specific planned interventions. Clinical Record 1: Patient with election of hospice benefit on 4/13/23. A skilled nurse visit note dated 5/17/23 documented, “Urinary tract infection assessment: onset date: 5/16/23, signs and symptoms: frequency, odor, urine dark in color, treatment: antibiotic ... antibiotic started yesterday for UTI." The plan of care did not include an individualized patient/family goal or measurable outcome related to the patient's genitourinary system or the urinary tract infection. Clinical Record 2: Patient with election of hospice benefit on 4/27/23. A skilled nursing visit note dated 5/24/23 included a comprehensive pain assessment that documented, “Pain location: left gluteal, type/duration: acute, chronic ... writer collaborated with facility DON and daughter and Norco 5/325mg ordered." The visit note also documented the patient was at risk for falling and had experienced a fall. The note stated “Patient found on floor and continues to complain of pain per facility staff nurse.” The Fall Risk Assessment Tool scored the patient at an 8. A score of 4 or more is considered at risk for falling. The plan of care did not include an individualized patient/family goal or measurable outcome related to pain or the patient's risk for falls/injury. Clinical Record 3: Patient with election of hospice benefit on 4/14/23. A skilled nurse visit note dated 4/28/23 documented, “Patient having frequent falls recently. Now has hospital bed, fall mat, bed and chair alarms. Staff to toilet patient every 2 hours." During a home visit on 6/7/23, the patient had a hospital bed, fall mat, and a chair alarm. The plan of care included an intervention which stated, "Assess need and proper use of DME/assistive devices." However, it did not include the specific intervention(s) for the bed/chair alarm, fall mats, or toileting every two hours. Clinical Record 4: Patient with election of hospice benefit on 4/29/23. A skilled nursing visit note dated 5/4/23 documented, "Received notification patient had a fall early this AM, no injuries noted. Patient states she hurts all over ... pain severity: moderate." The plan of care did not include an individualized patient/family goal or measurable outcome related to pain, or the patient's risk for falls/injury. Clinical Record 6: Patient with election of hospice benefit on 4/12/23 and terminal diagnosis of severe protein calorie malnutrition. The nursing initial assessment dated 4/12/23, documented that the patient had a decreased appetite and was taking a nutritional supplement. The physician certification of terminal illness was signed and dated by the hospice medical director on 5/1/23, and documented “Patient intake continues to be poor, now eating only 10% of all meals ... Weight 88.5 lbs with BMI 15.2." During a home visit on 6/7/23, the hospice nurse examined the contents of the patient's refrigerator, which contained several unopened bottles of Ensure nutritional supplement. The nurse confirmed that Ensure had been part of the treatment plan. However, the plan of care did not contain an order for Ensure, or an individualized patient/family goal or measurable outcome related to nutrition. Clinical Record 7: Patient with election of hospice benefit on 4/14/23. A skilled nursing initial assessment dated 4/14/23 documented, "Edema, right ankle: 2+, moderate pitting, left ankle: 1+, mild pitting ... patient is thin and frail with facial thinning noted, has had a decline in appetite with a weight loss of 20 pounds." The plan of care did not include an individualized patient/family goal or measurable outcome related to the edema or nutrition. An Interdisciplinary Group Meeting note dated 5/30/23 documented, “New wound to coccyx, area is treated with Calmoseptine and hydrocolloid dressing. Skin in the peri area remains red, now using antifungal cream and powder, showing improvement. Patient bilateral heels treated with offloading boots and skin prep, showing improvement." The plan of care did not contain an individualized patient/family goal or measurable outcome related to skin impairments, and did not include wound treatment orders. Clinical Record 10: Patient with election of hospice benefit on 4/12/23. The initial nursing assessment dated 4/12/23 documented that pain and dyspnea were active problems for the patient. The plan of care did not include an individualized patient/family goal or measurable outcome related to pain or dyspnea. The assessment also documented that the patient was taking Ensure nutritional supplement and was a "risk for aspiration." The plan of care did not contain an order for the Ensure nutritional supplement, or an individualized patient/family goal or measurable outcome related to the patient's nutritional status or risk for aspiration. Clinical Record 14: Patient with election of hospice benefit on 1/18/23 and a terminal diagnosis of Dysphagia. The initial nursing assessment dated 1/18/23 documented, "Speech Therapy (ST) recommended NPO and patient refuses and also refused pureed diet ... dysphagia has become increasingly worse in last two weeks." The plan of care did not include an individualized patient/family goal or measurable outcome related to the patient's dysphagia. During an interview on 6/8/23, the Administrator confirmed the findings.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure the aide care plan included specific instructions relevant to the care of the patient. Clinical Record 7: Patient with election of hospice benefit on 4/14/23. The nursing initial assessment dated 4/14/23, documented the patient used a Hoyer lift for transfers. The nursing assessment dated 5/30/23, confirmed continued use of the Hoyer lift and documented, “Patient uses a high back wheelchair for transportation and a Hoyer lift for transfers." The hospice aide care plan included an intervention for “Activity-Assist with transfers, start date 4/14/23.” However, the care plan did not instruct the aide to use a Hoyer lift. The patient received hospice aide visits twice per week. The aide visit notes dated 4/14/23 and 5/30/23 documented, "Assist with transfers. Done." During an interview on 6/7/23, the Administrator confirmed the finding.

Based on observation, record review, and interview, the agency failed to ensure staff followed appropriate infection prevention procedures during the hands-on provision of care of 1 of 3 (Patient #9) home visits observed. Findings include: --- 1. Review of an agency document titled, 'STANDARD PRECAUTIONS Policy No. 7-007,' page 1 stated, "PURPOSE To reduce the risk of exposure to and transmission of infections when caring for patients ...POLICY ... Organization personnel will adhere to the following precautions ... PROCEDURE General Precautions ... 1. Hand hygiene will be performed to prevent cross-contamination between the patient and personnel." page 2 stated, "1. Gloves: A. ... gloves are to be worn when: 1. There is actual or potential contact with ... potentially infectious materials ... 3. Touching contaminated items or surfaces ... C. Gloves are to be changed: 1. Between tasks and procedure on the same patient." 2. Review of an agency document titled, 'HAND HYGIENE Policy 7-009," page 1 stated, "PURPOSE To prevent cross-contamination and home care acquired infection s... PROCEDURE ... 3. Hand decontamination with alcohol-based hand rub should be performed: ... E. When moving from a contaminated body site to a clean body site during patient care." 3. On 3/28/23 at 11:00 AM during a home observation for Patient #9, Hospice Aide #1 was observed providing personal care. Patient #9 was seated on the commode and voiced their bottom still felt wet after drying off from a shower. Hospice Aide #1 reached for a clean white washcloth and assisted the patient to a standing position and thoroughly dried the patient's buttocks. The patient then sat down while the aide pumped lotion into the same gloved hands and applied this lotion to Patient #9's face. Later, with new gloves donned, the aide assisted the patient in dressing, including putting the patient's shoes on. Hospice Aide #1 then went to the sink to prepare the patient's toothbrush with toothpaste and handed this to Patient #9 for use. HHA #1 failed to change gloves and perform hand hygiene before going from dirty to clean sites. 4. On 3/28/23 at 3:25 PM, when informed of these observations during Patient #9's home visit, the Administrator indicated understanding these were infection control breaches and offered nothing further.

Based on record review and interview, the agency failed to ensure orientation to the philosophy of hospice care was provided to 1 of 1 Skilled Nursing Facilities. (Entity 11) Findings include: --- In a telephone interview on 3/28/23 at 1:00 PM, the Medical Director indicated plans were in the works to begin in-services/training for facility staff and agency staff related to hospice education, but that this had not yet occurred. 1. A review of an agency's policy, 'COORDINATION OF CARE WITH CONTRACTS/AGREEMENTS,' Policy No. 1-029, dated December 2022, revealed, "... 4. Hospice will provide education and training regarding hospice care to inpatient personnel at contracted facilities ..." A review of an agency's policy, 'PROVISION OF CARE TO RESIDENTS OF SNF/NF or ICF/IID' Policy No. 1-030 dated December 2022, revealed, "8. Luminary Hospice of Indiana LLC will consult with the SNF/NF or ICF/IID regarding the shared orientation and training responsibilities of staff furnishing care to patients, including A. Hospice philosophy ..." A review of an agency's policy 'ADDENDUM 1-030. A COMPLIANCE TOOL FOR HOSPICES THAT PROVIDE CARE TO RESIDENTS OF A SNF/NF, ICF/IID OR OTHER FACILITY' dated December 2022, revealed, "... Orientation of Facility Personnel...Resident Care Personnel - All Shifts, All Disciplines Hospice philosophy and care ... " 2. A review of a signed contract between Luminary Hospice of Indiana LLC and Entity 11 (a skilled nursing facility) dated 02/11/2023 revealed, " ... Hospice retains the responsibility to provide appropriate Hospice care training to personnel at Facility who will be providing care to Hospice patients ... " 3. During a home visit on 03/28/2023 at 11:15 AM at Entity 11 for Patient #4, an interview conducted with Person #12, an LPN (Licensed Practical Nurse), the Unit Manager, indicated Luminary Hospice of Indiana had not offered them training/orientation to their hospice philosophy. An interview on 03/28/2023 at 11:25 AM was conducted with Person #7, the DON (Director of Nursing) at Entity 11 indicated Luminary Hospice of Indiana had not conducted/provided their hospice philosophy in-service/training with their staff. During an interview on 03/28/2023 at 3:20 PM Brittney Brown, Director of Operations, Luminary Hospice of Indiana indicated training had not occurred at the facilities the agency has provided hospice services.