Every finding on record at Northern Indiana Interim Healthcare Company, LLC

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed and home visit observations, the agency did not ensure that the drug administration record was updated, which resulted in the medication reconciliation being incomplete. HOME VISIT 1/CLINICAL RECORD 1: This patient elected the hospice benefit on 03/20/2024 with a terminal diagnosis of senile degeneration of the brain. During the home visit observation on 04/22/2026 with the Registered Nurse (Personnel Record 1), a medication review was completed by comparing the hospice drug profile to the patient’s home medications. The patient's home medications included diclofenac sodium 1% gel apply a small amount to the affected area once a day as needed for pain, and collagen 1.7 grams with joint and mobility blend 325 mg 3 capsules a day. The hospice drug profile dated 03/01/2026-05/08/2026 did not include these medications. An interview was conducted on 04/22/2026 with the Director of Clinical Services (Personnel Record 1), and it was stated that the medications were not included in the patient’s drug profile and acknowledged that they were inadvertently omitted.

It is required that each patient’s individualized written plan of care 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 and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/25/2025 with a terminal diagnosis of chronic diastolic (congestive) heart failure. The registered nurse (RN)'s initial comprehensive assessment dated 04/25/2025 stated that the patient reported intense nausea after activities and eating, and the caregiver reported that the patient had nausea and vomiting multiple times per week. The drug profile dated 04/25/2025 included ondansetron 4 mg oral tablets by mouth every 8 hours as needed for nausea and vomiting. The plan of care was reviewed for the dates of 04/25/2025-10/28/2025 and included no interventions for nausea and vomiting based on problems identified in the initial comprehensive system. An interview was conducted on 04/22/2026 with the Director of Clinical Services (Personnel Record 1), and it was stated that the plan of care did not include interventions for the problem identified in the initial comprehensive assessment.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. DOCUMENT 1: Agency Policy Infection Prevention & Control in the Home Setting stated, in part: "Hand hygiene shall be performed at a minimum: before and after contact with a patient; after contact with the patient or objects in the immediate vicinity of the patient; after contact with the blood, body fluids or contaminated surfaces; immediately before applying PPE (e.g., gloves gown, facemask); immediately after removal of PPE (e.g., gloves, gown, facemask". HOME VISIT 3 / CLINICAL RECORD 3: This patient elected the hospice benefit on 09/12/2023 with a terminal diagnosis of COPD. During a home visit conducted on 04/22/2026 to observe the Hospice Aide (Personnel Record 3) [HA], the HA met me at the door with her gloves on. We proceeded to go back to the patient's bathroom, where the patient was sitting on the toilet. The HA cleansed the patient's perineal area and helped the patient to her chair in the living room without sanitizing her hands. Once the patient was settled in her chair, the HA removed her gloves and donned new gloves without sanitizing her hands. She then closed up the patient's garbage bag and asked the patient if she would like a drink. The patient stated she would like a drink of water. The HA reached into the refrigerator with the same gloves that she had touched the garbage bag without sanitizing her hands or changing her gloves. During an interview with the Director of Clinical Services (Personnel Record 1) on 04/23/2026, it was stated that the agency policy for hand hygiene was not observed during the home visit and that the hospice team would be re-educated on hand hygiene.

It is required that hospice aides are assigned to a specific patient by a registered nurse (RN) 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, interview, and observation. In 2 of 12 (17%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure that written patient care instructions for the hospice aide were clear and complete. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 03/20/2024 with a terminal diagnosis of senile degeneration of the brain. The updated plan of care dated 03/10/2026 included hospice aide visits 1X a week. The hospice aide care plan was reviewed for the dates of 03/10/2026-05/10/2026 and directed the Hospice Aide to provide a shampoo at each visit. During the home visit observation on 04/22/2026 with the Registered Nurse (Personnel Record 1), the caregiver/daughter of the patient stated that the patient received a tub bath and shampoo once a week. She stated the Hospice Aide used an inflatable basin for shampooing the hair. The hospice aide's care plan did not include instructions to use an inflatable basin to shampoo the patient's hair. CLINICAL RECORD 8: This patient elected the hospice benefit on 04/25/2025 with a terminal diagnosis of chronic diastolic heart failure. The RN's initial assessment dated 04/25/2025 was reviewed, and stated that the patient used a walker and wheelchair to ambulate. The hospice plan of care dated 04/25/2025 included orders for hospice aide visits 2X a week. The hospice aide care plan was reviewed for the dates of 05/01/2025-07/30/2025, and did not give clear instructions to use a walker and wheelchair for patient ambulation. During an interview conducted on 04/22/2026, the Director of Clinical Services (Personnel Record 1) stated, “The hospice aide care plans were not complete, and the RN staff would be re-educated to ensure that the hospice aide care plans would be completed correctly.”

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. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 04/23/2026, and the Volunteer Activity Report dated 01/01/2026 was reviewed, and revealed that the volunteer utilization for the year of 2025 was 2.05%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency recently hired a new Volunteer Coordinator who will collaborate with the corporate Volunteer Program to increase volunteer services. An interview was conducted with the Administrator and the Volunteer Coordinator (VC) on 04/23/2026 and the Volunteer Activity Report dated 01/01/2026 was reviewed and revealed that the volunteer utilization for the year of 2025 was 2.05%. This did not meet the requirement of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The agency recently hired a new Volunteer Coordinator who will collaborate with the corporate Volunteer Program to increase volunteer services.

It is required that per policy and procedure, the hospice responds to alleged violations involving anyone working on the hospice’s behalf by: Immediately investigating all alleged violations and taking immediate action to prevent further potential violations while the alleged violation is being verified. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 2 (50%) instances where there was an identified patient complaint, the agency did not ensure it followed it's own policy and procedure for documenting and investigating complaints and maintaining complaint logs when a complaint was voiced by a patient and/or caregiver. Document 1: stated in relevant part: "The Hospice administrator or designee documents the complaint upon receipt, the investigation, action taken, and all contact with the complainant, his/her response and the resolution (Refer to Addendum C- Hospice Complaint Form and to Addendum D – Hospice Complaint Log in this chapter)" and " The hospice administrator maintains complaint logs and records of individual complaints, the investigation and status upon closing, and any plan of action and the results in an administrative quality assessment and performance improvement file." Clinical Record 6: Patient with election of hospice benefit on 1/12/23. A review of the clinical record included the following: a care coordination note by the regional director of operations dated 1/25/23 documented, “Attempted to reach patient’s wife via phone in an effort to understand why she is dissatisfied with hospice as reported by the hospice RN after her last visit;" a care coordination note by the hospice medical social worker dated 1/26/23 documented, “(spouse) explained that (patient) might not be a part of the hospice program next week as they are very upset;" an IDG Summary/Comprehensive Assessment Update dated 1/31/23 documented, “Discussion between IDG members during the meeting: wife and patient hospice concerns to be addressed by hospice director this week;” a skilled nurse missed visit note on 2/1/23 documented, “The patient and the patient spouse do not want hospice services at this time;" a care coordination note by the regional director of operations on 2/1/23 documented, “Reached out via phone again in an attempt to discuss concerns with (spouse) but I was unable to reach her. She later informed the spiritual counselor that she definitely wanted her husband discharged from hospice and would like a hospice representative to come on Friday to sign the hospice revocation papers. She was unwilling to have further discussions about her concerns." Document 2: A review of the agency’s “complaint binder” with complaint logs labeled January 2023 and February 2023 did not include an entry for the concerns documented in Record 5. There was no evidence of a completed hospice complaint form, recording of the complaint, investigation, or plan of action or resolution for the concerns documented in record 5, as directed by agency policy . A review of the agency's Quality Assessment/Performance Improvement (QAPI) documentation included a meeting held on 4/27/23 to review January, February and March 2023 data. The "Hospice Monthly QAPI data Report" for January, February and March of 2023 had a section that identified the total number of complaints. For January and February, the document indicated zero complaints were received. During an interview on 5/23/23, the Administrator confirmed the finding and did not provide any additional information or documentation.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by clinical record review, observation, and interview. 1 of 5 (20%) records reviewed, revealed the agency did not ensure the drug profile in the clinical record was updated to include the patient's current prescription drug orders. Clinical Record 1: Patient with election of hospice benefit on 1/11/23. A home visit observation was conducted on 5/23/23, and the patient's daughter was interviewed regarding the patient's current medication regimen. When compared to the current drug profile provided by the agency in printed form on 5/22/23, the following discrepancies were noted. Apixaban 5mg was ordered by mouth twice a day. However, per the daughter, the patient was taking this medication once a day. Aspirin 81mg was ordered by mouth once daily in the morning. However, per the daughter, the patient was no longer taking this medication. Omeprazole 20mg oral, delayed release tablet, was ordered by mouth once daily in the morning. However, per the daughter, the patient does not take this medication on a daily basis. The daughter stated, “He only takes it when he needs it, and hasn’t taken it lately." Miralax 17g was ordered by mouth daily. However, per the daughter, the patient did not take this daily. The daughter stated, “He’s pretty regular. He does not take that every day, only every now and then." Torsemide 20mg was ordered per mouth once daily. However, per the daughter, the patient was only taking ½ tablet every day. The medication profile had been reviewed and signed by the registered nurse on 5/17/23, 5/15/23, and 5/10/23, as well as the agency's medical director on 5/9/23. During an interview on 5/23/22, the Administrator confirmed the drug profile was not updated to reflect the patient's current prescription drug orders.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Criminal background checks are obtained in accordance with state requirements. This standard was not met as evidenced by personnel record review, document review, and interview. 1 of 8 (12%) personnel records reviewed, revealed the agency did not obtain a criminal background check within three days as defined by state requirements. Indiana Code IC 16-25-6-2: Employee's or volunteer's criminal history states in relevant part: (a) A person who owns or operates a hospice program shall apply, not more than three (3) business days after the date that an employee or a volunteer begins to provide hospice services, for a copy of the employee's or volunteer's limited criminal history from the Indiana central repository for criminal history information under IC 10-13-3. (b) A hospice program may not employ an individual or allow a volunteer to provide hospice services for more than three (3) business days without applying for that individual's or volunteer's limited criminal history as required by subsection (a). Personnel Record 8: On 5/24/23, a review of the personnel record for the agency's alternate medical director, with a date of hire of 10/31/22, revealed there was no evidence of a completed criminal background check. During an interview on 5/24/23, the Administrator confirmed the findings and stated they were unable to locate a background check. Indiana Code IC 16-25-6-2: Employee's or volunteer's criminal history states in relevant part: (a) A person who owns or operates a hospice program shall apply, not more than three (3) business days after the date that an employee or a volunteer begins to provide hospice services, for a copy of the employee's or volunteer's limited criminal history from the Indiana central repository for criminal history information under IC 10-13-3. (b) A hospice program may not employ an individual or allow a volunteer to provide hospice services for more than three (3) business days without applying for that individual's or volunteer's limited criminal history as required by subsection (a).