Every finding on record at Peoplefirst Homecare & Hospice of Indiana, LLC

Upon patient record review, 1 of 14 (Patient #3) 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: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3: The medication profile has an active order for MiraLAX oral powder 17 grams daily. No evidence that a diluent was included.

Upon patient record review, 1 of 14 (Patient #4) 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 4: The patient was admitted on 11/11/25. There was no evidence that a bereavement risk assessment was completed within 5 days of admission. Assessment completed on 11/17/2025.

Upon patient record review, 3 of 14 (Patient #2,6,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: RN documentation indicated that the patient is legally blind. No evidence that goals and interventions related to visual impairment were added to the plan of care. Patient 6: Pre-bereavement risk assessment was completed by the MSW on 01/16/2026 and was scored as moderate. No evidence that a pre-bereavement care plan was added to reflect the caregivers needs. No evidence that the bereavement care plan was updated to reflect the caregivers needs. Patient 10: RN documentation indicated that patient is at high risk for falls due to altered mobility and continues to smoke with oxygen inside the home. No evidence that safety goals and interventions related to falls or oxygen was added to the plan of care.

Upon patient record review, 1 of 14 (Patient #3) 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 3: The plan of care has an active order for MiraLAX oral powder 17 grams daily. No evidence that a diluent was included on the order.

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: RN documentation indicated that the patient uses a wheelchair daily due to lower extremity weakness. No evidence that a wheelchair was included on the plan of care's DME list.

Upon patient record review, 1 of 14 (Patient #12) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 12: The patient was discharged due to extended prognosis on 01/22/2026. No evidence that the patient was notified of the discharge prior to the day of discharge. No evidence that discharge planning was added to the plan of care before the patient was discharged.

Upon patient record review 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 6: Pre-bereavement risk assessment was completed by the MSW on 01/16/2026 and was scored as moderate. No evidence that a follow-up was completed or that anything was done to start supporting the caregiver at the time that the need was identified. No evidence that the MSW communicated the moderate pre-bereavement risk with the IDG team.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: RN documentation indicated that the patient has an active wound. No evidence that wound precautions were added to current aide plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency did not utilize volunteers at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 0.3%

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient 7: Medical record indicated that the LPN added problems, goals, and interventions for anxiety and medication management to the plan of care. Patient is currently in his 9th benefit period and those problems, goals, and interventions remained active at the time the chart was surveyed. This is not within the LVN acceptable standards of practice.

Upon client record review, 1 of 14 (Patient #7) did not have evidence that the physician provides a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the recertification form, or as an addendum to the recertification form Patient 7: Recert CTI narrative for the 9th BP was an exact copy of the NP face to face narrative that occurred on 12/27/2025.

Based on record review and interview, the agency failed to ensure the social worker completed their psychosocial assessment as ordered on the plan of care in 1 of 9 active clinical records reviewed with orders for the social worker to evaluate. (Patients: #1, 2, 3, 4, 6, 7, 10, 11, and 12) Findings Include: --- 1. An agency policy revised 08-30-2023 titled ";The Plan of Care, Policy No. 4-027" indicated but was not limited to, "; ... The care provided to the patient must be in accordance with the plan of care. ..." 2. During a review of Patient #1s clinical record, the record evidenced a plan of care with a start of care date of 12-22-2023 and a benefit period from 12-22-2023 to 03-20-2024. The plan of care evidenced the patient had the following diagnoses, Chronic systolic and diastolic heart failure (the heart muscle is weak and stiff causing the ventricles to be unable to relax appropriately) and chronic kidney disease (a condition where the kidneys are damaged and are unable to filter the blood appropriately). The plan of care indicated the patient had an order dated 12-22-2023 for a Medical Social Worker evaluation for the patient. The Interdisciplinary group meeting date on 12-27-2023 indicated the patient was new and a Medical Social Worker (MSW) evaluation had not been completed yet by MSW 1. The clinical record failed to evidence an MSW evaluation was completed in a timely manner. The clinical record evidenced a Registered Nurse (RN) start of care assessment on 12-22-2023. The assessment evidenced in the narrative note, Patient #1 had an order for MSW to assist with Healthcare Representative completion. Patient #1s clinical record evidenced a coordination note on 02-05-2024 by MSW 2, the MSW contacted the patient and the patient indicated they wanted an MSW evaluation. The MSW evaluation was completed on 02-19-2024, according to the patients request. An MSW evaluation failed to be completed less than 5 days after the start of care on 12-22-2023. 3. During an interview with the Administrator and Regional Director of Operations on 12-21-2024 at 12:45 PM, they indicated for Patient #1, there was a start of care order for the patient to receive an MSW evaluation. They indicated there was an order for MSW evaluation for the start of care. They indicated the record failed to evidence an MSW evaluation within 5 days of the start of care as ordered by the physician. 4. During an interview with MSW 2 on 02-21-2024 at 11:42 AM, they indicated Person 11, a previous MSW with the agency, had left the agency in December of 2023. They indicated they started at this agencys office on 01-29-2024. They indicated the only other MSW at the agency since Person 11 left was MSW 1 until MSW 2 came from the south office to work at this office. 5. During an interview with MSW 1 on 02-21-2024 at 3:01 PM, they indicated if MSW was ordered at the start of care, they were to set up an evaluation within the 5-day window. In December Person 11, former MSW, left the agency and the patients were seen by MSW 1 and MSW 2. 6. During an interview with MSW 1 on 02-22-2024 at 9:05 AM, they indicated they had never contacted or visited Patient #1 or their family. They confirmed Person 11 had left the agency the day the patient started on 12-22-2023, and the patients evaluation was not completed within the allotted 5-day window from the start of care date.

Upon patient record review, 2 of 13 (Patient #1, #4) 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 #1- The medication profile contains Miralax 17gm oral powder daily prn for constipation. The profile does not contain a diluent. (corrected on site) Patient #4- The medication profile includes Tobramycin .3% eye drops 1-2 drops per eye three times daily. Upon interview and record review the correct orders were for the drops to be administered in the right eye. (corrected on site)

Upon patient record review, 2 of 13 (Patient #1, #4) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific and accurate orders for all medications. Patient #1- On 02/06/23 an order was received to update the plan of care for Miralax 17gm oral powder daily prn for constipation. The orders do not contain a diluent. (corrected on site) Patient #4- On 01/13/23 orders were written to update the plan of care for Tobramycin .3% eye drops 1-2 drops per eye three times daily. Upon interview and record review the correct orders were for the drops to be administered in the right eye. (corrected on site)

Upon patient record review, 4 of 13 (Patient #2, #5, #6, #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2-Effective 02/01/23 orders are on record for the Chaplain to visit once monthly for one month. The record documents the Chaplain visited twice monthly in February on 02/01/23 and 02/15/23 (corrected on site). Patient #5- On 02/13/23 the nurse documents the patient was agreeable to a Foley catheter. Once the prep was completed and patient was touched with the Foley catheter tube the patient subsequently refused the catheterization. There were no orders on record to initiate Foley catheterization. (corrected on site). Patient #6- On 01/23/23 a volunteer was ordered 2m1; 4m2. The record documents one visit was performed in January on 01/28/23. Patient #11-On 01/18/23 The Social Worker was ordered to visit once every 2 months. (1q2m2). Visits were performed 01/19/23 and and 02/03/23 (monthly).

Upon patient record review 1 of 13 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Included in the plan of care Patient #4-Effective 01/03/23 orders are on record for the aide to visit twice weekly. Between 01/01/23 and 02/11/23 the Aide visited the patient once weekly. (corrected on site)

Upon patient record review, 2 of 13 (Patient #1 and 10) did not have evidence that all entries are complete in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1-On 01/25/23 triage documented receiving a phone call from the patient with complaints of vomiting earlier, taking a pain pill and was no longer able to walk. Triage documented dispatching a call to the on call nurse for follow up. The agency's on call records contain documentation from the nurse on call to evidence the patient received education and the patients concerns were addressed; however a clinical note was not entered into the medical record. (late entry documentation corrected on site). Patient #10- The record indicates the patient revoked the hospice election on 01/10/23. The record also documents bereavement risk assessments were performed on three family members on 01/26/23 when the patient was not in the hospice program.

Upon patient record review, 1 of 13 (Patient #10) did not have evidence that the discharge summary includes all required information Patient #10- The 01/10/23 discharge summary on record does not include a summary of the patient's stay, including treatments, symptoms and pain management. The discharge summary only documents the patient revoked the election.