Every finding on record at Premier Hospice & Palliative Care - Indiana, LLC

Based on record review and interview, the registered nurse (RN) failed to ensure the hospice aide care plan included bleeding precautions for patients taking blood thinners for 2 of 2 records reviewed of patients taking blood thinners and receiving hospice aide services (Patient #3 and 18). Findings include: --- 2. Clinical record review for Patient #3 (benefit election date 12/16/2022) included a plan of care for the benefit period 03/16/2023 - 06/13/2023. The plan of care included a medication order for Eliquis (a medication which thins the blood) and indicated the patient was to receive hospice aide services for assistance with personal care needs "per aide plan of care." The record included an aide care plan for Patient #3 which failed to evidence bleeding precautions. Review of an agency policy dated 05/15/20- [sic] and titled ";Hospice Aide Services" indicated the RN develops the aide care plan. Clinical record review for Patient #18 included a plan of care for benefit period 03/18/2023 to 06/15/2023 that indicated a medication order for Xarelto (thins the blood). Review of an agency document dated as approved 05/08/2023 by the administrator and titled ";Aide Care Plan Report" failed to evidence bleeding precautions. During an interview on 05/15/2023 at 3:50 PM, the administrator indicated bleeding precautions were not on the hospice aide care plan.

Based on record review, observation, and interview, the hospice agency failed to ensure the hospice aide provided services as included in the aide care plan for 1 of 1 home visit observations with an aide (Patient #18). Findings include: --- Review of an agency policy dated 05/15/20- [sic] and titled ";Hospice Aide Services" indicated the hospice aide will provide services according to the aide care plan. Clinical record review for Patient #18 included an agency document dated as approved 05/08/2023 by the administrator and titled ";Aide Care Plan Report" that failed to evidence directions for the hospice aide to apply ointment to skin. During a home visit on 05/15/2023 at 11:00AM, observed certified nursing assistant (CNA) 2 apply A & D plus E ointment (temporarily protects and relieves chapped skin) to inner thighs of Patient #18. When asked where the CNA found the directions to apply the ointment, CNA 2 indicated the clinical supervisor in training gave him / her the directions. During an interview on 05/15/2023 at 4:26 PM the administrator indicated the aide tasks to be completed should be included in the aide care plan.

Based on record review and interview, the agency failed to ensure the plan of care included the duties to be performed by the patient care volunteer for 1 of 3 records with volunteer services (Patient #18). Findings include: --- Review of an agency policy dated 05/15/20- [sic] and titled ";Volunteer Services" indicated volunteer support to patient is to be in accordance with the plan of care. Clinical record review for Patient #18 included agency documents dated 04/13/2023 and 05/04/2023 that included one time orders for volunteer visits to provide respite; the documents failed to evidence the duties to be performed by the volunteer(s). During an interview on 05/15/2023 at 4:28 PM, the administrator indicated there were no volunteer duties within the plan of care.

Based on record review and interview, the hospice agency failed to ensure the patient had access to prescribed pain medication (see tag L512) and failed to ensure all staff recognized signs of patient neglect according to their policys definition (see tag L517). --- The severity of the findings resulted in Adoration Hospice being found out of compliance with Condition of Participation 42 CFR 418.52 Patient's Rights

Based on record review and interview, the hospice agency failed to ensure the patient had access to prescribed pain medication for 1 of 4 active records reviewed (Patient #1). --- Findings include: Review of agency policy #9-005.1 titled ";Bill of Rights – Indiana," revised 05/15/20, indicated the hospice patient had the right to ";receive effective pain management and symptom control from the hospice for conditions related to the terminal illness." Review of Patient #1s clinical record indicated a benefit election date of 03/04/2023 with a terminal diagnosis of liver cirrhosis and secondary diagnoses including but not limited to alcoholism. The patient had discharged from a local hospital to their private residence the same day of their admission to hospice. Hospice RN #1 completed Patient #1s admission assessment. The patient reported continuous pressure-like pain to their abdomen with a rating of an ";8" and a ";8.5" on a 0-10 numeric pain scale. The assessment indicated there was no pain medication available in the home and the patient had pain medication ordered by the hospital, but neither the patient nor caregiver could pick up the medication. The record included a plan of care for the benefit election period of 03/04/2023 – 06/01/2023 which indicated the patient was to take Oxycodone (an opioid pain medication) 5 milligrams every 4 hours as needed for pain. The plan of care indicated Patient #1s goals of care included but were not limited to the patient and/or caregiver would ";understand ... how to manage pain and report changes to hospice." The plan of care also indicated nursing interventions included but were not limited to monitoring the patients pain level and reporting changes in pain levels to the physician. During an interview with Hospice RN #1 on 03/16/2023 beginning at 5:06 PM, the nurse confirmed Patient #1 had a prescription for a pain medication from the discharging hospital, but they did not have transportation to the pharmacy to pick up the medication. During a follow up interview with Hospice RN #1 on 03/17/2023 beginning at 12:03 PM, the nurse confirmed Patient #1 did not have any of their pain medication in the home at the time of admission and no pain medication was ordered for the patient by the hospice. During an interview with the Administrator and Corporate Regional Compliance Employee #1 on 03/17/2023 at 2:08 PM, the Administrator reported the hospice agency had a contract with Contract Pharmacy #1 which could deliver medications for patients who ";struggled" with obtaining their own medications. The Administrator confirmed Patient #1 would have been an appropriate patient to have their medications delivered.

Based on record review and interview, the hospice agency failed to ensure all staff recognized signs of patient neglect according to their policys definition for 1 of 1 records reviewed of a patient who exhibited signs of neglect (Patient #1), which had the potential to affect all hospice patients. --- Findings include: Review of agency policy #9-005.1 titled ";Bill of Rights – Indiana," revised 05/15/20, indicated the hospice patient had the right to be free from neglect. Review of agency policy #9-013.1 titled ";Assessment of Possible Abuse/Neglect," indicated the hospice agency would report ";all suspected cases" of neglect to ";appropriate protection organizations." The policy defined neglect as ";failure of a caretaker to supply the patient with the necessary food, clothing, shelter, health care, or supervision; or the absence or likelihood of an absence of the necessary food, clothing, shelter, health care, or supervision for a patient. Review of Patient #1s clinical record indicated the patient was admitted to hospice on 03/04/2023 with a terminal diagnosis of liver cirrhosis and secondary diagnoses including but not limited to Type 2 Diabetes and alcoholism. The patient had discharged from a local hospital to their private residence the same day of their admission to hospice. Hospice RN #1 completed Patient #1s admission assessment. The nurse documented Patient #1 had been transported via EMS to their home immediately before the nurse arrived. The EMS reported upon arrival to the home, Patient #1s caregiver was confused and was under the bed looking for the patient. The nurse assessment indicated the patients living situation had "sanitation issues," the home was "cluttered" and "unclean," and the patient's significant other was "intoxicated and confused." The patient had durable medical equipment delivered prior to returning to their home, which included a hospital bed in their kitchen and a wheelchair and oxygen supplies in the living room. The living room also contained a hospital bed for the patients significant other, a bedside commode, furniture, and ";clutter." Hospice RN #1 moved the wheelchair and oxygen into a cluttered bedroom at the patients request. Patient #1 was observed taking a drink from their significant others liquor bottle in RN #1s presence. The patient reported continuous pressure-like pain to their abdomen with a rating of an ";8" and a ";8.5" on a 0-10 numeric pain scale. The assessment indicated there was no pain medication available in the home and the patient had pain medication ordered by the hospital, but neither the patient nor caregiver could pick up the medication. Patient #1 and their significant other asked the hospice nurse to pick up food for them, but Hospice RN #1 informed the patient they could not get food for the patient. The patient and significant other then discussed options for food delivery. Patient #1s nutritional assessment indicated the patient ate fewer than 2 meals per day, did not always have the financial means to obtain food, and the patient was not always physically able to shop, cook, and/or feed themself. Patient #1 also reported a weight loss of 80 pounds in the last 1 year. The assessment also indicated the patient was incontinent of bowels, ";especially at night." RN #1 documented the patient transferred from bed to chair with ";minimal assistance" and needed assistance with bathing, dressing, grooming, and toileting. Review of Patient #1s hospital records prior to their 03/04/2023 discharge included a physical therapy assessment, completed on 03/02/2023, which indicated the patient was ";not safe to be home without physical assistance," required ";heavy" assistance to stand from the end of bed, could only stand for 20 seconds, and their tolerance to therapy was limited by dizziness and weakness. The hospital records also included an occupational therapy evaluation, completed on 03/02/2023, which indicated the patient had ";decreased insight/safety awareness." During an interview with Hospice RN #1 on 03/16/2023 beginning at 5:06 PM, the nurse confirmed Patient #1s home was cluttered. The nurse reported the patient did not get out of their recliner for the length of the assessment. The nurse denied assessing for the presence of food in the home. Hospice RN #1 reported the patient had a prescription for Norco (opioid pain medication) from the hospital, but they did not have transportation to the pharmacy to pick up the medication. When queried if the nurse observed any signs of neglect or need to call Adult Protective Services, Hospice RN #1 stated ";just that [Patient #1] was unable to care of himself" and did not have a competent caregiver available. The nurse denied discussing any concerns for neglect with any hospice staff. During a follow up interview was conducted with Hospice RN #1 on 03/17/2023 beginning at 12:03 PM, the nurse confirmed Patient #1 did not have any of their pain medication in their home at the time of admission and no pain medication was ordered for the patient by the hospice. Hospice RN #1 also confirmed they did not assess the patients ambulation status. The clinical record indicated in the morning on 03/05/2023, Patient #1 called for EMS assistance and was found at the edge of their recliner sitting in stool. A police report from the call indicated neither the patient nor their caregiver could ";get up and around to care for themselves or each other, or even get food and water," and Patient #1 was found slumped at the side of their recliner sitting in stool. The police determined both the patient and their caregiver were severely disabled and a 24 hour Immediate Detention Order (IDO) was conducted. Patient #1 was taken to a local hospital and admitted for long term care placement. Emergency Personnel who responded to the scene referred the patient to Adult Protective Services for investigation of neglect. During an interview conducted on 03/17/2023 at 2:08 PM with the Administrator and Corporate Regional Compliance Employee #1, the Administrator confirmed they did speak with Hospice RN #1 regarding Patient #1, but the report received did not indicate a concern for neglect.

Based on record review and interview, the agency failed to reconcile (verify) medications of 2 of 4 active patient records reviewed (Patients #2, 4), with the potential to affect all patients. Findings include: --- Review of an agency policy ";Ongoing Comprehensive Assessment" indicated the physician would be notified of an approve any medication changes. Record review for Patient #2, benefit election date 3/6/2023, certification dated 3/6/2023 – 6/3/2023, evidenced a comprehensive assessment which identified hydromorphone (a narcotic pain reliever) 2 milligram (mg) one - half to one tablet to be taken every 4 hours as needed. The plan of care for the same certification period evidenced a medication list which identified hydromorphone 2 mg to be taken as one - half tablet every 4 hours. During an interview on 3/17/2023 at 2:08 PM, the Administrator confirmed there was a discrepancy in the hydromorphone order. Record review for Patient #4, benefit election date 1/5/2023, certification period 1/5/2023 – 4/4/2023, evidenced a nurse visit note dated 020/3/2023, which documented the patient took Seroquel for sleep. Review of the physician orders for Patient #4 indicated an order for Seroquel dated 2/16/2023. During an interview on 3/17/2023 at 2:08 PM, the Administrator confirmed the order should have been completed on 02/03/2023, the order was written late.

Based on record review and interview, the hospice agencys Interdisciplinary Group (IDG) failed to update the comprehensive assessment to reflect changes in the patient status for 1 of 1 records reviewed which indicated a change in patient status (Patient #1). --- Findings include: Review of agency policy #1-014.4 dated ";Comprehensive Assessment," revised 05/11/20, indicated the hospices interdisciplinary group (IDG) would update the patients comprehensive assessment a minimum of every 15 days. Review of Patient #1s clinical record indicated a benefit election date of 03/04/2023 with a terminal diagnosis of liver cirrhosis and secondary diagnoses including but not limited to alcoholism. The patient had discharged from a local hospital after a stay for peritonitis (infection of the peritoneum, the lining of the abdomen) to their private residence. The record indicated on 03/05/2023, Patient #1 summoned EMS to their home due to having slipped on stool on the floor and fallen. The patient was taken to a local hospital, admitted for long term care facility placement, and then discharged on 03/08/2023 to Skilled Nursing Facility #1. The record indicated bed side rails had been ordered as a fall risk measure, however the durable medical equipment company was unable to deliver the rails to the facility. The record included a ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," from the IDG meeting held 03/14/2023, which indicated Registered Nurse (RN) #2 documented Patient #1 had no falls within the last 2 weeks, had no infections within the last 2 weeks, and had side rails on their bed. During an interview with RN #2 on 03/17/2023 beginning at 1:40 PM, the nurse confirmed they were the nurse case manager for Patient #1. The nurse confirmed they had not seen and/or assessed the patient prior to the IDG meeting on 03/14/2023. RN #2 also confirmed Patient #1 did not have bed rails on their bed.

Based on record review and interview, the hospice agency's Interdisciplinary Group failed to ensure the plan of care identified the hospice care and services necessary to meet all patients needs, specific to level of care, patient ambulation, nutrition, and pain management.(see tag L539), failed to ensure the plans of care included measurable outcomes to demonstrate progress (see tag L548), failed to ensure all medications and treatments were identified on the plan of care (see tag L549), failed to provide medical equipment timely (see tag L550), failed to update the individualized plan of care with a change in patient condition (see tag L552), and failed to ensure nursing care was consistent with the plan of care and/ or physician orders (see tag L555). --- .The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.

Based on record review and interview, the hospice agency's Interdisciplinary Group failed to ensure the plan of care identified the hospice care and services necessary to meet all patients needs, specific to level of care, patient ambulation, nutrition, and pain management, for 1 of 1 patient re-admitted to a hospital within 24 hours of electing the hospice benefit (Patient #1). Findings include: --- 1. Review of agency policy #1-013.1 titled ";Initial Assessment," last revised 05/11/20, indicated the hospice registered nurse (RN) was to conduct an initial assessment to ";determine the patients and caregivers primary concern, goals, and immediate care needs ..." and the plan of care was to be initiated on the day of admission ";based on the initial assessment." 2. Review of agency policy #9-015.1 titled ";Admission for Respite Care," last revised 05/15/20, indicated respite care was indicated when: "1. The family/caregiver is unable to continue managing the patients physical, emotional, or psychological needs ... 2. Injury or impairment to the family/caregiver creates a need for respite to provide the family/caregiver and the interdisciplinary group an opportunity to problem solve." 3. Review of agency policy #9-017.1 titled ";The Plan of Care – Indiana," last revised 05/15/20, indicated the hospice was to establish a ";written individualized patient and family/caregiver plan of care," which was ";based on the initial, comprehensive ... assessments performed by members of the interdisciplinary group" and was focused on ";identified problems, goals, and interventions." The policy indicated after the admitting RN or RN case manager conducted the initial assessment and initiated the development of the plan of care, the nurse would ";notify the attending physician and a core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs." The policy indicated the plan of care ";will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief." The policy also indicated the plan of care would be ";reviewed by the rest of the interdisciplinary group within two (2) days of start of care." 4. Review of Patient #1s clinical record indicated the patient was admitted to the hospice on 03/04/2023 (a Saturday) with a terminal diagnosis of liver cirrhosis and secondary diagnoses including but not limited to Type 2 Diabetes and alcoholism. The patient had discharged from a local hospital to their private residence that same day, and the EMS who transported the patient were leaving as the nurse arrived. RN #1 performed an initial comprehensive assessment of Patient #1 on 03/04/2023 beginning at 3:43 PM in the patients residence. The assessment indicated the patient lived with their significant other and the EMS reported to the nurse the significant other was confused, used their Life Alert often, and was found under a bed looking for the patient. The assessment indicated the patients living situation had "sanitation issues," the home was "cluttered" and "unclean," and the patient's significant other was "intoxicated and confused." The patient had durable medical equipment delivered prior to returning to their home, which included a hospital bed in their kitchen and a wheelchair and oxygen supplies in the living room. The living room also contained a hospital bed for the patients significant other, a bedside commode, furniture, and ";clutter." Hospice RN #1 moved the wheelchair and oxygen into a cluttered bedroom at the patients request. Patient #1 was observed taking a drink from their significant others liquor bottle in RN #1s presence. The patient reported continuous pressure-like pain to their abdomen with a rating of an ";8" and a ";8.5" on a 0-10 numeric pain scale. The assessment indicated there was no pain medication available in the home and the patient had pain medication ordered by the hospital, but neither the patient nor caregiver could pick up the medication. Patient #1 and their significant other asked the hospice nurse to pick up food for them, but RN #1 informed the patient they could not get food for the patient. The patient and significant other then discussed options for food delivery. Patient #1s nutritional assessment indicated the patient ate fewer than 2 meals per day, did not always have the financial means to obtain food, and the patient was not always physically able to shop, cook, and/or feed themself. Patient #1 also reported a weight loss of 80 pounds in the last 1 year. The assessment indicated ";support services need" by the patient included ";food/nutritional resources – dietician." The assessment also indicated the patient was incontinent of bowels, ";especially at night." RN #1 documented the patient transferred from bed to chair with ";minimal assistance" and needed assistance with bathing, dressing, grooming, and toileting. Hospice RN #1 documented the patients re-hospitalization score was a ";3," which was a medium risk, and indicated per the assessment interventions to be done included but were not limited to notifying the IDG of the risk level, conducting daily nursing visits for 5 days, and notifying the triage/on-call nurse of the risk level and need for ";nightly phone call check at 8 PM" for 10 nights following admission. The assessment indicated Hospice RN #1 notified Hospice Physician #1 of the admission and received an order to admit Patient #1 to hospice for routine home care. Review of Patient #1s hospital records prior to discharge included a physical therapy assessment, completed on 03/02/2023, which indicated the patient was ";not safe to be home without physical assistance," required ";heavy" assistance to stand from the end of bed, could only stand for 20 seconds, and their tolerance to therapy was limited by dizziness and weakness. The hospital records also included an occupational therapy evaluation, completed on 03/02/2023, indicated the patient had ";decreased insight/safety awareness." During an interview with Hospice RN #1 on 03/16/2023 beginning at 5:06 PM, Hospice RN #1 confirmed Patient #1s home was cluttered. The nurse reported the patient did not get out of their recliner for the length of the assessment. The nurse denied assessing for the presence of food in the home. Hospice RN #1 reported the patient had a prescription for Norco (opioid pain medication) from the hospital, but they did not have transportation to the pharmacy to pick up the medication. When queried if the nurse observed any signs of neglect or need to call Adult Protective Services, Hospice RN #1 stated ";just that [Patient #1] was unable to care of himself" and his significant other was also unable to provide care. Hospice RN #1 reported they notified the Administrator of their concerns and was advised to speak with Hospice Physician #1 and ";see what [the doctor] says." Hospice RN #1 reported they then informed Hospice Physician #1 the patients home was ";crowded," the patients significant other was ";unable to take care of [the patient]," and the patient had no other available caregivers. The nurse reported the physician ordered to admit the patient for routine care and no other orders were received. Hospice RN #1 confirmed they did not speak with any other members of the interdisciplinary group (IDG) on 03/04/2023. During a follow up interview was conducted with Hospice RN #1 on 03/17/2023 beginning at 12:03 PM, the nurse confirmed Patient #1 did not have any supply of their pain medication in their home at the time of admission and no pain medication was ordered for the patient by the hospice. Hospice RN #1 confirmed they did not assess the patients ambulation status and they did not discuss the potential need for respite care for the patient with any members of the IDG at the time of admission. During an interview conducted with Hospice Physician #1 on 03/17/2023 beginning at 11:28 AM, the hospice physician could not recall the specific information Hospice RN #1 provided when they spoke regarding admitting the patient on 03/04/2023. The physician reported for a patient who was beginning services and was not in a safe home situation, one option would be to place the patient under respite care. The physician also reported respite care would not be an immediate solution, as it would take a few days to arrange. The clinical record included a plan of care for Patient #1 for the certification period 03/04/2023 – 06/01/2023. The plan of care indicated the patient was to receive skilled nursing services for 1 visit per week for 1 week, 2 visits per week for 1 week, 1 visit per week for 12 weeks, and 5 as needed visits for ";change in condition." The patient was also to receive hospice aide visits, effective 03/05/2023, for 2 visits per week for 12 weeks, then 1 visit per week for 1 week, and the medical social worker and chaplain were to conduct initial assessment visits. The plan of care indicated the hospice was to ";provide routine level of care for palliation and management of terminal illness and related conditions in coordination with the interdisciplinary group." The plan of care failed to evidence the agency addressed the patients needs specific to level of care, patient ambulation, nutrition, and pain management. The clinical record indicated on 03/05/2023 (a Sunday) at 9:10 AM Hospice Triage Nurse #3 was contacted by local EMS and informed Patient #1 had summoned EMS via their Life Alert button after a fall. The EMS reported the patients significant other was unable to care for the patient and Adult Protective Services would need to be called. Hospice Triage Nurse #3 documented they notified Hospice RN #1 and Medical Social Worker (MSW) #2 of the call. The clinical record indicated on 03/05/2023 at 9:16 AM Hospice RN #1 spoke with EMS regarding Patient #1. The nurses note indicated EMS reported the patient had been incontinent of stool, slid down their chair, and was found on the floor with ";feces all over" themselves. The EMS informed Hospice RN #1 the patients caregiver was unable to care for Patient #1, the home was unsafe, and Adult Protective Services had been called regarding the situation. The hospice nurse documented they began driving to the patients home to assess the patient. The record indicated on 03/05/2023 at an unspecified time MSW #2 was contacted by Hospice Triage Nurse #3 regarding the EMS report Patient #1 was not safe to be at home, the patients significant other was ";unable to properly care for [the patient]," the patient hadnt eaten in over 24 hours, was found sitting in feces, APS had been contacted, and the patient needed facility placement. The record indicated MSW #2 was ";unable to arrange facility placement at this time due to no admission staff available on the weekends." The social worker recommended Patient #1 be taken to a local hospital until placement could be arranged. During an interview with Medical Social Worker #2 conducted on 03/17/2023 beginning at 1:47 PM, the social worker confirmed the hospice agency was unable to place a patient in a nursing facility on the weekends as the facility admissions coordinators did not work on the weekends. MSW #2 reported if a patient required respite care on the weekend, the hospice could increase the frequency or length of visits or have an ";outside" home health or hospice agency assist with visits. The social worker was unsure if the hospice agency had any standing contracts with facilities to admit hospice patients for respite care, and reported despite an existing contract the hospice agency still would have been unable to admit Patient #1 to a nursing facility for respite care due to it being a weekend. Review of a local police report indicated the city police also responded to the patients EMS call. The police report indicated Patient #1 had not eaten since being discharged from the hospital the day prior, neither the patient nor their caregiver could ";get up and around to care for themselves or each other, or even get food and water." The police determined both the patient and their caregiver were severely disabled and a 24 hour Immediate Detention Order (IDO) was conducted. During an interview of Police Captain #2 on 03/16/2023 beginning at 12:43 PM, the captain reported the officers who responded to the EMS call for Patient #1 were ";very disturbed" by the patients living conditions. The captain also reported the EMS employees spoke with Hospice RN #1 regarding the patient and the nurse reportedly stated they had been told to ";go ahead and sign [the patient up for hospice]" despite their concerns. The clinical record indicated while driving to Patient #1s home, Hospice RN #1 were informed by the EMS they could not wait for the nurse to arrive and Patient #1 was being taken to a local hospital. The record indicated the nurse notified MSW #2 the patient was being taken to the hospital. MSW #2 documented they would notify MSWs #1 or #3 the next day (03/06/2023). The clinical record indicated Hospice RN #1 went to the local hospital and spoke with Patient #1. The patient reportedly blamed the hospice for their re-admission to the hospital due to ";all the equipment" in their home. Hospice RN #1 documented they notified the patient that neither the patient nor their caregiver were able to safely take care of him in their home and discussed admission to a nursing facility. Review of Patient #1s local hospital records indicated the patients blood sugar was 41 and 56 on arrival to the Emergency Department on 03/05/2023. The patient was admitted to the hospital for nursing facility placement and was discharged to a local skilled nursing facility on 03/08/2023. During an interview conducted on 03/17/2023 at 2:08 PM with the Administrator and Corporate Regional Compliance Employee #1, the Administrator confirmed the hospice agency did not have existing contacts in place with local nursing facilities to provide respite care to hospice patients. The Administrator stated a contract would be made with a facility when respite care was needed and the agency had the ability to contact local nursing facility directors to coordinate weekend admissions for respite care. The Administrator reported the agency had 24/7 medication delivery options through its pharmacy contract. The Administrator confirmed Hospice RN #1 should have collaborated with the hospices pharmacy regarding delivery service options to get Patient #1s pain medication delivered. The Administrator reported Hospice RN #1 and Hospice Physician #1 were responsible for determining the appropriate level of care for the patient. The Administrator confirmed they did speak with Hospice RN #1 on 03/04/2023 regarding Patient #1, and stated the hospice nurse reported Patient #1s ";roommate" was inebriated upon arrival, the home was cluttered, the patient was alert and oriented, and had elected their hospice benefit. The Administrator stated Hospice RN #1 did not report any concerns regarding the patients well-being and the Administrator advised the nurse to contact Hospice Physician #1 to discuss their assessment findings. Regarding the nurses assessment, the Administrator reported the nurse should have asked Patient #1 if they had the ability to obtain food. The Administrator stated generally the hospice nurse and physician were the only members of the IDG involved in the admission process. 5. During an interview with the hospice's Medical Director conducted on 3/17/2023 beginning at 11:20 AM, the Medical Director was queried on the admission criteria for hospice. The Medical Director indicated the patients must meet diagnostic criteria and be terminally ill. The Medical Director indicated the patient did not require a caregiver if they were competent to sign the hospice forms. The Medical Director indicated the patient's living condition, including if ";... the house has poop all over it or is dirty ...," did not impact whether the patient was admitted to hospice services. When queried what should be done if the admitting nurse expressed concern the patient was unable to care for self, the Medical Director indicated the patient should be informed the agency was not comfortable admitting the patient and the hospice tried not to admit patients in that condition. When queried how the IDG managed safety concerns, such as a patient unable to get up after a fall, the Medical Director indicated it would be discussed several times in IDG meetings. The Medical Director indicated Adult Protective Services would be notified and the patient could be discharged if safety concerns continued.

Based on record review and interview, the agency failed to ensure the plans of care included measurable outcomes to demonstrate progress in 4 of 4 active patient charts reviewed (Patients #1, 2, 3, 4), with the potential to affect all patients. Findings include: --- Review of an agency policy titled ";Plan of Care – Indiana" indicated the plan of care (POC) would be individualized and include measurable outcomes to determine progress. Record review for Patient #2, benefit election period 3/6/2023, certification period 3/6/2023 – 6/3/2023, evidenced a POC which failed to include measurable goals to determine the effectiveness of interventions to ";stabilize respiratory functioning to comfort as possible." Record review for Patient #4, benefit election date 1/5/2023, certification period 1/5/2023 – 4/4/2023, evidenced a POC which failed to include measurable goals to determine the effectiveness of interventions to ";stabilize respiratory functioning to comfort as possible." During an interview on 3/17/2023 at 2:08 PM, the Administrator indicated the respiratory functioning was assessed at each visit and relayed the respiratory assessment would indicate if the level of comfort was ";as possible." 2. Record review for Patient #1, benefit election date 03/04/2023, initial certification period 03/04/2023 – 06/01/2023. evidenced a POC which failed to include measurable goals to determine the effectiveness of interventions to "maintain optimal cardiac function within constraints of disease," stabilize the respiratory system "to comfort as possible," and the genitourinary system would be "free of signs/symptoms of discomfort." 4. Record review for Patient #3, benefit election date 12/16/2022, recertification benefit period 03/16/2023 – 06/13/2023, evidenced a POC which failed to include measurable goals to determine the effectiveness of interventions to "control" nausea by "the conclusion of each [Skilled Nurse] visit and the patient's respiratory status would be "stabilized to comfort at conclusion of each visit ...."

Based on observation, record review and interview, the agency failed to ensure all medications and treatments were identified on the plan of care in 1 of 4 active patient records reviewed (Patient #2), with the potential to affect all active patients. Findings include: --- Review of an agency policy titled ";Medication Profile" indicated all medications and nutritional supplements must be included on the medication profile and the medication profile will be kept current and accurate. During a home visit observation with registered nurse [RN] #2 at the residence of Patient #2 on 3/16/2023, RN #2 asked patient if they were still using Boost as a supplement to meals. Patient #2 indicated they still drank it. Record review for Patient #2, benefit election period 3/6/2023, certification period 3/6/2023 – 6/3/2023, evidenced a plan of care (POC) which failed to include Boost as a nutritional supplement. During an interview on 3/17/2023 at 2:08 PM, the Administrator confirmed Boost was not on the POC.

Based on record review and interview, the agency failed to provide medical equipment timely for 1 of 1 patient requesting a cane (Patient #4), with the potential to affect all patients requiring medical equipment. Findings include: --- Review of an agency policy titled Durable Medical Equipment and Supplies" indicated equipment and supplies were to be provided to hospice patients based on the patients assessed needs. Record review for Patient #4, benefit election date 1/5/2023, certification period 01/05/23 – 4/04/23, evidenced an as needed (PRN) nurse visit on Saturday, 01/28/2023, which indicated the patient requested a cane. Review of a nurse visit note dated 01/31/2023 indicated the nurse ordered a cane for the patient. During an interview on 3/17/2023 at 2:08 PM, the Administrator confirmed the cane was ordered on Wednesday 02/01/2023. The Administrator confirmed the agency had the ability to obtain the cane over the weekend.

Based on record review and interview, the hospice Interdisciplinary Group (IDG) failed to update the individualized plan of care with a change in patient condition for 1 of 1 records reviewed which indicated a change in patient condition (Patient #1). Findings include: --- Review of agency policy #9-017.2-IN titled ";The Plan of Care- Indiana," dated 05/15/20, indicated the hospice patients plan of care would be ";reviewed and revised" by the IDG with any change in the patient condition. Review of Patient #1s clinical record indicated a benefit election date of 03/04/2023 with a terminal diagnosis of liver cirrhosis. The patient had discharged from a local hospital after a stay for peritonitis (infection of the peritoneum, the lining of the abdomen) to their private residence with hospice services. The patient was re-admitted to the hospital on 03/05/2023 and had an Aspira drain (catheter used to drain excess fluid from the lungs or abdomen) placed into their peritoneum (lining of the abdomen) for draining of excess fluid buildup. The patient was discharged to Skilled Nursing Facility #1 on 03/08/2023. The record indicated Hospice Registered Nurse (RN) #1) conducted a visit on 03/08/2023 after the patient had arrived at SNF #1. The nurse noted the presence of the peritoneal drain but the record failed to evidence an order was obtained for the frequency the drain was to be used and/or amount of drainage to be removed. The record included a ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report," from the IDG meeting held 03/14/2023, which indicated RN #2 documented the presence of the peritoneal drain. The IDG meeting notes failed to evidence orders were placed for use of the Aspira drain for abdominal fluid removal. During an interview with RN #2 on 03/17/2023 beginning at 1:40 PM, the nurse confirmed they were the nurse case manager for Patient #1. The nurse also confirmed orders for the frequency of drainage and amount to be drained from Patient #1s peritoneal drain were not obtained until 03/15/2023.

Based on record review and interview, the agency failed to ensure nursing care was consistent with the plan of care and/ or physician orders in 1 of 1 patient with a foley catheter (tube placed into the bladder to drain urine), with the potential to affect all patients with a foley catheter [Patient #4]. Findings include: --- Review of an agency policy titled ";Ongoing Comprehensive Assessment" indicated the physician would be contacted for new or changed orders based on the patients condition. Review of an agency policy titled ";The Plan of Care – Indiana" indicated care provided to the patient is based on the plan of care. The clinical record for Patient #4, evidenced a benefit election date of 01/05/2023, current certification period 01/05/2023 – 4/4/2023, and evidenced a communication note dated 01/19/2023, which indicated the patient wanted their foley catheter removed. The note indicated the catheter was removed per the patient request. During an interview on 3/17/2023 at 2:08 PM, the Administrator confirmed there was no physician order to remove the foley catheter.

Based on record review and interview, the hospice agency failed to ensure the employee who received a physician order was the one to sign the order according to their physician order policy for 3 of 4 active records reviewed (Patient #1, 2, 4). Findings include: --- 1. Review of agency policy #1-007.1 titled ";Certification of Terminal Illness," revised 05/11/20, indicated physician certification of terminal illness (CTI) that could not be obtained in writing within 2 calendar days following the start of care should be obtained verbally and documented in the clinical record. 2. Review of agency policy #2-002.1 titled ";Verification of Physician Orders – Indiana," revised 05/11/20, indicated verbal orders should be documented, dated, and signed ";by the professional receiving the order." 3. Review of the clinical record for Patient #1 (benefit election date 03/04/2023) included an initial comprehensive assessment completed on 03/04/2023 by RN #1. The assessment indicated RN #1 received a verbal order from Hospice Physician #1 to admit the patient to hospice services. The record also included a physician order, dated 03/04/2023 at 4:35 PM and signed by Registered Nurse (RN) #4, to evaluate and admit Patient #1 to hospice and a verbal physician certification of terminal illness. The order was co-signed by the agencys Medical Director on 03/17/2023. 6. During an interview with RN #4 conducted on 03/17/2023 at 10:30 AM, RN #4 confirmed they did not receive orders to admit and verbal certification of terminal illness. RN #4 reported the nurse who completed the admission assessment would obtain an order to admit to hospice and a verbal CTI, then RN #4 would "process" the admission and CTI in the electronic medical record. The nurse confirmed they electronically signed this order. Record review for Patient #2, benefit election period 3/6/2023, certification period 3/6/2023 – 6/3/2023, evidenced an order dated 3/6/2023, to admit the patient to hospice. The document indicated RN 4 received the verbal order, evidenced by RN 4s signature on the order. Record review for Patient #4, benefit election date 1/5/2023, certification period 1/5/2023 – 4/4/2023, evidenced a verbal order for the certification of terminal illness, which indicated RN 2 received the verbal order. The order was electronically signed by Administrative Staff 1, an RN.