Every finding on record at Seasons Hospice & Palliative Care of Indiana LLC

Based on record review and interview the agency failed to investigate per agency policy an alleged violation of sexual abuse in 1 of 1 patients reviewed with an allegation of sexual abuse and failed to protect others from potential abuse during the investigation. (L509) The cumulative effects of these systemic problems resulted in the hospice agencys inability to ensure the provision of quality health care in a safe environment for the Condition of Participation 42 CFR 418.52 Patient's Rights. --- *

Based on record review and interview the Hospice failed to document the existence, investigation, and resolution per agency policy for 1 of 2 allegations of abuse for the past 6 months and failed to protect other patients for the potential for abuse during an investigation of an alleged abuse. (Patient #2). Findings Include: --- 1. A review of the Indiana Department of Health(IDOH) incidents dated 09-14-2023 intake #101428 indicated that the Director of Nursing at Entity 2, a long-term care facility, reported a hospice ";CNA" (certified nursing assistant) from AccentCare Hospice came in on 09-13-2023 and assisted Patient #2 with getting into their chair. On 09-14-2023 Patient #2 made a report to Entity 2 alleging that Hospice Aide 3 had assisted them in a chair and when the Hospice Aide attempted to pull them back in a seat, Patient #2 felt ";uncomfortable r/t [sic] ... hands touched [Patient #2s] breast area, as well, as areas on [gender of Patient] neck/head ... also reports the aide touched the top of [Patient #2s] head with [gender of hospice aide] lips. "; The Director of Nursing reported their facility administrator had them submit the report and indicated they investigated, informed the family, and informed AccentCare of the allegation. 2. A review of AccentCares adverse events and complaints log received from AccentCares Executive Director on 10-02-2023 at 12:07 PM failed to evidence the allegation reported about Patient #2 by Entity 2. 3. A policy titled ";CONCERN, COMPLAINT OR GRIEVANCE REPORTING INTERNAL AND EXTERNAL" Received from the Executive Director on 10-03-2023 at 12:55 PM, indicated but was not limited to ";It is the policy of this agency to investigate and resolve all concerns or complaints whether submitted internally or externally in a satisfactory and timely manner ..." Any complaint of ... sexual abuse ... is reported and investigated as an incident ...." A policy titled ";HOSPICE PATIENT BILL OF RIGHTS" received from the Executive Director on 10-03-2023 at 12:55 PM, indicated but was not limited to ";Complaints or Grievances ... to have their complaints heard and addressed. Also, to receive an investigation from the hospice of complaints from patient...regarding treatment or care, and to have staff document the existence of the complaint and resolution of the complaint." 4. A review of the clinical record for Patient #2, subject of the incident, evidenced an election of benefit of 06-22-2023 and a certification period of 06-22-2023 through 09-19-2023 with diagnoses including but not limited to chronic obstructive pulmonary disease (a group of lung diseases that block airflow), atherosclerotic heart disease (a thickening or hardening of arteries causing obstruction of blood flow) and type 2 diabetes mellites (disease in which your blood sugar levels are too high) and orders dated 08-31-2023 for skilled nursing 2 times a week for 1 week,1 time a week for 1 week and 2 skilled nursing visits as needed for symptom and crisis management and a home health aide (hospice aide) effective 09-03-2023 1 time a week for week 1, 2 times a week for 1 week, and 1 time a week for 1 week. The record indicated Patient #2 resided in a long-term care facility, Entity 2. A review of Hospice care provided for the week of 09-10-2023 through 09-16-2023 evidenced the patient was seen on 09-12-2023 by Employee 3, hospice aide identified in the incident, on 09-15-2023 by Registered Nurse RN 1 also the patients case manager, and on 09-16-2023 by RN 3. A review of Skilled Nursing visits evidenced the week of 09-10-2023 through 09-16-2023 Patient #2 was seen 2 times following the allegation. 5. During an interview with RN 1 on 10-04-2023 at 10:48 AM they reported the visit on 09-15-2023 was a routine visit and was not aware of the allegation until a few days later. During an interview with RN 3 on 10-06-2023 at 10:52 AM when queried if the visit on 09-16-2023 was related to the allegation. They reported it was related to another issue and did not know anything about the allegation. During an interview with the Administrator of Entity 2 on 10-03-2023 at 12:05 PM, they reported receiving a complaint from Patient #2 on 09-13-2023 about an AccentCare Hospice aide that had given care the previous day. They reported they informed the Hospice Executive Director of the allegation on 09-14-2023. Entity 2s Administrator reported conducting their own investigation. When queried if AccentCares Executive Director followed up with the results of their investigation, the Administrator reported they had not. During an interview with Patient #2s family member, identified as the contact person, on 10-03-23 at 9:59 AM they reported having a discussion with the Medical Director about recent hallucinations attributed to an infection. Patient #2s family member reported they had no concerns related to the caregivers from AccentCare Hospice and the communication with the nurses and the Medical Director. During an interview with Patient #2 on 10-03-2023 at 12:18 PM, when queried about the care they received from the hospice, they reported being happy with the care. When queried about any particular concerns about how the aides cared for them, they reported no concerns or recalled any previous concerns. 6. On 10-03-2023 at 1:33PM a second AccentCare adverse event and complaint log was received from the Executive Director and contained the allegation reported by Entity 2 on 09-13-2023. During an interview with the Executive Director and the Director of Clinical Services on 10-03-2023 at 2:20 PM when queried why Patient #2s allegation was not listed on the first adverse event and complaint log, the Executive Director reported they did not enter it in their system in a timely manner and confirmed being informed by the Administrator at Entity 2 on 09-13-2023. The Executive Director explained that they removed Hospice Aide 3 from all patients at Entity 2, after the report from Entity 2, and had the Hospice Aide come in, reviewed the incident, and had the aide write a statement. They emailed Entity 2s Administrator on 09-19-2023 the results of their investigation. Queried if there was any other follow-up and they reported they had requested Patient #2s Case Manager, Registered Nurse (RN)1 follow-up and send a statement but that was not completed. Queried as to how this Hospice typically investigated complaints or incidents. They reported they contact the patient caregiver, reassign the aide, do a back to bedside (the reeducation of an employee with the director of clinical services while working with the patient), and call all other patients receiving care from our employee. Asked if they did all of this with Patient #2 following the allegation. The Executive Director replied ";no". Queried if Employee 3 continued to see other patients following the allegation and they reported the Aide was reassigned after notification of the allegation and continues to care for 12 other patients. 7. A review of the Interdisciplinary Care Group (IDG) meeting following the accusation dated 09-27-2023 contained notes including but was not limited to, "; SOCIAL WORKER ...";NO PSYCHOSOCIAL NEEDS HAVE BEEN IDENTIFIED IN THE PAST 2 WEEK, "; ";HOSPICE PHYSICIAN...NOTIFIED OF ALL MISSED VISITS...REVIEWED MEDICATION PROFILE." ";REGISTERED NURSE...PLAN FOR LAST 2 WEEKS...OXYGENATION, PAIN, FALL SAFETY RISK...PLAN FOR NEXT 2 WEEKS...SN[SIC]VISITS 2X WEEKLY TO MONITOR AND ASSESS CONFUSION, PAIN, AND FALL SAFETY RISK...." The IDG meeting failed to evidence steps taken to further investigate the alleged incident and steps taken to prevent further violation. 8. On 10-03-2023 at 4:15 PM the Executive Director provided an updated document titled "; HHA Complaint [name of Patient #2] HHA COMPLAINT Closed (Last Modified on 10/2/2023 3:10 PM Created by [name of Executive Director] on 10/2/2023 3:07 PM." In the description of the event the documented indicated the Hospice received a call from the Administrator at Entity 2 that named an individual similar to the accused hospice aide that was allegedly involved in the incident with Patient # 2. The section titled "Resolution" indicated completed 10/2/2023 at 3:09 PM Pending update from [name of Entity 2]. An event outcome section reported ";Written statement sent to [name of Entity 2 Administrator] on 9.19.23 [sic]. HHA (Employee 3 name) removed from all cases at [name of Entity 2] Pending building follow-up on their internal investigation..." 9. During an interview with the Medical Director on 10-04-2023 at 11:28 AM, when queried regarding their knowledge of the allegation, they reported that they were made aware in their ";leadership" meeting where we discussed the reason the hospice aide was changed for Patient #2. The Medical Director reported they had talked with Patient # 2s family regarding the patients care and direction of treatment including increased confusion, falls, and pain noted in the interdisciplinary group plan of care update on 09-27-2023.

Based on record review and interview, the facility failed to ensure the comprehensive assessment regarded the patient's history of seizures, history of falls, cognitive status, and/or fall risk assessment results were possible risk factors and/or complications when establishing the plan of care for 1 of 15 active patient records reviewed (Patients #9) and 1 of 1 live discharge records reviewed. (Patient #7) Findings include: --- 1. A review of the history and physical for Patient #7, dated 01/11/23, indicated diagnoses including, but not limited to Chronic Kidney Disease (CKD - a condition where the kidney's no longer function properly), Congestive Heart Failure (CHF - a condition where the heart no longer pumps effectively and fluid builds up in the body), Organic Brain Syndrome (an older term more commonly referred to as neurocognitive disorder which refers to the fact that an illness or condition is having an adverse effect on an individual's mental abilities and cognition), Paroxysmal Atrial Fibrillation (PAF - fluttering and/or racing of the heart that resolves on its own within 7 days of symptom onset. Symptoms can include a racing heartbeat, unexpected dizziness, and lightheadedness), Chronic Obstructive Pulmonary Disease (COPD - scarring of the lungs resulting in airway constriction and difficulty breathing), and Type 2 Diabetes Mellitus (DM 2) with Peripheral Neuropathy (damage to the nerves outside of the brain and spinal cord, particularly in the hands and feet, and causing symptoms such as pain, burning, and numbness). A review of the admission comprehensive assessment for Patient #7, dated 03/17/23, indicated Patient #7 was advanced in age, at 91 years old, and resided in the memory care unit of Entity 10, a skilled nursing facility (SNF). The patient had a primary diagnosis of Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior) and comorbidities of senile brain degeneration (dementia causing mental decline and a decrease in cognitive abilities such as thinking, memory, and judgement), COPD, and stage 2 CKD. Patient #7 experienced a functional decline and weight loss in the last month and a half, had poor judgement, mild pain less often than daily, had a Palliative Performance Scale (PPS - a tool used to measure functional ability and physical progression toward the end of life) score of 50%, took 5 or more medications, and was incontinent of bowel and bladder several times a day. Patient #7 ambulated with an assistive device, had a Missouri Alliance for Homecare 10 (MACH 10) fall assessment (an assessment tool used to measure the patient's risk for falls based on 10 standardized items such as age, pain, prior falls, and cognitive status) score of 9/10, had decreased strength in all extremities, required assistance with bathing, dressing, grooming, and toileting, was oriented x1, forgetful, had a previous fall within the last month, and experienced sundowning (a state of confusion occurring in the late afternoon or evening and lasting through the night which often results in increased anxiety, aggression, pacing, and wandering). The patient was unable to understand the disease process or participate with meaningful conversation and required the daughter as the historian. The assessment indicated interventions including, but not limited to, "1. Instructed regarding pain relief measures and/or medications... 2. Instructed in how to monitor pain... " but failed to consider the patient lacked the ability to communicate meaningfully, comprehend and follow instructions, and retain new information. The assessment also failed to take into consideration the patient's high risk for falls with injury by establishing a patient-specific and individualized fall prevention plan to minimize falls. A review of a "Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report" dated 03/22/23 indicated a current problem of altered home safety, need for pain management, need for care coordination, need for medication management and instruction, and need for teaching of self-care deficits and pain management. The IDG note indicated "Falls: NA [not applicable]" and failed to evidence the patient's history of falls, fall risk assessment, declining functional status, and diminished cognitive statuses were considered related to the need for individualized fall precautions and prevention. A review of a skilled nurse visit note, dated 05/15/23, indicated the patient was seen due to an unwitnessed fall without injury. On 05/15/23, Patient #7 was found on the floor next to the bed, sitting between the legs of the walker. The visit note evidenced a fall risk assessment score of 6/10, however the clinician failed to correctly answer 3 of 10 questions affirmatively, based on the patient's history and current assessment, resulting in an actual fall risk score of 9/10. A review of a comprehensive assessment dated 05/22/23 evidenced the patient had increased edema of the lower extremities, tachycardia (rapid heartrate, usually >100 beats/minute), bradycardia (slow heartrate, usually < 60 beats/minute), and difficulty breathing. The patient had poor judgement, was incontinent, was oriented only to person, had decreased strength in the lower extremities, and had a MACH 10 fall risk score of 6/10, however, the clinician failed to answer 3 of 10 questions affirmatively based on the patient's history and current assessment, resulting in an actual fall risk score of 9/10. The interventions and goals were unchanged, and the comprehensive assessment failed to evidence the patient's history of falls, fall risk assessment, declining functional status, and diminished cognitive statuses were considered related to the need for individualized fall precautions and prevention. A review of a "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 05/24/23 evidenced the same problem list identified on the 03/22/23 IDG note and indicated unsteady ambulation, use of a walker, confusion, severe shortness of breath, and "Falls: NA." The IDG failed to evidence the patient's assessed risk factors and cognitive/functional decline were considered related to fall precautions and prevention. A communication note, dated 07/17/23 at 9:27 PM, indicated Entity 10 reported that Patient #7 had an unwitnessed fall and was found in their room with bruising over the ribs and knees. A review of a comprehensive assessment dated 0720/23, indicated Patient #7 was advanced in age, at 91 years old, and resided in the memory care unit of a SNF. The patient had poor judgement, was incontinent of bowel and bladder, had a decreased mid-arm circumference from 27 down to 24, and had a MACH 10 fall risk assessment score of 10/10. The patient was disoriented, forgetful, confused, had decreased strength in both lower extremities, had a cognitive impairment and pain affecting functioning, ambulated with an assistive device, and required assistance with all personal care. The assessment indicated the patient had no recent falls but failed to evidence the patient had a history of falls and 2 recent unwitnessed falls on 05/15/23 and 07/17/23. A review of the assessment interventions indicated an unknown caregiver was instructed regarding helping with hygiene, a pulse oximeter reading (a non-invasive measurement of oxygen level in the blood) was obtained, and the patient was monitored for side effects of medications. It failed to evidence individualized fall precautions and fall prevention interventions and goals were added based on consideration of the patient's fall risk factors and failed to consider complications in care planning and involvement of a patient with advanced dementia, diminished cognitive status, poor judgement, and communication deficits related to brain degeneration. A review of the "Hospice IDG Comprehensive Assessment and Plan of Care Update Report" dated 07/19/23 evidenced the problem list was unchanged, indicated "Falls: Yes," and evidenced skilled nurse visits for increased weakness and a fall prevention plan, however the IDG note failed to evidence a fall prevention plan was implemented based on the risks identified in the patient's comprehensive assessment. 2. A review of the hospital discharge summary for patient #9, dated 06/22/23, evidenced the patient had a primary diagnosis of acute and chronic respiratory failure and comorbidities including but not limited to mitochondrial disease (a terminal illness caused by an inability to store energy), anoxic brain injury, developmental delay, and epilepsy and failed to evidence a seizure plan, interventions, and goals were discussed in consideration of risk factors related to epilepsy. A review of the comprehensive admission assessment dated 06/23/23 indicated "the patient suffers from seizures." The comprehensive assessment failed to evidence a seizure plan or care coordination related to management of seizures, including but not limited to the type of seizures experienced, the average length of time for a seizure, and patient-specific orders for when to transport, how to position, and medications required to manage or mitigate during a seizure. 3. On 10/06/23 at 3:07 PM, Registered Nurse (RN) 2, the Director of Clinical Services (DOCS) indicated Patient #7 had fallen at least 3 times and indicated there were no individualized fall precautions put in place to decrease, stop, or protect the patient from falling and/or becoming injured. When asked about agency policy related to seizures, the DOCS indicated all patients had a seizure plan as part of their care plan. After a review of the record for Patient #9, the DOCS indicated a seizure plan was not developed and was not considered when developing the patient's plan of care.

Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately assessed the patient's functional status, including the ability to understand, communicate, and participate in their own care for 1 of 16 active patient records reviewed (Patient #3) and one live discharge patient record reviewed. (Patient #7) Findings include: --- 1. A review of agency policy HOS 2-030, titled "Plan of Care" and last revised 09/12/23, indicated but was not limited to "The plan of care shall be reviewed and revised with input from...the patient and the family/caregiver...based on ongoing comprehensive assessments ...The written care plan shall contain ... functional limitations ... Patient and family/caregiver... assessment of their ability to learn and understand." 2. A review of the "Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report" for Patient #3, dated 09/06/23, evidenced a primary diagnosis of Progressive Spinal Muscle Atrophy (a disorder affecting the nerve cells that control voluntary muscle movement resulting in muscle wasting) and comorbidities of Cerebellar Ataxia ((inability to coordinate muscle movement due to disease or injury to the cerebellum resulting in difficulty with walking, balance, speech and swallowing, eye movements, and coordination) Aphasia (a speech/language/communication disorder interfering with communication and understanding, often caused by damage to the left side of the brain), Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Alzheimer's Disease (a type of dementia), and Tremors (involuntary quivering of muscles). A review of the comprehensive assessment for Patient #3, dated 09/26/23, indicated the patient had poor judgement, anxiety, fatigue, arthritis, pain/stiffness, contractures, generalized muscle atrophy and abnormal tone, decreased strength in all extremities, diminished visual acuity, incontinence of bowel and bladder, decreased visual acuity, tremors, abnormal muscle tone, right sided hemiparesis (paralysis of one side of the body), and rigidity (stiffness) and had a fall risk assessment score of 9/10, which indicated a high risk for falls. The assessment indicated Registered Nurse (RN) 3 reinforced a fall prevention plan, including use of a call light and waiting for assistance. The assessment failed to evidence an individualized fall prevention plan that considered the patient's assessed functional status, degree of dementia, ability to communicate, and ability to follow instructions, retain information, and participate in their own care. 3. A review of the "Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report" for Patient #7, dated 07/19/23, evidenced a primary diagnosis of Senile Degeneration of the Brain (a degenerative brain condition resulting in dementia, confusion, poor judgement, memory loss, behavior changes which can be aggressive, and the inability to speak clearly and intelligibly.) The report also indicated the patient required maximum assist with bathing, continence care, grooming, and at times, feeding. The patient ambulated using a walker and had an unsteady gait. The patient spent most of the time in a recliner and listed to the left. A review of the comprehensive assessment for Patient #7, dated 07/20/23, evidenced the patient had poor judgement, was oriented only to person, had a history of falls (05/15/23 and 07/17/23), had a Missouri Alliance for Home Care (MAHC 10) fall risk assessment (a tool which measures the patient's fall risk based on 10 standardized items) of 10/10, and was unable to have meaningful conversation or retain new information due to dementia. The section for fall teaching/education indicated "Instructed patient to use good body mechanics when using the rollator" and indicated safety instructions were provided for "falls." The assessment failed to evidence an individualized fall prevention plan or interventions to minimize the risk of falling that considered the patient's functional status, degree of dementia, ability to follow instructions and retain information, ability to communicate, and the ability to participate in their own care. 4. On 10/10/23 at 2:50 PM, RN 2 indicated Patient #7 was unable to have meaningful conversation but remained pleasant. The patient frequently couldn't answer questions and would just smile when unable to retrieve an answer to a question or provide requested information.

Based on record review and interview, the agency failed to ensure the comprehensive assessment included the need for a therapy evaluation to assess for additional fall prevention and safety for 2 of 16 active patient records reviewed (Patient #3, 10) and 1 of 1 live discharge record reviewed (Patient #7) Findings include: --- 1. A review of the clinical record for Patient #3 evidenced the patient experienced falls on 09/05/23, 09/06/23, and 09/26/23. 2. A review of the "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated 07/19/23, 09/06/23, and 10/04/23 failed to evidence the patient was referred for a therapy evaluation to determine the possible benefit of palliative therapy or the addition of equipment or modalities to manage and mitigate falls. 3. A review of the clinical record for Patient #7 evidenced the patient experienced falls on 05/15/23, 07/17/23, and 07/25/23. A review of the "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated 05/24/23 and 07/18/23 failed to evidence the patient was referred for a therapy evaluation to determine the possible benefit of palliative therapy or the addition of equipment or modalities to manage and mitigate falls. 4. A review of the clinical record for Patient #10 evidenced the patient experienced a fall on 08/24/23. A review of the "Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report" dated 08/30/23 failed to evidence the patient was referred for a therapy evaluation to determine the possible benefit of palliative therapy or the addition of equipment or modalities to manage and mitigate falls. 5. On 10/05/23 at 12:29 PM, the Administrator and Director of Clinical Services (DOCS) indicated the patients were not referred for a therapy evaluation because they were not going to get better. When asked about palliative therapy and/or therapy to evaluate for possible beneficial interventions to prevent or minimize falls they had no further information.

Based on record review and interview, the agency failed to use Quality Assurance Performance Improvement (QAPI) data collected to monitor the safety of services and quality of care and failed to identify high risk/high volume trends and prioritize opportunities for improvement (L564); failed to ensure the frequency and type of data collected in the Quality Assessment Performance Improvement (QAPI) program was approved by the governing body (L565): failed to ensure the program monitored high-risk, high-volume, problem-prone areas (L566): failed to ensure its performance improvement activities (PIP) identified a trend with the prevalence and severity of patient falls (L567): and failed to analyze the cause(s) of excessive patient falls and implement preventative actions to minimize the number of falls with injury and the severity of the injuries (L569). The cumulative effects of these systemic problems resulted in the hospice agencys inability to ensure the provision of quality health care in a safe environment for the Condition of Participation §418.58 Quality Assessment and Performance Improvement. --- *

Based on record review and interview, the agency failed to use Quality Assurance Performance Improvement (QAPI) data collected to monitor the safety of services and quality of care and failed to identify high risk/high volume trends and prioritize opportunities for improvement for 1 of 1 agency QAPI program reviewed. Findings include: --- 1. A review of agency policy HOS 4-004 5007 Protocol "Quality Assessment Performance Improvement (QAPI)" indicated but was not limited to " ... The Hospice agency's performance improvement shall ... B. Focus on high-risk, high-volume, problem-prone areas and adverse events. C. Consider the incidence, prevalence, and severity of problems in those areas. D. Measures, analyzes, and tracks quality indicators to monitor program effectiveness, patient safety, and quality of care ... F. Utilize quality indicator data to identify opportunities and priorities for improvement ... 2. Patient-focused quality assurance and improvement activities include: ... I. Reprioritization of performance improvement activities ... 5. The number/scope of performance improvement projects ... is based on the needs of the hospice population ... D. Identify and set specific outcomes/priorities for improvement, adjusting priorities in response to unusual or urgent events ..." 2. A review of the agency's "Quality Improvement (QI) Report" for 01/01/23 - 10/04/23 indicated 144 witnessed and unwitnessed patient falls. 3. A review of the agency's Strategic Healthcare Programs (SHP) reports for 2023 indicated there were 52 falls in the Q1 adverse event category and 85 falls were reported in Q2. Statistics for Q3 were not available. 4. On 10/05/23 at 12:29 PM, the Administrator and Director of Clinical Services (DOCS) indicated they only reported falls with injury to the SHP Adverse Event category and it did not account for any patient falls without injury. The Administrator stated they tracked patient survey information and Consumer Assessment of Healthcare Provider and Systems (CAHPS- a collection of data used to measure agency performance) report information and provided a report that evidenced tracking such as level of care, infections, and falls with injury, but did not compile the SHP information and QI report information into meaningful information to identify trends and high-risk, high-volume, or problem prone areas, including falls and adverse events. The Administrator and DOCS indicated they were unaware of the total number of falls since 01/01/23. They had an active Performance Improvement Plan (PIP) concerning a new form, titled "Facility Integration Form," which was used to quickly identify wounds and care needs at the initial assessment and to improve communication between the hospice team, the other caregivers, families, patients, and physicians. A second active PIP was in place for the volunteer program, due to volunteer numbers being below 50%. When asked how the agency determined when a PIP was needed, the DOCS indicated they knew implementing a new form would require tracking and follow-up and they knew the volunteer program was low. A recent PIP monitored receipt of verbal orders on admission and was closed but no tracking was available for those PIPs as they identified the need in day-to-day business. The agency QAPI program failed to evidence that the falls being tracked were reviewed and monitored for trends and failed to evidence the agency prioritized high-risk, high-volume, problem-prone areas, including 144 falls since 01/01/23, and recognized areas for improvement.

Based on record review and interview, the agency failed to ensure the frequency and type of data collected in the Quality Assessment Performance Improvement (QAPI) program was approved by the governing body for 1 of 1 agency QAPI program. Findings include: --- 1. A review of agency policy HOS 4-004, titled "Quality Assessment Performance Improvement," last revised 0401/22, indicated but was no limited to "The Governing Body ensures its quality assurance performance improvement program is defined, followed, and evaluated annually by delegating leadership and management of the program to Executive Director/Administrator and appointing a multidisciplinary hospice Professional Advisory Committee (PAC)." The policy failed to evidence the type and frequency of data collected must be approved by the Governing Body. 2. A review of a document titled "QAPI Quarterly Report and Professional Advisory Committee Meeting," dated 08/30/23, evidenced a 13-page document with QAPI minutes from said date. The document included, but was not limited to, discussion of the scope of services, admissions/discharges, and the care planning process and indicated the recommended and action plans for Q2 included review of the following issues: utilizing all 4 levels of care, volunteer requirement was below 5%, use of the "Facility Integration Form," flu vaccination, gross margin, and Consumer Assessment of Healthcare Providers (CAHPS) survey results. The document failed to evidence the Governing Body had approved the active performance improvement plans, the current tracking, and the QAPI program. 3. A review of the Governing Body minutes for 03/28/23 and 07/18/23 evidenced the minutes encompassed discussion of AccentCare as a corporation and failed to evidence the minutes were specific to AccentCare in Indianapolis. The documents also failed to evidence the Governing Body approved the active performance improvement plans, the current tracking and frequency, and the QAPI program. 4. On 10/05/23 at 12:29 PM, the Administrator was asked for Governing Body minutes or notes that evidence the Governing Body approved the current Quality Indicators of shortness of breath and pain control within 48 hours of admission. The Administrator indicated those Quality Indicators were chosen because they are required. The Administrator failed to indicate the Governing Body approved the current performance improvement plans for a new form and increasing the number of volunteers.

Based on record review and interview, the agency failed to ensure agency's performance improvement program(s) focused on high-risk, high-volume, or problem-prone areas for 1 of 1 agency QAPI program. Findings include: --- 1. A review of agency policy HOS 4-004, "Quality Assessment/Performance Improvement," last revised 04/01/22, indicated the agency program should "B. Focus on high-risk, high-volume, problem-prone areas, and adverse patient events. 2. A review of the agency's QAPI program evidenced an active performance improvement program (PIP) was in place for the implementation of a new form, titled the "Agency Integration Form," and an active PIP was in place for increasing volunteers in the volunteer program. 3. A review of a Quality Improvement (QI) report for 01/01/23 - 10/04/23, evidenced 144 total falls were reported during that time. 4. A review of a QAPI report from a Strategic Healthcare Programs (SHP) report (a software report that tracks and aggregates data for the monitoring and tracking quality indicators) evidenced there were 52 reported falls with injury in Q1 and 85 reported falls with injury in Q2. A review of the "Quality Improvement (QI)" report for 01/01/23 - 10/04/23 evidenced there were 144 total falls for that time period. 5. On 10/05/23 at 12:21 PM, the Administrator indicated there was an active PIPs in place to resolve the lack of volunteers (<5%) and an active PIP to initiate a new agency form. A PIP was completed and closed concerning admission/assessment orders. The agency failed to evidence PIPs related to high-risk, high-volume, problem-prone areas including but not limited to the agency's current fall rates for Q1 and Q2.

Based on record review and interview, the agency failed to ensure its performance improvement activities (PIP) identified a trend with the prevalence and severity of patient falls for 1 of 1 agency's Quality Assessment Performance Improvement (QAPI) program reviewed. Findings include: --- 1. A review of agency policy HOS 4-004, "Quality Assessment/Performance Improvement," last revised 04/01/22, indicated the agency program should "B. Focus on high-risk, high-volume, problem-prone areas, and adverse patient events. 2. A review of the agency's QAPI program evidenced an active performance improvement program (PIP) was in place for the implementation of a new form, titled the "Agency Integration Form," and an active PIP was in place for increasing volunteers in the volunteer program and failed to evidence a PIP was in place for patient falls. 3. A review of a Quality Improvement (QI) report for 01/01/23 - 10/04/23, evidenced 144 total falls were reported during that time. 4. A review of a QAPI report from a Strategic Healthcare Programs (SHP) report (a software report that tracks and aggregates data for the monitoring and tracking quality indicators) evidenced there were 52 reported falls with injury in Q1 and 85 reported falls with injury in Q2. 5. On 10/05/23 at 12:21 PM, the Administrator indicated there was an active PIPs in place to resolve the lack of volunteers (<5%) and an active PIP to initiate a new agency form. A PIP was completed and closed concerning admission/assessment orders. The agency failed to evidence a PIPs related to the high-risk, high-volume, problem-prone area falls documented in Q1 and Q2.

Based on record review and interview, the agency's Quality Assessment Performance Improvement program (QAPI) failed to analyze the cause(s) of excessive patient falls and implement preventative actions to minimize the number of falls with injury and the severity of the injuries for 1 of 1 agency QAPI program reviewed. Findings include: --- 1. A review of agency policy HOS 4-004, "Quality Assessment/Performance Improvement," last revised 04/01/22, indicated the agency program should "B. Focus on high-risk, high-volume, problem-prone areas, and adverse patient events ... Performance improvement results are tracked, trended, analyzed, and used ... to address problem issues, improve the quality of care and patient safety ..." 2. A review of the agency's QAPI program evidenced an active performance improvement program (PIP) was in place for the implementation of a new form and an active PIP was in place for increasing volunteers in the volunteer program. The QAPI program failed to evidence a PIP was in place to minimize and mitigate falls. 3. A review of a Quality Improvement (QI) report for 01/01/23 - 10/04/23, evidenced 144 total falls were reported during that time. 4. A review of a QAPI report from a Strategic Healthcare Programs (SHP) report (a software report that tracks and aggregates data for the monitoring and tracking quality indicators) evidenced there were 52 reported falls with injury in Q1 and 85 reported falls with injury in Q2. A review of the "Quality Improvement (QI)" report for 01/01/23 - 10/04/23 evidenced there were 144 total falls for that time period. 5. On 10/05/23 at 12:21 PM, the Administrator indicated there was an active PIPs in place to resolve the lack of volunteers (<5%) and an active PIP to initiate a new agency form. A PIP was completed and closed concerning admission/assessment orders. There were no further active PIPs. The agency failed to evidence PIPs related to high-risk, high-volume, problem-prone areas including but not limited to the agency's current fall rates for Q1 and Q2.

Based on record review and interview agency failed to ensure a discharge summary was provided to the hospital upon the patient's transfer to the emergency department for 1 of 1 patient's reviewed for hospital transfer. (Patient #7) Findings include: --- 1. A review of the clinical record for Patient #7 evidenced the patient revoked hospice services to seek aggressive treatment for a fall-related injury and was transferred to the hospital emergency department on 07/25/23. The record failed to evidence a discharge summary was provided to the accepting hospital. 2. On 10/03/23 at 2:38 PM, the Director of Clinical Services indicated a discharge summary was provided to the accepting entity and primary physician for all patients who revoke services and transfer to the hospital. The Director of Clinical Services indicated no discharge summary was available in the clinical record for Patient #7 and the agency failed to send a discharge summary to the accepting hospital when the patient revoked and was transferred on 07/25/23

Based on record review and interview, the agency failed to ensure a discharge summary was forwarded to the patient's attending physician upon discharge due to revocation for 1 of 1 live patient discharged for revocation. (Patient #7) Findings include: --- A review of a comprehensive assessment for Patient #7, dated 07/25/23, evidenced the patient "fell in the night, "just after midnight, and complained of severe pain in the left hip." After discussion with the patient's daughter, the patient was transferred to the emergency department to seek aggressive treatment for a fractured left hip. Further review of the clinical record failed to evidence a discharge summary was created and forwarded to the patient's physician. On 10/04/23 at 4:18 PM, the Director of Clinical Services indicated there was no discharge summary in the clinical record for Patient #7.

Based on record review and interview, the agency failed to ensure a designated Interdisciplinary Group member provided coordination of care with the skilled nursing facility for 1 of 16 active patient records reviewed (Patient #9) and 1 of 1 live discharged records reviewed. (Patient #7) Findings include: --- 1. A review of agency policy HOS 2-034, titled "Interdisciplinary Group Coordination of Care," last revised 0215/23, indicated, but was not limited to "The interdisciplinary group ... is responsible to ... utilize a case management system to coordinate care ... facilitate communication about changes ... and coordinate communication between IDG [Interdisciplinary Group] members and the patient's attending community/physician ... " The policy failed to evidence a designated IDG member was responsible to ensure care coordination and failed to evidence responsibility to facilitate care coordination with the patient's skilled nursing facility for 1 of 1 active patient record reviewed (Patient #9) and 1 of 1 live discharge record reviewed. (Patient #7) 2. A review of the Hospice IDG [Interdisciplinary Group} Assessment and Plan of Care Update Report for Patient #9," dated 06/28/23, 08/23/23, 09/20/23, and 09/20/23," failed to evidence care coordination with Entity 14, a home health agency that provided skilled nursing care to the patient several days per week. 3. On 10/06/23 at 3:15 PM, Person 15, the primary caregiver for Patient #9, indicated the patient received several hours of skilled nursing care several days per week. 4. On 10/10/23 at 2:50 PM, Registered Nurse (RN) 2, the patient's case manager, indicated being unaware the patient received skilled home health services and stated they had never called Entity 14 to discuss the patient's care.

Observed in Record Review. In 3 of 14 patient records reviewed, the nurse surveyor noted that for HOSHV#4/RR#4, HOSRR#12, and HOSRR#13 the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the Director of Clinical Operations.

Observed in Record Review. In 1 of 14 patient records reviewed, it was noted by the nurse surveyor that the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. For example, for HOSHV#1/RR#1 the IDG notes did not reflect why the patient’s frequency was increased to daily visits or what changes had occurred in her condition. Finding was validated by the Director of Clinical Operations.

Observed in Patient Home. In 2 of 4 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand/Hygiene 4003 Protocol”. For example, during HOSHV#1/RR#1 the skilled nurse completed an assessment on the patient that included her back, hips, and bottom with gloves on. She then changed the patient’s soiled brief and cleaned her bottom all with the same pair of gloves on and reached into a jar of skin barrier to put on the patient’s bottom with the same soiled pair of gloves. She then changed gloves but did not hand sanitize between glove changes. For HOSHV#4/RR#4 the hospice aide wore the same pair of gloves during set up of patient bath, through assisting the patient to undress, through getting the patient into the shower and out. Findings were verified by the Director of Clinical Operations who was present during the visit.