Every finding on record at Transitions Indiana, LLC

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review, document review, and interview. In 5 of 17 (29%) clinical record review of patient that were seen by the License Practical Nurse (LPN) revealed the registered nurse did not provide supervision of nursing services. The agency policy titled Responsibilities/Supervision of Clinical Services Policy No. 1-031 (Corridor 2003) stated in part "A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services" CLINICAL RECORD 3: The patient’s election of benefits form was dated 07/02/2024. The clinical record lacked evidence of an LPN supervisory visit during the benefit period 04/28/2025 to 06/26/2025. The LPN supervisory visits were dated 05/05/2025 and 05/14/202. There was no documented evidence of an LPN supervisory visit for the month of June in accordance with agency policy of monthly supervisory visits for the LPN. CLINICAL RECORD 8: The patient’s election of benefits form was dated 03/06/2025. The clinical record lacked documented evidence of LPN supervisory visits during the benefit period 06/04/2025 to 09/01/2025. The LPN conducted a visit on the following dates 06/05/2025, 06/12/2025, 06/16/2025, 06/27/2025, 06/30/2025, 07/14/2025, 07/24/2025, and 08/12/2025. The LPN supervisory visits were not conducted in accordance with agency policy. CLINICAL RECORD 9: The patient’s election of benefits form was dated 05/20/2025. The clinical record lacked documented evidence of an LPN supervisory visit during the benefit period 05/20/2025 to 08/17/2025. The LPN conducted a visit on the following dates 06/18/2025, 07/04/2025, 07/16/2025, 07/25/2025, 08/01/2025, and 08/08/2025. LPN supervisory visits were documented on 07/29/2025 and 08/11/2025. There was no documented evidence of an LPN supervisory visit for the month of June. The LPN supervisory visits were not conducted in accordance with agency policy. CLINICAL RECORD 10: The patient’s election of benefits form was dated 01/09/2025.The clinical record lacked documented evidence of an LPN supervisory visit during the benefit period 04/09/2025 to 07/07/2025. The LPN conducted a visit on the following dates 04/10/2025, 04/17/2025, 04/22/2025, 04/24/2025, 05/01/2025, 05/03/2025, 05/08/2025, 05/16/2025, 05/23/2025, 05/27/2025, 06/02/2025, 06/17/2025, 06/27/2025, and 07/01/2025. An LPN supervisory visit was documented on 05/05/2025. There was no documented evidence of an LPN supervisory visit for the months of April or June. The LPN supervisory visits were not conducted in accordance with agency policy. CLINICAL RECORD 11: The patient’s election of benefits form was dated 08/16/2024. The clinical record lacked documented evidence of an LPN supervisory visit during the benefit period 06/04/2025 to 09/01/2025. The LPN conducted a visit on the following dates 06/17/2025, 06/27/2025, 07/01/2025, and 07/10/2025. There was no documented evidence of an LPN supervisory visit for the months of June, July, and August. The LPN supervisory visits were not conducted in accordance with agency policy. During an interview with the administrator (Personnel Record 5) on 09/10/2025 she stated that she also reviewed the record and could not find the LPN supervisory visits. She also stated they did identify that they had a problem with the supervisory visits being done and education was given to the clinical staff on 09/04/2025.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review, document review, and interview. In 8 of 18 (44%) clinical records reviewed of patients who elected hospice aide services, it was revealed that the agency did not ensure the hospice aides were supervised by a registered nurse with an on-site visit no less frequently than every 14 days. The agency policy titled, Responsibilities/Supervision of Clinical Services Policy No. 1-031 (XXX 2003) stated in part "Hospice aide supervisory visits will be conducted on site at least every two (2) weeks by a hospice registered nurse." CLINICAL RECORD 3: The patient’s election of benefits form was dated 07/02/2024. The clinical record lacked evidence of an aide supervisory visit in accordance with agency policy. A review of the benefit dates 04/28/2025-06/26/2025, 06/27/2025-08/25/2025, and 08/26/2025-10/24/2025. Hospice aide supervisory visits were dated 05/05/2025, 05/14/2025, and next aide supervisory visit was dated 08/01/2025 (78 days). CLINICAL RECORD 4: The patient’s election of benefits form was dated 12/06/2024. The clinical record lacked documented evidence of an aide supervisory visit at least every two weeks in accordance with agency policy. Aide supervisory visits were dated 07/01/2025 and 07/29/2025 (28 days). CLINICAL RECORD 6: The patient’s election of benefits form was dated 07/09/2025. The clinical record lacked documented evidence of an aide supervisory visit at least every two weeks in accordance with agency policy. Aide supervisory visits were dated 07/14/2025 and 07/30/2025 (16 days). CLINICAL RECORD 7: The clinical record lacked evidence of an aide supervisory visit every two weeks in accordance with agency policy. During the benefit period 03/09/2025-06/06/2025, the aide supervisory visit was dated 03/26/202 (19 days). CLINICAL RECORD 8: The clinical record lacked evidence of an aide supervisory visit every two weeks in accordance with agency policy. The review of the benefit period 03/06/2025 to 06/03/2025 the first aide visit was dated 03/11/2025 and the first aide supervisory visit by the hospice registered nurse was dated 04/01/2025 (21 days). CLINICAL RECORD 9: The clinical record lacked evidence of an aide supervisory visit every two weeks in accordance with agency policy. Aide supervisory visits were dated, 06/04/2025, 06/25/2025 (21 days), and 07/09/2025, 07/29/2025 (20 days). CLINICAL RECORD 10: The clinical record lacked evidence of an aide supervisory visit every two weeks in accordance with agency policy. During the benefit period 04/09/2025 to 07/07/2025 aide supervisory visits were dated 04/15/2025 and 05/05/2025 (20 days). There was no other documented aide supervision visit documented during the remaining days of the benefit period (63 days). CLINICAL RECORD 11: A review of the clinical record revealed for the benefit period 06/12/2025 to 08/10/2025 the aide was ordered two (2) times a week and patient was seen as ordered. There was no documented evidence of aide supervisory visits completed during the entire benefit period. During an interview with the administrator (Personnel Record 5) on 09/10/2025, she stated that she also reviewed the records and could not find the hospice aide supervisory visits. She also stated they did identify that they had a problem with the supervisory visits being done and education was given to the clinical staff on 09/04/2025.

Based on record review and interview Transitions Indiana LLC failed to uphold and maintain patient rights, when the Entity 17, a hospice located in Crown Point failed to document a complaint voiced by a caregiver, concerning care furnished to a hospice patient (see L505); failed to ensure a separate allegation of abuse was reported immediately by Entity 17 to the hospice Administrator of Transitions Indiana LLC (see L508); failed to evidence an investigation had been conducted when an allegation of abuse had been made, and failed to document same timely (see L509), failed to document their investigation of an allegation of abuse and subsequently failed to document the allegation was unfounded (see L510); and failed to maintain the confidentiality of patients records by allowing services to be provided by non-employees of hospice agencies: Entity 17 and Entity 18, located in Fort Wayne, who had access to Transitions Indiana LLC electronic medical record (EMR) (see L516). These practices impacted 1 of 5 (Patient: #1) discharged patients serviced by Entity 17, and had the potential to impact 39 active patients of Transitions Indiana, LLC, (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) being serviced by Entity 17 and Entity 18. The cumulative effect of these systemic problems resulted in the agencys inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. --- *

Based on record review and interview Transitions Indiana LLC failed to document a complaint voiced by a caregiver, concerning care furnished to a hospice patient by non-employees of Entity 17, a hospice agency located in Crown Point, in 1 of 1 undocumented complaint. (Patient #1) Findings include: --- 1. A review of an agency document dated December 2018, titled 'COMPLAINT/GRIEVANCE PROCESS - Policy No. 9-003' stated, "... Any difference of opinion, dispute, or controversy between a patient or family/caregiver or patient representative and Transitions Indiana LLC concerning any aspect of services or the application of policies or procedures will be considered a grievance ... The Executive Director/Administrator will be informed of situations that may become detrimental to good patient relations ... The organization member receiving the complaint will discuss verbally and in writing, the grievance with the supervisor within 5 days ... 4. Complaints and any action taken will be documented on a complaint form ... Corrective action will be specific and related to the complaint ... Resolution information will be communicated to the patient or his/her representative ..." 2. A review of an agency document dated December 2018, titled 'BILL OF RIGHTS - Policy No. 9-005' stated, "... the patient will be empowered with certain rights and responsibilities ... 1. The Bill of Rights statement defines the right of the patient to : ... B. Voice grievances regarding treatment or care that is (or fails to be) furnished ... Q. Receive an investigation by the organization of complaints made by the patient or the patient's family or guardian regarding treatment or care that is (or fails to be) furnished ... and that the organization will document the existence of the complaint and the resolution of the complaint ..." 3. A review of an agency document revised December 2018, titled 'INTERDISCIPLINARY GROUP MEETING Policy No. 1-036' stated, "... 12. Grievances ... will be discussed ..." 4. A review of an agency document revised December of 2018, titled, 'ADMINISTRATOR Policy No. 8-008' stated, "... 3. Responsibilities of the position will include but not be limited to: ... E. ... complaint management and resolution ..." 5. A review of the agency Complaint/Incident logs evidenced a document dated 11/21/2024, titled 'Complaint Follow Up Form' stated, "Complaint received by: [Person 32, Administrator for Entity 17] ... Manager Name: [Person 32] updating [Administrator] ... Date: 11/22/2024 ... Complaint Reported By: Date: 11/21/2024 ... Name: [Person 4] newly appointed POA [Power of Attorney] ... Type of Complaint: Expectations ... Date of Event: 11/22/2024 ... Location: Home ... Staff/Dept Involved : nursing ... Complaint Resolution: Description of Complaint: WRITER / LSCW [Licensed Clinical Social Worker] RETURNED CALL TO [Person4] REGARDING REQUEST TO TRANSFER TO [Entity 79, a hospice agency]. [Person 4] SPOKE IN A VERY RAPID ANGRY TONE AND STATED [Person 4] WAS UPSET REGARDING THE EVENTS OF WEEK ..." and the document failed to evidence what the 'events of the week' entailed. The document failed to evidence a complaint of excoriation to Patient #1's buttocks had been made by Person 4. 6. The inactive clinical record for Patient #1 with an election date of 05/17/2023 with benefit periods from 06/05/2024 to 07/08/2024 and 11/14/2024 to 11/22/2024 were reviewed and contained a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD - damage to the lungs which leads to inflammation and obstruction of the airways making it harder to breathe). Further review of the record indicated the patient was confused/forgetful at times, had poor intake, poor skin turgor, persisted in staying/sleeping in recliner for extended periods (causing unrelieved pressure), and had become increasingly incontinent (resulting in excess contact with moisture, exacerbating skin breakdown) and intermittent excoriation (the mechanical removal or abrasion of the skin's surface layer, resulting in superficial wounds or scratches where skin can appear red, raw, or irritated, and may be accompanied by pain, itching, or inflammation). A. A review of the historical 'Wound Record Report' from 05/17/2023 to 11/22/2024 failed to evidence documentation of impaired skin integrity to the buttocks or coccyx region. B. A review of serial nursing 'Visit Note Reports' evidenced: 06/12/2024, 'integumentary assessed:', 'no problems identified', 'skin remains intact' 06/18/2024, 'pale', 'poor turgor', 'shearing to [patient's] buttocks' 06/23/2024, 'wound(s)', 'number of pressure ulcers all stages:', 'one', and failed to evidence location, descriptors, and whether wound care had been ordered or provided and failed to evidence the buttocks/coccyx region had been re-assessed. 06/24/2024, 'no problems identified', and failed to evidence the buttocks/coccyx region had been re-assessed. 06/26/2024, 'wounds', onset of skin tear to left lower leg, wound care provided per orders. And failed to evidence the buttocks/coccyx region had been re-assessed. 06/28/2024, failed to evidence the buttocks/coccyx region had been re-assessed. 07/01/2024, failed to evidence buttocks/coccyx region had been re-assessed. 11/14/2024, the narrative indicated, "... Patient refused to get up for a skin assessment. [Person 3, a family member and caregiver] reported [patient's] buttocks are red. [Person 3] reported they ran out of barrier cream. Writer gave patient barrier cream ..." 11/19/2024, the narrative indicated, 'Excoriation to buttocks present. Barrier cream applied'. 11/21/2024, the narrative indicated, "... [Person 4] also stated [patient's] excoriation to [patient's] buttocks is unacceptable. Writer educated [Person 4] that patient has become more incontinent and refused to get up to be changed at times. Patient also refused to sleep in a bed so [patient] is always in [patient's] recliner. [Person 4] would not let writer do an assessment on patient and asked for writer to leave ..." And failed to evidence the patient's skin integrity was being tracked in a manner which could be consistently monitored or addressed for progression/worsening: C. Review of the record evidenced the following Interdisciplinary group (IDG) meeting notes from 11/19/2024 to 11/26/2026 indicated: An IDG note dated 11/19/2024 indicated the patient had moved back into Person 4's home on 11/17/2024, indicated 'no wounds'. The last IDG note dated 11/26/2024 failed to evidence the excoriation noted on the 11/19/2024 nursing visit, failed to evidence concerns/complaints voiced by Person 4, and evidenced a discharge date of 11/22/2024, with the patient transferring to another hospice provider the same day. D. The clinical record evidenced Patient #1 had received nursing visits while temporarily living with Person 4 from 06/18/2024 through 6/28/2024 and from 11/14/2024 through 11/22/2024. The record failed to evidence documentation of Person 4's complaints to Entity 17 staff related to patient's excoriated buttocks. 7. On 12/09/2024 at 1:40 PM, in an interview, Person 4, family member and Power of Attorney (POA) for Patient #1, indicated was a nurse themselves, indicated had concerns with patient's care previously, and again recently, regarding excoriation to the buttocks described as 'two wide swaths' of tissue which were bleeding. Indicated as a result of this concern, had switched hospice providers on 11/22/2024. When queried as to the other concerns, Person 4 indicated this past summer the patient had stayed with them for approximately two weeks (could not provide specific dates), Person 4 voiced concerns to Person 31, an RN with Entity 17 during a nursing visit. Indicated the patient had a quarter-sized wound to the buttocks. Indicated had clearly expressed concern at that visit, and felt wasn't being heard. Person 4 then indicated, at one of the last visits, had asked the nurse (whose name they could not recall) about the two swaths of excoriated tissue on the buttocks and expressed concern, and a nurse indicated 'it was like that at [Person 3's] house', 'that doesn't fall on our company', and further indicated Person 3, a family member, had reported to the nurse the patient often refused to be changed when their brief needed changing. Person 4 was frustrated staff had not indicated they had attempted to encourage, explain, or work with patient to gain compliance. Person 4 indicated after they had already decided to switch companies, had a conversation with the agency's 'director', Person 32 with Entity 17 regarding concern of excoriation, but by then they were 'beyond it all', and 'just wanted out'. 8. On 12-11-2024 at 9:34 AM in an interview, Person 23, Administrator for Entity 17 was queried as to what was meant by 'events of the week' documented in a Complaint Follow Up form. Person 23 indicated Patient #1 had recently moved in with a different family member, Person 4, the same week, and had been living with another family member previously. Person 23 indicated at a subsequent nursing visit Person 37, a nurse with Entity 17 was 'kicked out' of the home by Person 4, who then indicated wanted to switch hospice companies. Indicated Person 4 expressed their frustration, did not like the interaction, stated felt like was not being heard. Person 23 indicated Person 4 also brought up Patient #1 excoriation of the buttocks to Person 37, a nurse with Entity 17, and indicated to the nurse the patient did not have 'this' excoriation when the patient stayed with Person 4 in the summer. 9. On 12-11-2024 at 9:55 AM in an interview, Person 31, a director of nursing for Entity 17 indicated had made nursing visits to Patient #1, recalled having visited patient last summer while they stayed with Person 4 temporarily. Indicated Person 4 required a lot of education in those visits, 'lots of talks and adjusting things'. Indicated the first time they had seen Patient #1 at Person 3's home, the patient was very anxious and confused. When queried as to whether they recalled the patient having skin breakdown at the time, indicated the patient did not have any skin breakdown. When queried as to whether the patient had ever had a quarter-sized wound to the coccyx in June or July of this past summer, indicated the patient did have blanchable redness, and was provided education about not spending so much time in their recliner, but the patient did not want to comply. When asked if there had been any such skin issues more recently, indicated 'we check the patient's bottom every visit'. When queried as to if there had been excoriation, where might this be documented and how might this be tracked, Person 31 indicated would be documented in the notes. Indicated the patient did experience excoriation because they were not willing to get up as much to change (their brief), and indicated the majority of the time they saw the area in question and Person 3 had been taking really good care of it. Reiterated there had been no wound to the buttocks/coccyx region. Indicated patients were re-evaluated at every visit, skin integrity gets evaluated every visit. 10. On 12-11-2024 at 10:54 AM in a follow up call, Person 31, a director of nursing for Entity 17, indicated Person 4 had not blamed them or the agency directly for the excoriation to the patients buttocks, indicated 'never said that to me'. When queried if Person 31 had ever told Person 4 the excoriation was 'not on me' or 'not on the agency', indicated 'I would never say that'. 11. On 12-11-2024 at 11:06 AM, in an interview, Person 37 a nurse with Entity 17 indicated had seen patient once weekly for the past 9 weeks. Indicated when the patient moved into Person 4's home, 'it was crazy'. Indicated Person 4 'was accusing us of not properly changing the patient', 'accused us of not taking care of it'. Indicated Person 4 made the accusations, 'was very rude to me', 'didn't let me assess patient'. Person 37 indicated Person 4 was upset about the current excoriation to the buttocks and had indicated excoriation to the buttocks 'was not that bad' in the summer. Person 37 felt this was due in part to the patient refusing to be changed multiple times per day and indicated 'we were doing what we could, as much as the patient would let us'. Indicated the patient had a hospital bed in the home, but preferred to stay in their recliner and sleep in it. 12. On 12-12-2024 at 11:01 AM, in a follow-up interview, when queried about what the process should be, Person 23, Administrator for Entity 17 indicated the complaint process involved documenting on complaint form, then sending this to the Transitions Indiana LLC Administrator for review. Indicated the Administrator for Indianapolis had been made aware. This writer informed Person 23 the surveyors had all the agency's written complaints/incidents in hand on Monday and Person 4's complaint was not found among them. Informed Person 23 also the Transitions Indiana LLC Administrator had indicated was not aware of Person 4's complaint. Person 23 offered nothing further. When queried as to whether the DON had been pulled in on this complaint, Person 23 indicated Person 31, the DON for Entity 17, had been involved. When queried further as to whether the Indianapolis DON had been involved, indicated 'not that I'm aware of'. 13. On 12-11-2024 at 1:48 PM in an interview, Person 27 a nurse with Entity 17 indicated Person 4 had complained during the visit on 11/19/2024. Indicated the patient had excoriation to their bottom, indicated had a long conversation about using barrier cream, decreasing pressure, keeping the patient clean, patient would not leave her recliner for bed and then refused the hospital bed when they went to live with Person 4, indicated Patient #1 'didn't want it'. Indicated the excoriation was being managed more but it wasn't new. Indicated the decline in the patient's condition, poor diet and fluid intake, incontinence, and their staying in the recliner for sleeping contributed to this. 14. On 12/11/2024 at 2:16 PM, the DON from Transitions Indiana, LLC, indicated had not been aware of any complaints involving patients on the Indianapolis license, and indicated because they (Entity 17 and Entity 18) have directors of nursing of their own, they don't pull me in. Was not aware of complaints regarding Patient #1. Indicated expects to see excoriation documented and this should appear in the wound report, even if the wound is healed. Indicated wounds would not be able to be tracked if they were not documented in the wound record and instead only documented only in nursing narrative. Reiterated expectation was 'skin tears to bruises', should 'absolutely be documented from day of discovery' all the way through resolution, 'we talk about this in training'. 15. On 12/13/2024 at 3:17 PM, when queried as to whether she had been aware of any of the complaints that Person 4 had made in regards to the care for Patient #1 related to possible wounds or excoriation to the buttocks/coccyx, and the fact there had been no documented complaints regarding the same, the Administrator with Transition Indiana LLC, indicated was unaware and would have expected a discussion with IDG physician about concerns. Indicated Entity 17 employees were not great at communicating with her.

Based on record and interview the agency failed to ensure an allegation of abuse was reported immediately by non-employees of Entity 17, a hospice agency located in Crown Point, to the Administrator of Transitions Indiana LLC, for 1 of 1 undocumented patient incident. (Patient #1) Findings include: --- 1. A review of an agency document titled 'INCIDENT REPORTING Policy No. 3-004' stated, "... 1. Incident: An unusual event involving organization personnel, a patient, and family/caregiver. The event is considered unusual if the result was unintended, undesirable, or unexpected. Procedure: 1. When an incident occurs, the individual discovering the incident will: A. Notify Supervisor immediately with observations of identification of the incident ..." 2. Review of the Transitions Indiana LLC agency's Complaint/Incident logs for failed to evidence a possible allegation of abuse related to discovery of bruise to Patient #1's left arm had been investigated or documented. 3. A review of a Transitions Indiana LLC agency document, dated 12/11/2024, titled 'Client Coordination Note Report', 'LATE VISIT DOCUMENTATION', sent by email to this writer from Person 23, Administrator for Entity 17 on 12/13/2024 at 10:40 AM, and stated, "... Here is the documentation through the chain of events from the [Person 28, social worker for Entity 17] ... [Person 28] CONTACTED [Person 4] ON 11-19-24 TO FOLLOW-UP WITH A CONCERN VOICED BY NURSING INVOLVING THE PATIENT. [Person 4] DID NOT ANSWER [Person 28] LEFT A DETAILED MESSAGE AND RECIEVED A CALL BACK ON 11-20-24 ... [Person 28] CONTACTED [Person 4] AGAIN ON 11-20-24 TO INQUIRE ABOUT A BRUISE ON THE PATIENTS ARM. [Person 28] ATTEMPTED TO MAKE A VISIT, BOTH PATIENT AND [Person 4] DECLINED. [Person 28] WAS ABLE TO SPEAK WITH [Person 4], [Patient #1], AND THE [Person 86, a caregiver with Entity 85] AT LENGTH, DURING THIS TIME PATIENT REPORTED THAT [he/she] DID NOT REMEMBER HOW IT HAPPENED, BUT STATED THAT [Person 4] DID NOT HARM [him/her]. [Person 28] ASKED PATIENT DID [he/she] FEEL SAFE, PATIENT REPORTED YES. PATIENTS POA (Person 4) BECAME UPSET VERBALIZING [his/her] FRUSTRATION WITH THE INTERVIEW AND BEGAN STATING CONCERNS THAT [he/she] HAD WITH PATIENTS CARE UPON ADMISSION AND ISSUES WITHIN FAMILY DYNAMICS. [Person 28] REQUESTED A FOLLOW-UP CALL AND VISIT FROM NURSING TO ADDRESS CONCERNS FAMILY MAY HAVE AT THIS TIME ... IDT MADE AWARE OF CURRENT STATUS ... FAMILY APPEARED TO BE SATISFIED AFTER CALL WITH [Person 28]. NURSING SPOKE WITH [Person 28] ON 11-20-24 TO CONFIRM THAT THEY ATTEMPTED TO FOLLOW-UP WITH POA (Person 4) VIA PHONE BUT DID NOT RECIEVE AN ANSWER. NURSING LEFT A DETAILED MESSAGE AND SCHEDULE A FOLLOW-UP VISIT ... 11-21-24 [Person 28] RECEIVED UPDATED FROM [Person 37, a nurse with Entity 17] INFORMING [Person 28] THAT POA (Person 4) REFUSED VISIT AND TO LET STAFF ENTER HOME. [Person 28] CONTACTED POA AFTER ATTEMPTED VISIT AND DID NOT RECEIVE AN ANSWER ... 11-22-24- SW CONNECTD WITH POA TO DISCUSSED CARE PLAN MEETING. AT THIS TIME [Person 4] INDICATED THAT [he/she] WOULD LIKE TO POTENTIALLY SWITCH HOSPICE AGENCIES. ... [Person 4] INDICATED THAT THE ONLY AVAILABILITY [he/she] HAD WOULD BE ON THURSDAY 11-28-24, THANKSGIVING AT 9AM. SW SCHEDULE CARE PLAN AND INVITED [Person 87, a social worker with Entity 85]. IDT MADE AWARE ..." The incident failed to be documented timely. 4. A review of the inactive clinical record for Transitions Indiana LLC Patient #1 with a benefit of election date of 05/17/2023, was reviewed from 11/19/2024 to 11/22/2024 (date of discharge), contained a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD - caused by damage to the lungs that leads to inflammation and obstruction of the airways which makes it hard to breathe). Further review of the record indicated the patient was confused/forgetful at times, and had history of bruising (when blood leaks out of your veins and capillaries and pools under your skin because there isn't an opening for the blood to get out of your body). The medication list included but was not limited to: 'Aspirin (nonsteroidal anti-inflammatory drug (NSAID) that can treat mild to moderate pain, inflammation or arthritis, but can cause bleeding) 81 mg tablet delayed release, every other day, oral' and 'Dexamethasone (steroid medication which can reduce the inflammation in the lungs and make breathing easier, and can cause thinning of the skin and increased susceptibility to bruising) 4 mg tablets, 1 tablet, daily, oral'. A. Additional review of the clinical record contained serial 'Client Coordination Note Reports' (which contain the narrative of a nursing note) and evidenced the following: A review of a Client Coordination Note dated 06/05/2024, signed by Person 48, a Nurse Practitioner (NP) with Entity 17, indicated Patient #1 had bruising to the left arm. A review of a Client Coordination Note dated 08/30/2024, signed by Person 29, an RN with Entity 17, indicated Patient #1 had bruising to all extremities. A review of a Client Coordination Note dated 09/27/2024, signed by Person 27, an RN with Entity 17, indicated bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/01/2024,signed by Person 27, an RN with Entity 17, indicated bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/03/2024 signed by Person 37, an LPN with Entity 17 indicated Patient #1 had bruises scattered all over her body. A review of a Client Coordination Note dated 10/08/2024, signed by Person 27, an RN with Entity 17, indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/15/2024,signed by Person 27, an RN with Entity 17, indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 11/05/2024, signed by Person 27, an RN with Entity 17. indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 11/07/2024, signed by Person 37, an LPN with Entity 17 indicated Patient #1 had bruises scattered all over her body. A review of a Client Coordination Note dated 11/19/2024, signed by Person 27, an RN with Entity 17 indicated Patient #1 had bruising noted to left arm. B. Continued review of the clinical record for Patient #1 contained 'Wound Record Report' from 11/19/2024 to 11/22/2024, failed to evidence documentation of bruising to the left arm on 11/19/2024. C. Further review of the clinical record for Patient #1 contained IDG notes from 11/19/2024 - 11/26/2024, which failed to evidence documentation the IDG had been made aware of discovery of bruise to left arm, possible suspected abuse, and if any subsequent action had been taken. 5. On 12/11/2024 at 9:28 AM, queried Person 32, the Administrator of Entity 17, as to what was meant by 'events of the week' in a complaint they wrote up on 11/22/2024. Person 32 explained Patient #1 had just moved in with Person 4, after living with another family member Person 3 for the last few years. Indicated on 11/19/2024 at the home of Person 4, and another caregiver and Person 3 were present. Indicate, according Person 27, a nurse with Entity 17, noted there was a bruise to the right arm, 'not sure how that happened' and the patient indicated to the nurse 'look at what [Person 4] did to me'. 6. On 12-11-2024 at 11:06 AM, in an interview, Person 37 a nurse with Entity 17 indicated had seen patient once weekly for the past 9 weeks. Recalls a bruise was discovered by Person 27, a nurse with Entity 17, who had seen the patient for the first time and had not known the patient was prone to bruising and had new bruises often, had then reported this new bruise the social worker, Person 28 with Entity 17. 7. On 12/11/2024 at 11:40 AM, queried Person 28, MSW of Entity 17 regarding a reported incident on 11/20/2024. Person 28 indicated Person 27, RN of Entity 17, had reported to her Patient #1 had stated Person 4 had caused a bruise to Patient #1's arm. On 11/20/2024, Person 28 spoke with Person 4 and indicated they were upset Person 27 had reported incident. Person 28 indicated the conversation with Person 4 was not documented. At the time of the conversation with Person 4, Person 28 texted Person 31, DON of Entity 17, regarding Person 4 being upset. Person 28 indicated she had sent an email to the "interdisciplinary team" to arrange a care plan meeting to discuss the incident with the bruise ... Person 28 indicated staff left voicemails for Person 4 to invite him/her to a care plan meeting regarding Patient #1. Patient #1 was discharged/transferred before a care plan meeting could be scheduled. 8. On 12/11/2024 at 1:48 PM, Person 27 a nurse with Entity 17, indicated had a visit with Patient #1 on 11/19/2024, in Person 4's home while they were not present and Person 3 was there with another caregiver. Indicated this was their first visit with the patient, and had not met Person 4. Indicated during the visit the patient indicated they needed help and did not want to be there, asked Person 27 to look at her left arm, where a bruise was noted, and the patient indicated Person 4 had done this. Person 27 indicated had then asked patient if Person 4 had been hurting them, and the patient indicated 'don't bring [Person 4] into this'. 9. On 12/11/2024 at 11:54 AM, when queried regarding whether they had been aware of an allegation of abuse (related to bruising found) regarding Patient #1, the Administrator of Transitions Indiana LLC indicated the staff of Entity 17 were supposed to notify her of such events. Indicated normally with a complaint, I get notified and Person 32 the administrator for Entity 17, and I go through it together. Indicated was aware of the transfer, but not the other concerns. When queried as to what should have occurred, the Administrator indicated would have ensured the social worker provided emotional support to patient, ensured within 24 hours documentation would have been done, would have determined whether patient needed to be separated and indicated knew in this case there was an available family member who could have been utilized if need be until investigation was complete, would have had interviews with all parties, then based on the outcome, move on from there. Indicated further 'they should have pulled in the Director of Nursing (DON)' from Transitions Indiana LLC, and indicated the DON had only became aware of this as of yesterday. 10. On 12/11/2024 at 2:16 PM, in a follow up interview, the DON with Transitions Indiana LLC was queried as to whether they had knowledge of reported bruising to Patient #1's left arm, indicated was not aware, indicated would have expected to this to have been documented as well. Indicated had not been aware of any complaints involving patients on the Indianapolis license, and indicated because they (Entity 17 and Entity 18, a hospice located in Fort Wayne) have directors of nursing of their own, they don't pull me in. Expectation was 'skin tears to bruises', should 'absolutely be documented from day of discovery' all the way through resolution. 11. On 12-12-2024 at 11:01 AM, in a follow up interview, Person 23 administrator for Entity 17, indicated when there is an allegation of physical abuse, the social worker (Person 28, from Entity 17) would visit, verify if the patient was alert and oriented, explain reporting to the state, ensure the patient remained safe while we investigate, next steps would depend, was this a first bruise, is the story consistent. Indicated when they had queried Person 4, he/she was confident none of this had happened, APS (Adult Protective Services) would be called if specific for this, and would do a follow-up. Indicated had the patient's story stayed consistent, we would talk to MD, family, then make a report. When queried what their involvement was, indicated they and Person 28, a social worker form Entity 17, would bounce things off of each other, not the Administrator from Transitions Indiana LLC. Indicated the Administrator for Transitions Indiana LLC had been made aware. This writer informed Person 23, the administrator from Entity 17, the surveyors had all the agency's written complaints/incidents in hand on Monday and this complaint/incident of possible abuse was not found among those, also informed them the Administrator of Transitions Indiana LLC had indicated was not aware. Person 23 offered nothing further. When queried as to whether the DON had been pulled in on this complaint, Person 23 indicated Person 31, the DON for Entity 17, had been involved. When queried further as to whether the DON for Transitions Indiana LLC had been involved, indicated 'not that I'm aware of'. 12. On 12/13/2024 at 11:49 AM in a follow up interview, Person 4, a family member and POA for Patient #1 was queried about bruising discovered to the patient's left arm on 11/19/2024 during a nursing visit with Person 27, a nurse from Entity 17. Person 4 indicated the bruising was discovered the second day after Patient #1 had moved in, and Patient #1 had told the caregiver at home that day 'look at this' displaying the bruise and said simply '[Person 4]'. Person 4 was 'face timing' with the caregiver and indicated had asked Patient #1 'what do you mean'? Person 4 indicated Person 27, a nurse with Entity 17 came and saw patient that day as well. Person 4 indicated for some inexplicable reason, Patient #1 had claimed Person 4 had caused the bruise and stated what Patient #1 said can sometimes 'depend on who's in the room'. When queried if an investigation had been performed, indicated they had 'told Transition to get over there and take care of this', knew '[Patient #1] was okay', and indicated could not have their own nursing license in jeopardy over a false claim, and further, if the patient were saying these things, they could not have the patient in their home. When queried as to whether they, Person 4, had caused the bruising indicated 'I did not cause the bruising', 'I do not know how it happened'. Further indicated Patient #1's arms are always bruised to due to long term use of steroids.

Based on record review and interview Transitions Indiana LLC failed to evidence an investigation had been conducted for a suspected allegation of abuse timely, for 1 of 1 undocumented incident. (Patient #1) Findings include: --- 1. A review of a Transitions Indiana LLC agency document titled 'INCIDENT REPORTING Policy No. 3-004' stated, "... 1. Incident: An unusual event involving organization personnel, a patient, and family/caregiver. The event is considered unusual if the result was unintended, undesirable, or unexpected. Procedure: 1. When an incident occurs, the individual discovering the incident will: A. Notify Supervisor immediately with observations of identification of the incident. B. Follow-up with the patient/family caregiver, and/or patients' physician, if indicated by your supervisor or designee ... D. Complete an incident within 24 hours of the incident ... The form should include the following: a. Pertinent patient information b. Type of incident c. Description of the incident or injury in narrative form; if no injury, state "no apparent injury" d. Name of the family/caregiver, organization personnel, or another witness of the incident ... f. Name of person(s) who requested follow-up or needed notification; indicated who was notified, the time, and by whom. ... i. Nature of the injury; if other, please specify j. Names of any witnesses, the relationship to the patient or organization personnel, title, when applicable ... forward the incident and follow up forms to the Executive Director/Administrator ..." 2. A review of Transitions Indiana LLC agency's Complaint/Incident logs failed to evidence a possible allegation of abuse, related to discovery of a bruise to Patient #1's left arm, had been investigated or documented. 3. A review of an agency document, dated 12/11/2024, titled 'Client Coordination Note Report', 'LATE VISIT DOCUMENTATION', emailed to this writer from Person 23, Administrator for Entity 17, a hospice located in Crown Point, on 12/12/2024 at 11:29 AM, which stated, "Here is the documentation through the chain of events from the [Person 28, social worker for Entity 17] ": "... [Person 28] CONTACTED [Person 4] ON 11-19-24 TO FOLLOW-UP WITH A CONCERN VOICED BY NURSING INVOLVING THE PATIENT. [Person 4] DID NOT ANSWER [Person 28] LEFT A DETAILED MESSAGE AND RECIEVED A CALL BACK ON 11-20-24 ... [Person 28] CONTACTED [Person 4] AGAIN ON 11-20-24 TO INQUIRE ABOUT A BRUISE ON THE PATIENTS ARM. [Person 28] ATTEMPTED TO MAKE A VISIT, BOTH PATIENT AND [Person 4] DECLINED. [Person 28] WAS ABLE TO SPEAK WITH [Person 4], [Patient #1], AND THE [Person 86, a caregiver with Entity 85] AT LENGTH, DURING THIS TIME PATIENT REPORTED THAT [he/she] DID NOT REMEMBER HOW IT HAPPENED, BUT STATED THAT [Person 4] DID NOT HARM [him/her]. [Person 28] ASKED PATIENT DID [he/she] FEEL SAFE, PATIENT REPORTED YES. PATIENTS POA (Person 4) BECAME UPSET VERBALIZING [his/her] FRUSTRATION WITH THE INTERVIEW AND BEGAN STATING CONCERNS THAT [he/she] HAD WITH PATIENTS CARE UPON ADMISSION AND ISSUES WITHIN FAMILY DYNAMICS. [Person 28] REQUESTED A FOLLOW-UP CALL AND VISIT FROM NURSING TO ADDRESS CONCERNS FAMILY MAY HAVE AT THIS TIME PERTAINING TO OXYGEN AND MEDICATION. IDT MADE AWARE OF CURRENT STATUS ... FAMILY APPEARED TO BE SATISFIED AFTER CALL WITH [Person 28]. NURSING SPOKE WITH [Person 28] ON 11-20-24 TO CONFIRM THAT THEY ATTEMPTED TO FOLLOW-UP WITH POA (Person 4) VIA PHONE BUT DID NOT RECIEVE AN ANSWER. NURSING LEFT A DETAILED MESSAGE AND SCHEDULE A FOLLOW-UP VISIT ... 11-21-24 [Person 28] RECEIVED UPDATED FROM [Person 37, a nurse with Entity 17] INFORMING [Person 28] THAT POA (Person 4) REFUSED VISIT AND TO LET STAFF ENTER HOME. [Person 28] CONTACTED POA (Person 4) AFTER ATTEMPTED VISIT AND DID NOT RECEIVE AN ANSWER ... 11-22-24- SW CONNECTD WITH POA (Person 4) TO DISCUSSED CARE PLAN MEETING. AT THIS TIME [Person 4] INDICATED THAT [he/she] WOULD LIKE TO POTENTIALLY SWITCH HOSPICE AGENCIES. ... [Person 4] INDICATED THAT THE ONLY AVAILABILITY [he/she] HAD WOULD BE ON THURSDAY 11-28-24, THANKSGIVING AT 9AM. SW SCHEDULE CARE PLAN AND INVITED [Person 87, a social worker with Entity 85]. IDT MADE AWARE ..." The documentation failed to evidence the Transitions Indiana LLC had followed their policy investigation of the incident failed to be documented timely and completely, lacking resolution. 4. On 12/11/2024 at 11:40 AM, Person 28, a social worker with Entity 17 indicated the conversation with Person 4 was not documented. At the time of the conversation with Person 4, Person 28 texted Person 31, DON of Entity 17, regarding Person 4 being upset. Person 28 indicated she had sent an email to the "interdisciplinary team" to arrange a care plan meeting to discuss the incident with the bruise and Person 28 indicated staff left voicemails for Person 4 to invite him/her to a care plan meeting regarding Patient #1. Patient #1 was discharged/transferred before a care plan meeting could be scheduled. 5. On 12/11/2024 at 11:54 AM, when queried regarding whether they had been aware of an allegation of abuse (related to bruise found) regarding Patient #1, the Administrator of Transitions Indiana LLC indicated the staff of Entity 17 were supposed to notify her. When queried as to what should have occurred, the Administrator indicated would have ensured the social worker provided emotional support to patient, ensured within 24 hours documentation would have been done, would have determined whether patient needed to be separated an indicated in this case there was an available family member who could have been utilized if need be until investigation was complete, had interviews with all parties, then based on the outcome move on from there. Indicated further 'they should have pulled in the Director of Nursing (DON)' (from Transitions Indiana LLC), and indicated the DON only became aware of this as of yesterday. 6. On 12/11/2024 at 2:51 PM, the Administrator of Transitions Indiana LLC indicated was unaware of the report of bruising, there was no documentation on bruising, and indicated had she known at the time, would have contacted Ombudsmen, would have brought in APS, and would be investigating further now with this new information. 7. On 12/12/2024 at 11:01 AM, in a follow-up interview, when queried as to Patient #1's report of bruising, Person 23 administrator for Entity 17 indicated there were late entries being compiled, indicated there was a lot of documentation, needed to create a timeline, include IDG, and all specifics, indicated there were emails regarding related follow-ups, this writer requested those documents. Indicated when there is an allegation of physical abuse, the social worker would visit, verify if the patient was alert and oriented, explain reporting to the state, ensure the patient remained safe while we investigate, next steps would depend, was this a first bruise, is the story consistent. Indicated when they had queried Person 4, he/she was confident none of this had happened, APS (Adult Protective Services) would be called if specific for this, and would do a follow-up. Indicated had the patient's story stayed consistent, we would talk to MD, family, then make a report. When queried what their involvement was, indicated they and the social worker would bounce things off of each other, not the Administrator of Transitions Indiana LLC. Indicated the Administrator for Indianapolis had been made aware. This writer informed Person 23 the surveyors had all the agency's written complaints and incidents in hand on Monday, and this complaint/incident of possible abuse was not found among those, informed Person 23 also the Administrator of Transitions Indiana LLC had indicated was not aware. Person 23 offered nothing further.

Based on record review and interview Transitions Indiana LLC failed to document their investigation of an allegation of abuse and subsequently failed to document the allegation was unfounded, in 1 of 1 undocumented incident. (Patient #1) Findings include: --- 1. A review of a Transitions Indiana LLC agency policy revised December 2018, titled 'ASSESSMENT OF POSSIBLE ABUSE/NEGLECT Policy No. 9-013' stated, "... PURPOSE To provide guidelines for identification of suspected abuse victim for care and referral to community resources ... Any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. This includes: ... C. Reasonable cause to suspect abuse or neglect ... E. Any knowledge that a patient has sustained an injury that is not easily explained by the patient's history of injuries ..." 2. A review of the Transitions Indiana LLC complaint/incident logs failed to evidence an incident report had been documented related to an allegation of possible abuse related to Patient #1. 3. A review of the clinical record for Transitions Indiana LLC Patient #1 with a benefit of election date of 05/17/2023, was reviewed from 11/19/2024 to 11/22/2024 (date of discharge), contained a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD - caused by damage to the lungs that leads to inflammation and obstruction of the airways which makes it hard to breathe). Further review of the record indicated the patient was confused/forgetful at times, and had history of bruising (when blood leaks out of your veins and capillaries and pools under your skin because there isn't an opening for the blood to get out of your body). The medication list included but was not limited to: 'Aspirin (nonsteroidal anti-inflammatory drug (NSAID) that can treat mild to moderate pain, inflammation or arthritis, but can cause bleeding) 81 mg tablet delayed release, every other day, oral' and 'Dexamethasone (steroid medication which can reduce the inflammation in the lungs and make breathing easier, and can cause thinning of the skin and increased susceptibility to bruising) 4 mg tablets, 1 tablet, daily, oral'. Further review of the clinical record evidenced the following Client Coordination Note Reports (which contained the narrative portion of nursing visit notes): A review of a Client Coordination Note dated 06/05/2024, signed by Person 48, an NP with Entity 17, a hospice agency located in Crown Point, indicated Patient #1 had bruising to the left arm. A review of a Client Coordination Note dated 08/30/2024, signed by Person 29, an RN with Entity 17, indicated Patient #1 had bruising to all extremities. A review of a Client Coordination Note dated 09/27/2024, signed by Person 27, an RN with Entity 17, indicated bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/01/2024,signed by Person 27, an RN with Entity 17, indicated bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/03/2024 signed by Person 37, an LPN with Entity 17 indicated Patient #1 had bruises scattered all over her body. A review of a Client Coordination Note dated 10/08/2024, signed by Person 27, an RN with Entity 17, indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 10/15/2024,signed by Person 27, an RN with Entity 17, indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 11/05/2024, signed by Person 27, an RN with Entity 17. indicated Patient #1 had bruising to both hands and arms bilaterally. A review of a Client Coordination Note dated 11/07/2024, signed by Person 37, an LPN with Entity 17 indicated Patient #1 had bruises scattered all over her body. A review of a Client Coordination Note dated 11/19/2024, signed by Person 27, an RN with Entity 17 indicated Patient #1 had bruising noted to left arm. The agency failed to document a determination the allegation was unfounded, based on the patient's health history, medication history, and documented history of frequent/easy bruising which reasonably explained the discovery of a bruise. 4. On 12/11/2024 at 1:48 PM, Person 27 a nurse with Entity 17 indicated performed a visit with Patient #1 on 11/19/2024, in Person 4's, a family member and Power of attorney (POA), home while they were not present and Person 3, a family member, was there with another caregiver. Peron 27 indicated this was their first visit at Person 4's home and had not met Person 4. During the visit the patient indicated they needed help and did not want to be there, asked Person 27 to look at her left arm, where a bruise was noted, and the patient indicated Person 4 had done this. Person 27 then asked patient if Person 4 had been hurting them, and the patient indicated 'don't bring [Person 4] into this'. Person 27 contacted Person 4 to inform they (Person 27) had to make a report, and indicated Person 4 understood. Person 27 indicated had documented bruising and statements, and contacted Person 28, a social worker with Entity 17, after the visit. Indicated Person 28 then reached out to Person 4. 5. On 12/12/2024 at 11:01 AM, in a follow-up interview regarding the discovery of bruise to Patient #1, Person 23 administrator for Entity 17 indicated there were late entries being compiled, indicated there was a lot of documentation, needed to create a timeline, include IDG, and all specifics. Person 23 informed there were emails regarding related follow-ups, this writer requested those documents. Person 23 informed when there is an allegation of physical abuse, the social worker would visit, verify if the patient was alert and oriented, explain reporting to the state, ensure the patient remained safe while we investigate, next steps would depend, was this a first bruise, is the story consistent. Indicated when they had queried Person 4, he/she was confident none of this had happened, APS (Adult Protective Services) would be called if specific for this, and would do a follow-up. Had the patient's story stayed consistent, we would talk to MD, family, then make a report. Indicated in this case Person 28, the social worker with Entity 17, had asked specific questions of the patient, and the patient stated Person 4 had not harmed then and the patient felt safe and Person 28 had also spoken to them about having a care plan meeting, and seemed to be the end of the conversation. 6. On 12/13/2024 at 11:49 AM in a follow up interview, Person 4, a family member, was queried about bruising discovered to Patient #1's left arm on 11/19/2024 during a nursing visit with Person 27, a nurse from Entity 17. Person 4 indicated for some inexplicable reason, Patient #1 said Person 4 has caused the bruise. When queried as to whether they, Person 4, had caused the bruising indicated 'I did not cause the bruising', 'I do not know how it happened' and further, Patient #1's arms were always bruised to due to long term use of steroids.

Based on record review and interview Transitions Indiana LLC failed to maintain the confidentiality of patients records by allowing non-employees from Entity 17, a hospice located in Crown Point and Entity 18, a hospice located in Fort Wayne, access to the agency's patients electronic medical records (EMR), in 39 of 39 active records reviewed (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of a Transitions Indiana LLC agency document revised December 2018, titled 'BILL OF RIGHTS - Policy No. 9-005' stated, "... 1. The Bill of Rights statement defines the right of the patient to : ... H. Have a confidential record maintained by the organization ..." 2. A review of an agency document titled 'Client Census Report' indicated 15 Indianapolis patients were being serviced by Entity 17. 3. A review of an agency document titled 'Client Census Report' indicated 24 Indianapolis patients were being serviced by Entity 18. 4. A review of an agency document titled 'Client Schedule Report', evidenced Entity 17 and Entity 18 staff had access to Transitions Indiana LLC's confidential patient records and completed visits within the agency's Electronic Medical Record System: From Entity 17: Persons, including but not limited to: 26, 27, 28, 29, 30, 31, 32, 33, 37, 38, 42, 50, 51, 52, 53, 54, 55, 56, and 57 had conducted visits and documented in the agency's EMR for Transitions Indiana LLC Patients (#2, 4, 5, 8, 9, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50). From Entity 18: Persons, including but not limited to: 19, 20, 21, 22, 23, 39, and 82 had also conducted visit and documented in the EMR of Indianapolis patients on the Transitions Indiana LLC. license (Patients #6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40). The agency failed ensure the confidentiality of clinical records of 39 patients as records were accessible to non-employees of agencies Entity 17 and Entity 18. 5. On 12/11/2024 at 1:40 PM, regarding Transitions Indiana LLC patients who resided in the Crown Point area, the Indianapolis Administrator indicated Entity 17 staff provided all cares, there were not any employees from Traditions Indiana LLC providing care. 6. On 12/11/2024 at 2:16 PM, the DON from Traditions Indiana LLC indicated was responsible for nurses and patients in the Indianapolis location. When queried as to whether they knew there were Indianapolis patients in the Crown Point area, indicated honestly did not know and Entity 17 was caring for those Indianapolis patients. When queried as to the total number of patients being cared for by Entity 17 and Entity 18, a hospice located in Fort Wayne, indicated did not know the number of patients for either location. 7. On 12/12/2024 at 9:04 AM with Person 23, the DON for Entity 18, indicated knew who the Indianapolis patients were which Entity 18 serviced as they kept a spreadsheet. When queried as to who was the DON on the Indianapolis license, indicated did not know. 8. On 12/12/2024 at 11:02 AM with Person 32, an administrator with Entity 17, indicated Entity 17 was its own agency; no longer a branch of Indianapolis since Entity 17 received their own license a couple of years ago. Entity 17 provided hospice services to 15 Indianapolis patients. Indicated 15 Indianapolis patients were billed through Indianapolis office and in the Indianapolis electronic health record (EHR). The care for the Indianapolis patients was coordinated by communicating with the Indianapolis leadership when there was a specific need. 9. During an interview on 12/13/2024 at 12:47 PM, Person 22, RN Case Manager for Entity 18, indicated they oversee the patients admitted under the Transitions Indiana LLC, license their patients with Medicaid in the Fort Wayne location. Person 22 further indicated Person 19, RN Case Manager oversees their patients in Warsaw area. Person 22 confirmed they and Person 19 were an employees for Entity 18, and the patients were seen by employees of Entity 18. 10. On 12/13/2024 at 4:03 PM, with Person 50, a nurse with Entity 17 indicated provided care for five (5) patients from the Indianapolis office. Indicated was an employee of Entity 17. Indicated had no training conducted in Indianapolis. 11. On 12/13/2024 at 4:22 PM, with Person 27, a nurse with Entity 17 indicated was employed through Entity 17, not Indianapolis. Indicated provided cares for Indianapolis patients and reported to Person 31, a DON at Entity 17 for all patients, even Indianapolis patients. Indicated did not know who Indianapolis DON was. 12. On 12/13/2024 at 4:30 PM, with Person 28, a social worker with Entity 17 indicated was employed through Entity 17, not Indianapolis. 13. On 12/16/2024 at 1:02 PM, with Person 54, a chaplain with Entity 17 indicated was employed through Entity 17's office; not employed with Indianapolis office. Indicated provided services for a few of Indianapolis patients but could not recall the names. 14. On 12/16/2024 at 1:09 PM, with Person 42, a nurse with Entity 17 indicated was an employee of Entity 17 and made visits to Indianapolis patients in Entity's 17 region. When queried as to how they were able to tell which patients belonged to Indianapolis vs Entity 17, indicated there were separate lists, and they were broken up in IDG, and Indianapolis patients were reviewed first at IDG. 15. During an interview on 12/17/2024 at 10:17 AM, when queried regarding visits made by Entity 17 staff, and Entity 18 staff to patients under the Transitions Indiana LLC license, Corporate staff 1, the Vice President of Operations, indicated Entity 17 and 18 did not have a Medicaid license and had admitted patients under the Transitions Indiana LLC license and provided care and treatment.

Based on record review and interview, the agency failed to ensure the IDG meetings were facilitated by the Transitions of Indiana, LLC. Clinical Supervisor, failed to ensure the IDG members included a RN, Social Worker, and Counselor employed by Transitions Indiana, LLC (See L536); failed to designate an IDG composed of individuals who provide the care and services offered by the hospice agency (See L539); failed to include IDG members that were qualified employees of Transitions Indiana, LLC that included: a RN, Social worker, and pastoral or other counselor that provided care (See L541); failed to ensure the IDG maintained coordination supervising the care and services provided (See L554); and failed to ensure ongoing communication and coordination of care between all disciplines providing care (L557). These practices impacted 39 of 39 (Patients: #2, 4, 5, 6, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active records reviewed and 4 of 4 (Patient: #1, 12, 13, and 15) inactive records reviewed with services being provided by entity 17, a hospice agency located in Crown Pointe, and Entity 18, a hospice agency located in Fort Wayne. The cumulative effect of these systemic problems resulted in the agencys inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. --- In regards to L536: Based on record review and interview, the agency failed to ensure the agencys Clinical Supervisor facilitated the IDG, and the IDG members included a RN, Social Worker, and Counselor employed by Transitions Indiana, LLC. Findings Include: 1. A review of an agency policy dated December 2018 titled ";Interdisciplinary Group Meeting" indicated but was not limited to, "; ... To define the process for interdisciplinary group meetings ... The meeting will be facilitated by the hospice Clinical Supervisor ... The hospice Medical Director and all hospice interdisciplinary group members ... Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week ... " 2. A review of agency documents titled ";Indy IDG Agenda" dated 11/14/2024 through 12/12/2024, indicated IDG meetings were conducted on 11/14, 11/21, 11/27, 12/05, and 12/12/2024. The IDG meetings reviewed bereavements, transfers out, admissions, recertifications, upcoming recertifications, long-length patients, and routine patients. The Indy IDG failed to provide evidence of review of the active records of Patients #2, 4, 5, 6, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28. 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 being reviewed, or the inactive records of Patients #1, 12, 13, 14, and 15. A review of the agency of the documents titled ";IDG Attendance Sheets" dated 11/14/2024 through 12/12/2024, indicated IDG meetings were conducted on 11/14, 11/21, 11/27, 12/05, and 12/12/2024. The sign-in sheets contained the names of the agency DON, RM Case Managers, Medical Director, Chaplain, Quality Assurance, and Social Worker. 3. A review of documents titled ";Fort Wayne HIN IDG" from Entity 18, a hospice agency located in Fort Wayne, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings dated 11/27/2024 through 12/11/2024 were conducted on 11/27, 12/05, and 12/11/2024. The documents indicated the IDG meetings were conducted at Entity 18. The active Patients #6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40 were listed as reviewed during the IDG meetings. A review of the agency of the documents titled ";IDG Attendance Sheets" dated 11/14/2024 through 12/12/2024, indicated IDG meetings were conducted on 11/14, 11/21, 11/27, 12/05, and 12/11/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 18s Social Worker, Person 20; Chaplain, Person 21; Case Managers, Persons 19 and 22; and the DON, Person 23. The agency failed to provide evidence the Transitions Indiana LLC Clinical Supervisor facilitated the IDG meetings, and the Chaplain, Social Worker, and RN were employed by Transitions Indiana LLC on all patients under their license. During an interview on 12/12/2024 at 12:42 PM, when queried regarding the IDG meetings process and attendance, Person 22, the RN Case Manager at Entity 18, indicated they attend IDG every other week at Entity 18 with Entity 18s DON, MSW, Chaplain, and the Medical Director. Person 22 confirmed they were an employee of Entity 18, and they case managed and conducted visits, admissions, recertifications, and IDGs for the patients of Transitions Indiana LLC admitted in the Fort Wayne area who had Medicaid. During an interview on 12/13/2024 at 1:14 PM, when queried regarding the IDG meetings process and attendance, Person 19, the RN Case Manager at Entity 18, indicated they attend IDG meetings every other week and Entity 18 with Entity 18s DON, MSW, Chaplain, and the Medical Director. Person 22 confirmed they were an employee of Entity 18, and they case managed and conducted visits and IDGs for the patients of Transitions Indiana LLC admitted in the Warsaw area. 4. A review of documents titled ";CP HIN IDG" from Entity 17, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings dated 11/05/2024 through 11/26/2024 were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The documents indicated the IDG meetings were conducted at Entity 17.. The active Patients #2, 4, 5, 8, 9, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 were listed as reviewed during the IDG meeting. A review of the agency of the documents titled ";IDG Attendance Sheets," dated 11/05/2024 through 11/26/2024, indicated IDG meetings were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 17s, a hospice agency located in Crown Point, Social Worker, Person 17; Chaplain, Person 26; Case Managers, Person 33 and 34; Administrator, Person 32; and the DON, Person 31. The agency failed to provide evidence the Transitions Indiana LLC Clinical Supervisor facilitated the IDG meetings, and the Chaplain, Social Worker, and RN were employed by Transitions Indiana LLC on all patients under their license. During an interview on 12/11/2024 at 1:40 PM, when the Administrator was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but that Entity 17's staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency providing care.

Based on record review and interview, the agency failed to ensure all the IDG group members provided care and services offered by Transitions Indiana, LLC and supervised the care and services of 39 of 39 (Patients: #2, 4, 5, 6, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active clinical record reviewed and 4 of 4 (Patients: #1, 12, 13, and 15) inactive clinical records reviewed with services being provided by Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne. Findings Include: --- 1. A review of an agency policy dated December 2018 titled ";Interdisciplinary Group Membership and Responsibilities" indicated but was not limited to, "; ... The hospice interdisciplinary group membership includes at a minimum: A. Physician. B. Registered Nurse. C. Social worker. D. Pastoral or other counselor ... The interdisciplinary group responsibilities include but are not limited to: ... Provision or supervision of hospice care and services ... " 2. A review of documents titled ";Fort Wayne HIN IDG" from Entity 18, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings conducted by Entity 18 dated 11/27/2024 through 12/11/2024 were conducted on 11/27, 12/05, and 12/11/2024. The active Patients #6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40 were listed as reviewed during the IDG meetings. A review of the agency of the documents titled ";IDG Attendance Sheets" dated 11/14/2024 through 12/12/2024, indicated IDG meetings were conducted on 11/14, 11/21, 11/27, 12/05, and 12/11/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 18s, a hospice agency in Fort Wayne, Social Worker, Person 20; Chaplain, Person 21; Case Managers, Persons 19 and 22; and the DON, Person 23. The Attendance sheets failed to list Transitions Indiana, LLC Administrator, DON, Social worker, Chaplain, or RN. During an interview on 12/12/2024 at 12:42 PM, when queried regarding the IDG meetings process and attendance, Person 22, the RN Case Manager at Entity 18, indicated they attend IDG every other week at Entity 18 with Entity 18s DON, MSW, Chaplain, and the Medical Director. Person 22 confirmed they were an employee of Entity 18, and they case managed and conducted visits, admissions, recertifications, and IDGs for the patients of Transitions Indiana LLC admitted in the Fort Wayne. Person 22 indicated the other weeks Person 19 the other RN Case Manager with Entity 18 attended. 3. A review of documents titled ";CP HIN IDG" from Entity 17, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings at Entity 17 dated 11/05/2024 through 11/26/2024 were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The active Patients #2, 4, 5, 8, 9, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 were listed as reviewed during the IDG meeting. A review of the agency of the documents titled ";IDG Attendance Sheets," dated 11/05/2024 through 11/26/2024, indicated IDG meetings were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 17s, Social Worker, Person 17; Chaplain, Person 26; Case Managers, Person 33 and 34; Administrator, Person 32; and the DON, Person 31. The Attendance sheets failed to list Transitions Indiana, LLC Administrator, DON, Social worker, Chaplain, or RN. During an interview on 12/11/2024 at 1:40 PM, when the Administrator was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but that Entity 17's, staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency providing care.

Based on record review and interview the agency failed to include IDG members who were qualified employees of Transitions Indiana, LLC that included: a RN, Social worker, and pastoral or other counselor that provided care for 39 of 39 (Patients: #2, 4, 5, 6, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active clinical records reviewed with services being provided by Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne. Findings Include: --- 1. A review of an agency policy dated December 2018 titled ";Scope of Services" indicated but was not limited to, "; ... Transitions Indiana LLC will be open from 8:00 a.m. to 5:00 p.m. ... and core hospice services provided by nurses, social worker, physicians, and bereavement counselors ... " 2. A review of an agency policy dated December 2018 titled ";Interdisciplinary Group Membership and Responsibilities" indicated but was not limited to, "; ... The hospice interdisciplinary group membership includes at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor ... " 3. A review of documents titled ";CP HIN IDG" from Entity 17, a hospice agency located in Crown Point, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings at Entity 17 dated 11/05/2024 through 11/26/2024 were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The active Patients #2, 4, 5, 8, 9, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 were listed as reviewed during the IDG meeting. A review of the agency of the documents titled ";IDG Attendance Sheets," dated 11/05/2024 through 11/26/2024, indicated IDG meetings were conducted on 11/05, 11/12, 11/19, and 11/26/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 17s Social Worker, Person 17; Chaplain, Person 26; Case Managers, Person 33 and 34; Administrator, Person 32; and the DON, Person 31. The Attendance sheets failed to list Transitions Indiana, LLC Administrator, DON, Social worker, Chaplain, or RN. During an interview on 12/11/2024 at 1:40 PM, when the Administrator was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but that Entity 17's staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency providing care. 4. A review of the personnel files for Entity 17 evidenced the following: Review of Person 33's personnel record the social worker of Entity 17, evidenced a document titled "Safe Hiring Solutions" dated 08/08/2023, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Acknowledgement of Training" dated 08/14/2023 by Transitions Group. The personnel record failed to evidence Person 33 was employed by Transitions Indiana LLC. Review of Person 28's personnel record the RN Case Manager, for Entity 17, evidenced a document titled "Safe Hiring Solutions" dated 03/12/2024, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Acknowledgement of Training-Orientation" dated 03/04/2024 by Transitions Group. The personnel record failed to evidence Person 28 was employed by Transitions Indiana LLC. 5. A review of documents titled ";Fort Wayne HIN IDG" from Entity 18, provided by the Administrator on 12/12/2024, when requested IDG meetings. The IDG meetings conducted by Entity 18 dated 11/27/2024 through 12/11/2024 were conducted on 11/27, 12/05, and 12/11/2024. The active Patients #6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40 were listed as reviewed during the IDG meetings. A review of the agency of the documents titled ";IDG Attendance Sheets" dated 11/14/2024 through 12/12/2024, indicated IDG meetings were conducted on 11/14, 11/21, 11/27, 12/05, and 12/11/2024. The sign-in sheets contained the names of the agencys Medical Director, Entity 18s, Social Worker, Person 20; Chaplain, Person 21; Case Managers, Persons 19 and 22; and the DON, Person 23. The Attendance sheets failed to list Transitions Indiana, LLC Administrator, DON, Social worker, Chaplain, or RN as members of the IDG. During an interview on 12/12/2024 at 12:42 PM, when queried regarding the IDG meetings process and attendance, Person 22, the RN Case Manager at Entity 18, indicated they attend IDG at Entity 18 with Entity 18s DON, MSW, Chaplain, and the Medical Director. Person 22 confirmed they were an employee of Entity 18. 6. A review of the personnel files for Entity 18 evidenced the following: Review of Person 19's personnel record, the RN Case Manager for Entity 18, evidenced a document titled "Safe Hiring Solutions" dated 05/16/2024, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Acknowledgement of Training" dated 05/20/2024 by Transitions Group. The personnel record failed to evidence Person 19 was employed by Transitions Indiana LLC. Review of Person 20's personnel record, the social worker of Entity 18, evidenced a document titled "Safe Hiring Solutions" dated 04/11/2024, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Acknowledgement of Training-Orientation" dated 04/08/2024 by Transitions Group. The personnel record failed to evidence Person 20 was employed by Transitions Indiana LLC. Review of Person 21's personnel record, the chaplain of Entity 18, evidenced a document titled "Safe Hiring Solutions" dated 05/23/2023, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Acknowledgement of Training" dated 06/12/2023 by Transitions Group And Affiliates. The personnel record failed to evidence Person 20 was employed by Transitions Indiana LLC. Review of Person 22's personnel record the RN Case Manager, for Entity 18, evidenced a document titled "Safe Hiring Solutions" dated 08/29/2024, was completed by Entity 35, the corporate office. The personnel record further evidenced a document titled "Skills Demonstration Checklist" dated 06/01/2023 by Transitions Hospice. The personnel record failed to evidence Person 22 was employed by Transitions Indiana LLC.

Based on record review and interview the agency failed to ensure the Transitions Indiana LLC Interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided, by delegating the responsibility to non-employees of Entity 17, a hospice located in Crown Point, and Entity 18, a hospice located in Fort Wayne, for 39 of 39 active patients (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of an agency document revised December 2018, titled 'Interdisciplinary Group Membership and Responsibilities Policy No. 1-034' stated, "... The interdisciplinary group responsibilities include but are not limited to: ... C. Provision or supervision of hospice care and services ..." 2. A review of the job description for the Administrator of Transitions Indiana LLC, signed 07/02/2024, indicated, "... The Administrator is responsible for the overall direction of hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible to the provision of hospice services, directly ... ensuring interdisciplinary care is provided ..." 3. A review of the job description for the Director of Nursing (DON) of Transitions Indiana LLC, signed 06/27/2024, indicated duties and responsibilities included, "... provide leadership and guidance to the Interdisciplinary team ..." 4. A review of serial attendance sheets of IDG meetings conducted by Entity 17 for Indianapolis patients, evidenced meetings were held on: 11/05/2024, 11/12/2024, 11/19/2024 and 11/26/2024, and failed to evidence direct employees of Transitions Indiana LLC had conducted or been in attendance for IDG. 5. A review of serial attendance sheets of IDG meetings conducted at Entity 18 for Indianapolis patients, evidenced meeting were held on: 11/27/2024, 12/05/2024, and 12/11/2024, and failed to evidence direct employees of Transitions Indiana LLC had conducted or been in attendance for IDG. 6. On 12/11/2024 at 1:40 PM, the Administrator of Transitions Indiana LLC was queried as to whether they were involved in or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the Indianapolis DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17 staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff provided all cares, there were not any employees from this agency providing care. 7. On 12/12/2024 at 11:02 AM with Person 32, an administrator with Entity 17, indicated Entity 17 was its own agency; no longer a branch of Indianapolis since Entity 17 received their own license a couple of years ago. Entity 17 provides hospice services to 15 Indianapolis patients. The Interdisciplinary Group (IDG) meetings for the 15 Indianapolis patients were conducted by Entity 17's IDG team and not Indianapolis. 8. On 12/13/2024 at 3:17 PM, the Administrator for Transitions Indiana LLC indicated Entity 17 employees were not great at communicating with her. 9. On 12/13/2024 at 4:03 PM, with Person 50, a nurse with Entity 17, indicated provided cares for five (5) patients from the Indianapolis office. Indicated was an employee of Entity 17. Indicated had no training conducted in Indianapolis. Indicated the IDG meetings held by Entity 17 had no staff from Indianapolis office and Entity 17's IDG discussed Indianapolis patients first and then Entity 17 patients. 10. On 12/13/2024 at 4:22 PM, with Person 27, a nurse with Entity 17, indicated was employed through Entity 17, not Indianapolis. Indicated provided cares for Indianapolis patients. Indicated did not know who Indianapolis DON was. Indicated IDG at Entity 17 discussed Indianapolis and Entity 17 patients together; no Indianapolis staff were in attendance at IDG mtgs. 11. On 12/13/2024 at 4:30 PM, with Person 28, a social worker with Entity 17, indicated was employed through Entity 17, not Indianapolis. Indicated participated in IDG as a Medical Social Worker (MSW) for fifteen (15) of Indianapolis patients. Indicated no Indianapolis staff were present for IDG meetings of the Indianapolis patients. 12. On 12/16/2024 at 1:02 PM, with Person 54, a chaplain with Entity 17, indicated was employed through Entity 17's office; not employed with Indianapolis office. Indicated provided services for a few of Indianapolis patients but could not recall the names. Indicated Indianapolis patients were discussed at Entity 17's IDG; no Indianapolis staff were present at IDG in Entity 17's office to discuss Indianapolis patients. When queried was not sure of who the Administrator or DON were at Indianapolis office. 13. On 12/17/2024 at 1:22 PM in an interview, the Indianapolis DON, when queried whether Entity 17, and Entity 18 communicated with her about Transitions Indiana LLC patients, indicated 'not yet' and 'that concerns me'.

Based on record review and interview the agency failed to ensure the ongoing sharing of information between all disciplines providing care and services in all settings, when the agency utilized non-employees from Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne, to provide services for patients admitted under the Indianapolis license, and failed to report such information to Indianapolis employees, related to 39 of 39 active patients (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of an agency policy dated December 2018 titled ";Interdisciplinary Group Coordination of Care" indicated but was not limited to, "; ... Transitions Indiana, LLC will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families /caregivers serviced by the hospice ... " 2. On 12/11/2024 at 1:40 PM, On 12/11/2024 at 1:40 PM, the Indianapolis Administrator was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17, staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency providing care. 3. On 12/11/2024 at 2:16 PM, the DON for Transitions Indiana LLC, indicated was responsible for nurses and patients in the Indianapolis location. When queried as to whether they knew there were Indianapolis patient's in the Crown Point area, indicated honestly did not know, and Entity 17 was caring for those Indianapolis patients. When queried as to the total number of patients being cared for by Entity 17 and Entity 18, indicated did not know the number of patients for either location. The DON indicated because they (Entity 17 and Entity 18) have directors of nursing of their own, they don't pull me in. 4. On 12/12/2024 at 9:04 AM with Person 23, the DON for Entity 18, indicated knew who the Indianapolis patients were which Entity 18 serviced as they kept a spreadsheet. When queried as to who was the DON on the Indianapolis license, indicated did not know. 5. On 12/13/2024 at 3:17 PM, the Indianapolis Administrator indicated Entity 17, employees were not great at communicating with her. 6. On 12/13/2024 at 4:22 PM, with Person 27, a nurse with Entity 17, indicated provided cares for Indianapolis patients and reported to Person 31, a DON at Entity 17 for all patients, even Indianapolis patients. Indicated did not know who Indianapolis DON was. 7. On 12/13/2024 at 4:30 PM, with Person 28, a social worker with Entity 17, indicated reported to Entity 17's DON, Person 31, for any care coordination needs of Indianapolis patients, and Person 31 then reports any issues to Indianapolis office. 8. On 12/16/2024 at 1:02 PM, with Person 54, a chaplain with Entity 17, when queried was not sure of who the Administrator or DON were at Indianapolis office. 9. On 12/17/2024 at 11:15 AM, with Person 26, a chaplain with Entity 17, when queried indicated they reported to the Administrator or DON at Crown Point. 10. On 12/17/2024 at 1:22 PM in an interview, the DON, when queried whether Entity 17 and Entity 18's staff communicate with her about Transitions Indiana LLC patients, indicated 'not yet' and 'that concerns me'.

Based on record review and interview the agency failed to utilize direct employees of the Indianapolis agency and instead delegated the provision of core services to non-employees of unaffiliated agencies; the agency failed to ensure core nursing services (see L591), failed to ensure core social services (see L594), failed to ensure core bereavement services (L596), failed to ensure core spiritual counseling services (see L598) were provided to the agency's hospice patients. These practices impacted 39 of 39 (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active records reviewed receiving services from Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne. The cumulative effect of these systemic problems resulted in the agencys inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. --- *

Based on record review and interview the agency failed to ensure nursing services were qualified employees of Transitions Indiana, LLC, that provided care for 39 of 39 (Patients: #2, 4, 5, 6, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active clinical records reviewed receiving services from Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne. Findings Include: --- 1. A review of an agency policy dated December 2018 titled ";Scope of Services" indicated but was not limited to, ";Purpose: To describe Transitions Indiana LLC operations ... Transitions Indiana LLC provides hospice services that are intended to meet the physical, psychological, practical, and spiritual needs of hospice patients ... core hospice services provided by nurses, social workers, physicians, and bereavement counselors are available 24 hours a day, seven (7) days a week ... " 2. A review of the clinical record for Patient #2, election date 12/26/2022, contained a recertification POC for benefit period 10/31/2024 to 12/16/2024. The POC indicated Patient #2 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #2 had been provided the following visits from employees of Entity 17, Person 38, an RN, on 12/01/2024, 12/08/2024, and 12/15/2024; The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 3. A review of the clinical record for Patient #4, election date 01/17/2023, contained a recertification POC for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #4 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #4 had been provided the following visits from employee of Entity 17, Person 27, a RN Case Manager, on 12/01/2024, 12/08/2024, and 12/15/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 4. A review of the clinical record for Patient #5, election date 11/02/2023, contained a recertification POC for benefit period 10/22/2024 to 12/20/2024. The POC indicated Patient #5 had orders for a RN and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #19 had been provided the following visits from employee of Entity 18, Person 50, a RN Case Manager, on 12/05/2024 and 12/10/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 5. A review of the clinical record for Patient #6, election date 07/02/2023, contained a recertification POC for benefit period 10/28/2024 to 12/26/2024. The POC indicated Patient #6 had orders for a RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #6 had been provided the following visits from employee of Entity 18, : Person 22, a RN Case Manager, on 12/06/2024,12/08/2024, and 12/12/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 6. A review of the clinical record for Patient #7, election date 12/07/2024, contained an initial POC for benefit period 12/07/2024 to 03/06/2025. The POC indicated Patient #7 had orders for RN core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #7 had been provided the following visits from employee of Entity 17, Person 88, an RN, on 12/07/2024, and 12/10/2024. The record failed to evidence core services for an RN had been provided by Transitions Indiana LLC. 7. A review of the clinical record for Patient #8, election date 03/29/2023, contained a recertification POC for benefit period 11/27/2024 to 01/25/2025. The POC indicated Patient #8 had orders for a RN core service. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #8 had been provided the following visits from employee of Entity 17, Person 30, an RN, on 12/02/2024, 12/09/2024, and 12/16/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 8. A review of the clinical record for Patient #9, election date 02/22/2022, contained a recertification POC for benefit period 11/24/2024 to 01/22/2025. The POC indicated Patient #9 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #9 had been provided the following visits from employee of Entity 17, Person 50, a RN Case Manager, on 12/01/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 9. A review of the clinical record for Patient #18, election date 12/03/2024, for benefit period 12/03/2024 to 01/31/2025, contained a signed physician order dated 11/27/2024. The order indicated Patient #18 had orders effective 12/03/2024 for a RN and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #18 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/05/2024 and 12/08/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 10. A review of the clinical record for Patient #19, election date 11/03/2024, contained an initial POC for benefit period 11/05/2024 to 02/02/2025. The POC indicated Patient #19 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #19 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/05/2024 and 12/10/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 11. A focus review of the clinical record for Patient #20, election date 12/04/2024, contained recertification POC update for benefit period 12/14/2024 to 02/11/2025. The POC indicated Patient #20 had orders for a RN. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #20 had been provided the following visits from employee of Entity 18, Person 22, RN Case Manager, on 12/03, 12/05, and 12/12/2024; and Person 19, a RN Case Manager, on 12/10/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 12. A focus review of the clinical record for Patient #21, election date 11/04/2024, contained recertification POC update for benefit period 11/04/2024 to 01/02/2025. The POC indicated Patient #21 had orders for a RN and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #21 had been provided the following visits from employee of Entity 18, Person 22, RN Case Manager, on 12/03, 12/06/2024, and 12/12/2024; Person 19, a RN Case Manager, on 12/09/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 13. A focus review of the clinical record for Patient #22, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #22 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #22 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/02, 12/06, 12/09, 12/13, and 12/17/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 14. A focus review of the clinical record for Patient #23, election date 12/03/2024, contained recertification POC update for benefit period 12/13/2024 to 02/10/2025. The POC indicated Patient #23 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #23 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/10/2024 and 12/13/2024; Person 22, a RN Case Manager, on 12/03/2024, and 12/05/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 15. A focus review of the clinical record for Patient #24, election date 11/08/2024, contained recertification POC update for benefit period 11/08/2024 to 01/06/2025. The POC indicated Patient #24 had orders for a RN, and MSW. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #24 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/04/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 16. A focus review of the clinical record for Patient #25, election date 11/09/2024, contained recertification POC update for benefit period 11/09/2024 to 01/07/2025. The POC indicated Patient #25 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #25 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/04/2024 and 12/11/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 17. A focus review of the clinical record for Patient #26, election date 10/23/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #26 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #26 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/04, 12/06, and 12/13/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 18. A focus review of the clinical record for Patient #27, election date 10/30/2024, contained recertification POC update for benefit period 10/30/2024 to 12/28/2024. The POC indicated Patient #27 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #27 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/02, 12/06, and 12/15/2024; Person 22, a RN Case Manager, on 12/08/2024, and 12/12/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 19. A focus review of the clinical record for Patient #28, election date 11/06/2024, contained recertification POC update for benefit period 11/13/2024 to 01/11/2025. The POC indicated Patient #28 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #28 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/11/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 20. A focus review of the clinical record for Patient #29, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #29 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #29 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/02, 12/09, and 12/17/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 21. A focus review of the clinical record for Patient #30, election date 11/06/2024, contained recertification POC update for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #30 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #30 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/09/2024; Person 22, a RN Case Manager, on 12/03/2024, and 12/06/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 22. A focus review of the clinical record for Patient #31, election date 12/12/2024, contained recertification POC update for benefit period 12/12/2024 to 03/11/2025. The POC indicated Patient #31 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #31 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/12/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 23. A focus review of the clinical record for Patient #32, election date 12/05/2024, contained recertification POC update for benefit period 12/16/2024 to 02/13/2025. The POC indicated Patient #32 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #32 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/11/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 24. A focus review of the clinical record for Patient #33, election date 11/27/2024, contained recertification POC update for benefit period 11/30/2024 to 01/28/2025. The POC indicated Patient #33 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #33 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/06, 12/10, and 12/13/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 25. A focus review of the clinical record for Patient #34, election date 12/08/2024, contained recertification POC update for benefit period 12/08/2024 to 02/05/2025. The POC indicated Patient #34 had orders for a RN. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #34 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/04/2024.The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 26. A focus review of the clinical record for Patient #35, election date 11/01/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #35 had orders for a RN, MSW, and Chaplain. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #35 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/02, 12/09, and 12/17/2024. The record failed to evidence the core services for a RN had been provided by Transitions Indiana LLC. 27. A review of the clinical record for Patient #36, election date 08/10/2023, contained a recertification POC for benefit period 12/02/2024 to 01/30/2025. The POC indicated Patient #36 had orders for RN core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #36 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/05/2024, 12/08/2024, and 12/13/2024. The record failed to evidence core services for an RN had been provided by Transitions Indiana LLC. 28. A review of the clinical record for Patient #37, election date 04/19/2023, contained a recertification POC for benefit period 12/10/2024 to 02/07/2025. The POC indicated Patient #37 had orders for a RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #37 had been provided the following visits from employees of Entity 18, Person 22, an RN Case Manager, on 12/03/2024, and 12/11/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 29. A review of the clinical record for Patient #38, election date 10/19/2024, contained an initial POC for benefit period 10/19/2024 to 01/16/2025. The POC indicated Patient #38 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #38 had been provided the following visits from employee of Entity 18, Person 19, a RN Case Manager, on 12/03/2024, 12/05/2024, and 12/12/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 30.A review of the clinical record for Patient #39, election date 07/21/2023, contained a recertification POC for benefit period 11/12/2024 to 01/10/2025. The POC indicated Patient #39 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #39 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/03/2024, 12/07/2024, and 12/08/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 31. A review of the clinical record for Patient #40, election date 09/27/2023, contained a recertification POC for benefit period 11/29/2024 to 01/27/2025. The POC indicated Patient #40 had orders for a RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #40 had been provided the following visits from employee of Entity 18, Person 22, a RN Case Manager, on 12/03/2024, 12/07/2024, and 12/08/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. During an interview on 12/13/2024 at 12:47 PM, Person 22, RN Case Manager for Entity 18, a hospice agency in Fort Wayne, indicated they and Person 19, provide nursing services and case manager all the patients for Transitions Indiana LLC, located in the Fort Wayne/Warsaw areas due to their agency does not have a Medicaid license. 32. A review of the clinical record for Patient #41, election date 07/11/2021, contained a recertification POC for benefit period 10/23/2024 to 12/21/2025. The POC indicated Patient #41 had orders for a RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #41 had been provided the following visits from employee of Entity 17, Person 33, an RN Case Manager, on 12/06/2024 and 12/11/2024; Person 28, a MSW, on 12/02/2024 and 12/12/2024; and Person 26, a Chaplain, on 12/05/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 33. A review of the clinical record for Patient #42, election date 05/16/2023, contained a recertification POC for benefit period 11/27/2024 to 01/25/2025. The POC indicated Patient #42 had orders for RN core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #42 had been provided the following visits from employee of Entity 17, Person 29, a RN Case Manager, on 12/17/2024. The record failed to evidence core services for an RN had been provided by Transitions Indiana LLC. 34. A review of the clinical record for Patient #43, election date 02/02/2023, contained a recertification POC for benefit period 11/23/2024 to 01/21/2025. The POC indicated Patient #43 had orders for RN core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #43 had been provided the following visits from employee of Entity 17, Person 42, a RN Case Manager, on 12/02/2024, 12/05/2024, 12/09/2024, 12/12/2024 and 12/16/2024. The record failed to evidence core services for RN had been provided by Transitions Indiana LLC. 35. A review of the clinical record for Patient #44, election date 02/09/2023, contained a recertification POC for benefit period 12/01/2024 to 01/29/2025. The POC indicated Patient #44 had orders for RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #44 had been provided the following visits from employee of Entity 17, Person 27, a RN Case Manager, on 12/01/2024, 12/08/2024, and 12/15/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 36. A review of the clinical record for Patient #45, election date 05/24/2023, contained a recertification POC for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #45 had orders for RN, MSW, and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #45 had been provided the following visits from employee of Entity 17, Person 42, a RN Case Manager, on 12/03/2024, 12/06/2024, 12/14/2024, and 12/17/2024. The record failed to evidence core services for RN had been provided by Transitions Indiana LLC. 37. A review of the clinical record for Patient #46, election date 06/16/2023, contained a recertification POC for benefit period 12/11/2024 to 02/08/2025. The POC indicated Patient #46 had orders for RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #46 had been provided the following visits from employee of Entity 17, Person 42, an RN Case Manager, on 12/04/2024 and 12/11/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 38. A review of the clinical record for Patient #47, election date 09/23/2022, contained a recertification POC for benefit period 11/11/2024 to 01/09/2025. The POC indicated Patient #47 had orders for a RN and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #47 had been provided the following visits from employee of Entity 17, Person 56, an RN, on 12/12/2024 and 12/17/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 39. A review of the clinical record for Patient #48, election date 11/22/2021, contained a recertification POC for benefit period 11/08/2024 to 01/06/2025. The POC indicated Patient #48 had orders for RN and Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #48 had been provided the following visits from employee of Entity 17, Person 30, an RN, on 12/05/2024, 12/09/2024, 12/12/2024, and 12/16/2024. The record failed to evidence core services for a RN had been provided by Transitions Indiana LLC. 40. A review of the clinical record for Patient #49, election date 02/16/2023, contained a recertification POC for benefit period 12/09/2024 to 02/06/2025. The POC indicated Patient #49 had orders for a RN and MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #49 had been provided the following visits from employee of Entity 17, Person 30, an RN, on 12/04/2024, and Person 33, an RN, on 12/12/2024 and Person 29, an RN, on 12/17/2024. The record failed to evidence cor e services for a RN had been provided by Transitions Indiana LLC. 41. A review of the clinical record for Patient #50, election date 06/22/2022, contained a recertification POC for benefit period 12/08/2024 to 02/05/2025. The POC indicated Patient #50 had orders for RN core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #50 had been provided the following visits from employee of Entity 17, Person 50, an RN Case Manager, on 12/09/2024 and 12/13/2024. The record failed to evidence core services for RN had been provided by Transitions Indiana LLC. 42. On 12/11/2024 at 1:40 PM, the Administrator indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17's staff including their Administrator, DON, Social Worker, and Chaplain were all involved with Indianapolis patients' IDG meeting and Entity 17's staff were who provided all cares, and there were not any employees from this agency (Transitions Indiana, LLC.) providing care.

Based on record review and interview the agency failed to ensure core services were provided by staff on the Indianapolis license, and instead delegated social services to non-employees from an unaffiliated agency, in 23 of 23 active clinical records reviewed, of patients who received social services (Patients: #2, 4, 6, 9, 19, 20, 21, 22, 23, 24, 26, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) with services provided by Entity 17, a hospice agency in Crown Point, and Entity 18, a hospice agency in Fort Wayne. Findings include: --- 1. A review of an agency policy dated December 2018 titled 'Scope of Services' indicated but was not limited to, ";Purpose: To describe Transitions Indiana LLC operations ... Transitions Indiana LLC provides hospice services that are intended to meet the physical, psychological, practical ... needs of hospice patients ... core hospice services provided by ... social workers ... are available 24 hours a day, seven (7) days a week ... " 2.A review of the clinical record for Patient #2, election date 12/26/2022, contained a recertification POC for benefit period 10/31/2024 to 12/16/2024. The POC indicated Patient #2 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #2 had been provided the following visits from employees of Entity 17, Person 28, a MSW, on 12/12/2024. The record failed to evidence core services for MSW had been provided by Transitions Indiana LLC. 3.A review of the clinical record for Patient #4, election date 01/17/2023, contained a recertification POC for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #4 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #4 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/12/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 4.A review of the clinical record for Patient #6, election date 07/02/2023, contained a recertification POC for benefit period 10/28/2024 to 12/26/2024. The POC indicated Patient #6 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #6 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/03/2024. The record failed to evidence core services for a RN and Chaplain had been provided by Transitions Indiana LLC. 5.A review of the clinical record for Patient #9, election date 02/22/2022, contained a recertification POC for benefit period 11/24/2024 to 01/22/2025. The POC indicated Patient #9 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #9 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/13/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 6.A review of the clinical record for Patient #19, election date 11/03/2024, contained an initial POC for benefit period 11/05/2024 to 02/02/2025. The POC indicated Patient #19 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #19 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/13/2024. The record failed to evidence core services for MSW had been provided by Transitions Indiana LLC. 7.A focus review of the clinical record for Patient #22, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #22 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #22 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/06/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 8.A focus review of the clinical record for Patient #23, election date 12/03/2024, contained recertification POC update for benefit period 12/13/2024 to 02/10/2025. The POC indicated Patient #23 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #23 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/02/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 9.A focus review of the clinical record for Patient #24, election date 11/08/2024, contained recertification POC update for benefit period 11/08/2024 to 01/06/2025. The POC indicated Patient #24 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #24 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/10/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 10.A focus review of the clinical record for Patient #26, election date 10/23/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #26 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #26 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/10/2024 and 12/17/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 11.A focus review of the clinical record for Patient #29, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #29 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #29 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/06/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 12.A focus review of the clinical record for Patient #30, election date 11/06/2024, contained recertification POC update for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #30 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #30 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/12/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 13.A focus review of the clinical record for Patient #31, election date 12/12/2024, contained recertification POC update for benefit period 12/12/2024 to 03/11/2025. The POC indicated Patient #31 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #31 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/16/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 14.A focus review of the clinical record for Patient #33, election date 11/27/2024, contained recertification POC update for benefit period 11/30/2024 to 01/28/2025. The POC indicated Patient #33 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #33 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/09/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 15.A focus review of the clinical record for Patient #35, election date 11/01/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #35 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #35 had been provided the following visits from employee of Entity 18, a hospice agency located in Fort Wayne: Person 20, a MSW, on 12/06/2024. The record failed to evidence the core services for a MSW had been provided by Transitions Indiana LLC. 16.A review of the clinical record for Patient #37, election date 04/19/2023, contained a recertification POC for benefit period 12/10/2024 to 02/07/2025. The POC indicated Patient #37 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #37 had been provided the following visits from employees of Entity 18,Person 20, a MSW, on 12/12/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 17.A review of the clinical record for Patient #38, election date 10/19/2024, contained an initial POC for benefit period 10/19/2024 to 01/16/2025. The POC indicated Patient #38 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #38 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/16/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 18.A review of the clinical record for Patient #39, election date 07/21/2023, contained a recertification POC for benefit period 11/12/2024 to 01/10/2025. The POC indicated Patient #39 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #39 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/16/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 19.A review of the clinical record for Patient #40, election date 09/27/2023, contained a recertification POC for benefit period 11/29/2024 to 01/27/2025. The POC indicated Patient #40 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #40 had been provided the following visits from employee of Entity 18, Person 20, a MSW, on 12/16/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 20.A review of the clinical record for Patient #41, election date 07/11/2021, contained a recertification POC for benefit period 10/23/2024 to 12/21/2025. The POC indicated Patient #41 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #41 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/02/2024 and 12/12/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 21.A review of the clinical record for Patient #44, election date 02/09/2023, contained a recertification POC for benefit period 12/01/2024 to 01/29/2025. The POC indicated Patient #44 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #44 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/12/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 22.A review of the clinical record for Patient #45, election date 05/24/2023, contained a recertification POC for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #45 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #45 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/04/2024. The record failed to evidence core services for MSW had been provided by Transitions Indiana LLC. 23.A review of the clinical record for Patient #46, election date 06/16/2023, contained a recertification POC for benefit period 12/11/2024 to 02/08/2025. The POC indicated Patient #46 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #46 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/04/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 24.A review of the clinical record for Patient #49, election date 02/16/2023, contained a recertification POC for benefit period 12/09/2024 to 02/06/2025. The POC indicated Patient #49 had orders which included but were not limited to: MSW core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #49 had been provided the following visits from employee of Entity 17, Person 28, a MSW, on 12/04/2024 and 12/11/2024. The record failed to evidence core services for a MSW had been provided by Transitions Indiana LLC. 25.On 12/11/2024 at 1:40 PM, the Administrator indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17's, staff including their Administrator, DON, Social Worker, and Chaplain were all involved with Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, and there were not any employees from this agency (Transitions Indiana, LLC.) providing cares.

Based on record review and interview Transitions Indiana LLC failed to ensure core services were provided by staff on the Indianapolis license, and instead delegated bereavement services to non-employees from Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne, in 2 of 3 bereavement records reviewed. (Patients: 12 and 13). Findings include: --- 1. A review of an inactive clinical record for Patient #12, evidenced the date of death was 09/06/2024. Bereavement services were provided via phone on 09/06/2024 by Person 20, a social worker for Entity 18, a hospice agency located in Ft. Wayne. The inactive clinical record failed to evidence bereavement services were provided by Transitions Indiana LLC staff. 2. A review of an inactive clinical record for Patient #13, evidenced the date of death was 10/21/2024. Bereavement services were provided via phone on 10/23/2024 by Person 28, a social worker with Entity 17. The inactive clinical record failed to evidence bereavement services were provided by Transitions Indiana LLC staff. 3 . In an interview on 12/17/2024 at 11:15 AM, Corporate Staff 10, a bereavement coordinator, indicated social workers and chaplains are in regular communication with them. He/she further indicated that information on the 15 patients from Indianapolis is obtained from reviewing the narrative (from the electronic medical record (EMR)?) on these patients. 4. During an interview on 12/18/2024 at 1:35 PM with Person 28, a social worker with Entity 17, they indicated they were an employee of Entity 17. 5. During an interview on 12/18/2024 at 2:17 PM with Person 20, a social worker with Entity 18, they indicated they were an employee of Entity 18.

Based on record review and interview the agency failed to ensure core services were provided by staff on the Indianapolis license, and instead delegated spiritual counseling services to non-employees from Entity 17, a hospice agency in Crown Point, and Entity 18 a hospice agency in Fort Wayne, in 25 of 25 clinical records reviewed. (Patients: #2, 4, 5, 9, 18, 19, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 35, 38, 39, 41, 45, 47, and 48, 49) Findings include: --- 1. A review of an agency policy dated December 2018 titled ";Scope of Services" indicated but was not limited to, ";Purpose: To describe Transitions Indiana LLC operations ... Transitions Indiana LLC provides hospice services that are intended to meet the ... spiritual needs of hospice patients ... core hospice services provided by ... bereavement counselors are available 24 hours a day, seven (7) days a week ... " 2. A review of the clinical record for Patient #2, election date 12/26/2022, contained a recertification POC for benefit period 10/31/2024 to 12/16/2024. The POC indicated Patient #2 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #2 had been provided the following visits from employees of Entity 17, Person 26, a Chaplain, on 12/06/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 3. A review of the clinical record for Patient #4, election date 01/17/2023, contained a recertification POC for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #4 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #4 had been provided the following visits from employee of Entity 17, Person 54, a Chaplain, on 12/02/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 4. A review of the clinical record for Patient #5, election date 11/02/2023, contained a recertification POC for benefit period 10/22/2024 to 12/20/2024. The POC indicated Patient #5 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #19 had been provided the following visits from employee of Entity 18, the record review evidenced a visit had been completed by Person 26, a Chaplain, on 12/05/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 5. A review of the clinical record for Patient #9, election date 02/22/2022, contained a recertification POC for benefit period 11/24/2024 to 01/22/2025. The POC indicated Patient #9 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #9 had been provided the following visits from employee of Entity 17, Person 26, a Chaplain, on 12/05/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 6. A review of the clinical record for Patient #18, election date 12/03/2024, for benefit period 12/03/2024 to 01/31/2025, contained a signed physician order dated 11/27/2024. The order indicated Patient #18 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #18 had been provided the following visits from employee of Entity 18, Person 21, a chaplain, on 12/03/2024 and 12/06/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 7. A review of the clinical record for Patient #19, election date 11/03/2024, contained an initial POC for benefit period 11/05/2024 to 02/02/2025. The POC indicated Patient #19 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #19 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/09/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 8. A focus review of the clinical record for Patient #21, election date 11/04/2024, contained recertification POC update for benefit period 11/04/2024 to 01/02/2025. The POC indicated Patient #21 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #21 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/03/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 9. A focus review of the clinical record for Patient #22, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #22 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #22 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/04/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 10. A focus review of the clinical record for Patient #23, election date 12/03/2024, contained recertification POC update for benefit period 12/13/2024 to 02/10/2025. The POC indicated Patient #23 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #23 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/05/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 11. A focus review of the clinical record for Patient #25, election date 11/09/2024, contained recertification POC update for benefit period 11/09/2024 to 01/07/2025. The POC indicated Patient #25 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #25 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/16/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 12. A focus review of the clinical record for Patient #26, election date 10/23/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #26 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #26 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/09/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 13. A focus review of the clinical record for Patient #27, election date 10/30/2024, contained recertification POC update for benefit period 10/30/2024 to 12/28/2024. The POC indicated Patient #27 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #27 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/10/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 14. A focus review of the clinical record for Patient #28, election date 11/06/2024, contained recertification POC update for benefit period 11/13/2024 to 01/11/2025. The POC indicated Patient #28 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #28 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/10/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 15. A focus review of the clinical record for Patient #29, election date 11/06/2024, contained recertification POC update for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #29 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #29 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/04/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 16. A focus review of the clinical record for Patient #30, election date 11/06/2024, contained recertification POC update for benefit period 11/16/2024 to 01/14/2025. The POC indicated Patient #30 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #30 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/02/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 17. A focus review of the clinical record for Patient #31, election date 12/12/2024, contained recertification POC update for benefit period 12/12/2024 to 03/11/2025. The POC indicated Patient #31 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #31 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/16/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 18. A focus review of the clinical record for Patient #32, election date 12/05/2024, contained recertification POC update for benefit period 12/16/2024 to 02/13/2025. The POC indicated Patient #32 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #32 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/02/2024 and 12/16/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 19. A focus review of the clinical record for Patient #33, election date 11/27/2024, contained recertification POC update for benefit period 11/30/2024 to 01/28/2025. The POC indicated Patient #33 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #33 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/09/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 20. A focus review of the clinical record for Patient #35, election date 11/01/2024, contained recertification POC update for benefit period 11/01/2024 to 12/30/2024. The POC indicated Patient #35 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/02/2024 through 12/16/2024 indicated Patient #35 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/09/2024. The record failed to evidence the core services for a Chaplain had been provided by Transitions Indiana LLC. 21. A review of the clinical record for Patient #38, election date 10/19/2024, contained an initial POC for benefit period 10/19/2024 to 01/16/2025. The POC indicated Patient #38 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #38 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/12/2024. The record failed to evidence core services for a RN, MSW, and Chaplain had been provided by Transitions Indiana LLC. 22. A review of the clinical record for Patient #39, election date 07/21/2023, contained a recertification POC for benefit period 11/12/2024 to 01/10/2025. The POC indicated Patient #39 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/16/2024 indicated Patient #39 had been provided the following visits from employee of Entity 18, Person 21, a Chaplain, on 12/03/2024 and 12/17/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 23. A review of the clinical record for Patient #41, election date 07/11/2021, contained a recertification POC for benefit period 10/23/2024 to 12/21/2025. The POC indicated Patient #41 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #41 had been provided the following visits from employee of Entity 17, Person 26, a Chaplain, on 12/05/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 24. A review of the clinical record for Patient #45, election date 05/24/2023, contained a recertification POC for benefit period 11/14/2024 to 01/12/2025. The POC indicated Patient #45 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #45 had been provided the following visits from employee of Entity 17, Person 26, a Chaplain, on 12/06/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 25. A review of the clinical record for Patient #47, election date 09/23/2022, contained a recertification POC for benefit period 11/11/2024 to 01/09/2025. The POC indicated Patient #47 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #47 had been provided the following visits from employee of Entity 17, Person 54, a Chaplain, on 12/11/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. 26. A review of the clinical record for Patient #48, election date 11/22/2021, contained a recertification POC for benefit period 11/08/2024 to 01/06/2025. The POC indicated Patient #48 had orders which included but were not limited to: Chaplain core services. A review of an agency document titled ";Client Schedule Report" dated 12/01/2024 through 12/18/2024 indicated Patient #48 had been provided the following visits from employee of Entity 17, Person 26, a Chaplain, on 12/05/2024. The record failed to evidence core services for a Chaplain had been provided by Transitions Indiana LLC. On 12/11/2024 at 1:40 PM, the Administrator indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17's staff including their Administrator, DON, Social Worker, and Chaplain were all involved with Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, and there were not any employees from this agency (Transitions Indiana, LLC.) providing care.

Based on record review and interview Transitions Indiana LLC failed to ensure core nursing services to their patients by failing to obtain a waiver for contract nursing services(see L600), and instead delegated nursing services to non-employees from Entity 17, a hospice agency located in Crown Point and Entity 18, a hospice agency located in Fort Wayne. These practices impacted 39 of 39 (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active records reviewed in the northern state region. The cumulative effect of these systemic problems resulted in the agencys inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. --- *

Based on record review and interview the agency failed to appropriately contract nursing services to their patients and instead delegated nursing services to non-employees of the agency, Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne. Findings Include: --- 1. A review of an agency policy dated December 2018 titled " contracted services will be defined by a written agreements before individuals from that source will be permitted to provide service ... all services furnished under arrangement provided by other entities or meet the requirements of the Medicare Conditions of Participation and accreditation standards ... " 2.On 12/09/2024 at 9:38 AM, during the entrance conference the Administrator, when queried as to the agency's current census, indicated there was a rough total of 90 or so patients; some were 52 patients based out of Indianapolis, and there were also 15 patients in northern Indiana on the Transitions Indiana LLC license that were being serviced by another location in Crown Point, Indiana, and the remaining were serviced out of a Fort Wayne location. 3. A review of an agency document titled 'Client Census Report' dated 12/09/2024 evidenced the names of 52 patients serviced by Transitions Indiana LLC. 4. A review of an agency document titled 'Client Census Report' dated 12/09/2024 evidenced the names of 15 patients being serviced by Entity 17, a hospice agency located in Crown Point. 5. A review of an agency document titled 'Client Census Report evidenced the names of 24 patients being serviced by Entity 18, a hospice agency located in Fort Wayne. 6.During an interview on 12/17/2024 at 3:11 PM, when queried regarding contracts or verification of granted hardship waivers approved for contracted nursing services being provided by Entity 17's and Entity 18's nursing staff, the Administrator indicated they were unaware of any approvals for hardship or contracts for nursing services.

Based on record review and interview Transitions Indiana LLC failed to properly organize, manage, and administer it's resources in providing care and services to hospice patients by failing to ensure direct staff remained responsible for the oversight and delivery of care for patients on the Transitions Indiana LLC license but resided in the northern region of the state, and delegated these responsibilities to non-employees of separately licensed agencies, Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne: the Governing Body failed to maintain responsibility for the management of the hospice program and failed to appropriately manage hospice services, by failing to ensure the Administrator and Director of Nursing Services on the Transitions Indiana LLC license operated in their capacity, maintained responsibility for all patients under said license, and delegated responsibilities to non-employees from separately licensed agencies (see L651); failed to properly contract with an entity to furnish hospice services, and failed to maintain administrative management and oversight of non-employees from separately licensed agencies and the services provided under this arrangement (see L652), failed to provide administrative oversight of services provided by another entity and have appropriate written agreements for services provided by other entities (see L655), failed to ensure lines of authority and professional and administrative control were clearly delineated in the hospice organizational structure, were followed, and traced back to the location issued the CCN (Transitions Indiana, LLC) (see L658), failed to complete employee orientation and criminal history background checks and instead, orientation and criminal background checks were completed by an incorrect entity (see L663). These practices impacted 39 of 39 (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) active records reviewed in the northern state region. The cumulative effect of these systemic problems resulted in the agencys inability to ensure patients received appropriate care and services, which could result in the agency not providing quality care. --- *

Based on record review and interview the Governing Body for Transitions Indiana LLC failed to maintain responsibility for the management of the hospice program and failed to appropriately manage hospice services, by failing to ensure the Administrator and Director of Nursing Services on the Transitions Indiana LLC license operated in their capacity, maintaining responsibility for all patients under said license, and additionally failed to ensure responsibilities were not delegated to non-employees from separately licensed agencies: Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice located in Fort Wayne, for 39 of 39 active patients (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of an agency document revised December 2018 titled 'GOVERNING BODY Policy No. 8-003' stated, "... The Governing Body will assume full legal authority, responsibility and accountability for the overall management and operations, the provision of services ... and it's operational plans ..." 2. A review of an agency document revised December of 2018, titled, 'ADMINISTRATOR Policy No. 8-008' stated, "... 3. Responsibilities of the position will include but not be limited to: ... E. ... complaint management/resolution ... H. Ensuring ... appropriate staffing ... I. Ensuring that interdisciplinary care is provided ... P. Ensuring appropriate staff supervision during all services hours ... R. Ensuring services provided by other agencies are authorized by hospice ... W. Ensuring that structure and systems promote interdisciplinary care ..." 3. A review of an agency document titled '1202 - Director of Nursing (DON)' stated, "... Responsible for the support and overseeing of regional clinical services ... Hire, train, orient, supervise, and evaluate qualified Hospice interdisciplinary team personnel. Provide daily direction to the team ... Respond to customer complaints regarding patient care ... assure they are handled in accordance with Transitions policies and procedures ... Collaborate and direct coordinate with Administrator and the team in the region ..." 4. On 12/11/2024 at 1:40 PM, the Administrator of Transitions Indiana LLC was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17 staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency providing care. 5. On 12/11/2024 at 2:16 PM, the DON for Transitions Indiana LLC, indicated was responsible for nurses and patients in the Indianapolis location. When queried as to whether they knew there were Indianapolis patient's in the Crown Point area, indicated honestly did not know, and Entity 17 was caring for those Indianapolis patients. When queried as to the total number of patients being cared for by Entity 17 and Entity 18, indicated did not know the number of patients for either location. The DON indicated because they (Entity 17 and Entity 18) have directors of nursing of their own, they don't pull me in. 6. On 12/17/2024 at 1:22 PM in an interview, the DON for Transitions Indiana LLC, when queried whether Entity 17 and Entity 18 staff communicated with her about Transitions Indiana LLC patients, indicated 'not yet' and 'that concerns me'.

Based on record review and interview Transitions Indiana LLC failed to properly contract with an entity to furnish hospice services to patients on the Transitions Indiana LLC license, and failed to maintain administrative management and oversight of non-employees from separately licensed agencies (Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne) and of the services provided under this arrangement, for 39 of 39 active patients (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of an agency document revised December 2018, titled 'WRITTEN AGREEMENT FOR CONTRACTED SERVICES Policy No 8-018' stated, " ... 2. The organization shall ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of the Medicare Conditions of Participation ... 4. The organization will retain responsibility for evaluating services, maintaining professional management responsibility ..." 2. A review of two (2) agency contracts dated March 12, 2022, each indicated Transitions Indiana LLC (referred to as "Company") had separately contracted for supplemental staffing services with Entity 17 and Entity 18 (referred to as "Provider"). The contracts stated, "... 2.0 SERVICES ... 2.1 Supplemental Staffing by Company ... to provide or assist with home care services on a temporary basis ... 2.4 Professional Management of Provider Services: Provider assumes responsibility for professional management of the client's services ... and the applicable conditions of participation. Provider, through its Administrator, will retain full responsibility and authority over patient care ... 3.0 COMPANY PERSONNEL: ... 3.5 Supervision and Control: All health care services provided by Company personnel while assigned to Provider shall be under the direct supervision and control of the Provider ... Provider hereby assumes all supervisory and administrative responsibility for services rendered by Company personnel while assigned to Provider ..." 3. A review of Indiana Department of Health (IDOH) documents indicated: Transitions Indiana LLC, Entity 17 and Entity 18 were separately licensed hospice agencies and the documents failed to evidence Transitions Indiana LLC was under the same direct ownership as Entity 17 and Entity 18. 4. On 12/11/2024 at 1:40 PM, the Administrator of Transitions Indiana LLC was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17 staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency (Transitions Indiana LLC) providing care. 5. On 12/11/2024 at 2:16 PM, the DON of Transitions Indiana LLC indicated was responsible for nurses and patients in the Indianapolis location. When queried as to who was servicing the Indianapolis patients in Crown Point, the DON indicated they were unsure. When queried as to the total number of patients being cared for by Entity 17 and Entity 18 indicated did not know the number of patients for either location. The DON indicated because they (Entity 17 and Entity 18) had directors of nursing of their own, they don't pull me in. 6. On 12/17/2024 at 1:22 PM in an interview, the DON of Transitions Indiana LLC, indicated has been with the agency since August of this year. When queried whether Entity 17 and Entity 18 staff communicate with her about Transitions Indiana LLC patients, indicated 'not yet' and 'that concerns me'.

Based on record review and interview, Transitions Indiana, LLC failed to ensure written agreements for services were provided by other entities. Findings include: --- On 12/13/2024 at 2:13 PM the Administrator provided a contract which they believed to be between Transitions Indiana LLC, the agency and corporate, titled AGREEMENT BETWEEN TRANSITIONS INDIANA LLC AND TRANSITIONS INTEMEDIATE HOLDINGS LLC which evidenced a date of March 12, 2022. On 12/17/2024 at 9:30 AM with Corporate Person 1, Vice President of Operations, indicated all agencies (Transitions Indiana LLC, Entity 17, a hospice located in Crown Point, and Entity 18, a hospice located in Fort Wayne) all had the same ownership and indicated he/she reported to Corporate Person 9, COO of Entity 89. When queried as to what Entity 89 was, indicated the entire company, and all agencies were on separate licenses. On 12/17/2024 at 10:10 AM, Corporate Person 3 indicated it all rolls up to [Entity 35, the direct owners/corporation of Entity 17, a hospice agency locate in Crown Point, and Entity 18, a hospice agency located in Fort Wayne]. 1. A review of an agency policy dated December 2018 titled ";Scope of Services" indicated but was not limited to, ";Purpose: To describe Transitions Indiana, LLC operations ... Contractual agreements for provision of services by Transitions Indiana LLC to another entity will delineate the responsibilities of all parties ... " 2. A review of an agency policy dated December 2018 titled ";Written Agreement for Contracted Services" indicated but was not limited to, "; ... The organization shall ensure that all services furnished under arrangement provided by other entities or individuals meet the requirements of Medicare Conditions of Participation and accreditation standards ... " 3. A review of an agency contract dated 02/02/2024 titled ";King Communications" was provided by the Administrator on 12/13/2024 when queried regarding on call and phone system. The contract indicated the name on the account Entity 35, the corporation, and their address, The contract further indicated the services provided were answering service, set up fee, daily call report and secure messaging. The contract failed to evidence the services under arrangement were between Transitions Indiana LLC, and Entity 84, the on call answering service. 4. A review of employee records (Transitions Indiana, LLC: Administrative staff 1, 2,3, CNA 1, RN 1, and Entity 17, a hospice agency located in Crown Point: Person 27, Person 28, Person 31, Person 32, Person 37, and Entity 18 a hospice agency located in Fort Wayne: Person 22) evidenced criminal background checks and personnel record content were provided by Entity 35, direct owners/corporation of Entity 17 and Entity 18. 5. A focused review of Entity 17's, a hospice agency located in Crown Point, employee records (Employees: 29, 30, 33, 38, 40, 41, 42, 48, 53, 54, 55, 56, 57, 80, 83, 90, 92, 93, and 94) evidenced the criminal background checks and personnel record content were provided by Entity 35, direct owners/corporation of Entity 17 and Entity 18. 6. A focused review of Entity 18's, a hospice agency located in Fort Wayne, employee records (Employees: 1, 7, 8, 21, 77, 81, 82 and 91) evidenced criminal background checks and personnel record content were provided by Entity 35, direct owners/corporation of Entity 17 and Entity 18. 7. An interview with the Administrator on 12/13/2024 at 1:45 PM, they indicated employee criminal background checks are, "under an umbrella, not done separately." They explained criminal background checks are requested from Entity 35, direct owners/corporation of Entity 17 and Entity 18, whom they believed to be their corporation, Human Resources Department in order for the Administrator to view the records. 8. During an interview on 12/13/2024 at 2:10 PM, when queried regarding the responsibility of the answering service and on call contract, the Administrator confirmed they received the contract provided through Entity 35,direct owners/corporation of Entity 17 and Entity 18, whom they believed to be their corporation, and Entity 84, the on call answering service.

Based on record review and interview Transitions Indiana LLC failed to ensure patients who resided in the Crown Point region, were either transferred to Entity 17, once Transitions Indiana LLC had closed their Crown Point branch, or continued to receive services from staff of the Indianapolis location, and patients who resided in the Fort Wayne Area were not transferred to Entity 18. Additionally non-employees of Entity 17 and Entity 18 failed to follow the chain of command in reporting to Transitions Indiana LLC regarding Indianapolis patients, thereby failing to follow appropriate lines of authority. Findings include: --- 1. A review of an undated agency document titled 'Org Chart Transitions Hospice 2024' indicated field staff including but not limited to: Nursing staff, Chaplain, and Social Worker were to report to 'Nursing Managers', who were to report to the Alternate Administrator, who was then to report the Administrator. The chart failed to evidence Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne, were part of the reporting structure. The agency failed to follow appropriate lines of authority. 2. Review of the organizational chart failed to evidence Transitions Indiana LLC had multiple site locations in Crown Point or Fort Wayne. 3. On 12/11/2024 at 1:40 PM, On 12/11/2024 at 1:40 PM, the Administrator for Transitions Indiana LLC was queried as to whether they were involved or attended IDG meetings for patients on the Indianapolis license who resided in the Crown Point area, indicated 'no, not usually, unless requested', and further indicated the Indianapolis DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17 staff including their Administrator, DON, Social Worker, and Chaplain were all involved in those Indianapolis patients' IDG meeting and Entity 17 staff were who provided all cares, there were not any employees from this agency (Transitions Indiana LLC) providing care. Further indicated there had been discussion about changing this arrangement and transferring patients from the Transitions Indiana LLC license, who resided in Crown Point, to Entity 17 'soon'. 4. On 12/11/2024 at 2:16 PM, the DON for Transitions Indiana LLC indicated was responsible for nurses and patients in the Indianapolis location. When queried as to whether they knew there were Indianapolis patient's in the Crown Point area, indicated honestly did not know, and Entity 17 was caring for those Indianapolis patients. When queried as to the total number of patients being cared for by Entity 17 and Entity 18 indicated did not know the number of patients for either location. The DON indicated because they (Entity 17 and Entity 18) have directors of nursing of their own, they don't pull me in. When queried as to whether the other DONs from Entity 17 and Entity 18 were on the Transitions Indiana LLC license, indicated they all were. 5. On 12/11/2024 at 9:37 PM, Person 46, am LPN with Entity 17 indicated was on-call for Entity 17. When queried about receiving calls after hours, and if they knew which patients belonged to Indianapolis, indicated had no idea there were patients in Entity 17's service area who were considered Indianapolis patients. Indicated if they needed to make a visit after hours they would just go and complete the visit. When queried regarding who they report if there were a concern or complaint regarding an Indianapolis patient, indicated would report to Person 31, the DON for Entity 17, or Person 32, the Administrator for Entity 17, and indicated they did not know who the Administrator nor DON were for the Indianapolis office. 6. On 12/12/2024 at 9:04 AM with Person 23, the DON for Entity 18, indicated knew who the Indianapolis patients were, which Entity 18 serviced as they kept a spreadsheet. When queried as to who the DON on the Indianapolis license, indicated did not know. 7. On 12/12/2024 at 11:02 AM, Person 32, the Administrator for Entity 17, indicated Entity 17 was its own agency; no longer a branch of Indianapolis since Entity 17received their own license a couple of years ago. Entity 17 staff provided hospice services to 15 Transitions Indiana LLC patients. The 15 Transitions Indiana LLC patients were billed through Indianapolis office and were in the Indianapolis electronic medical record. IDG for the 15 Indianapolis patients is done by Entity 17's IDG team and not Indianapolis. The care for the Transitions Indiana LLC patients is coordinated by communicating with the Indianapolis leadership when there is a specific need. 8. On 12/13/2024 at 1:14 PM, Person 19, RN for entity 18, indicated they case managed all the hospice patients in Warsaw which included patients under the Transitions Indiana, LLC license. Person 19 further indicated the patients seen in that area for Transitions Indiana, LLC were seen by Entity 18s staff and they reported patient conditions to Entity 18s DON and Administration staff. 9. On 12/13/2024 at 3:17 PM, the Administrator indicated Entity 17 employees were not great at communicating with her. 10. On 12/13/2024 at 4:22 PM, with Person 27, a nurse with Entity 17, indicated provided cares for Indianapolis patients and reported to Person 31, a DON at Entity 17 for all patients, even Indianapolis patients. Indicated did not know who Indianapolis DON was. 10. On 12/13/2024 at 4:30 PM, with Person 28, a social worker with Entity 17 indicated reported to Entity 17's DON, Person 31, for any care coordination needs of Indianapolis patients, and Person 31 then reports any issues to Indianapolis office. 11. On 12/16/2024 at 1:02 PM, with Person 54, a chaplain with Entity 17 when queried was not sure of who the Administrator or DON were at Indianapolis office. 12. On 12/17/2024 at 9:30 AM, Corporate Person 1 indicated all 855's for each of the three hospice agencies; Transitions Indiana LLC, Entity 17 and Entity 18, had the same ownership. A review of the Indiana Department of Health (IDOH) records evidenced Transitions Indiana LLC was directly owned by Entity 89 since 2016, while Entity 17 and 18 were directly owned by Entity 35. 13. On 12/17/2024 at 11:15 AM, with Person 26, a chaplain with Entity 17, when queried indicated they reported to the Administrator or DON at Crown Point. 14. On 12/17/2024 at 1:22 PM in an interview, the DON for Transitions Indiana LLC, when queried whether Entity 17 and Entity 18, staff communicated with her about Transitions Indiana LLC patients, indicated 'not yet' and 'that concerns me'.

Based on record review an interview Transitions Indiana LLC failed to safeguard patients health information against unauthorized use, when Entity 17, a hospice agency located in Crown Point, and Entity 18, a hospice agency located in Fort Wayne, had access to Transitions Indiana LLC patient electronic medical records (EMR), in 39 of 39 active records reviewed (Patients: #2, 4, 5, 6, 7, 8, 9, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50) Findings include: --- 1. A review of a Transitions Indiana LLC agency document revised December 2018, titled 'HIPAA SECURITY AUDIT CONTROLS Policy No. 6-038' stated, "... To ensure the Transitions Indiana LLC's systems containing ePHI [electronic Protected Health Information] are regularly audited for HIPAA [Health Insurance Portability Act, federal standards established to protect sensitive health information from disclosure without patient's consent] compliance ..." 2. A review of a Transitions Indiana LLC agency document revised December 2018, titled 'BILL OF RIGHTS - Policy No. 9-005' stated, "... 1. The Bill of Rights statement defines the right of the patient to : ... H. Have a confidential record maintained by the organization ..." 3. A review of an agency document titled 'Client Census Report' indicated 15 Indianapolis patients were being serviced by Entity 17. 4. A review of an agency document titled 'Client Census Report' indicated 24 Indianapolis patients were being serviced by Entity 18. 5. A review of an agency document titled 'Client Schedule Report', evidenced Entity 17 and Entity 18 staff had access to Transitions Indiana LLC's confidential patient records and completed visits within the agency's Electronic Medical Record System: From Entity 17: Persons, including but not limited to: 26, 27, 28, 29, 30, 31, 32, 33, 37, 38, 42, 50, 51, 52, 53, 54, 55, 56, and 57 had conducted visits and documented in the agency's EMR for Transitions Indiana LLC Patients (#2, 4, 5, 8, 9, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50). From Entity 18: Persons, including but not limited to: 19, 20, 21, 22, 23, 39, and 82 had also conducted visit and documented in the EMR of Indianapolis patients on the Transitions Indiana LLC. license (Patients #6, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, and 40). The agency failed ensure the confidentiality of clinical records of 39 patients as records were accessible to non-employees of agencies Entity 17 and Entity 18. 6. On 12/11/2024 at 1:40 PM, the Administrator indicated the DON, Chaplain, and Social Worker did not take part in IDG, but indicated Entity 17's staff including their Administrator, DON, Social Worker, and Chaplain were all involved with Indianapolis patients' IDG meeting and Entity 17's staff were who provided all cares, and there were not any employees from this agency (Transitions Indiana, LLC.) providing care. 7. On 12/11/2024 at 2:16 PM, the DON from Transitions Indiana LLC indicated was responsible for nurses and patients in the Indianapolis location. When queried as to whether they knew there were Indianapolis patients in the Crown Point area, indicated honestly did not know and Entity 17 was caring for those Indianapolis patients. When queried as to the total number of patients being cared for by Entity 17 and Entity 18, indicated did not know the number of patients for either location. 8. On 12/12/2024 at 9:04 AM with Person 23, the DON for Entity 18, indicated knew who the Indianapolis patients were which Entity 18 serviced as they kept a spreadsheet. When queried as to who was the DON on the Indianapolis license, indicated did not know. 9. On 12/12/2024 at 11:02 AM with Person 32, an administrator with Entity 17, indicated Entity 17 was its own agency and no longer a branch of Indianapolis, since Entity 17 received their own license a couple of years ago. Indicated Entity 17 provides hospice services to fifteen (15) Indianapolis patients, and also provides services to all of their own patients. The fifteen (15) Indianapolis patients were billed through Indianapolis office and those patients were in the Indianapolis electronic health record (EHR). The care for the Indianapolis patients was coordinated by communicating with the Indianapolis leadership when there was a specific need. 10. During an interview on 12/12/2024 at 12:42 PM, when queried regarding the IDG meetings process and attendance, Person 22, the RN Case Manager at Entity 18, indicated they attend IDG every other week at Entity 18 with Entity 18s DON, MSW, Chaplain, and the Medical Director. Person 22 confirmed they were an employee of Entity 18, and they case managed and conducted visits, admissions, recertifications, and IDGs for the patients of Transitions Indiana LLC admitted in the Fort Wayne. Person 22 indicated the other weeks Person 19 the other RN Case Manager with Entity 18 attended. 11. During an interview on 12/13/2024 at 12:47 PM, Person 22, RN Case Manager for Entity 18, indicated they oversee the patients admitted under the Transitions Indiana LLC, license their patients with Medicaid in the Fort Wayne location. Person 22 further indicated Person 19, RN Case Manager oversees their patients in Warsaw area. Person 22 confirmed they and Person 19 were an employees for Entity 18, and the patients were seen by employees of Entity 18. 12. On 12/13/2024 at 4:03 PM, with Person 50, a nurse with Entity 17, indicated provided care for five (5) patients from the Indianapolis office. Indicated was an employee of Entity 17. Indicated had no training conducted in Indianapolis. 13. On 12/13/2024 at 4:22 PM, with Person 27, a nurse with Entity 17, indicated was employed through Entity 17, not Indianapolis. Indicated provided cares for Indianapolis patients and reported to Person 31, a DON at Entity 17 for all patients, even Indianapolis patients. Indicated did not know who Indianapolis DON was. 14. On 12/13/2024 at 4:30 PM, with Person 28, a social worker with Entity 17, indicated was employed through Entity 17, not Indianapolis. 15. On 12/16/2024 at 1:02 PM, with Person 54, a chaplain with Entity 17, indicated was employed through Entity 17's office; not employed with Indianapolis office. Indicated provided services for a few of Indianapolis patients but could not recall the names. 16. On 12/16/2024 at 1:09 PM, with Person 42, a nurse with Entity 17, indicated was an employee of Entity 17 and made visits to Indianapolis patients in Entity's 17 region. When queried as to how they were able to tell which patients belonged to Indianapolis vs Entity 17, indicated there were separate lists, and they were broken up in IDG, and Indianapolis patients were reviewed first at IDG. 17. During an interview on 12/17/2024 at 10:17 AM, when queried regarding visits made by Entity 17 staff, and Entity 18 staff to patients under the Transitions Indiana LLC license, Corporate staff 1, the Vice President of Operations, indicated Entity 17 and 18 did not have a Medicaid license and had admitted patients under the Transitions Indiana LLC license and provided care and treatment.

Based on record review and interview, the agency failed to ensure all core services provided by RNs, Social Workers, and counselors, were employed by Transitions Indiana, LLC for 24 of the 27 active clinical records reviewed of their patients who reside in a skilled nursing facility or an assisted living facility. (Patients: #2, 6, 9, 18, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 35, 40, 41, 42, 44, 45, 46, and 49) Findings include: --- 1. A review of an agency policy dated December 2018 titled ";Provision of Care to Residents of SNF/NF of ICF/IID" indicated but was not limited to, "; ... Core services including physician, nursing, social work, counselors, medical supplies, durable medical supplies and drugs will be directly provided by hospice ... " 2. A review of the clinical record for Patient #2 contained a recertification plan of care for benefit period 10/18/2024 to 12/16/2024. The plan of care indicated Patient #2 had orders for SN 2 times per week for 2 week, 2 times a week for 7 weeks, and 1 time a week for 1 week, and 4 PRN visits for symptom decline; MSW 1 time every 2 months for 2 months, 1 time per month for 1 month; HHA 1 time a week for 1 week, 5 times a week for 8 weeks, 1 time per week for 1 week; and Chaplain 1 time every 2 months for 2 months, 1 time per month, and 2 PRN visits for spiritual support. Further review of the record indicated Patient #2s place of residence was at Entity #66, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #2 by Person 38, an RN for Entity 17, a hospice agency located in Crown Point; Person 26, a chaplain for Entity 17, Person 80, an HHA for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #2 by Transitions Indiana LLC. 3. A review of the clinical record for Patient #6 contained a recertification plan of care for benefit period 10/24/2024 to 12/26/2024. The plan of care indicated Patient #6 had orders for SN 2 times per week for 9 weeks, and 4 PRN visits for symptom decline; HHA 3 times a week for 8 week, 2 times per week for 1 week; and MSW 2 times per month for 2 months and 2 PRN visits for social support. Further review of the record indicated Patient #6s place of residence was at Entity #6, an assisted living facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #6 by Person 19, an RN for Entity 18, a hospice agency located in Fort Wayne; Person 82 a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #18 by Transitions Indiana LLC. 4.A review of the clinical record for Patient #9 contained a recertification plan of care for benefit period 11/24/2024 to 01/22/2024. The plan of care indicated Patient #9 had orders for SN 2 times per week for 9 weeks, and 4 PRN visits for symptom decline; MSW 1 time every 2 months for 2 months, and 2 PRN for additional support; HHA 3 times a week for 8 weeks, 2 time per week for 1 week; and Chaplain 1 time every 2 months for 2 months, and 2 PRN visits for spiritual support. Further review of the record indicated Patient #9s place of residence was at Entity #68, an assisted living facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #9 by Person 50, an RN for Entity 17, Person 26, a chaplain for Entity 17, Person 83, an HHA for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #9 by Transitions Indiana LLC. 5. A review of the clinical record for Patient #18 contained a recertification plan of care for benefit period 10/04/2024 to 12/02/2024. The plan of care indicated Patient #18 had orders for SN 1time a week for 1 week, 2 times a week for 8 weeks, and 1 time a week for 1week, and 4 PRN visits for symptom decline; HHA 2 times a week for 8 week; and Chaplain 1 time a month for 2 months and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 10/04/2024 to 12/02/2024. The IDG report indicated Patient #18s place of residence was at Entity #24, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #18 by Person 22, a RN for Entity 18, Person 21, a chaplain for Entity 18, Person 78, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #18 by Transitions Indiana LLC. 6. A review of an agency document titled ";Hospice Agreement" signed and dated April 11, 2024, between Transitions Indiana LL and Entity 24 indicated but was not limited to, ";... B9. Core Hospice Services. The following services will be provided directly by Hospice employees on a routine basis: nursing care provided by or under the supervision of a registered nurse, medical social services ... and counseling ... " During an interview on 12/13/2024 at 12:48 PM Person 2, a RN for Entity 18, indicated they see all patients who have Medicaid under the Transitions Indiana LLC license due to their agency does not have a Medicaid license. Person 2 further indicated the patients in the skilled nursing facilities of Transition Indiana LLC in the Fort Wayne area were cased managed by them and were seen by the Chaplain, social worker, and CNAs of Entity 18. 7. A focused review of the clinical records for Patient # 22, contained a recertification plan of care for benefit period 11/14/2024 to 01/12/2025. The plan of care indicated Patient #22 had orders for SN 1 time a week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 1 time a month for 1 month, 2 times a month for 1 month, 1 time a month for 1 month, and 2 PRN visits for social support; HHA 1 time for 1 week, and 3 times a week for 8 weeks; and Chaplain 1 time a month for 2 months, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/14/2024 to 01/12/2025. The IDG report indicated Patient #22s place of residence was at Entity #61, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #22 by Person 22, a RN for Entity 18, Person 19 RN for Entity 18, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #22 by Transitions Indiana LLC. 8. A focused review of the clinical records for Patient # 29, contained a recertification plan of care for benefit period 11/14/2024 to 01/12/2025. The plan of care indicated Patient #29 had orders for SN 1 time every 2 weeks for 2 weeks, 1 times a week for 7 weeks, and 4 PRN visits for symptom decline; MSW 1 time a month for 1 month, 2 times a month for 1 month, 1 time a month for 1 month, and 2 PRN visits for social support; HHA 1 time for 1 week, and 2 times a week for 8 weeks: and Chaplain 1every 2 months for 2 months, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/14/2024 to 01/12/2025. The IDG report indicated Patient #29s place of residence was at Entity #61, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #29 by Person 22, a RN for Entity 18, Person 19 RN for Entity 18, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #29 by Transitions Indiana LLC. 9. A focused review of the clinical record for Patient #21 contained a recertification plan of care for benefit period 11/04/2024 to 01/02/2025. The plan of care indicated Patient #21 had orders for SN 1 time every 2 weeks for 2 weeks, 1 times a week for 7 weeks, and 4 PRN visits for symptom decline; MSW 1 time a month for 1 month, 2 times a month for 1 month, 1 time a month for 1 month, and 2 PRN visits for social support; HHA 1 time for 1 week, and 2 times a week for 8 weeks: and Chaplain 1every 2 months for 2 months, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/04/2024 to 01/02/2025. The IDG report indicated Patient #21s place of residence was at Entity #60, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #21 by Person 22, a RN for Entity 18, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #21 by Transitions Indiana LLC. 10. A review of an agency document titled ";Residential Hospice Care Agreement For Services To Residents of Nursing Facilities" signed and dated June 15, 2023, between Transitions Indiana LLC and Entity 60, the skilled nursing facility. indicated but was not limited to, ";... 2.1 Hospice Services. ... Transitions will make available Hospice Services in accordance with the Medicare Conditions of Participation for hospice care, 42 C. F. R Part 418 ... " 11. A focused review of the clinical record for Patient #24 contained a recertification plan of care for benefit period 11/08/2024 to 01/06/2025. The plan of care indicated Patient #24 had orders for SN 1 time every 2 weeks for 2 weeks, 1 times a week for 7 weeks, and 4 PRN visits for symptom decline; MSW 1 time a month for 1 month, 2 times a month for 1 month, 1 time a month for 1 month, and 2 PRN visits for social support; HHA 1 time for 1 week, and 2 times a week for 8 weeks: and Chaplain 1every 2 months for 2 months, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/04/2024 to 01/02/2025. The IDG report indicated Patient #24s place of residence was at Entity #62, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice had been provided to Patient #24 by Person 19, and Person 22, RNs for Entity 18, a hospice agency located in Fort Wayne, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #24 by Transitions Indiana LLC. 12. A focused review of the clinical record for Patient #26 contained a recertification plan of care for benefit period 11/01/2024 to 12/30/2024. The plan of care indicated Patient #26 had orders for SN 1 time a week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 2 times a month for 2 months, and 2 PRN visits for social support; HHA 1 time for 1 week, 3 times a week for 8 weeks, and 1 time a week for 1 week; and Chaplain 2 times a month for 2 months, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/01/2024 to 12/30/2024. The IDG report indicated Patient #26s place of residence was at Entity #62, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #26 by Person 19, and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #26 by Transitions Indiana LLC. During an interview on 12/13/2024 at 1:14 PM, Person 19, RN for Entity 18, indicated they case managed all the hospice patients in Warsaw which included patients under the Transitions Indiana, LLC license. Person 19 further indicated the patients seen in that area for Transitions Indiana, LLC were seen by Entity 18s staff and they reported patient conditions to Entity 18s DON and Administration staff. 13. A review of an agency document titled ";Residential Hospice Care Agreement For Services To Residents of Nursing Facilities" signed and dated February 18, 2022, between Transitions Indiana LLC and Entity 62, the skilled nursing facility. indicated but was not limited to, ";... 2.1 Hospice Services. ... Transitions will make available Hospice Services in accordance with the Medicare Conditions of Participation for hospice care, 42 C. F. R Part 418 ... " 14. A focused review of the clinical record for Patient #27 contained a recertification plan of care for benefit period 10/30/2024 to 12/28/2024. The plan of care indicated Patient #27 had orders for SN 2 time a week for 8 weeks, 1 time a week for 1 week, and 4 PRN visits for symptom decline; MSW 1 times a month for 2 months, and 2 PRN visits for social support; HHA 6 times for 8 weeks, 4 times a week for 1week; and Chaplain 2 times a month for 2 months, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 10/30/2024 to 12/28/2024. The IDG report indicated Patient #27s place of residence was at Entity #64, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #27 by Person 19, and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 81and Person 82, CNAs for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #27 by Transitions Indiana LLC. 15. A review of an agency document titled ";Residential Hospice Care Agreement For Services To Residents of Nursing Facilities" signed and dated July 21, 2022, between Transitions Indiana LLC and Entity 64, the skilled nursing facility. indicated but was not limited to, ";... 2.1 Hospice Services. ... Transitions will make available Hospice Services in accordance with the Medicare Conditions of Participation for hospice care, 42 C. F. R Part 418 ... " 16. A focused review of the clinical record for Patient #25 contained a recertification plan of care for benefit period 11/09/2024 to 01/07/2025. The plan of care indicated Patient #25 had orders for SN 1 time a week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 1 times a month for 2 months, and 2 PRN visits for social support; HHA 4 times for 8 weeks, 2 times a week for 1week; and Chaplain 2 times a month for 2 months, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/09/2024 to 01/07/2025. The IDG report indicated Patient #25s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #25 by Person 19, and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 81and Person 82, CNAs for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #25 by Transitions Indiana LLC. 17. A focused review of the clinical record for Patient #28 contained a recertification plan of care for benefit period 11/13/2024 to 01/11/2025. The plan of care indicated Patient #28 had orders for SN 1 time a week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 1 times a month for 2 months, and 2 PRN visits for social support; HHA 4 times for 8 weeks, 2 times a week for 1week; and Chaplain 2 times a month for 2 months, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/13/2024 to 01/11/2025. The IDG report indicated Patient #28s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #28 by Person 22, a RN for Entity 18, Person 21, a chaplain for Entity 18, Person 81and Person 82, CNAs for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #28 by Transitions Indiana LLC. 18. A focused review of the clinical record for Patient #30 contained a recertification plan of care for benefit period 11/16/2024 to 01/14/2025. The plan of care indicated Patient #30 had orders for SN 2 times every 2 weeks for 2 weeks, 2 times a week for 7 weeks, 1 time a week for 1 week, and 4 PRN visits for symptom decline; MSW 1 times a month for 2 months, and 2 PRN visits for social support; HHA 2 times for 8 weeks, 1 time a week for 1week; and Chaplain 1 time every 2 months for 2 months, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/16/2024 to 01/14/2025. The IDG report indicated Patient #30s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #30 by Person 19 and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 81and Person 82, CNAs for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #30 by Transitions Indiana LLC. 19. A focused review of the clinical record for Patient #31 contained an initial plan of care for benefit period 12/12/2024 to 03/11/2025. The plan of care indicated Patient #31 had orders for SN 2 times week for 13 weeks, 1 time a week for 1 week, and 4 PRN visits for symptom decline; MSW 1 time a month for 1 month for evaluation; HHA 2 times for 12 weeks, 1 time a week for 1week; and Chaplain 1 time every 1 months for 1 month for evaluation. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 12/12/2024 to 03/11/2025. The IDG report indicated Patient #31s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #31 by Person 19 and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 81, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #31 by Transitions Indiana LLC. 20. A focused review of the clinical record for Patient #32 contained a recertification plan of care for benefit period 12/16/2024 to 02/13/2025. The plan of care indicated Patient #32 had orders for SN 2 times a week for 8 weeks, 1 time a week for 1 week, and 4 PRN visits for symptom decline; HHA 2 times for 9 weeks; and Chaplain 1 time a month for 1 month, 2 times a months for 1 month, 1 time a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 12/16/2024 to 02/13/2025. The IDG report indicated Patient #32s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #32 by Person 19 and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, and Person 81, a CNA for Entity 18. The clinical record failed to evidence core services had been provided to Patient #32 by Transitions Indiana LLC. 21. A focused review of the clinical record for Patient #33 contained a recertification plan of care for benefit period 11/30/2024 to 01/28/2025. The plan of care indicated Patient #33 had orders for SN 2 times every 2 weeks for 2 weeks, 2 times a week for 7 weeks, 1 time a week for 1 week, and 4 PRN visits for symptom decline; MSW 2 times every 2 months for 2 months, 2 times month for 1 month, and 2 PRN visits for social support; HHA 2 times for 8 weeks, 1 time a week for 1week; and Chaplain 2 time every 2 months for 2 months, 2 times a month for 1 month, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/30/2024 to 01/28/2025. The IDG report indicated Patient #33s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #33 by Person 19 and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 77 and Person 78, CNAs for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #33 by Transitions Indiana LLC. 22. A focused review of the clinical record for Patient #35 contained a recertification plan of care for benefit period 11/01/2024 to 12/30/2024. The plan of care indicated Patient #35 had orders for SN 1 time every 2 weeks for 2 weeks, 1 time a week for 7 weeks, and 4 PRN visits for symptom decline; MSW 1 times a month for 2 months, and 2 PRN visits for social support; HHA 2 times for 8 weeks; and Chaplain 1 time a month for 2 months, and 2 PRN visits for spiritual support. A review of an agency document titled ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for the benefit period dated 11/01/2024 to 12/30/2024. The IDG report indicated Patient #35s place of residence was at Entity #63, a skilled nursing facility, receiving routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #35 by Person 19 and Person 22, RNs for Entity 18, Person 21, a chaplain for Entity 18, Person 77, a CNA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #35 by Transitions Indiana LLC. 23. A review of an agency document titled ";Residential Hospice Care Agreement For Services To Residents of Nursing Facilities" signed and dated December 23, 2021, between Transitions Indiana LLC and Entity 63, the skilled nursing facility. indicated but was not limited to, ";... 2.1 Hospice Services. ... Transitions will make available Hospice Services in accordance with the Medicare Conditions of Participation for hospice care, 42 C. F. R Part 418 ... " During an interview on 12/17/2024 at 10:17 AM, when queried regarding the patients under Transitions Indiana LLC being seen and managed by Entity 17's, a hospice agency located in Crown Point, and Entity 18's, staff, the Director of Operations, of Entity 35, indicated Entity 17 and 18 do not have their Medicaid license so the patients up north are admitted under the Transitions Indiana, LLC license. 24. A review of the clinical record for Patient #40 contained a recertification plan of care for benefit period 11/29/2024 to 01/27/2024. The plan of care indicated Patient #40 had orders for SN 1 time per week for 1 week, 3 times per week for 8 weeks, 1 time per week for 1 week and 4 PRN visits for symptom decline; MSW 1 time every 2 months for 2 months, and 2 PRN for additional support; HHA 1 time a week for 1 week, 2 times a week for 8 weeks, 1 time per week for 1 week; and MSW 1 time every 2 months for 2 months, 1 time per month for 1 month, and 2 PRN visits for social support. Further review of the record indicated Patient #40s place of residence was at Entity #24, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #40 by Person 22, an RN for Entity 18, Person 81, an HHA for Entity 18, and Person 20 the MSW for Entity 18. The clinical record failed to evidence core services had been provided to Patient #40 by Transitions Indiana LLC. 25. A review of the clinical record for Patient #41 contained a recertification plan of care for benefit period 10/23/2024 to 12/21/2024. The plan of care indicated Patient #41 had orders for SN 1 time per week for 1 week, 2 times per week for 8 weeks, and 4 PRN visits for symptom decline; MSW 1 time every 2 months for 2 months, and 2 PRN for additional support; HHA 3 times a week for 1 week, 5 times a week for 8 weeks; and Chaplain 1 time every 2 months for 2 months, and 2 PRN visits for spiritual support. Further review of th e record indicated Patient #41s place of residence was at Entity #71, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #41by Person 33, an RN for Entity 17, Person 26, a chaplain for Entity 17, Person 83, an HHA for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #41 by Transitions Indiana LLC. 26. A review of the clinical record for Patient #42 contained a recertification plan of care for benefit period 10/23/2024 to 12/21/2024. The plan of care indicated Patient #42 had orders for SN 1 time per week for 1 week, 2 times per week for 8 weeks, and 4 PRN visits for symptom decline; HHA 1 time per week for 1 week, 2 times a week for 8 weeks. Further review of the record indicated Patient #42s place of residence was at Entity #71, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #42 by Person 29, an RN for Entity 17, and Person 55 a CNA for Entity 17. The clinical record failed to evidence core services had been provided to Patient #42 by Transitions Indiana LLC. 27. A review of the clinical record for Patient #44 contained a recertification plan of care for benefit period 10/23/2024 to 12/21/2024. The plan of care indicated Patient #44 had orders for SN 2 times per week for 9 weeks, and 4 PRN visits for change in condition; MSW 2 times every month for 2 months, and 2 PRN for additional support; HHA 3 times a week for 8 weeks. Further review of the record indicated Patient #44s place of residence was at Entity #73, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #44 by Person 27, an RN for Entity 17, Person 80, an HHA for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #44 by Transitions Indiana LLC. 28. A review of the clinical record for Patient #45 contained a recertification plan of care for benefit period 11/14/2024 to 01/12/2025. The plan of care indicated Patient #45 had orders for SN 1 time per week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 2 times every months for 2 months; HHA 2 times per week for 1 week, 5 times a week for 8 weeks; and Chaplain 1 time per month for 1 month, 2 times per month for 1 month, 1 time per month for 1 month, and 2 PRN visits for spiritual support. Further review of the record indicated Patient #45s place of residence was at Entity #74, an assisted living facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #45 by Person 42, an RN for Entity 17, Person 26, a chaplain for Entity 17, Person 53, an aide for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #45 by Transitions Indiana LLC. 29. A review of the clinical record for Patient #46 contained a recertification plan of care for benefit period 12/11/2024 to 02/08/2025. The plan of care indicated Patient #46 had orders for SN 1 time per week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 1 time every 2 months for 2 months, 1 time per month for 1 month and 2 PRN visits for social support; and HHA 3 times per week for 1 week, 5 times a week for 8 weeks. Further review of the record indicated Patient #46s place of residence was at Entity #75, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #46 by Person 42, an RN for Entity 17, Persons 53 and 55, aides for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #46 by Transitions Indiana LLC. 30. A review of the clinical record for Patient #49 contained a recertification plan of care for benefit period 12/09/2024 to 02/06/2025. The plan of care indicated Patient #49 had orders for SN 1 time per week for 1 week, 2 times a week for 8 weeks, and 4 PRN visits for symptom decline; MSW 2 times per month for 2 months, 1 time per month for 1 month and 2 PRN visits for social support; and HHA 3 times per week for 8 week, 2 times per week for 1 week. Further review of the record indicated Patient #49s place of residence was at Entity #72, a skilled nursing facility, received routine homecare. The IDG report provided a comprehensive review of hospice care had been provided to Patient #49 had by Person 42, an RN for Entity 17, Person 55, an aide for Entity 17, and Person 28 the MSW for Entity 17. The clinical record failed to evidence core services had been provided to Patient #49 by Transitions Indiana LLC.

Based on record review and interview Transitions Indiana, LLC failed to conduct 'National' or 'Expanded' criminal background checks for 2 of 3 Nurse Practitioners who serviced their patients. (Corporate Employees: 7, and 8) Findings include: --- On 12/13/2024 at 2:13 PM the Administrator provided a contract which they believed to be between Transitions Indiana LLC, the agency and corporate, titled AGREEMENT BETWEEN TRANSITIONS INDIANA LLC AND TRANSITIONS INTEMEDIATE HOLDINGS LLC which evidenced a date of March 12, 2022. On 12/17/2024 at 9:30 AM with Corporate Person 1, Vice President of Operations, indicated all agencies (Transitions Indiana LLC, Entity 17, a hospice located in Crown Point, and Entity 18, a hospice located in Fort Wayne) all had the same ownership and indicated he/she reported to Corporate Person 9, COO of Entity 89. When queried as to what Entity 89 was, indicated the entire company, and all agencies were on separate licenses. On 12/17/2024 at 10:10 AM, Corporate Person 3 indicated it all rolls up to [Entity 35, the direct owners/corporation of Entity 17, a hospice agency locate in Crown Point, and Entity 18, a hospice agency located in Fort Wayne]. 1. A review of an agency document, titled '1-005– Selection/Hiring of Personnel' stated, "... A criminal background check will be obtained for positions as required by laws and regulations ..." 2. A review of the personnel file for Corporate Staff 7, Corporate Nurse Practitioner evidenced a National Sex Offender search performed on 09/26/2020, and failed to evidence a criminal history background check had been completed. 3. A review of the personnel file for Corporate Staff 8, Corporate Nurse Practitioner evidenced a National Sex Offender search and Office of the Inspector General (OIG) performed on 05/27/2022, and failed to evidence a criminal history background check had been completed. 4. An interview with the Administrator on 12/13/2024 at 1:45 PM, they indicated employee criminal background checks are, "under an umbrella, not done separately." They explained criminal background checks are requested from Entity 35, direct owners/corporation of Entity 17 and Entity 18, whom they believed to be their corporation, Human Resources Department in order for the Administrator to view the records 5. On 12/18/2024 at 4:02 PM, queried Administrator for Transitions Indiana, LLC regarding criminal background check not provided for Corporate Staff 7, indicated human resources for Entity 35, direct owners/corporation of Entity 17 and Entity 18, whom they believed to be their corporation informed them the Nurse Practitioners were ";consultants" and did not need criminal background checks completed. The Administrator indicated criminal history background checks were not performed for Corporate Staff 7 and Corporate Staff 8 and should have been done.

Based on record review and interview Transitions Indiana, Inc failed to evidence the employee criminal background checks were completed within 3 months of hire for 5 of 5 employees of Transitions of Indiana, LLC. (Employees: RN 1; CNA 1; the Administrator, DON, and the Medical Director). Findings include: --- On 12/13/2024 at 2:13 PM the Administrator provided a contract which they believed to be between Transitions Indiana LLC, the agency and corporate, titled AGREEMENT BETWEEN TRANSITIONS INDIANA LLC AND TRANSITIONS INTEMEDIATE HOLDINGS LLC which evidenced a date of March 12, 2022. On 12/17/2024 at 9:30 AM with Corporate Person 1, Vice President of Operations, indicated all agencies (Transitions Indiana LLC, Entity 17, a hospice located in Crown Point, and Entity 18, a hospice located in Fort Wayne) all had the same ownership and indicated he/she reported to Corporate Person 9, COO of Entity 89. When queried as to what Entity 89 was, indicated the entire company, and all agencies were on separate licenses. On 12/17/2024 at 10:10 AM, Corporate Person 3 indicated it all rolls up to [Entity 35, the direct owners/corporation of Entity 17, a hospice agency locate in Crown Point, and Entity 18, a hospice agency located in Fort Wayne]. 1. A review of an agency document, titled '1-005 – Selection/Hiring of Personnel' stated, "... A criminal background check will be obtained for positions as required by laws and regulations ..." 2. A review of personnel files, (Employees: RN 1; CNA 1; the Administrator, DON, and the Medical Director) for Transitions of Indiana LLC evidenced all employee background checks were completed by Entity 35, direct owners/corporation of Entity 17 and Entity 18, and not by the agency. 3. On 12/18/2024 at 4:02 PM, when queried regarding criminal background checks being completed within 3 months of hire, the Administrator for Transitions of Indiana, LLC indicated they were completed by 'corporate.'

Based on observation, record review, and interview, the agency failed to ensure the Registered Nurse (RN) and Certified Nursing Assistant (CNA) followed standard precautions to prevent the spread of infections and communicable diseases in 3 of 3 home visits. (Employees: RN 1 (twice), and CNA 1) (Patients: #1, 2, and 4) Findings include: --- 1. An agency policy revised December 2018, titled ";Hand Hygiene" indicated but was not limited to, ";Purpose: To prevent cross-contamination and home care-acquired infections ... Hand decontamination using an alcohol-based hand rub should be performed: A. Before having direct contact with patients ... C. After contact with a patients intact skin ... E. When moving from a contaminated body site to a clean body site during patient care ... F. After contact with inanimate objects (including medical equipment) ... G. After removing gloves ... Handwashing with Soap and Water ... 3. Rinse with warm water and dry hands with a disposable towel ... Use a dry disposable towel to run off faucet ... " 2. During a home visit at the residence of Patient #1, on 02-21-2024 at 9:00 AM, RN 1, was observed completing their physical assessment of Patient #1. The RN documented the patients response to pain, appetite, bowels, and bladder regime. RN 1 obtained blood pressure, temperature, and oxygen saturation (an instrument that measures the amount of oxygen circulating in the blood) readings. RN 1 removed their gloves, discarded their gloves into the trash receptacle, and performed hand hygiene. The RN obtained their tablet from the table, documented in the tablet, and then requested Patient #1 to sign the completed visit on the tablet screen with their finger. Patient #1 used their bare finger on the tablet screen to sign their name. RN 1 did not offer or instruct Patient #1 to use hand sanitizer after they used their bare finger on the tablet. 3. During a home visit at the residence of Patient #4, on 02-21-2024 at 10:10 AM, RN 1 was observed completing their assessment of Patient #4. RN 1 placed the oxygen saturation meter on Patient #4s left index finger. Patient #4 had hand tremors that caused the oxygen saturation meter to fall on the floor. RN 1 picked up the oxygen saturation meter off the floor, placed it back on the patients left index finger, then placed it on the right index finger to obtain a reading. RN 1 failed to clean the oxygen saturation meter after it fell on the floor and before they placed it back on Patient #4 finger. During an interview on 02-21-2024 at 10:46 AM, RN 1 confirmed they should have cleaned the pulse oximeter meter after it fell on the floor before placing it back on Patient #4s finger. RN 1 further indicated Patient #1 should have been offered hand hygiene after signing the tablet with their bare finger. 4. During a home visit at the residence of Patient #2, on 02-21-2024 at 11:35 AM, CNA 1 was observed in the bathroom to perform hand hygiene. The CNA washed their hands with soap and water, rinsed their hands, turned the faucet sink off with their clean hands, dried their hands with the tan guest towel that hung from the wall towel hook, and donned new gloves. CNA 1 assisted Patient #2 to the bathroom shower chair, assisted Patient #4 to remove their clothes, and removed the patient's soiled briefs. The CNA discarded the brief in the trash receptacle, removed their gloves, and discarded the gloves into the trash receptacle. CNA 1 again washed their hands with soap and water, rinsed their hands, turned the faucet sink off with their clean hands, dried their hands with the tan guest towel that hung from the wall towel hook, and donned new gloves. The CNA washed Patient #2s face, back, arms, and chest then rinsed each area. CNA 1 assisted the patient to stand and handed the washcloth to Patient #2 to wash their peri area. The CNA then obtained the washcloth from Patient #2 and washed Patient 2's buttocks, then rinsed the patients peri area and buttocks. After Patient #2 was assisted back on the shower chair, CNA 1 added more sop to the same washcloth and washed Patient #2s lower legs and feet. The CNA covered Patient #2 with a lavender towel, removed their gloves, and discarded their gloves in the trash receptacle. CNA 1 again washed their hands using soap and water, rinsed their hands, turned the faucet sink off with their clean hands, dried their hands with the tan guest towel that hung from the wall towel hook, and donned new gloves. The CNA dried the patient and then assisted with dressing. The CNA failed to use paper towels to turn off the faucet, failed to use paper towels to dry their hands, failed to use a different washcloth when going from a dirty area to a clean area, and failed to change gloves and perform hand hygiene after cleaning a dirty area and going to a clean area. During an interview on 02-21-2024 at 12:25 PM, CNA 1, confirmed they were to use a clean washcloth after they washed the peri and buttock area. CNA 1 further indicated they were to use paper towels after they washed and rinsed their hands. 5. During a review of the home visit observations on 02-21-2024 at 1:36 PM, the Administrator and Clinical Manager confirmed hand hygiene and glove changes should be performed when going from dirty to clean areas. The management team further confirmed the patients should be offered hand hygiene after signing the tablets with their bare fingers.

Based on record review and interview, the agency failed to ensure the individualized plan of care included aspiration (when food or liquid goes into the airway) precautions in 1 of 4 active patient records reviewed (Patient #1), with the potential to affect all patients. --- 1. Review of the clinical record for Patient #3, benefit period 4/4/2023 – 7/2/2023, evidenced a plan of care which identified nutritional requirements as a mechanical soft diet (food that is cut into small bites that do not need to be chewed) and thin liquids. The safety precautions in the plan of care failed to identify aspiration precautions. 2. During an interview on 5/3/2023 at 3:55 PM, the Administrator confirmed aspiration precautions were needed when a patient had a mechanical soft diet with thin liquids. The Administrator confirmed aspiration precautions were not on the plan of care. Findings include: 1. Review of agency policy #9-017 titled "The Plan of Care," revised 12/2018, indicated the plan of care should individualized and include "safety measures to protect against ... injury."

Based on record review and interview, the hospice interdisciplinary group (IDG) failed to ensure medication orders for the treatment of the patients end of life respiratory symptoms were obtained for 1 of 2 closed records reviewed (Patient #4) and failed to ensure medication orders for the treatment of urinary tract infection (UTI) symptoms were communicated to the skilled nursing facility staff for 1 of 4 active records reviewed (Patient #3). Findings include: --- Review of the clinical record for Patient #3, benefit election date 1/27/2023, evidenced a nurse visit note for 2/10/2023, completed by registered nurse (RN) 5. The note indicated Patient #3s family was concerned the patient had a urinary tract infection (UTI). RN 5 completed an assessment and contacted the Medical Director, who ordered Keflex (an antibiotic) for 7 days. Review of a nurse visit note for 2/14/2023, completed by RN 6 indicated the nurse at Entity 4, a nursing facility, did not know about an antibiotic for Patient #3. RN 6 indicated he / she wrote an order for the antibiotic, per the Medical Directors order on 2/10/2023. During a telephone interview on 5/4/2023 at 3:25 PM, Other Person 1, a nurse at Entity 4, indicated they received an order on 2/15/2023 for the antibiotic for Patient #3. During an interview on 5/4/2023 at 3:47 PM, the Administrator confirmed Patient #3 did not receive the antibiotic when it was ordered. 1. Review of agency policy #2-002 titled "Verification of Physician Orders," revised 12/2018, indicated orders would be obtained from from a licensed physician "for care and services to be provided to hospice patients." 2. Review of agency policy titled ";Standing Orders," revised 09/2022 and signed by the Medical Director on 10/06/2022, included the hospices standing orders for Morphine Sulfate (opioid medication given to treat pain and air hunger) liquid solution 20 milligrams (mg) per milliliter (ml). The standing order indicated the starting dose of Morphine was to be 5 mg every 1-2 hours as needed for moderate air hunger and call the MD if dose is ineffective after 15-20 minutes. If the air hunger continued after 30 minutes, the morphine was to be titrated to 10 mg every 1-2 hours as needed for severe air hunger. If there was still no relief, the morphine dosage was to be doubled every 2 hours for a maximum dosage of 40 mg. 4. Review of the clinical record for Patient #4 (benefit election date 02/14/2022, discharge date 04/02/2023) included a plan of care for the recertification period 02/09/2023 – 04/09/2023 which indicated Patient #4s terminal diagnosis was Chronic Obstructive Pulmonary Disease (COPD, a chronic respiratory disease) and secondary diagnoses including but not limited to anxiety. The plan of care indicated Patient #4 was to receive skilled nursing services with the frequency of 1 visit per week for 1 week then 3 visits per week for 8 weeks. The record indicated Patient #4s skilled nurse visit frequency was increased to daily on 03/31/2023 due to the patients death being imminent. On 04/01/2023, RN #3 obtained orders to increase the patients Morphine Sulfate 20mg/ml liquid solution from 5 mg to 10 mg, to be given once an hour as needed for severe pain and/or air hunger, and Lorazepam Intensol (medication given to treat anxiety, agitation, and/or restlessness) from 1mg to 2 mg, to be given every hour as needed for anxiety and/or agitation. The record included a ";Care Coordination Note," documented on 04/02/2023 by RN #3, which indicated RN #3 received a call from Patient #4s family member who reported the patient was ";gasping for air." The family member reported they had given the patient 10 mg of Morphine and 2mg of Lorazepam approximately 30 minutes prior to the call. RN #3 documented they instructed Patient #4s family member to administer an additional dose of 10 mg of Morphine to the patient immediately. The patient passed away later that day. The clinical record failed to evidence the nurse obtained an order for the additional 10 mg of Morphine given. During an interview conducted on 05/04/2023 beginning at 3:47 PM, the Administrator reviewed Patient #4s clinical record and confirmed there was no order for the additional 10 mg Morphine RN #3 advised Patient #4s family member to administer on 04/02/2023. The Administrator also confirmed this order did not adhere to the agencys standing orders for Morphine.

Based on observation, record review, and interview, the hospice agency failed to ensure all staff followed infection control policies and procedures specific to hand hygiene and bag technique for 1 of 2 home visit observations conducted (Registered Nurse (RN) #2). Findings include: --- Review of agency policy #7-009 titled ";Hand Hygiene," revised 12/2018, indicated staff should perform hand hygiene after removing gloves by using alcohol-based hand rub. Review of agency policy #7-016 titled ";Bag Technique," revised 12/2018, indicated after a visit was completed, reusable equipment would be cleaned and returned to the bag. During a home visit observation conducted on 05/03/2023 beginning at 11:15 AM with Patient #2 (benefit election date 05/27/2022), RN #2 completed their nurse assessment, wiped their reusable equipment with an alcohol disinfecting wipe, which included a stethoscope, wrist automatic blood pressure monitor, and oxygen saturation (SpO2) monitor, and immediately placed the equipment back into their nursing bag. The nurse wiped their reusable barrier drape with an alcohol disinfecting wipe but failed to wipe all surfaces of the barrier drape which came in to contact with the patients home surfaces. RN #2 folded the barrier drape and placed immediately into their nursing bag, failing to allow it to dry. The nurse then removed their gloves and failed to perform hand hygiene prior to transferring Patient #2 to their dining room via wheelchair. During an interview conducted on 05/03/2023 at beginning at 3:55 PM, the Administrator confirmed staff should perform hand hygiene after removing gloves and after wiping equipment with an alcohol disinfecting wipe, staff should allow equipment to dry prior to returning it to their nursing bag.

Based on observation, record review, and interview, the Registered Nurse (RN) failed to conduct a complete and thorough nursing assessment and medication reconciliation according to best practice and agency policies and procedures specific to lung sounds assessment, pain assessment, and post fall assessment, for 2 of 2 home visit observations conducted with an RN (RN 1 and 2). Findings include: --- During a home visit observation on 5/1/2023 with Patient #1, registered nurse (RN) 1 performed an assessment of the patient. Patient #1 indicated he / she fell on 4/30/2023, landing on his / her bottom. RN 1 failed to visually assess the buttocks area for bruising, skin tear or other injury. During an interview immediately following the home visit, RN 1 confirmed there was no skin assessment completed at the visit. RN 1 indicated a full skin assessment was required once per week and it would be done at the next visit on 5/4/2023. RN 1 confirmed there was no visual assessment for injury related to the fall. During the home visit, Patient #1 indicated there was a change in his / her meclizine (a medication to reduce dizziness). After the visit RN 1 went to the nurses station at Entity 5, an assisted living facility. RN 1 reviewed the medication book. During an interview immediately after the visit, RN 1 indicated there was no change in meclizine. During an interview on 5/3/2023 at 3:55 PM, the Administrator described the process to reconcile medications for a patient in a facility as getting a printed medication list from the facility, comparing it to the hospice medical records and addressing any discrepancies with the physician. The Administrator confirmed checking the medication book at the facility is not sufficient. During an interview on 5/4/2023 at 10:47 AM, RN 1 confirmed he / she did not request a printed medication list from Entity 5. RN 1 confirmed he / she checked for medication changes by looking at Entity 5s medication book. Review of agency policy #1-015 titled ";Ongoing Comprehensive Assessment," revised 12/2018, indicated during each visit, the nurse was to assess the patients pain, breath sounds, skin integrity, safety, and home environment. Review of agency policy #1-018 titled ";Pain Assessment," revised 12/2018, indicated when a clinical was assessing pain of a patient who was unable to communicate pain using a numeric pain rating scale and/or was cognitively impaired, the clinician would ";assess behavioral factors that signal pain or discomfort and include this information in the assessment." Review of agency policy #2-004 titled ";Medication Profile," revised 12/2018, indicated all hospice patients clinical record would have a ";current, accurate medication profile." The policy also indicated a drug regimen review would be performed during comprehensive assessment visits. During a home visit observation conducted on 05/03/2023 beginning at 11:15 AM with Patient #2 (benefit election date 05/27/2022), RN #2 failed to auscultate (listen with a stethoscope) the patients posterior lung lobes when assessing the patients lung sounds. Review of Patient #2s clinical record included a plan of care for the recertification period 03/23/2023 – 05/21/2023 which indicated the patient was to receive skilled nursing visits with the frequency of 2 visits every 2 weeks for 2 weeks, 2 visits per week for 7 weeks, then 1 visit per week for 1 week. The plan of care indicated nursing interventions included but were not limited to monitoring Patient #2s pain level using the PAINAD scale (Pain Assessment in Advanced Dementia Scale, used to assess pain in patients with dementia by measuring breathing, negative vocalization, facial expression, body language, and consolability) ";to monitor effectiveness of present medication regime, controlling pain 4/10 or below and report any changes in pain to physician." The record included a visit note from RN #2s 05/03/2023 visit with Patient #2. The note failed to evidence the nurse used the PAINAD scale to assess Patient #2s pain. During an interview conducted on 05/04/2023 beginning at 10:13 AM with RN #2, the nurse reported they assessed Patient #2s pain by looking for ";visual descriptors" and asking the patients memory care staff if the patient was exhibiting any signs or symptoms of pain. RN #2 was failed to report they used the PAIDAD scale to assess Patient #2s pain per the patients plan of care.

Based on observation, record review, and interview, the hospice agency failed to ensure the hospice aide care plan was patient-specific, included parameters for when the hospice aide was to report vital sign results, and included all safety precautions for 4 of 5 records reviewed of patients receiving hospice aide services (Patients #1, 2, 3, 6). Findings include: --- Review of the clinical record for Patient #1, benefit period 4/24/2023 – 7/22/2023, evidenced a plan of care which identified safety precautions which included, but was not limited to, falls, seizures, oxygen use, and bleeding. The clinical record included an aide care plan which failed to include safety precautions. During a telephone interview on 5/3/2023 at 12:32 PM, HA 1 indicated he / she did not recall safety precautions or knew where to find them for Patient #1. Review of the clinical record for Patient #3, benefit period 4/4/2023 – 7/2/2023, evidenced a plan of care which identified safety precautions which included, but not limited to fall and seizure precautions. The clinical record included an aide care plan which failed to include safety precautions. Review of the clinical record for Patient #6, benefit period 4/4/2023 – 7/2/2023, evidenced a comprehensive assessment dated 2/3/2023, which indicated the patient was a fall risk, used oxygen and had a risk for aspiration. Review of the aide care plan failed to identify safety precautions or vital sign parameters. During an interview on 5/3/2023 at 3:55 PM, the Administrator indicated HAs could not view safety precautions on the aide care plan. During an interview on 5/3/2023 at 1:15 PM, the quality nurse indicated there were safety precautions identified in the electronic medical record, but the aide was unable to see them as aides have limited access to the medical record. Review of agency policy #1-037 titled ";Hospice Aide Supervisory Visits," revised 12/2018, indicated the hospice case manager was responsible for creating the hospice aide care plan with ";instructions to ensure compliance." Review of Patient #2s (benefit election date 05/27/2022) clinical record included a plan of care for the recertification period 03/23/2023 – 05/21/2023 which indicated the patients terminal diagnosis Alzheimers Disease and the patient was to receive hospice aide services with the frequency of 1 visit per week for 1 week then 2 visits per week for 8 weeks. The record included a hospice aide care plan, entered and approved on 04/11/2023 by Registered Nurse (RN) #7, which indicated hospice aide tasks included but were not limited to obtaining Patient #2s temperature, blood pressure, respirations, and pulse on the first visit of the week and transferring the patient from the bed to their chair or chair to their bed ";when requested." The aide care plan failed to evidence parameters for when the hospice aide was to report vital sign results to the patients nurse and failed to evidence detailed instructions on when to transfer the patient. During a home visit observation conducted on 05/03/2023 beginning at 11:15 AM with Patient #2, the patient was observed to be non-verbal and unable to voice their need to transfer. During an interview conducted on 05/03/2023 beginning at 11:48 AM with RN #2, the nurse reported all hospice aides should know the ";normal" ranges of temperature, blood pressure, respirations, and pulse rate and would report results if outside of the ";normal" range. The nurse also reported the hospice aide would transfer Patient #2 from and to their chair and/or bed when requested by facility staff. During an interview conducted on 05/03/2023 beginning at 3:55 PM, the Administrator reviewed Patient #2s hospice aide care plan and reported the hospice aide was to transfer the patient to and from their bed or chair per the request of the memory care unit facilitys staff. The Administrator confirmed this was not specified on the aide care plan. The Administrator also confirmed the aide care plan should have vital sign parameters to guide the hospice aide on when to report vital sign results.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) revealed the agency did not ensure the pre-bereavement assessment was completed, or attempted to be completed, within 5 calendar days after the election of hospice care.. Clinical Record 13 was reviewed and identified the patient elected hospice care on 1/19/2022 with a primary diagnosis of CVA. The initial .bereavement assessment was not completed until 2/22/2022, 34 days after election of the hospice benefit. Interview #1 An interview on 9/15/2022 with the administrator confirmed this finding. The administrator was unable to state why this assessment was completed late.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 13 (15%) records reviewed revealed the agency did not ensure documentation of all problems with related interventions and goals were included on the plans of care.. Clinical Record 13 was reviewed and identified the patient elected hospice care on 1/19/2022 with a primary diagnosis of CVA. On 3/17/22 the patient was identified as having 'Behaviors' and started on medications, yet the plan of care was not updated to include problems, interventions with related goals related to "behaviors." On 5/10/22 nursing documentation revealed that the patient was having muscle spasms and was started on the medication Baclofen, but this newly identified problem was not added to the plan of care with the associated interventions or goals. Clinical Record 8 was reviewed and identified the patient elected hospice care on 6/8/2022 with a primary diagnosis of malignant neoplasm of the mouth. An order was entered on 8/4/2022 for a social worker in-person care plan meeting, This meeting occurred on 8/5/2022. On 8/25/2022 another order for social work services was entered stating a frequency of 1 time a month for 2 months. Plans of cares dated 8/9/2022, 8/18/2022, 8/25/2022, 9/01/2022,and 9/15/2022 were not updated to include social service related problems, interventions or goals. Clinical Record 7 was reviewed and identified the patient elected hospice care on 5/17/2022 with a primary diagnosis of cirrhosis of liver. The RN comprehensive assessment completed and documented on 8/8/2022 stated "red yeasty rash noted under BIL breast." An order was received for "Nystatin powder; apply to affected areas BID until healed. " Plans of care dated 8/16/2022, 8/25/2022 and 9/1/2022 did not include problems, interventions or goals for the rash documented by the registered nurse in the 8/8/2022 assessment. Interview #1 during an interview on 9/15/2022, the administrator agreed with these findings. The administrator stated education will be provided to the team on this requirement.

It is required that each patient’s individualized written plan of care includes drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (8%) reviewed revealed the agency failed to ensure that all drugs and treatments necessary to meet the needs of the patient were included on the plan of care.. Clinical Record 9 was reviewed and identified the patient elected hospice care on 9/21/2021 with a primary diagnosis of pancreatic cancer. The attending physician certification of terminal illness narrative dated 9/8/2022 states the patient is "utilizing zinc oxide for topical protectant of skin." There is no evidence of zinc oxide documented in the medication profile or plan of care reviewed on 9/15/2022. Interview #1 during an interview on 9/15/2022, the administrator agreed with these findings. The administrator stated education will be provided to the team on this requirement.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 8 (25%) clinical records of patients with hospice aide services reviewed revealed that the agency did not ensure there were clear, specific written instructions on the hospice aide plans of care related to wound care documented in the clinical records, thus leaving the aides to make decisions related to wound care that were out of their scope of practice.. Clinical Record 5 was reviewed and identified the patient elected hospice care on 5/9/2022 with a primary diagnosis of chronic kidney disease. The RN assessment on 8/31/2022 included documentation of 2 pressure ulcers with wound care orders to apply barrier cream. The hospice aide plan of care, effective 5/9/2022 was not updated to include written instructions related to the wounds. Clinical Record 1 was reviewed and identified the patient elected hospice care on 11/25/2019 with a primary diagnosis of CHF. The RN assessment on 7/26/2022 included documentation of wound care orders on the lower left calf stating "skin tear weeping, apply ointment, wrap with dressing." The hospice aide plan of care, effective 11/29/2019 was updated on 7/27/2022, 8/1/2022, 8/3/2022, and 8/8/2022. to include written instructions related to the wound. Interview #1 during an interview on 9/15/2022, the administrator agreed with these findings. The administrator stated education will be provided to the team on this requirement.