Every finding on record at Unity Hospice of Northwest Indiana LLC

Based on observation, record review, and interview, the hospice failed to ensure coordination of care between Entity A’s, a skilled nursing facility, and Entity D's, a skilled nursing facility, non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions in 1 of 1 clinical record reviewed with an observation visit completed at Entity A (Patient #3), and in 1 of 3 Entity D's patients' clinical record reviewed without an observation visit completed (Patient #5).Findings include: --- 1.An updated policy, dated January 2014, titled, “Facility Residents,” indicated the hospice care team would implement the plan of care to communicate with other healthcare providers participating in the provision of care for the terminal illness and related conditions to ensure quality of care for the patient.  The policy indicated a coordinated plan of care would identify the care and services that the hospice and the facility would provide to meet the needs of the patient and would be updated to meet the ongoing needs of the patient.  The policy indicated the facility, and the hospice would be aware of responsibilities of each.  2.  An updated policy, dated January 2014, titled, “Hospice Interdisciplinary Group,” indicated the interdisciplinary group would maintain  a system of communication to ensure that the patient care and services were provided according to the plan and care and based on assessments and family needs.  The policy indicated the interdisciplinary group would maintain responsibility for directing, coordinating, and supervising the care and services provided.  The policy indicated the interdisciplinary group would ensure for the ongoing sharing of information between all disciplines providing care in all settings, including sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 3. An updated policy, dated January 2014, titled, “Initial Hospice Assessment,” indicated during the initial assessment would include a physical assessment, and medications including prescription and over the counter medications.  4. An updated policy, dated January 2014, titled, “Medications,” indicated the hospice nurse was responsible for monitoring the usage of medication by the patient or caregiver to ensure appropriate administration schedule, a medication profile would be maintained for each patient, and periodic review and monitoring for appropriate medications and their use would be documented.  5. An updated policy, dated January 2014, titled, “Ongoing Assessment,” indicated during each home visit the hospice  would reevaluate the patient according to the problems identified during the initial visit that would include the nurse would assess each patient on each visit to include but not limited to pain, and alteration of skin integrity and wounds would be viewed and documented every visit.  The policy indicated clinicians would focus on patient’s response to care during reassessments, and verbal orders would be generated based upon the findings of the reassessment, and the physician would be notified to verify any changes in medications, treatment or interventions.  6. During an observation visit of Patient #3, at Entity A, a skilled nursing facility, beginning at 9:00 AM, RN 1 spoke to Person B, nurse at Entity A and indicated she was there to see the patient.  Patient #3 was observed in bed with eyes open, relaxed facial expression and would continually verbalize “yay” in an elevated voice.  RN 1 rolled patient to right side to perform wound care to sacrum and the patient verbalized in an elevated voice, “God dang you,” and face appeared grimaced.  During the observation of the wound dressing change to the sacrum that included removal of a foam adhesive bandage,  cleansed with saline, application of calcium alginate (a moisture absorbing substance that transforms to gel) and a foam adhesive dressing was applied patient stated, “God damn back”, eyes were squinted, and brows were lowered.  The patient stated, “ow,” when RN 1 rolled patient from right side to back and patient had no verbalization after movement. During an interview, on 05/21/2026, at 11:15 AM,  after Patient #3’s wound care was completed, RN 1 indicated the patient was in discomfort when he/she was rolled and when the sacral dressing was applied.  RN 1 indicated she noted the patient’s discomfort with different pitches the patient was verbalizing.  RN 1 indicated she had left a message with the facility to administer Morphine (narcotic pain medication) prior to her arrival to the facility to provide wound care.  During an interview, on 05/21/2026, beginning at 11:20 AM, Person B indicated he/she had not administered Morphine to the patient prior to the wound care, the last dose of Morphine the patient received was the day prior, on 05/20/2026, and requested RN 1 provide a Morphine refill.  During an interview, on 05/21/2026, beginning at 11:20 AM, RN 1 indicated she did not verify with Entity A’s staff that the patient received Morphine prior to providing wound care.  A RN 1 Nursing Visit Note, dated 05/21/2026, indicated RN 1 spoke with Person B pre-visit and Person B expressed no patient concerns at that time. The Visit Note indicated Patient #3 had a pain level of 3 (on a 0 to 10 scale with 0 being no pain and 10 being worst pain), failed to indicate a PAIN AD (pain assessment in advanced dementia) scale was utilized,  pain location was the sacrum with wound care and positioning, and Morphine relieved pain.  The Visit Note indicated wound care to an unstageable 16 centimeter by 10.2 centimeter by 0.3 centimeter in depth sacral wound was performed per order by cleaning with wound cleaner, pat dry, apply calcium alginate with silver, cover with bordered gauze daily, and response to wound care was patient tolerated well.  The Visit Note indicated RN 1 spoke with Person B at the end of the patient’s visit and during medication review the patient was noted to be out of Morphine.  A Hospice, Long Term Care Coordinated Task Plan of Care, located in Entity A’s hospice binder, dated 04/17/2026, was blank under hospice wound care schedule section.     A Plan of Care Safety Precautions Form, dated 04/17/2026, indicated under section Opioid Precautions, make sure patient had been given or taken pain medication before care if moving triggered pain.  An Interdisciplinary Group Update, dated 05/13/2026, indicated the patient had a primary diagnosis of senile degeneration of the brain (cognitive decline), the comfort kit medications included but not limited to Morphine concentrate solution 5 milligrams by mouth every 2 hours as needed for pain or shortness of breath,  the patient had intermittent pain and discomfort, and Morphine was utilized for pain.  An Initial Comprehensive Assessment, dated 04/17/2026, for Patient #3’s start of care date of 04/17/2026, indicated the patient had a foley catheter (tube into the bladder to drain urine). A Hospice Treatment Order, dated 04/17/2026, indicated the RN case manager was to change foley catheter every 30 days.  A Nursing Visit Note Update To The Comprehensive Assessment, dated 05/11/2026, indicated the patient’s last foley catheter change was 04/17/2026.  A Nursing Visit Note Update To The Comprehensive Assessment, dated 05/18/2026, indicated the patient’s last foley catheter change was 04/09/2026 with modification noted.  During an interview, on 05/21/2026, beginning at 11:00 AM,  RN 1 indicated she asked an Entity A’s staff member on 05/18/2026 when the patient’s foley catheter was last changed and was told it was on 05/09/2026 and modified the 05/18/2026 note to indicate the last foley catheter change by Entity A’s staff.    An Entity A’s Order Summary Report indicated foley catheter was to be changed as needed for dislodgement, leaking or blockage as needed with a start date of 03/24/2026.  During an interview, on 05/21/2026, beginning at 11:30 AM, Person C, the Director of Nursing at Entity A indicated there was no documentation the foley catheter was changed by Entity A’s facility staff, the facility staff would document when a foley catheter was changed, and the facility staff would change the foley catheter for leaking or dislodgement and would not change on a regular schedule.  A Hospice Long Term Care Coordinated Task Plan of Care, dated 04/17/2026, located in Entity A’s hospice binder, indicated the foley catheter was to be changed every 30 days and was blank under the section for party responsible for foley catheter treatment.  During an interview, on 05/21/2026, beginning at 11:15 AM, RN 1 indicated the Hospice Long Term Care Coordinated Task Plan of Care did not and should have included who was responsible for the  foley catheter change and care.    An Entity A Order Summary Report indicated Patient #3’s active medications included but not limited to Levaquin (antibiotic) 750 milligrams one tablet daily for wound infection with a start date of 05/01/2026, and Olanzapine (antipsychotic medication) 5 milligrams 2 tablets every night with a start date of 03/23/2026.    An Interdisciplinary Group Update, dated 05/13/2026, indicated a start of care date of 04/17/2026, and medication list failed to include  Levaquin, and Olanzapine dose indicated 5 milligrams one tablet every night with a start date of 04/17/2026.  A RN 1 Nursing Visit Note Update To The Comprehensive Assessment, dated 05/18/2026, indicated all medications were reviewed and reconciled with the facility staff and no issues nor changes to medications were noted.  A Hospice Service Agreement with Entity A, dated 08/31/2021, indicated the hospice would provide services at the same level and to the same extend as those services would be provided if the resident hospice patient were in their own home.  The Agreement indicated the interdisciplinary group responsibilities would include periodically reviewing and updating the plan of care for each resident hospice patient in coordination with the nursing facility.  During an interview, on 05/21/2026, beginning at 11:15 AM, RN 1 indicated she reconciled all patient’s medications at the comprehensive assessment visit on 05/18/2026, medications are to be reconciled every comprehensive assessment, and she would request a copy of the skilled nursing facilities medication list to review.  RN 1 indicated the patient was prescribed Levaquin by a non-hospice facility physician for a urinary tract infection.  7. A Nurse Progress Note, dated 05/15/2026, indicated Patient #5 was transferred to Entity D, a skilled nursing facility.  The Nurse Note indicated the patient had a right skin tear to the right hip measured at 3 centimeters by 3 centimeters.  An Initial Comprehensive Assessment, dated 05/16/2026, indicated the patient was bedbound and dependent for repositioning, and skin was intact.  A Nursing Visit Note, dated 05/17/2026, indicated the patient’s skin was clean, dry, and intact.  A Nursing Visit Note, dated 05/18/2026, indicated the facility did wound care prior to  the visit.  A LPN 1 Nursing Visit Note Update To The Comprehensive Assessment, dated 05/22/2026, indicated the patient’s skin temperature was warm, skin turgor was fair, and failed to evidence documentation of the right hip skin tear.  An Entity D’s Order Summary Report, dated 05/19/2026, indicated the patient’s left hip was to be cleansed with wound wash, pat dry, apply Thera Honey (wound dressing) Gel, and cover with a dry dressing every day shift and as needed, and was initiated on 05/18/2026.  Hospice Admission Orders, dated 05/15/2026, failed to evidence the patient’s right hip skin tear wound care orders.  A Hospice Service Agreement with Entity D, dated 03/29/2024, indicated the hospice would provide services at the same level and to the same extend as those services would be provided if the resident hospice patient were in their own home.  The Agreement indicated the interdisciplinary group responsibilities would include periodically reviewing and updating the plan of care for each resident hospice patient in coordination with the nursing facility.  During an interview, on 05/26/2026, beginning at 3:45 PM, the Clinical Manager indicated there was no documentation of the patient’s right hip wound assessment in the clinical record.  The Clinical Manager indicated a wound assessment would have been documented on the 05/16/2026 initial comprehensive assessment.  During an interview, on 05/27/2026, beginning at 12:20 PM, the Clinical Manager indicated LPN 1 relayed that the patient did have a wound, the skilled nursing facility was providing wound care and LPN 1 did not document an assessment of the wound nor write an order for wound care.

Based on record review and interview, the hospice failed to ensure 1 of 2 skilled nursing facility patients’ clinical records reviewed with an observation visit completed had a urinary tract infection tracked for quality improvement (Patient #4).Findings include: --- An updated policy, dated January 2014, titled, “Infection Control,” indicated the nursing supervisor was responsible for implementing and monitoring the infection control program and would oversee the reporting to the quality assessment and performance improvement committee infection control related incidents. An updated policy, dated January 2014, titled, “Incident Reporting,” indicated an incident report would be completed for infection of any wound or organ that was not present on admission to care. A Nurse Progress Note, dated 03/20/2026, indicated Patient #4, start of care of 11/11/2025,  had a possible urinary tract infection (infection in part of the urinary system to include kidneys, ureters, bladder and urethra) due to the patient had a fever and increased confusion and agitation.  The Note indicated Bactrim (antibiotic) was ordered for 7 days. The Infection Log for March 2026 failed to evidence Patient #4’s urinary tract infection.During an interview, on 05/21/2026, beginning at 1:30 PM, the Clinical Manager indicated the patient’s urinary tract infection was not identified on the infection log for quality assessment,  and indicated a patient was to have an infection report completed and added to the hospice’s infection log  when an antibiotic was initiated.

Based on record review and interview, the hospice’s performance improvement activities failed to evidence focus on high risk, high volume, nor problem prone areas related to patient’s falls and urinary tract infections (infection in part of the urinary system to include kidneys, ureters, bladder and urethra) in 1 of 1 agency. Findings include: --- 1. An updated policy, dated January 2014, titled, “Quality Assessment Performance Improvement [QAPI]”, indicated the hospice would measure, analyze causes, track quality indicators, including areas such as adverse patient events and aspects of performance that assess processes of care, and implement preventive actions.  The policy indicated the hospice would focus on high risk, high volume, and problem prone areas to identify the severity of a problem, give priority to improvement activities that affect palliative, patient safety, and quality of care outcomes.  The policy indicated when problems were identified in the provision of hospice services, the hospice would document evidence of corrective actions taken, including ongoing monitoring of effectiveness, revisions of policies and procedures, educational intervention, changes in the provision of services, and the effectiveness of actions taken to improve services or correct identified problems would be evaluated.  2. Infection Control Logs and Average Daily Census Reports for January 2025 to March 2026 evidenced the following for urinary tract infections (UTIs): A. January 2025 average daily census: 87, unduplicated foley catheter (tube into the bladder to drain urine) patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 3 (3.4%), total of 6 (6.9%) patients’ UTIs.   B. February 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 4 (4.7%), unduplicated non-foley catheter patients’ UTI’s: 2 (2.3%), total of 6 (7%) patients’ UTIs.  C. March 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 5 (5.8%), total of 7 (8%) patients’ UTIs. D. April 2025 average daily census: 79, unduplicated foley catheter patients’ UTIs: 2 (2.5%), unduplicated non-foley catheter patients’ UTIs: 1 (1.3%), total of 3 (3.8%) patients’ UTIs. E. May 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 3 (3.5%), total of 5 (5.8%) patients’ UTIs. F. June 2025 average daily census: 88, unduplicated foley catheter patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 4 (4.5%), total of 7 (8%) patients’ UTIs. G. July 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 1 (1.2%), unduplicated non-foley catheter patients’ UTIs: 6 (7%), total of 7 (8%) patients’ UTIs. H. August 2025 average daily census: 87, unduplicated foley catheter patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 3 (3.4%), total of 6 (6.9%) patients’ UTIs. I. September 2025 average daily census: 87, unduplicated foley catheter patients’ UTIs: 3 (3.4%), non-foley catheter patients’ UTIs: 7 (8%), total of 10 (11.5%) patients’ UTIs. J. October 2025 average daily census: 85, unduplicated foley catheter patients’ UTI’s 2 (2.4%), unduplicated non-foley catheter patients’ UTIs: 5 (5.9%), total of 7 (8.2%) patients’ UTIs. K. November 2025 average daily census: 88, unduplicated foley catheter patients’ UTI’s 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 0, total of 2 (2.3%) patients’ UTIs. L. December 2025 average daily census: 80, unduplicated foley catheter patients’ UTI’s 3 (3.8%), unduplicated non-foley catheter patients’ UTIs: 2 (2.5%), total of 5 (6.3%) patients’ UTIs. M. January 2026 average daily census: 76, unduplicated foley catheter patients’ UTI’s 4 (5.3%), unduplicated non-foley catheter patients’ UTI’s: 1 (1.3%), total of 5 (6.6%) patients’ UTI’s. N. February 2026 average daily census: 79, unduplicated foley catheter patients’ UTI’s 1 (1.3%), unduplicated non-foley catheter patients’ UTI’s 0, total of 1 (1.3%) patients’ UTI’s. O. March 2026 average daily census: 94, unduplicated foley catheter patients’ UTI’s 3 (3.2%), unduplicated non-foley catheter patients’ UTI’s 4 (4.3%), total of 7 (7.4%) patients’ UTI’s. During an interview, on 05/21/2026, beginning at 2:00 PM, the Clinical Manager indicated the hospice did not implement interventions nor preventative actions for quality improvement related to UTI’s. The Clinical Manager indicated a patient was to have an infection report completed for the infection log  when an antibiotic was initiated.  3. Occurrence Logs and Average Daily Census Reports for January 2025 to March 2025 evidenced the following related to patients’ falls: A. January 2025 average daily census: 87, 2 (2.3%) patients’ falls B. February 2025 average daily census: 86, 8 (9.3%) patients’ falls C. March 2025 average daily census: 86, 15 (17.4%) patients’ falls D. April 2025 average daily census: 79, 10 (12.7%) patients’ falls E. May 2025 average daily census: 86, 13 (15.1%) patients’ falls F. June 2025 average daily census: 88, 2 (2.3%) patients’ falls G. July 2025 average daily census: 86, 13 (15.1%) patients’ falls H. August 2025 average daily census: 87, 12 (13.8%) patients’ falls I. September 2025 average daily census: 87, 13 (15%) patients’ falls J. October 2025 average daily census: 85, 3 (3.5%) patients’ falls K. November 2025 average daily census: 88, 7 (8%) patients’ falls L. December 2025 average daily census: 80, 6 (7.5%) patients’ falls  M. January 2026 average daily census: 76, 6 (7.9%) patients’ falls  N. February 2026 average daily census: 79, 2 (2.5%) patients’ falls  O. March 2026 average daily census: 94, 8 (8.5%) patients’ falls During an interview, on 05/21/2026, beginning at 1:00 PM, the Clinical Manager indicated patients’ falls were not identified by the hospice’s quality assessment and performance improvement program as a concern and the hospice’s quality assessment and performance improvement program had not implemented interventions nor preventative actions for patients’ falls.

Based on record review and interview, the hospice agency failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials efforts to maintain an integrated response during an emergency situation. Findings include: --- Record review of an undated agency policy received on 06/28/2023, titled, ";Emergency Preparedness Policy," stated, ";... The plan will include a process for ensuring cooperation and collaboration with local, regional, state and federal emergency preparedness officials efforts to ensure an integrated response during a disaster or emergency situation ... The agency will maintain documentation of all communications with officials as well as any agency participation ...." Record review failed to evidence documentation of attempts to contact local, tribal, regional, State, and Federal emergency preparedness officials. During an interview on 06/28/2023, at 11:12 AM, the Administrator indicated there was no documented attempts to contact local and federal emergency preparedness officials.

Based on record review and interview, the hospice agency failed to include alternate means for communicating with facility staff and Federal, State, tribal, regional, and local emergency management agencies. Findings include: --- Review of an undated agency policy received on 06/28/2023, titled, ";Emergency Preparedness Policy," stated, ";... In the event of down conventional telephone communication, cellular phones will be utilized by administration, nursing personnel and coordination services. If cellular phone systems are not adequately functioning, the agency will utilize any available backup communication systems that include: smart phone technology, iPad and notepads...." During an interview on 06/28/2023, at 11:50 AM, the Administrator indicated the primary communication would be with cell phones and emails, however, the agency did not have an alternate communication plan to communicate with staff, federal, state, regional and local emergency preparedness officials.

Based on record review and interview, the hospice agency failed to include a method for sharing information and medical documentation for patients under the agencys care with other health providers to maintain continuity of care during an emergency. Findings include: --- Record review evidenced an undated agency policy received on 06/28/2023, titled, ";Emergency Preparedness Policy," which stated, ";... If internet is not available to access electronic chart, all charting will be done using paper forms...." Review failed to evidence a policy that included the method of sharing information and medical documentation to provide general information about the patients condition. During an interview on 06/28/2023, at 12:19 PM, the Administrator indicated the patients medical status would be shared with other health care providers verbally. During an interview on 06/28/2023, at 12:25 PM, the Clinical Manager indicated the agency would plan to print out patients summaries and add to emergency folder.

Based on record review and interview, the hospice agency failed to conduct an additional exercise at least every 2 years to include a full-scale community based or facility based functional exercise, a mock drill, or a tabletop exercise. Findings include: --- Record review of an undated agency policy received on 06/28/2023, titled, ";Emergency Preparedness Policy," stated, ";... The agency will participate in a community mock disaster drill at least annually. If a community drill is not available then the agency will conduct one on an annual basis. A paper-based mocked table-top exercise will be conducted on an annual basis...." Review failed to evidence a full-scale community based or facility based functional exercise, mock drill, or tabletop exercise every 2 years. During an interview on 06/28/2023, at 12:25 PM, the Administrator indicated the agency activated the emergency plan for a tornado on 03/31/2023, but had not done an additional exercise in the last 2 years.

Based on record review and interview, the agency failed to ensure all patient medication profiles were complete and accurate in 1 of 2 home visits conducted in a skilled nursing facility (#2). The findings include: --- Review of an agency policy titled, ";MEDICATIONS", dated 1/2014, indicated medication profiles shall be maintained, reviewed, and monitored for each patient. Review on 6/26/2023, of Patient #2s medication profile in their electronic medical record evidenced the following: Acetaminophen suppositories, Metoprolol (a heart and blood pressure medication) daily, Tears Again Eye Drops 1.4% one drop to the left eye every 4 hours as needed for eye discharge, Zofran (an anti-nausea medication) every 4 hours as needed, Albuterol (an inhaled breathing medication), ABHR suppositories (an anti-nausea medication), and Scopolamine gel (a medication used to dry secretions). The agency medication profile failed to evidence Acetaminophen extra strength liquid, Cholecalciferol tablet (Vitamin D3), Docusate Sodium tablet (stool softener), Ferrex (an iron supplement), and Nitroglycerin Patch (a medication to prevent chest pain) Review on 6/27/2023 of Patient #2s current medication list from skilled nursing facility 2 evidenced the following: Acetaminophen extra strength liquid, Cholecalciferol tablet (Vitamin D3), Docusate Sodium tablet (stool softener), Ferrex (an iron supplement), Metoprolol twice a day, Nitroglycerin Patch (a medication to prevent chest pain), Polyethyl Glycol-Propyl (lubricating eye drops) one drop in both eyes every 12 hours as needed for dry eyes, and Zofran every 6 hours as needed. The medication profile failed to evidence Albuterol, ABHR suppositories, and Scopolamine gel. Review evidenced no new medications were added to the skilled nursing facility medication list since 1/15/2023. During an interview on 6/30/2023 at 2:30 PM, the Clinical Manager indicated the nurse should reconcile the hospice medication list with the skilled nursing facility medication list at each visit, and if any discrepancy is found, the nurse should call the doctor because the medication lists should be the same.

Based on record review and interview, the hospice agency failed to update the comprehensive assessment every 15 days in 13 of 14 active clinical records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13). The findings include: --- 10. Clinical record review for Patient #2 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 6/9/2021. Review of the patients electronic medical record on 6/26/2023 failed to evidence a comprehensive assessment since 6/9/2021. 11. Clinical record review for Patient #4 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 5/11/2023. Review of the patients electronic medical record on 6/26/2023 failed to evidence a comprehensive assessment since 6/26/2023. 12. Clinical record review for Patient #5 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 4/21/2023. Review of the patients electronic medical record on 6/29/2023 failed to evidence a comprehensive assessment since 4/21/2023. 13. Clinical record review for Patient #8 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 6/5/2023. Review of the patients electronic medical record on 6/29/2023 failed to evidence a comprehensive assessment since 6/5/2023. 14. Clinical record review for Patient #9 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 6/4/2023. Review of the patients electronic medical record on 6/29/2023 failed to evidence a comprehensive assessment since 6/4/2023. 15. Clinical record review for Patient #13 evidenced an agency document titled, ";COMPREHENSIVE ASSESSMENT", dated 2/1/2023. Review of the patients electronic medical record on 6/29/2023 failed to evidence a comprehensive assessment since 2/1/2023. 1. Record review evidenced an agency policy dated January 2014, titled, ";Clinical Record," which stated, ";... The record will include ... initial, comprehensive and subsequent assessments ...." 2. Record review evidenced an agency policy dated January 2014, titled, ";Hospice Nursing Care," which stated, ";... The hospice nurse performs initial and ongoing assessments of hospice patients/families/caregivers needs ... The hospice nurse will participate in developing and implementing the Plan of Care, and reports the condition of patient/family/caregiver to the Interdisciplinary Group on a regular basis, as well as changes in the Plan of Care ...." Review failed to evidence an agency policy that addressed the comprehensive assessment updates to be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. 3. Clinical record review for patient #1, on 06/27/2023, hospice election date 03/21/2023, evidenced an agency document dated 03/21/2023, titled, ";Comprehensive Assessment." Review evidenced a Nurse Recertification completed on 06/05/2023. Review failed to evidence an update to the Comprehensive Assessment after the 06/05/2023 Recertification. 4. Clinical record review for patient #3, hospice election date 04/27/2023, evidenced an agency document dated 04/27/2023, titled, ";Comprehensive Assessment." Review failed to evidence an updated Comprehensive Assessment after the initial assessment. 5. Clinical record review for patient #6, hospice election date 04/22/023, evidenced an agency document dated 04/22/2023, titled, ";Comprehensive Assessment." Review failed to evidence an updated Comprehensive Assessment after the initial assessment. 6. Clinical record review for patient #7, hospice election date 04/08/2023, evidenced an agency document dated 04/08/2023, titled, ";Comprehensive Assessment." Review failed to evidence an updated Comprehensive Assessment after the initial assessment. 7. Clinical record review for patient #10, hospice election date 09/28/2021, evidenced an agency document dated 09/28/2021, titled, ";Comprehensive Assessment." Review evidenced an agency document dated 05/17/2023, titled, ";Nurse Recertification." Review failed to evidence an updated Comprehensive Assessment after 05/17/2023. 8. Clinical record review for patient #11, on 06/29/2023, hospice election date 06/09/2023, evidenced an agency document dated 06/09/2023, titled, ";Comprehensive Assessment." Review failed to evidence an updated Comprehensive Assessment after the initial assessment. 9. Clinical record review for patient #12, on 06/29/2023, hospice election date 06/08/2023, evidenced an agency document dated 06/08/2023, titled, ";Comprehensive Assessment." Review failed to evidence an updated Comprehensive Assessment after the initial assessment. 10. During an interview on 06/26/2023, at 3:30 PM, the Clinical Manager indicated the comprehensive assessment recertification/updates were to be completed 90 days after first certification period and then every 60 days.

Based on observation, record review and interview, the agency failed to ensure all care and services followed an individualized plan of care established by the IDG (Interdisciplinary Group) in 3 of 14 active clinical records reviewed (#2, 4, 14). The findings include: --- 1. Review of an agency policy titled, ";PATIENT PLAN OF CARE", revised 2/2014, indicated the hospice IDG shall prepare a written plan of care for each patient which includes the specific care and services needed by the patient. 2. Review of the agencys registered nurse (RN) job description, revised 1/2014, indicated the nurse shall provide care in accordance with the established plan of care. 3. During a home visit on 6/27/2023 at 9:20 AM, RN 1 was observed placing a small white dressing, identified by RN 1 as collagen, directly to Patient #2s foot and ankle wounds. Observation of the home visit failed to evidence RN 1 cleaning the patients PEG tube (a feeding tube inserted through the abdomen) site. Review of an update to the plan of care dated 4/19/2023 indicated the nurse was to cleanse the PEG tube site with saline, dry, apply a thin layer of Medihoney (a wound care ointment), and cover with a drain dressing every 3 days. Review of an update to the care plan dated 5/16/2023 evidenced the following wound care order: "; ... wound cleanser, medi honey [sic], calcium alginate [a specialized wound dressing], dressing Q3 days [every 3 days]....". Review of all skilled nurse visit notes for certification period 5/30/2023 to 7/28/2023 failed to evidence the nurse cleaned the PEG tube site on 6/6/2023, 6/9/2023, 6/16/2023, 6/20/2023, and 6/23/2023. During an interview on 6/30/2023 at 2:13 PM, the Clinical Manager indicated the nurse should document care performed in the visit notes. The Clinical Manager indicated the nurse visits were scheduled every 3 days, coinciding with wound and PEG tube care, and she didnt know why RN 1 did not clean the PEG tube site during the home visit. When queried, the Clinical Manager indicated RN 1 probably misspoke when she indicated the dressing she used was collagen. 4. Observation of a home visit on 6/27/2023 at 11:34 AM evidenced Patient #4 was bedbound, lethargic, and had minimal, weak body movements. Observation failed to evidence the nurse turning the patient to visualize the skin on the patients back side. Review of the initial comprehensive assessment, dated 5/11/2023, evidenced the Family Care Coordinator applied a dressing to a wound on Patient #4s left leg. Review of a skilled nurse visit note dated 5/12/2023 evidenced RN 1 changed the dressing on the patients left leg. Review of a skilled nurse visit note dated 5/18/2023 RN 1 educated the patients family member on wound care and schedule. Review of a skilled nurse visit note dated 5/22/2023 evidenced RN 1 performed wound care on the patients left leg. Review of an update to the plan of care dated 5/31/2023 indicated the nurse shall assess for skin breakdown every visit. Review of the plan of care failed to evidence any wound care orders prior to 5/23/2023. During an interview on 6/30/2023 at 2:34PM, the administrator indicated the nurse should get physician orders for wound care before the care is provided. When informed of the home visit findings, the administrator indicated the nurse should have turned the patient to assess for breakdown. 5. Review of a skilled nursing visit note dated 6/15/2023, indicated RN (registered nurse) 2 administered a Fleet enema to Patient #14 and provided them with Miralax (a laxative). Review of the patients plan of care and medication list failed to evidence orders for Miralax or Fleet enema. During an interview on 6/30/2023 at 3:48 PM, the Clinical Manager indicated not all patient medications go on the plan of care. After reviewing the patients record, the Clinical Manager indicated it failed to evidence an order for Miralax or Fleet enema.

Based on observation, record review and interview, the agency failed to ensure the plan of care included all drugs and treatments necessary for the patient in 10 of 19 clinical records reviewed (#2, 3, 5, 6, 7, 10, 11, 12, 18, 19). The findings include: --- 1. Clinical record review for patient #3, on 06/27/2023, evidenced an agency document dated 04//27/2023, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patient was taking medications including but not limited to Dicyclomine (irritable bowel syndrome medication), Omeprazole (acid reflux medication), Oxycodone (pain medication), Tylenol (pain medication), and Zofran (nausea medication), and were started on 04/27/2023. 2. Clinical record review for patient #6, on 06/28/2023, evidenced an agency document dated 04/22/2023, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patient was taking medications including but not limited to Hydromorphone (pain medication), Escitalopram (depression medication), Morphine (pain medication), and Ondansetron (nausea medication), and medications were started on 04/22/2023. 3. Clinical record review for patient #7, on 06/29/2023, evidenced an agency document dated 04/08/2023, titled, ";Comprehensive Assessment," which indicated the patient had a peg tube (feeding tube into the stomach) and was receiving tube feedings. Review of an agency document dated 04/08/2023, titled, ";Initial Plan of Care," failed to evidence the tube feeding treatment. 4. Clinical record review for patient #10, on 06/29/2023, evidenced an agency document dated 09/28/2021, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patient was taking medications including but not limited to Oxycontin (pain medication), and Percocet (pain medication), and medications were started on 09/29/2021. 5. Clinical record review for patient #11, on 06/29/2023, evidenced an agency document dated 06/09/2023, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patient was taking medications including but not limited to Lidocaine patch (pain medication) and Metoprolol (heart medication), and medications were started on 06/09/2023. 6. Clinical record review for patient #12, on 06/29/2023, evidenced an agency document dated 06/08/2023, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patients medications included but not limited to Lorazepam (anxiety medication) and Morphine (pain medication), and medications were started on 06/08/2023. 7. Clinical record review for patient #18, 06/29/2023, evidenced an agency document dated 11/16/2022, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document titled, ";Medication List," indicated patients medications included but not limited to Lorazepam and Morphine, and medications were started on 11/16/2022. 8. Clinical record review for patient #19, on 06/28/2023, evidenced an agency document dated 05/09/2023, titled, ";Initial Plan of Care," which failed to evidence patients medications. Review of an agency document dated 05/17/2023, titled, ";IDG [interdisciplinary group] Update," indicated the patient was taking medications including but not limited to Lorazepam and Morphine, and medications were started on 05/09/2023. 9. During an interview on 1. Review of an agency policy titled, ";PATIENT PLAN OF CARE", revised 1/2014, indicated the hospice shall prepare a written plan of care for each patient which includes the drugs and treatments necessary to meet the needs of the patient. 2. Review of an agency policy titled, ";PHYSICIAN ORDERS / PLAN OF CARE", revised 1/2014, stated, "; ... The contents of the orders (Plan of Care) will include: ... B. A description of the treatment and / or procedure to be done, including, when appropriate, the type, frequency and duration. C. Who is to perform the treatment or procedure. D. A description of equipment, if any, necessary in the provision of care. E. A description of current medication, including name, dose, frequency and route of each medication. F. A description of any medical, physical, psychosocial or environmental precautions or limitations that affect the implementation of the Plan of Care...." 3. During a home visit at skilled nursing facility 2 on 6/27/2023 at 9:20 AM, Patient #2 was observed to have 3 wounds: left foot, left ankle, and coccyx (tailbone area). After performing wound care, RN (registered nurse) 1 called the physician and received new wound care orders. RN 1 was observed informing the facility staff that the doctor ordered Silvadene (a wound care cream) to be used on the patient. Patient #2 was observed to be using oxygen via nasal cannula, and continuous tube feeding via a pump. Review of an update to the care plan dated 5/16/2023 evidenced the following (most recent) wound care order: "; ... wound cleanser, medi honey [a wound care ointment], calcium alginate [a specialized wound dressing], dressing Q3 days [every 3 days]....". The care plan failed to evidence the locations of the wounds for this treatment. Review of an update to the care plan dated 6/27/2023 evidenced the following wound care order: "; ... change wound to coccyx m-f daily....". The care plan failed to evidence any wound care products including Silvadene. Review of the plan of care failed to evidence the use of oxygen, and continuous tube feeding via a pump. During an interview on 6/30/2023 at 2:08 PM, the Clinical Manager indicated wound care orders should include what is being used to clean and dress the wound and how frequently wound care is to be performed. When queried, the Clinical Manager indicated the order may not include the location of the wound because when the nurse enters the wound care orders in the EMR (electronic medical record), they are ";attaching" them to an anatomical figure. 4. Review of an update to the plan of care for Patient #5, dated 6/23/2023, indicated the nurse provided wound care as per orders. Review of the plan of care failed to evidence the location of the wound, what wound care was to be performed, and at what frequency. During an interview on 6/30/2023 at 2:50 PM, the Clinical Manager indicated the plan of care may not have the wound care orders in it, but the nurse could refer to the physician orders.

Based on observation, record review and interview, the hospice agency failed to evidence the ongoing sharing of information with non-hospice providers furnishing services unrelated to the terminal illness and related conditions in 3 of 6 active clinical records reviewed with a wound. patients (#4, 5, 11). The findings include: --- XX. Review of a skilled nurse visit note dated 5/17/2023 evidenced Patient #4 began bleeding profusely from left leg wound while wound care was being performed. After the patient continued to bleed after 3 attempts were made to control bleeding with a pressure dressing, the patient was sent to the emergency room at Hospital 4. Review of a skilled nurse visit note dated 5/18/2023 failed to evidence any documentation about the emergency room visit or treatment. Clinical record review failed to evidence any communication with Hospital 4. On 6/30/2023 at 2:38 PM, when informed of the findings, the Clinical Manager stated, ";We never got anything from the hospital". XX. Review of a skilled nurse visit note dated 6/5/2023 evidenced Person 5 (caregiver to Patient #5) informed the nurse that the patient had gone to an appointment at Facility 6 where they assessed the patients wound and ordered a new wound ointment, which had not yet arrived. Clinical record review failed to evidence any communication with Facility 6. During an interview on 6/30/2023 at 3:04 PM, the administrator indicated the agency typically coordinates care with other providers, but it was difficult to get a hold of Facility 6. 1. Record review evidenced an agency policy dated January 2014, titled, ";Clinical Record," which indicated the hospice would have evidence of coordination of care/service provided by the hospice with others who were providing care; and include all services and events. 2. Clinical record review for patient #11, on 06/29/2023, evidenced an agency document dated 06/11/2023, titled, ";Nursing Visit Note (Abridged)," indicated the patient had extensive gangrene (death of skin tissue) noted to the right foot up to the calf area. Review of an agency document dated 06/19/2023, titled, ";Nursing Visit Note," indicated the right leg had a dressing that was clean, dry and intact. During an observation of the Interdisciplinary Group Meeting on 06/28/2023, from 8:45 AM-10:35 AM, the nurse indicated the right toes and heels were necrotic and draining. Observation evidenced the hospice nurse indicated the skilled nursing facility wound nurse had ordered Santyl (debriding agent) to the wound and the hospice care physician indicated the wound care should be changed to cleanse the right leg and foot with saline, apply betadine and warp with kerlix every 3 days. Review failed to evidence any wound care orders prior to the 06/28/2023 Interdisciplinary Group Meeting regarding the right foot/leg wound. Review failed to evidence documentation of coordination of care with the skilled nursing facility 3s wound care nurse. During an interview on 06/30/2023, at 11:52 AM, the Administrator indicated skilled nursing facility 3s wound care nurse provided wound care to the patient. During an interview on 06/30/2023, at 12:04 PM, the Clinical Manager indicated the patients clinical record should include the orders for the wound care from the skilled nursing facility to the right foot and leg. The Clinical Manager indicated the hospice nurse should have scheduled skilled nursing facility 3s wound care with the skilled nursing facilitys wound care nurse for assessment.

Based on record review and interview, the agency failed to ensure performance improvement activities analyzed the causes of adverse events. The findings include: --- Review of an agency policy titled, ";QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT [QAPI]", revised 1/2014, indicated the hospice will measure, analyze the causes of, and track quality indicators, including adverse patient events . Review of an agency document titled, ";QUARTERLY QAPI MEETINGS", dated 1/5/2016, indicated at the end of the QAPI meeting, PIP (performance improvement project) projects will be identified based on agency reports. The document failed to evidence adverse event cause analysis. Review of the quarterly QAPI meeting minutes dated 4/25/2023, 1/24/2023, 10/20/2023, and 7/26/2022 failed to evidence adverse event cause analysis. Review of the agency QAPI binder on 6/26/2023 failed to evidence performance improvement activities analyzed the causes of adverse events. During an interview on 6/26/2023 at 3:35 PM, the administrator indicated all documentation about QAPI meeting content was provided to the surveyors. The administrator indicated the agency uses their metrics to choose a topic for performance improvement, then work on fixing it.

Based on record review and interview, the agency failed to develop and evaluate performance improvement projects (PIP). The findings include: --- Review of an agency policy titled, ";QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT [QAPI]", revised 1/2014, indicated when problems are identified through the QAPI program, the PIP committee will determine and document corrective actions taken and monitoring of effectiveness. Review of the quarterly QAPI meeting minutes dated 4/25/2023, 1/24/2023, 10/20/2022, and 7/26/2022, failed to evidence development and evaluation of the PIPs. Review of the agencys QAPI binder evidenced a group of documents titled, ";Quarterly Report to the Governing Board". Reports dated 4/25/2023, 1/24/2023, 10/20/2022, and 7/26/2022, failed to evidence development and evaluation of the PIPs . Review of the agencys QAPI binder evidenced a group of notes from PIP meetings. A note dated 5/30/2023, titled ";PIP: Frequencies", indicated the staff will continue to educate all employees. Review of the notes and the QAPI binder failed to evidence documentation of the education and what information was being taught. A note dated 5/30/2023, titled ";PIP: Care Plans", stated, ";... Continue to audit care plans ... Focus on individualizing every plan of care update ... Always continue to educate new staff...." Review failed to evidence documentation of care plan audits, documentation of education provided and what information was being taught. A note dated 5/30/2023, titled ";PIP: CAHPS [Consumer Assessment of Healthcare Providers and Systems] Scores", stated ";... Next steps. Always work on getting our star rating up...." Review failed to evidence education provided to staff about interventions to improve ratings. During an interview on 6/26/2023 at 3:35 PM, the administrator indicated all documentation about QAPI meeting content was provided to the surveyors. When queried, the administrator indicated she did not have documentation of what was implemented by the PIP in order to improve outcomes.

Based on record review and interview, the agency failed to document the reasons for conducting their current performance improvement projects (PIPs), and the measurable progress achieved on these projects. The findings include: --- Review of an agency policy titled, ";QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT [QAPI]", revised 1/2014, indicated the hospice will document what improvement projects are being conducted, the reason for conducting them, and the measurable progress achieved on these projects. Review of the quarterly QAPI meeting minutes dated 4/25/2023, 1/24/2023, 10/20/2022, and 7/26/2022, failed to evidence measurable progress achieved by the current PIPs. Review of the agencys QAPI binder evidenced a group of documents titled, ";Quarterly Report to the Governing Board". Reports dated 4/25/2023, 1/24/2023, 10/20/2022, and 7/26/2022, failed to evidence measurable progress achieved by the current PIPs. Review of the agencys QAPI binder evidenced a group of notes from PIP meetings. Notes dated 1/23/2023, 2/28/2023, 3/28/2023, 4/25/2023, and 5/30/2023, which failed to evidence measurable progress achieved by the current PIPs. During an interview on 6/26/2023 at 3:35 PM, the administrator indicated all documentation about QAPI meeting content was provided to the surveyors. The administrator indicated the agency uses their metrics to monitor effectiveness and offered no further documentation.

Based on observation, record review, and interview the hospice agency failed to follow accepted standards of practice to prevent the transmissions of infections and communicable diseases, including the use of standard precautions in 1 of 1 skilled nursing home visit with a hospice aide. (#3) Findings include: --- Record review evidenced an agency policy dated January 2014, titled, ";Infection Control," which stated, ";... After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water ...." Review of Center for Disease Control Guidelines for Hand Hygiene in Healthcare Settings on 06/27/2023, website cdc/gov/handhygiene/providers/guidelines.html, indicated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water following clinical indications: Immediately after glove removal. Observation of a skilled nursing facility visit with a hospice aide for patient #3, on 06/27/2023, from 8:50 AM-9:45 AM, evidenced hospice aide 1 perform oral care to patient, left glove was removed and new left hand glove was applied, observation failed to evidence hand hygiene performed after left glove removed and prior to new left glove applied. Observation evidenced hospice aide 1 moved patient up in bed with facility staff assistance and then removed gloves, emptied garbage and then new gloves were applied, observation failed to evidence hand hygiene performed after gloves removed and before new gloves were applied. During an interview on 06/27/2023, at 4:18 PM, the Administrator indicated hand hygiene should occur after gloves are removed and prior to new gloves being applied.

Based on record review and interview, the hospice agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention control, and investigation of infectious diseases in 1 of 4 clinical records reviewed with a patient infection. (#10) Findings include: --- Record review evidenced an agency policy dated January 2014, titled, ";Infection Control," which stated, ";... Hospice shall maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases ... It shall include a method of identifying infectious and communicable disease problems and a plan for implementing the appropriate actions that are expected to result in improvement and disease prevention ... The documentation of infection control occurrences on the OSHA [occupational safety and health administration] log and notification of appropriate authorities as indicated. The report to the Continuous Quality Improvement (CQI)/QAPI [quality assessment performance improvement] committee infection control related incidents ...." Clinical record review for patient #10, evidenced an agency document dated 04/25/2023, titled, ";Nursing Visit Note," which indicated the patient had a cough with purulent productive sputum and Augmentin (antibiotic) was prescribed for a respiratory infection. Review of an agency document dated April 2023, titled, ";Infection Control Log," failed to evidenced patient #10s respiratory infection was documented. During an interview on 06/30/2023, at 11:20 AM, the Clinical Manager indicated the patients infection was not documented and should have been included on the April 2023 infection control log.

Based on observation, record review and interview, the hospice failed to ensure the nursing needs of the patient were met as identified in the patients initial assessment, comprehensive assessment, and updated assessments (See tag L591). These practices impacted 11 of 14 active clinical records reviewed (#1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13). The cumulative effect of these systemic problems has resulted in the hospice agency inability to ensure provision of quality health care in a safe environment for the condition of participation 418.64 Core Services.

Based on observation, record review and interview, the hospice agency failed to ensure the nursing needs of the patient were met as identified in the patients initial assessment, comprehensive assessment, and updated assessments in 11 of 14 active clinical records reviewed (#1, 2, 4, 5, 6, 7, 8, 10, 11, 12, 13). The findings include: --- XX. During a home visit at skilled nursing facility 2 on 6/27/2023 at 9:20 AM, Patient #2 was observed to have 3 wounds: left foot, left ankle, and coccyx (tailbone area), and a PEG tube (a feeding tube inserted through the abdomen). Review of all skilled nurse visit notes for certification period 5/30/2023 to 7/28/2023 failed to evidence the nurse assessed the PEG tube site on 6/6/2023, 6/9/2023, 6/13/2023 and 6/16/2023. Review failed to evidence wound or dressing assessments on skilled nurse visit notes dated 6/9/2023 and 6/16/2023. During an interview on 6/30/2023 at 2:13 PM, the Clinical Manager indicated the nurse should assess the PEG tube site at each visit including the patency of the tube and appearance of surrounding skin. The Clinical Manager indicated wounds should be assessed at each visit, and if the skilled nursing facility staff performed wound care the day of the hospice nurse visit, the hospice nurse should document an assessment of the dressings. XXX. Review of the initial comprehensive assessment, dated 5/11/2023, evidenced Patient #4 had a wound to the left leg. Review of skilled nurse visit notes dated 5/12/2023, 5/16/2023, 5/24/2023, 5/26/2023, 5/30/2023, 6/5/2023, 6/12/2023, 6/20/2023, 6/21/2023, and 6/23/2023, failed to evidence an assessment of the wound. Review of skilled nurse visit notes dated 5/27/2028 and 5/28/2023 evidenced the nurse did not perform wound care at the request of the family member but failed to evidence an assessment of the present dressing. Clinical record review failed to evidence wound measurements for the weeks of 5/14/2023 to 5/20/2023 and 5/21/2023 to 5/27/2023. During an interview on 6/30/2023 at 2:18 PM, the Clinical Manager indicated the nurse should assess a patients wounds at each visit including the location, type, condition of surrounding skin, appearance of wound bed, type and amount of drainage, and measurements once weekly, and if the wound care is not completed at a visit, the nurse should document an assessment of the dressing. XXX. Review of the initial comprehensive assessment, dated 4/21/2023, evidenced Patient #5 had a wound to the right foot and a Foley catheter (a tube inserted through the urethra to drain the bladder). Review on 6/29/2023 of all skilled nursing visit notes from start of care, 4/21/2023, to 6/27/2023 failed to evidence wound measurements. Review of skilled nurse visit notes dated 5/9/2023, 5/12/2023, 5/17/2023, 5/18/2023, 6/5/2023, 6/16/2023 and 6/27/2023 failed to evidence wound assessments. Review of skilled nurse visit notes dated 5/9/2023, 5/15/2023, 6/13/2023 and 6/20/2023 failed to evidence an assessment of the patients urine. During an interview on 6/30/2023 at 2:58 PM, the Clinical Manager indicated the nurse should assess and document the color, odor, and amount of urine for a patient with a Foley catheter at each visit. During an interview on 6/30/2023 at 2:18 PM, the Clinical Manager indicated the nurse should assess a patients wounds at each visit including the location, type, condition of surrounding skin, appearance of wound bed, type and amount of drainage, and measurements once weekly, and if the wound care is not completed at a visit, the nurse should document an assessment of the dressing. XXX. Review of the initial comprehensive assessment, dated 6/5/2023, evidenced Patient #8 had a wound to the left heel, a Foley catheter, and was receiving tube feedings. Review on 6/29/2023 of all skilled nurse visit notes from start of care, 6/5/2023, to 6/26/2023 failed to evidence wound assessments or measurements of the heel wound. Review of skilled nurse visit notes dated 6/5/2023, 6/6/2023, 6/16/2023, 6/19/2023, and 6/26/2023 failed to evidence an assessment of the patients feeding tube site. A skilled nurse visit note dated 6/13/2023 indicated the patient had a PEG tube (feeding tube inserted through the abdomen) which was patent, but failed to evidence assessment of the surrounding skin. Review of a skilled nurse visit note dated 6/13/2023 failed to evidence assessment of the Foley catheter and urine. Review of a skilled nurse visit note dated 6/19/2023 failed to evidence an assessment of the urine. Review of a skilled nurse visit note dated 6/6/2023 evidenced the patient had redness and a skin tear to the coccyx (tailbone area). Review of subsequent nurse visit notes dated 6/13/2023, 6/16/2023, 6/19/2023, and 6/26/2023 failed to evidence assessment of the skin tear to the coccyx. Clinical record review failed to evidence the nurse notified the physician of the new skin tear. During an interview on 6/30/2023 at 2:18 PM, the Clinical Manager indicated the nurse should assess a patients wounds at each visit including the location, type, condition of surrounding skin, appearance of wound bed, type and amount of drainage, and measurements once weekly, and if the wound care is not completed at a visit, the nurse should document an assessment of the dressing. During an interview on 6/30/2023 at 2:58 PM, the Clinical Manager indicated the nurse should assess and document the color, odor, and amount of urine for a patient with a Foley catheter at each visit. During an interview on 6/30/2023 at 3:16 PM, the Clinical Manager indicated the nurse should assess the patency of the tube and appearance of the surrounding skin for a patient with a PEG tube at each nursing visit. XXX. Review of a skilled nursing visit note dated 5/8/2023 indicated Patient #13s biggest concern was having swelling to their right foot. The nurse assessed the patient had 3+ edema (a rating of swelling severity, 4+ being highest possible) to the right foot. Review of a nursing visit note dated 5/26/2023 evidenced the patient had pain, swelling and tightness to the right foot. Review of skilled nursing visit notes dated 6/9/2023 and 6/12/2023, indicated Patient #13s biggest concern was having swelling to their right foot. Review of skilled nurse visit notes dated 6/16/2023, 6/20/2023 and 6/23/2023 evidenced the patient continued to complain of swelling and pain to the right foot. Clinical record review failed to evidence the nurse communicated with the physician about the patients continued foot pain and swelling. During an interview on 6/30/2023 at 3:25 PM, the Patient Care Coordinator indicated the patient had ongoing problems with swelling, for which the nurses were instructing the patient to elevate their legs. When queried, the Patient Care Coordinator indicated the nurse failed to communicate with the physician about the patients continued unilateral swelling and pain despite 9 weeks of the only nursing intervention being reminders to elevate the legs. XXX. Review of a Narrative Note dated 7/24/2022 indicated Patient #15 fell at home, and the agency sent a nurse out that day to evaluate the patient. Clinical record review failed to evidence any nurse visit notes from 7/20/2023 to 7/29/2023. During an interview on 6/30/2023 at 3:50 PM, the administrator indicated if a nurse gets called out to see a patient, they should document a nurses note for that visit. When queried, the administrator indicated the nurse did not document a visit note for 7/24/2023, but did enter they made a visit to the patient that day on their timecard. 1. Record review evidenced an agency policy dated January 2014, titled, ";Hospice Nursing Care," which stated, ";... The hospice nurse performs initial and ongoing assessments of hospice patients/families/caregivers needs ...." 2. Record review evidenced an agency policy dated January 2014, titled, ";Standard of Care and Practice," which stated, ";... Ongoing assessment should determine if the standards of care continue to be appropriate to patient/family/caregiver needs ...." 3. Record review evidenced an agency policy dated January 2014, titled, ";Ongoing Assessment," which stated, ";... The nurse will assess each patient on each visit, for: ... Skin integrity ... Elimination (urinary and bowel) ...." 4. Record review evidenced an undated policy resource, received on 06/30/2023, titled, ";Wound Care at End of Life," which indicated assessment and documentation of wounds should include wound bed size, type, location, odor, drainage type and amount, signs and symptoms of infections, wound edge assessment for tunneling, undermining, and peri-wound tissue. 5. Record review evidenced an agency policy dated January 2014, titled, ";Ongoing Assessment," which stated, ";... Alteration of Skin Integrity: Wounds should viewed/documented every visit unless the R.N. [registered nurse] Case Manager has documented a successful return demonstration of the wound care by an authorized person, in which case the R.N. Case Manager must view the wound minimally one time per week ...." 6. Record review evidenced an agency policy dated January 2014, titled, ";Clinical Records," stated, ";... Clinical notes shall be signed and dated by the person providing the services and submitted to the centralized location in person or by mail within 48 hours of the visit ...." 7. Clinical record review for patient #1, on 06/27/2023, evidenced an agency document dated 03/21/2023, titled, ";Comprehensive Assessment," which indicated the teaching/education provided to patient/family would include infection control, and universal precautions. During observation of a home visit on 06/26/2023, from 10:00 AM-10:10 AM, teaching/education to the patients family member included medication management review of plan of care. Review of an agency document dated 06/26/2023, titled, ";Nursing Visit Note," indicated communication with the family included review of infection control and handing washing with the patients family member. Observation of the home visit failed to evidence infection control or hand washing education with patients family member. During an interview on 06/30/2023, at 12:35 PM, the Clinical Manager indicated only education provided should be included on the nursing visit note. 8. Clinical record review for patient #10, on 06/29/2023, evidenced an agency document dated 05/17/2023, titled, ";Nurse Recertification," which indicated the patient had a suprapubic catheter (a urinary catheter inserted into the bladder from an incision in the abdomen) and a colostomy (an opening in the colon through the abdomen, by operation, that allows waste to leave the body through an opening [stoma]). Review of agency documents dated 05/24/2023, 05/30/2023, 06/05/2023, 06/13/2023, and 06/20/2023, titled, ";Nursing Note Visits," failed to document a colostomy stoma site or surrounding skin assessment. Review of an agency document dated 05/23/2023, titled, ";Treatment Orders," indicated suprapubic catheter site care should include cleanse catheter insertion site every week and inspect every visit to ensure patency and report significant findings to the physician. Review of an agency document dated 05/17/2023, titled, ";IDG [interdisciplinary group] Update," indicated patients skilled nursing visit frequency was 1-3 visits every 15 days. Review evidenced patient had nursing visit on 05/24/2023, 05/30/2023, 06/05/2023, and 06/13/2023. Review of agency documents dated 05/24/2023, and 05/30/2023 failed to evidence documentation of cleansing of catheter insertion site. During an interview on 06/30/2023, at 11:00 AM, the Clinical Manager indicated the ostomy site should be assessed and documented to include ostomy type, appearance and stoma site every nursing visit. During an interview on 06/30/2023, at 11:10 AM, the Administrator indicated the stoma site should be assessed at every nursing visit and the catheter site cleansing should be documented by the nurse when completed. 9. Clinical record review for patient #6, on 06/29/2023, evidenced an agency document dated 04/22/2023, titled, ";Comprehensive Assessment," which indicated the patient had a gastrointestinal ostomy in place. Review failed to evidence a stoma site assessment. Review of an agency document dated 04/23/2023, titled, ";Nursing Visit Note (Abridged)" failed to evidence stoma site assessment. Review of an agency document dated 05/05/2023, titled, ";Nursing Visit Note," failed to evidence documentation of colostomy or stoma site assessment. During an interview on 06/30/2023, at 11:29 PM, the Clinical Manager indicated colostomy and stoma site assessments should occur at every nursing visit and documented to include skin assessment surrounding the stoma site. 10. Clinical record review for patient #7, on 06/29/2023, evidenced an agency document dated 04/08/2023, titled, ";Comprehensive Assessment," which indicated the patient had a peg tube (feeding tube into the stomach). Review evidenced agency documents dated 04/10/2023, 04/18/2023, 05/04/2023, 05/15/2023, 05/29/2023, 06/05/2023, and 06/27/2023, titled, ";Nursing Visit Note," failed to evidence documentation of assessment of peg tube site. During an interview on 06/30/2023, at 10:29 AM, the Clinical Manager indicated documentation of the peg tube site should occur every nursing visit to include documentation of patency of tubing, and surrounding skin assessment. 11. Clinical record review for patient #11, on 06/29/2023, hospice election date 06/09/2023, evidenced an agency document dated 06/09/2023, titled, Comprehensive Assessment," indicated the patients right foot was cold, cyanotic (blue in color), and foot pulse was diminished. Review of an agency document dated 06/10/2023, titled, ";Nursing Visit Note (Abridged)," failed to evidence assessment of the right foot/leg. Review of an agency document dated 06/11/2023, titled, ";Nursing Visit Note (Abridged)," indicated the patient had extensive gangrene (death of skin tissue) noted to right foot up to calf area and a foam gauze dressing was applied. Review of an agency document dated 06/16/2023, titled, ";Care Plan," indicated the patient had redness and swelling to leg and patient to be premedicated prior to wound dressing change. Review of an agency document dated 06/19/2023, titled, ";Nursing Visit Note," indicated the right leg had a dressing that was clean dry and intact. Review of an agency document dated 06/20/2023, titled, ";Nursing Visit Note," indicated right foot pulse is diminished, cyanotic, erythema (redness), bruising and edema (swelling) was noted. Review of an agency document dated 06/27/2023, titled, ";Nursing Visit Note," indicated absent right foot pulse, right leg and foot were cyanotic, erythema noted. During an observation of the Interdisciplinary Group Meeting on 06/28/2023, from 8:45 AM-10:35 AM, the nurse indicated the right leg was cyanotic/red and the toes and heels were necrotic (dead skin tissue) with swelling that was weeping (fluid drainage from wound). Observation evidenced the hospice nurse indicated the skilled nursing facility wound nurse had ordered Santyl (debriding agent) to the wound and the hospice physician indicated the wound care should be changed to cleanse right leg and foot with saline, apply betadine and wrap with kerlix every 3 days. Review failed to evidence the hospice nurse notified the hospice physician of the right foot/leg assessment site prior to the 06/28/2023 Interdisciplinary Group Meeting. Review failed to evidence the right foot/leg was assessed to include weekly wound measurements, wound assessment to include wound bed size, odor, discharge type and amount, wound edges, and peri-wound tissue. Review failed to evidence wound care orders for the right foot/leg wound prior to the 06/28/2023 Interdisciplinary Group Meeting. During an interview on 06/30/2023, at 11:32 AM, the Clinical Manager indicated skin/wound assessment should be done at every nursing visit and documented, and wounds should be measured weekly. The Clinical Manager indicated the hospice should be assessing the wounds regardless of if the skilled nursing facilitys wound care nurse was addressing the wound care. During an interview on 06/30/2023, at 12:02 PM, the Administrator indicated the hospice agency was responsible for the wound care and assessment. 12. Clinical record review for patient #12, on 06/29/2023, evidenced an agency document dated 06/24/2023, titled, ";Triage Note," which indicated patients spouse called triage due to patient had been staring all night and was unclear if the patient passed. The document indicated multiple attempts to return call were made and the on call nurse is the RNCM (registered nurse case manager) and will follow up with the patient. Review failed to evidence documentation of the follow up regarding the patient. Review evidenced an agency document dated 06/29/2023, titled, ";Care Plan," which indicated patient was having Cheyne stokes (abnormal pattern of breathing) respirations, no intake in 72 hours and inability to close eyelids and mouth. Review failed to evidence documentation of follow up from the 06/24/2023 triage phone call. During an interview on 06/30/2023, at 12:25 PM, the Administrator indicated the triage nurse left on vacation and did not document follow up to the 06/24/2023 triage call. The Administrator indicated the patient was seen on 06/27/2023, 06/28/2023 and 06/29/2023.

Based on record review and interview, the hospice aide failed to complete appropriate records in compliance with the hospices policies and procedures in 1 of 5 active clinical records reviewed with a hospice aide. (#12) Findings include: --- Record review of an agency policy dated January 2014, titled, ";Clinical Records," stated, ";... Clinical notes shall be signed and dated by the person providing the services and submitted to the centralized location in person or by mail within 48 hours of the visit ...." Clinical record review for patient #12, on 06/29/2023, evidenced an agency document dated 06/08/2023, titled, ";Initial Plan of Care," which indicated the patient was to receive 7-11 hospice aide visits for the next 15 days. Review evidenced the last hospice aide note was on 06/16/2023. Review failed to evidence documentation of the hospice aide notes after 06/16/2023. During an interview on 06/30/2023, at 3:20 PM, the Administrator indicated the patient was seen 06/18/2023-06/2023, and 06/26/2023-06/30/2023, by the hospice aide, however the clinical notes were not completed since 06/16/2023.

Based on record review and interview, the hospice agency failed to include physician orders in the clinical records in 3 of 19 clinical records reviewed (#7, 11, 18) The findings include: --- 1. Record review evidenced an agency policy dated January 2014, titled, ";Clinical Record," which stated, ";... Hospice will establish and maintain a clinical record containing past and current findings for every individual receiving services ... The record will include ... physician orders ... treatments, and services ...." 2. Record review evidenced an agency policy dated January 2014, titled, ";Medications," which stated, ";... A medication list shall be maintained for each patient. Periodic review and monitoring for appropriate medications and their use shall be documented and recommendations made to the physician ...." 3. Record review evidenced an agency policy dated January 2014, titled, ";Physician Orders/Plan of Care," which stated, ";... All diagnostic and therapeutic orders, including verbal orders, will be signed by the physician and incorporated into the clinical record within fourteen days ...." 4. Clinical record review for patient #7, on 06/29/2023, evidenced an agency document dated 05/26/2023, titled, ";Nursing Visit Note (Abridged)," which indicated the patient had a seizure and a family member indicated the patient was taking Keppra (seizure preventing medication) three times a day and the family member was giving Keppra twice per day. Review of an agency document generated on 06/29/2023, titled, ";Medication List," indicated the patient was on no regular medications. Review failed to evidence a physician order for the Keppra. During an interview on 06/30/2023, at 10:35 AM, the Clinical Manager indicated the Keppra should be on the medication list, the medication list was not accurate, and there was no written order for the Keppra from the physician. 5. Clinical record review for patient #11, on 06/29/2023, evidenced an agency document dated 06/20/2023, titled, ";Nursing Visit Note," which indicated the patient was on scheduled Lorazepam (antianxiety medication) at night and was taking Norco (pain medication). Review of an agency document generated on 06/27/2023, titled, ";Medication List," indicated the patients regular medications included Timolol (eye drop), Tylenol, and oxygen and there were no medications under the comfort kit medications. Review failed to evidence a physician order for scheduled Lorazepam and there was no evidence of an order for the Norco. During an interview on 06/30/2023, at 11:37 AM, the Clinical Manager indicated there was not an order for the scheduled Lorazepam or the Norco and the medications were not on the medication list. 6. Clinical record review for patient #18, evidenced an agency document dated 01/31/2023, titled, ";Nursing Visit Note (Abridged)," which indicated oxygen was ordered for the patient. Review failed to evidence a physician order for oxygen. During an interview on 06/30/2023, at 10:53 AM, the Clinical Manager indicated the oxygen was delivered to the patient on 01/31/2023, and there was not an order for the oxygen and the clinical record should have a physician order for the oxygen and should be included in the plan of care and medication list.

Based on observation, record review and interview, the hospice agency failed to include written policies and procedures for the management and disposal of controlled drugs in the patients home in 1 of 4 home visits (#1). The findings include: --- Record review evidenced an agency document dated January 2014, titled, ";Home Use and Disposal of Controlled Substances," stated, ";... At the time when controlled drugs are first ordered, a member of the hospice staff will provide the patient/patient representative/family with a written copy of ... policy and procedures on the management and disposal of controlled medication ...." During an observation of a home visit for patient #1, on 06/26/2023, from 9:50 AM-10:10 AM, the patients hospice home binder failed to include a written medication disposal policy. Record review of an agency document titled, "Medication List," generated on 06/28/2023, evidenced Lorazepam ( controlled antianxiety medication) and Morphine ( controlled pain medication) were started on 03/21/2023. During an interview on 06/30/2023, at 12:39 PM, the Clinical Manager indicated medication disposal education was only provided verbally during nurse home visits.

Based on observation, record review and interview, the hospice agencys plan of care failed to identify the care and services that are needed and specifically identify which provider was responsible for performing the functions that have been agreed upon in 2 of 4 active clinical records reviewed for skilled nursing facility patients (#3, 11). The findings include: --- 1. Record review evidenced an agency policy dated January 2014, titled, ";Patient Plan of Care," which stated, ";...The Hospice care Team will complete an assessment of the patients care needs, and establish a written individualized plan of care in collaboration with the attending physician (if any), the patient/representative, and the primary caregiver in accordance with the patients needs ... The hospice must ensure that each patient and primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care ...." 2. Record review evidenced an agency policy dated January 2014, titled, ";Clinical Record," which stated, ";... The record will include ... evidence of coordination of care/service provided with others who may be providing care/service ...." 3. Clinical record review on 06/28/2023, for patient #3, start of care 04/27/2023, evidenced an agency document dated 04/27/2023, titled, ";Initial Plan of Care," which failed to indicate the care and services that were needed and specifically identify which provider was responsible for performing the functions. Review of skilled nursing facility 1s document, identified as the facilitys plan of care, indicated the patient was admitted on 04/27/2023. 4. Clinical record review 06/29/2023, for patient #11, start of care 06/09/2023, evidenced an agency document dated 06/09/2023, titled, ";Initial Plan of Care," which failed to indicate care and services that were needed and specifically identify which provider was responsible for performing the functions. Review of an agency document dated 06/11/2023, titled, ";Care Plan," indicated the patient resided in a skilled nursing facility. Review of an agency document dated 06/16/2023, titled, ";Care Plan," indicated the patient had redness and swelling to leg and patient was to be premedicated prior to wound dressing change. During an observation of the Interdisciplinary Group Meeting on 06/28/2023, from 8:45 AM-10:35 AM, the nurse indicated the right leg was cyanotic/red and the toes and the heels were necrotic (dead skin tissue) with swelling that was weeping (fluid discharge from wound). Observation evidenced the hospice nurse indicated the skilled nursing facility wound nurse had ordered a debriding agent to the wound and the hospice physician indicated the wound care should be changed to cleanse the right leg and foot with saline, apply betadine and wrap with kerlix every 3 days. Review of the plan of care failed to evidence the delineation of the wound care. 5. During an interview on 06/29/2023, at 4:20 PM, the Administrator indicated the hospice binder in a skilled nursing facility should include the skilled nursing facilitys responsibility for patient care.

Based on record review and interview, the agency failed to coordinate care with the skilled nursing facility in 1 of 2 home visits observed in a skilled nursing facility (#2). The findings include: --- Review of an agency policy titled, ";HOSPICE INTERDISCIPLINARY GROUP", revised 1/2014, indicated the hospice interdisciplinary group shall be responsible for directing, coordinating, and supervising the care and services provided in all care settings, including other non-hospice providers serving the patient. Review of an agency policy titled, ";CLINICAL RECORD", indicated the patients clinical record shall include evidence of coordination of care with other providers serving the patient. Clinical record review for Patient #2, resident at skilled nursing facility 2, evidenced an update to the agency care plan dated 5/16/2023, that containing the following (most recent) wound care order: ";... wound cleanser, medi honey [a wound care ointment], calcium alginate [a specialized wound dressing], dressing Q3 days [every 3 days]....". The plan of care failed to evidence who was responsible for performing wound care. Review of a skilled nurse visit note dated 6/9/2023, indicated the facilitys wound care nurse performed wound care for the patient every Monday, Wednesday, and Friday. Review of an agency document titled ";Hospice / LTC [long term care] Coordinated Task Plan of Care", updated by RN 1 on 6/27/2023, failed to evidence who was responsible for performing Patient #2s wound care. Review evidenced a physician order dated 1/5/2022, (most recent tube feeding order), which indicated the patient was receiving Jevity 1.5 (a liquid nutrition), 35mL / hr (milliliters per hour) for 19 hours daily with 240mL flush every 8 hours. Review of the patients current treatment orders for skilled nursing facility 2 evidenced the following orders: wound care for the left foot and left ankle--cleanse with saline, apply silver alginate to wound bed, and cover with dry dressing every Monday, Wednesday, and Thursday; tube feeding—Jevity 1.5 continuous at 35 mL / hr, 240 mL water flush every 6 hours. During an interview on 6/30/2023 at 2:11 PM, the Clinical Manager indicated the nurse should coordinate care with the facility staff at each visit. When informed of the findings, the Clinical Manager indicated the nurse should have notified the physician of the wound and tube feeding order discrepancies for clarification.

Based on observation, record review and interview, the hospice agency failed to provide the skilled nursing facility with required hospice patient information in 2 of 2 home visits conducted in a skilled nursing facility (#2, 3). The findings include: --- XX. Review of Patient #2s clinical record at Skilled Nursing Facility #2 failed to evidence the Hospice election form and physician certification of the terminal illness specific to the patient. During an interview on 6/27/2023 at 10:57 AM, Nurse 7 from Skilled Nursing Facility #2 indicated patient information received from the hospice goes into the Facilitys electronic medical record. Nurse 7 indicated the patients record failed to evidence a hospice election form and physician certification of the terminal illness specific to the patient. During an interview on 6/27/2023 at 10:55 AM, the Patient Care Coordinator indicated the hospice doesnt routinely provide a hospice election form and physician certification of the terminal illness specific to the patient, but it can be provided upon request. 1. Record review evidenced an agency policy dated January 2014, titled, ";Patient Plan of Care," stated, ";...The Hospice care Team will complete an assessment of the patients care needs, and establish a written individualized plan of care in collaboration with the attending physician (if any), the patient/representative, and the primary caregiver in accordance with the patients needs ... The hospice must ensure that each patient and primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care ...." 2. An observation of skilled nursing facility 1 visit for patient #3, on 06/27/2023, from 8:50 AM-9:45 AM, failed to evidence the facility had the patients hospice plan of care or medication list. Record review of skilled nursing facility 1s hospice binder evidenced an agency document titled, ";Hospice/LTC [long term care] Coordinated Task Plan of Care," that was blank. During an interview on 06/29/2023, at 4:20 PM, the Administrator indicated a skilled nurse facility should have the hospice plan of care in the hospice provided binder. During an interview on 06/28/2023, skilled nursing facility 1s Director of Nursing indicated the skilled nursing facilitys administrator called the hospice agency for the plan of care on 06/27/2023, due to the skilled nursing facility did not have the hospice agencys plan of care.

Based on record review and interview, the agency failed to ensure licenses for registered nurses (RN) were current and active in the state of Indiana in 3 of 7 active personnel records reviewed. (A, D, E) The findings include: 1. Review of an agency policy obtained 1/5/2022, and updated January 2014, titled "Personnel Record Contents" stated, "... Unity Hospice will maintain accurate and complete personnel files on all personnel. ... The content of the personnel files for full time personnel will include: ... Verified Professional Licenses ...." 2. Review of an agency policy obtained 1/5/2022, and updated January 2014, titled "Licensure/Certification/Registration" stated, "... All organization personnel must maintain and show proof of licensure/certification/registration as appropriate. ... Personnel must comply with requirements to maintain such licensure/certification/registration in accordance with applicable state law and regulation. A current copy of or other proof of licensure, certification, and/or registration will be kept in the personnel file." 3. Personnel record review on 1/5/2022, for RN A, date of hire 3/5/2020, evidenced a document identified by the Director of Human Resources to be the Indiana RN license verification. This document indicated the RN license expired 10/31/2021. No other document was provided to indicate the RN license was active. During an interview on 1/5/2022 at 11:33 AM, the Director of Human Resources indicated RN A accidentally marked he was not a United States citizen on his license renewal. When queried about what was the status of his license currently, the Director of Human Resources indicated he would go check. Review of a document provided by the Director of Human Resources on 1/5/2022 at 11:53 AM titled "Search Results" indicated the RN license for RN A was expired. During an interview on 1/5/2022 at 11:53 AM, the Director of Human Resources indicated there was no current license verification in the personnel record for RN A. The Director of Human Resources indicated he knew the license was pending and indicated he thought that maybe due to Covid the license renewal was "taking awhile." During an interview on 1/5/2022 at 12:18 PM, RN A indicated he was not aware his license was not renewed and the status was expired until today. 4. Personnel record review on 1/5/2022, for RN D, date of hire 12/7/2020, evidenced a document identified by the Director of Human Resources to be the Indiana RN license verification. This document indicated the RN license expired 10/31/2021. During an interview on 1/5/2022 at 12:36 PM, the Director of Human Resources indicated the RN's license renewal was on hold related to a "hold-up" during the time of renewal. The Director of Human Resources indicated he did not verify her license after expiration in October 2021 and print it for the personnel record. At 12:58 PM, the Director Human Resources indicated the agency was aware the RN had difficulty with her license renewal and indicated the RN license was not verified before today. 5. Personnel record review on 1/5/2022, for RN E, date of hire 1/30/2021, evidenced a document from entity A titled "Lookup Detail View" which evidenced the RN had an active RN license in the state of Illinois. Review failed to evidence the RN had an active license in the state of Indiana. During an interview on 1/5/2022 at 12:08 PM, the Director of Human Resources indicated he believed RN E had a compact nursing license. When queried if there was an Indiana license verification for RN E, the Director of Human Resources indicated no and indicated he "would go look it up." 6. During an interview on 1/5/2022 at 10:47 AM, the Director of Human Resources indicated he verified the licenses for nurses as they expired to ensure licenses were renewed and indicated the personnel file should contain verification of licensure.