Every finding on record at Visiting Nurse Association of Porter County In, Inc.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The agency did not include alternate means of communication for two staff members. Additionally, governmental agencies had primary contact only and no alternate method of communication in the Emergency Plan.

Upon patient record review, 9 of 21 (Patients #1,2,5,6,7,8,12,14,15) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1,2,5,6,7,8,12,14,15: Patients EOB indicated (check-mark) that "I do not wish to choose an attending physician." The physicians following these patients are referring physicians who work at the SNF (not hospice) where patients reside. There is evidence of hospice notification to attending physicians their responsibilities. However, there is no evidence in patient record of this choice of attending physician.

Upon patient record review, 20 of 21 (Patients #1,2,3,4,5,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #1,2,3,4,5,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21: These patient records did not specify if patient was imminent or not. The agency had self-identified this assessment was missing (prior to survey). This identification date was 10/1/25. Therefore all admissions after 10/1/25 have this assessment embedded into electronic medical record that Initial Nursing Comprehensive assesses for imminence of death.

Upon patient record review, 6 of 21 (Patients #1,5,7,8,11,14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During SNF visit medication reconciliation this patient had Pepcid 20 mg on hand (ordered 10/6/25). This medication was not included on the hospice medication profile. Corrected on site-RN obtained order and updated hospice med profile. Patient #5: This patient is prescribed Acetaminophen ES 500mg. 2 tablets two times daily as needed. Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed, and Hydrocodone/ Acetaminophen 5/325 one tablet 3 times daily as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #7: This patient is prescribed Acetaminophen ES 500mg. 1 tablet at bedtime. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/Acetaminophen 325 two tablets 4 times daily as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #8: This patient is prescribed Acetaminophen 325mg. 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #11: This patient is prescribed Acetaminophen 325mg. 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours. Patient #14: This patient is prescribed Acetaminophen 325mg. 2 tablets six times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, The medication profile did not specify a maximum dose of acetaminophen within 24 hours.

Upon patient record review, 5 of 21 (Patients #5,7,8,11,14) did not have evidence the plan of care (POC) must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: This patient is prescribed Acetaminophen ES 500mg, 2 tablets two times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 6 hours as needed, and Hydrocodone/ Acetaminophen 5/325 one tablet 3 times daily as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #7: This patient is prescribed Acetaminophen ES 500mg, 1 tablet at bedtime. Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed, and Hydrocodone/ Acetaminophen 325 two tablets 4 times daily as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #8: This patient is prescribed Acetaminophen 325mg, 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #11: This patient is prescribed Acetaminophen 325mg, 2 tablets four times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The POC did not specify a maximum dose of acetaminophen within 24 hours. Patient #14: This patient is prescribed Acetaminophen 325mg, 2 tablets six times daily as needed and Acetaminophen 650mg Suppositories 1 suppository every 4 hours as needed. The plan of care did not specify a maximum dose of acetaminophen within 24 hours.

Upon patient record review, 2 of 21 (Patients #1,2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: This patient had an alternating pressure mattress. This was not included on the Plan of Care. Patient #2: This patient had an alternating pressure mattress and fall mats x2. These were not included on the Plan of Care.

Upon patient record review, 1 of 21 (Patient #1) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The “Election of Benefit/Start of Care Effective Date” field was left blank on document.

Upon SNF/NF contract review, 1 of 5 (Valparaiso Care SNF/Routine Care Contract) The contract did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Condition of Participation: Hospices that Provide Inpatient Care Directly.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. The agency is completing the annual generator tests as appropriate but not completing the tri-annual 4 hour load test according to NFPA 110, 8.4.9.2.

Upon observation, there is no evidence the corridor walls and doors of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 "exception number 1 and 2 and 19.3.6.3.6 number 2". If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. During the building tour, it was observed that the smoke compartment wall above the double doors contained two unsealed penetrations where electrical wires pass through the gypsum board. These unsealed penetrations compromise the integrity of the smoke barrier.

Upon patient record review, 16 of 16 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16: The medication list entry for atropine drops, ordered as a part of the comfort kit for each patient, indicates atropine 0.01% 2 drops q 2 hours via ophthalmic PRN excessive secretions. This medication is ordered per the physician to be used orally/sublingual. (corrected onsite for all active patients) Patient 1: The medication list indicates Miralax 17g/dose oral powder take 17g daily po; however, there are no instructions for reconstitution of the powdered medication. (corrected onsite) Patient 4: The medication list indicates Miralax 17g/dose oral powder take 17g daily po; however, there are no instructions for reconstitution of the powdered medication. (corrected onsite) Patient 5: The medication list indicates oxygen 1-5L continuous; however, there is no indication of a delivery method for the oxygen. (corrected onsite) Patient 6: The initial comprehensive nursing assessment indicates the patient utilizes Miralax daily; however, the Miralax does not appear on the the patient's medication list. (corrected onsite) Patient 7: The SN note dated 10.25.2022 indicates the patient utilizes Colace 100mg bid po; however, the Colace does not appear on the patient's medication list. Additionally, the SN note dated 10.31.2022 indicates the patient's Lasix 40mg will be increased to bid usage; however, the increased dosage does not appear on the patient's medication list. (corrected onsite) Patient 9: The initial comprehensive nursing assessment, as well as subsequent SN notes dated 10.13.2022 and 10.18.2022, indicate the patient utilizes oxygen 3L via nasal canula PRN for dyspnea; however, the oxygen does not appear on the patient's medication list. (corrected onsite) Patient 10: The medication list indicates oxygen 1-10L PRN dyspnea; however, there is no indication of a delivery method for the oxygen. Additionally, the range of 1-10L/min is too broad to provide an appropriate therapeutic effect.(corrected onsite) Patient 12: The medication list indicates Miralax 17g/dose oral powder take 17g daily po; however, there are no instructions for reconstitution of the powdered medication. Additionally, the medication list indicates both Dorzolamide 2% 1 drop bid via ophthalmic and latanoprost 0.005% 1 drop every night via ophthalmic; neither medication indicates in which eye(s) the medication should be used. (corrected onsite) Patient 13: The initial comprehensive nursing assessment indicates the patient utilizes oxygen 2L via nasal canula PRN for dyspnea; however, the oxygen does not appear on the patient's medication list. (corrected onsite)

Upon patient record review, 3 of 16 (Patient #3, 4, 8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 3: SN notes dated October 17, 19, 21, 24, 26, 29, and November 01, 2022, all discuss the patient's reduced swallowing abilities including concerns relating to chewing/swallowing food, taking po medications, pocketing food and medications, coughing when drinking, etc. Interventions have been initiated such as crushing medications and monitoring oral intake to decrease risk of aspiration. However, there is no evidence of a care plan being developed to address aspiration risk or swallowing status/safety. (corrected onsite) Patient 4: The narrative portion of the SN visit note dated 09.26.2022 indicates cleanse coccyx wound with soap & water, pat dry, apply bordered sacryl dressing, change every three days & PRN soilage; a signed physician's order is present. However, the nursing care plan has not been updated to reflect the wound care interventions. (corrected onsite) Patient 8: The narrative portion of the SN visit note dated 09.12.2022 indicates hospice RN & family/CG perform wound care to right foot - cleanse with NS, pat dry with gauze, apply collagen powder, cover with 4x4 gauze, wrap with Kerlix & Coban, change every 2-3 days & PRN soilage; a signed physician's order is present. However, the nursing care plan has not been updated to reflect the wound care interventions. (corrected onsite)

Upon patient record review, 4 of 16 (Patient #6, 7, 9, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The initial comprehensive nursing assessment indicates the patient utilizes Miralax daily for management of the terminal illness; however, there is no evidence of a signed physician's order for the Miralax. (corrected onsite) Patient 7: The SN note dated 10.25.2022 indicates the patient utilizes Colace 100mg bid po for management of the terminal illness; however, there is no evidence of a signed physician's order for the Colace. Additionally, the SN note dated 10.31.2022 indicates the patient's Lasix 40mg will be increased to bid usage; however, there is no evidence of a signed physician's order for the increased Lasix dose. (corrected onsite) Patient 9: The initial comprehensive nursing assessment, as well as subsequent SN notes dated 10.13.2022 and 10.18.2022, indicate the patient utilizes oxygen 3L via nasal canula PRN dyspnea for management of the terminal illness; however, there is no evidence of a signed physician's order for the oxygen. (corrected onsite) Patient 13: The initial comprehensive nursing assessment indicates the patient utilizes oxygen 2L via nasal canula PRN dyspnea for management of the terminal illness; however, there is no evidence of a signed physician's order for the oxygen. (corrected onsite)

Upon patient record review, 5 of 13 (Patient #1, 5, 9, 10, 13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The initial comprehensive nursing assessment and HA care plan indicate that the patient utilizes a wheelchair for management of the terminal illness; the patient was also observed sitting in her wheelchair during the home visit. However, the wheelchair does not appear on the plan of care. (corrected onsite) Patient 5: The initial comprehensive nursing assessment indicates the patient utilizes a walker to ambulate and the HA care plan indicates that the patient utilizes a wheelchair for management of the terminal illness; however, the walker and wheelchair do not appear on the plan of care. (corrected onsite) Patient 9: Medication orders indicate the patient utilizes a nebulizer for administration of inhaled drugs and the initial comprehensive nursing assessment indicates the patient utilizes a biPAP for management of the terminal illness; however, the nebulizer and biPAP do not appear on the plan of care. (corrected onsite) Patient 10: Medication orders indicate the patient utilizes a nebulizer for administration of inhaled drugs; however, the nebulizer does not appear on the plan of care. (corrected onsite) Patient 13: The initial comprehensive nursing assessment indicates that the patient utilizes oxygen for management of the terminal illness; however, oxygen does not appear on the plan of care. A subsequent SN visit note indicates the patient utilizes a wheelchair for management of the terminal illness; the wheelchair does not appear on the plan of care either. (corrected onsite)

Upon observation, there was no evidence that the Hospice's inpatient facility maintains and documents an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases. Upon observation during the LSC inspection, a ceiling tile above the McGill nurse's station was observed to be wet or have an area of previous wetness saturating approximately 1/2 the ceiling tile. On further inspection by maintenance staff, it was determined to be a result of condensation from ductwork above in the ceiling; the tile was promptly replaced prior to the surveyor leaving the building on the same day, and the duct properly insulated. (corrected onsite)