The Center for Hospice and Palliative Care Inc.

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure an occupational therapy (OT) evaluation was conducted within 5 days of SOC for 1 of 1 records reviewed of a patient referred to the agency for OT (Patient #2). Findings include: 1. Patient #2’s clinical record indicated Patient was referred to the agency on 2/21/2024. A communication note, dated 2/21/2024, evidenced Patient was referred for SN, physical therapy, OT, and speech therapy. Patient’s SOC was 2/28/2024 and an OT evaluation was conducted on 3/08/2024, which was nine days after the SOC. The record failed to evidence Patient was notified and agreeable to the delay in OT evaluation. During an interview on 6/05/2025 beginning at 3:15 PM, RN 3 reported she thought there was a “miscommunication” among Entity F, a contracted outpatient therapy provider, staff regarding who was going to conduct the OT evaluation. The nurse stated Patient was aware and agreeable to delay in the evaluation, however the record failed to evidence this notification. During an interview on 6/09/2025 beginning at 9:42 AM, Person E, an employee of Entity F, reported the entity tried to see patients within “48 hours to 5 days” of receiving a referral for therapy services. Person E reported the agency received notification of an OT evaluation order on 3/01/2024. Person E was unsure of the reason Patient’s OT evaluation was not conducted until 3/08/2024 and was unsure if the entity had documentation that Patient was notified of the delay in evaluation. No further documentation was provided prior to the survey exit.”

“Patient’s needs CFR(s): 484.55(c)(4) The patient’s medical, nursing, rehabilitative, social, and discharge planning needs; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the initial comprehensive assessment included a complete assessment of the patient’s health needs for 1 of 1 record reviewed of a patient with a left ventricular assist device and wounds (Patient #1). Findings include: 1. Patient #1’s clinical record evidenced a SOC date of 8/02/2024. Patient was discharged on 8/01/2024 by Entity C, a hospital. Discharge instructions from Entity C included to notify Patient’s physician if there was a greater than 2 change in Patient’s Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood) parameter readings, including flow, power, and pulsatility index (PI, measures the native contractility of the heart). The discharge instructions also indicated Patient’s goal Mean Arterial Pressure (MAP, measurement of the average arterial pressure throughout one cardiac cycle, used to monitor LVAD patients as traditional blood pressure methods may not be accurate) was 65 – 90 millimeters mercury (mmHg). Former Employee D, an RN, documented an initial comprehensive assessment was completed on 8/02/2024. The visit note indicated Patient had a LVAD and two open wounds, one to the chest and one to the LVAD driveline (portion of the LVAD which connects the pump to the external battery). Both wounds required a wound Vacuum-Assisted Closure (VAC, negative pressure therapy used to help treat wounds). The note failed to evidence an assessment of Patient’s LVAD parameters, including the LVAD flow, power, and/or PI, failed to evidence a MAP was obtained, and failed to evidence an assessment of Patient’s wounds, including wound bed tissue, surrounding skin appearance, wound edges, and presence or absence of drainage, odor, etc. During an interview on 6/04/2025 beginning at 10:14 AM, Former Employee D reported when a patient was admitted to the home health agency with a wound, she would conduct a wound assessment including the “color” of the wound, presence or absence of slough (dead tissue), drainage, etc. The nurse stated her assessment of Patient’s LVAD consisted of listening to Patient’s heart and asking Patient if there were “any issues with it.” During an interview on 6/04/2025 beginning at 2:50 PM, CM reported on admission, the nurse assessment should include “all characteristics,” including the type of wound, wound “surface,” presence or absence of tunneling, etc. CM reported the nurse should be assess for LVAD parameters, including the LVAD flow, power, and PI. CM also stated a traditional blood pressure should not be obtained on an LVAD patient as it would not be accurate. 410 IAC 17-14-1(a)(1)(B)”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the POC included all nursing interventions for 1 of 2 records reviewed of patients who received more than one SN visit per week. (Patient #1) Findings include: 1. An agency policy “Plan of Care: Physician Certification,” revised 3/2024, indicated the POC should include “An assessment of the patient’s needs and identification of services. The scope … of services/disciplines needed in order to meet the patient’s/caregiver’s needs ….” 2. Patient #1’s clinical record included a POC for the initial certification period of 8/02/24 – 9/30/24. The POC included orders for SN visits three times per week. The record evidenced the SN conducted only a focused assessment of Patient’s wounds and/or midline IV on 8/16/25, 8/23/25, 8/28/25, 9/02/25, and 9/11/25. The POC failed to evidence a complete nursing head-to-toe assessment was to be completed only once per week. During an interview on 6/03/25 beginning at 1:38 PM, RN 1 reported she would conduct a head-to-toe physical assessment during the first visit of the week and a focused assessment on Patient’s wounds and/or IV during the other two visits. The nurse stated this was not indicated on the POC as the doctor had not sent an order indicating when to conduct a nurse assessment. During an interview on 6/04/25 beginning at 2:50 PM, CM reported the frequency of a full head-to-toe assessment depended on the physician order. The CM was unsure if the POC reflected a SN head-to-toe assessment was to only be completed once per week, and a focused assessment only was to be completed for the other two visits. 410 IAC 17-13-1(a)(1)(ix, xiii)”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the physician was notified for a change in wound bed tissue and/or measurements for 2 of 2 records reviewed with worsening of wound bed tissue or measurements (Patient #1, 3). Findings include: 1. The policy “Physician and Care Team Review of Plan of Care,” dated 11/2021, indicated “Verbal communication will be given to the physician and documented accordingly in the patient’s record indicating the condition of the patient, the plan of care, and that the physician was notified as frequently as the patient’s conditions warrant.” 2. Patient #1’s clinical record included a POC for the initial certification period of 8/02/2024 – 9/30/2024, which indicated Patient was to receive SN visits three times a week for wound care to Patient’s wounds to the chest and Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood for patients with advanced heart failure) driveline site. A SN visit dated 8/05/2024 evidenced the first documented assessment of Patient’s wounds. RN 1 noted slough (dead tissue which can impede wound healing) to 50% of Patient’s chest wound bed. The record failed to evidence the nurse notified Person A, Patient’s physician, of the slough. A SN visit dated 8/09/2024 evidenced RN 1 noted slough to 20% of Patient’s chest wound, which was a change from the 8/07/2024 assessment. The record failed to evidence the nurse notified Person A of the slough. A SN visit dated 8/12/2024 evidenced RN 1 noted slough to 20% of Patient’s LVAD driveline wound and measured the wound at 2.8 centimeters (cm) in length by 4.8 cm in width by 1.5 cm in depth (2.8 cm x 4.8 cm x 1.5 cm), which was an increase by 1.4 cm in width from the 8/09/24 assessment. The record failed to evidence the nurse notified Person A of the new slough or increase in wound width. During an interview on 6/03/2025 beginning at 1:38 PM, RN 1 stated she would report “any changes” to a wound, including new presence of slough and/or increase in wound measurement of “0.5 – 1 centimeter” or more, to the physician. When asked if the nurse reported any wound changes to Person A, RN 1 thought one of the wounds had “deepened” at one point, and she sent a photograph of the wound once a week to Person A. During an interview on 6/04/2025 beginning at 2:50 PM, CM stated “any change” to a wound should be reported to the physician, including new presence of slough and/or an increase in wound measurement. During an interview on 6/09/2025 beginning at 2:07 PM, Person B, an employee in Person A’s office, reported the first wound photographs received was on 8/23/2024. The physician office did not have record of receiving notification of the slough in wounds or change in wound measurement until 9/26/2024. 3. Patient #3’s clinical record included a POC for the initial certification period of 2/16/2024 – 4/15/2024 with a primary diagnosis of osteomyelitis (infection to the bone) in the ankle and foot. SN visits were to be done once a week for five weeks. Patient was admitted to the agency on 2/16/2024 with a non-removable dressing to the right foot. A photograph of Patient’s right foot, dated 2/17/2024, evidenced a diabetic ulcer wound to the right lateral (outside) foot below the fifth toe with scabbing over the wound. A SN visit, dated 3/13/2024, evidenced the dressing covering Patient’s diabetic ulcer wound had been removed. RN 4 failed to document an assessment of the wound bed tissue. A photograph of the wound, dated 3/13/2024, evidenced black eschar (dead tissue which can impede wound healing) to the wound bed. The record failed to evidence the nurse notified Person G, the physician managing Patient’s wounds, of the presence of eschar. A SN visit, dated 3/14/2024, evidenced RN 4 noted Patient’s diabetic ulcer wound bed was “dusky.” A SN discharge visit, dated 3/22/2024, failed to evidence an assessment of Patient’s diabetic ulcer wound. The visit note indicated Patient had a follow-up visit with their physician on 4/12/2024. The review of Person G’s office visit notes evidenced Patient went to the office on 3/29/2024 due to the diabetic ulcer wound worsening. Patient’s diabetic ulcer was debrided (procedure where dead or damaged tissue is removed) during the visit. During an interview on 6/06/2025 beginning at 1:35 PM, RN 4 stated a change in wound bed tissue to eschar would be reported to the physician. The nurse was unsure if Patient had any changes in his/her wound while on services. During an interview on 6/06/2025 beginning at 1:22 PM, Person H, an employee of Person G’s office, reported the office had no record it was notified by the home health agency of a change in Patient’s diabetic ulcer wound. During an interview on 6/06/2025 beginning at 2:25 PM, CM agreed the 3/13/2024 picture of the diabetic ulcer appeared to have eschar in the wound bed, which was a change from the previous photograph. CM stated this change should be reported to the physician. 410 IAC 17-13-1(a)(2)”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the skilled nurse failed to conduct a complete and thorough assessment of the patient for 3 of 7 records reviewed (Patient #1, 3, 7). Findings include: 1. An agency policy “Skin and Wound Care,” revised 11/2021, indicated wounds should be assessed “at a minimum of every seven days by a nurse and measurement documented in the EMR.” 2. Patient #1’s clinical record evidenced a SOC date of 8/02/24. Patient was discharged on 8/01/24 by Entity C, a hospital. Discharge instructions from Entity C included to notify Patient’s physician if there was a greater than 2 change in Patient’s Left Ventricular Assist Device (LVAD, a pump surgically implanted into the heart to assist with pumping blood) parameter readings, including flow, power, and pulsatility index (PI, measures the native contractility of the heart). The discharge instructions also indicated Patient’s goal Mean Arterial Pressure (MAP, measurement of the average arterial pressure throughout one cardiac cycle, used to monitor LVAD patients as traditional blood pressure methods may not be accurate) was 65 – 90 millimeters mercury (mmHg). A POC for the initial certification period of 8/02/2024 – 9/30/2024 and recertification period of 10/01/2024 – 11/29/2024 included orders for the home health agency to call Person A, Patient’s physician, for “… swelling of extremities … weight gain of 2-4 pounds over 1-3 days …” SN visits to be done three times a week until 9/23/24, when a new order was obtained for SN visits once per week. A SN visit note, dated 08/05/2024, indicated RN 1 documented a BP of “120/62.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 08/07/2024, indicated RN 1 documented a BP of “95/61.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 8/09/2024, indicated RN 1 documented a BP of “99/64.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN visit note, dated 8/12/2024, indicated RN 1 documented a BP of “96/66.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain A SN visit note, dated 8/14/2024, indicated RN 1 documented a BP of “98/66.” The record failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. SN visit notes, dated 8/16/2024, 8/19/2024, 8/21/2024, 8/23/2024, 8/26/2024, 8/28/2024, 8/30/2024, 9/02/2024, 9/04/2024, 9/06/2024, 9/09/2024, 9/11/2024, 9/13/2024, 9/16/2024, 9/18/2024, 9/23/2024, and 10/08/2024 failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN recertification visit note, dated 9/30/2024, failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. A SN discharge visit note, dated 10/15/2024, failed to evidence an assessment of Patient’s LVAD parameters and for the presence or absence of edema and weight gain. During an interview on 6/03/2025 beginning at 1:38 PM, RN 1 reported she would use an automatic BP cuff to obtain a BP on Patient. The nurse stated she would sometimes need to repeat the BP a few times due to an error in the reading. RN 1 reported she would not assess Patient’s LVAD parameters, including power, flow, or PI, as it was not within the physician orders. RN 1 reported Patient had “issues” with “peripheral swelling,” but she would only document if the swelling was present. RN 1 stated she did not attempt to obtain Patient’s weight. During an interview on 6/04/2025 beginning at 2:50 PM, CM reported the nurse should assess Patient’s LVAD parameters, including the LVAD flow, power, and PI. CM stated a blood pressure should not be obtained on an LVAD patient as it would not be accurate. CM stated the nurse should document the presence or absence of edema, but agency staff were able to chart by exception. CM reported Patient’s weight was only noted on admission. 3. Patient #3’s clinical record included a POC for the initial certification period of 2/16/2024 – 4/15/2024 with a primary diagnosis of osteomyelitis (infection to the bone) in the ankle and foot. SN visits were to be done once a week for five weeks. Patient was admitted to the agency on 2/16/2024 with a non-removable dressing to the right foot. A photograph of Patient’s right foot, dated 2/17/2024, evidenced a diabetic ulcer wound to the right lateral (outside) foot below the fifth toe with scabbing over the wound bed. A SN visit, dated 3/13/2024, evidenced the dressing covering Patient’s diabetic ulcer wound had been removed. RN 4 failed to document an assessment of the wound bed tissue nor measurement of the wound. A photograph of the wound, dated 3/13/2024, evidenced black eschar (dead tissue which can impede wound healing) to the wound bed. A SN visit, dated 3/14/2024, evidenced RN 4 noted Patient’s diabetic ulcer wound bed was “dusky.” The nurse failed to document an assessment of the wound which included measurements. A SN discharge visit, dated 3/22/2024, failed to evidence an assessment of Patient’s diabetic ulcer wound. The visit note indicated Patient had a follow-up visit with their physician on 4/12/2024. The review of office visit notes from Person G, a physician managing Patient’s wounds, evidenced Patient went to the office on 3/29/2024 due to the diabetic ulcer wound worsening. The wound was debrided (dead tissue removed) during the visit. During an interview on 6/06/2025 beginning at 1:35 PM, RN 4 reported a wound assessment included measurement and wound bed tissue/appearance. The nurse was unsure if she measured Patient’s diabetic ulcer wound after the dressing was removed. During an interview on 6/06/2025 beginning at 2:25 PM, CM reported there was no record of measurements for Patient’s diabetic ulcer wound after the dressing was removed. 4. Patient #7’s clinical record included a POC for the initial certification period of 3/23/2022 – 5/21/2022. The POC indicated Patient was to receive two SN visits per week, with SN interventions to include “Assess current pain management regimen including: effectiveness, relief measures, and side effects at each visit … Assess pain including: pain level, frequency, location, quality, precipitating factors, and side effects at each visit ….” The record evidenced Patient was hospitalized 3/24/2022 – 3/31/2022. Former Employee N, an RN, conducted a resumption of care visit on 4/01/2022. The nurse failed to document an assessment of Patient’s pain and pain management regimen. During an interview on 6/09/2025 beginning at 3:45 PM, CM reported a pain assessment should be completed at every SN visit.”