Compassus-Indianapolis Metro

“The documented comprehensive assessment must include a drug profile that includes the patient’s current prescription and over-the-counter (OTC) drugs, supplements, and herbal remedies. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 4 (25%) home visits observed revealed that the agency did not ensure that the drug profile included all of the patient’s current prescription and over-the-counter medications. CLINICAL RECORD 2/HOME VISIT2: The patient was admitted on 06/18/2025. During the home visit (Home Visit 2) at a facility on 07/29/2025 with a Registered Nurse [Personnel Record 3], it was revealed during medication reconciliation that the patient was ordered a sliding scale for insulin on 06/18/2025, which is based on her blood glucose levels: 0-149 = 0 units, 150-199= 2 units, 250-299= 3 units, 300-349= 4 units, 350-399= 5 units, 400-449= 6 units, greater than 449 contact MD. The agency’s current medication list was not specific, and the insulin order read: Insulin Aspar PRT-Insulin Aspart 100units/ml (70-30) 10 units with meals plus a sliding scale as directed. The agency’s medication list also did not include an MVI daily and Juven 7-7-1.5 gms 2 times daily, which is currently on the facility’s medication list. The Director of Nursing confirmed in an interview on 7/29/2025 that the medication list did not include specific insulin instructions related to the sliding scale, an MVI, and the supplement Juven.”

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%), of clinical records reviewed revealed that the agency did not ensure that the plan of care included necessary interventions identified in the initial and updated assessments. CLINICAL RECORD 3: The patient’s election of benefit (EOB)was dated 03/18/2025 with diagnoses of heart failure, a pulmonary embolism, and pulmonary hypertension. The skilled nurse initial comprehensive assessment dated 03/18/2025 revealed that the patient was short of breath and that Oxygen would be initiated. The plan of care dated 03/18/2025 did not include any interventions to assess or manage respiratory status. The skilled nurse (SN) visit note dated 03/19/2025 included documentation that oxygen was in the home and safely stored. In an interview on 07/29/2025, the Director of Clinical Services confirmed that the clinical record did not include required interventions and then stated, “ I have already educated staff to make sure they are including everything.””

“It is required that each patient’s individualized written plan of care included drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19(5%) clinical records reviewed revealed that the agency did not ensure that all medication and treatments were included on plan of care. CLINICAL RECORD 3: The patient was admitted on 03/18/2025 with a diagnosis of heart failure, pulmonary embolism, and pulmonary hypertension. The skilled nursing assessment on 03/18/2025 revealed that oxygen would be initiated due to patient shortness of breath. The plan of care did not include treatment orders for oxygen including frequency, route, and dose. The skilled nursing note on 03/19/2025 confirmed that the oxygen was safely stored. CLINICAL RECORD 10: The patient’s election of benefit was dated 05/02/2025, with a diagnosis of Malignant neoplasm of the colon. The skilled nurse initial comprehensive assessment dated 05/02/2025 included documentation that the patient had a Foley catheter 16fr. The plan of care effective 05/02/2025 did not include treatment orders for a Foley catheter or state the size of the catheter, balloon size, how and when to irrigate or how and when to change the catheter if necessary. In an interview on 07/29/2025 the Director of Nursing confirmed that oxygen was not included on the initial plan of care and that the clinical record did not include order for the foley catheter and stated, “because he was admitted with it, we don’t have anywhere to put orders” and reported that she would obtain orders to update the clinical record.””

“It is required that each patient’s individualized written plan of care include medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that the plan of care included all medical supplies necessary to meet the patient’s needs. CLINICAL RECORD 3: The patient elected hospice on 03/18/2025 with a diagnosis of heart failure, pulmonary embolism and pulmonary hypertension. The initial skilled nursing assessment on 03/18/2025 revealed that the patient was short of breath and oxygen was initiated. The plan of care dated 03/18/2025 read “NONE” under DME and supplies. CLINICAL RECORD 10: Patient admitted on 05/02/2025 with a Foley catheter in place as documented on the initial skilled nursing assessment on 05/02/2025. The plan of care dated 05/02/2025 read, “NONE” under DME and supplies. In an interview on 07/29/2025, the Director of Clinical Services confirmed the findings and stated that staff have already been educated to add supplies.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed with home health aide services revealed that the agency did not ensure that the aide’s care plan provided specific instructions. CLINICAL RECORD 5: The patient was admitted on 03/24/2025. The Skilled nurse’s initial assessment on 03/24/2025 revealed abnormal breath sounds and shortness of breath. Oxygen was ordered at 1-3 liters PRN. The aide care plan created on 03/24/2025 did not include oxygen or instructions if it can be removed during bathing. The Director of Nursing confirmed in an interview on 7/29/2025 that the home health aide plan of care did not include oxygen and instructions if it can be removed for care.”