Hospice of the Wabash Valley Inc.

“Based on record review and interview, the agency failed to complete a comprehensive assessment no later than 15 days before the end of the episode, resulting in a lack of accurate information necessary to develop a proper care plan for 9 of the 14 active records reviewed.(Patient #7, #8, #9, #10, #11, #12, #13, #16, #19) Findings include: 6. A review of Patient #11’s record evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the benefit period 11/15/2024 to 02/12/2025. The record included a Hospice Recertification Assessment visit dated 01/23/2025, 21 days before the end of the episode. The agency failed to complete a recertification visit within 14 days of the end of the benefit episode. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #11’s record. She stated she did not know why the staff completed the recertification early. 7. A review of Patient #12’s record evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the benefit period 11/11/2024 to 01/09/2025. The record included a Hospice Recertification Assessment visit dated 12/20/2024, 21 days before the end of the episode. The agency failed to complete a recertification visit within 14 days of the end of the benefit episode. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #12’s record. She stated she did not know why the staff completed the recertification early. 8. A review of Patient #13’s record evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the benefit period 01/01/2025 TO 03/01/2025. The record included a Hospice Recertification Assessment visit dated 02/10/2025, 20 days before the end of the episode. The agency failed to complete a recertification visit within 14 days of the end of the benefit episode. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #13’s record. She stated she did not know why the staff completed the recertification early. 9. A review of Patient #16’s record evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report for the benefit period 12/12/2024 to 03/11/2025. The record included a Hospice Recertification Assessment visit on 02/21/2025, 18 days before the end of the episode. The agency failed to complete a recertification visit within 14 days of the end of the benefit episode. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #16’s record. She stated she did not know why the staff completed the recertification early. 1. A 01/2025 revised policy titled “Certification/ Recertification” indicates patient recertification should be obtained no more than 15 days before the end of the benefit period. 2. A record review of Patient #7 evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dated 09/24/2024 to 12/22/2024, a visit note report RN Hospice Recert Assessment visit on 12/03/2024, 19 days before the end of the episode. The agency failed to complete a recertification visit within 15 days of the end of the episode. During an interview with Family Care Coordinator on 03/24/2025 at 1:25 PM, The Family Care Coordinator reviewed Patient #7’s chart and confirmed the recertification visit was not completed within 15 days of the end of the episode. 3. A record review of Patient #8 evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dated 01/14/2025 to 03/14/2025, a visit note report RN Hospice Recert Assessment visit on 02/21/2025, 21 days before the end of the episode. The agency failed to complete a recertification visit within 15 days of the end of the episode. During an interview with Family Care Coordinator on 03/24/2025 at 1:25 PM, reviewed Patient #8’s chart and confirmed the recertification visit was not completed within 15 days of the end of the episode. 4. A record review of Patient #9 evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dated 01/25/2025 to 03/25/2025, a visit note report RN Hospice Recert Assessment visit on 03/04/2025, 19 days before the end of the episode. The agency failed to complete a recertification visit within 15 days of the end of the episode. During an interview with Family Care Coordinator on 03/24/2025 at 1:25 PM, reviewed Patient #9’s chart and confirmed the recertification visit was not completed within 15 days of the end of the episode. 5. A record review of Patient #10 evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dated 12/18/2024 to 02/15/2025, a visit note report RN Hospice Recert Assessment visit on 01/27/2025, 19 days before the end of the episode. The agency failed to complete a recertification visit within 15 days of the end of the episode. During an interview with Family Care Coordinator on 03/24/2025 at 1:25 PM, reviewed Patient #10’s chart and confirmed the recertification visit was not completed within 15 days of the end of the episode. 9. A record review of Patient #19 evidenced a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dated 01/07/2025 to 03/07/2025, a visit note report RN Hospice Recert Assessment visit on 02/14/2025, 21 days before the end of the episode. The agency failed to complete a recertification visit within 15 days of the end of the episode. During an interview with Family Care Coordinator on 03/24/2025 at 1:25 PM, reviewed Patient #19’s chart and confirmed the recertification visit was not completed within 15 days of the end of the episode. 10. During an interview on 03/21/20205 at 1:20 PM, the Regulatory Director indicated a start of care and a recertification are the comprehensive assessments. 11. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Director indicated the policy on certification and recertification is used for guidelines for the registered nurse recertification visit; this visit should be done within 15 days of the end of the episode”

“Based on record review and interview, the agency failed to ensure staff included services and frequencies provided on the POC for 4 of 14 active record reviews, with the potential to affect all active patients. (Patients #9, #10, #17, #18) Findings include: 2. A record review of Patient #9 included a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dates 01/25/2025 to 03/25/2025 that failed to evidence discipline ordered frequency. During an interview with the Family Care Coordinator on 03/24/2025 at 1:25 PM, The Family Care Coordinator reviewed Patient #9’s chart and confirmed the updated Plan of care did not include discipline-ordered frequency. 3. A record review of Patient #10 evidenced a Client Coordination Note Report dated 09/09/2024 indicating the note type was for the Volunteer Referral Form. The form evidenced that Volunteers are needed one time per week or every other week. A Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dates 12/18/2024 to 02/15/2025 evidenced that the patient volunteer continues to visit the patient at least one time per week. The agency failed to obtain a physician order and frequency for volunteer services. During an interview on 03/24/2025 at 3:50 PM, the Regulatory Director indicated she could not locate a physician order for volunteer services on Patient #10. She could locate the staff requesting volunteer services to start for Patient #10. During an interview on 03/24/2025 at 4:15 PM, the Family Care Coordinator indicated there should be orders from a physician for volunteers to start providing services. 1. A revised 02/2025 policy titled “Plan of Care-Revised” indicated that staff should include the services and frequencies on the POC. The policy indicated that staff should include volunteers and adjunctive services on the POC. 4. A record review of Patient #17 included a Hospice IDG Comprehensive Assessment and Plan of Care Update Report with episode dates 02/14/2025 to 04/14/2025. The record failed to evidence the disciplines and frequencies ordered. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #17’s record and stated she did not know why the ordered discipline and frequencies did not carry over. She stated that it might be a computer glitch. 5. A review of Patient #18’s record, election date 02/03/2025 evidenced Massage Therapy notes dated 02/13/2025, 02/20/2025, and 02/27/2025. A review of the POC did not indicate massage therapy orders. The agency failed to obtain a physician order and frequency for Massage Therapy services. During an interview on 03/24/2025 at 1:25 PM, the Regulatory Nurse reviewed Patient #18’s record and did not find current Massage Therapy orders. She provided an old order dated 01/31/2024 for Massage Therapy one time a week for one week. She stated they did not need Massage Therapy orders since a contract employee provided the service.”

“Based on observation, record review, and interview, the agency failed to ensure staff followed infection control procedures during a bed bath for 1 of 1 in-patient observation (HHA 1) and failed to change gloves and perform hand hygiene during patient care and properly disinfect equipment for 2 of 3 RN home visit observations. (RN 3, RN 4) Findings include: 4. During an observation on 03/21/2025 at 10:36 AM, RN 3 inspected Patient #8’s genitalia area by placing gloved fingers into the leg elastic of the brief to extend the leg opening. RN 3 then covered Patient #8 with a blanket. RN3 failed to remove gloves and hand hygiene after touching Patient #8’s brief and before touching the blanket. RN 3 gathered a used disinfected wipe from the bedside table and placed it in the side pocket of the nursing bag. RN 3 failed to properly dispose of non-reusable items, contaminating the nursing bag. RN 3 documented on the electronic device after completing care on Patient #8, then went to the facility nurses’ station, laid the device on the counter, picked it up, and carried it down the hallway. RN 3 failed to disinfect the device before starting the visit, after providing care, before laying it at the facility nursing station, or after picking it up from the nursing station. During an interview on 03/21/2025 at 10:36 AM, RN 3 indicated that staff should change gloves when going from one area of care to another and that hand hygiene after providing care. RN 3 indicated the electronic device was last cleaned during the prior visit; no reason was provided for not cleaning it during the current visit. RN 3 indicated she put the used disinfectant wipe back in the nursing bag, but the pocket it was placed in was not currently used. 5. During an observation on 03/21/2025 at 9:08 AM, RN 4 documented visit information for Patient # 10 visit on the phone and gave the phone to Patient #10 to sign for the visit. Patient #10 returned the phone to RN 4, who placed the phone in her pocket. RN 4 failed to disinfect the electronic device before giving it to Patient #10, after receiving it from Patient # 10, and before placing it in the pocket. 6. During an interview on 03/21/2025 at 1:20 PM, the Regulatory Director indicated that the best practice is for staff to clean electronic devices between patients. She indicated staff should not return used disinfectant wipes to nursing bags. RN 3 should have removed gloves and hand hygiene after touching the patient’s brief and before touching the patient’s personal items. 1. An undated policy titled “Personal Care for Unconscious Patient” indicates that staff are to check the temperature of the bath water after washing the upper extremities (referring to the arm, forearm, wrist, and hand). The policy indicated that staff should change the bath water in the basin after washing the Patient’s upper body and before washing the abdomen. Staff are to wash the Patient’s perineum (the area between the anus and the scrotum or vulva), then clean and replace bathing equipment and remove gloves and perform hand hygiene. 2. A revised 12/2024 policy titled “Infection Control & Safety Management” indicated that staff should perform hand hygiene before and after direct contact with patients. Staff are to perform hand hygiene when moving from a contaminated body site to a clean one. The policy indicated staff are to perform hand hygiene after contact with inanimate objects (including medical equipment) and after removing gloves. 3. During an in-patient observation on 03/20/2025 at 1:30 PM, HHA 1 washed Patient #6’s arms, hands, and abdomen. She washed the perineum using bath wipes with gloved hands. HHA 1 touched Patient #6’s blanket and call light without changing gloves and performing hand hygiene. She used a soapy rag and scooped water from a bath basin to rewet the rag. With the assistance of RN 1, she continued to wash the Patient’s back and buttocks using the same pair of gloves. HHA 1 failed to change the water in the bath basin at any point during the bath or after perineum care and failed to change gloves and perform hand hygiene throughout the entire bed bath. During an interview on 03/21/2025 at 12:37 PM, RN 1 stated the HHA should change gloves and perform hand hygiene after perineum care and before touching clean items.”

“Based on observation, record review and interview the agency failed to obtain orders for care provided during 1 of 1 home visits with wound care (Patient #10) Findings include: A 01/2017 policy titled “Nursing Services” indicated nursing staff were to administer treatments as ordered by physician. During an observation on 03/21/2025 at 9:08 AM, RN 4 placed skin prep (a topical preparation used to prepare the skin for various procedures) around Patient #10’s wound. RN 4 failed to have the order to apply skin prep to Patient #10’s peri-wound area before applying it to the patient. In an interview on 03/21/2025 at 9:08 AM, RN 4 indicated the old order had skin prep ordered; she is unsure why the new one doesn’t. She indicated Patient #10’s wound care has always included skin prep. During an interview on 03/21/2025 at 1:20 PM, the Regulatory Director indicated if skin prep is used on a patient, the wound care order should include skin prep”

“Based on record review and interview, the agency failed to promptly investigate medication discrepancies, investigate the absence of a second witness to resolving medication discrepancies, and maintain written documents of investigations for 1 of 1 medication dispensers in the in-patient unit. (medication dispenser 1) Findings include: 1. A 02/2018 policy titled “Pharmacy Services” indicated an immediate investigation by the pharmacist, hospice clinical director, and IPU manager if there is a discrepancy in controlled medication. A written report of the investigation is required. A Controlled drug (a drug or chemical whose manufacture, possession, and use are regulated by a government, typically due to its potential for abuse or harm) is listed in Schedule I, II, II, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1976. 2. A 05/31/2024 document titled “William Bros Long Term Care Pharmacy Policy and Procedure” indicated the person to resolve the discrepancies must not be the individual who created the discrepancy. 3. A document titled “Discrepancy Summary, C43,” with a date range for 01/20/2025 to 03/21/2025, indicated there was a discrepancy in the medication Midazolam (used for sedation and anxiety) was provided by the Regulatory Director, who was unable to explain the report or what the numbers on the report represented. 4. A document titled “Discrepancy Summary, C43” with a date range for 01/01/2024 to 12/31/2024 indicated there was a discrepancy on the following medication: albuterol Sulfate (breathing medication), Diazepam (anxiety medication ), Diphenhydramine (allergies medication), Fentanyl (severe pain medication), Hydromorphone (severe pain medication), Lorazepam (anxiety medication), Midazolam (sedation and anxiety medication), Morphine (pain medication), Morphine Sulfate (pain medication), Ondansetron (prevent nausea and vomiting ) The document was provided by the Regulatory Director, who was unable to explain the report or what the numbers on the report represented. 5. A document titled “Resolved Discrepancies, C3” with a date range for 03/20/2024 to 03/20/2025 indicated the following: On 03/20/2024 at 8:10 PM, a medication discrepancy of Morphine, a schedule II controlled drug, was resolved by the discrepancy creator with no witness. On 03/21/2024 at 2:17 AM, a medication discrepancy of Midazolam, a schedule IV controlled drug, was resolved by the discrepancy creator with no witness. On 03/28/2024 at 8:06 AM, a medication discrepancy of Midazolam, a schedule IV controlled drug, was resolved by the discrepancy creator with no witness. On 03/28/2024 at 10:49 AM, a medication discrepancy of Midazolam, a schedule IV controlled drug, was resolved by the discrepancy creator with no witness. On 06/27/2024 at 9:43 AM, a medication discrepancy of Hydromorphone, a schedule II controlled drug, was resolved by the discrepancy creator with no witness. On 02/02/2025 at 1:27 PM, a medication discrepancy of Midazolam, a schedule IV controlled drug, was resolved by the discrepancy creator with no witness. On 02/02/2025 at 3:35 PM, a medication discrepancy of Midazolam, a schedule IV controlled drug, was resolved by the discrepancy creator with no witness. The agency failed to resolve discrepancies, with two staff members signing off, one not being the creator of the discrepancy. 6. During an interview on 03/21/2025 at 1:20 PM, the Regulatory Director indicated the agency does not have a policy on medication discrepancy for the in-patient unit. 7. During an interview on 03/21/2025 at 2:25 PM, the Regulatory Director indicated staff was expected to clear all medication discrepancies at the end of the shift. She indicated the discrepancy was cleared by the creator of the discrepancy and the next shift nurse. The Regulatory Director indicated Entity 1 would be notified via the medication dispenser as soon as the discrepancy occurred. 8. During an interview on 03/24/2025 at 9:24 AM, the Administrator indicated she was aware of medication discrepancies in the in-patient unit before the survey. She indicated the Regulatory Director had reported medication discrepancies to her. The Administrator indicated she had no reports provided by the Regulatory Director informing her of medication discrepancies, and she had no documentation of actions the agency had taken to correct mediation discrepancies. The Administrator indicated Entity 1 provided education to in-patient staff about medication discrepancies. The agency failed to provide documents of education provided by Entity 1 addressing medication discrepancies, the staff sign-in, and reports seen by the Administrator of medication discrepancies. 9. During an interview on 03/24/2025 at 9:34 AM, the Regulatory Director indicated in-patient staff was to resolve discrepancies at the end of each shift; this requires two staff members (the registered nurse who created the discrepancy and the registered nurse starting the new shift). The Regulatory Director indicated on the report she printed there were a few resolved discrepancies, with one staff member signing off, not the required two staff members signing off to resolve medication discrepancies. The Regulatory Director indicated as long as the staff corrected the discrepancies at the end of each shift, there would be no reason for management to look at discrepancies. She indicated the agency relied on Entity 1 to report issues with discrepancies and Entity 1 had not reported any concerns; therefore, the agency had not been monitoring the medication discrepancies.”