Good Samaritan Hospice

“Observed in Record Review. The surveyor noted that ((RRHOSNHV#3) the Foley catheter orders were incomplete and did not indicate when the catheter was to be changed. Also, the plan indicated irrigate device but did not include a solution, volume or frequency for irrigation. In (RRHOSNHV#9) the oxygen orders were incomplete and read Oxygen 3 LPM for comfort. The order did not include a frequency or route of administration. This was confirmed with the nurse manager. Observed in Record Review. In 6 of 10 patient records reviewed, The surveyor noted (RRHOSNHV#1) that the patient’s blood pressure on admission was 62/38 and that he was at high risk for falls; however, there was no care plan to manage the problems. The only care plan was for ileostomy care. In (RRHOSNHV#5) there was no care plan update since September of 2024. In (RRHOSNHV#8) there were no nursing care plan goals or interventions. The assessment indicated that the patient had a abdominal pain, anxiety and was experiencing agitation and delusions. A nursing visit note indicated that the patient had constant nausea and multiple bruises and skin tears and was prescribed oxygen; however, these problems were not addressed in a plan of care. In (RRHOSNHV#9), the assessment and visit notes indicated that the patient had a sacral wound, and a pain level of 5/10; however, there was no plan of care to manage the problems and in (RRHOSNHV#10) there was no care plan for a pain level of 5/10 and a nausea scale of 7/10. Also, the patient was experiencing intermittent bouts of constipation ad diarrhea that was not addressed in the plan of care. This was confirmed with the nurse manager.”

“Observed in Record Review. The surveyor noted (RRNHV#11) that the order for oxygen was incomplete and read supplemental oxygen and did not include a dose, route or frequency. This was confirmed with the nurse manager. Observed in Individual Tracer. The surveyor noted that (RRHOSV#3) that the dose order for Humalog insulin was incorrect. The order read Humalog Kwikpen subcutaneous Solution Pen-injector 100unit/ml 15 ml prn instead of 15 units. This order remained incorrect since the patient was admitted in 2024. Also, there was no indication for use or dosing parameters for prn administration of the insulin. It simply read prn. This was confirmed with the nurse manager. Observed in Record Review. The surveyor noted in (RRNHV#6) that there were no orders on the plan of care or in the EMR for Dilaudid being administered via a CADD pump as of day seven (7). In (RRNHV#10) that there were no medication orders on the plan of care until eight days after admission. In (RRNHV#12) there were no medication orders on the plan of care for 15 days after the patient was admitted. Also, the patient was ordered both Hydrocodone and Morphine as prn medications for pain; however, there was no indication as to when to give which medication by sequence or severity of the pain. The interdisciplinary plan of care policy required that the physician and the IDG develop the plan of care within 24 hours of admission and document within 72 hours. This was confirmed with the nurse manager. Observed in Individual Tracer. In 10 of 14 patient records reviewed, The surveyor noted (RRHOSV#1) that a nurse visit note indicated that the RN dug quite a bit of hard ingrown toenail out and applied peroxide on this diabetic patient and there was no order on file for the procedure. Also, an April note indicated that the nurse did a digital rectal exam and gave a Fleet enema to assist with disimpaction; however, there was no order. Also, the surveyor noted that Jardiance and Trulicity were removed from the medication list two weeks after admission; however, there was no order. Also, the supra-pubic catheter order did not include a catheter size; the nurse note indicated that she inserted a 16Fr per request of the patient. The surveyor noted (RRNHV#11) that the nurse indicated in a note that she administered one Ibuprofen; however, there was no order for Ibuprofen on the plan or care or in the medical record. This was confirmed with the nurse manager. Observed in Record Review. The surveyor noted in (RRHOSNHV#8) that a disimpaction procedure was performed without an order by the skilled nurse. The order was not obtained until the following week when a second disimpaction was needed. Reviewed by Nurse Manager Observed in Record Review. The surveyor noted in RRHOSHV#4 that the plan of care was not complete as there were no medication orders until fourteen days after the start of care.”

“Observed in Record Review. In 3 of 14 patient records reviewed, The surveyor noted (RRNHOV#6) that the social worker assessment was not complete and there was no indication in the record that the patient had refused. Also, in (RRHOSV#10) the social work assessment was delayed due to the social worker illness; however, there was no indication that the physician was notified. It was rescheduled and conducted by another social worker eight days after admission. Also, spiritual assessment was not completed until. In (RRNHV#12) there was no evidence that the Chaplain had visited and completed a spiritual assessment since the patient was admitted in March. There was no evidence that the patient had refused to visits. This was confirmed with the nurse manager.”

“Observed in Record Review. The surveyor noted (RRNHV#6) that there was no assessment of the severity of symptoms of constipation for this patient admitted with the secondary diagnosis and on Dilaudid via CADD pump. Also, in (RRNHV#11) an assessment of Diabetes was not completed for this patient on Jardiance daily. There was no assessment of the patient’s diet, appetite or oral intake or bowel elimination when the patient was admitted last May. In (RRNHV#12), there was no assessment of the severity of symptoms of the patient admitted with a urinary tract infection on Furadantoin. This was confirmed with the nurse manager. Observed in Individual Tracer. In 4 of 19 patient records reviewed, The surveyor noted (RRHOSV#1) that the assessment was incomplete and did not include the severity of symptoms of diabetes for this patient prescribed Jardiance 25 mg. oral daily and Trulicity 0.75 mg sq weekly. Also, on (RRHOSV#3), there was no indication that the severity of diabetes and seizures was assessed for the patient on both Lantus and Humalog insulin and anticonvulsant medications including Depakote and Keppra. This was confirmed with the nurse manager”

“Observed in Individual Tracer. The surveyor noted (RRHOSV#1) that the patient assessment indicated that the patient had a pain score of 7/10 and was prescribed Percocet and Morphine; however, there was no outcome measures or other interventions to manage the pain. Also, there was no care plan or outcome measures to manage diabetes treated with Jardiance daily and Trulicity. In (RRNHV#6), there were no outcome measures or interventions for managing constipation on the plan of care. The patient was admitted with constipation as indicated in the certification of terminal illness. This was confirmed with the nurse manager. Observed in Record Review. The surveyor noted during the record review (RRHOSHV#4) and (RRHOSNHV#8) that the plans of care did not include accurate orders. Example (RRHOSHV#4) both the Morphine and Tylenol were ordered for pain however the order did not specify when to give which. A second order for Acetaminophen Rectal Suppository 650 mg had the wrong indication and was ordered for constipation. Example (RRHOSNHV#8) Lorazepam 1.0 ml twice daily and Lorazepam 0.5 ml q two hours were ordered for anxiety without specifying when to give which. Reviewed with the Nurse Manager. Observed in Record Review. The surveyor noted in (RRHOSNHV#7) that the plan of care did not include interventions to manage the patient’s insulin dependent diabetes. In addition in (RRHOSNHV#8) the plan of care did not address environmental safety issues associated with long standing bug and bed bug infestation identified on admission and remains an active issue. Reviewed with Nurse Manager.”

“Observed in Record Review. The surveyor noted that (RRNHV#9) chaplain services ordered 1 x a week since admitted in August, had never been provided. Also, in (RRNHV#10) the orders for chaplain/spiritual services were1 x a week; however, there were no visits performed since March. In (RRNHV#11) chaplain was ordered once a month, but no visits were conducted since February. In (RRNHV#12) no chaplain was provided as ordered since March). This was confirmed with the nurse manager. Observed in Record Review. In 5 of 14 patient records reviewed, The surveyor noted during record review (RRHOSNHV#8) that Chaplain services were not provided as ordered. Example in the initial assessment conducted by the social worker indicated that services were requested. The Initial contact was not made for approximately one month and Chaplain visits were never made as ordered on the plan of care for 1 x wk. Reviewed with Nurse Manager.”

“Observed in Record Review. In 3 of 6 patient records with aide, The surveyor noted that (RRHOSV#3) the home health supervisions were not conducted every 14 days. One supervision in both February and April were done on day 16, and one supervision in May was done on day 15. In (RRNHV#10) the last supervision of March was completed on day 16. This was confirmed with the nurse manager. Observed in Record Review. The surveyor noted in record review (RRHOSHV#4) that Home Health Aide supervisory visits were not every 14 days. Example in November one supervisory visit was two days late and in February one supervisory visit was one day late. Reviewed with Nurse Manager.”

“Observed in Individual Tracer. In 4 of 5 facility patient records reviewed, The surveyor noted that (RRHOSV#3), the plan of care for this patient receiving hospice in a a skilled nursing facility, did not identify which provider was responsible for administering the medications including insulin and performing daily blood glucose monitoring since admission in July. Also, in (RRNHV#14), the plan of care did not specify which provider was to administer the medications and change the supra-pubic catheter. This was confirmed with the nurse manager. Observed in Individual Tracer. The surveyor noted in (RRHOSHV#4 and RRHOSNHV#7), the hospice and skilled nursing facility plan of care did not identify the care and services that are needed and did not identify which provider was responsible for performing the functions that have been agreed upon and included in the plan of care. Examples interventions for the management of agitation by non-pharmacological interventions, assess and monitor ability to communicate and signs of delirium, RN to monitor weights.”

“Observed in Individual Tracer. In 2 of 2 SNF records, The surveyor noted (RRHOSV#3) that the skilled nursing facility record did not contain the physician certification and recertification of the patient’s terminal illness since the patient was admitted in October. This was confirmed with the nurse manager. Observed in Individual Tracer. In 2 of 2 SNF Records, The surveyor noted in (RRHOS#4, that the physician certification and recertification of the patient’s terminal illness was not present in the facility record since the patient was admitted in September of 2024. This was confirmed with the Nurse Manager.”

“Based on record review and interview, the agency failed to ensure hospice staff were educated on the 2022 and 2023 emergency exercises and failed to analyze the hospice staff’s response to and maintain documentation of the exercises at the agency for 1 of 1 Emergency Preparedness program review. Findings include: A 2023 Good Samaritan Home Health Hospice-IN Emergency Plan review showed that the agency will participate in its own program. The agency’s readiness level will be evaluated during drills and emergency plan implementation. The agency will monitor the staff’s performance, knowledge, and skills regarding the actual or potential risk of the emergency. Any deficiencies and opportunities for improvement will be documented and communicated to improve team response. During an interview on 03/05/2024, the Administrator reviewed the Emergency Preparedness information and stated that they did not keep documentation on staff education for the Solar Flare 2023 and Armed Person 2022 exercises. The agency failed to maintain documentation of staff education, analysis, and the hospice’s response to the exercises.”

“Based on observation, record review, and interview, the agency failed to ensure each patient received a complete physical assessment of wound and skin issues and failed to ensure each nursing visit note was individualized for 3 of 3 record reviews with patients with skin/wound issues (Patients #6, #18, #20); failed to have specific orders for a catheter for 2 of 2 patients (Patient #10, #20); and failed to ensure all medications are included on the plan of care for 19 of 20 patient record reviews. (Patients #1 to #14 & Patients #16 to #20) with the potential to affect all active patients. Findings include: 5. During an observation on 02/27/2024, RN 3 failed to assess Patient #7’s feet, buttocks, and back for skin breakdown. At that time, Registered Nurse (RN) 3 and Entity 2’s RN did not discuss skin breakdown concerns. 6. The clinical record for Patient #10, benefit period 02/25/2024 to 05/21/2024, included an RN initial assessment, which evidenced patient #10 had a Foley catheter. No other information (type of catheter, size, bulb size, who manages, last date changed) about the Foley catheter was provided. During an interview on 02/29/2024 at 11:20 AM, the RN Manager was unable to locate additional information in patient #10 chart regarding foley catheter. 7. During an observation on 02/28/2024, RN 1 provided wound care to patient #18 but failed to collect measurements. The clinical record for Patient #18, benefit period 01/23/2024 to 03/22/2024, included a recertification visit on 01/23/2024 that indicated the patient had a wound to the bottom. The record also included the documents titled “RN – skilled nursing visit”, dated 01/25/2024, 01/29/2024, 02/07/2024, 02/14/2024, 02/15/2024, 02/26/2024, indicating the patient has a wound to coccyx that LTF staff reported as red, butt cream was ordered and will be applied at next visit. A document titled “Skilled Nursing Soap” visit dated 02/28/24 indicated wound care was provided but no details of wound condition. 8. The clinical record for Patient #20, benefit period 12/15/2023 to 03/13/2024, included a POC dated 02/28/2024. It did not contain wound orders for the bottom or suprapubic site and no orders for suprapubic catheter care. An RN—Skilled Nursing Visit dated 02/26/2024 indicates the patient has an infection around the suprapubic site, but documented the skin was normal. During an IDG meeting on 02/29/2024, RN 1 reported patient #20 has a suprapubic catheter that is being changed weekly, skin breakdown on patients bottom, and redness around the suprapubic site. During an interview on 03/01/2024, at 12:35 PM, the RN Manager could not find orders or measurements of wounds, and no order was found for suprapubic catheter care for Patient #20. They indicated during a nursing visit on 02/26/2024 that the nurse noted the skin was normal. They confirmed RN 1 reported wounds during an IDG meeting on 02/29/2024. 9. During an interview on 03/01/2024 at 9:45 AM, the RN Manager indicated the comments/notes on RN - Skilled Nursing Visits should be revised on each nursing visit; notes should be individualized and specific to each visit 1. A policy titled “Scope of Services” was provided by the Registered Nurse (RN) manager on 02/26/2024. The policy indicated that the RN would complete a visit note every visit. The assessment will be to the patient’s needs. The plan of care should be developed and initiated within 24 hours. The plan of care (POC) was to include a complete assessment of the patient/family needs and a medication/treatment sheet. 2. A review of active and closed records during the survey evidenced all medications were not listed on the patient’s POC. Each record reviewed indicated the medications are in “Epic,” the electronic medical record (EMR) at Entity 2. The agency failed to ensure all medications were included on the POC for the following patients: Patients #1 to #14 and Patients #16 to #20). 3. During an observation on 02/27/2024, RN 3 failed to assess Patient #6’s buttocks and back for skin breakdown. At that time, RN 3 and Entity 2’s RN did not discuss skin breakdown concerns. A review of Patient #6’s record, benefit period 02/25/2024 to 05/24/2024, included Entity 2’s flowsheets dated 02/25/2024, which indicated Patient #6 had a red buttock and right great toe. A review of the hospice Skilled Nursing SOAP Visit notes did not mention any skin issues. During an interview on 03/01/2024, the RN Manager reviewed Entity 2’s documentation about Patient #6’s red buttocks and right great toe. They stated that the hospice agency should have asked about skin integrity issues if the RN had not visually assessed the skin. 4. A review of Patient 13’s record, benefit period 01/29/2024 to 03/28/2024, included Skilled Nursing Visit notes from 01/31/2024 to 02/14/2024 that evidenced a new skin/wound developed, but the wound location, assessment, or measurements were not included in any of the notes. During an interview on 03/01/2024, the RN Manager reviewed Patient #13’s medical record and stated that each note should be individualized. The electronic medical record (EMR) system automatically carries previous information to each visit, so the nurse must enter an assessment that accurately reflects what was observed. The RN Manager stated that the agency should ensure the individualization of each nursing visit note.”

“Based on record review and interview, the agency failed to conduct a comprehensive assessment at least every 15 days, affecting 5 of 6 patients, on service for over 15 days. (Patient #5, #9, #13, #18, #20) Findings include: 1. A 08/2022 revised policy, titled “Hospice Assessment/Reassessment of the Patient,” indicates a reassessment of each patient to determine the patient’s response to treatments when a change occurs to the patient’s condition. The care and treatment will be based on data collected from patient assessments. 2. An 08/25/2017 document titled “Hospice Staff RN” indicates that one of the functions of a Registered Nurse (RN) is timely, accurate, and appropriate documentation of the initial nursing care admission visit. 4. The clinical record for Patient #9, benefit period 02/07/2024 to 05/06/2024, included a routine skilled visit for 02/07/2024, 02/09/2024, 02/12/2024, 02/14/2024, 02/16/2024, 02/21/2024, 02/22/2024, and 02/23/2024. No comprehensive assessment was identified. The record includes the IDG meetings that took place on 02/15/2024 and 02/29/2024.The agency failed to complete a comprehensive assessment every 15 days. 6. The clinical record for Patient #18, benefit period 01/23/2024 to 03/22/2024, included a recertification visit on 01/23/2024 that indicated the patient had a wound to the bottom. No comprehensive assessment, including wound assessment and measurement, was found in the patient’s record. The record included routine Skilled Visits for 02/14/2024, 02/21/2024, and 02/28/2024; no comprehensive assessment was identified. The record also includes the IDG meetings on 02/15/2024 and 02/29/2024. The agency failed to complete a comprehensive assessment every 15 days. During an interview on 02/28/2024 at 2:15 PM, The RN Manager could not find measurements or details about the wound to the coccyx or left ear in the clinical record for Patient #18. 7. The clinical record for Patient #19, benefit period 02/10/2023 to 04/09/2024, included a recertification visit on 02/07/2024 and routine RN Skilled Visits for 02/14/2024, 02/21/2024, and 02/28/2024. The record indicated the Interdisciplinary Group (IDG) meetings took place on 02/15/2024 and 02/29/2024. The agency failed to complete a comprehensive assessment every 15 days. 8. The clinical record for Patient #20, benefit period 12/15/2023 to 03/13/2024, included an initial assessment on 12/15/2024 and routine Skilled Visits for 12/18/2023, 12/22/2023, 12/27/2023, 12/29/2023, 01/03/2024, 01/05/2024, 01/09/2024, 01/10/2024, 01/11/2024, 01/15/2024, 01/17/2024, 01/22/2024, 01/26/2024, 01/29/2024, 02/02/2024, 02/05/2024, 02/09/2024,02/12/2024, 02/16/2024,02/19/2024, 02/23/2024, and 02/26/2024. The record indicated the IDG meetings took place on 01/21/2024, 01/04/2024, 01/18/2024, 02/01/2024, 02/15/2024 and 02/29/2024. The agency failed to complete a comprehensive assessment every 15 days. During an IDG meeting on 02/29/2024, RN 1 reported that patient #20 had a skin breakdown on the bottom, was using foam dressing, and had redness around the suprapubic site. No detailed report on wound condition or measurements was provided. 9. During an interview on 02/28/2024 at 2:15 PM, The RN Manager indicated a head-to-toe with wound assessment and measurements should be completed every two weeks. 10. During an interview on 03/01/2024 at 9:45 AM, The RN Manager indicated an in-depth assessment is to be done every two weeks, generally on the last nursing visit before the IDG meeting. They indicated that all nursing visits are labeled the same as RN—Skilled Nursing Visits; there is no way to determine which is focused and which is an in-depth, comprehensive visit. 3. The clinical record for Patient #5, election date 11/1/2023, benefit period 01/30/2024 to 04/28/2024 included routine Skilled Visit Notes for 02/01/2024, 02/08/2024, 02/14/2024, and 02/15/2024. All four skilled visit notes failed to evidence a comprehensive assessment was completed. During an interview on 03/01/2024, the RN manager reviewed Patient #5’s two electronic medical records (EMRs) and the paper record. The RN Manager stated that they felt like they did a comprehensive assessment before the IDG meetings but could not demonstrate that the skilled visit notes would show that. The RN Manager stated that a comprehensive assessment should be completed at the initial visit and recertification, but the agency does not conduct comprehensive assessments every 15 days. 5. The clinical record for Patient #13, benefit period 01/29/2024 to 03/28/2024, included routine Skilled Nursing Visit notes dated 01/31/2024, 02/07/2024, and 02/14/2024 that evidenced a new skin/wound developed. The notes did not include the wound location, assessment, or measurements. The visit notes did not indicate if the skin/wounds were healed. All three skilled visit notes failed to evidence a comprehensive assessment was completed every 15 days. During an interview on 03/01/2024, the RN manager reviewed Patient #13’s two electronic medical records (EMRs) and the paper record. The RN Manager stated that they felt like they did a comprehensive assessment before the IDG meetings but could not demonstrate that the skilled visit notes would show that. The RN Manager stated that a comprehensive assessment should be completed at the initial visit and recertification, but the agency does not conduct comprehensive assessments every 15 days.”

“Based on record review and interview, the agency failed to ensure the plan of care (POC) included the services being provided to the patients for 4 of 4 active clinical records reviewed with wounds (Patients #6, #13, #18, #20) and in 2 of 2 active clinical records reviewed with catheters. (Patient #10, #20) Findings include: 3. A review of Patient #13’s record, benefit period 11/30/2023 to 01/28/2024, includes Plan of Care (POC) orders dated 01/17/2024 that indicated the patient had multiple abrasions from steroid use. No anatomical location, assessment, or measurements were documented in the skin breakdown section of the note. The note indicated collagen lotion (toughened skin) and retinol (medication) are helping, and the patient uses Neosporin (antibiotic) at times. There were no specific orders on the POC regarding the location of wounds and medication instructions (how to apply, dosage, frequency, duration). A review of the Skilled Nursing Visit notes dated 12/20/2023 indicated that Patient #13 fell and skin tears on both thighs. On 12/25/2023 a Call Telephone Note indicated the family reported an infected skin tear on Patient #13’s arm. Patient #13 refused a visit and assessment, but antibiotics were delivered. A review of the Skilled Nursing Visit notes dated from 12/27/2023 to 01/10/2024 indicated that the wound to the left thigh measured 16 x 10 x 0 and was covered with Vaseline gauze and a Telfa dressing. There were no physician orders for this dressing, and there were no instructions on when and how to change it. The POC was not updated based on these skilled nursing visit notes. A review of the Skilled Nursing Visit notes on 01/17/2024 indicated that “new skin has developed, and the wound looks great.” A review of Patient #13’s record, benefit period 01/29/2024 to 03/2024. The POC orders dated 02/28/2024 were similar to those of the previous benefit period, with no details on the skin breakdown’s location, assessment, or measurements. The note stated that the patient was using collagen lotion, retinol medication, and Neosporin antibiotic at times. There were no specific orders on the POC regarding the location of wounds and medication instructions. The POC was not individualized based on prior skilled nursing visits. A review of the RN Recertification note dated 01/24/2024 described the wound as a 3 x 5 x 0 skin tear. The treatment ordered was telfa kerlix and paper tape. There were no details on the anatomic location or specific wound care instructions. The POC was not updated. A review of Patient #13’s record, benefit period 01/29/2024 to 03/28/2024, included Plan of Care orders dated 02/28/2024 that indicated the patient had multiple abrasions from steroid use. No anatomical location, assessment, or measurements were documented in the skin breakdown section of the note. The note indicated collagen lotion (toughened skin) and retinol (medication) are helping, and the patient uses Neosporin (antibiotic) at times. A review of the Skilled Nursing Visit notes from 01/31/2024 to 02/14/2024 indicated that new skin or wound had developed on each visit, but the wound location, assessment, or measurements were not included in any of the notes. During an interview on 03/01/2024, the RN Manager stated that each note should be individualized, and the POC should be updated based on previous skilled nursing visits. The electronic medical record (EMR) system automatically carries previous information for each visit, so the nurse must enter an assessment that accurately reflects what was observed. The RN manager stated that the agency should ensure the individualization of each nursing visit note and update the POC accordingly. 1. A policy dated 08/2022, titled “Timeframe for completion of Hospice Patient Record,” indicates that The Interdisciplinary Group (IDG) Plan of care (POC) should be reviewed and updated to include frequencies, problems, and POC orders. The IDG should ensure problems are still current; updates should be made if problems are not current. 2. A record review of the Registered Nurse’s (RN) initial assessment of patient #10 evidenced that patient #10 had a Foley catheter; no other information (type of catheter, size, bulb size, who manages, last date changed) about Foley was provided. A POC dated 02/22/2024 does not have evidence of the patient having a Foley catheter. During an interview on 02/29/2024 at 11:20 AM, the Administrator was unable to locate additional information regarding the Foley catheter in patient #10’s chart. 4. The clinical record for Patient #18, benefit period 12/19/2023 to 03/17/2024, included a recertification visit on 01/23/2024; the RN indicated the patient has a wound to the bottom, no measurement, no details documented about the wound to the coccyx on recertification, no other documentation noted, in the record, of other wounds present. A POC dated 01/31/2024 indicated patient #18 was at high risk for skin breakdown, and on 01/03/2024, the RN did a skin assessment and indicated the patient had a Kennedy ulcer to the bottom. POC identified skin breakdown as a problem; Weekly and as-needed skin assessments are to be completed by hospice RN. No wound orders were indicated on the POC date 01/31/2024 or 02/28/2024. During an interview on 02/29/2024 at 12:38 PM, The RN Manager indicated Patient #18 wounds are being managed by a wound nurse at Entity 1. 5. The clinical record for Patient #20, benefit period 12/15/2023 to 03/13/2024, included a POC dated 02/28/2024, did not contain wound orders for bottom or suprapubic site, and no orders for suprapubic catheter care. An RN-Skilled Nursing Visit dated 02/26/2024 indicates the patient has an infection around the suprapubic site. RN 1 documented under integumentary; the skin assessment was normal. RN 1 indicates that the suprapubic site appears to look better, but no measures or details of wound condition are found in the RN-skilled nursing visit document. During an IDG meeting on 02/29/2024, RN 1 reported patient #20 has a suprapubic catheter that is being changed weekly, skin breakdown on the bottom, using foam dressing to the bottom, and redness around the suprapubic site. During an interview on 03/01/2024, at 12:35 PM, the RN Manager could not find orders or measurements of wounds, and no order was found for suprapubic catheter care on Patient #20. They indicated during a nursing visit on 02/26/2024 that the nurse noted the skin was normal, and they confirmed RN 1 reported wounds during the IDG meeting on 02/29/2024. 6. During an interview on 03/01/2024 at 9:45 AM, the RN Manager indicated the agency does not have a policy for wound care or comprehensive assessments.”

“Based on record review and interview, the agency failed to create and maintain an accurate plan of care (POC) that included the services and frequency of care provided to patients, affecting 6 of 20 record reviews. (Patient #2, #7, #8, #10, #11, #13) Findings include: 4. A review of Patient #5’s record, benefit period 01/30/2024 to 04/28/2024, included an Initial Certification & Plan of Care with orders for aide services three times a week and a Care, Treatment/Service Plan for aide services three times a week. A review of the aide Plan of Care (POC) indicated services twice a week. The agency failed to ensure all documents matched the physician orders for frequencies and services. On 02/28/2024, the RN Manager reviewed Patient #5’s electronic medical record (EMR) and paper record while being interviewed. The RN Manager stated the aide POC frequencies should have matched what was on the orders. 9. A review of Patient #12’s record, benefit period 08/04/2024 to 08/07/2024, included an Initial Certification & Plan of Care order for skilled nursing services 1-3 times a week with no order for spiritual counselor services. The POC Order indicated skilled nursing services five times a week, but there was no Chaplain order. The record included a Care, Treatment/Service Plan for a one-time evaluation specifically with a Chaplain and to receive skilled nursing services 6-7 times a week. The agency failed to ensure all documents matched the physician’s orders regarding frequencies and services. On 02/28/2024, the RN Manager reviewed Patient #12’s electronic medical record (EMR) and paper record while being interviewed. The RN Manager stated that all frequencies should match the physician’s orders. 1. A 08/2022 policy, titled “Timeframe for completion of Hospice Patient Record,” indicates The Interdisciplinary Group (IDG) POC should be reviewed and updated to include frequencies, problems, and POC orders. The IDG should ensure that the frequencies ordered on POC for each discipline match how often the patient is being seen and updated if they are incorrect; if a change in the Aide frequency is made, then the Aide Care Plan should be updated. 2. A revised 04/2023 document titled “Hospice 2023 Scope of Services” indicated the criteria for the POC include that prior to providing care, the IDG and the MD must develop and initiate the IDG care plan within 24 hours. POC is based on the complete assessment of the patient’s physical, psychosocial, economic, and spiritual needs. The POC will be revised when the patient’s condition changes. The components of the POC include medication /treatments, types, and frequency of services required to meet goals. The IDG summarization sheet will be updated every 15 days and will document the visits and any changes in the POC. 3. A record review on Patient #2, episode 01/24/2024 to 01/31/2024, included a Care, Treatment, and Service document indicating skilled nursing, social worker, spiritual, and aide services were to be provided. A Plan of Care dated 01/24/2024 indicated no services were being provided; All entries were left blank. An Aide Care Plan dated 01/24/2024 indicated aide visits to be provided twice weekly. During an interview on 02/29/2024, at 11:20 AM, the Registered (RN) Manager indicated they could not find services or frequencies on POC for Patient #2; they confirmed aide visits were to be done twice weekly but were not on POC. 5. A record review on Patient #7, episode 02/25/2024 to 05/24/2024, included a Care, Treatment, and Service document dated 02/25/2024 and an Initial Certification & Plan of Care document dated 02/25/2024, both indicating skilled nursing, social worker, and spiritual services were to be provided. A Plan of Care dated 02/27/2024 indicated skilled nursing services were provided; all other entries were blank. During an observation on 02/27/2024 at 10:45 AM, the Chaplain was seen entering patient #7’s room and providing spiritual services to the family. During an interview on 02/29/2024 at 9:43 AM, the Chaplain indicated on 02/26/2024 and 02/27/2024, visits were provided to patient #7 and family members. 6. A record review on Patient #8, episode 02/05/2024 to 05/04/2024, included a Care, Treatment, and Service document and an Initial Certification & Plan of Care document, both indicating skilled nursing, social worker, and spiritual services were to be provided. A Plan of Care dated 02/08/2024 indicated MSW services were provided; all other entries were blank. 7. A record review on Patient #10, episode 02/22/2024 to 05/21/2024, included a Care, Treatment, and Service document and an Initial Certification & Plan of Care document, both indicating skilled nursing, social worker, spiritual, and aide services were to be provided. A Plan of Care dated 02/22/2024 indicated MSW services were provided, PRN; all other entries were blank. During an interview on 02/27/2024 at 12:12 PM, Patient #10 caregiver indicated they had received nursing aide and MSW services since the start of care on 02/22/2024 During an interview on 02/29/2024 at 11:20 AM, the RN Manager could not locate an aide visit that had been provided or an aide plan of care for Patient #10. They indicated the current POC showed MSW services being provided; no other services are on the POC. They indicated that, for new patients, the aides set visit frequency after receiving the report at the morning meeting. The aide provided a visit without a visit being assigned or aide POC. 8. A record review on Patient #11, episode 02/22/2024 to 05/21/2024, included a Care, Treatment, and Service document and an Initial Certification & Plan of Care document. Both indicated that skilled nursing, social worker, and spiritual services were to be provided. The Care, Treatment, and Service document also indicated that aide services were to be provided, but the Initial Certification & Plan of Care document does not. 10. During an interview on 02/28/2024 at 2:15 PM, The RN Manager indicated the frequencies on the Care, Treatment, and Service document, the Initial Certification & Plan of Care document, Aide POC on the computer system, and the POC on the computer system should all match.”

“Based on record review and interview, the agency failed to ensure nursing aides performed competency skills for a tub bath and shampooing hair in a sink, tub, and bed before providing patient care for 2 of 2 aide record reviews. (CNA 1, CNA 2) Findings include: 1. A review of Certified Nurse Assistant (CNA) 1’s personnel records failed to evidence the skills competency form included a tub bath or shampooing hair in a sink, tub, or bed as part of the skills competency. On 03/04/2024, the RN Manager provided a copy of the aide visit note dated 07/18/2024 that was used to do CNA 1’s skills competency check-off. The aide visit note did not mention that the RN Manager was present, but it indicated that the patient got a complete bed bath. 2. A review of CNA 2’s personnel records failed to evidence that the skills competency form included tub bathing or shampooing hair in a sink, tub, or bed as part of the skill competency. On 03/04/2024, the RN Manager was unable to provide a copy of the aide visit note used to complete CNA 2’s skills competency check-off. 3. During an interview on 03/04/2024, the RN Manager was asked to review the skills competency form. They stated they could not prove that CNAs had been checked off on tub baths and shampooing hair in a sink, tub, and bed as part of the skills competency.”

“Based on observation, record review, and interview, the Hospice Aide performed tasks not permitted under state law for 1 of 2 CNA observations. (CNA 1) Findings include: A review of the Indiana Code 16-25-2-4 indicated but was not limited to a hospice employee who was an RN, a Licensed Practical Nurse (LPN), or a licensed pharmacist who may store or transport medication in a sealed portable container. During an observation at Entity 1 on 02/29/2024, Certified Nurse Assistant (CNA) 1 was observed delivering Lorazepam (controlled medication for anxiety) for Patient #5 and Scopolamine (motion sickness medication) for Patient # 18 to the Director of Nursing (DON) at Entity 1. The DON signed each receipt and gave the receipt back to CNA 1. At that time, CNA 1 stated that the hospice nurse had given them the medications at the morning meeting at the agency for them to deliver. The CNA said they have delivered other medications before and feel comfortable doing it. CNA 1 stated the medications are not transported in a locked box but are kept in a hospital bag with a tie while in the car. During an interview on 02/29/2024, the RN Manager stated that anyone at the hospice agency can pick up and deliver medications to the home or nursing home. The agency has been doing medication delivery since 2021. The RN Manager was not aware of Indiana Code 16-25-2-4. During an interview on 03/01/2024, the RN Manager provided a statement from Entity 2’s pharmacist that indicated that the drugs the agency transports are prescription and already have an order from a licensed provider, and this “floorstock” type rule doesn’t apply. The agency failed to ensure licensed personnel transported and delivered medication based on the Indiana Code. During an interview on 03/04/2024, the Administrator revealed that the job description lists for CNAs include “other” job duties that imply delivering medication. When questioned about the training provided for the transportation and delivery of medications, the Administrator stated that the nurse accompanies the CNA during a visit to guide the process. Still, there would be no documentation of that training.”

“Based on record review and interview, the agency failed to have a Registered Nurse (RN) conduct an aide supervisory visit every 14 days, affecting 2 of 3 active patients receiving aide visits. (Patient #18, #20) Findings include: 1. The clinical record for Patient #18, benefit period 12/19/2023 to 03/17/2024, indicated the agency provided Certified Nursing visits (CNA) on 02/07/2024, 02/12/2024, 02/14/2024, 02/15/2024, and 02/19/2024. There were no Aide Supervisory Visits conducted between 01/30/2024 and 02/22/2024. During an interview on 02/28/2024, at 2:15 PM, the RN Manager indicated she could not find CNA (Certified Nursing Aide) supervisory visits done between 01/30/2024 and 02/22/2024 in Patient #18’s record. 2. The clinical record for Patient #20, benefit period 12/15/2023 to 03/13/2024, indicated the agency provided Certified Nursing visits (CNA) on 12/15/2023, 12/18/2023, 12/19/2023, 12/20/2023, 12/22/2023, 12/27/2023, and 12/29/2023. There were no Aide Supervisory Visits conducted between 12/15/2023 and 01/03/2024. The agency indicated CNA visits provided on 01/05/2024, 01/08/2024, 01/10/2024, 01/11/2024, 01/15/2024, 01/17/2024, 01/19/2024, and 01/31/2024. There were no Aide Supervisory visits conducted between 01/03/2024 and 02/02/2024. The agency indicated that CNA visits were provided on 02/05/2024, 02/07/2024, 02/09/2024, and 02/24/2024. No aide Supervisory visits were conducted between 02/02/2024 and 02/22/2024. During an interview on 03/01/2024, at 12:35 PM, the RN Manager indicated she was unable to find CNA supervisory visits done between 12/15/2023 and 01/03/2024, between 01/03/2024 and 02/02/2024, and between 02/02/2024 and 02/22/2024 in Patient #20’s record.”

“Based on record review and interview, the agency failed to ensure the Administrator managed the day-to-day operations of the hospice agency, failed to ensure the Administrator reported directly to the Governing Body, failed to appoint an alternate Administrator, and failed to follow the Hospice and Hospital Service Agreement for 1 of 1 hospice agency. Findings include: 1. An October 1, 2014, “Hospice and Hospital Services Agreement” was provided by the RN Manager on 03/01/2024. The agreement defines the hospice Administrator as a person appointed in writing by the governing body. The hospice Administrator organizes and directs the hospice’s services and functions of the hospice. The agreement indicated that the hospice and hospital are independent entities. Neither party is authorized to represent the other for any purpose. Entity 2’s CEO signed the agreement for both the hospice agency and Entity 2. 2. A 01/24/2023 “Board of Governors” list for Entity 2 was provided by the Administrator on 02/27/2024. Seven members were listed for the Board, but the Chief Executive Officer (CEO) and Chief Nursing Officer of Entity 2 were not listed as Board of Governors members. 3. A 10/09/2018 Hospice Indiana/Illinois Organizational Chart was provided by the Administrator on 02/26/2024. The chart indicates that the hospice clinical manager reports to the director of oncology services at Entity 2, who reports to Entity 2’s chief nursing officer. The agency failed to ensure that the Administrator reported directly to the Governing Body. 4. An 11/01/2023 Board of Governors (Governing Body) organization chart was provided by the RN Manager on 02/28/2024. The hospice agency Administrator reports to the Chief Nursing Officer of Entity 2, who then reports to Entity 2’s Emergency Medical Services, who reports to Entity 2’s CEO, who then reports to the Board of Governors. The agency failed to demonstrate that the hospice agency Administrator reports directly to the members of the Governing Body. 5. During the exit conference on 03/05/2024, the CEO of Entity 2 was informed that the hospice agency’s current organizational structure was unacceptable. Despite this, the CEO claimed that the structure involving the hospice Administrator reporting to Entity 2 personnel was fine. The CEO also stated that all hospice employees were Entity 2’s employees, and all departments, including the hospice agency Administrator, reported to Entity 2. At that time, Entity 2’s Quality & Risk Management personnel stated that they reported the QAPI on behalf of the hospice to the Governing Body. The surveyor explained that the hospice Administrator was supposed to report directly to the Governing Body without intermediaries. In response, the CEO of Entity 2 expressed his disagreement and said, “We will just see about that.” Entity 2 had signed a Hospice and Hospital Service Agreement, which required them to follow specific guidelines, including having the hospice Administrator report directly to the Governing Body. The agency failed to follow the agreement and comply with this requirement.”

“Based on a record review and interview, the hospice agency failed to ensure an initial orientation with job duties and responsibilities specific to the hospice agency for 2 of 5 personnel record reviews. (Administrator, RN Manager) Findings include: 1. A review of the Administrator personnel record indicated job duties related to the oncology services at Entity 2. The Essential Job duties were specific to the Cancer Center program. The agency failed to ensure an initial orientation with job duties and responsibilities specific to the hospice agency. On 02/26/2024, the Administrator stated that the Registered Nurse (RN) Manager was responsible for the hospice agency’s day-to-day operations. The Administrator said they were Entity 2’s Director of Oncology (cancer) services and the Administrator for Entity 3. The Administrator was unable to find an appointment letter for the RN Manager. On 02/27/2024, the Administrator was asked to find items within the electronic medical record (EMR) on several patients, to which they responded, “I don’t know. We will have to ask the [RN Manager].” 2. A review of the RN Manager personnel record indicated that they report to an unspecified “Director.” The record included a Hospice Administration Nurse Manager appraisal that indicated they were becoming more comfortable with the day-to-day operations of the outpatient oncology center. The agency failed to ensure a job description specific to the hospice agency for the RN Manager.”

“Based on record review and interview, the agency failed to create and forward a discharge summary to the patient’s primary physician upon discharge, affecting 2 of 3 live discharge records reviewed. (Patient #2, #12) Findings include: 3. A review of Patient #12’s record for the benefit period 08/04/2023 to 11/01/2023 included a Revocation Statement dated 08/07/2023 that indicated the patient was discharged. The record had a signed Hospice Medicare Benefit Revocation dated 08/07/2023 that indicated Patient #12 received a copy of the summary of care, progress toward goals, a written discharge summary, physician orders, plan of care, treatment of services, and kinds of continuing care. The record included a Hospice Item Sheet (HIS) Discharge note dated 08/08/2023 that indicated revoked as the reason for discharge. The agency failed to evidence that the patient’s hospice discharge summary and clinical record (if requested) were forwarded to the attending physician. The agency failed to ensure the discharge summary included the following: treatment and symptoms of pain management, the current plan of care, the latest physician orders, progress toward goals, and other documentation that would assist in post-discharge. On 03/05/2024, the RN manager reviewed Patient #12’s electronic medical record (EMR) and paper record while being interviewed. The RN manager said they were unsure why a detailed discharge summary was absent in the patient’s record and stated that it should have been maintained. 1. A revised 04/2023 document titled “Hospice 2023 Scope of Services” indicated a Change in Status form and a Discharge form. A member of the IDG will complete the form and give it to the patient/family with instructions on discharge. A copy will be sent to the attending physician, with the original placed in the patient’s medical chart. 2. A record review on Patient #2, episode 10/05/2023 to 01/02/2024, included a Discharge—Live document dated 01/02/2024 and a HIS discharge dated 01/08/2024. Neither document contained a summary, details of treatment, symptoms, pain management, current POC, or latest physician orders. The patient’s paper chart did not contain discharge paperwork. During an interview on 02/29/2024 at 11:20 AM, the Registered Nurse (RN) Manager indicated they could not locate documentation related to discussing discharge with the patient/family or communication with the primary physician regarding patient #2’s discharge from the agency.”