Hoosier Uplands Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed it was revealed that the agency did not ensure that the initial comprehensive assessments were completed within the required 5-day time frame. CLINICAL RECORD 3: The patient elected the hospice benefit on 10/06/2025. Review of the clinical record revealed the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. The assessment was completed on 10/17/2025 (9 days). There was no documentation explaining a missed visit or the reason for the delay. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025. Review of the clinical record revealed that the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. A missed visit was documented on 10/06/2025 due to scheduling conflicts, and the full assessment was not completed until 10/18/2025 (12 days). There was no documentation explaining the missed visit or the delay in completing the assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025. Review of the clinical record revealed that the social worker did not complete the initial comprehensive assessment within the required 5 calendar days. The assessment was completed on 03/20/2025 (7 days). There was no documentation explaining a missed visit or the delay in completing the assessment. During a joint record review and interview on 12/05/2025, the Director of Nursing confirmed that social worker assessments were not completed within the required 5 calendar days.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following intervention to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the agency did not ensure that the plans of care include all services necessary for palliation and management of the terminal illness including interventions to manage pain and symptoms. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed that the most recent plan of care for the certification period 11/30/2025–01/28/2026 did not include specific instructions for Foley catheter management. Under interventions, the plan only stated, “catheter care,” without detailed guidance such as frequency of catheter changes, monitoring for signs and symptoms of infection, maintaining catheter patency, or actions to take if complications occur. There was no evidence that the plan of care included all interventions related to Foley catheter management. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed that the initial plan of care sated 09/19/2025 did not include specific instructions for Foley catheter management. The plan only stated, “catheter care,” without detailed guidance such as frequency of catheter changes, monitoring for signs and symptoms of infection, maintaining catheter patency, or actions to take if complications occur. There was no evidence that the plan of care included all interventions related to Foley catheter management. Following a joint review of records and an interview on 12/05/2025 with the Director of Nursing, she confirmed that the patients’ written plans of care did not fully address all interventions required for effective pain and symptom management.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the patients’ current plans of care included all services necessary for palliation and management of the terminal illness including measurable outcomes from implementing and coordinating the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed that the patient was admitted with a Foley catheter, and the current plan of care did not specify interventions related to the maintenance of the foley catheter just “catheter care”. The plan of care did not include goals related to Foley catheter management or genitourinary status. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025. Review of the clinical record revealed that the initial comprehensive assessment completed on 10/02/2025 identified multiple problems, including pain, fall risk, confusion, and altered cardiopulmonary function. The plan of care, however, did not include individualized measurable goals addressing these issues. For example, a goal noted was “Maintain adequate cardiopulmonary status equal to disease process” and “demonstrate adequate ventilation and oxygenation”. CLINICAL RECORD 8: The patient elected the hospice benefit on 09/28/2024. Review of the clinical record showed that the comprehensive assessment dated 09/28/2024 and subsequent assessments identified multiple problems, including pain and shortness of breath, with the patient requiring oxygen at 2–4 liters via nasal cannula as needed. However, the plan of care did not include individualized, measurable goals based on these assessed needs. Goals noted were generic, such as “Maintain adequate cardiopulmonary status equal to disease process” and “Demonstrate adequate ventilation and oxygenation.” CLINICAL RECORD 9: The patient elected the hospice benefit on 10/11/2025. Review of the clinical record indicated that the comprehensive assessment on 10/11/2025 identified multiple problems, including confusion, hallucinations, forgetfulness, and leg pain. However, the plan of care did not include individualized goals addressing these issues. Specifically, there were no goals related to pain management, cognitive symptoms (confusion/hallucinations), or safety—such as fall prevention, the patient was assessed as high fall risk. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed that the patient was admitted with a Foley catheter and had physician orders for catheter changes every three weeks. However, the plan of care did not include goals related to Foley catheter management or genitourinary status, despite the patient’s documented history of recurrent urinary tract infections. Following a joint review of records and an interview with the Director of Nursing, she acknowledged that the goals were neither individualized to the assessed problems nor measurable.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. In 7 of 14 (50%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care was reviewed and revised as frequently as the patient’s condition requires but no less that every 15 days. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/28/2022. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. On 11/06/2025, nursing documented persistent abdominal pain rated 2.5/5, described as constant and cramp-like; the physician was notified, and liquid morphine was increased to 25 mg every 1–4 hours as needed. On 11/20/2025, nursing documented bilateral foot pain fluctuating up to 3/5. However, the Interdisciplinary Group (IDG) documentation for 11/26/2025 reflected only “Abdomen cramp-like medications effective” under the pain problem. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for managing pain over the next two weeks. CLINICAL RECORD 2: The patient elected the hospice benefit on 02/03/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 10/22/2025 noted a reddened gluteal area with wound care interventions and a Dulcolax suppository for constipation. However, the Interdisciplinary Group (IDG) documentation for 10/30/2025 did not include any skin/integumentary concerns and, under GU/GI, only noted “F/C sediment.” There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 3: The patient elected the hospice benefit on 10/06/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation noted a right lower arm skin tear on 10/28/2025 and additional skin tears with wound care orders on 11/05/2025. On 11/05/2025, nursing also documented chest pain, increased shortness of breath, and initiation of oxygen. However, the IDG documentation for 11/13/2025 only stated “skin tears noted” and did not address the chest pain episode. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 8: The patient elected the hospice benefit on 09/28/2024. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation noted increased pain and significant right shoulder edema on 10/08/2025, pain radiating from the shoulder to the hand on 10/14/2025 and continued right shoulder pain with noticeable swelling on 10/29/2025. Pain management progressed from tramadol to oxycodone and morphine as needed. However, the IDG documentation for 11/13/2025 only stated “pain right shoulder, medications effective,” with no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 10/27/2025 indicated the patient was started on Septra DS twice daily for a urinary tract infection (UTI). On 11/05/2025, doxycycline was ordered due to continued UTI symptoms. However, IDG documentation on 10/30/2025 noted only “F/C with sediment” under GI/GU status, and on 11/13/2025 noted “F/C urine clear.” There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 09/16/2025 indicated the patient’s granddaughter took the patient to the emergency room due to combative behavior and suspected urinary tract infection (UTI). However, IDG documentation on 09/18/2025 contained no update regarding UTI symptoms or the emergency room visit. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks CLINICAL RECORD 13: The patient elected the hospice benefit on 06/02/2022. Review of the clinical record revealed the individualized plan of care was not revised to reflect changes in the patient’s condition. Nursing documentation on 11/04/2023 noted an open area on the left buttock; however, the IDG meeting on 11/14/2023 contained no update regarding skin/integumentary status. On 11/26/2024, the patient was documented as impending death with daily visits ordered, yet the IDG meeting on 11/27/2024 only reflected “non-verbal, incontinent of bladder/bowel.” The patient died on 11/28/2024. There was no evidence of a comprehensive review of the prior two weeks, no indication of plan revisions based on ongoing assessments, and no documented plan for the next two weeks. During a joint record review and interview with the Director of Nursing on 12/05/2025, she confirmed that individualized care plans were not being updated as required to reflect changes in the patient’s condition.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by interview and observation. In 2 of 3 (67%) home visits it was revealed that the agency did not ensure that standards of practice to prevent transmission of infections and communicable diseases were followed related to hand hygiene. Hand Washing Policy: The agency policy “HAND WASHING POLICY”, which is undated, page 32 ,states: “POLICY: In an effort to reduce the risk for infection in clients and staff members, thorough hand washing is required of all employees. PURPOSE: To prevent the transmission of infectious agents between clients and health care workers or between staff via hands. SPECIAL INSTRUCTIONS: . Use of an alcohol based hand sanitizer is acceptable, unless: A. Hands are visibly soiled b. After known or suspected exposure to patients with infectious diarrhea during norovirus outbreaks. When washing hands with soap and water, wet hands first with water, apply soap to hands and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable paper towel. Use towel to turn off faucet. Avoid using hot water, to prevent drying of skin. You should keep soap and paper towels in an outer pocket of your bag. When decontaminating hands with an alcohol based hand sanitizer, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. This should take around 20 seconds. 4. Indications for hand washing include, but are not limited to: a. Before and after patient contact, b. After contact with objects in the immediate vicinity of the patient, before eating, drinking, or handling food, after using a restroom, After contact with blood, body fluids or excretions, mucous membranes, non-intact skin or wound dressing. Before and after invasive procedures (in addition to wearing gloves) Before and after performing aseptic technique (e.g. insertion of an IV, preparing an injection, performing wound care.) Between each glove change. Between activities on the same client involving different body site. Moving from a contaminated body site to a clean body site during patient care. After any contact with contaminated articles or surfaces; including PPE. HOME VISIT 2: The patient elected the hospice benefit on 08/05/2021. During a home visit, observation with the licensed practical nurse (LPN) (Personnel Record 4), the LP was observed accessing and re-accessing her nursing bag multiple times without sanitizing her hands before or after contact with the bag or patient care items. HOME VISIT 3: The patient elected the hospice benefit on 10/06/2025. During a home visit, observation with the licensed practical nurse (LPN) (Personnel Record 4), the LP was observed accessing and re-accessing her nursing bag multiple times without sanitizing her hands before or after contact with the bag or patient care items. During an interview on 12/05/2025, the Director of Nursing confirmed that, based on the observed practices, the nurse did not follow the agency’s hand hygiene protocol as required by infection control standards.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide, ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. This standard was not met as evidenced by clinical record review and interview. In 4 of 10 (40%) clinical records reviewed of patients receiving hospice aide service it was revealed that the agency did not ensure that the registered nurse completed a hospice aide supervisory visit no less than every 14 days. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/02/2025 and was ordered hospice aide services weekly. The hospice aide began providing services on 10/15/2025; however, the only documented supervisory visit occurred on 11/20/2025 (36 days). CLINICAL RECORD 10: The patient elected the hospice benefit on 09/19/2025 and was ordered hospice aide services twice weekly. The documented supervisory visits occurred on 10/08/2025 (16 days after the first hospice aide visit) and 10/27/2025 (19 days). CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025 and was ordered hospice aide services weekly. Documented supervisory visits occurred on 04/02/2025, 04/28/2025 (26 days), 05/08/2025, and 05/27/2025 (19 days.) CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025 and was ordered hospice aide services twice weekly. Documented supervisory visits occurred on 07/21/2025, 08/25/2025 (19 days), and 09/15/2025 (19 days) During a joint record review and interview conducted on 12/03/2025 with both the Director of Clinical Services and the Hospice Patient Care Coordinator, it was confirmed that the hospice aide supervisory visits were not conducted every 14 days as required. Both individuals acknowledged the oversight and agreed that the required supervisory visits had not been conducted as outlined in the plan of care.”

“It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review and interview. A review of “Board of Directors” (Governing Board) documented meeting dated 10/15/2024, 11/19/2024, 01/21/2025, 03/18/2025, 04/15/2025, 05/20/2025, 07/15/2025, 08/19/2025, 09/16/2025 and 10/01/2025 revealed that the agency did not ensure that when the Administrator is not available, a qualified, predesignated person, who is authorized in writing by the Administrator and the organization’s governance, assumes the same responsibilities and obligations as the Administrator. An unlabeled and undated document stated in part, “(Name), RN, has been appointed the Alternate Director of Nursing effective 12/09/24, in addition to her current duties,” and also stated, “(Name), CEO, has taken back the duties of Administrator to which he was previously appointed in 03/23/87.” This document did not clearly reflect the date on which the Administrator role was assumed and was not identifiable as a governing-body appointment. In a separate document, a letter dated 12/04/2024 was sent to the state department of health indicating that (Name) was re-appointed as the Administrator, effective 12/09/2024. Separately, a document dated “December 2, 2025,” documented the appointment of the Administrator and Alternate Administrator as approved by the board on August 25, 2025, and was signed by both the Administrator and Alternate Administrator for their roles. During an interview on 12/03/2025, the Administrator and Clinical Manager confirmed the evidence by stating they did not have board approval and authorization from the Administrator for approval of a predesignated person as the Alternate Administrator. A review of “Board of Directors” (Governing Board) documented meeting dated 10/15/2024, 11/19/2024, 01/21/2025, 03/18/2025, 04/15/2025, 05/20/2025, 07/15/2025, 08/19/2025, 09/16/2025 and 10/01/2025 revealed that the agency did not ensure that when the Administrator is not available, a qualified, predesignated person, who is authorized in writing by the Administrator and the organization’s governance, assumes the same responsibilities and obligations as the Administrator. An unlabeled and undated document stated in part, “Amanda Berent, RN, has been appointed the Alternate Director of Nursing effective 12/09/24, in addition to her current duties,” and also stated, “David Miller, CEO, has taken back the duties of Administrator to which he was previously appointed in 03/23/87.” This document did not clearly reflect the date on which the Administrator role was assumed and was not identifiable as a governing-body appointment. In a separate document, a letter dated 12/04/2024 was sent to the state department of health indicating that David Miller was re-appointed as the Administrator, effective 12/09/2024. Separately, a document dated “December 2, 2025,” documented the appointment of the Administrator and Alternate Administrator as approved by the board on August 25, 2025, and was signed by both the Administrator and Alternate Administrator for their roles.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following, a summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients discharged from the agency it was revealed that discharge summaries did not include all required elements. Missing components included, but were not limited to, a summary of the patient’s hospice stay, the patient’s current plan of care and the patient’s latest physician orders. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/13/2025 and was discharged on 06/23/2025 due to admission to a hospital, which is outside the agency’s service area. Upon review of the discharge summary, it was noted that the document did not include all required elements as per agency policy and regulatory standards. The summary only listed the start of care date, discharge date, and discharge disposition (“hospital”), with a brief note stating, “Pt discharged d/t out of service area.” No additional information regarding the patient’s condition at discharge, services provided, a comprehensive summary of the hospice episode, the current plan of care, most recent physician orders, medication reconciliation, or follow-up instructions was documented. CLINICAL RECORD 12: The patient elected the hospice benefit on 01/25/2025 and was discharged on 10/10/2025 following transfer to the emergency room. The discharge summary noted that the patient’s family was seeking aggressive treatment for stroke-like symptoms, including an episode of unconsciousness and facial drooping, and included the statement: “Caregiver frequently seeking treatment for patient; patient is not hospice appropriate.” However, the discharge summary did not include all required elements. Specifically, it lacked documentation of the patient’s condition at discharge, services provided, a comprehensive summary of the hospice stay, the current plan of care, and the most recent physician orders. During a joint record review and interview conducted on 12/05/2025 with the Director of Nursing she acknowledged that the discharge summaries reviewed did not contain all required information.”