Heart to Heart Hospice of Eastern Indiana LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #TX.17 “Medication List and Monitoring” dated 01/10/2021 read in part, “A Hospice Registered Nurse will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all Hospice staff involved in the patient’s care, including the pharmacist. A medication profile/list will be maintained on all patients. Medication monitoring will include appropriate date/information to develop an accurate patient medication history and a current, complete medication profile.” In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that all current medications were included in the patient’s drug profile. Clinical Record 4: The patient elected hospice care on 09/27/2024. The initial nursing assessment dated 09/27/2024 documented, “The patient was on 4 liters of oxygen while in the emergency room and is now on 3 liters.” A clinical record review revealed the patient’s medication profile dated 09/27/2024 did not document oxygen. Clinical Record 6: The patient elected hospice care on 08/01/2024. The initial nursing assessment dated 08/01/2024 documented, “The patient is on supplemental oxygen at 2 liters.” A clinical record review revealed the patient’s medication profile dated 08/01/2024 did not document oxygen. Clinical Record 7: The patient elected hospice care on 08/29/2024. On 08/29/2024, the physician ordered: “Oxygen via nasal cannula at 2 liters as needed for shortness of breath or comfort.” A clinical record review revealed the patient’s medication profile dated 08/29/2024 did not document oxygen. Clinical Record 8: The patient elected hospice care on 06/25/2024. The initial plan of care dated 06/25/2025 through 09/22/2024 documented, “Administer oxygen as required.” A clinical record review revealed the patient’s medication profile dated 06/25/2024 did not document oxygen. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, “Oxygen is not listed on these patients’ medication profiles.””

“It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 10/16/2024 with a diagnosis of multiple sclerosis. The patient resided in a skilled nursing facility (SNF). The initial nursing assessment dated 10/16/2024 documented, “Patient has dysphagia.” The POC dated 10/16/2024 through 01/13/2025 did not include documentation of planned interventions related to the patient’s dysphagia. Clinical Record 3: The patient elected hospice care on 05/21/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a SNF. The initial nursing assessment dated 05/21/2024 documented, “Patient has dysphagia.” The POC dated 05/21/2024 through 08/18/2024 did not include documentation of planned interventions related to the patient’s dysphagia. Clinical Record 10: The patient elected hospice care on 02/06/2024 with a diagnosis of pulmonary fibrosis. On 02/06/2024, the physician ordered: “Warfarin (anticoagulant) 5mg tablet by mouth daily.” The POC dated 02/06/2024 through 05/05/2024 did not include documentation of planned interventions related to the patient’s risk for bleeding. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, “There are no interventions in the plan of care for these patients regarding dysphagia or bleeding risk.””

“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: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included drugs and treatments necessary to meet the patient’s needs. Clinical Record 7: The patient elected hospice care on 08/29/2024 with a diagnosis of multiple myeloma. The plan of care for the certification period dated 08/29/2024 through 10/27/2024 ordered, “Maintain indwelling foley catheter. Flush with 30 ml normal saline as needed for patency. Replace foley catheter Q4 weeks or PRN if dislodged or occluded.” The plan of care orders did not document the size of the Foley catheter to be used. Clinical Record 8: The patient elected hospice care on 06/25/2024 with a diagnosis of end-stage heart failure. The initial plan of care dated 06/25/2024 through 09/22/2024 ordered: “Administer oxygen as required.” The plan of care orders did not include documentation of the route of oxygen administration, the flow rate of the oxygen, or the frequency of oxygen administration until 07/29/2024. Clinical Record 14: The patient elected hospice care on 06/17/2024 with diagnoses of diffuse traumatic brain injury and chronic respiratory failure. The initial plan of care dated 06/17/2024 through 07/22/2024 ordered: “Change trach inner cannula and trach sponge daily.” The plan of care orders did not include documentation of the size of the tracheostomy tube. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the findings, stating, “There are no orders for oxygen, Foley, and tracheostomy size in these patient charts.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 15 (20%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that all written patient care instructions were included in the HA care plan. Clinical Record 14: The patient elected hospice care on 06/17/2024 with diagnoses of diffuse traumatic brain injury and chronic respiratory failure. On 06/17/2024, the physician ordered wound care with dressings to wounds on the patient’s coccyx and ankles. The plan of care (POC) dated 06/17/2024 through 07/22/2024 ordered “Aide 3x per week.” The HA care plan dated 06/17/2024 assigned the HA the relevant task of a “Bed bath at every visit.” The HA care plan did not provide the HA with instructions addressing the coccyx and ankle dressings during the bed bath should the dressing become wet or dislodged. Clinical Record 18: The patient elected hospice care on 05/31/2024 with a diagnosis of malignant neoplasm of the lung. On 06/01/2024, the physician ordered wound care with a dressing to a wound on the patient’s coccyx. The plan of care dated 05/31/2024 through 06/18/2024 ordered “Aide 3x per week.” The aide care plan dated 05/31/2024 assigned the HA the relevant task of a “Bed bath at every visit.” The HA care plan did not provide the HA with instructions addressing the coccyx dressing during the bed bath should the dressing become wet or dislodged. Clinical Record 19: The patient elected hospice care on 04/09/2024 with a diagnosis of senile degeneration of the brain. On 05/30/2024, the physician ordered wound care with dressings to wounds on the patient’s coccyx and ankles. The plan of care dated 04/09/2024 through 06/28/2024 ordered “Aide 4x per week.” The HA care plan dated 04/09/2024 assigned the HA the relevant task of a “Shower at every visit.” The HA care plan did not provide the HA with instructions addressing the coccyx dressing during the shower should the dressing become wet or dislodged. During an interview and a joint record review on 10/30/2024, the Executive Director confirmed the findings, stating, “There are no wound dressing instructions on these aide care plans.””

“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. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 15 (13%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that HA supervisory visits were completed no less frequently than every 14 days. Clinical Record 1: The patient elected hospice care on 07/02/2024 with the diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). The plans of care dated 08/03/2024 through 10/01/2024 and 10/02/2024 through 12/01/2024 ordered “Aide 2x per week.” Hospice Aide supervisory visits were documented as completed on 08/13/2024 and 08/29/2024, with sixteen (16) days outstanding, and 09/25/2024 and 10/14/2024, with nineteen (19) days outstanding. Clinical Record 13: The patient elected hospice care on 05/30/2024 with a diagnosis of end-stage renal disease. The patient resided in a skilled nursing facility (SNF). The plans of care dated 05/30/2024 through 08/27/2024 and 08/28/2024 through 11/25/2024 ordered “Aide 3x per week.” Hospice Aide supervisory visits were documented as completed on 06/11/2024 and 06/28/2024, with seventeen (17) days outstanding; on 07/16/2024, with nineteen (19) days outstanding; and on 07/31/2024, with fifteen days outstanding. Hospice Aide supervisory visits were documented as completed on 09/18/2024 and 10/03/2024, with fifteen (15) days outstanding. During an interview and a joint record review on 10/30/2024, the Executive Director confirmed the findings, stating, “There are no other aide supervisory visits in these records.”.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure that the patient’s clinical record contained physician orders for all care and services. Clinical Record 4: The patient elected hospice care on 09/27/2024 with a diagnosis of congestive heart failure. The initial nursing assessment dated 09/27/2024 documented, “The patient was on 4 liters of oxygen while in the emergency room and is now on 3 liters.” A clinical record review revealed no documentation of a physician’s order for oxygen. Clinical Record 6: The patient elected hospice care on 08/01/2024 with a diagnosis of malignant neoplasm of the lung. The initial nursing assessment dated 08/01/2024 documented, “The patient is on supplemental oxygen at 2 liters.” A clinical record review revealed no documentation of a physician’s order for oxygen. Clinical Record 16: The patient elected hospice care on 10/31/2023 with a diagnosis of senile degeneration of the brain. The hospice discharge visit note dated 06/19/2024 documented, “Patient is being discharged due to no longer being terminally ill.” A clinical record review revealed no documentation of a physician’s order for discharge. During an interview and a joint record review on 10/29/2024, the Executive Director confirmed the finding, stating, “There are no orders for oxygen in these patient charts. There is not an order for discharge in the discharged patient’s chart.””