Southerncare Indianapolis

“Upon patient record review, 3 of 23 (Patient #3,12,18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #3: DME indicated oxygen supplies and the nurse documentation indicated that the patient was on oxygen 2L/min. There was no evidence that oxygen was on the medication profile. Corrected on site. Patient #12: Duplicate drug therapy - the MAR has both Colace and Miralax listed as daily for constipation. No evidence that instructions were given to on which medication to give first for treating constipation. Corrected during survey. Patient #18: Duplicate drug therapy - the MAR has both Colace and Miralax listed as daily for constipation. No evidence that instructions were given to on which medication to give first for treating constipation. Corrected during survey.”

“Upon patient record review, 4 of 23 (Patient #3,8,16,21) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #3: No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed during survey. Patient #8: No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed on 05/06/2022. Patient admitted on 01/21/2022. Patient #16 : No evidence that the bereavement risk assessment was completed within 5 days after the election. Patient admitted on 01/06/2024. Patient #21 : No evidence that the bereavement risk assessment was completed within 5 days after the election. Completed on 07/10/2023. Patient admitted on 06/22/2022.”

“Upon patient record review, 2 of 23 (Patient #11,17) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #11: The record indicated that the patient is currently receiving Phyisical therapy. Order written on 04/08/2024. No evidence that the plan of care included goals and interventions related to therapy. Corrected during survey Patient #17: The patient was admitted with a diagnosis of major depressive disorder. Currently on 2 medications for depression. No evidence that the plan of care included goals and interventions related to depression. Corrected during survey.”

“Upon patient record review, 1 of 23 (Patient #13) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #13: The initial visit frequency for the spiritual care counselor was 1 prn visit.”

“Upon patient record review, 2 of 23 (Patient #1,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The record indicated that the patient had oxygen at 2L/min continuously via nasal cannula. Current oxygen order was for 3L/min PRN for shortness of breath. No evidence of a titration order or an order to change the flow of oxygen. Corrected on site. Patient #3: DME indicated oxygen supplies and the nurse documentation indicated that the patient was on oxygen 2L/min. There was no evidence that oxygen was ordered on the POC. Corrected on site.”

“Upon patient record review, 6 of 23 (Patient #4,5,6,10,11,12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #4: The record shows that patient uses a walker and a wheelchair to help with mobility daily. Aide plan of care has orders for the aide to use the walker and wheelchair at every visit. No effective that a walker or a wheelchair was added to the medical supply list. Corrected during survey. Patient #5: The record indicated that the patient was using a wheelchair to help with mobility. Aide plan of care has orders for the aide to use the wheelchair at every visit. No evidence that a wheelchair was added to the supply list. Corrected during survey. Patient #6: Patient currently on PRN oxygen via nasal cannula. No evidence that oxygen was added to the current supply list. Corrected during survey. Patient #10: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey. Patient #11: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey. Patient #12: Wound care on supply list at the start of survey. No evidence that the patient ever had wound during time on service. Corrected during survey.”

“Upon client record review, 3 of 23 (Patient #3,16,#18) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Order written on 04/10/2024 to start music therapy. No evidence that a follow up visit occurred. Patient 16: Volunteer services ordered as one weekly tuck in calls. No evidence that those calls were completed weekly pass 02/08/2024. No evidence of a physicians order to end those calls. Patient 18: Plan of care SN frequency as twice a week. No evidence that 2 visits occurred for the week of 03/24/2024, the record shows documentation for one visit that occurred on 03/26/2024.”

“Upon patient record review 2 of 23 (Patient #14,#15) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 14: Plan of care has aide visit frequency ordered as 2 times a week. No evidence that 2 visits occurred on the week of 05/26/2024. The record shows that one visit was completed that week on 05/30/2024. Patient 15: Plan of care has aide visit frequency ordered as 3 times a week. No evidence that 3 visits occurred on the week of 05/26/2024. The record shows that two visits were completed that week, on 05/29/2024 and 05/31/2024. Also, aide plan of care has nail care ordered as once a week, on the first visit of the week. The record shows that aide performed nail care on all visits from 04/15/2024 through 05/31/2024.”

“Upon patient record review 1 of 23 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made 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 and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 8: No evidence that on-site supervised visits occurred every 14 days between March 14th and March 29th then again between April 3rd and April 18th.”

“Upon patient client record review, 6 of 23 (Patient #4,7,12,13,14,15) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4: The record contained a missed visit coordination note 5/17/24 with no information in the template to explain the reason for the frequency not met. The provided template in the note was empty except for a follow up completed by the RN reporting that she informed the aide that she needed to complete the note. Patient #7: The record contained a missed visit coordination note on 06/03/2024 that does not include indication if the aide notified the RN of the missed visit. Patient #12: The record contains a missed visit coordination note that listed the reason for missed visit as “Patient prefers her SW”. No evidence of a visit date or who was notified that the visit did not occur. Patient #13: The record contains missed visit coordination notes entered on 04/11/2024, 4/16/2024, 4/24/2024, and 04/29/2024 with no visit dates. Also, the missed visits notes dated for 04/11/2024, 04/24/2024, and 04/29/2024 did not contain evidence pf a reason these visits were missed. Patient #14: Record shows the Consent to share information form was not signed or dated by the patient. Patient #15: Indiana POST and Indiana out of hospital DNR form missing MD license number.”

“Based on record review and interview, the agency failed to ensure staff followed the aide plan of care for 1 of 4 active record reviews (Patient #1) and 1 of 1 closed record review (Patient #5). Findings include: 1. A revised 08/30/2023 policy titled “;The Plan of Care” was provided by the Administrator on 01/10/2024. The policy indicated that care provided to the patient would follow the care plan. 2. A revised 06/15/2023 policy titled “;Hospice Aide Services” was provided by the Administrator on 01/11/2024. The policy indicated the services the aide would provide. Hospice aide duties include but are not limited to bathing, dressing, toileting, and transferring. Hospice aide duties may also include housekeeping, family/caregiver respite, and meal preparation. A Registered Nurse develops the aide plan of care. Hospice aides are to review the plan of care before providing care. 3. An undated Registered Nurse (RN) job description was provided by the Administrator on 01/10/2024. The policy indicates the RN maintains an accurate and updated medical record, including ongoing assessments and any other information pertinent to the patient’s care. The RN was responsible for educating the patient and staff and communicating with the interdisciplinary team. 4. The clinical record for Patient #1 was reviewed and included Certified Nursing Assistant (CNA) visit notes from 10/10/2023. There was no documentation of CNA 1 providing shopping service for Patient #1, and no communication was made to the case manager about additional services needed to meet the needs of Patient #1. A review of the aide’s plan of care did not include the task of using a patient credit card or money to purchase items on behalf of the patient. During a phone interview on 01/10/2024, Patient #1s spouse stated they gave 2 (two) Humana Flex cards to CNA 1 to use to buy them snacks and groceries. CNA 1 was allowed to keep the cards with them for convenience but the spouse could not recall the time frame during which CNA 1 had the cards. CNA 1 provided care for Patient #1 from September to November 2023. Social Worker (SW) 1 from the hospice agency also visited. The spouse stated they allowed a friend and two of Entity 1s personnel (Activity Director & Activity Assistant) to use the cards to purchase items for the patient and spouse. The spouse said another number would show up on the receipts or would not receive a receipt, and that was around the time CNA 1s new boyfriend moved in with CNA 1. The spouse stated if they did not use the money within the month, it would not roll over to the next month. The spouse stated they were having a hard time remembering but said they did not receive some of the receipts from October and November. The spouse could not recall which month but stated Patient #1 had $40.00 left on the card, but $120.00 should have been available. During an interview on 01/10/2024, CNA 1 stated they had bought Patient #1 milk, bread, and protein snacks using Patient #1 and their spouse’s Human Flex cards weekly. CNA 1 stated they used both the spouse’s and patient’s Humana Flex cards because they would use the other if one card ran low on money. CNA 1 said the spouse allowed them to keep the cards with them for convenience but was unsure of the time frame. CNA 1 failed to follow the aide’s plan of care. 5. The clinical record for Patient #5 was reviewed and included CNA visit notes from 01/04/2023 to 08/30/2023. There was no documentation of CNA 3 providing shopping service for Patient #5, and no communication was made to the case manager about additional services needed to meet the needs of Patient #5. A review of the aide’s plan of care did not include the task of using a patient credit card or money to purchase items on behalf of the patient. During an interview on 01/10/2024, CNA 3 noted that about six months ago Patient #5 asked them to do shopping, which CNA 3 did. CNA 3 indicated Patient #5 would give CNA 3 cash or card, and they would purchase items and then return items, card/cash, and receipts to Patient #5. CNA 3 indicated they were not supposed to provide this service for the patient but were trying to help the patient. CNA 3 failed to follow the aide’s plan of care. 6. During an interview on 01/10/2024, the Administrator stated no employee was to purchase items or run errands for the agencys patients. The Administrator stated the aides were to follow the aide plan of care.”

“Based on record reviews and interviews, the agency failed to provide in-service / education for staff regarding following the aide plan of care and handling patient money for 9 of 9 personnel record reviews, with the potential to affect all hospice aides. (CNAs 1, 2, 3, 6, 7, 8, 11, 13, 14) Findings include: 1. An undated Certified Nursing Aide (CNA) job description was provided by the Administrator on 01/10/2024. The job description indicated but was not limited to the duties the CNA may not do, including providing personnel care services or housekeeping services which have yet to be included in the hospice aide care plan developed by the Registered Nurse (RN). 2. A 04/2023 document titled “;Maintain Professional Relationships” education activity was reviewed and indicated staff should know the agencys policy on handling patients money and obtaining receipts for record keeping if shopping for the patient was part of their responsibility. 3. Personnel Record review evidenced the following: Personnel Record review for CNAs 1, 2, 3, 7, and 13 evidenced the Professional Boundaries and Ethics for Hospice Employees in-service / re-education were completed in December 2023 and January 2024. The material did not cover handling patients money, obtaining receipts for record-keeping, or following the aide plan of care. Personnel Record review for CNAs 6, 8, 11, and 14 evidenced that they did not complete any in-service or re-education for December 2023 or January 2024 about handling patients money, obtaining receipts for record-keeping, or following the aide plan of care. 4. A review of the Professional Boundaries and Ethics for Hospice Employees modules provided by the Administrator evidenced that they failed to address how to handle patients requesting shopping and handling patients money and receipts. No information in modules or other in-service was provided to CNAs regarding following the aide plan of care. 5. CNA phone interviews evidenced the following: During an interview on 01/10/2024, CNA 2 indicated they had completed an online in-service about professional boundaries. During an interview on 01/10.2024, CNA 1 stated they had bought Patient #1 milk, bread, and protein snacks using Patient #1 and their spouse’s Human Flex cards weekly. CNA 1 stated they did not purchase items for other patients on their schedule. CNA 1 said they received education from the Administrator and the Patient Care Manager after the occurrence and completed Relias training regarding “;boundaries.” During an interview on 01/10/2024, CNA 3 indicated they had completed an online in-service about professional boundaries in the last three months. They indicated that about six months ago, Patient #5 asked them to do shopping, which CNA 3 did. CNA 3 stated Patient #5 would give CNA 3 cash or card, and they would purchase items then return items, card/cash, and receipts to Patient #5. CNA 3 indicated they were not supposed to provide this service for the patient but were trying to help the patient. During an interview on 01/11/2024, CNA 13 indicated that a patient had never asked them to pick up items from a store or run errands but wouldnt have a problem with it. CNA 13 indicated they were unsure how the exchange of money would be handled and werent 100% sure they could provide that service. CNA 13 indicated online and in-person in-services are done monthly, and the last professional boundary in-service was during the summer. During an interview on 01/11/2024, CNA 11 indicated an in-service on 01-10-2024 on burnout and self-care. CNA 11 indicated they had been off from August 2023 to the start of December 2023 and are currently working as needed (PRN) but were not required to have all in-services assigned to them completed before returning to caring for patients. They indicated that the in-services assigned for September, October, and November have not been completed. During an interview on 01/11/2024, CNA 7 indicated that in-services are assigned monthly and must be completed within the month. They indicated that if a patient needed assistance with errands, CNA 7 would contact the office to inquire about volunteers providing that service. CNA 7 indicated there had been no education provided by the agency related to running errands or shopping for patients. During an interview on 01/11/2024, CNA 5 stated a patient had never asked them to pick up items from a store or run errands. CNA 5 could not recall any recent online training or in-services regarding following the plan of care. 6. During an interview on 01/11/2024, the Administrator stated the Professional Boundaries and Ethics for Hospice Employees in-service in December and January provided to the CNAs did not specifically talk about handling patients money and receipts when purchasing items on behalf of patients. The in-service did not discuss the importance of following the aide plan of care. The Administrator stated the in-service was isolated to the Bloomington parent office and not provided to the Terre Haute and New Albany branches.”