Heartland Hospice (Indianapolis)

“Upon patient record review, 7 of 19 records (Patient #5,#8,#9,#10,#11,#13,#14) 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 #5: The medication profile contained Insulin Aspart 100u/ml sliding scale per facility requirements. Corrected on site. Patient #8: Upon visit, the facility MAR included Multi-vitamins, Acetaminophen, Cyclobenzaprine, Ibuprofen, Loperamide and Salonpas which were not in the medication profile of the hospice. Corrected on site Patient #9: Upon visit, the hospice medication profile listed Atorvastatin, Metoprolol, and Miralax which were not on the MAR at the facility. Corrected on site. Patient #10: Upon visit, the hospice medication profile listed Mirtazapine. There was not evidence that this was in the patient home. Corrected on site. Patient #11: Upon visit, Miralax was in the patient home. There was not evidence that this was on the hospice medication profile. Corrected on site. In addition, nursing documentation indicated that the patient wears oxygen 4-4.5L/min via nasal cannula. There was not evidence that this was in the medication profile. Corrected on site. Patient #13:The record indicated that the patient had oxygen intermittent at 2L/min via nasal cannula. There was not evidence that this was in the medication profile. Corrected on site. Patient #14: The medication profile contained Polyethylene Glycol 17 GM, 1 packet, mix with 30 ml water. Corrected on site.”

“Upon patient record review, 1 of 19 records (Patient #11) 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 #11: The patient was admitted on 7/12/24. The bereavement risk assessment was completed on 8/16/24.”

“Upon patient record review, 6 of 19 records (Patient #6,#7,#9,#12,#13,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #6: The patient was admitted with a diagnosis of COPD. She also had a dementia diagnosis and resided in a Memory care unit. She had dysphagia, intermittent anxiety and required assistance with all ADLs. There was not evidence that the care plan included patient/family goals and interventions related to her neurological or cognitive problems. Corrected on site. Patient #7: The patient was on Eliquis 5m po BID. There was not evidence that the care plan included safety regarding bleeding precautions. Corrected on site. Patient #9: The patient was admitted with a diagnosis of Alzheimer’s Disease. She had non-sensible speech, required assistance with all ADLs, was disoriented, had a history of aggression and falls. There was not evidence that the care plan included patient/family goals and interventions related to her neurological, Alzheimer’s or cognitive problems. Corrected on site. Patient #12: The record indicated that the patient had a colostomy. There was not evidence that this was addressed in the plan of care. Corrected on site. In addition, the record indicated that the patient was on Plavix 75mg daily. There was not evidence that bleeding precaution or safety was in the plan of care. Corrected on site. Patient #13: The record indicated that the patient was on Plavix 75mg daily. There was not evidence that bleeding precaution or safety was in the plan of care. Corrected on site. Patient #14: The record indicated that the patient had a trach. There was not evidence that the care plan included goals and interventions related to the trach. Corrected on site.”

“Upon patient record review, 8 of 19 records (Patient #6,#7,#8,#9,#10,#11,#12,#13) did not have evidence the plan of care 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 #6,#7,#8,#9,#10,#11,#12,#13: The initial visit frequency for both the social worker and the spiritual care counselor was 1 prn.”

“Upon patient record review, 5 of 19 records (Patient #5,#8,#11,#13,#14) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #5: The record contained an order for Insulin Aspart 100u/ml sliding scale per facility requirements. Corrected on site. Patient #8: The facility MAR included Multi-vitamins, Acetaminophen, Cyclobenzaprine, Ibuprofen, Loperamide and Salonpas. There was not evidence of an order in the hospice record. Corrected on site. Patient #11: Miralax was in the patient home. There was not evidence of an order in the hospice record. Corrected on site. In addition, nursing documentation indicated that the patient wears oxygen 4-4.5L/min via nasal cannula. There was not evidence of an order. Corrected on site. Patient #13:The record indicated that the patient had oxygen intermittent at 2L/min via nasal cannula. There was not evidence of an order. Corrected on site. Patient #14: The record indicated Polyethylene Glycol 17 GM, 1 packet, mix with 30 ml water. Corrected on site.”

“Upon patient record review, 2 of 19 records (Patient #10,#14) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #10: The Plan of care did not list any DME. Upon observed home visit, the patient stated that the hospice got him a medical bed upon admission. Corrected on site. Patient#14: DME and supplies were listed as none on the initial plan of care. The record indicated that the patient had a trach, G-tube, Supra-pubic tube, oxygen continuously, Feedings and a wheelchair. Corrected on site.”

“Upon client record review, 6 of 19 records (Patient #6,#7,#9,#11,#12,#13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: The spiritual care counselor visit frequency was 2 every 2m2, 2m2. The record indicated that the spiritual care counselor conducted visits on 7/24/24, 8/5/24, 8/23/24, and 9/11/24. Patient #7: The visit frequency for the social worker was 1 every 2m2, 1m1. The record indicated that visits were conducted on 7/12/24 and 8/27/24. Patient #9: The visit frequency for the social worker and the spiritual care counselor was 1 every 2m2, 1m1. The record indicated that the spiritual care counselor conducted visits on 6/5/24, 7/2/24, and 8/1/24. The social worker conducted visits on 6/7/24, 7/5/24, and 8/1/24. Patient #11: The visit frequency for the skilled nurse was 2w1, 3w1, 2w11. Visits were conducted on 7/12/24 for week 1 and 7/14/24, and 7/17/24 for week 2. In addition, the visit frequency for the social worker was 1 every 2m2, 1m2. visits were conducted on 7/17/24 and 8/15/24. Patient #12: The skilled nurse visit frequency was 2w1, 1w12. The record indicated only 1 visit during week 1. In addition, The social worker visit frequency was 1 every 3m3, 1m1. Visits were conducted on 6/26/24, 7/23/24, and 8/23/24. Also, the spiritual care counselor visit frequency was 2 every 2m2, 2m2. Visits were conducted on 6/24/24, 7/8/24, 7/26/24, 8/9/24 and 8/22/24. Patient #13: The visit frequency for the social worker and the spiritual care counselor was 1 every 2m2, 1m1. The spiritual care counselor conducted visits on 7/8/24, 8/7/24, and 9/16/24. The social worker conducted visits on 7/5/24 and 8/7/24.”

“Upon observation there was no evidence the hospice physicians providing care, receive oversight while working under the hospice medical director who is responsible for the palliation and management of the terminal illness and conditions related to the terminal illness. This is demonstrated by any of the following: 1. All physician employees and those under contract must function under the supervision of the hospice medical director. 2. All physician employees and those under contract shall meet this requirement by either providing the services directly or through coordinating patient care with the attending physician. 3. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient.”

“Upon patient record review, 2 of 19 records (Patient #5,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions including alerts and precautions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care specifically indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #5: The aide plan of care dated 7/7/24 indicated for dressing and shaving every visit, offer - if wanted. Corrected on site. Patient #13: The record indicated that the patient was on Plavix 75mg daily. There was not evidence of bleeding precautions on the aide plan of care. Corrected on site.”

“Upon patient client record review, 2 of 19 records (Patient #9,#14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #9: The benefit election statement (dated 6/3/24) indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished. Patient #14: The benefit election statement (dated 6/28/24) indicated that the patient/caregiver wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. There was not evidence that this document was furnished.”

“Upon client record review, 2 of 19 records (Patient #5,#14) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #5: The skilled nurse frequency for the benefit period beginning 7/17/24 was 1 every 2w2, 1w7. The record indicated that visits were conducted on 7/22/24, 7/9/24 and 8/5/24. Patient #14:The skilled nurse visit frequency was 2w13. The record indicated only 1 visit for week 1 (on 6/28/24). In addition, the social work visit frequency was for an evaluation then 1 every 2m2, 1m1. The evaluation was conducted on 7/2/24 with subsequent visits on 8/1/24 and 9/3/24.”

“Upon client record review, 1 of 19 records (Patient #3) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #3: The record indicated wound care orders to an abrasion on the patient’s left forearm, cleanse with wound cleanser, pat dry, skin prep to peri wound, apply xeroform cut to size to wound bed,cover with border foam. change daily. Wound care to be performed by hospice nurse or facility nurse. There was not evidence specifically which provider was to perform the wound care.”

“Based on observation and interview, the agency failed to complete hand hygiene upon entering the patient’s home and handling the patient’s personal items, and failed to ensure the patient was protected from potentially contaminated items for 2 of 4 patients observed during home visits. (Patients #8, 15) Findings include: 1. A review of the agency’s “Home Care Infection Prevention and Control Program 2023 “ indicated “ ... Perform hand hygiene ... A. Immediately before having direct contact with a patient ... I. Immediately after removing gloves.” 2. On 03/08/24 at 10:20 AM, Registered Nurse, RN 4 was observed entering the home of Patient #4, where she picked up the patient’s binder from a dresser and reviewed the contents. After greeting the patient, RN 4 completed hand hygiene, donned gloves, assessed the patient, discarded the gloves, and exited the room. RN 4 failed to complete hand hygiene upon entering the patient’s home and handing personal items, and after removing her gloves. When asked about hand hygiene, RN 4 indicated she should have performed hand hygiene upon entry and after removing her gloves, 3. On 03/12/24 at 11:05 AM, Home Health Aide, HHA 1 was observed providing bathing and personal care to Patient #15. During the application of lotion and Vaseline to the patient’s skin, HHA 1 placed the lotion bottle and the Vaseline tube on the floor. HHA 1 completed hand hygiene, donned gloves, and retrieved the lotion bottle from the floor. The aide rested the base of the lotion bottle, which was just previously in contact with the facility floor, on her leg, and dispensed some lotion into her hand. After placing the bottle back on the floor, HHA 1 obtained the Vaseline tube, which was resting in an inverted position with its cap touching the floor, opened the contaminated cap with her gloved hand, dispensed Vaseline onto the palm of the same hand, then closed the tube and returned it to the floor. HHA 1 repeated the process several times as she applied lotion and Vaseline to the patients limbs and trunk. When asked about infection control, HHA 1 was unable to identify any concerns until the bottles on the floor were pointed out, at which point she indicated the bottles should not be placed on the floor.”