Unity Hospice of Northwest Indiana LLC

“Based on observation, record review, and interview, the hospice failed to ensure coordination of care between Entity A’s, a skilled nursing facility, and Entity D’s, a skilled nursing facility, non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions in 1 of 1 clinical record reviewed with an observation visit completed at Entity A (Patient #3), and in 1 of 3 Entity D’s patients’ clinical record reviewed without an observation visit completed (Patient #5).Findings include: 1.An updated policy, dated January 2014, titled, “Facility Residents,” indicated the hospice care team would implement the plan of care to communicate with other healthcare providers participating in the provision of care for the terminal illness and related conditions to ensure quality of care for the patient. The policy indicated a coordinated plan of care would identify the care and services that the hospice and the facility would provide to meet the needs of the patient and would be updated to meet the ongoing needs of the patient. The policy indicated the facility, and the hospice would be aware of responsibilities of each. 2. An updated policy, dated January 2014, titled, “Hospice Interdisciplinary Group,” indicated the interdisciplinary group would maintain a system of communication to ensure that the patient care and services were provided according to the plan and care and based on assessments and family needs. The policy indicated the interdisciplinary group would maintain responsibility for directing, coordinating, and supervising the care and services provided. The policy indicated the interdisciplinary group would ensure for the ongoing sharing of information between all disciplines providing care in all settings, including sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. 3. An updated policy, dated January 2014, titled, “Initial Hospice Assessment,” indicated during the initial assessment would include a physical assessment, and medications including prescription and over the counter medications. 4. An updated policy, dated January 2014, titled, “Medications,” indicated the hospice nurse was responsible for monitoring the usage of medication by the patient or caregiver to ensure appropriate administration schedule, a medication profile would be maintained for each patient, and periodic review and monitoring for appropriate medications and their use would be documented. 5. An updated policy, dated January 2014, titled, “Ongoing Assessment,” indicated during each home visit the hospice would reevaluate the patient according to the problems identified during the initial visit that would include the nurse would assess each patient on each visit to include but not limited to pain, and alteration of skin integrity and wounds would be viewed and documented every visit. The policy indicated clinicians would focus on patient’s response to care during reassessments, and verbal orders would be generated based upon the findings of the reassessment, and the physician would be notified to verify any changes in medications, treatment or interventions. 6. During an observation visit of Patient #3, at Entity A, a skilled nursing facility, beginning at 9:00 AM, RN 1 spoke to Person B, nurse at Entity A and indicated she was there to see the patient. Patient #3 was observed in bed with eyes open, relaxed facial expression and would continually verbalize “yay” in an elevated voice. RN 1 rolled patient to right side to perform wound care to sacrum and the patient verbalized in an elevated voice, “God dang you,” and face appeared grimaced. During the observation of the wound dressing change to the sacrum that included removal of a foam adhesive bandage, cleansed with saline, application of calcium alginate (a moisture absorbing substance that transforms to gel) and a foam adhesive dressing was applied patient stated, “God damn back”, eyes were squinted, and brows were lowered. The patient stated, “ow,” when RN 1 rolled patient from right side to back and patient had no verbalization after movement. During an interview, on 05/21/2026, at 11:15 AM, after Patient #3’s wound care was completed, RN 1 indicated the patient was in discomfort when he/she was rolled and when the sacral dressing was applied. RN 1 indicated she noted the patient’s discomfort with different pitches the patient was verbalizing. RN 1 indicated she had left a message with the facility to administer Morphine (narcotic pain medication) prior to her arrival to the facility to provide wound care. During an interview, on 05/21/2026, beginning at 11:20 AM, Person B indicated he/she had not administered Morphine to the patient prior to the wound care, the last dose of Morphine the patient received was the day prior, on 05/20/2026, and requested RN 1 provide a Morphine refill. During an interview, on 05/21/2026, beginning at 11:20 AM, RN 1 indicated she did not verify with Entity A’s staff that the patient received Morphine prior to providing wound care. A RN 1 Nursing Visit Note, dated 05/21/2026, indicated RN 1 spoke with Person B pre-visit and Person B expressed no patient concerns at that time. The Visit Note indicated Patient #3 had a pain level of 3 (on a 0 to 10 scale with 0 being no pain and 10 being worst pain), failed to indicate a PAIN AD (pain assessment in advanced dementia) scale was utilized, pain location was the sacrum with wound care and positioning, and Morphine relieved pain. The Visit Note indicated wound care to an unstageable 16 centimeter by 10.2 centimeter by 0.3 centimeter in depth sacral wound was performed per order by cleaning with wound cleaner, pat dry, apply calcium alginate with silver, cover with bordered gauze daily, and response to wound care was patient tolerated well. The Visit Note indicated RN 1 spoke with Person B at the end of the patient’s visit and during medication review the patient was noted to be out of Morphine. A Hospice, Long Term Care Coordinated Task Plan of Care, located in Entity A’s hospice binder, dated 04/17/2026, was blank under hospice wound care schedule section. A Plan of Care Safety Precautions Form, dated 04/17/2026, indicated under section Opioid Precautions, make sure patient had been given or taken pain medication before care if moving triggered pain. An Interdisciplinary Group Update, dated 05/13/2026, indicated the patient had a primary diagnosis of senile degeneration of the brain (cognitive decline), the comfort kit medications included but not limited to Morphine concentrate solution 5 milligrams by mouth every 2 hours as needed for pain or shortness of breath, the patient had intermittent pain and discomfort, and Morphine was utilized for pain. An Initial Comprehensive Assessment, dated 04/17/2026, for Patient #3’s start of care date of 04/17/2026, indicated the patient had a foley catheter (tube into the bladder to drain urine). A Hospice Treatment Order, dated 04/17/2026, indicated the RN case manager was to change foley catheter every 30 days. A Nursing Visit Note Update To The Comprehensive Assessment, dated 05/11/2026, indicated the patient’s last foley catheter change was 04/17/2026. A Nursing Visit Note Update To The Comprehensive Assessment, dated 05/18/2026, indicated the patient’s last foley catheter change was 04/09/2026 with modification noted. During an interview, on 05/21/2026, beginning at 11:00 AM, RN 1 indicated she asked an Entity A’s staff member on 05/18/2026 when the patient’s foley catheter was last changed and was told it was on 05/09/2026 and modified the 05/18/2026 note to indicate the last foley catheter change by Entity A’s staff. An Entity A’s Order Summary Report indicated foley catheter was to be changed as needed for dislodgement, leaking or blockage as needed with a start date of 03/24/2026. During an interview, on 05/21/2026, beginning at 11:30 AM, Person C, the Director of Nursing at Entity A indicated there was no documentation the foley catheter was changed by Entity A’s facility staff, the facility staff would document when a foley catheter was changed, and the facility staff would change the foley catheter for leaking or dislodgement and would not change on a regular schedule. A Hospice Long Term Care Coordinated Task Plan of Care, dated 04/17/2026, located in Entity A’s hospice binder, indicated the foley catheter was to be changed every 30 days and was blank under the section for party responsible for foley catheter treatment. During an interview, on 05/21/2026, beginning at 11:15 AM, RN 1 indicated the Hospice Long Term Care Coordinated Task Plan of Care did not and should have included who was responsible for the foley catheter change and care. An Entity A Order Summary Report indicated Patient #3’s active medications included but not limited to Levaquin (antibiotic) 750 milligrams one tablet daily for wound infection with a start date of 05/01/2026, and Olanzapine (antipsychotic medication) 5 milligrams 2 tablets every night with a start date of 03/23/2026. An Interdisciplinary Group Update, dated 05/13/2026, indicated a start of care date of 04/17/2026, and medication list failed to include Levaquin, and Olanzapine dose indicated 5 milligrams one tablet every night with a start date of 04/17/2026. A RN 1 Nursing Visit Note Update To The Comprehensive Assessment, dated 05/18/2026, indicated all medications were reviewed and reconciled with the facility staff and no issues nor changes to medications were noted. A Hospice Service Agreement with Entity A, dated 08/31/2021, indicated the hospice would provide services at the same level and to the same extend as those services would be provided if the resident hospice patient were in their own home. The Agreement indicated the interdisciplinary group responsibilities would include periodically reviewing and updating the plan of care for each resident hospice patient in coordination with the nursing facility. During an interview, on 05/21/2026, beginning at 11:15 AM, RN 1 indicated she reconciled all patient’s medications at the comprehensive assessment visit on 05/18/2026, medications are to be reconciled every comprehensive assessment, and she would request a copy of the skilled nursing facilities medication list to review. RN 1 indicated the patient was prescribed Levaquin by a non-hospice facility physician for a urinary tract infection. 7. A Nurse Progress Note, dated 05/15/2026, indicated Patient #5 was transferred to Entity D, a skilled nursing facility. The Nurse Note indicated the patient had a right skin tear to the right hip measured at 3 centimeters by 3 centimeters. An Initial Comprehensive Assessment, dated 05/16/2026, indicated the patient was bedbound and dependent for repositioning, and skin was intact. A Nursing Visit Note, dated 05/17/2026, indicated the patient’s skin was clean, dry, and intact. A Nursing Visit Note, dated 05/18/2026, indicated the facility did wound care prior to the visit. A LPN 1 Nursing Visit Note Update To The Comprehensive Assessment, dated 05/22/2026, indicated the patient’s skin temperature was warm, skin turgor was fair, and failed to evidence documentation of the right hip skin tear. An Entity D’s Order Summary Report, dated 05/19/2026, indicated the patient’s left hip was to be cleansed with wound wash, pat dry, apply Thera Honey (wound dressing) Gel, and cover with a dry dressing every day shift and as needed, and was initiated on 05/18/2026. Hospice Admission Orders, dated 05/15/2026, failed to evidence the patient’s right hip skin tear wound care orders. A Hospice Service Agreement with Entity D, dated 03/29/2024, indicated the hospice would provide services at the same level and to the same extend as those services would be provided if the resident hospice patient were in their own home. The Agreement indicated the interdisciplinary group responsibilities would include periodically reviewing and updating the plan of care for each resident hospice patient in coordination with the nursing facility. During an interview, on 05/26/2026, beginning at 3:45 PM, the Clinical Manager indicated there was no documentation of the patient’s right hip wound assessment in the clinical record. The Clinical Manager indicated a wound assessment would have been documented on the 05/16/2026 initial comprehensive assessment. During an interview, on 05/27/2026, beginning at 12:20 PM, the Clinical Manager indicated LPN 1 relayed that the patient did have a wound, the skilled nursing facility was providing wound care and LPN 1 did not document an assessment of the wound nor write an order for wound care.”

“Based on record review and interview, the hospice failed to ensure 1 of 2 skilled nursing facility patients’ clinical records reviewed with an observation visit completed had a urinary tract infection tracked for quality improvement (Patient #4).Findings include: An updated policy, dated January 2014, titled, “Infection Control,” indicated the nursing supervisor was responsible for implementing and monitoring the infection control program and would oversee the reporting to the quality assessment and performance improvement committee infection control related incidents. An updated policy, dated January 2014, titled, “Incident Reporting,” indicated an incident report would be completed for infection of any wound or organ that was not present on admission to care. A Nurse Progress Note, dated 03/20/2026, indicated Patient #4, start of care of 11/11/2025, had a possible urinary tract infection (infection in part of the urinary system to include kidneys, ureters, bladder and urethra) due to the patient had a fever and increased confusion and agitation. The Note indicated Bactrim (antibiotic) was ordered for 7 days. The Infection Log for March 2026 failed to evidence Patient #4’s urinary tract infection.During an interview, on 05/21/2026, beginning at 1:30 PM, the Clinical Manager indicated the patient’s urinary tract infection was not identified on the infection log for quality assessment, and indicated a patient was to have an infection report completed and added to the hospice’s infection log when an antibiotic was initiated.”

“Based on record review and interview, the hospice’s performance improvement activities failed to evidence focus on high risk, high volume, nor problem prone areas related to patient’s falls and urinary tract infections (infection in part of the urinary system to include kidneys, ureters, bladder and urethra) in 1 of 1 agency. Findings include: 1. An updated policy, dated January 2014, titled, “Quality Assessment Performance Improvement [QAPI]”, indicated the hospice would measure, analyze causes, track quality indicators, including areas such as adverse patient events and aspects of performance that assess processes of care, and implement preventive actions. The policy indicated the hospice would focus on high risk, high volume, and problem prone areas to identify the severity of a problem, give priority to improvement activities that affect palliative, patient safety, and quality of care outcomes. The policy indicated when problems were identified in the provision of hospice services, the hospice would document evidence of corrective actions taken, including ongoing monitoring of effectiveness, revisions of policies and procedures, educational intervention, changes in the provision of services, and the effectiveness of actions taken to improve services or correct identified problems would be evaluated. 2. Infection Control Logs and Average Daily Census Reports for January 2025 to March 2026 evidenced the following for urinary tract infections (UTIs): A. January 2025 average daily census: 87, unduplicated foley catheter (tube into the bladder to drain urine) patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 3 (3.4%), total of 6 (6.9%) patients’ UTIs. B. February 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 4 (4.7%), unduplicated non-foley catheter patients’ UTI’s: 2 (2.3%), total of 6 (7%) patients’ UTIs. C. March 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 5 (5.8%), total of 7 (8%) patients’ UTIs. D. April 2025 average daily census: 79, unduplicated foley catheter patients’ UTIs: 2 (2.5%), unduplicated non-foley catheter patients’ UTIs: 1 (1.3%), total of 3 (3.8%) patients’ UTIs. E. May 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 3 (3.5%), total of 5 (5.8%) patients’ UTIs. F. June 2025 average daily census: 88, unduplicated foley catheter patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 4 (4.5%), total of 7 (8%) patients’ UTIs. G. July 2025 average daily census: 86, unduplicated foley catheter patients’ UTIs: 1 (1.2%), unduplicated non-foley catheter patients’ UTIs: 6 (7%), total of 7 (8%) patients’ UTIs. H. August 2025 average daily census: 87, unduplicated foley catheter patients’ UTIs: 3 (3.4%), unduplicated non-foley catheter patients’ UTIs: 3 (3.4%), total of 6 (6.9%) patients’ UTIs. I. September 2025 average daily census: 87, unduplicated foley catheter patients’ UTIs: 3 (3.4%), non-foley catheter patients’ UTIs: 7 (8%), total of 10 (11.5%) patients’ UTIs. J. October 2025 average daily census: 85, unduplicated foley catheter patients’ UTI’s 2 (2.4%), unduplicated non-foley catheter patients’ UTIs: 5 (5.9%), total of 7 (8.2%) patients’ UTIs. K. November 2025 average daily census: 88, unduplicated foley catheter patients’ UTI’s 2 (2.3%), unduplicated non-foley catheter patients’ UTIs: 0, total of 2 (2.3%) patients’ UTIs. L. December 2025 average daily census: 80, unduplicated foley catheter patients’ UTI’s 3 (3.8%), unduplicated non-foley catheter patients’ UTIs: 2 (2.5%), total of 5 (6.3%) patients’ UTIs. M. January 2026 average daily census: 76, unduplicated foley catheter patients’ UTI’s 4 (5.3%), unduplicated non-foley catheter patients’ UTI’s: 1 (1.3%), total of 5 (6.6%) patients’ UTI’s. N. February 2026 average daily census: 79, unduplicated foley catheter patients’ UTI’s 1 (1.3%), unduplicated non-foley catheter patients’ UTI’s 0, total of 1 (1.3%) patients’ UTI’s. O. March 2026 average daily census: 94, unduplicated foley catheter patients’ UTI’s 3 (3.2%), unduplicated non-foley catheter patients’ UTI’s 4 (4.3%), total of 7 (7.4%) patients’ UTI’s. During an interview, on 05/21/2026, beginning at 2:00 PM, the Clinical Manager indicated the hospice did not implement interventions nor preventative actions for quality improvement related to UTI’s. The Clinical Manager indicated a patient was to have an infection report completed for the infection log when an antibiotic was initiated. 3. Occurrence Logs and Average Daily Census Reports for January 2025 to March 2025 evidenced the following related to patients’ falls: A. January 2025 average daily census: 87, 2 (2.3%) patients’ falls B. February 2025 average daily census: 86, 8 (9.3%) patients’ falls C. March 2025 average daily census: 86, 15 (17.4%) patients’ falls D. April 2025 average daily census: 79, 10 (12.7%) patients’ falls E. May 2025 average daily census: 86, 13 (15.1%) patients’ falls F. June 2025 average daily census: 88, 2 (2.3%) patients’ falls G. July 2025 average daily census: 86, 13 (15.1%) patients’ falls H. August 2025 average daily census: 87, 12 (13.8%) patients’ falls I. September 2025 average daily census: 87, 13 (15%) patients’ falls J. October 2025 average daily census: 85, 3 (3.5%) patients’ falls K. November 2025 average daily census: 88, 7 (8%) patients’ falls L. December 2025 average daily census: 80, 6 (7.5%) patients’ falls M. January 2026 average daily census: 76, 6 (7.9%) patients’ falls N. February 2026 average daily census: 79, 2 (2.5%) patients’ falls O. March 2026 average daily census: 94, 8 (8.5%) patients’ falls During an interview, on 05/21/2026, beginning at 1:00 PM, the Clinical Manager indicated patients’ falls were not identified by the hospice’s quality assessment and performance improvement program as a concern and the hospice’s quality assessment and performance improvement program had not implemented interventions nor preventative actions for patients’ falls.”