Heart to Heart Hospice of Central Indiana LLC

“It is required that each patient’s individualized written plan of care: 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, document review, and interview. Agency policy #TX.06 stated in part, “The plan of care includes, but it not limited to: Interventions to manage pain and symptoms and identified issues/problems. In 5 of 19 (26%) clinical records reviewed, the agency did not ensure that all problems identified in the initial and updated comprehensive assessment were documented with interventions for care. Clinical Record 1: The patient elected hospice care on 02/16/2024 with a diagnosis of congestive heart failure (CHF). The updated comprehensive assessment on 04/23/2024 documented that the patient was “quite restless and becoming agitated and combative” and Lorazepam was started. The plan of care was not updated to include interventions for the patient’s identified problems with restlessness, agitation, and combativeness as of the patient’s revocation for aggressive care on 05/02/2024. During an interview, the Regional Director stated that this update was not documented. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses of cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The updated comprehensive assessment dated 01/18/2024 documented an emergent nursing visit made for a fall and a skin tear on the right wrist requiring a gauze dressing. On 01/23/2024, a skin tear was identified on the left wrist, requiring a dressing. The plan of care was not updated to include documentation of interventions for skin integrity problems. Clinical Record 10: The patient elected hospice care on 03/10/2024 with a diagnosis of breast cancer. The updated comprehensive assessments dated 03/26/2024 and 05/07/2024 documented the patient’s symptoms of a UTI (urinary tract infection) treated with antibiotics. The updated comprehensive assessment dated 05/21/2024 documented a repeat UTI and the decision to treat prophylactically. The plan of care was not updated with interventions to address the identified problems with multiple UTIs. Additionally, the updated assessment dated 03/18/2024 documented the patient’s problem with anxiety, and the updated assessment dated 05/07/2024 documented the patient’s increased confusion. The plan of care was not updated to include interventions to address the patient’s anxiety and increased confusion as of this review on 08/01/2024. Clinical Record 11: The patient elected hospice care on 05/22/2024 with a diagnosis of CHF. The patient resided in a SNF. The updated comprehensive assessment dated 01/17/2024 documented the patient’s need for oxygen related to dyspnea. The plan of care for the patient’s cardiopulmonary problem identified interventions related to edema and fluid retention relief but did not address the patient’s increased dyspnea and need for oxygen. The plan of care did not include documentation of an intervention to address the patient’s identified problems with dyspnea. During an interview, the Executive Director and Regional Manager confirmed that the plans of care were not updated to include all interventions for care.”

“It is required that each patient’s individualized written plan of care: 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 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the plan of care included drugs and treatments necessary to meet the needs of the patient. Clinical Record 12: The patient elected hospice care on 05/06/2024 with the diagnosis of chronic obstructive pulmonary disease (COPD). The patient had a right nephrostomy tube. The nursing assessments dated 05/07/2024 documented the nephrostomy tube was dressed using a drain sponge. The nursing assessment dated 05/31/2023 documented that the nephrostomy dressings at times were a T-Drain sponge, non-adherent pad, and transparent film. The nursing visit note dated 06/11/2024 documented that the nephrostomy tube was dressed with a border foam dressing. The initial plan of care dated 05/06/2024 and updated every two weeks included documentation of a problem for drains with an intervention to change the dressings weekly and pro re nata/as needed (prn). The plan of care did not include specific orders for the nephrostomy tube dressing. During an interview, the Regional Director stated that there was no documented physician orders in the record.”

“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 5 of 17 (29%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the Registered Nurse (RN) prepared a HA care plan that contained clear and specific instructions to meet the patient’s needs. Clinical Record 2: The patient elected hospice care on 02/01/2024 with a diagnosis of congestive heart failure (CHF). Oxygen for the patient was started on 02/15/2024. The HA care plan dated 02/01/2024 and updated on 02/19/2024 did not document oxygen precautions. Clinical Record 4: The patient elected hospice care on 03/18/2024 with a diagnosis of esophageal cancer. The patient resided in a skilled nursing facility (SNF). The initial and updated comprehensive assessments documented the patient’s need for continuous oxygen until the patient’s death on 04/04/2024. The HA care plan dated 03/18/2024 and updated on 03/28/2024. The HA care plan did not document oxygen precautions. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses: cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The updated comprehensive assessment dated 01/18/2024 documented falls and a skin tear on the right wrist requiring a gauze dressing. On 01/23/2024, a skin tear was identified on the left wrist, requiring a dressing. The HA care plan dated 01/22/2024 and updated through 03/22/2024 assigned the HA the relevant task: showering two times a week. The HA care plans did not provide the HA with instructions of what to do with the kerlix dressings on the right and left wrists during the showers. The skin tear resolution date was unclear but continued to be documented on the nursing visit notes through 02/22/2024. Clinical Record 11: The patient elected hospice care on 05/22/2024 with a diagnosis of CHF. The patient resided in a SNF. The nursing assessment dated 07/17/2024 documented that the patient had increased dyspnea and was using oxygen at 2 liters. Oxygen at 2 liters was added to the medication profile as a prn (as needed) medication. The HA care plan last updated on 07/17/2024 assigned the HA the relevant task: shower every visit. The HA care plan did not document oxygen precautions and instructions for the patient’s use of oxygen during personal care and the shower. Clinical Record 12: The patient elected hospice care on 05/06/2024 with the diagnosis of chronic obstructive pulmonary disease. The patient had a right nephrostomy tube. The HA care plan dated 05/06/2024, assigned the HA the relevant task: shower every visit. There were no documented updates to the HA care plan. The HA care plan did not document the presence of the nephrostomy tube ( and dressing, instructions for the HA regarding the care of the nephrostomy tube, and what to do if the dressing was saturated or fell off during the shower. There was no identification of the nephrostomy tube on the aide plan of care as of review 08/01/2024. During an interview, the Executive Director and the Regional Director confirmed that the aide care plans did not include the required details.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; This standard was not met as evidenced by clinical record review and interview. In 2 of 17 (12%) clinical records reviewed of patients that received Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care. Clinical Record 6: The patient elected hospice care on 12/08/2022 with a diagnosis of senile dementia. The HA care plan dated 12/08/2022 and updated HA care plans through 08/11/2023, assigned the HA the relevant task: weekly weights. The HA documented the patient’s weights on 01/09/2023 and 01/23/2023, with 12 days outstanding; 06/05/2023 and 06/26/2023, with 21 days outstanding; and 07/10/2023 and 08/11/2023, with 32 days outstanding. A review of the clinical record revealed no documented reasons for the weights not obtained weekly. Clinical Record 8: The patient elected hospice care on 01/27/2024 with the diagnoses: cerebral vascular accident (CVA) and dementia. The patient resided in a SNF. The HA care plan dated 01/22/2024 and updated through 03/22/2024, assigned the HA the relevant task: showering 2 times a week. For the week of 02/26/2024, a shower was provided all five (5) days. A review of the clinical record revealed no documented reason the patient was showered five (5) times that week. During the interview with the executive director and regional director stated that the aide did not provide care included in the care plan.”

“It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I; and The patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. Agency policy #PE.4 stated in part, “Documentation that the patient’s attending physician or practitioner was notified of the date of discharge...The Hospice will forward copies of the following to the patient’s attending physician upon discharge from the hospice services: The hospice discharge summary, which includes but is not limited to... A summary of the patient care. the patient’s current plan of care, including the current medication profile, the last physician orders, and any other documentation requested or that may assist with the patient’s post-discharge continuity of care.” In 1 of 1 (100%) clinical record review of a patient that was discharged to a hospital, the agency did not ensure that a discharge summary was sent to the hospital. Clinical Record 1: The patient elected hospice care on 02/16/2024 with a diagnosis of congestive heart failure (CHF). The patient was transferred to the hospital to seek aggressive treatment and revoked the hospice benefit on 05/01/2024. The discharge summary was documented. There was no evidence that the discharge summary was sent to the hospital. During an interview, the Regional Director stated that there was no documentation that any part of the clinical record was sent to the hospital. The hospice Medical Director had agreed to follow this patient at his practice after the patient was discharged from the hospital.”