Heart to Heart Hospice of Indianapolis 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 following: 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 observation, clinical record review, and interview. In 3 of 4 (75%) home visits observed, the agency did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current medications. Home Visit 1/Clinical Record 1: The patient elected the hospice benefit on 12/16/2024 with a diagnosis of chronic systolic heart failure. The patient resided in an assisted living facility (ALF). During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the ALF medication profile (printed on 09/23/2025). The following medications were documented on the ALF medication profile and not on the hospice medication profile: ferrous sulfate 325 mg, one (1) tablet daily (ordered 03/20/2025). The last comprehensive nursing visit was dated 09/18/2025. Home Visit 2/Clinical Record 2: The patient elected the hospice benefit on 11/21/2023 with a diagnosis of Alzheimer’s disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the SNF medication profile (printed on 09/23/2025). The following medications were documented on the SNF medication profile and not on the hospice medication profile: artificial tears, one (1) drop in the left eye four times daily (ordered 08/15/2025); and bisacodyl 10 mg suppository, one (1) every 24 hours as needed (ordered 11/22/2024). The last comprehensive nursing visit was dated 09/20/2025. Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 08/09/2025 for a diagnosis of intrahepatic bile duct carcinoma. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 09/23/2025, the hospice medication profile (printed on 09/22/2025) was compared to the SNF medication profile (printed on 09/23/2025). The following medications were listed on the SNF medication profile and not on the hospice medication profile: nitroglycerin, one (1) tablet every 5 minutes as needed for chest pain (ordered 09/13/2025); oxycodone 10 mg, one (1) tablet every 4 hours as needed (ordered 08/09/2025); polyethylene glycol, 17 grams by mouth as needed (ordered 08/09/2025); and Senna S 8.6-50 mg, two (2) tablets twice daily (ordered 08/12/2025). The last comprehensive nursing visit was dated 09/16/2025. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings, stating, “The nurses should be doing medication reconciliations with every visit.””

“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 observation. clinical record review, and interview. In 1 of 4 (25%) home visits observed, the agency did not ensure that the patient’s written plan of care included the necessary drugs and treatments to meet the patient’s needs. Home Visit 3/Clinical Record 3: The patient elected the hospice benefit on 08/09/2025 for a diagnosis of intrahepatic bile duct carcinoma. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 09/23/2025, the following medications were listed on the SNF medication profile and not on the patient’s plan of care: nitroglycerin, one (1) tablet every 5 minutes as needed for chest pain (ordered 09/13/2025); oxycodone 10 mg, one (1) tablet every 4 hours as needed (ordered 08/09/2025); polyethylene glycol, 17 grams by mouth as needed (ordered 08/09/2025), and Senna S 8.6-50 mg, two (2) tablets twice daily (ordered 08/12/2025). The last comprehensive nursing visit was dated 09/16/2025. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings, stating, “These medications were not included in the hospice list.””

“It is required that 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 16 (19%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions to meet the patient’s needs. CLINICAL RECORD 1: The patient elected the hospice benefit on 12/16/2024 with a diagnosis of chronic systolic heart failure. The patient resided in an assisted living facility (ALF). The HA care plan dated 07/30/2025 assigned the HA the relevant tasks: “Bathing-shower, foot care, hair care, nail care-clean and filing, perineal care, shampoo (weekly) skin care, skin care-lotion, transfer client from bed/chair, transfer client from chair to bed, offer fluids, wheelchair bound, RN notified of changes, diabetic precautions, fall precautions, standard precautions.” All tasks were to be completed on every visit, except shampoo. The HA services were ordered twice weekly. The skilled nursing (SN) visit note dated 08/24/2025 documented a “new wound to right leg.” The physician’s order dated 09/09/2025 ordered: “Mid back wound. Cleanse with wound cleanser twice weekly, pat dry, and place a 4 x 4 foam dressing. Measure weekly.” The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the shower. CLINICAL RECORD 5: The patient elected hospice care on 03/24/2025 with a diagnosis of sarcopenia. The patient resided in an ALF. The HA care plan revision dated 08/08/2025 assigned the HA the relevant tasks: “Bathing-bed bath, dressing-apply compression stockings, glasses, hair care, nail care-clean, oral care-brush, perineal care, skin care-lotion, review patient diet, two person transfer, wheelchair bound, companionship (three times a week), narrative, RN notified of changes, bleeding, fall precautions, take patient’s weight (monthly).” A revision on 08/11/2025 included “assist with feeding.” All tasks were to be completed on every visit unless otherwise specified. HA services were ordered seven (7) times weekly. The physician’s order dated 08/11/2025 ordered: “Wound care to BLE (bilateral lower extremity). Clean the wound with wound cleanser or normal saline (NS). Pat dry, cover open areas with non-adherent dressing, wrap with kerlix, secure with tape, and apply Tubigrip.” The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the bed bath. CLINICAL RECORD 6: The patient elected hospice care on 04/20/2024 with a diagnosis of end-stage heart failure. The patient resided in a skilled nursing facility (SNF). The HA care plan revision dated 08/04/2025 assigned the HA the relevant tasks: “Bathing-bed bath, shampoo, hair care, skin care-deodorant, lotion, perineal care, oral care, nail care-clean, dressing, hearing aides, change linens, tidy patient area.” All tasks were to be completed on every visit. HA services were ordered twice weekly. The physician’s order dated 08/29/2025 ordered: “Right calf skin tear. Apply Xero foam and wrap with kerlix.” The HA care plan did not notify the HA of the wound, nor did it provide specific instructions to notify the RN if the wound dressing became soiled, dislodged, or wet during the bed bath. During a joint clinical record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the findings. He agreed that the HA care plans should provide “specific instructions for the wound dressings.””

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.60 “Employee Supervision” (revised 12/06/2024) stated in relevant part: “A RN must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care.” In 1 of 1 (100%) personnel records reviewed for a Hospice Aide (HA), the agency did not ensure that a Registered Nurse (RN) made an annual on-site visit to the location where a patient was receiving care, to observe and assess each HA while they were performing care. Personnel Record 7: The Hospice Aide was hired on 03/30/2017. A personnel record review revealed that no documented annual on-site supervisory visit was conducted in 2024. During a joint personnel record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the finding and stated that the “previous Administrator/Executive Director had not documented the completion of many items in 2024.””

“It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by document review, interview, and personnel record review. Agency policy #HR.10 “Staff Competency” (revised 11/15/2024) stated in relevant part: “The Hospice will provide for competency assessments by qualified individuals on hire and annually to assess direct care staff’s basic skill levels for all staff providing care, including volunteers (if applicable), contracted staff, paraprofessionals, and professionals.” In 3 of 9 (33%) personnel records reviewed of individuals providing care, the agency did not ensure that the skills and competencies of all individuals providing care, including volunteers, were assessed. Personnel Record 3: The Registered Nurse was hired on 08/12/2024. A personnel record review revealed that no initial skills competencies were documented at the time of hire. Personnel Record 5: The Social Worker was hired on 05/26/2021. A personnel record review revealed that no annual skills competency was completed in 2024. Personnel Record 8: The Social Worker/Bereavement Coordinator was hired on 05/31/2008. It was confirmed with the Administrator that this employee “sometimes functions as a social worker.” A personnel record review revealed that no annual skills competency was completed in 2024. During a joint personnel record review and interview on 09/24/2025, the Administrator/Executive Director confirmed the finding, stating that the “previous Administrator/Executive Director had not documented the completion of many items in 2024.””