Every finding on record at Care Initiatives, Inc

Based on hospice staff interview and clinical record review, the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient's clinical record, any advance directives executed by the patient for 1 of 19 sampled patients (Patient #2).   Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out.   Findings include: --- According to the hospice policy titled Advance Directives, dated 3/11/26, during the admission interview, and prior to receiving care, the hospice nurse or social worker provides the patient with written information and instruction on advance directives. If the patient is unable to understand the information, it is given to the patient's legal healthcare representative or proxy. The written information includes hospice policy on the implementation of advanced directives, including any limitations; and a description of the patient's rights under state law, including the right to formulate an advanced directive and the right to accept or refuse medical or surgical treatment, including Do-Not-Resuscitate (DNR) orders. During an interview on 5/26/26 at 4:05 PM, the Clinical Manager stated the patient's decision for do not resusitate status usually occured the day after the hospice admission. Patient #2 had a hospice admission date of 9/11/25, and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The Plans of Care (POC), dated 9/11/25 to 12/9/25, 12/10/25 to 3/9/26, 3/10/26 to 5/8/26 and 5/9/26 to 7/7/26, identified the patient's advance directive information as "no" for do not resuscitate order (full code).   b. The Out of Hospital Do Not Resuscitate Order, dated 9/12/25, signed by the patient's physician revealed a DNR order. The hospice agency failed to include accurate advance directive information on the patient's plan of care.   The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.

Based on clinical record reviews and hospice policy review, the hospice failed to perform an initial bereavement assessment within 5 days of the patient's election of the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care for 3 of 19 sampled hospice patients (Patients #10, #11 and #18).     Failure to complete an initial bereavement assessment increased the risk that patient's or family's/caregiver's bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors.    Findings include: --- 2.  Patient #11 had a hospice admission date of 2/14/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 2/14/26 to 4/14/26, identified the patient had a primary diagnosis of pantocytopenia (blood disorder) and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. Skilled nurse initial comprehensive assessment, dated 2/14/26, completed by Staff N, RN, lacked an initial bereavement risk assessment. c. Chaplain initial evaluation visit note, dated 2/16/26, completed by Staff L, Chaplain, lacked an initial bereavement risk assessment. d. Social work initial evaluation visit note, dated 2/17/26, completed by Staff H, Social Worker, lacked an initial bereavement risk assessment.   The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment.    3.  Patient #18 had a hospice admission date of 9/17/25, a death date of 10/10/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 9/17/25 to 12/15/25, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. Skilled nurse initial comprehensive assessment, dated 9/17/25, completed by Staff O, RN, lacked an initial bereavement risk assessment. c. Chaplain visit note, dated 9/18/25, completed by Staff P, Chaplain, lacked an initial bereavement risk assessment. d. Social work initial evaluation visit note, dated 9/19/25, completed by Staff H, Social Worker, lacked an initial bereavement risk assessment. e. Social work visit note, dated 10/2/25, completed by Staff H, Social Worker, included an initial bereavement risk assessment, 15 days after admission, 10 days later than regulated.   The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment.    The above findings were shared with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.    According to the hospice policy titled Comprehensive Assessment, dated 7/19/23, the hospice Interdisciplinary Group (IDG) conducts and documents a patient specific comprehensive assessment no later than 5 calendar days after the patient elects the hospice benefit.  The comprehensive assessment consists of the nursing assessment, with psychosocial, spiritual and bereavement components or the components are assessed separately through the psychosocial assessment, spiritual care assessment and bereavement assessment.    1.Patient #10 had a hospice admission date of 1/5/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 1/5/25 to 4/4/25, identified the patient had a primary diagnosis of breast cancer and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. Skilled nurse initial comprehensive assessment, dated 1/5/25, completed by Staff B, Registered Nurse (RN), lacked an initial bereavement risk assessment. c. Social work visit note, dated 1/9/25, completed by Staff H, Social Worker, lacked an initial bereavement risk assessment.    The hospice failed to complete a bereavement risk assessment as part of the initial comprehensive assessment.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the patient's individualized plan of care was reviewed, revised and documented in the patient's electronic medical record (EMR) at least every 15 days for 11 of 19 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #12).  Failure of the Interdisciplinary Group (IDG) to review, update and document the individualized plan of care in the EMR at least every 15 days placed hospice staff at risk of not knowing what care and services to provide to meet the patient's assessed needs and/or placed the hospice patients at risk for not receiving appropriate care to have needs met.    Findings include: --- 7. Patient #2 had a hospice admission date of 9/11/25 and received hospice services while residing in a private residence.   Clinical record review revealed:   a. The POCs, dated 3/10/26 to 5/8/26 and 5/9/26 to 7/7/26, identified the patient had a primary diagnosis of chronic pulmonary lung disease and included orders for skilled nurse, hospice aide, chaplain, social work and volunteer services.   b. The EMR included documentation of IDG on 4/29/26.   c. IDG notes, dated 5/13/26, uploaded into the EMR 5/26/26 (13 days after the IDG occurred and 27 days after the previous IDG).  The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   8. Patient #3 had a hospice admission date of 2/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/3/26 to 7/1/26, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for skilled nurse, chaplain, hospice aide, music therapy and social work services.   b. The EMR included documentation of IDG on 4/29/26.   c. IDG notes, dated 5/13/26, uploaded into the EMR 5/26/26 (13 days after the IDG occurred and 27 days after the previous IDG).  The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.  9. Patient #6 had a hospice admission date of 4/13/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 4/13/26 to 7/11/26, identified the patient had a primary diagnosis of dysphagia and included orders for skilled nurse, hospice aide, chaplain and social work services.   b. The EMR included documentation of IDG on 4/22/26.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (20 days after the IDG occurred and 34 days after the previous IDG). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).    The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   10. Patient #9 had a hospice admission date of 9/4/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/2/26 to 6/30/26, identified the patient had a primary diagnosis of atherosclerotic heart disease and included orders for skilled nurse, chaplain, hospice aide and social work services.   b. The EMR included documentation of IDG on 4/29/26.   c. IDG notes, dated 5/13/26, uploaded into the EMR 5/26/26 (13 days after the IDG occurred and 27 days after the previous IDG).  The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   11. Patient #12 had a hospice admission date of 9/5/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 4/13/26 to 7/11/26, identified the patient had a primary diagnosis of dysphagia and included orders for skilled nurse, hospice aide, chaplain and social work services.   b. The EMR included documentation of IDG on 4/22/26.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (20 days after the IDG occurred and 34 days after the previous IDG). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).    The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.     6. Patient #7 had a hospice admission date of 4/29/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 4/29/26 to 7/27/26, identified the patient had a primary diagnosis of respiratory failure and included orders for skilled nurse, chaplain and social work services.   b. The EMR lacked documentation of an initial IDG meeting.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (27 days after the hospice admission). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).   The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.    According to the agency policy titled Interdisciplinary Care Plan Process, dated 3/11/26, the Interdisciplinary Group (IDG) collaborates to develop a comprehensive interdisciplinary care plan that identifies individualized patient and family care needs, goals (outcomes), and interventions to accomplish the goals from findings of the comprehensive assessments and drug regimen review.  Updates and revisions to the care plan are based on patient and family needs/assessments and are made as often as needed, with a minimum of every 15 day review.    According to the agency policy titled Clinical Records, dated 2/1/23, a clinical record is established and maintained for every patient receiving care and services from the agency.  The clinical record documentation is accurate, timely and complete, readily accessible and systemically organized to facilitate retrieval.  Each patient's clinical record includes, but is not limited to the following: identification data, referral information and pertinent medical history, the care plan, initial assessment, comprehensive assessment and updated comprehensive assessments, clinical notes and progress notes and physician orders.    1.Patient #1 had a hospice admission date of 8/13/24 and received hospice services while residing in a private residence.   Clinical record review revealed:   a. The Plan of Care (POC), dated 4/5/26 to 6/3/26, identified the patient had a primary diagnosis of heart failure and included orders for skilled nurse, hospice aide, chaplain and social work services.   b. The EMR included documentation of IDG on 4/22/26.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (20 days after the IDG occurred and 34 days after the previous IDG). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).    The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.    2. Patient #4 had a hospice admission date of 1/9/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/4/26 to 7/2/26, identified the patient had a primary diagnosis of traumatic bilateral subdural hematomas and included orders for skilled nurse, hospice aide, chaplain and social work services.   b. The EMR included documentation of IDG on 4/22/26.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (20 days after the IDG occurred and 34 days after the previous IDG). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).    The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.    3. Patient #5 had a hospice admission date of 3/16/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 3/16/26 to 6/13/26, identified the patient had a primary diagnosis of Alzheimer's disease and included orders for skilled nurse, chaplain and social work services.   b. The EMR included documentation of IDG on 4/22/26.   c. IDG notes, dated 5/6/26, uploaded into the EMR 5/26/26 (20 days after the IDG occurred and 34 days after the previous IDG). d. IDG notes, dated 5/20/26, uploaded into the EMR 5/26/26 (6 days after IDG occurred and 20 days after the previous IDG).    The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   4. Patient #8 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 5/3/26 to 7/1/26, identified the patient had a primary diagnosis of Parkinson's disease and included orders for skilled nurse, chaplain, hospice aide, music therapy, massage therapy and social work services.   b. The EMR included documentation of IDG on 4/29/26.   c. IDG notes, dated 5/13/26, uploaded into the EMR 5/26/26 (13 days after the IDG occurred and 27 days after the previous IDG).  The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.   5. Patient #10 had a hospice admission date of 1/5/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/30/26 to 6/28/26, identified the patient had a primary diagnosis of breast cancer and included orders for skilled nurse, chaplain, hospice aide and social work services.   b. The EMR included documentation of IDG on 4/29/26.   c. IDG notes, dated 5/13/26, uploaded into the EMR 5/26/26 (13 days after the IDG occurred and 27 days after the previous IDG).  The hospice failed to review, revise and document the patient's individualized care plan no less frequently than every 15 days.

Based on review of bereavement documentation and staff interview, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved.  The survey identified this concern with 3 of 3 sampled bereavement records (Patient #17, #18 and #19).  The hospice reported a total of 182 deaths in the past 12 months. Failure to provide bereavement counseling according to identified needs, placed the bereaved at increased risk for worsening severe grief and increased the potential for self-harm. Findings include: --- According to the hospice policy, titled Bereavement Services, dated 6/29/23, the Spiritual Coordinator or Social Worker updates in the electronic medical record (EMR) the bereaved party and develops the bereavement care plan including the kind of bereavement services required and the frequency of service delivery.  All ongoing bereavement visits or calls are documented in the EMR. During an interview, on 5/19/26 at 10:35 AM, Staff L, Bereavement Coordinator explained the bereavement documentation would be found under the communication notes section in the electronic medical record (EMR).  All bereaved receive mailings, this is documented on the spreadsheet. Staff L clarified, the bereavement plan of care is tracked in a spreadsheet and includes attempted contacts and expedited contact information.  If a bereavement plan of care is needed, this would be if initial phone call was made and a follow up phone call was needed, it would be entered under communication notes section. 1.  Patient #17 had a hospice admission date of 6/12/25, a death date of 8/29/25 and received services while residing in a private home. Clinical record review revealed no bereavement plan of care or bereavement documentation in the EMR. On 5/19/26 at 10:35 AM, during an interview, Staff L, Bereavement Coordinator, reported review of the clinical record and confirmed no bereavement plan of care or bereavement documentation in the EMR. The hospice failed to complete a bereavement plan of care. 2.  Patient #18 had a hospice admission date of 9/17/25, a death date of 10/10/25 and received services while residing in a nursing home. Clinical record review revealed no bereavement plan of care or bereavement documentation in the EMR. On 5/19/26 at 10:35 AM, during an interview, Staff L, Bereavement Coordinator, reported review of the clinical record and confirmed no bereavement plan of care or bereavement documentation in the EMR. The hospice failed to complete a bereavement plan of care. 3.  Patient #19 had a hospice admission date of 11/11/25, a death date of 12/10/25 and received services while residing in a private home. Clinical record review revealed no bereavement plan of care or bereavement documentation in the EMR. The hospice failed to complete a bereavement plan of care. The above findings were shared with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.

Based on review of written contractual agreements, the hospice failed to ensure the written agreement between the hospice and 2 of 3 sampled services under arrangement included all of the required contract components. The hospice reported a total of 7 written agreements for services under arrangement with individuals/companies at the lime of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care.Findings Include: --- 1. A hospice music therapy contract, dated 6/28/24, failed to include the following contractual language: the hospice retains administrative management, the hospice retains financial management, oversight of staff and services and all services are authorized by the hospice. 2. A physical therapy, occupation therapy, and speech language therapy services contract, dated 3/8/24, failed to include the following contractual language: the hospice retains administrative management, the hospice retains financial management, oversight of staff and services and all services are authorized by the hospice. The above findings were reviewed with the Administrator, Clinical Manager, Director of Hospice Clinical Operations, Hospice Clinical Support Coordinator, Vice President of Clinical Services.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 4 of 19 sampled patients (Patients #2, #3, #8 and #13).   Failure to ensure all documentation was completed, dated, and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: --- 4. Patient #8 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 3/4/26 to 5/2/26, identified the patient had a primary diagnosis of Parkinson's disease and included orders for music therapy services.   b. The music therapy visit notes, dated 3/18/26, 3/25/26, 4/15/26 and 4/27/26, completed by Staff G, Music Therapist, lacked a signature, staff credentials and date of authentication.    The Music Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice.   The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.      3.  Patient #18 had a hospice admission date of 9/17/25, a death date of 10/10/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 9/17/25 to 12/15/25, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for skilled nurse, social work, chaplain and hospice aide services.   b. The POC, dated 9/17/25 to 12/15/25, signed by Staff K, Business Office Manager.  The hospice failed to ensure the POC signed by appropriate member of the IDG.  According to the hospice policy titled Plan of Care, dated 5/31/23, once the comprehensive assessments are completed on or before day 5 not including the day of admission and following the interdisciplinary group (IDG) collaboration to develop the Care Plan, the Regestered Nurse Case Manager (RNCM) creates the POC clinical document in the electronic health record. The RNCM will generate/submit and synd to submit the finalized plan of care (POC) for review.  According to the hospice policy titled Clinical Records, dated 2/1/23, all entries into the clinical record must be legible, clear, complete, and appropriatley authenticated and dated in accordance with hospice policy and accepted standards of practice.  During an interview on 5/26/26 at 4:20 PM, the Administrator stated the hospice had previously identified but had not yet corrected the lack of signature and credentials for Music Terapy services.  During an interview on 5/27/26 at 9:30 AM, Staff K, Business Office Manager, revealed she lacked credentials and had not been a member of the IDG.  1.Patient #2 had a hospice admission date of 9/11/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 3/10/26 to 5/8/26 and 5/9/26 to 7/7/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker, chaplain, volunteer and massage therapy services.    b. The initial POC, dated 9/11/25 to 12/9/26, signed by Staff K, Business Office Manager.  The hospice failed to ensure the POC signed by appropriate member of the IDG.  2. Patient #3 had a hospice admission date of 2/17/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/13/26 to 6/11/26, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for music therapy services.    b. The music therapy visit notes, dated 3/18/26, 3/25/26 and 4/15/26, completed by Staff G, Music Therapist, lacked a signature, staff credentials and date of authentication.    The Music Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice.

Based on staff interview, clinical record reviews and review of nursing home medication administration records and agency policy review, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 1 of 2 sampled patients (Patient #4) with a nursing home medication review.  Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.  Findings include: --- According to the hospice policy titled Nursing Facility Care Plan, Coordination and Communication, dated 12/22/25, Registered Nurse case managers are responsible for coordinating and implementing patient care plans in collaboration with members of the Interdisciplinary Group (IDG), facility representative and the attending physician.  Care plans for facility patients are reviewed and updated by the IDG in collaboration with the facility representatives every 15 days at a minimum or more frequently if needed.   During an interview on 5/19/26 at 4:00 PM, Staff M, Registered Nurse (RN), stated she communicates with a facility nurse regarding each patient when visiting the patient and also communicates through phone calls between visits with new or changed orders.   Patient #4 had a hospice admission date of 1/9/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 5/4/26 to 7/2/26, identified the patient had a primary diagnosis of traumatic bilateral subdural hematomas and included IDG orders for skilled nursing services 1 time per week and included physician orders for medications. b. Review of the patient's nursing home Medication Administration Record (MAR), dated 5/21/26, identified the following medication discrepancy with the hospice's POC and Medication Profile for the patient:  The hospice POC had an order for Ondansetron 4 milligram (mg) tablet with instructions to take 4 mg by mouth every 6 hours as needed for nausea.  The hospice Medication Profile identified a start date for the medication, dated 1/9/25.  The nursing home MAR failed to include an order for Ondansetron.   Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home.   The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.

Based on staff interview, clinical record review, nursing home clinical record review and agency policy review, the hospice failed to ensure the nursing home received a copy of the patient's hospice plan of care/most recent updates for 1 of 2 sampled patients (Patient #4) with home visit observations in nursing homes.   Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.   Findings include: --- According to the hospice policy titled Nursing Facility Care Plan, Coordination and Communication, dated 12/22/25, at the time of recertification, the business office manager/office coordinator is responsible for ensuring the Plan of Care (POC) are incorporated into the nursing facility record timely.   Patient #4 had a hospice admission date of 1/9/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POCS, dated 3/5/26 to 5/3/26 and 5/4/26 to 7/2/26, identified the patient had a primary diagnosis of traumatic bilateral subdural hematomas and included orders for skilled nursing services.b. During a home observation visit on 5/21/26 at 11:00 AM, Staff J, Registered Nurse (RN) reviewed the nursing facility electronic medical record and was unable to find the POCs dated 3/5/26 to 5/3/26 and 5/4/26 to 7/2/26.  c. During an interview on 5/21/26 at 11:22 AM, Staff J, RN, stated hospice documents, including the POC, are uploaded into the nursing home record by hospice staff.  Staff J confirmed she could not see where the two most recent POCs had been uploaded into the nursing home electronic medical record.   Hospice staff failed to provide the required documentation, including plans of care, to nursing home staff. The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services, Director of Hospice Clinical Operations and Clinical Documentation Coordinator.

The lowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the lowa Single Information Repository (SING), or using both the lowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the lowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The lowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on staff interview and review of employee personnel files, the hospice failed to ensure completion of a criminal background check for 1 of 1 sampled contracted employee who began serving hospice patients since their last survey, dated 9/27/23. The hospice reported hiring 1 contract employee since the last survey. Failure to complete criminal background checks as required by federal regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact. Findings include: --- During an interview on 5/19/26 at 10:24 AM, the Administrator reported that no additional SING background checks were completed for Staff G, Music Therapist.Staff G had a hire date of 7/2/24. Staff G's personnel file included documentation of a completed criminal history background check, dated 5/21/24, 42 days prior to Staff G's hire date. Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on contracted staff prior to hiring. The above findings were reviewed with the Administrator, Clinical Manager, Director of Hospice Clinical Operations, Hospice Clinical Support Coordinator, Vice President of Clinical Services.

The lowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the lowa Single Information Repository (SING), or using both the lowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the lowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The lowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on staff interview and review of employee personnel files, the hospice failed to ensure completion of a criminal background check for 1 of 1 sampled contracted employee who began serving hospice patients since their last survey, dated 9/27/23. The hospice reported hiring 1 contract employee since the last survey. Failure to complete criminal background checks as required by federal regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact. Findings include: --- During an interview on 5/19/26 at 10:24 AM, the Administrator reported that no additional SING background checks were completed for Staff G, Music Therapist.Staff G had a hire date of 7/2/24. Staff G's personnel file included documentation of a completed criminal history background check, dated 5/21/24, 42 days prior to Staff G's hire date. Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on contracted staff prior to hiring. The above findings were reviewed with the Administrator, Clinical Manager, Director of Hospice Clinical Operations, Hospice Clinical Support Coordinator, Vice President of Clinical Services.

Based on clinical record review, hospice policy review, and staff interview, the hospice failed to maintain documentation in the patient clinical record as evidence instruction was given to the patient and/or caregiver(s) regarding disposal of controlled drugs for 1 of 1 sampled patients (Patient #4) who died in their home while receiving hospice services. Failure to ensure patients and/or caregivers received adequate education on the disposal of controlled drugs increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: --- The hospice policy, titled Medication-Management, Education, Tracking and Disposing of Controlled Drugs, dated 4/25/22, indicated a nurse/social worker, accompanied by a witness, is responsible for disposing of the patients drugs by mixing the medications with kitty litter, coffee grounds, dishwashing soap (any noxious agent) and discarding in the household trash when the patient no longer needs the medications. In the event agency staff is not present, the agency hospice nurse instructs the family on the disposal of narcotics. The instruction and discussion is documented in the electronic health record (EHR). During an interview on 3/4/24 at 3:11 PM, Patient #4's caregiver reported no instruction was given by the hospice agency to the caregiver on how to dispose of the narcotic medication following patients death. The caregiver reported the only instruction provided for disposal of narcotic medication was when she contacted a state agency. The caregiver destroyed the narcotic medication in used coffee grounds after receiving instruction from the agency. During an interview on 3/5/24 at 12:45 PM, Staff A, Program Director, reported the expectation for staff is to destroy controlled medication in the patients home with a witness present. If staff is unable to be present in the home to destroy controlled medication, verbal instruction can be given to the family. Instruction and discussion of controlled medication(s) needs to be documented in the EHR. Staff A reported, on 1/18/24, she contacted Patient #4's caregiver and was informed the patient's controlled medication had been disposed of in used coffee grounds per instruction from a state agency. Staff A reported, no documentation of the conversation about the medication disposal would be found in the EHR. Patient #4 had a hospice admission date of 1/8/24 and received hospice services while residing in a private residence. Patient died on 1/13/24. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/8/24 to 4/6/24. b. The verbal order, signed by the physician 1/9/24, included orders for morphine 20milligrams(MG)/millimeters (ML) oral concentrate; administer 0.25-1 ML oral every hour as needed for pain, shortness of breath, restlessness. c. The patient died on 1/13/24 at his/her home. Agency staff was not present at the time of death. The clinical record lacked documentation of hospice staff providing instruction to caregivers regarding the policy for disposal of controlled drugs after the patient died. The above findings were reviewed with the Program Director and the Clinical Manager. Hospice staff did not provide any additional information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the drug regimen review identified need for laboratory monitoring associated with all medications taken by the patient for 8 of 19 sampled patients (Patients #1, #4, #6, #12, #14, #16, #17 and #18). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: --- According to the hospice policy, titled Drug Regimen Review-Initial and Ongoing, dated 2/1/23, on admission a nurse documents all medications in the patient's Electronic Health Record (EHR) Medication Profile. The review of the patient's current medications includes: therapeutic effectiveness, therapeutic duplication, appropriate dose, frequency and route of administration, adherence to drug regimen, potential drug/food/diagnostic test interactions/disease limits, lab or clinical monitoring methods to detect drug effectiveness, side effects, toxicity or adverse effects, storage specifics/availability/tracking issues, quality versus cost effectiveness and appropriate alternatives. Documentation of the drug regimen discussion is captured in the IDG note. During an interview on 9/14/23 at 9:59 AM, the Clinical Manager stated a drug regimen review is completed every 2 weeks and documented in a skilled nurse visit note. The Drug Regimen review is completed during the IDG meetings. 1. Patient #1 had a hospice admission date of 8/9/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/9/23 to 11/6/23, included physician orders for duplicate pain medications and duplicate bowel medications. b. The IDG meeting notes, dated 8/16/23, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate pain and bowel medications. The DRRs failed to identify the patient had duplicate orders for pain and bowel medications. 2. Patient #4 had a hospice admission date of 7/11/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 7/11/23 to 10/8/23, included physician orders for duplicate duplicate bowel medications. b. The IDG meeting notes, dated 7/12/23, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate bowel medications. The DRRs failed to identify the patient had duplicate orders for bowel medications. 3. Patient #6 had a hospice admission date of 9/5/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 9/5/23 to 12/3/23, included physician orders for duplicate bowel medications. b. The IDG meeting notes, dated 9/6/23, failed to include a DRR completed. The IDG failed to identify completion of a DRR. 4. Patient #12 had a hospice admission date of 8/23/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 8/23/23 to 10/21/23, included physician orders for duplicate bowel medications. b. The IDG meeting notes, dated 8/30/23, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included bowel medications. The DRRs failed to identify the patient had duplicate orders for bowel medications. 5. Patient #14 had a hospice admission date of 8/17/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 8/17/23 to 11/14/23, included physician orders for duplicate pain medications and duplicate bowel medications and an order for Levothyroxine, which indicated laboratory monitoring. b. The IDG meeting notes, dated 8/23/23, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate pain and bowel medications and Levothyroxine for routine laboratory monitoring. The DRRs failed to identify the patient had duplicate orders for pain and bowel medications. 6. Patient #16 had a hospice admission date of 8/4/23 and discharge date of 9/13/23, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 8/4/23 to 11/1/23, included physician orders for duplicate pain medications, duplicate respiratory and duplicate bowel medications. The orders included Levothyroxine and diabetic medications, which i ndicate the need for routine laboratory monitoring. b. The IDG meeting notes, dated 8/9/23, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate pain, respiratory and bowel medications. The DRR also lacked documentation of Levothyroxine and diabetic medications for routine laboratory monitoring. The DRRs failed to identify the patient had duplicate orders for pain, respiratory and bowel medications or the need for routine laboratory monitoring. 7. Patient #17 had a hospice admission date of 9/15/22 and date of death of 10/2/22, received hospice services while residing in a nursing home setting. Review of the clinical record revealed the following: a. The POC, dated 9/15/22 to 11/28/22, included physician orders for duplicate pain medications. b. The IDG meeting notes, dated 9/21/22, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate pain medications. The DRRs failed to identify the patient had duplicate orders for pain medications. 8. Patient #18 had a hospice admission date of 12/1/22 and date of death of 1/17/23, received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The POC, dated 12/1/22 to 2/28/22, included physician orders for duplicate respiratory medications. b. The IDG meeting notes, dated 12/7/22, included a DRR reviewed for drug therapy that included duplicate medications . The DRR lacked documentation of outcomes of the review that included duplicate respiratory medications. The DRRs failed to identify the patient had duplicate orders for respiratory medications. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview, patient representative interview and hospice staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and patients attending physician to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 5 of 19 sampled patients (#3, #9, #11, #15 and #17). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: --- According to the policy, titled Plan of Care, dated 5/31/23, during the patient's admitting visit, the Registered Nurse (RN) creates the Medication Profile, listing all known medications, treatments, identifies diet, supplies and durable medical equipment (DME). Up to 15 days prior to the beginning date of the recertification period, the Diagnosis, Care plan, DME, supplies, treatments, diet, and medication profile are reviewed by the IG as part of the recertification process. During an interview on 9/26/23 at 3:00 PM the Clinical Manager identified the hospice's work week included Wednesday through Tuesday. She further stated the patient's missed visits were not identified during the IDG meetings. 1. Patient #3 had a hospice admission date of 5/9/22 and received routine home care hospice services while residing in a nursing facility (nursing home). a. Review of the Plans of Care (POCs), dated 7/3/23 to 8/31/23 and 9/1/23 to 10/30/23, included orders for hospice aide services 2 times a week b. Review of the hospice aide visit notes, dated the week of 8/16/23 to 8/28/23, included documentation of 1 visit completed on 8/18/23. c. Review of the IDG meeting note, dated 8/23/23, failed to identify the missed aide visit. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to missed visits. 2. Patient #9 had a hospice admission date of 8/1/23 and received routine home care hospice services while residing in a private home setting. a. Review POCs, dated 8/1/23 to 10/29/23, included orders for skilled nursing services 1 to 2 times a week and 5 visits as needed. b. Review of the skilled nurse visit notes, dated the week of 8/2/23 to 8/8/23, lacked documentation of a skilled nurse visit. c. Review of the IDG meeting note, dated 8/9/23, failed to identify the missed skilled nurse visit. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to missed visits. 3. Patient #11 had a hospice admission date of 7/18/23 and received routine home care hospice services while residing in a private home setting. a. Review of the POC, dated 7/18/23 to 10/15/23, included orders for hospice aide services 1 times a week b. Review of the hospice aide visit notes, dated the week of 8/9/23 to 8/15/23, lacked documentation of a hospice aide visit completed. c. Review of the IDG meeting note, dated 8/16/23, failed to identify the missed aide visit. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to missed visits. 4. Patient #15 had a hospice admission date of 5/11/23 and discharge date of 5/22/23 and received routine home care hospice services while residing in a private home setting. a. Review of the POCs), dated 5/11/23 to 8/8/23, included orders for skilled nurse services 1 to 3 times a week and 5 visits as needed. The POC also included orders for the medication Edoxaban (blood thinner) 60 milligrams once a day. b. Review of the skilled nurse visit note, dated 5/18/23, included documentation an as needed visit completed by the Licensed Practical Nurse (LPN) due to reported dark phlegm. The patient was found resting in bed with eyes closed and easily woken, alert and friendly. Small amount dark brown tenacious phlegm noted in the emesis basin. The patient's spouse advised the patient had hiccups on and off throughout the day. Skin warm and dry and vital signs stable. Lung sounds clear, no cough or shortness of breath and bowel sounds present time 4 quadrants. Previous bowel movement on 5/17/23. No signs or symptoms of pain or distress noted. Peri care completed and the patient repositioned. No further emesis noted. The patient resting quietly at the end of the visit. The noted failed to include documentation of notification of the change in condition to the Registered Nurse (RN) or physician. During an interview on 9/26/23 at 3:45 PM the Clinical Manager stated she talked with both LPNs employed at the time and identified the hospice expected staff to triage and call the RN Nurse or physician. There is always a backup RN and backup Administrator always available for questions. No call had been made on 5/18/23. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to a change in condition. 5. Patient #17 had a hospice admission date of 9/15/22 and date of death of 10/2/22 and received routine home care hospice services while residing in a nursing facility. a. Review of the POC, dated 9/15/22 to 11/28/22, included orders for hospice aide services 1 time a week b. Review of the hospice aide visit notes, dated the week of 9/21/22 to 9/27/22, failed to include documentation of a hospice aide visit completed. c. Review of the IDG meeting note, dated 9/28/22, failed to identify the missed aide visit. The hospice IDG failed to ensure they maintained a system of communication which allowed for the hospice's coordination of the patient's care in relation to missed visits. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient interview and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 6 of 15 sampled patients receiving hospice aide services. (Patients #1, #7, #13, #14, #16 and #17). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. Findings include: --- Review of the hospice's policy, titled Hospice Aise Services, dated 2/1/23, the registered nurse case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. The hospice aide care plan is reviewed as often as necessary and at a minimum every 14 days by the registered nurse case manager. 1. Patient #1 had a hospice admission date of 8/9/23 and received routine home care hospice services while residing in a nursing home (nursing facility). Review of the clinical record revealed the following: a. The POC, dated 8/9/23 to 11/6/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with positioning, report changes in skin, range of motion with each visit, transfer to bed/chair hoyer and 2 person, turn every 2 hours, up in chair/wheelchair, assist with meal-set-up, feeding, Incontinent care, assist with dressing if not done, weekly bath, may trim or file long or uneven fingernails, may trim or file long or uneven toenails, shampoo with bath, fall precautions and standard precautions. b. The hospice aide assignment (care plan), dated 8/10/23, included the same interventions for the hospice aide to complete each visit (assist with positioning, report changes in skin, range of motion with each visit, transfer to bed/chair hoyer and 2 person, turn every 2 hours, up in chair/wheelchair, assist with meal-set-up, feeding, Incontinent care, assist with dressing if not done, weekly bath, may trim or file long or uneven fingernails, may trim or file long or uneven toenails, shampoo with bath, fall precautions and standard precautions) as the POCs. c. The IDG meetings, dated 8/16 and 8/30/23, continued to include the same interventions for the hospice aide to complete each visit (assist with positioning, report changes in skin, range of motion with each visit, transfer to bed/chair hoyer and 2 person, turn every 2 hours, up in chair/wheelchair, assist with meal-set-up, feeding, Incontinent care, assist with dressing if not done, weekly bath, may trim or file long or uneven fingernails, may trim or file long or uneven toenails, shampoo with bath, fall precautions and standard precautions). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of which type of bath to give the patient. 2. Patient #7 had a hospice admission date of 8/31/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/31/23 to 11/28/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, one time per week: assist with transfers-1 person transfer, incontinent care if requested, clean living area of the patient if requested, make patient bed if requested, bath if requested, may trim any long or uneven finger fails and oral care if requested. . b. The hospice aide assignment (care plan), dated 8/31/23, included the same interventions for the hospice aide to complete each visit (assist with transfers-1 person transfer, incontinent care if requested, clean living area of the patient if requested, make patient bed if requested, bath if requested, may trim any long or uneven finger fails and oral care if requested) as the POCs. c. The IDG meetings, dated 9/6/23, continued to include the same interventions for the hospice aide to complete each visit (assist with transfers-1 person transfer, incontinent care if requested, clean living area of the patient if requested, make patient bed if requested, bath if requested, may trim any long or uneven finger fails and oral care if requested). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of which type of bath to give the patient. 3. Patient #13 had a hospice admission date of 8/22/23 and received routine home care hospice services while residing in a nursing home (nursing facility). Review of the clinical record revealed the following: a. The POC, dated 8/22/23 to 10/20/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfers if requested, incontinent care if requested, clean living area of the patient if requested, bath if requested and may trim any long or uneven fingernails. b. The hospice aide care plan, dated 8/22/23, included the same interventions for the hospice aide to complete each visit (assist with transfers if requested, incontinent care if requested, clean living area of the patient if requested, bath if requested and may trim any long or uneven fingernails) as the POCs. c. The IDG meetings, dated 8/23, 8/30 and 9/6/23, continued to include the same interventions for the hospice aide to complete each visit (assist with transfers if requested, incontinent care if requested, clean living area of the patient if requested, bath if requested and may trim any long or uneven fingernails). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of which type of bath to give the patient. 4. Patient #14 had a hospice admission date of 8/17/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/17/23 to 11/14/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: bath, may trim or file long or uneven fingernails, may trim or file any long or uneven toe nails, perineal care, skin care, oxygen precautions and standard precautions. b. The hospice aide care plan, dated 8/10/23, included the same interventions for the hospice aide to complete each visit (bath, may trim or file long or uneven fingernails, may trim or file any long or uneven toe nails, perineal care, skin care, oxygen precautions and standard precautions) as the POCs. c. The IDG meetings, dated 8/23 and 9/6/23, continued to include the same interventions for the hospice aide to complete each visit (bath, may trim or file long or uneven fingernails, may trim or file any long or uneven toe nails, perineal care, skin care, oxygen precautions and standard precautions). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. During an interview on 9/20/23 at 3:20 PM Staff E, LPN stated she did assist with patient with transfers and used a hoyer lift. She also stated she gave the patient bed baths. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of transferring with a hoyer lift and which type of bath to give the patient. 5. Patient #16 had a hospice admission date of 8/4/23 and discharge date of 9/13/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/4/23 to 11/1/23, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: assist with transfers, incontinent care if requested, bath if requested, may trim any long or uneven fingernails if requested and provide facility with pullups, wipes and chux with each visit. b. The hospice aide care plan, dated 8/10/23, included the same interventions for the hospice aide to complete each visit (assist with transfers, incontinent care if requested, bath if requested, may trim any long or uneven fingernails if requested and provide facilityw ith pullups, wipes and chux with each visit) as the POCs. c. The IDG meetings, dated 8/9, 8/16, 8/30 and 9/6/23, continued to include the same interventions for the hospice aide to complete each visit (assist with transfers, incontinent care if requested, bath if requested, may trim any long or uneven fingernails if requested and provide facility with pullups, wipes and chux with each visit). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of which type of bath to give the patient. 6. Patient #17 had a hospice admission date of 9/15/23 and date of death of 10/2/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 9/15/22 to 11/28/22, included IDG orders for hospice aide and skilled nursing services. The POCs included the following assigned interventions for the hospice aide to complete each visit, two times per week: shave, transfer belt, assist with meal preparation, standard precautions, assist with transfers, clean kitchen after meal preparation, incontinent care if incontinent, bath as will allow, if refuses, attempt sponge bath and lotions to upper and lower extremities with bath. b. The hospice aide care plan, dated 12/15/22, included the same interventions for the hospice aide to complete each visit (have, transfer belt, assist with meal preparation, standard precautions, assist with transfers, clean kitchen after meal preparation, incontinent care if incontinent, bath as will allow, if refuses, attempt sponge bath and lotions to upper and lower extremities with bath) as the POCs. c. The IDG meetings, dated 9/21 and 9/28/22, continued to include the same interventions for the hospice aide to complete each visit (have, transfer belt, assist with meal preparation, standard precautions, assist with transfers, clean kitchen after meal preparation, incontinent care if incontinent, bath as will allow, if refuses, attempt sponge bath and lotions to upper and lower extremities with bath). The IDG meetings all included documentation the hospice aide reported they continued to assist the patient with the assigned tasks. The hospice aide assignment developed by the nurse continued to lack direction for the hospice aide to complete the tasks of which type of bath to give the patient. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 1 sampled patients (Patient #10) who received routine home care while living in a private home residence and had a physician ordered controlled medication after the start of hospice services. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. --- According to the undated hospice policy titled Patient and Family Rights and Responsibilities, receipt of education from hospice staff included safe medication disposal-instruction sheet and policy and procedure. 1. Patient #10 had a hospice admission date of 8/7/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 8/7/23 to 11/4/23, included orders for skilled nursing services and lacked orders for narcotic medication. b. Review of the physician orders, dated 8/18/23, included the following new medications: Lorazepam (antianxiety) 2 milligrams/milliliters (mg/ml) give 0.25 ml to 1 ml by mouth every 2 hour as needed for anxiety, shortness of breath or restlessness and Morphine (narcotic analgesic) concentrate 20 mg/ml give 0.25 to 1 ml by mouth every hour as needed for pain, shortness of breath or restlessness. c. The medication profile, dates 8/18/23, included the following new medications: Lorazepam (antianxiety) 2 mg/ml give 0.25 ml to 1 ml by mouth every 2 hour as needed for anxiety, shortness of breath or restlessness and Morphine (narcotic analgesic) concentrate 20 mg/ml give 0.25 to 1 ml by mouth every hour as needed for pain, shortness of breath or restlessness. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, onsite visit observation, nursing home medication and treatment administration records, nursing home staff interview, patient representative interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 2 of 3 sampled patients (Patients #3 and #4) residing in a nursing home and receiving an onsite visit observation. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- Review of the hospice's policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 2/3/2023, revealed staff provide patient care in accordance with a written plan of care established by the IDG. The hospice assumes full responsibility for professional management and coordination and the registered nurse case manager is responsible for coordinating and implementing patient care plans in collaboration with members of the IDG, facility staff and the attending physician. 1. Patient #3 had a hospice admission date of 5/9/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 9/1/23 to 10/30/23, included Interdisciplinary group (IDG) orders for skilled nursing services 1 to 2 times per week and included physician orders for medications. b. Review of the patient's nursing home Medication Administration Record (MAR) for September, 2023 identified the following medication discrepancies with the hospice's POC and Medication Profile, dated 9/28/23, for the patient: a. The hospice POC had an order for Acetaminophen Extra Strength gelcaps 500 mg, take 2 tablets every 6 hours as needed for mild pain. The hospice's Medication Profile identified a start date for the medication, dated 5/9/22. The nursing home's MAR included the order for Acetaminophen give 500 mg every 6 hours as needed for pain with a start date of 1/10/22. b. The nursing home's MAR included an order for Diphenhydramine HCL give 25 mg by mouth every 6 hours as needed for rash, with a start date of 12/16/22. The hospice POC lacked an order for the medication Diphenhydramine. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home. 2. Patient #4 had a hospice admission date of 7/11/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 7/11/23 to 10/8/23, included Interdisciplinary group (IDG) orders for skilled nursing services 1 to 2 times a week and included physician orders for medications. b. Review of the patient's nursing home Medication Administration Record (MAR) for September, 2023 identified the following medication discrepancies with the hospice's POC and Medication Profile, dated 9/28/23, for the patient: c. The hospice POC had an order for Lorazepam (antianxiety) 0.5 mg 1 tablet every 4 hours effective 7/11/23 and Lorazepam 0.5 mg tablet take 0.5 to 4 tablets oral every 2 hours as needed for anxiety, sob, and terminal restlessness. The hospice's Medication Profile identified a start date for the medication, dated 8/24/23. d. The nursing home's MAR included the order for Lorazepam 0.5 mg 1 tablet by mouth every 4 hours as needed for anxiety and Lorazepam 0.5 mg every 2 hours as needed for anxiety, take 0.5 to 4 tabs oral every 2 hours as needed for anxiety, sob, terminal restlessness. The medication included a start date of 9/22/23. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.