Every finding on record at Cedar Valley Hospice Inc.

Based on hospice policy review and clinical record review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 2 of 3 sampled patients with a wound (Patients #3 and #6).  Failure to ensure the plan of care included physician orders for all necessary medications, treatments and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- According to the hospice policy, titled Skin/Wound: Assessment and Treatment, dated 08/2024, identified physician orders for wound care treatment must be obtained and documented in the patient’s medical record. The orders may include dressing changes, including frequency and dressing type; possible wound cleaner and a type of wound fill such as gauze or alginate and cover dressing (Stage III); and/or wound cleaner, a type of wound fill and a cover dressing (Stage IV).  1.  Patient #3 had a hospice admission date of 2/17/25 and received hospice services while residing in a private home.  Clinical record review revealed:   a.  Skilled nurse visit note, dated 2/2/26 at 2:00 PM, completed by Staff J, Hospice House Registered Nurse (HH RN), included documentation wound cleaned, cleansed area, placed Mepilex, to be changed when soiled.  b.  Interim physician order, dated 2/4/26, apply Mepilex 4x4 (foam dressing) to open area on sacral area, change every 3 days and as needed soiled.  c.  Interim physician order, dated 2/6/26, Mepilex 4x4 bandage to sacral area and Silvadene topical cream twice daily and as needed.  d.  Interdisciplinary Group (IDG) update to the plan of care, dated 2/17/26, included interim physician orders, dated 2/4/26 and 2/6/26, but lacked documentation of orders for wound cleansing instructions.  2.  Patient #6 had a hospice admission date of 8/4/25, a death date of 2/11/26, and received hospice services while residing in a private home.  Clinical record review revealed:  a.  Skilled nurse visit note, dated 12/7/25, completed by Staff K, RN, included documentation open area left buttock, area cleansed with warm water, pat dry, applied barrier cream and Mepilex 3x3.  b.  Interim physician order, dated 12/7/25, Mepilex border 4x4 bandage to left buttock every 3 days and as needed.  c.  IDG update to the plan of care, dated 12/11/25, included interim physician order, dated 12/7/25, but lacked documentation of orders for wound cleansing instructions.  The hospice failed to document physician orders for specific cleansing instructions for wound care.  The above findings were reviewed with Clinical Manager and Chief Clinical Officer.

Based on interviews, clinical record reviews and agency policy review, the hospice failed to maintain documentation in the patient clinical records as evidence 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 2 sampled patients who received routine home care while living in a private residence and received physician orders for controlled medications after the start of care (Patient #1).  Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for who the medication was prescribed.    Findings include: --- According to the hospice policy titled Medication Management, dated July 2016, the hospice nurse provides written and oral information to the patient/caregiver regarding the safe management and disposal of controlled drugs in a language and manner they understand when controlled substances are first ordered and documents in the patient's clinical record the oral and written information was provided.    During an interview on 4/7/26 at 4:19 PM, Staff G, Clinical Services Manager, stated patients/caregivers are educated on the disposal of controlled medications when the controlled medications are first ordered, when controlled medications are discontinued and when the patient dies.    During an interview on 4/8/26 at 8:33 AM, Patient #1's primary caregiver stated they did not recall receiving verbal or written education on the disposal of controlled medication at the time the physician first ordered the controlled medication.    Patient #1 had a hospice admission date of 1/13/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial Plan of Care (POC), dated 1/13/26 to 4/12/26, identified the patient had a primary diagnosis of Alzheimer's disease and included physician orders for medications, but no controlled medications.    b. The skilled nurse visit note, dated 1/20/26, completed by Staff I, Registered Nurse (RN), identified the patient started hydrocodone (controlled substance for pain) on 1/18/26.  c. A Interdisciplinary Group (IDG) meeting note, dated 1/29/26, included physician orders (effective 1/18/26) for hydrocodone; controlled medication.    The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.    The above findings were reviewed with the Chief Clinical Officer and the Clinical Manager.

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; 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 clinical record review and interview. In 1 of 3 (33%) In clinical records in which infusions were ordered, the agency did not ensure that all flushes were documented on the medication profile and reviewed for all potential interactions. Clinical Record 25: A patient was admitted on 11/24/2024 with injectable medications of hydromorphone (pain control), haloperidol (anti-anxiety), chlorpromazine (mood-altering) with PRN (as needed) dosages. These medications were all administered through a PICC (peripherally inserted central catheter) line no saline was documented on the medication profile as of 12/12/2024 for saline flush between medications, which would be required to minimize medication reactions. The saline flushes were not listed on the medication profile as a medication nor were they listed as a treatment. During an interview on 12/11/2024 with the Director of Compliance who reviewed the record and stated that the saline had been left off of the medication profile.

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care. Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative if any of them so desire; The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 2 of 23 (9%) In clinical records reviewed in which the community patient had an order of care for a procedure, the agency did not ensure that all care was implemented and documented according to the physician's orders on the plan of care. Clinical Record 7: The patient was admitted on 11/01/2024 with a CADD pump and Foley catheter. The initial plan of care dated 11/04/2024 included an order for the Foley catheter to be changed monthly and PRN (as needed). The clinical record lacked documentation that the Foley catheter had been changed as of review 12/10/2024. The updated plan of care on 11/20/2024 documented that the placement of the subcutaneous (SQ) site and equipment would be changed every 10 days. There was a documented site change on 12/02/2024 (2 days late) however, there was no documented reason for the late site change. There was no documented site irritation with the dressing change. Clinical Record 20: The plan of care was updated on 12/09/2024 for skin integrity with interventions documented for the dorsal foot. The nursing visit note dated 12/06/2024 documented the nurse cleaned the foot and applied a Mepilex dressing to be changed every 3 days. There were no documented dressing changes as of the review on 12/12/2024. This was 6 days and no reason for not documenting the dressing change. The wound was documented as improving. The case manager stated that the facility changed the dressing but that this was not documented. During an interview with the Director of Compliance who reviewed the records and stated care had not been documented according to the physician's orders.

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 and interview. In 3 of 23 (13%) clinical records of community hospice patients reviewed, it was revealed that the agency did not ensure the plans of care documented all interventions for the care of the patients. Clinical Record 1: The initial nursing assessment dated 11/15/2024 documented a history of falls of 10, with unsteady gait of 5 and urinary incontinence. The initial plan of care (11/15/2024) and updated plans of care did not document any interventions for fall precautions. The instruction on admission was for non-skid shoes, moving throw rugs, and obstacles, and monitoring for risk but this was not in the care plan. It was documented that the patient was using lorazepam (anti-anxiety) and morphine (pain control) for symptom control and was a continued fall risk. Clinical Record 18: The initial plan of care was dated 10/17/2023, with documented intervention for the Foley catheter to be changed monthly and performed by skilled nursing (SN) or facility nurse. The nursing assessment dated 02/16/2024 documented that the facility nurse asked about flushing the catheter and was instructed to flush the catheter as needed. There was no documented intervention for catheter flushes as of 12/12/2024 with updated plans of care. The facility did have an order to flush the catheter. Clinical Record 20: The plan of care was updated on 12/09/2024 for skin integrity with interventions documented for the dorsal foot. It was not specific to which foot was to be treated. The intervention was documented to assess the wound for changes in pain, drainage, stage and healing but was not specific to the wound care provided. The nursing visit note dated 12/06/2024, documented that the nurse cleaned the foot and applied a Mepilex dressing to be changed every 3 days. These interventions were not documented in the plan of care. During an interview, the Director of Compliance stated that the interventions were not complete, and that new staff had completed the documentation.

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 1 of 18 (6%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. Clinical Record 7: The aide care plan dated 11/04/2024 included a task assigned for bed bath every visit and a visit frequency of 2 times a week. Updated nursing comprehensive assessment dated 11/24/2024 documented starting a subcutaneous site in the abdomen to begin an infusion of hydromorphone. This was not updated for the aide to direct that this was placed in the abdomen or what to do if the dressing was off or saturated. During an interview on 12/12/2024 with the Director of compliance who reviewed the record, and the Administrator stated that the plan did not provide direction related to the dressing and pump.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) In clinical records reviewed, for patients that had documented infusions, it was revealed that the agency did not ensure all physician orders were documented for required flushes and care. Clinical Record 25: A patient was admitted on 11/24/2024 with injectable medications of hydromorphone (pain control), haloperidol (anti-anxiety), and chlorpromazine (mood-altering) with PRN (as needed) dosages. These medications were all administered through a PICC (peripherally inserted central catheter) line. The line would require flushes of saline between medications to prevent medication interactions. There was no documented physician’s order for saline. Additionally, there was no documented order for dressing change for the PICC line. interview with the staff stated that saline was used between medications. During the interview with the Director of Compliance who reviewed the chart and stated that the orders were not documented.

Based on observation and interview the facility failed to comply with the building rehabilitation, renovation, modification and reconstruction requirements set forth in Chapter 18 and 19 sections 43.3, 43.4, 43.5 and 43.6. This affects one of two smoke zones and all occupants in the facility. Findings include: Observation and interview on 5/2/2022 at 11:59 a..m., revealed the facility contained six old inert interconnected smoke detectors. One in each of the six resident rooms. The Maintenance Director verified this at the time of the survey process.

Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 6 and a census of 5. Findings include: Review of the facility's fire drill records on 5/2/2022 at 11:31 a.m., revealed the facility failed to conduct at least one fire drill per shift per quarter of 2021 and 2022. The facility has two twelve hour shifts and failed to provide documentation of any fire drills being conducted on the second shift, fourth quarter of 2021 or second shift first quarter of 2022. The Maintenance Director verified this through record review at the time of the survey process.

Based on observation and record review, the facility did not maintain the diesel emergency generator in accordance with National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4, 5.6.5.6, and 8.4.2 respectively. The facility failed to maintain monthly generator documentation. This deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator affects all occupants in the facility. This facility had a capacity of 6 and a census of 5. The Maintenance Director verified this through record review at the time of the survey process. Findings include: 1. Observations and record review on 5/2/2022 at 11:55 a.m., revealed the facility failed to document amps of legs of their monthly load tests. The Maintenance Director verified this through record review at the time of the survey process. 2. Observations and record review on 5/2/2022 at 11:54 a.m., revealed the facility failed to document start and stop times of their monthly load tests. The Maintenance Director verified this through record review at the time of the survey process.

Based on hospice policy review, clinical record review and hospice staff interview, the hospice failed to ensure the drug regimen review included a complete review of all of the patients medications, documenting any identified concerns related to all required components within the first 5 days of the patient's election to hospice benefits and at least every 15 days with the update to the comprehensive assessment for 7 of 16 sampled patients (Patient #1, #2, #5, #6, #10, #12, and #14). Failure to ensure the interdisciplinary group (IDG) members completed a drug regimen review (DRR) of all of the patients medications and all the required components with the initial and with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: Review of the hospice's policy, titled Comprehensive Assessment of the Patient, dated 11/2008, identified members of the Interdisciplinary Group (IDG) complete the comprehensive assessment in consultation with the patient's attending physician no later than 5 calendar days after the patient elects hospice benefits. The hospice registered nurse (RN) coordinates the comprehensive assessment process and the IDG members use discipline-specific tools to obtain accurate and timely information. The IDG members update the patient's comprehensive assessment at least every 15 days. Review of the hospice's Drug Regimen Review (DRR) Form, dated 5/28/19, revealed IDG members use the form to document a review of the components of the DRR with each IDG meeting, including effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with laboratory monitoring. On 4/27/22 at 8:22 AM, during an interview, the Clinical Manager reported the contracted pharmacy completed a DRR every 15 days. The RN Case Manager was responsible for reviewing the pharmacy's report, reconciling and making sure medication were correct and then bringing this information to IDG. The IDG members completed a DRR with each IDG meeting and the RN documented this information on a DRR form. 1. Patient #6 had a hospice admission date of 3/19/2022 and received hospice services from the Grundy Center multiple location while residing in a nursing home. Review of the clinical record revealed the following: a. The hospice Plan of Care, dated 3/24/2022, included the following medications: bisacodyl, Milk of Magnesia, Fleets enema and polyethylene glycol, all medications containing a laxative. b. The updates to the Plan of Care, dated 3/24/2022, 4/7/2022 and 4/21/2022, documented the IDG reviewed the medications for duplication, ineffectiveness, side effects, medication interactions and medications requiring laboratory testing. The updates referred review of the medications to form PF 99- a form used by the hospice to document the findings of the drug regimen review. c. The forms PF 99, dated 3/24/2022, 4/7/2022 and 4/21/2022, documented the IDG reviewed the patient's medications finding no duplicate drug therapy. The patient had 4 medications containing laxative. The hospice failed to identify the duplicate laxatives when completing the drug regimen reviews. 2. Patient #2 had a hospice admission date of 12/22/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 12/22/21 to 3/21/22 and 3/22/22 to 6/19/22, included physician orders for medications, including morphine and Tylenol (analgesics) and miralax and senna plus (bowel medications). b. The IDG meetings, dated 2/24/22, 3/9, 3/24/22, 4/7 and 4/21/22, included documentation of completed DRR. The clinical record lacked documentation of the identification of duplicate medications for pain and bowel. The DRRs failed to include an accurate and complete review of all the patient's medications. 3. Patient #10 had a hospice admission date of 10/29/19 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/15/22 to 4/15/22 and 4/16/22 to 6/14/22, included physician orders for medications, including Morphine, oxycodone and Lorazepam. b. The IDG meetings, dated 3/1, 3/15, 3/29/22 and 4/12/22, included documentation of completed DRR. The clinical record lacked documentation of the identification of potential interactions between Morphine and Lorazepam. The DRRs failed to include an accurate and complete review of all the patient's medications. 4. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: a. The patient's paper chart clinical record included documentation of physician orders for 16 medications, all with a start date of 12/23/21. b. The initial IDG meeting, dated 12/30/21, included documentation the IDG members completed a DRR. The DRR form, dated 12/30/21, included documentation of a DRR completed in conjunction with the IDG meeting and signed by a RN. c. The clinical record lacked documentation of a DRR completed prior to 12/30/21 (2 days late for the initial DRR). On 5/2/22 at 1:43 PM, during an interview, the Clinical Manager reported the initial DRR completed by the pharmacy, dated 12/26/21, was in the computer system, but not in the patient's clinical record. The pharmacy report lacked a signature of review by a RN. 5. Patient #1 had a hospice admission date of 1/28/22 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The initial Interdisciplinary Group (IDG) meeting note, dated 1/25/22 to 2/1/22, included a list of current medications that included tessalon perles (cough medicine), benzonatate (cough medicine), robitussin cough and cold (cough medicine); losartan (high blood pressure medicine), metoprolol (high blood pressure medicine) and synthroid (thyroid hormone, associated with laboratory monitoring). b. Palliative Drug Care Company (PDC Rx) medication profile review sheet, dated 1/30/22, signed by registered nurse (RN), dated 2/2/22, included a drug regimen review (DRR) with check boxes for duplicate drug therapy and drug therapy currently associated with lab monitoring, checked. c. The IDG meeting notes, dated 2/15/22, 3/1/22, 3/15/22, 3/29/22, 4/12/22 and 4/19/22, included a DRR that identified no new duplicate drug therapy and no labs ordered/scheduled. The DRR failed to identify what specific medications were duplicate drug therapy and what specific medication was associated with laboratory monitoring. 6. Patient #5 had a hospice admission date of 11/1/21 and received hospice services while residing in a private residence and the hospice house. Review of the clinical record revealed the following: a. The initial interdisciplinary care plan dated, 11/1/22 to 1/29/22 identified medications. b. The patient medication profile dated 11/30/21 to 4/25/22, identified the following medications currently used by the patient: i. Tussin DM and Tessalon Perles for cough. ii. Morphine and Acetaminophen for pain. iii. Morphine and Lorazepam The same medication profile failed to identify duplicate drug therapy and actual or potential drug interactions. c. The drug regimen reviews dated 2/24, 3/10, 3/24, 4/7, and 4/21/22 completed by the RN, registered nurse, failed to identify duplicate medications the patient is currently using and failed to identify actual or potential drug interactions. d. The Interdisciplinary Group (IDG) meeting notes dated and 3/3 to 3/10/22, 3/17 to 3/24/22, 3/31 to 4/7/22 and 4/14 to 4/21/22 noted the drug regimen review, failed to identify duplicate medications and actual or potential drug interactions. The hospice failed to complete all requirements of the drug regimen review including duplicate medications and actual or potential drug interactions. 7. Patient #14 had a hospice admission date of 12/1/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial interdisciplinary care plan dated, 12/3/21 failed to identify medications. b. The Interdisciplinary Group (IDG) meeting notes dated 12/01 to 12/15/21, 12/23 to 12/30/21, 12/30/21 to 01/06/22, 01/06 to 01/13/22 and 01/13 to 01/20/22 identified current medications taken by the patient: metformin 500 mg tablet, gabapentin 100 mg capsule, trazadone 50 mg tablet carvedilol 25 mg tablet, lantus U-100 insulin, warfarin 3 mg tablet, hydrochlorothiazide 25 mg tablet, furosemide 20 mg tablet escitalopram oxalate 20 mg tablet, entresto 49-51 mg tablet, tylenol arthritis pain 650 mg tablet ER, aspirin low dose 81 mg tablet, centrum silver vitamin, morphine 10 mg/5 ml solution, and oxygen 2L. The drug regimen review was noted by the physician. c. The drug regimen reviews dated 12/22, 12/30/21 and 1/6/22 completed by the RN, registered nurse, failed to identify duplicate medications the patient is currently using for pain; morphine and trazadone and for blood pressure; carvedilol and hydrochlorothiazide. The hospice failed to identify duplicate 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 clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice Interdisciplinary Group members provided care in accordance with the patient's plan of care for 3 of 16 sampled (Patients #11, #12 and #13). Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 7/2016, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice IDG and attending physician. 1. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: a. The initial/comprehensive assessment completed by a registered nurse (RN), dated 12/23/21, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and a co-morbid diagnosis of congestive heart failure (symptoms include fluid retention and weight gain). The assessment did not include a weight of the patient. 1) The POC, dated 12/23/21, included orders for the skilled nurse to monitor the patient's weight. 2) The skilled nursing visits, dated 1/12, 1/21, 1/24, 1/31, 2/2, 2/4, 2/9, 2/11 and 2/16/22, failed to include any documentation to indicate the nurses were monitoring the patient's weight. b. A skilled nursing visit, dated 2/18/22, included documentation the nurse started a 16 French Foley urinary catheter with a 10 milliliter bulb inflation amount. The visit note and clinical record lacked documentation of a physician order for the catheter. On 5/2/22 at 1:43 PM, during an interview, the Clinical Manager confirmed the nurses had missed monitoring the patient's weight every visit. She reported the patient's RN did not realize when the POC did not specify a frequency for monitoring the patient's weight, this meant she needed to monitor the patient's weight every visit. She confirmed the inability to find an order for the urinary catheter. 2. Patient #13 had a hospice admission date of 1/11/22, a revocation date of 3/10/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Skilled nurse visit note, dated 2/8/22, included documentation of a left buttock wound and a foam dressing used for wound care. b. Skilled nurse visit note, dated 2/21/22, included documentation of a left buttock wound, cleansed with soap and water and foam dressing applied. The clinical record lacked documentation of an interim physician order for wound care to left buttock wound. 3. Patient #11 had a hospice admission date of 3/10/22 and received hospice services from the Waterloo parent office while residing in a private home residence. Clinical record review revealed: a. IDG updates to the POC, dated 3/15/22, 3/29/22, and 4/12/22, included orders for skilled nursing services two times per week. b. The skilled nursing visit notes, dated 3/28/22, 4/4/22, 4/7/22, 4/11/22, 4/14/22, 4/18/22, and 4/21/22, documented the patient's use of 2 L of oxygen as needed and documented the patient wears oxygen at night time. c. IDG updates to the POC, dated 3/15/22, 3/29/22, and 4/12/22, included orders for oxygen 2 liters (L) continuously via nasal cannula, stating the patient may remove for short periods of time. The clinical record lacked an updated order for the use of the oxygen as needed and only at night. Hospice staff furnished services to the patient without collaborating with the attending physician and receiving an order for the change in oxygen. 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 hospice staff interview, the hospice failed to ensure the Plan of Care and all updates included a specific frequency for the planned delivery of hospice services for 7 of 16 sampled patients (Patients #2, #4, #6, #9, #10, #12, and #14). Failure to establish an individualized Plan of Care placed patients at a potential risk of receiving medications, treatments and/or services that did not adequately meet the needs of hospice patients. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 7/2016, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice Interdisciplinary Group (IDG) and attending physician. The POC specifies the services necessary to meet the needs of the patient and caregiver. 1. Patient #6 had an admission date of 3/19/2022 and received services from the Grundy Center multiple location while residing in a nursing home. Clinical record review revealed: a. The general clinical note, dated 3/21/2022, documented a plan for the skilled nurse to visit the patient twice weekly. b. The initial Interdisciplinary Group (IDG) Plan of Care, dated 3/19/2022, and the updates to the Plan of Care, dated 3/24/2022, 4/7/2022 and 4/21/2022, lacked a planned frequency for skilled nursing visits. c. The clinical record included documentation of skilled nurse visit notes twice weekly from 3/19/2022 through the end of the survey. The hospice IDG failed to include and approve the planned frequency for skilled nurse visits as part of the Plan of Care. During hospice staff interview on 4/26/2022 at 12:50 PM, Staff E, Registered Nurse (RN) Grundy Center Manager, reported she was unable to find inclusion of the skilled nurse planned frequency for visits in the initial Plan of Care and all updates as identified above when she reviewed the patient's electronic clinical record. 2. Patient #2 had a hospice admission date of 12/22/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, 2/24/22, included IDG orders for skilled nursing services 2 times a week and prn (as needed), social services 1 time biweekly and prn and chaplain services 1 time a month. b. The music therapy visit notes, dated 2/21/22, 3/7, 3/21/22, 4/4 and 4/19/22, included documentation the patient had received music therapy services. c. The IDG meetings to update the POC, dated 2/24/22, 3/9, 3/24/22, 4/7 and 4/21/22, documented skilled nursing and social services services "as needed" and lacked documentation of an IDG order for a frequency of the skilled nursing and social services. The POC failed to identify specific frequencies for music therapy visit. 3. Patient #4 had a hospice admission date of 3/24/22 and received hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 3/31/22, included IDG orders for hospice aide 4 times a week, skilled nursing services 2 times a week and "as needed" and social services 1 time every 2 weeks. b. The IDG meetings to update the POC, dated 4/14/22, documented skilled nursing services "as needed" and lacked documentation of an IDG order for a frequency of the skilled nursing. The POC failed to identify specific frequencies for skilled nursing visits. 4. Patient #10 had a hospice admission date of 10/29/19 and received hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The IDG meeting notes, 3/1/22, included IDG orders for skilled nursing services 2 times a week and "as needed", social services 1 times a month and "as needed" and chaplain services 1 time a week and "as needed" and lacked documentation of an IDG order for a frequency of the chaplain and social services. b. The music therapy visit notes, dated 2/24/22, 3/15/22 and 4/4/22, included documentation the patient had received music therapy services. c. The IDG meetings to update the POC, dated 3/1, 3/15, 3/31/22 and 4/12/22, documented lacked documentation of an IDG order for a frequency of the music therapy services. The POC failed to identify specific frequencies for music therapy visit. 5. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: a. The POC, dated 12/23/21, included IDG orders for goals and interventions for skilled nursing. The POC included an update, dated 12/27/21 with social work interventions and goals, and an update, dated 1/3/22, with spiritual care counseling (SCC) services goals and interventions. The POC did not identify a frequency for services. b. The initial IDG meeting, dated 12/30/21, included IDG orders for skilled nursing 1 time per week, social worker 2 times per month and PRN (as needed) without a specific number or range of PRN visits anticipated. The SCC reported an inability to meet and a plan to meet with the patient/caregiver the next week. c. The IDG meeting, dated 1/12/22, included IDG orders for the skilled nurse to provide services one time per week, the social worker and SCC to provide services bi-weekly. The meeting included documentation of conflicting orders for the social worker to provide services 2 times per month and PRN and the SCC to provide services 1 time the first week beginning 1/13/22 and then PRN. d. The IDG meeting, dated 1/27/22, included IDG orders for the skilled nurse to provide services 3 times per week, the social worker to provide services bi-weekly and SCC 2 times per month. The meeting included documentation of conflicting orders for the skilled nurse to provide services 2 to 3 times per week, the social worker to provide services 2 times per month and PRN, and included orders for SCC to provide an unspecified amount of PRN visits along with visits 2 times per month. e. The IDG meeting, dated 2/11/22, included IDG orders for the skilled nurse to provide services 3 times per week and conflicting orders for the skilled nurse to provide services 2 times per week. The meeting included IDG orders for social work services 1 time bi-weekly and orders for 2 times per month and an unspecified amount of PRN visits. The meeting included IDG orders for SCC services 2 times per month and an unspecified amount of PRN visits. 5/2/22 at 1:43 PM, during an interview, the Clinical Manager explained they recognized they had a problem with putting in frequencies in relation to their new software system. They were working with the software company on fixing issues and with staff on how to enter information into the system. 6. Patient #9 had a hospice admission date of 12/17/21 and received hospice services from the Waverly location while residing in a private residence. Review of the clinical record revealed the following: a. The initial plan of care, dated 12/17/2021 to 3/16/2022 failed to include physician orders for frequencies for skilled nursing, social worker or chaplain services. b. The Interdisciplinary Group (IDG) meeting notes dated 12/16 to 12/23/21, 2/24 to 3/3/22, 3/10 to 3/17/22, 3/24 to 3/31/22 and 4/7 to 4/14/22 included orders for skilled nurse 1 time per week and prn, social worker 1 time every 2 weeks and chaplain 1 time per month. Hospice aide services starting 3/30/22 1 time per week. The same IDG meeting notes failed to identify music therapy orders for services. c. The Music Therapy notes dated 2/25, 3/31 and 4/22 identified a frequency for services 1 time every 2 weeks. The hospice plan of care failed to identify orders for music therapy. 7. Patient #14 had a hospice admission date of 12/1/21 transferred to another hospice on 1/18/22 and received hospice services while residing in a private residence and at the hospice house. Review of the clinical record revealed the following: a. The initial plan of care, dated 12/1/2021 to 1/18/2022 failed to include physician orders for frequencies for skilled nursing, social worker or chaplain services. b. The Interdisciplinary Group (IDG) meeting notes dated 12/01 to 12/15/21 failed to include orders for skilled nurse services , 12/23 to 12/30/21 failed to include orders for social worker services, 01/06 to 01/13/22 failed to include orders for social worker services and 01/13 to 01/20/22 failed to include orders for skilled nurse, social worker or hospice aide. c. The skilled nurse visit notes identified the skilled nurse performed visits dated 12/3, 12/8, 12/14, 12/15/21, 1/13, 1/14, 1/15, 1/16, 1/17, and 1/18/22. d. The social worker visit notes identified the social worker performed visits dated 12/30/21 and 1/12/22. e. The hospice aide visit notes identified the hospice aide performed visits dated 1/13, 1/14, 1/15, 1/16 and 1/17/22. The hospice plan of care failed to accurately identify the services the patient received. 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 Interdisciplinary Group failed to establish patient-specific and measurable outcomes as goals to reach from the implementation of interventions on the Plan of Care in order to manage to the patient condition regarding music therapy services for 4 of 4 sampled patients with music therapy services (Patients #1, #2, #10 and #13). Failure by the hospice Interdisciplinary Group (IDG) music therapist to establish measurable and patient-specific outcome goals increased the risk hospice personnel would not recognize unmet patient needs and/or satisfactory palliation of the patient's symptoms. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 7/2016, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice Interdisciplinary Group (IDG) and attending physician. The POC specifies the services necessary to meet the needs of the patient and caregiver. Review of the hospice's policy, titled Interdisciplinary Team, dated 12/2008, the IDG is responsible for establishing, implementing, reviewing and revising the patient's POC. The IDG is responsible for providing and coordinating care and services in accordance with the patient's POC. 1. Patient #2 had a hospice admission date of 12/22/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, 2/24/22, included IDG orders for skilled nursing services 2 times a week, social services 1 time biweekly and chaplain services 1 time a month. b. The music therapy visit notes, dated 2/21/22, 3/7, 3/21/22, 4/4 and 4/19/22, included documentation the patient had received music therapy services. The Plan of Care, dated 12/22/21 to 3/21/22 and 3/22/22 to 6/19/22, identified goals of a Plan of Care will be established that meets the patient needs. The Plan of Cares failed to identify measurable outcomes related to the goals for music therapy. 2. Patient #10 had a hospice admission date of 10/29/19 and received hospice services while residing in a private home residence. Review of the clinical record revealed the following: a. The IDG meeting notes, 3/1/22, included IDG orders for hospice aide services 2 times a week, social services 1 times a month and as needed and chaplain services 1 time a week and as needed. b. The music therapy visit notes, dated 2/24/22, 3/15/22 and 4/4/22, included documentation the patient had received music therapy services. The Plan of Care, dated 2/15/22 to 4/15/22 and 4/16/22 to 6/14/22, identified goals of a Plan of Care will be established that meets the patient needs. The Plans of Care failed to identify measurable outcomes related to the goals for music therapy. 3. Patient #1 had a hospice admission date of 1/28/22 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. Referral for music therapy, dated 2/4/22. b. The Interdisciplinary Group (IDG) meeting notes, dated 2/15/22, 3/1/22, 3/15/22, 3/29/22, 4/12/22, 4/19/22 and 4/26/22, included documentation of music therapy frequency of 2 times a month but lacked documentation of goals and interventions for music therapy. 4. Patient #13 had a hospice admission date of 1/11/22, a revocation date of 3/10/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting note, dated 1/6/22 through 1/13/22, included documentation of music therapy to visit to offer improved quality of life but lacked documentation of music therapy frequency, goals and interventions. b. IDG meeting notes, dated 1/20/22 through 1/27/22, 2/3/22 through 2/10/22, 2/17/22 through 2/24/22 and 3/3/22 through 3/10/22, included documentation of music therapy to visit to offer improved quality of life but lacked documentation of music therapy frequency, goals and interventions. 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 policy review, clinical record review, and hospice staff interview, the hospice failed to ensure the Plan of Care included all medical equipment and supplies necessary to meet identified patient needs for 5 of 16 sampled patients (Patients #1, #4, #6, #7, and #13). Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 7/2016, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice Interdisciplinary Group (IDG) and attending physician. The POC specifies the care and services necessary to meet the needs of the patient and caregiver. 1. Patient #6 had a hospice admission date of 3/19/2022 and received hospice services from the Grundy Center multiple location while residing in a nursing home. The clinical record review revealed the following: a. The initial assessment, dated 3/19/2022, identified the patient used incontinence briefs. b. The history and physical, completed by the patient's physician on 2/3/2022, documented the patient was legally blind, requiring a white cane when ambulating. c. The Interdisciplinary Group (IDG) updates to the Plan of Care, dated 3/24/2022, 4/7/2022 and 4/21/2022, lacked identification of the patient's use of the incontinence briefs or the white cane used by the patient with ambulation. During hospice staff interview on 4/26/2022 at 12:50 PM, Staff E, Registered Nurse (RN) Grundy Center Manager, reported an inability to find the patient's use of the incontinence briefs and white cane identified in the Plans of Care as equipment used by the patient when she reviewed the patient's electronic clinical record. 2. Patient #4 had a hospice admission date of 3/24/22 and received hospice services and received services in a private home residence. Review of the clinical record revealed the following: a. The POC, dated 3/24/22 to 6/22/22, identified the patient had a wheeled walker commode and gloves for medical equipment and supplies. b. The IDG meeting, dated 3/31/22 and 4/14/22, did not identify any additional medical equipment and supplies used by the patient. On 4/26/22 at 3:45 PM, during a nursing home visit observation with Staff F, Registered Nurse (RN) the surveyor identified the patient also used a lifeline. In an interview, during the same nursing home visit observation, the patient stated he/she used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 3. Patient #1 had a hospice admission date of 1/28/22 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 3/1/22, included documentation the patient had bedside commode, hospital bed, half bed rails, wheeled walker, wheelchair and incontinent briefs, as medical equipment and supplies use by the patient. b. During a home observation visit on 4/26/22 at 9:05 AM, with Staff G, RN, the surveyor observed a shower chair, hand held shower head, and grab bars in the bathroom. Staff G reported the hospice aide assisted the patient with showering using this equipment. c. The Interdisciplinary Group (IDG) meeting notes, dated 1/25/22 to 2/1/22, 2/8/22 to 2/15/22, 2/22/22 to 3/1/22, 3/8/22 to 3/15/22, 3/22/22 to 3/29/22, 4/5/22 to 4/12/22, 4/12/22 to 4/19/22, and 4/19/22 to 4/26/22, failed to identify shower chair, hand held shower head, and grab bars, as medical equipment and supplies use by the patient. The Plan of Care failed to identify all current medical equipment and supplies used by the patient. 4. Patient #13 had a hospice admission date of 1/11/22, a revocation date of 3/10/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 1/11/22, lacked documentation of medical equipment and supplies used by the patient. b. The Plan of Care, updated 2/11/22, included medical equipment and supplies use by the patient. The IDG meeting notes, dated 1/6/22 through 1/13/22, 1/13/22 through 1/20/22, 1/20/22 through 1/27/22 and 2/3/22 through 2/10/22; lacked documentation of medical equipment and supplies used by the patient. 5. Patient #7 had a hospice admission date of 7/28/2021 and received hospice services from the Waverly multiple location while residing in a private home residence. The clinical record review revealed the following: a. The skilled nurse visit notes, dated 3/7/22, 3/23/22, and 4/6/22, documented the nurse noted moderate amount of foul smelling drainage on the old dressings and chux underneath the patient. b. The Interdisciplinary Group (IDG) updates to the Plan of Care, dated 3/29/22, and 4/12/2022, lacked identification of incontinence supplies (chux) as supplies needed to meet the patient's needs. Interview on 5/2/22 at 10:04 AM, with Staff F, revealed she added chux to the list of supplies used by the patient this weekend after she was told by the Clinical Manager the surveyor did not find them. 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 policy review, clinical record review, and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 9 of 16 sampled patients (Patients #1, #2, #3, #8, #9, #12, #13, #14, and #15). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 7/2016, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice Interdisciplinary Group (IDG) and attending physician. Review of the hospice's policy, titled Interdisciplinary Team, dated 12/2008, the IDG is responsible for establishing, implementing, reviewing and revising the patient's POC. The IDG is responsible for providing and coordinating care and services in accordance with the patient's POC. 1. Patient #3 had a hospice admission date of 10/30/2022 and received hospice services from the Grundy Center multiple location while residing in a private home residence. Clinical record review revealed the following: a. The IDG update to the Plan of Care, dated 3/9/2022, included IDG approval to provide hospice aide visits 5 times per week. b. The clinical record included documentation of 4 hospice aide visit notes, dated 3/14, 3/15, 3/17 and 3/18/2022, during the week of 3/13-19/2022. c. The electronic clinical record lacked documentation of any communication with the IDG members between 3/16/2022, the date of the missed visit, and the next IDG meeting on 3/24/2022. d. The IDG update to the Plan of Care, dated 3/24/2022, lacked documentation indicating the IDG was aware of the missed hospice aide visit and/or approved the missed visit. 2. Patient #2 had a hospice admission date of 4/22/21, and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting note, dated 2/24/22, 3/9, 3/24/22, 4/7/22 and 4/21/22, included documentation the IDG had ordered skilled nursing services 2 times a week. The week of 3/13/22 to 3/19/22 included documentation of 1 skilled nurse visit. The IDG meeting note, dated 3/24/22, lacked documentation the IDG was aware of the missed skilled nurse visit on 3/16/22. 3. Patient #15 had a hospice admission date of 1/18/22, a discharge date of 4/16/22, and received hospice services while residing in a private home. Clinical record review revealed: a. IDG meeting note, dated 2/17/22, 3/3, 3/17, 3/31/22 and 4/14/22, included documentation the IDG had ordered hospice aide services 3 times a week. The week of 2/13/22 to 2/19/22 included documentation of 2 hospice aide visits. The IDG meeting note, dated 2/17/22 and 3/3/22, lacked documentation the IDG was aware of the missed hospice aide visit on 2/15/22. 4. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: a. The POC, dated 12/23/21, included IDG orders for skilled nursing, spiritual care counseling and social worker services. b. The initial IDG meeting, dated 12/30/21, included IDG orders for skilled nursing 1 time per week. c. The week of 1/3/22, included documentation of 2 skilled nursing visits, dated 1/4 and 1/5/22. d. The IDG meeting, dated 1/12/22, included IDG orders for the skilled nurse to provide services one time per week and did not include documentation which identified the IDG members' awareness of the extra skilled nursing visit the week of 1/3/22. e. The week of 1/16/22, included documentation of 2 skilled nursing visits, dated 1/19 and 1/21/22. f. The IDG meeting, dated 1/27/22, included conflicting IDG orders for the skilled nurse to provide services 3 times per week and to provide services 2 to 3 times per week starting the week of 1/27/22. The meeting notes lacked documentation of IDG awareness of the extra skilled nursing visit the week of 1/16/22. 5. Patient #1 had a hospice admission date of 1/28/22 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. Progress note, dated 3/29/22, included documentation of a missed nursing visit on 3/29/22. The Interdisciplinary Group (IDG) meeting note, dated 4/12/22, failed to identify the missed nursing visit on 3/29/22. b. IDG meeting notes, dated 3/1/22 and 3/29/22, included skilled nursing frequency of 2 times a week with an effective date of 2/1/22. The weeks of 2/27/22 through 3/5/22 and 4/10/22 through 4/16/22, included one skilled nursing visit and failed to include documentation of a missed nursing visit for the week. The IDG meeting notes failed to identify all discipline frequency updates including interim physician orders and missed visits. 6. Patient #8 had a hospice admission date of 12/23/21 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting notes, dated 2/8/22 through 2/15/22, 2/15/22 through 2/22/22, 3/1/22 through 3/8/22, 3/15/22 through 3/22/22; included a skilled nurse frequency of 2 times a week with an effective date of 12/27/21. b. The weeks of 2/20/22 through 2/26/22, 2/27/22 through 3/5/22, 3/6/22 through 3/12/22, 3/13/22 through 3/19/22 and 3/20/22 through 3/26/22; included one skilled nursing visit per week and failed to include documentation of a missed nursing visit for the week. c. IDG meeting note, dated 3/29/22 through 4/5/22, included a chaplain frequency of 1 time a month and a narrative note that included a chaplain frequency of 2 times a month and prn (as needed), creating conflicting order frequency. d. The month of April included 2 chaplain visits and the IDG meeting notes failed to include documentation of a physician order for the extra chaplain visit in April. e. IDG meeting notes, dated 2/8/22 through 2/15/22, 2/15/22 through 2/22/22, 3/1/22 through 3/8/22, 3/15/22 through 3/22/22, 3/29/22 through 4/5/22, 4/5/22 through 4/12/22, 4/12/22 through 4/19/22; included social work visit frequency of 1 time bi-weekly and a narrative note that included a social work frequency of 2 times a month and prn, creating conflicting order frequency. The IDG meeting notes failed to identify missed/extra visits and current visit frequency. 7. Patient #13 had a hospice admission date of 1/11/22, a revocation date of 3/10/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting notes, dated 2/3/22 through 2/10/22 and 2/17/22 through 2/24/22, included a chaplain visit frequency of 1 time a month and a narrative note that included a chaplain frequency of 1 time a month and prn, creating conflicting order frequency. b. The month of February included 2 chaplain visits and the IDG meeting notes failed to include documentation of a physician order for the extra chaplain visit in February. 8. Patient #9 had a hospice admission date of 12/17/21 and received hospice services from the Waverly location while residing in a private residence. Review of the clinical record revealed the following: a. The initial plan of care, dated 12/17/2021 to 3/16/2022 failed to include physician orders for frequencies for skilled nursing, social worker or chaplain services. b. The Interdisciplinary Group (IDG) meeting notes dated 12/16 to 12/23/21, 2/24 to 3/3/22, 3/10 to 3/17/22, 3/24 to 3/31/22 and 4/7 to 4/14/22 included orders for skilled nurse 1 time per week and prn, social worker 1 time every 2 weeks and chaplain 1 time per month. Hospice aide services starting 3/30/22 1 time per week. c. Skilled nurse visit notes documented the nurse performed 2 visits per week dated 2/23, 2/25, 3/8, 3/11, 3/15, 3/18, 3/29, 4/1, 4/12 and 4/15. The hospice failed to ensure that the care and services are provided in accordance with the plan of care. 9. Patient #14 had a hospice admission date of 12/1/21 transferred to another hospice on 1/18/22 and received hospice services while residing in a private residence and at the hospice house. Review of the clinical record revealed the following: a. The initial plan of care, dated 12/1/2021 to 1/18/2022 failed to include orders for hospice aide services. b. The Interdisciplinary Group (IDG) meeting notes dated 12/01 to 12/15/21, 12/23 to 12/30/21, 01/06 to 01/13/22 included orders for hospice aide services 5 times a week. c. Hospice aide visit documentation identified 4 of 5 visits performed the weeks of 12/26/21 to 01/01/21 and 1/2 to 1/8/22. The hospice failed to ensure that the care and services are provided in accordance with the plan of care. 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 ensure patient clinical records included a physician order for all treatments for 2 of 16 sampled patients (Patients #7 and #12). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: Review of the hospice's policy, titled Documentation Requirements, dated 10/21, identified hospice staff are to complete all documentation, including contact with a physician or healthcare provider within 24 hours of the contact. 1. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office while residing in a private residence and died on 2/20/22. Review of the clinical record revealed the following: a. The skilled nursing phone call notes, dated 1/1/22, included documentation the patient was having difficulty with an elevated blood pressure and pulse. The nurse documented she contacted the physician and got a one time order for Carvedilol 12.5 milligrams (mg) 1 tab by mouth. The clinical record lacked documentation the nurse wrote the verbal order and signature of the physician giving the order. b. An interim physician order, dated 2/17/22, included orders for Morphine 20 mg per milliliter (ml) 5 to 10 mg by mouth or sublingual every 2 hours as needed and Lorazepam 2 mg/ml 0.5 to 1 mg by mouth or sublingual every 2 hours as needed. The orders failed to include directions for how the patient/caregiver should know which dose to administer the medications since the medications both included a range of doses. On 5/2/22 at 1:43 PM, during an interview, the Clinical Manager agreed the Morphine and Lorazepam orders lacked specific direction for administering the medications. She was unable to find a signed, written order for the one time Carvedilol order. 2. Patient #7 had a hospice admission date of 7/28/21 and received hospice services from the Waverly multiple location while residing in a private residential home. The clinical record review revealed the following: a. The initial comprehensive assessment completed by the nurse on 7/28/21, documented the patient was a quadriplegic for the past 20 years and had a suprapubic catheter. b. The initial Plan of Care, dated 7/29/21, lacked documentation of an order for the suprapubic catheter. c. The skilled nurse visit note, dated 3/2/22, documented the patient had a 24 french catheter in place inserted on 2/14/22 and due to be changed on 3/14/22. d. The skilled nurse progress note, dated 3/7/22, documented the suprapubic catheter was changed last night due to the catheter leaking. e. The skilled nurse visit note, dated 4/6/22, documented the suprapubic catheter was changed by family last night. The hospice lacked an order to identify the size of the catheter, frequency of catheter changes and who is responsible for catheter changes. Interview on 5/2/22 at 10:04 AM, with Staff F, Registered Nurse (RN), revealed the patient did have a suprapubic catheter since admission and the nurse had checked and was unable to find any orders for the catheter. The nurse stated the family usually changed the catheter for the patient, but the nurse would also irrigate the suprapubic catheter on occasion if the patient became ornery or agitated with 60 cc of normal saline. She stated she added orders for the suprapubic catheter this weekend to the chart after discussion with the Clinical Manager regarding the surveyor not finding an order.. f. IDG updates to the POC, dated 3/15/22, 3/29/22, and 4/12/22, included orders for skilled nursing services two times per week. g. The on call nursing record note, dated 3/13/22, documented a phone call was received from patient's caregiver regarding frequency and urgency with urination with concerns of a urinary tract infection. The nurse documented contacting the on call primary care provider and received a new order for a urinalysis with culture and sensitivity. h. The general note, dated 3/13/22 included documentation by the nurse made a visit to pick up the urine specimen collected by the family. The clinical record lacked a signed order for the urinalysis and culture and sensitivity by the provider. Interview on 5/2/22 at 12:04 PM with the hospice Clinical Manager reported they obtained the order from the provider. The hospice Clinical Manager confirmed the order was not in the chart originally. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional 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 disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients (Patients #7 and #12) who received routine home care while living in a private home and had physician ordered controlled medications, not on admission, but some time after the patient's admission to hospice. 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. Findings include: Review of the hospice policy, titled Disposal of Controlled Medications, dated 7/2016, identified the hospice staff would provide the policy and instruct the patient/ caregiver on disposal of controlled medications (medications which distribution and use are controlled by the government) based on Federal guidelines. The policy identified hospice staff would provide the written information and instruction with the patient's admission packet On 5/2/22 at 1:43 PM, during an interview, the Clinical Manager and Administrator reported the nurses provided information in writing and verbally to the patient/caregiver on the disposal of medications at the time of the patient's admission to hospice. 1. Patient #12 had a hospice admission date of 12/23/21, received hospice services from the Waterloo parent office and died on 2/20/22. Review of the clinical record revealed the following: a. The patient's paper chart clinical record included documentation of physician orders for 16 medications, all with a start date of 12/23/21. None of the ordered medications were a controlled medication. b. The comprehensive assessment completed by a RN, dated 12/23/21, lacked documentation the nurse provided the patient or caregiver instructions verbally and writing on the disposal of controlled medications per hospice policy. c. An interim physician order, dated 1/4/22, included an order for Morphine, a controlled medication. d. The skilled nursing visit note, dated 1/4/22, identified the patient had a new order for Morphine and had received the medication. The visit note and clinical record lacked documentation the nurse provided instruction or written material on the disposal of controlled medications per Federal regulation. 2. Patient #7 had a hospice admission date of 7/28/2021 and received hospice services from the Waverly multiple location office while residing in a private home residence. Clinical record review revealed: The Plan of Care, dated 1/24/22 to 3/24/22, included IDG orders for skilled nursing services. The IDG update to the POC, dated 2/3/22, included orders for Morphine concentrate 20 milligrams (mg) per 1 milliliter (ml) and orders to administer 5 mg every 1 hour as needed. The visit notes lacked documentation the nurse provided the written policy and education on the disposal of controlled medications to the patient/caregiver. Interview on 5/2/22 at 10:04 AM with Staff F, Registered Nurse (RN), reported the nurse found out from Clinical Manager that no documentation was done when the morphine was initiated about providing the written policy and education on disposal of the controlled medications. The nurse stated the old electronic health record had a simple box to check and got used to that so has not been documenting anything when controlled medications are initiated. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on observation and interview, the hospice failed to ensure food items stored had not expired and expired food was not prepared and served to hospice patients at the hospice house. The hospice reported 1 current patient residing at the hospice house at the time of the survey. Failure to ensure food items stored were not expired placed the hospice patients at risk of potentially receiving and consuming expired food items which were not palatable and attractive. Findings include: On 4/25/21, beginning at 11:07 AM, during an observational tour of the facility with Staff C, the hospice house manager, the surveyor observed the following expired food items in the patient kitchen area in the refrigerator, freezer and dry storage cabinet: 9 undated snack size zip lock bags of frozen applesauce, 1 undated Ziploc bag containing 6 breadsticks, 3 undated hot pockets, 1 undated container labeled powder sugar, 1 undated container labeled pancake mix, 1 undated container labeled rice krispees, 1 undated container labeled raisin bran, 1 undated container labeled cheerios, 1 undated container labeled mashed potatoes, 1 undated container labeled sugar, special k dated 10/21, malto meal dated 2/21, 1 can stax chips dated 3/21, 14 undated popsicles, carnation essentials drink mix dated 8/21, 1 ensure enlive beverage dated 7/21, 4 barqs rootbeer floats dated 3/21, 1 bottle A/W rootbeer dated 7/21, A1 sauce dated 12/21, pickles dated 8/21, spaghetti noodles dated 10/21 1 bottle grape juice dated 12/21, shake and bake chicken coating dated 7/2020, frozen carrots dated 2/22, 1 progresso bread crumbs dated 1/22, 1 progresso bread crumbs dated 1/21, malted chocolate milk mix dated 8/21, malted milk mix dated 7/21, peanut butter smart balance dated 2/21, minced garlic dated 1/19, garlic powder dated 7/2020, Mrs dash dated 9/21, cumin dated 10/2020, 2 containers beef bullion dated 1/2020, kayro syrup dated 1/19, canned sliced potatoes dated 2/21, canned red grapefruit dated 7/21, sliced almonds dated 9/2020, undated poultry seasoning, undated cinnamon and undated black pepper. In an interview during the same observational tour, the Hospice House Manager revealed hospice staff prep the food in the kitchen for patients that are eating. Hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, surveyor observation, nursing home clinical record review and hospice policy review, the hospice failed to maintain all required hospice documents/information at the long term care facilities where hospice patients reside for 1 of 2 patients receiving surveyor on-site visit to the nursing home (Patient #6). Failure to communicate hospice information to long term care staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: Review of the hospice's policy, titled Coordination of Services, dated 12/2008, identified the Interdisciplinary Group ensures there is a coordinated effort and effective ongoing sharing of information with all contracted service providers in all settings. Patient #6 had a hospice admission date of 3/19/2022 and received hospice services from the Grundy Center multiple location while residing in a nursing home. The Interdisciplinary Group (IDG) updates to the Plan of Care, dated 3/24/2022, 4/7/2022 and 4/21/2022, documented Patient #6 received skilled nursing, medical social work and spiritual care services from the hospice. On 4/26/2022 at 2:40 PM, while accompanied by Staff D, Registered Nurse Manager, the surveyor reviewed Patient #6's hospice nursing home chart. During chart review, the surveyor observed the chart was labeled with a hospice form attached to the front cover of the binder and on the inside of the binder. The label gave directions to the nursing home staff of reasons to contact the hospice and included a toll-free number to use for contact. The form also included spaces to identify the names of the hospice staff caring for Patient #6. The space available on both copies of the form were left blank. The clinical record lacked documentation identifying the staff caring for Patient #6. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #2 had a hospice admission date of 12/22/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The POC, dated 3/22/22 to 6/19/22, included orders for skilled nursing, social work and chaplain services. On 4/27/22 at 9:30 AM, during a home visit at the patient's nursing home, the surveyor requested to review the information in the hospice's chart for the patient provided for the nursing home staff and maintained at the nursing home. The hospice chart did not include a hospice benefit election form. The Hospice Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.