Every finding on record at Evangelical Lutheran Good Samaritan Society

Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to have all members of the interdisciplinary group (IDG) complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 3 of 14 sampled patients (Patients #1, #4, and #13). Failure to have all disciplines complete the comprehensive assessment within 5 calendar days of the election of hospice care puts patients at risk for inconsistent care that may not meet the needs of the patient.  Findings include: --- 3. Patient #4 had a hospice admission date of 2/18/26 and received hospice services while residing in a private home. Clinical record review revealed:  a. The Hospice Consent and Authorization for Treatment signed by the patient, dated 2/18/26, included an initial visit plan that included chaplain visits 2 times per month.   b.The POC, dated 2/18/26 to 5/18/26, included orders for chaplain services 1 time a month for 1 month and then 2 times a month.  c. The chaplain visit note, dated 2/24/26, occured 5 days after the start of care (1 day late per regulation).  The clinical record failed to include the chaplain visit within 5 calendar days after the hospice consent and authorization was signed.  The above findings reviewed with the Administrator and Clinical Manager.  According to the hospice policy titled Assessments: Initial, Comprehensive and Ongoing Hospice, last reviewed/revised 1/27/25, the comprehensive assessment is completed within 5calendar days after the election of hospice care by the IDG, in consultation with the patient’s attending physician (if any).   In an interview on 3/24/26 at 1:49 PM, the Administrator reported that the agency has been without a social worker on staff from 1/2/26 until March 2026 when the social worker started working for the agency.     1.Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed:   a.The Hospice Consent and Authorization for Treatment signed by the patient’s representative on 3/16/26 included an initial visit plan that included social worker visits 1 per month.   b.Plan of Care (POC), dated 3/16/26 to 6/13/26, included a primary diagnosis of Alzheimer's disease and physician orders for social work services 1 visit per month for 3 months.   The clinical record review failed to reveal that a social worker visited the patient within 5 calendar days after the election was signed.   2.Patient #13 had a hospice admission date of 2/5/26 and date of death on 3/20/26 and received hospice services while residing in a private home. Clinical record review revealed:   a.The Hospice Consent and Authorization for Treatment signed by the patient’s representative on 2/5/26 included an initial visit plan that included 1 visit per month by the social worker.   b.POC, dated 2/5/26 to 4/5/26, included physician orders for social work services 1 visit per month for 2 months.   The clinical record failed to include that a social worker visited the patient within 5 calendar days after the election was signed.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) Ensure social worker member of the interdisciplinary group participated in all interdisciplinary group meetings. (L541) 2) Ensure physician orders were obtained and wrote for all treatments in the plan of care. (L549) 3) Ensure all medical equipment and supplies were included in the plan of care. (L550) 4) Ensure physician and IDG members were notified of missed visits. (L555) --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group meetings were attended by all core members and plans of care were updated as needed for hospice patients.

Based on clinical record review, interdisciplinary group (IDG) meeting sign-in sheets, hospice policy review and staff interview, the hospice failed to ensure a social worker participated in each interdisciplinary group meeting held over a 3 month time frame (January 2026 through March 2026) and participated in the review and updating of the patient's plan of care through the interdisciplinary team meeting.  Failure of the hospice to ensure all 4 required core members of the interdisciplinary group (IDG) doctor of medicine or osteopathy, registered nurse, social worker and pastoral or other counselor, participated in each IDG meeting placed hospice patients at risk for not having all of their medical needs identified and met. --- Findings include:  According to the hospice policy, titled Interdisciplinary Group Hospice, dated 4/8/25, the core members of the IDG are physician, registered nurse, social worker and pastoral or other counselor.  Review of the hospice's IDG meeting sign-in sheets for 2026, dated 1/13/26, 1/27/26, 2/10/26, 2/24/26, 3/10/26 and 3/24/26, identified a lack of signature of attendance for a social worker.  During an interview on 3/24/26 at 1:49 PM, the Administrator reported the hospice social worker left at the beginning of the year and it took the hospice a while to find a replacement.  No social worker attended IDG meetings since January 2026, a new social worker has been hired and will start seeing patients soon.  The new social worker is a bachelor of social work and will be overseen by the masters of social work staff that work in the affiliated long term care facility.  The Administrator received the above findings.

Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 5 of 14 sampled patients (Patients #4, #6, #7, #9 and #11).   Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms.  Findings include: --- 5. Patient #4 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/18/26 to 5/18/26, identified the patient had a primary diagnosis of interstitial pulmonary disease and included orders for skilled nurse and hospice aide services. The POC also included orders for the skilled nurse to educate the patinet/caregivers regarding care of Foley catheter including: cleaning perineal area properly, emptying catheter bag, placement drain tube for safety during ambulation, cleaning spout and closing drain and if foley isn't draining to contact the facility to assess. b. The skilled nurse note, dated 2/19/26, included documentation the patinet had an indwelling suprapubic catheter #16.  b. The physician's order, dated 3/10/26, included orders for Foley change monthly and flush prn for occlusion. The order included a 16 French foley. The order lacked orders for balloon size.  The hospice failed to include order for the Foley catheter balloon size.  The above findings reviewed with the Administrator and Clinical Manager. 3. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services to educate caregivers in performing wound care.  b. Initial comprehensive assessment, dated 2/18/26, completed by Staff F, RN, identified wound was cleaned, barrier cream applied, covered with mepilex (silicone foam dressing) and patient tolerated well.  c. Interim physician order, dated 3/2/26, included physician direction to clean wound area with soap and water, apply barrier cream, cover with mepilex dressing and use skin prep (transparent film on intact skin to protect against adhesive trauma or friction) to keep mepilex in place.  Family educated and will change dressing every 5-7 days or as needed.  Hospice failed to obtain specific wound care order until 3/2/26, 13 days after wound care performed.  During an interview on 3/31/26 at 11:16 AM, Administrator reported clinical record was reviewed and the initial plan of care lacked specific wound care orders, specific wound care order was obtained on 3/2/26.  4. Patient #11 had a hospice admission date of 1/9/26, a discharge date of 1/28/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 1/9/26 to 4/8/26, included a primary diagnosis of chronic hepatic (liver) failure and physician orders for skilled nurse services.  b. IDG meeting notes, dated 1/13/26 and 1/27/26, lacked physician orders for massage therapy services.  c. Massage therapy visit notes, dated 1/22/26 and 1/26/26, completed by Staff G, Massage Therapist, identified massage therapy services were provided.  Hospice failed to obtain physician orders for massage therapy prior to massage therapy services being provided.  During an interview on 3/31/26 at 11:20 AM, Administrator reported clinical record was reviewed and no massage therapy orders were in the clinical record.   2. Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services.  b. Massage therapy visit notes, dated 2/25/26 and 3/2/26, completed by Staff G, Massage Therapist, identified massage therapy services were performed.    c. The IDG meeting notes, dated 2/24/26 and 3/10/26, lacked documentation of an IDG order for massage therapy.    The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services.    According to hospice policy titled Plan of Care, Hospice, last reviewed/revised 7/30/25, hospice care follows a written Plan of Care (POC) established and reviewed by the Interdisciplinary Group (IDG) in collaboration with the patient’s attending provider, if any.  Services are provided under this POC.  Therapeutic orders are obtained from the attending physician or their designee, according to policy and applicable law and regulation.  The review of and revisions to the POC by the IDG occurs at least every 15 days.  The contents of the POC includes:  interventions to manage pain and symptoms and drugs and treatments necessary to meet the needs of the patient.  In an interview on 3/31/26 at 10:21 AM, the Administrator reported that this was an issue found during the first week in March 2026 where the issue with the missing orders was identified and the agency started working towards correcting this.   1.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following:   a.POC, dated 2/5/26 to 4/5/26, identified the patient had a diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and included orders for skilled nurse and social work services.   b.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 2/24/26, identified a massage therapy evaluation to be completed for pain management.   c. The patient's clinical record included massage therapy visit notes, dated 3/4/26 and 3/9/26, by Staff G, massage therapist.   d.   IDG meeting notes for the patient on 3/10/26 or 3/24/26 lacked massage therapy orders.   The patient’s clinical record failed to reveal orders for the massage therapy visits on 3/4/26 and 3/9/26.    The hospice provided massage services without an order.

Based on home visit observation, patient interviews, clinical record reviews and agency policy review, the hospice failed to ensure the Plans of Care for 4 of 14 sampled patients (Patients #1, #2, #3 and #7) included all medical equipment and supplies necessary to meet identified patient needs.   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: --- 4. Patient #3 had a hospice admission date of 2/3/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/3/26 to 5/3/26, identified the patient had a primary diagnosis of vascular dementia and identified the patient used the following medical equipment and supplies: shower/tub equipment.    b. The skilled nurse initial assessment, dated 2/3/26, completed by Staff F, RN, identified the patient used the following medical equipment and supplies: shower chair.    c. During a home observation visit on 3/24/26 at 2:00 PM with Staff F, RN, the surveyor observed a lift chair in the patient's living room.  An interview with the patient's spouse during the same home observation visit revealed the patient has utilized the  for greater than two months.   The POC failed to identify all necessary medical equipment and supplies used by the patient, including BIPAP, diabetic supplies, raised toilet seat, shower chair and lift chair.    The above findings were reviewed with the Administrator and Clinical Manager.  3. Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed:  a. The POC, dated 3/16/26 to 6/13/26, identified the patient had a diagnosis of Alzheimer’s disease and did not include any supplies and equipment the patient used.  b.Skilled nursing visit note, dated 3/16/26, by Staff D, RN, indicated the supplies and equipment used by the patient included chair lift, grab bars, hospital bed, wheelchair, and pommel cushion.   b. During a home observation visit on 3/24/26 at 12:45 PM, with Staff D the surveyor observed the following supplies and equipment used by the patient and/or stored in the patient’s room for use: disposable overlay for incontinence, bedside table, urinal, wheelchair, pommel cushion, and hospital bed with a positioning rail.   c.In an interview on 3/24/26 at 12:45 PM, Staff D reported that additional equipment supplies and equipment that is used by the patient includes: a sit to stand mechanical lift, incontinence briefs, and shower chair.   d.The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 3/24/26, did not include supplies and equipment used by the patient.  The hospice failed to include all medical equipment and supplies utilized by the patient including disposable overlay for incontinence, bedside table, urinal, wheelchair, pommel cushion, hospital bed with a positioning rail, sit to stand mechanical lift, incontinence briefs, and shower chair in the POC. Review of the hospice policy titled Plan of Care, last revised July 2025, identified the content of the Plan of Care (POC) includes medical supplies and appliances necessary to meet the needs of the patient.    1.Patient #2 had a hospice admission date of 2/5/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/5/26 to 5/5/26, identified the patient had a primary diagnosis of pancreatic cancer and identified the patient used the following medical equipment and supplies: cane and commode.    b. The skilled nurse initial assessment, dated 2/5/26, completed by Staff F, Registered Nurse (RN), identified the patient used the following medical equipment and supplies: bilevel positive airway pressure (BIPAP), diabetic supplies, raised toilet seat and shower chair.    c. During a home observation visit on 3/24/26 at 9:15 AM with Staff E, Licensed Practical Nurse (LPN), the surveyor observed a lift chair in the patient's living room.  An interview with the patient during the same home observation visit revealed the patient has utilized the lift chair for greater than two months.   The POC failed to identify all necessary medical equipment and supplies used by the patient, including BIPAP, diabetic supplies, raised toilet seat, shower chair and lift chair.    2. Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 12/22/25 to 2/19/26, identified the patient had a primary diagnosis of congestive heart failure and identified the patient used the following medical equipment and supplies: grab bars, walker and wheelchair.    b. The skilled nurse initial assessment, dated 12/22/25, completed by Staff D, RN, identified the patient used the following medical equipment and supplies: commode and incontinence products.  The POC failed to identify all necessary medical equipment and supplies used by the patient, including commode and incontinence products.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group 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 3 of 14 sampled patients (Patients #6, #8 and #12).  Failure of the hospice interdisciplinary group (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. --- 3. Patient #8 had a hospice admission date of 9/13/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 12/12/25 to 3/12/26, identified the patient had a primary diagnosis of sarcopenia and included physician orders for skilled nursing services weekly and hospice aide services twice a week.    b. The clinical record failed to include any aide visit notes the week of 2/22/26 to 2/28/26.    c. The IDG update to the POC, dated 2/24/26 and 3/8/26, failed to identify any missed aide visits.    The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC.   The above findings reviewed with the Administrator and Clinical Manager. 2. Patient #12 had a hospice admission date of 4/15/25, a discharge date of 5/10/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 4/15/25 to 7/13/25, identified the patient had a primary diagnosis of malignant melanoma of right lower limb and included physician orders for skilled nursing services weekly and hospice aide services twice a week.    b. The clinical record failed to include any aide visit notes.    c. The IDG update to the POC, dated 4/22/25, failed to identify any missed aide visits.    The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC.   Findings include:  Review of the hospice policy, titled Interdisciplinary Group, dated 4/8/25, the attending physician is informed of any changes to the plan of care (POC) by the IDG.  1. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services and hospice aide services effective 2/22/26 twice a week for twelve weeks.  b. Hospice aide visit notes, dated 3/9, 3/12 and 3/18/26, completed by Staff I, Hospice Aide, identified services were provided.   c. IDG update to the POC, dated 3/24/26, failed to identify missed hospice aide visit for the week of 3/15/26.  Hospice failed to provide a second hospice aide visit the week of 3/15/26 or document a reason why a visit was not provided and notify the physician and IDG of the missed hospice aide visit.  During an interview on 3/31/26 at 11:13 AM, Administrator reported the missed visit the week of 3/15/26 should have been reported at the IDG meeting on 3/24/26 but the agency failed to do that.  Hospice failed to provide hospice aide services as ordered in the plan of care.

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 1 of 2 sampled bereavement records (Patient #14).   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: --- Review of the hospice policy, titled Bereavement, dated 4/8/25, bereavement services are provided based on the assessment of the family/caregiver needs, the presence of any risk factors associated with the patient’s death, and the ability of the family/caregiver to cope with grief.  After death occurs, the Hospice Social Worker or Bereavement Coordinator initiates bereavement services.  A bereavement plan of care is developed based on the findings of the hospice bereavement assessment and includes frequency and types of services offered.  Bereavement documentation is included in the patient’s medical record.  During an interview on 3/31/26 at 3:07 PM, Administrator reported bereavement mailings are sent after a patient’s death to the primary contact.  Patient #14 had a hospice admission date of 8/7/25, a death date of 8/10/25 and received services while residing in a private residence.  During an interview on 3/30/26 at 2:30 PM, Staff N, Administrative Assistant, reported she sends out the bereavement mailings and confirmed Patient #14’s primary caregiver should receive bereavement mailings.  Clinical record review revealed no documentation of a bereavement assessment or bereavement plan of care.  Administrator and Clinical Manager received the above findings.

Based on hospice staff interview, hospice policy review, hospice personnel file review and clinical record review, the hospice failed to:  1)  Ensure hospice aides are competency tested prior to providing extra skills. (L613)  2) Ensure hospice aides receive at least 12 hours of in-service training during each 12-month period. (L620)  3) Ensure hospice aide assignments are patient specific. (L625)  4) Ensure hospice aide performs tasks assigned. (L626)  5) Ensure registered nurse complete hospice aide supervision every 14 days. (L629)  6) Ensure registered nurse supervision of hospice aide services includes required elements. (L633) --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure hospice aide services are provided by individuals who meet specified requirements, hospice aides follow patient specific assignments and registered nurses supervise hospice aide services to ensure care provided is appropriate and meets the needs of the hospice patient.

Based on staff interview, clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 1 of 2 sampled hospice aides (Staff I) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 6 sampled patients (Patient #1 and #9) who required an extra skill be performed.    Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care.    Findings include: --- 1. Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed:   a. The POC, dated 3/16/26 to 6/13/26, identified the patient had a diagnosis of Alzheimer’s disease and orders for skilled nursing and hospice aide (HA) services.   b. The Aide Care Plan Report, dated 3/17/26, by Staff B, Clinical Manager, included Registered Nurse (RN) instructions for the aide to assist the patient with feeding.   c. Review of the clinical record showed Staff I, HA, provided aide services independently for Patient #1.   d. Staff I had a hire date of 1/5/26. Staff I's personnel file lacked documentation that a RN observed Staff I competently perform the task of assisting the patient with feeding.   In an interview on 3/31/26 at 1:49 PM, the Administrator reported that they do not understand why feeding was not part of the training that Staff I had during orientation, they thought this skill was a line item on the competency checklist.   2.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following:   a.The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 1/27/26, included orders for skilled nursing and aide services.   b.The Aide Care Plan Report, dated 2/2/26, by the Administrator, included instructions for the aide to trim the patient’s nails.   c.Review of the clinical record showed that Staff I provided aide services independently for Patient #9.   d. Staff I had a hire date of 1/5/26.  Staff I’s personnel file lacked documentation that a RN had observed Staff I competently perform the task of trimming nails.   The above findings were reviewed with the Administrator, Staff K, Clinical Quality Specialist,  and Staff N, Administrative Assistant.  The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan.    According to the agency's policy titled Aide Training Program, last revised in July 2025, the hospice agency is responsible for training aides in skills not covered in the basic checklist.

Based on staff interview, in- service education training documentation, and hospice policy review, the hospice failed to maintain documentation that 1 of 1 sampled hospice aides, employed for more than 1 year, completed a minimum of 12 hours of in- service educational training annually (Staff C).    The agency employed 2 hospice aides at the time of the survey.   Failure to have hospice aides receive 12 hours of in-service training annually increased the potential that hospice aides lacked updated and current information related to the care provided by the hospice aides.   Findings include: --- According to hospice policy titled Aide Hiring Requirements, Home Health and Hospice, updated 7/30/25, the aide must receive at least 12 hours of in-service training during each 12 month period.   In an interview on 3/31/26 at 10:08 AM, the Administrator reported that Staff C, Hospice Aid (HA), should have at least 12 hours of in service for 2024 and 2025.    Staff C, Hospice Aide, had a hire date of 2/16/21. Staff C's personnel file contained documentation of more than 12 in-service hours in 2025 and only 6.67 in-service hours in 2024.   The above findings were reviewed with the Administrator, Staff K and Clinical Quality Specialist.

Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to ensure registered nurses (RN) developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 1 of 8 patients receiving hospice aide services (Patient #9.  Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk that hospice patients did not receive the services to meet each patient’s assessed needs.  Findings include: --- According to hospice policy titled Aide Services, Hospice, dated 1/27/25, the RN arranges the aide services, assigns the care, and supervises the aide, which are completed per regulation.  Written instructions for the aide are prepared by the RN.   In an interview on 3/31/26 at 10:08 AM, Administrator reported  the task to trim the nails included both fingernails and toenails.   Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following:   a.The Plan of Care (POC) dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services.   b. The IDG meeting notes to update the POC, dated 2/24/26, 3/10/26, and 3/24/26, included IDG orders for hospice aide services.   c.Hospice Aide Care Plan, dated 2/2/26,  included RN instruction to the hospice aide to complete the task for trimming the nails however it did not specify if fingernails and/or toenails were to be trimmed.   The hospice RN failed to ensure a hospice aide care plan specified to which nails were to be trimmed and filed.   The above findings were reviewed with the Administrator, Staff K, Clinical Quality Specialist and Staff N, Administrative Assistant.

Based on staff interview, clinical record reviews and hospice agency policy review, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 1 of 8 sampled patients receiving hospice aide services (Patient #7).    Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients' personal care needs were not adequately met.    Findings include: --- According to the agency policy titled Aide Services, dated July 2025, the hospice aide provides care according to the established Plan of Care and documents all care in the medical record.    During an interview on 3/24/26 at 1:49 PM, Staff A, Administrator, stated the aide contacts the registered nurse (RN) if a patient requests an unassigned task be completed and the RN adds the task to the aide care plan if appropriate.    Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence.  Clinical record review revealed:    a. The Plan of Care (POC), dated 12/22/25 to 2/19/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services.    b. The hospice aide care plan, dated 12/22/25, included aide instructions to provide a bed bath.    c. Hospice aide visit note, dated 2/3/26, completed by Staff I, Hospice Aide, documented the task as completed and documented she applied lotion to the patient.  The hospice aide failed to provide services only as ordered and according to the hospice aide care plan.    The above findings were reviewed with the Administrator and Staff K, Clinical Quality Specialist.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit at least once every 14 days for 3 of 8 sampled patients (Patients #6, #7 and #9) that required supervision.    Failure to supervise hospice aides at least every 14 days placed patients at risk for a delay in identification of potential problems and/or patient needs and placed patients at risk for not receiving the services needed to meet the assessed patient needs.    Findings include: --- 3. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 3/2/26 and 3/18/26, completed by Staff F, RN, included documentation the nurse supervised the hospice aide, 16 days apart, 2 days late per regulation and policy.  During an interview on 3/31/26 at 11:20 AM, Administrator reported clinical record review was completed and she agreed the supervision was late.   The hospice failed to document aide supervision every 14 days.  Administrator and Clinical Quality Specialist received the above findings   2.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following:   a.The Plan of Care dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services.    b.Skilled nurse visit note, dated 3/3/26, by Staff D, RN, included documentation hospice aide supervision had been completed.    c. Skilled nurse visit note, dated 3/18/26, by Staff F included documentation the nurse supervised the hospice aide, 15 days apart, 1 day late per regulation and policy.    The hospice failed to document aide supervision every 14 days. According to the hospice policy titled Aide Services, last revised January 2025, the Registered Nurse (RN) arranges the aide services, assigns the care and supervises the aide, which are completed per regulation.  An on-site supervisory visit will be done by an RN at least every 14 days.    During an interview on 3/31/26 at 11:54 AM, Staff A, Administrator, confirmed aide supervision is required every 14 days and stated there should be documentation in the clinical record if the RN was unable to complete the supervision timely.    1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care, dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services.    b. The skilled nurse visit note, dated 2/24/26, signed completed on 2/24/26 by Staff F, RN, included hospice aide supervision.    c. The skilled nurse visit note, dated 3/12/26, signed completed on 3/12/26 by Staff F, RN, included hospice aide supervision (2 days late per regulation).    The RN failed to supervise hospice aide services every 14 days.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to document all required components of hospice aide supervision for 6 of 8 sampled patients with aide services (Patients #6, #7, #8, #9, #10 and #13).    Failure to ensure the supervision of hospice aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs.  Findings include: --- 6. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services.  b. Skilled nurse visit notes, dated 3/2/26 and 3/18/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.  Hospice failed to document all required elements of aide supervision  Administrator and Clinical Quality Specialist received the above findings.   4.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following:  a.POC dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services.  b.Skilled nurse visit notes by Staff D, RN,  on 1/28/26, 2/11/26, 2/17/26, 2/25/26, and 3/3/26 included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.   c.Skilled nursing note on 3/18/26 by Staff F, RN, included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.   The hospice failed to document all required elements of aide supervision.  5.Patient #13 had a hospice admission date of 2/5/26 and date of death of 3/20/26 and received hospice services while residing in a private home. Clinical record review revealed:  a.POC dated 2/5/26 to 4/5/26 included a primary diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and orders for skilled nursing and aide services and orders for skilled nursing and aide services.   b.Skilled nursing visit notes by Staff D, RN,  on 2/17/26, 3/3/26, and 3/17/26 included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.    The hospice failed to document all required elements of aide supervision.  2. Patient #8 had a hospice admission date of 9/13/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 3/12/26 to 5/10/26, included a primary diagnosis of sarcopenia and physician orders for skilled nurse and hospice aide services.  b. Skilled nurse visit notes, dated 3/17/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.  The hospice failed to document all required elements of aide supervision.  3. Patient #10 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 1/20/26 to 4/19/26, included a primary diagnosis of colon cancer and physician orders for skilled nurse and hospice aide services.  b. Skilled nurse visit notes, dated 3/17/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition.  The hospice failed to document all required elements of aide supervision. According to the hospice policy titled Aide Services, last revised January 2025, the Registered Nurse (RN) arranges the aide services, assigns the care and supervises the aide, which are completed per regulation.    During an interview on 3/31/2026 at 11:54 AM, Staff A, Administrator,  confirmed the electronic medical record does not capture all required components of aide supervision.    1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plans of Care (POCs), dated 12/22/25 to 2/19/26 and 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services.    b. Skilled nurse visit note, dated 1/19/26, completed by Staff D, RN, included documentation the hospice nurse provided aide supervision: followed the patient's plan of care, demonstrated competency with assigned tasks and complied with infection control policies and procedures.  The skilled nurse visit note lacked documentation the aide created successful interpersonal relationships with the patient and family and reported changes in the patient's condition.    c. Skilled nurse visit note, dated 2/2/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient's plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures.  The skilled nurse visit note lacked documentation the aide reported changes in the patient's condition.    d. Skilled nurse visit note, dated 2/10/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient's plan of care, demonstrated competency with assigned tasks and complied with infection control policies and procedures.  The skilled nurse visit note lacked documentation the aide created successful interpersonal relationships with the patient and family and reported changes in the patient's condition.  e. Skilled nurse visit note, dated 2/24/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient's plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures.  The skilled nurse visit note lacked documentation the aide reported changes in the patient's condition.   f. Skilled nurse visit note, dated 3/12/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient's plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures.  The skilled nurse visit note lacked documentation the aide reported changes in the patient's condition.   The hospice failed to document all required components of hospice aide supervision.

Based on review of written hospice agreements for services under arrangement and agency policy review, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 3 sampled services (Massage therapy provider).    Failure to include this provision 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: --- According to the agency policy titled Contractual Agreements, last revised February 2026, the agency provides oversight for all contractual agreements which provide patient care, treatment and services. The agency retains Quality Improvement responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in its settings.    Review of the contract between the hospice and sampled massage therapy provider, dated 12/1/2024, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management,   b. The hospice retains oversight of staff and services,  c. All services are authorized by the hospice and  d) All services are delivered in accordance with the patient's plan of care.  The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement.    The above findings were reviewed with the Administrator.

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 7 of 14 sampled patients (Patients #3, #6, #7, #8, #9, #11 and #14).    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 it's patients.    Findings include: --- 5. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services.  b. Handwritten paper massage therapy visit notes, dated 3/2/26 and 3/9/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature.  6. Patient #11 had a hospice admission date of 1/9/26, a discharge date of 1/28/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 1/9/26 to 4/8/26, included a primary diagnosis of chronic hepatic (liver) failure and physician orders for skilled nurse services.  b. Handwritten paper massage therapy visit notes, dated 1/22/26 and 1/26/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature.  7. Patient #14 had a hospice admission date of 8/7/25, a death date of 8/10/25 and received services while residing in a private residence.  a. Plan of Care, dated 8/7/25 to 11/4/25, included primary diagnosis of myelodysplastic syndrome (bone marrow disorder causing insufficient healthy blood cell production) and physician orders for skilled nurse and hospice aide services.  b. Initial comprehensive assessment, dated 8/8/25, completed by Staff A, Administrator/RN, included electronic signature and date but lacked staff credentials with signature.  c. Skilled nurse visit note, dated 8/9/25 and 8/10/25, completed by Staff R, RN, included electronic signature and date but lacked staff credentials with signature.  d. Hospice aide visit note, dated 8/8/25, completed by Staff C, Administrative Assistant/Hospice aide, included electronic signature and date but lacked staff credentials with signature.  Administrator and Clinical Quality Specialist received the above findings.   4. Patient #9 had a hospice admission date of 8/13/25 and received services while residing in a private home. Clinical record review revealed:   a. The POC, dated 2/5/26 to 4/5/26, identified the patient had a diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and included orders for skilled nurse and social work services.   b.Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 2/24/26, identified a massage therapy evaluation to be completed for pain management.   c. Massage therapy visit notes, dated 3/4/26 and 3/9/26, completed by Staff G, massage therapist, lacked a signature with title of individual completing the visit notes.      In an interview on 3/31/26 at 10:17 AM, the Administrator reported that during the current survey, they have talked with the massage therapist about this finding. The massage therapist will start to add credentials to their signature.    The hospice failed to ensure appropriate authentication of all documentation.    2. Patient #3 had a hospice admission date of 2/3/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. Plan of Care, dated 2/3/26 to 5/3/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services.  b. Handwritten paper massage therapy visit notes, dated 2/11/26 and 3/2/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature.  3. Patient #8 had a hospice admission date of 9/13/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 12/12/25 to 3/11/26 and 5/10/26, included a primary diagnosis of lung sarcopenia and physician orders for skilled nurse and hospice aide services.  b. The handwritten paper massage therapy visit notes, dated 3/9/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature.     According to the agency policy titled Documentation in the Electronic Medical Record (EMR), last revised October 2024, documentation for all care, services, observations, assessments and communication are done within 24 hours of the contact.  Entries are documented by the full given name, full surname and initials or licensing credentials.    During an interview on 3/24/26 at 1:49 PM, Staff A, Administrator, stated staff are expected to complete documentation in the EMR within 24 hours of contact.    1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed:   a. The Plan of Care (POC), dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services.    b. The massage therapy visit notes, dated 2/25/26 and 3/2/26, completed by Staff G, Massage Therapist, lacked a signature with title of individual completing the visit notes.    The hospice failed to ensure appropriate authentication of all documentation.

Based on staff interview and clinical record 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 2 of 2 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #8 and #10).   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 Disposal of Controlled Medications, Hospice-Enterprise, dated 3/18/25, the patient/family/caregiver are educated regarding proper storage, management, and disposal of controlled medications when ordered for a patient.   During an interview on 4/22/25 at 11:10 AM, the Administrator stated the hospice did not have documentation of patient education on the disposal of controlled medications policy at the time when controlled medications ordered.  1.Patient #8 had a start of care date of 9/13/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial plan of care (POC), dated 9/13/25 to 12/11/25, included physician orders for medications, but no controlled medications.  The POC identified the patient had a diagnosis of sarcopenia.    b. A skilled nurse visit note, dated 2/16/25, completed by the Administrator, identified the physician ordered Morphine and Ativan that would be delivered later on this date.    c. A physicians order, dated 2/24/25, identified new orders including morphine and lorazepam (controlled medications).    d. An Interdisciplinary Group (IDG) meeting note, dated 3/10/26, included physician orders (effective 2/24/26) for morphine and lorazepam; controlled medications.    The clinical record lacked documentation hospice staff reviewed with patient #8 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.  2. Patient #10 had a start of care date of 1/20/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial POC, dated 1/20/26 to 4/19/26, included physician orders for medications, but no controlled medications.  The POC identified the patient had a diagnosis of colon cancer.    b. A physicians order, dated 2/5/26, identified new orders including lorazepam (controlled medication).    d. An IDG meeting note, dated 2/10/26, included physician orders (effective 2/5/26) for lorazepam; controlled medication.    The clinical record lacked documentation hospice staff reviewed with patient #10 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.  The hospice failed to review the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.  The above findings reviewed with the Administrator and Clinical Manager.

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, review of employee personnel files, and hospice policy review, the hospice failed to ensure completion of a criminal background check for 1 of 6 sampled employees who began serving hospice patients since their last survey, dated 6/8/23.  The hospice reported hiring 17 employees 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: --- According to the hospice policy titled Hiring and Screening, dated 3/28/25, in those states where state law requires an in-state agency check, state law will supersede.      Interview on 3/31/26 at 2:58 PM, the Administrator reported that the central office human resources department performs background checks and monitors the timeliness of background checks with the employee's date of hire.     Staff E, Licensed Practical Nurse (LPN), had a hire date of 1/8/25. Staff E's personnel file included documentation of a completed criminal history background check, dated 12/6/24, 32 days prior to Staff E's hire date.     Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on all staff prior to hiring.     The above findings were reviewed with the Administrator and Staff K, Clinical Quality Specialist.

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 review of employee personnel files, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 6 sampled employees who began serving hospice patients since their last survey, dated 6/8/23.    The hospice reported hiring 17 employees since the last survey.   Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact.  Findings include: --- According to the hospice policy titled Hiring and Screening, dated 3/28/25, in those states where state law requires an in-state agency check, state law will supersede.  If the location’s state requires a state -specific background check, the location must fulfill the state’s requirements.   Interview 3/31/26 at 2:58 PM, the Administrator reported that the central office human resources department performs background checks.   Staff E, Licensed Practical Nurse (LPN), had a hire date of 1/8/25. Staff E's personnel file included documentation of completed dependent adult and child abuse record checks, dated 12/6/24, 32 days prior to Staff E's hire date.   Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.    The above findings were reviewed with the Administrator, Staff K, Clinical Quality Specialist,  and Staff N, Administrative Assistant.

Based on hospice clinical record review, hospice policy review, nursing home record review, patient and patient representative interview and hospice staff interview, the hospice failed to ensure the the documentation and correct identification, in a prominent part of the patient's record, any advance directives executed by the patient or patient's representative for 4 of 14 sampled patients (Patients #7, #9, #12 and #14). 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: --- 4. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The Medicare Benefit Election form and Hospice Admission and Service Agreement forms, both dated 4/12/23, included a signature of agreement by the patient's representative and legal durable power of attorney (DPOA) for healthcare decisions. b. The clinical record included a copy of the patients Medical Power of Attorney legal document, dated 1/16/22. c. The patient's hospice Face Sheet, dated 5/2/23, Plan of Care (POC), dated 4/12/23 to 7/10/23, and Interdisciplinary Group (IDG) meetings, dated 5/9 and 5/23/23, lacked identification of the patient having a DPOA. The IDG meeting, dated 4/25/23, included a statement buried in a lengthy narrative which identified the patient had a DPOA. On 6/6/23 at 4:05 PM, during an interview, the Clinical Manager identified the hospice staff prominently identified the patient's advance directives on the patient's Face Sheet, POC and in the IDG meeting notes. The hospice failed to ensure the identification of the patient's choice in all advance directives in a prominent location in the patient's record. The Clinical Manager and Senior Director received the above findings and hospice staff provided no further information prior to the end of the survey. According to the undated hospice policy titled Advance Directives Policies and Procedure, the hospice recognizes that every competent adult has the right to control decisions relating to their own medical care including decisions to have life prolonging medical or surgical procedures provided, withheld or withdrawn. This right is protected by the United States Constitution and the laws of Iowa. While it is our mission to provide all medically appropriate treatment to our clients, we also recognize that no client should be obligated to endure unwanted or unduly burdensome intervention. 1. Patient #9 had a hospice admission date of 5/5/23 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 5/5/23 to 8/2/23, identified the patient had orders to do resuscitate. b. The Face Sheet, dated 5/12/23, lacked identification of a Durable Power of Attorney. c. The comprehensive assessment completed at the start of care by a registered nurse (RN), dated 5/5/22, included documentation the patient had chosen to not be resuscitated (DNR) in the event the patient stopped breathing or the patient's heart stopped. d. The advance directive, dated 2/20/2020, identified the patient requested "no, I do not want resuscitation efforts initiated at the time of cardiopulmonary or respiratory arrest. e. The Iowa Physician Order for scope of treatment, dated 2/20/2020, identified the patient had a durable power of attorney for health care. f. The IDG meetings, dated 5/9 and 5/23/23, all identified the patient did not have any advance directives in place. Review of the clinical record lacked a copy of the living will and durable power of attorney for health care decisions or identification in a prominent place in the clinical record and included conflicting code status information. 2. Patient #12 had a hospice admission date of 11/11/22 and discharge date of 12/2/22 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 1111/22 to 2/8/22, identified the patient had orders to do not resuscitate but failed to identify advanced directives including a power of attorney. b. The Face Sheet, dated 5/12/23, lacked identification of a Durable Power of Attorney. c. The patient consent forms, dated 11/11/22, identified the signature of an identified power of attorney. d. The IDG meetings, dated 11/22/22, identified the patient did not have any advance directives in place. Review of the clinical record lacked a copy of the living will and durable power of attorney for health care decisions or identification in a prominent place in the clinical record. 3. Patient #14 had a hospice admission date of 5/20/22 and died 6/7/22 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 5/20/22 to 8/17/22, identified the patient had orders to do resuscitate. b. The comprehensive assessment completed at the start of care by a registered nurse (RN), dated 5/20/22, included documentation the patient had chosen to not be resuscitated (DNR) in the event the patient stopped breathing or the patient's heart stopped. b. The advance directive, dated 5/12/22, identified the patient had an advance directive in place for durable power of attorney. c. The Iowa Physician Order for scope of treatment, dated 5/20/22, identified the patient requested to do not attempt resuscitation. e. The IDG meetings, dated and 5/24/23, all identified the patient did not have any advance directives in place. f. The Face Sheet, dated 5/22/23, lacked identification of a Durable Power of Attorney. Review of the clinical record lacked a copy of the living will and durable power of attorney for health care decisions or identification in a prominent place in the clinical record and included conflicting code status information.

Based on clinical record review, hospice policy review, Interdisciplinary Group meeting observation 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 6 of 14 sampled patients (Patients #3, #7, #9, #10, #12 and #14). 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: --- 5. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/12/23 to 7/10/23, included physician orders for the following medications: duplicate medications to treat pain (Acetaminophen and Oxycodone-Acetaminophen), duplicate medications to treat high blood pressure (Metoprolol and Losartan), duplicate medications to treat agitation (Hydroxyzine and Ativan) and duplicate medications to treat glaucoma (eye pressure) (Latanoprost-Timolol and Cosopt). The POC also included medications with potential serious drug interactions (Ativan and Oxycodone). The POC included a medications associated with laboratory monitoring (Metformin related blood sugar level monitoring and Losartan related to blood monitoring for renal function and potassium levels). b. The comprehensive assessment completed by a registered nurse (RN) at the start of care, dated 4/12/23, included documentation the nurse assessed the patient did not take any medications with actual or potential drug interactions and did not take any medications with duplicate drug therapies. The DRR completed the by the RN lacked documentation the RN reviewed the patient's medications for drug therapy associated with laboratory monitoring. c. A pharmacy DRR, dated 4/13/23, included documentation the pharmacist reviewed the patient's medications for effectiveness, duplicate therapy, drug interactions and side effects. The DRR did not identify if the pharmacist found any duplicate drug therapy and potential drug interactions, and lacked documentation the pharmacist reviewed the medications for drug therapy associated with laboratory monitoring. d. The IDG clinical notes, dated 4/25, 5/9 and 5/23/23, included documentation by the RN that the IDG completed a DRR which included a review of duplicate medications, drug interactions and side effects, effectiveness of medications and any medications associated with laboratory monitoring. The DRR lacked any detailed information on the findings of the review. e. The clinical record included documentation of a list of the patient's medications at the time of each Interdisciplinary Group (IDG) meeting, dated 4/25 and 5/9/23, and documentation of the Medical Director's signature and date of the review. The signed medication lists by the Medical Director contained no further information regarding what the Medical Director specifically reviewed regarding each of the medications. On 6/6/23 at 8:00 AM, observation of the IDG meeting revealed a review of the hospice's patient's included deaths, admits and ongoing patients. The IDG members did not complete a discussion on the DRR for any of the patients. Hospice staff did discuss the effectiveness of pain and other medications for 7 of 16 live patients reviewed. On 6/6/23 at 9:21 AM, during an interview, Staff G, RN, reported that for the DRR, the hospice nurses sent the pharmacy a form and the patient medication list for review upon admission and with medication changes. Staff G, RN, reported the hospice staff send a full list of each patient's medications to the hospice Medical Director for review every 2 weeks for every IDG meeting. Staff G, RN, explained the clinical record included documentation of a DRR with each IDG clinical note. Staff G, RN, stated, "You may not hear us discuss it in IDG, but it's (DRR) done with each one." On 6/8/23 at 9:08 AM, during an interview, the Medical Director explained by signing the patient's medication list with every IDG meeting, they are acknowledging those are the patient's current medications and the Medical Director approves of those medications. When asked what components the hospice staff review as part of the DRR, the Medical Director was unsure. The Medical Director reported the pharmacist reviews the medications for interactions and other things, but ultimately, the Medical Director is responsible for the patient's DRR. 6. Patient #10 had a hospice admission date of 5/26/23 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 5/26/23 to 8/23/23, included physician orders for duplicate medications to treat pain (Acetaminophen 325 milligrams two tabs every 4 hours as needed and Tylenol 8 hour Arthritis extended release 650 milligram tablet one tablet twice per day). The POC included a physician order for Levothyroxine, a medication associated with laboratory monitoring for thyroid functioning. b. The comprehensive assessment completed by a RN at the start of care, dated 5/26/23, lacked documentation the nurse completed a DRR. c. A pharmacy DRR, dated 5/30/23, indicated the hospice was covering the cost of the patient's medications, but lacked any other documentation which indicated the pharmacist reviewed the patient's medications for the required DRR components. On 6/6/23 at 8:00 AM, observation of the IDG meeting revealed the IDG members discussed the addition of Tramadol, a medication to treat pain, to the patient's medications, but lacked any other discussion related to the DRR. d. The IDG meeting note, dated 6/6/23, included documentation the IDG completed a DRR on the patient for the required components of duplicate medications, drug interactions and side effects, effectiveness of medications and any medications associated with laboratory monitoring. The DRR lacked any detailed information on the findings of the review. The Clinical Manager and Senior Director received the above findings and hospice staff provided no further information prior to the end of the survey. According to the hospice policy, titled Medication Profile, dated November 2022, a drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will identify: effectiveness, actual or potential side effects, toxic effects, allergic reactions, immediate desired effects, unusual and unexpected effects, changes in the patient's condition, drug related laboratory results, actual and potential drug interactions, duplicate drug therapy and the need for pharmacological or non-pharmacological interventions for pain and other symptom management as applicable to the patient. During an interview on 6/6/23 at 4:05 PM, the Clinical Manager stated a drug regimen review is completed at the start of care by the Registered Nurse and with a change in medication. 1. Patient #3 had a hospice admission date of 4/10/23, received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/10/23 to 7/8/23, included physician orders for acetaminophen and lidocaine external patch (pain relievers) and docusate/senna, miralax (bowel medications). b. The IDG meeting notes, dated 3/8/23, included a DRR reviewed for drug therapy duplicate medications. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient had duplicate drug therapy medications. 2. Patient #9 had a hospice admission date of 5/5/23, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/5/23 to 8/2/23, included physician orders for bisacodyl and glycolax (bowel medications). b. The IDG meeting notes, dated 5/9/23 and 5/23/23, included a DRR reviewed for drug therapy duplicate medications. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient had duplicate drug therapy medications. 3. Patient #12 had a hospice admission date of 11/11/22 and discharge dated of 12/2/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 11/11/22 to 2/8/22, included physician orders for miralax and sennosides/docusate (bowel medications) amlodipine and metoprolol (antihypertensives) and calcium, vitamin D3 and magnesium oxide (supplements). b. The IDG meeting notes, dated 11/22/23, included a DRR reviewed for drug therapy duplicate medications. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient had duplicate drug therapy medications. 4. Patient #9 had a hospice admission date of 5/20/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 5/20/22 to 8/17/22, included physician orders for acetaminophen, duragesic, dilaudid and hydromorphone (pain relief) dulcolax and senna (bowel medications). b. The IDG meeting notes, dated 5/24/22, included a DRR reviewed for drug therapy duplicate medications. The DRR lacked documentation of outcomes of the review. The DRRs failed to identify the patient had duplicate drug therapy medications.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound measurements for 2 of 4 sampled patients with an open wound (Patients #4 and #11). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- Findings include: According to the hospice policy, titled Wound Care, dated 5/18/23, wounds will be measured in centimeters (length by width by depth) at least weekly unless covered by a non-removable dressing. During an interview on 6/6/23 at 4:05 PM, the Clinical Manager reported at a minimum documentation for wounds should include a length, width and depth. 1. Patient #4 had a hospice admission date of 5/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. An initial comprehensive assessment completed by a registered nurse (RN), dated 5/18/23, included documentation the patient had a stage 3 pressure ulcer on the left heel with a diameter of approximately 1 inch. The assessment failed to include documentation of length, width and depth of the pressure ulcer. b. The skilled nurse visit note, dated 5/24/23, included documentation the left heel pressure ulcer measured 4 centimeters (cm) in length by 4 cm in width but lacked documentation of a wound depth. c. The skilled nurse visit, dated 6/2/23 included documentation the left heel pressure ulcer measured 3.8 cm in length by 3.8 cm in width but lacked documentation of a wound depth. 2. Patient #11 had a hospice admission date of 8/30/22, a revocation date of 9/12/22 and received hospice services while residing in a private home. Clinical record review revealed: a. The skilled nurse visit notes, dated 9/7/22 and 9/9/22, included documentation of a non-surgical wound caused by trauma between the eyes. The documentation lacked wound measurements. b. The skilled nurse visit, dated 9/12/ included documentation of a non-surgical wound caused by trauma between the eyes with a length of 1.5 cm and the area was scabbed. The documentation lacked wound measurements for width. The Clinical Manager and Senior Director received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice admission packet review 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 1 of 2 sampled bereavement records (Patient #14). 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 Interdisciplinary Group Plan of Care, dated November, 2022, core hospice services will be available 24 hours a day, seven days a week, as will be drugs, biologicals, and medical supplies. Other services may be available as needed and will include hospice aide, homemaker, therapies and volunteer and bereavement services. During an interview on 6/7/23 at 3:06 PM The Bereavement Coordinator stated she develops a plan of care for each family and determine the frequency and amount of services. She completes an assessment, paper charting and charts monthly, based on the care plan. During an interview on 6/8/23 at 10:15 AM the Nurse Consultant stated the hospice unable to locate any documentation of bereavement services completed for the patient. 1. Patient #14 had a hospice admission date of 5/20/22 and died on 6/7/22. Review of the hospices' clinical record for hospice services provided to the identified bereaved individual revealed the following: a. The Plan of Care (POC), dated 5/20/22 to 8/7/22, included IDG orders for skilled nurse 1 to 3 visits a month. b. The initial skilled nurse assessment, dated 5/20/22, included documentation there were no bereavement risks identified. c. The Spiritual Care assessment, dated 5/24/22, lacked documentation of bereavement risks identified. d. The social worker visit note, dated 5/31/22, lacked documentation of bereavement risks identified. e. The clinical record failed to include documentation of a bereavement plan of care or any phone calls, visits or mailings completed. The hospice failed to provide bereavement services for the patient's bereaved individuals. The Administrative Management and Nurse Consultant received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 2 of 2 sampled hospice aides (Staff E and H) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a RN with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 9 of 11 sampled patients who requires the task be performed (Patients #3, #4, #5, #7, #8, #10, #11 and #13). The hospice employed 2 hospice aides at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation require hospices direct that the hospice aide may not independently provide any patient cares beyond the basic skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. During an interview on 6/8/23 at 11:36 AM, Staff D, Administrative Management reported Staff E had training in meal preparation but unable to locate competency for feeding assistance. 1. Patient #1 had an admission to hospice on 9/8/20, received services while residing in a nursing home. The Plan of Care, dated 5/6/23 to 7/4/23, included orders for hospice aide services. The nursing home care plan dated 5/18/23, identified the patient utilized a gait belt for transfers: a. Staff H, Hospice Aide, had a hire date of 6/13/20. Staff H's personnel file lacked documentation a RN had observed Staff H competently demonstrate the tasks of use of a gait belt. 2. Patient #3 had an admission to hospice on 4/10/23 and received services while residing in a private residence. The Plans of Care, dated 4/10/23 to 7/8/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills shaving. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the tasks of Shaving. 3. Patient #4 had an admission to hospice on 5/18/23 and received services while residing in a nursing home. The Plans of Care, dated 5/18/23 to 8/15/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills of feeding. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the tasks of feeding. 4. Patient #5 had an admission to hospice on 4/25/23 and received services while residing in a private residence. The Plans of Care, dated 4/25/23 to 7/23/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills shaving. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the tasks of Shaving. 5. Patient #7 had an admission to hospice on 4/12/23 and received services while residing in a nursing home. The Plans of Care, dated 4/12/23 to 7/10/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills shaving and use of a gait belt. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the tasks of shaving or use of a gait belt. 6. Patient #8 had an admission to hospice on 4/21/23 and received services while residing in a nursing home. The Plans of Care, dated 4/21/23 to 7/19/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills of feeding. a. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the task of feeding. b. Staff E, Hospice Aide, had a hire date of 6/29/22. Staff E's personnel file lacked documentation a RN had observed Staff E competently demonstrate the tasks of feeding. 7. Patient #10 had an admission to hospice on 5/23/23 and received services while residing in a nursing home. The Plans of Care, dated 5/26/23 to 8/23/23, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills of feeding. a. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the task of feeding. b. Staff E, Hospice Aide, had a hire date of 6/29/22. Staff E's personnel file lacked documentation a RN had observed Staff E competently demonstrate the tasks of feeding. 8. Patient #11 had an admission to hospice on 4/21/23 and discharge date of 9/12/22 and received services while residing in a private residence. The Plans of Care, dated 8/30/22 to 11/27/22, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills of shaving. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the task of shaving. 9. Patient #13 had an admission to hospice on 6/10/22 and date of death of 7/5/22 and received services while residing in a nursing home. The Plans of Care, dated 6/10/22 to 9/7/22, included orders for hospice aide services. The aide care plan included RN instructions to the aide to complete the extra skills of shaving. Staff H, Hospice Aide, had a hire date of 6/13/2000. Staff H's personnel file lacked documentation a RN had observed Staff D competently demonstrate the task of shaving. The Administrative Management and Nurse Consultant received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, policy review 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 11 of 12 sampled patients receiving hospice aide services. (Patients #1, #3, #4, #5, #7, #8, #9, #10, #11, #12 and #13). The hospice reported a total of 15 patients who received hospice aide services at the time of the survey. 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: According to the hospice Policy titled Hospice Aide Services, dated 11/2022, arrangements for hospice aide services will be made by either the Case Manager or the Clinical Supervisor. The hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. Hospice aides will document care provided in accordance with the hospice aide assignment. During an interview on 6/6/23 at 4:05 PM, the Clinical Manager stated the Registered Nurse (RN) case manager creates and updates the aide care plan. --- 8. Patient #3 had a hospice admission date of 5/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 4/10/23 to 7/8/23, included primary diagnosis of Congestive Heart Failure. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of nail care. The hospice aide care plan failed to identify what nail care included. 9. Patient #5 had a hospice admission date of 4/25/23 and received hospice services while residing in a private home residence. Clinical record review revealed: a. Hospice plan of care, dated 4/25/23 to 7/23/23, included primary diagnosis of Lung Cancer. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of nail care. The hospice aide care plan failed to identify what nail care included. 10. Patient #9 had a hospice admission date of 5/5/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 5/5/23 to 8/2/23, included primary diagnosis of Alzheimers Disease. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of partial/complete bed bath and nail care. The hospice aide care plan failed to identify what nail care included and who would make the determination of which bath type the aide should perform, a partial bed bath or a complete bed bath. 11. Patient #12 had a hospice admission date of 11/11/22 and discharge date of 12/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 11/11/22 to 2/8/22, included primary diagnosis of Renal cell Carcinoma. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of partial/complete bed bath and nail care. The hospice aide care plan failed to identify what nail care included and who would make the determination of which bath type the aide should perform, a partial bed bath or a complete bed bath. The Administrative Management and Nurse Consultant received the above findings and hospice staff provided no further information prior to the end of the survey. 5. Patient #1 had a hospice admission date of 9/18/2020 and received routine home care services through hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 3/7/23 to 5/5/23 and 5/6/23 to 7/4/23, included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 1/30/23 and updated on 5/3/23, included directions to the hospice aide to complete a partial or complete bed bath and to provide nail care. The hospice aide care plan did not include any further directions for what the task of nail care specifically included for this patient. c. The hospice aide visit notes, dated 4/17, two undated hospice aide visit notes, 4/24, 4/27, 5/8 and 5/11/23, included documentation the hospice aide assisted the patient with taking a shower. The clinical record lacked documentation the hospice aide received approval for the RN to assist the patient with completing a shower. d. An aide visit note, dated 6/1/23, included documentation of an updated hospice aide care plan which included a bath type of a shower for the patient. The aide care plan also included directions for the hospice aide to complete the task of perineal/catheter care. e. The clinical record included documentation of a physician order, dated 4/24/23, for the discontinuation of the patient's urinary catheter. On 6/5/23 at 1:00 PM, in an interview, during a nursing home visit observation with Staff G, RN, the patient and Staff G both reported the hospice aide cut the patient's nails and helped to clean underneath the nails. The patient filed the patient's nails. Both the patient and Staff G, RN, reported the hospice aide had been assisting the patient with taking showers. On 6/6/23 at 9:21 AM, during an interview, Staff G, RN, reported they review hospice aide care plan every 2 weeks and update the hospice aide care plan as needed with changes. Staff G, RN, reported that they overlooked updating the patient's bathing to a shower on the hospice aide care plan. The patient had a period of time prior to the patient's admission to the nursing home (admitted on 3/29/23) when the patient had not been able to stand to shower, but had been able to shower since being at the nursing home. Staff G, RN, confirmed the patient did not currently have a urinary catheter and they had removed the catheter in April. On 6/7/23 at 11:45 AM, during an interview, Staff G, RN, reported that when they assign the hospice aide the task of nail care for this patient and other patients, this means the home health aide clips the nails, files and cleans under the fingernails. For Patient #1, the patient files the patient's own nails. Typically, the hospice aide just does patients' fingernails, otherwise, a foot doctor typically does the toenails. On 6/7/23 at 2:50 PM, during an interview, Staff H, Hospice Aide, reported that for the task of nail care for Patient #1 trim, file and clean underneath the finger nails. A podiatrist does the toe nails on patients. 6. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The POC, dated 4/12/23 to 7/10/23, included IDG orders for skilled nursing and hospice aide services. The POC included a physician order for Metformin 500 milligrams (mg) by mouth twice per day to treat diabetes. The POC did not identify diabetes as one of the patient's diagnoses. b. The hospice aide care plan, dated 4/13/23, included directions to the hospice aide to complete a partial or complete bed bath, nail care, shave, mouth care, assist with transfers as needed, mouth care, brush/comb hair, perineal care if soiled or wet and apply lotion to the arms, legs and back. The hospice aide care plan did not include any further directions for what the task of nail care specifically included for this patient and did not specify under what circumstances the hospice aide should transfer the patient. The hospice aide care plan identified the patient was a 1 to 2 person pivot transfer, but did not include any instructions to the hospice aide on use of a gait belt to assist with the safety of transfers. On 6/7/23 at 2:50 PM, during an interview, Staff H, Hospice Aide, reported for Patient #7's nail care, they trimmed, filed and cleaned underneath the patient's fingernails. On 6/8/23 at 10:28 AM, Staff H, Hospice Aide, called the surveyor to report they do not trim the nails of diabetic patients. When asked how Staff H, Hospice Aide, knows not to do trim a diabetic patient's nails, Staff H, explained the RN gives them a verbal report. The hospice aide care plan failed to include written instructions to the hospice aide which identified the patient was diabetic and whether or not nail trimming should be done by the hospice aide. c. An IDG meeting note, dated 5/9/23, identified the patient had moved to a nursing home during the last 2 week time frame. On 6/7/23 at 3:00 PM, during an interview, Staff H, Hospice Aide, reported they had been using the gait belt with the patient for transfers since the patient moved to the nursing home on 5/3/23. d. The hospice aide visits, dated 5/3, 5/8, 5/10, 5/15, 5/17 and 5/30/23, included documentation the hospice aide assisted the patient with transfers, but did not include any documentation of the use of a gait belt. On 6/8/23 at 8:01 AM, during an interview, Staff F, RN, reported being aware of the hospice aide's use and the patient's need to use a gait belt for transfers for safety. The hospice aide care plan, dated 4/13/23, did not include the use of a gait belt for transfers on the assignment and the hospice RN did not update the patient's hospice aide care plan when the patient moved into the nursing home. 7. Patient #10 had a hospice admission date of 5/26/23 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 5/26/23 to 8/23/23, included IDG orders for skilled nursing and hospice aide services. b. The comprehensive assessment completed by the RN at the start of care, dated 5/26/23, identified the patient was incontinent of urine and used adult incontinence briefs. b. The hospice aide care plan for hospice aide services starting on 5/31/23 included RN instructions to the hospice aide to complete the following tasks: partial/complete bed bath, nail care, perineal care/catheter care, assist with feeding, observe skin condition, turn and reposition, assist with transfers, encourage fluids, dressing, mouth care, shampoo and bed pan/urinal/commode. The hospice aide care plan did not specify what the hospice aide needed to specifically do for nail care and included instructions for urinary catheter care. On 6/7/23 at 2:50 PM, during an interview, Staff H, Hospice Aide, reported for Patient #10's nail care, they trimmed, filed and cleaned underneath the patient's fingernails. On 6/8/23 at 8:01 AM, during an interview, Staff F, RN, confirmed the patient did not have a urinary catheter. On 6/8/23 at 12:47 AM, during an interview, the Clinical Manager reported they were able to fix all the care plans for the hospice aides to be more specific to the patient including the use of a gait belt for Patient #7, nail care to be specific to the patients and perineal care to be specific to the patients. 1. Patient #4 had a hospice admission date of 5/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 5/18/23 to 8/15/23, included primary diagnosis of Alzheimers Disease. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of partial/complete bed bath and nail care. The hospice aide care plan failed to identify what nail care included and who would make the determination of which bath type the aide should perform, a partial bed bath or a complete bed bath. 2. Patient #8 had a hospice admission date of 4/21/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 4/21/23 to 7/19/23, included primary diagnosis of Alzheimers Disease. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of partial/complete bed bath and nail care. The hospice aide care plan failed to identify what nail care included and who would make the determination of which bath type the aide should perform, a partial bed bath or a complete bed bath. 3. Patient #11 had a hospice admission date of 8/30/22, a revocation date of 9/12/22 and received hospice services while residing in a private home. Clinical record review revealed: a. Hospice plan of care, dated 4/21/23 to 7/19/23, included primary diagnosis of Alzheimers Disease. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task of nail care. The hospice aide care plan failed to identify what nail care included. 4. Patient #13 had a hospice admission date of 6/10/22, a discharge date of 7/5/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice plan of care, dated 6/10/22 to 9/7/22, included primary diagnosis of renal failure and secondary diagnoses of unspecified intellectual disabilities, Alzheimers Disease and dementia in other diseases classified elsewhere with behavioral disturbance. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of partial/complete bed bath and nail care. The hospice aide care plan failed to identify what nail care included and who would make the determination of which bath type the aide should perform, a partial bed bath or a complete bed bath.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 9 of 12 sampled patients receiving hospice aide services. (Patients #2, #3, #4, #5, #7, #8, #10, #11, #12 and #13). The hospice reported a total of 15 patients who received hospice aide services at the time of the survey. Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: According to the hospice Policy titled Hospice Aide Services, dated 11/2022, arrangements for hospice aide services will be made by either the Case Manager or the Clinical Supervisor. The hospice aide assignments, plan of care, and interventions will be documented and included in the patient's clinical record. Hospice aides will document care provided in accordance with the hospice aide assignment. During an interview on 6/6/23 at 4:05 PM, the Clinical Manager stated the Registered Nurse (RN) case manager creates and updates the aide care plan. If the aide is unable to complete a task, they are to document the reason why, inform the RN case manager and document when the RN was contacted. --- 7. Patient #3 had a hospice admission date of 4/10/23 and received hospice services while residing in a private home setting. Clinical record review revealed: a. The IDG meeting notes, dat ed,4/11/23, 4/25/23, 5/9/23 and 5/23/23, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task to assist with perineal care. c. The hospice aide visit note, dated 5/18/23, 5/24/23, lacked documentation the task to assist with perineal had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan. 8. Patient #4 had a hospice admission date of 4/25/23 and received hospice services while residing in a private home setting. Clinical record review revealed: a. The IDG meeting notes, dated, 5/9/23 and 5/23/23, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task to assist with perineal care. c. The hospice aide visit note, dated 5/4/23, 5/8/23, 5/11/23, 5/18/23, lacked documentation the task to assist with perineal care had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan. 10. Patient #12 had a hospice admission date of 11/11/2 and discharge date of 12/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The interdisciplinary group (IDG) meeting notes, dated, 11/22/22, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task to assist with perineal care. c. The hospice aide visit note, dated 11/15/22, 11/17/22, 11/28/22, lacked documentation the task to assist with perineal care had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan. The Administrative Management and Nurse Consultant received the above findings and hospice staff provided no further information prior to the end of the survey. 5. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The POC, dated 4/12/23 to 7/10/23, included IDG orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 4/13/23, included directions to the hospice aide to complete a partial or complete bed bath, nail care, shave, mouth care, assist with transfers as needed, mouth care, brush/comb hair, perineal care if soiled or wet and apply lotion to the arms, legs and back. c. A hospice aide visit, dated 4/13, 4/20 and 4/27/23, included documentation the hospice aide shampooed the patient's hair. The hospice aide care plan did not include instructions for the hospice aide to complete this task, and the clinical record lacked documentation the hospice aide received approval for this task prior to completing the unassigned task. d. The hospice aide visit, dated 4/17 and 4/24/23, included documentation the hospice aide assisted the patient with a shower. The hospice aide care plan did not include instructions for the hospice aide to complete this task, and the clinical record lacked documentation the hospice aide received approval for this task prior to completing the unassigned task. e. The hospice aide visit, dated 5/17/23, included documentation the hospice aide assisted the patient with turning and repositioning. The hospice aide care plan did not include instructions for the hospice aide to complete this task, and the clinical record lacked documentation the hospice aide received approval for this task prior to completing the unassigned task. f. The hospice aide visit, dated 5/23/23, lacked documentation the hospice aide completed the task of transferring the patient as needed and lacked a reason why the hospice aide did not complete the task. g. The hospice aide visit, dated 5/24/23, included documentation of the visit date and length of the visit (7:18 AM to 7:57 AM), but lacked documentation of completion of any of the assigned tasks and lacked any documentation to explain if the hospice aide failed to complete any of the assigned tasks. On 6/7/23 at 3:00 PM, during an interview, Staff H, Hospice Aide, reported they reach out to nurse first prior to doing unassigned tasks. Staff H, Hospice Aide, believed they documented this somewhere, but they were not sure where. Staff H, Hospice Aide, clarified that both the hospice aide and nurse document the approval for the task. 6. Patient #10 had a hospice admission date of 5/26/23 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 5/26/23 to 8/23/23, included IDG orders for skilled nursing and hospice aide services. b. The hospice aide care plan for hospice aide services starting on 5/31/23 included RN instructions to the hospice aide to complete the following tasks: partial/complete bed bath, nail care, perineal care/catheter care, assist with feeding, observe skin condition, turn and reposition, assist with transfers, encourage fluids, dressing, mouth care, shampoo and bed pan/urinal/commode. c. The hospice aide visit, dated 6/1/23, included documentation the hospice aide completed the tasks of assisting to feed the patient and encouraged fluids. The hospice aide marked "NA (not applicable)" for all other tasks without documenting a reason why the assigned tasks did not apply to the patient on that day. d. The hospice aide visit, dated 6/5/23, included documentation the hospice aide marked "NA" for the tasks of shampooing, providing feeding assist, encouraging fluids and completing perineal care. The visit note lacked documentation of a reason why the assigned tasks did not apply to the patient on that day. The hospice aide marked they completed the task of "partial/complete bed bath", but did not identify if the patient received a complete bed bath or just a partial bed bath. 1. Patient #4 had a hospice admission date of 5/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The interdisciplinary group (IDG) meeting notes, dated, 5/23/23, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task to assist with feeding/feed patient (if at meal time). c. The hospice aide visit note, dated 5/23/23, lacked documentation the task to assist with feeding/feed patient (if at meal time) had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan. 2. Patient #8 had a hospice admission date of 4/21/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG meeting notes, dated, 4/25/23, 5/9/23 and 5/23/23, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task to assist with feeding/feed patient (if at meal time) and shampoo. c. The hospice aide visit note, dated 4/24/23, 4/26/23, 5/1/23, 5/4/23, 5/10/23, 5/15/23, 5/17/23 and 5/23/23, lacked documentation the task to assist with feeding/feed patient (if at meal time) had been completed or a reason why the task was not completed. d. The hospice aide visit note, dated 4/26/23 and 5/4/23, lacked documentation the task perineal care (if soiled or wet) had been completed or a reason why the task was not completed. e. The hospice aide visit note, dated 5/15/23, lacked documentation the task shampoo had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan. 3. Patient #11 had a hospice admission date of 8/30/22, a revocation date of 9/12/22 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 8/30/22 to 11/27/22, included orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks tub bath and partial/complete bed bath. c. The hospice aide visit note, dated 9/1/23, included documentation the tasks shower and partial/complete bed bath were completed. The task shower was not on the hospice aide care plan and no documentation to indicate the aide contacted the nurse for approval to complete a shower. The hospice aide failed to document approval for completion of a task not assigned on the hospice aide care plan. 4. Patient #13 had a hospice admission date of 6/10/22, a death date of 7/5/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG meeting notes, dated 6/21/22, included IDG orders for hospice aide services. b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks catheter care, empty drainage bag, perineal care (if soiled or wet), mouth care, encourage fluids and apply lotion: arms, legs and back. c. The hospice aide visit note, dated 6/13/22, lacked documentation the tasks catheter care, empty drainage bag had been completed or a reason why the tasks were not completed. d. The hospice aide visit note, dated 6/29/22 lacked documentation the tasks catheter care, empty drainage bag, perineal care (if soiled or wet), mouth care, encourage fluids and apply lotion: arms, legs and back had been completed or a reason why the task was not completed. The hospice aide failed to complete all assigned tasks on the hospice aide care plan.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to document all required components of hospice aide supervision including following the patient plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 7 of 7 sampled patients (Patients #1, #3, #4, #5, #7, #8 and #9) with hospice aide services that required and received hospice aide supervision. The hospice reported 15 patients received hospice aide services at the time of the survey. Failure to ensure the supervision of hospice aide by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. --- 6. Patient #1 had a hospice admission date of 9/18/2020 and received routine home care services through hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/6/23 to 7/4/23, included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide services. b. The skilled nursing visits, dated 5/12, 5/17, 5/19, 5/22, 5/30, 5/31 and 6/2/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. 7. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The POC, dated 4/12/23 to 7/10/23, included IDG orders for for skilled nursing and hospice aide services. b. The skilled nursing visit notes, dated 5/12, 5/19, 5/26 and 6/1/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. The Clinical Manager and Senior Director received the above findings and hospice staff provide no further information prior to the end of the survey. 3. Patient #3 had a hospice admission date of 4/10/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 4/10/23 to 7/8/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/12/23, 5/16/23 and 5/30/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. 4. Patient #5 had a hospice admission date of 4/25/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 4/25/23 to 7/23/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/16/23, 5/23/23 and 5/30/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. 5. Patient #9 had a hospice admission date of 5/5/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/5/23 to 8/2/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/12/23, 5/19/23, 5/26/23 and 6/2/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. Findings include: Review of the hospice policy, titled Hospice Aide Services, dated November 2022, identified the hospice aide provides services in accordance with the plan of care and physician orders and will be supervised by a hospice registered nurse. During an interview on 6/7/23 at 8:50 AM, Staff F, Registered Nurse (RN), reported hospice aide supervision is documented in the electronic medical record under a section called care plan charting. The statement supervised the hospice aide at least every two weeks is marked as completed. 1. Patient #4 had a hospice admission date of 5/18/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/18/23 to 8/15/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/24/23 and 6/2/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition. 2. Patient #8 had a hospice admission date of 4/21/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/21/23 to 7/19/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/17/23, 5/25/23 and 5/31/23, included documentation the nurse supervised the hospice aide at least every two weeks. The visit notes failed to address the required components of following the plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control policies and procedures, and reporting changes in the patient condition.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure all documentation was included in the clinical record (bereavement risk assessment) and included an appropriate date and signature for 14 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14). Failure to ensure all clinical record documentation, and each patient's clinical record was complete, timely and appropriately authenticated, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to its patients. --- 10. Patient #3 had a hospice admission date of 4/10/23 and received services while residing in a private home. a. The POC, dated 4/10/23 to 7/8/23, included orders for spiritual care and hospice aide services. b. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 4/13/23, included an electronic signature but lacked a discipline title. c. The hospice aide visit notes, dated 4/11/23, 4/17/23, 4/20/23, 4/27/23, 5/4/23, 5/823, 5/11/23, 5/15/23, 5/18/23, 5/24/23, 5/31/23 and 6/5/23, included a hand written signature but lacked a discipline title. 11. Patient #5 had a hospice admission date of 4/25/23 and received services while residing in a private home. a. The POC, dated 4/25/23 to 7/23/23, included orders for spiritual care and hospice aide services. b. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 4/26/23, 5/2/23 and 5/22/23 included an electronic signature but lacked a discipline title. c. The hospice aide visit notes, dated 5/1/23, 5/4/23, 5/8/23, 5/11/23, 5/18/23 and 5/23/23, included a hand written signature but lacked a discipline title. 12. Patient #9 had a hospice admission date of 5/5/23 and received services while residing in a nursing home. a. The POC, dated 5/5/23 to 8/2/23, included orders for spiritual care and hospice aide services. b. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 5/9/23 and 5/25/23, included an electronic signature but lacked a discipline title. c. The hospice aide visit notes, dated 5/11/23, 5/16/23, 5/18/23 and 5/30/23, included a hand written signature but lacked a discipline title. 13. Patient #12 had a hospice admission date of 11/1123 and discharge date of 12/2/22 and received services while residing in a private home. a. The POC, dated 11/11/22 to 2/8/22, included orders for spiritual care and hospice aide services. b. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 11/14/22 and 11/22/22, included an electronic signature but lacked a discipline title. c. The hospice aide visit notes, dated 11/15/23, 11/17/23, 11/21/23 and 11/28/23 included a hand written signature but lacked a discipline title. 14. Patient #14 had a hospice admission date of 5/20/23 and received services while residing in a private home. a. The POC, dated 5/20/23 to 8/17/23, included orders for spiritual care services. b. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 5/24/23 and 5/31/23, included an electronic signature but lacked a discipline title. The Administrative Management and Nurse Consultant received the above findings and hospice staff provided no further information prior to the end of the survey. On 6/6/23 at 4:05 PM, during an interview, the Clinical Manager reported authentication of visit notes includes the signature of the person completing the visit, credentials and title, date and time of the visit. 7. Patient #1 had a hospice admission date of 9/18/2020 and received routine home care services through hospice while residing in a nursing home. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 3/7/23 to 5/5/23 and 5/6/23 to 7/4/23, included Interdisciplinary Group (IDG) orders for spiritual care counseling (chaplain) and hospice aide services. b. The clinical record included documentation of spiritual care counseling visit notes, dated 4/18, 5/3, 5/18 and 6/1/23. The visit notes included a date and signature by the staff person completing the visit, but lacked documentation of the title or credentials with the staff person's signature. c. The hospice aide visit notes, dated 4/10, 4/11, 4/17, 4/18, 4/24, 4/25, 4/27, 5/1, 5/2, 5/4, 5/8, 5/9, 5/11, 5/15, 5/16, 5/18, 5/23, 5/25, 5/30 and 5/31/23, included documentation of a signature by the person completing the visit, but lacked documentation of a title with the signature. d. A hospice aide visit note, undated, included documentation of the hospice aide's signature, but lacked a title and a date for the visit. A hospice registered nurse (RN), documented they reviewed the visit note on 5/2/23. e. A hospice aide visit note, undated, included documentation of the hospice aide's signature, but lacked a title and a date for the visit. A hospice RN, documented they reviewed the visit note on 5/9/23. 8. Patient #7 had a hospice admission date of 4/12/23, received routine home care hospice services while residing in a private residence and then transferred to a nursing home on 5/3/23. Review of the clinical record revealed the following: a. The POC, dated 4/12/23 to 7/10/23, included IDG orders for hospice aide, social worker and spiritual care counseling services. On 6/7/23 at 3:06 PM, during an interview, Staff I, Social Worker/Bereavement Coordinator, reported Staff I was responsible for the completion of the initial bereavement risk assessment. b. On 6/7/23, review of the clinical record revealed a lack of documentation of an initial bereavement risk assessment. On 6/8/23 at 9:23 AM, during an interview, Staff I, Social Worker/Bereavement Coordinator, provided documentation of the patient's initial bereavement risk assessment, dated 4/13/23. Staff I, Social Worker/Bereavement Coordinator, reported the initial bereavement risk assessment had been located in their office in a file separate from the patient's clinical record. They reported Staff L, Administrative Assistant, was responsible for scanning documents into an electronic medical record (EMR) separate from the patient's primary EMR, and Staff L had scanned the patient's initial bereavement risk assessment into this EMR. On 6/8/23 at 9:25 AM, during an interview, Staff L, Administrative Assistant, reported having access to the EMR system used to place scanned documents in including the bereavement risk assessments and volunteer visits. Staff L, Administrative Assistant, did not know who else had access to the separate EMR beyond themselves and Staff D, Administrative Management Staff. On 6/8/23 at 9:26 AM, during an interview, Staff I, Social Worker/Bereavement Coordinator, reported they had not been in the computer system that contained scanned volunteer and bereavement risk assessments and did not know how to get in. Staff I, Social Worker/Bereavement Coordinator, could not recall if someone had shown them how to get in when they started with the hospice. On 6/8/23 at 9:33 AM, during an interview, Staff D, Administrative Management Staff, reported the whole team should have access to the separate EMR system with all scanned documents. On 6/8/23 at 9:40 AM, during an interview, Staff L, Administrative Assistant, completed a review of the EMR system containing scanned documents. They reported that they had not received the bereavement risk assessment on Patient #7 yet to scan into the EMR system. The patient's clinical record failed to include documentation of the initial bereavement risk assessment completed by Staff I, Social Worker/Bereavement Coordinator. c. The hospice aide visit notes, dated 4/13, 4/17, 4/20, 4/24, 4/27, 5/1, 5/3, 5/8, 5/10, 5/15, 5/17, 5/23, 5/24 and 5/30/23, included documentation of a signature by the person completing the visit, but lacked documentation of a title with the signature. d. The clinical record included documentation of spiritual care counseling visit notes, dated 4/17 and 5/24/23. The visit notes included a date and signature by the staff person completing the visit, but lacked documentation of the title or credentials with the staff person's signature. 9. Patient #10 had a hospice admission date of 5/26/23 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 5/26/23 to 8/23/23, included IDG orders for spiritual care counseling services. b. The clinical record included documentation of a spiritual care counseling visit note, dated 5/30/23. The visit note included a date and signature by the staff person completing the visit, but lacked documentation of the title or credentials with the staff person's signature. Findings include: Review of the hospice policy, titled Contents of Clinical Record, dated November 2022, identified documentation will include signed and dated clinical notes. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. Review of the hospice policy, titled Clinical/Service Data Collection, dated November 2022, identified documentation in the clinical/service record will by timely, detailed, accurate, and reflect the care or services provided. The clinical record will include: signature authorization of clinical/service documentation will include the staff members name and credentials; and all entries will reflect the date care was provided, including the month, day and year. 1. Patient #6 had a hospice admission date of 5/5/23 and received services while residing in a private home. a. The clinical record lacked documentation of a bereavement risk assessment. During an interview on 6/8/23 at 9:20 AM, Staff I, Bereavement Coordinator, provided a paper copy of the bereavement risk assessment. Staff I reported she keeps the paper copies of the bereavement risk assessments in a file in the filing cabinet by her desk. Staff I reported she did not have access to the OnBase computer program. During the same interview on 6/8/23 at 9:20 AM, Staff J, Nurse Consultant, reported the paper bereavement risk assessments are scanned into the OnBase computer program. Staff J reported the hospice had discovered through an audit that the bereavement risk assessment was not being completed. Hospice staff were trained on 1/18/23 regarding bereavement risk assessment completion. Staff J provided documentation of the training to the surveyors. Any bereavement risk assessments prior to January 2023 were not completed. During an interview on 6/8/23 at 9:30 AM, Staff D, Administrative Management Staff, reported all staff have access to the OnBase computer program. The surveyor reviewed the OnBase computer program and was unable to find the scanned bereavement risk assessments for Patients #6 and #7. b. The hospice aide paper visit note, dated 5/17/23, included a handwritten signature but lacked a discipline title. 2. Patient #2 had a hospice admission date of 4/14/23 and received services while residing in a private home. The clinical record review revealed Spiritual Care Coordinator visit notes, dated 4/19/23, 5/4/23 and 5/15/23, included an electronic signature but lacked a discipline title. 3. Patient #4 had a hospice admission date of 5/18/23 and received services while residing in a nursing home. Clinical record review revealed: a. Spiritual Care Coordinator visit notes, dated 5/22/23 and 5/31/23, included an electronic signature but lacked a discipline title. b. Hospice aide paper visit notes, dated 5/23/23 and 5/24/23, included a handwritten signature but lacked a discipline title. 4. Patient #8 had a hospice admission date of 4/21/23 and received services while residing in a nursing home. Clinical record review revealed: a. Spiritual Care Coordinator visit notes, dated 4/25/23, 5/11/23 and 5/30/23, included an electronic signature but lacked a discipline title. b. Hospice aide paper visit notes, dated 4/24/23, 4/26/23, 5/1/23, 5/4/23, 5/8/23, 5/10/23, 5/15/23, 5/17/23, 5/23/23 and 5/25/23, included a handwritten signature but lacked a discipline title. 5. Patient #11 had a hospice admission date of 8/30/22, a revocation date of 9/12/22 and received services while residing in a private home. Clinical record review revealed: a. Spiritual Care Coordinator visit notes, dated 8/30/22 and 9/6/22, included an electronic signature but lacked a discipline title. b. Hospice aide paper visit notes, dated 9/1/22, 9/6/22 and 9/8/22, included a handwritten signature but lacked a discipline title. 6. Patient #13 had a hospice admission date of 6/10/22, a death date of 7/5/22 and received services while residing in a nursing home. Clinical record review revealed: a. Spiritual Care Coordinator visit notes, dated 6/10/22 and 6/22/22, included an electronic signature but lacked a discipline title. b. Hospice aide paper visit notes, dated 6/13/22, 6/15/22, 6/20/22, 6/22/22, 6/27/22 and 6/29/22, included a handwritten signature but lacked a discipline title.

Based on clinical record review, nursing home clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the nursing home received the required copies of the hospice election form and interdisciplinary group updates to the plan of care for 1 of 1 sampled patients (Patient #1) with home observation visits in a nursing home. 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. --- Review of the hospice policy, titled Interdisciplinary Group (IDG) Plan of Care, dated 11/2022, revealed the hospice utilizes a Registered Nurse (RN) Case Manager to guide the IDG in providing comprehensive, coordinated health care to patients and their families. Patient #1 had a hospice admission date of 9/18/2020 and received routine home care services through hospice while residing in a nursing home. On 6/5/23 at 1:47 PM, during an interview and review of the nursing home's documents provided by the hospice for Patient #1, the nursing home's Director of Nursing (DON) reported an inability to find the patient's Plans of Care (POCs), dated 3/7/23 to 5/5/23 and 5/6/23 to 7/4/23, any Certificates of Terminal Illness (CTIs), and did not have a copy of the patient's Medicare Benefit Election form. Staff G, Hospice RN, reported they had not been providing the nursing homes with copies of the patients' CTIs and Medicare Benefit Election forms. Staff G, Hospice RN, explained they may not have provided a copy of the Patient #1's POC, dated 3/7/23 to 5/5/23, due to the patient being admitted to the nursing home during the middle of that certification period. Review of the hospice clinical record revealed the following: a. A Medicare Benefit Election form, dated 9/18/2020. b. An IDG meeting, dated 3/28/23, which identified the patient would be admitted to the nursing home on 3/29/23. c. CTIs, dated 3/7/23 to 5/5/23 and 5/6/23 to 7/4/23. d. Hospice POCs, dated 3/7/23 to 5/5/23 and 5/6/23 to 7/4/23. The Clinical Manager and Senior Director 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 plan of care failed to specify the hospice care and services necessary to meet the patient-family specific needs identified in the comprehensive assessment for 1 of 7 sampled patients (Patients #5). The hospice reported a current census of 15 patients. Failure to ensure the hospice plan of care specified the care and services necessary to meet the patient-family specific needs identified in the comprehensive assessment placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to hospice policy, titled Provider Orders and dated 4/21/2020, it is the professional employee's responsibility to contact the provider to obtain the necessary orders to facilitate care based upon the patient's symptom and care management needs. Treatment orders include the type of treatment, applicable specific requirements, and frequency of treatment. Patient #5 was admitted to the agency on 1/29/21 and revoked services on 3/22/21. Clinical record review revealed the following: a. The Plan of Care, dated 1/29/21 to 4/28/21, identified the patient's use of oxygen. b. The initial comprehensive assessment, dated 1/29/21, documented the patient's use of oxygen 5 liters (L) continuous per nasal cannula. c. The IDG update to the Plan of Care, dated 2/2/21, documented the patient's use of 5 L of oxygen per nasal cannula. d. The skilled nurse visit note, dated 3/12/21, documented the patient's use of 5 1/2 L of oxygen per nasal cannula continuously. e. The skilled nurse visit note, dated 3/16/21, documented the patient's use of 6 1/2 L of oxygen per nasal cannula continuously. f. The skilled nurse clinical note, dated 3/16/21, documented the patient's spouse increased the oxygen to 6 1/2 L per nasal cannula on 3/15/21 due to the patient having decreased oxygen saturation readings in the 50's. g. The skilled nurse visit note, dated 3/17/21, documented the patient's use of 6 1/2 L of oxygen per nasal cannula continuously. h. The skilled nurse visit note, dated 3/20/21, documented the patient's use of 5 1/2 L of oxygen per nasal cannula continuously. The Plan of Care and IDG updates to the Plan of Care, lacked identification of the correct amount of oxygen used to meet the patient's needs. The above findings were reviewed with the Hospice Administrator. 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 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 7 sampled patients (Patients #2 and #3). The hospice reported a current census of 15 patients. Failure to ensure the plan of care included physician orders for all necessary medications and and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to hospice policy, titled Provider Orders and dated 4/21/2020, it is the professional employee's responsibility to contact the provider to obtain the necessary orders to facilitate care based upon the patient's symptom and care management needs. Treatment orders include the type of treatment, applicable specific requirements, and frequency of treatment. 1. Patient #2 had an initial hospice admission date of 6/15/21 and revoked from hospice services on 8/8/21 and readmitted to the agency on 8/9/21 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care, dated 6/15/21 to 9/12/21, documented the patient must use latex catheters and included orders to insert the catheter and change as ordered. Foley/Coude catheter 16 French 5-10 cubic centimeter (cc) bulb as needed (PRN). The order failed to specify what size of catheter and size of balloon the patient used. b. The initial comprehensive assessment completed at start of care, dated 6/15/21, documented the presence of a foley catheter and stated must be changed every 2 weeks. c. The skilled nurse visit note, dated 6/23/21, documented the presence of a catheter with a coude tip. d. The skilled nurse visit note, dated 6/25/21, documented the presence of a 18 french foley catheter with a 15 cubic centimeter (cc) balloon size with a coude tip last changed on 6/23/21. e. The IDG meeting notes, dated 7/6/21, included orders to perform the catheter change every two weeks. f. The skilled nurse visit note, dated 7/7/21, documented the presence of a 18 french foley catheter with a 30 cc balloon size with a coude tip last changed on 7/7/21. g. The skilled nurse visit note, dated 7/11/21, documented the presence of a 18 french foley catheter with a 25 cc placed in balloon last changed on 7/11/21. h. The skilled nurse visit note, dated 7/12/21, documented the presence of a 18 french foley catheter with a 30 cc balloon size last changed on 7/11/21. i. The skilled nurse visit note, dated 7/19/21, documented the presence of a 20 french latex foley catheter with a 30 cc balloon last changed on 7/19/21. j. The skilled nurse visit note, dated 8/2/21, documented the presence of a 20 french foley catheter with a 30 cc balloon last changed on 8/2/21. k. The skilled nurse visit note, dated 8/4/21, documented the presence of a 24 french foley catheter with a 30 cc balloon last changed on 8/4/21. l. The skilled nurse clinical note, dated 8/6/21, documented the patient's catheter was replaced with a catheter two sizes larger. The Plan of Care and IDG updates to the Plan of Care, lacked specific orders for the size and type of catheter to be used and the amount of solution to be used to inflate the balloon. m. The Plan of Care, dated 8/8/21 to 11/6/21, documented orders for a 24 french with 30 cc balloon latex catheters to be changed every two weeks and as needed. n. The skilled nurse visit notes, dated 8/18/21, 8/30/21, 9/13/21, 9/27/21, 10/11/21, and 10/25/21, documented the presence of a 24 french foley catheter with a 30 cc balloon changed during the visit. The Plan of Care and IDG updates to the Plan of Care, lacked specific orders for the amount of solution to be used to inflate the balloon. 2. Patient #3 had a start of care date of 6/29/2021 and continued to receive services from the hospice at the time of the survey. Clinical record review revealed the following: a. The hospice Plan of Care documented the patient's terminal diagnosis as hypertensive chronic kidney disease Stage 5; documented secondary diagnoses of history of prostate cancer and long term use of a urinary catheter. b. The initial skilled nurse assessment, dated 6/29/2021, documented Patient #3 used a urinary catheter. The urine in the catheter bag was clear. c. The initial Plans of Care/Physician Orders, dated 6/29/2021 to 9/26/2021 and 9/27/2021 to 12/25/2021, included physician orders for the skilled nurse to "insert catheter and change as ordered monthly". The Plans lacked the size of the catheter and bulb size the nurse should insert each month. d. The clinical record lacked any physician's interim orders directing the size of the catheter or the bulb. e. The skilled nurse visit note with attached coordination notes, dated 7/22/2021, documented the patient's caregiver had contacted the on-call nurse to report the patient was experiencing intense pain in the lower abdominal area and the output of urine had been decreased. The nurse contacted the physician, obtaining a physician order to collect a urine sample to evaluate for a urinary tract infection. The nurse visited the patient, removed the old urinary catheter, inserted a 20 French catheter with a 5 milliliter (ml) bulb then obtained the urine sample. f. The physician's interim order, dated 7/22/2021, ordered a urine specimen collected for urinalysis with culture and sensitivity. The order did not include identification of the size of the catheter or bulb. g. The skilled nurse visit note with attached coordination notes, dated 7/29/2021, documented the patient's caregiver called the office to report the patient's catheter kept getting kinked up, decreasing the flow of urine which resulted in increased lower abdominal pain described by the patient. The nurse documented the silicone catheter previously inserted did have a tendency to kink up so the nurse removed the catheter and replaced the catheter with a 20 French coude catheter. The document lacked identification of contact with the physician to discuss use of the different type of urinary catheter. The clinical record lacked any physician interim orders changing the type of catheter. h. The skilled nurse visit note with attached coordination notes, dated 9/3/2021, documented the nurse removed the coude catheter and replaced the urinary catheter with a 20 French silicone catheter with a 10 ml bulb. The clinical record lacked any physician order directing the catheter or bulb size. i. The skilled nurse visit note with attached coordination notes, dated 10/19/2021, documented the nurse changed the patient's catheter but lacked any identifying information about the catheter that was reinserted. During hospice staff interview on 12/8/2021 at 1:55 PM, the hospice Administrator reported the Veteran's Administration (VA)sent the urinary catheters to the patient's home. When time to change the patient's catheter, she just used whatever the VA had sent. The Administrator concurred she had not added the specific catheter or bulb size to the Plan of Care. j. The skilled nurse visit note, dated 8/13/2021, documented the nurse observed a 4 inch by 1 inch excoriated open wound on the patient's left buttocks high near the coccyx. The nurse documented directing the patient's caregiver to apply barrier cream to the wound until the nurse could order Allevyn patches and bring to the patient for use. The Interdisciplinary Group notes, dated 8/17/2021, documented the nurse reported the new open area; however, lacked any direction from the physician on how to treat the wound. The skilled nurse visit note, dated 8/17/2021, documented the nurse took multiple Allevyn wound dressing patches to the patient's home, covered the open areas with the Allevyn patches and instructed the patient's caregiver to apply the patch to the open wound, changing the patch every 3-4 days. The skilled nurse visit note, dated 10/25/2021, documented the wound was nearly healed so the nurse directed the patient's caregiver to discontinue use of the Allevyn to the wound, instead apply barrier cream to the area. The nurse documented noting a new, smaller area present on the left buttocks so directed the patient's caregiver to begin applying the Allevyn to the new wound. The clinical record lacked documentation of any physician communication related to the new wound and lacked a physician's order directing the nurse/caregiver to apply the Allevyn. During hospice staff interview on 12/8/2021 at 1:55 PM, the hospice Administrator reported she was the patient's primary registered nurse. The Administrator reported she decided to try the Allevyn dressing on the wound but stated "I will be honest I didn't get permission or order from the physician and I should have." The Administrator reported she took the Allevyn patches from stock dressings stored by the hospice. The above stated findings were reviewed with Administrator. The hospice provided no additional information prior to the end of the complaint investigation.