Every finding on record at Hospice Inc Serving Davis & Wapello Counties

Based on observations, record review and staff interview, the facility is not maintaining, conducting and documenting annual testing of all fire door assemblies as required by NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition. The deficient practice affects 3 out of 6 smoke zones, including facility staff and residents. The facility has a capacity of 6 with a census of 3 residents. --- Findings include: Observations, record review and staff interview on 3/29/24, between 11:00 a.m. and 1:00 p.m., revealed the following deficiencies: There was no available documentation for annual testing of the fire door assemblies separating smoke zones throughout the facility. The labels on all fire door assemblies throughout the facility were painted over, which did not allow for the fire resistance rating to be seen. Administrative Staff verified observations and record review during the survey process.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group completed performed an accurate and complete drug regimen review for 6 of 16 sampled patients (Patients #1, #4, #5, #7, #8 and #10). 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. --- The hospice's policy, titled Medication Reconciliation/Drug Regimen Review (DRR), dated 2/28/2023, identified the hospice patients will undergo a comprehensive assessment which will include a review of all medications the patient is currently using including over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy in order to identify any potential adverse effects and drug reactions. This includes, but is not limited to identification of the following: effectiveness of drug therapy, significant drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy currently associated with laboratory monitoring and noncompliance with drug therapy, The hospice's policy, titled Ongoing Assessment, dated 4/2023, identified the hospice Interdisciplinary Group (IDG) will reassess the patient's medications every 15 days at a minimum. On 7/24/23 at 11:10 AM, during an interview, the Administrator reported that the pharmacist completes a DRR initially and during IDG meetings. 1. Patient #1 had a hospice admission date of 3/13/24 and received routine home care hospice services while residing in the hospice house. Review of the clinical record revealed the following: a. The Medication Profile, dated 3/13/24, included physician orders for medications with the following potential drug interactions: Diazepam and Morphine may increase the risk of central nervous system (brain and spinal cord) depression of function. b. The comprehensive assessment completed by the registered nurse (RN) at the start of care, dated 3/14/24, included documentation the RN assessed the patient did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any drug interactions. c. The initial IDG meeting, dated 3/20/24, included documentation which identified the patient did not take any medications associated with potential or actual drug interactions. The patient continued to have active orders for Morphine and Diazepam. 2. Patient #4 had a hospice admission date of 2/14/24 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/14/24 to 5/13/24, included physician orders which included duplicate pain medications including Acetaminophen and Fentanyl. The POC also included duplicate bowel medications including Dulcolax laxative, Polyethylene and Senna. b. The comprehensive assessment completed by the RN at the start of care, dated 2/14/24, included documentation the RN assessed the patient did not take any duplicate medications. The DRR completed by the RN failed to identify any duplicate medications c. The initial IDG meeting, dated 2/21/24, included documentation which identified the patient did not take any duplicate medications. The patient continued to have active orders for Acetaminophen, Fentanyl, Dulcolax, Polyethylene and Senna. 3. Patient #5 had a hospice admission date of 11/22/23 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 11/22/23 to 2/19/24 and 2/20/24 to 5/19/24, included physician orders for medications with the following potential drug interactions: Lorazepam and Morphine may increase the risk of central nervous system (brain and spinal cord) depression of function. b. The comprehensive assessment completed by the registered nurse (RN) at the start of care, dated 11/22/23, included documentation the RN assessed the patient did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any drug interactions. c. The initial IDG meeting, dated 11/30/23, included documentation which identified the patient did not take any medications associated with potential or actual drug interactions. The patient continued to have active orders for Morphine and Lorazepam. 4. Patient #10 had a hospice admission date of 3/6/24 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 3/6/24 to 6/3/24, included physician orders which included the medication Levothyroxine which is associate with laboratory monitoring b. The comprehensive assessment completed by the RN at the start of care, dated 3/6/24, included documentation the RN assessed the patient did not take any medications associated with laboratory monitoring. The DRR completed by the RN failed to identify any medications associated with laboratory monitoring. c. The initial IDG meeting, dated 3/6/24, included documentation which identified the patient did not take any medications associated with laboratory monitoring. The patient continued to have active orders for Levothyroxine. 5. Patient #7 had a hospice admission date of 2/29/24 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 2/29/24 to 5/28/24, included physician orders which included duplicate pain medications included Acetaminophen disintegrating oral tablet started on 2/29/24 and Acetaminophen oral tablet started on 3/6/24. b. The initial IDG meeting notes, dated 3/6/24, included documentation which identified the patient did not take any duplicate medications. The patient continued to have active orders for Acetaminophen disintegrating oral tablet and Acetaminophen oral tablet. The hospice DRR failed to identify duplicate drug therapy. 6. Patient #8 had a hospice admission date of 3/12/24 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 3/12/24 to 6/9/24, included physician orders for medications with the following potential drug interactions: Hydrocodone and Lorazepam may increase the risk of central nervous system depression and function. b. The initial comprehensive assessment completed by the RN at the start of care, dated 3/12/24, included documentation the RN assessed the patient did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any drug interactions. c. The initial IDG meeting notes, dated 3/13/24, included documentation which identified the patient did not take any medications associated with potential or actual drug interactions. The patient continued to have active orders for Hydrocodone and Lorazepam. d. The RN telephone call note, dated 3/19/24, documented verbal orders given for Morphine. The RN delivered to medication to the patient's home and provided instruction on this date. e. The IDG meeting notes, dated 3/21/24, reflected the addition of Morphine 20 milligrams (MG)/milliliters (ML) 5mg every hour as needed for pain. The IDG meeting notes included documentation which identified the patient did not take any medications associated with potential or actual drug interactions and did not have duplicate drug therapy. The patient continued to have active orders for hydrocodone, morphine, and lorazepam. The hospice DRRs failed to identify duplicate drug therapy and potential or actual major drug interactions. The Administrator and Clinical Manager were given the above findings. The hospice team did not provide any further information prior to the end of the survey.

Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound description, measurements, and changes to treatment for 4 of 6 sampled patients with a wound (Patients #2, #4, #10, and #14). Failure by the hospice IDG registered nurses to update the comprehensive assessment with complete wound descriptions and 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: --- 3. Patient #4 had a hospice admission date of 2/14/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting note dated 2/21/24, included orders for skilled nursing services 2 times per week. b. The skilled nurse notes, completed by the RN, dated 2/14/24, 2/15/24, 2/16/24, and 2/20/24 included documentation of a right posterior inner buttock wound. The notes included measurements of length 0.2 cm by 0.2 cm. The measurement failed to include depth of the wound. The hospice failed to document complete measurements of the patient's wound. 4. Patient #10 had a hospice admission date of 3/6/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting note dated 3/6/24, included orders for skilled nursing services 2 times per week. b. The skilled nurse note, completed by the RN, dated 3/18/24, included documentation of a right buttock open wound. The notes included measurements of length 0.5 cm. The measurement failed to include width or depth of the wound. The hospice failed to document complete measurements of the patient's wound. The above findings shared the Administrator and Clinical Manager. No further information provided prior to the end of the survey. According to the hospice policy titled, Wound Care, dated 2/28/23, a baseline comprehensive assessment of any wound includes the location, length, width, and depth. The RN/Case Manager will conduct ongoing wound assessments, assessing and documenting the patient's wound in the clinical record at least weekly but more if necessary. During an interview on 3/20/24 3:17 PM, the Clinical Manager reported wounds should be assessed at least weekly, more if needed. 1.Patient #2 had a hospice admission date of 11/15/23 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The IDG meeting note dated 3/8/24, included an for skilled nursing services 2 times per week. b. Comprehensive assessments completed by the RN, dated 2/6/24, 2/13/24, 2/20/24, and 2/27/24 included documentation of a small pressure, edema area on top of the right foot being treated by the facility. The assessments failed to include any further description or measurements of the wound. c. A comprehensive assessment completed by the RN, dated 3/5/24 included documentation of a new area on right foot for a total of two wounds being treated by the facility. The assessment failed to include a description or measurements of the wounds. 2. Patient #14 had a hospice admission date of 1/24/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The RN comprehensive assessment, dated 1/29/24, included documentation of a left lateral umbilicus wound measuring <.1cm (length) X <.1cm (width). The documentation lacked depth of the wound. b. The RN comprehensive assessment, dated 1/29/24, included documentation of a right upper buttocks/decubitus/pressure ulcer state 1. The documentation lacked wound measurements. The hospice staff failed to fully assess the patients' wounds in order to provide a complete description of the patient's current physical status with updates to the comprehensive assessment.

Based on hospice clinical record review, hospice policy review, nursing home staff interview, home visit observation, patient interview, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure all hospice care and services furnished to patients and families must follow an individualized written plan of care (L0543); 2) ensure all treatments necessary to meet the needs of the patient are on the plan of care (L0549); and, 3) ensure the revised Plan of Care includes information form the patient's updated comprehensive assessment and notes the patient's progress toward outcomes and goals specified in the plan of care (L0553); --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure that all hospice care and services furnished to patients and their families, followed an individualized written plan of care, established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver, in accordance with the patients needs. (Patient #1 and #14) Failure to initiate the individualized written plan of care as directed by the Interdisciplinary Group (IDG), placed the patient at risk for inconsistent care and the risk of not meeting the patients needs. --- 2. Patient #1 had a hospice admission date of 3/13/24 and received hospice services while residing in the hospice house. Clinical record review revealed: a. IDG meeting notes, dated 3/20/24, include physician orders for skilled nursing and social worker services. The orders also included medications and treatments provided for the patient. b. Review of the medical record lacked documentation of a POC to include current orders for services provided, medications or treatments.. During an interview on 3/26/24 at 3:30 PM the Administrator stated he did not generate the POC due to the social worker did not complete her orders for services. He further stated his predecessor advised him to get the orders for the nurse and the social worker The hospice failed to complete a POC to include physician orders for services, treatments and medication provided. The above findings provided to the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey. According to the policy titled, Plan of Care dated 2/28/23, hospice care and services are provided to patients and their families are in accordance with an individualized, written plan of care (POC) established by the hospice IDG in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver. 1.Patient #14 had a hospice admission date of 1/24/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. Verbal orders were given to begin hospice care on 1/24/24. b. Review of the medical record lacked documentation of a POC. c. The patient revoked hospice services on 1/30/24. During an interview on 3/26/24 at 2:18 PM, the Administrator stated the patient was admitted to hospice after IDG on 1/24/24 and revoked hospice care on 1/30/24 (prior to the next IDG) so the patient was on the task hot list which would have triggered the initiation of the POC. The hospice failed to complete a POC for the patient.

Based on clinical record review, policy review, and staff interviews, the agency failed to ensure the hospice plan of care, included all necessary medications and treatments and/or a complete physician's order for all mediations and treatments, to meet the needs of the patient in 2 of 3 sampled patients with home observation visits. (Pt #3 and #10) Failure to ensure the plan of care included complete orders for medications and treatments, placed patients at risk to receive inapprorpriate treatment of symptoms, and/or not meet the needs of the patients. --- 2. Patient #10 had a start of care date of 3/6/24 and received hospice services in a private residence. a. The POC, dated 3/6/24 to 6/3/24, include physician orders for medications and treatments. b. The Comprehensive assessment note at admission, dated 3/6/24, included documentation the patient required oxygen at 4 liters per nasal cannula and had a 16 French Foley catheter with 10 ml balloon to bedside drainage. c. The POC failed to include physician orders for oxygen or a Foley catheter. The hospice failed to have include physician orders on the POC required by the patient. The above findings shared with the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey. Findings include: According to the agency policy titled Plan of Care - Content, dated 2/28/23, The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care includes drugs and treatment necessary and medical supplies and appliances necessary to meet the needs of the patient. 1. Patient #3 had a start of care date of 11/29/22. The Plan of Care (POC) dated 3/23/24 through 5/21/24, included physician orders for medications. The POC failed to include an order for Liquid Children's Tylenol 20 milliliters, which the patients spouse indicated he was currently using on a as needed basis for pain or discomfort. Failure to update the plan of care with medications administered by the spouse, increased the potential for medication errors, possible adverse interactions and inaccurate provision of care.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice interdisciplinary Group revied the patient's plan of care based on the updated comprehensive assessment and include the patient's progress towards outcomes and goals specified in the plan of care for 3 of 16 sampled patients (Patients #6, #8 and #10) requiring an updated comprehensive assessment and Interdisciplinary Group meeting review. Failure of the hospice to ensure the Interdisciplinary Group (IDG_ reviewed the patient's plan of care based on the updated comprehensive assessment and include patient's progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings Include: According to the hospice policy titled Plan of Care, dated 2/28/23, the plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. The plan of care is reviewed and updated by the IDG every 15 days or more frequently if needed. --- 3. Patient #8 had a hospice admission date of 3/12/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/12/24 to 6/9/24, included IDG identified orders, interventions, and goals for skilled nursing, social worker, and hospice aide services. b. The IDG meeting notes, dated 3/13/24 and 3/20/24, identified the patient declined aide services. The documentation included updates for the registered nurse and social worker but lacked progress toward the patient goals for hospice aide services. The hospice failed to include updates to the POC for hospice aide services. The Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey. According to the hospice policy titled 1. Patient #6 had a start of care date of 12/4/2 and received hospice services in a the hospice house. Review of the clinical record revealed the following: a. The Plan of Care (POC) dated 12/4/23 to 3/2/24 and 3/3/24 to 5/31/24, revealed the physician orders for skilled nursing and hospice aide services. b. The IDG note, dated 1/23, 1/31/24, 2/7, 2/14, 2/21, 2/28/24, 3/6 and 3/13/24, identified the patient declined aide services. The documentation included updates for the registered nurse, social worker and chaplain services but lacked progress towards the patient goals for hospice aide services. The IDG meeting lacked information on the update of interventions and outcomes of hospice aide services. 2. Patient #10 had a start of care date of 3/6/24 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/6/24 to 6/3/24, revealed the physician orders for skilled nursing and hospice aide services. b. The IDG note, dated 3/6 and 3/13/24, identified the patient declined aide services. The documentation included updates for the registered nurse, social worker and chaplain services but lacked progress towards the patient goals for hospice aide services. The IDG meeting lacked information on the update of interventions and outcomes of hospice aide services.

Based on clinical record review, agency policy review and home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 2 of 3 sampled patients (Pt #3 and #1) with home visits. Failure to follow accepted standard of practice for infection control may put the patient at risk of receiving unsafe care , or care that allows the spread of infection. --- 2. Patient #1 had a start of care date of 3/13/24 and received hospice services while residing in the hospice house. 3. The hospice aide care plan, dated 3/17/24, included the assignment for the hospice aide to complete catheter care. 4. During a home observation visit on 3/25/23 at PM, the surveyor observed Staff K, Hospice Aide empty the patient's suprapubic catheter bag. Staff K donned gloves and emptied the urine from the catheter bag into a plastic graduate. She then carried the graduate to the sink area in the room and opened the drawer and removed items with the contaminated gloves. She cleansed the graduate with water and spiled contaminated water on the counter. She cleansed the counter with a wipe and removed her gloves. The hospice staff failed to removed soiled gloves prior to handling clean surfaces and items. The above findings shared with the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey. According to the policy titled Infection Control - Standard Precautions, dated 02/28/23, Hospice staff use standard precautions in the care of all hospice patients, regardless of diagnosis or presumed infection status. Policy states to remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments. According to the policy entitled wound care, dated 02/28/2023, General infection control practices will be maintained during wound care and dressing changes. 1. Patient #3 had a start of care date of 11/29/22 and received hospice services while residing in the home. Clinical record review and home visit observation revealed: The patients Plan of Care (POC), dated 1/26/24, for the certification period of 3/23/24 through 5/21/24, included physician orders for wound care to Decubitus/Pressure Ulcer Stage III / Right Lateral Foot. Orders included to cleanse with wound wash, and cleanse peri wound with mild soap and water and pat dry. Pack with calcium alginate cut to size, cover with dry gauze and comfort foam. Wrap with rolled gauze. Change twice weekly and as needed in between if soiled. The surveyor accompanied Staff I, Registered Nurse (RN) to a home visit on 3/21/24 at 0930 and observed wound care to the wound on the right Lateral Foot. Surveyor observed RN taking the wash cloth from the tub of water used for the complete bed bath just prior, to cleanse the wound with soapy water. RN failed to obtain clean water for cleansing the wound. During the same home visit, Staff L, Home Hospice Aide removed her contaminated gloves following completion of shaving the patient, and placed the gloves into the pocket of her scrub top. The agency failed to ensure infection control standards were followed during patient care.

Based on hospice policy review, clinical record review, review of employee personnel files, and hospice staff interview, the hospice failed to ensure 2 of 5 hospice aides (Staff G and Staff L) demonstrated competency in the performance of any skills which exceed 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 3 of 7 sampled patients who required an extra skill to be performed (Patients #2, #4 and #8). 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: The Medicare Conditions of Participation direct that 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. Review of the hospices policy, titled, Hospice Aide Assignments and Duties, dated 2/28/23, hospice aides are assigned to specific patients by a Hospice RN and follow written patient care instructions in providing care to assigned patients. A hospice aide provides services that are consistent with the hospice aide training. 1. Patient #2 had a start of care date of 11/15/23, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the gait belt (an assistive device secured around the waist to help safely transfer). Review of the clinical record showed Staff F, Hospice Aide, provided aide services independently for Patient #2. Staff F, Hospice Aide, had a hire date of 10/10/23. Staff Fs personnel file lacked documentation RN had observed Staff F competently perform the task utilizing a gait belt. 2. Patient #4 had a start of care date of 2/14/24, and received hospice services while residing at home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the gait belt (an assistive device secured around the waist to help safely transfer). Review of the clinical record showed Staff L Hospice Aide, provided aide services independently for Patient #4. Staff L, Hospice Aide, had a hire date of 10/24/16. Staff Ls personnel file lacked documentation RN had observed Staff L competently perform the task utilizing a gait belt. 3. Patient #8 had a start of care date of 3/12/24, and received hospice services while residing at home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the gait belt (an assistive device secured around the waist to help safely transfer). Review of the clinical record showed Staff F Hospice Aide, provided aide services independently for Patient #8. Staff F, Hospice Aide, had a hire date of 10/10/23. Staff Fs personnel file lacked documentation RN had observed Staff F competently perform the task utilizing a gait belt. The above findings were reviewed with the Administrator and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient interview and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 8 of 16 sampled patients receiving hospice aide services. (Patients #1, #2, #4, #5, #6, #10, #15 and #19). 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: --- 6. Patient #2 had a hospice admission date of 11/15/23 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 2/13/24 to 5/12/24, included orders for skilled nursing services 2-3 times a week and hospice aide services 2 times a week. b. The hospice aide assignment (care plan), dated 2/13/24, included the interventions of the aide to complete the following: assess skin integrity and overall condition of skin, change adult diapers, incontinent care, trim or file any long or uneven fingernails, oral care, perineal care, and skin care. The hospice aide assignment developed by the nurse lacked direction for frequency for the hospice aide to complete tasks. 7. Patient #15 had a hospice admission date of 8/17/23 and received routine home care hospice services while residing at a private residence. a. The POC, dated 8/17/23 to 11/14/23, included orders for skilled nursing services daily and aide services 2 times a week. b. The hospice aide assignment (care plan), dated 8/22/23, included the interventions of the aide to complete the following: change patient linen, bed bath, skin care, apply lotion to dry skin, assess pain and notify RN if pain rated above 5. The hospice aide assignment developed by the nurse lacked direction for frequency for the hospice aide to complete tasks. Review of the hospice's policy, titled Interdisciplinary Team Meetings, dated 7/28/21, identified the Interdisciplinary Group (IDG) is responsible for providing and coordinating care and services in accordance with the POC. 1. Patient #1 had a hospice admission date of 3/14/24 and received routine home care hospice services while residing in a hospice house. Review of the clinical record revealed the following: a. The hospice aide assignment (care plan), dated 2/18/22, included the interventions of the aide to complete the following: patient to be on bedrest, apply lotion after bath, catheter care, bed bath and oxygen precautions. The hospice failed to include frequencies of the assigned tasks individualized to the specific patient needs. 2. Patient #4 had a start of care date of 2/14/24 and received hospice services in a private home setting. a. The Plan of Care (POC), dated 2/14/24 to 5/13/24, included physician orders for the hospice aide to complete the following tasks: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, oxygen, assist with positioning, repositioning, alignment, assist with transfers, ambulation using gait belt and walker, recognize and report changes in the patient's skin condition,, transfer to bed/chair with assistance, assist with bedside commode/toilet, change adult diapers, incontinent care, report to nurse if no bowel movement, make patient bed assist with dressing, shower chair, foot care apply lotion as needed, may trim or file any long or uneven finger nails, may trim of file any long or uneven toe nails, oral care, perineal care, shampoo, skin care apply lotion and barrier cream as needed, fall precautions and transfer belt. b. The hospice aide care plan, dated 2/16/24, included the same interventions for the hospice aide to complete: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, oxygen, assist with positioning, repositioning, alignment, assist with transfers, ambulation using gait belt and walker, recognize and report changes in the patient's skin condition,, transfer to bed/chair with assistance, assist with bedside commode/toilet, change adult diapers, incontinent care, report to nurse if no bowel movement, make patient bed assist with dressing, shower chair, foot care apply lotion as needed, may trim or file any long or uneven finger nails, may trim of file any long or uneven toe nails, oral care, perineal care, shampoo, skin care apply lotion and barrier cream as needed, fall precautions and transfer belt. The hospice failed to include frequencies for the assigned tasks individualized to the specific patient needs. 3. Patient #5 had a start of care date of 11/22/23 and received hospice services in a private home setting. a. The POCs, dated 11/22/23 to 2/19/24 and 2/20/24 to 5/19/24, included physician orders for the hospice aide to complete the following tasks: assist with transfers, transfer to bed/chair with assistance, assist to bedside commode/toilet, shower chair, nail care, safety razor, skin care, apply lotion to dry skin as needed, fall precautions and transfer belt. b. The hospice aide care plan, dated 2/16/24, included the same interventions for the hospice aide to complete: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, oxygen, assist with positioning, repositioning, alignment, assist with transfers, ambulation using gait belt and walker, recognize and report changes in the patient's skin condition,, transfer to bed/chair with assistance, assist with bedside commode/toilet, change adult diapers, incontinent care, report to nurse if no bowel movement, make patient bed assist with dressing, shower chair, foot care apply lotion as needed, may trim or file any long or uneven finger nails, may trim of file any long or uneven toe nails, oral care, perineal care, shampoo, skin care apply lotion and barrier cream as needed, fall precautions and transfer belt. The hospice failed to include frequencies for the assigned tasks individualized to the specific patient needs. 3. Patient #6 had a start of care date of 12/4/23 and received hospice services in a private home setting. a. The POCs, dated 12/4/23 to 3/2/24 and , included physician orders for the hospice aide to complete the following tasks: assist with positioning, repositioning, alignment, recognize and report changes in the patient's skin condition, feed patient, meal planning/preparation, change adult diapers, incontinent care, clean living area, do patient laundry, make patient bed, bed bath, shower chair, foot care apply lotion as needed, may trim or file any long or uneven finger nails, perineal care, skin care apply lotion and barrier cream as needed, fall precautions. b. The hospice aide care plan, dated 2/6/24, included the same interventions for the hospice aide to complete: ambulate only with assistance, ambulate patient using assistive device (cane, crutches, walker, oxygen, assist with positioning, repositioning, alignment, assist with transfers, ambulation using gait belt and walker, recognize and report changes in the patient's skin condition,, transfer to bed/chair with assistance, assist with bedside commode/toilet, change adult diapers, incontinent care, report to nurse if no bowel movement, make patient bed assist with dressing, shower chair, foot care apply lotion as needed, may trim or file any long or uneven finger nails, may trim of file any long or uneven toe nails, oral care, perineal care, shampoo, skin care apply lotion and barrier cream as needed, fall precautions and transfer belt. The hospice failed to include frequencies for the assigned tasks individualized to the specific patient needs. 5. Patient #10 had a start of care date of 3/6/24 and received hospice services in a private home setting. a. The POC, dated 3/6/24 to 6/3/24, included physician orders for the hospice aide to complete the following tasks: assist with positioning, repositioning, alignment, transfer to bed/chair with assistance, turn every 2 hours, catheter care, change adult diapers, empty foley catheter, incontinent care wash, dry, apply barrier cream if needed, report to nurse if no bowel movement, change patient linen and make patient bed, bed bath, foot care lotion, may trim or file nay long or uneven fingernails, may trim or file any long or uneven toe nails, perineal care, skin care lotion, fall precautions, oxygen precautions, side rails up and universal precautions. b. The hospice aide care plan, dated 3/11/24, included the same interventions for the hospice aide to complete: assist with positioning, repositioning, alignment, transfer to bed/chair with assistance, turn every 2 hours, catheter care, change adult diapers, empty foley catheter, incontinent care wash, dry, apply barrier cream if needed, report to nurse if no bowel movement, change patient linen and make patient bed, bed bath, foot care lotion, may trim or file nay long or uneven fingernails, may trim or file any long or uneven toe nails, perineal care, skin care lotion, fall precautions, oxygen precautions, side rails up and universal precautions. The hospice failed to include frequencies for the assigned tasks individualized to the specific patient needs.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice aides provided care to the patients only as directed by the interdisciplinary group, (IDG) and according to the hospice aide care plan for 2 of 8 sampled patients receiving hospice aide services.( Patient #2 and #3) Failure to ensure that the 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. --- 2. Patient #2 had a hospice admission date of 11/15/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC dated 2/13/24 to 5/12/24, included written instructions for the hospice aide to provide services 2 times a week and complete the following tasks: assess skin integrity and overall condition of the skin, change adult diapers, incontinent care, may trim or file any long or uneven fingernails, oral care, perineal care, and skin care. b. The hospice aide visit note, dated 3/7/24, included documentation the hospice aide had transferred the patient to the recliner using a gait belt as facility staff informed the hospice aide they were now using a gait belt to transfer the patient. The hospice aide care plan lacked instruction for the hospice aide to transfer the patient using a gait belt. The hospice aide failed to provide services as instructed by the RN assignment. The Administrator and Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey. Findings include: According to the agency policy titled, Hospice Aide Assignments and Duties, dated 2/28/23, hospice aide provides services that are: ordered by the interdisciplinary group, included in the plan of care, permitted to be performed under State law by hospice aides, consistent with the hospice aide's training and assigned by the hospice nurse. 1. Patient #3 had a start of care date of 11/29/23 and received hospice services while residing in the home. Clinical record review revealed the following: The plan of care dated, 1/23/24 through 3/22/24, did NOT included Registered Nurse (RN ) instructions to the hospice aide to perform the task of shaving patients facial hair. During a home visit on 3/21/24 at 9:30 am, the surveyor observed the hospice aide using a disposable razor to shave patients face. The hospice aide failed to provide services as instructed by the RN assignment.

Based on hospice policy review, clinical record review, and staff interview, the hospice failed to ensure registered nurses (RN) performed a hospice aide supervisory visit, at least once every 14 days, for 3 of 8 sampled patients (Patients #2, #4, and #6) that received aide services. Failure to supervise hospice aides at least every 14 days placed patients at risk for delay in identification of potential problems and/or patient needs, and placed the patients at risk for not receiving the services needed to meet the assessed patient needs. Findings include: --- 2.Patient #4 had an admission to hospice on 2/14/24 and received services while residing in a nursing facility. Clinical record review revealed the following: a. The POC, dated 2/14/24 to 5/13/24, included orders for skilled nursing and hospice aide services. b. The skilled nursing visit notes, dated 2/14, 2/15, 2/16, 2/20, 2/23, 2/27/24, 3/1, 3/5, 3/8, 2/20, 3/12, 3/15, and 3/19/24, failed to include hospice aide supervision. The RN failed to supervise the hospice aide services every 14 days. Review of hospice policy, titled Hospice Aide Supervision, dated 2/28/23, a RN makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the Interdisciplinary Group (IDG) and provided by the aide are meeting the patient's needs. 3. Patient #6 had an admission to hospice on 12/4/23 and received services while residing in the hospice house. Clinical record review revealed the following: a. The POCs, dated 12/4/23 to 3/2/24 and 3/3/24 to 5/31/24, included orders for skilled nursing and hospice aide services. b. The comprehensive skilled nursing visit notes, dated 1/22, 1/29/24, 2/5, 2/12, 2/19, 2/26/24, 3/4, 3/11 and 3/18/24, failed to include hospice aide supervision. The RN failed to supervise the hospice aide services every 14 days. The above findings shared with the Administrator and Clinical Manager. The hospice provided no further information prior to the end of the survey. Review of hospice policy, titled Hospice Aide Supervision, dated 2/28/23, a RN makes an on-site visit to the patient's home no less frequently than every 14 days to ensure that the services ordered by the Interdisciplinary Group (IDG) and provided by the aide are meeting the patient's needs. 1.Patient #2 had an admission to hospice on 11/15/23 and received services while residing in a nursing facility. Clinical record review revealed the following: a. The Plans of Care (POC), dated 11/15/23 to 2/12/24 and 2/13/24 to 5/12/24, included orders for skilled nursing and hospice aide services. b. The skilled nursing visit notes, dated 1/23/24, 1/30/24, 2/6/24, 2/13/24, 2/20/24, 2/27/24, 3/5/24, and 3/15/24, failed to include hospice aide supervision. c. During an interview on 3/19/24 at 2:24 PM, Staff G, RN stated she observes the aide in person one time every quarter and the aide reports off to her each week. Staff G also reported she has a section she fills out on the comprehensive assessment to document aide supervision. The RN failed to supervise the hospice aide services every 14 days.

Based on policy review, patient clinical record review, and hospice staff interview, the hospice failed to ensure the hospice medical director or the hospice physician designee, provided written Certification of Terminal Illness (CTI) and the CTI was part of the clinical record, for 1 of 16 sampled patients (Patient #14). Failure of the hospice to ensure the medical director or physician designee provided a written CTI placed patients at risk for not meeting the eligibility requirements for hospice and potentially having unexpected medical expenses. Findings include: --- According to the hospice policy titled, Admission to Hospice-Certification of Terminal Illness (CTI), dated 2/28/23, the hospice Medical Director and the patient's attending physician sign a written statement certifying the patient's prognosis is 6 months or less if the terminal illness follows its normal course. Patient #14 had a hospice admission date of 1/24/24, a revocation date of 1/30/24, and received routine home care hospice services while residing at a private residence. Clinical record review revealed the following: a. The electronic medical record (EMR) included documentation which identified the hospice medical director as the attending physician. b. The EMR lacked documentation of an initial, written, and signed CTI completed by the hospice's Medical Director or hospice physician designee. During an interview on 3/26/24 at 2:18 PM, the Administrator stated patient #14 was admitted after the Interdisciplinary Group (IDG) meeting on 1/24/24 and revoked hospice care prior to the next IDG meeting. The Administrator reported the patient was not listed on the task hot list which would have triggered him to initiate the CTI. The hospice failed to complete a CTI for the patient. The above findings were reviewed with the Administrator and Clinical Manager. Hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice staff interview, the hospice failed to: 1) Ensure all entries in the clinical record are appropriately authenticated in accordance with hospice policy and currently accepted standards of practice (see L679); and 2) Ensure all revoked or discharged patients have a discharge summary completed and forwarded to the patients attending physician (see L683). --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the plans of care were completed and signed by core members of the hospice interdisciplinary group in accordance with currently accepted standards of practice.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure all plans of care were appropriately authenticated in accordance with accepted standards of practice and hospice policy for 14 of 16 sampled patients (Patients #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15 and #16). Failure to ensure all plans of care were appropriately authenticated in accordance with accepted standards of practice, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to its patients. --- Findings include: According to the National Hospice and Palliative Care Organization document, titled Standards of Practice for Hospice Programs Professional Development and Resource Series, dated 2018, a written individualized plan of care is developed by the hospice registered nurse in collaboration with the other members of the hospice interdisciplinary group. The care plan is based on information gathered from clinical information about the patient as well as the initial nursing assessment, and reflects the needs of the patient and family/caregiver, and addresses care and services to be provided. The hospice interdisciplinary group must include: hospice physician, registered nurse, social worker, and pastoral or spiritual counselor. Review of the hospice policy, titled Plan of Care, dated 2/28/23, identified the patients plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. Review of the hospice policy, titled Plan of Care Content, dated 2/28/23, identified the plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. Clinical records for all sampled patients reviewed contained individualized initial and recertification plans of care signed by the Hospice Medical Director and electronically signed by the Hospice Executive Director, not a clinical discipline. During an interview on 3/26/24 at 2:05 PM, Hospice Executive Director, reported the nurse filled out the information and got the orders. The Hospice Executive Director generates/signs the plan of care and takes to the interdisciplinary group meeting for the Hospice Medical Director to sign. The Hospice Executive Director has a Masters degree in Health Administration and is not a registered nurse, social worker, pastoral or spiritual counselor. The plans of care failed to include an electronic signature from the hospice registered nurse who developed the plan of care in collaboration with the other members of the hospice interdisciplinary group. The Hospice Executive Director received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on policy review, clinical record review, and staff interview, the hospice failed to ensure the hospice staff sent a copy of the discharge summary to the attending physician for 2 of 2 sampled (live) discharged patients (Patients #13 and #14). Failure to ensure the hospice staff included the attending physician in the process for imminent discharge placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patients. Findings include: --- 2. Patient #13 was admitted to hospice on 7/28/23, received services while residing in a private home, and revoked hospice care on 8/29/23. Review of the clinical record lacked documentation the discharge summary was completed or forwarded to the patient's attending physician. In an interview conducted with the the agency administrator and the agency clinical manager on 3/26/2024, at 4:15 pm, it was stated the hospice had not been completing discharge summaries on patients who were discharged for any reason except for death. The above findings were shared with the hospice administrator and clinical manager, the hospice provided no additional information prior to the end of survey. According to the hospice policy titled Discharge For Reasons Other Than Death, dated 2/28/23, the hospice provides a copy of the clinical record (if requested) and the hospice discharge summary to the patient's attending physician. 1. Patient #14 was admitted to hospice on 1/24/24, received services while residing in a private home, and revoked hospice care on 1/30/24. Review of the clinical record lacked documentation the discharge summary was completed or forwarded to the patient's attending physician.

Based on record review, hospice policy review and staff interview the hospice failed to ensure medication secured and available for patients and not expired. The survey identified concerns with medications stored in the medication room. Failure to have a system puts patients at risk of receiving outdated drugs and biologicals. --- According to the hospice policy titled Medication-Labeling, Disposing and Storing of Drugs and Biologicals, dated 2/28/23, drugs and biologicals are labeled in accordance with currently accepted professional practice that includes appropriate usage and cautionary instructions as well as an expiration date (if applicable). During an interview on 3/20/24 at 10:50 AM Staff C, Registered Nurse (RN) stated the weekend staff check the medications for expiration dates every month. During the medication administration, observation with Staff C, RN of the medication room revealed the following expired stock medications: a. Lidocaine 1% 5 milliliter (ml) vial expiration date 12/3023. b. Biotin dental rinse 473 mg bottle expiration date 1/11/24. c. Epinephrine 0.3 mg 2 unit containers expiration 11/2023. The hospice failed to ensure the medications were maintained without expiration dates. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on policy review, clinical record review, nursing home medication and treatment administration records, and staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 1 of 1 sampled patients (Patient #2). Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: --- According to the hospice policy titled Hospice Care For Nursing Facility Residents-Coordination of Care, dated 2/28/23, the hospice designates a Registered Nurse (RN) case manager who is responsible for the patient who is a resident of a facility. The RN case manager provides overall coordination of the hospice care of the resident with facility representatives. Information provided to the facility includes the most recent hospice plan of care (POC) and hospice medication information specific to the patient. During an interview on 3/18/24 at 2:24 PM, Staff G, RN stated changes in the plan of care are discussed with the facility nurse. The nursing home gives hospice their care plan and it is compared to the hospice care plan. If there are new orders, a doctor's order sheet is completed and new orders are faxed to the nursing home. Patient #2 had a hospice admission date of 11/15/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The hospice POC dated 2/13/24 to 5/12/24, included Interdisciplinary Group (IDG) orders for skilled nursing services 2-3 times per week and included physician orders for medications. Review of the patient's current nursing home medication list and treatment record for March 2024 identified the following discrepancies with the hospice's POC and medication profile, dated 3/19/24, for the patient: a. The hospice POC had an order for Biofreeze 4% topical gel with instructions to apply 4% topically every 2 hours as needed for joint pain. The hospice's medication profile identified a start date for the medication, dated 11/15/23. The nursing home's Medication Administration Record (MAR)/Treatment Administration Record (TAR) did not include an order for Biofreeze. b. The hospice POC had an order for Santyl 250 units/grams topical ointment with instructions to apply 1% topically once a day, Monday through Friday to the top of the right foot. Cleanse the area with wound cleanser soaked 4X4s, pat dry, and apply Santyl. Cover with Xeroform, cover with foam, wrap with rolled gauze and secure with tape. The hospice's medication profile identified a start date for the medication, dated 11/15/23. The nursing home TAR had orders to cleanse full thickness injury to top of right foot/distal area with wound cleanser soaked 4X4s, pat dry with clean 4X4s, cut calcium alginate to fit and apply mepilex daily and prn until healed. The nursing home TAR identified a start date for the treatment, dated 2/29/24. c. The nursing home MAR had an order for Zeasorb (antifungal) external powder 2% with instructions to apply between toes topically every day shift every Monday and Thursday for cutaneous candidiasis to be done after showers. The nursing home MAR identified a start date for the medication, dated 1/4/24. The hospice POC did not include an order for Zeasorb. d. The nursing home MAR had an order for Novolin R (insulin) solution with instructions to inject 10 units subcutaneously as needed for accu checks above 400. The nursing home MAR identified a start date for the medication, dated 8/24/23. The hospice POC did not include an order for Novolin R. e. The nursing home MAR had an order for Glucagon Emergency Kit 1 milligram(MG) with instructions to inject 1mg intramuscularly as needed for low blood sugar. The nursing home MAR identified a start date for the medication, dated 9/19/21. The hospice POC did not include an order for Glucagon. f. The nursing home MAR had an order for Clopidogrel Bisulfate (antiplatelet medicine) 75mg tablet with instructions to give 1 tablet by mouth daily. The nursing home MAR identified a start date for the medication, 11/19/20. The hospice POC did not include an order for Clopidogrel Bisulfate. Hospice staff failed to ensure the coordination of the patient's medications and treatments with the nursing home. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history background record check on all prospective directly hired or contracted employees and all volunteers with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check.Based on review of hospice personnel files and hospice staff interview, the hospice failed to ensure completion of a criminal background history check for 4 of 7 sampled employees (Staff B, D, E and F) who began serving hospice patients since their last survey, dated 3/10/21.The hospice reported hiring 10 employees since the last survey.Failure to complete criminal background checks as required by Federal and State regulation, increased the potential risk of harm to hospice patients.Findings include: --- Interview on 3/25/24 at 3:35 PM with Staff A, Administrator, I was starting people before background checks were done. I had asked former supervisor and was informed that I could hire people before background checks were completed, if they didn't provide direct care. Review of hospice personnel files revealed the following: a. Staff B, Registered Nurse, had a hire date of 10/9/23. Staff B's personnel file included documentation of a criminal history check completed through SING, dated 10/16/23, 7 days after the hospice had hired Staff B. b. Staff D, Social Worker, had a hire date of 9/13/23. Staff D's personnel file included documentation of a criminal history check completed through SING, dated 7/27/23, 48 days before the hospice had hired Staff D c. Staff E, Hospice Aide, had a hire date of 10/10/23. Staff E's personnel file included documentation of a criminal history check completed through SING, dated 10/24/23, 14 days after the hospice had hired Staff E. d. Staff F, Hospice Aide, had a hire date of 10/10/23. Staff Fs personnel file included documentation of a criminal history check completed through SING, dated 10/24/23, 14 days after the hospice had hired Staff F. The hospice failed to complete the criminal history background check within 30 days of employment with the hospice. The above findings were reviewed with the Hospice Administrator and Clinical Manager. Hospice staff provided no additional information prior to the end of the survey.

Based on observation and staff interview, the hospice failed to ensure staff stored, prepared and served meal under sanitary conditions in the hospice house. The hospice reported providing services to 4 patients at the Hospice House at the time of the survey.Failure to ensure sanitary conditions maintained during meal preparation and storage of food under sanitary conditions put the patients at risk for food borne illness. Findings --- During an interview on 3/26/24 at 4:10 PM the Administrator stated the hospice did not have a policy for food storage or preparation but identified the staff were trained in food safety. Observation on 3/21/24 at 10:10 AM with the Administrator and Clinical Manager revealed: 2-20 ounce cans apple filling expired 1/2024. Refrigerator in kitchen with subway sandwich not dated. 3 eggs out of the shell, covered with plastic wrap, not dated. Observation on 3/21/24 at 10:30 AM revealed Staff K, Hospice Aide prepared the morning meal. She washer her hands and donned gloves. She gathered the eggs, sausage and cooking utensils. She changed her gloves and prepared the French toast batter. She placed 2 pieces of sausage in the pan. She handled the cabinet handles and retrieved 2 spatulas. She removed 4 slices of bread out of the bread bag with the contaminated gloves. She returned to batter the bread and place in the pan with the contaminated gloves. Staff K then removed her gloves and finished cooking the morning meal. She checked the temperature of the sausage and ran the thermometer under the faucet with tap water and failed to sanitize it. She then checked the temperature of the French toast. The above findings reviewed with the Administrator and Clinical Manager. No further information provided prior to the end of the survey.