Every finding on record at Hospice of Palo Alto County

Based on clinical record review and agency policy review, the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient's clinical record, any advance directives executed by the patient for 1 of 14 sampled patients (Patient #13).    Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out.    Findings include: --- According to the hospice policy, titled Admission Process for Hospice Care, dated 2/2025, the hospice nurse will assess patient advanced directives/code status wishes and document in the patient's chart.    1.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care, dated 1/21/25 to 4/20/25, identified the patient's advance directive information as do not resuscitate.    b. The admission consent forms, signed by the patient on 1/21/25 identified the patient wanted resuscitative measures.    The hospice agency failed to include accurate advance directive information on the patient's plan of care at the time of admission to hospice services.    The above findings were reviewed with the Administrator.

Based on clinical record review and agency policy review,  the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 5 of 5 sampled patients (Patient #2, #9, #10, #13 and #14), with wounds.     Failure to complete an initial wound assessment increased the risk patient's needs would not be identified and/ or addressed appropriately, and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings Include: --- 4. Patient #9 had a hospice admission date of 11/14/24, a death date of 12/22/24 and received hospice services while residing in a nursing home.    a. The POC, dated 11/14/24 to 2/11/25, identified the patient had a diagnosis of heart failure and included physician orders for skilled nurse to assess skin integrity and overall condition of the skin.    b. The skilled nurse initial assessment, dated 11/14/24, completed by Staff A, Administrator, identified patient had a decubitus pressure ulcer but lacked further description and/or measurements.    c. The skilled nurse visit note, dated 11/15/25, completed by Staff B, RN, identified the patient had a wound to inner buttocks coccyx/decubitus/pressure ulcer stage II but failed to include wound measurements.    The initial comprehensive assessment lacked documentation of wound measurements to wound on the coccyx.   5. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.    a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse services 1-7 times a week.   b.  The skilled nurse visit note, dated 3/11/25, completed by Staff D, RN, identified the patient had sustained the following wounds:   1) Skin tear to left arm, wound bed clean and red.  Documentation identified wound measurements of 2.5 cm X 0.5 cm but failed to include a measurement for the depth of the wound.    2) Skin tear to midline chest, wound bed clean and red.  Documentation identified wound measurements of 2 cm X 1.5 cm but failed to include a measurement for the depth of the wound.  3) Skin tear to right hand, wound bed clean and red.  Documentation identified wound measurements of 1 cm X 1cm but failed to include a measurement for the depth of the wound.    4) Skin tear to right medial hand between third and fourth digit, wound bed clean.  Documentation identified wound measurements of 2 cm X 0.5 cm but failed to include a measurement for the depth of the wound.    The skilled nurse assessment lacked documentation of depth to the newly identified wounds.   The above findings were reviewed with the Administrator.     According to the hospice policy titled Wound Care, dated 2/2025, wounds should be measured at a minimum of once a week by the home care nurse and documented in the electronic medical record. Documentation of the wound includes the length, width and depth measurements recorded in centimeters. During an interview on 11/10/15 at 10:23 AM the Administrator/Clinical Manager stated the expectation for staff to complete weekly wound measurements that include the length, width and depth of the wound. 1.Patient #2 had a start of care date of 6/18/25, and received hospice services in a long term care facility.  a. The Plans of Care (POCs), dated 6/18/25 to 9/15/25 and 9/16/25 to 12/14/25, included a diagnosis of a Parkinsonism, and physician orders for skilled nurse to provide wound care to the great toe on the right foot and the 2nd toe on the left foot. b. The initial comprehensive assessment completed on 6/18/25, by Staff D, Registered Nurse (RN), identified the following wounds: 1) Skin tear on the left outer shin. The assessment failed to include measurements.2) Skin tear on the right fore arm. The assessment failed to include measurements.3) Skin tear on the right outer shin. The assessment failed to include measurements.4) Wound on 2nd toe of the left foot. The assessment included measurements of legnth 0.5 centimeters (cm) by width 0.1 cm. The assessment failed to include measurements of wound depth. The initial comprehensive assessment lacked documentation of complete measurements of the patient's wounds.  2. Patient #10 had a start of care date of 12/26/24 and date of death of 2/23/25 and received hospice services in a long term care facility.  a. The POC, dated 12/26/24 to 3/25/25, included a diagnosis of Alzheimer's disease and physician orders for skilled nurse services 1 to 5 times a week to assess skin integrity and overall condition of skin including: signs/symptoms of breakdown, friction, shearing, or pressure areas. b. The skilled nurse visit note, dated 2/10/25, Staff G, RN identified the patient had a blister located on the upper medial buttocks/coccyx. The assessment lacked documentation of wound measurements. c. The skilled nurse visit note, dated 2/13/25, Staff G, RN, identified a stage 2 wound on the left inner buttock/coccyx. The wound included documentation of a newly reopened wound. The assessment lacked measurements of the wound. The assessment also included identification of an intack blister on the upper medial buttocks/coccyx. The assessment lacked documentation of measurements of the wound. The hospice lacked documentation of complete measurements of the patient's wounds.  3. Patient #10 had a start of care date of 12/26/24 and date of death of 2/23/25 and received hospice services in a long term care facility.  a. The POC, dated 12/26/24 to 3/25/25, included a diagnosis of Alzheimer's disease and physician orders for skilled nurse services 1 to 5 times a week to assess skin integrity and overall condition of skin including: signs/symptoms of breakdown, friction, shearing, or pressure areas. b. The skilled nurse visit note, dated 10/15/24, by Staff G, RN, identified the following wounds: 1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 7.8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 6 cm by 5 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3.5 cm by 4 cm. The wound assessment lacked measruements of wound depth. b. The skilled nurse visit note, dated 10/22/24, by Staff G, RN, identified the following wounds:1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 5.5 cm by 5 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3 cm by 4 cm. The wound assessment lacked measurements of wound depth. c. The skilled nurse visit note, dated 10/29/24, by Staff A, Administrator/Clinical Manager, identified the following wounds:1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 5 cm by 4 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3 cm by 3.5 cm. The wound assessment lacked measurements of wound depth. d. The skilled nurse visit note, dated 11/5/25, Staff D, RN, identified the patient had a fall and sustained the following injuries:1) Skin tear to left arm: 20 cm. The wound assessment lacked measurements of wound width or depth.2) Skin tear left arm, shoulder area: 4 cm by 5 cm. The wound assessment lacked measurements of wound depth.3) Skin tear left hand: 3 cm. The wound assessment lacked measurements of wound width or depth.4) Skin tear forehead: 2 cm. The wound assessment lacked measurements of wound width or depth.5) Skin tear left shin 7 cm by 2.5 cm. The wound assessment lacked measurements of wound depth.6) Skin tear left calf: 4 cm. The wound assessemnt lacked measurements of width and depth. The hospice lacked documentation of complete measurements of the patient's wounds.

Based on Interdisciplinary Group (IDG) observation, staff interviews, clinical record reviews and agency policy review, the hospice failed to:   1) Ensure the hospice Interdisciplinary Group included a pastoral or other counselor (see L0541);  2) Ensure the hospice developed a written plan of care with routine orders individualized to meet the specific needs of the patient (See L0547) and   3) Ensure the hospice plans of care included all necessary drugs and treatment to meet the needs of the patient (See L0549). --- 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 Interdisciplinary Group (IDG) observation, staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure a pastoral or other counselor participated in IDG meetings and participated in the review and updating of the patient's plan of care through the IDG meeting for 5 of 5 sampled patients (Patients #1, #2, #3, #4 and #5).    The hospice reported a current census of 5 patients at the time of they survey.    Failure of the hospice to ensure a pastoral or other counselor participated in each IDG meeting placed hospice patients at risk for not having all of their spiritual needs identified and addressed.    Findings include: --- According to the agency policy, titled The Interdisciplinary Team, dated 8/2025, the provision of total care by an Interdisciplinary Group (IDG) requires participation and coordination of a variety of personnel with different resources and skills.  The four core services will participate in the initial plan of care of the hospice client.  The four core services include physician, nursing, social worker and counseling.  All core services will provide input prior to providing care or as soon after admission as possible.    During an IDG meeting observation on 11/6/25, the Surveyor identified no chaplain/pastoral counselor participated in the IDG meeting.    During an interview on 11/12/25 at 10:10 AM, Staff A, Administrator, identified the hospice does not have a chaplain/pastoral counselor on staff.    Review of the clinical records for Patients #1, #2, #3, #4 and #5 revealed a lack of documented attendance and coordination with a hospice chaplain/pastoral counselor (a core hospice service).    The above findings were reviewed with the Administrator.

Based on staff interviews and clinical record reviews, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care which specified the scope and frequency (acceptable, small interval ranges) for all services required by and provided to patients for 5 of 14 sampled patients (Patients #1, #2, #3, #12 and #13).    Failure to identify acceptable scopes and frequencies specific to meet patient needs increased the potential for hospice services to not adequately meet the needs of hospice patients and families.    Findings include: --- 5. Patient #2 had a hospice admission date of 6/18/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POCs, dated 6/18/25 to 9/15/25 and 9/16/25 to 12/14/25, identified the patient had a primary diagnosis of Parkinsonism and included IDG orders for nursing 1-5 times a week, massage therapy services 1-5 times a month and social work services 1-5 times a month.      b. The IDG meeting note, dated 11/6/25, included orders for nursing 1-5 times a week, massage therapy services 1-5 times a month and social work services 1-5 times a month.   c. Review of the clinical record revealed the nurse saw the patient 1-3 times a week in the months of  September and October, massage therapy saw the patient 2 month in September and October, and the social worker saw the patient 1 time a month in September and October.   The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs.   The above findings reviewed with the Administrator/Clinical Manager.  On 11/12/25 at 11:28 AM, the Administrator reported the hospice agency does not have a policy addressing content of the plan of care.    During an interview on 11/5/25 at 3:57 PM, Staff B, Registered Nurse (RN), stated patient's plans of care are developed based on assessment of patient needs.    1.Patient #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 8/28/25 to 11/25/25, identified the patient had a primary diagnosis of cirrhosis of the liver and included Interdisciplinary Group (IDG) orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month.      b. The IDG meeting note, dated 11/6/25, included orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month.    c. Review of the clinical record revealed the nurse seeing the patient 1-2 times a week in the months of August, September and October, massage therapy seeing the patient 1-2 month in August, September and October, and the social worker seeing the patient 1-2 times a month in August, September and October.    The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs.    2.Patient #3 had a hospice admission date of 7/31/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   The POC, dated 10/29/25 to 1/26/26 identified the patient had a primary diagnosis of malignant neoplasm of peritoneum and included IDG orders for nursing services.    The IDG failed to include a detailed scope and frequency of all services necessary to meet the specific patient/family needs.    3.Patient #12 had a hospice admission date of 11/26/24, a discharge date of 5/21/25 and received hospice services while residing in a nursing home.    a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a primary diagnosis of congestive heart failure and included IDG orders for nursing 1-5 times a week and massage therapy services 1-4 times a month.      b. The IDG meeting note, dated 5/1/25, included orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month.    c. Review of the clinical record revealed the nurse seeing the patient 1 time a week in the months of April and May, massage therapy seeing the patient 1-2 month in April and May, and the social worker seeing the patient 1 time a month in April and May.    The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs.    4. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.    a. The POC, dated 1/21/25 to 4/21/25, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included IDG orders for nursing 1-7 times a week, hospice aide services 1-4 times a week, massage therapy services 1-4 times a month and social work to assess and evaluate.       b. The IDG meeting note, dated 4/10/25, failed to include a detailed scope and frequency of all services necessary to meet the patient/family needs.     The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs.

Based on staff interviews and clinical record reviews, the hospice failed to ensure the hospice plan of care included complete orders for all necessary medications and treatments to meet the needs of the patients for 5 of 14 sampled patients (Patients #1, #3, #5, #10 and #13).    Failure to ensure the plan of care included complete orders for medications and treatments placed the patients at risk to received inappropriate treatment of symptoms and/or not meet the needs of the patients.    Findings include: --- 5. Patient #10 had a hospice admission date of 12/26/25 and date of death of 2/23/24 received hospice services while residing in a nursing home.  Review of the clinical record revealed:  a. The POC, dated 12/26/24 to 3/25/25, identified the patient had a diagnosis of Alzheimer's disease, included orders for skilled nurse visits and included physician orders for medications and treatment.   b. The skilled nurse visit notes, dated 2/10/25 and 2/17/25, Staff G, RN and Staff D, RN, respectively, identified the patient had a blister to the upper medial buttock. The nurse provided wound treatment that included skin prep to the wound. c. The skilled nurse visit notes, dated 2/13/25 and 2/17/25, Staff G, RN,identified the patient had an open wound to the left inner buttock/coccyx area. The nurse provided wound treatment that included cleanse with soap and water and cover with meplex dressing. c. The IDG update to the POC, dated 2/13, 2/20 and 2/27/25, lacked physician orders for wound treatment to the upper medial buttock or the left inner buttock/coccyx area. The hospice failed to include all physician orders for necessary drugs and treatment on the patient's plan of care.   The above findings reviewed with the Administrator /Clinical Manager. On 11/12/25 at 11:28 AM, the Administrator reported the hospice agency does not have a policy addressing content of the plan of care.    During an interview on 11/5/25 at 3:57 PM, Staff B, Registered Nurse (RN), stated patients' plans of care are developed based on assessment of patient needs.    1.Patient #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:    a. The Plan of Care (POC), dated 8/28/25 to 11/25/25, identified the patient had a diagnosis of cirrhosis of the liver, included orders for skilled nurse visits and included physician orders for medications and treatment.    b. The Interdisciplinary Group (IDG) update to the POC, dated 11/6/25, identified the patient had an indwelling catheter but lacked complete orders with French size and balloon volume.    The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care.    2. Patient #3 had a hospice admission date of 7/31/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 10/29/25 to 1/26/25, identified the patient had a diagnosis of malignant neoplasm of peritoneum, included orders for skilled nurse visits and included physician orders for medications and treatments.  b. The POC, dated 10/29/25 to 1/26/25, identified the patient had an indwelling foley catheter with orders to insert 16 French catheter, change every 6 weeks and as needed.  Flush with 30-60 cubic centimeters (cc) normal saline as needed for clogging.  The physician order failed to include catheter balloon inflation volume.  The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care.    3.Patient #5 had a hospice admission date of 12/4/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 9/30/25 to 11/28/25, identified the patient had a diagnosis of end stage heart failure, included orders for skilled nurse visits and included physician orders for medications and treatment.    b. The skilled nurse visit note, dated 10/14/25, completed by Staff C, Registered Nurse (RN), identified the patient utilized a heating pad for comfort.    c. The IDG update to the POC, dated 10/23/25, lacked physician orders for heat therapy.    The hospice failed to include all physician orders for necessary drugs and treatment on the patient's plan of care.    4.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease, included orders for skilled nurse visits and included physician orders for medications and treatment.    b. The skilled nurse visit note, dated 3/12/25, completed by Staff D, RN, identified the patient sustained four new skin tears, wounds were cleansed with normal saline, a non-adherent dressing applied and secured with tape.     c. The IDG update to the POC, dated 3/13/25, lacked physician orders for wound care.    The hospice failed to obtain physician orders for wound care.

Based on clinical record review, hospice staff interview and policy reviews, 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 for 2 of 2 sampled bereavement records (Patient #13 & #14).   Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief.   Findings include: --- 2. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   A skilled nurse visit note, dated 4/14/25, completed by Staff G, Registered Nurse (RN), identified the patient had died.    During an interview on 11/10/25 at 2:10 PM, the Administrator stated bereavement documentation is kept in a binder until family is discharged from bereavement and then it is scanned into the patient's chart.  The Administrator reviewed the binder and identified it lacked bereavement information for Patient #13.    The clinical record failed to include any documentation bereavement services had been offered to the patient.    The above findings were reviewed with the Administrator.    According to the hospice policy titled Philosophy, Purpose and Goals, dated 3/2008, the hospice program provides eotional, physical, and spiritual care during the illness and continued support for the family during the bereavement period. 1.Patient #12 had a start of care date of 8/16/24, a death date of 11/7/24 and received hospice services while residing in a nursing home.  Review of the clinical record revealed:  a. A bereavement assessment post death form, dated 11/7/24, was completed and identified the daughter of Patient #14 as the bereaved.   b. The social service assessment/reassessment, dated 12/10/25, revealed a call placed to the bereaved. c. The bereavement, dated 12/17/25, documented a choice for card mailing sent. d. Review of the clinical record lacked further contact with the bereaved. e. During an interview on 11/12/25 at 9:25 AM the Social Worker stated patinet #14's bereaved declined further bereavement services. She further stated she failed to document the bereaved declinied in the clinical record. The hospice failed to complete further contact according to the plan/interventions with the bereaved following the death of the patient.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient's needs for 2 of 5 sampled patients receiving hospice aide services (Patients #9 and #13).    Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner.    Findings include: --- According to the hospice policy titled Home Care Aide (HCA) Supervision and HCA Duties, dated 2/2024, the Registered Nurse (RN) evaluates and updates, as necessary, the home care aide plan of care.    During an interview on 11/10/25 at 10:23 AM, the Administrator stated the admission nurse is responsible for creating the aide care plan.    1.Patient #9 had a hospice admission date of 11/14/24, a death date of 12/22/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care (POC), dated 11/14/24 to 2/11/25, identified the patient had a diagnosis of heart failure and include physician orders for skilled nurse and hospice aide services.    b. The skilled nurse visit note, dated 11/22/25, completed by Staff B, RN, identified the patient was transferred to wheelchair with gait belt and two person assist.    c. The aide care plan, dated 11/18/24, included aide instructions to assist with transfers.  The assignment did not include specific instructions on what assistive device should be used when transferring the patient.    The hospice RN failed to include what specific assistive device the aide should use when transferring the patient.    2.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services.  b. The hospice aide care plan, dated 1/27/25, included aide instructions to provide foot care per client request, provide skin care per client request and provide nail care per client request.  The assignment did not include specific instructions on what foot care, nail care and skin care the aide should provide.   The hospice RN failed to include specific instructions on what foot care, nail care and skin care the aide should provide to the patient.    The above findings were reviewed with the Administrator.

Based on 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 2 of 5 sampled patients receiving hospice aide services (Patients #8 and #13).    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: --- 2. Patient #8 had a hospice admission date of 6/27/25, a death date of 8/7/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The POC, dated 6/27/25 to 9/24/25, identified the patient had a diagnosis of malignant neoplasm of the esophagus and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 6/27/25, included aide instructions to shower per client request and provide bed complete bed bath per client request.    c. Hospice aide visits notes, dated 7/15/25, 7/18/25 7/25/25 and 7/29/25, completed by Staff E, Hospice Aide, documented completing both a shower and a bed bath.    The hospice aide failed to accurately document completion of a shower or bed bath per RN instruction.    The above findings reviewed with the Administrator/Clinical Manager.   According to the hospice policy titled Home Care Aide (HCA) Supervision and HCA Duties, dated 2/2024, the Registered Nurse (RN) evaluates and updates, as necessary, the home care aide plan of care.  The home care aide communicates any changes or need to revise the home care aide care plan to the RN.    1.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The Plan of Care (POC), dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services.   b. The hospice aide care plan, dated 1/27/25, included aide instructions to shower per client request and provide bed bath per client request.    c. Hospice aide visits notes, dated 3/4/25 and 3/14/25, completed by Staff E, Hospice Aide, documented completing both a shower and a bed bath.    The hospice aide failed to accurately document completion of a shower or bed bath per RN instruction.

Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contractual 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: --- Review of the contract between the hospice agency and Staff F, Massage Therapist, dated 7/5/2022, identified the contract lacked a signature by the massage therapist.    The hospice failed to ensure the contractual agreement contained all required components.    The above findings were reviewed with the Administrator.

Based on review of contracts for inpatient services, the hospice failed to ensure contracts with facilities providing inpatient level of care services to hospice patients included specifications of the requirement that staffing schedules included registered nurse shifts as required at 418.110 (b) and (f) regarding 24 hour nursing services and patient areas for 1 of 1 sampled inpatient facility contracts (hospital contract).    Failure to ensure contractual agreements with inpatient providers included necessary provisions placed patients at risk of not having their needs met in a comfortable atmosphere.    Findings include: --- Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, failed to include specifications regarding registered nurse staffing requirements and requirements for patient care areas.    The above findings were reviewed with the Administrator.

Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and a hospital to provide respite inpatient care included a provision which specified the hospice patient would receive respite care in a facility which provided physical space for private patient and family visiting, accommodations for family members to remain with the patient throughout the night, physical space for family privacy after a patient's death and the opportunity for patients to receive visitors at any hour.    Failure to include this provision within the contractual agreement increased the potential of hospice and inpatient facility staff not meeting patient needs 24 hours a day.    Findings include: --- Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, lacked a provision which required the inpatient facility to provide care in a home-like atmosphere and ensure that patient areas are designed to preserve dignity, comfort and privacy of patients.   The above findings were reviewed with the Administrator.

Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and a hospital to provide inpatient care included a method for verifying all necessary requirements are met while a patient receives inpatient care.   Failure to identify a method for verifying requirements are met for patient's receiving inpatient care increased the potential of hospice and inpatient facility staff not meeting patient needs 24 hours a day.    Findings include: --- Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care.    The above findings were reviewed with the Administrator.

Based on staff interview, clinical record reviews and review of nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient's medications with the nursing home for 2 of 3 sampled patients (Patients #1 and #2) with a nursing home medication review.  Failure to ensure the hospice staff provided overall coordination of the patient's medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient.    Findings include: --- 2. Patient #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 8/28/25 to 11/25/25, identified the patient had a diagnosis of cirrhosis of the liver, included orders for skilled nursing services and included physician orders for medications.    b. Review of the patient's nursing home MAR, dated 10/29/25, identified the following medication discrepancy with the hospice's POC and Medication Profile for the patient:   The nursing home MAR identified an order for Tums 500 mg oral chewable tablets with instructions to give 1 tablet by mouth every 6 hours as needed for indigestion.  The nursing home's MAR identified a start date for the medication, dated 9/24/25.  The hospice IDG update to the POC, dated 10/23/25 lacked an order for this medication.     Hospice staff failed to ensure the coordination of the patient's medication with the patient's nursing home.    The above findings were reviewed with the Administrator.     During an interview on 11/4/25 at 4:00 PM the Administrator/Clinical Manager stated the hospice current medications listed on the Medication Profile. 1.Patient #2 had a hospice admission date of 6/18/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 9/16/25 to 12/14/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications.   b. Review of the patient's nursing home Medication Administration Record (MAR), dated 11/2/25 to 11/30/25, identified the following medication discrepancy with the hospice's POC and Medication Profile for  patient #2: 1) Nursing home MAR included Salonpas pain releiving external patch 4%. Apply to right shoulder topically as needed for pain/discomfort, may apply daily as needed. Start date 10/11/23. The hospice failed to include orders for the medication Salonpas pain releiving patch. 2: Nursing home MAR included Artifical tears opthalmic solution 1-0.3%. Instil 1 drop in both eyes as needed for dry eyes, may administer up to 4 times a day. Start date of 6/26/25. The hospice included the following duplicate orders: Artificial tears opthalmic solution 1-0.3% 1 drop, administer in each eye 4 times a day as needed for dry eyes, artificial tears opthalmic sollution 1%, 1 drop in each eye 2 times a day as needed for dry eyes and tears naturale opthalmic solution appy 1 drop in each ey 4 times a day as needed for dry eyes. Hospice staff failed to ensure the coordination of the patient's medications with the patient's nursing home.

The Iowa 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 Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa 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 criminal background check for 1 of 3 sampled employees who began serving hospice patients since their last survey, dated 7/19/23. The hospice reported hiring 3 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 hospice volunteers and/or employees who had direct patient contact. Findings include: --- Staff H, Volunteer, had a hire date of 1/17/25.  Staff H's personnel file included documentation of a completed criminal history background check, dated 2/6/25, 20 days after Staff H’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 reviewed with the Administrator/Clinical Manager.

Based on hospice policy review, clinical record review and staff interview, the hospice failed to perform an initial bereavement assessment, within 5 days of the patient's election to the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care in a timely manner for 7 of 14 sampled patients (Patients #5, #8, #9, #10, #11, #12 and #13) receiving hospice services for more than 5 days. Failure to complete an initial bereavement assessment increased the risk that patient or family/caregiver grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: --- According to the hospice policy titled Admission Process for Hospice Care, dated 5, 2023, the hospice nurse will complete an initial assessment within 48 hours of election of hospice care. Initial assessment will address the patients critical physical, psychosocial and emotional status and needs related to the terminal illness. On 7/19/23 at 8:27 AM, during an interview, the Social Worker/Bereavement Coordinator stated the initial bereavement assessment completed by the hospice nurse during the initial assessment. She further stated she visits with patients and families throughout the hospice services. 1. Patient #5 had a hospice admission date of 11/29/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 11/29/22, lacked documentation of an initial bereavement assessment. b. The IDG meetings, dated 5/18, 5/25/23, 6/1, 6/8, 6/15, 6/22 and 6/29/23, lacked documentation of comprehensive assessment information obtained by the hospice nurse, in regards to the initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 2. Patient #8 had a hospice admission date of 1/17/23, received hospice services while residing in a nursing home and died on 1/25/23. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 1/25/23, lacked documentation of an initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 3. Patient #9 had a hospice admission date of 12/1/22 and received hospice services while residing in a private residence and died on 12/21/22. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 12/1/22, lacked documentation of an initial bereavement assessment. b. The IDG meetings, dated 12/8/22, lacked documentation of comprehensive assessment information obtained by the hospice nurse, in regards to the initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 4. Patient #10 had a hospice admission date of 11/18/22 and received hospice services while residing in a nursing home and died 11/23/22. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 11/18/22, lacked documentation of an initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 5. Patient #11 had a hospice admission date of 11/3/22 and received hospice services while residing in a nursing home and discharge on 3/23/23. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 11/3/22, lacked documentation of an initial bereavement assessment. b. The IDG meetings, dated 2/9, 2/16/23, 3/2 and 3/16/23, lacked documentation of comprehensive assessment information obtained by the hospice nurse, in regards to the initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 6. Patient #12 had a hospice admission date of 10/12/22 and received hospice services while residing in a nursing home and discharged 1/1/23. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 10/12/22, lacked documentation of an initial bereavement assessment. b. The IDG meetings, dated 11/10, 11/17/22, 12/1, 12/8 and 12/22/22, lacked documentation of comprehensive assessment information obtained by the hospice nurse, in regards to the initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. 7. Patient #5 had a hospice admission date of 9/25/22 and received hospice services while residing in a nursing home and died on 9/29/22. Review of the clinical record revealed the following: a. The skilled nurse initial assessment, dated 9/25/22, lacked documentation of an initial bereavement assessment. b. The IDG meetings, dated 9/29/22, lacked documentation of comprehensive assessment information obtained by the hospice nurse, in regards to the initial bereavement assessment. Hospice staff failed to document completion of the initial bereavement risk assessment within 5 days after the patient's election of the hospice benefit. The Administrator/Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review 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 description and measurements for 3 of 4 sampled patients with an open wound (Patients #3, #12 and #14). The hospice reported a current census of 5 patients. Failure by the hospice Interdisciplinary Group (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: --- During an interview on 4/4/23 at 2:46 PM, the Administrator/Clinical Manager stated staff are expected to take pictures and assess the wound measurements once a week, and include length by width by depth. Dressing changes are completed per physician orders. 1. Patient #3 had a hospice admission date of 1/4/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/4/23 to 7/2/23, included physician orders for skilled nursing services 1 to 7 times per week. b. The skilled nurse visit note, dated 6/21/23, included documentation a new open area, stage 2 pressure ulcer on the left posterior foot/heel, first noted on 6/15/23 measured 1.8 centimeters (cm) length by 0.8 cm width by 0.1 cm depth. c. The skilled nurse visit notes, dated 6/28, 6/29, 7/5 and 7/11/23, failed to include documentation of wound measurements. Hospice staff failed to provide complete assessment of the patient's wound. 2. Patient #12 had a hospice admission date of 10/12/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 10/12/22 to 1/9/23, included physician orders for skilled nursing services 1 to 4 times per week. b. The skilled nurse visit note, dated 10/12/22, included documentation an open area to the left doral foot that measured 5 cm by 4 cm by 0.2 cm. c. The skilled nurse visit note, dated 11/7/22, included measurement of 3.2 cm length by 2.8 cm width but failed to include documentation of wound depth measurements. d. The skilled nurse visit notes, dated 12/12, 12/19 and 12/21/22, lacked documentation of wound measurements. Hospice staff failed to provide complete assessment of the patient's wound. 3. Patient #14 had a hospice admission date of 6/9/22 and received hospice services while residing in a nursing home and expired 7/13/22. Review of the clinical record revealed the following: a. The POC, dated 6/9/22 to 9/6/22, included physician orders for skilled nursing services 1 to 7 times per week. b. The skilled nurse visit note, dated 7/7/22, included documentation a wound on the coccyx that measured 5 cm by 6 cm with an open area of 2 cm by 1 cm, but failed to measure wound depth. c. The skilled nurse visit notes, dated 7/12/22, included documentation a wound on the coccyx with a noted decline in status that measured 5 cm by 3.9 cm, but failed to measure wound depth. Hospice staff failed to provide complete assessment of the patient's wound. The Administrator/Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and hospice policy review, the hospice failed to ensure 1 of 1 sampled hospice aide (Staff E) satisfactorily 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 1 of 1 sampled patients who required an extra skill task to be performed (Patient #3). The hospice reported 4 current patients at the time of the survey. The hospice employed a total of 3 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 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. According to the hospice policy titled Hospice Aide Training, dated April 2018, the hospice will schedule training/competency testing time, competencies and skills will be assessed prior to delivery of services and updated every 12 months. Competency evaluations will be signed and date by the registered nurse and will be maintained in the personnel file. During an interview on 7/19/23 at 8:30 AM, the Administrator/Clinical Manager, reported Staff E, Hospice Aide did not have documentation of competency training for competency of gait belt use. Patient #3 had a hospice admission date of 1/4/23, and received hospice services while residing in a nursing home. The plan of care, dated 4/4/23 to 7/2/23, identified the patient required the use of a gait/transfer belt. The aide care plan included Registered Nurse (RN) instructions to ambulate with assist of 2 staff when the patient cooperates with the activity. Review of the clinical record showed Staff E, Hospice Aide, provided aide services independently for Patient #3. Staff E, Hospice Aide, had a hire date of 9/3/19. Staff E's personnel file lacked documentation RN had observed Staff E competently perform the task of the use of a gait/transfer belt for patients. The above findings were reviewed with the Administrator/Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Group according to an individualized plan of care for 4 of 5 sampled patients who received hospice aide services. (Patient #3, #4, #5 and #14). Failure to provide hospice aide services as ordered on the plan of care increased the risk that hospice patients' personal care needs were not met. Findings include: --- Review of the hospice's policy, titled Home Care Aide Supervision and HCA Duties, dated 2/2022, identified the hospice aides duties include: personal care, ambulation assistance, assistance with prescribed exercise program, assist with household services essential to health care at home, remind patents on medication that is to be self-administered, report changes in patient condition, complete appropriate documentation. During an interview on 7/11/23 at 8:30 AM the Administrator stated the hospice aide documents why a task not completed. 1. Patient #3 had a hospice admission date of 1/4/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/4/23 to 7/2/23, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the tasks of ambulate with assist of 2 staff when patient cooperates with activity, clean up as needed, massage hands and feet, check client for incontinent and change as needed, oral care-brush teeth, companionship, read to client, play games or puzzles, feed patient and skin care. The POC identified the patient required use of a gait/transfer belt. b. The hospice aide visit note, dated 5/16, 5/17, 5/18, 5/23, 5/24, 5/25. 5/31/23, 6/1, 6/6, 6/7, 6/8, 6/13. 6/14, 6/15, 6/20, 6/21, 6/22, 6/27, 6/28 snf 6/29/23, failed to include documentation the hospice aide utiliZed a gait/transfer belt for transfer or ambulation. The hospice aide failed to identify all tasks completed. 2. Patient #4 had a hospice admission date of 3/14/23, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 3/1/23 to 6/11/23 and 6/12/23 to 9/9/23, included IDG orders for skilled nursing and hospice aide services. b. The POC included the following assigned interventions for the hospice aide to complete the following tasks: electric shave, partial bath, make bed, clean bathroom after care, clean living area, assist patient with dressing, lotion skin, perineal care, shower, oral care and shampoo. c. The hospice aide visit notes, dated 6/5/23 and 6/12/23, included documentation the aide completed a visit. The visit note included documentation the hospice aide completed both a shower and partial bath. d. The hospice aide visit notes, dated 6/5, 6/9, 6/12, 6/14, 6/16 and 6/19/23, included documentation the following tasks not completed and documented "not applicable this visit": Shave, make patient bed, clean bathroom after patient care, oral care and shampoo. The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. 3. Patient #5 had a hospice admission date of 11/29/22, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POCs, dated 2/27/23 to 5/27/23 and 5/28/23 to 7/26/23, included IDG orders for skilled nursing and hospice aide services. b. The POC included the following assigned interventions for the hospice aide to complete the following tasks: assist with transferring client to bed following meal if request, clean up clients chair/bedside table following meals, assist to commode as needed, lotion extremities per request, encourage wear glasses/hearing aid, transfer to bed/chair with assistance, cleanse clients face and hands with warm washcloth following meals, may provide oral care as needed and ensure clean of any incontinent episodes. c. The hospice aide visit notes, dated 6/5/23 and 6/12/23, included documentation the aide completed a visit. The visit note included documentation the hospice aide completed both a shower and partial bath. d. The hospice aide visit notes, dated 6/5, 6/9, 6/12, 6/14, 6/16 and 6/19/23, included documentation the following tasks not completed and documented "not applicable this visit": Shave, make patient bed, clean bathroom after patient care, oral care and shampoo. e. During an interview on 7/11/23 at 9:30 AM, Staff E, Hospice Aide stated she does feed the patient during the hospice visit during meal time. The hospice aide failed to document the task feeding the patient completed. 4. Patient #14 had a hospice admission date of 6/9/23, received hospice services while residing in a nursing home and died on 7/13/22. Review of the clinical record revealed the following: a. The POCs, dated 6/9/22 to 9/6/22, included IDG orders for skilled nursing and hospice aide services. b. The POC included the following assigned interventions for the hospice aide to complete the following tasks: tub bath, lotion, feed patient, assist with transfers, bed bath, oral care and shampoo. c. The hospice aide visit notes, dated 6/5/23 and 6/12/23, included documentation the aide completed a visit. The visit note included documentation the hospice aide completed both a shower and partial bath. c. The hospice aide visit notes, dated 7/9, 7/12 and 7/11/22, included documentation the following tasks not completed and documented "not applicable this visit": feed patient, oral care, assist with transfers documented "not applicable this visit". The hospice aide failed to complete all assigned tasks on the aide care plan or document a reason why the tasks were not completed. The above findings were reviewed with the Administrator/Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to 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 2 of 4 sampled patients (Patients #3 and #5) with hospice aide services that required and received hospice aide supervision. The hospice reported 4 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. Findings include: --- Review of the hospice's policy, titled Home Care Aide Supervision and HCA Duties, dated 2/2022, identified supervision of the hospice aide is provided in accordance with Federal and State regulations and is documented within the electronic medical record. The Registered Nurse must make a supervisory visit to the client's residence no less frequently than every 14 days (either direct when the aide is present to observe and assist or indirect when the aide is absent) for patients receiving skilled services. During an interview on 7/11/23 at 8:30 AM the Administrator stated the supervision is completed by all of the nurses and they have continued to provide the supervision. 1. Patient #3 had a hospice admission date of 1/4/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 4/4/23 to 7/2/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/24/23, 6/14/23 and 6/28/23, included documentation the nurse supervised the hospice aide. c. The skilled nursing visit notes, dated 5/31, 6/7, 6/28, 7/5 and 7/11/23, failed to include documentation the nurse supervised the hospice aide. (5/24/23 to 6/14/23=3 weeks) (6/28/23 to 7/14/23=3 weeks) The hospice failed to document aide supervision every 14 days. 2. Patient #5 had a hospice admission date of 11/29/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care, dated 2/27/23 to 5/27/23 and 5/28/23 to 7/26/23, included orders for hospice aide and skilled nursing services. b. The skilled nursing visit notes, dated 5/24/23 and 6/14/23, included documentation the nurse supervised the hospice aide. c. The skilled nursing visit notes, dated 5/31, 6/7, 6/21, 6/28, 7/5 and 7/11/23, failed to include documentation the nurse supervised the hospice aide. (5/24 to 6/14/23=3 weeks) and (6/14/23 to 7/14/23=4 weeks). The hospice failed to document aide supervision every 14 days. The Administrator/Clinical Manager received the above findings and hospice staff provide no further information prior to the end of the survey.

Based on review of employee personnel files and staff interview, the hospice failed to ensure the hospice provided orientation on the hospice's philosophy for 2 of 4 sampled staff (Staff G and H). The hospice reported hiring 18 employees since the last survey. Failure to provide orientation on hospice's philosophy increased the potential for provision of services in a manner contradictory to the hospice's philosophy. Findings include: --- During an interview on 7/18/23 at 11:15 AM the HR manager stated the training for therapists is completed for home care but not specifically for hospice philosophy or advance directives. 1. Staff G, Occupational Therapist, had a hire date of 2/6/23. Staff Gs personnel file failed to include documentation of orientation on the hospices philosophy or advanced directives. 2. Staff H, Physical Therapist, had a hire date of 10/18/21. Staff Hs personnel file lacked documentation of orientation on the hospices philosophy or advanced directives. The above findings were reviewed with the Hospice Administrator/Clinical Manager and Human Resource Manager. The hospice provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to ensure all documentation was included in the clinical record in a timely manner for 9 of 14 sampled patients (Patients #2, #3, #4, #5, #8, #9, #11, #12 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. Findings include: --- During an interview on 7/11/23 at 8:30 AM the Administrator stated routine visits are expected to completed in 48 hours. 1. Patient #2 had a hospice admission date of 2/9/23 and received services while residing in a private home. a. The social worker visit note, dated 7/5/23, signed completed on 7/9/23 (2 days late). 2. Patient #3 had a hospice admission date of 1/4/23 and received services while residing in a nursing home. a. The social worker visit note, dated 6/6/23, signed completed on 6/9/23 (1 day late). b. The social worker visit note, dated 6/27/23, signed completed on 7/3/23 (4 days late). 3. Patient #4 had a hospice admission date of 3/14/23 and received services while residing in a nursing home. a. The social worker visit note, dated 6/27/23, signed completed 7/3/23 (4 days late). 4. Patient #5 had a hospice admission date of 11/29/22 and received services while residing in a nursing home. a. The social worker visit note, dated 6/6/23, signed completed 6/9/23 (1 day late). b. The social worker visit note, dated 6/27/23, signed completed on 7/3/23 (5 days late). 5. Patient #8 had a hospice admission date of 1/17/23 and received services while residing in a private home and died on 1/25/23. a. The social worker visit note, dated 1/23/23, signed completed 1/30/23 (5 days late). 6. Patient #9 had a hospice admission date of 12/1/22 and received services while residing in a private home and died on 12/21/23. a. The social worker visit note, dated 12/6/22, signed completed 12/12/22 (4 days late). b. The social worker visit note, dated 12/7/22, signed completed on 12/12/22 (3 days late). 7. Patient #11 had a hospice admission date of 11/3/23 and received services while residing in a nursing home and discharged on 1/31/23. a. The social worker visit note, dated 11/8/22, signed completed 11/15/22 (5 days late). b. The social worker visit note, dated 2/8/23, signed completed 2/21/23 (11 days late). 8. Patient #12 had a hospice admission date of 10/12/22 and received services while residing in a nursing home and discharged on 1/1/23. a. The social worker visit note, dated 12/5/22, signed completed 12/12/22 (5 days late). b. The social worker visit note, dated 12/19/22, signed completed on 12/28/22 (7 days late). c. The social worker visit note, dated 12/29/22, signed completed on 1/3/23 (3 days late). 9. Patient #14 had a hospice admission date of 6/9/22 and received services while residing in a nursing home and died on 7/13/22. a. The social worker visit note, dated 6/9/22, signed completed 7/5/22 (26 days late). b. The social worker visit note, dated 6/23/22, signed completed 6/28/22 (3 days late). The Administrator/Clinical Manager received the above findings. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to ensure the hospice staff sent a copy of the patient's transfer summary to the facility the patient transferred to for 2 of 2 sampled transferred patients (Patients #8 and #9). Failure to ensure the hospice staff sent a copy of the patient's transfer summary to the facility accepting transfer of the patient placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. Findings include: --- During an interview on 7/19/23 at 4:10 AM, Administrator stated she was unable to locate transfer summaries for the patients. 1. Patient #8 had a start of care date of 1/17/23 and received services in a private home and died on on 1/25/23. Review of the clinical record revealed the following: a. The Plan of Care, dated 1/17/23 to 4/6/23, included Interdisciplinary Group (IDG) orders for skilled nursing and social worker services. The skilled nurse visit note, dated 1/21/23, identified the patient transferred to the hospital for respite care. Review of the medical record revealed no transfer summary completed and sent to the receiving hospital. 2. Patient #9 was admitted to hospice on 12/1/22, received services while residing in a private home and died on 12/21/22. The skilled nurse visit note, dated 12/15/22, identified the patient transferred to the hospital for respite care. Review of the medical record revealed no transfer summary completed and sent to the receiving hospital. The Administrator/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, 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 Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa 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 and staff interview, the hospice failed to ensure completion of a criminal background check for 4 of 4 sampled employees (Staff F, G, H and I) who began serving hospice patients since their last survey, dated 9/24/2020. The hospice reported hiring 5 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 hospice employees who had direct patient contact. Findings include: --- According to the hospice policy titled Orientation, dated 2, 2023, before performing duties, each nurse and aide must successfully pass a moving violation check, criminal background check and abuse check. During an interview on 7/18/23 at 10:20 AM, the Human Resources manager stated the criminal background checks are completed by using a 3rd party vendor and not completed through SING. 1. Staff F, Registered Nurse, had a hire date of 9/13/21. Staff F's personnel file lacked a criminal history background check completed by the hospice through either the Iowa Single Information Repository (SING) or the Iowa Division of Criminal Investigation (DCI). 2. Staff G, Occupational Therapist, had a hire date of 2/6/23. Staff G's personnel file lacked a criminal history background check completed by the hospice through either the Iowa Single Information Repository (SING) or the Iowa Division of Criminal Investigation (DCI). 3. Staff H, Physical Therapist, had a hire date of 10/18/21. Staff H's personnel file lacked a criminal history background check completed by the hospice through either the Iowa Single Information Repository (SING) or the Iowa Division of Criminal Investigation (DCI). 4. Staff I, Volunteer, had a hire date of 10/27/22. Staff I's personnel file lacked a criminal history background check completed by the hospice through either the Iowa Single Information Repository (SING) or the Iowa Division of Criminal Investigation (DCI). The above findings were reviewed with the Hospice Administrator/Clinical Manager and Human Resource Manager. Hospice staff provided no further information prior to the end of the survey.