Every finding on record at Hospice of Siouxland

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review, interview and observation. In 10 of 13 (77%) clinical records reviewed revealed that the agency did not ensure that all hospice care and services required to meet the patient needs were included in the plan of care. Clinical Record 1: Date of election: 2/15/23. In the initial comprehensive nursing assessment (2/15/23), the patient with seizures and cancer of the brain was assessed using the Missouri Alliance for Home Care (MAHC-10) Fall Risk assessment tool and scored 8 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plan of care. In addition, during home visit one, the patient was observed with a foam bordered dressing on coccyx and there were no wound dressing orders included in the plan of care. Clinical Record 2: Date of election 11/30/22. In the initial comprehensive nursing assessment (11/30/22), the patient with pulmonary fibrosis was assessed using the MAHC-10 Fall Risk assessment tool and scored 8 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plan of care effective from 11/30/22 to current. Clinical Record 3: Date of election 2/13/23. In the initial comprehensive nursing assessment (2/13/23), the patient with cerebral ischemia was assessed using the MAHC-10 Fall Risk assessment tool and scored 8 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plan of care effective from 2/13/23 to current. Clinical Record 4: Date of election 10/3/22. In the initial comprehensive nursing assessment (10/3/22), the patient with congestive heart failure was assessed using the MAHC-10 Falls Risk assessment and scored 6 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the care plan effective from 10/3/22 to current. Clinical Record 5: Date of election 6/20/22. In the initial comprehensive nursing assessment, (6/20/22), the patient with Alzheimer's disease was assessed using the MAHC-10 and scored 8 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plans of care, or updated care plans, effective from 6/20/22 to current. Clinical Record 7: Date of election 1/6/23. In the initial comprehensive nursing assessment (1/6/23), the patient with Leukemia was assessed using the MAHC-10 fall risk assessment and scored 5 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plan of care effective from 1/6/23 to current. Clinical Record 8: Date of election 9/28/22. In the initial comprehensive nursing assessment (9/28/22), the patient with Chronic Obstructive Pulmonary Disease (COPD) was assessed using the MAHC-10 fall risk assessment and scored 6 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plans of care, or updated care plans, effective from 9/28/22 to current. Clinical Record 9: Date of election 1/5/23. In the initial comprehensive nursing assessment (1/5/23), the patient with respiratory failure was assessed using the MAHC-10 fall risk assessment and scored 4 which equaled "at risk for falls". There were no fall precautions or safety measures addressed in the plan of care effective from 1/5/23 to current. Clinical Record 10: Date of election: 2/8/23. In the initial comprehensive nursing assessment (2/28/23), the patient with COPD was assessed using the MAHC-10 fall risk assessment scored 6 which equaled "at risk of falls". There were no fall precautions or safety measures addressed in the plan of care effective 2/8/23 to current. Clinical Record 13: Date of election: 10/28/22. In the initial comprehensive nursing assessment (10/28/22), the patient with Parkinson's disease was assessed using the MAHC-10 fall risk assessment tool and scored 6 which equaled "at risk for falls". In addition, the patient was assessed to have a suprapubic catheter. The plans of care and updated plans of care, from 10/28/22 to current, did not address the fall precautions or safety measures, the suprapubic catheter or orders to change (or not) the suprapubic catheter. Personnel Record 7: The clinical record reviews were completed jointly with the Quality Manager on 3/1/23. The Quality Manager confirmed that the fall precautions and/or safety measures should have been included in the plan of care if the patient was determined to be at risk of falls. In addition, the Quality Manager confirmed that the plans of care for record 1 should have included wound care orders and record 13 should have included catheter care and orders.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 13 (23%) clinical records reviewed revealed that the agency did not ensure nursing services were provided in accordance with the ordered visit frequency. Clinical Record 1: Election of benefit effective 2/15/23. Supplemental physician order dated 2/19/23 changed the nursing visit frequency to two times per week. For the billing week starting 2/19/23 the only documented nursing visit was on 2/21/23. Clinical Record 7: Election of benefit 1/6/23. Supplemental physician order dated 1/11/23 changed the ordered nursing visit frequency to one time per week. There was no documented nursing visit for the week of 1/15/23. Clinical Record 9: Election of benefit effective 1/5/23. Plan of care effective 1/5/23 ordered nursing visit frequency at one time per week for 13 weeks. There was no documented nursing visit the week of 2/19/23. Personnel Record 7: During an interview on 3/1/23 the Quality Manager confirmed that there was no documentation that the nursing visits were made as ordered. The agency was unable to produce physician order changes or missed visit documentation.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed, in which hospice aide services were accepted, it was revealed that the agency did not ensure that the ordered visit frequency for the hospice aide was followed. Clinical Record 6: Election of benefit 2/19/23. Physician order effective 2/21/23 was for the aide visit two times per week, that week the only documented aide visit was on 2/21/23. In addition, the patient was assessed on 2/19/23 and determined to have a MAHC-10 fall risk assessment score of 8. Fall precautions or safety precautions were not addressed in the Hospice aide plan of care. Personnel Record 7: During an interview on 3/1/23 the Quality Manager confirmed that there was only one visit documented for the billing week of 2/19/21-2/25/23. The agency was unable to produce physician order changes or missed visit documentation. The Quality Manager also confirmed that the safety precautions were not included in the hospice aide plan of care effective as of 2/19/23.

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, Orientation on the hospice philosophy is also provided to all employees and contracted staff who have patient and family contact. (L661) Orientation includes the following, as appropriate to the employee’s specific job duties: the needs and concerns of patients and families coping with a terminal illness; education regarding the hospice’s policies and procedures on advance directives. This standard was not met as evidenced by interview and personnel record review. In 2 of 13 (15%) personnel records reviewed revealed that the agency did not ensure that personnel records contained documentation that the employees received the required educational elements specific to their job duties. Personnel Record 3: Date of hire 5/31/21. The personnel file did not contain documentation that all components of orientation education were completed. Personnel Record 10: Date of hire 3/1/21 The personnel file did not contain documentation that all components of orientation education were completed.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 2 of 13 (15%) personnel records reviewed revealed that the agency did not ensure that the employees received competency evaluations prior to providing care. Personnel Record 3: Date of hire: 5/31/21. The personnel file did not contain evidence of an initial skills competency test. Personnel Record 10: Date of hire: 3/1/21. The personnel file did not contain evidence of an initial skills competency test.

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. This standard was not met as evidenced by interview and personnel record review. In 1 of 13 (8%) personnel files reviewed revealed that the agency did not ensure that criminal background checks were obtained for all direct care employees or those with access to patient records. Personnel Record 3: Date of hire: 5/3/21. The personnel record did not contain evidence that a criminal background check was obtained.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by interview and personnel record review. In 1 of 13 (8%) personnel records reviewed revealed that the agency did not ensure that the volunteer personnel records contained evidence of COVID-19 vaccination or religious or medical exemptions. Personnel Record 12: Date of hire February 2016. This personnel file did not contain evidence that the individual had been vaccinated for COVID-19 nor any documented religious or medical exemptions. Personnel Record 6: In an interview on 3/2/23 the Volunteer Coordinator confirmed the personnel file did not contain evidence of COVID-19 vaccination, or an exemption, and reported that she was not aware that she needed to collect that information for volunteers.