Every finding on record at Hospice of Siouxland - Ss

It is required that each patient’s individualized written plan of care reflects the patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 14 (43%) clinical records reviewed, the agency did not ensure the patient's individualized plan of care reflected the patient and family goals and identified planned interventions based on problems identified in the initial and updated comprehensive assessments related to massage therapy. CLINICAL RECORD 2: The patient elected hospice care on 05/07/2025. A physician order was obtained on 05/05/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/11/2026 documented, "What medical indications were addressed at this session: reduce anxiety, reduce restlessness, reduce muscle tension/affect contractures, reduce pain." The Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 3: The patient elected hospice care on 03/18/2026. A physician order was obtained on 05/12/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/20/2026 documented, "What medical indications were addressed at this session: Increase comfort/relaxation." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 6: The patient elected hospice care on 01/13/2026. A physician order was obtained on 05/14/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/20/2026 documented, "What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce muscle tension/affect contractures, reduce pain, increase comfort/relaxation." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/21/2026 and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 7: The patient elected hospice care on 04/14/2026. A physician order was obtained on 04/23/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 05/01/2026 documented, "What medical indications were addressed at this session: reduce muscle tension/affect contractures, reduce pain, reduce edema/increase circulation, increase comfort/relaxation." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 8: The patient elected hospice care on 04/02/2026. A physician order was obtained on 04/20/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 04/27/2026 documented, "What medical indications were addressed at this session: reduce anxiety, reduce agitation, reduce restlessness, reduce muscle tension/affect contractures, improve skin condition, increase comfort/relaxation." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy. CLINICAL RECORD 11: The patient elected hospice care on 03/24/2026. A physician order was obtained on 04/20/2026 for a Massage Therapy Evaluation. The massage therapist evaluation dated 04/29/2026 documented, "What medical indications were addressed at this session: reduce anxiety, reduce muscle tension/affect contractures, reduce pain, improve skin condition, increase comfort/relaxation." The Hospice IDG Comprehensive Assessment and Plan of Care Update Report for IDG dated 05/07/2026, 05/21/2026, and 06/04/2026 did not include documentation of patient and family goals or planned interventions for the massage therapy.. During a joint record review and interview on 06/16/2026, the Administrator/Regional Director of Operations (Personnel Record 7) confirmed the findings and stated in part, "These will be updated today."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided day-to-day administrative or direct patient care services equal to five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. A joint review of the "Volunteer Hours " report dated 01/01/2025 through 12/31/2025 with the Administrator and the Volunteer Coordinator on 06/15/2026 revealed that volunteers provided 3.23% of day-to-day administrative and/or direct patient care services for 2025. The Volunteer Coordinator confirmed that volunteer utilization was below the required 5% for 01/01/2025 through 12/31/2025. During an interview on 06/15/2026, the Administrator (Personnel Record 7) confirmed that volunteer utilization was below 5% for 12/31/2025 through 03/31/2026, and stated, "We have one volunteer; if we are unable to match a patient with our volunteer, our Volunteer Coordinator visits those patients."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure that initial bereavement risk assessments were completed as part of the initial comprehensive assessments. Clinical Record 2: The initial nursing comprehensive assessment dated 5/17/23, included a bereavement section which asked, "was a bereavement risk assessment completed?" The RN documented, "No, completed by the social worker." The initial social worker visit was completed on 5/19/23 but did not contain a bereavement risk assessment. Clinical Record 8: The initial nursing comprehensive assessment dated 7/3/23, included a bereavement section which asked, "was a bereavement risk assessment completed?" The RN documented, "No, completed by the social worker." The initial social worker visit was also completed on 7/3/23 but did not contain a bereavement risk assessment. Personnel Record 2: During an interview with the clinical manager, on 7/21/23, it was confirmed that neither of these records contained documentation that the initial bereavement risk assessment was completed. It was further reported that upon switching to the new electronic medical record system (in May 2023) the social workers now have to click on multiple tabs to locate the bereavement risk assessment.

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) records reviewed, in which aide services were accepted, it was revealed that the agency did not ensure that the hospice aides were providing all services as listed within the plan of care. Clinical Record 3: Hospice aide care plan, effective from 5/15/23 to current, ordered aide visits at two times per week with all tasks to be performed at every visit. For the weekly visits, on 7/10/23 and 7/13/23, the aide documented the following tasks as being "not applicable to this visit": incontinent care, range of motion exercises, and oral care. Personnel Record 2: During an interview with the clinical manager, on 7/20/23, it was confirmed that the aide should have performed the tasks or informed the RN why they were not provided as those tasks were applicable to be performed at every visit.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) records reviewed it was revealed that the agency did not ensure the clinical record contained physician orders for all medications being utilized by the patient. Clinical Record 2: The election of benefit was dated 5/17/23 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The physician order dated 5/19/23, was written for "oxygen 1-5 liters per nasal cannula, continuous, as needed for shortness of breath." The RN visit note, from 6/1/23, documented the patient was using oxygen at 7 liters per nasal cannula and the visit note from 7/6/23, documented oxygen at 6 liters. During home visit observation (7/20/23) the patient utilized oxygen at 6 liters per nasal cannula and the wife commented that he had been doing better with this dose. The clinical record did not include physician orders for the increased doses of oxygen. Clinical Record 9: The election of benefit was dated 4/28/23 with a terminal diagnosis of COPD. An RN communication note from 6/25/23 documented, "patient reports that both legs are sore and was wondering what to take for the pain, this RN encouraged use of Tylenol." The Medication profile, effective 4/28/23 to current, did not contain any active or discontinued orders for Tylenol. Personnel Record 2: These records were reviewed by the clinical manager and during an interview on 7/21/23 it was confirmed that neither of these items were included in the drug profile and the records did not contain orders.