Every finding on record at Hospice of the Heartland

Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness provided to all current staff at time of hire.  Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: --- According to the hospice policy titled Emergency Operations Plan, dated 6/2025, the current staff will be trained on the Emergency Operations Plan initially and annually. All new staff will be trained on the plan within 30 days of start date. Volunteers must have emergency preparedness training initially and then yearly. a. Review of Staff G, Chaplain employee record revealed a start dated of 11/13/24. b. Review of the agency's emergency preparedness plan lacked documentation of initial training completed for Staff G. During an interview on 6/25/25 at 2:35 PM, the Administrator stated no training completed for the emergency preparedness plan for Staff G.  The above findings were reviewed with the Agency Administrator and the Clinical Manager.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care that specified scope and frequency for all services required by and provided to patients for 3 of 3 sampled patients (Patient #6, #12 and #14) who received general inpatient and/or respite services.   Failure to identify scope and frequency for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families.   Findings include: --- 2. Patient #6 had a hospice admission date of 12/30/24, a discharge date of 1/8/25, received hospice services while residing in a private residence from 12/30/24 to 12/31/24, received hospice services while residing at the hospital for general inpatient care from 12/31/24 to 1/3/25, and received hospice services while residing at the hospital in respite care from 1/3/25 to 1/8/25.  Clinical record review revealed:   a. The POC, dated 12/30/24 to 3/29/25, included physician orders to admit patient to hospice services with skilled nursing, social worker and massage therapy services.   b. Patient admission setting documentation, dated 12/30/24, identified the patient received routine home care services at home; dated 12/30/24; identified the patient received general inpatient services at the hospital; dated 12/31/24; identified the patient received inpatient respite services at the hospital; dated 1/3/25; and identified the patient revoked hospice care at the hospital on 1/8/25.    The hospice clinical record failed to identify interim physician orders to change level of care from routine to general inpatient to respite.    3. Patient #14 had a hospice admission date of 7/18/24, a death date of 7/24/24, received hospice services while residing in a private residence from 7/18/24 to 7/20/24 and received hospice services while residing at the hospital for respite care from 7/20/24 to 7/24/24.  Clinical record review revealed:   a. The POC, dated 7/18/24 to 10/15/24, included physician orders to admit patient to hospice services with skilled nursing and social work services.   b. Patient admission setting documentation, dated 7/18/24, identified the patient received routine home care services at home; dated 7/18/24; identified the patient received inpatient respite services at the hospital; dated 7/20/24; and identified the patient expired at the hospital on 7/24/24.      The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite.    The above findings were reviewed with the Administrator and Clinical Manager.     According to the agency policy titled Plan of Care, dated 5/2025, the written plan of care will include all services necessary for the palliation and management of the related condition. Review of the plan of care will be done by the interdiscipliary team, in collaboration with the patient's attending physician. During an interview on 6/25/25 at 2:12 PM, the Clinical Manager stated hospice staff did not always write orders for the change in service to respite services. The written order identified did not flow over to IDG as it should have and will look into the reason it did not. 1.Patient #12 had a hospice admission date of 12/16/24, a death date of 12/30/24, received hospice services while residing in a private residence from 12/16/24 to 12/18/24 and 12/23/24 to 12/29/24. The patient received hospice services while residing at the hospital in respite care from 12/18/24 to 12/23/24 and 12/29/24 to 12/30/24.  Clinical record review revealed:  a. The Plan of Care (POC), dated 12/16/24 to 3/15/25, included physician orders to admit the patient to hospice services with skilled nursing, social worker and hospice aide services.  b. The physicians order, dated 12/18/24, included an order to transfer the patient to the hospital for inpatient hospice respite care.  c. IDG meeting note, dated 12/31/24, included documentation nursing services were provided during respite care and the patient returned to the private residence to receive services in the home. The note failed to include the order to transfer to the hospital for inpatient respite services or an order to transfer back to the private residence to receive services in the home. The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite and to return from respite to routine level of care.

Based on staff interview, clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 3 of 3 hospice aides (Staff D, Staff E and Staff H) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 5 of 10 sampled patients (Patient #4, #5, #7, #8 and #12) who required an extra skill be performed.    Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care.    Findings include: --- The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan.    According to the agency's policy titled Hospice Aide Services, dated 6/2025, the hospice aide's supervising clinical manager will be responsible to maintain documentation regarding any specific skills taught to the hospice aide as assigned to provide cares.    During an interview on 6/25/25 at 8:30 AM, the Administrator identified Staff I, Registered Nurse (RN), is responsible for training and competency testing hospice aides in the skills beyond basic skills.    1.Patient #4 had a hospice admission date of 4/16/24, a discharge date of 6/24/24, and received hospice services while residing in a nursing home.    a. The aide care plan included RN instructions to the aide to perform nail care; trim nails.  b. Review of the clinical record showed Staff D, Hospice Aide, Staff E, Hospice Aide and Staff H, Hospice Aide, provided aide services independently for Patient #4.    c. Staff D, Hospice Aide, had a hire date of 8/2/16.  Staff D's personnel file lacked documentation an RN had observed Staff D competently perform the task trim nails.    d. Staff E, Hospice Aide, had a hire date of 10/4/04.  Staff E's personnel file lacked documentation an RN had observed Staff E competently perform the task trim nails.   e. Staff H, Hospice Aide, had a hire date of 9/16/14.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails.    2.Patient #5 had a hospice admission date of 4/15/24, a discharge date of 9/30/24, and received hospice services while residing in a private residence.    a. The aide care plan included RN instructions to the aide to apply ace wrap to left knee for comfort.  b. Review of the clinical record showed Staff D, Hospice Aide, provided aide services independently for Patient #5.    c. Staff D, Hospice Aide, had a hire date of 8/2/16.  Staff D's personnel file lacked documentation an RN had observed Staff D competently perform the task apply ace wrap.    3. Patient #7 had a hospice admission date of 9/4/26, a discharge date of 9/26/24 and received hospice services in a nursing home.    a. The aide care plan included RN instructions to the aide to assist with transfers using an EZ stand (a device that provides assistance for individuals with difficulty standing from chairs etc.).  b. Review of the clinical record showed Staff D, Hospice Aide, provided aide services independently for Patient #7.    c. Staff D, Hospice Aide, had a hire date of 8/2/16.  Staff D's personnel file lacked documentation an RN had observed Staff D competently perform the task assist with transfers using an EZ stand.    4.Patient #8 had a hospice admission date of 7/8/24, a discharge date of 8/2/24, and received hospice services while residing in a private residence.    a. The aide care plan included RN instructions to the aide to perform nail care; trim nails.  b. Review of the clinical record showed Staff E, Hospice Aide and Staff H, Hospice Aide, provided aide services independently for Patient #8.    c. Staff E, Hospice Aide, had a hire date of 10/4/04.  Staff E's personnel file lacked documentation an RN had observed Staff E competently perform the task trim nails.   d. Staff H, Hospice Aide, had a hire date of 9/16/14.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails.     5.Patient #12 had a hospice admission date of 12/16/24, a discharge date of 12/30/24, and received hospice services while residing in a nursing home.    a. The aide care plan included RN instructions to the aide to perform nail care; trim nails.  b. Review of the clinical record showed Staff H, Hospice Aide, provided aide services independently for Patient #12.    c. Staff H, Hospice Aide, had a hire date of 9/16/14.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the task trim nails.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 9 of 11 sampled patients receiving hospice aide services (Patients #1, #2, #3, #4, #7, #8, #10, #12 and #13).    The hospice reported a current census of 3 patients, including 3 who received hospice aide services at the time of the survey.  Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients' personal care needs were not adequately met. --- 7. Patient #2 had a hospice admission date of 3/4/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC's, dated 3/4/25 to 6/1/25 and 6/2/25 to 8/30/25, identified the patient had a diagnosis of cancer of the lung and included physician orders for hospice aide services.   b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: assist the patient with oral care, shower with use of shower chair and whirlpool. c. Hospice aide visit note, dated 5/7/25, included documentation the hospice aide provided both a whirlpool bath and shower.   d. Hospice aide visit notes, dated 4/21/25 and 4/28/25, identified oral care not completed and documented "not applicable this visit". The notes failed to document the reason the oral care not completed.   The hospice aide failed to provide services as instructed by the RN assignment.   8. Patient #7 had a hospice admission date of 9/4/24 and revoked services on 9/26/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 9/4/24 to 12/2/24, identified the patient had a diagnosis of end stage renal disease and included physician orders for hospice aide services.   b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: provide Foley catheter care and empty the Foley catheter bag. c. Hospice aide visit note, dated 9/11/24, failed to included documentation the hospice aide provided Foley catheter care or empty the Foley catheter bag.  d. Hospice aide visit notes, dated 9/18/24, failed to include the patients weight. The documentation included "unable to obtain" but failed to identify the reason the aide unable to obtain the patient's weight. The hospice aide failed to provide services as instructed by the RN assignment.   9. Patient #12 had a hospice admission date of 12/16/24 and date of death of 12/30/24 and received hospice services while residing in a private residnence.  Clinical record review revealed:  a. The POC, dated 12/16/24 to 3/1/25, identified the patient had a diagnosis of degeneration of the automatic nervous system and included physician orders for hospice aide services.   b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks: assist the patient with a shower, assist the patient with a sponge bath if unable to shower, assist with shaving and empty the Foley catheter bag.  c. Hospice aide visit notes, dated 12/17/24 and 12/24/24, identified oral care and empty the Foley catheter bag not completed and documented "not applicable this visit". The notes failed to document the reason the oral care and empty the Foley catheter bag not completed.   d. Hospice aide visit note, dated 12/27/24, identified staff provided both a shower and sponge bath for the patient. The hospice aide failed to provide services as instructed by the RN assignment.   The above findings were reviewed with the Administrator and Clinical Manager.  4. Patient #1 had a hospice admission date of 4/17/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 4/17/25 to 7/15/25, identified the patient had a diagnosis of Cirrhosis of the liver and included physician orders for hospice aide services.    b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks:   i. weight (every other week), with a start date of 4/17/25; and   ii. change patient linen once per week, with a start date of 4/17/25 and a resolved date of 6/9/25.  c. Hospice aide visit notes, dated 4/25/25, 5/2/25, 5/6/25, 5/16/25, 5/20/25, 5/23/25, 5/27/25, 5/30/25, 6/6/25, 6/10/25, 6/17/25 and 6/20/25, included documentation of patient's weight obtained.    d. Hospice aide visit note, dated 5/6/25, identified patient linen not changed.    e. Hospice aide visit note, dated 5/9/25, included documentation the task change patient linen once a week, not applicable this visit but lacked a reason why this task was not completed as assigned.    The hospice aide failed to provide services as instructed by the RN assignment.    5. Patient #4 had a hospice admission date of 4/16/24, a discharge date of 6/24/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/16/24 to 7/14/24, identified the patient had a diagnosis of Chronic respiratory failure and included physician orders for hospice aide services.    b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task; weight (every other week), with a start date of 4/16/24 and a resolved date of 6/24/24.     c. Hospice aide visit note, dated 4/24/24, included documentation of patient's weight.  d. Hospice aide visit notes, dated 5/8/24, 5/22/24 and 6/5/24 failed to include documentation of patient's weight.    The hospice aide failed to provide services as instructed by the RN assignment.    6. Patient #8 had a hospice admission date of 7/8/24, a discharge date of 8/2/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 7/8/24 to 10/5/24, identified the patient had a diagnosis of Breast cancer and included physician orders for hospice aide services.    b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks:   i. nail care (file, trim, clean), with a start date of 7/8/24 and a resolved date of 8/2/24; and   ii. change patient linen once per week, with a start date of 7/8/24 and a resolved date of 8/2/24.  c. Hospice aide visit notes, dated 7/15/24, 7/22/24, 7/24/24, 7/29/24, 7/31/24 and 8/2/24, included documentation the task nail care, not applicable this visit but lacked a reason why the task was not completed as assigned.    d. Hospice aide visit notes, dated 7/24/24, 7/26/24, 7/29/24, 7/31/24 and 8/2/24, included documentation the task change patient linen once per week not applicable this visit but lacked a reason why the task was not completed as assigned.    The hospice aide failed to provide services as instructed by the RN assignment.    Findings include:  According to the hospice Policy, titled Hospice Aide Services, dated 6/2025, the hospice aide received patient care assignments from a Registered Nurse (RN) utilizing the individual patient electronic medical record.  1.Patient #3 had a hospice admission date of 12/27/24 and received hospice services while residing in an assisted living facility.  Clinical record review revealed the following:  a. Interdisciplinary group (IDG) meeting notes, dated, 4/8/25, 4/22/25, 5/6/25, 5/20/25, 6/3/25 and 6/17/25, included IDG orders for hospice aide services.  b. Undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks:  i. weight (every other week), with a start date of 12/27/24 and a resolved date of 6/11/25; and  ii. nail care (file, trim, clean), with a start date of 12/27/24.  c. Hospice aide visit notes, dated 4/21/25, 4/24/25, 4/28/25, 5/1/25, 5/5/25, 5/8/25, 5/12/25, 5/15/25, 5/19/25, 5/22/25, 5/27/25, 5/30/25, 6/2/25, 6/5/25 and 6/9/25, included documentation of patient weights obtained.  d. Hospice aide visit notes, dated 4/21/25, 4/23/25, 4/24/25, 4/30/25, 5/1/25, 5/5/25, 5/7/25, 5/8/25, 5/12/25, 5/14/25, 5/15/25, 5/19/25, 5/21/25, 5/22/25, 5/27/25, 5/28/25, 5/30/25, 6/2/25, 6/4/25, 6/5/25, 6/9/25, 6/11/25, 6/12/25, 6/16/25 and 6/18/25, included documentation the task nail care, not applicable this visit but lacked a reason why this task was not completed as assigned.  The hospice aide failed to provide services as instructed by the RN assignment.    2. Patient #10 had a hospice admission date of 2/11/25, a death date of 2/26/25 and received hospice services while residing in a private home.  Clinical record review revealed the following:  a. Plan of Care, dated 2/11/25 to 4/11/25, included physician orders for hospice aide services.  b. IDG meeting note, dated, 2/25/25, included IDG orders for hospice aide services.  c. Undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks assist with transfers, empty foley catheter, assist patient with dressing, shower, shampoo, oral care and report patient pain to nurse; with start dates of 2/11/25 and resolved date of 2/26/25.  d. Hospice aide visit notes, dated 2/12/25, 2/17/25 and 2/21/25, included documentation the tasks oral care and report patient pain to nurse, not applicable this visit but lacked a reason why these tasks were not completed as assigned.  e. Hospice aide visit note, dated 2/26/25, included documentation the tasks assist with transfers, empty foley catheter, assist patient with dressing, shower and shampoo, not applicable this visit but lacked a reason why these tasks were not completed as assigned.  The hospice aide failed to provide services as instructed by the RN assignment.  3. Patient #13 had a hospice admission date of 12/23/24, a death date of 1/7/25 and received hospice services while residing in a private home from 12/23/24 to 12/29/24 and a nursing home from 12/30/24 to 1/7/25.  Clinical record review revealed the following:  a. Plan of Care, dated 12/23/24 to 3/22/25, included physician orders for hospice aide services.  b. IDG meeting note, dated, 12/31/24, included IDG orders for hospice aide services.  c. Undated hospice aide care plan included RN instructions to the hospice aide to perform the task nail care (clean, file, trim), with start date of 12/23/24 and resolved date of 1/7/25.  d. Hospice aide visit notes, dated 12/24/24, 12/27/24 and 1/2/25, included documentation the task nail care, not applicable this visit but lacked a reason why this task was not completed as assigned.  The hospice aide failed to provide services as instructed by the RN assignment.

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 contract components for 1 of 2 sampled services (Medical equipment/supply 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 and sampled medical equipment/supply provider, dated 4/1/2016, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management and   b. All services are authorized by hospice and delivered in accordance with the patient's plan of care.    The hospice failed to ensure the contractual agreement with the medical equipment/supply provider contained all required components for safe and effective patient care.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on review of the emergency preparedness plan and related policies and staff interview, the agency failed to complete a written policy or procedure to outline the use of emergency staffing strategies which included State and Federally designated health care professionals. Failure to ensure the agency developed policies and procedures to address the use of State and Federally designated volunteers during an emergency, placed agency patients at risk for not having help to meet safety and health care needs in the event of a man made or natural disaster. Findings include: During an interview on 6/22/2020 at 2:15 PM, Staff F, Registered Nurse reported not finding written policy and procedure for the use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, staff interview and home observation visit, hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient physical condition including wound measurements for 4 of 8 sampled patients (Patients #2, #7, #8 and #10) with wounds. Failure by the hospice Interdisciplinary Group (IDG) registered nurses (RNs) 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: According to hospice policy, titled Wound Care Assessment and Documentation, dated 4/2022, complete wound assessment, including measurement of wound is to be done at the minimum of weekly with the first visit of the week, per physician order, or if the wound has deteriorated. Assessment/documentation includes: measurements - width, length, depth and wound care treatment/procedure used. During an interview on 6/20/22 at 10:22 AM, the Patient Care Coordinator reported wound are to be measured the first nursing visit of the week and measurements include length, width and depth. 1. Patient #10 had a hospice admission date of 4/26/22, death date of 5/4/22 and received hospice services while residing in a hospital. Clinical record review revealed: a. Plan of Care (POC), dated 4/26/22 to 7/24/22, included orders for nystatin powder to bilateral groin and bag balm to left breast cancerous lesion. b. Skilled nurse visit note, dated 5/3/22, included documentation of wound care provided to bilateral groin and left breast cancerous lesion, but lacked wound measurements. The hospice nurse failed to document weekly wound measurements that included length, width and depth. 2. Patient #8 had a hospice admission date of 5/9/22, death date of 5/21/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. POC, dated 5/9/22 to 8/6/22, included orders for wound care to coccyx ulcer. b. Skilled nurse visit note, dated 5/16/22, lacked documentation of wound care to coccyx and coccyx wound measurements. The hospice nurse failed to document weekly wound measurements that included length, width and depth. 3. Patient #2 had a hospice admission date of 1/14/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG meeting note, dated 5/10/22, included orders for mepilex dressing to bilateral posterior lower legs with a start date of 4/27/22. b. Skilled nurse visit note, dated 5/11/22, included documentation of wound measurements length and width for right lower posterior distal leg but lacked documentation of wound depth. The hospice nurse failed to document weekly wound measurements that included length, width and depth. 4. Patient #7 had a hospice admission date of 4/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/22 to 7/24/22, included Interdisciplinary (IDG) orders for skilled nursing services. b. The week of 6/5/22 included documentation of a skilled nursing visit note, dated 6/7/22. The visit note included documentation the nurse assessed the patient had 2 open wounds bilaterally to the coccyx. The visit note identified only one set of wound measurements including a length of 3.5 cm, a width of 5.5 cm and a depth of 0.1 cm. c. The week of 6/12/22 included documentation of a skilled nursing visit note, dated 6/13/22. The visit note included documentation the nurse assessed the patient had 2 open wounds bilaterally to the coccyx. The visit note identified only one set of wound measurements including a length of 2.5 cm, a width of 5.0 cm and a depth of 0.1 cm. On 6/21/22 at 3:50 PM, during an interview, Staff B, Patient Care Coordinator (Clinical Manager), reported the patient did have 2 open wounds, one on each side of the buttocks. She explained the skin was pink between the 2 open areas and thought of it all as one wound. The weeks of 6/5 and 6/12/22, lacked documentation of wound measurements for both coccyx wounds per hospice policy. 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 clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice Interdisciplinary Group members provided care in accordance with the patient's plan of care for 4 of 8 sampled (Patients #2, #3, #5 and #7) with a wound. Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 4/2022, identified the hospice IDG and attending physician will develop and individualized written plan of care which will include interventions to manage physical needs. Review of the hospice's policy, titled Wound Care Assessment and Documentation, dated 4/2022, identified all products used on a patient must have a physician's order and nursing staff must perform wound care per physician's order. 1. Patient #3 had a hospice admission on 3/29/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included IDG orders for skilled nursing services. b. A skilled nursing visit note, dated 4/6/22, included documentation the nurse assessed the patient had a bilateral open coccyx wound measuring 1.3 centimeters (cm) in length, 2.6 cm in width and 0.1 cm in depth. The nurse documented she cleaned the wound with soap and water and applied an Aquacel dressing. c. The IDG meeting, dated 4/12/22, included an interim physician order, dated 4/6/22, for an Aquacel dressing to the pressure area on the coccyx and change 3 times per week and as needed. The order did not identify a method for cleansing the wound. The nurse cleansed the patient's wound with soap and water without an order from the physician. 2. Patient #5 had a hospice admission date of 2/9/22 and received hospice services from 2/9 to 4/4/22 while residing in an assisted living and then continued to receive hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/10/22 to 8/7/22, included IDG orders for skilled nursing services. b. A skilled nursing visit note, dated 5/18/22, included documentation the nurse assessed the patient had a posterior medial open coccyx wound measuring 0.2 cm in length, 0.2 cm in width and 0.1 cm in depth. The nurse documented she cleaned the wound with soap and water and applied an Chamosyn with Manuka Honey. c. The IDG meeting, dated 5/24/22, included an interim physician order, dated 5/18/22, treat the pressure area on the coccyx with Chamosyn with Manuka Honey twice per day. The order did not identify a method for cleansing the wound. d. The skilled nursing visit notes, dated 5/23, 6/1 and 6/7/22, included documentation the nurse cleansed the coccyx wound with soap and water prior to applying Chamosyn with Manuka Honey to the coccyx wound. The nurse cleansed the patient's wound with soap and water without an order from the physician. 3. Patient #7 had a hospice admission date of 4/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 4/26/22 to 7/24/22, included IDG orders for skilled nursing and hospice aide services. a. The POC included IDG orders for skilled nursing services 2 times per week and physician orders for Aquacel AG and Cosmopor dressing to the pressure area on the right outer heel 2 times per week and as needed. b. The comprehensive assessment completed by the Registered Nurse (RN), dated 4/26/22, included an assessment of the right outer ankle pressure wound which measured 2.2 cm in length and 3 cm in width. The nurse documented she was unable to obtain a depth due to the presence of eschar (dead) tissue in the wound. The nurse documented she cleansed the wound with soap and water and applied Aquacel AG and a dry dressing. The wound care orders lacked an order related to the cleansing of the wound. c. The subsequent nursing visit (the same week as the 4/26/22 visit), dated 4/28/22, lacked any documentation of wound care to the right outer ankle pressure wound. The visit included documentation the nurse assessed the patient had a right posterior arm skin tear measuring 4 cm in length, 3 cm in width and 0.1 cm in depth. The nurse documented she cleansed the wound with soap and water and applied a Band-Aid. d. The clinical record included documentation of an order for a dry dressing to the skin tear above the right elbow and change daily and to change the right outer heel dressing to Aquacel AG and Mepilex 2 times per week and as needed and a start date of 4/28/22. The order did not include any direction for the cleansing of the 2 wounds. e. The clinical record included documentation of a physician order, dated 5/3/22, for the nurse to change the treatment to the right elbow skin tear to a Transderm (occlusive, transparent, sterile dressing that keep water and dirt out) dressing and leave the dressing in place until healed. The order did not include any directions for cleansing the wound. f. The week of 5/1/22, included documentation of 2 skilled nursing visits, dated 5/3 and 5/6/22. The visit, dated 5/3/22, included documentation of wound care to both the right outer heel and right posterior arm. The nurse documented she cleansed both wounds with soap and water. She documented she applied Aquacel AG and a Mepilex dressing to the right outer heel and applied a non-adherent dressing to the right posterior arm. The nurse did not document applying either the Transderm dressing or an occlusive transparent dressing to the wound. The visit, dated 5/6/22, lacked documentation the nurse performed wound care to the right outer heel. g. The clinical record included documentation of physician orders, dated 5/10/22, to discontinue would care to the right outer heel and right elbow skin tear. h. A skilled nursing visit, dated 5/10/22, included documentation the nurse cleansed the right outer heel wound and right posterior arm wound with soap and water. She documented the measurements of both wounds and documented she left both wounds open to air. i. The skilled nursing visits, dated 5/17 and 5/24/22, included documentation the nurse measured and continued to cleanse the right outer heel wound with soap and water. The clinical record continued to lack an order for cleansing the wound. j. A skilled nursing visit, dated 5/31/22, included documentation the patient had a wound to the left anterior medial leg. The nurse documented she measured and cleansed both the left anterior leg wound and right outer heel wound with soap and water. The nurse documented she applied a transparent, occlusive dressing to the left anterior medial leg wound. k. The clinical record included documentation of physician orders, dated 5/31/22, to apply a Transderm dressing to the left lower leg skin tear, change as needed, otherwise leave in place until healed and an order to apply Aquacel AG to the coccyx area for preventative care and change 2 times per week and as needed. The orders did not include directions for cleansing the wounds. l. The IDG meeting, dated 6/7/22, included IDG orders for the hospice aide to apply Aquacel AG to the coccyx area for preventative care and change 2 times per week and as needed and a effective date of 5/31/22. m. A skilled nursing visit note, dated 6/7/22, included documentation the patient had 2 open areas on bilaterally on the coccyx. She documented she measured the coccyx wounds and right outer heel wound and cleansed the wounds with soap and water. She documented she applied Calmoseptine cream and an Aquacel foam dressing. n. The clinical record included documentation of a physician order, dated 6/7/22, to change wound care to the coccyx to Aquacel AG dressing with Calmoseptine 2 times per week and as needed. The wound care order did not include an order to cleanse the wound. o. The hospice aide visit notes, dated 6/9, 6/10, 6/13, 6/14, 6/16 and 6/17/22, included documentation the hospice aide continued to complete the task of applying Aquacel AG to the coccyx for preventative care. The hospice RN failed to update the hospice aide assignment to reflect the current physician order. p. A skilled nursing visit note, dated 6/13/22, included documentation the nurse measured and cleansed the bilateral coccyx wounds, left lower anterior leg wound and right outer heel wound with soap and water. She documented applying Calmoseptine and Aquacel AG to the coccyx wounds per orders. On 6/21/22 at 3:50 PM, during an interview, Staff B, Patient Care Coordinator (Clinical Manager), explained when the patient had wound care orders to the right outer heel for 2 times per week and as needed, she only performed wound care one time per week and the family did wound care the other time. She reported she should have updated the hospice aide assignment when the wound care order changed on 6/7/22. She explained the hospice should not have been doing wound care to the coccyx once it was no longer preventative. She reported she did take it off the hospice aide assignment on 6/17/22. On 6/21/22 at 4:14 PM, during an interview, Staff D, Hospice Aide, reported she continued to apply the Aquacel AG to the coccyx wounds after 6/7/22, but the family helped with cares and the family applied the Calmoseptine. 4. Patient #2 had a hospice admission date of 1/14/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Interdisciplinary Group meeting note, dated 6/7/22, included interim physician order, dated 5/30/22, to change treatment to left upper back skin tear to cleanse with wound cleanser and cover with a mepilex dressing 3 times a week and as needed. b. Skilled nurse visit notes, dated 6/8/22 and 6/15/22, included documentation left upper back skin tear cleansed with soap and water. The skilled nurse failed to follow the order to cleanse wound with wound cleanser. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 2 of 2 sampled hospice aides (Staff D and H) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a 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 8 sampled patients who required an extra skill task to be performed (Patients #4 #7 and #11). 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 Services, dated 3/2022, the Hospice Aide's supervising Clinical Manager will be responsible to maintain documentation regarding appropriate annual inservice training and any specific skills taught to the Hospice Aide as assigned to provide patient cares. During an interview on 6/22/22 at 2:30 PM, the Hospice Aide Supervisor stated she could not locate further documentation of the extra skills. 1. Patient #4 had a hospice admission date of 2/8/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plans of care (POC's), dated 4/9/22 to 6/7/22 and 6/8/22 to 8/6/22, included interdisciplinary group (IDG) orders for skilled nursing and hospice aide services. The POC included instructions for the hospice aide to complete the task of trimming and filing the patient's toenails every visit. b. The local coverage determination document (LCD) completed by the RN, dated 6/6/22, identified the patient had a diagnosis of diabetes mellitus. Review of the clinical record revealed Staff H, Hospice Aide, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #4. a. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of trimming and filing the patients's toenails. b. Staff H, Hospice Aide, had a hire date of 10/4/2004. Staff H's personnel file included documentation a RN had observed Staff H competently perform the task of Diabetic Foot Observation and Care. The instruction included to file nails as needed. (If nails need to be cut, have the client see podiatrist or notify RN) Staff H's personnel file lacked documentation a RN had observed Staff H competently perform the task of trimming a diabetic patients toenails. 2. Patient #7 had a hospice admission date of 4/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/26/22 to 7/24/22, included Interdisciplinary (IDG) orders for skilled nursing and hospice aide services. The POC included instructions for the hospice aide to complete the task of trimming and filing the patient's toenails every visit. b. The comprehensive assessment completed by the RN, dated 4/26/22, identified the patient had a diagnosis of diabetes. Review of the clinical record revealed Staff H, Hospice Aide, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #4. a. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of trimming and filing the patients's toenails. b. Staff D, Hospice Aide, had a hire date of 8/2/2016. Staff D's personnel file lacked documentation a RN had observed Staff D competently perform the task of Diabetic Foot Observation and Care or trimming a diabetic patient's toenails. 3. Patient #11 had a hospice admission date of 4/4/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/8/22 to 7/2/22, included IDG orders for skilled nursing and hospice aide services. The POC included instructions for the hospice aide to complete the task of trimming and filing the patient's toenails every visit. b. The LCD completed by the RN, dated 4/8/22, identified the patient had a diagnosis of diabetes mellitus. Review of the clinical record revealed Staff H, Hospice Aide, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #4. a. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of trimming and filing the patients's toenails. b. Staff D, Hospice Aide, had a hire date of 8/2/2016. Staff D's personnel file included documentation a RN had observed Staff H competently perform the task of Diabetic Foot Observation and Care or trimming and filing a diabetic patient's toenails. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the registered nurses developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 3 of 8 sampled patients receiving hospice aide services. (Patients #7, #8 and #11). Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk hospice patients did not receive the services to meet each patient's assessed needs. Findings include: According to the hospice policy titled Home Health Aide Services, dated April 2022, home health aides are assigned to a specific patient by a Registered Nurse. Home health aide services provided are included in the plan of care. During an interview on 6/21/22 at 10:22 AM, the Patient Care Coordinator stated the admission nurse completes the hospice aide care plan. 1. Patient #11 had a hospice admission date of 4/4/22 and date of death of 4/19/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: Clinical record review revealed hospice aide care plan, dated 4/4/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included nail care. The care plan failed to include specific instructions regarding what nail care included. 2. Patient #7 had a hospice admission date of 4/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/22 to 7/24/22, included Interdisciplinary (IDG) orders for skilled nursing and hospice aide services. The POC included instructions for the hospice aide to complete the task of trimming and filing the patient's toenails every visit. The comprehensive assessment completed by the RN, dated 4/26/22, identified the patient had a diagnosis of diabetes. The POC included a task for the hospice aide to trim nails on a diabetic's patient's toe nails and did not identify the patient had a diagnosis of diabetes to ensure the hospice aide was aware of the patient's condition (trimming diabetic toe nails requires special care and training above that of a hospice aide). b. The POC included IDG instructions for the hospice aide to assist the patient with bathing, oral care, nail care, dressing, assisting to the toilet or bedside commode, shaving, transfers, positioning, ambulating, incontinent care and skin care. The POC lacked any instruction for the hospice aide to assist the patient with shampooing hair. The hospice aide visit notes, dated 4/28, 5/3, 5/6, 5/10, 5/13, 5/17, 5/20, 5/24, 5/27, 5/31, 6/3, 6/7, 6/9, 6/10, 6/13, 6/14, 6/17 and 6/20/22, lacked documentation Staff D, Hospice Aide, assisted the patient with shampooing hair. c. The IDG meeting, dated 6/7/22, included an interim physician order, dated 5/31/22, to apply Aquacel AG dressing for preventative care to the coccyx 2 times per week and as needed. The IDG meeting included instructions for the hospice aide to apply the Aquacel AG dressing starting 5/31/22. 1) A skilled nursing visit note, dated 6/7/22, included documentation the nurse assessed the patient had 2 open wounds bilaterally to the coccyx. She documented she applied Calmoseptine cream and an Aquacel dressing. 2) An interim physician order, dated 6/7/22, included an order to change the treatment to the coccyx wound to Calmoseptine and Aquacel foam dressing 2 times per week and as needed. 3) The hospice aide visit notes, dated 6/7, 6/9, 6/10, 6/13, 6/14, 6/16 and 6/17/22, continued to include the same IDG instructions to the hospice aide to apply the Aquacel AG dressing for preventative care, but lacked any instructions regarding applying the Calmoseptine. Staff D, Hospice Aide, documented she completed the task of applying the Aquacel AG dressing each visit. On 6/21/22 at 3:50 PM, during an interview, Staff B, Patient Clinical Coordinator (Clinical Manager), reported she should have taken the task off the hospice aide's assignment for treatment to the coccyx once the wound opened and the treatment was no longer preventative. She explained she had taken it off the assignment now, but realized she had done this late. On 6/21/22 at 4:14 PM, during an interview, Staff D, Hospice Aide, reported she had applied a shampoo cap to the patient's hair every visit and the patient loved it. She reported she was only applying the Aquacel dressing every visit since assigned, not the Calmoseptine. She reported the family helps with the patient's cares and they took care of applying the Calmoseptine. On 6/22/22 at 11:27 AM, during an interview, Staff B, Patient Clinical Coordinator (Clinical Manager), confirmed the patient was diabetic. She also reported being unaware the task to shampoo should have been on the hospice aide's assignment and she was unaware it was not. 3. Patient #8 had a hospice admission date of 5/9/22, death date of 5/21/22 and received hospice services while residing in a private residence. Clinical record review revealed hospice aide care plan, dated 5/9/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included nail care. The care plan failed to include specific instructions regarding what nail care included. The Administrator and Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided services as ordered by the Interdisciplinary Team according to an individualized plan of care for 7 of 8 sampled patients who received hospice aide services (Patients #3, #4, #5, #6, #7, #8 and #11). 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: According to the hospice policy titled Home Health Aide Services, dated April 2022, home health aides are assigned to a specific patient by a Registered Nurse. Home health aide services provided are ordered by the physician and included in the plan of care. During an interview on 6/21/22 at 10:22 AM, the Patient Care Coordinator stated the hospice aide are to document and notify the nurse if they are not able to complete a task and notify the nurse if a task is required prior to completing if it is not on the care plan. 1. Patient #4 had a hospice admission date of 2/8/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plans of care (POC), dated 4/9/22 to 6/7/22 and 6/8/22 to 8/6/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 2/8/22, included the following assignments to occur: assist with positioning, recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, offer fluid intake, change adult diapers, incontinent care, gentle body massage, change patient linen, assist patient with dressing, bed bath, shave, skin care, fall precautions and standard precautions. c. The aide visit notes, dated 4/21, 5/4, 5/11, 5/18, 5/25, 6/1, 6/8 and 6/15/22, failed to include documentation the following tasks completed or addressed as the reason for omission: transfer to bed/gerichair with assistance, change patient linen and shaving. The aide failed to follow the care plan as written. 2. Patient #6 had a hospice admission date of 2/16/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC's, dated 2/16/22 to 5/16/22 and 5/17/22 to 8/14/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 2/8/22, included the following assignments to occur: assist with positioning, recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, catheter care, change adult diapers, empty foley catheter, incontinent care, gentle body massage, heel protectors and blanket lifter to bed, clean shower room and/or patient room, make patient bed, assist patient with dressing, bath-shower chair. Okay to do sponge bath if patient doesn't want to shower, encourage to wear glasses/hearing aide, nail care, oral care, shampoo, skin care and standard precautions. c. The aide visit note, dated 4/21/22, failed to include documentation the following tasks completed or document the reason for omission: transfer to bed/gerichair with assistance, recognize and report any changes in the patients skin condition, transfer to bed/gerichair with assistance, heel protectors and blanket lifter to bed, assist with dressing and shampoo. d. The aide visit note, dated 5/4/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, heel protectors and blanket lifter to bed, make patient bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care. e. The aide visit note dated 5/11/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, heel protectors and blanket lifter to bed, clean shower room and/or patient room, make patient bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care, shampoo. f. The aide visit note dated 5/18/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, catheter care, change adult diapers, empty foley catheter, heel protectors and blanket lifter to bed, make patient bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care. g. The aide visit note dated 5/25/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, empty foley catheter, heel protectors and blanket lifter to bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care. h. The aide visit note dated 6/1/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, change adult diapers, heel protectors and blanket lifter to bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care. i. The aide visit note dated 6/8/22, failed to include documentation the following tasks completed or document the reason for omission: recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, empty foley catheter, heel protectors and blanket lifter to bed, assist patient with dressing, encourage to wear glasses/hearing aide. j. The aide visit note dated 6/15/22, failed to include documentation the following tasks completed or document the reason for omission: assist with positioning, recognize and report any changes in the patient's skin condition, transfer to bed/gerichair with assistance -use Hoyer lift, empty foley catheter, heel protectors and blanket lifter to bed, assist patient with dressing, encourage to wear glasses/hearing aide, oral care. The aide visit notes, dated 4/21, 5/4, 5/11, 5/18, 5/25, 6/1, 6/8 and 6/15/22, included documentation the aide performed the bath-shower chair-may have sponge bath if patient doesn't want a shower. The aide failed to document which bath had been completed. The aide failed to follow the care plan as written. 3. Patient #11 had a hospice admission date of 4/4/22 and date of death of 4/19/22 and received hospice services while residing in a private residence . Review of the clinical record revealed the following: a. The POC, dated 4/4/22 to 7/2/22, included orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 4/4/22, included the following assignments to occur: assist with positioning, transfer to bed/chair, up in chair/wheelchair, assist with toilet use, change adult diapers, incontinent care, change patient linen, clean bathroom after patient care, clean living area, make patient bed, assist patient with dressing, bath-shower chair-may have sponge bath per patient/family request, may trim or file any long or uneven finger nails, may trim or file any long or uneven toe nails, nail care, oral care, shampoo, shave, skin care, fall precautions and standard precautions. c. The aide visit notes, dated 4/5, 4/6, 4/8, 4/11 and 4/13/22, included documentation the aide performed the bath-shower chair-may have sponge bath per patient/family request. The aide failed to document which bath had been completed. 4. Patient #3 had a hospice admission on 3/29/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/29/22 to 6/26/22, included Interdisciplinary Group (IDG) orders for hospice aide services 2 times the first week and then 3 times per week. The POC included instruction to the hospice aide to complete the task of shower or sponge bath every visit. b. The hospice aide visit notes, dated 4/18, 4/20, 4/22, 4/25, 4/27, 4/29, 5/2, 5/4, 5/6, 5/9, 5/11, 5/13, 5/16, 5/18, 5/20, 5/23, 5/25, 5/27, 5/30, 6/1, 6/3, 6/6, 6/8, 6/10, 6/13, 6/15, 6/17 and 6/20/22, included documentation Staff D, Hospice Aide, completed both a shower and a sponge bath. On 6/21/22 at 4:14 PM, during an interview, Staff D, Hospice Aide, explained sometimes she would do a sponge bath and sometimes a shower with the patient. She reported she usually gave the patient a shower. She will give the patient a shower if the private duty caregiver is present to assist; otherwise, she will give the patient a sponge bath. The hospice aide documentation was inconclusive in identifying which assigned bath type the hospice aide performed for each of the visits. 5. Patient #5 had a hospice admission date of 2/9/22 and received hospice services from 2/9 to 4/4/22 while residing in an assisted living and then continued to receive hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 4/12, 4/26, 5/10 and 5/24/22, included instructions for the hospice aide to complete the tasks of a bed bath. b. The hospice aide visit notes, dated 4/13 and 5/19/22, included documentation the hospice aide assisted the patient with a shower. The visit note and clinical record lacked documentation the hospice aide received RN approval to provide a different bath type prior to performing the task. 6. Patient #7 had a hospice admission date of 4/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/22 to 7/24/22, included Interdisciplinary (IDG) orders for skilled nursing and hospice aide services. The POC included instructions for the hospice aide to complete the tasks of either showering or providing a sponge bath as the patient requests, ambulate the patient using assistive device (either walker or 2 person handheld assist with gait belt and weigh the patient if able. b. The hospice aide visit notes, dated 4/28, 5/3, 5/6, 5/10, 5/13, 5/17, 5/20, 5/24 and 5/27/22, included documentation Staff D, Hospice Aide, completed the task of either showering or providing a sponge bath, but failed to document which type of bath she completed. c. The hospice aide visit note, dated 4/28/22, included the documentation of "NA" by Staff D, Hospice Aide, for the assigned task of ambulating with the patient without explaining why the aide did not have to complete the task for this visit. The visit note lacked any documentation on the assigned task of weighing the patient. d. The hospice aide visit note, dated 5/3/22, included the documentation of "NA" by Staff D, Hospice Aide, for the assigned tasks of ambulating with the patient and weighing the patient without explaining why the aide did not have to complete the tasks for this visit. Staff D, Hospice Aide, did document assisting the patient to either the bedside commode or toilet. e. A skilled nursing visit note, dated 6/16/22, included documentation Staff B, Patient Care Coordinator (Clinical Manager), assessed the patient wanted and would benefit from range of motion. She informed the hospice aide of the need to do range of motion with the patient during the hospice aide visit that day. A hospice aide visit note, dated 6/16/22, lacked documentation the hospice aide completed the task of range of motion. On 6/21/22 at 4:14 PM, during an interview, Staff D, Hospice Aide, reported she did do range of motion on 6/16/22. She explained she was unable to document on tasks if they had not been added to her assignment (in the electronic system). She reported she had attempted to shower the patient during a visit, and it was unsuccessful. She reported doing a sponge bath with the patient every visit. She reported she had not been able to weigh the patient due to difficulties with the patient standing. 7. Patient #8 had a hospice admission date of 5/9/22, death date of 5/21/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 5/9/22 to 8/6/22, included orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 5/9/22, included instructions to the hospice aide to complete the tasks of assist with transfers and ambulation using gait belt, walker and 1-2 person assist; recognize and report any changes in the patient's skin condition; transfer to bed/chair with gait belt, walker and 1-2 person assist; assist to bedside commode/toilet with gait belt, walker and 1-2 person assist; catheter care; change adult diapers; empty foley catheter; incontinent care; gentle massage to hands, feet, arms, legs, back; clean patient care area after patient care; bath - bedside commode, if unable to get in shower or patient refuses, okay to do sponge bath; may trim or file any long or uneven finger nails; may trim or file any long or uneven toe nails; nail care; oral care; shampoo; shave - electric; skin care (lotion to back, legs, feet, arms, hands); fall precautions; oxygen precautions; standard precautions; and transfer belt. c. The hospice aide visit note, dated 5/11/22, failed to identify any tasks completed or reasons why the tasks were not completed. 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 review of written contractual agreements, the hospice failed to ensure the written agreement between the hospice and 2 of 2 sampled services under arrangement included all of the required contract components. The hospice reported a total of 2 written agreements for services under arrangement with individuals/companies at the time of the survey. Failure to include the required contract components 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: 1. A massage therapy contract, dated 4/12/22, failed to include the following contractual language: the hospice retains administrative management and all services are authorized by the hospice. 2. A durable medical equipment contract, dated 4/1/16, failed to include the following contractual language: all services are authorized by the hospice and delivered in accordance with the patient's plan of care. The Administrator 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 all entries completed in the clinical records included an appropriate date and signature and completed timely for 4 of 11 sampled patients (Patients #2, #4, #6 and #10). Failure to ensure all clinical record documentation included accurate information and were completed timely may result in ineffectively coordinated patient care. Findings include: During an interview on 6/20/22 at 10:22 AM the Patient Care Coordinator stated staff expected to complete documentation within 2 business days. 1. Patient #4 had a hospice admission date of 2/8/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. A hospice Aide visit note, dated 5/18/22, was signed as completed on 6/2/22, 10 business days after the visit date, exceeding the hospice expectation by 8 days. A hospice Aide visit note, dated 6/15/22, was signed as completed on 6/20/22, 3 business days after the visit date, exceeding the hospice expectation by 1 day. 2. Patient #6 had a hospice admission date of 2/16/22 and received hospice services while residing in a nursing home. Clinical record review revealed: A hospice Aide visit note, dated 6/15/22, was signed as completed on 6/20/22, 3 business days after the visit date, exceeding the hospice expectation by 1 day. 3. Patient #2 had a hospice admission date of 1/14/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Chaplain visit note, dated 4/21/22, was signed as completed on 4/26/22, 3 business days after the visit date, exceeding the hospice expectation by 1 day. b. Chaplain visit note, dated 5/17/22, was signed as completed on 6/1/22, 10 business days after the visit date, exceeding the hospice expectation by 8 days. 4. Patient #10 had a hospice admission date of 4/26/22, a death date of 5/4/22 and received hospice services while residing in a hospital. Clinical record review revealed: a. Skilled nurse visit note, dated 4/27/22, was signed as completed on 5/2/22, 3 business days after the visit date, exceeding the hospice expectation by 1 day. b. Skilled nurse visit note, dated 5/2/22, was signed as completed on 5/5/22, 3 business days after the visit date, exceeding the hospice expectation by 1 day. The Administrator and Patient Care Coordinator 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 policy review the hospice failed to ensure completion of a criminal background history check for 1 of 5 sampled employees (Staff G) who began serving hospice patients since their last survey, dated 8/8/19. The hospice reported hiring 7 employees, 1 contract staff and 1 volunteer 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: According to the hospice policy titled Criminal background/Abuse Medicare Fraud Check, dated 6/2021, The hospice will conduct a criminal record check. If no record found is indicated,, then they have passed the record check. If criminal history record is found, then the applicant may be required to complete page 2 of the record check evaluation form. If the form is completed, the form is sent back to Department of Human Services. The state determines whether the applicant is eligible for hire. Review of hospice personnel files revealed the following: Staff G, Massage Therapist, had a hire date of 3/17/2022. The Massage Therapist's personnel file included documentation of a criminal history check completed through SING, dated 9/22/2022, with a positive criminal history. The hospice failed to have the background check evaluated for employment by the Department of Human Services prior to employment with the hospice. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.