Every finding on record at Hospice Preferred Choice, Inc.

Upon patient record review, 4 of 19 (Patients #6, 9, 13, and 14) did not contain documented evidence that a Registered Nurse had been designated to ensure continuous assessment of the patient and family's needs: Patient #6: The 06/10/24 RN SOC assessment reflected, "Some redness on coccyx." On the next two subsequent SN visits (06/11 and 06/17/24) there was no documentation of the nurse having re-assessed for this area of concern. Patient #9: The 06/05/24 RN SOC assessment reflected, "Redness under breasts and in peri-area." On the next two subsequent SN visits (06/06 and 06/10/24) there was no documentation of the nurse having re-assessed for this area of concern. Patient #13: The 05/03/24 (Friday) RN SOC assessment reflected, "Pain of 5 moderate, with a patient goal of "0". Back pain is continuous." The nurse obtained a Physician order for multiple pain medication options. On (Saturday) 05/04/24, a Hospice nurse made a return home visit which reflected, "Pain of 4, with a revised patient goal of "2". The patient reported to the nurse that she had not been able to obtain the ordered pain medications. "H" Pharmacy was not able to access some of the ordered medications until (Monday) 06/06/24. The Hospice nurse contacted H Pharmacy and told them to cancel the previous order, and then contacted "W" Pharmacy to re-order those same pain medications. There was not documented evidence that a Hospice nurse had then re-contacted the patient on (Sunday) 06/05/24, in order to confirm that the patient had indeed obtained her needed pain medications, and pain status. Patient #14: A verbal order was obtained on 06/07/24 for, "May straight catheterize patient in order to obtain a UA." There was documentation of the Hospice RN and the SNF nurse discussing this need/order. However, there was not documented evidence of the Hospice having followed up to ascertain that a urine sample had been obtained, and forwarded to lab.

Upon patient record review, 1 of 19 (Patient #8) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #8: The RN SOC assessment reflected, "Implanted Vascular Access Device. (Not using)." However, this implanted port was not included on the initial Hospice POC.

Upon patient record review, 5 of 19 (Patients #5, 7, 8, 9, and 10) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: A detailed statement of both the scope and frequency of the services necessary to meet the specific patient and family needs: Patients #5, 7, 8, 9, and 10: The most recent IDG Plan(s) of Care for each of these patients contained a Chaplain entry of, "Chaplain services declined. Chaplain available as needed for visits per patient/family request". A PRN visit frequency is not allowable without a baseline frequency in place.

Upon patient record review, 1 of 19 (Patient #1) did not contain evidence that the Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: The SOC POC included a wound care order, "Cleanse with normal saline, apply xeroform gauze, then telfa, then Kerlix. No tape to skin. Change QD and PRN. SNF nurses can do on alternate days." There was no indication for such PRN dressing changes.

Upon patient record review 1 of 19 (Patient #12) did not contain evidence that a Registered Nurse had made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the Hospice aide, and to ensure that services ordered by the Hospice Interdisciplinary Group meet the patient's needs: Patient #12: An Aide supervisory visit was made on 05/13/14, and then not again until 05/29/2024.

Upon observation, there was not documented evidence that the Hospice's use of Volunteers, providing day to day administrative and/or direct patient care services, is an amount that at a minimum equals 5 percent of the total patient care hours of all paid Hospice employees and contract personnel. The Administrator provided their 2023 calendar-year Volunteer report, which totaled 1.72%.

Upon patient record review, 1 of 19 (Patient #5) did not contain evidence that all entries were clear, in accordance with the organizations policies and procedures and currently accepted standards of practice: Patient #5: The Physician CTI dated 06/27/24 reflected, "Oxygen 3 liters continuous." However, both the POC and the Medication Profile listed "Oxygen 2 liters continuous." This is unclear/conflicting documentation.

Upon patient record review, 1 of 19 (Patient #16) did not contain evidence that the Hospice had forwarded a Transfer Summary, and a copy of the patient record if requested, to the receiving Hospice when transferring the patient to such Hospice: Patient #16: Transferred to an other Hospice on 12/21/2023. There was not evidence that a transfer summary had been forwarded to that receiving Hospice.

Upon client record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #2: On 06/21/24 the Aide reported to the Hospice nurse, "Left armpit red and raw, skin peeling and sore." An order was obtained that same date for, "Left armpit excoriation. Apply antifungal topically BID." The next subsequent SN visit was not made until 06/25/24. The Hospice nurse documented, "Excoriation left armpit." There was no documentation that the Hospice nurse had care coordinated with the SNF nurse to ascertain that the SNF nurses had indeed been providing such BID treatment, nor how the area was progressing/not progressing toward healing over the past 4 days.

Upon patient record review, 1 of 19 (Patient #2) did not contain evidence that the Hospice Plan of Care identified the care and services that are needed, and specifically identify which provider (Nursing Facility or Hospice) is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care: Patient #2: On 06/21/24 the Aide reported to the Hospice nurse, "Left armpit red and raw, skin peeling and sore." An order was obtained for, "Left armpit excoriation. Apply antifungal topically BID." This order did not include 'who' would be providing such BID treatment, Hospice staff or SNF staff.

Upon personnel record review, 1 of 13 (Personnel #11) did not contain evidence of Criminal Background Checks having been obtained in accordance with Iowa State requirements: Personnel #11: DOH was 03/11/19, and she had worked for the Iowa-based Hospice location for the last 2-3 years, per the Regional VP OPS. There was no documented evidence that the Hospice had obtained/was in compliance with the following Iowa requirement: There is evidence in the personnel files (direct care personnel, contract direct care personnel, direct care volunteers and employees with access to patient protected information) for an Iowa Hospice agency of the following background checks, these checks must be performed within 30 days prior to employee's date of hire. If the employee has a break in employment, of any length of time (excluding vacations or illness while the employee maintains their employment), and later returns to the employer, the three required background checks must be repeated as if the employee was a brand new employee. If an employee received a conviction or has a founded abuse during their employment the employee is required to notify the employer within 48 hours of either occurrence. These checks must be done through the State of Iowa Single Information Repository (SING), or that the criminal background check is completed through the Iowa Dept. of Criminal Investigation (DCI,) and the abuse background checks be completed through the Iowa Dept. of Human Services (DHS): • Dependent adult abuse background check • Child abuse background check • Criminal background check

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure the hospice nurse member of the interdisciplinary team updated the comprehensive assessment with changes to the patient's condition at least once every 21 days and included wound assessment and measurements. (See L0533) --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and service needs in a timely manner to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to document process toward desired outcomes and reassessment of the patient's response to wound care by failing to document weekly wound measurement per agency policy for 4 of 4 sampled patients with an open wound (Patients #1, #2, #3 and #4). 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: --- According to the hospice policy titled The Provision of Wound and Skin Care, dated 1/20/22, in accordance with best practice and standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. The preferred day for measuring is the first visit of each week. Patients who are seen at a frequency of one time a week should have the wound measured at that visit. Interview on 3/7/23 at 4:06 PM, the Administrator stated our hospice nurse needs to visually see the wound every week with measurements completed on open wounds. Measurements should include width, length and depth. Any open wound requires depth measurements. Staff have a wound assessment tool to use for wounds. If a patient is in a facility wound cares may be done by the facility staff. 1. Patient #1 had a hospice admission date of 11/14/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 12/28/22, 1/11/23, 1/25/23, 2/9/23 and 2/23/23, included IDG orders for skilled nursing services 4 times per month. b. The skilled nurse visit note, dated 3/1/23, identified the patient had a stage 2 (shallow, crater-like wound or blister containing clear or yellow fluid) wound to the coccyx area that measured 0.5 centimeters (cm) length by 0.5 cm width by 0.2 cm depth. The wound had no exudate and surrounding skin color normal with no swelling or edema and no peripheral tissue induration. c. A skilled nurse visit, dated 3/7/23, included documentation the stage 2 coccyx wound measured 0.4 cm length by 0.4 cm width by 0 cm depth. The wound had no exudate and surrounding skin color normal with no swelling or edema and no peripheral tissue induration. The skilled nurse visit note failed to identify depth to the wound. d. During an interview on 3/8/23 at 2:10 PM Staff D, Registered Nurse (RN) confirmed she received wound measurement from the wound nurse at the nursing home and did not assess the wound herself. Hospice staff work with the nursing home wound nurse. Hospice staff also work with the corporate wound nurse and the corporate wound nurse instructed hospice staff; when a patient has an open wound it would have at least a 0.1 cm depth measurement. Staff D concurred the wound had depth that was not measured. 2. Patient #2 had a hospice admission date of 9/21/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 1/5/23, 1/11/23, 1/25/23, 2/9/23 and 2/23/23, included IDG orders for skilled nursing services of 2 time per week. b. The skilled nurse visit note, dated 1/4/23, identified the patient had a stage 3 (full-thickness skin loss extending into the subcutaneous tissue layer) wound to the coccyx that measured 0.3 cm length by 0.3 cm width by 0 cm depth. The skilled nurse visit note failed to identify depth to the wound. c. The skilled nurse visit notes, dated 1/16/23, 1/20/23, 1/24/23, 1/27/23, 1/30/23, 2/8/23, 2/10/23, 2/14/23, 2/20/23, 2/24/23, 2/27/23 and 3/3/23, identified the patient had a stage 3 wound to the coccyx but failed to include documentation of wound measurements. d. During an interview on 3/7/23 at 11:30 AM Staff E, RN stated the patient had improvement in the coccyx wound. She further stated the wound had some tunneling (formed passageways under the skin) noted which also had improved. This was observed during completion of the wound cares to the patient. The hospice failed to document progress toward desired outcomes and reassessment of the patients response to wound care by failing to document weekly wound measurements per agency policy. 3. Patient #3 had a hospice admission date of 1/11/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 2/2/23, 2/15/23 and 3/1/23, included IDG orders for skilled nursing services of 2 times per week. b. The skilled nurse visit note, dated 3/2/23, identified the patient had a wound to the right heel with eschar (dry dead tissue within a wound) noted, that measured 3 cm length by 3 cm width by 0 cm depth. The skilled nurse visit note failed to identify depth to the wound. 4. Patient #4 had a hospice admission date of 5/23/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 1/11/23, 1/25/23, 2/9/23 and 2/23/23, included IDG orders for skilled nursing services of 2 times per week. b. The skilled nurse visit note, dated 1/26/23, indicated the patient had a wound to the penis shaft that measured 2.5 cm length by 0.5 cm width by 0.1 cm depth. c. The skilled nurse visit notes, dated 1/30/23, 2/2/23, 2/7/23, 2/9/23, 2/13/23, 2/15/23, 2/20/23, 2/23/23, 2/27/23 and 3/2/23 lacked documentation of wound measurements. 3/8/23 at 2:10 PM Staff D, RN stated she doesn't always measure wounds and it depends on the type of wound the patient has. The patient's wound was kind of a tedious wound, and would come and go. Nursing home staff treat the wound with ointment. She measures pressure wounds but not wounds with excoriation. Staff D, RN stated it has been a while since she has seen his wound and she counts on facility nurses to complete assessments. The hospice failed to document progress toward desired outcomes and reassessment of the patients response to wound care by failing to document weekly wound measurements per agency policy. The above findings were reviewed with the Area Vice President of Clinical. No additional information provided prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure the hospice Interdisciplinary Group members collaborated and communicated to ensure hospice staff provided care and services in accordance with the Plan of Care (see L0555). --- 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 hospice policy review, clinical record review, and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 1 of 4 sampled patients (Patients #3). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: --- Review of the hospice's policy, titled Interdisciplinary Team, dated 8/1/22, the IDG review is part of the overall agency evaluation process and assists the agency in meeting patient care objectives by: providing a means for effective interchange, reporting and coordination of patient care, establishing and coordinating patient care goals and services being provided, identifying and reviewing the effectiveness of the plan of care in meeting established goals, providing for periodic review and update of the updated assessment/plan of care, determining the appropriateness of continuation of services, and review of patient scheduling, supplemental orders and unscheduled visits that impact the coordination of care. 1. Patient #3 had a hospice admission date of 1/11/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/11/23 to 4/10/23, included IDG orders for skilled nursing and hospice aide services 2 times per week and social services and chaplain services 1 time per month. b. The skilled nurse visit note, dated 1/17/23, revealed the hospice nurse to look into a tilt in space (tilting wheelchair for repositioning) wheelchair for patient comfort and better positioning. c. The physician's order, dated 1/30/23, included an order for a 1 time physical therapy visit for wheelchair positioning. d. The Physical therapy contract, dated 2/13/23, lacked signature and date of the physical therapy contract. e. The skilled nurse visit note, dated 2/20/23 at 2:58 PM revealed the patient had a right heel, unstageable wound. The wound measured 4 centimeters (cm) length by 2.8 cm width by 0.5 cm depth. No exudate and skin color surrounding the wound normal. Orders include to paint the wound with betadine twice daily and leave open to air. f. The physician's order, dated 2/20/23, included an order to cleanse right heel wound with normal saline, apply betadine twice a day and apply a gauze dressing to the wound. g. The physicians order, dated 2/27/23, included an order to paint the right heel wound with betadine 2 times a day, and leave open to air. h. The skilled nurse visit note, dated 3/2/23, identified the patient had a wound to the right heel that measured 3 cm length by 3 cm width by 0 cm depth with eschar (dry dead tissue within a wound) noted. i. During an interview on 3/7/23 at 4:06 PM, Staff A, Administrator stated the hospice did have Contracts with therapy. She further stated the hospice needed to do a 1 time therapy visit for patient #3, for wheelchair positioning as the wheelchair not fitting well. The therapy company that hospice had a contract with had a contract that was outdated, and the hospice needed to get a new one. j. The IDG meeting notes, dated 2/1/23, 2/15/23 and 3/1/23, lacked documentation of IDG member awareness of the order for physical therapy services. The clinical record lacked documentation of a physical therapy assessment. The hospice failed to coordinate services for the physical therapy assessment for wheelchair positioning per Patient #3's plan of care. The above findings were reviewed with the Area Vice President of Clinical. No additional information provided prior to the end of the survey.