Every finding on record at Ida County Iowamcommunity Hospice

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure updates to the plan of care and the services provided to the patients were according to assessed needs and team decisions established on the plans of care.  The survey identified this concern with 2 of 14 sampled patients. (Patients #9 and #12). Failure of the hospice team members to accurately update the plan of care and collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. Findings include: --- 2. Patient #12 had a start of care date of 6/13/24, a death date of 7/30/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 6/13/24 to 9/10/24, identified the patient had a diagnosis of Congestive heart failure and included physician orders for skilled nursing, social worker, hospice aide and chaplain services.    b. Review of the electronic medical record revealed a lack of chaplain services in the month of June.    c. The IDG meeting notes, dated 6/24/24 and 7/8/24 lacked any documentation regarding missed chaplain visits.    The hospice failed to collaborate with the IDG and update the POC based on services provided.    The above findings were reviewed with the Administrator and Clinical Manager.    According to the hospice policy, titled Interdisciplinary Care Conference Update Meeting, last revised 12/2024, identified the team will review the following information if pertinent to the patient: patient information, contact information, medical information, service information, admission status, level of care, education profile, care plan, diagnosis codes, orders, anthropometric, height and weight, infections, prep notes, symptom assessment, additional notes, wounds and assignments. 1.  Patient #9 had a hospice admission date of 3/14/24 and date of death of 5/31/24 and received hospice services while residing in a private residence.  Clinical record review revealed: a.  The Plan of Care (POC), dated 3/14/24 to 6/11/24, identified the patient had a daignosis of liver cancer and included physician orders for skilled nursing, social worker and hospice aide services. b. The skilled nursing note, dated 4/18/25, included documentation the patient received massage therapy services. c. Review of the massage therapy notes, dated 4/12/25, 5/1/25 and 5/22/25, revealed massage therapy services provided for the patient. d. Review of the electronic medical record revealed a lack of a physician's order for massage therapy services.  e. The interdiciplinary group (IDG) notes, dated 4/1, 4/15, 4/29/25, 5/13 and 5/17/25, lacked orders for massage therapy services. f. During an interview on 5/19/25 at 3:05 PM, Staff H, Registered Nurse (RN) stated she did not write an order for the massage therapy services. The hospice failed to include orders for ancillary services for the patient.

Based on clinical record reviews and policy reviews, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 2 of 2 sampled bereavement records (Patients #13 and #14).    Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief.    Findings include: --- 2. Patient #14 had a start of care date of 2/17/25, and date of death of 4/23/25 and received hospice services while residing in a private residence.  Review of the clinical record revealed:  a. A bereavement post death form was completed and identified the spouse of Patient #14 as the bereaved.   b. The post death form identified a sympathy card and funeral flowers had been sent to the bereaved but lacked documentation of any direct contact with the bereaved. The hospice failed to complete a bereavement risk assessment and failed to develop a plan of care with the bereaved following the death of the patient. The above findings reviewed with the Administrator and Clinical Manager. According to the policy titled Bereavement Referral/Contact, dated 7/2024, the hospice Bereavement Coordinator is responsible for initiating the bereavement contact form.  An assessment of the bereaved will be made by a hospice Registered Nurse (RN), social worker or other Interdisciplinary Group (IDG) member shortly following the death of the hospice patient.  The bereavement contact form may be used at IDG meetings to help develop a plan of care for assisting the bereaved family members.    According to the hospice policy titled Bereavement Risk Assessment, dated 7/2024, the hospice Social Worker or Bereavement Coordinator will document a baseline assessment identifying the applicable factors as risks or strengths to ensure survivors of hospice patients have a comprehensive and uniform assessment of risk factors.  These factors are to be assessed on an initial visit, at the first recertification and again after the patient dies.    1.Patient #13 had a start of care date of 7/30/24, a death date of 9/16/24 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. A bereavement post death form was completed and identified the wife of Patient #13 as the bereaved.    b. The post death form identified a sympathy card and quarterly mailings had been sent to the bereaved but lacked documentation of any direct contact with the bereaved.  The hospice failed to complete a bereavement risk assessment and failed to develop a plan of care with the bereaved following the death of the patient.

Based on clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient's needs for 1 of 3 sampled patients with Alzheimer's disease receiving hospice aide services (Patient #6).    Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task leads to the potential risk that patients may fail to receive necessary services ordered on the plan of care.    Findings include: --- According to the hospice policy titled Home Care Aide Plan of Care, dated 4/2024, the admitting registered nurse (RN) is responsible for completing the home care aide plan of care.  The RN selects patient specific interventions for the cares assigned and identifies the frequency of cares assigned (not per request needed).    Patient #6 had a start of care date of 2/11/25, a death date of 3/8/25 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:   a. The Plan of Care (POC), dated 2/11/25 to 5/11/25, included orders for aide services 5 times a month for 1 month and 8-9 times a month for 2 months.   The POC identified the patient had a diagnosis of Alzheimer's Disease.    b. The undated aide assignment sheet included aide instructions to perform incontinent care per patient request and give a sponge bath or whirlpool bath per patient request.    c.  The start of care assessment dated 2/11/25, completed by Staff H, RN, identified the patient had Alzheimer's disease, oriented to person only, described patient thought processes as "word salad" and noted the patient was very confused with irrelevant replies to RN.    The hospice RN failed to include patient specific instructions with specific frequencies of cares based on patient's needs.    The above information was reviewed with the Administrator and Clinical Manager.

Based on clinical record reviews, 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 6 of 10 sampled patients receiving hospice aide services. (Patients #1, #2, #4, #6, #7 and #10).  Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients' personal care needs were not adequately met. Findings include: --- 5. Patient #2 had a start of care date of 4/23/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/23/25 to 7/21/25, identified the patient had diagnoses of Malignant neoplasm and secondary malignant neoplasm of bone.  The POC included orders for skilled nursing, social worker, hospice aide and volunteer services.    b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task of obtain vital signs (temperature, pulse, respirations, blood pressure) one time per week.  c. The hospice aide visit note, dated 4/25/25, signed completed by Staff E, lacked documentation of the patient's vital signs and documented not applicable.    The hospice aide failed to complete the vital signs task as instructed by the RN assignment.    6. Patient #6 had a start of care date of 2/11/25, a death date of 3/8/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/11/25 to 5/11/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nursing, social worker and hospice aide services.    b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of sponge bath or whirlpool bath.    c. The hospice aide visit notes, dated 2/18/25, 3/4/25 and 3/7/25, signed completed by Staff G, lacked documentation of the specific task completed; sponge bath or whirlpool bath.    d. The hospice aide visit note, dated 2/21/25, signed completed by Staff F, lacked documentation of the specific task completed; sponge bath or whirlpool bath.    e. The hospice aide visit note, dated 2/25/25, signed completed by Staff E, lacked documentation of the specific task completed; sponge bath or whirlpool bath.    The hospice aide failed to identify the specific services provided as instructed by the RN assignment.    The above findings were reviewed with the Administrator and Clinical Manager.    According to the aide care plan, titled Home Care Aide Plan of Care, last revised, 4/2024, the home care aide plan of care will be doveloped by the RN at admission or if a home care aide is ordered during the care. The RN will select patinet specific interventions for the cares assigned and fill in the frequency of cares assigned. The home health aide will complete documentation during the time of the visit at the patiet's place of residency within the patinet's electronic medical record. The home health aide will report to the case manager if a task assigned is not completed or if a visit is missed.  During an interview on 5/13/25 at 9:32 AM, the Clinical Manager stated the RN case manager is responsible for creating the aide care plan. The aide documents if the patient refuses. If the refusal becomes an every visit type of situation, the aide needs to notify the nurse and document that the communication occured. 1. Patient #1 had a hospice admission date of 7/25/24 and received hospice services while residing in a nursing home.  Clinical record review revealed: a. The plans of care (POC's), dated 1/21/25 to 3/21/25 and 3/22/25 to 5/20/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nursing, social worker and hospice aide services. b.  The undated hospice aide care plan,  included RN instructions to the hospice aide to perform the tasks of assist with a bed bath or sponge bath every visit. c.  The hospice aide visit note, dated 3/11, 3/14/25 and 4/29/25, Staff E, Hospice Aide, lacked documentation the specific task completed, a bed bath or sponge bath. d. The hospice aide visit note, dated 5/9/25, Staff I, Hospice Aide, lacked documentation the specific task completed, a bed bath or sponge bath. The hospice aide failed to identify the specific services provided as instructed by the RN assignment. 2. Patient #4 had a hospice admission date of 3/12/24 and date of death of 1/21/25 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC's, dated 11/7/24 to 1/5/25 and 1/6/25 to 3/625, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nursing, social worker and hospice aide services. b.  The undated hospice aide care plan,  included RN instructions to the hospice aide to perform the tasks of assist with a spone bath or shower bath every visit or may do a whirlpool per patient request. c.  The hospice aide visit note, dated 1/7, 1/20 and 1/21/25, Staff E, Hospice Aide, lacked documentation the specific task completed, a bed bath or sponge bath. d. The hospice aide visit note, dated 1/13/25, Staff I, Hospice Aide, documented a whirlpool bath and sponge bath or shower "done". The note lacked documentation the specific task completed, a sponge bath, shower or whirlpool bath. The hospice aide failed to identify the specific services provided as instructed by the RN assignment. 3. Patient #7 had a hospice admission date of 5/8/24 and date of death of 7/29/24 and received hospice services while residing in a nursing home.  Clinical record review revealed: a. The POC's, dated 5/8/24 to 7/6/24 and 7/7/24 to 9/4/24, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nursing, social worker and hospice aide services. b.  The undated hospice aide care plan,  included RN instructions to the hospice aide to perform the tasks of measure the patinet's blood pressure 1 time a week. c.  The hospice aide visit note, dated 7/9/24, Staff E, Hospice Aide, lacked documentation of the patient's blood pressure and documented blood pressure already done for the week. d. The hospice aide visit note, dated 7/12/24, Staff G, Hospice Aide, lacked documentation of the patient's blood pressure and documented the blood pressure "not applicable". The hospice aide failed to complete the blood pressure task as instructed by the RN assignment. 4. Patient #10 had a hospice admission date of 10/11/24 and date of death of 11/23/24 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The POC, dated 10/11/24 to 1/8/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nursing, social worker and hospice aide services. b.  The undated hospice aide care plan, included RN instructions to the hospice aide to perform the tasks of measure the patient's blood pressure 1 time a week. c.  The hospice aide visit note, dated 10/15/24, Staff E, Hospice Aide, lacked documentation of the patient's blood pressure and documented blood pressure already "not applicable ". d. The hospice aide visit note, dated 7/12/24, Staff G, Hospice Aide, lacked documentation of the patient's blood pressure and failed to documented the reason the blood pressure not measured. The hospice aide failed to complete the blood pressure task as instructed by the RN assignment.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 2 of 3 sampled patients with ancillary services (#5 and #9). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up to date information related to the patient's condition, and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: --- 2. Patient #5 had a start of care date of 2/19/24, a death date of 5/13/24 and received hospice services while residing in a private residence.  Review of the clinical record revealed:   a. The POC, dated 2/19/24 to 5/18/24, identified the patient had a diagnosis of Kidney cancer and included orders for skilled nursing and social work services.    b. The Interdisciplinary Group (IDG) meeting notes, dated 3/18/24, identified Massage therapy to visit 1-2 times a month for 75 days, effective 3/5/24.    c. The skilled nurse visit note, dated 3/22/24, included documentation the patient received massage therapy services earlier in the week.    d. On 5/13/25, review of the electronic medical record revealed a lack of visit notes for massage therapy services.    e. On 5/19/25, review of the electronic medical record revealed visit notes, dated 3/5/24, 3/19/24 and 4/11/24, scanned to the electronic medical record on 5/15/25.  The hospice staff failed to include documentation of massage therapy notes into the clinical record.    The above findings were reviewed with the Administrator and Clinical Manager.    According to the hospice policy, titled Filing Patient Information, last revised 7/2024, when patinet information is rceived in the office, it will be given to the administrative assistant in the front office. The administrative assistant will file in a timely manner of 1 to 2 times per week. During an interview on 5/19/25 at 3:00 PM the Clinical Manager stated the Massage therapist had the documentation. She further stated the notes may have been emailed to the office at an earlier date but failed to be uploaded into the clinical record. 1.  Patient #9 had a hospice admission date of 3/14/24 and date of death of 5/31/24 received hospice services while residing in a private residence.   Review of the clinical record revealed the following: a.  The plan of care (POC), dated 3/14/24 to 6/11/24, identified the patient had a diagnosis of liver cancer and included orders for skilled nursing, social worker and hospice aide services. b. The skilled nurse note, dated 4/18/24, included documentation the patient received massage therapy services. c.  On 5/14/25, review of the electronic medical record revealed a lack of visit notes for massage therapy services.  d. On 5/19/25, review of the electronic medical record revealed visit notes, dated 4/12/24, 5/1/24 and 5/22/24, scanned to the electronic medical record on 5/16/25 (after notified by the surveyor). The hospice staff failed to include documentation of massage therapy notes into the clinical record.

Based on staff interview, clinical record reviews and agency policy reviews, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 7 of 14 sampled patients (Patients #1, #3, #5, #7, #9, #11 and #14).    Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients.    Findings include: --- 4. Patient #1 had a start of care date of 7/25/24, and received hospice services while residing in a nursing home.  Clinical record review revealed the following:  a. The POC, dated 3/22/25 to 5/20/24, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker and hospice aide services.  b. The skilled nursing visit note, dated 5/8/24, completed and signed 5/16/25 by the Staff C, RN, 8 days after the visit and 5 days late (per agency policy).   The hospice failed to ensure timely completion of all documentation.   5. Patient #7 had a start of care date of 5/8/24, a date of death of 7/29/24 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:  a. The POC, dated 7/7/24 to 9/4/24, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker and hospice aide services.  b. The social worker narrative note, dated 7/11/24, completed and signed 7/23/24 by the social worker, 7 days after the visit and 4 days late (per agency policy).   c. The social worker narrative note, dated 7/12/24, completed and signed 7/23/24 by the social worker, 6 days after the visit and 3 days late (per agency policy).   The hospice failed to ensure timely completion of all documentation.   6. Patient #9 had a start of care date of 3/14/24, a death date of death of 5/31/24 and received hospice services while residing in a private residence.  Clinical record review revealed the following:  a. The POC, dated 3/14/24 to 6/11/24, identified the patient had a diagnosis of liver cancer and included orders for skilled nurse, social worker, hospice aide and massage therapy services.  b. The massage therapy visit note, dated 4/12/24, completed by Staff L, Massage Therapist, lacked a signature with a full name and title of clinician completing the visit note.  The hospice failed to ensure appropriate authentication of all documentation.   7. Patient #14 had a start of care date of 2/17/25, a death date of death of 4/23/25 and received hospice services while residing in a private residence.  Clinical record review revealed the following:  a. The POC, dated 2/17/25 to 5/17/25, identified the patient had a diagnosis of lung cancer and included orders for skilled nurse and social worker services.  b. The massage therapy visit notes, dated 2/20/25, 3/11 and 3/25/25 completed by Staff L, Massage Therapist, lacked a signature with a title of clinician completing the visit note.  The hospice failed to ensure appropriate authentication of all documentation.   The above findings were reviewed with the Administrator and Clinical Manager. According to the agency policy titled Timely Documentation, dated 12/2024, documentation for nursing and therapy visits will be completed no later than 72 hours following the visit.    According to the agency policy titled Signature Log, dated 7/1998, the signature of each person who documents in the medical record shall be identified with the individuals name, either typed or legibly printed and their credentials.    During an interview on 5/13/25 at 9:32 AM, the Clinical Manager identified staff have 72 hours to complete daily documentation and 5 days to complete an initial comprehensive assessment.    1.Patient #3 had a start of care date of 7/17/23, a discharge date of 7/3/24 and received hospice services while residing in a private residence.  Clinical record review revealed the following:   a. The Plan of Care (POC), dated 5/12/24 to 7/10/24, identified the patient had a diagnosis of Respiratory cancer and included orders for skilled nurse and social worker services.   b. The skilled nurse visit note, dated 5/23/24, completed and signed 5/29/24 by Staff C, Registered Nurse (RN), 6 days after the visit and 3 days late (per agency policy).    c. The skilled nurse visit note, dated 7/1/24, completed and signed 7/9/24 by Staff B, RN, 8 days after the visit and 5 days late (per agency policy).    d. The skilled nurse visit note, dated 7/3/24, completed and signed 7/9/24 by Staff B, RN, 6 days after the visit and 3 days late (per agency policy).   The hospice failed to ensure timely completion of all documentation.    2. Patient #5 had a start of care date of 2/19/24, a death date of 5/13/24 and received hospice services while residing in a private residence.  Clinical record review revealed the following:   a. The POC, dated 2/19/24 to 5/18/24, identified the patient had a diagnosis of Kidney cancer and included orders for skilled nurse, social worker and massage therapy services.   b. The massage therapy visit note, dated 3/5/24, completed by Staff L, Massage Therapist, lacked a signature with full name and title of clinician completing the visit note.    c. The massage therapy visit note, dated 3/19/24, completed by Staff L, Massage Therapist, lacked a signature with full name and title of clinician completing the visit note.      d. The massage therapy visit note, dated 4/11/24, completed by Staff L, Massage Therapist, lacked a signature with full name and title of clinician completing the visit note.  The hospice failed to ensure appropriate authentication of all documentation.    3. Patient #11 had a start of care date of 7/24/24, a death date of 7/31/24 and received hospice services while residing in a nursing home.  Clinical record review revealed the following:   a. The POC, dated 7/24/24 to 10/21/24, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, hospice aide and social worker services.   b. The skilled nurse visit note, dated 7/25/24, completed and signed 7/29/24 by Staff C, RN, 4 days after the visit and 1 day late (per agency policy).    c. The skilled nurse visit note, dated 7/26/24, completed and signed 7/30/24 by Staff C, RN, 4 days after the visit and 1 day late (per agency policy).    d. The skilled nurse visit note, dated 7/27/24, completed and signed 8/2/24 by Staff H, RN, 6 days after the visit and 3 days late (per agency policy).    e. The skilled nurse visit note, dated 7/28/24, completed and signed 8/2/24 by Staff B, RN, 5 days after the visit and 2 days late (per agency policy).    The hospice failed to ensure timely completion of all documentation.

Based on clinical record review and agency policy review the hospice failed to ensure the hospice staff sent a copy of the patient's discharge summary to the attending physician for 1 of 1  sampled discharged patients (Patient #3) who was no longer terminally ill.    Failure to ensure the hospice staff included the attending physician in the process of discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patient.    Findings include: --- According to the agency policy titled Discharge Summary, dated 3/2024, the discharge summary will be completed upon discharge and faxed to the attending physician.  The discharge summary provides a patient-specific, comprehensive assessment that accurately reflects the patient's current health status.  A copy of the discharge summary will be stored in the patient's electronic medical record.  Patient #3 had a start of care date of 7/17/23, a discharge date of 7/3/24 (no longer terminally ill) and received hospice services while residing in a private residence.  a. The Plan of Care (POC), dated 5/12/24 to 7/10/24, identified the patient had a primary diagnosis of Respiratory cancer.  The POC included orders for skilled nursing services.   b. Clinical record review lacked documentation the discharge summary was forwarded to the patient's attending physician.   The above findings were reviewed with the Administrator and Clinical Manager.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 3 of 5 sampled employees (Staff I, J & K) who began serving hospice patients since their last survey, dated 6/15/22.  The hospice reported hiring 5 new staff since the last survey.   Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. --- Findings include:  According to the hospice policy titled Fraud, Waste and Abuse Screening and Evaluation of Employees and Agents, dated 6/2021, all individuals will undergo Office of the Inspector General (OIG), and the System of Award Management (SAM) background checks prior to hire.  Any individuals found to be the subject of current sanctions or have been convicted of other violations of criminal law shall not be hired or contracted without the express written approval of the Compliance Officer and after consultation with legal council. The screening will include any other legal names.   During an interview on 5/14/25 at 10:15 AM, the Administrator stated Staff I and Staff K had background checks completed when they previously worked at the hospital. Staff transferred to work for hospice.  1.  Staff I, Hospice Aide, had a hire date of 4/9/25.  A criminal background check was completed and dated 10/9/24. The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire. Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  2. Staff J, Chaplain, had a hire date of 6/1/23.  A criminal background check was completed and dated 8/21/23. The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  3. Staff K, Administrative Assistant, had a hire date of 8/23/23.  A criminal background check was completed and dated 2/8/22. he hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person to have access to the records of the hospice patients.   The above findings were reviewed with the Administrator.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 3 of 5 sampled employees (Staff I, J and K) who began serving hospice patients since their last survey, dated 6/15/22.  The hospice reported hiring 5 staff since the last survey.  Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. --- Findings Include : According to the hospice policy titled Fraud, Waste and Abuse Screening and Evaluation of Employees and Agents, dated 6/2021, all individuals will undergo Office of the Inspector General (OIG), and the System of Award Management (SAM) background checks prior to hire.  Any individuals found to be the subject of current sanctions or have been convicted of other violations of criminal law shall not be hired or contracted without the express written approval of the Compliance Officer and after consultation with legal council. The screening will include any other legal names.   During an interview on 5/14/25 at 10:15 AM, the Administrator stated Staff I and Staff K had background checks completed when they previously worked at the hospital. Staff transferred to work for hospice. 1.  Staff I, Hospice Aide, had a hire date 4/29/25.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 10/9/24.  The hospice failed to complete dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  2. Staff J, Chaplain,  had a hire date of 6/1/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 8/1/23.  The hospice failed to dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of Health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  3. Staff K, Administrative Assistant had a hire date of 8/28/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 2/8/22. The hospice failed to complete an additional dependent adult abuse child abuse check with the Iowa SING or the Iowa Department of Health within 30 days prior to the date of hire. Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  The above findings were reviewed with the Administrator.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure all members of the hospice Interdisciplinary Group completed a comprehensive assessment within 5 days after the patient's election of the hospice care for 7 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7). Failure of all members of the Interdisciplinary Group to complete a comprehensive assessment of the patient's condition increased the risk in the delay of identification and meeting of all the patient needs. Findings include: Review of the hospice policy, titled Initial Comprehensive and Recertification Assessment, dated 3/2022, revealed the Interdisciplinary Group (IDG) in consultation with the patient's attending physician will complete the comprehensive assessment no later that five calendar days after the patient elects the hospice benefit and updated at least every 15 days. The Social Worker is responsible for completion of the spiritual and bereavement assessment. The comprehensive assessment must identify the physical, psychosocial, emotional and spiritual needs related to the terminal illness. Review of the hospice policy, titled Hospice Clergy, dated 3/2022, identified the hospice Social Worker will complete the spiritual assessment within 5 days of the patient's admission to hospice and will make any necessary additions to the Plan of Care (POC). On 6/14/22 at 1:17 PM, during an interview, Staff D, Social Worker/Bereavement Coordinator, explained she is responsible for completing the bereavement risk assessment and care plan, survivor risk assessment, social history, spiritual assessment and social history for the patient and caregiver. She does not sign and date the documentation of these visits until after she reviews the documentation with Staff H, Masters in Social Work (MSW). She reported she usually completes documentation of the visit within 72 hours of the visit, but agreed there was no documentation to show this. She confirmed some of the forms she completed did not identify the date when the visit occurred, only the date when she reviewed the documentation with the MSW. 1. Patient #5 had a hospice admission date of 3/24/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The hospice forms, titled Social History, Caregiver Self-Assessment Questionnaire and Social Work Assessment Tool, all identified a visit date of 3/28/22 and included documentation of a discussion with the MSW by Staff D, Social Worker/Bereavement Coordinator, dated 3/30/22. The form did not include any other date to indicate when Staff D completed the documentation prior to 3/30/22. b. A hospice form, titled Spiritual Care Assessment, lacked documentation to identify when Staff D, Social Worker/Bereavement Coordinator, obtained the information from the patient and family. The form included documentation of a discussion with the MSW by Staff D, dated 3/30/22, but lacked any other date to indicate when Staff D completed the documentation. The Social Worker/Bereavement Coordinator failed to complete documentation of her part of the comprehensive assessment within the first 5 days after the patient elected the hospice benefit. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The hospice form, titled Caregiver Self-Assessment Questionnaire, with an identified visit date of 3/7/22, and the hospice forms, titled Social History and Social Work Assessment Tool, with an identified visit date of 3/10/22, included documentation of a discussion with the MSW by Staff D, Social Worker/Bereavement Coordinator, dated 3/18/22. The form did not include any other date to indicate when Staff D completed the documentation prior to 3/18/22. b. The hospice forms, titled Spiritual Care Assessment and Psychosocial Assessment, lacked documentation to identify when Staff D, Social Worker/Bereavement Coordinator, obtained the information from the patient and family. The form included documentation of a discussion with the MSW by Staff D, dated 3/18/22, but lacked any other date to indicate when Staff D completed the documentation. The Social Worker/Bereavement Coordinator failed to complete documentation of her part of the comprehensive assessment within the first 5 days after the patient elected the hospice benefit. 3. Patient #1 had a hospice admission date of 2/21/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC, dated 2/21/22 to 5/21/22, included orders for skilled nursing and social worker services. b. The patient's election of hospice care dated 2/21/22. c. The initial comprehensive assessment at start of care, completed by the social worker, lacked a visit date, included a signature date of 3/4/22, 11 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 7 days. d. The initial comprehensive assessment at start of care, completed by the chaplain/social worker, lacked a visit date, included a signature date of 3/4/22, 11 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 7 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. 4. Patient #2 had a hospice admission date of 4/27/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC, dated 4/27/22 to 7/25/22, included orders for skilled nursing, chaplain and social worker services. b. The patient's election of hospice care dated 4/27/22. c. The initial comprehensive assessment at start of care, completed by the social worker, lacked a visit date, included a signature date of 5/5/22, 8 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 3 days. d. The initial comprehensive assessment at start of care, completed by the chaplain/social worker, lacked a visit date, included a signature date of 5/5/22, 8 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 3 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. 5. Patient #3 had a hospice admission date of 5/20/22 and received hospice services while residing in a nursing home residence. Clinical record review revealed: a. The plan of care, dated 5/20/22 to 8/17/22, included orders for social work and spiritual care services. b. The initial comprehensive assessment at start of care, completed by the social worker, lacked a visit date, included a signature date of 6/3/22, 14 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 9 days. c. The initial comprehensive assessment at start of care, completed by the chaplain/social worker, lacked a visit date, included a signature date of 6/3/22, 14 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 9 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. 6. Patient #4 had a hospice admission date of 3/7/22 and received hospice services while residing in a nursing home residence. Clinical record review revealed: a. The plan of care, dated 3/7/22 to 5/5/22, included orders for social work and spiritual care services. b. The initial comprehensive assessment at start of care, completed by the social worker, lacked a visit date, included a signature date of 3/18/22, 11 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 6 days. c. The initial comprehensive assessment at start of care, completed by the chaplain/social worker, lacked a visit date, included a signature date of 3/18/22, 11 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 6 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. 7. Patient #7 had a hospice admission date of 5/24/22, a death date of 6/2/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The plan of care, dated 5/24/22 to 8/21/22, included orders for social work and spiritual care services. b. The initial comprehensive assessment at start of care, completed by the social worker, lacked a visit date, included a signature date of 6/3/22, 10 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 5 days. c. The initial comprehensive assessment at start of care, completed by the chaplain/social worker, lacked a visit date, included a signature date of 6/3/22, 10 days after the start of care date, which exceeded the requirement for the initial comprehensive assessment by 5 days. Hospice staff failed to complete the initial comprehensive assessment 5 days following the election of hospice care. The Administrator, Clinical Manager and Staff C, Registered Nurse 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, nursing home medication and treatment administration record review and staff interview, review the hospice failed to ensure the drug regimen review included a complete review of all of the patients medications and all the required components within the first 5 days of the patient's election to hospice benefits and at least every 15 days with the update to the comprehensive assessment for 2 of 11 sampled patients (Patients #1 and #8). Failure to ensure the interdisciplinary group (IDG) members completed a drug regimen review (DRR) of all of the patients medications and all the required components with the initial and with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. Findings include: Review of the hospice's policy, titled Initial Comprehensive and Recertification Assessment, dated 3/2022, revealed hospice IDG staff will complete a comprehensive assessment no later than 5 days after the patient signed the hospice benefit election form and includes a review of the patient's medications. Review of the hospice's policy, titled Drug Regimen Review (DRR), Home Health and Hospice, dated 4/2022, identified the DRR will include a review of the patients medications with each comprehensive assessment for ineffective drug therapy, drug side effects; drug interactions, duplicate drug therapy and non-compliance. On 6/14/22 at 1:00 PM, during an interview, the Clinical Manager reported the hospice registered nurse (RN) goes through the patient's medications at admission and sends the medication list to the pharmacist. The pharmacist provides input on the DRR at each IDG meeting. 1. Patient #8 had a hospice admission date of 3/25/22, received hospice general inpatient services while in a local hospital and died on 3/28/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/25/22 to 6/22/22, included physician orders for Morphine and Lorazepam intravenous. b. The DRR, dated 3/25/22, included documentation which identified the patient did not take any medications related to any actual or potential interactions. The DRR failed to identify a potentially major interaction between Morphine and Lorazepam (can cause central nervous system depression). 2. Patient #1 had a hospice admission date of 2/21/22 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POCs, dated 2/21/22 to 5/21/22, and 5/22/22 to 7/20/22, included the following medication orders: sertraline, benazepril, acetaminophen, levothyroxine, miralax (order date 2/21/22) and lorazepam (order date 4/12/22). The DRR, dated 2/21/22, included the medications for sertraline, benazepril, acetaminophen, levothyroxine, miralax. The DRR, dated 4/18, 5/2, 5/16 and 5/31/22, included the orders for sertraline, benazepril, acetaminophen, levothyroxine, miralax and lorazepam. During a observation home visit on 6/13/22 at 11/15 AM with Staff G, RN (Registered Nurse) the caregiver identified the patient had an order for tramadol prior to the start of hospice services. Observation of the empty bottle of tramadol included a fill date of October, 2021. The hospice lacked documentation of a DRR identifying all medications at the time of start of care and the IDG updates to the POC occurred. The Administrator, Clinical Manager and Staff C, Registered Nurse received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on hospice policy review, clinical record review and staff interview, the hospice failed to perform an initial bereavement assessment, within 5 days of the patient's election to the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care in a timely manner for 7 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #7) receiving hospice services for more than 5 days. Failure to complete an initial bereavement assessment increased the risk that patient or family/caregiver grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: Review of the hospice policy, titled Initial Comprehensive and Recertification Assessment, dated 3/2022, revealed the Interdisciplinary Group (IDG) in consultation with the patient's attending physician will complete the comprehensive assessment no later that five calendar days after the patient elects the hospice benefit and updated at least every 15 days. The Social Worker is responsible for completion of the spiritual and bereavement assessment. The comprehensive assessment must identify the physical, psychosocial, emotional and spiritual needs related to the terminal illness. Review of the hospice policy, titled Bereavement Risk Assessment, dated 6/2022, revealed the Social Worker/Bereavement Coordinator completes the bereavement risk assessment and determines the need for more focused follow up based on the caregivers bereavement patterns. The bereavement risk assessment begins with admission and is ongoing every visit. Review of the hospice's policy, titled Hospice Initial Plan of Care, dated 5/2022, all hospice patient's will have an initial Plan of Care (POC) completed at the time of admission. The POC will include an identification of services the patient will receive. The hospice IDG updates the POC. On 6/14/22 at 1:17 PM, during an interview, the Social Worker/Bereavement Coordinator explained she is responsible for completing the bereavement risk assessment and care plan, survivor risk assessment, social history, spiritual assessment and social history for the patient and caregiver. She does not sign and date the documentation of these visits until after she reviews the documentation with Staff H, Masters in Social Work (MSW). She reported she usually completes documentation of the visit within 72 hours of the visit, but agreed there was no documentation to show this. She confirmed some of the forms she completed did not identify the date when the visit occurred, only the date when she reviewed the documentation with the MSW. She confirmed the Plan of Care and IDG meetings did not include identification of interventions or goals based on her assessment of the patient and family. 1. Patient #5 had a hospice admission date of 3/24/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The hospice forms, titled Survivor Risk Assessment, Bereavement Risk Assessment and Bereavement Care Plan, lacked documentation to identify when Staff D, Social Worker/Bereavement Coordinator, obtained the information from the patient and family. The form included documentation of a discussion with the MSW by Staff D, dated 3/30/22, but lacked any other date to indicate when Staff D completed the documentation. b. The POC and IDG meetings, dated 4/4, 4/18, 5/2, 5/16 and 5/31/22, lacked documentation of comprehensive assessment information obtained by Staff D, Social Worker/Bereavement Coordinator, in regards to the initial bereavement assessment. The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The hospice forms, titled Survivor Risk Assessment, Bereavement Risk Assessment and Bereavement Care Plan, lacked documentation to identify when Staff D, Social Worker/Bereavement Coordinator, obtained the information from the patient and family. The form included documentation of a discussion with the MSW by Staff D, dated 3/18/22, but lacked any other date to indicate when Staff D completed the documentation. b. The POC and IDG meetings, dated 3/21, 4/4 and 4/18/22, lacked documentation of comprehensive assessment information obtained by Staff D, Social Worker/Bereavement Coordinator, in regards to the initial bereavement assessment. The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 3. Patient #1 had a hospice admission date of 2/21/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC, dated 2/21/22 to 5/21/22, included orders for skilled nursing and social worker services. b. The patient's election of hospice care dated 2/21/22. c. The initial comprehensive assessment completed by the skilled nurse, dated 2/1/22, lacked an initial bereavement risk assessment. d. The comprehensive assessment completed by the social worker, dated 3/4/22, included an initial bereavement risk assessment signed completed on 3/4/22 (11 days after the start of care). The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 4. Patient #2 had a hospice admission date of 4/27/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC, dated 4/27/22 to 7/25/22, included orders for skilled nursing, chaplain and social worker services. b. The patient's election of hospice care dated 4/27/22. c. The initial comprehensive assessment completed by the skilled nurse, dated 4/27/22, lacked an initial bereavement risk assessment. d. The comprehensive assessment completed by the social worker, dated 5/5/22, included an initial bereavement risk assessment signed completed on 5/5/22 (8 days after the start of care). The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 5. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. Clinical record review revealed the undated bereavement risk assessment form was signed as completed on 6/3/22, 14 days after the start of care, which exceeded the requirement for the initial comprehensive assessment by 9 days. The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 6. Patient #4 had a hospice admission date of 3/7/22 and received hospice services while residing in a nursing home residence. Clinical record review revealed the undated bereavement risk assessment form was signed as completed on 3/18/22, 11 days after the start of care, which exceeded the requirement for the initial comprehensive assessment by 6 days. The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. 7. Patient #7 had a hospice admission date of 5/24/22, a death date of 6/2/22 and received hospice services while residing in a private residence. Clinical record review revealed the undated bereavement risk assessment form was signed as completed on 6/3/22, 10 days after the start of care, which exceeded the requirement for the initial comprehensive assessment by 5 days. The clinical record failed to include a bereavement risk assessment completed within the 5 days after the patient's election of the hospice benefit. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 2 of 4 sampled patients (Patients #2 and #4) 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/Surgical Incision Assessment, dated 5/2022, the wound/surgical incision will be assessed and documented by the nurse with the admission, follow up assessment and every nursing visit. Documentation under skin section on nursing visits record will include wound measurement length, depth and width to be done weekly and with wound deterioration. During an interview on 6/14/22 at 1:00 PM the Clinical Manager stated the nurse expected to assess and measure wounds every visit. The wound measurement includes length, width, depth and any tunneling. 1. Patient #4 had a hospice admission date of 3/7/22 and received hospice services while residing in a nursing home residence. Clinical record review revealed: a. Plan of Care (POC), dated 3/7/22 to 5/5/22, included orders for right buttock wound care. b. The initial comprehensive assessment completed by registered nurse (RN), dated 3/7/22, included documentation of an extremely small open area to right buttock. c. Skilled nurse visit notes, dated 4/25/22, included documentation of a gluteal cleft area with top layer of skin off, depth about less than 1 centimeter (cm) in size, but lacked length and width measurements. d. Skilled nurse visit notes, dated 4/28/22, included documentation nursing home nurse stated area on bottom was almost healed but lacked documentation of length, width and depth wound measurements. The hospice nurse failed to document weekly wound measurements that included length, width and depth. 2. Patient #2 had a hospice admission date of 4/27/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 5/2/22, included IDG orders for skilled nursing services 1 to 2 times every week and identified the patient had an open area on his/her middle neck due to pendant irritation. b. The skilled nurse visit note, dated 5/2/22 and 5/5/22, lacked documentation the wound assessed. c. The skilled nurse visit note, dated 5/16/22 and 5/19/22, lacked documentation the wound assessed. Hospice staff failed to provide assessment of the patient's wound per policy. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 the hospice Interdisciplinary Group (IDG) developed an individualized plan of care which included goals and interventions of all services ordered based on the assessed needs of the patient and caregiver for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #9) who received hospice services longer than 5 days. Failure to develop a plan of care with goals and interventions for all services ordered by the IDG placed patients and families at risk for not having their assessed needs met. Findings include: Review of the hospice's policy, titled Hospice Initial Plan of Care, dated 5/2022, all hospice patient's will have an initial Plan of Care (POC) completed at the time of admission. The POC will include an identification of services the patient will receive. The hospice IDG updates the POC. Review of the hospice policy, titled Hospice Clergy, dated 3/2022, identified the hospice Social Worker will complete the spiritual assessment within 5 days of the patient's admission to hospice and will make any necessary additions to the Plan of Care (POC). The Social Worker will share the spiritual assessment and plan at IDG meetings. On 6/14/22 at 1:17 PM, during an interview, the Social Worker/Bereavement Coordinator explained she is responsible for completing the bereavement risk assessment and care plan, survivor risk assessment, social history, spiritual assessment and social history for the patient and caregiver. She confirmed the Plan of Care and IDG meetings did not include identification of interventions or goals based on her assessment of the patient and family. On 6/14/22 at 1:59 PM, during an interview, the Clinical Manager and Staff C, RN, confirmed the RN creates the Hospice Interdisciplinary Care Plan which includes goals and interventions based on the RN comprehensive assessment. 1. Patient #5 had a hospice admission date of 3/24/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial POC, dated 3/24/22 to 6/21/22, included IDG orders for skilled nursing, hospice aide and social worker services. The POC identified the patient would receive spiritual support by family clergy. The POC identified the social worker would complete an assessment of the patient/family's psycho-social and community resource needs and support system. The POC included documentation of completion, dated 3/24/22. b. A form, titled Hospice Interdisciplinary Care Plan, dated 3/24/22, included documentation of interventions and goals established by the registered nurse (RN) on 3/24/22 (prior to the assessment completed by the social worker). The RN documented spiritual needs would be determined during the course of care and the social worker and/or spiritual counselor would provide optimal interventions to meet the goal of the patient/caregiver achieving optimal grief reaction prior to the patient's death. c. The forms, titled Spiritual Care Assessment, Social History, Caregiver Self-Assessment Questionnaire and Social Work Assessment Tool, included documentation of comprehensive assessment information completed by Staff D, Social Worker/Bereavement Coordinator, dated 3/30/22. Staff D identified the patient/family needed the following interventions: encourage expression of spiritual needs, encourage use of spiritual comfort measures, encourage life process review, encourage expression of questions and fears, involve clergy of choice or offer hospice spiritual care support, provide supportive counseling and encourage patient to express unresolved guilt. d. The initial POC and the IDG meetings, dated 4/4, 4/18, 5/2, 5/16 and 5/31/22, failed to include documentation of the specific interventions needed by the patient/family identified by Staff D, Social Worker/Bereavement Coordinator, in the comprehensive assessment. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The initial POC, dated 3/7/22 to 6/4/22, included IDG orders for skilled nursing, hospice aide, spiritual care counseling and social worker services. The POC identified the social worker would complete an assessment of the patient/family's psycho-social and community resource needs and support system. The POC included documentation of completion, dated 3/7/22. b. A form, titled Hospice Interdisciplinary Care Plan, dated 3/7/22, included documentation of interventions and goals established by the registered nurse (RN) on 3/7/22 (prior to the assessment completed by the social worker). The RN documented spiritual needs would be determined during the course of care and the social worker and/or spiritual counselor would provide optimal interventions to meet the goal of the patient/caregiver achieving optimal grief reaction prior to the patient's death. c. The forms, titled Spiritual Care Assessment, Social History, Psychosocial Assessment, Caregiver Self-Assessment Questionnaire and Social Work Assessment Tool, included documentation of comprehensive assessment information completed by Staff D, Social Worker/Bereavement Coordinator, dated 3/18/22. Staff D identified the patient/family needed the following interventions: encourage expression of spiritual needs, encourage use of spiritual comfort measures, encourage life process review, encourage expression of questions and fears, involve clergy of choice or offer hospice spiritual care support, provide supportive counseling, encourage patient to express unresolved guilt, explore patient/family ethical values related to end of life issues, instruct on impact of emotions on pain and coping techniques, encourage expression of feelings and concerns, normalize feelings and concerns, provide emotional support, refer to desired spiritual care provider, explore emotional factors contributing to symptoms, encourage verbalization of fears related to dyspnea and encourage utilization of on-call system. d. The initial POC, Hospice Interdisciplinary Care Plan and the IDG meetings, dated 3/21, 4/4 and 4/18/22, failed to include documentation of the specific interventions needed by the patient/family identified by Staff D, Social Worker/Bereavement Coordinator, in the comprehensive assessment. 3. Patient #1 had a hospice admission date of 2/21/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/21/22 to 5/21/22 and 5/22/22 to 7/20/22, included IDG orders for social worker services 2 to 3 times a month. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 3/4/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 3/4/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 3/4/22, included patient specific bereavement goals and interventions. e. The IDG meeting notes, dated 4/18, 5/2, 5/16 and 5/31/22, lacked documentation of the social worker, spiritual care and bereavement goals and interventions. 4. Patient #2 had a hospice admission date of 4/27/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/27/22 to 7/25/22, included IDG orders for social worker services 1 to 2 times a month and chaplain service 1 to 2 times a month. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 5/5/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 5/5/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 5/5/22, included patient specific bereavement goals and interventions. e. The IDG meeting notes, dated 5/16 and 5/31/22, lacked documentation of the social worker, spiritual care and bereavement goals and interventions. 5. Patient #9 had a hospice admission date of 4/20/22 and date of death of 6/6/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/20/22 to 7/18/22, included orders for social worker services 1 to 2 times a month and chaplain services 1 to 2 times a month. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 4/22/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 4/22/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 4/22/22, included patient specific bereavement goals and interventions. e. The IDG meeting notes, dated 5/2, 5/16 and 5/31/22, lacked documentation of the social worker, spiritual care and bereavement goals and interventions. 6. Patient #4 had a hospice admission date of 3/7/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The initial IDG meeting note, dated 3/21/22, included documentation social worker will meet more with spouse, not much conversation with patient; patient has own clergy, no update from pastor. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 3/18/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 3/18/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 3/18/22, included patient specific bereavement goals and interventions. e. The IDG meeting note, dated 4/4/22, included documentation social worker will visit 1-2 times per month, enjoyed last visit, recommends to see patient 1 time per month; and patient has own clergy, no updates. f. The IDG meeting note, dated 4/18/22, included documentation social worker will visit 1-2 times per month, visits 1 time per month and will make phone calls to spouse, patient is difficult to have conversation with; and hospice clergy will visit 1-2 times per month, patient sleepy last visit, did visit with spouse, family does not have a pastor. g. The IDG meeting note, dated 5/2/22, included documentation social worker will visit 1-2 times per month, up in chair, no real response besides "Hi", phone call to spouse, coping well, makes regular visits; and hospice clergy will visit 1-2 times per month, visits difficult, patient very sleepy, good visit with spouse, plan to see next week. h. The IDG meeting note, dated 5/16/22, included documentation social worker will visit 1-2 times per month, no updates, will see next week, spouse coping well; and hospice clergy will visit 1-2 times per month, will see in June. i. The undated social worker visit notes, dated as completed on 4/22/22 and 6/3/22, included documentation of goals and interventions. j. The clinical record lacked documentation of hospice clergy visits for April, May and June. The IDG meeting notes lacked documentation of the social worker, spiritual care and bereavement goals and interventions. 7. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The initial Interdisciplinary Group (IDG) meeting note, dated 5/31/22, included documentation social worker visit on 5/24/22 with patients child, good coping and understanding and hospice clergy to visit every other month and will alternate with family clergy every other month. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 6/3/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 6/3/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 6/3/22, included patient specific bereavement goals and interventions. The IDG meeting note lacked documentation of the social worker, spiritual care and bereavement goals and interventions. 8. Patient #7 had a hospice admission date of 5/24/22, a death date of 6/2/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The initial IDG meeting note, dated 5/31/22, included documentation social worker will visit 1-2 times per month, initial visit on 5/27/22, social worker will assist in finding someone to come to patient for a haircut, granddaughter getting married 7/16/22, patient not sure about making it, good discussion and using own clergy. b. The initial undated comprehensive assessment completed by the social worker and signed as completed on 6/3/22, included patient specific social worker goals and interventions. c. The initial undated comprehensive assessment completed by the chaplain/social worker and signed as completed on 6/3/22, included patient specific spiritual care goals and interventions. d. The undated bereavement care plan completed by the social worker and signed as completed on 6/3/22, included patient specific bereavement goals and interventions. The IDG meeting note lacked documentation of the social worker, spiritual care and bereavement goals and interventions. The Administrator, Clinical Manager and Staff C, Registered Nurse 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, home visit observation and patient interview the hospice failed to ensure the Plans of Care for 2 of 11 sampled patients (Patients #1 and #6) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: According to the hospice policy titled Hospice Initial Plan of Care, dated May, 2022, every hospice patient will have an initial plan of care completed at the time of admission. Equipment needed by the patient will need to be filled in and ordered if needed. According to he hospice policy titled Interdisciplinary Care Conference Update, dated April, 2022, when completing the IDG care conference update for each hospice patient, the following information needs to be completed: list all equipment supplied. 1. Patient #1 had a hospice admission date of 4/27/22 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/27/22 to 7/25/22, identified the patient had the following medical equipment and supplies: hospital bed and side rails, wheelchair, pressure relieving device, walker, colostomy supplies, incontinent supplies, grabber, hearing aids, lifeline and medication box. b. The IDG meeting, dated 5/2/22, identified additional medical equipment and supplies, shower wand, overlay mattress and high rise toilet, used by the patient. c. The IDG meeting, dated 5/31/22, identified no additional medical equipment and supplies used by the patient. On 6/13/22 at 12:45 PM, during a home visit observation with Staff J, Licensed Practical Nurse (LPN) the surveyor identified the patient also used a shower bench and grab bars. In an interview, during the same nursing home visit observation, the patient stated he/she has used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/7/22 to 6/4/22, identified the patient used the following medical equipment and supplies: hospital bed, wheelchair, walker, shower bench, incontinent supplies and gait belt. b. A hospice equipment list form, dated 3/7/22, identified the patient used an electric lift chair. c. The POC and/or IDG meetings, dated 3/21, 4/4 and 4/18/22, failed to identify the patient used a lift chair. On 6/14/22 at 1:59 PM, during an interview, Staff C, Registered Nurse, confirmed the patient had a lift chair and staff used the functions of the lift chair to assist with transferring the patient. 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 the hospice Interdisciplinary Group revised the patient's plan of care based on the updated comprehensive assessment and include the patient's progress towards outcomes and goals specified in the plan of care for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7 and #9) requiring an updated comprehensive assessment and Interdisciplinary Group meeting review. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: Review of the hospice policy, titled Hospice Initial Plan of Care, dated 5/2022, all hospice patient's will have an initial Plan of Care (POC) completed at the time of admission. The POC will include an identification of services the patient will receive. The hospice Interdisciplinary Group (IDG) updates the POC. Review of the hospice policy, titled Interdisciplinary Care Conference Update, dated 4/2022, identified the hospice registered nurse (RN) who last sees the patient prior to the IDG meeting will complete the IDG Care Conference Update form. The IDG Care Conference Update form includes information on the patient's medications, frequency of services, physician orders, changes and summary of the patient's status for the last 14 days and progress towards patient goals. The IDG members will review and/or update the POC based on the information provided by the RN. Review of the hospice policy, titled Hospice Clergy, dated 3/2022, identified the hospice Social Worker will complete the spiritual assessment within 5 days of the patient's admission to hospice and will make any necessary additions to the Plan of Care (POC). The Social Worker will share the spiritual assessment and plan at IDG meetings. The hospice clergy will be responsible for monitoring the spiritual care plan for each patient, apprising the IDG of spiritual needs and documentation of pertinent information in the appropriate progress notes. On 6/14/22 at 1:17 PM, during an interview, the Social Worker/Bereavement Coordinator explained she is responsible for completing the bereavement risk assessment and care plan, survivor risk assessment, social history, spiritual assessment and social history for the patient and caregiver. She confirmed the Plan of Care and IDG meetings did not include identification of interventions or goals based on her assessment of the patient and family, only the nurses. She confirmed the IDG meetings did not include documentation of patient progress based on interventions provided by her and assessments completed by her. On 6/14/22 at 1:43 PM, during an interview, Staff I, Clergy, reported he never completes the initial spiritual assessment for hospice patients and has never or heard of the document. He explained the admitting nurse lets him know if the patient wants hospice spiritual care counseling services. When asked how he knows what interventions he is supposed to provide to the patient, he reported he assesses the patient's spiritual background and needs when he goes out to see them. He will also talk with the family if they are present. He reported he attends hospice IDG meetings when he is available and completes visit notes and submits them to the Volunteer Coordinator. On 6/14/22 at 1:59 PM, during an interview, the Clinical Manager and Staff C, RN, confirmed the RN completes the IDG Care Conference Update which identifies the patient's goal progress prior to the IDG meeting. The IDG then discusses this information in the meeting. 1. Patient #5 had a hospice admission date of 3/24/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. See L0545 b. The IDG meeting, dated 4/4/22, included documentation by the registered nurse (RN) of the patient's and family progress towards goals in relation to those established by the RN. For terminal care and impending death, the RN identified the patient was accepting and coping well. For psychosocial/mental/emotional status, the RN documented the patient was doing very well, seems happy and accepting diagnosis very well. For spiritual need status, the RN documented the patient had personal clergy that may come every week to visit. For anticipatory grief and bereavement, the RN identified the patient's spouse was coping well and starting to accept the patient's diagnosis. Staff D, Social Worker/Bereavement Coordinator, documented the spouse had poor coping strategies and was in denial. c. The IDG meeting, dated 4/18/22, included the exact same documentation as 4/4/22 IDG meeting by the RN for terminal care and impending death, psychosocial/emotional status, spiritual need status and anticipatory grief and bereavement. The RN also documented the patient refused volunteer services. Staff D, Social Worker/Bereavement Coordinator, documented "enjoyed last visit and arranged for volunteer to take pictures". d. The IDG meeting, dated 5/2/22, included the exact same documentation as 4/4/22 by the RN for terminal care and impending death, psychosocial/emotional status, spiritual need status and anticipatory grief and bereavement. The RN also documented the patient refused volunteer services. Staff D, Social Worker/Bereavement Coordinator, documented the visits "go well", "was given recordable books" and "volunteer for family pictures Sunday". e. The IDG meeting, dated 5/16/22, included the exact same documentation as 4/4/22 by the RN for terminal care and impending death, psychosocial/emotional status and anticipatory grief and bereavement. The RN did document for spiritual needs status that the patient's clergy had not been coming to visit in a month, but the spouse brings communion weekly and communicates with the pastor weekly. The RN documented the patient watched church on the TV daily. Staff D, Social Worker/Bereavement Coordinator, documented "tearful" (did not identify if this was the patient, family or both) and "did recorded books. Helped with getting them done". f. The IDG meeting, dated 5/31/22, included the exact same documentation as 4/4/22 by the RN for terminal care and impending death, psychosocial/emotional status and anticipatory grief and bereavement. The RN did document for spiritual needs status that a family member visits, who was also a clergy, spouse brings communion weekly and communicates with the pastor weekly. The RN documented the patient watched church on the TV daily. Staff D, Social Worker/Bereavement Coordinator, documented "no update. Last visit everyone coping well." The IDG meetings lacked information on the update of interventions and outcomes Staff D, Social Worker/Bereavement Coordinator, assessed the patient/family needed. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. See L0545 b. The IDG meetings, dated 3/21, 4/4 and 4/18/22, included documentation by the RN of the patient's and family progress towards goals in relation to those established by the RN. For terminal care and impending death, the RN identified the patient was accepting of the diagnosis and does not seem anxious. For psychosocial/mental/emotional status, the RN documented the patient did not appear to be upset or anxious and will become anxious during urticaria (skin rash) episodes. For spiritual need status, the RN documented the family would like a pastoral visit. For anticipatory grief and bereavement, the RN identified the family seemed to be doing well. The IDG meeting, dated 3/21, lacked documentation of input by Staff D, Social Worker/Bereavement Coordinator, or Staff I, Clergy. The IDG meeting, dated 4/4, Staff D, Social Worker/Bereavement Coordinator, talked about a family member's dog and a planned visit for the next day; she did not provide any other input. Staff I, Clergy, documented he completed a visit on 3/21/22 and "did prayer". The IDG meeting, dated 4/18, included documentation by Staff D, Social Worker/Bereavement Coordinator, had no update and "enjoyed visit". Staff I, Clergy, had no update to provide. The IDG meetings lacked information on the update of interventions and outcomes Staff D, Social Worker/Bereavement Coordinator, assessed the patient/family needed. 3. Patient #1 had a hospice admission date of 2/21/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/21/22 to 5/21/22 and 5/22/22 to 7/20/22, included IDG orders for social worker services 2 to 3 times a month. b. The IDG meeting, dated 4/18, 5/2, 5/16 and 5/31/22, lacked documentation of progress towards interventions and the goal related to social worker services. The hospice failed to include updates to the POC for social worker services. 4. Patient #2 had a hospice admission date of 4/27/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/27/22 to 7/25/22, included IDG orders for social worker services 1 to 2 times a month and chaplain service 1 to 2 times a month. b. The IDG meeting, dated 5/2, 5/16 and 5/31/22, lacked documentation of progress towards interventions and the goal related to chaplain and social worker services. The hospice failed to include updates to the POC for chaplain and social worker services. 5. Patient #9 had a hospice admission date of 4/20/22 and date of death of 6/6/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/20/22 to 7/18/22, included orders for social worker services 1 to 2 times a month and chaplain services 1 to 2 times a month. b. The IDG meeting, dated 5/2, 5/16 and 5/31/22, lacked documentation of progress towards interventions and the goal related to chaplain and social worker services. The hospice failed to include updates to the POC for chaplain and social worker services. 6. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Plan of Care, dated 5/2022 to 8/17/22, included Interdisciplinary Group (IDG) orders, interventions and goals for skilled nursing, hospice aide, social worker and spiritual care services. b. The IDG meeting note, dated 5/31/22, lacked documentation of progress towards interventions and the goal related to hospice aide, social worker and spiritual care services. The hospice failed to include updates to the Plan of Care for hospice aide, social worker and spiritual care services. 7. Patient #4 had a hospice admission date of 3/7/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Plans of Care, dated 3/7/22 to 5/5/22 and 5/6/22 to 7/4/22, included IDG orders, interventions and goals for skilled nursing, hospice aide, social worker and spiritual care services. b. The IDG meetings, dated 4/4/22, 4/18/22, 5/2/22 and 5/16/22, lacked documentation of progress towards interventions and the goal related to hospice aide, social worker and spiritual care services. The hospice failed to include updates to the Plan of Care for hospice aide, social worker and spiritual care services. 8. Patient #7 had a hospice admission date of 5/24/22, a death date of 6/2/22 and received hospice services while residing in a private home residence. Clinical record review revealed: a. The Plan of Care, dated 5/2422 to 8/21/22, included IDG orders, interventions and goals for skilled nursing, social worker and spiritual care services. b. The IDG meeting note, dated 5/31/22, lacked documentation of progress towards interventions and the goal related to social worker and spiritual care services. The hospice failed to include updates to the Plan of Care for social worker and spiritual care services. The Administrator, Clinical Manager, Social Worker and Staff C, RN received the above findings and hospice staff provided no further evidence prior to the end of the survey.

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 4 of 11 sampled patients (Patients #1, #4, #6 and #9). 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 policy, titled Interdisciplinary Care Conference Update, dated 4/2-22, every hospice patient's care plan will be updated at least every 14 days, more frequently if indicated, to assure that each patient's unique needs are being met. The RN seeing the hospice patient prior to the IDT meeting will be responsible for completing the Interdisciplinary Care Conference update The IDT update drives the POC for each individual patient. It is essential that all information is updated & accurate. 1. Patient #1 had a hospice admission date of 2/21/22 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 2/21/22 to 5/21/22 and 5/22/22 to 7/20/22, included physician orders for skilled nursing services 2 times a week, social work services 2 to 3 times a month and hospice aide services 2 times a week. b. The clinical record lacked documentation social worker services were completed. c. The IDG update to the POC, dated 5/2, 5/16, and 5/31/22, lacked documentation of the missed social worker services. 2. Patient #9 had a hospice admission date of 4/20/22 and date of death of 6/6/22 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The POC, dated 4/22/22 to 7/18/22, included physician orders for skilled nursing services 2 times a week, social work services 1 to 2 times a month and chaplain services 1 to 2 times a month. b. The clinical record lacked documentation social worker services were completed. c. The clinical record lacked documentation chaplain services were completed. c. The IDG update to the POC, dated 5/2, 5/16, and 5/31/22, lacked documentation of the missed social worker and chaplain services. 3. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/7/22 to 6/4/22, included IDG orders for hospice aide services 2 times per week. b. The week of 4/10/22 included documentation of one hospice aide visit, dated 4/15/22. The clinical record included documentation the hospice aide attempted to complete a visit on 4/12/22, but the patient was sleeping and the hospice aide did not provide services that day. c. The IDG meeting, dated 4/18/22, lacked documentation of the IDG members' awareness of the missed hospice aide visit the week of 4/10/22. 4. Patient #4 had a hospice admission date of 3/7/22 and received hospice services while residing in a nursing home residence. Clinical record review revealed: a. Plans of Care, dated 3/7/22 to 5/5/22 and 5/6/22 to 7/4/22, included orders for spiritual care coordinator services with a frequency of 1-2 times per month, patient/family request spiritual support and social worker services with a frequency of 1-2 times per month. b. Interdisciplinary Group (IDG) meeting note, dated 3/7/22, included physician order for hospice clergy 1-2 times per month, own clergy. c. IDG meeting note, dated 4/4/22, included physician order for hospice clergy 1-2 times per month, own clergy, no pastor updates. d. IDG meeting note, dated 4/18/22, included physician order for hospice clergy 1-2 times per month, hospice chaplain had a nice visit, family does not have a pastor. e. IDG meeting note, dated 5/2/22, included physician order for hospice clergy 1-2 times per month, hospice chaplain last month visits difficult patient sleepy, good visit with wife. f. IDG meeting note, dated 5/16/22, included physician order for hospice clergy 1-2 times per month, hospice chaplain will visit patient in June. g. No spiritual care visit notes were located in the patient's clinical record. h. IDG meeting note, dated 4/4/22, included documentation social worker enjoyed last visit, recommends to see patient 1 time per month. i. IDG meeting note, dated 4/18/22, included social worker frequency 1-2 times per month, visits 1 time per month and will make phone call to visit, patient difficult to have conversation with, plan to visit tomorrow. j. IDG meeting note, dated 5/2/22, included social worker frequency 1-2 times per month, last visit was Wednesday, up in chair, no real response besides "Hi", phone call to spouse, coping well, makes regular visits. k. IDG meeting note, dated 5/16/22, included social worker frequency 1-2 times per month, no updates, will visit patient next week, spouse coping well. l. Social worker visit notes lacked visit dates but were signed 4/22/22 and 6/3/22. No social worker visits made in May. The IDG meeting notes lacked documentation of missed spiritual care/chaplain and/or social worker visits. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 6 of 8 sampled patients receiving hospice aide services. (Patients #1, #3, 34, #6, #8 and #10). 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 Care Aide Plan of Care, dated July, 2019, the admitting RN is responsible for completing he Home Care Aide Plan of Care. The home care aide plan of care will be developed by the RN at admission or if a Home Care Aide is ordered during the care and include the following information: home care aide assignment/activities and special instructions. During an interview on 6/14/22 at 1:00 PM, the Clinical Manager stated the admission nurse or the nurse available when aide services are requested completes the hospice aide care plan. 1. Patient #1 had a hospice admission date of 2/22/22 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 2/22/22 to 5/21/22 and 5/22/22 to 7/20/22, identified the patient had a diagnoses of end stage Alzheimer's dementia and chronic kidney disease and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 2/21/22, included the following assignments to occur per patient request: shower, shampoo/comb hair, assist in dressing, oral care, nail care, position, ambulate, gait belt, wheelchair, laundry/change linens and commode. The RN failed to ensure the hospice aide assignment completed to meet the needs of the patient with end stage Alzheimer's dementia and unable to perform decision making. 2. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/7/22 to 6/4/22, included IDG orders for skilled nursing and hospice aide services 2 times per week. b. The hospice aide care plan, dated 3/7/22, included RN instructions to the hospice aide to complete the task of nail care per patient request. The aide care plan failed to specify what the hospice aide needed to do (file, clean and/or trim) in order to complete the assigned task. 3. Patient #8 had a hospice admission date of 3/25/22, received hospice general inpatient services while in a local hospital and died on 3/28/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/25/22 to 6/22/22, included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide services. b. The Medicare Benefit Election form, dated 3/25/22, included documentation of a signature by the patient's Power of Attorney due to the patient's altered level of consciousness. c. The comprehensive assessment completed by a RN upon admission to hospice, dated 3/25/22, identified the patient had an altered level of consciousness and she could not assess neurological and communication functions due to this. The RN also assessed the patient had difficulty swallowing/chewing due to level of consciousness. d. The hospice aide care plan, dated 3/25/22, included RN instructions to the hospice aide to complete the tasks of vitals including blood pressure, temperature, pulse and respirations, bed bath, shampoo and comb hair, assist with dressing, shaving, nail care, catheter care, reinforce dressing (s) and positioning. The hospice aide assignment included the instructions for the hospice aide to complete the tasks per patient request. The hospice aide care plan failed to identify what dressing the hospice aide needed to reinforce, what the hospice aide needed to specifically do in order to complete the task of nail care and inappropriately identified the patient's need to request assigned tasks in order for the tasks to be done. On 6/14/22 at 4:30 PM, during an interview, the Clinical Manager reported she mistakenly put the task of reinforcing a dressing on the hospice aide care plan. She explained the patient did not have a dressing to reinforce and the hospice aide did not perform this task. 4. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Plan Of Care, dated 5/20/22 to 8/17/22, included diagnosis of senile degeneration of the brain, patient mental status is confused and interdisciplinary group orders for skilled nursing and hospice aide services. b. The Hospice Aide Plan of Care, dated 5/20/22, instructed the aide to provide whirlpool, shower, bed bath or sponge bath every visit, skin care: lotion and powder, shampoo/comb, assist in dressing, oral care, shave, nail care, position, and hoyer lift with assist of 2 per patient request. c. The aide plan of care failed to identify who would give the hospice aide direction on what bath type to provide at every visit. The confused patient with the diagnosis of senile degeneration of the brain would not be able to direct the cares needed. d. The aide plan of care failed to identify what specific instructions the task of nail care included. The aide assignment lacked specific instructions to direct the aide on assigned tasks. 5. Patient #4 had a hospice admission date of 3/7/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Plans Of Care, dated 3/7/22 to 5/5/22 and 5/6/22 to 7/4/22, included diagnosis of Parkinson's, patient mental status is confused and interdisciplinary group orders for skilled nursing and hospice aide services 2 times a week. b. The Hospice Aide Plan of Care, dated 3/7/22, instructed the aide to provide whirlpool, bed bath or sponge bath, shampoo/comb, assist in dressing, oral care, shave, nail care, reinforce dressing, position assist of 2, ambulate: gait belt, walker, wheelchair per patient request and skin care: lotion and powder every visit. Position assist of 2, gait belt and walker added with every visit, dated 3/18/22. c. The aide plan of care included a frequency of visits 1-2 times a week d. The confused patient with the diagnosis of Parkinson's would not be able to direct the cares needed. e. The aide plan of care failed to identify what specific instructions the task of nail care and reinforce dressing included. The aide assignment lacked specific instructions to direct the aide on frequency of services and assigned tasks. 6. Patient #10 had a hospice admission date of 2/25/2022, a hospice death date of 3/1/22 and received services while residing in the hospital. Clinical record review revealed: a. The Plan Of Care, dated 2/25/22 to 5/25/22, included diagnosis of subdural hematoma, patient mental status is comatose and interdisciplinary group orders for skilled nursing and hospice aide services. b. The Hospice Aide Plan of Care, dated 2/25/22, instructed the aide to provide bed bath or sponge bath every visit, skin care: lotion and powder every visit, shampoo/comb, assist in dressing, oral care, shave, nail care, catheter care, reinforce dressing and position per patient request. c. The aide plan of care failed to identify who would give the hospice aide direction on what bath type to provide at every visit. The comatose patient with the diagnosis of subdural hematoma would not be able to direct the cares needed. d. The aide plan of care failed to identify what specific instructions the task of nail care included. The aide assignment lacked specific instructions to direct the aide on assigned tasks. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 #1, #3, #4, #5, #6, #8 and #10). 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 Care Aide Job Description, dated June, 2019, the home care aide provides personal and environmental care. Examples of personal cares include bathing, toileting, shampoo, skin care, mouth care, catheter care, recording vital signs, weights, assist with normal range of motion and body repositioning, observe medication regime under supervision of RN and any other assignments on the plan of care. During an interview on 6/13/22 at 3:40 PM, the Administrator reported the hospice aides will make a dash in the box on the flow sheet correlating to the task to indicate the task was not completed. During an interview on 6/14/22 at 1:00 PM, the Clinical Manager 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 #1 had a hospice admission date of 2/22/22 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 2/22/22 to 5/21/22 and 5/22/22 to 7/20/22, identified the patient had a diagnoses of end stage Alzheimer dementia and chronic kidney disease and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker and hospice aide. b. The Home Care Aide Plan of Care, dated 2/21/22, included the following assignments to occur per patient request: shower, shampoo/comb hair, assist in dressing, oral care, nail care, position, ambulate, gait belt, wheelchair, laundry/change linens and commode. c. The aide visit notes, dated 4/12, 4/15, 4/19, 4/22, 4/26, 4/29, 5/3, 5/6, 5/10, 5/13, 5/17, 5/20, 5/25, 5/27 and 5/31/22, lacked documentation the aide offered or completed the task oral care, nail care, laundry/change linens and commode. The visit notes lacked a reason why the hospice aide failed to complete the assigned tasks. The aide failed to follow the care plan as written. 2. Patient #5 had a hospice admission date of 3/24/22 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 3/24/22 to 6/21/22, included IDG orders for hospice aide services 1 to 2 times per week. b. The hospice aide care plan, dated 3/24/22, included RN instructions to the hospice aide to complete the following tasks: vitals including temperature, pulse, respiration and blood pressure, shower, bed bath or sponge bath, skin care to include lotion and powder, shampoo and comb hair, assist in dressing, oral care, nail care for finger nails, position, ambulate with a gait belt and walker or wheelchair. c. The hospice aide visit notes, dated 4/5, 4/26, 5/3, 5/10 and 5/17/22, lacked documentation the hospice aide completed the assigned tasks of shampooing, oral care, positioning, nail care and using the gait belt with ambulation. The visit notes lacked a reason why the hospice aide failed to complete the assigned tasks. d. The hospice aide visit note, dated 4/21/22, lacked documentation the hospice aide completed the assigned tasks of taking the patient's vitals, shampooing, oral care, positioning, nail care and using the gait belt with ambulation. The visit note lacked a reason why the hospice aide failed to complete the assigned tasks. e. The hospice aide visit notes, dated 5/24 and 5/31/22, lacked documentation the hospice aide completed the assigned tasks oral care, positioning, nail care and using the gait belt with ambulation. The visit note lacked a reason why the hospice aide failed to complete the assigned tasks. 3. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/7/22 to 6/4/22, included IDG orders for skilled nursing and hospice aide services 2 times per week. b. The hospice aide care plan, dated 3/7/22, included RN instructions to the hospice aide to complete the tasks of vitals including temperature, pulse, respiration and blood pressure, shower, whirlpool, bed bath or sponge bath, skin care to include lotion and powder, shampoo and comb hair, assist in dressing, oral care, nail care, position, provide feeding assistance and ambulate with a gait belt and walker or wheelchair. The RN instructed the hospice aide to complete the task of vitals weekly, complete either a shower, whirlpool, bed bath or sponge bath every visit or per patient request, and to complete all other tasks per patient request. c. The hospice aide visit, dated 3/11/15, lacked documentation the hospice aide completed or offered to complete the assigned tasks of bathing the patient (either whirlpool, bed bath, sponge bath or shower), shampooing, providing assistance with dressing, oral care, nail care, positioning, ambulation and feeding assist. d. The hospice aide visit, dated 3/15/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of bathing the patient, shampooing and combing the patient's hair, providing assistance with dressing, oral care, nail care, positioning, ambulation and feeding assist. e. The hospice aide visits, dated 3/18 and 3/29/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of shampooing the patient's hair, providing assistance with dressing, oral care, nail care, positioning, ambulation and feeding assist. f. The hospice aide visits, dated 3/22 and 3/25/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of shampooing and combing the patient's hair, providing assistance with dressing, oral care, nail care, positioning, ambulation and feeding assist. g. The hospice aide visit, dated 4/1/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of bathing the patient, shampooing the patient's hair, providing assistance with dressing, oral care, nail care, positioning and feeding assist. h. The hospice aide visit, dated 4/5/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of shampooing the patient's hair and nail care. i. The hospice aide visits, dated 4/8, 4/15 and 4/20/22, lacked documentation the hospice aide completed or offered to complete the assigned tasks of shampooing the patient's hair, use of the gait belt with transfers, feeding assist and nail care. On 6/14/22 at 10:34 AM, during an interview, Staff E, Hospice Aide, reported she remembered definitely using the gait belt one time when transferring the patient and then maybe another time without it. She explained she transferred the patient with nursing home facility staff. She reported most of the time the patient just sat in the chair. She did not shampoo the patient's hair, because the patient's hair was already done and she never did anything with the patient's nails. On 6/14/22 at 10:40 AM, during an interview, Staff F, Hospice Aide reported she used a gait belt when she transferred the patient. She reported she never assisted with feeding the patient or provided nail care. She explained the patient did not want a shampoo of the hair. 4. Patient #8 had a hospice admission date of 3/25/22, received hospice general inpatient services while in a local hospital and died on 3/28/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/25/22 to 6/22/22, included Interdisciplinary Group (IDG) orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 3/25/22, included RN instructions to the hospice aide to complete the tasks of vitals including blood pressure, temperature, pulse and respirations, bed bath, shampoo and comb hair, assist with dressing, shaving, nail care, catheter care, reinforce dressing (s) and positioning. The hospice aide assignment included the instructions for the hospice aide to complete the tasks per patient request. c. The hospice aide visit note, dated 3/28/22, lacked documentation the hospice aide completed the assigned tasks of taking the patient's vitals, shampooing, nail care, reinforce dressing and catheter care. The visit note lacked a reason why the hospice aide failed to complete the assigned tasks. On 6/14/22 at 4:30 PM, during an interview, the Clinical Manager reported she mistakenly put the task of reinforcing a dressing on the hospice aide care plan. She explained the patient did not have a dressing to reinforce and the hospice aide did not perform this task. 5. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Hospice Aide Plan of Care, dated 5/20/22, instructed the aide to provide whirlpool, shower, bed bath or sponge bath every visit, skin care: lotion and powder, shampoo/comb, assist in dressing, oral care, shave, nail care, position, and hoyer lift with assist of 2 per patient request. b. Hospice Aide Flow Sheet included documentation of visits, dated 5/23/22 and 5/31/22, included documentation of tasks completed: sponge bath, skin care lotion and assist with dressing. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool, shower, bed bath were not marked as refused or a reason why the bath was not completed. The task skin care powder was not marked as refused or a reason why the task was not completed. c. Hospice Aide Flow Sheet included documentation of visit, dated 5/27/22, included documentation of tasks completed: sponge bath, skin care lotion, assist with dressing, and position assist of 2. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool, shower, bed bath were not marked as refused or a reason why the bath was not completed. The task skin care powder was not marked as refused or a reason why the task was not completed. The hospice aide failed to follow the written hospice aide plan of care. 6. Patient #4 had a hospice admission date of 3/7/2022 and received services while residing in a nursing home residence. Clinical record review revealed: a. The Hospice Aide Plan of Care, dated 3/7/22, instructed the aide to provide whirlpool, bed bath or sponge bath, shampoo/comb, assist in dressing, oral care, shave, nail care, reinforce dressing, position assist of 2, ambulate: gait belt, walker, wheelchair per patient request and skin care: lotion and powder every visit. Position assist of 2, gait belt and walker added with every visit, dated 3/18/22. b. Hospice Aide Flow Sheet included documentation of visit, dated 4/15/22, included documentation of tasks completed: bath - hands and face, skin care lotion, comb, assist with dressing, shave. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool, bed bath, sponge bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. c. Hospice Aide Flow Sheet included documentation of visit, dated 4/20/22, included documentation of tasks completed: whirlpool bath, skin care lotion, shampoo/comb, assist with dressing, and ambulate wheelchair. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types bed bath and sponge bath were not marked as refused or a reason why the bath was not completed. The task skin care powder were not marked as refused or a reason why the task was not completed. d. Hospice Aide Flow Sheet included documentation of visits, dated 4/22/22, 4/29/22 and 5/13/22, included documentation of tasks completed: sponge bath, skin care lotion, comb, assist with dressing, oral care, and shave. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool and bed bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. e. Hospice Aide Flow Sheet included documentation of visit, dated 4/26/22, included documentation of tasks completed: sponge bath, skin care lotion, comb, assist with dressing and ambulate gait belt with wheelchair. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool and bed bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. f. Hospice Aide Flow Sheet included documentation of visit, dated 5/3/22, included documentation of tasks completed: sponge bath, comb, assist with dressing, oral care, shave and position assist of 2. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool and bed bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. g. Hospice Aide Flow Sheet included documentation of visit, dated 5/6/22, included documentation of tasks completed: bath - hands and face, skin care lotion, comb, assist with dressing, oral care, and shave. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool, bed bath, sponge bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. h. Hospice Aide Flow Sheet included documentation of visit, dated 5/10/22, included documentation of tasks completed: bath - hands and face, skin care lotion, comb, assist with dressing, oral care, and ambulate wheelchair. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath types whirlpool, bed bath, sponge bath were not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. The hospice aide failed to follow the written hospice aide plan of care. 7. Patient #10 had a hospice admission date of 2/25/2022, a hospice death date of 3/1/22 and received services while residing in the hospital. Clinical record review revealed: a. The Hospice Aide Plan of Care, dated 2/25/22, instructed the aide to provide bed bath or sponge bath every visit, skin care: lotion and powder, shampoo/comb, assist in dressing, oral care, shave, nail care, catheter care, reinforce dressing and position per patient request. b. Hospice Aide Flow Sheet included documentation of visit, dated 2/25/22, included documentation of tasks completed: sponge bath, skin care lotion, comb, assist with dressing, oral care, shave, nail care, catheter care and position. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath type bed bath was not marked as refused or a reason why the bath was not completed. The tasks shampoo and skin care powder were not marked as refused or a reason why the task was not completed. c. Hospice Aide Flow Sheet included documentation of visit, dated 2/28/22, included documentation of tasks completed: bed bath, skin care lotion, shampoo, assist with dressing, oral care, shave, catheter care and position. The other assigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The unassigned tasks on the flow sheet had a dash through the box correlating to the task indicating the task had not been completed. The assigned bath type sponge bath was not marked as refused or a reason why the bath was not completed. The tasks comb and skin care powder were not marked as refused or a reason why the task was not completed. The hospice aide failed to follow the written hospice aide plan of care. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 4 of 4 sampled services under arrangement included all of the required contract components. The hospice reported a total of 8 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 pharmacy contract, dated 4/9/20, failed to include the following contractual language: the hospice retains administrative management, financial management, oversight of staff and services, all services are authorized by the hospice and all services are delivered in accordance with the patient's plan of care. 2. A hospice chaplain contract, dated 6/20/11, failed to include the following contractual language: the hospice retains administrative management, financial management, oversight of staff and services, and all services are authorized by the hospice. 3. A hospice social worker contract, dated 2/8/19, failed to include the following contractual language: the hospice retains administrative management, financial management, oversight of staff and services, and all services are authorized by the hospice. 4. A medical director contract, dated 5/10/21, failed to include the following contractual language: the hospice retains administrative management and oversight of staff and services. The Administrator, Clinical Manager and Staff C, Registered Nurse received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and policy review, the hospice failed to ensure patient clinical records included a physician order for all treatments for 1 of 11 sampled patients (Patient #11). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: Review of the hospice's policy, titled Hospice Initial Plan of Care, dated 5/2022, all hospice patient's will have an initial Plan of Care (POC) completed at the time of admission. The POC will include medications and treatments. Review of the hospice's policy, titled Physician Orders, dated 6/2022, identified hospice nursing staff will consult the attending physician for any changes or modifications to the POC. Hospice staff will include all verbal and written physician orders in the patient's medical record. Patient #11 had a hospice admission date of 3/15/22, received hospice services while residing in a private residence and died on 3/19/22. Review of the clinical record revealed the following: a. A physician order for Normal Saline 500 milliliters intravenous 2 times per week, dated 3/15/22. The order failed to identify a flow rate. b. The comprehensive assessment completed by the registered nurse (RN), dated 3/15/22, identified the patient used oxygen at 4 liters per minute. c. A skilled nursing visit, dated 3/17/22, identified the patient used oxygen at 4 liters per minute via nasal cannula and 5 liters per minute with activity. d. The initial POC, dated 3/15/22 to 6/12/22, identified the patient used oxygen. e. The clinical record lacked documentation of a physician order for oxygen which identified a flow rate and route of use. On 6/14/22 at 1:59 PM, during an interview, the Clinical Manager reported the patient did not get the Normal Saline, because 2 days later the family decided against it. 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, staff interview and hospice policy review the hospice failed to ensure all entries completed in the clinical records included an appropriate date and signature and completed timely for 5 of 11 sampled patients (Patients #2, #4, #6, #10 and #11). Failure to ensure all clinical record documentation included accurate information and were completed timely may result in ineffectively coordinated patient care. Findings include: Review of the hospice policy, titled Timely Documentation (Skilled Nursing Notes/Therapy Notes), dated 3/2020, identified hospice nursing and therapy staff are required to complete and place visit notes in the patient's medical record within 72 hours of the visit. Review of the hospice policy, titled Documentation, dated 5/20/22, revealed hospice staff need to date, time and sign each entry into the clinical record. Hospice staff should provide accurate and detailed documentation. Review of the hospice policy, titled Hospice Clergy, dated 3/2022, identified the hospice Social Worker will complete the spiritual assessment within 5 days of the patient's admission to hospice and will make any necessary additions to the Plan of Care (POC). The Social Worker will share the spiritual assessment and plan at Interdisciplinary Group (IDG) meetings. The hospice clergy will be responsible for monitoring the spiritual care plan for each patient, apprising the IDG of spiritual needs and documentation of pertinent information in the appropriate progress notes. The spiritual assessment and spiritual care progress notes will become part of the patient's medical record. On 6/14/22 at 1:00 PM, during an interview, the Clinical Manager reported the expectation hospice staff complete documentation within 5 calendar days from the visit. On 6/14/22 at 1:17 PM, during an interview, Staff D, Social Worker/Bereavement Coordinator, explained she is responsible for completing the bereavement risk assessment and care plan, survivor risk assessment, social history, spiritual assessment and social history for the patient and caregiver. She does not sign and date the documentation of these visits until after she reviews the documentation with Staff H, Masters in Social Work (MSW). She reported she usually completes documentation of the visit within 72 hours of the visit, but agreed there was no documentation to show this. She confirmed some of the forms she completed did not identify the date when the visit occurred, only the date when she reviewed the documentation with the MSW. 1. Patient #6 had a hospice admission date of 3/7/22, received hospice services while residing in a nursing home and died on 4/21/22. Review of the clinical record on 6/14/22 revealed the following: a. The POC, dated 3/7/22 to 6/4/22, included IDG orders for spiritual care counseling services 1 to 2 times per month. A form, titled Spiritual Care Assessment, completed and dated 3/18/22 by Staff D, Social Worker/Bereavement Coordinator, identified patient/family assessed needs and interventions in relation to spiritual care. The clinical record lacked documentation of a visit completed by Staff I, Clergy. On 6/15/22 at 9:24 AM, during an interview, the Administrator provided a copy of visit provided by Staff I, Clergy, dated 3/21/22. She confirmed the document was not signed and not in the patient's medical record. She explained Staff I, Clergy, was good at signing visit notes, and thought hospice staff had somehow lost the originals. b. A social worker visit note with the patient included only a documentation review date with the MSW, dated 4/22/22 (a day after the patient's death). The note failed to identify the date the social worker met with the patient. 2. Patient #11 had a hospice admission date of 3/15/22, received hospice services while residing in a private residence and died on 3/19/22. Review of the clinical record revealed the following: a. The hospice forms, titled Social History, Caregiver Self-Assessment Questionnaire and Social Work Assessment Tool, all identified a visit date of 3/16/22 and included documentation of a discussion with the MSW by Staff D, Social Worker/Bereavement Coordinator, dated 3/30/22. The form did not include any other date to indicate when Staff D completed the documentation prior to 3/30/22 (exceeding the hospice's policy completion timeframe). b. The hospice forms, titled Psychosocial Assessment, Spiritual Care Assessment, Survivor Risk Assessment, Bereavement Risk Assessment and Bereavement Care Plan, lacked documentation to identify when Staff D, Social Worker/Bereavement Coordinator, obtained the information from the patient and family. The form included documentation of a discussion with the MSW by Staff D, dated 3/30/22, but lacked any other date to indicate when Staff D completed the documentation. 3. Patient #2 had a hospice admission date of 4/27/22, received hospice services while residing in a private residence. Review of the clinical record revealed the following: The chaplain visit notes, dated 5/5/22, failed to included documentation of a signature of completion by the chaplain and credentials. On 6/15/22 at 9:25 AM, during an interview, the Administrator stated she received an email of the visit note on 6/15/22. 4. Patient #10 had a hospice admission date of 2/25/22, a death date of 3/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Comprehensive assessment completed by the social worker lacked a visit date but was signed as completed on 3/4/22, 3 days after the patient's death. b. Comprehensive assessment completed by the social worker/spiritual care coordinator lacked a visit date but was signed as completed on 3/4/22, 3 days after the patient's death. c. Spiritual Care visit note, dated 2/25/22, included hand written signature, dated as completed 2/28/22, lacked a signature title. 5. Patient #4 had a hospice admission date of 3/7/22 and received hospice services while residing in a nursing home. Clinical record review revealed skilled nursing visit note, dated 6/9/22, lacked a handwritten signature, title and date of signature. The Administrator, Clinical Manager and Staff C, Registered Nurse 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 maintain documentation in the patient clinical records as evidence that patients received a copy of the hospice policy concerning the disposition of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients (Patients #1 and #5) who received routine home care while living in a private home and had physician ordered controlled medications, not on admission, but some time after the patient's admission to hospice. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: According to the hospice policy titled home care Medication Disposal, dated 5/20/22, a nurse who generates pharmaceutical waste during a home visit is responsible for its proper disposal; however, the nurse is also responsible for educating the patient and family on proper disposal methods. According to the hospice policy titled Disposition of Unused Medication, dated April, 2022, upon admission of a Hospice patient, the front page of the disposition of unused medication form will be filled out, signed by patient and/or family member and witnessed by RN. On 6/14/22 at 3:05 PM, during an interview, the Administrator stated staff educate and give patient's a copy of the Narcotic medication destruction policy at the start of care. She further stated staff had not been providing education on the policy if the patient narcotic medication not started until some time after the start of care. 1. Patient #1 had a hospice admission date of 2/21/22, and received services while residing in a private residence. Review of the clinical record revealed the following: a. The patient's paper chart clinical record included documentation of physician orders for 16 medications, all with a start date of 2/21/22. None of the ordered medications were a controlled medication. b. The comprehensive assessment completed by a RN, dated 2/21/22, included documentation the nurse discussed with the patient or caregiver instructions and the policy for managing controlled drugs given. c. An interim physician order, dated 4/14/22, included an order for Lorazepam, a controlled medication. d. The skilled nursing visit note, dated 4/18/22, identified the patient had a new order for Lorazepam. The visit note and clinical record lacked documentation the nurse provided instruction or written material on the disposal of controlled medications per Federal regulation. 2. Patient #5 had a hospice admission date of 3/24/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial Plan of Care, dated 3/24/22 to 6/21/22, included physician orders for medications, but no controlled medications. b. A hospice form, titled Disposition of Unused Medications, dated and signed by the patient on 3/24/22, included documentation of review and identification of receipt of the hospice's policy on the disposal of medications including controlled substances. c. A physician order, dated 5/24/22, included an order for Tramadol, a controlled medication. d. The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered a controlled medication per federal regulation. On 6/14/22 at 1:59 PM, during an interview the Administrator reported she remembered taking the Tramadol out to the patient and explaining the use of the medication, but she did not document this. She confirmed there was no documentation of discussing the disposal 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 hospice clinical record review, skilled nursing facilities/nursing facilities (nursing home) clinical record review, nursing home staff interview and hospice staff interview, the hospice failed to maintain all required hospice documents/information at the nursing homes where hospice patients reside for 2 of 2 patients receiving a surveyor on-site visit to the nursing home (Patients #3 and #4). Failure to communicate hospice information to nursing home staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: According to the undated hospice policy, titled Hospice Nursing Home Policy, the hospice will provide the nursing home with the following information: the most recent hospice plan of care specific to each patient; hospice election form and any advanced directives specific to each patient; physician certification and recertification of terminal illness specific to each patient; names and contact information for hospice personnel involved in hospice care of each patient; instructions of how to access the hospice's 24 hour on-call system; hospice medication information specific to each patient; and hospice physician and attending physician orders specific to each patient. 1. Patient #3 had a hospice admission date of 5/20/2022 and received services while residing in a nursing home residence. During a home observation visit on 6/15/22 at 10:00 AM, with Staff C, Registered Nurse (RN), the surveyor and Staff C reviewed the hospice binder in the nursing home for hospice documents provided. The surveyor was unable to find a copy of the hospice benefit election form for Patient #3. On 6/15/22 at 11:20 AM, Staff C confirmed the hospice benefit election form was not in the hospice binder at the nursing home. The clinical record review revealed the hospice benefit election form was completed on admission to hospice. The hospice staff failed to ensure the nursing home had a copy of the hospice benefit election form. 2. Patient #4 had a hospice admission date of 3/7/2022 and received services while residing in a nursing home residence. During a visit to the nursing home on 6/15/22 at 10:00 AM, the surveyor and Staff C reviewed the hospice binder at the nursing home for hospice documentation provided. The surveyor was unable to find a copy of the certification and recertification of terminal illness forms and the IDG (interdisciplinary group) meeting note, dated 5/2/22, for Patient #4. On 6/15/22 at 11:23 AM, Staff C confirmed the certification and recertification of terminal illness forms and the 5/2/22 IDG meeting note were not in the hospice binder at the nursing home. On 6/15/22 at 11:30 AM, the nursing home director of nursing, reported she looked for the terminal illness forms and IDG meeting note and was not able to find the documentation. The clinical record review revealed the certification and recertification of terminal illness forms and 5/2/22 IDG meeting note were completed. The hospice staff failed to ensure the nursing home had a copy of the certification and recertification of terminal illness forms and IDG meeting note. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.