Every finding on record at Iowa Hospice, L L C

Based on home observation visits, interviews, clinical record reviews and agency policy reviews, the hospice failed to ensure the Plans of Care (POC) for 1 of 1 sampled patients with home observation visits (Patient #1) 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 POC placed the patients at risk of unanticipated decline or injury and of needs not met.   Findings include: --- According to the hospice policy titled The Plan of Care, last revised 9/8/25, the written plan of care will contain, but will not be limited to, the following: durable medical equipment and medical supplies necessary to meet patient needs.  1.Patient #1 had a hospice admission date of 10/4/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 7/31/25 to 9//2825, identified the patient had a diagnosis of Hemiplegia post Cerebral Vascular Accident and used the following medical equipment and supplies: alternating-pressure mattress, bariatric bed, broda chair, gel wheelchair cushion, hospital bed, hoyer lift, low-air loss mattress, rails/grab bars, ROHO wheelchair cushion, trapeze, gloves, incontinence products, skin protectant. b. During a home observation visit on 9/30/25 at 11:00 AM, with the Staff B, Registered Nurse (RN), the surveyor observed the patient utilized positioning wedges, urinal, heel protectors and an elbow protector.   c. During an interview on 9/30/25 during the same observation visit, both the patient and Staff B, RN confirmed the medical equipment and supplies had been utilized since prior to the most recent recertification.   d. The IDG meeting notes, dated 8/10/25, 9/3 and 9/17/25, failed to identify the positioning wedges, urinal, heel protectors and elbow protector utilized by the patient.   The hospice failed to include all medical equipment and supplies utilized by the patient.   The above findings reviewed with the Administrator and Regional Director of Clinical Operations.

Based on staff interview, clinical record reviews, and hospice policy review the hospice agency 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 3 of 6 sampled patients (Patients #1, #3, and #4).   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: --- According to the hospice policy titled Interdisciplinary Group Plan of Care, last revised 9/8/25, it will be the responsibility of the Case Manager to facilitate communication about changes in the patient's status between interdisciplinary group members and the patient's attending physician if any.  1.Patient #1 had a hospice admission date of 10/4/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 7/31/25 to 9/28/25, identified the patient had a diagnosis of Hemiplegia post Cerebrovascular Accident and included orders for hospice aide visits 2 times a week in addition to skilled nurse, social worker and chaplain visits.   b. The clinical record included documentation of only one hospice aide visit the week of 8/24/25.   c. The IDG meeting notes to update the POC, dated 9/3/25, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 8/24/25.   The hospice failed to provide hospice aide visits as ordered per the POC.   2. Patient #3 had a hospice admission date of 4/21/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 7/20/25 to 10/27/25, identified the patient had a diagnosis of Cerebral palsy and included orders for skilled nurse visits 2 times a week in addition to hospice aide, social worker and chaplain visits.   b. The clinical record included documentation of only one skilled nurse visit the week of 8/3/25.   c. The IDG meeting notes to update the POC, dated 8/20/25, lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 8/3/25.   d. The clinical record included documentation of no skilled nurse visit the week of 8/17/25. e. The IDG meeting notes to update the POC, dated 9/3/25, included documentation the IDG was notified of only one missed skilled nurse visit for the week of 8/17/25. The hospice failed to provide hospice aide visits as ordered per the POC.   3. Patient #4 had a hospice admission date of 7/29/25 and revoked services on 9/18/25. Patient #4 received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 7/29/25 to 10/26/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse visits 2 times a week in addition to hospice aide, social worker and chaplain visits.   b. The clinical record included documentation of only one skilled nurse visit the week of 8/10/25.   c. The IDG meeting notes to update the POC, dated 8/20/25, lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 8/10/25.   The hospice failed to provide hospice aide visits as ordered per the POC.   The above concerns reviewed with the Administrator and Regional Director of Clinical Operations.

Based on policy review, hospice staff interview and clinical record review, the hospice failed to ensure patient clinical records included a physician order for all medications and treatments for 1  of 6 sampled patients (Patient #5) Failure to have a physician order for all medications and treatments increased the potential for patients to receive incorrect or ineffective treatment to meet assessed needs.   Findings include: --- According to the hospice policy, titled The Plan of Care (POC), last revised 9/8/25, any change in the patient's condition must result in a change in the plan of care, prior to implementation of the new service. The Plan of Care will include pain and symptom management interventions and medications and treatments. Patient #5 had a hospice admission date of 5/8/25 and date of death of 7/21/24 and received hospice services while residing in a private residence (Assisted Living Facility).  Clinical record review revealed:  During an interview on 10/1/25 at 8:35 AM  Staff B, Registered Nurse stated the patient fell on 7/17/25 and noted to have deformity and swelling of the right shoulder area. She identified the family chose no x-rays or treatment. She further stated she contacted the Medical Director and he wrote scripts for comfort medications and sent the scripts to the pharmacy to be filled and delivered. Staff B identified the Medical Director sent screenshots of the medication orders to her phone. She stated the screenshots remained on her phone and not part of the patient's clinical record. Staff B further stated she failed to add the orders to the patient's clinical record and identified the Assisted Living had the orders from the Medical Director and medications sent by the pharmacy. a. The POC, dated 5/8/25 to 8/5/25, identified the patient had a diagnosis of Atherosclerotic Heart disease and included orders for medications including Acetaminophen 325 milligrams (mg), 2 capsules every 6 hours as needed for pain. b. The skilled nurse note, dated 7/17/25, Staff B, Registered Nurse, (RN) documented the patient had a fall and assessed bruising to the right clavicle, neck, shoulder, bicep and chest area. The patient visualized to be lying crosswise, staff stated afraid to turn the patient. The hospice nurse and hospice aide arrived. Hospice nurse instructed staff to give the patient comfort medications. Hospice nurse straightened (repositioned) and changed the patient. The patient much more comfortable when hospice staff left. c. The screen shots, dated 7/17/25, visualized on Staff B, RN cellular phone included the following physician orders: Morphine sulfate, 15 mg tablet dissolved under tongue or in cheek every 3 hours scheduled and every 1 hour as needed for moderate to severe pain, dyspnea, or significant agitation or restlessness, Atropine sulfate ophthalmic solution 1%,1 to 2 drops every 1 hour as needed for excessive secretions or rattling, and Lorazepam tablet 0.5 mg dissolve under tongue or in cheek every 3 hours scheduled and every 1 hour as needed for anxiety, agitation, dyspnea, or restlessness. d. Review of the clinical record failed to include physician orders for Morphine, Atropine or Lorazepam. The hospice failed to document complete medication orders. The above findings reviewed with the Administrator and Regional Director of Clinical Operations.

Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 4 of 6 sampled patients (Patients #1, #3, #4 and #5).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: --- According to the hospice policy titled Clinical Record, last revised 7/31/25, entries into the clinical/service record will be made timely to document the services provided to the patient. During an interview on 9/30/25 at 9:05 AM the Administrator stated the expectation of staff is to complete documentation by 9:00 AM the following calendar day after the service provided. 1.Patient #3 had a hospice admission date of 10/4/24 and received services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 10/4/25, identified the patient had a diagnosis of Hemiplegia post Cerebrovascular Accident and included orders for skilled nurse, social work, hospice aide and chaplain services.   b. The skilled nurse visit note, dated 8/6/25, completed and signed 8/10/25 by Staff B, Registered Nurse (RN), 4 calendar days after the visit and 3 days late (per agency policy). b. The skilled nurse visit note, dated 8/14/25, completed and signed 8/17/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). c. The skilled nurse visit note, dated 9/16/25, completed and signed 9/21/25 by Staff B, RN, 5 calendar days after the visit and 4 days late (per agency policy). The hospice failed to have all documentation completed timely.   2. Patient #3 had a hospice admission date of 4/21/25 and received services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 7/20/25 to 10/27/25, identified the patient had a diagnosis of Cerebral Palsy and included orders for skilled nurse, social work, hospice aide and chaplain services.   b. The skilled nurse visit note, dated 8/6/25, completed and signed 8/10/25 by Staff B, Registered Nurse (RN), 4 calendar days after the visit and 3 days late (per agency policy). b. The skilled nurse visit note, dated 8/14/25, completed and signed 8/17/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). c. The skilled nurse visit note, dated 8/29/25, completed and signed 9/1/25, by Staff B, RN,  3 calendar days after the visit and 2 days late (per agency policy). e. The skilled nurse visit note, dated 9/16/25, completed and signed 9/21/25 by Staff B, RN, 5 calendar days after the visit and 4 days late (per agency policy). The hospice failed to have all documentation completed timely.   3. Patient #4 had a hospice admission date of 7/29/25 and revoked services on 9/18/25 and received services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 7/29/25 to 10/26/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, hospice aide and chaplain services.   b. The skilled nurse visit note, dated 8/1/25, completed and signed 8/4/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). b. The skilled nurse visit note, dated 8/5/25, completed and signed 8/7/25 by Staff B, RN, 2 calendar days after the visit and 1 day late (per agency policy). c. The skilled nurse visit note, dated 8/7/25, completed and signed 9/10/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). The hospice failed to have all documentation completed timely.   4. Patient #5 had a hospice admission date of 5/8/25 and date of death of 7/21/25 and received services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 5/8/25 to 8/5/25, identified the patient had a diagnosis of Atherosclerotic Heart disease and included orders for skilled nurse, social work, hospice aide and chaplain services.   b. The skilled nurse visit note, dated 6/12/25, completed and signed 6/16/25 by Staff B, RN, 4 calendar days after the visit and 3 days late (per agency policy). b. The skilled nurse visit note, dated 6/13/25, completed and signed 6/16/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). c. The skilled nurse visit note, dated 6/27/25, completed and signed 6/29/25 by Staff B, RN, 2 calendar days after the visit and 1 day late (per agency policy). d. The skilled nurse visit note, dated 7/16/25, completed and signed 7/20/25 by Staff B, RN, 4 calendar days after the visit and 3 days late (per agency policy). e. The skilled nurse visit note, dated 7/17/25, completed and signed 7/20/25 by Staff B, RN, 3 calendar days after the visit and 2 days late (per agency policy). f. The skilled nurse visit note, dated 7/18/25, completed and signed 7/20/25 by Staff B, RN, 2 calendar days after the visit and 1 days late (per agency policy). The hospice failed to have all documentation completed timely.   The above findings reviewed with the Administrator and Regional Director of Clinical Operations.

Based on review of the hospice staff interview, record review, hospice incident investigation and policy review the hospice failed to report suspected allegations of dependent adult abuse (exploitation by theft) as required by agency policy for 1 of 1 patient reviewed with allegations of abuse. (Patient #5) Failure to report suspected abuse to the appropriate authorities, increased the risk of continued abuse by the alleged perpetrator with patients of the hospice. Findings include: --- According to the policy, titled Assessment of Possible Abuse/Neglect and dated as revised 10/12/23, any clinician who discovers, within the course of rendering care, any suspected abuse or neglect will immediately report such occurrences to his/her immediate supervisor. The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident. The policy defined abuse/domestic violence as any act that constitutes a violation of the prostitution, criminal, or sexual conduct statutes; the intentional and nontherapeutic infliction of pain, injury, or any persistent course of conduct intended to produce mental or emotional distress. The policy defined caregiver as an individual or facility responsible for all or some of the care voluntarily or by agreement, such as a relative, friend or organization personnel. The policy directed the clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities in accordance with state law and complete a suspected abuse and/or neglect investigation report within 24 hours of the incident. The policy defined report as any report received by the local welfare organization, police department, county sheriff, or licensing organization; a verbal and/or written statement of abuse and/or neglect that states what has happened, to whom it happened, when it happened, where it happened and who was responsible for the abuse or neglect. The policy defined an individual mandated to report as a professional or the professional's delegate who is engaged in the care of the patient, who had knowledge of the abuse or neglect of a patient, or who has reasonable cause to believe that a patient is being or has been abused or neglected, or who has knowledge that a patient has sustained a physical injury that is not reasonable explained by the history of injuries provided by the caretaker or caregiver of the patient. Review of the hospice incident report, dated 4/30/24, indicated Staff G, Registered Nurse (RN) reported to the office that Patient #5 stated the patient's spouse was verbally abusive and threw an inhaler at him/her and threatened to hit him/her. Patient #5 had stated his/her spouse stated he/she was a burden and everything was his/her fault and he/she was worthless. The report also indicated the patient had a history of making allegations and then denying them upon further questioning and adamantly denied ever making allegations. The hospice care team and the hospice corporate personnel were notified. On 5/6/24 the hospice social worker was notified by the hospice corporate personnel to make a Department of Human Services (DHS) referral. On 5/6/24 the hospice social worker filed a formal report with DHS. During an interview on 6/12/24 at 10:39 AM, Staff D, Social Worker stated she had been notified patient #5 reported to Staff G, RN the patient's spouse threw an inhaler at him/her, called him/her names and stated they did not want to care for Patient #5 anymore. Staff D stated she contacted their hospice corporate personnel and called DHS the next day (5/7/24). During an interview on 6/12/24 at 10:39 AM, Staff G, RN stated Patient #5 had reported that her husband thought Patient #5 were using the inhaler too often. The patient reported to Staff G that his/her spouse had his/her inhalers. The patient also stated he/she begged for the inhaler and the patient's spouse threw the inhaler at him/her. The patient also reported the spouse stated the patient a burden and no longer wanted to care for him/her. Patient #5 had a start of care date of 10/20/23 and discharge date of 5/16/24. a. The plan of care, dated 4/17/24 to 6/15/24, included orders for skilled nursing, social worker and chaplain services. b. The skilled nurse note, dated 4/30/24, identified the patient alert to person, place, time and situation. The note also identified the patient had periods of confusion. The patient required total care with dressing and bathing and needs extensive assistance required for toileting and bed mobility. The note included documentation the patient stated his/her husband threw an inhaler at him/her last night and threatened to hit him/her, The patient stated the spouse repeatedly tells him/her how he/she is a burden, everything is his/her fault and he/she is worthless. The Interdisciplinary Group (IDG) note, dated 5/15/24, included documentation from Staff G, RN the Department of Human Services was contacted due to patient stated his/her spouse threw an inhaler at him/her and threatened to hit him/her. The patient not a dependent adult and can make their own decisions. The above stated findings were reviewed with the Clinical Manager, Staff C, Vice President of Clinical and Staff J, Area Director of Clinical Operations.

Based on hospice staff interview, clinical record review, hospice policy review the hospice failed to develop and maintain a system of communication and integration, to provide for and ensure the ongoing sharing of information between all disciplines providing care for 1 of 6 sampled patients (Patient #5). Failure to ensure hospice staff provide care and services in accordance with the Plan of Care developed by the interdisciplinary Group (IDG) placed the patient at risk for not receiving necessary care and services to meet the needs of the patient. Findings include: --- According to the hospice policy titled Interdisciplinary Group Meeting, dated 12/24/15, the hospice must designate a Registered Nurse who is a member of the IDG to provide coordination of care and ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care. Review of the hospice incident report, dated 4/30/24, indicated Staff G, Registered Nurse (RN) reported to the office that Patient #5 stated the patient's spouse was verbally abusive and threw an inhaler at him/her and threatened to hit him/her. Patient #5 had stated his/her spouse stated he/she was a burden and everything was his/her fault and he/she was worthless. The report also indicated the patient had a history of making allegations and then denying them upon further questioning and adamantly denied ever making allegations. The hospice care team and the hospice corporate personnel were notified. On 5/6/24 the hospice social worker was notified by the hospice corporate personnel to make a Department of Human Services (DHS) referral. On 5/6/24 the hospice social worker filed a formal report with DHS. During an interview on 6/11/24 at 3:53 PM, Staff B, Clinical Manager stated Staff G, RN reported an incident that the patient stated occurred the previous evening. The incident reported by Staff G, RN on 4/30/24. The hospice Corporate personnel were involved to to make sure the hospice did the right thing. The Social Worker called the department of human services to make the report (DHS). During an interview on 6/12/24, Staff D, Social Worker, stated on 5/13/24, she had been told Staff G. RN had a report from the patient his/her spouse had thrown an inhaler at him/her and stated Patient #5 no longer wanted the hospice agency to care for him/her. The next day, 5/14/24, a report was made to DHS about Patient #5 treatment by her/his spouse. During an interview on 6/13/24 at 11:55 AM Staff G. RN stated she reported Patient #5 incident on 4/30/24 to the Administrator. She further stated the IDG discussed the incident with Patient #5, on 5/1/24 during the IDG meeting. 1. Patient #5 was admitted to hospice on 2/27/23 and had a discharge date of 5/16/24. a. The plan of care (POC), dated 2/27/23 to 5/27/23, included physician orders for skilled nursing, social worker and chaplain services. b. The skilled nurse note, dated 4/30/24, Staff G RN, identified the patient alert to person, place, time and situation. The note also identified the patient had periods of confusion. The patient required total care with dressing and bathing and needs extensive assistance required for toileting and bed mobility. The note included documentation the patient stated his/her husband threw an inhaler at him/her last night and threatened to hit him/her, The patient stated the spouse repeatedly tells him/her how he/she is a burden, everything is his/her fault and he/she is worthless. c. The IDG note, dated 5/1/24, failed to include documentation of allegations of potential patient abuse regarding Patient #5 stated his/her spouse threw inhalers to him/her and threatened to hit him/her. d. The IDG note, dated 5/15/24, included documentation from Staff G, RN that Department of Human services was involved due to Patient # 5 stated his/her spouse threw inhalers to him/her and threatened to hit him/her. The patient not a dependent adult and can make own decisions. The hospice failed to develop and maintain a system of communication and integration, in accordance with the IDG in relation to a report of an allegation of abuse, failed to investigate and report in a timely manner. The above stated findings were reviewed with the Clinical Manager, Staff C, Vice President of Clinical and Staff J, Area Director of Clinical Operations.

Upon patient record review 1 of 14 records (Patient #3) did not have evidence in the patient record that the comprehensive assessment identifies the spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #3: There was not evidence of a spiritual assessment.

Upon client record review, 1 of 14 records (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5: The skilled nurse visit frequency was 7x/week. There was not evidence of 7 visits for the week of 10/29/23-11/4/23. (6 routine visits were conducted this week).

Upon patient record review 1 of 14 records (Patient #2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #2: The aide plan of care dated 9/12/23 indicated to shampoo 1x/week. The aide visit frequency was 3x/week. For the week of 10/15/23-10/21/23, the aide documentation indicated that a shampoo was provided on 10/16/23 and 10/18/23. And for the week of 10/29/23-11/4/23, on all 3 visits, the aide documented 'per frequency not needed.'

Upon personnel record review, 1 of 12 records (Personnel # 11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #11: The staff member held the role of SW and VC. There was not evidence of a competency for the role of volunteer coordinator.

Upon patient client record review, 2 of 14 records (Patient #2,#4) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #2: The record indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. This was requested on the day of admission (4/14/23). There was not evidence that this was furnished and signed until 5/23/23. Patient #4: The record indicated that the patient/representative wished to receive the Patient Notification of Hospice Non-Covered Items, Services, and Drugs. This was requested on the day of admission (5/17/23). There was not evidence of the date that the document was furnished. The document was signed on 6/5/23.

Upon patient client record review, 1 of 14 records (Patient #11) did not evidence that each patient record contains physician orders. Patient #11: The record indicated that the patient was discharged due to moving to a non-contracted facility. There was not evidence of a discharge order from the medical director.

Upon client record review, 2 of 14 records (Patient #11,#12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11,#12: There was not evidence that any discharge documents were forwarded to the attending physician.

Upon client record review, 2 of 14 records (Patient #11,#12) did not have evidence that the discharge summary includes all required information. Patient #11,#12: There was not evidence that the discharge summary included a summary of the patient's stay, including treatments, symptoms and pain management.

Upon client record review, 1 of 14 records (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #8: An order for wound care dated 10/24/23 indicated that the hospice nurse/facility nurse to perform wound care to left buttocks wound daily. Clean with NS, rinse with NS, apply collagen, secure with optifoam or mepilex. The order did not specifically indicate which provider (nursing facility or hospice) was responsible for performing the wound care.