Every finding on record at Iowa Hospice, LLC

Upon patient record review 2 of 14 (Patient #4, 6) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and 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 4 and 6, no evidence of an initial spiritual assessment.

Upon patient record review, 5 of 14 (Patient #2, 4, 5, 6, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2 AYR nasal spray on medication profile does not include which nostril or both. Nursing visit on 10/2/24 includes oxygen at 2-4LPM, medication profile includes 2LPM. Patient 4 Flonase nasal spray on medication profile does not include which nostril or both. Patient 5 nursing visit 4/29/24 documents oxygen 2-4LPM, and nursing visit 11/1/24 documents encouraged use of prn oxygen. NO evidence of oxygen on medication profile. Patient 6 nursing visits 10/4/24, 10/9, 10/11, 10/15 document the use of Zoloft, no evidence of Zoloft on medication profile. Patient 9 artificial tears are on medication profile without including which eye or both. Oxygen on medication profile at 2LPM, no evidence of a route. Miralax on medication profile, no evidence of mixing instructions.

Upon patient record review, 3 of 14 (Patient 4, 6, 7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 4 admitted 4/16/24, initial bereavement risk assessment completed on 6/13/24. Patient 6 admitted 10/1/24, no evidence of an initial bereavement risk assessment. Patient 7 admitted 8/19/24, no evidence of an initial bereavement risk assessment.

Upon patient record review, 6 of 14 (Patient #1, 2, 4, 7, 8, 9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1 initial nursing visit documents high risk for aspiration, no evidence of aspiration precautions. Patient 2 on Aspirin, no evidence of bleeding precautions. Diet mechanical soft with high risk for aspiration, no evidence of aspiration precautions. Patient 4 initial plan of care under Advance Directives includes POST, no evidence of code status on the plan of care. Patient 7 nursing visit on 8/19/24 documents dysphagia. Nursing visits in October document change of diet to mechanical soft. No evidence of aspiration precautions. Patient 8 on Aspirin, no evidence of bleeding precautions. Patient 9 initial plan of care under Advance Directives states none, no evidence of the code status on the plan of care.

Upon patient record review, 5 of 14 (Patient #2, 4, 5, 6, 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2 AYR nasal spray order does not include which nostril or both. Nursing visit on 10/2/24 includes oxygen at 2-4LPM, order includes 2LPM. Patient 4 Flonase nasal spray order does not include which nostril or both. Patient 5 nursing visit 4/29/24 documents oxygen 2-4LPM, and nursing visit 11/1/24 documents encouraged use of prn oxygen. No evidence of an order for oxygen. Nursing visits throughout the hospice admission document a foley in place, no evidence of an order for the foley. Patient 6 nursing visits 10/4/24, 10/9, 10/11, 10/15 document the use of Zoloft, no evidence of an order for Zoloft. Patient 9 artificial tears are ordered without including which eye or both. Oxygen ordered at 2LPM, no evidence of a route. Miralax ordered, no evidence of mixing instructions.

Upon patient record review, 3 of 14 (Patient #1, 5, 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1 nursing visit on 4/18/24 documents walker and over bed table in use, nursing visit on 10/9 documents a wheelchair in use. No evidence of an ordered for the needed DME. Patient 5 nursing visits on 4/29/24 and 11/1 document oxygen in use, no evidence of a DME order for oxygen. Patient 8 nursing visits on 5/10/24 and 10/24/24 document hospital bed, mattress, over bed table and wheelchair in use. No evidence of an order for the needed DME.

Upon client record review, 3 of 14 (Patient #1, 2, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1 order on 7/31/24 for SW effective 8/10/24 of 1m3 and 2prn. No evidence of visit or refusal in October that was due by 10/9 (10/9 new cert period). Patient 2 order on 8/21/24 for SW effective 9/1/24 of 2m2 and 2prn. No evidence of 2 visits or refusal on October that was due by 10/24 (10/25 began the new cert period). Patient 4 Order on 7/3/24 for SW effective 7/15/24 of 1m4 and 2prn. Routine SW visits completed on 8/21 and 8/29. Order on 10/2/24 for SW effective 10/13/24 of 2m3 and 2prn. Routine SW visit completed on 10/28/24, no evidence of a second visit or refusal for October.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 2 SC placed computer bag, tablet, and devotional book on the table in the facility's community room without a barrier and without cleaning the surface. The devotional book was placed into the computer bag without cleaning the book. Patient 3 RN reached into nursing side pocket to obtain gloves several times throughout the visit with dirty hands, she provided patient care and did not sanitize or wash hands prior to reaching into the nursing bag to obtain more gloves.

Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 13- 1 month bereavement letter due to be sent on 5/7/24 and 3 month letter due to be sent on 7/6/24, both were sent 9/19/24. Patient 14- 2 week letter due to sent on 2/19/24, it was sent on 4/17/24. 1 month bereavement letter due to be sent on 3/5/24, it was sent on 4/24/24. 3 month letter due to be sent on 5/4/24, it was sent on 9/19/24. 6 month letter due to be sent on 8/2/24, it was sent on 9/19/24.

Upon patient record review, 3 of 14 (Patient #1, 8, 10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1 initial nursing visit documents high risk for aspiration, no evidence of aspiration precautions on aide care plan. Patient 8 care plan includes aspiration precautions, no evidence of aspiration precautions on the aide care plan. Patient 10 care plan includes fall and aspiration precautions, no evidence of fall or aspiration precautions on the aide care plan.

Upon patient record review 6 of 14 (Patient #1, 2, 3, 4, 7, 9) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1 the 10/9/24 aide visit documented bath, shampoo, and hair care not needed. The 10/17 aide visit documented tub bath, shampoo and hair care not needed this visit. The 10/21 aide visit documented tub bath and shampoo not needed this visit. The 10/28 aide visit documented shampoo and tub bath not needed this visit. All tasks were every visit on the aide care plan. Patient 2 aide care plan included shower every visit, dressing weekly, skin care weekly. The following visits the aide documented shower not needed this visit: 10/8/24, 10/14, 10/23, 10/29. The aide completed dressing and skin care on the following visits: 10/2/24, 10/4, 10/8, 10/11. Patient 3 aide care plan included shower, dressing, hair care, nail care and skin care all as weekly. These were all completed on the following visits: 9/30/24, 10/4, 10/16, 10/18, 10/21, 10/24. Patient 4 the 10/30/24 aide visit documented tub bath not needed this visit, should be every visit. Patient 7 aide care plan included skin care weekly. Aide completed skin care on 10/21/24, 10/24, 10/28, 10/29. Patient 9 aide care plan includes hair care and nail care weekly. Hair care and nail care were completed 2x week throughout October.

Upon patient record review 1 of 14 (Patient #1) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1 aide supervisory visits completed on 9/20/24 and then again on 10/23/24.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Volunteer percentage for 2023 and to date in 2024 is 0%.

Upon personnel record review, 1 of 14 (Personnel #8) 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 8 no evidence of an initial competency hired 6/29/22.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 9 initial nursing visit documented PCA under supplies/equipment, there is no additional evidence that a PCA is needed for the patient or in use for the patient.

Upon client record review, 2 of 14 (Patient #7, 8) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 7 order on 8/21/24 for SW effective 8/19/24 of 1m1, 2m2, and 2prn. SW visits completed on 8/21 and 8/29, ordered for one visit. No evidence of any visits or a refusal for October. Patient 8 order on 5/16/24 for SW effective 5/10/24 of 2m3 and 2prn. SW visit completed 5/16, no evidence of a second visit for May or refusal. SW visit completed on 8/6 and no order for this visit.

Based on clinical record review, hospice policy review, hospice admission packet review, patient interview, family interview and staff interview, the hospice failed to: Ensure hospice staff protected and promoted the right of the patient to exercise his/her rights (see L0512) --- The cumulative effects of these practices resulted in the failure of the hospice staff to promote and honor the exercising of patient rights and provide services the hospice assessed the patient needed for the hospice's 31 patients.

Based on clinical record review, hospice policy review, patient representative and staff interview, the hospice failed to ensure hospice staff honored the right of the patient to receive effective pain management and symptom control while the patient received hospice services for 1 of 4 sampled hospice patients (Patients #3). Failure to ensure hospice staff ensured the patient received effective pain management and symptom control from the hospice for conditions related to the terminal illness, the patient did not have their rights honored in regards to pain management. Findings include: --- According to the hospice policy titled Patient Bill of Rights, dated 1/12/23, patients have the right to receive effective pain management, choose attending physician, receive information regarding the scope of services and services under the hospice benefit and be free from mistreatment, neglect or verbal, mental, sexual and physical abuse. Patient #3 had a hospice admission date of 1/31/23 and received hospice services while residing in a nursing home and had a discharge date of 2/7/23. Review of the clinical record revealed the following: a. The plan of care (POC), dated 1/31/23 to 2/7/23, included orders for skilled nursing services to monitor pain level using appropriate pain scale and goal of patient/caregiver will understand the pain scale, how to manage pain and report changes to hospice. The POC also included instructions to family to notify hospice nurse of any change in patient's pain intensity or if pain medication is not adequately controlling pain. The POC included the following medications for pain: Acetaminophen 500 mg (milligrams) 4 times a day, oral, Acetaminophen 650 mg every 4 hours as needed for main management with a maximum dose of 3,000 mg daily and Norco (Hydrocodone/Acetaminophen narcotic analgesic) 7.5 mg-325 mg 1 tablet every 6 hours as needed for pain management. b. The skilled nurse visit note, dated 2/5/23 from 4:41 PM to 6:01 PM, revealed an, as needed, skilled nurse visit made due to report of increased coccyx pain. Stage 4 decubitus ulcer with tunneling noted. The pain assessed in the coccyx area was mild and continuous with worsening with movement. The pain described throbbing, aching and deep. The pain worsened with change in position and improvement with lying still. The patient's family asked that the patient have a scheduled pain medication stronger than Tylenol. The patient currently takes Norco (narcotic analgesic) 7.5 mg (milligrams)/325 mg every 6 hours as needed. The hospice nurse talked with the medical director regarding increasing the pain medication and was informed the doctor will address pain medication on 2/6/23. The patient rates the pain as mild unless he/she is moving. Then it's worse. The patient had been given the prn Norco at 4:44 PM and patient tolerated the Norco well. The hospice nurse reviewed the administration of the Norco medication prn as ordered with nursing home staff to administer through the night for maximum comfort. Understanding voiced from nursing home staff. The facility will call hospice with concerns or changes. Family voices satisfaction with prn Norco being given. c. The nursing home document titled Medication Administration Record, dated 2/1/23 through 2/28/23, included administration of Acetaminophen 500 mg 4 times a day. Norco tablet administered and pain level rating from 0 to 10 (0 no pain and 10 the worse you can imagine) at the following dates and times: 2/1/23 at 12:18 PM, pain level 9 and 11:44 PM pain level 8 2/2/23 at 11:15 AM pain level 4 and 4:18 PM pain level 8 2/3/23 at 4:33 AM pain level 7, 11:30 AM pain level 7 and 10:28 PM pain level 8 2/4/23 at 7:11 AM pain level 3 and 3:49 PM pain level 3 2/5/23 at 10:32 AM pain level 4 and 4:44 PM pain level 5. d. The SN visit note dated 2/6/23 from 1:49 PM to 7:58 PM, Staff B, RN had been contacted by the facility due to patient has had a noted decline. When Staff B entered the room, patient's daughter was present and insisted patient to go to the Emergency Room (ER). Patient noted to be lethargic and not responding to verbal stimuli. Ambulance arrived and took patient to the ER. Staff B followed patient to the ER. Intravenous (IV) Fluids were started in the ER. After a while the patient started showing signs of pain and discomfort. ER physician gave patient an IV dose of Fentanyl. Patient started waking up and talking. Patient became alert and oriented x 3. e. The Social worker (SW) visit note dated 2/6/23 from 2:15 PM to 3:30 PM Staff D, Upon SW arrival to the nursing facility, patient was in bed with her eyes closed and breathing with her mouth open. Patient mumbled a few words, when SW spoke to her, otherwise she remained nonverbal. Ambulance arrived and took patient to the ER. f. Client episode coordination note dated 2/7/23 at 2:10 AM, Patient's daughter notified the hospice that the patient was admitted to the hospital for dehydration and failure to thrive. g. During an interview on 2/22/23 at 10:44 Am Staff D, SW, reported on 2/6/23, she made an as needed visit. Patient was nonresponsive, eyes open, mouth open, mouth breathing and unable to have a conversation. The ambulance was contacted and the patient went to the emergency room. h. During an interview on 2/22/23 at 8:35 AM Staff B, (RN) she made an as needed skilled nurse visit on 2/6/23, due to family reported a change in the patient's condition. The patient transported to the hospital via ambulance per family request. The hospice nurse met the family and patient at the emergency room. The patient started showing signs of pain and discomfort. The hospice nurse asked the Doctor to give the patient pain medication. The Doctor gave the patient IV fentanyl. The patient then started to wake up and talking and was alert and oriented. i. During interview on 3/6/23 at 2:43 PM Staff B, RN, reported she entered the ER at approximately 3:00 PM to 3:20 PM and left the ER at approximately 8:00 PM. At approximately 6:00 PM, Patient #3 started to move her legs and arms around and looked uncomfortable as if the patient was trying to reposition but was unable to reposition. Patient #3's daughter and Staff B, RN asked Patient #3 if she was having any pain and she was able to say ";yes". Patient #3 was not very responsive and not able to verbalize the type of pain or where it was located. She was only moving around and looked uncomfortable. The hospice nurse asked the Doctor to give the patient pain medication. The Doctor gave the patient IV fentanyl. The patient then started to wake up and talking and was alert and oriented. The above findings were reviewed with the agency Administrator and Regional Director of Clinical Operations. The agency provided no additional information prior to the end of the survey.

Upon patient record review, 1 of 11 (Patient #7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #7- The record indicated the 2 following entries on the medication list - Biofreeeze (Menthol) 4% topical gel QID as needed for pain apply to affected area and Diclofenac 1% topical gel 2x/day pain, apply 2gms transdermal to affected area. There was no evidence in either entry of the area of the patient's body that the gels were to be applied. COS

Upon patient record review, 2 of 11 (Patient #3,5) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3- The record indicated that the patient's primary terminal diagnosis was metastatic colon cancer. The patient was incontinent of bowel and was on 3 bowel medications. There was no evidence on the plan of care of a gastrointestinal problem with individualized goals and interventions. COS Patient #5- Documentation revealed in the initial nurse's note that the patient had 2 falls in the past 2 months and ambulated with assist of 1 with a walker, was forgetful, orientated to person only and had a primary terminal diagnosis of senile degeneration of the brain. The nurse's initial assessment determined the patient to be a high fall risk. There was no evidence in the plan of care of a safety problem with individualized goals and interventions. COS

Upon patient record review, 1 of 11 (Patient #7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #7- The record indicated the following 2 orders: Biofreeze (Menthol) 4% topical gel QID as needed for pain apply to affected area and Diclofenac 1% topical gel 2x/day pain, apply 2gms transdermal to affected area. There was no evidence in either order of the area of the patient's body that the gels were to be applied. COS

Upon patient record review, 1 of 11 (Patient #1) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1 - The record indicated the patient had falls on 10/7/21, 10/23/21 and 11/20/21. There was no evidence the plan of care had been updated to include a safety problem with individualized goals and interventions. COS

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #5 - The aide was observed providing nail care during the visit with gloves on. She did not remove the soiled gloves and perform hand hygiene prior to going back into her bag to retrieve lotion to use with the patient. The agency's policy stated, "Do not reenter the bag with gloves on. Remove the gloves if worn, perform hand hygiene, and then reenter the bag."

Upon patient record review, 1 of 11 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #2 - The record indicated the patient was on Eliquis. There was no evidence of a bleeding precautions listed on the aide care plan. COS