Every finding on record at Iroquois Memorial Hospital and Resident Home

Observed in Document Review. The organization had not defined in writing, the scope and content of reassessment information it collects. In review of the organization's documents and policies the hospice nurse surveyor noted they had defined in writing the scope and content of the Comprehensive Assessment however they had not identified the content and information they collect for reassessments. This was validated with the Hospice Nurse Manager.

Observed in Record Review. In 2 of 14 patient records reviewed, the written plan of care was not based on the patient and family needs as identified in the comprehensive assessment. In review of the medical record for HOS RRHV #2 the oxygen safety risk assessment completed at the start of care identified risks including; smoking materials in home and other fire safety risks in the home. Additionally, during the home visit the Hospice Nurse and the Hospice Surveyor noted that there were two e-tanks that were secured in a stand however stored in an area without adequate ventilation behind a mattress in a storage room. In review of the medical record it was noted that there were no goals or interventions on the Plan of Care regarding Oxygen Safety. Also, in review of the medical record for HOS RRNHV #2 the oxygen safety risk assessment completed at the start of care identified safety risks including clutter however the surveyor noted that Oxygen Safety was not addressed on the Plan of Care. This was validated with the Hospice Nurse Manager.

Observed in Tracer Activities. The organization was not able to demonstrate savings achieved by volunteer staff providing day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The Hospice documented a savings of 4.1% for 2025. This was validated by the Home Health & Hospice Director and the Hospice Nurse Manager.

Observed in Leadership Session. The hospice had not designated a physician to assume the same responsibilities as the Hospice Medical Director when she is not available. In discussion with the Home Health & Hospice Director and the Hospice Nurse Manager they confirmed that the contract with the medical director did provide for back up coverage from the medical group but a specific physician was not identified.

Observed in Patient Home. with registered nurses, the patient record was not complete and included information that reflected the patient's care and treatment. For HOS RRHV #1 the medication profile was inaccurate and included Macrobid 100 mg , Meropenem 1000mg and Levofloxacin 750 mg as active medications when all had end dates of 08/30/2022. Additionally, the patient had Bisacodyl suppository 10 mg 1 daily prn for constipation in the home which was not on the medication profile. For HOS RRHV #2 the medication profile included Ropinirole 5 mg daily however the patient reported that she had discontinued that medication 2 months ago at the time of election of the hospice benefit. Also, the comfort medications Acetaminophen 650 mg suppository and Bisacodyl 10 mg suppositories were on the medication profile but were not in the home. This was validated with the Hospice Nurse Manager.

Observed in Record Review. In 7 of 14 patient records reviewed, the patient record was not complete and documented in accordance with the organization's Policy: Documentation of Written Records which states; the recorded information includes but is not limited to; observations and assessments of patient, family and environment, vital signs taken, care provided and interventions carried out, patient/family input and response, teaching instructions given, all phone calls and conferences concerning patient, plans for follow up care and treatment. In review of the medical record for HOS RRHV #2 8 out of 13 skilled nursing visit notes were narrative notes and did not include required elements, for example the SNV documentation on 11/28/2025 documented that the patient's port was re-accessed per protocol, dressing to patient coccyx are was changed, however the documentation did not fully describe the treatments and dressing changes performed. This was also observed in review of medical records HOS RRHV # 1, HOS RRNHV #4, HOS RRNHV # 5, HOS RRNHV # 6, HOS RRNHV # 8, and HOS RRNHV 10 where the surveyor noted SNV notes were narrative notes that failed to include required elements. This was validated with the Hospice Nurse Manager.

Observed in Document Review. the organization's written agreement with the contracted durable medical equipment company did not include a stipulation that they will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was validated with the Hospice Nurse Manager.

Observed in HR File Review. In 5 of 6 HR files reviewed, the organization had not documented orientation of its staff to the key safety content it identifies before staff provides care, treatment, or services. There was no department specific orientation documented in any file for any hospice employee except for the Volunteer. The Home Health Supervisor was able to speak to Home Health and Hospice practices, however verified that this was not documented. Observed in HR File Review. In 6 of 6 HR files reviewed, the organization had not documented training staff for their assigned emergency response roles. The organization had documented initial emergency plan training only for the hospital emergency plan, not the home health and hospice EM plan.

Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not include information that documented the patient’s response to care, treatment, or services provided. In the chart for HSRR#7, the patient revoked hospice services, yet there was no documentation in the record to indicate why the patient revoked services, how the organization was informed about the decision, etc. This was confirmed with the Hospice Supervisor

Observed in Record Review. In 3 of 13 patient records reviewed, the plan of care (POC) did not include an assessment of the patient’s needs and an identification of the provided services, including the management of discomfort and symptom relief. In the chart for HSHV#1, the patient was assessed upon admission to have had a two night history of inability to urinate one week prior to hospice admission which prompted a hospitalization, yet the urinary system on assessment indicated no urinary problems. The hospice POC did not address this potential problem with any interventions. Additionally, the patient was assessed to be at risk for falls yet the POC did not include any specific interventions for fall precautions. In the chart for HSRR#3, the patient was assessed to be at risk for pressure ulcer development, yet the POC did not include any interventions related to this risk. The patient was also on oxygen, yet there were no interventions related to teaching about safe use of oxygen. In the chart for HSRR#8, the patient was assessed to be at high risk for pressure ulcer development and education was provided to the primary caregiver re: pressure ulcer prevention, however this was not on the hospice POC. This was discussed with the Hospice Supervisor. Observed in Record Review. In 8 of 13 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for HSHV#1, the patient was assessed to be at risk for falls and was newly on home oxygen at the admission to hospice. The plan of care had no goals related to the safe use of oxygen. The time frame for the fall goal was not appropriate to the patients needs and read patient will not have a fall during the benefit period. The patient was admitted with a history of inability to urinate, yet there was no goal related to this problem. In the chart for HSRR#3, the pain goal for the patient was expected to be met 2 months after admission, not individualized appropriately for this palliative problem. The patient was on oxygen, yet there was no goal related to this safety issue. In the chart for HSRR#2, goals had not been individualized to the patient. The patient was actively dying on admission, yet the pain and SOB management goals were the last day of the 90 day benefit period. In the chart for HSRR#1, the goals were not individualized to he patient; target dates were the end of the benefit period. No goals for the wound, no goals for oxygen/falls safety. In the chart for HSRR#7, the goals were not individualized to the patient's status. The target date for understanding use of oxygen and comfort kit medications was the last day of the first benefit period. In the chart for HSRR#8, the anticipated target date for all goals are toward the end of the benefit period, even goal of no falls. There was no goal for oxygen safety issue; no goals re: wound or wound care except that the patient will not develop any further wounds during the benefit period. In the charts for HSRR#9 and HSRR#9, all goals were the last week of the admission benefit period. This was discussed with the Hospice Supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, the POC was not updated with changes in treatment. In the chart for HSRR#1, the POC was not updated to include the amount and frequency of contacts when the IDT added volunteer services. This was discussed with the Hospice Supervisor.

Observed in Record Review. In 2 of 13 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HSRR#2, the orders lacked clarity. The patient had oxygen at 15 lpm on assessment, the POC stated the patient was to be on oxygen at 15 lpm, yet the medication order for oxygen on the POC was 2-4lpm prn SOB. In the chart for HSRR#5, on the POC there is an order to administer oxygen 2-4 liters per minute per nasal canula as needed for Shortness of breath Start Date: 03/22/2022; however elsewhere on the POC oxygen is ordered at 2lpm. This was discussed with the Hospice Supervisor.

Observed in Record Review. In 1 of 13 patient records reviewed, plan of care revisions were not based on information from updates to the patient's comprehensive assessment and did not address progress toward goals. In the chart for HSRR#7, the anticipated goal achievement dates were moved out to the end of the benefit period with each new benefit period, including the goal of the patient will understand use of oxygen and comfort kit medications which was added upon admission to the organization. This was discussed with the Hospice Supervisor.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Improving compliance with hand hygiene guidelines. As discussed with the Hospice Supervisor, the organization had no measurable goals for hand hygiene compliance other than increase the number of departments consistently doing hand hygiene. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. There were no measurable goals for the organization's IC prevention program excepting employee flu vaccination as discussed with the Hospice Supervisor.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100 and §418.116.

Observed in Patient Home. In 1 of 3 home visits conducted, The patient record did not contain a complete list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. During HSHV#1, the patient indicated that he had been taking Tamsulosin which was not on the hospice plan of care, nor the list in the home. He indicated he had been on that medication for more than 2 months as discussed with the hospice supervisor. Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain full clinical documentation. In the chart for HSRR#8, the RN documented Dressing to wound changed without difficulty to gluteal fold by writer. rather than what actual care was provided during the visit. This was discussed with the Hospice Supervisor.

Observed in Record Review. In 2 of 3 patient records reviewed, in which the patient was discharged alive, the hospice had not prepared a discharge summary. In the chart for HSRR#5, the patient's guardian revoked hospice services. In the chart for HSRR#7, the patient revoked hospice services. There was no discharge summary in either patient's chart as confirmed with the Hospice Supervisor.

Observed in Tracer Activities. At the time when controlled medications were first ordered, the hospice had not provided a copy of its written policies and procedures on the management and disposal of controlled medications to the patient or the patient’s representative and family. In the chart for HSHV#1, there was no documentation that the policy had been provided to the family upon admission when the comfort pack medications were ordered which included Morphine. Upon discussion with the Hospice Supervisor, it was discovered that it is not the practice of the organization to provide the policy to patients, rather a statement that the hospice staff will dispose of controlled substances.

Observed in Tracer Activities. The organization did not provide care, treatment, or services in accordance with licensure requirements, laws, and rules and regulations. During tracer activities, the hospice surveyor became aware that the hospice did not have a process in place to present the Hospice Addendum. The leaders were unaware of the requirement of the Hospice Addendum as confirmed with the Administrator.