Every finding on record at Lee County Auditor

Based on clinical record review and agency policy review,  the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 1 of 5 sampled patients (Patient #10), with wounds.     Failure to complete an initial wound assessment increased the risk patient's needs would not be identified and/ or addressed appropriately, and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. --- Findings Include: According to the undated agency policy titled Homecare and Hospice Wound Care, nurses will use the wound assessment tool in the clinical Electronic Medical Record (EMR), software system on admission and weekly, and at the onset of new wounds or as specified in the plan of care. Documentation will include size of wound including length, width and depth.  Patient #10 had a start of care date of 2/27/25 and a death date of 3/4/25, and received hospice services in a long term care facility.  a. The Plan of Care (POC), dated 2/27/25 to 5/27/25, included a primary diagnosis of a stroke, and physician orders for skilled nurse to assess and evaluate for admission to hospice services.  b. The initial comprehensive assessment completed on 2/27/25, by Staff C, Registered Nurse (RN), identified a stage 2 pressure ulcer (a partial-thickness skin loss characterized by a shallow, open wound) on patients coccyx. Documentation identified wound measurements:  length of 2.4 centimeters (cm) and width of 0.3 cm but failed to include a measurement for the depth of the wound.  The initial comprehensive assessment lacked documentation of depth to the wound on the coccyx.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to:  1) Ensure a Registered Nurse provided coordination of care and completed IDG meeting notes for each patient and (see L540)  2) Ensure care and services are provided according to the plan of care. (see L555) --- The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure a Registered Nurse provided coordination of care, continuous assessment of each patient’s and family’s needs and implementation of the IDG plan of care.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure a Registered Nurse provided coordination of care and implementation of the interdisciplinary plan of care for 4 of 14 sampled patients (Patient #3, #4, #8 and #9).   Failure of the hospice to ensure a Registered Nurse (RN) participated in each interdisciplinary group meeting and completed interdisciplinary group meeting notes placed hospice patients at risk for not having all of their medical needs identified and met. --- 3. Patient #3 had a start of care date of 12/30/24 and received services from the hospice while residing in a private home.   Clinical record review revealed IDG meeting notes, dated 1/29/25, 2/13/25, 2/26, 3/12/25 and 3/26/25 were written and completed by Staff F, LPN.  The IDG failed to ensure an RN completed the IDG meeting notes for the patient.   4. Patient #8 had a start of care date of 04/24/24 and a discharge date of 10/8/24 and received services from the hospice while residing in a private home.   Clinical record review revealed IDG meeting note, dated 6/25/24 was written and completed by Staff F, LPN.  The IDG failed to ensure an RN completed the IDG meeting notes for the patient.  The above findings were reviewed with the Administrator and the Clinical Manager.  Findings include:  According to the hospice policy, titled Interdisciplinary Group, dated 2/2024, the interdisciplinary group (IDG) includes at a minimum: a doctor of medicine or osteopathy, a registered nurse, a social worker and a pastoral or other counselor.  A registered nurse member of the IDG is designated as the RN Case Manager for each patient and is responsible for coordinating care and services provided by the IDG, ensuring continuous assessment of the patient/caregiver needs, and implementing the IDG plan of care.  According to the hospice policy, titled Assessment – Updates to the Comprehensive Assessment, dated 4/2019, patient’s progress toward desired outcomes and response to care is reassessed as often as required by the patient’s condition but no less frequently than every 15 days.  Information from the updated comprehensive assessment is reviewed by the IDG at the IDG meeting and is used to revise the patient’s plan of care as needed.  During an interview on 4/8/25 at 1:05 PM, Clinical Manager reported the Licensed Practical Nurse (LPN) completes IDG meeting notes on weeks opposite the RN for patients seen by the LPN.  1.Pateint #4 had a start of care date of 12/5/24 and received services from the hospice while residing in a private home.   Clinical record review revealed IDG meeting notes, dated 12/31/24, 1/15/25 and 3/19/25, were written and completed by Staff F, LPN.  The IDG failed to ensure an RN completed the IDG meeting notes for the patient.  2. Patient #9 had a start of care date of 4/10/24, a discharge date of 7/5/24 and received services from the hospice while residing in a private home.  Clinical record review revealed IDG meeting note, dated 6/12/24, was written and completed by Staff F, LPN.  The IDG failed to ensure an RN complete the IDG meeting note for the patient.

Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure care and services were provided in accordance with the plan of care or the Interdisciplinary Group was notified of change in service frequency or missed visits for 2 of 14 sampled patients (Patients #3 and #8).    Failure to provide services in accordance with the plan of care and/or to update the Interdisciplinary Group (IDG) of changes in service frequency or missed visits increased the potential that patients might not receive services in a manner to meet individualized patient needs. --- Findings include:According to the hospice policy, titled Interdisciplinary Group, dated 2/2024, identified any change in service frequency or missed visits will be documented on the Interdisciplinary Group meeting note by the nurse, social worker, Registered Nurse case manager or designated nurse. 1.Patient #3 had a hospice admission date of 12/30/24 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The Plan of Care (POC), dated 12/30/24 to 3/29/24, included primary diagnosis of lung cancer and included physicians orders for social work visits 2 times per month. b. During an interview on 4/8/25, at 2:30 PM, Staff E, Licensed Social Worker (LSW),  acknowledged a missed a visit due to patient refusal on 2/6/25 and failed to complete a missed visit notification. c. The clinical record included a visit note completed by Staff E, LSW, on 2/19/24, but lacked a second visit note for the month of February.    d. The IDG meeting notes to update the POC, dated 2/13/25, lacked documentation the IDG was notified LSW missed a visit  for the week of 2/2/25.  The hospice failed to provide social work visits as ordered per the POC.    2. Patient #8 had a start of care date of 4/12/24, and a discharge date of 10/8/24, and received hospice services in a private home. Clinical record review revealed: a. The POC, dated 7/11/24 to 10/8/24, included a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and included physician orders for massage therapy visits 2 times per month.  b. The clinical record included a visit note completed by Staff H, Licensed Massage Therapist (LMT), on 7/10/24, but lacked a second visit note for the month of July.  c. The clinical record included a visit note completed by Staff H, LMT,  on 8/9/24, but lacks a second visit note for the moth of August.  d. The IDG meeting notes to update the POC, dated 7/17/24, 7/31/24, 8/21/24 and 9/4/24, lacked documentation IDG team was notified of missed LMT visits.  The hospice failed to provide LMT visits as ordered per the POC. The above findings were shared with the Administrator and the Clinical Manager.

Based on family and staff interviews, clinical record review, and agency policy review, the hospice agency failed to ensure that services were provided based on the assessments of the patient and family needs, including medical equipment and supplies for 1 of 14 (Patient #3) sampled patients.  Failure to ensure that services and medical supplies are provided that meet the needs of the patient and family based on comprehensive assessments, puts patients at risk for not having their needs met. --- Findings include: According to the agency policy titled Durable Medical Equipment, dated 10/2024, the hospice maintains contacts with accredited DME providers for the provision of safe and effective DME or the hospice clients.  The DME must be approved by the hospice IDG, ordered by the client's attending physician, and included in the clients plan of care.  The RN Clinical Case Manager requests the ordered DME from the provider and informs the client of the expected delivery and ensures adequate instruction and information related to the equipment is given to the client Patient #3 had a start of care date of 12/30/24, and received hospice services in a private home.  During an interview on 4/8/25, at 10:56 AM with a patient family member, he/she indicated that both patient and spouse had requested portable oxygen several different times and stated the agency staff did not provide portable oxygen, stating the patient wasn't safe walking to the garage with oxygen. The patient had wanted to go out to his/her garage and go on car rides and it would be hard without portable oxygen to go out to the garage. He/she also reported they still did not have portable oxygen in the home, but that he/she wasn't even sure patient could go out to his garage now as health had declined.   During an interview on 4/8/25, at 1:30 PM, Clinical Manager stated the portable oxygen had not been ordered for the home because of safety concerns and the agency felt that the house had to many fall risks for the patient to attempt to get out to the garage and that the agency was concerned it was to cold for the patient to leave the home. The Clinical Manager stated they were going to get the portable oxygen out to the home this week as the weather had warmed up, but acknowledged the safety risks, clutter and fall risk had not changed. The patient had declined physically and may not be able to out of bed.  Clinical record review revealed the following.  a. The Plan of Care (POC), dated 12/30/24 to 3/29/25, included a primary diagnosis of lung cancer, and included physician orders for skilled nurse visits 1-2 times a week and continuous oxygen at 3-4 liters per nasal cannula.  b. The skilled nurse visit note dated 1/7/25 noted the patient spouse requesting portable oxygen so patient could get out of the house, the Registered Nurse (RN) documented safety concerns with patient getting out of the house and that safety education had been completed with the patient and spouse.  c. The Interdisciplinary group note (IDG), dated 1/29/25 noted patient needs continuous oxygen at 4 Liters through a nasal cannula, but lacked  documentation about family and patient request for portable oxygen.  d. The IDG note, dated 2/13/25, noted patient requested portable oxygen and wanted to be able to get out of the house, agency documented continued safety concerns including cold weather for why the agency would not provide the portable oxygen and to continue to remind patient and family of safety concerns. The IDG note included documentation of possibly ordering the portable oxygen when the weather became warmer.   e. The IDG note, dated 3/12/25, documented patient was scheduled for an appointment with the attending physician on 3/26/25, but lacked documentation of how patient would be able to go to the physicians office without portable oxygen.  The agency failed to provide portable oxygen to enable to patient to leave home.  The above findings were reviewed with the Administrator and the Clinical Manager.

Based on personnel file review, staff interview and policy review the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a performance aide's performance of all required hospice aide skills on a hospice patient or pseudo-patient to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 1 of 3 sampled hospice aides (Staff D) hired since the last recertification survey (3/21/22).    At the time of the survey, the agency employed 4 hospice aides and provided hospice aide services to 3 patients.   Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services.  Findings include: --- The Medicare Conditions of Participation require hospices to ensure all newly hired hospice aides are competent in all of the basic hospice aide skills by successfully demonstrating competency in the performance of all of the "hands on" basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently.  The list of "hands on" basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation and range of motion and positioning.  Basic hospice aide competencies may be demonstrated using a patient or pseudo-patient.  According to the hospice policy titled Homemaker/Home Health Aide/Hospice Aide Training and Competency Evaluation, last revised February 2024, when a Homemaker/Home Health Aide/Hospice Aide is hired and prior to assignment of any client cares the Homemaker/Home Health Aide/Hospice Aide must demonstrate competency and Documentation of competent performance will be recorded in the Homemaker/Home Health Aide/Hospice Aide personnel records.  During an interview on 2/25/24 at 3:10 PM The Clinical Manager stated Staff D, Hospice Aide contracted through another agency and already had competency testing completed.  1.  Staff D, Hospice Aide, had a hire date of 5/4/22.  Staff D's personnel file included competency documentation on 5/8/19. The competency documentation failed to include competency testing completed by the hiring hospice.  Staff D provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills.  The above findings were reviewed with the Clinical Manager.

Based on personnel file review and staff interview the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed a written competency test to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 1 of 3 sampled hospice aides (Staff D) hired since the last recertification survey (3/21/22).   At the time of the survey, the agency employed 4 hospice aides and provided hospice aide services to 3 patients.   Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services.  Findings include: --- According to the hospice policy titled Homemaker/Home Health Aide/Hospice Aide Training and Competency Evaluation, last revised February 2024, competency will be evaluated by written examination, oral examination or observation of the Homemaker/Home Health Aide/Hospice Aide performance of the task on a person.   During an interview on 2/25/24 at 3:10 PM The Clinical Manager stated Staff D, Hospice Aide contracted through another agency and already had competency testing completed. She further stated unable to locae the written competency test.  1.  Staff D, Hospice Aide, had a hire date of 5/4/22.  Staff D's personnel file included competency documentation on 5/8/19. The competency documentation failed to include written competency testing completed by the hiring hospice.  Staff D provided care independently to agency patients without successfully completing the written test demonstrating competency in the performance of all required basic skills.  The above findings were reviewed with the Clinical Manager.

Based on agency interviews, clinical record review, and agency policy review, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 2 of 7  sampled patients receiving hospice aide services. (Patients #3 and #9). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. --- 2.  Patient #9 had a start of care date of 4/10/24, a discharge date of 7/5/24 and received services from the hospice while residing in a private home.  Clinical record review revealed:  a.  The undated hospice aide care plan included Registered Nurse (RN) instructions to the hospice aide to perform the task of Vital Signs – weight prn (as needed), with a start date of 4/10/24 and a resolved date of 7/5/24.  b.  The hospice aide visit notes, dated 4/30/24, 5/9/24, 5/23/24, 5/28/24 and 6/11/24, included documentation the task of Vital Signs – weight prn was not applicable.  The aide care plan failed to provide specific instructions to the hospice aide on when the weight was to be obtained or when to not obtain a weight for the patient.  During an interview on 4/8/25 at 1:05 PM, Clinical Manager reported the care plan was not specific with the instructions to the aide on when to obtain or not obtain a weight on patient.  The above findings were reviewed with the Administrator and Clinical Manager.   Findings include: According to the agency policy titled Hospice Aide Assignments and Duties, dated 2/2024, hospice aides are assigned to specific clients and follow written client care instructions in providing care to assigned clients.  A hospice aide provides services that are approved by the IDT group and included in the patient plan of care.  During an interview on 4/8/25 at 1PM, the Clinical Manager stated the Registered Nurse (RN) case manager creates and updates the aide care plan.  1. Patient #3 had a hospice admission date of 12/30/24 and received hospice services while residing in a private home.   Clinical record review revealed:  a. The Plan of Care (POC), dated 12/30/24 to 3/29/24, included primary diagnosis of lung cancer and included physicians orders for hospice aide services two times per week.   b. The undated hospice aide care plan included RN instructions to the hospice aide to perform the task of a complete bath.  c. The hospice aide visit notes dated 2/4/24,  2/25/24, and 3/4/24 documented complete bath performed as a bed bath.  d. The hospice aide visit notes dated 1/3/24 and 2/14/24 documented complete bath performed as a shower.  e. The hospice aide visit note dated 2/28/24 documented complete bath performed as a partial bed bath. f. The hospice aide visit notes dated 2/18/24,  2/21/24,  3/7/24,  3/11/24 and 3/14/24 did not specify the type of complete bath was performed.   The hospice aide care plan failed to identify what kind of complete bath the aide should perform, bed bath, shower, or tub bath.

Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 2 of 2 sampled services (Medical equipment/supply provider and Pharmacy provider).    Failure to include this provision 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.Review of the contract between the hospice and sampled medical equipment/supply provider, dated 7/29/2011, identified the contract lacked the following required components:  a. The hospice retains administrative and financial management,  b. The hospice retains oversight of staff and services and   c. All services are delivered in accordance with the patient's plan of care.    2. Review of the contract between the hospice and sampled pharmacy provider, dated 12/19/2014, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management,  b. The hospice retains oversight of staff and services and   c. All services are delivered in accordance with the patient's plan of care.   The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement.    The above findings were reviewed with the Clinical Manager.

Based on staff interview, clinical record review and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 4 of 14 sampled patients (Patients #1,#6, #8 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 #14 had a hospice admission date of 5/14/24, a revocation date of 5/31/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The Plan of Care, dated 5/14/24 to 8/11/24, identified the patient had a diagnosis of Congestive Heart Failure and included orders for skilled nurse, social worker, hospice aide and music therapy.    b. The skilled nurse visit note, dated 5/20/24, completed and signed 6/5/24, 11 working days after the visit and 6 days late.    The agency failed to ensure timely completion of routine visit documentation.    The above findings were reviewed with the Administrator and Clinical Manager.   2.  Patient #6 had a hospice admission date of 7/17/24, a death date of 8/5/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care, dated 7/17/24 to 10/14/24, identified the patient had a diagnosis of bladder cancer and included orders for skilled nurse, social worker, hospice aide, massage therapy  and music therapy.   b. The skilled nurse visit note, dated 7/22/24, completed by Staff C, RN, signed 8/1/24 (3 days late).   c. The skilled nurse visit note, dated 7/31/24, completed by Staff C, RN, signed 8/7/24 ( 1 day late).  The agency failed to ensure timely completion of routine visit documentation.    3.  Patient #8 had a hospice admission date of 4/12/24 and received hospice services while residing in a private home.  Clinical record review revealed:   a. The Plan of Care, dated 7/11/24 to 10/8/24, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social worker, and massage therapy. b. The skilled nurse visit note, dated 8/7/24, completed by Staff C, RN, signed 8/17/24 (3 days late).   c. The skilled nurse visit note, dated 9/11/24, completed by Staff C, RN, signed 9/25/24 (10 days late). d. The skilled nurse visit note, dated 9/17/24, completed by Staff C, RN singed 9/25/24 (1 day late). e. The skilled nurse visit note, dated 9/24/24, completed by Staff C, RN signed 10/4/24 (3 days late). f. The skilled nurse visit note, dated 10/1/24, completed by Staff C, RN signed 10/21/24 ( 9 days late).     The agency failed to ensure timely completion of routine visit documentation.   According to the hospice policy titled Clinical Records, revised in January 2024, required documentation for each service of care provided by the hospice agency must be completed (confirmed with e-signature for computerized charting) and available to file in the clinical record within five working days for nursing notes, social worker notes and bereavement notes for hospice patients.    During an interview on 4/1/25 at 11:15 AM, Staff B, Clinical Manager stated agency staff have five working days to complete routine visit notes.    1.Patient #1 had a hospice admission date of 3/6/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plan of Care (POC), dated 3/6/25 to 6/3/25, identified the patient had a diagnosis of Lung Cancer and included orders for skilled nurse, social worker, chaplain, massage therapy and music therapy.    b. The skilled nurse visit note, dated 3/12/25, completed by Staff C, Registered Nurse (RN), signed 3/26/25 (5 days late).    The agency failed to ensure timely completion of routine visit documentation.

Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospital would send a copy of the hospice patient's discharge summary to the hospice at the time of discharge from the hospital for 1 of 2 sampled written agreements reviewed (Hospital A).  Failure to ensure the hospital provided the hospice with a discharge summary upon hospital discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home.    Findings include: --- The hospice had a contractual agreement with Hospital A, dated 1/23/23.  The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge and failed to specify a copy of the inpatient clinical record is available to the hospice at the time of discharge.    The above findings were reviewed with the Clinical Manager.

Based on review of the written agreement between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospice's responsibility to maintain a description of the training and documentation of the names of those giving the training for 1 of 2 sampled written agreements (Hospital A).    Failure to ensure the written agreements with hospitals specified the hospice's responsibility to ensure hospital staff caring for hospice patients received training and the hospice maintained appropriate documentation of the training placed hospice patients at risk for receiving inpatient care in conflict with the hospice philosophy.    Findings include: --- The hospice agency had a contractual agreement with Hospital A, dated 1/23/23.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators.    The above findings were reviewed with the 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 1 of 4 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 4/21/22.  The hospice reported hiring 5 contracted 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. --- According to the hospice policy titled Employment, last revised October 2023, offers of employment are based upon having acceptable results from the abuse registries background check. A criminal history check, dependent adult abuse record check and child abuse record check for each prospective employee will be completed within 30 days prior to the hire date of the prospective employee.  During an interview on 4/3/25 at 10:40 AM, the Clinical Manager stated Staff D, Hospice Aide lived in Illinois and worked out of the Illinois office. The Criminal Background check ran in Illinois.  1.  Staff D, Hospice Aide, had a hire date of 5/4/22.  A criminal background check was completed using Illinois Department of Public Health and dated 3/24/22.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI  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.  The above findings were reviewed with the 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 dependent adult abuse or child abuse record checks for 1 of 4 sampled employees (Staff D) who began serving hospice patients since their last survey, dated 4/21/22.  The hospice reported hiring 5 contracted 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. --- According to the hospice policy titled Employment, last revised October 2023, offers of employment are based upon having acceptable results from the abuse registries background check. A criminal history check, dependent adult abuse record check and child abuse record check for each prospective employee will be completed within 30 days prior to the hire date of the prospective employee.  During an interview on 4/3/25 at 10:40 AM, the Clinical Manager stated Staff D, Hospice Aide lived in Illinois and worked out of the Illinois office. The Criminal Background check ran in Illinois.   1.  Staff D, Hospice Aide, had a hire date of 5/4/22.  A criminal background check, dated 3/24/22, was completed using the Illinois De[artment of Public Health.  The hospice failed to follow through to complete adult abuse and child abuse registry checks with the Iowa department of human services 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 Clinical Manager.

Based on personnel file review and staff interview, the hospice failed to ensure hospice contract staff providing direct patient care received education on the hospice's policy and procedures related to advance directives for 1 of 3 sampled contract workers (Staff G, Hospice Aide) hired since the last survey, dated 4/1/2019. The hospice reported 3 new contract staff had provided direct patient care since the last survey. Failure to ensure hospice contract staff received education on the hospice's advance directives policy and procedures placed hospice patients at risk for not having their wishes and rights honored in regards to advance directives. Findings include: Staff G, contracted Hospice Aide, had a start date of 4/16/19. Review of Staff G's personnel file revealed the file lacked documented evidence hospice staff had provided education on advance directives. On 4/20/22 at 4:19 PM, during an interview, the Clinical Manager reported an inability to find evidence Staff G, had received hospice orientation training including training on the hospice's policies and procedures on advance directives. 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 hospice staff interview, the hospice failed to: 1) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive and update to the comprehensive assessment (see L0530); 2) ensure a member of the hospice IDG completed an initial assessment including documentation of a bereavement assessment, (see L0531); and, 3) ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (see L0533). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and service needs in a timely manner to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice staff completed medication reviews which included all the required components of a drug regimen review for 9 of 11 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #10 and #11). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed a drug regimen review (DRR) based on a review of all of the patient's medications and included all the required components of the DRR with each update to the comprehensive assessment increased the risk of the patient developing an undetected side effect or adverse reaction in relation to medication therapy. Findings include: According to a hospice policy titled Medication Management, dated 8/2021, the medication management form will be reviewed and updated at a minimum every 15 days and as needed. The review will include new medications or medication changes - including: effectiveness of drug therapy, side effects, actual or potential drug interactions, duplicate drug therapy and drug therapy associated with laboratory monitoring. On 4/18/22 at 10:47 AM, during an interview, the Clinical Manager reported the admitting registered nurse completed the initial drug regimen review and then the hospice IDG completes the DRR every 2 weeks. The DRR includes a review of all the medications the patient is taking and evaluates side effects, drug effectiveness, duplicate drug therapies, drug interactions and drug therapy requiring laboratory monitoring. 1. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/20/22 to 6/17/22, included physician orders for medications, including Basaglar Kwik Pen (insulin), Farxiga, Januvia, and Metformin (diabetic medications); Bisacodyl suppository and Milk of Magnesia (bowel medications). b. Initial comprehensive skilled nursing assessment visit note, dated 4/6/22, included documentation of completed DRR with duplicate drug therapy identified that included Januvia, Metformin, Basaglar Kwik Pen, Farxiga, Bisacodyl and Milk of Magnesia. c. The IDG meeting note, dated 4/12/22, included documentation of completed DRR and marked duplicate drug therapy but failed to identify what medications were identified as duplicate therapy. The DRR failed to identify duplicate drug therapy. 2. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/15/22 to 5/15/22, included physician orders for medications, including Alprazolam, Lorazepam (anti-anxiety medications) and Morphine (pain medication). b. Initial comprehensive skilled nursing assessment visit note, dated 2/15/22, included documentation of completed DRR with duplicate drug therapy identified that included Alprazolam and Lorazepam. c. Fax cover sheet to the Medical Director/Attending Physician, dated 2/15/22, included documentation of severe possible drug/drug interactions related to Alprazolam and Morphine, and Lorazepam and Morphine, faxed on 2/15/22. d. The IDG meeting notes, dated 2/15/22 and 3/2/22, included documentation of completed DRR but marked no duplicate drug therapy and no significant drug interactions, actual or potential. e. The IDG meeting notes, dated 3/16/22 and 3/30/22, included documentation of completed DRR, marked duplicate drug therapy but failed to identify what medications were identified as duplicate therapy and marked no significant drug interactions, actual or potential. f. The IDG meeting note, dated 4/12/22, included documentation of completed DRR, marked duplicate drug therapy and significant drug interactions, actual or potential; but failed to identify what medications were identified as duplicate therapy and what medications had actual or potential significant drug interactions. The DRR failed to identify duplicate drug therapy and/or actual or potential significant drug interactions. 3. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/1/22 to 6/29/22, included physician orders for medications, including Tramadol and Acetaminophen (pain medications), Methocarbamol (muscle relaxant), Promethazine (nausea medication), Donepezil (medication for Alzheimer's disease) and Bisacodyl (bowel medication). b. Initial comprehensive skilled nursing assessment visit note, dated 4/1/22, included documentation of completed DRR and no issues identified. c. Fax cover sheet to the Attending Physician, dated 4/1/22, included documentation of possible severe drug/drug interactions related to Methocarbamol and Tramadol, Promethazine and Tramadol, and Tramadol and Donepezil, faxed on 4/1/22. d. The IDG meeting note, dated 4/6/22, included documentation of completed DRR, marked duplicate drug therapy but failed to identify what medications were identified as duplicate therapy and marked no significant drug interactions, actual or potential. The DRR failed to identify duplicate drug therapy and/or actual or potential significant drug interactions. 4. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/3/21 to 3/2/22, included physician orders for medications, including Albuterol inhaler, Ipratropium (breathing medications), Bisacodyl suppository, Docusate sodium and Milk of Magnesia (bowel medications). b. Initial comprehensive skilled nursing assessment visit note, dated 12/3/22, included documentation of completed DRR and no issues identified. c. The IDG meeting note, dated 12/6/21, included documentation of completed DRR including side effects, ineffective therapy, significant drug therapy, actual or potential and medications requiring laboratory monitoring but failed to address if there were or were not duplicate drug therapy. d. The IDG meeting note, dated 1/5/22, lacked documentation of a completed DRR. e. The IDG meeting notes, dated 1/19/22 and 2/2/22, included documentation of completed DRR, marked duplicate drug therapy but failed to identify what medications were identified as duplicate therapy. f. The IDG meeting note, dated 2/16/22, included documentation of completed DRR, marked no duplicate drug therapy. The DRR failed to identify duplicate drug therapy. 5. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: a. The Plan of Care (POC), dated 2/9/22 to 5/9/22, included physician orders for Acetaminophen, MS Contin and Oxycodone, all medications used to treat pain, and an order for Ondansetron, a medication used to treat nausea. 1) The initial DRR completed by an RN as part of the comprehensive assessment, dated 2/9/22, identified the patient took duplicate medications to treat pain. 2) An interim physician order, dated 3/1/22, included an order for Prochlorperazine, a medication used to treat nausea. 3) The IDG meeting, dated 3/2/22, included documentation of the identification of duplicate drug therapy as part of a DRR, but failed to identify the specific duplicate medication therapies. b. An interim physician order, dated 3/31/22, included orders for Morphine oral concentrate (liquid), Morphine tablets (medications used to treat pain) and Lorazepam (medication used to treat anxiety and known to cause a potential significant drug interaction between Morphine, MS Contin and Oxycodone). The patient continued to have orders for Acetaminophen, MS Contin and Oxycodone to treat pain. 1) An interim order, dated 4/7/22, included an order for Senna S, a medication used to treat constipation. 2) An interim order, dated 4/11/22, included an order for a Saline Enema, a medication used to treat constipation. 3) The subsequent IDG meeting, dated 4/12/22, identified the patient was taking medications with duplicate drug therapies and taking medications with actual or potential drug interactions, but failed to identify the specific duplicate drug therapies and medication interactions. 6. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 3/7/22 to 6/4/22, included physician orders for medications, including Bisacodyl (medication to treat constipation), Mirtazapine (medication being used to treat insomnia) and Tylenol (medication to treat pain). a. The initial DRR documented in the comprehensive assessment completed by the RN, dated 3/7/22, and initial IDG meeting, dated 3/8/22, identified no drug regimen review issues. b. An interim physician order, dated 3/11/22, included orders for a Lidocaine 2 percent mucous membrane solution for pain and Acetaminophen- Codeine liquid for pain. c. The subsequent IDG meeting, dated 3/22/22, included documentation which identified the patient had not had any medication changes. The DRR failed to identify the patient had orders for duplicate medication therapies to treat pain. d. The DRR completed with the IDG meeting, dated 4/6/22, also failed to identify the patient had orders for duplicate medication therapies. 7. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 3/9/22 to 6/6/22, included physician orders for the following medications with duplicate therapies: Albuterol and Flovent to treat difficulty breathing; Dilaudid, Fentanyl, Methocarbamol and Tylenol Extra Strength to treat pain; vitamin supplements including Ferrous Fumerate and a Multivitamin; and, Prochlorperazine and Ondansetron to treat nausea. The POC included additional medication orders for Cephalexin, Warfarin, Prednisone, Sertraline, Aspirin, Melatonin, Atenolol, Atorvastatin, Lumigan, Docusate Sodium and Pregabalin. b. The initial DRR documented in the comprehensive assessment completed by the RN, dated 3/9/22, identified the patient took duplicate drug therapies for pain, nausea and vitamin supplements. c. An interim physician order, dated 3/28/22, included orders to discontinue the patient's medications with the exception of Albuterol, Docusate Sodium (treat constipation), Fentanyl 100 micrograms (mcg) patch, Ondansetron, Prochlorperazine and Dilaudid. The interim order included new orders for Morphine oral concentrate (to treat pain), Fentanyl 50 mcg patch, Miralax (to treat constipation) and Lorazepam to treat anxiety. d. The DRR documented in the IDG meeting, dated 3/30/22, included documentation of new orders for Morphine, Fentanyl patch changes and Lorazepam for shortness of breath and difficulty sleeping. The DRR failed to identify duplicate drug therapies and the potential for drug interactions between Lorazepam and Morphine, Dilaudid and Fentanyl. 8. Patient #4 had a hospice admission date of 2/26/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial interdisciplinary care plan dated, 2/26/22 to 5/26/22 identified current medications. b. The patient medication profile dated 2/26/22 to 3/21/22, identified the following medications: i. Benefiber and Miralax for constipation. ii. Bimatoprost and Dorzolamide-Timolol for glaucoma. iii. Gabapentin, Tramadol, Tizonidine and Acetaminophen for pain. The same medication profile failed to identify duplicate drug therapy. The drug regimen review failed to identify duplicate medications the patient is using. c. The Interdisciplinary Group (IDG) meeting notes dated 3/2, 3/16, 3/30 and 4/12/22 noted drug regimen review. The drug regimen review failed to identify the duplicate medications the patient uses. 9. Patient #7 had a hospice admission date of 2/8/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The initial interdisciplinary care plan dated, 2/8/22 to 5/8/22 identified medications used by the patient: bisacodyl 10mg suppository and Tylenol 325mg tablet. b. The patient medication profile dated 2/8/22, printed for the surveyor on 4/20/22 identified the following medications used by the patient: bisacodyl 10mg suppository and Tylenol 325mg tablet. c. The Interdisciplinary Group (IDG) meeting notes dated 2/22, 3/8, 3/22, and 4/6/22 noted drug regimen review. The clinical manager documented in comments: "taking no meds." The Interdisciplinary Group failed to ensure the that the care and services are provided in accordance with the plan of care. 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 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 and as part of the initial comprehensive assessment, to determine patient and/or family bereavement needs and risk factors in a timely manner for 8 of 11 sampled patients (Patients #1, #2, #3, #5, #7, #8, #9 and #10). 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: According to the hospice policy, titled Assessment - Content of the Comprehensive Assessment, dated 8/2021, the comprehensive assessment will include a grief (bereavement) assessment when the comprehensive assessment is the initial assessment. According to the policy, titled Assessment - Comprehensive Assessment of the Patient, dated 1/2022, the registered nurse case manager coordinates the comprehensive assessment process and ensures that the patient's physical, emotional, psychosocial, spiritual and bereavement needs are assessed. On 4/19/22 at 2:22 PM, during an interview, the Clinical Manager explained the Staff I, Social Worker, was responsible for completing the initial bereavement risk assessment for all patients. On 4/20/22 at 8:20 AM, during an interview, Staff I, Social Worker, reported she was doing an anticipatory grief assessment, but she was documenting this information on a form, titled Anticipatory Grief Update Form. She identified she maintained the documentation on this form in her computer, but this was not part of the patient record. This form and information did not become part of the patient record until after the patient's death. She provided copies of the completed form at this time for all of the patient's in the sample. Staff I, Social Worker, reported the bereaved family member's (or other individual's) bereavement risk assessment did not include an assessment of the bereaved's risk level (low, moderate or high) until after the patient's death. 1. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 4/6/22, lacked an initial bereavement risk assessment. b. The comprehensive assessment completed by the social worker, dated 4/8/22, lacked an initial bereavement risk assessment. c. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 4/6/22, the Interdisciplinary Group (IDG) meeting date of 4/12/22 and was not kept in the clinical record. d. The anticipatory grief update form included documentation of the spouse processing the patient's decline and understanding the patient will not get better but it failed to identify the bereavement risk status of low, moderate or high risk or if any social, spiritual or cultural factors could possibly impact the spouse at the time of the patient's death. The clinical record failed to include a completed bereavement risk assessment. 2. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 2/15/22, lacked an initial bereavement risk assessment. b. The comprehensive assessment completed by the social worker, dated 2/15/22, lacked an initial bereavement risk assessment. c. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 2/15/22, the IDG meeting date of 2/16/22 and was not kept in the clinical record. d. The anticipatory grief update form included documentation of the spouse coping and additional visits assessing spouse coping and possibility of discharge from hospice services. The assessment failed to identify the bereavement risk status of low, moderate or high risk or if any social, spiritual or cultural factors could possibly impact the spouse at the time of the patient's death. The clinical record failed to include a completed bereavement risk assessment. 3. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 4/1/22, lacked an initial bereavement risk assessment. b. The comprehensive assessment completed by the social worker, dated 4/1/22, lacked an initial bereavement risk assessment. c. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 4/1/22, the IDG meeting date of 4/6/22 and was not kept in the clinical record. d. The anticipatory grief update form included documentation of the child's coping with the anticipated death of the parent failed to identify the bereavement risk status of low, moderate or high risk or if any social, spiritual or cultural factors could possibly impact the child at the time of the patient's death. The clinical record failed to include a completed bereavement risk assessment. 4. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 12/3/21, lacked an initial bereavement risk assessment. b. The comprehensive assessment completed by the social worker, dated 12/3/21, lacked an initial bereavement risk assessment. c. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 12/3/21, the IDG meeting date of 12/7/21 and was not kept in the clinical record. d. The anticipatory grief update form included documentation of the children's coping with the patient's (parent) behaviors, mental status and documentation of the patient's discharge from hospice services. The assessment failed to identify the bereavement risk status of low, moderate or high risk or if any social, spiritual or cultural factors could possibly impact the children at the time of the patient's death. The clinical record failed to include a completed bereavement risk assessment. 5. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: a. The Plan of Care (POC), dated 2/9/22 to 5/9/22, identified a diagnosis of pancreatic cancer and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker and chaplain services. b. The comprehensive assessment completed by a registered nurse (RN), dated 2/9/22, included documentation the nurse did not complete an initial bereavement risk assessment of the patient's family or other individuals. c. An initial evaluation completed by Staff I, Social Worker, dated 2/9/22, included documentation which identified the completion of an assessment of spiritual, emotional and psychosocial concerns of the patient and spouse. Staff I, Social Worker, documented the spouse of the patient did not want to talk about the patient's cancer and was in denial. The social worker identified a goal to work on abnormal grief based on this information, but did not quantify the spouse's bereavement risk or identify how the spouse's social, emotional and spiritual factors may impact the spouse's ability to cope with the patient's death. Review of the Anticipatory Grief Update Form for Patient #1 included documentation of entries made with each of the patient's IDG meetings, dated 2/16, 3/2, 3/30 and 4/12/22. The note, dated 2/16/22, included documentation the patient felt the spouse was uncomfortable talking about the patient being sick and the patient was tearful and not wanting to talk about this being the end of the patient's life. The note, dated 4/12/22, included documentation the spouse opened up about being married before and that spouse died of cancer too. The spouse discussed the pain with the loss and impending pain with the upcoming loss of the patient. Review of the IDG meetings, dated 2/16, 3/2, 3/30 and 4/12/22, revealed the Staff I, Social Worker, did not document the information in the Anticipatory Grief Update Form in the IDG meeting note. On 4/19/22 at 2:34 PM, during an interview, the Administrator reported the bereavement plan for the patients family or other individuals should start on admission. 6. Patient #9 had a hospice admission date of 1/11/22, received hospice services from the parent office in Fort Madison and died on 1/24/22. Review of the clinical record revealed the following: a. The POC, dated 1/11/22 to 4/10/22, included IDG orders for skilled nursing, social work and chaplain services. b. The comprehensive assessment completed by a RN, dated 1/11/22, included documentation the nurse did not complete an initial bereavement risk assessment of the patient's family or other individuals. c. The initial social worker assessment, dated 1/14/22, included documentation the social worker assessed the patient and caregiver's (patient's spouse) ability to cope, social needs and spiritual concerns. The social worker identified a goal to assess for abnormal grief based on this information, but did not quantify the spouse's bereavement risk or identify how the spouse's social, emotional and spiritual factors may impact the spouse's ability to cope with the patient's death. On 4/20/22 at 8:20 AM, Staff I, Social Worker, provided a copy of form, titled Anticipatory Grief Update Form, and included documentation of entries made with each of the patient's IDG meetings, dated 1/19 and 1/25/22. The note, dated 1/19/22, included documentation the patient's spouse reported crying at times, but coping well and having support from another family member. The note, dated 1/25/22, identified the patient had died. The form included an identification of a moderate risk for grief. The clinical record lacked documentation of the Anticipatory Grief Update Form. d. Review of the IDG meeting, dated 1/18/22, did not include any of the information documented in the Anticipatory Grief Update Form. 7. Patient #7 had an admission to hospice on 2/8/22 and received services in a private residence. The clinical record review revealed: The social worker visit completed by the social worker, dated 2/8/22, lacked an initial bereavement assessment. The hospice failed to complete the bereavement assessment. 8. Patient #8 had an admission to hospice on 2/24/22 and date of death 3/17/22 received services in assisted living. The clinical record review revealed: a. The social worker visit completed by the social worker, dated 2/24/22, lacked an initial bereavement assessment. b. The initial skilled nurse visit, dated 2/24/22, identified the bereavement risk assessment not assessed. The hospice failed to complete the bereavement assessment. 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, 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 1 of 2 sampled patients (Patient #2) 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 the hospice policy, titled Wound Care, dated 12/2021, the wound is measured weekly and as needed, or as specified on the plan of care, and documented in the wound assessment. On 4/18/22 at 10:47 AM, during an interview, the Clinical Manager, reported wounds should be measured upon discovery and weekly. The wound measurements should include length, width and depth. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: Plan of Care (POC), dated 3/20/22 to 6/17/22, included orders for Venelex topical ointment to be applied three times daily for stage II coccyx wound. The initial comprehensive assessment completed by RN, dated 4/6/22, included documentation of a bilateral upper medial proximal buttocks coccyx stage II pressure ulcer that included length, width and depth measurements. Skilled nurse visit note, dated 4/18/22, included documentation of a bilateral upper medial proximal buttocks coccyx stage II pressure ulcer that included length, width and depth measurements. Skilled nurse visit notes, dated 4/11/22 and 4/14/22, lacked documentation of wound measurements. The clinical notes lacked documentation of any wound measurements for the open wound on the coccyx the week of 4/10/22 through 4/16/22 per hospice policy. During a home observation visit on 4/19/22 at 9:15 AM, Staff C, RN, reported wounds are measured weekly. 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, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure the hospice provided care and services to patients and their families that followed an individualized written plan of care established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician (see L0543); 2) ensure the hospice IDG developed a Plan of Care (POC) for each patient with routine orders specific to the needs of the patient (see L0547); 2) ensure the hospice IDG developed a POC which included all necessary drugs and treatments to meet the needs of the patient (see L0549); 3) ensure the hospice IDG developed a POC which included all medical supplies and appliances necessary to meet the needs of the patient (see L0550); 4) ensure the hospice Interdisciplinary Group members collaborated and communicated to ensure hospice staff provided care and services in accordance with the Plan of Care (see L0555). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, hospice policy review, observation and staff interview, the hospice failed to ensure hospice Interdisciplinary Group members provided care in accordance with the patient's plan of care for 5 of 11 sampled (Patients #1, #2, #6, #9 and #11). Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 8/2021, identified hospice staff provide care and services to the patient in accordance with a written, individualized plan of care established by the hospice IDG and attending physician. Review of the hospice's policy, titled Physician Orders, dated 10/2018, revealed clinical staff are to obtain verbal physician orders for medication changes and wound care orders and maintain documentation of the receipt of the order in the clinical record. 1. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: The POC, dated 2/9/22 to 5/9/22, included IDG orders for skilled nursing services and for the skilled nurse to assess skin integrity every visit. The POC did not include any orders for wound care. a. A skilled nursing visit, dated 4/13/22, included documentation the nurse assessed the patient had a dark purple, unstageable pressure area on the right side of the patient's back. The skin was intact. The nurse documented she placed Duoderm (a type of wound dressing) on the wound. The nurse documented she called and left a message for the patient's physician. An interim physician order, dated 4/14/22, included an order to monitor a decubitus/pressure ulcer suspected deep tissue injury on the right upper posterior back. Hospital staff to monitor the wound daily and as needed and hospice to assess the wound as needed. The order did not include directions to the nurse to apply Duoderm to the right shoulder wound. The nurse applied the Duoderm without direction from a physician. On 4/21/22 at 8:30 AM, during an interview, the Clinical Manager confirmed the nurse notified the physician of the patient's condition after placing the Duoderm and without physician direction. b. Interim physician orders, dated 4/18/22, included orders to cleanse wounds with Normal Saline and apply Mepilex (a type of wound dressing) weekly and as needed to pressure areas on the left heel, right lateral hip, right lateral distal knee, bilateral posterior buttocks and right upper posterior outer back. The order included directions to the hospital staff to check the patient's wounds daily and as needed, and hospice nurse to assist as needed and measure wounds weekly. 1) A skilled nursing visit completed by Staff D, Hospice Registered Nurse (RN), dated 4/18/22, included a documented assessment of the following wounds: bilateral posterior buttocks pressure ulcer with suspected deep tissue injury with with a beefy red wound bed, slough and moist and no measurements; left posterior foot heel blanchable red area measuring 4 centimeters (cm) in length and 2.5 cm in width; right lateral distal knee pressure ulcer with suspected deep tissue injury measuring 1 cm in length and 0.6 cm in width; right lateral hip with a red blanchable area measuring 3 cm in length and 2.5 cm in width; and, right upper posterior outer back pressure area, Stage 2 (open, shallow wound), measuring 6 cm in length, 1.5 cm in width and 0.1 cm in depth. Staff D, Hospice RN, documented she cleansed all of the wound with Normal Saline with the exception of the right upper posterior outer back wound. She documented she cleansed this wound with soap and water. She then documented she covered the wounds with Mepilex. The hospice RN did not follow the physician order for cleansing the right shoulder wound with Normal Saline. 2) On 4/19/22 at 10:20 AM, during an observation visit at the patient's hospital room with the patient, patient's spouse and Staff D, Hospice RN, the surveyor observed Staff D complete an assessment on the patient. Staff D, viewed the patient's wounds. Observation revealed the left heel wound and right lateral knee wounds did not have any type of wound dressing. Staff D commented on the 2 wounds not having a wound dressing. The left heel wound covered the patient's entire heel and appeared to deeply reddened with skin intact, but with a spongy appearance and a suspected deep tissue wound. The right lateral knee wound was a deep purple, nonblanchable area with intact skin. During the observation, the patient's hospital RN for the day came into the room. Staff D, Hospice RN, told the hospital RN about the uncovered wounds on the left heel and right knee. The hospital RN responded that she would get the wounds covered. Staff D, Hospice RN, directed the hospital RN not to cover the wounds, as she did not feel the wounds needed it. On 4/19/22 at 11:06 AM, during an observation, Staff D, Hospice RN, had the patient's hospital physician sign orders from the previous day. She did not discuss changing wound care orders with the physician. The surveyor and Staff D, Hospice RN, exited the hospital together. 2. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/7/22 to 6/4/22, included orders for skilled nursing and hospice aide services and orders for the nurse to assess the patient's skin for possible breakdown. The POC included instructions to the hospice aide to complete the task of "skin care" without any specific direction. b. The comprehensive assessment completed by a RN, dated 3/7/22, identified the patient had reported pressure pain and discomfort to coccyx area. The RN assessed the patient's skin, but did not identify a wound. c. A skilled nursing visit note completed by Staff E, RN, dated 3/18/22, included documentation the nurse assessed a red, pea-sized area on the patient's coccyx. The skin was intact. Staff E, RN, documented she observed the hospice aide apply skin protectant to the tailbone. d. The skilled nursing visits, dated 3/19, 4/1, 4/11 and 4/14/22, included documentation the nurse applied a skin protective or barrier ointment to the patient's coccyx. The visit note, dated 4/14/22, identified the patient complained of pain in the coccyx and the nurse assessed the patient had a reddened area. On 4/20/22 at 9:54 AM, during an interview, Staff G, contracted Hospice Aide, reported she has been putting barrier ointment on the patient's coccyx since the patient's admission to hospice and prior to this. She reported she had been providing home health aide services to the patient through another agency prior to hospice. The patient had an open pressure ulcer to the coccyx area prior to hospice, and Staff G, contracted Hospice Aide, had been applying barrier ointment to the open area. The wound had healed when the patient started services, but she continued to apply the barrier ointment as a preventative measure. On 4/21/22 at 8:44 AM, during an interview, the Clinical Manager confirmed Staff E, RN and Case Manager for the patient, was aware the hospice aide had been applying a protective cream to the patient's coccyx. The POC failed to identify the need for the nurses and hospice aides to apply a barrier cream or ointment to prevent skin breakdown. 3. Patient #9 had a hospice admission date of 1/11/22, received hospice services from the parent office in Fort Madison and died on 1/24/22. Review of the clinical record revealed the following: a. The POC, dated 1/11/22 to 4/10/22, included IDG orders for skilled nursing services. b. A skilled nursing visit note completed by Staff J, Licensed Practical Nurse (LPN), dated 1/24/22, included documentation she inserted a urinary catheter size 16 French with 10 milliliter (ml) bulb inflation amount into the patient's bladder. c. The clinical record lacked documentation of physician contact prior to insertion of the catheter and lacked documentation of a physician order. On 4/20/22 at 9:20 AM, during an interview, the Clinical Manager reported an inability to find a catheter or or evidence of contact with the physician. 4. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/9/22 to 6/6/22, included IDG orders for skilled nursing services. The POC included orders for the patient to take Warfarin (an anticoagulant medication) and for the nurse to obtain International Normalizing Ratio (INR- blood test associated with blood clotting ability) as ordered. b. The comprehensive assessment completed by Staff C, RN, dated 3/9/22, included documentation which identified a plan for the nurse to obtain the patient's INR blood test at the next visit. c. A skilled nursing visit note completed by Staff J, LPN, dated 3/11/22, included documentation the nurse obtained the patient's INR blood draw. d. A skilled nursing visit note completed by Staff E, RN and patient's Case Manager, included documentation she had contacted the patient's cardiologist with INR blood test results. She documented the cardiologist questioned why the hospice was doing INR blood draws on a hospice patient. e. The clinical record lacked documentation of an order to complete an INR blood test on 3/11/22. On 4/21/22 at 9:44 AM, during an interview, the Clinical Manager reported an inability to find an INR order for 3/11/22. She explained there had been some confusion between the primary attending physician and the cardiologist about who was going to take over care. She reported both Staff C, RN, and Staff E, RN, were unsure about the order. Staff C, RN, reported the patient came home from the hospital just prior to hospice and the patient had said the INR blood test was due. 5. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care (POC), dated 3/20/22 to 6/17/22, included orders for Venelex topical ointment to be applied three times daily for stage II coccyx wound. b. An interim physician order, dated 4/6/22, included Venelex ointment three times daily, apply to top of gluteal cleft three times daily. c. A skilled nursing visit notes, dated 4/6/22 and 4/18/22, included documentation the nurse cleansed the wound with soap and water and applied Venelex ointment. d. During a home observation visit on 4/19/22 at 9:15 AM, Staff C, registered nurse (RN), provided wound care. Staff C cleansed wound with normal saline and applied Venelex ointment. Staff C confirmed the solution in the bottle used to cleanse the wound was normal saline. The clinical record failed to include a physician order specifying what solution to cleanse the wound. 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 and hospice policy review, the hospice failed to ensure the ensure hospice staff used routine orders specific and individualized to the patient's assessed needs for 1 of 11 sampled patients (Patient #6). Failure to individualize routine orders rather than generalized, non-specific orders placed patients for potential risk of receiving medications or treatments that did not adequately meet the individualized needs of hospice patients. Findings include: Review of the hospice's policy, titled Plan of Care- Content, dated 8/2021, the plan of care (POC) includes all medications and treatment necessary to meet the specific needs of the patient. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN, dated 3/7/22, identified the patient had a "port" (peripherally inserted central catheter) located on the upper left chest. b. The POC, dated 3/7/22 to 6/4/22, included physician orders for the RN to flush the patient's left catheter port every 4 to 6 weeks and as needed. The POC failed to specify what the nurse was supposed to use to flush the port with and how much. The POC failed to specify under what circumstances the nurse would need to flush the port as needed. 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, medication/treatment administration record, hospice policy review, patient caregiver and hospice staff interview, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or a complete order for all medications and treatments to meet the needs of the patient for 1 of 3 sampled patients with a home visit (Patient #3) and 1 of 2 patients with onsite visit to the nursing home (Patient #5). Failure to ensure the plan of care included physician orders for all necessary medications and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: According to the hospice policy, titled Plan of Care - Content, dated 8/2021, the plan of care includes medications and treatments necessary to meet the needs of the patient and responsible party for administering medications and completing the treatment. Medication list will include all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. 1. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 2/15/22 to 5/15/22, included orders for current medications. b. The medication list printed on 4/18/22 for the surveyor, included Alprazolam and Clonazepam both as current medications. During a home observation visit on 4/19/22 at 10:45 AM, with Staff C, registered nurse (RN), the patient's spouse reported the patient did not use Alprazolam. Staff C reported the Alprazolam was discontinued on 3/4/22 when the Clonazepam was started. c. The Interdisciplinary Group (IDG) meeting notes, dated 3/16/22, 3/30/22 and 4/12/22, failed to identify the Alprazolam had been discontinued and the Clonazepam had been started. The clinical record failed to include an updated and accurate medication list. 2. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/1/22 to 6/29/22, included orders for promethazine 12.5 milligrams (mg), bisacodyl, and methocarbamol. b. The nursing home medication and treatment administration record for the month of April, included orders for promethazine 12.5 mg discontinued on 4/8/22, promethazine 25 mg started on 4/15/22, bisacodyl discontinued on 4/8/22 and methocarbamol discontinued on 4/8/22. The IDG meeting held on 4/20/22 at 12:27 PM, Staff C failed to report the above changes in the medications. c. The medication list printed on 4/20/22 for the surveyor, included promethazine 12.5 mg, bisacodyl and methocarbamol as current medications. The clinical record failed to include an updated and accurate medication list. 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, home visit observation, caregiver and hospice staff interview, the hospice failed to ensure the Plans of Care for 4 of 11 sampled patients (Patients #1, #3, #6 and #8) 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 Plan of Care - Content, dated 8/2021, the plan of care includes medical supplies and appliances necessary to meet the needs of the patient. 1. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 2/15/22 to 5/15/22, included documentation the patient had oxygen, hospital bed, pressure relieving mattress, bed rails, wheelchair, bedside commode, and shower chair, as medical equipment and supplies use by the patient. b. During a home observation visit on 4/19/22 at 10:45 AM, with Staff C, RN (registered nurse), surveyor observed a trapeze over the hospital bed and washable chux on the hospital bed. The patient's spouse reported the patient has a walker that is used when the patient is having increased weakness and the VA (Veteran's Administration) has provided the patient with a floor mat alarm, this will notify the spouse when the patient tries to get out of the bed when the spouse is not in the room. Staff C reported the VA has supplied the patient with all medical equipment needed. The Plan of Care failed to identify all current medical equipment and supplies used by the patient. 2. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. On 4/19/22 at 10:20 AM, during an observation visit at the patient's hospital room with the patient, patient's spouse and Staff D, RN, the surveyor observed Staff D assess the patient and then change the patient's incontinent brief. In an interview, during the same observation, Staff D, RN, reported the patient had been using incontinent briefs since prior to hospice admission; she was unsure of the exact start date. Review of the clinical record revealed: A Plan of Care (POC), dated 2/9/22 to 5/9/22, identified medical equipment and supplies used by the patient, but did not include incontinent briefs. The IDG meetings, dated 2/16, 3/2, 3/16, 3/30 and 4/13/22, did not identify the patient's use of incontinent briefs. 3. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/7/22 to 6/4/22, identified the patient used a walker and had a left catheter port (peripherally inserted central catheter) for medical equipment and supplies. b. A skilled nursing visit, dated 3/14/22, included documentation the nurse assessed the patient needed a gel cushion to relieve pressure on the patient's coccyx. c. The skilled nursing visit, dated 3/18/22, included documentation the patient was using the gel cushion. d. The IDG meeting notes, dated 3/22 and 4/6/22, did not identify the patient was using a gel cushion. On 4/21/22 at 8:30 AM, during an interview, the Clinical Manager reported Staff, E, RN, had assessed the patient needed a gel cushion on 3/14/22 and then brought the gel cushion out to the patient on the next visit. 4. Patient #8 had a hospice admission date of 2/24/22 and a date of death 3/17/22 and received hospice services while residing in assisted living. a. The plan of care (POC), dated 2/24/22 to 5/24/22, identified the patient used the following medical equipment and supplies: oxygen, walker, grab bars/safety rails. b. The skilled nursing visit notes dated 2/28, 3/3, 3/7, and 3/15/22 identified the patient uses briefs due to incontinence of urine. c. The interdisciplinary group (IDG) meeting note, dated 3/2/22 identified the patient incontinent of urine at times. The same note failed to identify any patient medical equipment and supplies. The POC and IDG updates to the POC failed to identify all necessary medical equipment and supplies used by the patient, including incontinence briefs. 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 and hospice policy review, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure patient plan of care was followed for 4 of 11 sampled hospice patients (Patients #3, #7, #10 and #11). Failure of the hospice team members to coordinate and collaborate services and communicate effectively increased the risk that patients did not receive services to meet needed services. Findings include: According to the hospice policy, titled Plan of Care - Content, dated 8/2021, the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. Updates to the plan of care will be documented in the Multidisciplinary Patient Review form from the Interdisciplinary Group meeting to include approval, understanding, involvement and agreement with the update to the plan of care. 1. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Interdisciplinary Group (IDG) meeting note, dated 12/14/21, included physician order for massage therapy one time a month for one month. b. Interim physician order, dated 1/1/22, for massage therapy one time a month for 6 months. c. IDG meeting notes, dated 1/5/22, 1/19/22, 2/2/22 and 2/16/22, failed to identify the new order for massage therapy one time a month for 6 months. d. RN (registered nurse) missed visit documentation, dated 12/30/21, included documentation of a missed nursing visit on 12/30/21. e. IDG meeting note, dated 1/5/22, failed to identify the missed nursing visit on 12/30/21. The IDG meeting notes failed to identify all discipline frequency updates including interim physician orders and missed visits. 2. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. Interim physician order, dated 3/9/22, for Clotrimazole topical cream twice a day for rash. b. Interim physician order, dated 3/10/22, for Tylenol. c. Interim physician order, dated 3/11/22, for Metoprolol. d. Interim physician order, dated 3/24/22, for Melatonin. e. IDG meeting notes, dated 3/16/22, 3/30/22 and 4/12/22, lacked documentation of the above interim physician orders. The IDG meeting notes failed to identify all interim physician orders. 3. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/9/22 to 6/6/22, included IDG orders for skilled nursing, hospice aide, social worker, chaplain and massage therapy services. b. The hospice aide visit note, dated 3/24/22, included documentation the patient had refused hospice aide services that day due to being in too much pain. c. The subsequent IDG meeting, dated 3/30/22, lacked documentation of the IDG members awareness of the missed hospice aide visit on 3/24/22 due to the patient's refusal. 4. Patient #7 had a hospice admission date of 2/8/22, received hospice services while residing in a private residence. a. The plan of care dated 2/8/22 to 5/8/22 included orders for hospice aide services 2 times a week. b. The week of 2/20 to 2/26/22 included documentation of only 1 hospice aide visit, dated 2/22/22. The week of 3/6 to 3/12/22 included documentation of only 1 hospice aide visit dated 3/8/22. c. The IDG meeting notes, dated 3/8 and 3/22/22, documented there had been no missed visits. 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 hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 9 of 9 sampled patients receiving hospice aide services (Patients #1, #2, #3, #6, #7, #8, #9 and #11). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. Findings include: Review of the hospice's policy, titled Hospice Aide Services, dated 10/2021, identified the registered nurse (RN) develops a written hospice aide care plan based on the comprehensive assessment. The written hospice aide care plan provides instructions to the hospice aide to follow. On 4/18/22 at 10:47 AM, during an interview, the Clinical Manager reported the admission RN or RN Case Manager created the hospice aide care plan. 1. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: a. The comprehensive assessment completed by the registered nurse (RN), dated 2/9/22, included documentation the nurse assessed the patient had poor coordination and balance and needed assistance to prevent falls. b. The Plan of Care (POC), dated 2/9/22 to 5/9/22, included IDG orders for skilled nursing and hospice aide services. The POC included directions to the hospice aide to complete the tasks of assisting with ambulation and transfers with a rollator walker and to provide "foot care". The POC did not specify what the hospice aide needed to do in order to complete the task of "foot care". c. The hospice aide visit notes completed by Staff H, Hospice Aide, dated 2/11, 2/25, 3/2, 3/4, 3/7, 3/9, 3/11, 3/16, 3/21, 3/23 and 3/25/22, included documentation Staff H assisted the patient with ambulation and transfers with the walker. Hospice Aide visit notes, dated 4/1, 4/4, 4/6, 4/8, 4/11 and 4/13/22, identified the patient was unable to transfer or ambulate. d. The IDG meeting, dated 3/2/22, identified the patient used a gait belt for medical supplies. e. The skilled nursing visit notes, dated 3/10 and 3/14/22, included documentation the patient needed and used a gait belt for transfers and ambulation. On 4/20/22 at 9:59 AM, during an interview, Staff H, Hospice Aide, reported after the first visit (2/11/22), she did not assist the patient with ambulation, only with pivot transfers due to the patient being too weak. She initially used a gait belt for ambulation, but did not really use the gait belt for transfers. The patient became bed bound and she no longer transferred the patient. She was not sure of the dates. She reported for the task of foot care, she put lotion on and massaged the patient's feet. After the patient became bed bound, she checked for pressure sores on the patient's feet. The hospice RN failed to include directions to the hospice aide to use a gait belt for transfers and ambulation, failed to specify what the hospice aide needed to do in order to complete the task of foot care and failed to update the hospice aide care plan when the patient was bed bound and could no longer transfer or ambulate. 2. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN, dated 3/7/22, identified the patient had reported pressure pain and discomfort to coccyx area. The RN assessed the patient's skin, but did not identify a wound. b. The POC, dated 3/7/22 to 6/4/22, included orders for skilled nursing and hospice aide services. The POC included instructions to the hospice aide to complete the task of "skin care" and "nail care" without any specific direction. c. The hand-written hospice aide care plan, dated 3/7/22 and signed by Staff E, RN, included instructions to the hospice aide to complete the tasks of skin care and nail care without any specific instruction for how the hospice aide should complete these assigned tasks. d. A skilled nursing visit note completed by Staff E, RN, dated 3/18/22, included documentation the nurse assessed a red, pea-sized area on the patient's coccyx. The skin was intact. Staff E, RN, documented she observed the hospice aide apply skin protectant to the tailbone. d. The skilled nursing visits, dated 3/19, 4/1, 4/11 and 4/14/22, included documentation the nurse applied a skin protective or barrier ointment to the patient's coccyx. The visit note, dated 4/14/22, identified the patient complained of pain in the coccyx and the nurse assessed the patient had a reddened area. e. The hospice aide visit notes, dated 3/11, 3/14, 3/17, 3/21, 3/24, 3/28, 3/31, 4/4, 4/7 and 4/11/22, included documentation Staff G, Contracted Hospice Aide, completed the visits. On 4/20/22 at 9:54 AM, during an interview, Staff G, contracted Hospice Aide, reported she has been putting barrier ointment on the patient's coccyx since the patient's admission to hospice and prior to this. She reported she had been providing home health aide services to the patient through another agency prior to hospice. The patient had an open pressure ulcer to the coccyx area prior to hospice, and Staff G, contracted Hospice Aide, had been applying barrier ointment to the open area. The wound had healed when the patient started services, but she continued to apply the barrier ointment as a preventative measure. Staff G, contracted Hospice Aide, reported she applied lotion to the patient's skin also. She explained for nail care, she trimmed and filed the patient's nails. On 4/21/22 at 8:44 AM, during an interview, the Clinical Manager confirmed Staff E, RN and Case Manager for the patient, was aware the hospice aide had been applying a protective cream to the patient's coccyx. The hospice RN failed to write a hospice aide care plan specific to the needs of the patient. 3. Patient #9 had a hospice admission date of 1/11/22, received hospice services from the parent office in Fort Madison and died on 1/24/22. Review of the clinical record revealed the following: The POC, dated 1/11/22 to 4/10/22, included IDG orders for skilled nursing and hospice aide services. The POC included instructions to the hospice aide to provide a complete bed bath, shower or partial bed bath without any further instruction on how the hospice aide should determine which bath type to provide. The POC also included instructions for the hospice aide to provide "skin care" and "nail care" without any specific direction on what the hospice aide needed to do in order to complete the tasks. On 4/20/22 at 9:59 AM, during an interview, Staff H, Hospice Aide, reported she only saw the patient one time, and then after that the family had canceled hospice aide services. She reported the patient was able to choose, and wanted a shower. She put lotion all over the patient's body for skin care and did not do nail care. 4. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 3/9/22 to 6/6/22, included IDG orders for skilled nursing and hospice aide services. The POC included instructions to the hospice aide to complete the tasks of nail care and skin care without an specific direction on what the hospice aide needed to do in order to complete those tasks. b. The hand-written hospice aide care plan lacked a date or RN signature. The care plan included instructions to the hospice aide to provide a complete bed bath, nail care, assist with dressing/undressing, assist with positioning/repositioning, empty Foley catheter, empty ostomy bag, provide ostomy care and incontinent care. The written assignment did not include skin care, as identified on the patient's POC, dated 3/9/22 to 6/6/22. On 4/20/22 at 9:43 AM, during an interview, the Clinical Manager reported Illinois patient's used the contract hospice aide. She explained the hospice contract aide followed the hand-written paper assignment and documented on paper, while all other hospice aides followed the assignment on the computer and documented in the computer system. The contacted hospice aide made copies of the hospice aide care plan to document on. 5. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice aide care plan, dated 4/6/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included skin care and nail care. The care plan failed to include specific instructions regarding what skin care and nail care included. b. The hospice aide visit notes, dated 4/7/22 and 4/12/22, included the task skin care was completed but failed to identify the task of nail care. 6. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. Hospice aide care plan, dated 2/15/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included skin care and nail care. The care plan failed to include specific instructions regarding what skin care and nail care included. b. The hospice aide visit notes, dated 2/16, 18, 23, 25, 28/22 and 3/2/22, included the task skin care was completed and the task nail care was refused or not completed. c. The hospice aide visit note, dated 2/21/22, included the tasks skin care and nail care were completed. 7. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Hospice aide care plan, dated 4/1/22, included tasks assigned by the registered nurse for the aide to complete. The tasks included skin care and nail care. The care plan failed to include specific instructions regarding what skin care and nail care included. b. The hospice aide visit notes, dated 4/6/22 and 4/13/22, included the task skin care was completed and the task of nail care was refused. c. The hospice aide visit note, dated 4/8/22, included the tasks skin care and nail care were completed. 8. Patient #7 had a hospice admission date of 2/8/22 and received hospice services while residing in a private residence. The Plan of Care, dated 2/8/22 to 5/8/22, documented the hospice provided hospice aide services. The clinical record review revealed the following: The hospice aide care plan, dated 2/8/22 included RN instructions for the hospice aide to provide, nail care, skin care and foot care. During an interview on 4/20/22 at 11:28 AM, Staff F, hospice aide, reported skin care is lotion from head to toe and report to the nurse skin breakdown, nail care is trim and file finger nails and foot care is trim toenails, lotion to feet and report any skin issues to the registered nurse. The aide care plan failed to provide specific instructions to the hospice aide. 9. Patient #8 had a hospice admission date of 2/24/22 and date of death 3/17/22 and received hospice services while residing in assisted living. The Plan of Care, dated 2/24/22 to 5/24/22, documented the hospice provided hospice aide services. The clinical record review revealed the following: The hospice aide care plan, dated 2/25/22 included RN instructions for the hospice aide to provide, nail care and foot care. During an interview on 4/20/22 at 11:28 AM Staff F, hospice aide, reported nail care is trim and file finger nails and foot care is trim toenails, lotion to feet and report any skin issues to the registered nurse. The aide care plan failed to provide specific instructions to the hospice aide. 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 hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide assignment for 2 of 9 sampled patients receiving hospice aide services (Patients #6 and #11). Failure to ensure hospice aides provided services only as ordered by the physician and according to the hospice aide assignment increased the risk that patients' personal care needs wound not be adequately met. Findings include: Review of the hospice's policy, titled Hospice Aide Assignments and Duties, dated 1/2022, identified the hospice aides provide care according the the plan of care and approved by the IDG. On 4/18/22 at 10:47 AM, during an interview, the Clinical Manager reported if a hospice aide is unable to complete an assigned task, the hospice aide will document the reason why and call and report this to the nurse. If the patient or family requests the hospice aide to complete an unassigned task, the hospice aide calls the RN for approval and the RN updates the aide care plan. 1. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/7/22 to 6/4/22, included orders for skilled nursing and hospice aide services. The POC included instructions to the hospice aide to complete the task of "skin care" and "nail care" without any specific direction, assist with dressing and undressing and provide a complete bed bath. b. The hand-written hospice aide care plan, dated 3/7/22 and signed by Staff E, RN, included instructions to the hospice aide to complete the tasks of "skin care" and "nail care" without any specific direction, assist with dressing and undressing and provide a complete bed bath. c. The hospice aide visit notes completed by Staff G, Contracted Hospice Aide, dated 3/11, 3/14, 3/17, 3/21, 3/24, 3/28, 3/31, 4/4, 4/7 and 4/11/22, included additional documentation by the hospice aide which identified she received direction by the hospice nurse to clean/trim nails, apply lotion to arm and legs, complete perineal care and oral care every visit. The clinical record lacked documentation of contact between a hospice nurse and Staff G, Contracted Hospice Aide, for each of the visits to account for the change in the hospice aide assigned tasks. d. The hospice aide visit note, dated 3/14/22, included documentation the hospice aide completed the task of bed shampoo per the nurses request, but the clinical record lacked documentation a RN directed the hospice aide to complete the unassigned task. e. The hospice aide visit notes, dated 3/14, 3/17 and 3/28/22, lacked documentation the hospice aide completed the assigned task of assisting the patient with undressing and dressing or a reason why the hospice aide failed to complete the assigned task. On 4/20/22 at 9:43 AM, during an interview, the Clinical Manager reported Illinois patient's used the contract hospice aide. She explained the hospice contract aide followed the hand-written paper assignment and documented on paper, while all other hospice aides followed the assignment on the computer and documented in the computer system. The contracted hospice aide made copies of the hospice aide care plan to document on. She did not know why the hospice aide visit notes differed from the RN hand-written hospice aide care plan. 2. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 3/9/22 to 6/6/22, included IDG orders for skilled nursing and hospice aide services. The POC included instructions to the hospice aide to complete the tasks of skin care, nail care, empty Foley catheter, empty ostomy bag, incontinent care, ostomy care, assist with dressing and provide a complete bath. b. The hand-written hospice aide care plan lacked a date or RN signature. The care plan included instructions to the hospice aide to provide a complete bed bath, nail care, assist with dressing/undressing, assist with positioning/repositioning, empty Foley catheter, empty ostomy bag, provide ostomy care and incontinent care. c. The hospice aide visit notes, dated 3/14 and 3/17/22, included documentation Staff G, Contracted Hospice Aide, completed the unassigned task of shampooing the patient's hair. The hospice aide documented this was per the nurses request, but the clinical record lacked documentation a RN directed the hospice aide to complete the unassigned task. d. The hospice aide visit note, dated 3/30/22, the hospice aide documented she repositioned the patient, but did not document the completion of any other assigned tasks or a reason why she failed to complete the assigned tasks. 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 personnel file review and staff interview, the hospice failed to ensure the hospice provided orientation about the hospice philosophy for contracted staff for 1 of 3 sampled contracted staff (Staff G, Hospice Aide) hired since the last survey, dated 4/1/19. The hospice reported 3 new contract staff had provided direct patient care since the last survey. Failure to provide orientation on hospice philosophy increased the potential for provision of services in a manner contradictory to the hospice philosophy. Findings include: Staff G, contracted Hospice Aide, had a start date of 4/16/19. Review of Staff G's personnel file revealed the file lacked documented evidence hospice staff had provided orientation training about the hospice's philosophy. On 4/20/22 at 4:19 PM, during an interview, the Clinical Manager reported an inability to find evidence Staff G, contracted Hospice Aide, had received hospice orientation training including orientation about the hospice's philosophy. 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 review of a personnel file review and staff interview, the hospice failed to ensure hospice staff provided an initial orientation to address the specific job duties, for 1 of 3 sampled contracted staff (Staff G, Hospice Aide) hired since the last survey, dated 4/1/19. The hospice reported 3 new contract staff had provided direct patient care since the last survey. Failure to address specific job duties at the time of employee orientation increased the potential that specialized patient care services not be provided according to hospice expectations. Findings include: Staff G, contracted Hospice Aide, had a start date of 4/16/19. Review of Staff G's personnel file revealed the file lacked documented evidence hospice staff had provided an initial orientation for Staff G's specific job duties. On 4/20/22 at 4:19 PM, during an interview, the Clinical Manager reported an inability to find evidence Staff G, contracted Hospice Aide, had received hospice orientation training including orientation to Staff G's specific job duties. 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 patient clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the medical director of the hospice or the hospice physician designee, signed the initial written certification of terminal illness, for 7 of 7 sampled patients (Patients #1, #4, #5, #6, #7, #10 and #11) who had chosen a attending physician to provide primary hospice care and was not identified as the hospice's Medical Director or physician designee. Failure of the hospice to ensure the medical director or designee signed the Certificate of Terminal Illness placed patients at risk for not meeting the eligibility requirements for hospice and have unexpected medical expenses. Findings include: Review of the hospice's policy, titled Plan of Care (POC), dated 8/2021, identified the documentation of the attending physician and Medical Director's involvement in the development and updating of the POC is evidenced by review and signature on the hospice's Physician Certification of Terminal Illness (CTI) and POC. 1. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed the following: a. The POC, dated 2/9/22 to 5/9/22, included documentation which identified the patient had chosen an attending physician that was not the hospice's own medical director or hospice physician designee as the primary hospice care physician. b. The clinical record lacked documentation of an initial, written and signed CTI completed by the hospice's Medical Director or hospice physician designee. On 4/18/22 at 4:05 PM, during an interview, Staff I, Social Worker, reviewed the patient's record and agreed she could not find documentation of an initial, written CTI signed by the hospice's Medical Director or hospice physician designee. 2. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/7/22 to 6/4/22, included documentation which identified the patient had chosen an attending physician that was not the hospice's own medical director or hospice physician designee as the primary hospice care physician. b. The clinical record lacked documentation of an initial, written and signed CTI completed by the hospice's Medical Director or hospice physician designee. On 4/18/22 at 4:15 PM, during an interview, the surveyor notified the Clinical Manager of the inability to find a written, signed CTI completed by the hospice's Medical Director or hospice physician designee for Patients #1 and #6. She explained the patient's attending physician signs off on the CTIs and the Medical Director signs the POC. 3. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 3/9/22 to 6/6/22, included documentation which identified the patient had chosen an attending physician that was not the hospice's own medical director or hospice physician designee as the primary hospice care physician. b. The clinical record lacked documentation of an initial, written and signed CTI completed by the hospice's Medical Director or hospice physician designee. 4. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review reveal on 4/18/22 revealed hospice certification of terminal illness for certification period, dated 4/1/22 to 6/29/22, signed by attending physician on 4/6/22 but lacked a signature from the medical director. On 4/19/22 at 8:15 AM, the social worker provided the surveyor with paperwork that was in filing, this included hospice certification of terminal illness signed by the medical director on 4/19/22 and faxed to the hospice office on 4/19/22 at 7:13 AM. 5. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed hospice certification of terminal illness for certification period, dated 12/3/21 to 3/2/22, signed by the attending physician on 12/13/21 but lacked a signature from the medical director. 6. Patient #4 had an admission to hospice on 2/26/22 and received services while residing in a private residence. The clinical record lacked evidence of completion of an initial certification of terminal illness by the medical director. During an interview on 4/20/22 at 9:02 AM the administrator reported the medical director had not completed the certification of terminal illness. 7. Patient #7 had an admission to hospice on 2/8/22 and received services while residing in a private residence. The clinical record lacked evidence of completion of an initial certification of terminal illness by the medical director. During an interview on 4/20/22 at 9:02 AM the administrator reported the medical director had not completed the certification of terminal illness. 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 clinical records contained pertinent, up-to-date and complete information in a timely manner according to agency policy for 11 of 11 sampled patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11). 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: Review of the hospice's policy, titled Interdisciplinary Group (IDG), dated 1/2022, identified IDG members are responsible for documenting all care and services provided in a timely manner and in accordance with hospice's documentation requirements. Review of the hospice's policy, titled Clinical Records, dated 12/2021, revealed the patient clinical record will include all progress and clinical notes. 1. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: a. See L0531 for evidence of documentation missing from the patient's record. b. The Plan of Care (POC), dated 2/9/22 to 5/9/22, included IDG orders for hospice aide services 3 times per week. The POC included orders for the hospice aide to assist the patient with ambulation and transfers with the rollator (walker). The hospice aide visit notes completed by Staff H, Hospice Aide, dated 2/11, 2/25, 3/2, 3/4, 3/7, 3/9, 3/11, 3/16, 3/21, 3/23 and 3/25/22, included documentation Staff H assisted the patient with ambulation and transfers with the walker. On 4/20/22 at 9:59 AM, during an interview, Staff H, Hospice Aide, reported after the first visit (2/11/22), she did not assist the patient with ambulation, only with pivot transfers due to the patient being too weak. The hospice aide visit note documentation incorrectly identified the hospice aide assisted the patient with ambulation for visits, dated 2/25, 3/2, 3/4, 3/7, 3/9, 3/11, 3/16, 3/21, 3/23 and 3/25/22. 2. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/7/22 to 6/4/22, included IDG orders for social worker services. b. On 4/20/22 at 8:20 AM, Staff I, Social Worker, provided a copy of the patient's Anticipatory Grief Update Form. The form included documentation of notes for each IDG meeting by Staff I, Social Worker, dated 3/8, 3/22 and 4/6/22. The notes were not part of the patient's record, but contained information related to the patient's spouse's struggle with anticipatory grief. 3. Patient #9 had a hospice admission date of 1/11/22, received hospice services from the parent office in Fort Madison and died on 1/24/22. Review of the clinical record revealed the following: See L0531 for missing documentation from the patient's clinical record. 4. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. The POC, dated 3/9/22 to 6/6/22, included IDG orders for social worker services. b. On 4/20/22 at 8:20 AM, Staff I, Social Worker, provided a copy of the patient's Anticipatory Grief Update Form. The form included documentation of notes for each IDG meeting by Staff I, Social Worker, dated 1/19 and 1/25/22. The notes were not part of the patient's record, but contained information related to the patient's spouse's struggle with anticipatory grief. 5. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The comprehensive assessment completed by the social worker, dated 4/8/22, lacked an initial bereavement risk assessment. b. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 4/6/22, the Interdisciplinary Group (IDG) meeting date of 4/12/22 and was not kept in the clinical record. 6. Patient #3 had a hospice admission date of 2/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The comprehensive assessment completed by the social worker, dated 2/15/22, lacked an initial bereavement risk assessment. b. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 2/15/22, the IDG meeting date of 2/16/22 and was not kept in the clinical record. 7. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The comprehensive assessment completed by the social worker, dated 4/1/22, lacked an initial bereavement risk assessment. b. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 4/1/22, the IDG meeting date of 4/6/22 and was not kept in the clinical record. 8. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The comprehensive assessment completed by the social worker, dated 12/3/21, lacked an initial bereavement risk assessment. b. On 4/20/22 at 8:45 AM, the social worker provided the surveyor with a paper copy of an anticipatory grief update form that was printed as a word document and signed by the social worker. This form is considered the bereavement risk assessment, includes the admit date of 12/3/21, the IDG meeting date of 12/7/21 and was not kept in the clinical record. 9. Patient #4 had a hospice admission date of 2/26/22 and received hospice services while residing in a private residence. A anticipatory grief update form dated 3/2, 3/16, 3/30 and 4/12/22 completed by the social worker was stored on the social workers computer and not within the clinical record. 10. Patient #7 had a hospice admission date of 2/8/22 and received hospice services while residing in a private residence. A anticipatory grief update form dated 2/8, 2/22, 3/2, 3/16, 3/30 and 4/12/22 completed by the social worker was stored on the social workers computer and not within the clinical record. 11. Patient #8 had a hospice admission date of 2/24/22 and date of death of 3/17/22. Hospice services provided while patient residing in assisted living. A anticipatory grief update form dated 3/2, 3/16 and 3/22 completed by the social worker was stored on the social workers computer and not within the clinical record. 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 and hospice policy review the hospice failed to ensure all entries completed in the clinical records included an appropriate date, signature and title for 5 of 11 sampled patients (Patients #1, #6, #9, #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: According to the hospice policy titled Clinical Records, dated 12/2021, identified handwritten records must include the date and signature of the individual, complete with his/her title to authenticate an entry in the clinical record. The time of the entry must be included. 1. Patient #10 had a hospice admission date of 12/3/21, a discharge date of 3/2/22 and received hospice services while residing in a nursing home. Clinical record review revealed massage therapy visit note, dated 1/6/22, included a handwritten signature and date of signature but lacked a title. 2. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: a. A massage therapy visit note, dated 3/25/22, included documentation of a signature of completion and date by the massage therapist, but lacked inclusion of the massage therapist's title. b. The chaplain visit notes, dated 3/15, 3/16, 3/30, 4/9 and 4/12/22, included documentation of a date and signature of completion by the chaplain, but lacked documentation of a title with the signature. 3. Patient #6 had a hospice admission date of 3/7/22 and received hospice services from the Illinois multiple location office while residing in a private residence. Review of the clinical record revealed the following: A massage therapy visit note, dated 4/5/22, included documentation of a signature of completion and date by the massage therapist, but lacked inclusion of the massage therapist's title. 4. Patient #9 had a hospice admission date of 1/11/22, received hospice services from the parent office in Fort Madison and died on 1/24/22. Review of the clinical record revealed the following: A chaplain visit note, dated 1/24/22, included documentation of a date and signature of completion by the chaplain, but lacked documentation of a title with the signature. 5. Patient #11 had a hospice admission date of 3/9/22, received hospice services from the Illinois office while residing in a private residence and died on 3/31/22. Review of the clinical record revealed the following: a. A massage therapy visit note, dated 3/25/22, included documentation of a signature of completion and date by the massage therapist, but lacked inclusion of the massage therapist's title. b. A chaplain visit note, dated 3/30/22, included documentation of a date and signature of completion by the chaplain, but lacked documentation of a title with the signature. On 4/20/22 at 10:25 AM, during an interview, the Administrator confirmed the chaplain should be including a title with his signature when completing visit notes, as the chaplain is providing a core service. 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, review of short-term inpatient care contract with the local hospital, hospital and hospice staff interview, the hospice failed to ensure hospice staff provided training on the hospice philosophy and providing patient care according to the hospice plan of care to hospital staff prior to hospital staff providing inpatient care to a hospice patient (Patient #1). Failure to ensure hospital staff providing short-term inpatient care to hospice patients receive training on the hospice philosophy and providing patient care according the hospice plan of care placed hospice patients at risk for not receiving care and services according to the hospice's Interdisciplinary Group's (IDG) decisions and patient's wishes. Findings include: Review of the hospice's contract for short-term inpatient care with the local hospital , dated 9/27/16, revealed the hospice agreed to provide training on hospice patient care to hospital staff providing hospital services to hospice patients. The hospice shall maintain a description of the training and the names of those giving the training. Patient #1 had a hospice admission date of 2/9/22, received routine home care hospice services while residing at a private residence until 4/13/22, and then was admitted to general inpatient hospice services on 4/14/22 for pain management at the local hospital. Review of the clinical record revealed: The Plan of Care (POC), dated 2/9/22 to 5/9/22, identified a diagnosis of pancreatic cancer and included IDG orders for skilled nursing, social worker, hospice aide, massage therapy and chaplain services. On 4/19/22 at 9:50 AM, during an interview, Staff D, hospice Registered Nurse (RN) and Case Manager for Patient #1, expressed concern over a lack of coordination with hospital staff and hospice staff on the patient's care. She reported she went to see the patient Monday, 4/18/22, and the patient had several medication order changes and wound treatment order changes. She reported no one with the hospital had coordinated those changes with her or any of the other hospice staff. Staff D, RN, provided a copy of the updated physician orders. Review of the updated physician orders, dated 4/18/22, revealed a total of 23 order changes made by the patient's hospital physician without consulting hospice staff. On 4/19/22 at 10:20 AM, during a on-site hospital visit observation with the patient, patient's spouse and Staff D, RN, the surveyor observed the patient's room had a dry erase board which identified the hospital staff working with the patient and pain treatment plan options. The dry erase board did not identify the patient as a hospice patient or the names of any of the hospice staff working with the patient. On 4/19/22 at 11:00 AM, during an interview, the patient's hospital nurse reported she had not received any training from the hospice. She explained hospital staff orientation did not include hospice training and it was not offered as a part of any other training. She reported she was doing the best she could on working with a hospice patient and having no training. On 4/19/22 at 11:02 AM, during an interview, Staff D, RN, reported the hospice had provided information to the hospital on the patient including a face sheet, transfer summary, medication profile at the time of admission to the hospital, advance directives and the Plan of Care. In an observation during the same interview, the surveyor observed the medical record for the patient that had the information as described by Staff D, RN, located in the nurses station at the hospital. On 4/19/22 at 11:06 AM, during an interview, the hospital physician designated as being responsible for the patient's hospital care and services reported he had not been offered any training in hospice philosophy or following the hospice POC. On 4/19/22 at 2:40 PM, during an interview, the Administrator and Clinical Manager both reported previously offering training to hospital staff on hospice, but have not offered anything since the pandemic started (March 2020). They reported rarely getting patients that need general inpatient level of care. The Administrator and Clinical Manager received the above findings and hospice staff offered 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 #2 and #5). Failure to communicate hospice information to nursing home staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: 1. Patient #2 had a hospice admission date of 4/6/22 and received hospice services while residing in a nursing home. During a home observation visit on 4/19/22 at 9:15 AM, with Staff C, Registered Nurse (RN), the surveyor reviewed the facility chart for hospice documents provided. The surveyor was unable to find a copy of the certification of terminal illness form for Patient #2. Staff C reported the patient had been a transfer from another hospice and this receiving hospice had not completed the certification of terminal illness form. On 4/20/22 at 11:08 AM, the Clinical Manager confirmed the certification of terminal illness form from the transferring hospice would be the form this hospice would use and should be at the nursing facility. The clinical record review revealed the certification of terminal illness form was received from the transferring hospice for certification period 3/20/22 to 6/17/22. The hospice staff failed to ensure the nursing home had a copy of the patient's current certification of terminal illness order for the certification period 3/20/22 to 6/17/22. 2. Patient #5 had a hospice admission date of 4/1/22 and received hospice services while residing in a nursing home. Clinical record review revealed: During an unannounced visit to the nursing facility on 4/19/22 at 9:15 AM, the surveyor reviewed the facility chart for hospice documentation provided. The surveyor was unable to find a copy of the certification of terminal illness form for Patient #5. Staff C reviewed the facility chart and was unable to find the certification of terminal illness. Staff C reported the form is copied and placed in her mailbox to bring out to the facility, the form may not have been copied yet or it may still be in the her mailbox. The hospice staff failed to ensure the nursing home had a copy of the patient's current certification of terminal illness order for the certification period 4/1/22 to 6/29/22. The Administrator and Clinical Manager received the above findings and hospice staff provided no further information prior to the end of the survey.