Every finding on record at Mahaska County Hospital

Observed in Record Review. In 5 of 5 patient records reviewed, it was noted that the organization did not ensure that the Hospice Election and Consent Form(s) were completed as required. The organization did not ensure the patient's right to choose an attending provider was implemented. For example, during a review of the consent in the medical record for HosInptRR#1, HosInptRR#2, HosRRHV#1, and HosRRHV#2, HosRRHV#3, the primary physician line did not include the physician’s full name. This observation was reviewed with the Director of Hospice.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record for HosRRNHV#6, the clinician documented the presence of a stage 3 ulcer at the right shoulder, and a stage 3 ulcer at the coccyx. The wound assessment did not include wound measurements. This observation was reviewed with the Director of Hospice.

Observed in Data Session. During the Hospice QAPI session it was noted that the percentage of patients involved in a fall event was 8% in the year 2023. The percentage of patients involved in a fall event was 18% in the year 2024. The organization did not document steps to achieve success or change outcomes related to fall prevention for the years 2023 and 2024. Since the organization did not document steps to achieve success or change outcomes related to fall prevention. The hospice did not track its performance related to fall prevention improvement goals. This observation was reviewed with the Director of Hospice.

Observed in Individual Tracer. In 1 of 3 Individual Tracers, it was noted that the organization did not ensure its infection prevention and control activities to eliminate the risk of infection were implemented. For example, during home visit activity for HosRRHV#1, it was noted that after equipment cleaning was completed the clinician placed the equipment (stethoscope, blood pressure machine, thermometer) directly into the nursing bag. The clinician used Sani-Cloth germicidal disposable wipes for equipment cleaning. The manufacturer instructions for use included the following information: Unfold a clean wipe and thoroughly wet surface. Allow surface to remain wet for two (2) minutes. Let air dry. This observation was reviewed with the Director of Hospice.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the Certification of Terminal Illness statement(s) for benefit period #2, for HosRRHV#1, and HosRRHV#2, revealed that the Certifying Physician Summary documenting clinical information to support the medical prognosis and support for recertification of hospice services was not present in the medical record. This area of the document was left blank. This observation was reviewed with the Director of Hospice Services.

Observed in Infection Control System Tracer. During the Infection Control System Tracer, since it was noted that the organization had not identified infection risks, the organization did not develop written infection prevention and control goals improving compliance with hand hygiene for 2020 and 2021. This observation was reviewed with the Director of Quality and Compliance. Observed in Infection Control System Tracer. During the Infection Control System Tracer, since it was noted that the organization had not identified infection risks, the organization did not develop written infection prevention and control goals limiting unprotected exposure to pathogens for 2020 and 2021. This observation was reviewed with the Director of Quality and Compliance. Observed in Infection Control System Tracer. During the Infection Control System Tracer, since it was noted that the organization had not identified infection risks, the organization did not develop written infection prevention and control goals limiting the spread of infections associated with the use of medical equipment, devices, and supplies for 2020 and 2021. This observation was reviewed with the Director of Quality and Compliance. Observed in Infection Control System Tracer. During the Infection Control System Tracer, since it was noted that the organization had not identified infection risks, the organization did not develop written infection prevention and control goals limiting the spread of infections associated with procedures for 2020 and 2021. This observation was reviewed with the Director of Quality and Compliance. Observed in Infection Control System Tracer. During the Infection Control System Tracer, since it was noted that the organization had not identified infection risks, the organization did not develop written infection prevention and control goals addressing its prioritized risks for 2020 and 2021. This observation was reviewed with the Director of Quality and Compliance.

Observed in HR File Review. In 1 of 8 HR files reviewed, the surveyor observed that the organization had not documented competency assessment every 3 years as required by agency policy and TJC. Observed in HR file review #7 for a MSW, competency had not been documented since 2018. This observation was discussed and verified with the credentialing and HR staff. The HR director found a self evaluation completed by the MSW, but not a skills verification by another MSW since 2018.

Observed in HR File Review. In 1 of 8 HR files reviewed, the surveyor observed that primary source verification of license had not been verified when the credential was renewed. Observed in HR file review #8, the Hospice Aide license expired the end of December and there was no documentation in the HR file that primary source verification had occurred when the licensed was renewed. This observation was discussed and verified with the credentialing and HR staff. HR staff was able to verify that the Aide still had an active license and did primary license verification during survey. This was not completed when the credential had been renewed in December.