Every finding on record at Orange City Hospice

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 care plan for 3 of 9 sampled patients receiving hospice aide services ( Patient #1, #4 and #6).  Failure to ensure the hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients personal care needs were not adequately met.   Findings include: --- 3. Patient #4 had a start of care date of 4/26/25 and received hospice services while residing in a private residence.  Clinical record review revealed the following:   a. The POC, dated 4/26/25 to 7/23/25, included orders for hospice aide services 1 to 2 times a week.  The POC identified the patient had a diagnosis of Acute kidney failure.    b. The hospice aide care plan, dated 4/27/25, included the following RN assigned hospice aide tasks: apply lotion to legs and back, assist with ambulation, assist with dressing, assist with eating/feeding, assist patient with oral care, assist with repositioning patient, assist with shampoo and haircare, assist with shaving, provide routine catheter care according to policy, tidy room, provide companionship and entertainment, assist patient with partial/complete bed bath, perform back rub, remove trash, assist with transfers using gait belt and change bed linens.    c. The hospice aide visit notes, dated 4/29/25 and 5/2/25, completed by Staff K, LPN, documented the tasks of assist patient with partial/complete bed bath accomplished.  The documentation failed to include which of the tasks were accomplished.    The above findings were reviewed with the Administrator and Clinical Manager.     According to the agency policy titled, Hospice Aide Services, dated 2/5/24, home health aides are assigned to a patient assignment by the RN who determines the appropriate home health aide schedule for the patient based on their individual needs.   During an interview on 4/29/25 at 3:06 PM, the Clinical Manager stated if the hospice aide unable to complete a task, the hospice aide would mark they didn't complete it. If the task routinely not completed, the hospice aide would talk to the nurse and the task would be addressed and modified or removed. 1.Patient #1 had a start of care date of 8/8/24 and received hospice services while residing in a nursing home.   Clinical record review revealed the following:  a. The plans of care (POCs), dated 1/4/25 to 4/4/25 and 4/5/25 to 6/3/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of Alzheimer's disease.  b. The hospice aide care plan, dated 4/28/25, the Registered Nurse (RN) assigned the following hospice aide tasks: apply compression stocking, apply lotion to patient’s skin, assist incontinence care, whirlpool baths on Mondays, assist with elimination with EZ stand, assist with dressing, assist with eating/feeding, assist with oral care, assist with repositioning, assist with shampoo and haircare, assist with shaving, partial/complete bed bath on Mondays if refuses whirlpool and collaborate with facility/agency staff,   c. The hospice aide visit notes, dated 3/31/25 and 4/14/25, Staff K, Licensed Practical Nurse (LPN), documented the task of a whirlpool and partial/complete bed bath accomplished. She also documented the task of  shampoo and/or using brush or comb accomplished. The documentation failed to include which of the task instructions were accomplished.  d. The hospice aide visit note, dated 4/7/25, Staff L, Hospice Aide (HA), documented the task of  shampoo and/or using brush or comb accomplished. The documentation failed to include which of the task instructions were accomplished. The hospice aide failed to identify which specific services were provided as instructed by the RN assignment.  2. Patient #6 had a start of care date of 9/3/24 and received hospice services while residing in a private home residence.   Clinical record review revealed the following:  a. The POCs, dated 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25, included orders for hospice aide services 1 to 2 times a week. The POC identified the patient had a diagnosis of chronic obstructive pulmonary disease.  b. The hospice aide care plan, dated 4/29/25, the RN assigned the following hospice aide tasks: remove trash, clean bathroom, clean/tidy room, perform nail filing, perform back rub, assist with dressing, apply lotion, assist with foot care, assist with shower, assist with bath-able to decide sponge or shower, prepare meal, apply compression stocking, assist with shampoo and haircare-and/or brush or comb, provide companionship and entertainment and assist with ambulation  c. The hospice aide visit notes, dated 3/25/25 and 4/1/25, Staff K, LPN, documented the task of shampoo and/or using brush or comb accomplished. The documentation failed to include which of the task instructions were accomplished.   d. The hospice aide visit note, dated 3/28/25, Staff L, HA, documented the task of both a shower and sponge bath accomplished. The hospice aide visit notes, dated 3/28/25 and 4/4/25, Staff L documented the task of shampoo and/or using brush or comb accomplished. The documentaion failed to include which of the task instructions were accomplished.  The hospice aide failed to identify which specific services were provided as instructed by the RN assignment.

Based on review of written hospice agreements for services under arrangement, the hospice failed to ensure written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 2 of 3 sampled services (Massage therapy 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 therapeutic massage provider, dated 2/6/23, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management and   b. The hospice retains oversight of staff and services.    2. Review of the contract between the hospice and sampled pharmacy provider, dated 5/13/14, 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,   c. All services are delivered in a safe and effective manner by qualified personnel and   d. 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 Administrator and Clinical Manager.

Based on clinical record review and agency staff interview,  the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards for 7 of 14 sampled patients (Patients #1, #2, #6, #7, #8, #9 and #12).     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: --- 5. Patient #2 had a start of care date of 1/8/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 1/8/25 to 4/7/25 and 4/8/25 to 7/6/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker, chaplain, massage therapy and music therapy services.    b. The chaplain visit notes, dated 3/8/25, 4/3/25 and 4/17/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit notes.   c. The massage therapist visit notes, dated 3/13/25 and 3/28/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature.    The hospice failed to ensure all completed documentation included appropriate authentication.    6. Patient #9 had a start of care date of 1/21/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of Heart disease and included orders for skilled nurse, social worker, hospice aide, chaplain, music therapy, massage therapy and volunteer services.    b. The chaplain visit note, dated 2/19/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit note.   c. The massage therapist visit notes, dated 3/12/25 and 3/27/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature.    The hospice failed to ensure all completed documentation included appropriate authentication.    7. Patient #12 had a start of care date of 10/4/24 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/1/25 to 4/1/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker, chaplain, music therapy, massage therapy and volunteer services.     b. The chaplain visit note, dated 2/2/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit note.   c. The massage therapist visit notes, dated 2/25/25 and 3/25/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature.    The hospice failed to ensure all completed documentation included appropriate authentication.    The above findings were reviewed with the Administrator and Clinical Manager.     During and interview on 5/6/25 at 2:30 PM the Administrator stated the expectation for the written staff signature to include the name, credentials and date of completion of the documentation of services provided.  1.Patient # 1 had a start of care date of 8/8/24 and received hospice services in a nursing home. Clinical record review revealed the following:  a. The Plan of Cares (POCs), dated 1/4/25 to 4/4/25 and 4/5/25 to 6/3/25, identified the patient had a diagnosis of Alzhiemer's Disease and included orders for skilled nurse, social worker,chaplain, massage therapy, music therapy  and  hospice aide.  b. The chaplain visit notes, dated 3/7/25 and 4/13/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.    2. Patient # 6 had a start of care date of 9/3/24 and received hospice services in a private home setting. Clinical record review revealed the following:  a. The POCs, dated 3/2/25 to 4/30/25 and 5/1/25 to 6/29/25, identified the patient had a diagnosis of chronic obstructive lung disease and included orders for skilled nurse, social worker,chaplain, massage therapy, music therapy  and  hospice aide.  b. The chaplain visit notes, dated 3/26/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit notes.    c. The massage therapist notes, dated 2/11/25 and 3/12/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature.  The hospice failed to ensure all completed documentation included appropriate authentication.    3. Patient # 7 had a start of care date of 12/12/24 and received hospice services in a private home setting. Clinical record review revealed the following:  a. The POCs, dated 12/12/25 to 3/11/25 and 3/12/25 to 6/9/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social worker,chaplain, massage therapy, music therapy  and  hospice aide.  b. The chaplain visit notes, dated 3/8/25 and 4/27/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit notes.    c. The massage therapist notes, dated 3/3/25 and 3/28/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature.  The hospice failed to ensure all completed documentation included appropriate authentication.    4. Patient #8 had a start of care date of 5/9/24 and received hospice services in a private home setting. Clinical record review revealed the following:  a. The POCs, dated 1/4/25 to 3/4/25 and 3/5/25 to 5/3/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social worker,chaplain, massage therapy, music therapy, volunteer and hospice aide.  b. The chaplain visit notes, dated 3/24/25 and 4/8/25, completed by Staff C, Chaplain, included a signature and date but lacked a title of the clinician completing the visit notes.    c. The massage therapist notes, dated 2/4, 2/20 and 2/25/25 and 3/17/25, completed by Staff H, Massage Therapist, included a signature but lacked a title of the clinician completing the visit notes and date of signature. The hospice failed to ensure all completed documentation included appropriate authentication.

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 3 sampled written agreements (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 1/28/25.  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 Administrator and Clinical Manager.

Based on review of the written agreements 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 3 of 3 sampled written agreements (Hospital A, B and C).    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: --- 1.The hospice agency had a contractual agreement with Hospital A, dated 1/28/25.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators.    2. The hospice agency had a contractual agreement with Hospital B, dated 1/29/25.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided and documentation of the training facilitators.    3. The hospice agency had a contractual agreement with Hospital C, dated 1/8/13.  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 Administrator and 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 2 of 6 sampled employees (Staff E & L) who began serving hospice patients since their last survey, dated 5/12/22.  The hospice reported hiring 7 new 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.   Findings include: --- According to the hospice policy titled Background Check Procedures, last revised 11/20/23, criminal history, sex offender, dependent adult abuse, and child abuse histories are conducted through the Single Contact Repository Site (SING) for all applicants following an initial offer of employment.   During an interview on 5/6/25 at 11:05 AM, the Administrator stated Staff E and Staff L had background checks completed when they previously worked at the hospital. Staff  transferred to work for hospice.  1.  Staff E, Medical Director, had a hire date of 12/21/23.  A criminal background check was completed and dated 2/3/2020.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  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.  2. Staff L, Hospice Aide, had a hire date of 2/11/25.  A criminal background check was completed and dated 7/3/19.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  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 reviewed with the Administrator and 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 2 of 7 sampled employees (Staff E and L) who began serving hospice patients since their last survey, dated 5/12/22.  The hospice reported hiring 7 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.  Findings include: --- According to the hospice policy titled Background Check Procedures, last revised 11/20/23, criminal history, sex offender, dependent adult abuse, and child abuse histories are conducted through the Single Contact Repository Site (SING) for all applicants following an initial offer of employment.   During an interview on 5/6/25 at 11:05 AM, the Administrator stated Staff E and Staff L had background checks completed when they previously worked at the hospital. Staff  transfered to work for hospice.     1.  Staff E, Medical Director, had a hire date of 12/21/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 2/3/2020.  The hospice failed to complete dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of health 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.  2. Staff L, Hospice Aide, had a hire date of 2/11/25.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 7/3/19.  The hospice failed to complete dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of health 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 reviewed with the Administrator and Clinical Manager.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure members of the interdisciplinary group completed a comprehensive assessment which included a wound assessment within 5 days after the patient's election of hospice care for 1 of 11 sampled patients (Patient #5). Failure to complete an initial spiritual assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison. Findings include: According to the hospice policy titled Hospice Initial and Comprehensive Assessment and Plan of Care, dated 9/2015, the content of the comprehensive assessment will include; physical, psychosocial, emotional and spiritual needs related to the terminal illness and related conditions. Pain, dyspnea, nausea, vomiting, constipation, restlessness, anxiety, sleep, skin status, confusion, emotional distress, spiritual needs, support systems, and family need for education and/or counseling. According to hospice policy, titled Wound Care, dated 4/2022, wounds will be measured upon initial discovery/admission and then at a minimum of weekly thereafter. Patient #5 had a hospice admission date of 12/30/21, received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The comprehensive assessment completed by the Registered Nurse (RN) Clinical Manager, dated 3/25/22, included documentation the patient had a wound to the heel. The patient already dressed and unable to assess. The comprehensive assessment failed to include measurements of the wound. During an interview on 5/10/22 at 1:45 PM, the Clinical Manager stated an assessment weekly with measurements expected. The surveyor reviewed the above findings with the Administrator and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review the hospice failed to ensure hospice staff completed medication reviews which included all the required components of a drug regimen review for 4 of 11 sampled patients (Patients #1, #7, #8 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 Drugs and Biologicals, dated 809/2015, the updates to the comprehensive assessment will address duplicate drug therapy, drug side effects, untoward interactions, and effectiveness of drug therapy. 1. Patient #7 had a hospice admission date of 3/15/22 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Interdisciplinary group, (IDG) updates to the plan of care dated 3/15, 3/29, 4/5, 4/12, 4/19, 4/26 and 5/3/22 included physician orders for medications, including: i. pain medications; morphine, tylenol, tramadol, voltaren, gabapentin and hydrocortisone. ii. diuretic medications; furosemide and spironolactone. c. The same IDG updates to the plan of care included documentation the skilled nurse completed the DRR. The DRR failed to identify duplicate drug therapy. 2. Patient #1 had a hospice admission date of 4/20/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. POC, dated 4/20/22 to 7/18/22, included physician orders for Lorazepam and oxycodone. Lorazepam can potentially interact with oxycodone. b. The initial DRR documented in the comprehensive assessment completed by the RN, dated 4/20/22, identified no potential drug interactions identified. 3. Patient #8 had a hospice admission date of 9/7/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. POC, dated 3/6/22 to 5/4/22 and 5/5/22 to 7/3/22, included physician orders for Lorazepam and Morphine. Lorazepam can potentially interact with Morphine. b. The initial DRR documented in the comprehensive assessment completed by the RN, dated 9/7/22, identified no potential drug interactions identified. c. The DRR documented in the IDG, dated 3/8, 3/22, 3/29//22, 4/5, 4/12, 4/19 and 4/26/22, identified no potential drug interactions identified. 4. Patient #11 had a hospice admission date of 2/28/22, a death date of 3/5/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. POC, dated 2/28/22 to 5/28/22, included physician orders for Hydrocodone - Acetaminophen, Morphine Sulfate, Lorazepam and Seroquel. Lorazepam and Seroquel can potentially interact with both Hydrocodone - Acetaminophen and Morphine Sulfate. b. The initial DRR documented in the comprehensive assessment completed by the RN, dated 2/28/22, identified no potential drug interactions identified. The above information was reviewed with the hospice Administrator 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 nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 1 of 2 sampled patients with a wound (Patient #5). Failure by the hospice Interdisciplinary Group (IDG) registered nurses 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 hospice policy, titled Wound Care, dated 4/2022, wounds will be measured upon initial discovery/admission and then at a minimum of weekly thereafter. During an interview on 5/10/22 at 1:45 PM, the Clinical Manager stated an assessment weekly with measurements expected. Patient #5 had a hospice admission date of 12/30/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, dated 3/8/22, included IDG orders for skilled nursing services 1 to 2 times every week and 2 to 3 as needed. b. The skilled nurse visit note, dated 3/8/22 and 3/11/22, included documentation the wound dressing clean, dry and intact. The wound not assessed. c. The skilled nurse visit note, dated 3/15/22 and 3/18/22, included documentation the wound dressing clean, dry and intact. The wound not assessed. Hospice staff failed to provide assessment of the patient's wound per policy. The above information was reviewed with the hospice Administrator 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 the hospice Interdisciplinary Group developed an individualized plan of care which included interventions for 8 of 11 sampled patients (#1, #2, #4, #5, #6, #8, #9 and #11). Failure to include interventions on the Plan of Care increased the potential that hospice services did not adequately meet the needs of hospice patients and families. Findings include: According to the hospice Policy titled Interdisciplinary Team (IDT) approach to Patient Care, dated 9/2015, each patient will have a primary nurse who in consultation with the Patient Care Coordinator and Nurse Manager will ensure coordination of care, continuous assessment of each patient and families needs and ensure implementation and revision of the plan of care. The IDT will provide oversight for the establishment of day-to-day policies and procedures of hospice are and services. The agenda of the weekly meeting will include these items as necessary. 1. Patient #1 had a hospice admission date of 4/20/22 and received hospice services while residing in a private home. Review of the clinical record revealed the Plan of Care (POC), dated 4/20/22 to 7/18/22, included IDG orders for the following: a. Massage therapy services as needed. The POC lacked any goals or interventions for the massage therapy services. 2. Patient #4 had a hospice admission date of 4/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the POC, dated 4/28/22 to 7/26/22, included IDG orders for the following: a. home health aide services 1 to 2 visits a week, b. massage therapy services 1 to 2 visits a month. c. music therapy services 1 to 2 visits a month. The POC lacked any goals or interventions for the hospice aide, music therapy and massage therapy services. 3. Patient #5 had a hospice admission date of 12/30/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the POC, dated 3/30/22 to 6/27/22, included IDG orders for the following: a. home health aide services 1 to 2 visits a week, b. massage therapy services 1 to 2 visits a month. c. music therapy services as needed. The POC lacked any goals or interventions for the hospice aide, music therapy and massage therapy services. 4. Patient #8 had a hospice admission date of 9/7/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the POC, dated 3/6/22 to 5/4/22, included IDG orders for the following: a. home health aide services 1 to 2 visits a week, b. massage therapy services 1 to 2 visits a month. The POC lacked any goals or interventions for the hospice aide and massage therapy services. 5. Patient #6 had a hospice admission date of 1/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/28/22 to 4/27/22, included IDG orders for massage therapy services, but lacked a frequency, intervention and goal related to the service. b. The IDG meeting, dated 2/8/22, included IDG orders for massage therapy 1 to 2 times per month, but continued to lack a goal or intervention related to the service. c. The IDG meetings, dated 2/15, 2/22, 3/8, 3/22 and 3/29/22, lacked documentation of any IDG identification of any interventions or goals related massage therapy services. The IDG meeting, dated 4/5/22, included documentation the IDG had discontinued massage therapy services. 6. Patient #9 had a hospice admission date of 1/29/22, received hospice services while residing in a nursing home and died on 2/6/22. Review of the clinical record revealed the following: a. The POC, dated 1/29/22 to 4/28/22, included IDG orders for music and massage therapy services 1 to 2 times per month starting on 1/31/22. The POC lacked an intervention and goal for music and massage therapy services. The clinical record lacked documentation hospice IDG members added an intervention or goal for the services. b. The POC, dated 1/29/22 to 4/28/22, included a physician order for Clotrimazole-Betamethasone 1-0.5 percent cream, apply topically 2 times per day as needed for rash or itching. Apply sparingly to itchy, reddened area approximately 2 centimeters beyond the left peri-ulcer ankle wound. The comprehensive assessment completed by Staff D, Registered Nurse (RN), did not identify the patient had a wound. On 5/11/22 at 3:05 PM, during an interview, Staff D, RN, explained the Clotrimazole-Betamethasone cream order was an old order from when the patient had been on services with their home health agency. She reported the patient did not have a left ankle wound and the order should not have been included on the hospice POC. During the same interview, the Administrator explained old orders would pull from previous admissions in the electronic record if nursing staff did not discontinue the order. 7. Patient #11 had a hospice admission date of 2/28/22, a death date of 3/5/22 and received hospice services while residing in a private home. Review of the clinical record revealed the POC, dated 2/28/22 to 5/28/22, included IDG orders for the following: a. home health aide services 1 to 2 visits a week, b. massage therapy services 1 to 2 visits a month. The POC lacked any goals or interventions for the hospice aide and massage therapy services. 8. Patient #2 had a hospice admission date of 11/11/21 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/9/22 to 5/9/22 included IDG orders for interventions and goals for skilled nursing, chaplain and social worker. b. The IDG meeting notes, dated 3/7, 3/21, 3/28, 4/4, 4/11, 4/18/ 4/25, 5/2 and 5/5/22 included IDG orders for massage therapy services 1 to 2 times per month and music therapy services 1 to 2 times per month. c. The clinical record included documentation of massage therapy visits dated 3/15 and 4/25. d. The POC and IDG meeting notes lacked documentation of any interventions or goals related to massage therapy services. e. The clinical record included documentation of music therapy visits dated 3/15, 3/31, 4/12 and 4/26/22. d. The POC and IDG meeting notes lacked documentation of any interventions or goals related to music therapy services. The above information were reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, staff interview and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 4 of 11 sampled patients (Patients #1, #5, #6 and #11) Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: According to the hospice Policy titled Interdisciplinary Team (IDT) approach to Patient Care, dated 9/2015, each patient will have a primary nurse who in consultation with the Patient Care Coordinator and Nurse Manager will ensure coordination of care, continuous assessment of each patient and families needs and ensure implementation and revision of the plan of care. The IDT will provide oversight for the establishment of day-to-day policies and procedures of hospice are and services. The agenda of the weekly meeting will include these items as necessary. 1. Patient #1 had a hospice admission date of 4/20/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a The Plan of Care (POC), dated 4/20/22 to 7/18/22, included IDG orders for skilled nursing, social worker, chaplain and massage therapy services. a. Massage therapy services ordered prn (as needed). The massage therapy services order lacked a frequency for the services. 2. Patient #5 had a hospice admission date of 12/30/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 3/30/22 to 6/27/22, included IDG orders for skilled nursing, social worker, chaplain, music therapy and massage therapy services. b. Music therapy services ordered prn. The music therapy services order lacked a frequency for the services. 3. Patient #6 had a hospice admission date of 1/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/28/22 to 4/27/22, included IDG orders for skilled nursing services 1 to 2 times per week and 2 to 3 as needed visits. b. The IDG meeting, dated 3/29/22, included conflicted orders for skilled nursing frequency of visits, with one order for skilled nursing visits 1 to 2 times per week and 2 to 3 visits as needed (PRN) and another order documented by the skilled nurse for 1 visit per week and PRN. On 5/11/22 at 3:00 PM, during an interview, the Administrator reported hospice staff were able to update the frequency orders in the IDG meeting notes to accurately reflect provision of services. 4. Patient #11 had a hospice admission date of 2/28/22, a death date of 3/5/22 and received hospice services while residing in a private home. Review of the clinical record revealed the following: a. The POC, dated 2/28/22 to 5/28/22, included IDG orders for skilled nursing, hospice aide, social worker, chaplain services, music therapy services and volunteer services. b. The order for volunteer services was PRN (as needed). The volunteer services order lacked a frequency for the services. The above information was reviewed with the hospice Administrator 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, the hospice failed to ensure the Plans of Care for 2 of 11 sampled patients (Patients #1 and #2) 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 Hospice Plan of Care dated 09/2019, the plan of care will include all drugs, treatments, medical supplies and equipment. 1. Patient #2 had a hospice admission date of 11/11/21 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 11/11/21 to 2/8/22 and 2/9/22 to 5/9/22 identified the patient uses the following medical equipment and supplies; bath bench/chair, bed/personal alarm, bed side table, bedside commode, gaitbelt, gloves, grab bars, handheld shower, hospital bed, incontinent supplies/linen savers, wheelchair and wheelchair cushion. b. During a home visit observation on 5/10/22 at 10:10 AM with Staff C, RN, (registered nurse). The surveyor observed the patient using a fall mat on the floor next to her bed and air mattress overlay. 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 4/20/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/20/21 to 7/18/22 identified the patient uses the following medical equipment and supplies; CPAP, cane, grab bars, handheld shower, spirometer, lift chair, nebulizer, oxygen concentrator, scale, chair side table, oxygen supplies, walker and toilet safety frame. b. During a home visit observation on 5/10/22 at 10:30 AM with Staff G, RN, (registered nurse). The surveyor observed the patient used a reacher and shower chair. During an interview during the same home visit the patient identified the equipment in use prior to the start of hospice services. The Plan of Care failed to identify all current medical equipment and supplies used by the patient. The above information was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, staff interview and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team revised the patient's plan of care to include the patient's progress towards outcomes and goals specified in the plan of care for 4 of 11 sampled patients (Patients #2, #3, #4 and #6) requiring an updated plan of care. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: According to the hospice Policy titled Interdisciplinary Team (IDT) approach to Patient Care, dated 9/2015, each patient will have a primary nurse who in consultation with the Patient Care Coordinator and Nurse Manager will ensure coordination of care, continuous assessment of each patient and families needs and ensure implementation and revision of the plan of care. The IDT will provide oversight for the establishment of day-to-day policies and procedures of hospice are and services. The agenda of the weekly meeting will include these items as necessary. 1. Patient #4 had a hospice admission date of 4/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/28/22 to 7/26/22, included IDG identified interventions and goals for skilled nursing, social worker, hospice aide and chaplain services. The POC included IDG orders for hospice aide services, but identified interventions and no goals. b. The IDG meeting, dated 5/3/22, lacked documentation of progress towards interventions and the goal related to hospice aide services. The hospice failed to include updates to the POC for hospice aide services. 2. Patient #6 had a hospice admission date of 1/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 1/28/22 to 4/27/22, included IDG identified interventions and goals for skilled nursing, social worker, hospice aide and chaplain services. The POC included IDG orders for massage therapy services, but identified interventions or goals. The POC, dated 4/28/22 to 7/26/22, included IDG orders for goals and interventions related to skilled nursing, social worker, hospice aide and chaplain services. a. The IDG meetings, dated 2/8, 2/15, 2/22, 3/8, 3/22 and 3/29/22, lacked documentation of IDG discussion towards the progress of any outcomes or goals related massage therapy services. The IDG meeting, dated 4/5/22, included documentation the IDG had discontinued massage therapy services. b. The IDG meetings, dated 2/8, 2/15, 2/22, 3/8, 3/22, 3/29, 4/5, 4/12, 4/19, 5/3 and 5/10/22, lacked documentation of progress towards interventions and the goal related to hospice aide services. c. The IDG meetings, dated 3/29 and 5/3/22, lacked documentation of progress towards interventions and goals related to social worker and chaplain services. 3. Patient #2 had a hospice admission date of 11/11/21 and received hospice services while residing in a nursing facility. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/9/22 to 5/9/22 included IDG orders for interventions and goals for skilled nursing, chaplain and social worker. b. The IDG meeting notes, dated 3/7, 3/21, 3/28, 4/4, 4/11, 4/18/ 4/25, 5/2 and 5/5/22 included IDG orders for massage therapy services 1 to 2 times per month and music therapy services 1 to 2 times per month. c. The clinical record included documentation of massage therapy visits dated 3/15 and 4/25. d. The POC and IDG meeting notes lacked documentation of outcomes or patient response related to massage therapy services. e. The clinical record included documentation of music therapy visits dated 3/15, 3/31, 4/12 and 4/26. d. The POC and IDG meeting notes lacked documentation of outcomes or patient response related to music therapy services. 4. Patient #3 had a hospice admission date of 4/16/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/16 to 7/14/22 included IDG orders for interventions and goals for skilled nursing, social worker and hospice aide services. b. The IDG meeting notes, dated 4/26 and 5/3/22 included IDG orders for hospice aide services 1 to 2 times per week. c. The clinical record included documentation of hospice aide visits, dated 4/19, 4/22, 4/26, 4/29, 5/3 and 5/6/22. d. The POCs and IDG meeting notes lacked documentation of any outcomes related to hospice aide services, any progress the patient was making in relation to receiving hospice aide services, or any response to the service. The above information was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review the hospice failed to ensure the Interdisciplinary Group maintained a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 11 sampled patients (Patients #6) with Interdisciplinary Group meeting updates. Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: According to the hospice Policy titled Interdisciplinary Team (IDT) approach to Patient Care, dated 9/2015, each patient will have a primary nurse who in consultation with the Patient Care Coordinator and Nurse Manager will ensure coordination of care, continuous assessment of each patient and families needs and ensure implementation and revision of the plan of care. The IDT will provide oversight for the establishment of day-to-day policies and procedures of hospice are and services. The agenda of the weekly meeting will include these items as necessary. Patient #6 had a hospice admission date of 1/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 1/28/22 to 4/27/22, included IDG identified goals and interventions for chaplain services and a frequency order for hospice aide services of 1 to 2 times per week for 13 weeks. The POC did not include an identified frequency for chaplain services. a. The IDG meeting, dated 2/22/22, included IDG orders for chaplain services 1 to 2 times per month. The IDG meetings prior to this date, dated 2/8 and 2/15/22, did not identify a frequency for chaplain services. The month of February included 4 chaplain visits, dated 2/1, 2/9, 2/16 and 2/25/22. The subsequent IDG, dated 3/8/22, failed to included documentation which identified the IDG was aware of the increase in chaplain visits. b. The IDG meeting, dated 4/5/22, included IDG orders for chaplain services 1 to 2 times per month. 1) The social worker visit, dated 4/6/22, included documentation the patient no longer wanted chaplain services and had discontinued chaplain services. 2) The IDG meetings, dated 4/12 and 4/19/22, continued to have goals and interventions related to chaplain services and did not identify the patient wanted to discontinue chaplain services. 3) The POC, dated 4/28/22 to 7/26/22, continued to have goals and interventions related to chaplain services, but did not include a scope and frequency for the service. 4) The clinical record included documentation of a chaplain visit note, dated 5/3/22. 5) The IDG meeting, dated 5/3/22, lacked any documentation regarding an update of chaplain services related to outcomes or goal progress and did not include a scope and frequency for the service. 6) The IDG meeting, dated 5/10/22, included documentation which identified the IDG had discontinued chaplain services. c. The weeks of 4/10 and 4/17/22 lacked documentation of a hospice aide visit. The IDG meetings, dated 4/5, 4/12, 4/19 and 5/3/22, lacked documentation of IDG awareness of missed hospice aide visits the weeks of 4/10 and 4/17/22. On 5/11/22 at 11:33 AM, during an interview, Staff E, Registered Nurse (RN), reported the patient was due for recertification and they were not sure if she still qualified. After talking with the patient's attending physician, they determined to start decreasing services. The patient then had a decline and did recertify for hospice services. Hospice aide services were put back in with the new certification starting on 4/28/22. The above information was reviewed with the hospice Administrator 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 3 of 11 sampled patients receiving hospice aide services (Patients #3, #6 and #8). 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 Home Health and Hospice Aide in-service, Competency and Delegation of Tasks dated 5/2021, identified the purpose to assure competency of each home health and hospice nurse aide in the performance of all assigned home health and hospice aide's duties. 1. Patient #3 had a hospice admission date of 4/16/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/16 to 7/14/22 included IDG orders for hospice aide services. b. The Interdisciplinary group, (IDG), meeting notes, dated 4/26 and 5/3/22 included IDG orders for hospice aide services 1 to 2 times per week. c. The same POC and IDG updates to the plan of care identified the skilled nurse assignment the hospice aide complete the following tasks at each visit: change bed linens, perform fingernail filing, assist patient with shower. d. The hospice aide documentation, dated 4/19/22 identified the tasks fingernail filing and change bed linens, variance: patient not scheduled. e. The hospice aide documentation, dated 4/22/22, identified the task change bed linens, variance: patient not scheduled. f. The hospice aide documentation, dated 4/26/22, identified the task assist patient with shower, variance: patient not scheduled. g. The hospice aide documentation, dated 5/3/22, identified the task assist patient with shower, variance: patient not scheduled. The aide failed to follow the care plan as written. 2. Patient #8 had a hospice admission date of 9/7/21 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 11/20/21 to 2/17/22 and 2/18/22 to 4/18/22, identified the patient had a diagnoses of chronic obstructive pulmonary disease and included Interdisciplinary Group (IDG) orders for skilled nursing, social worker, chaplain services, hospice aide and massage therapy. b. The undated Aide Assignment Sheet included the following assignments to occur: perform back rub, assist with exercises, apply lotion, tub/shower bath, partial/complete bed bath, incontinent care and shaving. c. The aide visit note, dated 3/11 and 3/19/22, included documentation the aide completed the task of both a tub/shower bath and partial/complete bed bath. The aide failed to follow the care plan as written. 3. Patient #6 had a hospice admission date of 1/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/28/22 to 4/27/22, included IDG identified an order for hospice aide services 1 to 2 times per week for 13 weeks. The POC included a medication order for Calmoseptine ointment 1 application 3 times per day as needed. The POC included orders for the hospice aide to apply the Calmoseptine to the patient's coccyx area after perineal cares. b. The interdisciplinary group (IDG) meeting , dated 2/15/22, included an order for Calmoseptine ointment twice per day and as needed to coccyx with each incontinence episode. c. The hospice aide visit notes completed by Staff F, Hospice Aide, dated 4/28 and 5/5/22, included documentation she did not complete the assigned task of applying Calmoseptine to the patient's coccyx area. She documented "not scheduled". On 5/11/22 at 11:10 AM, during an interview, Staff F, Hospice Aide, explained a nursing home staff person told her not to apply the Calmoseptine. She reported the nursing home staff person told her the patient did not have a coccyx wound any longer and did not need the Calmoseptine. She did not know which nursing home staff person told her this and she did not contact the hospice nurse to let her know. On 5/11/22 at 11:33 AM, during an interview, Staff E, Hospice RN, reported being unaware the hospice aide had not completed the assigned task of applying Calmoseptine. She reported the patient continued to have a sore on the patient's buttocks area and needed to have the Calmoseptine applied. She last assessed the patient on Monday (5/9/22). She reported the nursing home staff continued to apply the Calmoseptine and did not know who would have told the hospice aide not to do apply it. The above information was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to ensure the clinical record contained documentation of a discharge summary which included a summary of the patient's symptoms, treatment and pain management, current plan of care and latest physician orders for 1 of 1 sampled discharged patients (Patient #10) who discharged from hospice services. Failure to complete a discharge summary with all required components increased the potential of the physician being unaware of the patient's condition at time of discharge from services and negatively impact the patient's continuity of care. Findings include: Patient #10 had a hospice admission date of 12/29/21, received hospice services while residing in a nursing home and revoked hospice services on 3/2/22 to actively seek treatment. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 12/29/21 to 3/28/22, included IDG orders for skilled nursing, social worker and hospice aide. b. A skilled nursing note, dated 3/4/22, due to the patient wanting to seek active treatment. c. The hospice clinical record lacked documentation of a discharge summary being sent to the patient's attending physician that included a summary of the patient's symptoms, treatment and pain management, current plan of care and latest physician orders. On 5/11/22 at 3:50 PM, during an interview with the Administrator, she confirmed an inability to find evidence of a discharge summary being sent to the patient's attending physician that included the required content. She reported the discharge summary should include current medications, orders, most recent vital signs and goals. The above information was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

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 prior to hiring for 1 of 5 sampled paid employees and 2 sampled unpaid employees (volunteers) who began serving hospice patients since their last survey, dated 6/27/19. The hospice reported hiring a total of 13 employees and starting 5 unpaid employees 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. Findings include: Staff A, Hospice Aide, had a hire date of 7/13/2020. Staff A's personnel file included a criminal history background check completed on 6/4/2020, 39 days prior to the hire date and exceeding the required time frame by 9 days. During an interview with the Administrator on 5/11/22 at 3:20 PM, she reported not being able to recall the circumstances regarding the hire date for Staff A, she would discuss the 30 day time frame with Human Resources department. The above information for Staff A was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.

The Iowa Administrative Code, Chapter 135C.33 requires that a Hospice Agency complete a criminal history background check, dependent adult abuse background check and child abuse background check on all prospective employees prior to employment by the hospice. Chapter 50 identifies that results from a background check are valid for only 30 days and therefore the law requires the agency to complete the three required background checks within 30 days prior to the prospective employees date of hire. If the required background checks are completed earlier than 30 days prior to the employee's date of hire, the hospice must complete the background checks again before hiring the employee. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of dependent adult abuse and child abuse background check for 1 of 5 sampled paid employees and 2 sampled unpaid employees (volunteers) who began serving hospice patients since their last survey, dated 6/27/19. Failure to complete dependent adult abuse and child abuse background checks as required by Iowa regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact. Findings include: Staff A, Hospice Aide, had a hire date of 7/13/2020. Staff A's personnel file contained dependent adult abuse background checks and child abuse background checks, dated 6/4/2020, 39 days prior to the hire date and exceeding the required time frame by 9 days. During an interview with the Administrator on 5/11/22 at 3:20 PM, she reported not being able to recall the circumstances regarding the hire date for Staff A, she would discuss the 30 day time frame with Human Resources department. The above information for Staff A was reviewed with the hospice Administrator and hospice staff provided no further information prior to the end of the survey.