Every finding on record at Sioux Center Community Hospital and Health Center

Based on staff interviews, clinical record reviews and policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care which include orders for complimentary therapies and volunteers provided to patients for 6 of 14 sampled patients (Patients #2, #5, #6, #7 #12 and #13).   Failure to identify acceptable scopes and frequencies specific to meet patient needs increased the potential for hospice services to not adequately meet the needs of hospice patients and families.   Findings include: --- 5.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home.  Clinical record review revealed: a.The POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of cancer of the rectosigmoid junction and included orders for nursing services 2 times a week, social services 2 times in 2 weeks and 2 times a month and aide services 2 times a week. b.The skilled nurse note at admission, dated 3/18/26, signed as completed by Staff E, RN identified the patient wanted music and massage services. c.The massage therapy visit note, dated 4/8/26, signed as completed by Staff F, Massage Therapist, identified the patient received massage therapy services.d. The music therapy visit note, dated 4/29/26, signed as completed by Staff O, Music Therapist, identified the patient received music therapy services.e.During an interview on 5/12/26 at 2:08 PM, the Administrator reported that the agency has always used the same process to include the music therapist, massage therapist, hospice chaplain, and volunteer in the initial POC by including the information that the patient accepts these services.  The Administrator reported that they will talk with the social workers about this process so that orders for every discipline are complete and specific for each patient. The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice.    6.Patient #13 had a hospice admission date of 11/5/25 and received hospice services while residing in a private home.  Clinical record review revealed: a.The POC, dated 11/5/25 to 2/2/26, identified the patient had a primary diagnosis of nutrition deficiency and included orders for nursing services 2 times a week, social services 2 times a month and aide services 5 times a week. b.The skilled nurse note at admission, dated 3/18/26, signed as completed by Staff E, RN identified the patient wanted hospice chaplain services, music services and massage services. c.The hospice chaplain visit note, dated 11/10/25, signed as completed by Staff L, Hospice Chaplain, identified the patient received hospice chaplain services.d.The music therapy visit note, dated 11/11/25, signed as completed by Staff O, Music Therapist, identified the patient received music therapy services.e.The massage therapy visit note, dated 11/12/25, signed as completed by Staff F, Massage Therapist, identified the patient received massage therapy services.The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice.    The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager, and Staff M, Support Specialist.  2. Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included orders for nursing services 3 times a week, social services 2 times a month and aide services 2 times a week.  b. The skilled nurse note at admission, dated 4/22/26, completed by Staff J, RN, identified the patient wanted chaplain services. c. The chaplain visit note, dated 4/27/26, completed by Staff L, Chaplain, identified chaplain services provided to the patient.   The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice.     3. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 4/7/26 to 7/5/26, identified the patient had a primary diagnosis of Parkinson's disease and included IDG orders for nursing services 2 times a week, social services 2 times a month and aide services 2 times a week.  b. The skilled nurse note at admission, dated 4/7/26, completed by Staff E, RN, identified the patient accepted music therapy and massage therapy services.  c. The music therapy visit note, dated 4/8/26, completed by Staff O, Music Therapist, identified the patient received music therapy services.  d. The massage therapy visit note, dated 4/9/26, completed by Staff F, Massage Therapist, identified the patient received massage therapy services.   The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice.   4. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 8/26/25 to 11/23/25, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included IDG orders for nursing services 2 times a week, social services 3 visits every 5 weeks and aide services 1 time a week.  b. The skilled nurse note at admission, dated 8/26/25, completed by Staff E, RN, identified the patient accepted music therapy and massage therapy services.  c. The music therapy visit note, dated 8/27/25, completed by Staff O, Music Therapist, identified the patient received music therapy services.  d. The massage therapy visit note, dated 8/27/25, completed by Staff F, Massage Therapist, identified the patient received massage therapy services.   The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice.   According to the hospice policy titled Care Planning, dated 5/2025, at the time of the initial referral and assessment, the primary RN along with key Hospice team members develop the patinet plan of care based upon the patinet's/family's identified needs, along with information obtained frm physician and medical records. These are reviewed with the patinet and/or family caregivers. 1.Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The Plan of Care (POC), dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzheimer's disease and included Interdisciplinary Group (IDG) orders for nursing services 2 times a week, social services 2 times a month and aide services 2 times a week. b. The skilled nurse note at admission, dated 3/18/26, identified the patient accepted music and massage services. c. The massage therapy visit note, dated 4/8/26, included massage therapy provided to the patient. d. The music therapy visit note, dated 3.25.26, included music therapy provied to the patient. e. The IDG meeting notes, dated 3/25/27, identified IDG orders for massage therapy every 2 weeks. f. The IDG meeting note, dated 4/8/26, identified IDG orders for massage therapy every 2 weeks and music therapy 1 to 2 time every 2 weeks. c. Review of the clinical record revealed the patient requested music and massage therapy at the start of care. The hospice failed to include music and massage therapy orders on the plan of care. The POC failed to include orders for all services necessary to meet the specific patient/family needs.

Based on clinical record reviews and agency policy review, the hospice failed to ensure the hospice plan of care included complete orders for all necessary treatments to meet the needs of the patients for 2 of 2 sampled patients with a catheter (Patients #2 and #6).    Failure to ensure the plan of care included complete orders for all treatments placed the patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients.   Findings include: --- According to the hospice policy titled Care Planning, dated 5/2025, all hospice team members consider the initial and ongoing assessments in their care planning process.  Based on those assessments and physician orders, the Plan of Care (POC), includes specific services and equipment to be provided.   1.Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included physician orders for skilled nurse visits, medications and treatment.  b. The Interdisciplinary Group (IDG) update to the POC, dated 5/6/26, identified the patient had a foley catheter but lacked complete orders with catheter size and balloon volume.   The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care.   2. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 4/7/26 to 7/5/26, identified the patient had a primary diagnosis of Parkinson's disease and included physician orders for skilled nurse visits, medications and treatments.   b. The IDG update to the POC, dated 4/8/26, identified the patient had a foley catheter but lacked complete orders with catheter size and balloon volume.   The hospice failed to include complete physician orders for necessary treatment on the patient's plan of care.   The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager, and Staff M, Support Specialist.

Based on agency document review and staff interview, the hospice failed to: Ensure the agency provided spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service, and in a manner consistent with patient and family beliefs and desires (L0598). Findings include: --- The cumulative effects of this systemic practice resulted in failure to provide spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service and in a manner consistent with patient and family beliefs and desires.

Based on agency document review and staff interview, the hospice failed to ensure the agency provided spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service, and in a manner consistent with patient and family beliefs and desires.  Failure to provide spiritual counseling to meet these needs in accordance with the patient’s and family’s acceptance of this service, and in a manner consistent with patient and family beliefs and desires.Findings include: --- During an interview on 5/12/26 at 2:08 PM, the Administrator reported that when the hospice chaplain was hired, leadership from the health care system advised the Administrator that the chaplain would be a contracted service. 1.The list of contracted staff provided by the agency included Staff L, Hospice Chaplain.2.Review of the agency document titled Agreement for Professional Services, dated 7/9/25, identified that Staff L was a contracted employee of the agency.The agency failed to ensure that Staff L was an employee of the agency, defined an an employee who: (1) works for the hospice and for whom the hospice is required to issue a W-2 form on his or her behalf; or (2) if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice; or (3) is a volunteer under the jurisdiction of the hospice.

Based on clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 3 of 3 sampled hospice aides (Staff H, Staff I and Staff P) demonstrated competency in the performance of any skills which exceeded the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 8 of 10 sampled patients (Patients #1, #3, #6, #7, #9, #10, #11 and #12) who required an extra skill be performed.   Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: --- The Medicare Conditions of Participation direct the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan.   According to the agency's policy titled Comprehensive Policies, dated 3/2026, the agency will assure competency of each hospice aide in performance of all assigned hospice aide duties.  The hospice aide will not be assigned tasks for which competency has not been demonstrated except under the direct supervision of a nurse.  Documentation of competent performance will be recorded and filed at the agency. 1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The aide care plan included Registered Nurse (RN) instructions to the aide to trim fingernails and toenails, offer every visit.   b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #1.   c. Staff H, Hospice Aide, had a hire date of 4/7/99.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the task of trimming nails.   d. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails.   2. Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in an assisted living facility.  Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to perform a whirlpool bath as the patient, family or staff requests.   b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #3.   c. Staff H, Hospice Aide, had a hire date of 4/7/99.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the task of giving a whirlpool bath.   d. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of giving a whirlpool bath. 3. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to trim fingernails/toenails and perform a whirlpool bath.   b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #6.   c. Staff H, Hospice Aide, had a hire date of 4/7/99.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath.   d. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. 4. Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home.    Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to trim fingernails/toenails.   b. Review of the clinical record showed Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #7.   c. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails. d. Staff P, Hospice Aide, had a hire date of 5/14/24.  Staff P's personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails. 5. Patient #9 had a hospice admission date of 10/14/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to trim fingernails/toenails and perform a whirlpool bath.   b. Review of the clinical record showed Staff H, Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #9.   c. Staff H, Hospice Aide, had a hire date of 4/7/99.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath.   d. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. e. Staff P, Hospice Aide, had a hire date of 5/14/24.  Staff P's personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails and giving a whirlpool bath.   6. Patient #10 had a hospice admission date of 2/10/26, a discharge date of 2/27/26 and received hospice services while residing in a private residence.  Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails and toenails, offer every visit.   b. Review of the clinical record showed Staff P, Hospice Aide, provided aide services independently for Patient #10.   c. Staff P, Hospice Aide, had a hire date of 5/14/24.  Staff P's personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails. 7. Patient #11 had a hospice admission date of 5/20/25, a discharge date of 11/12/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to trim fingernails/toenails per patient request.   b. Review of the clinical record showed Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #11.   c. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails. d. Staff P, Hospice Aide, had a hire date of 5/14/24.  Staff P's personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails.   8. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The aide care plan included RN instructions to the aide to trim fingernails/toenails, offer every visit and perform a whirlpool bath.   b. Review of the clinical record showed Staff H, Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #12.   c. Staff H, Hospice Aide, had a hire date of 4/7/99.  Staff H's personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath.   d. Staff I, Hospice Aide, had a hire date of 4/18/25.  Staff I's personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. e. Staff P, Hospice Aide, had a hire date of 5/14/24.  Staff P's personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails and giving a whirlpool bath.   The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to ensure registered nurses (RN) developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 6 of 8 patients receiving hospice aide services (Patient #1, #2, #3, #4, #5, and #12). Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk that hospice patients did not receive the services to meet each patient's assessed needs. Findings include: --- 4. Patient #3 had a hospice admission date of 4/11/24, and received hospice services while residing in a private residence.  a. The POCs, dated 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 3/18/26, completed by Staff B, Clinical Manager, included RN instructions to the hospice aide to provide skin care; apply lotion of choice. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion.  5. Patient #4 had a hospice admission date of 4/15/26, and received hospice services while residing in a nursing home. a. The POC, dated 4/15/26 to 7/13/26, identified the patient had a diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 4/15/26, completed by the Staff J, RN, included RN instructions to the hospice aide to provide skin care; apply patient choice of lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion.  6. Patient #5 had a hospice admission date of 3/18/26, and received hospice services while residing in a nursing home. a. The POC, dated 3/18/26 to 6/18/26, identified the patinet had a diagnosis of Alzheimer's disease and included orders for skilled nurse and aide services. b. The hospice aide care plan, dated 3/18/26, completed by Staff K, RN, included RN instructions to the hospice aide to provide skin care; apply choice of lotion.. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion.  The above findings were reviewed with the Administrator, Staff B, Clinical Manager, StaffD, Clinical Manager and Support Secialist. 2. Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included physician orders for skilled nurse and hospice aide services.  b. The undated hospice aide care plan included aide instructions to apply patient's choice of lotion every visit.  The assignment did not include specific instructions on where on the patient the aide should apply lotion.   The hospice RN failed to include specific instructions on where on the patient the aide should apply lotion.   3. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included physician orders for skilled nurse and hospice aide services.  b. The undated hospice aide care plan included aide instructions to make sure the patient uses a walker when transferring.  c. The skilled nurse visit note, dated 12/17/25, completed by Staff K, RN, identified the patient is a 2 assist with a sit to stand transfer aide.   The hospice RN failed to include specific, up to date instructions to the aide on how the patient transfers.   According to agency policy titled Assignment of Staff Responsibility, dated March 2008, home health aides services provided are based on the initial and ongoing assessments of patient/client needs and are conducted by a registered nurse in the patient's /client's home. The primary nurse is responsible for the initial assessment and assignment of the home health aide. Assignments are updated at least every sixty (60) days, or more often if needed. During an interview on 5/5/26 at 11:44 AM, Staff B, Clinical Manager, reported that the patient's admitting nurse creates the hospice aide care plan.1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 4/6/26 to 6/4/26, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for skilled nursing and aide services. b. The undated Hospice Aide Care Plan identified that the patient used a gait belt as a safety measure and included hospice aide instructions that the patient uses an assistive device of motorized wheelchair, to make sure that they use it when transferring. The assignment did not include the use of a gait belt with transfers.The hospice RN failed to include specific instructions on using a gait belt with transfers.

Based on staff interview, clinical record reviews and hospice agency policy review, 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 4 of 8 sampled patients receiving hospice aide services (Patients #3, #5, #11 and #12).   Failure to ensure that 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: --- According to the hospice policy titled Assignment of Staff Responsibility, dated 3/2026, the  personal care and support services provided are based on the initial and ongoning assessments of patient/client needs and are conducted by a registered nurse in the patinet's/client's home. The primary nurse is responsible for the initial assessment and assignmnet of the home health aide. Assignments are updated at least every 60 days, or more often if needed.  During an interview on 5/5/26 at 11:44 AM, Staff B, Clinical Manager stated the admitting nure creates the aide care plan. If the aide is unable to complete a task, or complete an unassigned task, the aides are educated to call the office. There is always a nurse available and the task can be added to the care plan. The aide shouldn't do a task until they've spoken with a nurse.  1.Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The Plans of Care (POCs), dated 1/33/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a primary diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services.  The POC included skilled nurse interventions for compression hose.  b. The hospice aide care plan, dated 3/9/26, included aide instructions to provide the following: assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior and report concern to primary clinician.   c. Hospice aide visit notes, dated 4/22/26, 4/25/26, 4/29/36 and 5/1/26, completed by Staff I, Hospice Aide, documented tasks provide:  assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior, report concern to primary clinician.   d. During an interview on 5/11/26 at 3:56 PM, Staff I, Hospice Aide, stated she applied the patient's compression hose after bathing if they were available. The aide documentation failed to include compression hose.  The hospice aide failed to follow the aide care plan as written.    2. Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzeimer's disease and included orders for skilled nurse and hospice aide services.  The POC included medical equipment the patient requires as compression hose.  b. The undated hospice aide care plan included aide instructions to provide the following: apply patient choice of lotion (not specific), assist feeding, assist shower (may give bath at sink or bed, (notify clinician if declines planned bathing method, brush/comb hair, shampoo/condition every visit, skin care-apply choice of lotion, observe and report open areas on skin, red areas or changes in skin condition, pressure relief-cushion to wheelchair and recliner, assist dress upper body, assist dress lower body, incontinent brief, incontinent care-bathroom privileges, transfer with Hoyer lift, wheelchair for all locomotion, report falls, dependent for transfers with hoyer lift, clean bathroom after patient use, trash removal in patient care area, offer companionship every visit, document specific observations.  c. Hospice aide visit notes, dated 4/14/26, 4/17/26, 4/21/26, 4/24/26, 4/28/36 and 5/1/26, completed by Staff I, Hospice Aide, documented tasks provide:  assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior, report concern to primary clinician.   d. During an interview on 5/11/26 at 3:56 PM, Staff I, Hospice Aide, stated she applied the patient's compression hose after bathing if they were available. Compression hose not included on the aide documentation  The hospice aide failed to follow the aide care plan as written.    3. Patient #11 had a hospice admission date of 5/20/25 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 8/15/25 to 15/15/26 and 11/16/25 to 1/14/26, identified the patient had a primary diagnosis of Alzeimer's disease and included orders for skilled nurse and hospice aide services.    b. The undated hospice aide care plan included aide instructions to provide the following: shower or whirlpool bath.  c. Hospice aide visit notes, dated 10/21, 10/28/25, 11/4 and 11/11/25 , completed by Staff I, Hospice Aide, documented tasks provide both a shower and whirlpool bath.  The hospice aide failed to follow the aide care plan as written.      4. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included physician orders for skilled nurse and hospice aide services.  b. The undated hospice aide care plan, included aide instructions to provide the following: assist with food/drink, apply lotion, assist with bath-shower every visit, offer whirlpool bath every visit, brush/comb hair, shave patient, trim/file fingernails and toenails, assist with dressing, provide incontinence care and assist with transfers.c. Hospice Aide visit notes, dated 12/17/25, 12/22/25 and 12/29/25, completed by Staff H, Hospice Aide, documented task of bath-shower every visit as not accomplished, not patient's bath day.  d.  Hospice Aide visit note, dated 12/24/25, completed by Staff I, Hospice Aide, documented task of bath-shower every visit as not accomplished, not patient's bath day.   The hospice aides failed to follow the aide care plan as written.   The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on review of the 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 (Spiritual Counselor 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 spiritual counselor, dated 7/9/25, 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 authorized by hospice,  d. All services are delivered in a safe and effective manner by qualified personnel and  e. 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 3/3/22, 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 authorized by hospice,  d. All services are delivered in a safe and effective manner by qualified personnel and  e. 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, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on staff interview, clinical record reviews 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 standard for 10 of 14 sampled patients (Patients #1, #3, #5, #7, #8, #10, #11, #12, and #13).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 patients.Findings include: --- 5. Patient #8 had a hospice admission date of 9/5/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POCs, dated 12/8/25 to 3/7/26 and 3/8/26 to 5/6/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse, social work, music therapy and massage therapy services.  b. Massage therapy visit note, dated 3/10/26, signed completed 3/17/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation.  c. Skilled nurse visit note, dated 3/20/26, signed completed 3/24/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.  d. Skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.  e. Massage therapy visit note, dated 3/25/26, signed completed 3/31/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation.  f. Massage therapy visit note, dated 4/8/25, signed completed 4/14/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation.  g. Skilled nurse visit note, dated 4/21/26, signed completed 4/26/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.   6. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included orders for skilled nurse, aide, social work, volunteer, music therapy and massage therapy services.  b. Massage therapy visit note, dated 12/23/25, signed completed 12/31/25 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation.  c. Skilled nurse visit note, dated 12/26/25, signed completed 12/30/25 by Staff E, RN, 5 days after the visit and 3 days late per agency expectation.  d. Massage therapy visit note, dated 1/20/26, signed completed 1/28/26 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.    7. Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in a private residence.  Clinical record review revealed:  a. The POCs, dated 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a primary diagnosis of peripheral vascular disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services.   b. The massage therapy visit note, dated 3/24/26, signed completed 3/31/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation.   c. The massage therapy visit note, dated 4/6/26, signed completed 4/14/26 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation.   d. The skilled nurse visit note, dated 4/23/26, signed completed 4/27/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.    e. The skilled nurse visit note, dated 4/28/26, signed completed 5/3/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.    The agency failed to ensure timely completion of routine visit documentation.   8. Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POCs, dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services.   b. The massage therapy visit note, dated 4/19/26, signed completed 3/31/26 by Staff F, Massage Therapist, 12 days after the visit and 10 days late per agency expectation.   c. The skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.    d. The massage therapy visit note, dated 4/14/26, signed completed 4/21/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.   9. Patient #11 had a hospice admission date of 5/20/25 and discharge date of 11/12/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:  a. The POC, dated 8/15/25 to 11/15/25, identified the patient had a primary diagnosis of Alzheimer's disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services.   b. The massage therapy visit note, dated 9/16/25, signed completed 9/26/25 by Staff F, Massage Therapist, 10 days after the visit and 8 days late per agency expectation.   c. The skilled nurse visit note, dated 9/18/25, signed completed 9/22/25 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.    d. The skilled nurse visit note, dated 10/16/25, signed completed 10/21/25 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.    e. The massage therapy visit note, dated 10/29/25, signed completed 11/8/25 by Staff F, Massage Therapist, 10 days after the visit and 8 days late per agency expectation.   The agency failed to ensure timely completion of routine visit documentation.   The above findings reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and the Support Specialist. According to agency policy titled Documentation of Nursing, dated March 2022, the purpose of the policy is to accurately record the continuum of events that occurs during a patient's stay to provide for continuity of care in the inpatient and outpatient settings, and to assure a permanent legal record for each hospital patient.  All entries should be dated, timed and signed. During an interview on 5/5/26 at 10:38 AM, the Administrator reported that notes from disciplines should be signed with name, title, date within 48 hours.  Even though the policy may say notes are to be completed timely, the Administrator clarified that the best practice is within 48 hours. 1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home.  Clinical record revealed:a.Plan of Care (POC), dated 4/6/26 to 6/4/26, identified the patient had a primary diagnosis of senile degeneration of the brain and orders for skilled nurse services.b.Interdisciplinary Group (IDG) note, dated 4/8/26, included orders for massage therapy services.c. Skilled nurse visit note, dated 4/21/26, signed completed 4/26/26 by Staff C, Licensed Practical Nurse (LPN), 5 days after the visit and 3 days late per agency expectation.d.Skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.e.Skilled nurse visit note, dated 3/26/26, signed completed 3/29/26 by Staff C, LPN, 3 days after the visit and 1 day late per agency expectation.f.Skilled nurse visit note, dated 3/20/26, signed completed 3/24/26 by Staff C, LPN, 4 days after the visit and 2  days late per agency expectation.g.Skilled nurse visit note, dated 3/13/26, signed completed 3/16/26 by Staff C, LPN, 3 days after the visit and 1 day late per agency expectation.h.Massage therapy visit note, dated 4/15/26, signed completed 4/21/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.   2.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home.  Clinical record revealed:a.POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of cancer of the rectosigmoid junction and included orders for skilled nurse services.b.Skilled nurse visit note, dated 4/30/26, signed completed 5/4/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.   3.Patient #10 had a hospice admission date of 2/10/26 and received hospice services while residing in a private home.  Clinical record revealed:a.POC, dated 2/10/26 to 5/10/26, identified the patient had a primary diagnosis of pancreas cancer and orders for skilled nurse services.b.Skilled nurse visit note, dated 2/20/26, signed completed 2/25/26 by Staff E, Registered Nurse (RN), 5 days after the visit and 3 days late per agency expectation.c.Skilled nurse visit note, dated 2/24/26, signed completed 2/82/26 by Staff G, RN, 4 days after the visit and 2 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.   4.Patient #13 had a hospice admission date of 11/5/25 and received hospice services while residing in a private home.  Clinical record revealed:a.POC, dated 11/5/25 to 2/2/26, identified the patient had a primary diagnosis of nutritional deficiency and orders for skilled nurse services.b.Massage visit note, dated 11/12/26, signed completed 11/18/26 by Staff F, 6 days after the visit and 4 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.

Based on staff interview, clinical record review and agency policy review, the hospice failed to ensure the hospice staff sent a copy of the patient's transfer summary to the receiving facility for 1 of 1 sampled, transferred patients (Patient #8).   Failure to ensure the hospice staff included the receiving facility in the process of transfer placed the patient at risk for not receiving ongoing medical care and services necessary to meet the needs of the patient.   Findings include: --- According to the agency policy titled Comprehensive Policies, dated 3/2026, the Interdisciplinary team members will send a transfer summary to the physician upon transfer.   Patient #8 had a hospice admission date of 9/9/25 and received hospice services while residing in a nursing home.   a. The Plan of Care (POC), dated 3/8/26 to 5/6/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nursing services.   b. The skilled nurse visit note, dated 4/25/26, identified the patient transferred to a hospital due to a fall and broken arm.   c. The clinical record failed to include documentation a transfer summary was completed and forwarded to the receiving facility.   The hospice agency failed to complete and forward the transfer summary to the receiving facility.   On 5/7/26 at 10:25 AM, the Administrator confirmed the agency did not complete a transfer summary for Patient #8.  The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreements identified the hospice's responsibility to maintain a description of the training provided to hospital personnel providing care for hospice patient's during an inpatient stay and documentation of the names of those giving the training for 3 of 3 sampled written agreements (Hospitals 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 3/1/19.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators.   2.The hospice agency had a contractual agreement with Hospital B, dated 3/1/19.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators.   3.The hospice agency had a contractual agreement with Hospital C, dated 3/1/19.  The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators.   The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and a hospital to provide inpatient care included a method for verifying all necessary requirements are met while a patient receives inpatient care for 3 of 3 sampled written agreements (Hospitals A, B and C).   Failure to identify a method for verifying requirements are met for patient's receiving inpatient care increased the potential of hospice and inpatient facility staff not meeting patient needs 24 hours a day.   Findings include: --- 1.Review of the inpatient facility agreement between the hospice agency and Hospital A, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care.   2.Review of the inpatient facility agreement between the hospice agency and Hospital B, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care.   3.Review of the inpatient facility agreement between the hospice agency and Hospital C, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care.   The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.

Based on personnel file review, contract review and staff interview, the hospice failed to ensure training in emergency preparedness policies and procedures for 1 of 1 contract staff hired since the last survey (Staff E, Massage Therapist) and 1 of 1 sampled hospice volunteers starting with the hospice since the last survey (Staff F). Failure to ensure the agency provided training in emergency preparedness policies and procedures to all staff placed patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. --- 1. Staff E, Massage Therapist, had a signed contract date with the hospice, dated 6/21/21. 2. Review of the personnel file for Staff F, Volunteer, revealed a start date of 5/17/22. The personnel file lacked documentation of emergency preparedness training either initially when Staff F, Volunteer started with hospice or since that time. On 8/2/23 at 2:08 PM, during an interview, the Administrator confirmed Staff E, Massage Therapist, first signed a contract with the hospice on 6/21/21. The Administrator reported an inability to find documentation of any emergency preparedness training for either Staff E, Massage Therapist, or Staff F, Volunteer. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, family and staff interview, the hospice failed to ensure the patient or patient's representative received information about services and other items not covered, such as medications, under the hospice benefit for 14 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14). Failure of the hospice to ensure the patient received information about the services and other items not covered under the hospice benefit increased the risk that patients would have burden of unexpected expenses. --- 11. Patient #10 had a hospice admission date of 4/19/23 and received routine home care hospice services while residing in a private home. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 4/19/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 12. Patient #11 had a hospice admission date of 10/7/22, a revocation date of 1/26/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 10/7/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 13. Patient #12 had a hospice admission date of 9/9/22, a discharge date of 12/7/22 and received routine home care hospice services while residing in a private home from 9/9/22 to 9/27/22 and a nursing home from 9/28/22 to 12/7/22. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 9/9/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 14. Patient #13 had a hospice admission date of 8/3/22, a death date of 8/27/22 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 8/3/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. 5. Patient #1 had a hospice admission date of 6/23/23 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 6/23/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 6. Patient #2 had a hospice admission date of 7/6/23 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 7/6/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. During an interview during a home visit with home health on 7/25/23 at 10:45 AM the patient stated not notified of medications or other items not covered. Only thing the hospice told the patient/family, the diabetic medication not covered and stated it is confusing. Would like to have the information in writing. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 7. Patient #3 had a hospice admission date of 3/2/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 3/2/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 8. Patient #6 had a hospice admission date of 7/3/23 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 7/3/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 9. Patient #7 had a hospice admission date of 7/7/23 and received routine home care hospice services while residing in a private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 7/7/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 10. Patient #8 had a hospice admission date of 2/13/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 2/13/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 1. Patient #4 had a hospice admission date of 10/19/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 10/19/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 2. Patient #5 had a hospice admission date of 4/26/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 4/26/23, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 3. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 6/8/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election. 4. Patient #14 had a hospice admission date of 8/2/22, received routine home care hospice services while residing in an assisted living facility and died on 9/13/22. Review of the clinical record revealed the following: A Medicare Benefit Election form, dated 8/2/22, included documentation the patient's representative had elected for the patient to receive hospice services. The Medicare Benefit Election form informed the patient's representative of their right to receive information that explained what items the hospice would not cover under the benefit, but failed to identify whether or not the patient's representative requested or denied to receive this information via an addendum to the Medicare Benefit Election form. The clinical record lacked documentation the hospice provided an addendum to the Medicare Benefit Election.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group completed performed an accurate and complete drug regimen review for 6 of 14 sampled patients (Patients #1, #2, #5, #6, #9 and #14). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified side effects and actual interactions of medications. --- 4. Patient #1 had a hospice admission date of 6/23/23, received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The POC, dated 6/23/23 to 9/20/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for the following medications with potential drug interactions: Fentanyl and Morphine. 5. Patient #2 had a hospice admission date of 7/6/23, received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The POC, dated 7/6/23 to 10/3/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for the following medications with duplicate medications for bowels: Miralax and Senna-S. The POC also identified the patient had a diagnosis of Diabetes Mellitus and included the diabetic medications: Jardiance, glipizide and Metformin which are associated with laboratory monitoring. b. During a home visit observation on 7/25/23 at 10:45 AM with Staff C, RN, the patient stated he/she did do glucometer (blood sugar) checks when needed. b. The IDG meeting, dated 7/19/23, included documentation which failed to identify the patient took duplicate medications or medications associated with laboratory monitoring. 6. Patient #6 had a hospice admission date of 7/3/23, received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 6/23/23 to 9/20/22, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for the following medications with potential drug interactions: Quetiapine and Morphine and medication Levothyroxine associated with laboratory monitoring. b. The IDG meetings, dated 7/5/23 and 7/19/23, included documentation which failed to identify the patient took medications with potential drug interactions or medications associated with laboratory monitoring. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. The hospice's policy, titled Drug Regimen Review (DRR), dated 4/2023, identified the registered nurse would complete the DRR on admission and with the update to each comprehensive assessment. The DRR will include a review of all medications including over the counter and herbal remedies for duplicate drug therapies, drug interactions, ineffective drug therapies and non-compliance. The hospice's policy, titled Ongoing Assessment, dated 4/2023, identified the hospice Interdisciplinary Group (IDG) will reassess the patient's medications every 15 days at a minimum. On 7/24/23 at 11:10 AM, during an interview, the Administrator reported that the pharmacist completes a DRR initially and during IDG meetings. 1. Patient #5 had a hospice admission date of 4/26/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/23 to 7/24/23, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for the following duplicate drug therapies: Dulcolax, Miralax and Bisacodyl to treat constipation; Lorazepam, ABHR (combination of Ativan, Haldol, Reglan and Diphenhydramine) cream and CBD oil to treat anxiety/restlessness; Hydrocodone-Acetaminophen, Roxanol, Acetaminophen to treat pain; Ondansetron and Prochlorperazine to treat nausea. The POC included medications with the following potential drug interactions: Lorazepam and Morphine may increase the risk of central nervous system (brain and spinal cord) depression of function. The POC included an order for the nurse to access the patient's infusion port (implanted device allowing access into a central vein) on the right upper chest every 6 weeks per protocol (the hospice's protocol includes an order for the nurse to flush the port with Normal Saline and Heparin). b. The comprehensive assessment completed by the registered nurse (RN) at the start of care, dated 4/26/23, included documentation the RN assessed the patient did not have any duplicate drug therapy, did not take any medications with actual or potential drug interactions or adverse reactions. The DRR completed by the RN failed to identify any duplicate drug therapy or drug interactions. c. The DRR completed by the pharmacist, dated 4/26/23, identified the patient took the following duplicate drug therapies: Ondansetron, Prochlorperazine and Reglan in the ABHR cream (all used to treat nausea); the Ativan in the ABHR cream and Lorazepam (same medication) and Acetaminophen orally and by suppository for pain. The pharmacist identified potential drug interactions between Morphine (Roxanol) and Lorazepam (Ativan) and potential drug interactions between Haldol, Prochlorperazine and Reglan. The list of medications used for the pharmacist's review failed to include Heparin (a drug used to treat/prevent blood clots). d. The initial IDG meeting, dated 5/10/23, included documentation which identified the patient did not take any medications associated with potential or actual drug interactions which contradicted the pharmacists DRR findings from 4/26/23. The patient continued to have active orders for Morphine and Lorazepam. 2. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The DRR completed by the pharmacist, dated 6/7/23, identified the patient took the following medications with potential drug interactions: Haldol and Reglan and Ativan and Tramadol. b. The IDG meeting, dated 6/7/23, included a review of the same medications the pharmacist reviewed, but failed to identify the patient took medications with potential drug interactions. 3. Patient #14 had a hospice admission date of 8/2/22, received routine home care hospice services while residing in an assisted living facility and died on 9/13/22. Review of the clinical record revealed the following: a. The POC, dated 8/2/22 to 10/30/22, included IDG orders for skilled nursing services and physician orders for medications. The POC included orders for the following medications with potential drug interactions: Lorazepam and Roxanol. b. The IDG meeting, dated 8/3/22, included documentation which failed to identify the patient took medications with any actual or potential drug interactions.

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 measurements for 3 of 3 sampled patients with an open wound (Patients #4, #6 and #7). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. --- 2. Patient #6 had a hospice admission date of 7/3/23 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. A skilled nursing visit, dated 7/18/23, included documentation the patient had an open area on the coccyx. The note failed to include assessment of the open area or include wound measurements. The hospice nurse failed to complete an assessment of a skin change related to a wound per the hospice's policy. 3. Patient #8 had a hospice admission date of 2/13/23 and received routine home care hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. A skilled nursing visit, dated 5/18/23, included documentation the patient had skin issues on the right great toe and right heel. The note failed to include assessment of the skin issues or include wound measurements. b. The skilled nursing visit note, dated 6/1/23, included documentation the patient had skin issues on the right great toe and right heel. The note failed to include assessment of the skin issues or include wound measurements. c. The skilled nursing visit note, dated 7/5/23, included documentation the patient had 2 wounds on the side of the coccyx. Facility staff will monitor this and put a dressing on it. The note failed to include assessment of the open area or include wound measurements. d. The skilled nursing visit note, dated 7/12/23, included documentation the patient had a coccyx sore that scabbed over. The note failed to include assessment of the open area or include wound measurements. e. The skilled nursing visit note, dated 7/19/23, included documentation the staff continue to monitor a sore on the patient's bottom and heal. The note failed to include assessment of the open area or include wound measurements. The hospice nurse failed to complete an assessment of a skin change related to a wound per the hospice's policy. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's policy, titled Wound Care, dated 9/2022, the nurse is responsible for completing a head to toe skin assessment on admission, with any new findings or any changes in the skin assessment. The nurse will assess the location, wound size which includes weekly measurements of length, width and depth, and notify the provider of any new occurrences or changes. On 7/24/23 at 11:10 AM, during an interview, the Administrator reported nursing staff are to assess wounds at a minimum of weekly and include a length, width and depth. 1. Patient #4 had a hospice admission date of 10/19/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. A skilled nursing visit, dated 5/23/23, included documentation the hospice aide reported to the hospice nurse that the patient had a small pinpoint open area on the patient's coccyx area. The hospice nurse spoke with the assisted living facility registered nurse (RN) about the wound. The hospice nurse reported neither the hospice nurse nor the facility RN observed the patient's wound in order to assess the area. The hospice nurse documented the wound had a "new" dressing covering it. b. A hospice aide visit note, dated 5/23/23, included documentation the hospice aide reported the patient had a "healing pressure relief" on the patient's bottom. The hospice aide documented "the nurses knew about" and an "Optifoam (type of foam dressing) put over". The hospice aide assignment starting on 5/23/23 included new instructions to the hospice aide to change the protective foam dressing as needed. The clinical record lacked documentation of an assessment of the wound, physician notification of the wound or physician orders for the treatment of the wound. b. The subsequent skilled nursing visit, dated 5/30/23, included documentation the nurse reported no skin issues reported or observed. The hospice nurse failed to complete an assessment of a skin change related to a wound per the hospice's policy.

Based on clinical record review, review of hospice standing orders, family interview and staff interview, the hospice failed to ensure the ensure hospice staff used standing orders specific and individualized to the patient's assessed needs for 14 of 14 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14). Failure to establish the use of individualized standing orders rather than generalized, non-specific standing orders placed patients for potential risk of receiving medications, treatments and services that did not adequately meet the individualized needs of hospice patients. --- 3. Patient #2 had a hospice admission date of 7/6/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The POC, dated 7/6/23 to 10/3/23, included diagnosis of pancreatic cancer. The POC included orders for skilled nursing and medications including: morphine concentrate; 100 mg (milligrams)/5 ml give 0.5 ml to 2 ml every hour as needed for pain or shortness of breath b. The hospice standing orders, signed by the patient's healthcare practitioner on 7/6/23, included an order for morphine concentrate 10 to 40 mg every hour as needed for pain or shortness of breath. The order failed to specify how the patient would know under what circumstances the patient should use 10 mg to 40 mg. During an interview on 6/25/23 at 10:45 AM the patient's spouse stated hospice nurse instructed the patient/spouse to start out with the low dose of morphine and increase if needed. 4. Patient #6 had a hospice admission date of 7/3/23 and received routine home care hospice services while residing in an assisted living. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 7/3/23, included documentation that the patient had Alzheimer's disease. The nurse documented the patient had blood oxygen saturation levels at 94 percent with room air. The nurse documented the patient had oxygen concentrator set at 2 liters.. b. The hospice standing orders, signed by the patient's healthcare practitioner on 4/25/23, included an order for oxygen 1 to 5 liters as needed for shortness of breath. The order failed to specify a route of delivery (such as via a nasal cannula or mask) and failed to specify how the patient would know under what circumstances the patient should use 1 liter of oxygen (per minute) versus 5 liters per minute, or a rate of oxygen in between. c. The POC, dated 7/3/23 to 9/30/23, lacked documentation of a physician order or any indication that the hospice RN had implemented an order for oxygen specific to the needs of the patient. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. The hospice's policy, titled Plan of Care (POC), dated 4/2023, identified the registered nurse, in consultation with the attending physician and hospice Interdisciplinary Group (IDG) develop an individualized POC based on the assessed needs of the patient and family. On 7/24/23 at 11:10 AM, during an interview, the Administrator reported the hospice used standing orders for patients at the discretion of the the registered nurse (RN) and based on the symptoms of the patient. The Administrator explained the hospice nursing staff have the patient's physician sign the hospice's standing orders at the start of care for all patients. These orders are not added to the POC until the hospice nurse implements the orders. On 7/25/23 at 3:15 PM, during an interview, the Patient Care Coordinator reported the hospice used the same standing orders on all hospice patients. The Patient Care Coordinator confirmed there were a wide range of dose choices with Morphine and Lorazepam. The Patient Care Coordinator reported the nurses explain to the patient how to use the standing order medications when they are implemented and tell the patients to start with the lowest dose. The Patient Care Coordinator agreed there were no orders in writing for the patient from the physician to direct the patient in the use of the medications. On 8/2/23 at 8:30 AM, during an interview, the Medical Director for the hospice reported being responsible for overseeing the medical component of the hospice. When asked how the Medical Director ensures the standing orders are individualized for each patient, the Medical Director reported the hospice nurse goes through the standing orders with the patient's attending physician when they are admitting a patient. The Medical Director will review the standing orders for a patient if the nurse asks. If the patient has a change in condition which results in the implementation of a standing order, the Medical Director does not expect the hospice nurse to notify the Medical Director or attending physician of the change. When asked how patient are supposed to know what dose to use when some of the standing order medications had a wide range, for example Morphine 10-40 mg every 2 hours as needed by mouth, the Medical Director responded, "That's a good question. That is a wide range. " The Medical Director explained that the hospice nurses were "more in tune" to the patients pain medication needs then the Medical Director. The hospice nurse explains to the patient how to take the medication. 1. All sampled patients admitted prior to 4/18/23 (Patients #3, #4, #8, #9. #11, #12 and #14) had the following signed standing orders documented in their clinical record: a. Roxanol (Morphine) 20 milligrams (mg) per milliliters (ml), 0.5 (10 mg) to 2 ml (40 mg) every hour as needed for pain or respiratory distress by mouth or sublingual (under the tongue). The order failed to specify under what circumstances the patient should use 0.5 ml versus 2 ml, or any of the dose amounts in between. b. Guaifenesin 1 to 2 teaspoons as needed for a cough. The order failed to specify a route, dose or frequency, such as daily or every 6 hours. c. Oxygen 1 to 6 liters as needed for shortness of breath. The order failed to specify a route of delivery (such as via a nasal cannula or mask) and failed to specify how the patient would know under what circumstances the patient should use 1 liter of oxygen (per minute) versus 6 liters per minute, or a rate of oxygen in between. d. ABHR three times per day (Ativan 1 mg, Benadryl 12.5 mg, Haldol 2 mg and Reglan 10 mg) and 1 extra dose as needed for anxiety. The order failed to specify a route of delivery (this is a topical cream). and the frequency of the extra as needed dose. e. Bisacodyl suppository rectally as needed for constipation. The order failed specify a frequency or dose. f. Fleets enema rectally as needed for constipation. The order failed to specify a frequency. e. Senna S 1 to 2 tabs, 1 to 2 times per day (1 to 4 tabs per day) by mouth for constipation. The order failed to include a dose and failed to specify how the patient should determine whether to take 1 or 4 tablets, or some dose amount in between. The standing orders included 3 different medications to treat constipation and lacked any direction on which medication should be used first for treatment or if they should all be used at the same time. g. Foley (urinary) catheter if needed, size 14 to 18 French with 5 to 30 cubic centimeter (cc) balloon (fluid-filled device used to hold the catheter in place in the bladder); change as needed for loss of function and irrigate with Normal Saline as needed. The order did not specify under what circumstances a urinary catheter would need to be placed, why the catheter would need to be irrigated with Normal Saline and what amount of Normal Saline should be used to irrigate the catheter. h. The orders stated the following: " these standing orders are in affect for all hospice patients unless the plan of care states otherwise or contraindicated by allergies." The standing orders were not specific or individualized to the needs of any specific patient. 2. All sampled patients admitted after 4/18/23 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) had the following signed standing orders documented in their clinical record: a. Scopolomine 1 mg patch transdermal every 3 days as needed. The order failed to specify a reason why the patient would use the medication. b. Senna Plus 8.6 mg- 50 mg, 1 to 2 tabs, 1 to 2 times per day (1 to 4 tabs per day) by mouth as needed. The order failed to specify a reason why the patient would need to use the medication and failed to specify how the patient should determine whether to take 1 or 4 tablets, or some dose amount in between. c. Artificial Tears eye drops (Dextran 1.1 percent, Hypromel 0.3 percent, Glycern 0.2 percent). The order contained no further instructions on use, such as as needed or a scheduled frequency, or a reason for use. d. Artificial Saliva spray. The order contained no further instructions on use. e. Morphine concentrate 20 milligrams (mg) per milliliters (ml), 0.5 (10 mg) to 2 ml (40 mg) every hour as needed for pain or respiratory distress by mouth. The order failed to specify under what circumstances the patient should use 0.5 ml versus 2 ml, or any of the dose amounts in between. f. Lorazepam 0.5 mg tablet, 0.5 mg to 2 mg by mouth every 2 hours as needed for anxiety. The order failed to specify under what circumstances the patient should use 0.5 mg versus 2 mg, or any of the dose amounts in between. g. Lorazepam oral concentrate 2 mg per ml, 0.5 to 2 mg by mouth every 2 hours as needed for anxiety. The order failed to specify under what circumstances the patient should use 0.5 ml versus 2 ml, or any of the dose amounts in between. 3. Patient #5 had a hospice admission date of 4/26/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN at the start of care, dated 4/26/23, included documentation that the patient had kidney cancer with metastasis to the lungs. The nurse documented the patient was short of breath with blood oxygen saturation levels at 90 to 91 percent with room air. The nurse documented that they ordered an oxygen concentrator to be delivered to the patient's home that day. 1) The hospice standing orders, signed by the patient's healthcare practitioner on 4/25/23, included an order for oxygen 1 to 5 liters as needed for shortness of breath. The order failed to specify a route of delivery (such as via a nasal cannula or mask) and failed to specify how the patient would know under what circumstances the patient should use 1 liter of oxygen (per minute) versus 5 liters per minute, or a rate of oxygen in between. 2) The POCs, dated 4/26/23 to 7/24/23 and 7/25/23 to 10/22/23, lacked documentation of a physician order or any indication that the hospice RN had implemented an order for oxygen specific to the needs of the patient. 3) The skilled nursing visit notes, dated 5/15, 5/16, 5/19, 5/22 and 5/30/23, included documentation the patient was using oxygen at a rate of 6 liters per minute via nasal cannula at rest. The clinical record lacked an order which reflected the rate of oxygen the patient was using. b. The hospice standing orders, signed by the patient's healthcare practitioner on 4/25/23, included an order for a Foley catheter if needed, size 14 to 18 French with 5 to 30 cc balloon; change as needed for loss of function and irrigate with Normal Saline as needed. The order did not specify under what circumstances a urinary catheter would need to be placed, why the catheter would need to be irrigated with Normal Saline and what amount of Normal Saline should be used to irrigate the catheter. The order did not include any direction on removal of the catheter, only directions to change the catheter for loss of function. A skilled nursing visit, dated 5/17/23, included documentation the nurse implemented a standing order to place a 16 French Foley urinary catheter due to the patient having issues with urinary retention. The nurse did not document the amount of fluid used to inflate the balloon.

Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview and patient interview, the hospice failed to ensure the Plans of Care for 2 of 3 home visits (Patients #2 and #3) 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 Care Planning, dated 4/2023, the written plan of care will include, but is not limited to the following: specific services and equipment to be provided. 1. Patient #2 had a hospice admission date of 7/6/23 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/6/23 to 10/3/23, identified the patient had the following medical equipment and supplies: medication box. b. The Interdisciplinary Group (IDG) meeting, dated 7/19/23, identified no additional medical equipment and supplies used by the patient. c. On 7/25/23 at 8:30 AM, during a home visit observation with Staff C, Registered Nurse (RN), the surveyor identified the patient also glucometer and supplies. d. In an interview, during the same home observation, the patient stated he/she has used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 2. Patient #3 had a hospice admission date of 3/2/23 and received hospice services in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 5/31/23 to 8/28/23, identified the patient had the following medical equipment and supplies: wheelchair, walker, incontinent supplies, grab bars, gait/transfer belt. b. The Interdisciplinary Group (IDG) meeting, dated 5/24, 6/1, 6/21, 7/9, and 7/19/23, identified no additional medical equipment and supplies used by the patient. c. On 7/25/23 at 10:30 PM, during a home visit observation with Staff N, RN, the surveyor identified the patient also had a sit to stand lift. d. In an interview, during the same nursing home visit observation, the nursing home staff stated he/she has used the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. The Patient Coordinator 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 Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 5 of 5 sampled patients (Patients #4, #7, #9, #11 and #14) with a missed visit. Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of 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. --- 5. Patient #11 had a hospice admission date of 10/7/22, a revocation date of 1/26/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG updates to the POC, dated 11/23/22, 12/7/21 and 12/21/22, included IDG direction to provide one massage therapy visit every 2 weeks. b. Massage therapy visits were completed, dated 11/28/22 and 12/28/22. c. The week of 12/11/22 lacked documentation of a completed hospice massage therapy visit. d. The IDG updates to the POC, dated 12/21/22, lacked documentation the IDG was notified of missed hospice massage therapy visit for the week of 12/11/22. The hospice failed to provide hospice massage therapy visits as ordered per the IDG updates to the POC or to document notification of reason for missed massage therapy visit. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. 2. Patient #4 had a hospice admission date of 10/19/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The POC, dated 4/27/23 to 6/15/23, included IDG orders for hospice aide services 2 times a week for 9 weeks and orders for skilled nursing and social worker services. b. The IDG meetings, dated 5/10, 5/24 and 6/7/23, all included IDG orders for hospice aide services 2 times per week and IDG orders for skilled nursing, SW, volunteer services and music therapy. c. The clinical record included documentation of only one hospice aide visit the week of 5/28/23, dated 5/30/23. d. The IDG meetings, dated 5/24 and 6/7/23, lacked documentation of IDG awareness of a missed hospice aide visit the week of 5/28/23. 3. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The POC, dated 6/3/23 to 8/1/23, included IDG orders for hospice aide services 5 times per week for 8 weeks and IDG orders for skilled nursing and social work services. b. The IDG meetings, dated 6/21, 7/5 and 7/19/23, included IDG orders for hospice aide services 5 times per week for 8 weeks and IDG orders for skilled nursing, massage therapy and social work services. c. The clinical record included documentation of 4 hospice aide visits the week of 7/2/23, dated 7/3, 7/5, 7/6 and 7/7/23. d. The IDG meetings, dated 6/21, 7/5 and 7/19/23, lacked documentation of IDG awareness of a missed hospice aide visit the week of 7/2/23. 4. Patient #14 had a hospice admission date of 8/2/22, received routine home care hospice services while residing in an assisted living facility and died on 9/13/22. Review of the clinical record revealed the following: a. The POC, dated 8/2/22 to 10/30/22, included IDG orders for hospice aide services 2 times per week for 13 weeks and IDG orders for skilled nursing and social work services. b. The IDG meeting, dated 8/3/22, included IDG orders for hospice aide services 2 times per week, music therapy 1 to 2 times every 14 days and massage therapy one time within the next 14 days. c. The IDG meeting, dated 8/17/22, included IDG orders for hospice aide services 2 times per week, music therapy 1 to 2 times every 14 days and massage therapy one time every 2 weeks. d. The clinical record included documentation of only one massage therapy visit, dated 8/16/22. The IDG meetings, dated 8/17, 8/31 and 9/14/22, lacked documentation of IDG member awareness of the patient not receiving any further massage therapy visits. e. The clinical record included documentation of a music therapy visit, dated 8/17/22, and a subsequent music therapy visit, dated 9/9/22 (23 days between visits). The IDG meetings, dated 8/17, 8/31 and 9/14/22, lacked documentation of IDG member awareness of the patient not receiving music therapy visits as ordered by the IDG. f. The clinical record included documentation of only one hospice aide visit the week of 8/21/22, dated 8/25/22. The IDG meeting, dated 8/31/22, lacked documentation of IDG member awareness of the missed hospice aide visit. On 8/2/23 at 3:16 PM, during an interview, the Administrator reported the hospice had a system in place to notify the patient's physician of missed visits, but confirmed they did not have a system in place to notify the IDG members of missed hospice services. According to the hospice policy titled Care Planning, dated 4/2023, the frequency of the review of the Plan of Care is a minimum of every 15 days at IDG or as patient's health status, needs and the environmental factors affecting care change. The primary RN or other appropriate IDG member is responsible to revise or update the Plan of Care based on changes in the patient and family's status and response to care. 1. Patient #7 had a hospice admission date of 7/7/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 7/7/23 to 10/4/23, included IDG orders for hospice aide services 2 times a week. b. The IDG meeting notes, dated 7/19/23, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to notify the IDG of hospice aide missed visits.

Based on clinical record review, review of employee personnel files, hospice policy review and staff interview, the hospice failed to ensure 6 of 7 sampled hospice aides (Staff G, H, I, J, K and L) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse prior to being assigned to perform the task independently for 3 of 11 sampled patients who requires the task be performed (Patients #3, #4 and #5). The hospice employed 7 hospice aides at the time of the survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. --- The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. 1. Patient #3 had an admission to hospice on 3/2/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The hospice aide care plan directed the hospice aide to transfer the patient with a sit-to-stand lift (one type of mechanical lift) and to provide feeding assistance. b. The clinical record showed Staff G, Staff H, Staff I and Staff J, Hospice Aides, provided services for Patient #3. 1) Staff G, Hospice Aide, had a hire date of 6/26/19. Staff G's personnel file lacked documentation that a registered nurse (RN) had observed Staff G competently perform the task of providing feeding assistance to a patient. 2) Staff H, Hospice Aide, had a hire date of 5/12/23. Staff H's personnel file lacked documentation that a RN had observed Staff H competently perform the tasks of providing feeding assistance to a patient and transferring a patient with the sit-to-stand lift. 3) Staff I, Hospice Aide, had a hire date of 4/7/99. Staff I's personnel file lacked documentation that a RN had observed Staff I competently perform the task of transferring a patient with the sit-to-stand lift. 4) Staff J, Hospice Aide, had a hire date of 4/2/23. Staff J's personnel file lacked documentation that a RN had observed Staff J competently perform the task of transferring a patient with the sit-to-stand lift. 2. Patient #4 had a hospice admission date of 10/19/22 and received hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The hospice aide care plan included directions for the hospice aide to assist the patient with transfers using an assistive device, but the hospice aide care plan did not identify the assistive device used. b. The clinical record showed Staff G, Staff H, Staff I, Staff J and Staff K, Hospice Aides, provided services for Patient #4. On 7/26/23 at at 10:52 AM, during an interview, the assisted living RN reported all staff including hospice staff use a gait belt to transfer the patient. On 7/26/23 at 3:27 PM, during an interview, Staff I, Hospice Aide, reported using a gait belt and assisted living staff assistance when transferring the patient from one surface to another. On 7/26/23 at 4:30 PM, during an interview, Staff H, Hospice Aide, reported using a gait belt and assisted living staff assistance when transferring the patient from one surface to another. 1) Staff G's personnel file lacked documentation that a RN had observed Staff G competently perform the task of assisting the patient transfer from one surface to another with a gait belt. 2) Staff H's personnel file lacked documentation that a RN had observed Staff H competently perform the task of assisting the patient transfer from one surface to another with a gait belt. 3) Staff I's personnel file lacked documentation that a RN had observed Staff I competently perform the task of assisting the patient transfer from one surface to another with a gait belt. 4) Staff J's personnel file lacked documentation that a RN had observed Staff J competently perform the task of assisting the patient transfer from one surface to another with a gait belt. 5) Staff K, Hospice Aide, had a hire date of 8/15/22. Staff K's personnel file lacked documentation that a RN had observed Staff K competently perform the task of assisting the patient transfer from one surface to another with a gait belt. 3. Patient #5 had a hospice admission date of 4/26/23 and received hospice services while residing in a private residence. a. The hospice aide care plan directed the hospice aide to task of assisting the patient transfer from one surface to another with a gait belt. b. The clinical record showed Staff G, Staff H, Staff I, Staff K and Staff L, Hospice Aides, provided services for Patient #5. Their personnel files lacked documentation that a RN had observed Staff G, H, I, K and L competently perform the task of assisting the patient transfer from one surface to another with a gait belt. On 8/2/23 at 10:05 AM, during an interview, Staff G, Hospice Aide/Aide Coordinator and Scheduler, reported not having any specific documentation of the hospice aides having demonstrated competency in the use of a gait belt or feeding assistance. Staff G explained she did have mechanical lift training, but agreed it did not specify which type of mechanical lift. The Administrator reported the last skills check done with the hospice aides involved the Hoyer mechanical lift. The hospice did not have documentation to support the hospice aides had training with the sit-to-stand lift. The Administrator 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 hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 4 of 11 sampled patients receiving hospice aide services. (Patients #3, #4, #8 and #9). Failure to ensure that 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. --- 3. Patient #4 had a hospice admission date of 10/19/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 4/17/23 to 6/15/23 and 6/16/23 to 8/14/23, included IDG orders for hospice aide services 2 times per week. b. The undated hospice aide care plan included instructions to the hospice aide to complete the tasks of oral care by brushing the patient's teeth every visit and shampooing the patient's hair every visit per the patient's request. c. A hospice aide visit note, dated 5/23/23, included documentation that the hospice aide did not complete the assigned task of brushing the patient's teeth due to the caregiver not requesting the completion of the task. The hospice aide care plan did not include directions for the hospice aide to only complete the task if the caregiver (assisted living staff) requested the task to be done. The hospice aide failed to follow the hospice aide assignment. d. A hospice aide visit note, dated 5/30/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented the patient's staff told the hospice aide that the patient only gets their hair washed on Fridays. The hospice aide care plan did not include directions for the hospice aide to only complete shampooing on the patient's hair on the days the assisted living staff directed the hospice aide. The hospice aide failed to following the hospice aide assignment. e. A hospice aide visit note, dated 6/7/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "not a hair day". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. f. A hospice aide visit notes, dated 6/13 and 6/20/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "care did not need to be done". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. g. A hospice aide visit note, dated 6/27/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "not a shampoo day". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. h. A hospice aide visit note, dated 6/30/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "got it washed on Wednesday". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. i. A hospice aide visit note, dated 7/5/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "it was not (patient's) hair wash day". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. j. A hospice aide visit note, dated 7/12/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "no hair today". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. 4. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The POCs, dated 4/4/23 to 6/2/23 and 6/3/23 to 8/1/23, included IDG orders for hospice aide services 5 times per week. b. The hospice aide care plan included instructions to the hospice aide to complete the task of shampooing the patient's hair every visit per the patient's request. c. A hospice aide visit note, dated 5/30/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "did not need done today". A hospice aide visit note, dated 5/31/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "was done yesterday". The hospice aide failed to provide a valid reason for not completing the assigned task. d. A hospice aide visit note, dated 6/22/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "was done yesterday". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. e. A hospice aide visit notes, dated 6/27 and 6/28/23, included documentation that the hospice aide did not complete the assigned task of shampooing the patient's hair per the patient's request. The hospice aide documented, "not today". The hospice aide failed to following the hospice aide assignment and let the patient decide if they wanted their hair shampooed that day. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. During an interview on 7/24/23 at 11:10 AM, the Administrator stated the Registered Nurse (RN) completes the aide care plan and the hospice aide documents a reason why a task was not completed. 1. Patient #3 had a hospice admission date of 3/2/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of feeding, skin care, whirlpool, may give bath at sink or bed bath, oral care, hair care, dressing-upper body, dressing-lower body, incontinence care, mobility-transfer-hoyer lift, clean bathroom, trash removal and companionship. b. The hospice aide visit note, dated 6/28/23, lacked documentation the tasks of assist with observation and report, denture care, hair care, shampoo, assist with dressing were completed and provided reason "not today". The hospice aide failed to provide services as instructed by the RN assignment. 2. Patient #8 had a hospice admission date of 2/13/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The undated hospice aide care plan included RN instructions to the hospice aide to perform the tasks of, offer food and/or drink, supplements, observe and report open areas on skin, red areas or changes in skin condition, bed bath every visit, brush teeth, hair care, dress upper body, dress lower body, incontinence care, assist with repositioning, uses hoyer, clean bathroom, socialization and observe and document in the note box. b. The hospice aide visit note, dated 6/7, 6/29 and 7/23 lacked documentation the tasks of assist with offer supplements and brush teeth, was completed. The document identified "staff did not request it". The hospice aide failed to provide services as instructed by the RN assignment.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to document all required components of hospice aide supervision including following the patient plan of care, creating successful interpersonal relationships with the patient and family, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition every 14 days when the patient receives skilled services in conjunction with the hospice aide services for 3 of 7 sampled patients (Patients #3, #4 and #8) with hospice aide services that required and received hospice aide supervision since the end of the pandemic and resumption of the requirement of hospice aide supervision. The hospice reported 12 patients received hospice aide services at the time of the survey. Failure to ensure the supervision of hospice aide by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients' personal care needs. Findings include: --- 3. Patient #4 had a hospice admission date of 10/19/22 and received routine home care hospice services while residing in an assisted living facility. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/17/23 to 6/15/23, included IDG orders for hospice aide and skilled nursing services 2 times per week. b. The clinical record included documentation of a skilled nursing visit with hospice aide supervision, dated 5/30/23, and the next subsequent skilled nursing visit with hospice aide supervision, dated 6/14/23 (1 day late). The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's policy, titled Comprehensive Policies, dated 1/2023, identified all supervisory visits will be made by an RN. Patients will receive a home health aide supervisory visit every two weeks if also receiving skilled nursing services. If the patient is receiving personal care services only without skilled nursing, a visit will be made every 60 days with the nurse directly observing the home health aide during the visit. During an interview on 7/11/23 at 8:30 AM the Staff C, RN stated the supervision is completed by the nurse every 2 weeks and the process is to complete the supervision in person or to ask the patient/caregiver how services are going. 1. Patient #3 had a hospice admission date of 3/2/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 5/31/23 to 8/28/23, included orders for hospice aide and skilled nursing services. c. The skilled nursing visit notes, dated 6/13/23, included documentation the nurse supervised the hospice aide. b. The skilled nursing visit notes, dated 5/16, 6/23 and 5/30/23, failed to include documentation the nurse supervised the hospice aide. c. The skilled nursing visit notes, dated 6/13/23, included documentation the nurse supervised the hospice aide. (5/15/23 to 6/13/23=4.5 weeks) The hospice failed to document aide supervision every 14 days. 2. Patient #8 had a hospice admission date of 2/13/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care, dated 5/14/23 to 8/11/23, included orders for hospice aide (start 6/1/23) and skilled nursing services. b. The skilled nursing visit notes, dated 6/7, 6/14, 6/21, 7/5, 7/12 and 7/19/23, failed to include documentation the nurse supervised the hospice aide. c. The skilled nursing visit notes, dated 6/28/23, included documentation the nurse supervised the hospice aide. (no supervision from 6/1 to 6/28/23=4 weeks) and (6/28/23 to 7/19/23=3 weeks). The hospice failed to document aide supervision every 14 days.

Based on review of a written hospice agreement for services under arrangement and staff interview, the hospice failed to ensure the hospice provided orientation about the hospice philosophy for contracted staff with patient and family contact for 1 of 1 sampled contracted staff (Staff E, Massage Therapist). The hospice reported one new contract staff starting since their last survey (9/10/2020). Failure to provide orientation on hospice philosophy increased the potential for provision of services in a manner contradictory to the hospice philosophy. --- 1. A contract, dated 6/21/21, identified the hospice contracted massage therapy services with Staff E, Massage Therapist. The contract included a job description, but lacked any documentation related to the orientation of the hospice's philosophy. 2. On 8/2/23 at 2:08 PM, during an interview, the Administrator reported an inability to find documentation of training provided to Staff E, Massage Therapist on the hospice's philosophy. The Administrator explained she knew the hospice would have provided this training and the hospice needed to be more intentional in documenting the training the hospice did provide. 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 maintain written documentation of in-service training, such as required advance directive training per federal regulation, and assessment of skills and competency for 1 of 1 sampled contracted employees (Staff E, Massage Therapist). The hospice reported one new contract staff since the last hospice survey, dated 9/10/2020. Failure to provide in-service training for all contracted employees placed hospice patients at risk for inadequate and/or undiscovered problematic care. --- 1. The hospice maintained a massage therapy contract, dated 6/21/21, with Staff E, Massage Therapist. Staff E's personnel file lacked documentation of any in-service training, such as the required advance directive training or assessment of Staff E's skills and competency. 2. On 8/2/23 at 2:08 PM, during an interview, the Administrator reported an inability to find documentation of advance directives training or any assessment of Staff E's, Massage Therapist, skills and competency. 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 patient/ caregiver received a copy of the hospice policy for management and disposal of controlled medications at the time when the controlled medication is first ordered for 7 of 7 sampled patients who received hospice services in a private residence and had physician ordered controlled medications (Patient #1, #2, #5, #6, #9, #10 & #14). Failure to provide patients and/or caregivers with a copy of the hospice management and disposal of controlled medications policy increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: --- 7. Patient #10 had a hospice admission date of 4/19/23 and received hospice services while residing in a private home. Clinical record review revealed: a.The Plan of Care, dated 4/19/23 to 7/17/23, included orders for extended release morphine twice a day for pain, a controlled substance. b.The initial comprehensive assessment, dated 4/19/23, lacked evidence the hospice provided a copy of the medication disposal policy to the patient/caregiver at the time of admission to hospice services. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's packet of admission provided to patient's and their families upon admission to hospice, titled Admission Packet, revealed the packet contained only a a one sentence reference to the hospice nurse destroying any unused Schedule 2 medications when no longer needed on the hospice form, titled Patient/Family Informed Consent and Release of Information. The form did not include an explanation for the definition of a Schedule 2 drug and the hospice Admission Packet lacked the hospice's actual policy on the disposal of controlled medication. On 7/25/23 at 3:15 PM, during an interview, the Patient Care Coordinator confirmed the hospice staff do not provide the patient's and their families the hospice's controlled drug disposal policy. The Patient Care Coordinator confirmed hospice staff only provided and discussed the information found on the form, titled Patient/Family Informed Consent and Release of Information in relation to drug disposal. 4. Patient #5 had a hospice admission date of 4/26/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/23 to 7/24/23, included physician orders for the following controlled medications: Roxanol, Hydrocodone-Acetaminophen, Lorazepam and ABHR (Ativan, Benadryl, Haldol and Reglan, with Ativan being the controlled medication). b. The comprehensive assessment completed by a registered nurse (RN), dated 4/26/23, included pre-typed documentation which identified the nurse provided and discussed written policies and procedures for managing controlled drugs and a separate pre-typed documentation which identified the nurse reviewed from the hospice's "Admission Packet" the safe disposal of medications. While the hospice record included documentation the hospice staff provided a copy of the hospice's policy for managing controlled drugs, review of the hospice admission packet and staff interview revealed this documentation to be incorrect. 5. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The hospice's medication profile, dated 6/8/22, revealed the patient did not take any controlled medications. b. The comprehensive assessment completed by Staff D, RN, dated 6/8/22, included pre-typed documentation which identified the nurse provided and discussed written policies and procedures for managing controlled drugs and a separate pre-typed documentation which identified Staff D reviewed from the hospice's "Admission Packet" the safe disposal of medications. c. A physician order, dated 6/28/22, included an order for Ativan (a controlled medication) 0.5 milligrams (mg) 1 to 2 tabs as 4 hours as needed for anxiety/restlessness. The clinical record lacked documentation that hospice staff provided a copy of the hospice's policy for disposal of controlled drugs on or since 6/28/22. On 8/2/23 at 8:43 AM, during an interview, Staff D, RN, reported for the drug disposal policy, Staff D just reviews with the patient and family what is in the admission packet on the informed consent and release of information form. The patient/family did not receive a copy of the hospice's policy on disposal of controlled medications per federal regulation. 6. Patient #14 had a hospice admission date of 8/2/22, received routine home care hospice services while residing in an assisted living facility and died on 9/13/22. Review of the clinical record revealed the following: a. The POC, dated 8/2/22 to 10/30/22, included the following physician orders for controlled medications: Roxanol and Lorazepam. b. The comprehensive assessment completed by a RN, dated 8/2/22, included pre-typed documentation which identified the nurse reviewed from the hospice's "Admission Packet" the safe disposal of medications. Based on Admission Packet review and staff interview, the patient and family did not receive a copy of the hospice's controlled drug disposal policy. According to the hospice policy titled Home Use and Disposition/Disposal of Controlled Drugs, dated 5/2023, the Home Use and Disposition/Disposal of Controlled Drugs policy will be given to all hospice patients/families. During an interview on 7/26/23 at 2:00 PM the Patient Care Coordinator stated the hospice did not provide the patient with a copy of the Drug Disposal Policy but did provide a form to document drug disposal when completed. 1. Patient #1 had a hospice admission date of 6/23/23 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 6/30/23 to 9/20/23, included orders for skilled nursing services and included the following orders for narcotic medication: Fentanyl, Lorazepam and Morphine concentrate. The clinical record lacked documentation of hospice staff providing a copy of a policy for disposal of controlled drugs at the time of ordering the controlled drug. 2. Patient #2 had an admission to hospice on 10/28/22 and received services while residing in a private residence. Clinical record review revealed: a. POC, dated 7/6/23 to 10/3/23, included orders for the following controlled substances: Morphine concentrate and Tramadol. The clinical record lacked documentation of hospice staff providing a copy of a policy for disposal of controlled drugs at the time of ordering the controlled drug. 3. Patient #6 had an admission to hospice on 7/3/23 and received services while residing in a private residence. Clinical record review revealed: a. POC, dated 7/3/23 to 9/30/23, included orders for the following controlled substance: Morphine. The clinical record lacked documentation of hospice staff providing a copy of a policy for disposal of controlled drugs at the time of ordering the controlled drug.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice staff discussed the hospice's policy for the disposal of controlled medications with the patient/caregiver at the time when a physician first ordered a controlled medication for 7 of 7 sampled patients (Patients #1, #2, #5, #6, #9, #10 & #14) who received routine home care while living in a private home residence and had a physician ordered controlled medication. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: --- 7. Patient #10 had a hospice admission date of 4/19/23 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care, dated 4/19/23 to 7/17/23, included orders for extended release morphine twice a day for pain, a controlled substance. b. The clinical record lacked evidence the hospice provided education on the hospice policy for disposal of controlled substances to the patient/caregiver. The Administrator or Patient Care Coordinator received the above findings and hospice staff provided no further information prior to the end of the survey. Review of the hospice's packet of admission provided to patient's and their families upon admission to hospice, titled Admission Packet, revealed the packet contained only a a one sentence reference to the hospice nurse destroying any unused Schedule 2 medications when no longer needed on the hospice form, titled Patient/Family Informed Consent and Release of Information. The form did not include an explanation for the definition of a Schedule 2 drug and the hospice Admission Packet lacked the hospice's actual policy on the disposal of controlled medication. On 7/25/23 at 3:15 PM, during an interview, the Patient Care Coordinator confirmed the hospice staff do not provide the patient's and their families the hospice's controlled drug disposal policy. The Patient Care Coordinator confirmed hospice staff only provided and discussed the information found on the form, titled Patient/Family Informed Consent and Release of Information in relation to drug disposal. 4. Patient #5 had a hospice admission date of 4/26/23 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 4/26/23 to 7/24/23, included physician orders for the following controlled medications: Roxanol, Hydrocodone-Acetaminophen, Lorazepam and ABHR (Ativan, Benadryl, Haldol and Reglan, with Ativan being the controlled medication). b. The comprehensive assessment completed by a registered nurse (RN), dated 4/26/23, included pre-typed documentation which identified the nurse provided and discussed written policies and procedures for managing controlled drugs and a separate pre-typed documentation which identified the nurse reviewed from the hospice's "Admission Packet" the safe disposal of medications. While the hospice record included documentation the hospice staff discussed the hospice's policy for managing controlled drugs, review of the hospice admission packet and staff interview revealed this documentation to be incorrect. 5. Patient #9 had a hospice admission date of 6/8/22 and received routine home care hospice services while residing in private residence. Review of the clinical record revealed the following: a. The hospice's medication profile, dated 6/8/22, revealed the patient did not take any controlled medications. b. The comprehensive assessment completed by Staff D, RN, dated 6/8/22, included pre-typed documentation which identified the nurse provided and discussed written policies and procedures for managing controlled drugs and a separate pre-typed documentation which identified Staff D reviewed from the hospice's "Admission Packet" the safe disposal of medications. c. A physician order, dated 6/28/22, included an order for Ativan (a controlled medication) 0.5 milligrams (mg) 1 to 2 tabs as 4 hours as needed for anxiety/restlessness. The clinical record lacked documentation that hospice staff provided a copy of the hospice's policy for disposal of controlled drugs on or since 6/28/22. On 8/2/23 at 8:43 AM, during an interview, Staff D, RN, reported for the drug disposal policy, Staff D just reviews with the patient and family what is in the admission packet on the informed consent and release of information form. The hospice nurse did not discuss the hospice's policy on the disposal of controlled medications with the patient/family per federal regulation. 6. Patient #14 had a hospice admission date of 8/2/22, received routine home care hospice services while residing in an assisted living facility and died on 9/13/22. Review of the clinical record revealed the following: a. The POC, dated 8/2/22 to 10/30/22, included the following physician orders for controlled medications: Roxanol and Lorazepam. b. The comprehensive assessment completed by a RN, dated 8/2/22, included pre-typed documentation which identified the nurse reviewed from the hospice's "Admission Packet" the safe disposal of medications. Based on Admission Packet review and staff interview, the hospice nurse did not discuss the hospice's controlled drug disposal policy with the patient and family. According to the hospice policy titled Home Use and Disposition/Disposal of Controlled Drugs, dated 5/2023, the Home Use and Disposition/Disposal of Controlled Drugs policy will be given to all hospice patients/families. The nurse will provide medication safety and disposal instructions to the patient/family/caregiver/patient representative upon admission. The nurse will verbally discuss the instructions in plain language to ensure the patient and patient representative's understanding of safe use and disposal of controlled drugs. The discussion between the nurse and the patient/patient representative on safe use and disposal of controlled substances must be documented in the clinical record. During an interview on 7/26/23 at 2:00 PM the Patient Care Coordinator stated the hospice did not provide the patient with a copy of the Drug Disposal Policy but did provide a form to document drug disposal when completed. 1. Patient #1 had a hospice admission date of 6/23/23 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 6/30/23 to 9/20/23, included orders for skilled nursing services and included the following orders for narcotic medication: Fentanyl, Lorazepam and Morphine concentrate. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug. 2. Patient #2 had an admission to hospice on 10/28/22 and received services while residing in a private residence. Clinical record review revealed: a. POC, dated 7/6/23 to 10/3/23, included orders for the following controlled substances: Morphine concentrate and Tramadol. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug. 3. Patient #6 had an admission to hospice on 7/3/23 and received services while residing in a private residence. Clinical record review revealed: a. POC, dated 7/3/23 to 9/30/23, included orders for the following controlled substance: Morphine. The clinical record lacked documentation of hospice staff providing a discussion of policy for disposal of controlled drugs at the time of ordering the controlled drug.

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 including a child abuse and dependent adult abuse record check for 1 of 1 sampled contract staff (Staff E, Massage Therapist) who started to provide services since the hospice's last survey (9/10/2020). The hospice only had 1 contract person start since the last hospice survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients. --- 1. Staff E, Massage Therapist, had a signed contract date with the hospice, dated 6/21/21. 2. On 8/2/23 at 2:08 PM, during an interview, the Administrator confirmed Staff E, Massage Therapist, first signed a contract with the hospice on 6/21/21. The Administrator reported an inability to find the background check on Staff E, Massage Therapist. 3. On 8/7/23 at 11:07 AM, the Administrator sent the following email: "Please review the attached addendum to (Staff E, Massage Therapists) contract in regards to the background check. My understanding is that the addendum that (Staff E, Massage Therapist) signed states that if we requested, (Staff E) would provide us with background check information. When you requested (Staff E, Massage Therapist) background check earlier, we requested it from (Staff E, Massage Therapist) and (Staff E) was not able to produce it so we started the process of running our own background check – which we have not yet received the results on." The hospice failed to ensure all staff had criminal background checks completed as well as a child abuse and dependent adult abuse record check completed prior to providing services to hospice patients. Hospice staff provided no further information prior to the end of the survey.