Every finding on record at St. Anthony Regional Hospital and Nursing Home

Based on clinical record review, hospice policy review, home visit observation, patient interview and staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care (POC) for 6 of 14 sampled patients (Patient #2, #4, #5, #6, #8, and #12).    Failure to follow the patient's POC as directed by the Interdisciplinary Group (IDG) put the patients at risk for inconsistent care that may not meet the needs of the patients.    Findings include: --- 5. Patient #2 had a start of care date of 5/8/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 1/3/25 to 3/3/25, identified the patient had a diagnosis of Bladder cancer.  The POC included orders for the skilled nurse to assess skin condition.    b. The skilled nurse visit note, dated 2/11/25, completed by Staff D, LPN, identified the patient had a skin tear to the right forearm and noted the dressing was changed.  The LPN failed to obtain wound care orders and failed to measure the wound.    The hospice failed to provide weekly wound measurements and failed to provide services only as ordered by the physician.    6. Patient #6 had a start of care date of 2/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/24/25 to 4/24/25, identified the patient had a diagnosis of Alzheimer's disease.  The POC included orders for skilled nurse to assess skin condition.    b.  The skilled nurse visit note, dated 2/25/25, completed by Staff D, LPN, identified the patient fell last night and had a laceration above his/her right eye.   The LPN failed to document measurements of the laceration.  c. The skilled nurse visit notes, dated 2/27/25, 3/6/25, 3/10/25, 3/13/25, 3/20/25 and 3/25/25, completed by Staff B, Clinical Manager, failed to include a wound assessment with wound measurements.    The hospice failed to complete weekly wound assessments and measurements.    The above findings were reviewed with the Administrator and Clinical Manager.   Review of the hospice policy, titled Wound Care, last revised 8/2024, wounds should be pictured, assessed and measured (length, width, and depth) on a weekly basis and PRN (as needed) with wound care. This should be documented in the clinical record.  During an interview on 4/15/25 at 10:30 AM the Clinical Manager stated the skin assessment included wound measurements completed weekly. The measurements expected to include length, width and depth.  1.Patient #4 had a hospice admission date of 2/20/25 and received hospice services while residing in a private residence.    Clinical record review and home visit observation revealed the following:   a. The plan of care (POC), dated 2/20/25 to 5/20/25, identified the patient had a diagnosis of lung cancer. The POC included orders for the skilled nurse to assess the patient's weight and measurements.    b. The skilled nurse visit notes, dated 2/18/25, 3/6/25, 4/1 and 4/5/25, Staff H, Registered Nurse (RN), failed to include documentation of the patient's weight and measurements.  c. The skilled nruse visit note, dated 3/14/25, by Staff D, Licensed Practical Nurse (LPN), failed to inlcude documentation of the patient's weight and measurements.  The hospice failed to follow all orders as written on the POC.  2. Patient #5 had a hospice admission date of 7/22/25 and received hospice services while residing in a private residence.    Clinical record review and home visit observation revealed the following:   a. The POCs, dated 1/18/25 to 3/18/25 and 3/19/25 to 5/27/25, identified the patient had a diagnosis of Parkinson's disease. The POC included orders for the skilled nurse to assess the patient's weight and measurements and assess skin condition.    1). The skilled nurse visit notes, dated 2/10, 2/13/25, 3/20, 3/24, 3/27, 4/7 and 4/10/25, by Staff L, RN, failed to include documentation of the patient's weight and measurements.  2). The skilled nurse visit notes, dated 2/20, 2/27/25 and 4/3/25, by Staff D, LPN, failed to include documentation of the patient's weight and measurements.  b. The skilled nurse visit note, dated 3/20/25, Staff L, RN, identified the patient had a new small area opened to the coccyx. Staff L failed to document an assessment of the wound or document measurements of the wound.  1) The skilled nurse visit note, dated 3/24 and 3/27/25, Staff L, RN identified the patient's wound healing. Staff L failed to document an assessment of the wound or document measurements of the wound.  2) The skilled nurse visit note, dated 3/31/25 and 4/3/25, Staff L, RN, identified the patient's wound healing. Staff L failed to document an assessment of the wound or document measurements of the wound.  3). The skilled nurse visit note, dated 4/7/25, Staff L, RN documented the patient's wound with no drainage and no odor. The wound measurements documented 1 inch by 1 inch width and 0 depth. Staff L failed to document measurements of the wound depth.  The hospice failed to follow all orders as written on the POC or complete wound assessment and measurements.  3. Patient #8 had a hospice admission date of 1/7/25 and received hospice services while residing in a private residence.    Clinical record review and home visit observation revealed the following:   a. The POCs, dated 1/7/25 to 4/6/25 and 4/7/25 to 7/5/25, identified the patient had a diagnosis of Gastrointestional bleeding with unknown orgin. The POC included orders for the skilled nurse to assess the patient's weight and measurements and assess skin condition.    1). The skilled nurse visit note, dated 2/25/25, by Staff D, LPN, failed to inlcude documentation of the patient's weight and measurements.  b. The comprehensive assessment at recertification, dated 4/3/25, Staff F, RN identified the patient had a stage 1 irregular pressure ulcer on the left buttock. No open sore at this time. The area measured length 0.08 inches by width 0.04 inches and no depth observed.  c. The skilled nurse visit note, dated 4/10/25, Staff F, RN identified the patinet had pressure ulcer described clean, pink with wound edges attached to the wound bed. The wound measured 0.08 inches by 0.04 inches and 0 depth identified.   d. During an interview on 4/22/25 at 8:21 AM, Staff F, RN stated the wound open but had a very shallow depth. Stated she had not been able to get an accurate depth with the q-tip and identified the area had a break in the top layer of the skin. Staff failed to measure the depth of an open wound.  The hospice failed to follow all orders as written on the POC or complete wound assessment and measurements.  4. Patient #12 had a hospice admission date of 7/2/24 and discharge date of 8/5/24 and received hospice services while residing in a private residence.    Clinical record review and home visit observation revealed the following:   a. The POC, dated 7/2/24 to 9/40/45, identified the patient had a diagnosis of Atherosclerotic heart disease. The POC included orders for the skilled nurse to assess the patient's weight and measurements.    a. The skilled nruse visit note, dated 8/22/24, by Staff D, LPN, failed to inlcude documentation of the patient's weight and measurements.  b. The skilled nurse visit notes, dated 8/29/24 and 9/18/24, by Staff M, Registered Nurse (RN) failed to include documentation of the patient's weight and measurements.  c. The skilled nurse visit note, dated 9/18/24, by Staff B, RN, failed to include documentation of the patient's weight and measurements.  The hospice failed to follow all orders as written on the POC.

Based on home observation visits, interviews, clinical record review and agency policy review, the hospice failed to ensure accurate completion of all components comprising the Plan of Care, including all medical supplies/equipment used by the patient for 4 of 14 sampled patients (Patients #1, #3, #4 and #14).  Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. --- 4. Patient #1 had a start of care date of 4/10/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 4/10/25 to 7/8/25, identified the patient had a primary diagnosis of Alzheimer's disease and required the use of the following medical equipment and supplies: call light, wheelchair, tray table, toilet riser, lift chair, incontinent supplies, hospital bed, grab bars and EZ stand lift aide.  b. Home visit observation on 4/15/25 at 8:30 AM with Staff H, RN, revealed the patient had bolster supports in his/her wheelchair.   c. During an interview at the same home visit observation the nursing home RN stated the patient utilized the bolster since the start of hospice services.  d. The POC failed to identify the bolster supports used by the patient.    The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including bolster supports.    5. Patient #4 had a start of care date of 2/20/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 2/20/25 to 5/20/25, identified the patient had a primary diagnosis of lung cancer and required the use of the following medical equipment and supplies: wheelchair cushion, wheelchair, walker, shower bench, pulse oximeter, oxygen, lift chair and gaitbelt.  b. The skilled nurse note, dated 3/4/25, Staff D, LPN, identified the following medical supplies and equipment ordered for the patient: hospital bed and lifeline.  c. The IDG notes, dated 3/13, 3/27/25 and 4/10/25, failed to identify the lifeline used by the patient.    The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including lifeline. The above findings were reviewed with the Administrator and Clinical Manager.   The above findings reviewed with the Administrator and Clinical Manager. 3.Patient #2 had a start of care date of 5/8/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POC, dated 3/4/25 to 5/2/25 identified the patient had a primary diagnosis of Bladder cancer and required the use of the following medical equipment and supplies: walker, shower chair/bench, incontinent supplies, handheld shower, grab bars, cell phone and cane.    b. During a home observation visit on 4/15/25 at 10:00 AM with Staff F, RN, the surveyor observed the patient using a heating blanket.  During an interview, the patient stated he/she has had the heating blanket for greater than three months and uses the heating blanket often due to always being cold.    c. The IDG meeting notes, dated 3/13/25, 3/27/25 and 4/10/25, failed to identify the heating blanket used by the patient.    The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including a heating blanket.   Findings include: According to the policy titled Comprehensive Assessment and Plan of Care, dated 11/2024, the Hospice Interdisciplinary group (IDG), conducts and documents a patient-specific comprehensive assessment that identifies the patient's needs for hospice care, including medical, nursing, psychosocial, emotional and spiritual care. The IDT uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver. A patient's progress towards desired outcomes and response to care is reassessed as often as required by the patient's condition but no less frequently than every 15 days. 1.Patient #3 had a start of care date of 9/18/24 and received hospice services in the home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 3/17/25 to 5/15/25, identified a primary diagnosis of colon and liver cancer, and required the use of the following medical equipment and supplies: cell phone, bed rails, wheelchair cushion, walker, shower chair bench, pill box, Incontinent supplies, hospital bed, handheld shower and grab bars.  b. During a home observation visit with Staff L, Registered Nurse (RN), 4/15/25 at 10:30 AM, patient stated the chair lift is utilized to get up and down the stairs and the patient is weighed on routine basis, by spouse and by the skilled nurse.  c. The Interdisciplinary Group (IDG) notes, dated 2/13/25, 2/27/25, 3/13/25 and 3/27/25, failed to identify the chair lift and the scale as medical supplies in the home used by the patient.  The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including a chair lift and scale.   2. Patient #14 had a start of care date of 08/14/24 and received hospice services in a private home. Clinical record revealed the following: a. The POC, dated 8/14/24 to 11/11/24, included a primary diagnosis of Gastrointestinal hemorrhage, and required the use of the following medical equipment and supplies: Walker, Shower Bench and Shower Wand, Oxygen Concentrator and Supplies, Incontinent Supplies, Hospital Bed, Bedside Commode. b. The skilled nurse visit note dated 8/17/24, completed by Staff D, Licensed Practical Nurse (LPN),  revealed patient needed a wheelchair for transfers and transportation related to patient weakness and decline.  c. The IDG notes dated, 8/15/24 and 8/29/24, failed to identify the wheelchair as a medical supply in the home used by the patient.  The hospice failed to update the POC to identify all medical supplies and equipment used by the patient, including a wheelchair.

Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 3 samples services (Medical equipment/supply 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: --- Review of the contract between the hospice and sampled medical equipment/supply provider, dated 11/7/2012, identified the contract lacked the following required components:   a. The hospice retains administrative and financial management,  b. The hospice retains oversight of staff and services and  c. All services are approved by hospice and delivered in accordance with the patient's plan of care.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on clinical record review and agency policy review,  the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards for 9 of 14 sampled patients (Patients #2, #3, #5, #6, #7, #9, #10, #11 and #14).     Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. --- 9. Patient #5 had a start of care date of 7/22/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 1/8/25 to 3/18/25 and 3/19/25 to 5/27/25, identified the patient had a diagnosis of Bladder cancer and included orders for skilled nurse, social worker, hospice aide, massage therapy and chaplain.    b. The Social Worker visit notes, dated 4/8/25, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    c. The hospice aide visit notes, dated 4/3, 4/7 and 4/10/25, completed by Staff G, Hospice Aide, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.   The above findings were reviewed with the Administrator and Clinical Manager. 5.Patient #2 had a start of care date of 5/8/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 1/3/25 to 3/3/25 and 3/4/25 to 5/2/25, identified the patient had a diagnosis of Bladder cancer and included orders for skilled nurse, social worker, hospice aide and chaplain.    b. The Social Worker visit notes, dated 2/13/25, 3/13/25 and 4/9/25, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.    6. Patient # 6 had a start of care date of 2/24/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 2/24/25 to 4/24/25, identified the patient had a diagnosis of Alzheimer's disease and included orders for skilled nurse, social worker, hospice aide and chaplain.    b. The Social Worker visit notes, dated 2/25/25, 3/12/25 and 4/1/25, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    c. The Hospice Aide visit notes, dated 2/26/25 and 3/12/25, completed by Staff G, Hospice Aide, included a signature and date but lacked a title of the clinician completing the visits.    The hospice failed to ensure all completed documentation included appropriate authentication.    7.Patient #9 had a start of care date of 12/3/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The POCs, dated 12/3/24 to 3/2/25 and 3/3/25 to 5/31/25  identified the patient had a diagnosis of Retroperitoneum cancer and included orders for skilled nurse, social worker and hospice aide services.    b. The Social Worker visit notes, dated 2/13/25, 3/12/25 and 4/6/25, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.    8.Patient #11 had a start of care date of 9/4/24, a discharge date of 11/6/25 and received hospice services while residing in a nursing home.  Clinical record review revealed:   a. The POC, dated 9/4/24 to 12/2/24, identified the patient had a diagnosis of Hypertensive heart disease with heart failure and included orders for skilled nurse, social worker, hospice aide and chaplain services.    b. The Social Worker visit note, dated 11/1/24, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.   Findings include: According to the agency policy titled Entries into Clinical Records, dated 7/2023, all agency employees, approved students and/or contractors have authority to make entries into theclinical record. Documentation in the clinical record will be timely, detailed, accurate and reflect the care or services provided. Home care personnel will document all care/service provided within a timely manner following provision of service and incorporated into the home care record within 7 days. The entries should be documented by the first initial of the given name, full surname, and initials or licensing credentials. 1.Patient # 3 had a start of care date of 9/18/24 and received hospice services in the home. Clinical record review revealed the following: a. The POCs, dated 12/17/24 to 3/16/25 and 3/17/25 to 5/15/25, identified the patient had a diagnosis of liver/colon cancer and included orders for skilled nurse, social worker, and  hospice aide  b. The Social Worker visit notes, dated 1/16/25, 2/24/25, 3/13/25, and 4/10/25 completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.   2.Patient # 7 had a start of care date of 3/12/25 and received hospice services in the home. Clinical record review revealed the following: a. The POC, dated 3/12/25 to 6/9/25, identified the patient had a diagnosis of bladder cancer and included orders for skilled nurse, social worker, chaplain and  hospice aide  b. The Social Worker visit notes, dated 3/14/25 and 4/10/25, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.    3.Patient # 10 had a start of care date of 12/202/4 and received hospice services in an assisted living facility. Clinical record review revealed the following: a. The POCs, dated 12/20/24 to 3/19/25 and 3/20/25 to 6/17/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social worker, chaplain, music therapy and  hospice aide.  b. The Social Worker visit notes, dated 12/23/24, 1/14/25, 2/11/25, 3/11/25 and 4/2/25 completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit notes.    The hospice failed to ensure all completed documentation included appropriate authentication.   4.Patient # 14 had a start of care date of 8/14/24 and received hospice services in the home. Clinical record review revealed the following: a. The POC, dated 08/14/24 to 11/11/24, identified the patient had a diagnosis of gastrointestinal hemorrhage and included orders for skilled nurse, social worker, and hospice aide. b. The Social Worker visit note, dated 8/14/24, completed by Staff C, Social Worker, included a signature and date but lacked a title of the clinician completing the visit note.    The hospice failed to ensure all completed documentation included appropriate authentication.

Based on staff interview and clinical record review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 3 of 3 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #8, #9 and #13).    Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for who the medication was prescribed.    Findings include: --- 3. Patient #8 had a start of care date of 1/7/25 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial POC, dated 1/7/25 to 4/6/25, included physician orders for medications, but no narcotic medications.  The POC identified the patient had a diagnosis of gastrointestinal bleed with unknown orgin.    b. The interim physician's order, dated 3/4/25, included orders for the following controlled substance narcotic medications: oxycodone 5 milligrams (mg), q tablet every 8 hours as needed for pain and morphine concentrate 20 mg/milliliters (ml), give 0.25 ml every 4 hours as needed for pain/breathing.   b. A skilled nurse visit note, dated 3/4/25, completed by the Staff F, Registered Nurse (RN), identified the physician ordered Morphine and Oxycocone.  Staff failed to provide education on the hospice policy for the disposal of controlled medications.  c. A skilled nurse visit date, dated 3/6/25, completed by Staff F, RN, identified patient had new medications Morphine and Oxycodone, however had not taken the medication. Staff failed to provide education on the hospice policy for the disposal of controlled medications.  d. An IDG meeting note, dated 3/13/25, included physician orders for Morphine and Oxycodone; controlled medications.    The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.  The above findings reviewed with the Administrator and Clinical Manager.  During an interview on 4/22/25 at 11:10 AM, the Administrator stated the hospice gives the drug disposal policy and education to the patient at admission.  Moving forward, the Administrator reported it will also be an expectation for the nurse to document in the patient's clinical record that the written policies and procedures for managing the controlled substances was provided and discussed at the time a narcotic is first ordered.    1.Patient #9 had a start of care date of 12/3/24 and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial plan of care (POC), dated 12/3/24 to 3/2/25, included physician orders for medications, but no controlled medications.  The POC identified the patient had a diagnosis of Retroperitoneum cancer.    b. A skilled nurse visit note, dated 2/16/25, completed by the Administrator identified the physician ordered Morphine and Ativan that would be delivered later on this date.    c. A skilled nurse visit date, dated 2/17/25, completed by Staff D, Licensed Practical Nurse (LPN), identified patient took his/her first dose of morphine.    d. An Interdisciplinary Group (IDG) meeting note, dated 2/27/25, included physician orders (effective 2/16/25) for Morphine and Ativan; controlled medications.    The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.  2.Patient #13 had a start of care date of 6/21/24, a death date of 7/13/24, and received hospice services while residing in a private residence.  Clinical record review revealed:   a. The initial POC, dated 6/21/24 to 9/18/24, included physician orders for medications, but no controlled medications.  The POC identified the patient had a diagnosis of Pancreatic cancer.    b. A skilled nurse visit note, dated 7/5/24, completed by Staff H, Registered Nurse (RN), identified the physician ordered Hydrocodone Acetaminophen (controlled medication) as needed and the RN educated the patient on how to take the medication.    The clinical record lacked documentation hospice staff reviewed the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications.

Based on review of written contracts, the hospice failed to ensure the written agreements for short-term inpatient services specified the provider would have patient care policies consistent with hospice policies for 2 of 2 sampled contracts (Hospital A and Hospital B).  Failure to ensure the patient care provider had policies consistent with the hospice's own policies increased the potential for services to be provided in a manner contradictory to hospice policies.    Findings include: --- 1.A contractual agreement with Hospital A, dated 8/25/22, lacked the provision that the patient care provider will have policies consistent with the hospice provider's policies and the patient care provider will abide by the plan of care established by the hospice for its patients.    2. A contractual agreement with Hospital B, dated, 8/25/22, lacked the provision that the patient care provider will have policies consistent with the hospice provider's policies.    The above findings were reviewed with the Administrator and Clinical Manager.

Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreement identified the hospital would send a copy of the hospice patient's discharge summary to the hospice at the time of discharge from the hospital for 1 of 2 sampled written agreements reviewed (Hospital B).   Failure to ensure the hospital provided the hospice with a discharge summary upon hospital discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home.     Findings include: --- The hospice had a contractual agreement with Hospital B, dated 8/25/22.  The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge and failed to specify a copy of the inpatient clinical record is available to the hospice at the time of discharge.    The above findings were reviewed with the Administrator and Clinical Manager.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check for 4 of 7 sampled employees (Staff G, I, J & K) who began serving hospice patients since their last survey, dated 5/5/22.  The hospice reported hiring 8 new staff since the last survey.   Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice employees who had direct patient contact.   Findings include: --- According to the hospice policy titled Recruitment and Selection Process, last revised 3/2024, all offers of employment are contingent upon clear results of a thorough backgroun check. Background checks will be conducted on all final candidates. Background checks will include: Iowa Health Care Facility Record check, The Divistion of Criminal Investigation (DCI) at the Department of Public Safety to perform a criminal, child, and dependent adult abuse record check. If the person has been convicted of a crime under the law of any state or has a record of founded child or dependent adult abuse, the Department of Hyman Services will perform an evaluation to determine whether the crime or founded cheld or dependent adult abuse warrants prohibition of employment.  During an interview on 4/3/25 at 10:40 AM, the Administrator stated Staff G, Staff I, Staff K had background checks completed when they previously worked at the hospital. Staff  transfered to work for hospice.  1.  Staff G, Hospice Aide, had a hire date of 8/10/23.  A criminal background check was completed and dated 3/15/05.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  2. Staff I, Hospice Volunteer, had a hire date of 8/17/23.  A criminal background check was completed and dated 4/21/05.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  3. Staff J, Pastoral Care, had a hire date of 11/27/23.  A criminal background check was completed and dated 10/6/23, 52 days prior to the date of hire.  The hospice failed to complete an additional criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  4. Staff K, Licensed Practical Nurse, had a hire date of 4/7/25.  A criminal background check was completed and dated 4/21/05.  The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI within 30 days prior to the date of hire.  Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients.  The above findings were reviewed with the Administrator and Volunteer Coordinator.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks.  The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor.  Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 4 of 7 sampled employees (Staff G, I, J and K) who began serving hospice patients since their last survey, dated 5/5/22.  The hospice reported hiring 8 staff since the last survey.  Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from staff who had direct patient contact. Findings include: --- According to the hospice policy titled Recruitment and Selection Process, last revised 3/2024, all offers of employment are contingent upon clear results of a thorough backgroun check. Background checks will be conducted on all final candidates. Background checks will include: Iowa Health Care Facility Record check, The Divistion of Criminal Investigation (DCI) at the Department of Public Safety to perform a criminal, child, and dependent adult abuse record check. If the person has been convicted of a crime under the law of any state or has a record of founded child or dependent adult abuse, the Department of Hyman Services will perform an evaluation to determine whether the crime or founded cheld or dependent adult abuse warrants prohibition of employment.  During an interview on 4/3/25 at 10:40 AM, the Administrator stated Staff G, Staff I, Staff K had background checks completed when they previously worked at the hospital. Staff  transfered to work for hospice.      1.  Staff G, Hospice Aide, had a hire date of 8/10/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 3/15/05.  The hospice failed to complete dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  2. Staff I, Hospice Volunteer, had a hire date of 8/17/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 4/21/05.  The hospice failed to dependent adult abuse and child abuse checks with the Iowa SING or the Iowa Department of Health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  3. Staff J, Pastoral Care, had a hire date of 11/27/23.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 10/6/23, 52 days prior to the date of hire.  The hospice failed to complete an additional dependent adult abuse child abuse check with the Iowa SING or the Iowa Depertmant of Health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  4. Staff K, Licensed Practical Nurse, had a hire date of 4/7/25.  A criminal background check, dependent adult abuse and child abuse checks were completed and dated 4/21/05.  The hospice failed to complete a dependent adult abuse and child abuse check with the Iowa SING or the Iowa Department of health within 30 days prior to the date of hire.  Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring.  The above findings were reviewed with the Administrator and Volunteer Coordinator.

Based on clinical record review, home visit observation, hospice policy review and staff interview the hospice failed to ensure hospice staff completed medication reviews which included all the required components of a Drug Regimen Review (DRR) for 9 of 11 sampled patients (Patients #1, #2, #3, #4, #6, #7, #8, #10 and #11). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs completed a DRR based on a review of all of the patient's medications and included all the required components of the DRR with each update to the comprehensive assessment increased the risk of the patient developing an undetected a side effect or adverse reaction in relation to medication therapy. Findings include: According to a hospice policy titled Drug Regimen Review, dated 4/2022, a drug regimen review will reflect and take into consideration the medication history, safe and proper use and storage of drugs, possible ineffective drug therapy, potential effects and adverse reactions, significant side effects, contraindicated medications, duplicate drug therapy and non-compliance and the proper interpretation and application of laboratory tests as they relate to the clinical use of mediation. During an interview on 5/3/22 at 8:25 AM the Clinical Manager stated a Drug regimen review (DRR) completed on paper form for duplicates, interactions, side effects. The DRR also generated with new medications. 1. Patient #1 had a hospice admission date of 3/2/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/2/22 to 5/30/22, included physician orders for medications, including synthroid. b. The IDG meetings, dated 3/1, 3/17, 3/31/22 4/14 and 4/28/22, included documentation of completed DRR. The clinical record lacked documentation of the identification synthroid as associate with laboratory monitoring The DRRs failed to include an accurate and complete review of all the patient's medications. 2. Patient #2 had a hospice admission date of 2/11/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/11/22 to 5/11/22, included physician orders for medications, including bowel medications, Miralax and Bisacodyl. b. The IDG meetings, dated 2/11/22, 3/3, 3/27, 3/31/21 4/14 and 4/28/22, included documentation of completed DRR. The clinical record lacked documentation of the identification of duplicate bowel medications. The DRRs failed to include an accurate and complete review of all the patient's medications. 3. Patient #3 had a hospice admission dated of 4/29/22 and received hospice services while residing in a private home residency. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 6/27/22, included physician orders for medication, including plavix and aspirin. The DRR, dated 4/29/22, included documentation of completed DRR. The clinical record lacked documentation of the potential for significant side effects of plavix and aspirin. 4. Patient #8 had a hospice admission dated of 4/29/22 and received hospice services while residing in an inpatient setting. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included physician orders for medication, including Fentanyl, Morphine and Acetaminophen. The DRR, dated 4/29/22, included documentation of completed DRR. The clinical record lacked documentation of the duplicate pain medications including Fentanyl, Morphine and Acetaminophen. 5. Patient #10 had a hospice admission date of 1/13/22 and date of discharge of 4/12/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/13/22 to 4/12/22, included physician orders for medications, including Levothyroxine. b. The IDG meetings, dated 2/17, 3/3 3/17 and 3/31/22, included documentation of completed DRR. The clinical record lacked documentation of the identification levothyroxine as associated with laboratory monitoring The DRRs failed to include an accurate and complete review of all the patient's medications. 6. Patient #4 had a hospice admission date of 3/12/22 and received hospice services while residing in a nursing home (long term care facility). Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/12/22 to 6/9/22, included physician orders for the following duplicate medication therapies: Asmanex inhaler and Albuterol Sulfate Inhaler to treat breathing difficulties and Plavix and Aspirin to prevent blood clots. The POC included orders for Tylenol to treat pain and an order for Metoprolol and Potassium. The POC included an order for a complete blood count (CBC) every 3 months and blood sugar level monitoring weekly (Aspirin can cause low blood sugar levels and Metoprolol may cause an increase in blood sugar levels). b. The initial DRR, dated 3/12/22, and subsequent DRRs, dated 3/17, 3/31, 4/14 and 4/28/22, failed to identify if the patient had any drug therapy associated with laboratory monitoring and failed to identify if the patient was taking any duplicate medication therapy. c. The patient's nursing home medication and treatment administration records, dated April 2022, included an ongoing order for a complete metabolic panel (CMP) every 4 months (related to Metoprolol and Potassium medication use), and documentation of the last laboratory blood draw on 4/6/22. d. A physician order, dated 3/25/22, included an order for Fentanyl ( a medication used to treat pain). The patient continued to have an order for Tylenol to treat pain. On 5/5/22 at 8:36 AM, during an interview, Staff D, hospice RN, reported the patient's family wanted the laboratory monitoring done for the CMP and CBC; she did not know why the physician had ordered the laboratory tests. 7. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The POCs, dated 12/23/21 to 3/22/22 and 3/23/22 to 6/20/22, included orders for Lantus Insulin, Novolog Insulin and Basaglar Insulin (all medications associated with blood sugar level testing). The POCs included orders for the facility staff to check blood sugars 4 times per day. b. The DRRs, dated 12/23/21 and 1/6, 1/8, 1/20, 2/3, 2/17, 3/3, 3/17, 3/22 and 4/13/22, documented the patient did not have any drug therapy associated with laboratory monitoring. The DRR failed to identify the patient had drug therapy associated with lab monitoring. 8. Patient #6 had a hospice admission date of 3/3/22 and received services while residing in a private residence. a. The plan of care (POC), dated 3/3/22 to 5/31/22 identified physician orders for skilled nurse services. Medication orders included liver complex 250-250 mg tablet 1 every morning, Senna-S-S 8.6-50 tablet take 1 daily as needed, Tylenol 325 mg take 2 every 8 hours as needed, furosemide 40 mg tablet take 1 every morning, lactulose 10 gram/15 ml take 10 mls 2 times daily, lorazepam 0.5 mg tablet take 1 every 6 hours as needed, ondansetron 4 mg tablet take 1 every 8 hours as needed, pantoprazole 40 mg tablet take 1 tablet 2 times daily, rifaximin 550 mg tablet take 1 tablet 2 times daily, spironolactone 50 mg tablet take 1 every morning, trazadone 50 mg tablet take 1 at bedtime. b. The medication profile, dated 5/3/2022, identified the following medications; Senna-S 8.6-50 tablet take 1 daily as needed, furosemide 40 mg tablet take 1 every morning, lorazepam 0.5 mg tablet take 1 every 6 hours as needed, rifaximin 550 mg tablet take 1 tablet 2 times daily, morphine 20 mg/ml take 0.25 ml every 4 hours as needed for mild symptoms or 0.5 ml every 4 hours for severe symptoms and lorazepam intensol 2 mg/ml take 0.25 ml for mild anxiety every 4 hours as needed or 0.5 ml high anxiety every 4 hours as needed. c. During a home visit with Staff A, Registered Nurse (RN), the patient's medications were reviewed. The surveyor observed furosemide 20 mg tablet take 1 every morning dated 10/11/2021, morphine 20 mg/ml take 0.25 ml every 2 hours as needed for mild symptoms or 0.5 ml every 2 hours for severe symptoms, lorazepam intensol 2mg/ml take 0.5 ml for anxiety every 2 hours as needed, senna-S 8.6-50 mg tablet take 1 tablet 2 times daily as needed, lorazepam 0.5 mg tablet take 1 tablet 2 times daily as needed and rifaximin 550 mg tablet take 1 tablet 2 times daily. d. During the same home visit with Staff A, RN she reported the rifaximin had been discontinued since the first week the patient received hospice care. The hospice failed to identify current orders for furosemide, morphine, loraxepam, senna-S, and rifaximin on the medication profile. 9. Patient #7 had a hospice admission date of 3/31/22 and received services while residing in a private residence. a. The plan of care (POC), dated 3/31/22 to 6/28/21 identified physician orders for skilled nurse services. Medication orders identified famatodine 20 mg tablet 2 times daily. b. The medication profile, dated 5/2/22 identified the following medications, famatodine 20 mg tablet 2 times daily. c. During a home visit with Staff B, Registered Nurse (RN), the patient's medications were reviewed. The surveyor observed famatodine 40 mg tablet 2 times daily dated 1/12/22. The hospice failed to identify current orders for famatodine on the medication profile. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 4 of 4 sampled patients with a wound (Patients #4, #9, #10 and #11). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient's wound status and effectiveness of treatments and interventions. Findings include: According to hospice policy, titled Wound Care, dated 12/2014, wounds shall be assessed and measured on a weekly basis and as needed with wound care. During an interview on 5/3/22 at 8:25 AM, the Clinical Manager stated a full assessment completed including measurements weekly. The measurements include width, length, depth and description odor and drainage. 1. Patient #10 had a hospice admission date of 1/13/22 and date of discharge of 4/12/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The IDG meeting notes, 2/17/22, included IDG orders for skilled nursing services 1 to 2 times every week and 2 as needed. b. The skilled nurse visit note, dated 3/3/22, included documentation the patient had a white reddened area on the 2nd toe of the left foot. A picture taken and measurments included length 0.7 centimeters (cm) width 0.4 cm and depth 0 cm. d. The skilled nurse visit note, dated 3/7/22 and 3/9/22, included documentation the patient had a blister like area. The area not measured. c. The skilled nurse visit note, dated 4/15/22, failed to included documentation the patient's wound addressed. d. The skilled nurse visit note, dated 4/17/22, included documentation the patient's toe slightly reddened. The area mot measured. Hospice staff failed to provide assessment of the patient's wound per policy. 2. Patient #4 had a hospice admission date of 3/12/22 and received hospice services while residing in a nursing home. Review of the patient's nursing home clinical record revealed the following: a. The nursing home medication and treatment administration record, dated March 2022, included an order for Mercy Butt Cream twice a day bilaterally to buttocks until healed with a start date of 3/14/22 and an end date of 3/21/22, and an order for Calmoseptine Ointment 0.44-20.6 percent apply topically one time per day to friction area and Mepilex border to buttocks area daily and as needed until healed with a start date of 3/21/22 and an end date of 4/25/22. b. A nursing home skilled nurse weekly wound assessment note, dated 3/21/22, included documentation the patient had a 3 centimeter (cm) (length) by 3 cm (width) wound, superficial in depth with the top layer of skin sheared off. The nurse documented the skin around the wound was macerated. The nurse documented the wound was "more open than last week" and she contacted the nurse practitioner to get a wound care order change. The note identified the wound started on 3/14/22. Review of the patient's hospice clinical record revealed the following: a. The hospice clinical record lacked an order for the Mercy Butt Cream. b. The skilled nursing visit notes, dated 3/14 and 3/17/22, lacked documentation the hospice nurse was aware of the patient having a wound. c. A faxed order from the patient's nursing home, dated 3/21/22, included documentation the nursing home staff reported the patient had a friction area measuring "3 by 3 with a pinpoint open area" and they had an order to use Mercy Butt Cream. The nursing home reported today (3/21/22) the wound was sheared and open and measured "2 by 2 1/2 cm". The nursing home staff requested an order for the Calmoseptine and Mepilex border. d. The skilled nursing visits notes, dated 3/22 and 3/24/22, included documentation the nurse was unable to assess the patient's wound. On 3/24/22, the nurse documented the nursing home nurse reported the wound remained open, but was healing. e. The week of 3/28/22 included documentation of 2 skilled nursing visits, dated 3/28 and 3/30/22. Both visits lacked documentation of a wound assessment and lacked a reason why the nurse failed to assess the wound per the hospice's policy. f. The weeks of 4/4, 4/11 and 4/18/22, each included documentation of 2 skilled nursing visits, dated 4/5, 4/7, 4/11, 4/13, 4/18 and 4/20/22. The nursing visits each included documentation which identified the wound was healing, but lacked any further assessment information on the wound. On 5/5/22 at 8:36 AM, during an interview, Staff D, hospice RN, explained she did not really think the patient had a wound. She reported it was not really a sore, they were just being over protective, so it did not turn into something. 3. Patient #9 had a hospice admission date of 8/11/21, received hospice services while residing in a nursing home and discharged from hospice services on 2/3/22. Review of the clinical record revealed the following: a. The comprehensive assessment completed by the Registered Nurse (RN) Clinical Manager, dated 8/11/21, included documentation she assessed the patient had skin cancer lesion (abnormal tissue) that was left open to air. She assessed the lesion had a scant amount of foul drainage and included a picture of the lesion. The assessment lacked documentation of measurements. The picture of the cancerous lesion included a picture of a ruler in centimeters. The lesion measured approximately 4.5 centimeters (cm) in width, the length appeared greater than the width and appeared to have a height and not a depth. b. The Plan of Care (POC), dated 8/11/21 to 11/8/21, included physician orders for Vaseline Topical Gel twice per day to the crusted areas on the scalp and forehead for 14 days and then alternate with Triamcinolone Acetonide 0.1 percent topical cream twice per day for 14 days. c. The POC, dated 11/9/21 to 2/3/22, included an order to apply Vaseline Topical Gel three times per day as needed to scalp area if dry looking. The POC included orders for skilled nursing 1 to 2 times per week and for the nurse to assess the patient's skin condition. d. The week of 12/5/21 included documentation of 2 skilled nursing visits, dated 12/7 and 12/8/21. The visit, dated 12/7/21, included documentation under the wound section of a growth and a picture of the patient's forehead and head which identified 3 cancerous lesion areas. The visit note lacked any measurements and failed to include further assessment information such as if the lesions had any wounds that were draining. e. The week of 12/12/21 included documentation of 2 skilled nursing visits, dated 12/14 and 12/16/21. The visit, dated 12/14/21, included documentation under the wound section of a cancerous growth and a picture of the patient's forehead and head which identified 3 cancerous lesion areas. The visit note lacked any measurements and failed to include further assessment information such as if the lesions had any wounds that were draining. The visit, dated 12/16/21, identified the patient had a head wound. f. The week of 12/19/21 included documentation of 2 skilled nursing visits, dated 12/21 and 12/23/21. The visit, dated 12/19/21, included documentation under the wound section of a cancerous growth and a picture of the patient's forehead and head which identified 3 cancerous lesion areas. The visit note lacked any measurements and failed to include further assessment information such as if the lesions had any wounds that were draining. The visit, dated 12/21/21, identified the patient had a cancerous growth. g. The week of 12/26/21 included documentation of one skilled nursing visit, dated 12/28/21. The visit included a picture of 3 lesions on the patient's forehead and head and documentation of a small amount of bloody drainage from one of the lesions. The visit note lacked any measurements and failed to include further assessment information. h. The week of 1/2/22 included documentation of 2 skilled nursing visits, dated 1/4 and 1/6/22. The visit, dated 1/4/22, identified the patient had a cancerous growth without any further assessment information under the wound section and included a picture of 3 cancerous lesions on the forehead and head. The visit, dated 1/6/22, lacked any documentation related to the skin lesions. i. The week of 1/9/22 included documentation of 2 skilled nursing visits, dated 1/10 and 1/13/22. Neither visit contained any documentation related to the patient's cancerous lesions. j. The week of 1/16/22 included documentation of 2 skilled nursing visits, dated 1/18 and 1/20/22. The visit, dated 1/18/22, lacked any information related to the patient's cancerous lesions. The visit, dated 1/20/22, identified the patient had a cancerous growth with a small amount of bloody drainage and included a picture of the cancerous lesions. The visit note lacked any further assessment information. k. The week of 1/23/22 included documentation of 2 skilled nursing visits, dated 1/24 and 1/27/22. The visit, dated 1/24/22, identified the patient had a cancerous growth with a small amount of bloody drainage and included a picture. The visit note lacked any further assessment information. The visit, dated 1/27/22, identified the patient had a head wound with a scant amount of serosanguineous (blood-tinged) drainage and no further assessment information. l. The week of 1/30/22 included documentation of 2 skilled nursing visits, dated 1/31 and 2/3/22. The visit, dated 1/31/22, identified the patient had a head wound with a scant amount of serosanguineous drainage and no further assessment information. The visit, identified as a discharge visit, dated 2/3/22, lacked any documentation related to the patient's cancerous lesions. On 5/5/22 at 10:12 AM, during an interview, the Clinical Manager explained she considered the patient to have a cancerous growth and not a wound requiring measurements. She was taking pictures to monitor the growth. 4. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. A physician order, dated 3/25/22, included an order to apply an abdominal (ABD) pad to the left forearm, cover with Tubigrip and then wrap with an Ace wrap, on in the AM and off at bedtime, change if soiled. b. The week of 3/27/22 included documentation of 2 skilled nursing visits, dated 3/28 and 4/1/22. The visit, dated 3/27/22, included documentation the patient had a new coccyx wound. The patient refused wound care on the left forearm. The visit, dated 4/1/22, lacked documentation regarding the wound on the left forearm. c. The week of 4/10/22 included documentation of 2 skilled nursing visits, dated 4/5 and 4/8/22. The visit, dated 4/5/22, include documentation the skilled nurse completed the wound dressing change, but failed to identify which wound the nurse completed the dressing change on. The visit, dated 4/8/22, included documentation of an assessment of the coccyx wound, but not an assessment of the left forearm wound. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the provision of care in accordance with the patient's plan of care for 11 of 11 sampled patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11) requiring weight monitoring. Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice policy, titled Nursing Services, dated 7/1999, identified the hospice registered nurse assesses each patient/family needs. The registered nurse participates in developing the team plan of care, supervises the coordination of all services to the patient and family and evaluates all services to the patient and family. 1. Patient #1 had a hospice admission date of 3/2/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/2/22 to 5/30/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 3/8, 3/16, 3/22,3/28/22, 4/1, 4/4, 4/11, 4/14, 4/18, 4/19, 4/20, 4/22, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30/22 and 5/2/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 2. Patient #2 had a hospice admission date of 2/11/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 2/11/22 to 5/11/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 3/3, 3/8, 3/11, 3/14, 3/16, 3/21, 3/24, 3/30, 4/1, 4/4, 4/8, 4/11, 4/15, 4/18, 4/21, 4/25 and 4/28/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 3. Patient #3 had a hospice admission date of 4/29/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 6/27/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visit, dated 5/3/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 4. Patient #5 had a hospice admission date of 4/28/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 4/28/22 to 7/26/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 5/3/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 5. Patient #7 had a hospice admission date of 3/31/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/31/22 to 6/28/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 4/8, 4/14, 4/22 and 4/29/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 6. Patient #1 had a hospice admission date of 4/29/22 and received hospice services while residing in an inpatient setting. Review of the clinical record revealed the following: a. The POC, dated 4/29/22 to 7/27/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 4/30, 5/1, 5/2 and 5/3/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 7. Patient #10 had a hospice admission date of 1/13/22 and date of discharge of 4/12/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 1/13/22 to 4/312/22, included IDG orders for skilled nursing services and included orders to assess the patient's weight. b. A skilled nursing visits, dated 2/15, 2/22, 3/3. 3/15, 3/17, 4/7 and 4/12/22, included documentation the nurse assessed the patient but failed to document assessment of the patient's weight. The hospice nurse failed to follow orders identified on the POC. 8. Patient #4 had a hospice admission date of 3/12/22 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/12/22 to 6/9/22, included orders for the skilled nursing to check the patient's blood sugar level one time per week on Fridays and to assess the patient's weight (to be done every visit, as the order lacked a frequency). b. The weeks of 3/13, 3/20, 4/3, 4/10, 4/17 and 4/24/22, lacked documentation of an assessment of the patient's blood sugar levels. c. The skilled nursing visits, dated 3/14 and 4/7/22 lacked documentation of a weight. The skilled nursing visit, dated 3/28/22, included documentation of a weight done on 3/23/22, and lacked a reason why the nurse had not obtained a current weight. On 5/5/22 at 9:48 AM, during an interview, the Administrator reported an inability to add a frequency to the weights and measurements order on the POC. 9. Patient #6 had a hospice admission date of 3/3/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 3/3/22 to 5/31/22, included orders for the skilled nurse to assess the patient's weights and measurements. 1) The skilled nursing visits, dated 3/3, 3/4, 3/7, 3/9, 3/11, 3/14, 3/16, 3/18, 3/21, 3/25, 4/4, 4/11, 4/15, 4/18, 4/21, 4/25, 4/28, 4/29 and 4/30/22, lacked documentation of an assessment of the patient's weight. 2) The skilled nursing visits, dated 3/4, 3/7, 3/9, 3/11, 3/16, 3/18, 3/21, 3/25, 4/4, 4/18, 4/25, 4/28, 4/29 and 4/30/22, lacked documentation of an assessment of the patient's measurements. b. The POC, dated 3/3/22 to 5/31/22, included orders for the skilled nurse to set up the patient's medications weekly. The skilled nursing visit the week of 4/3/22, dated 4/4, and the visits the week of 4/17/22, dated 4/18 and 4/21, lacked documentation the nurse set up the patient's medications. c. A physician order, dated 3/3/22, included an order to assist family with pleurX catheter drainage from the right abdomen with teaching and instructions to change the dressing with each access of the tubing. A skilled nursing visit, dated 3/14/22, lacked documentation the nurse changed the dressing for the pleurX catheter or instructed the patient/caregiver to do this. 10. Patient #9 had a hospice admission date of 8/11/21, received hospice services while residing in a nursing home and discharged from hospice services on 2/3/22. Review of the clinical record revealed the following: a. The POC, dated 11/9/22 to 2/3/22, included an order for the skilled nurse to assess the patient's weight and obtain the patient's vital signs. b. The skilled nursing visits, dated 12/7, 12/9, 12/14, 12/16, 12/21 and 12/23/21, 1/6, 1/13 and 1/18/22, lacked documentation the nurse assessed the patient's weight. The skilled nursing visit, dated 1/31/22, included documentation the nurse used a weight from 1/26/22. c. The skilled nursing visit, dated 1/18/22, lacked documentation the nurse assessed the patient's blood pressure. On 5/5/22 at 10:12 AM, during an interview, the Administrator reported vital signs included a blood pressure. 11. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The POCs, dated 12/23/21 to 3/22/22 and 3/23/22 to 6/20/22, included orders for glucose monitoring and to assess the patient's weight. 1) The skilled nursing visits, dated 2/18, 3/28, 4/8 and 4/11/22, lacked documentation the nurse assessed the patient's weight. 2) The skilled nursing visits, dated 2/22, 3/3 and 4/1/22, lacked documentation the nurse monitored the patient's blood glucose. 3) The skilled nursing visits, dated 2/14 and 2/28/22, lacked documentation the nurse monitored the patient's blood glucose and assess the patient's weight. b. The POC, dated 3/23/22 to 6/20/22, included a physician order for oxygen 4 liters per minute per nasal cannula; 4 liters and as needed for shortness of breath or to keep oxygen saturation levels over 90 percent. The skilled nursing visits, dated 3/28, 4/5, 4/11 and 4/12/22, included documentation the patient was using oxygen 3 liters per minute. The nurse did not document providing education to the caregiver on the patient's oxygen rate being set at the wrong amount or document contacting the physician if there was a need to change the oxygen order. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group developed an individualized plan of care which included interventions for 2 of 2 sampled patients (#9 and #10) with massage therapy services. Failure to include interventions on the Plan of Care increased the potential that hospice services did not adequately meet the needs of hospice patients and families. Findings include: According to the policy, titled Plan of Care and dated 7/1999, the Plan of Care will include interventions agreed upon by the patient/family and the attending physician and scope and frequency of service and an identification of the personnel providing service. 1. Patient #19 had an admission to hospice on 1/13/22 and received services while residing in a nursing home. The Plan of Care (POC), dated 1/13/22 to 4/12/22, included orders for massage therapy 2 to 5 times a month. The IDG meeting notes lacked goals and interventions for massage therapy. 2. Patient #9 had a hospice admission date of 8/11/21, received hospice services while residing in a nursing home and discharged from hospice services on 2/3/22. Review of the clinical record revealed the following: a. The IDG meeting, dated 12/9/21, included IDG orders for massage therapy services 2 to 5 times a month with an 11/18/21 start date. b. The IDG meetings, dated 11/24, 12/9 and 12/23/21, 1/6 and 1/20/22, lacked documentation of a massage therapy intervention and goal. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 2 of 13 sampled patients (Patients #6 and #11) Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: According to the hospice policy titled Interdisciplinary Team, dated 9/95, the interdisciplinary team meets at a minimum of every 2 weeks to establish, update, review and evaluate service delivery and determine the scope of service. 1. Patient #6 had a hospice admission date of 3/3/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/3/22 to 5/31/22, included an order for the skilled nurse to teach the patient/caregiver about the drainage, complications and signs and symptoms to report in relation to the pleurX catheter. b. A separate physician order, dated 3/3/22, included an order to assist family with pleurX catheter drainage from the right abdomen with teaching and instructions to change the dressing with each access of the tubing. The POC failed to include the separate physician order, dated 3/3/22 and failed to specify a frequency to drain the catheter and what type of dressing should be used. 2. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: The POCs, dated 12/23/21 to 3/22/22 and 3/23/22 to 6/20/22, included the following orders: a. Morphine Concentrate 100 milligrams (mg) per 5 milliliters (ml), 5 to 20 mg every hour as needed for pain. The order lacked direction to the caregiver on how to determine which dose to administer to the patient. b. Lorazepam Intensol 2 mg per ml, give 0.5 to 1 mg every 2 hours as needed for restlessness. The order lacked direction to the caregiver on how to determine which dose to administer to the patient. c. Oxygen 4 liters per minute per nasal cannula; 4 liters and as needed for shortness of breath or to keep oxygen saturation levels over 90 percent. The order had conflicting information and failed to specify if the oxygen was continuous or intermittent. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Team revised the patient's plan of care to include the patient's progress towards outcomes and goals specified in the plan of care for 3 of 11 sampled patients (Patients #6, #9 and #11) requiring an updated plan of care. The hospice reported no current patients at the time of the survey. Failure of the hospice to ensure the Interdisciplinary Group (IDG) revised the patient's plan of care based on the updated comprehensive assessment and include patients' progress towards outcomes and goals placed patients at risk to not receive care and services based on their current assessed needs. Findings include: According to the hospice policy titled Interdisciplinary Team, dated 9/95, the interdisciplinary team meets at a minimum of every 2 weeks to identify long and short term goals and establish, update, review and evaluate service delivery and determine the scope of service. 1. Patient #6 had a hospice admission date of 3/3/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/3/22 to 5/31/22, included orders for the skilled nursing services 2 times per week. The POC included interventions and goals for skilled nursing services. b. The IDG meeting, dated 3/17/22, lacked documentation of interventions, goal progress or outcomes for the patient related to skilled nursing services. 2. Patient #9 had a hospice admission date of 8/11/21, received hospice services while residing in a nursing home and discharged from hospice services on 2/3/22. Review of the clinical record revealed the following: a. The IDG meeting, dated 12/9/21, included IDG orders for massage therapy services 2 to 5 times a month with an 11/18/21 start date. b. The IDG meetings, dated 11/24, 12/9 and 12/23/21, 1/6 and 1/20/22, lacked documentation of a massage therapy intervention, goal, progress or outcome of services provided. 2. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The POC, dated 12/23/21 to 3/22/22, included IDG orders for massage therapy services 2 to 5 times per month. The POC included intervention for the massage therapist to provide comfort, relaxation and stress reduction and a goal to provide relaxation and comfort. b. The IDG meetings, dated 1/6, 1/20 and 2/3/22, lacked any documentation regarding massage therapy services interventions, goal progress and outcomes. The IDG meeting, dated 2/17/22, included documentation the hospice no longer offered massage therapy services. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members and patients attending physician to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 2 of 11 sampled patients (#2 and #10). Failure of the hospice IDG members to communicate and collaborate with each other to update the plan of care increased the risk that patients did not receive services and treatments to meet the needs of the patients. Findings include: According to the hospice policy titled Interdisciplinary Team, dated 7/1999, the interdisciplinary team meets at a minimum of every 2 weeks to establish, update review and evaluate service delivery. Responsibilities of the team include to facilitate the exchange of information among the team, the patient and the family and the attending physician. 1. Patient #2 had a hospice admission date of 2/11/22 and received hospice services while residing in a private residence. a. The Plan of Care (POC), dated 2/11/22 to 5/11/22, included IDG orders for skilled nursing services. b. A physicians order, dated 4/1/22, included the order for morphine 5 mg (milligrams) every 4 hours and oxygen 2 to 4 liters per minute. c. The IDG meeting, dated 4/14/22, included documentation the patient had oxygen supplies. The IDG meeting lacked documentation of any discussion of oxygen or morphine orders. The clinical record lacked documentation of a discussion with the IDG about the orders for oxygen and morphine. 2. Patient #10 had a hospice admission date of 1/13/22 and date of discharge of 4/12/22 and received hospice services while residing in a nursing home. a. The POC, dated 1/13/22 to 4/12/22, included IDG orders for skilled nursing services. b. A physicians order, dated 3/3/22, included the order for Cephalexin (antibiotic) 500 1 tablet morning, noon and night for 10 days for cellulitus and Betadine to the white reddened area on the 2nd toe of the left foot daily for 10 days. c. The IDG meeting, dated 3/3/22 and 3/17/22, lacked documentation of any discussion of Cephalexin or Betadine orders. The clinical record lacked documentation of a discussion with the IDG about the orders for Betadine and Cephalexin. The Administrator, Clinical Manager and Quality Assurance Nurse received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review the hospice failed to ensure the Interdisciplinary Group maintained a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care for 2 of 8 sampled patients (Patients #6 and #11) with Interdisciplinary Group meeting updates. Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication for patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: According to the hospice policy titled Comprehensive Assessment, dated 9/95, the hospice's IDG updates the comprehensive assessment and reassesses the patient's response to care on a regular basis. Information from the updated comprehensive assessment is reviewed by the IDG at care planning meetings and is used to revise the patient's plan of care as needed. 1. Patient #6 had a hospice admission date of 3/3/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/3/22 to 5/31/22, included orders for the skilled nursing services 2 times per week. b. The clinical record included documentation of one skilled nursing visit the week of 4/3/22, dated 4/4. c. The subsequent IDG meeting, dated 4/14/22, lacked documentation the IDG was aware of the decrease in skilled nursing visit frequency for the week of 4/3/22. 2. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The POCs, dated 12/23/21 to 3/22/22 and 3/23/22 to 6/20/22, included IDG orders for spiritual care counseling services 1 to 3 times per month. 1) The clinical record lacked documentation of spiritual care counseling services in the month of March 2022. 2) The IDG meetings, dated 3/31 and 4/14/22, failed to include documentation of IDG awareness of the lack of provision of spiritual care counseling services in the month of March 2022. b. The POC, dated 3/23/22 to 6/20/22, included IDG orders for skilled nursing services 1 to 3 times per week. 1) A physician order, dated 4/13/22, included a verbal order by the attending physician for skilled nursing services 1 time per day for 10 days starting 4/13/22. 2) The IDG meeting, dated 4/14/22, lacked documentation of IDG awareness or order for skilled nursing services 1 time per day for 10 days starting 4/13/22. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review, nursing home treatment administration record and staff interview, the hospice failed to ensure patient clinical records included a physician order for all treatments for 2 of 11 sampled patients (Patient #6 and #11). Failure to have physician order for all medications and treatments created the potential for patients to receive incorrect or ineffective treatment to meet assessed needs. Findings include: Review of the hospice's policy, titled Hospice Physician Orders, dated 1/2022, the licensed nurse receives the order form the physician. The nurse then records the verbal order in the electronic medical record. The original is then sent to the physician for his/her signature. 1. Patient #6 had a hospice admission date of 3/3/22 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: A physician order, dated 3/25/22, included an order for the skilled nursing or family to drain the pleurX drain to the right lower abdomen as needed for comfort and the dressing (covering the catheter site entrance to the body) to be changed weekly and as needed when soiled. The order failed to specify what type of dressing should be used. 2. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The POC, dated 3/23/22 to 6/20/22, included orders for Aspercreme, Aspirin, Basaglar Insulin, Colace, Dulcolax, Lantus Insulin, Lorazepam Intensol, Milk of Magnesia, Fresh Tears, Novolog Insulin, Reglan, Tussin Cough-Chest Congestion, Zofran, Acetaminophen, Atropine, Baclofen, Bumetanide, Fluticasone, Hydroxyzine, Melatonin, Morphine Concentrate, Pantoprazole, Pramoxine-Zinc Oxide, Prednisone, Sertraline, Simethicone, Spironolactone and Witch Hazel. b. A skilled nursing visit, dated 4/14/22, included documentation the family voiced concerns they were not notified of the discontinuation of routine medications; however, another family member stated being aware of the discontinuation of routine medications and the patient's difficulty with swallowing. c. The IDG meeting, dated 4/14/22, included documentation the nurse reported the patient was no longer taking the patient's pills. d. The clinical record lacked documentation of a physician order to discontinue routine medications. On 5/5/22 at approximately 11:15 AM, the Clinical Manager provided documentation of a physician progress that was not kept in the patient's hospice clinical record. The progress note, dated 4/12/22, included documentation the nurse practitioner documented the patient's insulin and routine medications were held unless the patient requested to take them. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review and hospice policy review the hospice failed to ensure all entries completed in the clinical records included an appropriate date, signature and title for 7 of 11 sampled patients (Patients #1, #2, #5, #7, #9 #10 and #11). Failure to ensure all clinical record documentation included accurate information and were completed timely may result in ineffectively coordinated patient care. Findings include: According to the hospice policy titled Rntries Into The Clinical Record, dated 12/2011, entries will be made onkly by the personnel of the agency and/or by contract agency personnel. The entries will be documentaed bby the first initial of the given name, full surname and initials or licensing credentials. All entries will reflect the date care/service was provided, including yhe month, date and year. On 5/5/22 at 10:12 AM, during an interview, the Administrator confirmed the hospice required credentials with signatures of hospice staff when completing documentation. 1. Patient #1 had a hospice admission date of 3/2/22 and received services while residing in a private residence. The clinical record review revealed the following: a. The Chaplain note, dated 4/20/22, included an electronic signature and date of signature but lacked a title. 2. Patient #2 had a hospice admission date of 2/11/22 and received services while residing in a private residence. The clinical record review revealed the following: a. The Chaplain note, dated 3/28/22 and 4/8/22, included an electronic signature and date of signature but lacked a title. 3. Patient #5 had a hospice admission date of 4/28/22 and received services while residing in a nursing home. The clinical record review revealed the following: a. The Chaplain note, dated 5/2/22, included an electronic signature and date of signature but lacked a title. 4. Patient #7 had a hospice admission date of 3/31/22 and received services while residing in a private residence. The clinical record review revealed the following: a. The Chaplain note, dated 4/6/22, included an electronic signature and date of signature but lacked a title. 5. Patient #10 had a hospice admission date of 1/13/21 and discharge date of 4/12/22 and received services while residing in a nursing home. The clinical record review revealed the following: a. The Massage Therapy note, dated 1/21/22, failed to include a signature or title. b. The Massage Therapy note, dated 1/27 and 2/3/22, incuded a handwritten signature and date of sugnature but lacked a title. c. The Chaplain note, dated 2/23 and 2/10/22, included an electronic signature and date of signature but lacked a title. 6. Patient #9 had a hospice admission date of 8/11/21, received hospice services while residing in a nursing home and discharged from hospice services on 2/3/22. Review of the clinical record revealed the following: The massage therapy visit notes, dated 12/10, 12/17 and 12/21/21, 1/7, 1/13, 1/21, 1/27 and 2/3/22, included documentation of a signature of completion by the therapist, but lacked the person's credentials with the signature. 7. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The massage therapy visit notes, dated 1/13, 1/27 and 2/3/22, included documentation of a signature of completion by the therapist, but lacked the person's credentials with the signature. b. The massage therapy visit note, dated 1/21/22, lacked documentation of a signature of completion by the therapist. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the clinical record contained documentation of a discharge summary which included a summary of the patient's symptoms, treatment and pain management, current plan of care and latest physician orders for 1 of 1 sampled discharged patients (Patient #11) who revoked hospice services. Failure to complete a discharge summary with all required components increased the potential of the physician being unaware of the patient's condition at time of discharge from services and negatively impact the patient's continuity of care. Findings include: According to the hospice policy titled Discharge of the Hospice Patient, dated 7/1999, if a patient or family refuse hospice care after admission the the program, clearly record patient/family's stated wishes in the clinical record. Record in nursing notes reason for and date of revocation. Inform attending physician of patient/family decision and assist patient/family in identifying appropriate services or treatment. Patient #11 had a hospice admission date of 12/23/21, received hospice services while residing in a nursing home and revoked hospice services on 4/15/22 to actively seek treatment. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/23/22 to 6/20/22, included IDG orders for skilled nursing, social worker, spiritual care counseling, hospice aide and volunteer services. The POC identified the patient had Foley urinary catheter, pleural chest drain, pureed diet, oxygen at 4 liters per minute per nasal cannula, orders for medications and a coccyx wound with wound care orders. b. A physician order to discharge, dated 4/15/22, due to the patient wanting to seek active treatment. c. The hospice clinical record lacked documentation of a discharge summary being sent to the patient's attending physician that included a summary of the patient's symptoms, treatment and pain management, current plan of care and latest physician orders. On 5/5/22 at 10:38 AM, during an interview with the Clinical Manager, confirmed an inability to find evidence of a discharge summary being sent to the patient's attending physician that included the required content. She reported the discharge summary should include current medications, orders, most recent vital signs and goals. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

Based on clinical record review, hospice policy review, nursing home medication and treatment administration records, nursing home staff interview and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the long-term care (nursing home) staff for 1 of 1 sampled patients (Patient #4) with a review of the patient's nursing home residence medication and treatment administration records. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings Include: According to the hospice policy, titled Interdisciplinary team, dated 7/99, revealed all hospice services are delivered under the direction, supervision, and evaluation of the interdisciplinary group (IDG) which meets at least every two weeks to review and update each plan of care. The IDG members facilitate the exchange of information among the team, the patient and the family and the attending physician. Patient #4 had a hospice admission date of 3/12/22 and received hospice services while residing in a nursing home. Review of the hospice and patient's nursing home clinical record revealed the following discrepancies: a. The hospice Plan of Care (POC), dated 3/12/22 to 6/9/22, included an order for nursing staff to check the patient's blood pressure every Wednesday and to report any abnormal readings to the physician. The POC lacked any directions on identifying abnormal readings for the patient. The nursing home medication and treatment administration record (MAR and TAR), dated March, April and May 2022, included an order to check the blood pressure every Wednesday, report abnormal findings to the physician, and specified abnormal readings to report included a systolic blood pressure of greater than 190 or less than 85 and a diastolic blood pressure of greater than 115 (millimeters of Mercury). b. The nursing home MAR and TAR, dated March 2022, included an order for Mercy Butt Cream twice a day bilaterally to buttocks until healed with a start date of 3/14/22 and an end date of 3/21/22. The hospice clinical record lacked documentation of the order. c. The nursing home MAR and TAR, dated March, April and May 2022, included an order for skin prep bilaterally to heels twice a day and a start date of 3/4/22. The hospice clinical record lacked documentation of the order. d. The hospice POC included an order, dated 3/12/22, for Tussin Cough Syrup 10-100 milligrams (mg) per 5 milliliters (ml), give 5 ml twice per day. The nursing home MAR, dated March, April and May 2022, included an order for Tussin Cough Syrup 5 ml three times per day and a start date of 2/28/22. e. The hospice POC included an order, dated 3/12/22, for Albuterol Sulfate 2.5 mg per 3 ml inhalation nebulizer solution four times per day. The nursing home MAR, dated March, April and May 2022, included an order for Ipratropium-Albuterol 0.5-2.5 mg per 3 ml nebulizer solution four times per day and a start date of 2/28/22. The nursing home record did not have an order for Albuterol Sulfate nebulizer solution. f. The hospice POC included an order, dated 3/12/22, for Ativan 2 mg per ml solution, inject 0.5 to 1 ml every 2 hours; give 0.5 ml for mild agitation and 1 ml for moderate agitation. The nursing home MAR, dated March 2022, included the same order for Ativan to start on 3/12/22 and discontinue on 3/29/22. On 5/4/22, review of the hospice clinical record revealed the hospice continued to have the same Ativan order. g. The hospice POC included an order, dated 3/12/22, for Tylenol Extra Strength 500 mg 2 tablets twice per day. The nursing home MAR, dated April 2022, included the following orders: an order to discontinue Tylenol Extra Strength, dated 4/11/22; a new order to start Tylenol 8 hours Arthritis 650 mg twice per day; an order to change the Tylenol 8 hours Arthritis dose to 1350 mg twice per day, dated 4/12 to 4/18/22; an order to change the Tylenol 8 hours Arthritis dose to 1300 mg twice per day with a 4/19/22 start date. The nursing home MAR, dated May 2022, continued to have an order for Tylenol 8 hours Arthritis 1300 mg twice per day. The hospice clinical record lacked documentation of any of the orders to change the type and dose of Tylenol the patient was taking. On 5/4/22, review of the hospice clinical record revealed the hospice continued to have the same Tylenol Extra Strength 500 mg 2 tablets twice per day order. h. The nursing home MAR and TAR, dated April 2022, included an order for a complete metabolic panel every 4 months on the 6th of the month and identified the lab was drawn on 4/6/22. The hospice clinical record lacked documentation of the order. On 5/4/22 at 9:45 AM, during an interview, the nursing home's Director of Nursing reported the hospice RN mostly coordinated and communicated order changes with the nursing home staff. On 5/5/22 at 8:36 AM, during an interview, Staff D, hospice RN, reported she reconciled treatment and medication orders when hospice patient's recertified (once every 90 days for this patient) for services. She reported she wrote orders on the nursing home chart when she contacted the physician to change them. The nursing home either called or faxed the hospice when they obtained a change in orders. The hospice RN and IDG failed to ensure coordination of patient care with nursing home staff. The Administrator and Clinical Manager received the above findings and hospice staff provided no further evidence prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history background 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 the Iowa Department of Criminal Investigation (DCI). Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a criminal background check prior to 1 of 1 contract staff (Staff C, Medical Director) who began providing services to hospice patients since their last survey, dated 7/18/19. The hospice reported a total of 1 contract staff, who started since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from contract personnel who had direct patient contact. Findings include: Review of the personnel file for Staff C, Medical Director revealed a contract start date of 7/14/21. The personnel file lacked documentation of a criminal background check completed through either SING or DCI. On 5/4/22 at 1:40 PM, during an interview, the Administrator reported neither the hospice nor the hospital had documentation of a criminal background check completed through either SING or DCI. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a 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 the Iowa Department of Human Services (DHS) to conduct the dependent adult abuse and child abuse background checks. Based on review of employee personnel files and staff interview, the hospice failed to ensure completion of a dependent adult abuse and child abuse background check prior to 1 of 1 contract staff (Staff C, Medical Director) who began providing services to hospice patients since their last survey, dated 7/18/19. The hospice reported a total of 1 contract staff, who started since the last survey. Failure to complete a dependent adult abuse and child abuse background check as required by Iowa Code, increased the potential risk of harm to agency patients from hospice contracted personnel who had direct patient contact. Findings include: Review of the personnel file for Staff C, Medical Director revealed a contract start date of 7/14/21. The personnel file lacked documentation of a dependent adult abuse or child abuse background check completed through either SING or DCI. On 5/4/22 at 1:40 PM, during an interview, the Administrator reported neither the hospice nor the hospital had documentation of a dependent adult abuse or child abuse background check completed through either SING or DCI. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.