Every finding on record at St Croix Hospice LLC

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours. During a joint document review and interview with the Administrator on 10/09/2025, it was revealed that the agency’s volunteer percentage for the past year (January 2024 to December 2024) was below five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The volunteer percentage was calculated at 0.1%. The percentage for the period from January 2025 to September 2025 was 1.14%. The Administrator stated, "they are having problems with getting enough volunteers and are working on increasing outreach." The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. An interview and document review conducted with the Administrator on 10/09/2025 revealed that the volunteer percentage for the past year (January 2024 to December 2024) was below five percent (5%) of the total patient care hours of all paid hospice employees and contract staff and calculated at 0.1%. The percentage for the period from January 2025 to September 2025 is 1.14%. The Administrator stated, " they are having problems with getting enough volunteers and are working on increasing outreach."

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interview. In 3 of 13 (23%) clinical records reviewed it was revealed that the agency did not ensure the written plans of care included the specific spiritual and safety needs of the patients. Clinical Record 5: The patient elected the hospice benefit on 7/15/22. The chaplain add-on evaluation, completed on 7/19/22, documented "chaplain provided compassionate supportive presence and active supportive listening, played hymns, closed visit in prayer, and updated daughter." Also documented "outcomes: that pt (patient) and family feel supported and at peace." Chaplain services continued to be provided; the most recent interdisciplinary (IDG) meeting note, dated 11/29/22, stated "current plan effective, patient benefits from chaplain visits" but did not contain any specific goals or interventions to define the plan. The POC effective 7/15/22 to current, listed "hospice chaplain eval performed. Additional visits to be provided" but did not include any specific goals or interventions to define how the chaplain was meeting patient/family needs. Clinical Record 6: The patient elected the hospice benefit on 11/11/22. The chaplain add-on evaluation, completed on 11/14/22, documented "chaplain provided compassionate supportive presence and active supportive listening, healing touch, and empathetic listening, hymns, and prayers" and, "pt (patient) and family will feel supported and at peace." The IDG meeting note dated 11/29/22, stated "current spiritual plan effective: patient is benefitting from ongoing spiritual support" but did not contain any detailed goals or interventions. The POC effective 11/14/22 to current listed, "hospice chaplain eval performed. Additional visits to be provided." The POC did not include any specific goals or interventions to define how the chaplain was meeting patient/family needs. Clinical Record 11: The patient elected the hospice benefit on 6/14/22. The initial comprehensive nursing assessment dated 6/14/22, documented a fall risk assessment score of "7" and "based on the score, the patient is: at risk for falling." On 7/19/22 an occurrence report documented the patient was found on the floor by the bed with bruising noted to the head. It was documented that a "concave mattress" was ordered, this was listed under the durable medical equipment (DME) on the POC effective 9/12/22 to 12/10/22. The POCs, effective for benefit periods 6/14/22 to 9/11/22 and 9/12/22 to 12/10/22, did not contain any goals or interventions related to safety or fall precautions. In an interview with the Manager of Accreditation conducted on 12/7/22 it was confirmed that the plans of care did not contain goals or interventions related to the spiritual needs identified for records 5 and 6, nor the safety needs for record 11.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by a review of clinical records, document review and interviews. In 3 of 7 (43%) records with Licensed Practical Nurse (LPN) services, LPN supervision was not documented in accordance with policy. Policy No. 1-031 Responsibilities/Supervision of Clinical Services Agency policy states in relevant parts, "A monthly patient visit will be completed by a registered nurse to supervise licensed practical/vocational nursing services," and "supervisory contacts and visits will be documented, dated, and signed by the supervising professional." Clinical Record 1: The patient elected the hospice benefit on 12/27/21. A review of the current benefit period (10/23/22 to 12/21/22) revealed that on 10/27/22 a nursing visit was documented by a licensed practical nurse (LPN). At time of record review (12/5/22) there were no documented LPN supervisory visits. Clinical Record 4: The patient elected the hospice benefit on 4/19/22. A review of the current benefit period (10/6/22 to 12/14/22) revealed that on 10/18/22 a nursing visit was documented by an LPN. At the time of record review (12/5/22) there were no documented LPN supervisory visits. Clinical Record 11: The patient elected the hospice benefit on 6/14/22. A review of the current benefit period (9/12/22 to 12/10/22) revealed that on 9/23/22 a nursing visit was documented by an LPN. At the time of record review (12/7/22) there were no documented LPN supervisory visits. An interview with the Manager of Accreditation (Staff 17), conducted on 12/7/22, confirmed that there were no documented supervisory visits for those LPN visits, and stated that they should be completed "every 30 days".

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 12 (8%) clinical records reviewed in which aide services were accepted it was revealed that the agency did not ensure the hospice aide care plan was updated to meet the specific needs of the patient. Clinical Record 11: The patient elected the hospice benefit on 6/14/22 with a terminal diagnosis of Alzheimer's Disease; hospice aide services were accepted at that time. A physician order dated 8/26/22 ordered "pureed diet." The revised hospice aide care plan effective 7/18/22 contained a care plan service: "Assist with feeding. Every visit. Diet: Mechanical Soft texture; regular fluids." The current hospice aide care plan with effective date of 12/5/22 still contained the care plan service: "Assist with feeding. Every visit. Diet: Mechanical Soft texture; regular fluids." The hospice aide care plan was not updated to reflect the diet modifications. In an interview with the Manager of Accreditation (Staff 17), conducted on 12/7/22, it was confirmed that the patient was on a pureed diet, and this was not reflected on the aide care plan.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure a hospice registered nurse completed an initial assessment including documentation of wound assessment and measurements, (See L0524) 2) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive assessment, (See L0530) 3) ensure the hospice nurse member of the interdisciplinary team updated the comprehensive assessment with changes to the patient condition at least once every 21 days and included wound assessment and measurements. (See L0533) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel completed a comprehensive assessment of all patient care and service needs in a timely manner to their hospice patients.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements within 5 days after the patient's election of the hospice care for 1 of 1 sampled patients (Patient #10) with a wound at the time of admission to hospice services. Failure to complete an initial wound assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings include: Review of the hospice policy, titled Comprehensive Assessment, dated 4/2019, identified the need for registered nurse (RN) Case Manager in coordination with members of the interdisciplinary group (IDG) to complete an initial comprehensive assessment within 5 calendar days of the patient's election to the hospice benefit which includes an assessment of the patient's physical skin condition. On 12/6/21 at 12:45 PM, during an interview, the Clinical Manager for Strawberry Point reported she expected staff to measure wounds upon discovery and weekly including length, width and depth. On 12/6/21 at 1:35 PM, during an interview, the Clinical Manager for Cedar Rapids reported she expected staff to measure wounds upon discovery and weekly including length, width and depth. On 12/7/21 at 12:20 PM, during an interview, the Vice President of Clinical Services explained, while the hospice did not have a wound assessment policy, hospice nursing staff did receive education on wound assessment and she thought this was apart of the skills and competency testing. She agreed to try to find education provided to the nurses on wound assessment. Patient #10 had a hospice admission date of 10/12/21 and received services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The initial comprehensive assessment completed by a registered nurse (RN), dated 10/12/21, included documentation the patient had a skin tear on left forearm and ulcer on top of right foot, both wounds not assessed. The nurse failed to assess the length, width, and depth of the patient wounds. b. A subsequent skilled nursing visit, dated 10/13/21 (within the first 5 days of care), included documentation the patient had a skin tear on left forearm and ulcer on top of right foot, both wounds not assessed. The nurse failed to assess the length, width, and depth of the patient wounds. The RN failed to fully assess the patients wounds in order to provide a complete description of the patient's current physical status. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the drug regimen review (DRR) included the identification any drug therapy associated with laboratory monitoring for 9 of 9 sampled patients (Patients #5, #6, #7, #8, #9, #10, #11 and #12). Failure to ensure the interdisciplinary group (IDG) members involved in the assessment of patient needs identified actual or potential issues when performing the drug regimen review in relation to drug therapy associated with laboratory monitoring 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: Review of the hospice policy, titled Comprehensive Assessment, dated 4/2019, identified the comprehensive assessment will include a review of current and related past medications and include a review of the following: effectiveness of drug therapy, unwanted and toxic side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring and whether the medication is unrelated to the terminal illness or related conditions. The IDG members will complete the comprehensive assessment within 5 calendar days of the patient's election to the hospice benefit and then update the comprehensive assessment at least once every 15 days. On 12/6/21 at 12:45 PM, during an interview, the Clinical Manager for Strawberry Point reported the registered nurse (RN) completes the drug regimen review (DRR) with the admission comprehensive assessment and reviews the information found with the Medical Director and the patient's attending physician. The IDG members including the Medical Director complete the DRR during each IDG meeting and this information is sent to the attending physician. 1. Patient #6 had a hospice admission date of 11/1/21 and received hospice services from the multiple location office in Davenport while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/1/21 to 11/29/21, included physician orders for medications. b. The DRR documented on the hospice's "Client Medication Report" included documentation of a DRR done by a RN and Quality Assurance Nurse on 11/3/21 and the Medical Director on 11/8/21. The DRRs failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. c. The initial Interdisciplinary group (IDG) meeting, dated 11/3/21, included the following documented statement by the Medical Director: "I have reviewed the medication profile and diagnoses list and agree with the plan of care." The IDG meeting included the following documentation by the nurse: "current medication and treatment plan effective." d. The IDG meetings, dated 11/16 and 11/30/21, included the same statements documented in the IDG meeting, dated 11/3/21, by the Medical Director and RN. On 12/7/21 at 12:50 PM, during an interview, the Vice President of Clinical Services reported being unaware of the requirement of the DRR to include a review of the component of drug therapy associated with laboratory monitoring. 2. Patient #7 had a hospice admission date of 11/19/21 and received hospice services from the Cedar Rapids office while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 11/19/21 to 1/25/22, included physician orders for Hydralazine, Furosemide, Toprol XL, Metformin, Basaglar Insulin associated with lab monitoring. The initial IDG meeting, dated 12/1/21, failed to include documentation regarding drug therapy currently associated with lab monitoring. 3. Patient #11 had a hospice admission date of 9/15/21 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 9/15/21 to 12/13/21, included physician orders for Lisinopril associated with lab monitoring. b. The DRR documented on the hospice's "Client Medication Report", dated 9/20/21, 9/22, 10/6, 10/20, 11/4, 11/17 and 12/2/21. The DRRs failed to include a review of the medications for the required component of drug therapy associated with lab monitoring. c. The IDG meetings, dated 9/22, 10/6, 10/20, 11/3, 11/17 and 12/1/21 failed to include documentation regarding drug therapy currently associated with lab monitoring. 4. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/20/21 to 8/17/21, included physician orders for Insulin Lispro, Semglee Insulin and Levothyroxine associated with lab monitoring. b. The DRR documented on the hospice's "Client Medication Report" dated 5/20/21, failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. c. The initial IDG meeting, dated 6/2/21, failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. 5. Patient #13 had a hospice admission date of 6/11/21, received hospice services from the multiple location office in Cedar Rapids while residing in a nursing home and discharged from services due to moving on 9/30/21. Review of the clinical record revealed the following: a. The POC, dated 6/11/21 to 9/8/21, included physician orders for medications. b. The DRR documented on the hospice's "Client Medication Report" dated 6/11/21 failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. c. The initial IDG meeting, dated 6/16/21, failed to include a review of the medications for the required component of drug therapy associated with laboratory monitoring. 6. Patient #5 had a hospice admission date of 11/20/19 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/20/19 to 2/17/2020, included physician order for lasix medication associated with lab monitoring. b. The IDG meeting notes, dated 9/22/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21, and 12/1/21, failed to include documentation regarding drug therapy currently associated with lab monitoring. The DRRs failed to identify the medication associated with lab monitoring the patient was taking. 7. Patient #8 had a hospice admission date of 6/29/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The POC, dated 6/29/21 to 8/27/21, included physician order for Levothyroxine, medication associated with lab monitoring. b. The IDG meeting notes, dated 6/30/21, 9/22/21, 10/6/21, 10/20/21, 11/3/21, and 11/17/21, failed to include documentation regarding drug therapy currently associated with lab monitoring. The DRRs failed to identify the medication associated with lab monitoring the patient was taking. 8. Patient #9 had a hospice admission date of 4/5/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The POC, dated 4/5/21 to 7/3/21, included physician orders for Metformin, spironolactone, and torsemide, medications associated with lab monitoring. b. The IDG meeting notes, dated 4/7/21, 9/22/21, 10/6/21, 10/20/21, 11/3/21, and 11/17/21, failed to include documentation regarding drug therapy currently associated with lab monitoring. The DRRs failed to identify the medications associated with lab monitoring the patient was taking. 9. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 10/12/21 to 1/9/22, included physician orders for spironolactone, potassium, and torsemide, medications associated with lab monitoring. b. The IDG meeting notes, dated 10/20/21, 11/3/21, and 11/17/21, failed to include documentation regarding drug therapy currently associated with lab monitoring. The DRRs failed to identify the medications associated with lab monitoring the patient was taking. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group updated the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 2 of 3 sampled patients with an open wound (Patients #6 and #12) and failed to ensure the update of the comprehensive assessment by the registered nurse at least once every 21 days per the 1135 pandemic blanket waiver. 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: Review of the hospice policy, titled Comprehensive Assessment, dated 4/2019, identified the comprehensive assessment will include an assessment of the patient's skin integrity. The IDG members will complete the comprehensive assessment within 5 calendar days of the patient's election to the hospice benefit and then update the comprehensive assessment as frequently as the patient's condition requires, but at least once every 15 days. If there has been a change in the patient's condition/status, then hospice staff must update the comprehensive assessment. On 12/6/21 at 12:45 PM, during an interview, the Clinical Manager for Strawberry Point reported she expected staff to measure wounds upon discovery and weekly including length, width and depth. On 12/6/21 at 1:35 PM, during an interview, the Clinical Manager for Cedar Rapids reported she expected staff to measure wounds upon discovery and weekly including length, width and depth. 1. Patient #6 had a hospice admission date of 11/1/21 and received hospice services from the multiple location office in Davenport while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/1/21 to 11/29/21, included interdisciplinary group (IDG) orders for skilled nursing and hospice aide services. b. A skilled nursing visit note, dated 11/4/21 starting at 9:58 AM, did not include an assessment of the patient's skin. c. A hospice aide visit note, dated 11/4/21 starting at 2:01 PM, included documentation which identified the patient had change in skin condition with a skin tear on the right wrist. The hospice aide documented she contacted the hospice registered nurse (RN) and facility staff. d. A skilled nursing visit, dated 11/5/21, included documentation of a skin assessment, but lacked documentation of the status of the patient's skin tear. e. A skilled nursing visit, dated 11/9/21, which identified the visit was a comprehensive assessment for the recertification of the patient's hospice services. The nurse documented the patient had a wound, but did not include any further assessment or treatment information in regards to the wound. Review of the patient's nursing home treatment record for November 2021 revealed the following: A physician's order, dated 11/6/21 to 11/10/21, included orders to cleanse the right wrist skin tear with Normal Saline, apply a Xeroform dressing and Kerlix daily and as needed until resolved. 2. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: The initial POC, dated 5/20/21 to 8/17/21, included IDG orders for skilled nursing and hospice aide services and a goal for the caregiver to verbalize/prevent measures for skin breakdown. a. The hospice recertification order, dated 8/18/21 to 11/15/21, included orders to continue hospice nursing services 2 times per week. The clinical record included documentation of a skilled nursing visit by a RN on 9/18/21, and then visits by licensed practical nurses (LPNs) until 10/13/21 (25 days between RN skilled nursing visits and comprehensive assessments). b. The hospice recertification order, dated 11/16/21 to 1/14/22, included orders to continue hospice services with nursing services 2 times per week and hospice aide services 3 times per week, with a hospice aide assist at one visit per week (2 aides providing cares together to the patient). 1) The clinical record included included documentation of 2 hospice aides providing cares on the morning of 11/29/21. Both aides documented he/she observed the patient had a red open area above the right buttock and this was reported to the hospice nurse. 2) The skilled nursing visit, dated 11/29/21, included documentation the nurse assessed the patient had a superficial area on the right buttock. The visit lacked any further assessment of the wound and lacked wound measurements. On 12/7/21 at 12:20 PM, during an interview, the Vice President of Clinical Services explained, while the hospice did not have a wound assessment policy, hospice nursing staff did receive education on wound assessment and she thought this was apart of the skills and competency testing. She agreed to try to find education provided to the nurses on wound assessment. The Administrator, Clinical Manager for Strawberry Point and Vice President of Clinical Services received findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to: 1) ) Ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group in collaboration with the attending physician (see L0550); 2) Ensure the hospice Interdisciplinary Group developed and maintained a system of communication to direct, coordinate and supervise the care and services provided (see L0554); 3) Ensure the hospice Interdisciplinary Group members ensured that the care and services are provided in accordance with the Plan of Care (see L0555) and 4) Ensure the hospice Interdisciplinary Group members provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all setting, whether the care and services are provided directly or under arrangement (see L0557). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.

Based on clinical record review, hospice policy review, home visit observation, nursing home staff interview and hospice staff interview, the hospice failed to ensure the Plans of Care for 8 of 9 sampled patients (Patients #6, #7, #8, #9, #10, #11, #12 and #13) identified all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: Review of the hospice's policy, titled The Plan of Care (POC), dated 12/2018, the hospice staff will establish a written, individualized POC for each patient. The POC will include identification of medical equipment and supplies necessary to meet the needs of the patient. The hospice IDG members will review and revise the POC as frequently as deemed necessary, but no less than every 15 days. 1. Patient #6 had a hospice admission date of 11/1/21 and received hospice services from the multiple location office in Davenport while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 11/1/21 to 11/29/21, identified the patient had a urinary catheter for medical equipment and supplies. b. The initial Interdisciplinary Group (IDG) meeting, dated 11/3/21, identified the patient also used a Broda chair (specialized high-back wheelchair) and a Hoyer mechanical lift for transfers. c. The IDG meetings, dated 11/16 and 11/30/21, did not identify any additional medical equipment and supplies used by the patient. On 11/30/21, during a nursing home visit observation with Staff G, Registered Nurse (RN) Case Manager for the Davenport Office, and the patient's Power of Attorney (POA) for health care decisions, the surveyor observed the patient also used a hospital bed with rails, floor mat and overbed table. In an interview, during the same nursing home visit observation, Staff G, RN, and the patient's POA confirmed the patient had been using the hospital bed in low for safety with a floor mat and overbed table. Staff G, RN, also reported the hospice aides showered the patient in a shower chair for the patient's safety and the hospice has been providing incontinence briefs for the patient to use. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 2. Patient #7 had a hospice admission date of 11/19/21 and received hospice services from the Cedar Rapids office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 11/19/21 to 1/25/22, identified the patient used incontinence supplies, wheelchair, walker, nursing supplies, "top items" and wound care supplies. The POC did not explain what it meant for the patient to use"top items". b. The initial comprehensive assessment completed by a RN, dated 11/19/21, identified the patient had grab bars and walker and the nurse ordered a wheelchair, hospital bed with rails, bedside commode and raised toilet seat based on the patient's assessed needs. c. The initial IDG meeting, dated 12/1/21, included documentation the nurse ordered a gel cushion with Dycem for comfort and to prevent skin breakdown. On 12/1/21 at 1:05 PM, during a home visit observation with Staff F, RN Case Manager for the Cedar Rapids Office, and the patient's family member/caregiver, the surveyor observed grab bars in the shower, a shower chair, hand held shower, lift chair, raised toilet seat, hospital bed with rails, wheelchair and a gait belt. The surveyor observed the patient use the lift chair functions to assist with transfer and a walker for ambulation. In an interview during the same home visit observation, Staff F, RN Case Manager for the Cedar Rapids Office, reported she had just brought out the gait belt at the last visit and the patient had not used it yet. The family member/caregiver reported the patient had been using the shower chair for safety, handheld shower, grab bars, hospital bed with rails, incontinent briefs and raised toilet seat. The patient and family member/caregiver denied the patient had a wound or used any wound care supplies. On 12/7/21 at 12:02 PM, during an interview, the Administrator reported the RNs would chose a broad category of medical equipment and supplies (such as "top item") to make it easier to add specific supplies under this category later. The POC and/or IDG meeting failed to identify all necessary medical equipment and supplies used by the patient. 3. Patient #11 had a hospice admission date of 9/15/21 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 9/15/21 to 12/13/21, identified the patient used "skin care", "nursing supplies", "top items", wound care/debridement supplies. The POC did not specify the specific medical supplies the patient used. b. The initial comprehensive assessment completed by a RN, dated 9/15/21, identified the patient had a colostomy and no other medical equipment or supplies. The nurse did not identify the patient had a wound. c. The IDG meetings, dated 10/6, 10/20 and 12/1/21, did not identify any other medical equipment or supplies used by the patient. The clinical record lacked documentation of the patient having a wound or need for debridement supplies. The POC incorrectly identified the patient's use of these supplies. 4. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/20/21 to 8/17/21, identified the patient used the following medical equipment and supplies: wheelchair, Hoyer lift, skin care and "top items". b. The initial IDG meeting, dated 6/2/21, identified the patient also used a high-low hospital bed with rails. c. The hospice aide assignment identified the patient used incontinence briefs and toothettes. This was not identified on the POC. d. The hospice recertification orders, dated 8/18/21 to 11/15/21 and 11/16/21 to 1/14/22, did not identify the use of any medical equipment and supplies. e. The IDG meetings, dated 9/22, 10/6, 10/20, 11/3, 11/16 and 11/30/21, did not identify any additional medical equipment and supplies used by the patient. On 11/30/21 at 10:05 AM, in an interview during an on-site visit to the patient's nursing home, the facility's Assistant Director of Nursing reported the patient used incontinence briefs and an overbed table. The POC and/or IDG meetings failed to identify all medical equipment and supplies used by the patient. 5. Patient #13 had a hospice admission date of 6/11/21, received hospice services from the multiple location office in Cedar Rapids while residing in a nursing home and discharged from services due to moving on 9/30/21. Review of the clinical record revealed the following: a. The POC, dated 6/11/21 to 9/8/21, identified the patient used the following medical equipment and supplies: oxygen, wheelchair, walker, incontinence pads,"nursing supplies", "top items", skin care, oral care supplies and respiratory supplies. The POC did not specify what nursing supplies or top items the patient used. b. The initial comprehensive assessment completed by a RN, dated 6/11/21, identified the patient used a hospital bed with rails, incontinent briefs, overbed table and walker. c. The hospice aide assignment included RN instructions to the hospice aide to shower the patient while seated, indicating the patient required the use of a shower chair. d. The IDG meetings, dated 9/8, 9/22 and 10/6/21, did not identify the patient's use of any additional medical equipment and supplies. e. The hospice recertification order, dated 9/9/21 to 12/7/21, did not identify the patient's use of any additional medical equipment and supplies. The POC and IDG meetings did not identify all medical equipment and supplies used by the patient. 6. Patient #8 had a hospice admission date of 6/29/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/29/21 to 8/27/21, included documentation the patient used skin care and top items as medical equipment or supplies, but failed to identify what specific items were included under these categories. b. The IDG meeting notes, dated 6/30/21, 9/22/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21 and 12/1/21, did not identify the patient's use of any additional medical equipment and supplies. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient. 7. Patient #9 had a hospice admission date of 4/5/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The POC, dated 4/5/21 to 7/3/21, included documentation the patient used skin care and top items as medical equipment or supplies, but failed to identify what specific items were included under these categories. b. The IDG meeting notes, dated 4/7/21, 9/22/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21 and 12/1/21, did not identify the patient's use of any additional medical equipment and supplies. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient. 8. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 10/12/21 to 1/9/22, included documentation the patient used skin care and top items as medical equipment or supplies, but failed to identify what specific items were included under these categories. b. The IDG meeting notes, dated 10/20/21, 11/3/21, 11/17/21 and 12/1/21, did not identify the patient's use of any additional medical equipment and supplies. The POC and IDG meeting notes failed to identify all necessary medical equipment and supplies used by the patient. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the coordination and collaboration among Interdisciplinary Group (IDG) members occurred to ensure hospice staff provided treatment and services to the patients according to team decisions. The survey identified this concern with 3 of 9 sampled patients (#10, #11 and #12). 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: Review of the hospice's policy, titled The Plan of Care (POC), dated 12/2018, the hospice staff will establish a written, individualized POC for each patient. The hospice IDG members will review and revise the POC as frequently as deemed necessary, but no less than every 15 days. Review of the hospice's policy, titled Interdisciplinary Group Coordination of Care, dated 12/2018, identified the Registered Nurse (RN) Case Manager is responsible for the facilitation of communication about changes in the patient's status between IDG members and the patient's attending physician. 1. Patient #11 had a hospice admission date of 9/15/21 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 9/15/21 to 12/13/21, identified the patient had diagnoses of colon cancer and constipation. The POC included physician orders for Methadone and Morphine (both Opiod class of pain medications and with a common side effect of constipation). The POC did not include any orders for medications to prevent/treat constipation. b. The initial comprehensive assessment completed by the Clinical Manager for the Cedar Rapids office, dated 9/15/21, identified the patient had a colostomy (surgically created opening in the abdominal wall to divert a piece of the colon), included documentation the nurse assessed the patient had abdominal distension and the patient varying bowel habits with the last bowel movement on 9/14/21. The nurse assessed the patient initiated or continued taking an Opiod medication and initiated or continued with a bowel regimen (a schedule for taking medicines regularly to prevent or relieve constipation). c. The skilled nursing visit note completed by the Clinical Manager for the Cedar Rapids office, dated 9/16/21, included documentation the nurse assessed the patient had constipation with abnormal and hypoactive bowel sounds. The nurse documented the patient had laxatives and used as needed. The nurse documented she gave the patient education on the importance of using laxatives as directed. The nurse documented the patient's last bowel movement was on 9/12/21. d. The skilled nursing visit note completed by Staff F, RN Case Manager for the Cedar Rapids Office, dated 9/22/21, included documentation the nurse assessed the patient had bowel incontinence and flatulence and a bowel movement on 9/22/21. e. The initial IDG meeting, dated 9/22/21, identified the patient had an ostomy, but lacked any information/discussion regarding a bowel regimen for the patient f. The skilled nursing visit note by Staff F, RN Case Manager for the Cedar Rapids Office, dated 9/30/21, included documentation the nurse assessed the patient's bowel status had no change and the patient reported nausea upon waking in the morning. g. The skilled nursing visit note by Staff F, RN Case Manager for the Cedar Rapids Office, dated 10/4/21, included documentation the nurse assessed the patient's bowel status had no change. She also assessed the patient had abdominal pain and bowel incontinence. h. The IDG meeting, dated 10/6/21, lacked any documentation regarding the patient's bowel status, use of laxatives or discussion of the patient's bowel regimen. i. The skilled nursing visit note by Staff F, RN Case Manager for the Cedar Rapids Office, dated 10/8/21, included documentation the nurse assessed the patient's bowel status had no change. j. The skilled nursing visit note by Staff F, RN Case Manager for the Cedar Rapids Office, dated 10/12/21, included documentation the nurse assessed the patient's bowel status was deteriorating with constipation, abdominal distension and bowel incontinence. The last bowel movement was on 10/11/21. The nurse documented the patient as using Colace 3 tabs every day as needed and Miralax every day as needed (both medications used to treat/prevent constipation). k. The IDG meeting, dated 10/20/21, included physician's orders by the hospice Medical Director, dated 10/18/21, for Miralax 17 grams daily as needed, Senna S 3 tablets daily and Dulcolax liquid 30 milliliters daily as needed if no stool within 24 hours. The clinical record lacked documentation of a discussion with the hospice Medical Director or orders for medications to treat constipation prior to 10/18/21. On 12/7/21 at 9:34 AM, during an interview, the Clinical Manager for the Cedar Rapids Office explained at the initial visit with the patient on 9/15/21, the patient reported having a bowel regimen, but was unable to state what the patient was taking. The Clinical Manager reported the patient's medications were all jumbled in a medication planner with no way to identify what the patient was actually taking. The family was unaware of what medications the patient was taking. She confirmed Staff F, RN Case Manager for the Cedar Rapids Office, was the nurse that continued to see the patient and would have further information. On 12/7/21 at 10:06 AM, during an interview, Staff F, RN Case Manager for the Cedar Rapids Office, explained she took over the patient's case about a month after the patient started services. Staff F reported she thought the patient had more problems with diarrhea at the start of care and not constipation. On 12/7/21 at 12:06 PM, during an interview, the Vice President for Clinical Services reported it was the hospice's protocol to place patient's on a bowel regimen when the patient started taking Opiods. She confirmed the patient was already taking Methadone upon admission to the hospice. She explained hospice staff had difficulty obtaining information from the Methadone clinic. She further explained, because the patient did not have issues with constipation at the start of care, but was struggling with managing pain, this trumped the constipation issue. Hospice IDG members failed to coordinate treatment to ensure the prevention/treatment of constipation in relation to establishing a bowel regimen with Opiod use. 2. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: a. The initial POC, dated 5/20/21 to 8/17/21, included IDG orders for skilled nursing and hospice aide services and a goal for the caregiver to verbalize/prevent measures for skin breakdown. b. The hospice recertification order, dated 11/16/21 to 1/14/22, included orders to continue hospice services with nursing services 2 times per week and hospice aide services 3 times per week, with a hospice aide assist at one visit per week (2 aides providing cares together to the patient). c. The clinical record included documentation of 2 hospice aides providing cares on the morning of 11/29/21. Both aides documented separately they observed the patient had a red open area above the right buttock and this was reported to the hospice nurse. d. The skilled nursing visit, dated 11/29/21, included documentation the nurse assessed the patient had a superficial area on the right buttock. The visit lacked any further assessment of the wound and lacked wound measurements. e. The IDG meeting, dated 11/30/21, lacked documentation the hospice nurse reported the concern in the patient's skin breakdown to the other IDG members including the hospice Medical Director. 3. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The IDG meeting note, dated 11/17/21, included physician order for wound care to blister that has opened on top of right foot, wash with soap and water, pat dry, apply vaseline gauze, wrap with kerlix daily, wound care to be completed by facility nurse, hospice nurse to assess weekly. b. Skilled nurse visit notes, dated 11/29/21 and 12/2/21, included documentation of blister that has opened on top of right foot, wound not assessed, caregiver completed care. The clinical record lacked documentation of wound measurements the week of 11/28/21 to 12/4/21. The above findings with were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. 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 4 sampled patients (Patients #1 and #2) 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: 1. Patient #1 had a hospice admission date of 2/12/21, a discharge date of 7/14/21, and received hospice services while residing in a private home. Clinical record review revealed: a. Skilled nursing visit note, dated 5/18/21, included documentation the nurse applied barrier cream to the groin area. The clinical record lacked documentation of an interim physician order for barrier cream. The IDG meeting note, dated 5/19/21, lacked documentation the IDG was aware of the addition of barrier cream to the patient's plan of care. b. Skilled nursing visit note, dated 6/29/21, included documentation the spouse applied neosporin and a band aid to the pinky finger right hand cuticle slightly red. The clinical record lacked documentation of an interim physician order for neosporin. The IDG meeting note, dated 6/30/21, lacked documentation the IDG was aware of the addition of neosporin for the finger to the patient's plan of care. c. Skilled nursing visit note, dated 7/2/21, included documentation the spouse applied neosporin and a band aid to an abrasion to the right temple. The clinical record lacked documentation of an interim physician order for neosporin. The IDG meeting note, dated 7/14/21, lacked documentation the IDG was aware of the addition of neosporin for the abrasion to the patient's plan of care. 2. Patient #2 had a hospice admission date of 6/8/21, a discharge date of 10/1/21, and received hospice services while residing in a long term care facility. Clinical record review revealed the following: IDG meeting note, dated 7/28/21, included documentation the IDG had ordered hospice aide services 2 times a week. Client missed visit report, dated 8/6/21, included documentation the patient refused aide services on 8/5/21. IDG meeting note, dated 8/11/21, lacked documentation the IDG was aware of the missed hospice aide visit on 8/5/21. The above findings were reviewed with the Administrator. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication for sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement for 2 of 4 sampled patients (Patients #1 and #2) with massage therapy services. Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication for patient care and services to ensure sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement, increased the risk that patients did not receive services to meet assessed needs. Findings include: During an interview on 10/25/21 at 3:45 PM, the Administrator reported the massage therapist communicates with the hospice nurse through email. Massage therapy is listed in the IDG meeting notes if they are involved in patient's care, this is usually on the first IDG meeting note. Administrator was unable to locate massage therapy information in the IDG notes reviewed with surveyor. During an interview on 10/25/21 at 4:46 PM, the Administrator reported all disciplines involved in patient's care show up on a report that is run as an agenda for each IDG meeting. This report is not visible in the patient's IDG meeting notes. During an interview on 10/26/21 at 10:51 AM, Staff C, massage therapist, reported she receives emails from the hospice nurse with information regarding new referrals. She reads lots of coordination notes and will update the nurse if she sees her at a home visit. 1. Patient #1 had a hospice admission date of 2/12/21, a discharge date of 7/14/21, and received hospice services while residing in a private home. Clinical record review revealed: a. Skilled nursing visit note, dated 5/18/21, included documentation the nurse applied barrier cream to the groin area. The clinical record lacked documentation of an interim physician order for barrier cream. The interdisciplinary group (IDG) meeting note, dated 5/19/21, lacked documentation the IDG was aware of the addition of barrier cream to the patient's plan of care. b. Skilled nursing visit note, dated 6/29/21, included documentation the spouse applied neosporin and a band aid to the pinky finger right hand cuticle slightly red. The clinical record lacked documentation of an interim physician order for neosporin. The IDG meeting note, dated 6/30/21, lacked documentation the IDG was aware of the addition of neosporin for the finger to the patient's plan of care. c. Skilled nursing visit note, dated 7/2/21, included documentation the spouse applied neosporin and a band aid to an abrasion to the right temple. The clinical record lacked documentation of an interim physician order for neosporin. The IDG meeting note, dated 7/14/21, lacked documentation the IDG was aware of the addition of neosporin for the abrasion to the patient's plan of care. 2. Patient #2 had a hospice admission date of 6/8/21, a discharge date of 10/1/21, and received hospice services while residing in a long term care facility. Clinical record review revealed the following: a. IDG meeting note, dated 6/30/21, included documentation massage therapy services were ordered for 2 times for 1 month and 1 time for 1 month. b. IDG meeting notes, dated 7/14/21, 8/11/21, 8/25/21, 9/8/21, and 9/22/21, lacked documentation massage therapy services were provided as ordered or communication between the massage therapist and members of the IDG. c. Coordination notes lacked documentation of communication between the massage therapist and members of the IDG. The above findings were reviewed with the Administrator and Clinical Manager. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, review of employee personnel files and staff interview, the hospice failed to ensure 4 of 9 sampled hospice aides (Staff I, J, K and L) satisfactorily demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient's bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 1 of 6 sampled patients who required an extra skill task to be performed (Patient #10). The hospice reported 83 of its 91 patients received hospice aide services at the time of the extended complaint survey. Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice aide skills increased the risk that patients received inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Review of the clinical record revealed Staff I, J, K and L, all Hospice Aides from the parent office, provided hospice aide services independently (without direct, on-site registered nurse supervision) to Patient #10. The hospice aide care plan included registered nurse (RN) instructions to the hospice aide to complete the task of ensuring proper technique, fit and placement of the patient's lower left prosthetic equipment. a. Staff I, Hospice Aide, had a hire date of 3/25/19. Staff I's personnel file lacked documentation a RN had observed Staff I competently perform the task of ensuring the proper technique, fit and placement of the patient's lower left prosthetic equipment. b. Staff J, Hospice Aide, had a hire date of 4/11/16. Staff J's personnel file lacked documentation a RN had observed Staff J competently perform the task of ensuring the proper technique, fit and placement of the patient's lower left prosthetic equipment. c. Staff K, Hospice Aide, had a hire date of 2/15/21. Staff K's personnel file lacked documentation a RN had observed Staff K competently perform the task of ensuring the proper technique, fit and placement of the patient's lower left prosthetic equipment. d. Staff L, Hospice Aide, had a hire date of 9/7/21. Staff L's personnel file lacked documentation a RN had observed Staff L competently perform the task of ensuring the proper technique, fit and placement of the patient's lower left prosthetic equipment. The Administrator, Clinical Manager for the parent office and Vice President of Clinical Services received the above findings. On 12/7/21 at 2:50 PM, during an interview, the Vice President of Clinical Services reported not having a specific competency for the hospice aides to perform the task of ensuring proper technique, fit and placement of the prosthetic for Patient #10.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide assignment for 5 of 9 sampled patients receiving hospice aide services (Patients #5, #8, #10, #12 and #13). Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide assignment increased the risk that patients' personal care needs were not adequately met. Findings include: Review of the hospice's policy, titled Interdisciplinary Group Coordination of Care, dated 12/2018, identified the Registered Nurse (RN) Case Manager is responsible for the coordination of services with the IDG members from referral to discharge. On 12/6/21 at 12:45 PM, during an interview, the Clinical Manager for Strawberry Point identified the RN Case Manager creates the hospice aide care plan/assignment and updates that assignment with any changes. The hospice aide will document the reason why they are unable to complete an assigned task and contact the RN Case Manager. The hospice aide will contact the RN Case Manage for approval prior to the completion of any unassigned task and document this. On 12/6/21 at 1:35 PM, during an interview, the Clinical Manager for Cedar Rapids identified the RN Case Manager creates the hospice aide care plan/assignment and updates that assignment with any changes. The hospice aide will document the reason why they are unable to complete an assigned task and contact the RN Case Manager. The hospice aide will contact the RN Case Manage for approval prior to the completion of any unassigned task and document this. 1. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: a. The POC recertification orders, dated 8/18/21 to 11/15/21, included IDG orders for hospice aide services 2 times per week. The hospice aide assignment included registered nurse (RN) instructions to the hospice aide to complete nail care, shampoo and shaving the last visit of the week. b. The clinical record included documentation of 2 hospice aide visits the week of 9/26/21, dated 9/29 and 10/1. The aide visit note, dated 9/29/21 (first visit of the week) included documentation the hospice aide completed the tasks of shampoo, shaving and nail care. c. The IDG meeting, dated 10/6/21, included IDG orders for hospice aide services 3 times per week effective 10/3/21. d. The clinical record included documentation of 3 hospice aide visits the week of 10/10/21, dated 10/11, 10/13 and 10/15. The hospice aide documented on 10/13/21 (the second visit of the week) she completed the tasks of shampoo, nail care and shaving. e. A hospice aide visit note, dated 11/29/21 (first visit of the week), included documentation the hospice aide completed the tasks of shampoo, nail care and shaving. The hospice aide failed to follow the hospice aide assignment or contact the RN to get directions on changes to the care plan prior to implementing those changes. 2. Patient #13 had a hospice admission date of 6/11/21, received hospice services from the multiple location office in Cedar Rapids while residing in a nursing home and discharged from services due to moving on 9/30/21. Review of the clinical record revealed the following: a. The POC recertification orders, dated 9/9/21 to 12/7/21, included IDG orders for hospice aide services 2 times per week. b. The hospice aide assignment included RN instructions to the hospice aide to shower the patient every visit. c. The hospice aide visit notes, dated 9/12 and 9/15/21, included documentation the hospice aide gave the patient a bed bath. The clinical record lacked documentation the hospice aide contacted the RN to obtain approval to provide a different bath type. 3. Patient #5 had a hospice admission date of 11/20/19 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The IDG meeting notes dated, 11/3/21 and 12/1/21, included physician orders for skilled nursing services and hospice aide services three times a week. b. The hospice aide care plan, dated 8/25/21, included RN instruction to the aide to provide the tasks of bed bath, shampoo and nail care, first visit of the week. i. Hospice aide visit notes dated, 9/29/21 and 9/30/21, included documentation the aide completed the task of bed bath. The aide completed the task of bed bath on visits after the first visit of the week. ii. Hospice aide visit notes dated, 10/3/21, 10/6/21 and 10/8/21, included documentation the aide completed the tasks of bed bath, shampoo and nail care. The aide completed the tasks bed bath and shampoo on the second and third visits of the week and the task of nail care on the third visit of the week. iii. Hospice aide visit notes dated, 10/10/21, 10/13/21 and 10/15/21, included documentation the aide competed the tasks of bed bath, shampoo and nail care. The aide completed the tasks bed bath and nail care on the second and third visits of the week and the task of shampoo on the third visit of the week. c. The hospice aide care plan, dated 10/18/21, included RN instruction to provide the tasks of bed bath, shower bath, shampoo and nail care, first visit of the week. i. Hospice aide visit notes dated, 10/18/21 and 10/20/21, included documentation the aide completed the task of bed bath. The aide completed the task of bed bath on the second visit of the week. ii. Hospice aide visit notes dated, 10/26/21 and 10/29/21, included documentation the aide completed the task of bed bath. The aide completed the task of bed bath on the third visit of the week. iii. Hospice aide visit notes dated, 11/2/21, 11/3/21 and 11/5/21, included documentation the aide completed the tasks of bed bath and shampoo. The aide completed the tasks of bed bath and shampoo on the second and third visits of the week. iv. Hospice aide visit notes dated, 11/10/21 and 11/13/21, included documentation the aide completed the tasks of bed bath and shampoo. The aide completed the tasks of bed bath and shampoo on the third visit of the week. v. Hospice aide visit notes dated, 11/16/21 and 11/17/21, included documentation the aide completed the tasks of bed bath, shampoo and nail care. The aide completed the tasks of bed bath, shampoo and nail care on the second visit of the week. vi. Hospice aide visit notes dated, 11/23/21, 11/24/21 and 11/26/21, included documentation the aide completed the tasks of bed bath, shampoo and nail care. The aide completed the tasks of bed bath, and nail care on the second and third visits of the week and the task of shampoo on the third visit of the week. During an interview on 12/1/21 at 4:25 PM, the Administrator reported when a task is assigned for the first visit of the week, the aide is directed to completed the task on the first visit unless the patient refuses, then the aide may attempt to completed the task on another visit later in the week. 4. Patient #8 had a hospice admission date of 6/29/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The Plan of Care dated, 6/29/21 to 8/27/21, included physician orders for skilled nursing and hospice aide services two times a week. b. The hospice aide care plans, dated 6/29/21 and 11/12/21, included RN instruction to the aide to provide the task of nail care, last visit of the week. c. Hospice aide visit notes dated, 9/28/21, 10/1, 10/5, 10/8, 10/12, 10/15, 10/19, 10/22, 10/26, 10/29, 11/16, 11/19, 11/23 and 11/26/21, included documentation the aide completed the task of nail care. The aide completed the task of nail care on both visits of the week for the weeks of 9/26/21 to 10/30/21 and 11/14/21 to 11/27/21. 5. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care dated, 10/12/21 to 1/9/22, included physician orders for skilled nursing and hospice aide services two times a week. b. The hospice aide care plan, dated 10/12/21, included RN instruction to provide the tasks of bathing (shower), shampoo and skin care, first visit of the week. c. Hospice aide visit notes dated, 10/25/21, 10/29/21, 11/10/21 and 11/12/21, included documentation the aide completed the task of skin care. The aide complete the task of skin care on both visits of the week for the weeks of 10/24/21 to 10/30/21 and 11/7/21 to 11/13/21. d. The hospice aide care plan, dated 11/11/21, included RN instruction to provide the tasks of shampoo and skin care, first visit of the week. i. Hospice aide visit notes dated, 11/16/21, 11/19/21, 11/23/21 and 11/26/21, included documentation the aide completed the tasks of shampoo and skin care. ii. Hospice aide visit notes dated, 11/30/21 and 12/3/21, included documentation the aide completed the task of skin care. The aide completed the tasks of shampoo and skin care on both visits of the week for the weeks of 11/14/21 to 11/20/21 and 11/21/21 to 11/27/21; and the task of skin care on both visits of the week for the week of 11/28/21 to 12/4/21. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and hospice policy review, the hospice failed to: 1) Ensure clinical records contained accurate and complete information. (see L0671) The cumulative effects of these systemic practices resulted in the failure to ensure the hospice staff documented all patient diagnoses and related medications for all their patients.

Based on clinical record review and hospice policy review, the hospice failed to ensure clinical records contained accurate and complete information according to agency policy for 2 of 9 sampled patients (Patients #8 and #10). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up to date information related to the patient's condition, and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: Review of the hospice policy, titled the Plan of Care, dated 12/2018, identified a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be reviewed on a regular basis but no less than every 15 days. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with. 1. Patient #8 had a hospice admission date of 6/29/21 and received hospice services from the parent office while residing in a private home. Clinical record review revealed the following: a. The Plan of Care, dated 6/29/21 to 8/27/21, included primary hospice diagnosis of hypertensive heart disease without heart failure and other diagnoses listed in the following order: senile degeneration of brain, not elsewhere classified; essential (primary) hypertension (blood pressure); mild cognitive impairment, so stated; restless legs syndrome; other allergic rhinitis; other hereditary and idiopathic neuropathies; and chronic obstructive pulmonary disease with (acute) exacerbation (COPD) with exacerbation dates of 6/29/21. Medications listed as provider coverage include acetaminophen (pain/fever), amlodipine (blood pressure), bisacodyl (bowels), hyoscyamine (secretions), lorazepam (anxiety), morphine concentrate (pain/shortness of breath), oxygen (anxiety/shortness of breath), and senna with docusate sodium (bowels); and medications listed as patient coverage include cetirizine (allergies), levothyroxine (thyroid), and simethicone (flatulence). b. CTI (certification of terminal illness) forms dated, 7/14/21, 8/22/21 and 10/20/21, included hospice medical physician narrative that stated primary diagnosis of hypertensive heart disease without heart failure with secondary diagnosis of COPD. c. IDG (interdisciplinary group) meeting notes dated, 6/30/21, 9/22/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21 and 12/1/21, include documentation the primary hospice diagnosis is hypertensive heart disease without heart failure; essential (primary) hypertension, related to terminal prognosis; and COPD, not related to terminal prognosis. The clinical record included conflicting documentation regarding primary hospice diagnosis and related secondary diagnosis. 2. Patient #10 had a hospice admission date of 10/12/21 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care, dated 10/12/21 to 1/9/22, included primary hospice diagnosis atherosclerotic heart disease of native coronary artery without angina pectoris and other diagnoses listed in the following order: other persistent atrial fibrillation, venous insufficiency (chronic) (peripheral), other specified peripheral vascular diseases, type 2 diabetes mellitus with diabetic nephropathy, alzheimers disease unspecified, generalized anxiety disorder, chronic kidney disease stage 3B, adult failure to thrive, chronic idiopathic constipation, and restless legs syndrome. Medications listed as provider coverage include acetaminophen suppository (pain/fever), bisacodyl suppository (bowels), bisacodyl tablet (bowels), hyoscyamine (secretions), linzess (constipation), lorazepam (anxiety), nitroglycerin (cardiac), polyethylene glycol (bowels), ropinirole (pain), senna-s (bowels), sertraline (anxiety), tramadol (pain), and tylenol tablet (pain/fever); medications listed as patient coverage include allopurinol (gout), clonidine patch (blood pressure), cod liver oil capsule (supplement), cranberry tablet (renal), cyanocobalamin (supplement), eliquis (blood thinner), FE bisgly - vitamin C (supplement), glucagon (diabetes), humalog insulin (diabetes), isosorbide mononitrate (blood pressure), metalozone (renal), metoprolol succinate (blood pressure/renal), olopatadine eye drops (allergies), potassium chloride (supplement), singulair (allergies), spironolactone (blood pressure/renal), torsemide (renal), solostar insulin (diabetes), vitamin B (supplement), vitamin D (supplement), and vitamin E (supplement). b. IDG meeting notes dated, 10/20/21, 11/3/21 and 11/17/21, include documentation the primary hospice diagnosis is atherosclerotic heart disease of native coronary artery disease without angina pectoris; other persistent atrial fibrillation, related to terminal prognosis; venous insufficiency (chronic) (peripheral), related to terminal diagnosis; and other specified peripheral vascular diseases, related to terminal prognosis. The hospice failed to cover medications related to the hospice primary terminal diagnosis and diagnoses related to the terminal prognosis. The above findings were reviewed with Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, onsite visit observation, 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 2 of 3 sampled patients (Patients #5 and #6) 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: Review of the hospice's policy, titled Interdisciplinary Group Coordination of Care, dated 12/2018, identified the Registered Nurse (RN) Case Manager is responsible for the facilitation of communication about changes in the patient's status between IDG members and the patient's attending physician. 1. Patient #6 had a hospice admission date of 11/1/21 and received hospice services from the multiple location office in Davenport while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/1/21 to 11/29/21, included interdisciplinary group (IDG) orders for skilled nursing, social work, hospice aide and chaplain services. b. A skilled nursing visit note, dated 11/4/21 starting at 9:58 AM, did not include an assessment of the patient's skin. The nurse documented the facility reported obtaining a urinary analysis on 11/3/21 and they were waiting for the results. c. A hospice aide visit note, dated 11/4/21 starting at 2:01 PM, included documentation which identified the patient had change in skin condition with a skin tear on the right wrist. The hospice aide documented she contacted the hospice registered nurse (RN) and facility staff. d. A skilled nursing visit, dated 11/5/21, included documentation of a skin assessment, but lacked documentation of the status of the patient's skin tear. e. A skilled nursing visit, dated 11/9/21, which identified the visit was a comprehensive assessment for the recertification of the patient's hospice services. The nurse documented the patient had a wound, but did not include any further assessment or treatment information in regards to the wound. The nurse documented they continued to await the results of a urinary analysis for a possible urinary tract infection. f. The hospice chart lacked documentation of a physician order for treatment of the skin tear to the right wrist and lacked documentation of an order for a urinary analysis. Review of the patient's nursing home treatment record for November 2021 revealed the following: a. A physician's order, dated 11/6/21 to 11/10/21, included orders to cleanse the right wrist skin tear with Normal Saline, apply a Xeroform dressing and Kerlix daily and as needed until resolved. b. A physician's order, dated 8/19/21 to 11/15/21, included orders to monitor for signs and symptoms of a urinary tract infection and instructions to order a urinary analysis with culture and sensitivity if signs and symptoms were present. On 11/30/21 at 11:20 AM, during a home visit observation at the patient's nursing home with Staff G, Registered Nurse (RN), the facility nurse reported calling the hospice with any new orders. 2. Patient #5 had a hospice admission date of 11/20/19 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. Client Medication Report printed, 11/30/21 at 7:36 AM, included the following medication orders: Lorazepam 0.5 milligram (mg) tablet, 1 tablet orally every 6 hours as needed for anxiety with a start date of 11/5/2020; Lorazepam 2 mg/ml (milliliter), 0.25 ml every 4 hours as needed for anxiety or restlessness with a start date of 8/13/21; Systane 0.4%-0.3% eye drops, 1 drop in each eye 4 times a day as needed with a start date of 8/20/21; and Omeprazole 20 mg capsule delayed release, 1 capsule orally daily with a start date of 11/20/19; and lacked documentation of an order for Flonase 50 micrograms (mcg) nasal spray, 2 sprays in each nostril one time a day. b. The IDG meeting notes dated, 9/22/21, 10/6/21, 10/20/21, 11/3/21 and 11/17/21, included physician orders for the following medications: Lorazepam 0.5 mg tablet, 1 tablet orally every 6 hours as needed for anxiety with a start date of 11/5/2020; Lorazepam 2 mg/ml, 0.25 ml every 4 hours as needed for anxiety or restlessness with a start date of 8/13/21; Systane 0.4%-0.3% eye drops, 1 drop in each eye 4 times a day as needed with a start date of 8/20/21; Omeprazole 20 mg capsule delayed release, 1 capsule orally every other day; and Flonase 50 mcg nasal spray, 2 sprays in each nostril one time a day with a start date of 8/28/21. c. During a home observation visit on 11/30/21 at 9:00 AM, with Staff E, Registered Nurse (RN), the surveyor obtained a copy of the Medication Administration Record from the facility nurse for the months of October 2021 and November 2021. Medication Administration Record from the facility dated, 10/1/21 to 10/31/21 and 11/1/21 to 11/30/21, included documentation of medication orders for Omeprazole 20 mg capsule one time a day every other day with a start date of 7/23/21, and Flonase 50 mcg nasal spray 2 sprays in each nostril one time a day with a start date of 9/29/21, and lacked documentation of the Lorazepam orders from 11/5/2020 and/or 8/13/21, and the Systane order from 8/20/21. d. The IDG meeting note dated, 12/1/21, included documentation the Omeprazole order was changed to read a frequency of every other day with an order date of 11/29/21 and an approved date of 11/30/21, Flonase order was added with an order date of 11/29/21 and an approved date of 11/30/21, Lorazepam orders dated, 11/5/2020 and 8/13/21, were discontinued on 11/29/21 and the Systane order dated, 8/20/21, was discontinued on 11/29/21. The hospice RN failed to ensure coordination of medications with the nursing home staff. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.

Based on hospice clinical record review, nursing home clinical record review, nursing home staff interview and hospice staff interview, the hospice failed to maintain all required hospice documents/information at the long term care facilities (nursing homes) where hospice patients reside for 3 of 3 patients receiving surveyor on-site visit to the nursing home (Patients #5, #6 and #12). Failure to communicate hospice information to long term care staff placed patients at risk for not receiving effective, coordinated necessary care and services. Findings include: 1. Patient #6 had a hospice admission date of 11/1/21 and received hospice services from the multiple location office in Davenport while residing in a nursing home. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 11/1/21 to 11/29/21, included interdisciplinary group (IDG) orders for skilled nursing, social work, hospice aide and chaplain services. The POC included documentation of certification of the terminal illness (CTI) and identified the patient had advance directives. b. The clinical record included documentation of IDG meetings, dated 11/3 and 11/16/21. On 11/30/21 at 11:20 AM, during a home visit observation at the patient's nursing home with Staff G, Registered Nurse (RN), the surveyor requested to review the information in the hospice's chart for the patient provided for the nursing home staff and maintained at the nursing home. The surveyor was unable to locate a POC, updates to the POC (IDG meeting notes), hospice benefit election form, CTI, advanced directives and information on the hospice personnel involved in the patient's care. In an interview during the same home visit observation, Staff G, RN, reported she was responsible for bringing the necessary forms to the nursing home. She explained she had not been able to get into the office prior to today, and then forgot to bring the necessary documentation with her today. 2. Patient #12 had a hospice admission date of 5/20/21 and received hospice services from the Davenport multiple location office while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 5/20/21 to 8/17/21, included IDG orders for skilled nursing, social worker, hospice aide and chaplain services. The POC included documentation of the initial CTI and identification of advance directives. The initial IDG meeting, dated 6/2/21, included IDG orders for music therapy services, documentation of IDG meetings every 2 weeks after the initial IDG meeting and documentation of hospice recertification orders with the CTI, medication orders and IDG discipline frequency orders for certification periods, dated 8/18/21 to 11/15/21 and 11/16/21 to 1/14/22. On 11/30/21 at 10:05 AM, during an onsite visit to the nursing home, the surveyor requested to see the information the hospice provided to the nursing home on the patient. The Assistant Director of Nursing (ADON) provided the hospice chart kept at the facility. The hospice chart provided to the nursing home failed to include IDG meetings from 7/28 to 10/6/21, 11/3 and 11/17/21. The hospice chart failed to include hospice recertification orders which contained POC information and the CTI recertification for 11/16/21 to 1/14/22. On 12/7/21 at 12:50 PM, during an interview, the Administrator reported the RN case manager, hospice aide or Care Transition Coordinator deliver required documentation to the nursing home for patients. 3. Patient #5 had a hospice admission date of 11/20/19 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed the following: IDG meeting notes, dated 9/22/21, 10/6/21, 10/20/21, 11/3/21, 11/17/21 and 12/1/21. Face to face visit documentation dated, 6/21/21, 9/3/21 and 10/13/21, including documentation related to certification of terminal illness (CTI) correlating to the face to face visits. On 11/30/21 at 9:00 AM, during an on-site visit to the patient's nursing home, Staff E, Registered Nurse (RN), requested the patient's hospice binder from the facility nurse and provided this to the surveyor for review. The surveyor was unable to locate the CTI and face to face documentation for the last 3 recertifications periods, 7/12/21 to 9/9/21, 9/10/21 to 11/8/21 and 11/9/21 to 1/7/22. The surveyor identified IDG meeting notes dated 10/6/21 and 10/20/21, but was unable to locate IDG meeting notes dated, 9/22/21, 11/3/21 and 11/17/21. During the on-site visit, the facility nurse reported there may be additional filing in the back room for the hospice patient. Facility nurse went to back room and provided surveyor with hospice documentation that needed to be filed, this included IDG (Interdisciplinary Group) meeting note dated, 11/17/21. Staff E reviewed the binder and confirmed she was unable to locate the CTIs or IDG meeting notes dated 9/22/21 and 11/3/21. Staff E reported hospice staff deliver paperwork to facility staff. During an interview on 11/20/21 at 11:30 AM, the Vice President of Clinical Services reported hospice staff deliver paperwork to the nursing home staff and they (hospice staff) have no control over what the nursing home staff does with the paperwork after that. The hospice failed to provide current CTI and IDG meeting notes to the patient's nursing home. The above findings were reviewed with the Administrator, Clinical Manager for Strawberry Point, and Vice President of Clinical Services. Hospice staff provided no further information prior to the end of the survey.