Every finding on record at Unitypoint at Home

Upon patient record review, 3 of 26 (Patient #5, 12, 20 ) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 05: The medication profile includes menthol-methyl muscle rub apply topically to affected area twice daily for pain, it does not include an application site. (Profile corrected and updated on site.) Patient 12: The medication profile includes Nystatin powder, apply topically 2 times daily, it does not include an application site. (Profile corrected and updated on site.) Patient 20: The medication profile includes polyethylene glycol 17g by mouth daily for constipation, it does not include a diluent. (Profile corrected and updated on site.)

Upon patient record review, 3 of 26 (Patient #5, 12, 20) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 05: Medication orders on 2/7/25 for menthol-methyl muscle rub, apply topically to affected area twice daily for pain, it does not include an application site. (Order corrected and updated on site.) Patient 12: The medication order entered on 3/7/25 for Nystatin powder, apply topically 2 times daily, does not include an application site. (Order corrected and updated on site.) Patient 20: The medication order on 3/10/25 for polyethylene glycol 17g by mouth daily for constipation, does not include a diluent. (Order corrected and updated on site.)

Upon patient record review, 2 of 26 (Patient #5, 7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 05: The patient record includes new onset of anxiety and agitation documented on 3/11/25 with new orders for lorazepam 0.5mg by mouth every 2 hours as needed for anxiety, the plan of care was not updated to include a problem statement for anxiety/agitation with interventions and goals. Patient 07: The patient is prescribed Coumadin 2.5mg with routine lab monitoring every month, for a diagnosis of paroxysmal atrial fibrillation, related to the hospice diagnosis. The plan of care does not include a problem statement with interventions and goals for the cardiovascular/hematology issues.

Upon client record review, 1 of 26 (Patient #17) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 17: MSW visits are ordered for 2 times per month, the patient record indicates 1 visit was made in the month of December, no evidence of refused visit.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 06: Upon home visit, it was observed that the visiting RN removed needed assessment tools from her bag and placed the tools on top of the patients bed. Agency policy for proper bag technique indicates that all items are to be placed on top of a barrier.

Upon patient record review, 1 of 26 (Patient #11) the agency did not have evidence that the hospice has offered and/or provided spiritual counseling in accordance with the patient/family's desires which include: •Providing spiritual counseling to meet these needs in accordance with the patient's and family's acceptance of this service and in a manner consistent with their beliefs and desires Patient 11: Spiritual Care visits are ordered for 2 x per month effective 1/30/25 - 4/24/25. The patient record indicates missed visits x 2 for the month of February and no visits currently in March for Spiritual Care, noted as "unable to contact son." The RN documentation for 2/10/25, 2/13/25, 2/25/25 and 2/26/25 indicated needs for spiritual and emotional support and referral to chaplain. (Patient died on 3/13/25 during the survey window with no spiritual visit made.)

Upon observation, there was no evidence the furnishing and decorations of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction A.7.1.10.1 A proper means of egress allows unobstructed travel at all times. An example of an obstruction or impediment to full instant use of means of egress is any security device or system that emits any medium that could obscure a means of egress. It is, however, recognized that obstructions occur on a short-duration basis. In these instances, awareness training should be provided to ensure that blockages are kept to a minimum and procedures are established for the control and monitoring of the area affected. It was identified during the life safety inspection that the means of egress located in the south hallway (a protected area) and identified as door set #31 do have latching hardware contained within the fire rated doors. It was identified that the latching hardware is faulty and does not allow for a means of egress when attempting to disengage the latching mechanism. The door requires an excessive amount of force to disengage the latching mechanism and can substantially delay the exit time of any person who attempts to exit through the corridor doors.

Based on clinical record review, home visit observation, hospice policy review and staff interview, the hospice failed to ensure the hospice nurse obtained a physician order for the correct time for administration of scheduled medications for 1 of 4 sampled patients (Patient #4). The hospice reported a current census of 118 patients at the time of survey 95 in the Des Moines parent office, 8 in the hospice house, 2 in the osceola branch, 2 in the Jefferson branch and 11 in the Grinnell branch. Failure to ensure the hospice nurse obtained a physician order for correct for time for administration of medications placed the patient at potential risk to receive incorrect or ineffective treatment to meet assessed needs. Findings include: --- Review of the hospice policy, titled Hospice Medication Management, dated 3/2018, all medication errors are documented in a Risk Report and reported immediately to the patient's attending physician. Medication errors include, but are not limited to administered at the wrong time. Patient #2, a pediatric patient had a hospice admission date of 2/18/21, and hospice house admission dated of 11/1/22 for respite services. Patient #2 received hospice services while residing in a private home setting. Review of the clinical record revealed the following: a. The physician order, dated 11/1/22, revealed the following medications: Gabapentin 62.5 mg (milligrams) every 8 hours, Glycerin suppository 1 daily prn (as needed), Keppra 60 mg every 12 hours, Clonazepam 0.02 mg/ml (milliliters) 0.5 ml every 6 hours prn. Review of the patients home schedule revealed the following schedule for Keppra. Keppra 0.6 ml (milliliters) at 6:00 AM and 6:00 PM. Review of the progress notes, dated 11/1/22 at 11:58 AM revealed the patient admitted to the hospice house for respite care for the next 5 days. Reviewed the patient's schedule with parents and written schedule given to staff. Review of the MAR (medication administration record), dated 11/1/22 at 2:30 PM revealed the following medications administered: Keppra 60 mg and gabapentin 62.5 mg. Review of the progress notes, dated 11/1/22 at 2:30 PM revealed the patient tolerated bottle feed and medications easily. During an interview on 12/6/22 at 3:10 PM the Director stated the hospice house Medical Director wrote the patient's orders and put the orders into the electronic record. She did a reconciliation of the medications and the electronic system defaulted and put the Keppra on a 2:30 AM and 2:30 PM schedule. The system has an over-ride to change the schedule to meet the patient's needs but the required change did not occur. The hospice had made changes as the result and updated the hospice house admission report sheet. All staff have been educated on the changes to provide better communication for new admissions of patients. During an interview on 12/7/22 at 8:22 AM Staff A, Registered Nurse (RN) stated she was the nurse working with the patient on 11/1/22 and worked the 7:00 AM to 3:00 PM shift. The patient had orders to hold the feedings and medications due to the PEG changed around 4:00 PM. The admission nurse did the admission and initial assessment. The Medical Director gave the orders and reconciled the medications. The electronic medical record defaults so sometimes the administration times need to be adjusted to match the correct times they are to be given. She stated she went to the electronic medication administration record and saw 2 meds ordered. She drew up the medications and gave them to the patient at approximately 2:00 PM. The patient also had 1 bottle of breast milk orally and tolerated OK. She stated she knew the medication cart had a typed up list of medications and schedule from the patient's parents but did not consider this as orders as the physician orders were already in the system. She stated she didnt think she looked at the paper and no one informed her the time medications were given at home prior to admission. During an interview on 12/7/22 at 3:44 PM Staff B, Admission nurse, stated she admitted the patient and he/she came to the hospice house around 10:00 AM. The parents had printed off a list of schedules, including medications, feeding times and what he/she likes. She gave report to Staff A, RN around 11:30 AM and gave her the paper with the patient's schedule. During an interview on 12/7/22 at 2:30 PM the Physician stated he would not worry about the Keppra being given 4 hours early. He further stated he would not worry about the Keppra causing an overdose for the patient. The Administrator received the above findings and agency 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 staff obtained a signature confirming the patient or representative of the patient received a copy of the notice of patient's rights and responsibilities for 2 of 16 (Patients #5 and #13) sampled patients. Failure to ensure hospice staff obtained a signature confirming the patient or representative of the patient receiving a copy of the notice of patient's rights and responsibilities placed patients at risk for not Findings include: Review of the hospice's policy, titled Rights/Responsibilities, dated 3/2018, revealed hospice staff will request the patient or patient representative sign receipt of the patient Rights/Responsibilities and hospice will maintain documentation of this signature in the record. 1. Patient #5 had a hospice admission date of 3/9/22 and received hospice services while residing in the hospice's own hospice house. Review of the clinical record on 3/23/22 revealed the following: a. The comprehensive assessment completed by a registered nurse, dated 3/9/22, included documentation the nurse provided the patient/patient representative with a copy of the patient rights and responsibilities and provided instruction on the materials provided. The nurse documented the patient's spouse signed the consent for hospice treatment. b. A hospice document, titled Patient/Family Informed Consent, included documentation of a signature by the patient's representative (patient's spouse) for a release of information, do not resuscitate, consent for admission to hospice and consent for treatment. A later section in the form included a place for hospice staff to check off if they provided the patient or patient representative with a copy of the patient rights and responsibilities, answered all related questions posed by the patient or patient representative and the patient/patient representative signed receipt of this information. The form lacked any indication hospice staff had provided the required information and lacked a signature of receipt by the patient or patient's representative. A hospice nurse signed completion of the form and documented the patient was "weak" and unable to sign. On 3/23/22 at 3:53 PM, during an interview, the Administrator confirmed the Patient/Family Informed Consent form lacked documentation the nurse had provided and discussed the patient rights and responsibilities with the patient or patient's representative and lacked documentation of receipt of the form by the patient or patient's representative. On 3/23/22, the Administrator provided a copy of an updated Patient/Family Informed Consent form with the patient's representative signature of understanding and receipt of the patient rights and responsibilities, dated 3/23/22. 2. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. The initial comprehensive assessment completed by a registered nurse (RN), dated 3/4/22, included documentation the nurse provided the patient with instructions and materials on the Patient Bill of Rights/Responsibilities. b. A Hospice Patient/Family Informed Consent form, dated 3/4/22, included boxes to be checked in relation to the patient/representative receiving information regarding Patient Rights and Responsibilities. The form included a signature at the bottom of the page by the patient representative, dated 3/4/22. The boxes lacked a check mark to indicate the patient had received and understood the Patients Rights and Responsibilities information. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) ensure the hospice interdisciplinary group (IDG) completed the initial comprehensive assessment no later than 5 days after the patient elected to receive the hospice benefit (see L0523); 2) ensure a hospice staff completed a comprehensive assessment which included a complete physical and spiritual assessment (see L0524); 2) ensure the hospice interdisciplinary group completed a drug regimen review that included the required components with each comprehensive and update to the comprehensive assessment (see L0530); 3) ensure a member of the hospice IDG completed an initial assessment including documentation of a bereavement assessment, (see L0531); and, 4) ensure the hospice nurse member of the interdisciplinary group updated the comprehensive assessment with changes to the patient condition and included wound assessment and measurements per hospice policy (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 all members of the hospice Interdisciplinary Group completed a comprehensive assessment within 5 days after the patient's election of the hospice care for 2 of 16 sampled patients (Patients #7 and #12). Failure of all members of the Interdisciplinary Group to complete a comprehensive assessment of the patient's condition increased the risk in the delay of identification and meeting of all the patient needs. Findings include: According to the hospice policy, titled Initial and Comprehensive Hospice Assessment, dated 7/2017, the comprehensive assessment of the patient is completed by designated members of the Interdisciplinary Group (IDG) in consultation with the patient's attending physician no later that five calendar days after the patient elects the hospice benefit. Each member of the IDG provides input into the comprehensive assessment within the scope of his/her practice and in accordance with the needs and desires of the patient. During an interview on 3/21/22 at 2:15 PM with the Hospice Administrator, she reported the Hospice expectation is for the admission to be completed within 5 days. 1. Patient #12 had a hospice admission date of 1/20/22, and received services from the parent office while residing in a nursing home. The Plan of Care, dated 1/20/22 to 4/19/22, included IDG orders for skilled nursing, social work, and spiritual care services. The clinical record review revealed a skilled nursing initial comprehensive assessment, dated 1/20/22, and electronically signed as completed on 1/27/22, 7 days after the start of hospice services and 2 days late per regulations. 2. Patient #7 had a hospice admission date of 2/17/22, received hospice services from the parent office while residing in an assisted living apartment and died on 2/20/22. Review of the clinical record revealed the following: A comprehensive assessment completed by a RN, dated 2/17/22, included documentation of a signature of completion, dated 2/24/22 (completed 2 days late). The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure members of the interdisciplinary group completed a comprehensive assessment which included a complete physical and spiritual assessment within 5 days after the patient's election of hospice care for 5 of 16 sampled patients (Patients #5, #6, #8, #9 and #10). Failure to complete an initial spiritual assessment increased the risk that patient's needs would not be identified and/ or addressed appropriately and the hospice would have an incomplete baseline assessment for comparison. Findings include: Review of the hospice's policy, titled Initial and Comprehensive Hospice Assessment, dated 7/2017, revealed 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 in order to promote the patient's well-being, comfort and dignity throughout the dying process. The Registered Nurse (RN) Case Manager coordinates the comprehensive assessment process and ensures the assessment of the patient's physical, psychosocial, spiritual and bereavement needs no later than 5 calendar days after the patient elects the hospice benefit. Review of the hospice's policy, titled Wound Addendum, dated 11/18/21, identified alterations in skin integrity include, but are not limited to, pressure injury, friction injury, moisture associated skin damage, rashes, burns, blisters, ulcers and skin tears. The nurses are to assess and document wounds on a weekly basis and include wound identification, measurements, wound bed, wound drainage, peri-wound condition, wound pain and photographs of the wound. Wound measurements include a length, width and depth. Open areas with skin loss have depth, and if superficial, should be measured at 0.1 centimeters (cm). Hospice RNs are to do a complete wound assessment as part of every comprehensive assessment. On 3/22/22 at 2:15 PM, during an interview, the Administrator, who also identified herself as the Clinical Manager, reported an expectation for hospice nurses to measure and take pictures of wounds weekly. Measurements include length, width and depth. 1. Patient #5 had a hospice admission date of 3/9/22 and received hospice services while residing in the hospice house. Review of the clinical record revealed the following: A Plan of Care (POC), dated 3/9/22 to 6/6/22, identified a primary diagnosis of lung cancer and included IDG orders for skilled nursing, social worker, hospice aide and chaplain services. The POC identified the patient had a small shearing wound to the sacrum and the wound was "covered by barrier cream on admit". The POC included orders for the skilled nurse to assess the patient's pulmonary (lung) status. a. The comprehensive assessment completed by a RN, dated 3/9/22, included documentation the nurse assessed the patient had an open area, described as a small abrasion noted on the buttocks. The nurse documented hospice provided wound care and specified applying protective ointment to the area. The assessment lacked documentation of any wound measurements. The same comprehensive assessment identified the patient used 6 liters of oxygen continuous via nasal cannula, had a non-productive cough and shortness of breath at rest day or night. The nurse documented she did not assess the patient's lung sounds, but did not provide a reason why she failed to do a complete assessment of the patient's lungs. b. The comprehensive assessment completed by a RN, dated 3/9/22, included documentation the patient/family declined chaplain services. The assessment lacked documentation of a spiritual assessment. An initial social worker assessment, dated 3/11/22, lacked documentation of a spiritual assessment. The social worker documented she did not ask if the patient/family if their spiritual well-being was essential to them. The clinical record lacked documentation of a spiritual assessment of the patient/family within 5 days after the patient's election of the hospice benefit. 2. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/28/21 to 3/27/22, included IDG orders for skilled nursing services. The POC included orders for the nurse to assess skin integrity management and identified the patient had a wound on the coccyx. b. The comprehensive assessment completed by a RN, dated 12/28/21, included documentation the nurse assessed the patient had open areas, wounds, pressure areas or unstageable areas identified. The nurse documented the patient had a Stage 1 pressure ulcer on the coccyx ( a non-blanchable reddened area of the skin related to pressure injury). The visit note lacked any further description or measurements of the wound. c. A skilled nursing visit note, dated 12/29/21, included documentation the RN first observed the patient's pressure injury on 12/29/21. She documented the wound was located on the left gluteus maximus (buttock) and identified the wound as a Stage 1. She documented a picture of the wound. Review of the wound picture revealed the left gluteus to have maceration and obvious loss of skin, which indicated the wound was a Stage 2 pressure ulcer (the skin is open, wears away or forms an ulcer and is shallow with a reddish base and is usually tender and painful). The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 2 out of 10 (with 10 being the worst). The visit note lacked documentation of any measurements of the wound. The clinical record lacked documentation of any further in person skilled nursing visits within 5 days after the patient's election of the hospice benefit. The comprehensive assessment, dated 12/28, and subsequent skilled nursing visit, dated 12/29/21, included an inaccurate and incomplete description of the patient's wound. 3. Patient #6 had an admission to hospice on 2/1/22 and received services from the Jefferson office and received services in a private residence. The clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 2/1/22, lacked an initial spiritual risk assessment. b. The comprehensive assessment completed by the social worker, dated 2/17/22, included an initial bereavement risk assessment signed completed on 2/17/22 (12 days after the start of care). The hospice failed to complete a spiritual assessment as part of the comprehensive assessment. 4. Patient #8 had an admission to hospice on 2/16/22 and received services from the Osceola office and received services in a private residence. The clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 2/17/22, lacked an initial spiritual risk assessment. b. Review of the clinical record revealed no spiritual assessment completed. The hospice failed to complete a spiritual assessment as part of the comprehensive assessment. 5. Patient #9 had an admission to hospice on 3/2/22 and received services out of the Jefferson office and received services in a private residence. The clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 3/2/22, lacked an initial spiritual risk assessment. b. Review of the clinical record revealed no spiritual assessment completed. The hospice failed to complete a spiritual assessment as part of the comprehensive assessment. The Administrator received the above findings. No further information was provided prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview the hospice failed to ensure the accurate completion of a drug regimen review by the Interdisciplinary Group at least every 15 days with the update to the comprehensive assessment for 2 of 16 sampled patients (Patients #12 and #13). Failure to ensure the interdisciplinary group members involved in the assessment of patient needs completed all components of the drug regimen review with each update to the comprehensive assessment increased the risk of unidentified potential or actual adverse effects of medication combinations and/or ineffectiveness of medication therapy. Findings include: Review of the hospice policy, titled Hospice Medication Management/Drug Regimen Review (DRR), dated 3/2018, revealed a review of all the patient's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could effect drug therapy is completed by the hospice pharmacist at the time of the comprehensive assessment in collaboration with the admitting or primary nurse, and with each update to the comprehensive assessment (at a minimum every 15 days), at time of hospice recertification and as needed with medication additions or significant patient changes. The DRR includes an assessment of patient and all medicines (including herbal and over the counter) the patient is taking in the home to determine the following components: effectiveness of drug therapy, drug side effects, actual or potential drug interaction, duplicate drug therapy, and drug therapy currently associated with lab monitoring. During an interview on 3/21/22 at 2:15 PM, with the Hospice Administrator, the drug regimen review is completed with the Interdisciplinary Group (IDG) meetings. 1. Patient #12 had a hospice admission date of 1/20/22, and received services from the parent office while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 1/20/22 to 4/19/22, included medication orders for Bumex, Aldactone (fluid medications), Senna, Bisacodyl, milk of magnesia (bowel medications), acetaminophen and morphine (pain medications). b. The IDG meeting note, dated 1/26/22, included documentation a DRR was completed and no duplicate drug therapy was identified. The DRR failed to identify the duplicate medications the patient was taking. 2. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 3/4/22 to 6/1/22, included medication orders for Senokot, psyllium, milk of magnesia (bowel medications), Tylenol and morphine (pain medications). b. The IDG meeting note, dated 3/9/22, included documentation "full DRR pending" and the components of drug side effects and drug therapy associated with laboratory monitoring were completed as part of a DRR. The DRR lacked completion of all required components including effectiveness of drug therapy, actual or potential drug interactions and duplicate drug therapy. The DRR did not identify the duplicate bowel and pain medications. The DRR failed to identify the duplicate medications the patient was taking and failed to include all required components. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on hospice policy review, clinical record review and staff interview, the hospice failed to perform an initial bereavement assessment, within 5 days of the patient's election to the hospice benefit and as part of the initial comprehensive assessment, to determine patient and/or family bereavement needs and risk factors in a timely manner for 4 of 16 sampled patients (Patients #4, #6, #13 and #15). Failure to complete an initial bereavement assessment increased the risk that patient or family/caregiver grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: According to the policy and procedure titled Initial and Comprehensive Hospice Assessment, dated 7/2017, based on the patient's needs and findings from the initial assessment, the hospice RN coordinates and designates disciplines that must participate in the comprehensive assessment of the patient with 5 days of his or her election of hospice care. The comprehensive assessment includes an initial assessment of the bereavement needs of the patient's family and other involved individuals. During an interview on 3/21/22 at 2:15 PM, the Administrator stated the admission comprehensive assessment expected to be completed in 5 business days. 1. Patient #6 had an admission to hospice on 2/1/22 and received services out of the Jefferson office and received services in a private residence. The clinical record review revealed: a. The initial comprehensive assessment completed by the skilled nurse, dated 2/1/22, lacked an initial bereavement risk assessment. b. The comprehensive assessment completed by the social worker, dated 2/17/22, included an initial bereavement risk assessment signed completed on 2/17/22 (12 days after the start of care). 2. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/21/21 to 12/19/21, included IDG orders for skilled nursing, hospice aide, social worker and chaplain services. b. The clinical record included documentation of skilled nursing visits, dated 10/21, 10/22, 10/23 and 10/25/21, and an initial chaplain visit, dated 10/25/21. The visits lacked documentation of an initial bereavement risk assessment. c. An initial social worker visit, dated 10/27/21, included documentation of an initial bereavement risk assessment (completed 1 day late). 3. Patient #4 had an admission to hospice on 6/14/21 and received services from the multiple location office in Grinnell while residing in a nursing home. Clinical record review revealed: a. Skilled nurse initial comprehensive assessment, dated 6/14/21, lacked documentation a bereavement risk assessment had been completed. b. Social work initial comprehensive assessment, dated 6/14/21, lacked documentation a bereavement risk assessment had been completed. The hospice failed to complete a bereavement risk assessment. 4. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. Skilled nurse initial comprehensive assessment, dated 3/4/22, lacked documentation a bereavement risk assessment had been completed. b. Social work initial comprehensive assessment, dated 3/8/22, lacked documentation a bereavement risk assessment had been completed. The hospice failed to complete a bereavement risk assessment. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient physical condition including wound measurements for 2 of 13 sampled patients (Patients #5 and #10) requiring an update to the comprehensive assessment. Failure by the hospice Interdisciplinary Group (IDG) registered nurses (RNs) 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's policy, titled Initial and Comprehensive Hospice Assessment, dated 7/2017, revealed the hospice 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 in order to promote the patient's well-being, comfort and dignity throughout the dying process. The IDG members update the comprehensive assessment at least every 15 days or more frequently if needed by the patient. Review of the hospice's policy, titled Wound Addendum, dated 11/18/21, identified alterations in skin integrity include, but are not limited to, pressure injury, friction injury, moisture associated skin damage, rashes, burns, blisters, ulcers and skin tears. The nurses are to assess and document wounds on a weekly basis and include wound identification, measurements, wound bed, wound drainage, peri-wound condition, wound pain and photographs of the wound. Wound measurements include a length, width and depth. Open areas with skin loss have depth, and if superficial, should be measured at 0.1 centimeters (cm). Hospice RNs are to do a complete wound assessment as part of every comprehensive assessment. On 3/22/22 at 2:15 PM, during an interview, the Administrator, who also identified herself as the Clinical Manager, reported an expectation for hospice nurses to measure and take pictures of wounds weekly. Measurements include length, width and depth. 1. Patient #5 had a hospice admission date of 3/9/22 and received hospice services while residing in the hospice's own hospice house. Review of the clinical record revealed the following: A Plan of Care (POC), dated 3/9/22 to 6/6/22, identified a primary diagnosis of lung cancer and included IDG orders for skilled nursing, social worker, hospice aide and chaplain services. The POC identified the patient had a small shearing wound to the sacrum and the wound was "covered by barrier cream on admit". The POC included orders for oxygen 6 liters per nasal cannula continuously. The POC included orders for the skilled nurse to assess the patient's cardiopulmonary status, nutrition, elimination and skin integrity. The POC included orders that the patient's medications could be crushed if appropriate. The comprehensive assessment completed by a RN, dated 3/9/22, included documentation the nurse assessed the patient had an open area, described as a small abrasion noted on the buttocks. The RN assessed the patient had shortness of breath at rest day or night. The RN also assessed the patient's cardiovascular system and identified the patient had 3 plus (pressure leaves an indentation of 5 to 6 millimeters) edema to the left upper extremity, 4 plus edema (pressure leaves an indentation of 8 millimeters of deeper) right upper extremity, a peripherally inserted central catheter (PICC) in the right arm with edema to the site and covered with a dressing, weak pedal pulses and discoloration of the skin/cyanosis. The assessment identified the patient was taking an Opiod for pain, a bowel regimen was implemented and the last bowel movement was 3/8/22. The assessment identified the patient had less than one meal per day with only bites of food for the last week, loss of appetite and sips of fluid. a. A skilled nursing clinical note, dated 3/15/22 at 1:57 PM, identified the patient had no intake of solid foods, but took in a "good amount" of fluids. 1) A skilled nursing clinical note, dated 3/15/22 at 8:55 PM, included documentation the patient reported difficulty swallowing and requested medications to be crushed. 2) Clinical notes, dated 3/18, 3/19, 3/20, 3/21 and 3/23/22, identified the patient's last bowel movement was 3/10/22. 3) A skilled nursing clinical note, dated 3/21/22 at 8:03 AM, included documentation the nurse assessed the patient still had a PICC line intact under the right arm. 4) A skilled nursing clinical note, titled 14 day comprehensive assessment and completed by a RN, dated 3/23/22, included documentation the nurse did not assess the patient's cardiovascular assessment and edema. The assessment included an assessment of location of lung sounds in "all lung fields", but gave no further information on what type of lung sounds the nurse assessed or if the lung sounds had been diminished. The RN identified the patient had "oral nutrition", but failed to identify the patient's difficulty following or an assessment of the patient's oral intake. The RN documented the initiation of a bowel regimen for the patient and the use of daily stool softeners and suppository as needed, but failed to identify the patient had not had a bowel movement since 3/10/22. The assessment lacked any information regarding whether or not the patient's PICC line was still present. b. The week of 3/13/22 included documentation of the following: A skilled nursing clinical note, dated 3/15/22 at 4:57 PM, included documentation the nurse assessed the patient had 2 open areas on both sides of the inner buttocks. A skilled nursing clinical note, dated 3/15/22 at 5:37 PM, included the documentation of an assessment of one wound on the left buttock (gluteus maximus) which measured 4 cm in length, 3.5 cm in width and 0.01 cm in depth. The clinical notes lacked documentation of any wound measurements for the open wound on the right inner buttock the week of 3/13/22 per hospice policy. b. The week of 3/20/22 included documentation of the following: A skilled nursing clinical note, titled 14 day comprehensive assessment and completed by a RN, dated 3/23/22, lacked documentation of a skin or wound assessment. A separate skilled nursing clinical note, dated 3/23/22 at 2:05 PM, included documentation of a wound assessment and measurements for a wound on the left buttocks which measured 4 cm in length, 5 cm in width and 0.01 cm in depth. The clinical notes lacked documentation of any wound measurements for the open wound on the right inner buttock the week of 3/20/22 per hospice policy. On 3/30/22 at 9:32 AM, during an interview, Staff P, Hospice House RN, reported the patient's wounds were both open the previous week (week of 3/20/22). She reported the patient still had the PICC line in place on the right arm, but it was not in use. On 3/30/22 at 1:10 PM, during an interview, the Administrator agreed the patient had 2 wounds, a right and left buttock wound. She explained the nurses measured the wounds as one wound instead of 2 separate wounds. 2. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: See L0524 for evidence pertaining to initial wound assessment of the left gluteus maximus (buttock). a. The week of 1/2/22 included documentation of 3 skilled nursing visits, dated 1/3, 1/4 and 1/7/22. The skilled nursing visits, dated 1/3 and 1/4/22, lacked any assessment information in relation to the patient's left buttock wound. The skilled nursing visit note, dated 1/7/22, included documentation the nurse assessed the wound did not have drainage and the wound bed was covered 100 percent with epithelial tissue. She continued to classify the wound as a Stage 1. The nurse documented a picture taken of the wound. Review of the picture revealed maceration and loss of skin to the right and left buttocks. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 3 out of 10. The wound assessment lacked any measurements. b. The week of 1/9/22 included documentation of 2 skilled nursing visits, dated 1/10 and 1/13/22. The skilled nursing visit, dated 1/10/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 1/13/22, included documentation the nurse assessed the left buttock wound to measure 6.0 centimeters (cm) in length, 5.0 cm in width and had no depth. The nurse continued to document the wound as a Stage 1. Review of the picture taken by the nurse revealed the wound bed to be red on both the right and left buttock and a loss of a layer of skin at the superficial level. The visit note lacked documentation the nurse assessed both the right and left buttocks and assessed a depth. c. The week of 1/16/22 included documentation of 2 skilled nursing visits, dated 1/17 and 1/21/22. The skilled nursing visit, dated 1/17/22, included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 1/21/22, included documentation the nurse assessed the Stage 1 left buttock wound to continue to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 2 out of 10. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed loss of a layer of skin to both the right and left buttocks and a reddened wound bed. d. The week of 1/23/22 included documentation of 2 skilled nursing visits, dated 1/24 and 1/27/22. The skilled nursing visit, dated 1/24/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 1/27/22, included documentation the nurse assessed the Stage 1 left buttock wound to continue to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 2 out of 10. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed loss of a layer of skin to both the right and left buttocks and a reddened wound bed. e. The week of 1/30/22 included documentation of 3 skilled nursing visits, dated 1/31, 2/3 and 2/4/22. The skilled nursing visits, dated 2/3 and 2/4/22, lacked any assessment information in relation to the patient's left buttock wound. The skilled nursing visit note, dated 1/31/22, included documentation the nurse assessed the wound did not have drainage and the wound bed was covered 100 percent with epithelial tissue. She continued to classify the wound as a Stage 1. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 3 out of 10. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed maceration of the skin with a red wound bed to the right and left buttocks. f. The week of 2/6/22 included documentation of 2 skilled nursing visits, dated 2/9 and 2/11/22. The skilled nursing visit, dated 2/9/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 2/11/22, included documentation the nurse now assessed the left buttock wound to be a Stage 2 pressure ulcer. She continued to assess the wound to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 3 out of 10. The wound assessment lacked any measurements. g. The week of 2/13/22 included documentation of 2 skilled nursing visits, dated 2/14 and 2/18/22. The skilled nursing visit, dated 2/14/22, included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 2/18/22, included documentation the nurse assessed the Stage 2 left buttock wound to continue to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 1 out of 10. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed loss of a layer of skin to both the right and left buttocks and a reddened wound bed. h. The week of 2/20/22 included documentation of 2 skilled nursing visits, dated 2/21 and 2/25/22. The skilled nursing visit, dated 2/21/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the nurse did not assess the patient's wound to the buttocks. The skilled nursing visit note, dated 2/25/22, included documentation the nurse assessed the left buttock wound to be a Stage 2 pressure ulcer. She continued to assess the wound to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was not experiencing pain associated with the wound. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed maceration, loss of a layer of skin to both the right and left buttocks and a reddened wound bed. i. The week of 2/27/22 included documentation of 2 skilled nursing visits, dated 2/28 and 3/3/22. The skilled nursing visits, dated 2/28 and 3/3/22, included documentation the nurse did not assess the patient's wound to the buttocks. j. The week of 3/6/22 included documentation of 2 skilled nursing visits, dated 3/7 and 3/10/22. The skilled nursing visit, dated 3/7/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the patient refused for the nurse to assess the patient's buttock wound. The skilled nursing visit note, dated 3/10/22, included documentation the nurse assessed the left buttock wound to be a Stage 2 pressure ulcer. She continued to assess the wound to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was not experiencing pain associated with the wound. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed maceration, loss of a layer of skin to both the right and left buttocks and a reddened wound bed. k. The week of 3/13/22 included documentation of 3 skilled nursing visits, dated 3/14, 3/15 and 3/17/22. The skilled nursing visit, dated 3/14/22, included identification of the visit as a "recert visit" (comprehensive assessment for recertification of hospice services). The visit notes, dated 3/14 and 3/15/22, lacked documentation of an assessment of the patient's buttocks wounds. The skilled nursing visit note, dated 3/17/22, included documentation the nurse assessed the left buttock wound to be a Stage 2 pressure ulcer. She continued to assess the wound to have 100 percent epithelial tissue and no drainage. The nurse documented the patient was experiencing intermittent pain associated with the wound at a level of 3 out of 10. The wound assessment lacked any measurements. Review of the picture taken by the nurse revealed loss of a layer of skin to both the right and left buttocks and a reddened wound bed. l. The week of 3/20/22 included documentation of 3 skilled nursing visits, dated 3/21, 3/22 and 3/24/22. The skilled nursing visit, dated 3/21/22, included identification of the visit as a "14 day comp assess". The visit note included documentation the patient refused for the nurse to assess the patient's buttock wound. The visit notes, dated 3/22 and 3/24/22, lacked documentation of an assessment of the patient's buttocks wounds. The hospice RN failed to accurately and completely assess the wounds to the patient's right and left buttocks per hospice policy. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient representative interview and hospice staff interview, the hospice failed to: 1) ensure the hospice provided care and services to patients and their families that followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (See L543); 2) ensure the hospice Plan of Care (POC) included all necessary drugs and treatments to meet the needs of the patient (see L549); 3) ensure the medical supplies and appliances necessary to meet the needs of the patient are provided as directed by the Interdisciplinary Group (IDG) in collaboration with the attending physician (see L0550); 4) ensure the hospice IDG members provided all necessary care and services to meet the assessed needs of the patient in accordance with the Plan of Care and IDG meetings (see L0556). 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 and staff interview, the hospice failed to ensure hospice Interdisciplinary Group members provided care in accordance with the patient's plan of care for 3 of 16 sampled (Patients #7, #10 and #11). Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) puts the patient at risk of inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice's policy, titled Interdisciplinary Team Plan of Care, dated 9/2016, identified hospice staff provide care and services to the patient in accordance with an individualized, written plan of care established by the hospice IDG and attending physician. The POC includes drugs and treatments necessary to meet the needs of the patient. 1. Patient #7 had a hospice admission date of 2/17/22, received hospice services from the parent office in Des Moines while residing in an assisted living apartment and died on 2/20/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/17/22 to 5/17/22, identified the patient had an oxygen concentrator with oxygen tanks and that hospice staff would teach the patient/family oxygen therapy safety precautions, but lacked documentation of an oxygen order. b. An interim physician order, dated 2/18/22, included an order for oxygen 2 liters per minute per nasal cannula as needed for dyspnea (difficulty breathing) or air hunger. c. A skilled nursing visit, dated 2/20/22, included documentation the nurse assessed the patient had labored breathing and oxygen on at 3 liters per minute continuously. The visit note lacked documentation the nurse had contacted the physician about the patient's use of oxygen at a rate greater than ordered or obtained an order to alter the POC. On 3/30/22 at 1:10 PM, during an interview, the Administrator reported while she could find the oxygen order for 2 liters per minute as needed, she was unable to find an order to support the patient's use of oxygen at 3 liters per minute. 2. Patient #11 had a hospice admission date of 3/24/22, received hospice services while residing at home until 3/27/22, and then was transferred to the hospice's own hospice house under general inpatient level of care. Review of the clinical record revealed the following: a. The POC, dated 3/24/22 to 6/21/22, included IDG orders for skilled nursing services and for the skilled nurse to manage the patient's skin integrity. b. A skilled nursing clinical note, dated 3/28/22, included documentation the patient had wound to the left anterior knee caused by trauma. The nurse assessed the wound measured 2 centimeters (cm) in length, 3 cm in width and 0.01 cm in depth. The nurse documented she performed wound care, but not the specifics. c. A skilled nursing clinical note, dated 3/29/22, the wound specialist nurse assessed the patient had a skin tear to the left knee and the skin flap remained partially open. The wound specialist nurse documented to cleanse the wound, keep the wound covered with a Mepilex border and change weekly. The clinical record lacked documentation of physician contact or wound care orders. 3. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: The POC, dated 12/28/21 to 3/27/22, included IDG orders for skilled nursing services. The POC included orders for the nurse to assess skin integrity management. A skilled nursing visit, dated 1/4/22, included documentation the patient had an injury to the right elbow due to trauma. The wound measured 5.0 cm in length, 4.0 cm in width and 0.1 cm in depth. The nurse documented she placed a transparent dressing over the wound and took a picture. The clinical record lacked documentation of physician contact or an order for wound care to the right elbow skin tear. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments and/or accurate orders for all medications and treatments to meet the needs of the patient for 2 of 16 sampled patients (Patients #13 and #15). Failure to ensure the plan of care included physician orders for all necessary medications and and complete orders for medications placed patients at risk to receive inappropriate treatment of symptoms. Findings include: Review of the hospice policy, titled Interdisciplinary Team Plan of Care, dated 9/2016, revealed the plan of care includes, but is not limited to: drugs and treatment necessary to meet the needs of the patient. Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice Interdisciplinary Group in collaboration with the patient's attending physician and, if appropriate, the patient or representative and the primary caregiver. The plan of care is reviewed and updated by the Interdisciplinary Group (IDG) every 15 days or more frequently if needed when plan of care changes are made. Review of the hospice policy, titled Physician Orders/Plans of Treatment, dated 3/2017, revealed the contents of the medical plan of care will include a description of the treatment and/or procedures to be done, including when appropriate, the type, frequency and duration and a description of current medication, including name, dose, frequency and route of each medication, as appropriate. 1. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 3/4/22 to 6/1/22, included IDG orders for levsin, lorazepam, naloxone, senokot, tylenol, fexofenadine, levothyroxine, milk of magnesia, melatonin, metoprolol, mirtazapine, pantoprazole, psyllium, and morphine 5 milligrams (mg) every 2 hours as needed for pain. b. Review of the nursing home medication administration record, dated 3/1/22 to 3/31/22, included physician orders for morphine 10 mg every 2 hours as needed for pain and Bisacodyl suppository as needed for constipation with effective dates of 3/4/22. The hospice failed to include all medications the patient was taking at the time of admission on the plan of care. 2. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: The Plan of Care (POC), dated 10/21/21 to 12/19/21, included physician orders for current medications, but also continued to list medications the patient was no longer taking. The POC included the following medications the patient no longer took: multiple different doses of Prednisone ranging from 5 milligrams (mg) to 60 mg multiple doses per day and dating back to orders ending in January 2021, Divalproex 500 mg one time per day ending 1/12/21 and Hydrocodone 5 mg- Acetaminophen 325 mg 1 tablet twice per day ending 10/14/21. The POC failed to only include a current list of medications ordered and taken by the patient. On 3/30/22 at 11:05 AM, during in interview, the Administrator reported the old medications should not have come over to the POC, there is a button to push and it was something the RN did not do when creating the POC. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, home visit observation and patient interview the hospice failed to ensure the Plans of Care for 2 of 16 sampled patients (Patients #2 and #10) 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 Interdisciplinary Team Plan Of Care, dated 9/2016, The plan of care includes, but is not limited to drugs and treatment necessary to meet the needs of the patient; evaluation of the 5 elements of the drug regimen review and medical supplies and appliances necessary to meet the needs of the patient. 1. Patient #2 had a hospice admission date of 3/1/22 and received hospice services out of the Des Moines office and received services in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 3/1/22 to 5/29/22, identified the patient had a wheeled walker for medical equipment and supplies. b. The IDG meeting, dated 3/2/22, did not identify any additional medical equipment and supplies used by the patient. c. The IDG meeting, dated 3/16/22, identified the patient had orders for wound care and supplies. On 3/22/22, during a nursing home visit observation with Staff L, Registered Nurse (RN) the surveyor identified the patient also used a shower bench, hand held shower and grab bars. In an interview, during the same nursing home visit observation, the patient stated he/she had the equipment prior to the start of hospice services. The POC, and IDG meetings to update the POC, failed to identify all medical equipment and supplies used by the patient. 2. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/28/21 to 3/27/22, identified the patient used the following medical equipment and supplies: bed side commode, grab bars, hand held shower, hospital bed, incontinent supplies, oxygen supplies, wheeled walker and nebulizer. b. A skilled nursing visit note, dated 3/22/22, included documentation the patient reported using a gait belt for ambulation due to unsteady gait. c. The IDG meeting, dated 3/24/22, failed to identify the patient was using a gait belt. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, complaint log review, patient representative interview and staff interview, the hospice failed to ensure the patient received hospice services as identified in the comprehensive assessment and Interdisciplinary Group meetings for 2 of 16 sampled patients (Patients #7 and #15). Failure to ensure hospice staff communicate and coordinate assessment findings with all members of the interdisciplinary Group (IDG) increased the risk that care and services did not address all areas of concern and assessed needs of the patient and/or family members. Findings include: Review of the hospice's policy, titled Interdisciplinary Team Plan of Care, dated 9/2016, identified hospice staff provide care and services to the patient in accordance with an individualized, written plan of care (POC) established by the hospice IDG and attending physician. The POC will include a detailed statement of scope and frequency of services necessary to meet the needs of the patient. The IDG will review and update the POC every 15 days or more frequently if needed. Review of the hospice's policy, titled Initial and Comprehensive Hospice Assessment, dated 7/2017, revealed 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 in order to promote the patient's well-being, comfort and dignity throughout the dying process. 1. Patient #7 had a hospice admission date of 2/17/22, received hospice services from the parent office in Des Moines while residing in an assisted living apartment and died on 2/20/22. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 2/17/22 to 5/17/22, included IDG orders for skilled nursing and hospice aide services 5 to 7 days per week starting on 2/17/22. b. The comprehensive assessment completed by Staff I, Registered Nurse (RN), dated 2/17/22, identified the patient had 2 medical power of attorneys (MPOAs) who consented to hospice treatment for the patient. Staff I, RN, assessed the patient was non-responsive, bedbound, dependent on others for movement and care and incontinent of bowel and bladder. Staff I, RN, documented the family wanted hospice aide services. c. The clinical record lacked documentation the patient received hospice aide services. Review of the hospice's complaint log revealed the following: On 2/20/22 (a Sunday), family of the patient called to complain about the nurse who came to see the patient on 2/19/22 (a Saturday). The family reported they had asked Staff H, RN, if the patient could get a bath. According to the family, Staff H, RN, told them there were no bath aide available on the weekends and he would put an order in for a hospice aide to come at the beginning of the week. Staff H did not offer to bathe the patient. Additionally, on 2/19/22, the family reported Staff H, RN, told them the patient's blood oxygen saturation level was 28 percent and the patient would be passing away in the next few minutes. Staff H, RN, then realized after multiple family members had arrived that the blood oxygen saturation level actually read 82 percent and not 28 percent. The family reported Staff H, RN, came on 2/20/22, did not assess the patient's vitals, did not explain what signs and symptoms Staff H assessed and what it meant and did not help or offer to help with repositioning the patient. d. The skilled nursing visit notes completed by Staff H, RN, dated 2/19/22 and 2/20/22, lacked any documentation about a family request for assistance with bathing the patient. The skilled nursing visit, dated 2/19/22, included documentation the nurse assessed the patient had a pulse of 26, respirations of 20, a temperature of 97.9 degrees Fahrenheit and a blood oxygen saturation level of 92 percent. The skilled nursing visit, dated 2/20/22, included documentation the nurse assessed the patient had a pulse of 56, respirations of 24, a temperature of 97.1 degrees Fahrenheit and a blood oxygen saturation level of 78 percent. Staff H, RN, documented on 2/20/22 that he assisted the assisted living facility certified nursing aide with repositioning the patient. On 3/29/22 at 10:15 AM, during an interview, one of the MPOAs, identified as MPOA (1) for the patient reported not being present on 2/19/22 when one of the family members had requested the bath aide to come. MPOA (1) reported hearing about the concern from other family members the next day, but had little information on this. MPOA (1) explained the patient was in excruciating pain when moved and had not been as concerned about the patient getting a bath. On 3/29/22 at 10:25 AM, during an interview, Staff I, RN, reviewed the patient record to remind herself of the patient and confirmed she performed the comprehensive assessment and admission to hospice for the patient. Staff I, RN, explained the patient had a probable stroke and was minimally responsive. She determined the patient was at the End of Days. She further explained during the End of Days, hospice nursing and aide staff, if needed, try to see the patient daily. Staff I, RN, reported the patient also had nursing and aide services from the assisted living staff and lots of family support. She was unsure if it was her or the RN Case Manager, Staff J, that had put in the request for daily hospice aide services. Staff I, RN, reported she did the admissions for the hospice and then the RN Case Managers would take over On 3/29/22 at 10:33 AM, during an interview, Staff J, RN, reported she had been the RN Case Manager for the patient. She reported Staff I, RN, did the initial visit with the comprehensive assessment. She reported Staff I, RN, would have put the initial order in for hospice aide services on 2/17/22. Staff J, RN, confirmed the need for daily aide and nursing visits at the End of Days for the patient. On 3/29/22 at 10:53 AM, during an interview, Staff H, RN, reported not being familiar with the patient at first. He then said he went to the patient's home on Saturday (2/19/22) for a medication refill and then came back on Sunday (2/20/22). He reported MPOA (2) asked him about a hospice aide visit. He further explained there was not a large time frame between when MPOA (2) made the request for the bath aide and the patient died; "maybe 1 to 2 hours". Staff H, RN, denied he told MPOA (2) that the hospice did not have a hospice aide available. He explained he told MPOA (2) the hospice normally does not schedule a hospice aide on the weekend, but that they could get one there. Staff H, RN, explained the hospice does have 2 aides available, and if needed, the hospice will provide the service. When asked about the End of Days for the patient, Staff H, RN, reported it was usual for a nurse to see the patient daily, but he did not know about the hospice aide. He explained he only works weekends, he does not do (create) the patient's care plan and he's not a case manager. On 3/29/22 at 11:27 AM, during an interview, MPOA (2) reported the male nurse (Staff H, RN) came out 2 times on the weekend (2/19 and 2/20/22) and never really checked the patient's vitals. On 2/19/22, MPOA (2) asked Staff H, RN, about bathing the patient. The patient had not had a bath in a week at that point and was in adult diapers (due to incontinence of bowel and bladder). MPOA (2) reported Staff H, RN told MPOA (2) hospice aides did not work the weekend and it would be Monday before a hospice aide could get out to see the patient. Staff H, RN, did not offer to bathe the patient and the patient passed away the next day. MPOA (2) reported the patient's cleanliness had been concerning in regards to the patient's comfort and dignity. On 3/30/22 at 10:29 AM, during an interview, the Administrator reported she addressed the concerns voiced by the family for Patient #7 with Staff H, RN and Staff H, RN, was aware of the complaints made by the family. She confirmed there were 2 hospice aides available on the weekend and the nurse was also able to bath the patient. On 3/30/22 at 3:42 PM, during an interview, the Administrator provided a copy of a written report of concerns addressed with Staff H, RN on 3/14/22. The Administrator was unable to find any information on why hospice staff did not schedule a hospice aide with the patient. 2. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: a. The comprehensive assessment completed by a RN, dated 10/21/21, identified the patient reported experiencing excruciating, unbearable pain with minimal relief from pain medication, applying hot or cold, position changes, rest, distraction and relaxation. The patient rated the intensity of pain on admission at a 6 out of 10 (with 10 being the worst). The patient reported frequent sleep disturbance due to pain. The patient identified the most important thing hospice could do for the patient that day was to provide better pain control. b. The POC, dated 10/21/21 to 12/19/21, included IDG orders for skilled nursing, hospice aide, social worker and chaplain services. The POC also included the following: alternative therapies, the patient would like massage therapy when available. The POC identified the patient reported a 6 level of pain intensity as acceptable. c. The skilled nursing visit notes, dated 10/22, 10/25, 10/27, 11/1, 11/2 and 11/21/21, included a patient pain intensity rating of 9. d. The IDG meeting notes, dated 10/27 and 11/20/21, identified the patient wanted massage therapy when it became available. e. The skilled nursing visit notes, dated 11/5, 11/6, 11/12, 11/13, 11/15 and 11/18/21, included a patient pain intensity rating of 6. f. The skilled nursing visit notes, dated 11/8 and 11/17/21, included a patient pain intensity rating of 8. g. A skilled nursing visit note, identified by the hospice as a 14 day comprehensive assessment, dated 11/22/21, identified the patient continued to want massage therapy services when it became available. The patient reported a pain intensity rating of 6. On 3/30/22 at 11:05 AM, during an interview, the Administrator reported, during the time the patient wanted massage therapy services, the hospice was offering massage therapy to some of it's patients, depending on where the patient's lived. She explained she had 2 massage therapists, one full-time and one part-time. The full-time massage therapist quit and had been providing services to patients in the Des Moines area, Osceola and Jefferson multiple location offices. She reported the part-time therapist kept her caseload and did not take on any more patients. The part-time massage therapist provided massage therapy to patient's in Grinnell, the hospice house and some patient's in Des Moines parent office area. She then reported the part-time therapist had taken on new patient's as other patients died/discontinued services in Grinnell, the hospice house and part of Des Moines. The part-time therapist would take on patient's in some of the other areas especially if there was a patient in excruciating pain. The Administrator reported having had the position posted for massage therapy up until just recently. The part-time massage therapist just accepted the full-time position and the hospice hired another massage therapist to start in April 2022. The hospice IDG failed to ensure a patient received needed hospice massage therapy services. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient interview and hospice staff interview, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 7 of 10 sampled patients receiving hospice aide services (Patients #2, #3, #8, #10, #12, #13 and #15). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient's physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient's needs. Findings include: Review of the hospice's policy, titled Hospice Aide Services and Supervision, dated 9/2016, identified the registered nurse (RN) develops a written hospice aide care plan based on the comprehensive assessment. The written hospice aide care plan provides instructions to the hospice aide to follow. On 3/22/22 at 2:15 PM, during an interview, the Administrator, who also identified herself as the Clinical Manager, reported the Registered Nurse (RN) Case Manager was responsible for creating the hospice aide care plan. 1. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/28/21 to 3/27/22, included IDG orders for hospice aide and skilled nursing services. b. The comprehensive assessment, dated 12/28/21, and the update to the comprehensive assessment, dated 3/14/22, both completed by Staff C, RN, identified the patient needed moderate assistance with a shower and minimal assistance with dressing. c. Review of the hospice aide care plan revealed instructions by the RN to the hospice aide to assist the patient with showering and shampooing hair twice per week and applying lotion every visit. On 3/30/22 at 8:51 AM, during an interview, Staff D, Hospice Aide, reported the patient had difficulty with the right arm and required assistance with taking off and putting on the patient's shirt. On 3/30/22 at 9:01 AM, during an interview, Staff E, Hospice Aide, reported she did assist the patient with dressing and undressing on shower days. On 3/30/22 at 9:08 AM, during an interview, Staff F, Hospice Aide, reported the patient had limited mobility and required assistance with dressing and undressing. On 3/30/22 at 9:45 AM, during an interview, Patient #10 reported due to arthritis in the patient's shoulder, the patient needed help with dressing and hospice aide staff helped the patient with dressing and undressing on shower days. On 3/30/22 at 9:38 AM, during an interview, Staff C, RN, reported while the patient would benefit from assistance with dressing and undressing, and could use some assistance, the patient dresses and undresses by him/herself. The hospice RN failed to include dressing and undressing assistance on the hospice aide assignment. 2. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: a. The POC, dated 10/21/21 to 12/19/21, included IDG orders for hospice aide services three times per week and skilled nursing services. b. The comprehensive assessment completed by a RN, dated 10/21/21, identified the patient required moderate assistance with dressing and undressing. c. The hospice aide care plan, documented on the hospice aide visit notes, dated 10/27, 10/29, 11/1, 11/3, 11/5, 11/8, 11/10, 11/12, 11/15, 11/17 and 11/22/21, included direction for the hospice aide to assist with showering the patient every visit. The hospice aide care plan and visit note documentation lacked direction and documentation on whether or not the hospice aide assisted the patient with undressing and dressing. On 3/30/22 at 9:13 AM, during an interview, Staff G, Hospice Aide, confirmed she had provided hospice aide services to the patient throughout the time the patient received hospice aide services. She reported the patient "definitely" needed assistance with dressing and undressing and she had provided this assistance. The hospice aide care plan failed to include instructions for the hospice aide to assist the patient with dressing and undressing. 3. Patient #2 had a hospice admission date of 3/1/22 and received hospice services out of the Des Moines office while residing in a private residence. Review of the clinical record revealed the following: a. The POC dated 3/1/22 to 5/29/22, identified the patient had a diagnoses of lung cancer and included written instructions to the hospice aide to provide services. b. The comprehensive assessment, dated 3/1/22, identified the patient required moderate assistance with dressing. c. The hospice aide care plan, dated 3/2/22, included registered nurse (RN) instructions to the hospice aide to complete bed bath, shower, shampoo, oral hygiene, nail care and regular diet every visit. d. During an interview on 3/30/22 at 9:20 AM, Staff G, Hospice Aide stated the patient required minimal assistance with dressing. The RN failed to ensure the hospice aide assignment for assistance with dressing to meet the individual needs of the patient. 4. Patient #3, a pediatric patient, had a hospice admission date of 1/17/22 and received hospice services out of the Des Moines office while residing in a private residence. Review of the clinical record revealed the following: a. The POC dated 1/17/22 to 4/16/22, identified the patient had a diagnoses of neuronal ceroid lipofuseinosis and included written instructions to the hospice aide to provide services. b. The comprehensive assessment, dated 1/17/22, identified the patient required compete assistance with dressing. c. The hospice aide care plan, dated 1/17/22, included RN instructions to the hospice aide to complete bath, shampoo, oral hygiene, incontinent care, application of ointment, nail care, linen change and companionship every visit. The RN failed to ensure the hospice aide assignment for assistance with dressing to meet the individual needs of the patient. 5. Patient #8 had a hospice admission date of 2/16/22 and received hospice services out of the Osceola office while residing in a private residence. Review of the clinical record revealed the following: a. The POC dated 2/16/22 to 5/16/22, identified the patient had a diagnoses of heart failure and included written instructions to the hospice aide to provide services. b. The comprehensive assessment, dated 2/16/22, identified the patient required moderate assistance with dressing. c. The hospice aide care plan, dated 2/18/22, included RN instructions to the hospice aide to complete sponge bath or shower, shampoo, oral hygiene, nail care and companionship every visit. The RN failed to ensure the hospice aide assignment for assistance with dressing to meet the individual needs of the patient. 6. Patient #12 had a hospice admission date of 1/20/22, and received services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The hospice aide care plans, dated 1/20/22, 2/3/22 and 3/10/22, included the tasks of shower with assist and bed bath every visit. b. The skilled nursing comprehensive assessment, dated 1/20/22, included documentation the patient required moderate assistance with the task of dressing. During an interview on 3/30/22 at 9:13 AM with Staff G, Hospice Aide, the aide reported helping the patient with dressing. The hospice aide care plan lacked documentation of tasks to assist the patient with undressing and dressing for the shower with assist or bed bath. 7. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 3/4/22, included the tasks of shower with assist and partial bath every visit. b. The skilled nursing comprehensive assessment, dated 3/4/22, included documentation the patient required moderate assistance with the task of dressing. The hospice aide care plan lacked documentation of tasks to assist the patient with undressing and dressing for the shower with assist or partial bath. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review, patient interview 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 4 of 10 sampled patients receiving hospice aide services (Patients #2, #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 Hospice Aide Services and Supervision, Dated 9/2016, hospice aide services are assigned based on the Registered Nurse ) RN's comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living. The RN develops a written hospice aide plan of care that provides instructions to the hospice aide of the care to be provided. The hospice aide's services are ordered by the interdisciplinary group, included in the patient's plan of care, permitted to be performed under State law by such hospice aide, and are consistent with the hospice aide's training/competencies. On 12/6/21 at 12:45 PM, during an interview, the Administrator stated the RN, Case Manager is responsible to create the hospice aide care plan. 1. Patient #2 had a hospice admission date of 3/1/22 and received hospice services out of the Des Moines office while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC) orders, dated 3/1/22 to 5/29/22, included IDG orders for hospice aide services 1 to 3 times per week. b. The hospice aide care plan, dated 3/2/22, included registered nurse (RN) instructions to the hospice aide to complete bed bath, shower, shampoo, oral hygiene, nail care and regular diet every visit. c. The clinical record included documentation of hospice aide visits dated, 3/3, 3/5 and 3/10/22, included documentation the hospice aide completed the tasks of both shower and bed bath during the same visit. Hospice staff failed to identify correct tasks completed during the visit. 2. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/28/21 to 3/27/22, included IDG orders for hospice aide and skilled nursing services. b. The comprehensive assessment, dated 12/28/21, and the update to the comprehensive assessment, dated 3/14/22, both completed by Staff C, RN, identified the patient needed moderate assistance with a shower and minimal assistance with dressing. Both assessments identified the patient had a wound or wounds on the patient's coccyx. c. Review of the hospice aide care plan revealed instructions by the RN to the hospice aide to assist the patient with showering and shampooing hair twice per week and applying lotion every visit. d. An interim physician order, dated 2/11/22, included orders to apply Calmoseptine 0.44 percent-20.6 percent topical ointment 2 times per day as needed for redness on buttocks. On 3/30/22 at 8:51 AM, during an interview, Staff D, Hospice Aide, reported she had not been applying Calmoseptine on the patient's coccyx wound. On 3/30/22 at 9:01 AM, during an interview, Staff E, Hospice Aide, reported she had been applying Calmoseptine to the patient's coccyx wound after assisting the patient with a shower. She did not apply the Calmoseptine on non-shower days. She reported the patient or family applied the medicated ointment on non-shower days. On 3/30/22 at 9:08 AM, during an interview, Staff F, Hospice Aide, reported she had not assisted the patient with a shower or with applying Calmoseptine. On 3/30/22 at 9:45 AM, during an interview, Patient #10 reported due to arthritis in the patient's shoulder, the patient needed help with dressing and hospice aide staff helped the patient by applying Calmoseptine to the patient's buttocks on shower days. On 3/30/22 at 9:38 AM, during an interview, Staff C, RN, reported being unaware of hospice aides applying Calmoseptine. She reported the patient or the patient's family applied the Calmoseptine. A hospice aide applied medicated ointment with written or verbal direction from a RN. 3. Patient #12 had a hospice admission date of 1/20/22, and received services from the parent office while residing in a nursing home. Clinical record review revealed the following: a. The hospice aide care plans, dated 1/20/22, 2/3/22 and 3/10/22, included the tasks of shower with assist and bed bath every visit. b. The hospice aide visit notes, dated 1/24/22, 1/26/22, 3/4/22, 3/13/22 and 3/22/22, documented the shower with assist and the bed bath were completed. During an interview on 3/30/22 at 9:13 AM with the Administrator, she agreed only one bath type should be marked as completed. The aide visit notes failed to correctly identify which bath type had been provided for the patient. 4. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. The hospice aide care plan, dated 3/4/22, included the tasks of shower with assist and partial bath every visit. b. The hospice aide visit note, dated 3/12/22, documented the shower with assist and the partial bath were completed. The aide visit notes failed to correctly identify which bath type had been provided for the patient. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review and policy review, the hospice failed to ensure patient clinical records included a physician order for all treatments for 2 of 16 sampled patients (Patients #10 and #13). 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 policy, titled Physician Orders/Plans of Treatment, dated 3/2017, revealed the contents of the medical plan of care (initial plan of care and subsequent/verbal/interim orders) will include: a description of the treatment and/or procedures to be done, including when appropriate, the type, frequency and duration; who is to perform the treatment or procedure if applicable; and a description of current medication, including name, dose, frequency and route of each medication, as appropriate. 1. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. a. Review of the nursing home medication administration record, dated 3/1/22 to 3/31/22, included orders for oxygen per nasal cannula, titrate to keep oxygen saturation greater than 90%, with an effective date of 3/18/22. b. Clinical record review revealed: i. Skilled nursing visit note, dated 3/21/22, included documentation the patient was using oxygen at 1.5 liters per nasal cannula. ii. The Interdisciplinary Group (IDG) meeting note, dated 3/23/22, lacked documentation of an order for oxygen for use by the patient. The clinical record lacked documentation of a physician order for oxygen for the patient. 2. Patient #10 had a hospice admission date of 12/28/21 and received hospice services from the Grinnell office while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/28/21 to 3/27/22, included IDG orders for skilled nursing services. b. A skilled nursing visit note, dated 3/15/22, included documentation the patient reported symptoms of a urinary tract infection. The nurse documented she contacted the hospice Medical Director. She documented the Medical Director told her to obtain a urinary analysis (UA). c. The clinical record lacked documentation of an order for there nurse to obtain a UA. On 3/30/22 at 10:15 AM, during an interview, the Administrator agreed to look for the UA order in the patient's clinical record. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, staff interview and hospice policy review the hospice failed to ensure all entries completed in the clinical records included an appropriate date and signature and completed timely for 4 of 16 sampled patients (Patients #3, #4, #13 and #14). 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 Entries Into Clinical Record, dated 7/2021, when patient record are signed electronically, the electronic signature must be appropriately authenticated and dated. Authentication must include signatures, written name or initials, or computer secure entry by a unique identifier of a primary author who has reviewed and approved the entry. Safeguards must be in place to prevent unauthorized access to the records and process for reconstruction of the records in the event of a system breakdown. During an interview on 3/21/21 at 2:15 PM, the Administrator stated hospice visit notes are expected to be completed in 2 business days. Admission assessments are to be completed in 5 business days. 1. Patient #3 had a hospice admission date of 1/17/22 and received services out of the Des Moines office while residing in a private residence. The clinical record review revealed the following a. Skilled Nurse Visit Note, dated 2/1/22, documented completed on 2/8/22, 3 business days late. 2. Patient #14 had a hospice admission date of 4/24/22 and received services while residing in a nursing home. The clinical record review revealed the following: a. Music therapy note, dated 4/29/21, included a handwritten signature and date of signature but lacked a title. 3. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. Clinical record review revealed: a. Skilled nursing visit note, dated 3/23/22, lacked documentation of the nursing visit and was not locked as of 3/30/22, the date the surveyor reviewed the clinical record. The visit note failed to be completed within 2 business days as required by agency expectation. b. Music therapy visit notes, dated 3/7/22 and 3/21/22, included electronic signature that included the staff name and date but lacked identification of the staff title. c. Paper volunteer visit note, dated 3/16/22, included the volunteer handwritten signature and date, and the volunteer coordinator handwritten signature and date, but lacked documentation of the volunteer coordinator title. 4. Patient #4 had an admission to hospice on 6/14/21 and received services from the multiple location office in Grinnell while residing in a nursing home. Clinical record review revealed paper volunteer visit notes, dated 2/12/22, 2/19/22, 2/26/22 and 3/5/22, included the volunteer handwritten signature and date, and the volunteer coordinator handwritten signature and date, but lacked documentation of the volunteer coordinator title. The Hospice Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the hospice staff sent a discharge summary to for 1 of 2 sampled (live) discharged patients (Patient #15) who revoked hospice services. Failure to ensure the hospice staff sent the attending physician a copy of the patient's discharge summary placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patients. Findings include: Review of the hospice's policy, titled Discharge from Hospice, dated 2/2018, revealed upon live discharge, hospice staff will provide the patient's attending physician with a copy of the patient's medical record if requested and a discharge summary that includes the current plan of care (POC), any advance care planning, medication profile, latest physician orders, current status of patient, brief summary of hospice services provided and any other documentation that will assist with post-discharge planning. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/21/21 to 12/19/21, included IDG orders for skilled nursing, hospice aide, social worker and chaplain services. b. A skilled nursing visit note, dated 11/23/22, included documentation which identified the patient's family determined to revoke hospice services due to actively wanting to seek treatment. c. The clinical record lacked documentation hospice staff sent a discharge summary to the patient's physician. On 3/30/22 at 10:11 AM, during an interview, the Administrator reported hospice staff did send a discharge summary or any other information. The nurse thought that because the patient revoked hospice services, she did not need to complete a discharge summary. The Administrator received the above findings and Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review 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 2 sampled discharged patients (Patient #15) 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: Review of the hospice's policy, titled Discharge from Hospice, dated 2/2018, revealed upon live discharge, hospice staff will provide the patient's attending physician with a copy of the patient's medical record if requested and a discharge summary that includes the current plan of care (POC), any advance care planning, medication profile, latest physician orders, current status of patient, brief summary of hospice services provided and any other documentation that will assist with post-discharge planning. Patient #15 had a hospice admission date of 10/21/21, received hospice services while residing in a private residence from the Jefferson multiple location office and revoked hospice services on 11/23/21. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 10/21/21 to 12/19/21, included IDG orders for skilled nursing, hospice aide, social worker and chaplain services. b. A skilled nursing visit note, dated 11/23/22, included documentation which identified the patient's family determined to revoke hospice services due to actively wanting to seek treatment. c. The clinical record lacked documentation hospice staff completed a discharge summary. On 3/30/22 at 10:11 AM, during an interview, the Administrator reported hospice staff did not complete a discharge summary. The nurse thought that because the patient revoked hospice services, she did not need to complete a discharge summary. The Administrator received the above findings and Hospice staff provided no further information prior to the end of the survey.

Based on clinical record review, nursing home medication and treatment administration records, hospice policy review and hospice staff interview, the hospice failed to ensure hospice staff provided overall coordination of the hospice care with the nursing home for 1 of 2 sampled patients (Patient #13) with a review of the patient's nursing home record. Failure to ensure the hospice staff provided overall coordination of patient care with the nursing home placed the patient at risk for not receiving care and/or treatment according to the hospice philosophy. Findings Include: According to the hospice policy, titled Coordination of Care/Services with Contracts/Agreements, dated 7/2016, the Hospice program retains responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in all settings through its Performance Improvement Program. Patient #13 had a hospice admission date of 3/4/22 and received hospice services from the parent office while residing in a nursing home. 1. Review of the nursing home medication administration record, dated 3/1/22 to 3/31/22, revealed an order for atropine sulfate solution 1%, give 2 drops sublingually every 8 hours as needed for secretions, with an effective date of 3/17/22; and an order for lorazepam 0.5 mg tablet, give 1 tablet every 6 hours for restlessness, with an effective date of 3/23/22. 2. Clinical record review revealed: a. Skilled nursing visit note, dated 3/21/22, included documentation a nursing visit was completed but lacked documentation of the atropine order on 3/17/22. b. Skilled nursing visit note, dated 3/23/22, lacked documentation a nursing visit had been completed or documentation of the atropine order on 3/17/22 or the lorazepam order on 3/23/22. c. Interdisciplinary Group meeting note, dated 3/23/22, lacked documentation of the orders for atropine on 3/17/22 or lorazepam on 3/23/22. The hospice failed to coordinate care with the nursing facility staff providing care for Patient #13. The above findings were reviewed with the Hospice Administrator, no further information was provided prior to the end of the survey.

Based on hospice clinical record review, hospice policy review, long term care (nursing home) clinical record review and hospice staff interview, the hospice failed to ensure the nursing home where hospice patients resided received all required hospice documentation for 1 of 2 sampled patients who received a facility record review (Patient #4). Failure to communicate hospice information to nursing home staff placed patients at risk to not receiving necessary care and services. Findings include: According to the hospice policy, titled Coordination of Care/Services with Contracts/Agreements, dated 7/2016, the Hospice program retains responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in all settings through its Performance Improvement Program. Patient #4 had an admission to hospice on 6/14/21 and received services from the multiple location office in Grinnell while residing in a nursing home. During an onsite visit on 3/24/22 at 10:55 AM, Staff K, Registered Nurse, (RN), reviewed the hospice documentation provided to the facility with the surveyor, Staff K and the surveyor were unable to locate the certification of terminal illness for December 2021. Staff K reported the hospice prints off all electronic documentation and provides to Staff K to hand deliver to the facility. Staff K reported not reviewing documentation taken to the facility. The above findings were reviewed with the Hospice Administrator, no further information was provided 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 J, Registered Nurse) who began providing services to hospice patients since their last survey, dated 3/21/19. The hospice reported using a total of 6 contract staff, 3 of whom 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 J, Registered Nurse (RN) revealed a contract start date of 10/4/21. The personnel file lacked documentation of a criminal background check completed through either SING or DCI. On 3/30/22 at 4:50 PM, during an interview, the Administrator reported neither the hospice nor the contract company had documentation of a criminal background check completed through either SING or DCI. On 3/31/22 at 8:40 AM, the Administrator reported hospice staff have now requested a criminal background check through 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 J, Registered Nurse) who began providing services to hospice patients since their last survey, dated 3/21/19. The hospice reported using a total of 6 contract staff, 3 of whom 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 J, Registered Nurse (RN) revealed a contract start date of 10/4/21. The personnel file lacked documentation of a dependent adult abuse or child abuse background check completed through either SING or DHS. On 3/30/22 at 4:50 PM, during an interview, the Administrator reported neither the hospice nor the contract company had documentation of a dependent adult abuse or child abuse background check completed through either SING or DHS. On 3/31/22 at 8:40 AM, the Administrator reported hospice staff have now sent a request to DHS for the dependent adult and child abuse background checks. The Administrator received the above findings and hospice staff provided no further information prior to the end of the survey.

Based on record review and interview, the facility failed to maintain the battery-backup emergency lights in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 7.9.2.1 and 19.2.9.1, by not ensuring emergency illumination be provided for a minimum of 1 1/2 hours in the event of failure of normal lighting. This deficient practice affects 5 patients in 3 of 3 zones. The facility had a capacity of 12 and a census of 5 residents at the time of the survey. Findings include: Record review and interview on 03/29/22 at 2:35 p.m., revealed the facility failed to provide documentation of monthly (30 second) and annual (90 minute) tests of the battery-backup emergency lights. Administrative Staff A and Maintenance Staff A verified these observations at the time of the survey process.

Based on record review and interview, the facility failed to maintain the sprinkler system in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.1.1.2, by ensuring that the sprinkler system was inspected and tested at least quarterly. This deficient practice of failing to provide complete, verifiable documentation on the maintenance and repair history did not ensure proper operation and prompt repair of the system. This deficient practice affected 5 patients in 3 of 3 zones. The facility has a capacity of 12 and a census of 5 patients at the time of the survey. Findings include: Record review and interview on 03/29/22 at 2:03 p.m., revealed the facility failed to provide documentation of quarterly maintenance of the sprinkler system for the 4th quarter of 2021. Administrative Staff A and Maintenance Staff A observed this finding.

Based on interview and record review, this facility did not assure that a complete policy is in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than 10 hours in any 24-hour period in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, Chapter 15. Lack of complete written policies and procedures could result in staff failing to implement interim safety measures in the event of an emergency. This deficient practice affects 5 patients in 3 of 3 zones. This facility had a capacity of 12 and a census of 5 patients at the time of the survey. Findings include: Record review and interview on 03/29/22 at 1:45 p.m. of the fire watch procedures revealed the facility did not have a complete policy regarding the procedures to be taken in the event that the sprinkler system was out of service for more than 10 hours in a 24-hour period. The policy failed to have the following information included in their policy as required by NFPA 25, 2011 Edition (Chapter 15): 1. The sprinkler system outage policy did not address contacting the Iowa Department of Inspections and Appeals. 2. The sprinkler system outage policy failed to designate an impairment coordinator. 3. The sprinkler system outage policy failed to address a tag impairment system. 4. The sprinkler system outage policy failed to address system leakage, interruption of water supply, ruptured piping, or equipment failure. 5. The sprinkler system outage policy failed to address contacting the Iowa State Fire Marshal, the Iowa Department of Inspections and Appeals, the facility's insurance carrier, and the local fire department at the conclusion of the fire watch. 6. The sprinkler system outage policy stated fire watch rounds shall be completed every 30 minutes. However, the policy failed to state fire watch rounds shall be continuous with rounds of the affected areas completed at least every 30 minutes. Administrative Staff A and Maintenance Staff A observed these findings.

Based on record review and interview, the facility failed to hold fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, 19.7.1.6. This had the potential of affecting staff preparation and experience in providing for the protection of all residents in the event of a fire. This deficient practice affects 5 patients in 3 of 3 zones. The facility had a capacity of 107 and a census of 5 residents at the time of the survey. Findings include: Record review and interview on 03/29/22 at 2:06 p.m., of the facility fire drill documentation revealed the following deficiencies: 1. No documentation of fire drills conducted on the 2nd and 3rd shifts of the 3rd quarter of 2021. Results of the record review were acknowledged by Administrative Staff A and Maintenance Staff A.