Every finding on record at Visiting Nurse Services of Iowa

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following, Intervention to manage pain and symptoms, and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 26 (12%) clinical records reviewed it was revealed that the agency did not ensure that the plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. CLINICAL RECORD 1: The patient elected hospice services on 01/23/2025 with a diagnosis of Malignant neoplasm of lower-outer quadrant of right female breast. During the initial nursing assessment on 01/23/2025 the RN documented that the patient was having issues with getting her pain managed specifically "pain in upper right shoulder, shooting pain and into back also pain in torso." On 01/30/2025 the RN documented "Tramadol not working well, states she has been using 2 tablets. Pain gets up to 7 or 8." Medication changes were made on this visit to Dilaudid 2mg. On 02/02/2025 the RN documented "patient reports she started out taking a half tab of Dilaudid but is now taking a whole tablet about 2 to 3 times a day." On 02/11/2025 the RN documented "pain reported down the right ribs, taking Dilaudid 2mg 3 times a day." On 02/17/2025 the RN documented "patient would like a long-acting pain medication due to increased pain." Morphine ER was started on this date. On 03/11/2025 the Morphine ER was discontinued and Fentanyl 15mcg was added. The problem of pain was identified on the plan of care however during interview and joint review with the VP of clinical services there was no evidence documented of specific measurable patient goals or interventions documented on the plan of care. The patient was also admitted to hospice services with a peritoneal dialysis catheter. She manages her own dialysis at night. During joint review of the clinical record and interview with the VP of clinical services it was revealed there was no documented evidence of any monitoring or care for the peritoneal catheter. During the interview with the VP of clinical services on 03/12/2025 she agreed that there should have been risk for peritonitis and the RN should have been monitoring for signs and symptoms of infection as well as fluid overload due to her kidney failure. CLINICAL RECORD 8: The patient elected hospice services on 12/10/2024 with a diagnosis of Malignant neoplasm of the prostate. The RN documented that the patient had a wound on her left buttock and right heel. During joint review of the clinical record and interview with the VP of clinical services on 03/12/2025 there was no documented evidence of any measurable goals for the patient's wound.   CLINCIAL RECORD 25: The patient was admitted to the IPU with uncontrolled pain and was receiving dilaudid. Pain was identified as a problem and there was no documented measurable goal to achieve to ensure the patient's pain was managed.

It is required that Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) bereavement records reviewed it was revealed that the agency did not ensure that a bereavement plan of care was developed for the bereaved. CLINICAL RECORD 23: The patient elected the hospice benefit on 09/06/2024 and expired on 09/30/2024. A phone call was made to the family on 10/04/2024 by the bereavement coordinator and it was documented as, "condolence call - left voicemail - will reach out for the bereavement assessment in the next few weeks." During joint review of the record and interview with the VP of Clinical services there was no documented evidence found that there were any follow up phone calls or bereavement services offered to this family.

Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure the individualized plan of care was reviewed and revised based on the comprehensive assessment at least every 15 days for 1 of 6 sampled patients (Patient #3). Failure of the interdisciplinary group (IDG) to review and update the individualized plan of care at least every 15 days placed hospice staff at risk of not knowing what care and services to provide to meet the patient's assessed needs and/or placed the hospice patients at risk for not receiving appropriate care to have their needs met. Findings include: --- Review of the hospice policy titled Care Coordination, Care Planning and IDG, dated 6/17/24, identified the IDG, in collaboration with the patient's attending physician reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. Patient #3 had a start of care date of 8/30/23 and received hospice services in a private home prior to moving to a skilled nursing facility on 9/26/24. Clinical record review revealed documentation of IDG meetings on 9/17/24 and 10/9/24, 22 days apart, which exceeded the requirement by 7 days. On 10/22/24 at 11:42 AM, during an interview, Staff A, Vice President of Clinical Services identified an IDG meeting was missed due to the patient moved into a skilled nursing facility which placed the patient on a different team with a different IDG meeting day. The above findings were shared with the Vice President of Clinical Services and the Quality Management Director.

Based on hospice policy review, clinical record review, and hospice staff interview, the hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 4 sampled patients (Patient #4). Failure of the hospice to maintain a system for communication and integration of patient care and services to ensure staff provide care in accordance with the plan of care placed patients at risk to not receive services and medications according to assessed needs and physician orders. Findings include: --- Review of the hospices policy, titled, Care Coordination, Care Planning, and IDG, dated 11/14/18, all care and services furnished to patients and their families follows the individualized written plan of care (POC) established by the Interdisciplinary Group (IDG) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patients needs. The IDG, in collaboration with the patients attending physician, reviews, revises, and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15 calendar days. Review of the hospices policy, titled, Physician Orders, dated 11/1/22, verbal orders are put in writing and signed and dated by qualified staff responsible for furnishing or supervising the care. 1. Patient #4 had a hospice admission date of 1/11/24 and received hospice services while residing at home. Review of the clinical record and interview with staff revealed the following: a. The POC, dated 1/11/24 to 4/6/24, included orders for Morphine Sulfate (MS) (concentrate) by mouth solution 20 milligrams (MG)/millileters (ML) 3 times a day by mouth per request as needed (PRN) for air hunger/pain. b. The Team Director (TD) phone call note, dated 1/15/24, revealed patients spouse was concerned about running out of MS. Spouse reported 15ml left in bottle. TD informed spouse that equates to about 30 doses so about 1 week of 0.5ml 4 times a day. Spouse indicated pulmonologist said patient could take MS 4 times a day but the chart still reads 3 times a day. TD reported the nurse visiting on Wednesday (1/17/24) would address this further. c. Staff C, Registered Nurse (RN), note dated, 1/17/24, did not indicate any changes in orders or POC to reflect patients current MS usage. d. Staff C, RN, visit note dated, 1/19/24, revealed collaboration regarding MS script and progress. The RN noted the doctors office returned call during visit and gave verbal confirmation previous requests received by RN and order in progress will be ready later today. e. The IDG notes dated, 1/24/24 and 2/7/24, revealed no updates to the POC regarding increased frequency of MS. f. The medical record lacked any written documentation of the verbal orders given regarding MS frequency being changed. g. During an interview on 2/14/24 at 3:12 PM, with agency Regional Director (RD), RD reported Staff C, RN, confirmed receipt of new verbal order for MS 20 mg/ml 4 times a day by mouth PRN for air hunger/pain, on 1/19/24. Staff C reported failure to enter the verbal order into patient record and Staff C failed to update the POC. The hospice agency failed to follow the plan of care and failed to update the plan of care with new physician orders. The above findings were reviewed with the hospice Regional Director. Hospice staff did not provide any additional information prior to end of the survey.

Based on clinical record review, hospice policy review and staff interview, the hospice failed to ensure the hospice Interdisciplinary Group reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included the patient's progress towards outcomes and goals for care and services specified in the plan of care for 3 of 6 sampled patients (Patients #1, #3 and #6). Failure of the hospice to ensure the Interdisciplinary Group (IDG) reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included patients' progress towards outcomes and goals for care and services provided by the hospice placed patients at risk to not receive care and services based on their current assessed needs. Findings include: --- According to the hospice's policy, titled Assessment-Initial and Comprehensive, dated 8/31/21, the comprehensive assessment will include date elements that allow for measurement of outcomes. The hospice will measure and document data in the same way for all patients. The data elements will take into consideration aspects of care related to hospice and palliation. The data elements for each patient will be used in individual patient care planning and in the coordination of services and will be used in the aggregate for hospices quality improvement program. During an interview on 9/5/23 at 1:30 PM, the Administrator stated the hospice has a discussion of all the services provided to the patients during the IDG meetings. 1. Patient #1 had a hospice admission date of 7/24/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 7/24/23 to 10/21/23, included IDG orders for skilled nursing, social worker, spiritual care, hospice aide and volunteer services. b. The IDG meeting, dated 8/2/23 and 8/16/23, included documentation of interventions and outcome goals for skilled nursing, social worker, spiritual care, hospice aide and volunteer services, but lacked any documentation of updates regarding the services. The hospice failed to include updates to the Plan of Care for skilled nursing, social worker, spiritual care, hospice aide and volunteer services. 2. Patient #3 had a hospice admission date of 8/21/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 8/21/23 to 11/18/23, included IDG orders for skilled nursing, social worker, spiritual care and hospice aide services. b. The IDG meetings, dated 8/23/23, included documentation of interventions and outcome goals for skilled nursing, social worker, spiritual care, hospice aide and volunteer services, but lacked any documentation of updates regarding the services. The hospice failed to include updates to the Plan of Care for skilled nursing, social worker, spiritual care and hospice aide services. 3. Patient #6 had a hospice admission date of 3/21/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 3/21/23 to 6/15/23, included IDG orders for skilled nursing, social worker, spiritual care, hospice aide and massage therapy. b. The IDG meeting, dated 5/10/23, 5/24/23, 6/7/23 and 6/21/23, included documentation of interventions and outcome goals for skilled nursing, social worker, spiritual care, hospice aide and massage therapy services, but lacked any documentation of updates regarding the services. The hospice failed to include updates to the Plan of Care for skilled nursing, social worker, spiritual care, hospice aide and massage therapy services. The above findings were reviewed with the Administrator. Hospice staff provided no further information prior to the end of the survey.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by review of clinical record, and interview that in 1 of 13 (7%) records in which a hospice aide was accepted for care, revealed a lack of clear and specific written instruction for the aide assignment, thus leaving the aide to make decisions outside of the aide scope of practice. Record #82108: The hospice aide plan documented 11/12/2021 with assigned tasks not limited to shower, shampoo every visit. The patient developed a left heel ulcer on 12/04/2021 that involved a Kling dressing but the aide plan was not updated for direction during the shower of how to protect this heel dressing or what to do if this dressing fell off or was saturated. On 12/16/2021 a Foley catheter was inserted but the aide plan was not updated for the Foley catheter care and how to manage the catheter during the ordered bath of a shower. Interview with the Regional Director and Vice President of Clinical Services stated that the nurse would have called the aide but that the aide plan should have been updated and specific

It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by review of clinical record, and interview that in 2 of 13 (15%) in which an aide provided service failed to document the aide compliancy with the assigned plan visit frequency or to document the reason it was not followed. Record # 67511 with aide ordered frequency of two times a week. The week beginning 08/29/2021 the aide provided one visit and not the second visit, with no documentation for why the second visit was not provided. Record #28883 with aide ordered frequency of one time a week. The week of 09/05/2021 no visit was provided and no documentation for why the visit was not provided. Interview with the Regional Director and Director of Quality stated that we have reached out to the branches and the supervisors have agreed there is not documentation for why the visits were missed.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by review of clinical record, and interview that in 3 of 13 (23%) records in which aide services were accepted for care, failed to document that the aide reported to the nurse when tasks were not completed that were assigned each visit for the aide. Record #67511 with assigned tasks not limited to shower, bed bath each visit. Aide visits 09/30/202, 09/28/2021, and 09/23/2021 'HC" [HC is patient refused] was documented and the nurse or case manager were not updated that the task was not provided. Record #44257 with assigned tasks not limited to partial bed bath, shampoo, oral care and lotion to skin assigned every visit. Aide visit 06/10/2022 partial bath refused, 06/01/2022 partial bed bath and shampoo refused, and visit 05/20/2022 partial bed bath, oral care, lotion to skin all refused by the patient and the nurse or case manager were not updated that the task was not provided Record #82108 with assigned tasks not limited to shower, shampoo every visit. Aide visit 12/20/2021 was documented patient refused shower, 12/09/2021 shampoo refused by patient, 11/22/2021 shower documented as DK [ demonstrate knowledge] and 11/19/2021 NA [not applicable] for shower and shampoo. The nurse or case manager were not updated that the task was not provided. Interview with Regional Director stated that the nurse was likely updated but agreed that the documentation of this was not documented

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: Current subjective and objective medical findings. This standard was not met as evidenced by review of clinical record, document review and interview that in 1 of 16 (06%) of records reviewed the physician signed certification of terminal illness did not document current subjective and objective medical findings. Agency Policy HOS-CM-74 [review date 08/31/2021] stated in part, " The duties and responsibilities of the Medical Director include, but not limited to including current subjective and objective findings." Record #87783 with a physician signed certification of terminal illness (CTI) on 02/11/2022 documented, "6 month terminal diagnosis." No supportive information documented on the CTI. Interview with the Regional Director on 06/16/2022 stated that the patient was under the PACE program who was the only payor source so the CTI was computer generated and had no additional information on it.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: A copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by review of clinical records, document review and interview that 1 of 2 (50%) of live discharged patients failed to document that the discharge summary was sent to the primary care physician. Agency Policy HOS-CM-5 [effective date 03/31/2021] stated in part, "A copy of the discharge summary and the patient's clinical record (if requested) is sent to the patients physician. Record #87783 who revocated on 02/18/2022 and printed 02/19/2022 but no evidence of documentation that the summary was sent to the primary care physician as of review 06/16/2022. Interview with the Regional Director who communicated with the Branch Director stated that no documentation was located that the summary was faxed to the primary care physician.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are: Checked for expiration dates. This standard was not met as evidenced by observation during site visit and interview with the Facility Director that in 1 of 2 (50%) facilities observed failed to check all patient supply areas for expirations dates. The hospice owned in patient unit toured on 06/15/2022 had a zip lock bag on the patient supply area with six Kaltostat dressing [primary dressing for the management of heavily exuding wounds], that expired on 10/10/2020. The director of the facility disposed of these. Interview with the director of the facility stated that the supplies should not have been on the shelf.

It is required that the hospice inpatient facility provides meals to each patient that are: Obtained, stored, prepared, distributed, and served under sanitary conditions. The Interdisciplinary Group (IDG) is kept informed of the patient’s response to their prescribed diet. This standard was not met as evidenced by observation during agency owned in patient unit that was toured on 06/15/2022. During 2 of 2 (100%) agency owned in patient units had food in the patient/family area refrigerator with open bottles with no label of date opened, or who the bottle belonged to. Both refrigerators observed had large signs posted on the door, "3 day rule, all food items must be labeled with the date opened and the room number of the patient." In patient unit #1 observed during tour 06/15/2022 an open 28 ounce bottle of ranch dressing had no label of owner or date opened. In patient unit #2 observed during tour 06/15/2022 and open 28 ounce bottle of ranch dressing and a 12 ounce bottle of catchup with no label of owner or date opened. In the kitchen on a shelf of dry goods was a large box of Rice Krispy cereal that was opened with no label of date opened. The staff in the kitchen stated that they were not sure when the box had been opened and would dispose of it. Interview with the Directors from the facilities stated that all food should be labeled and that they work to assure that it is.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by review of clinical records, document review and interview that in 1 of 4 (25%) of records in which a patient was in a skilled facility failed to document the responsibility of wound care to be provided for the patient. Agency Policy HOS-COS -70 [review date 05/20/2022] stated in part, "The hospice plan of care will identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the plan of care. Record #66464 documented wound care for a left elbow wound that started 08/13/2021 and continued through 06/01/2022 with no identification in the plan of care of who was responsible for the dressing change that was daily and at times three times a week. Documentation of wound status did progress to healed by 06/01/2022 with no evidence of infection during the time period of care. Interview with the Regional Director stated that the specific facility provided the wound care for all of their patients but agreed that it was not documented.