Every finding on record at Winneshiek Medical Center

Observed in Record Review. In 10 of 10 patient records reviewed, the hospice had not provided a written description of state law concerning advance directives. In review of the hospice admission packet and in discussion with the Home Health & Hospice Director there was no evidence that the organization had provided a written description of Iowa state law concerning advance directives. This occurred in 10 out of 10 records reviewed.

Observed in Record Review. In 10 of 12 patient records reviewed, the hospice did not include measurable goals for all disciplines/services included on the plan of care. In review of the medical record for HOSRRHV #1 the surveyor noted that Music and Pet Therapy were included on the plan of care 3-5 times per month and had included interventions however there was no evidence of documented goals for either service. Additionally in review of the medical record for HOSRRHV #2 the plan of care did not include goals for Massage Therapy which was ordered 3-5 times per month. This was also observed in review of the medical records for HOSRRHV #3 HOSRRNHV #1, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #5, HOSRRNHV #6, HOSDC #8 and HOSDC #9. This was validated with the Home Health & Hospice Director.

Observed in Data Session. The organization's governing body had not evaluated and approved the Hospice Quality Assessment and Performance Improvement (QAPI) program. In review of the governing board meeting minutes there was no documentation to indicate that they had evaluated and approved the Hospice QAPI plan including performance improvement projects and frequency of data collection for 2026, 2025 or 2024. This was validated with the Home Health & Hospice Director.

Observed in Document Review. The hospice had not documented its efforts to recruit and retain volunteers. The Home Health & Hospice Director reported that the Volunteer Coordinator for the hospital does the recruitment for the hospice volunteers however there is no documentation of recruitment efforts.

Observed in Data Session. Volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. In review of the Volunteer Program the hospice documented a 4.7 % cost savings for 2025. This was validated with the Home Health & Hospice Director.

Observed in HR File Review. In 5 of 8 HR files reviewed, the hospice did not have written policies and procedures that describe its method of assessing skills and competence for all individuals furnishing care and services, including volunteers. In review of the personnel records for the hospice social worker, hospice medical director, hospice chaplain, music specialist and hospice volunteers there was no evidence that competencies had been assessed or that there was a process in place for assessing skills and competence of those disciplines. This was validated with the Home Health & Hospice Director.

Observed in Record Review. In 1 of 3 home visits conducted, for patients who resided in Skilled Nursing Facilities (SNF), the hospice had not provided the skilled nursing facility with all required documents. In review of the SNF medical record for HOS RRHV #3 and in discussion with the Director of the SNF there was no evidence that the SNF had been provided with the physician certification and recertification of the patient’s terminal illness. This was validated with the Home Health & Hospice Director.

Observed in Record Review. In 1 of 13 records reviewed, the initial bereavement assessment was not completed. Agency policy states that the social worker will assess bereavement risk as part of patient's comprehensive assessment. On review of HSRR #13, the patient was admitted to service and an initial bereavement assessment was not completed. This finding was reviewed with the Hospice Director.

Observed in Record Review. In 6 of 13 patient records reviewed, the Hospice surveyor noted the goals in patient records were not specific to the intervention and care needs of the patient. For example, in HSHV/RR #1, the patient was a fall risk and had Alzhiemers and had interventions including chair alarm but there were no goals related to falls. On review of HSHV/RR #2, the patient has had falls and also has transitioned to bed bound and there is no goals related to fall prevention or skin integrity. On review of HSRR #6, the patient was on oxygen but there were no goals related to the oxygen. On review of HSRR # 9, the patient had a history of recent falls but there were no goals related to falls. On HSRR #10, patient had history of falls and issues with constipation but no goals related to either issue. On HSRR #13, the patient had a urinary catheter and pain issues and there were no goals related to either issue. This was reviewed with the Hospice Director.

Observed in Record Review. In 13 of 13 patient records reviewed, the plan of care did not have interventions that were individualized to the patient. On review of the patient records care was not individualized to the patient's need. Examples include: Placement of a condom catheter for urinary incontinence on a female patient, dry mouth or lips using Vaseline (if not on oxygen) or Lubricating Jelly, placement of indwelling catheter with 14 Fr catheter on all the patients, use of alternating pressure reduction mattress or egg crate if patient is bed bound. This finding was reviewed with the Hospice Director.

Observed in Patient Home. In 1 of 3 hospice home visits conducted, the organization’s infection prevention and control activities related to equipment disinfection were not implemented. The manufacture instructions for Saniwipes states a two minute wet time for cleaning. During HSHV/RR #2, the RN was observed cleaning her vital sign equipment with Saniwipes and did not observe the 2 minute wet time before placing the before placing it in her bag. This was discussed with the clinical manager who was present during the visit.

Observed in Record Review. In 1 of 3 patient records where the patient had passed away on service, the bereavement plan of care was not developed. On review of HSRR #13, the patient had passed away and no bereavement plan was initiated for the bereaved. This finding was reviewed with the Hospice Director.

Observed in Record Review. In 1 out of 1 patient records reviewed, that had ordered aide services, the Aide Care Plan did not have specific instructions for the aide. During the home visit for HSHV/RR #1, the assigned tasks did not include specific instructions for care needs of the patient. For example the patient required transfer from wheelchair to shower chair, use of a shower chair for the shower, and use of incontinence briefs, all of which were not instructed on the aide care plan. This finding was reviewed and validated with the Clinical Manager who was present for the visit.