Iowa City Hospice

“Based on clinical record review, hospice wound job aid and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group failed to update the comprehensive assessment with changes to the patient condition regarding wound description and measurements for 2 of 4 sampled patients with a wound (Patients #1 and #16). Failure by the hospice Interdisciplinary Group (IDG) registered nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding patient’s wound status and effectiveness of treatments and interventions. 1.Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 1/2/24, 1/16/24, 1/23/24, and 1/30/21, included orders for skilled nursing services 1 time per week. b. A comprehensive assessment, dated 1/11/24, included documentation the Registered Nurse (RN) assessed the patient had a wound that is open/pink and pea sized on the left buttock. The assessment failed to include a description of the measurements of the wound. c. Comprehensive assessments completed by the RN, dated 1/16/24, 1/30/24, and 2/6/24 included documentation of a wound to the right and left buttock. The documentation lacked wound measurements for the right and left buttock wounds. The hospice failed to document complete assessment including measurement of wounds. 2. Patient #16 had a hospice admission date of 10/5/23 and received hospice services while residing in a private residence. a. The IDG meeting notes, dated 12/13/23, 12/20/23, 12/27/23, 1/10/24, and 1/24/24, included orders for skilled nursing services 1 time per week. b. Comprehensive assessments completed by the RN, dated 12/18/23 and 1/2/24, included documentation the patient had wounds sites. The assessments failed to include identification of the wound sites and a description or measurements of the wounds. c. Comprehensive assessments completed by the RN, dated 12/29/23,1/19/24, and 2/2/24, included documentation the patient had wounds on the left lateral foot, posterior foot arch, right anterior lateral leg calf, right dorsal foot bottom of foot, and right hand thumb. The assessments lacked wound measurements for any of the identified wounds. Failure by the hospice nurses to update the comprehensive assessment with complete wound descriptions and measurements placed the patient at risk for ineffective staff collaboration and communication regarding wound status and effectiveness of treatments and interventions. The above findings were shared with the Administrator, Clinical Manager, and Quality Manager and the hospice provided no further information prior to the end of the survey. Findings include: According to hospice wound job aid, titled Wound Assessment and Documentation, dated 5/15/15, assess the wound location and size, measure the length, width and depth. The nurse must assess the patients wound every 2 weeks. During an interview on 2/26/24 4:19 PM, the Clinical Manager reported wounds should be assessed at least every comprehensive assessment, measurements include length, width and depth.”

“Based on hospice clinical record review, hospice policy review, home visit observation, nursing home record review, nursing home staff interview and patient interview, the hospice failed to ensure the Plans of Care for 2 of 4 home visits (Patients #2 and #3) 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: 2. Patient #2 had a hospice admission date of 1/5/24 and received hospice services while residing in a private home. a. Plan of Care, dated 1/5/24 to 4/3/24, identified the patient used the following medical equipment and supplies: overbed table, electric wheelchair, blue pads/chux, gloves, oxygen, pressure relief mattress, gait/transfer belt, bed rails, shower chair, hospital bed and ostomy bags. b. Interdisciplinary Group Update to the Plan of Care, dated 1/8/24, 1/15/24, 1/29/24 and 2/12/24, identified the patient used the following medical equipment and supplies: hospital bed with side rails, air mattress and pump, shower chair, CPAP (continuous positive air pressure), motorized wheelchair, overbed table, disposable chux, disposable wipes, gloves and ostomy supplies. c. On 2/20/24 at 12:25 PM, during a home visit observation with Staff H, Registered Nurse (RN), the surveyor identified the patient utilized a reacher that was on the bed next to the patient and the patient was wearing zippered compression knee high socks. The POC and IDG updates to the POC failed to identify all necessary medical equipment and supplies used by the patient, including the compression socks and reacher. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey. According to the hospice policy titled Plan of Care, dated 6/2023, the patient’s plan of care specified the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. 1. Patient #2 had a hospice admission date of 10/13/23 and received hospice services in a private residence. Review of the clinical record revealed the following: a. The Plans of Care (POC), dated 10/13/23 to 1/10/24, identified the patient had the following medical equipment and supplies: adult diapers, blue pads/chux, moisture barrier, walker, wheelchair, skin prep wipes, bed rails, bedside commode, hospital bed, overbed table, oxygen, shower chair. b. The Interdisciplinary Group (IDG) meeting, dated 12/27/, 1/3, 1/17, 1/31, 2/7 and 2/14/24, identified no additional medical equipment and supplies used by the patient. c. On 2/20/23 at 11:00 AM, during a home visit observation with Staff F, Registered Nurse (RN), the surveyor identified the patient also had a reacher and hand held shower. d. In an interview, during the same home observation, the patient’s family stated he/she has used 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.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 6 of 6 sampled patients (Patients #1, #3, #5, #7, #10 and #15) with a missed visit. Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings 6. Patient #15 had a hospice admission date of 10/20/23, a death date of 11/20/23, and received hospice services while residing in a private home from 10/20/23 to 10/29/23 and 11/4/23 to 11/20/23 and residing in an inpatient facility from 10/30/23 to 11/3/23. Clinical record review revealed the following: a. The IDG update to the Plan of Care, dated 10/17/23 to 10/31/23, included IDG orders for hospice aide to provide services 2 times a week for 12 weeks, effective 10/29/23. b. The week of 10/29/23 to 11/4/23 lacked documentation of a completed hospice aide visit. c. The week of 11/5/23 identified a completed hospice aide visit on 11/7/23 but lacked a 2nd visit for the week. d. The IDG update to the Plan of Care, dated 10/30/23 to 11/13/23, lacked documentation the IDG was notified of missed hospice aide visits for the week of 10/29/23 and 11/5/23. The hospice failed to provide hospice aide visits as ordered per the IDG update to the Plan of Care. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey. 5. Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The POC, dated 12/3/23 to 1/31/24, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of aide visits the weeks of 1/7/24 to 1/12/24 and 1/14/24 to 1/20/24. c. The IDG meeting notes, dated 1/16/24 and 1/23/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified IDG of hospice aide missed visits. 4. Patient #5 had a hospice admission date of 12/07/23, and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/7/2023 to 3/5/2024, included IDG orders for hospice aide services 1 time a week. b. The clinical record included documentation of a missed hospice aide visit, dated 1/6/24. c. The IDG meeting notes, dated 1/31/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. According to the hospice policy titled Care Planning, dated 10/2023, the documentation of the IDG’s care planning meetings reflects the ongoing reassessment of the patient/family’s status and needs. 1. Patient #3 had a hospice admission date of 10/13/23 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 1/11/24 to 4/9/24, included IDG orders for hospice aide services 1 time a week. b. The clinical record laced documentation of a hospice aide visit the week of 1/28/24 to 2/3/24. c. The IDG meeting notes, dated 7/131/24 and 2/7/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. 2. Patient #7 had a hospice admission date of 1/25/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 1/25/24 to 4/23/24, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of 2 hospice aide visits the week of 2/11/24 to 2/17/24. c. The IDG meeting notes, dated 2/20/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits. 3. Patient #10 had a hospice admission date of 12/15/24 and received hospice services while residing in a private residence. Review of the clinical record revealed the following: a. The POC, dated 12/15/23 to 3/13/23, included IDG orders for hospice aide services 2 times a week. b. The clinical record lacked documentation of 2 hospice aide visits the week of 12/24/23 to 12/30/24 and 2 hospice aide visits the week of 1/7/24 to 1/13/24. c. The IDG meeting notes, dated 1/2/24 and 1/9/24, lacked documentation of IDG member awareness of missed visits for hospice aide services. The hospice failed to include documentation the hospice notified the IDG of hospice aide missed visits.”

“Based on clinical record review, hospice policy review and home visit observation, the hospice failed to ensure staff performed tasks during home visits in a manner to prevent contamination and/ or the spread of infection. The survey identified concerns with 2 of 4 home visit observations (Patients #1 and #4). Failure to ensure services during home visits follow accepted standards of practice for infection control increased the risk of contamination during the home visit, the development of an infection and/or transmission of organisms from home to home. 1.Patient #1 had a hospice admission date of 6/6/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: The Plan of Care (POC), dated 2/1/24 to 3/31/24, included Interdisciplinary Group (IDG) orders for skilled nursing services. On 2/20/24 at 9:05 AM, during a home visit observation, Staff E, Registered Nurse (RN), completed an assessment of the patient in bed. Staff E, RN placed nursing bag on overbed table, checked patients pulse and oxygen with pulse oximeter, took patients temperature and blood pressure. Staff E documented in the notebook, placed dirty equipment on the notebook, and listened to patients lungs, abdomen, and heart. Staff E, utilized a wipe to clean equipment, placing clean thermometer on notebook before putting it in nursing bag with other cleaned equipment. The hospice nurse failed to wipe down all equipment and allow it to dry on a clean surface/barrier prior to putting it back in bag. 2. Patient #4 had a hospice admission start date of 5/25/23 and received hospice services while residing in a nursing home. The Plan of Care (POC), dated 1/20/24 to 3/19/24, included Interdisciplinary Group (IDG) orders for skilled nursing services. On 2/27/24 at 8:15 AM, during a home visit observation, Staff E, Registered Nurse (RN), completed an assessment of the patient in bed. Staff E, RN placed nursing bag on dresser with no barrier. She listened to patients lungs, abdomen, and heart and checked patients pulse, oxygen, and temperature. Staff E recorded vital signs on notebook and placed equipment on dresser prior to sanitizing it. She utilized a sanitizing wipe to clean equipment, placing clean oximeter on notebook before putting it in nursing bag with other cleaned equipment. The hospice nurse failed to wipe down all equipment and allow it to dry on a clean surface/barrier prior to putting it back in bag. The Administrator, Clinical Manager, and Quality Manager received the above findings and hospice staff provided no further information prior to the end of the survey. Findings include: According to the hospice policy titled Infection Control - Program, dated 12/2023, the agencys infection control program includes education and training for staff on the principles of infection identification, prevention and control, including the use of standard and transmission-based precautions.”

“Based on hospice policy review, clinical record review, review of employee personnel files, and hospice staff interview, the hospice failed to ensure 1 of 6 hospice aides (Staff G) demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient’s bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 10 sampled patients who required an extra skill to be performed (Patients #4 and #13). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. Review of the hospices policy, titled, Hospice Aide Services, dated 11/20/08, the hospice ensures individuals who meet the personnel requirements specified in the hospice regulations and who have successfully completed a competency evaluation as required by regulations, provide hospice aide services under the supervision of a hospice registered nurse. During an interview on 12/27/24 at 2:05 PM, Clinical Manager reported no other skills competency forms that identified hoyer lift transfer, feeding patient, and weighing patient available for Staff G, Hospice Aide. 1.Patient #4 had a start of care date of 5/25/23, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the hoyer lift with transfers. The aide care plan included RN instructions for the aide to assist the patient to eat a regular diet. Review of the clinical record showed Staff G, Hospice Aide, provided aide services independently for Patient #4. Staff G, Hospice Aide, had a hire date of 1/15/24. Staff Gs personnel file lacked documentation RN had observed Staff G competently perform the tasks of transferring patient with hoyer lift and assisting the patient to eat a regular diet. 2. Patient #13 had a start of care date of 1/22/24, and received hospice services while residing at home. The aide care plan included RN instructions to obtain patients weight monthly. Review of the clinical record showed Staff G, Hospice Aide, provided aide services independently for Patient #13. Staff G, Hospice Aide, had a hire date of 1/15/24. Staff Gs personnel file lacked documentation RN had observed Staff G competently perform the task of weighing the patient. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Manager. 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 all documentation was included in the clinical record in a timely manner for 8 of 19 sampled patients (Patients #1, #3, #4, #7, #8, #9, #13 and #17). Failure to ensure all clinical record documentation, and each patient’s clinical record was complete, timely and appropriately authenticated, decreased the ability of hospice staff to communicate and coordinate patient care effectively, and to provide safe, effective hospice services to its patients. Findings include: 7. Patient #1 had a hospice admission date of 6/6/23 and received services while residing in a nursing home. a. The hospice aide visit note, dated, 12/22/23, signed completed on 12/26/23 (3 days late). b. The hospice aide visit note, dated, 1/3/24, signed completed on 1/10/24 (6 days late). c. The hospice aide visit note, dated, 1/5/24, signed completed on 1/10/24 (4 days late). d. The hospice aide visit note, dated, 1/24/24, signed completed on 1/29/24 (4 days late). e. The hospice aide visit note, dated 1/26/24, signed completed on 1/29/24 (2 days late). f. The hospice aide visit note, dated 1/31/24, signed completed on 2/14/24 (13 days late). The hospice clinical record failed to include timely documentation. 8. Patient #9 had a hospice admission date of 1/18/24 and received services while residing at home. a. The skilled nurse visit note, dated 2/7/24, signed completed on 2/20/24 (12 days late). b. The skilled nurse visit note, dated 2/14/24, signed completed on 2/26/24 (11 days late). The hospice clinical record failed to include timely documentation. The above findings were shared with the Administrator, Clinical Manager, and Quality Manager and the hospice provided no further information prior to the end of the survey. During an interview on 2/26/24 at 4:19 PM the Clinical Manager stated the expectation for staff to complete documentation in 24 hours. 1. Patient #3 had a hospice admission date of 10/13/23 and received services while residing in a private home. a. The skilled nurse visit note, dated 1/16/24, signed completed on 1/21/24 (3 days late). b. The skilled nurse visit note, dated 2/13/24, signed completed on 2/19/24 (6 days late). The hospice clinical record failed to include timely documentation. 2. Patient #4 had a hospice admission date of 5/25/23 and received services while residing in a nursing home. a. The hospice aide visit note, dated 12/22/23, signed completed on 12/26/23 (3 days late). b. The hospice aide visit note, dated 1/3/24, signed completed on 1/10/24 (6 days late). c. The hospice aide visit note, dated 1/5/24, signed completed on 1/10/24 (4 days late). d. The hospice aide visit note, dated 1/17/24, dated completed on 1/29/24 (11 days late). e. The hospice aide visit note, dated 1/24/24, dated completed on 1/29/24 (4 days late). f. The hospice aide visit note, dated 1/31/24, dated completed on 2/14/24 (13 days late). The hospice clinical record failed to include timely documentation. 3. Patient #7 had a hospice admission date of 1/25/24 and received services while residing in a private residence. a. The hospice aide visit note, dated 2/15/24, signed completed on 2/19/24 (3 days late). 4. Patient #8 had a hospice admission date of 1/31/24 and received services while residing in a private residence. a. The skilled nurse visit note, dated 2/8/24, signed completed on 2/20/24 (11 days late). b. The skilled nurse visit note, dated 2/15/24, signed completed on 2/26/24 (10 days late). The hospice clinical record failed to include timely documentation. 5. Patient #13 had a hospice admission date of 1/22/24 and received services while residing in a private residence. a. The hospice aide visit note, dated 1/25/24, signed completed on 1/29/24 (3 days late). The hospice clinical record failed to include timely documentation. 6. Patient #17 had a hospice admission date of 10/13/23 and received services while residing in a private residence. a. The hospice aide visit note, dated 11/16/23, signed completed on 11/21/23 (4 days late). b. The hospice aide visit note, dated 11/21/23, signed completed on 11/27/23 (5 days late). The hospice clinical record failed to include timely documentation.”

“Based on clinical record review and hospice policy review, the hospice failed to educate patients and/or family/caregivers on the hospice policy and procedure concerning the disposal of controlled substances for 1 of 2 sampled patients who received hospice services in a private residence after transferring out of a facility and had physician ordered controlled medications (Patient #11). Failure to educate hospice patients and/or family members/caregivers about the hospice protocol for disposal of controlled substances, increased the risk that the patient/caregiver discarded controlled substances in a way which might be hazardous for others. Findings include: The hospice policy, titled Medications – Labeling Disposing and Storing of Drugs and Biologicals, dated 08/2023, indicated at the time when controlled substances are first ordered, the hospice nurse, discusses the hospices policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and documents in the patients clinical record that the written policies and procedures for managing controlled drugs were provide and discussed. Patient #11 had an admission to hospice on 10/27/23 and received services in a long term care facility from 10/27/23 to 2/7/24 and started in a private home on 2/8/24. Clinical record review revealed the following: a. The Plan of Care, dated 1/25/24 to 4/23/24, included orders for Morphine Sulfate and Lorazepam, both controlled substances. b. Skilled nursing visit note, dated 2/8/24, included documentation the nurse made a visit to the patients home to fill the medication planner and prefill syringes of morphine sulfate. The clinical record lacked documentation that the patient had received education on and a copy of the hospice policy for disposal of controlled medications. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey.”

“Based on clinical record review and hospice policy review, the hospice failed to maintain documentation in the patient clinical record as evidence that patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 1 of 2 sampled patients (Patient #11) who received routine home care while living in a private home residence after transferring out of a facility and had a physician ordered controlled medication. Failure to ensure patients and/or caregivers received adequate education on the use and disposition of controlled (medication whose manufacture, possession and use is controlled by the government) increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for whom the medication was prescribed. Findings include: The hospice policy, titled Medications – Labeling Disposing and Storing of Drugs and Biologicals, dated 08/2023, indicated at the time when controlled substances are first ordered, the hospice nurse documents in the patients clinical record that the written policies and procedures for managing controlled drugs were provide and discussed. Patient #11 had an admission to hospice on 10/27/23 and received services in a long term care facility from 10/27/23 to 2/7/24 and started in a private home on 2/8/24. Clinical record review revealed the following: a. The Plan of Care, dated 1/25/24 to 4/23/24, included orders for Morphine Sulfate and Lorazepam, both controlled substances. b. Skilled nursing visit note, dated 2/8/24, included documentation the nurse made a visit to the patients home to fill the medication planner and prefill syringes of morphine sulfate. The clinical record lacked documentation that the patient had received a copy of the hospice policy for disposal of controlled medications. The Administrator and Quality Manager received the above findings and no additional information was provided prior to the end of the survey.”