Sioux Center Health Home Care and Hospice

“Based on staff interviews, clinical record reviews and policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care which include orders for complimentary therapies and volunteers provided to patients for 6 of 14 sampled patients (Patients #2, #5, #6, #7 #12 and #13). Failure to identify acceptable scopes and frequencies specific to meet patient needs increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: 5.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of cancer of the rectosigmoid junction and included orders for nursing services 2 times a week, social services 2 times in 2 weeks and 2 times a month and aide services 2 times a week. b.The skilled nurse note at admission, dated 3/18/26, signed as completed by Staff E, RN identified the patient wanted music and massage services. c.The massage therapy visit note, dated 4/8/26, signed as completed by Staff F, Massage Therapist, identified the patient received massage therapy services.d. The music therapy visit note, dated 4/29/26, signed as completed by Staff O, Music Therapist, identified the patient received music therapy services.e.During an interview on 5/12/26 at 2:08 PM, the Administrator reported that the agency has always used the same process to include the music therapist, massage therapist, hospice chaplain, and volunteer in the initial POC by including the information that the patient accepts these services. The Administrator reported that they will talk with the social workers about this process so that orders for every discipline are complete and specific for each patient. The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice. 6.Patient #13 had a hospice admission date of 11/5/25 and received hospice services while residing in a private home. Clinical record review revealed: a.The POC, dated 11/5/25 to 2/2/26, identified the patient had a primary diagnosis of nutrition deficiency and included orders for nursing services 2 times a week, social services 2 times a month and aide services 5 times a week. b.The skilled nurse note at admission, dated 3/18/26, signed as completed by Staff E, RN identified the patient wanted hospice chaplain services, music services and massage services. c.The hospice chaplain visit note, dated 11/10/25, signed as completed by Staff L, Hospice Chaplain, identified the patient received hospice chaplain services.d.The music therapy visit note, dated 11/11/25, signed as completed by Staff O, Music Therapist, identified the patient received music therapy services.e.The massage therapy visit note, dated 11/12/25, signed as completed by Staff F, Massage Therapist, identified the patient received massage therapy services.The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager, and Staff M, Support Specialist. 2. Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included orders for nursing services 3 times a week, social services 2 times a month and aide services 2 times a week. b. The skilled nurse note at admission, dated 4/22/26, completed by Staff J, RN, identified the patient wanted chaplain services. c. The chaplain visit note, dated 4/27/26, completed by Staff L, Chaplain, identified chaplain services provided to the patient. The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice. 3. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/7/26 to 7/5/26, identified the patient had a primary diagnosis of Parkinson’s disease and included IDG orders for nursing services 2 times a week, social services 2 times a month and aide services 2 times a week. b. The skilled nurse note at admission, dated 4/7/26, completed by Staff E, RN, identified the patient accepted music therapy and massage therapy services. c. The music therapy visit note, dated 4/8/26, completed by Staff O, Music Therapist, identified the patient received music therapy services. d. The massage therapy visit note, dated 4/9/26, completed by Staff F, Massage Therapist, identified the patient received massage therapy services. The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice. 4. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/26/25 to 11/23/25, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included IDG orders for nursing services 2 times a week, social services 3 visits every 5 weeks and aide services 1 time a week. b. The skilled nurse note at admission, dated 8/26/25, completed by Staff E, RN, identified the patient accepted music therapy and massage therapy services. c. The music therapy visit note, dated 8/27/25, completed by Staff O, Music Therapist, identified the patient received music therapy services. d. The massage therapy visit note, dated 8/27/25, completed by Staff F, Massage Therapist, identified the patient received massage therapy services. The POC failed to include a detailed scope and frequency of all services accepted by the patient at the time of admission to hospice. According to the hospice policy titled Care Planning, dated 5/2025, at the time of the initial referral and assessment, the primary RN along with key Hospice team members develop the patinet plan of care based upon the patinet’s/family’s identified needs, along with information obtained frm physician and medical records. These are reviewed with the patinet and/or family caregivers. 1.Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included Interdisciplinary Group (IDG) orders for nursing services 2 times a week, social services 2 times a month and aide services 2 times a week. b. The skilled nurse note at admission, dated 3/18/26, identified the patient accepted music and massage services. c. The massage therapy visit note, dated 4/8/26, included massage therapy provided to the patient. d. The music therapy visit note, dated 3.25.26, included music therapy provied to the patient. e. The IDG meeting notes, dated 3/25/27, identified IDG orders for massage therapy every 2 weeks. f. The IDG meeting note, dated 4/8/26, identified IDG orders for massage therapy every 2 weeks and music therapy 1 to 2 time every 2 weeks. c. Review of the clinical record revealed the patient requested music and massage therapy at the start of care. The hospice failed to include music and massage therapy orders on the plan of care. The POC failed to include orders for all services necessary to meet the specific patient/family needs.”

“Based on clinical record reviews and agency policy review, the hospice failed to ensure the hospice plan of care included complete orders for all necessary treatments to meet the needs of the patients for 2 of 2 sampled patients with a catheter (Patients #2 and #6). Failure to ensure the plan of care included complete orders for all treatments placed the patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: According to the hospice policy titled Care Planning, dated 5/2025, all hospice team members consider the initial and ongoing assessments in their care planning process. Based on those assessments and physician orders, the Plan of Care (POC), includes specific services and equipment to be provided. 1.Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included physician orders for skilled nurse visits, medications and treatment. b. The Interdisciplinary Group (IDG) update to the POC, dated 5/6/26, identified the patient had a foley catheter but lacked complete orders with catheter size and balloon volume. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. 2. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/7/26 to 7/5/26, identified the patient had a primary diagnosis of Parkinson’s disease and included physician orders for skilled nurse visits, medications and treatments. b. The IDG update to the POC, dated 4/8/26, identified the patient had a foley catheter but lacked complete orders with catheter size and balloon volume. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager, and Staff M, Support Specialist.”

“Based on agency document review and staff interview, the hospice failed to ensure the agency provided 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 patient and family beliefs and desires. Failure to provide 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 patient and family beliefs and desires.Findings include: During an interview on 5/12/26 at 2:08 PM, the Administrator reported that when the hospice chaplain was hired, leadership from the health care system advised the Administrator that the chaplain would be a contracted service. 1.The list of contracted staff provided by the agency included Staff L, Hospice Chaplain.2.Review of the agency document titled Agreement for Professional Services, dated 7/9/25, identified that Staff L was a contracted employee of the agency.The agency failed to ensure that Staff L was an employee of the agency, defined an an employee who: (1) works for the hospice and for whom the hospice is required to issue a W-2 form on his or her behalf; or (2) if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is assigned to the hospice; or (3) is a volunteer under the jurisdiction of the hospice.”

“Based on clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 3 of 3 sampled hospice aides (Staff H, Staff I and Staff P) demonstrated competency in the performance of any skills which exceeded 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 8 of 10 sampled patients (Patients #1, #3, #6, #7, #9, #10, #11 and #12) who required an extra skill be performed. 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 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. According to the agency’s policy titled Comprehensive Policies, dated 3/2026, the agency will assure competency of each hospice aide in performance of all assigned hospice aide duties. The hospice aide will not be assigned tasks for which competency has not been demonstrated except under the direct supervision of a nurse. Documentation of competent performance will be recorded and filed at the agency. 1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included Registered Nurse (RN) instructions to the aide to trim fingernails and toenails, offer every visit. b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #1. c. Staff H, Hospice Aide, had a hire date of 4/7/99. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the task of trimming nails. d. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails. 2. Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to perform a whirlpool bath as the patient, family or staff requests. b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #3. c. Staff H, Hospice Aide, had a hire date of 4/7/99. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the task of giving a whirlpool bath. d. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of giving a whirlpool bath. 3. Patient #6 had a hospice admission date of 4/7/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails/toenails and perform a whirlpool bath. b. Review of the clinical record showed Staff H and Staff I, Hospice Aides, provided aide services independently for Patient #6. c. Staff H, Hospice Aide, had a hire date of 4/7/99. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath. d. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. 4. Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails/toenails. b. Review of the clinical record showed Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #7. c. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails. d. Staff P, Hospice Aide, had a hire date of 5/14/24. Staff P’s personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails. 5. Patient #9 had a hospice admission date of 10/14/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails/toenails and perform a whirlpool bath. b. Review of the clinical record showed Staff H, Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #9. c. Staff H, Hospice Aide, had a hire date of 4/7/99. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath. d. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. e. Staff P, Hospice Aide, had a hire date of 5/14/24. Staff P’s personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails and giving a whirlpool bath. 6. Patient #10 had a hospice admission date of 2/10/26, a discharge date of 2/27/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails and toenails, offer every visit. b. Review of the clinical record showed Staff P, Hospice Aide, provided aide services independently for Patient #10. c. Staff P, Hospice Aide, had a hire date of 5/14/24. Staff P’s personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails. 7. Patient #11 had a hospice admission date of 5/20/25, a discharge date of 11/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails/toenails per patient request. b. Review of the clinical record showed Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #11. c. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails. d. Staff P, Hospice Aide, had a hire date of 5/14/24. Staff P’s personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails. 8. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to trim fingernails/toenails, offer every visit and perform a whirlpool bath. b. Review of the clinical record showed Staff H, Staff I and Staff P, Hospice Aides, provided aide services independently for Patient #12. c. Staff H, Hospice Aide, had a hire date of 4/7/99. Staff H’s personnel file lacked documentation an RN had observed Staff H competently perform the tasks of trimming nails and giving a whirlpool bath. d. Staff I, Hospice Aide, had a hire date of 4/18/25. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the task of trimming nails and giving a whirlpool bath. e. Staff P, Hospice Aide, had a hire date of 5/14/24. Staff P’s personnel file lacked documentation an RN had observed Staff P competently perform the task of trimming nails and giving a whirlpool bath. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”

“Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to ensure registered nurses (RN) developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 6 of 8 patients receiving hospice aide services (Patient #1, #2, #3, #4, #5, and #12). Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk that hospice patients did not receive the services to meet each patient’s assessed needs. Findings include: 4. Patient #3 had a hospice admission date of 4/11/24, and received hospice services while residing in a private residence. a. The POCs, dated 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 3/18/26, completed by Staff B, Clinical Manager, included RN instructions to the hospice aide to provide skin care; apply lotion of choice. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 5. Patient #4 had a hospice admission date of 4/15/26, and received hospice services while residing in a nursing home. a. The POC, dated 4/15/26 to 7/13/26, identified the patient had a diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 4/15/26, completed by the Staff J, RN, included RN instructions to the hospice aide to provide skin care; apply patient choice of lotion. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 6. Patient #5 had a hospice admission date of 3/18/26, and received hospice services while residing in a nursing home. a. The POC, dated 3/18/26 to 6/18/26, identified the patinet had a diagnosis of Alzheimer’s disease and included orders for skilled nurse and aide services. b. The hospice aide care plan, dated 3/18/26, completed by Staff K, RN, included RN instructions to the hospice aide to provide skin care; apply choice of lotion.. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, StaffD, Clinical Manager and Support Secialist. 2. Patient #2 had a hospice admission date of 4/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/22/26 to 7/20/26, identified the patient had a primary diagnosis of malignant neoplasm of the rectum and included physician orders for skilled nurse and hospice aide services. b. The undated hospice aide care plan included aide instructions to apply patient’s choice of lotion every visit. The assignment did not include specific instructions on where on the patient the aide should apply lotion. The hospice RN failed to include specific instructions on where on the patient the aide should apply lotion. 3. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included physician orders for skilled nurse and hospice aide services. b. The undated hospice aide care plan included aide instructions to make sure the patient uses a walker when transferring. c. The skilled nurse visit note, dated 12/17/25, completed by Staff K, RN, identified the patient is a 2 assist with a sit to stand transfer aide. The hospice RN failed to include specific, up to date instructions to the aide on how the patient transfers. According to agency policy titled Assignment of Staff Responsibility, dated March 2008, home health aides services provided are based on the initial and ongoing assessments of patient/client needs and are conducted by a registered nurse in the patient’s /client’s home. The primary nurse is responsible for the initial assessment and assignment of the home health aide. Assignments are updated at least every sixty (60) days, or more often if needed. During an interview on 5/5/26 at 11:44 AM, Staff B, Clinical Manager, reported that the patient’s admitting nurse creates the hospice aide care plan.1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The Plan of Care (POC), dated 4/6/26 to 6/4/26, identified the patient had a primary diagnosis of senile degeneration of the brain and included orders for skilled nursing and aide services. b. The undated Hospice Aide Care Plan identified that the patient used a gait belt as a safety measure and included hospice aide instructions that the patient uses an assistive device of motorized wheelchair, to make sure that they use it when transferring. The assignment did not include the use of a gait belt with transfers.The hospice RN failed to include specific instructions on using a gait belt with transfers.”

“Based on staff interview, clinical record reviews and hospice agency policy review, 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 care plan for 4 of 8 sampled patients receiving hospice aide services (Patients #3, #5, #11 and #12). Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: According to the hospice policy titled Assignment of Staff Responsibility, dated 3/2026, the personal care and support services provided are based on the initial and ongoning assessments of patient/client needs and are conducted by a registered nurse in the patinet’s/client’s home. The primary nurse is responsible for the initial assessment and assignmnet of the home health aide. Assignments are updated at least every 60 days, or more often if needed. During an interview on 5/5/26 at 11:44 AM, Staff B, Clinical Manager stated the admitting nure creates the aide care plan. If the aide is unable to complete a task, or complete an unassigned task, the aides are educated to call the office. There is always a nurse available and the task can be added to the care plan. The aide shouldn’t do a task until they’ve spoken with a nurse. 1.Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plans of Care (POCs), dated 1/33/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a primary diagnosis of peripheral vascular disease and included orders for skilled nurse and hospice aide services. The POC included skilled nurse interventions for compression hose. b. The hospice aide care plan, dated 3/9/26, included aide instructions to provide the following: assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior and report concern to primary clinician. c. Hospice aide visit notes, dated 4/22/26, 4/25/26, 4/29/36 and 5/1/26, completed by Staff I, Hospice Aide, documented tasks provide: assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior, report concern to primary clinician. d. During an interview on 5/11/26 at 3:56 PM, Staff I, Hospice Aide, stated she applied the patient’s compression hose after bathing if they were available. The aide documentation failed to include compression hose. The hospice aide failed to follow the aide care plan as written. 2. Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzeimer’s disease and included orders for skilled nurse and hospice aide services. The POC included medical equipment the patient requires as compression hose. b. The undated hospice aide care plan included aide instructions to provide the following: apply patient choice of lotion (not specific), assist feeding, assist shower (may give bath at sink or bed, (notify clinician if declines planned bathing method, brush/comb hair, shampoo/condition every visit, skin care-apply choice of lotion, observe and report open areas on skin, red areas or changes in skin condition, pressure relief-cushion to wheelchair and recliner, assist dress upper body, assist dress lower body, incontinent brief, incontinent care-bathroom privileges, transfer with Hoyer lift, wheelchair for all locomotion, report falls, dependent for transfers with hoyer lift, clean bathroom after patient use, trash removal in patient care area, offer companionship every visit, document specific observations. c. Hospice aide visit notes, dated 4/14/26, 4/17/26, 4/21/26, 4/24/26, 4/28/36 and 5/1/26, completed by Staff I, Hospice Aide, documented tasks provide: assist with shower, assist with whirlpool, assist with manicure, hair care-brush, comb, shampoo/condition, style, skin care, apply patient choice of lotion, notify of open areas on skin, red areas or changes in skin condition, report falls, transfer with uses or a walker, document mood/behavior, report concern to primary clinician. d. During an interview on 5/11/26 at 3:56 PM, Staff I, Hospice Aide, stated she applied the patient’s compression hose after bathing if they were available. Compression hose not included on the aide documentation The hospice aide failed to follow the aide care plan as written. 3. Patient #11 had a hospice admission date of 5/20/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 8/15/25 to 15/15/26 and 11/16/25 to 1/14/26, identified the patient had a primary diagnosis of Alzeimer’s disease and included orders for skilled nurse and hospice aide services. b. The undated hospice aide care plan included aide instructions to provide the following: shower or whirlpool bath. c. Hospice aide visit notes, dated 10/21, 10/28/25, 11/4 and 11/11/25 , completed by Staff I, Hospice Aide, documented tasks provide both a shower and whirlpool bath. The hospice aide failed to follow the aide care plan as written. 4. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included physician orders for skilled nurse and hospice aide services. b. The undated hospice aide care plan, included aide instructions to provide the following: assist with food/drink, apply lotion, assist with bath-shower every visit, offer whirlpool bath every visit, brush/comb hair, shave patient, trim/file fingernails and toenails, assist with dressing, provide incontinence care and assist with transfers.c. Hospice Aide visit notes, dated 12/17/25, 12/22/25 and 12/29/25, completed by Staff H, Hospice Aide, documented task of bath-shower every visit as not accomplished, not patient’s bath day. d. Hospice Aide visit note, dated 12/24/25, completed by Staff I, Hospice Aide, documented task of bath-shower every visit as not accomplished, not patient’s bath day. The hospice aides failed to follow the aide care plan as written. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”

“Based on review of the written hospice agreements for services under arrangement, the hospice failed to ensure written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 2 of 3 sampled services (Spiritual Counselor and Pharmacy provider). Failure to include this provision within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: 1.Review of the contract between the hospice and spiritual counselor, dated 7/9/25, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services, c. All services are authorized by hospice, d. All services are delivered in a safe and effective manner by qualified personnel and e. All services are delivered in accordance with the patient’s plan of care. 2.Review of the contract between the hospice and sampled pharmacy provider, dated 3/3/22, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services, c. All services are authorized by hospice, d. All services are delivered in a safe and effective manner by qualified personnel and e. All services are delivered in accordance with the patient’s plan of care. The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standard for 10 of 14 sampled patients (Patients #1, #3, #5, #7, #8, #10, #11, #12, and #13).Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to patients.Findings include: 5. Patient #8 had a hospice admission date of 9/5/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 12/8/25 to 3/7/26 and 3/8/26 to 5/6/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse, social work, music therapy and massage therapy services. b. Massage therapy visit note, dated 3/10/26, signed completed 3/17/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation. c. Skilled nurse visit note, dated 3/20/26, signed completed 3/24/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation. d. Skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation. e. Massage therapy visit note, dated 3/25/26, signed completed 3/31/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation. f. Massage therapy visit note, dated 4/8/25, signed completed 4/14/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation. g. Skilled nurse visit note, dated 4/21/26, signed completed 4/26/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 6. Patient #12 had a hospice admission date of 8/26/25, a discharge date of 2/3/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/24/25 to 2/21/26, identified the patient had a primary diagnosis of nontraumatic chronic subdural hemorrhage and included orders for skilled nurse, aide, social work, volunteer, music therapy and massage therapy services. b. Massage therapy visit note, dated 12/23/25, signed completed 12/31/25 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation. c. Skilled nurse visit note, dated 12/26/25, signed completed 12/30/25 by Staff E, RN, 5 days after the visit and 3 days late per agency expectation. d. Massage therapy visit note, dated 1/20/26, signed completed 1/28/26 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 7. Patient #3 had a hospice admission date of 4/11/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 1/31/26 to 3/31/26 and 4/1/26 to 5/30/26, identified the patient had a primary diagnosis of peripheral vascular disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services. b. The massage therapy visit note, dated 3/24/26, signed completed 3/31/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation. c. The massage therapy visit note, dated 4/6/26, signed completed 4/14/26 by Staff F, Massage Therapist, 8 days after the visit and 6 days late per agency expectation. d. The skilled nurse visit note, dated 4/23/26, signed completed 4/27/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation. e. The skilled nurse visit note, dated 4/28/26, signed completed 5/3/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 8. Patient #5 had a hospice admission date of 3/18/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 3/18/26 to 6/15/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services. b. The massage therapy visit note, dated 4/19/26, signed completed 3/31/26 by Staff F, Massage Therapist, 12 days after the visit and 10 days late per agency expectation. c. The skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation. d. The massage therapy visit note, dated 4/14/26, signed completed 4/21/26 by Staff F, Massage Therapist, 7 days after the visit and 5 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. 9. Patient #11 had a hospice admission date of 5/20/25 and discharge date of 11/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/15/25 to 11/15/25, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, chaplain, music therapy, massage therapy and hospice aide services. b. The massage therapy visit note, dated 9/16/25, signed completed 9/26/25 by Staff F, Massage Therapist, 10 days after the visit and 8 days late per agency expectation. c. The skilled nurse visit note, dated 9/18/25, signed completed 9/22/25 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation. d. The skilled nurse visit note, dated 10/16/25, signed completed 10/21/25 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation. e. The massage therapy visit note, dated 10/29/25, signed completed 11/8/25 by Staff F, Massage Therapist, 10 days after the visit and 8 days late per agency expectation. The agency failed to ensure timely completion of routine visit documentation. The above findings reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and the Support Specialist. According to agency policy titled Documentation of Nursing, dated March 2022, the purpose of the policy is to accurately record the continuum of events that occurs during a patient’s stay to provide for continuity of care in the inpatient and outpatient settings, and to assure a permanent legal record for each hospital patient. All entries should be dated, timed and signed. During an interview on 5/5/26 at 10:38 AM, the Administrator reported that notes from disciplines should be signed with name, title, date within 48 hours. Even though the policy may say notes are to be completed timely, the Administrator clarified that the best practice is within 48 hours. 1.Patient #1 had a hospice admission date of 7/16/25 and received hospice services while residing in a nursing home. Clinical record revealed:a.Plan of Care (POC), dated 4/6/26 to 6/4/26, identified the patient had a primary diagnosis of senile degeneration of the brain and orders for skilled nurse services.b.Interdisciplinary Group (IDG) note, dated 4/8/26, included orders for massage therapy services.c. Skilled nurse visit note, dated 4/21/26, signed completed 4/26/26 by Staff C, Licensed Practical Nurse (LPN), 5 days after the visit and 3 days late per agency expectation.d.Skilled nurse visit note, dated 3/24/26, signed completed 3/29/26 by Staff C, LPN, 5 days after the visit and 3 days late per agency expectation.e.Skilled nurse visit note, dated 3/26/26, signed completed 3/29/26 by Staff C, LPN, 3 days after the visit and 1 day late per agency expectation.f.Skilled nurse visit note, dated 3/20/26, signed completed 3/24/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.g.Skilled nurse visit note, dated 3/13/26, signed completed 3/16/26 by Staff C, LPN, 3 days after the visit and 1 day late per agency expectation.h.Massage therapy visit note, dated 4/15/26, signed completed 4/21/26 by Staff F, Massage Therapist, 6 days after the visit and 4 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation. 2.Patient #7 had a hospice admission date of 4/21/26 and received hospice services while residing in a nursing home. Clinical record revealed:a.POC, dated 4/21/26 to 7/19/26, identified the patient had a primary diagnosis of cancer of the rectosigmoid junction and included orders for skilled nurse services.b.Skilled nurse visit note, dated 4/30/26, signed completed 5/4/26 by Staff C, LPN, 4 days after the visit and 2 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation. 3.Patient #10 had a hospice admission date of 2/10/26 and received hospice services while residing in a private home. Clinical record revealed:a.POC, dated 2/10/26 to 5/10/26, identified the patient had a primary diagnosis of pancreas cancer and orders for skilled nurse services.b.Skilled nurse visit note, dated 2/20/26, signed completed 2/25/26 by Staff E, Registered Nurse (RN), 5 days after the visit and 3 days late per agency expectation.c.Skilled nurse visit note, dated 2/24/26, signed completed 2/82/26 by Staff G, RN, 4 days after the visit and 2 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation. 4.Patient #13 had a hospice admission date of 11/5/25 and received hospice services while residing in a private home. Clinical record revealed:a.POC, dated 11/5/25 to 2/2/26, identified the patient had a primary diagnosis of nutritional deficiency and orders for skilled nurse services.b.Massage visit note, dated 11/12/26, signed completed 11/18/26 by Staff F, 6 days after the visit and 4 days late per agency expectation.The agency failed to ensure timely completion of routine visit documentation.”

“Based on staff interview, clinical record review and agency policy review, the hospice failed to ensure the hospice staff sent a copy of the patient’s transfer summary to the receiving facility for 1 of 1 sampled, transferred patients (Patient #8). Failure to ensure the hospice staff included the receiving facility in the process of transfer placed the patient at risk for not receiving ongoing medical care and services necessary to meet the needs of the patient. Findings include: According to the agency policy titled Comprehensive Policies, dated 3/2026, the Interdisciplinary team members will send a transfer summary to the physician upon transfer. Patient #8 had a hospice admission date of 9/9/25 and received hospice services while residing in a nursing home. a. The Plan of Care (POC), dated 3/8/26 to 5/6/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nursing services. b. The skilled nurse visit note, dated 4/25/26, identified the patient transferred to a hospital due to a fall and broken arm. c. The clinical record failed to include documentation a transfer summary was completed and forwarded to the receiving facility. The hospice agency failed to complete and forward the transfer summary to the receiving facility. On 5/7/26 at 10:25 AM, the Administrator confirmed the agency did not complete a transfer summary for Patient #8. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”

“Based on review of the written agreements between the hospice and inpatient facilities (hospitals), the hospice failed to ensure the written agreements identified the hospice’s responsibility to maintain a description of the training provided to hospital personnel providing care for hospice patient’s during an inpatient stay and documentation of the names of those giving the training for 3 of 3 sampled written agreements (Hospitals A, B and C). Failure to ensure the written agreements with hospitals specified the hospice’s responsibility to ensure hospital staff caring for hospice patients received training and the hospice maintained appropriate documentation of the training placed hospice patients at risk for receiving inpatient care in conflict with the hospice philosophy. Findings include: 1.The hospice agency had a contractual agreement with Hospital A, dated 3/1/19. The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators. 2.The hospice agency had a contractual agreement with Hospital B, dated 3/1/19. The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators. 3.The hospice agency had a contractual agreement with Hospital C, dated 3/1/19. The contractual agreement failed to specify the agency responsibility to include a description of the training provided to hospital personnel providing care to hospice patients during an inpatient stay and documentation of the training facilitators. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”

“Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and a hospital to provide inpatient care included a method for verifying all necessary requirements are met while a patient receives inpatient care for 3 of 3 sampled written agreements (Hospitals A, B and C). Failure to identify a method for verifying requirements are met for patient’s receiving inpatient care increased the potential of hospice and inpatient facility staff not meeting patient needs 24 hours a day. Findings include: 1.Review of the inpatient facility agreement between the hospice agency and Hospital A, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care. 2.Review of the inpatient facility agreement between the hospice agency and Hospital B, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care. 3.Review of the inpatient facility agreement between the hospice agency and Hospital C, dated 3/1/19, lacked a provision which identified a method for verifying all necessary requirements are met while a patient receives inpatient care. The above findings were reviewed with the Administrator, Staff B, Clinical Manager, Staff D, Clinical Manager and Staff M, Support Specialist.”