Sanford Home Health and Hospice Sheldon

“The Iowa Administrative Code, Chapter 78, identifies the hospice must obtain certification that an individual is terminally ill in accordance with the following procedures: ( 1) The hospice may obtain verbal orders to initiate hospice services from the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician. The verbal order shall be noted in the patient’s record. The verbal order must be given within two days of the start of care and be followed up in writing no later than eight calendar days after hospice care is initiated. The certification must include the statement that the individual’s medical prognosis is that the individual’s life expectancy is six months or less if the illness runs its normal course. ( 2) When verbal orders are not secured, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and by the individual’s attending physician. ( 3) Hospice care benefit periods consist of up to two periods of 90 days each and an unlimited number of subsequent 60-day periods as elected by the individual. The medical director or a physician must recertify at the beginning of each benefit period that the individual is terminally ill. Based on review of clinical records, the hospice failed to ensure timely completion of the Certification of Terminal Illness for 7 of 14 sampled patients (Patients#2, #3, #4, #6, #7, #11 and #12). Failure to obtain the physician’s certification of terminal illness put the patient’s at risk of receiving hospice care inappropriately and/or without a funding source. The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 5 sampled employees who began serving hospice patients since their last survey, dated 7/27/22. The hospice reported hiring 12 employees since the last survey. Failure to complete dependent adult and child abuse record checks as required by State regulation, increased the potential risk of harm to agency patients from employees who had direct patient contact. 5. Patient #2 had a hospice admission date of 6/5/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/24, identified the patient had a diagnosis of Huntington’s disease and included orders for skilled nurse, social work, hospice aide and volunteer services. b. CTI form, dated 4/11/25 to 6/9/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 4/11/25 to 6/9/25, dated 7/8/25 by the Medical Director. d. CTI form, dated 6/10/25 to 8/8/25, included a verbal CTI, dated 6/3/25, but lacked the written attestation statement and physician electronic signature. e. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for both, 4/11/25 to 6/9/25, and 6/10/25 to 8/8/25, dated 7/8/25 with attestation statement and physician electronic signature by the Medical Director. The hospice failed to complete a CTI within 8 calendar days after the care initiated. 6. Patient #11 had a hospice admission date of 3/28/25 and revoked services on 5/23/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/28/25 to 6/25/25, identified the patient had a diagnosis of metastatic melanoma and included orders for skilled nurse and social work services. b. CTI form, dated 3/28/25 to 6/25/25, included a verbal CTI, dated 3/28/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 3/28/25 to 6/25/25, dated 7/8/25, by the Medical Director. The hospice failed to obtain the written CTI within 8 calendar days after the care initiated.. 7. Patient #12 had a hospice admission date of 5/23/25 and revoked services on 5/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 5/23/25 to 8/20/25, identified the patient had a diagnosis of chronic kidney disease and included orders for skilled nurse and social work services. b. CTI form, dated 5/23/25 to 8/20/25, included a verbal CTI, dated 5/23/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI in the electronic record within 8 days after the care initiated. They above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. 4.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 4/12/25 to 6/10/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy services. b. The Certification of Terminal Illness (CTI) form, dated 4/12/25 to 6/10/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25, the Administrator and Clinical Quality Specialist gave Surveyor a CTI dated 4/12/25 to 6/10/25, signed completed by the Medical Director on 7/8/25 at 2:02 PM, 87 days after the start of the benefit period. According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness. The email noted the agency follows regulatory requirements. The hospice failed to obtain the written CTI at the time of recertification. Findings include: According to the hospice policy titled Hiring and Screening, last reviewed 3/28/25, Human Resources will conduct background checks on all new employees and transfers prior to beginning employment or transferring to a new position. All offers of employment are contingent upon successful completion of the background check and state-specific background check. Background checks and verification checks may include but are not limited to: Criminal background check(s) and Local and state-specific background and/or registry checks. These checks can include, but are not limited to: abuse registry, sexual misconduct registry and nurse aide registry. Staff I, Chaplain, had a hire date of 5/5/25. Staff I’s personnel file included documentation of completed dependent adult and child abuse record checks, dated 4/2/25, 33 days prior to Staff I’s hire date. Hospice staff failed to complete dependent adult and child abuse record checks within 30 days prior to the date of hire on all staff prior to hiring. The surveyor reviewed the above findings with the Administrator, Clinical Manager and Clinical Quality Specialist. 1. Patient #6 had a hospice admission date of 9/18/24 and received services in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 3/17/25 to 5/15/25, included a verbal CTI, dated 3/11/25, but lacked the written attestation statement and physician electronic signature. c. CTI form, dated 5/16/25 to 7/14/25, included a verbal CTI, dated 5/7/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI within the required time frame of 8 days. 2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 6/5/25 to 9/2/25, included a verbal CTI, dated 6/4/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI within the required time frame of 8 days. 3. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 6/20/25 to 9/17/25, included a verbal CTI, dated 6/20/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI within the required time frame of 8 days.”

“Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure emergency preparedness training every two years to all current staff members. Lack of emergency preparedness training for staff put patients at risk should an emergency situation arise and staff be needed to assist patients to ensure patient safety. Findings include: According to the agency policy titled Emergency Preparedness, dated 5/27/25, the agency must develop and maintain an emergency preparedness training and testing program based on the Emergency Management Plan (EMP). Staff training includes: initial training training on emergency preparedness policies and procedures to all new and existing staff, including those who provide services under contract; training must be provided every 2 years; the agency must maintain documentation of the training; and staff must demonstrate knowledge of the training procedures. 1.Review of the agency’s Emergency Preparedness trainings lacked documentation of training since 8/24/2019 for contracted Staff G, Massage Therapist. 2. Review of the agency’s Emergency Preparedness trainings lacked documentation of training since 10/13/2016 for contracted Staff H, Music Therapist. During an interview on 7/2/25 at 10:50 AM, the Administrator stated no additional training had been done for contracted Staff G and contracted Staff H and they do not participate in Emergency Preparedness drills. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on clinical record review, hospice policy review, patient representative interview and staff interview, the hospice failed to ensure hospice staff honored the right of the patient to receive effective pain management and symptom control while the patient received hospice services for 1 of 5 sampled hospice patients (Patient #14), while residing in a nursing home and deceased. Failure to ensure hospice staff ensured the patient received effective pain management and symptom control from the hospice for conditions related to the patient’s terminal illness, the patient did not have their rights honored in regard to pain management. Findings include: According to the hospice policy titled Patient Rights, dated 7/30/24, patients have the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #14 had a hospice admission date of 7/11/23, a death date of 7/18/23 and received hospice services while residing in a nursing home. Review of the clinical record revealed the following: a. The plan of care (POC), dated 7/11/23 to 10/8/23, identified the patient had diagnoses that included myelodysplastic syndrome (a group of disorders caused by blood cells that don’t work properly), chronic diastolic heart failure, emphysema, pulmonary fibrosis, thrombocytopenia, atrial fibrillation and dependence on supplemental oxygen. The POC included orders for skilled nursing services to collaborate with facility/agency staff to discuss/review POC, provide certificate of terminal illness (CTI), Plan of Care and future updates to facility/agency. Instruct how to order/obtain hospice covered medications, instruct on the role of hospice at the facility/agency, and discuss schedule of facility/agency Interdisciplinary Group (IDG). The POC also included intervention the patient/caregiver will demonstrate/verbalize medication needs, side effects and correct use/care of medications: Acetaminophen 500 milligrams (mg) 2 tablets by mouth 3 times a day as needed (prn) for mild pain or headache, Lorazepam (Ativan) 0.5 mg 1 tablet by mouth every 4 hours prn for anxiety, Oxycodone 5 mg 1 tablet by mouth 4 times daily for pain, Oxygen therapy 3 to 4 liters per minute (LPM) per nasal cannula, Eliquis 2.5 mg by mouth 2 times a day (blood thinner). b. The medication update, dated 7/18/23, revealed a physician’s order for Roxanol (Morphine) 20 mg/ml, give 10 mg (0.5 ml) sublingual every 1 hour prn shortness of breath, restlessness or pain. c. The (as needed) skilled nurse visit note, dated 7/17/23 from 7:00 PM to 8:30 PM, Staff M, Registered Nurse (RN), revealed, skilled nurse visit was made due to request of the nursing home to evaluate the patient due to oxygen saturation (the measure of how much oxygen is carried in blood) readings in the 60’s, even with oxygen at 5 liters per minute (LPM). The nursing home staff had just given an Ativan prn (as needed) and family present. The nursing home nurse had placed the patient’s portable oxygen concentrator on the patient at 3 LPM via nasal cannula and also had the oxygen concentrator on at 5 LPM via mask. Patient’s oxygen saturation (O2 Sat) varied between 75% and 80%, heart rate 96 to 104 beats per minute and respirations rapid and shallow, 24 to 30 breaths per minute and the patient denied distress during the skilled nurse visit. Patient also had a positive Homan’s (pain or discomfort in the calf when pointing the foot upwards) on the left leg. Patient alert and speaking with family with mild confusion noted. Staff M, RN documented she advised the family the patient should be given the prescribed Ativan, oxycodone and Eliquis if no other medications were given, which would help the most if patient had an embolism (sudden blockage of a blood vessel by a traveling clot or other substance, such as air or fat). The nursing home nurse informed of medications to be given. d. The hospice case communication note, dated 7/18/23 at 4:00 AM, Staff M, RN included documentation after phone calls at 2:21 AM, 2:47 AM and 3:25 AM, Staff M, RN, called the on call physician and got a telephone order for roxanol 20 mg/milliliter (ml), give 10 mg (0.5 ml) sublingual every hour as needed for shortness of breath, restlessness or pain. The nursing home nurse stated the medication available in the emergency kit. e. The hospice skilled nurse note, dated 7/18/23 at 6:25 AM, Staff M, RN revealed the hospice nurse received a call from the nursing home nurse who reported the patient passed away at 4:55 AM with family at the bedside. The body released to the funeral home at 6:15 AM. f. The nursing home document, titled Medication Administration Record, dated 7/1/23 to 7/30/23, included the following medications administered: Oxycodone 5 mg administered on 7/18/23 at 2:50 AM-ineffective, Lorazepam (Ativan) 0.5 mg administered on 7/17/23 at 7:00 PM-effective, 11:00 PM-ineffective and 2:25 AM-ineffective. g. The nursing home progress note, dated 7/17/23 at 5:45 PM, documented the patient’s family informed the nurse the resident’s O2 Sat registering 65%. The nursing home nurse measured the O2 Sat at 64%. The oxygen concentrator tubing changed to shorter tubing and oxygen delivered at 5 LMP via the nasal cannula. The O2 Sat remained at 64% to 65%. Hospice contacted to request a as needed (prn) visit. The patient’s respirations at 28 breaths per minute and skin warm and dry. The patient’s O2 Sat rose to 76% to 77 % on 5 LPM, and the patient noted to be alert and responded appropriately. h. The nursing home progress notes, dated 7/18/23 at 1:55 AM, documented the hospice nurse arrived at approximately 7:00 PM and informed the nursing home nurse the patient had a positive Homan’s sign in the left leg that could be causing the shortness of breath and low oxygen saturation. Family at the bedside and request to keep the patient comfortable at this time. The O2 Sat ranged from 74% to 77% on 5 LPM oxygen mask and 3 LPM portable oxygen per nasal cannula. When the patient repositioned, oxygen saturation ranged form 61% to 64%. Family request both the oxygen mask and nasal cannula remain in place. The patient received Ativan at 7:00 PM and 11:00 PM for increased restlessness and seemed to help the patient calm down. Oxycodone administered as scheduled per family request. i. The nursing home progress note, dated 7/18/23 at 2:30 AM, documented a call placed to the hospice nurse at 2:20 AM due to the patient’s family reported the patient had shortness of breath and just can’t catch their breath. The hospice nurse (Staff M, RN) instructed the nurse to administer Ativan dose of 0.5 mg. The nursing home nurse requested hospice change the frequency of the Ativan to be less than every 4 hours between doses or to increase the Ativan dose. The hospice nurse (Staff M, RN) reported she will get the patient something in the morning and instructed the nursing home staff to give the as needed Ativan dosage at this time. The patient continued to gasp for breath and still unable to rest due to shortness of breath. The patient’s oxygen saturation dropped to 35% during repositioning at 1:30 AM, oxygen continued to be on at 5 LPM per oxygen mask and 3 Liters per nasal cannula on portable oxygen. At 2:50 AM the patient’s family reported the Ativan not working and the patient gasping for air. A telephone call was placed to the hospice nurse (Staff M, RN) again and hospice nurse (Staff M, RN) instructed nursing home staff to give oxycodone now for relief as the combination of oxycodone and Ativan should help. Nursing Home staff administered Oxycodone as ordered. At 3:25 AM, the patient’s family requested morphine ordered as the combination of oxycodone and Ativan did not help the patient at all. The patient continued to be extremely short of breath, continued to be gasping for air and cannot get any rest with ongoing shortness of breath present. A telephone call placed to hospice nurse (Staff M, RN) and discussed the family request. At 4:00 AM the nursing home nurse received a call back from the hospice nurse (Staff M, RN) for an order for morphine sulfate 10 mg, give 0.5 ml every 1 hour as needed for shortness of breath/anxiety or pain. Morphine 0.5 ml administered and tolerated well. The patient continued to gasp for air. j. The nursing home progress note, dated 7/18/23 at 4:55 AM, documented the patient had passed away with no blood pressure, pulse or respirations. At 5:25 AM telephone call to hospice nurse (staff M, RN) to report of the patient’s death. Unable to leave message, no call or voicemail on, will continue to try calling. At 6:35 AM, the hospice nurse (Staff M, RN) notified of the patient death at 4:55 AM. k. The hospice untitled document, dated 7/17, 7/18 and 7/24/23, revealed the hospice received a complaint from the nursing home. The complaint included pain/comfort not addressed appropriately, hospice only suggestion to give Ativan and oxycodone that were already ordered and the patient “gasping” for air and roxanol not brought up as a medication option. On 7/24/23 an investigation of the complaint completed. Education on end of life signs and symptoms and interventions with Staff M, RN occurred. During an interview on 7/7/25 at 10:15 AM, Staff M, RN stated she did not have any memory of patient #14. She did, however remember an instance getting calls from the nursing home. Staff M further stated she did not remember any complaint made concerning her and did not remember any re-education or training regarding end of life signs and symptoms and interventions provided by hospice Administrator or Clinical Manager. During an interview on 7/7/25 at 10:40 AM, the Administrator stated the hospice received a complaint and had reported they felt the patient’s pain and comfort not addressed appropriately by the on-call hospice nurse. She also stated she completed education/counseling with Staff M, RN. The expectation is to ensure the patient is comfortable. The above findings were reviewed with the agency Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to perform an initial bereavement assessment within 5 days of the patient’s election of the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care for 4 of 13 sampled patients (Patients #2, #4, #5 and #6) receiving hospice services for more than 5 days. Failure to complete an initial bereavement assessment increased the risk that patient’s or family’s/caregiver’s grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: 2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment. 3. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 9/18/24, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 10/10/24, lacked an initial bereavement risk assessment. d. Bereavement risk assessment, dated 12/12/24, completed. The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation. 4. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington’s disease and included orders for skilled nurse, social work, hospice aide and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 12/12/24, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 12/23/24, included a bereavement risk assessment. (6 days after the 5 day post election of benefits) The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation. The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. According to the hospice policy titled Assessments: Initial, Comprehensive and Ongoing, dated 1/27/25, the initial assessment will assess the patient’s need for hospice care/services and gather critical information necessary to treat the patient/family’s immediate physical, psychosocial, emotional and spiritual needs as related to the terminal illness and related conditions. The comprehensive assessment is completed within 5 calendar days after the election of hospice care by the Interdisciplinary Group (IDG), in consultation with the patient’s attending physician. This may be completed at the same time as the initial assessment. The assessments should guide: patient problems and needs related to the terminal illness, patient goals related to the terminal illness, patient/caregiver goals related to pain management and anticipated discharge needs, including bereavement and funeral needs. During an interview on 7/1/25 at 9:25 AM, the Social Worker identified agency Registered Nurses (RN) complete the initial bereavement assessment within 5 days of admission. 1.Patient #5 had a hospice admission date of 6/28/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 6/28/25, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 7/1/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment. 2. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 6/5/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment. 3. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 9/18/24, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 10/10/24, lacked an initial bereavement risk assessment. d. Bereavement risk assessment, dated 12/12/24, completed. The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation. 4. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington’s disease and included orders for skilled nurse, social work, hospice aide and volunteer services. b. Skilled nurse initial comprehensive assessment, dated 12/12/24, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 12/23/24, included a bereavement risk assessment. (6 days after the 5 day post election of benefits) The hospice failed to complete an initial bereavement risk assessment with the initial comprehensive assessment as required by regulation. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on hospice interview, clinical record review and hospice policy review, the hospice failed to perform comprehensive patient assessments for patient’s identified wounds for 1 of 2 patients with wounds receiving services in the home (Patient #1). Failure of the hospice staff to perform comprehensive wound assessments placed the patient at risk for ineffective staff collaboration and communication regarding the patient’s hospice care and care of the patient’s wound including effectiveness of treatments and interventions. Findings include: According to hospice policy titled, Wound Care, dated 7/30/24, the wounds will be measured in centimeters (length x width x depth) at least weekly unless covered with a non-removable dressing during the nurse visit. Wound and peri-wound appearance will be assessed each visit unless covered with a non-removable dressing. Wound assessment will include, but is not limited to; color, odor, drainage, tunneling/undermining, and character of wound bed tissue. During an interview on 7/7/25 at 10:55 AM, the Clinical Manager stated the expectation for staff to assess the wound every visit. Measurements are to be completed every week and include length, width and depth. 1.Patient #1 had a hospice admission date of 6/19/25, and received hospice services in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 6/19/25 to 9/16/25, identified the patient had diagnoses of cirrhosis of the liver, lymphedema and non-pressure chronic ulcer of the right heel and midfoot. The POC included orders for skilled nursing visits 3 times a week and wound dressing changes to the right heel and right knee surgical incision. b. The skilled nurse visit note, dated 6/19/25, included the following wound measurements: right heel:1.2 centimeters (cm) length by 1.2 cm width by 1 cm depth. Right knee #1: 2 cm by 2 cm by 0.1 cm and right knee #2: 2 cm by 2 cm by 0.1 cm. c. The skilled nurse visit notes, dated 6/25/25, included the following wound measurements: right heel: 2 cm by 2 cm by 1 cm. Right knee #1: 2 cm by 2 cm by 0.1 cm and right knee #2: 2 cm by 2 cm by 0.1 cm. During a home observation visit on 7/1/25 at 3:30 PM with the Administrator and ,Staff C, Registered nurse (RN) stated the patient had an open wound noted beneath the current 2 wounds on the right knee 1 week ago. Staff C pointed to area on the right knee that she placed a dressing for a total of 3 wound dressings. She stated the wound is now closed. During the same home visit the Administrator stated the patient had a wound on the right shin area that is now closed. Review of the clinical record lacked documentation of an assessment or treatment of wound #3 to the right knee or the right shin. The hospice failed to complete wound assessments on all identified wounds. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on home observation visits, interviews, clinical record reviews and agency policy reviews, the hospice failed to ensure the Plans of Care (POC) for 2 of 3 sampled patients with home observation visits (Patient #1 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 POC placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: 2. Patient #1 had a hospice admission date of 6/19/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 6/19/25 to 9/16/25, identified the patient had a diagnosis of cirrhosis of the liver and used the following medical equipment and supplies: hospital bed, Foley catheter and supplies, wheelchair, wheelchair cushion, walker, Hoyer, mediset, incontinence supplies and urinal. b. During a home observation visit on 7/1/25 at 3:30 PM, with the Administrator and Staff C, RN, the surveyor observed the patient had a reacher. During an interview with the patient’s spouse during the same home visit, he/she stated the patient does use the reacher although does not use it as often as he/she used to. c. During an interview on 7/9/25 at 9:25 AM, the Clinical Manger stated the reacher not added to the POC due to the patient did not have the dexterity to use it anymore. The hospice failed to include all medical equipment and supplies utilized by the patient including the reacher. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. According to the hospice policy titled Plan of Care, dated 1/27/25, hospice care follows a written Plan of Care (POC) established and reviewed by the Interdisciplinary Group (IDG) in collaboration with the patient’s attending physician. The content of the POC includes but is not limited to: Interventions to manage pain and symptoms, drugs and treatments necessary to meet the needs of the patient, medical supplies and appliances necessary to meet the needs of the patient and a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. 1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and used the following medical equipment and supplies: bedrails, hospital bed, oxygen supplies and concentrator, incontinence supplies, bedside table, high back wheelchair, gait belt, gloves, grab bars and walker. b. During a home observation visit on 7/1/25 at 10:20 AM, with the Administrator and Staff C, Registered Nurse (RN), the surveyor observed the patient utilized a lift chair, a wheelchair cushion and a high rise toilet seat. c. During an interview on 7/1/25, the Administrator confirmed the medical equipment and supplies had been utilized since prior to the most recent recertification. d. The IDG meeting notes, dated 7/2/25, failed to identify the lift chair, wheelchair cushion and high rise toilet seat utilized by the patient. The hospice failed to include all medical equipment and supplies utilized by the patient.”

“Based on staff communication and clinical record reviews, the hospice agency failed to ensure the Interdisciplinary Group (IDG) 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 5 of 14 sampled patients (Patients #2, #3, #8, #10 and #13). Failure of the hospice 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 include: 3. Patient #2 had a hospice admission date of 12/12/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/25, identified the patient had a diagnosis of Huntington’s disease and included orders for skiled nurse visits, social worker, hospice aide visits 5 days per week and volunteer visits. b. The clinical record included documentation of 4 hospice aide visits the week of 4/27/25 through 5/3/25. c. The IDG meeting notes, dated 5/7/25, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 4/27/25 through 5/3/25. The hospice failed to provide hospice aide visits as ordered per the POC. 4. Patient #8 had a hospice admission date of 2/19/25, a date of death of 2/25/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of chronic kidney disease and included orders for skilled nurse, social worker, hospice aide, music therapy 1 time a week, massage therapy and volunteer visits. b. The clinical record lacked documentation of a music therapy visit the week of 2/19/25 through 2/22/25. c. The IDG meeting notes, dated 2/26/25, lacked documentation the IDG was notified of the missed music therapy visit for the week of 2/19/25 through 2/22/25. The hospice failed to provide music therapy visits as ordered per the POC. 5. Patient #3 had a hospice admission date of 10/4/24, a date of death of 10/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/4/24 to 1/1/25, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nurse, social worker, hospice aide, music therapy, massage therapy and volunteer visits. b. The clinical record lacked documentation of a massage therapy visit the weeks of 10/6/24 and 10/12/24 and 10/13/24 to 10/19/24. c. The IDG meeting notes, dated 10/23/25, lacked documentation the IDG was notified of the missed massage therapy visit for the weeks of 10/6/24 and 10/12/24 and 10/13/24 to 10/19/24. The hospice failed to provide massage therapy visits as ordered per the POC. They above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy for missed visits. Missed visits are reported to the IDG team at each IDG meeting and included in the IDG notes. 1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse visits 1 time weekly, social worker, hospice aide, music therapy, massage therapy and volunteer visits. b. The clinical record lacked documentation of a skilled nurse visit the week of 6/15/25. c. The IDG meeting notes to update the POC, dated 7/2/25 lacked documentation the IDG was notified of the missed skilled nurse visit for the week of 6/15/25. The hospice failed to provide skilled nurse visits as ordered per the POC. 2. Patient #10 had a hospice admission date of 1/22/25, a death date of 2/10/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/22/25 to 4/21/25, identified the patient had a diagnosis of Atherosclerotic heart disease and included orders for skilled nurse, social worker, hospice aide, music therapy and massage therapy 1 time a week effective 1/22/25. b. The clinical record lacked documentation of a massage therapy visit the week of 1/22/25. c. The IDG meeting notes to update the POC, dated 1/29/25 lacked documentation the IDG was notified of the missed massage therapy visit for the week of 1/22/25. The hospice failed to provide massage therapy visits as ordered per the POC.”

“Based on review of written hospice agreements for services under arrangement, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 3 sampled services (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: Review of the contract between the hospice and sampled pharmacy provider, date amended 9/27/24, identified the contract lacked the following required component: The hospice retains oversight of staff and services. The hospice failed to ensure contractual agreements contained all required components for safe and effective patient care. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on hospice staff communication and clinical record review, the hospice failed to ensure all required components of physician initial certification of the terminal illness (CTI) were completed, appropriately authenticated and included in the patient’s clinical record for 4 of 14 sampled patients (Patients #4, #7, #11 and #12). Failure to obtain the physician’s certification of terminal illness put the patients at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: 5. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 6/5/25 to 9/2/25, included a verbal CTI, dated 6/4/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI. 6. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 6/20/25 to 9/17/25, included a verbal CTI, dated 6/20/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI. Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist. 1.Patient #11 had a hospice admission date of 3/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/28/25 to 6/25/25, identified the patient had a diagnosis of metastatic melanoma and included orders for skilled nurse and social work services. b. CTI form, dated 3/28/25 to 6/25/25, included a verbal CTI, dated 3/28/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 3/28/25 to 6/25/25, dated 7/8/25, by the Medical Director. The hospice failed to obtain the written CTI in the electronic record. 2. Patient #12 had a hospice admission date of 5/23/25 and revoked services on 5/28/25 and received services while residing in a private residence. Clinical record review revealed: a. The POC, dated 5/23/25 to 8/20/25, identified the patient had a diagnosis of chronic kidnew disease and included orders for skilled nurse and social work services. b. CTI form, dated 5/23/25 to 8/20/25, included a verbal CTI, dated 5/23/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI in the electronic record. According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness. The email noted the agency follows regulatory requirements.”

“Based on staff communication and clinical record reviews, the hospice failed to ensure the hospice medical director reviewed clinical documentation and completed a recertification of terminal illness for 3 of 4 sampled patients receiving services longer than the initial certification period at the time of the survey (Patients #2, #3 and #6). Failure to obtain the physician’s certification of terminal illness put the patients at risk of receiving hospice care inappropriately and/or without a funding source. Findings include: 3. Patient #6 had a hospice admission date of 9/18/24 and received services in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 9/18/24 to 12/16/24, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. CTI form, dated 3/17/25 to 5/15/25, included a verbal CTI, dated 3/11/25, but lacked the written attestation statement and physician electronic signature. c. CTI form, dated 5/16/25 to 7/14/25, included a verbal CTI, dated 5/7/25, but lacked the written attestation statement and physician electronic signature. The hospice failed to obtain the written CTI. Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist. 2. Patient #2 had a hospice admission date of 6/5/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 4/11/25 to 6/9/25 and 6/10/25 to 8/8/24, identified the patient had a diagnosis of Huntinton’s disease and included orders for skilled nurse, social work, hospice aide and volunteer services. b. CTI form, dated 4/11/25 to 6/9/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for 4/11/25 to 6/9/25, dated 7/8/25 by the Medical Director. d. CTI form, dated 6/10/25 to 8/8/25, included a verbal CTI, dated 6/3/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25 at 9:20 AM, the hospice produced a CTI form for both, 4/11/25 to 6/9/25, and 6/10/25 to 8/8/25, dated 7/8/25 with attestation statement and physician electronic signature by the Medical Director. The hospice failed to complete a CTI. According to email communication between the Clinical Quality Specialist and Administrator, dated 7/7/25, the hospice agency does not have a policy on Certification of Terminal Illness. The email noted the agency follows regulatory requirements. 1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 4/12/25 to 6/10/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy services. b. The Certification of Terminal Illness (CTI) form, dated 4/12/25 to 6/10/25, included a verbal CTI, dated 4/1/25, but lacked the written attestation statement and physician electronic signature. c. On 7/9/25, the Administrator and Clinical Quality Specialist gave Surveyor a CTI dated 4/12/25 to 6/10/25, signed completed by the Medical Director on 7/8/25 at 2:02 PM, 87 days after the start of the benefit period. The hospice failed to obtain the written CTI at the time of recertification.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 3 of 14 sampled patients (Patients #2, #3 and #6). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient’s condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: 3. Patient #2 had a hospice admission date of 12/12/24 and received services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the POC, dated 5/7/25, identified the patient had a diagnosis of Huntington’s disease and included orders for skilled nurse, social work, hospice aide and volunteer services. b. IDG update to the POC, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date and 27 days late per agency policy. The hospice failed to have all documentation completed timely. The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. 2. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the Plan of Care, dated 4/23/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Massage therapy visit notes, dated 4/29/25 and 5/5/25, identified being scanned into the electronic medical record on 6/10/25, 42 and 35 days after the visits, and 41 and 34 days late per agency policy. c. IDG update to the Plan of Care, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date, and 27 days late per agency policy. The hospice failed to have all documentation completed timely. According to the hospice policy titled Documentation in the Electronic Medical Record (EMR), dated 10/18/24, hospice clinical records are a combination of paper based and electronic medical records. Documentation in the clinical record is timely, detailed, accurate and reflects the care and services provided. Entries are made for all care, services, observations and assessments, communication and are signed by the person providing services no longer than 24 hours after the contact. All written entries are legible, complete and scanned into the EMR. 1.Patient #3 had a hospice admission date of 6/22/23 and received services while residing in a nursing home. Clinical record review revealed: a. The Interdisciplinary Group (IDG) update to the Plan of Care (POC), dated 5/21/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. IDG update to the POC, dated 6/4/25, identified a finalization date of 7/2/25, 28 days after the meeting date and 27 days late per agency policy. The hospice failed to have all documentation completed timely.”

“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 standards for 5 of 14 sampled patients (Patients #3, #4, #5, #6 and #7). 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 its patients. Findings include: 3. Patient #4 had a hospice admission date of 6/5/25 and received services while residing in an assisted living facility. Clinical record review revealed: a. The Plan of Care, dated 6/5/25 to 9/2/25, identified the patient had a diagnosis of Hypertensive heart disease without heart failure and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Hospice aide visit note, dated 6/6/25, signed and closed on 6/12/25, 6 days after the visit and 5 days late. c. Skilled nurse visit note, dated 6/13/25, signed and closed on 6/17/24, 4 days after the visit and 3 days late. d. Hospice aide visit note, dated 6/9/25, signed and closed on 6/11/25, 2 days after the visit and 1 day late. e. Hospice aide visit note, dated 6/13/25, signed and closed on 6/15/25, 2 days after the visit and 1 day late. f. Volunteer visit note, dated 6/9/25, signed and dated 6/15/25, 6 days after the visit. g. Music therapy visit notes, dated 6/12, 6/19 and 6/26/25, lacked handwritten or electronic signature, title and date completed. During an interview on 7/2/25 at 3:00 PM, Staff J, Lead Administrative Assistant, reported music therapist usually provides the hospice with visit notes at the end of the month. They will contact music therapist regarding missing visit notes. On 7/2/25 at 3:55 PM, Staff J, Lead Administrative Assistant, provided music therapy notes, dated 6/12, 6/19 and 6/26/25, to surveyor and reported they were just emailed to hospice staff. On 7/8/25 at 3:00 PM, Staff L, Clinical Quality Specialist, provided music therapy notes, dated 6/12/25, 6/19/25 and 6/26/25, to surveyor with handwritten signature and dated the date of visit. The agency failed to ensure timely completion of routine visit documentation. 4. Patient #6 had a hospice admission date of 9/18/24 and received services while residing in a nursing home. Clinical record review revealed: a. The IDG update to the Plan of Care, dated 4/23/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Hospice aide visit note, dated 5/6/25, signed and closed on 5/9/25, 3 days after the visit and 2 days late. c. Volunteer visit note, dated 6/16/25, lacked a signature or date of signature. The agency failed to ensure timely completion of routine visit documentation. 5. Patient #7 had a hospice admission date of 6/20/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 6/20/25 to 9/17/25, identified the patient had a diagnosis of Dementia of the Alzheimer’s type with late onset without behavioral disturbance and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Hospice aide visit note, dated 6/24/25, signed and closed on 6/27/25, 3 days after the visit and 2 days late. The agency failed to ensure timely completion of routine visit documentation. Findings were given to the Administrator, Clinical Manager and Clinical Quality Specialist. According to the hospice policy titled Documentation in the Electronic Medical Record (EMR), dated 10/18/24, hospice clinical records are a combination of paper based and electronic medical records. Documentation in the clinical record is timely, detailed, accurate and reflects the care and services provided. Entries are made for all care, services, observations and assessments, communication and are signed by the person providing services no longer than 24 hours after the contact. All entries reflect the date care, treatment and/or service was provided, including the month, date and year, time and authentication. All written entries are are legible, complete and scanned into the EMR. 1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plans of Care (POC), dated 4/12/25 to 6/10/25 and 6/11/25 to 8/9/25, identified the patient had a diagnosis of Hypertensive heart and chronic kidney disease and included orders for skilled nurse, social work, hospice aide, massage therapy, music therapy and volunteer services. b. Hospice aide visit note, dated 5/6/25, signed completed 5/9/25, 3 days after the visit and 2 days late per agency policy. c. Hospice aide visit note, dated 5/7/25, signed completed 5/9/25, 2 days after the visit and 1 day late per agency policy. d. Hospice aide visit note, dated 6/12/25, signed competed 6/15/25, 3 days after the visit and 2 days late per agency policy. The agency failed to ensure timely completion of routine visit documentation. 2.Patient #5 had a hospice admission date of 6/28/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, hospice aide, massage therapy and music therapy. b. Skilled nurse visit note, dated 6/30/25, signed completed 7/2/25, 2 days after the visit and 1 day late per agency policy. The agency failed to ensure timely completion of routine visit documentation.”

“Based on review of the written agreements between the hospice and hospitals providing short-term inpatient care or respite care, the hospice failed to ensure the written agreements identified the hospitals would send a copy of the hospice patient’s discharge summary to the hospice at the time of discharge from the facility for 2 of 2 sampled written agreements (Hospital A and Hospital B). Failure to ensure the hospitals provided the hospice with a discharge summary upon hospital discharge of a hospice patient decreased the possibility of continuity of care when the patient returned home. Findings include: 1.The hospice had a contractual agreement with Hospital A, dated 8/28/2022. The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge. 2.The hospice had a contractual agreement with Hospital B, dated 8/22/2022. The contractual agreement failed to specify the hospital would provide the hospice agency with a copy of the discharge summary at the time of discharge. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“Based on staff interview, clinical record reviews and review of nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient’s medications with the nursing home for 2 of 2 sampled patients (Patients #2 and #3) with a nursing home medication review. Failure to ensure the hospice staff provided overall coordination of the patient’s medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: 2. Patient #2 had a hospice admission date of 12/12/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/10/25 to 8/8/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications. b. Review of the patient’s nursing home MAR, dated 7/1/25 through 7/30/25, identified the following medication discrepancy with the hospice’s POC and Medication Profile for the patient: The hospice POC had an order for atropine sulfate ophthalmic solution 1%, give 2 drop every 4 hours as needed for increased secretions. The nursing home MAR included the order for atropine sulfate ophthalmic solution 1%, give 1 drop every 4 hours as needed for increased secretions. The nursing home identified a start datd of 8/16/2024. Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home. The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist. During an interview on 7/1/25 at 12:22 PM, Staff C, Registered Nurse (RN), identified anytime an update or change to the patient’s plan of care occurs, the facility is notified via telephone call or in person regarding the update or change. 1.Patient #3 had a hospice admission date of 6/22/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 6/11/25 to 8/9/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications. b. Review of the patient’s nursing home Medication Administration Record (MAR), dated 7/1/25, identified the following medication discrepancy with the hospice’s POC and Medication Profile for the patient: The hospice POC had an order for Lorazepam (Ativan) 0.5 milligram (mg) tablet with instructions to take 0.5mg by mouth every 2 hours as needed for agitation or anxiety. The hospice’s Medication Profile identified a start date for the medication, dated 3/6/25. The nursing home’s MAR had an order for Ativan (Lorazepam) 1 mg oral tablet with instructions to give 0.5 mg by mouth every 4 hours as needed for repetitive “help me”, “we gotta go”. The nursing home MAR identified a start date for the medication, dated 4/2/25. Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home.”

“Based on staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure the substantial provision of a core hospice service, medical social services, complied with the educational and supervisory requirements for personnel providing medical social services for 12 of 14 sampled hospice patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #13) who received social worker services. Failure of the hospice to ensure a qualified social worker provided and documented regular and timely supervision of the delivery of medical social services increased the risk the delivery of this core service may not have adequately or safely met the needs of hospice patients and/or families. Findings include: According to the agency policy titled Social Services, dated 10/1/2024, social services are provided by qualified social workers (Master of Social Work or Baccalaureate of Social Work), licensed in the state in which they practice, under the direction of a physician and in accordance with the plan of care. A social worker with a baccalaureate degree will be supervised by a Master of Social Work (MSW) who is employed or contracted by the hospice. The clinical records of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #13 included documentation the patients received social work services by Staff F, Social Worker. During an interview on 7/1/2025 at 9:25 AM, Staff F, Social Worker, reported having a Baccalaureate degree in Social Work (BSW) and several years of experience working in a healthcare setting. Staff F stated he has not received supervision from an MSW since he was hired on 9/3/24. During an interview on 7/8/2025 at 10:02 AM, Staff L, Clinical Quality Specialist, reported Staff F, BSW had not had supervision since he was hired on 9/3/24. The agency failed to ensure a qualified Master of Social Work provided and documented regular supervision of the baccalaureate level hospice social worker. The above findings were reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”

“The Iowa Code, Chapter 135C.33 requires hospice agencies to complete a criminal history, a dependent adult abuse, and child abuse record check on all prospective direct or contracted employees with the potential for direct patient contact, within 30 days prior to the date of hire, using either the Iowa Single Information Repository (SING), or using both the Iowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the Iowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The Iowa Administrative Code, Chapter 119, requires the hospice agency to obtain authorized clearance from the Department of Human Services (DHS) prior to hiring any prospective employee who DCI has reported has a criminal record for any conviction more severe than a simple misdemeanor. Based on review of employee personnel files, the hospice failed to ensure completion of a criminal background check for 1 of 5 sampled employees who began serving hospice patients since their last survey, dated 7/27/22. The hospice reported hiring 12 employees since the last survey. Failure to complete criminal background checks as required by Federal regulation, increased the potential risk of harm to agency patients from hospice volunteers and/or employees who had direct patient contact. Findings include: Staff I, Chaplain, had a hire date of 5/5/25. Staff I’s personnel file included documentation of a completed criminal history background check, dated 4/2/25, 33 days prior to Staff I’s hire date. Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on all staff prior to hiring. The above findings reviewed with the Administrator, Clinical Manager and Clinical Quality Specialist.”