Hospice of Palo Alto County

“Based on Interdisciplinary Group (IDG) observation, staff interviews, clinical record reviews and agency policy review, the hospice failed to: 1) Ensure the hospice Interdisciplinary Group included a pastoral or other counselor (see L0541); 2) Ensure the hospice developed a written plan of care with routine orders individualized to meet the specific needs of the patient (See L0547) and 3) Ensure the hospice plans of care included all necessary drugs and treatment to meet the needs of the patient (See L0549). The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group of personnel promoted and supported the safe, comprehensive and effective delivery of patient care to their hospice patients.”

“Based on clinical record review and agency policy review, the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient’s clinical record, any advance directives executed by the patient for 1 of 14 sampled patients (Patient #13). Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: According to the hospice policy, titled Admission Process for Hospice Care, dated 2/2025, the hospice nurse will assess patient advanced directives/code status wishes and document in the patient’s chart. 1.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 1/21/25 to 4/20/25, identified the patient’s advance directive information as do not resuscitate. b. The admission consent forms, signed by the patient on 1/21/25 identified the patient wanted resuscitative measures. The hospice agency failed to include accurate advance directive information on the patient’s plan of care at the time of admission to hospice services. The above findings were reviewed with the Administrator.”

“Based on clinical record review and agency policy review, the hospice failed to ensure the hospice registered nurse completed a comprehensive assessment which included wound measurements for 5 of 5 sampled patients (Patient #2, #9, #10, #13 and #14), with wounds. Failure to complete an initial wound assessment increased the risk patient’s needs would not be identified and/ or addressed appropriately, and the hospice would have an incomplete baseline assessment for comparison in order to determine effectiveness of wound treatments and interventions. Findings Include: 4. Patient #9 had a hospice admission date of 11/14/24, a death date of 12/22/24 and received hospice services while residing in a nursing home. a. The POC, dated 11/14/24 to 2/11/25, identified the patient had a diagnosis of heart failure and included physician orders for skilled nurse to assess skin integrity and overall condition of the skin. b. The skilled nurse initial assessment, dated 11/14/24, completed by Staff A, Administrator, identified patient had a decubitus pressure ulcer but lacked further description and/or measurements. c. The skilled nurse visit note, dated 11/15/25, completed by Staff B, RN, identified the patient had a wound to inner buttocks coccyx/decubitus/pressure ulcer stage II but failed to include wound measurements. The initial comprehensive assessment lacked documentation of wound measurements to wound on the coccyx. 5. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse services 1-7 times a week. b. The skilled nurse visit note, dated 3/11/25, completed by Staff D, RN, identified the patient had sustained the following wounds: 1) Skin tear to left arm, wound bed clean and red. Documentation identified wound measurements of 2.5 cm X 0.5 cm but failed to include a measurement for the depth of the wound. 2) Skin tear to midline chest, wound bed clean and red. Documentation identified wound measurements of 2 cm X 1.5 cm but failed to include a measurement for the depth of the wound. 3) Skin tear to right hand, wound bed clean and red. Documentation identified wound measurements of 1 cm X 1cm but failed to include a measurement for the depth of the wound. 4) Skin tear to right medial hand between third and fourth digit, wound bed clean. Documentation identified wound measurements of 2 cm X 0.5 cm but failed to include a measurement for the depth of the wound. The skilled nurse assessment lacked documentation of depth to the newly identified wounds. The above findings were reviewed with the Administrator. According to the hospice policy titled Wound Care, dated 2/2025, wounds should be measured at a minimum of once a week by the home care nurse and documented in the electronic medical record. Documentation of the wound includes the length, width and depth measurements recorded in centimeters. During an interview on 11/10/15 at 10:23 AM the Administrator/Clinical Manager stated the expectation for staff to complete weekly wound measurements that include the length, width and depth of the wound. 1.Patient #2 had a start of care date of 6/18/25, and received hospice services in a long term care facility. a. The Plans of Care (POCs), dated 6/18/25 to 9/15/25 and 9/16/25 to 12/14/25, included a diagnosis of a Parkinsonism, and physician orders for skilled nurse to provide wound care to the great toe on the right foot and the 2nd toe on the left foot. b. The initial comprehensive assessment completed on 6/18/25, by Staff D, Registered Nurse (RN), identified the following wounds: 1) Skin tear on the left outer shin. The assessment failed to include measurements.2) Skin tear on the right fore arm. The assessment failed to include measurements.3) Skin tear on the right outer shin. The assessment failed to include measurements.4) Wound on 2nd toe of the left foot. The assessment included measurements of legnth 0.5 centimeters (cm) by width 0.1 cm. The assessment failed to include measurements of wound depth. The initial comprehensive assessment lacked documentation of complete measurements of the patient’s wounds. 2. Patient #10 had a start of care date of 12/26/24 and date of death of 2/23/25 and received hospice services in a long term care facility. a. The POC, dated 12/26/24 to 3/25/25, included a diagnosis of Alzheimer’s disease and physician orders for skilled nurse services 1 to 5 times a week to assess skin integrity and overall condition of skin including: signs/symptoms of breakdown, friction, shearing, or pressure areas. b. The skilled nurse visit note, dated 2/10/25, Staff G, RN identified the patient had a blister located on the upper medial buttocks/coccyx. The assessment lacked documentation of wound measurements. c. The skilled nurse visit note, dated 2/13/25, Staff G, RN, identified a stage 2 wound on the left inner buttock/coccyx. The wound included documentation of a newly reopened wound. The assessment lacked measurements of the wound. The assessment also included identification of an intack blister on the upper medial buttocks/coccyx. The assessment lacked documentation of measurements of the wound. The hospice lacked documentation of complete measurements of the patient’s wounds. 3. Patient #10 had a start of care date of 12/26/24 and date of death of 2/23/25 and received hospice services in a long term care facility. a. The POC, dated 12/26/24 to 3/25/25, included a diagnosis of Alzheimer’s disease and physician orders for skilled nurse services 1 to 5 times a week to assess skin integrity and overall condition of skin including: signs/symptoms of breakdown, friction, shearing, or pressure areas. b. The skilled nurse visit note, dated 10/15/24, by Staff G, RN, identified the following wounds: 1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 7.8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 6 cm by 5 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3.5 cm by 4 cm. The wound assessment lacked measruements of wound depth. b. The skilled nurse visit note, dated 10/22/24, by Staff G, RN, identified the following wounds:1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 5.5 cm by 5 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3 cm by 4 cm. The wound assessment lacked measurements of wound depth. c. The skilled nurse visit note, dated 10/29/24, by Staff A, Administrator/Clinical Manager, identified the following wounds:1) Right distal foot on the 3rd toe: 5 cm by 5 cm. The wound assessment lacked measurements of wound depth.2) Right distal foot on the great toe: 8 cm by 6 cm. The wound assessment lacked measurements of wound depth.3) Right medial distal foot 2nd toe: 5 cm by 4 cm. The wound assessment lacked measurements of wound depth.4) Right proximal foot 4th toe: 3 cm by 3.5 cm. The wound assessment lacked measurements of wound depth. d. The skilled nurse visit note, dated 11/5/25, Staff D, RN, identified the patient had a fall and sustained the following injuries:1) Skin tear to left arm: 20 cm. The wound assessment lacked measurements of wound width or depth.2) Skin tear left arm, shoulder area: 4 cm by 5 cm. The wound assessment lacked measurements of wound depth.3) Skin tear left hand: 3 cm. The wound assessment lacked measurements of wound width or depth.4) Skin tear forehead: 2 cm. The wound assessment lacked measurements of wound width or depth.5) Skin tear left shin 7 cm by 2.5 cm. The wound assessment lacked measurements of wound depth.6) Skin tear left calf: 4 cm. The wound assessemnt lacked measurements of width and depth. The hospice lacked documentation of complete measurements of the patient’s wounds.”

“Based on Interdisciplinary Group (IDG) observation, staff interviews, clinical record reviews and agency policy review, the hospice failed to ensure a pastoral or other counselor participated in IDG meetings and participated in the review and updating of the patient’s plan of care through the IDG meeting for 5 of 5 sampled patients (Patients #1, #2, #3, #4 and #5). The hospice reported a current census of 5 patients at the time of they survey. Failure of the hospice to ensure a pastoral or other counselor participated in each IDG meeting placed hospice patients at risk for not having all of their spiritual needs identified and addressed. Findings include: According to the agency policy, titled The Interdisciplinary Team, dated 8/2025, the provision of total care by an Interdisciplinary Group (IDG) requires participation and coordination of a variety of personnel with different resources and skills. The four core services will participate in the initial plan of care of the hospice client. The four core services include physician, nursing, social worker and counseling. All core services will provide input prior to providing care or as soon after admission as possible. During an IDG meeting observation on 11/6/25, the Surveyor identified no chaplain/pastoral counselor participated in the IDG meeting. During an interview on 11/12/25 at 10:10 AM, Staff A, Administrator, identified the hospice does not have a chaplain/pastoral counselor on staff. Review of the clinical records for Patients #1, #2, #3, #4 and #5 revealed a lack of documented attendance and coordination with a hospice chaplain/pastoral counselor (a core hospice service). The above findings were reviewed with the Administrator.”

“Based on staff interviews and clinical record reviews, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care which specified the scope and frequency (acceptable, small interval ranges) for all services required by and provided to patients for 5 of 14 sampled patients (Patients #1, #2, #3, #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 #2 had a hospice admission date of 6/18/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 6/18/25 to 9/15/25 and 9/16/25 to 12/14/25, identified the patient had a primary diagnosis of Parkinsonism and included IDG orders for nursing 1-5 times a week, massage therapy services 1-5 times a month and social work services 1-5 times a month. b. The IDG meeting note, dated 11/6/25, included orders for nursing 1-5 times a week, massage therapy services 1-5 times a month and social work services 1-5 times a month. c. Review of the clinical record revealed the nurse saw the patient 1-3 times a week in the months of September and October, massage therapy saw the patient 2 month in September and October, and the social worker saw the patient 1 time a month in September and October. The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs. The above findings reviewed with the Administrator/Clinical Manager. On 11/12/25 at 11:28 AM, the Administrator reported the hospice agency does not have a policy addressing content of the plan of care. During an interview on 11/5/25 at 3:57 PM, Staff B, Registered Nurse (RN), stated patient’s plans of care are developed based on assessment of patient needs. 1.Patient #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/28/25 to 11/25/25, identified the patient had a primary diagnosis of cirrhosis of the liver and included Interdisciplinary Group (IDG) orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month. b. The IDG meeting note, dated 11/6/25, included orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month. c. Review of the clinical record revealed the nurse seeing the patient 1-2 times a week in the months of August, September and October, massage therapy seeing the patient 1-2 month in August, September and October, and the social worker seeing the patient 1-2 times a month in August, September and October. The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs. 2.Patient #3 had a hospice admission date of 7/31/25 and received hospice services while residing in a nursing home. Clinical record review revealed: The POC, dated 10/29/25 to 1/26/26 identified the patient had a primary diagnosis of malignant neoplasm of peritoneum and included IDG orders for nursing services. The IDG failed to include a detailed scope and frequency of all services necessary to meet the specific patient/family needs. 3.Patient #12 had a hospice admission date of 11/26/24, a discharge date of 5/21/25 and received hospice services while residing in a nursing home. a. The POC, dated 2/24/25 to 5/24/25, identified the patient had a primary diagnosis of congestive heart failure and included IDG orders for nursing 1-5 times a week and massage therapy services 1-4 times a month. b. The IDG meeting note, dated 5/1/25, included orders for nursing 1-5 times a week, massage therapy services 1-4 times a month and social work services 1-4 times a month. c. Review of the clinical record revealed the nurse seeing the patient 1 time a week in the months of April and May, massage therapy seeing the patient 1-2 month in April and May, and the social worker seeing the patient 1 time a month in April and May. The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs. 4. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. a. The POC, dated 1/21/25 to 4/21/25, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included IDG orders for nursing 1-7 times a week, hospice aide services 1-4 times a week, massage therapy services 1-4 times a month and social work to assess and evaluate. b. The IDG meeting note, dated 4/10/25, failed to include a detailed scope and frequency of all services necessary to meet the patient/family needs. The IDG failed to include a detailed scope and frequency (with small intervals) of all services necessary to meet the specific patient/family needs.”

“Based on staff interviews and clinical record reviews, the hospice failed to ensure the hospice plan of care included complete orders for all necessary medications and treatments to meet the needs of the patients for 5 of 14 sampled patients (Patients #1, #3, #5, #10 and #13). Failure to ensure the plan of care included complete orders for medications and treatments placed the patients at risk to received inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: 5. Patient #10 had a hospice admission date of 12/26/25 and date of death of 2/23/24 received hospice services while residing in a nursing home. Review of the clinical record revealed: a. The POC, dated 12/26/24 to 3/25/25, identified the patient had a diagnosis of Alzheimer’s disease, included orders for skilled nurse visits and included physician orders for medications and treatment. b. The skilled nurse visit notes, dated 2/10/25 and 2/17/25, Staff G, RN and Staff D, RN, respectively, identified the patient had a blister to the upper medial buttock. The nurse provided wound treatment that included skin prep to the wound. c. The skilled nurse visit notes, dated 2/13/25 and 2/17/25, Staff G, RN,identified the patient had an open wound to the left inner buttock/coccyx area. The nurse provided wound treatment that included cleanse with soap and water and cover with meplex dressing. c. The IDG update to the POC, dated 2/13, 2/20 and 2/27/25, lacked physician orders for wound treatment to the upper medial buttock or the left inner buttock/coccyx area. The hospice failed to include all physician orders for necessary drugs and treatment on the patient’s plan of care. The above findings reviewed with the Administrator /Clinical Manager. On 11/12/25 at 11:28 AM, the Administrator reported the hospice agency does not have a policy addressing content of the plan of care. During an interview on 11/5/25 at 3:57 PM, Staff B, Registered Nurse (RN), stated patients’ plans of care are developed based on assessment of patient needs. 1.Patient #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/28/25 to 11/25/25, identified the patient had a diagnosis of cirrhosis of the liver, included orders for skilled nurse visits and included physician orders for medications and treatment. b. The Interdisciplinary Group (IDG) update to the POC, dated 11/6/25, identified the patient had an indwelling catheter but lacked complete orders with French size and balloon volume. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. 2. Patient #3 had a hospice admission date of 7/31/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/29/25 to 1/26/25, identified the patient had a diagnosis of malignant neoplasm of peritoneum, included orders for skilled nurse visits and included physician orders for medications and treatments. b. The POC, dated 10/29/25 to 1/26/25, identified the patient had an indwelling foley catheter with orders to insert 16 French catheter, change every 6 weeks and as needed. Flush with 30-60 cubic centimeters (cc) normal saline as needed for clogging. The physician order failed to include catheter balloon inflation volume. The hospice failed to include complete physician orders for necessary treatment on the patient’s plan of care. 3.Patient #5 had a hospice admission date of 12/4/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 9/30/25 to 11/28/25, identified the patient had a diagnosis of end stage heart failure, included orders for skilled nurse visits and included physician orders for medications and treatment. b. The skilled nurse visit note, dated 10/14/25, completed by Staff C, Registered Nurse (RN), identified the patient utilized a heating pad for comfort. c. The IDG update to the POC, dated 10/23/25, lacked physician orders for heat therapy. The hospice failed to include all physician orders for necessary drugs and treatment on the patient’s plan of care. 4.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease, included orders for skilled nurse visits and included physician orders for medications and treatment. b. The skilled nurse visit note, dated 3/12/25, completed by Staff D, RN, identified the patient sustained four new skin tears, wounds were cleansed with normal saline, a non-adherent dressing applied and secured with tape. c. The IDG update to the POC, dated 3/13/25, lacked physician orders for wound care. The hospice failed to obtain physician orders for wound care.”

“Based on clinical record review, hospice staff interview and policy reviews, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 2 of 2 sampled bereavement records (Patient #13 & #14). Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief. Findings include: 2. Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. Clinical record review revealed: A skilled nurse visit note, dated 4/14/25, completed by Staff G, Registered Nurse (RN), identified the patient had died. During an interview on 11/10/25 at 2:10 PM, the Administrator stated bereavement documentation is kept in a binder until family is discharged from bereavement and then it is scanned into the patient’s chart. The Administrator reviewed the binder and identified it lacked bereavement information for Patient #13. The clinical record failed to include any documentation bereavement services had been offered to the patient. The above findings were reviewed with the Administrator. According to the hospice policy titled Philosophy, Purpose and Goals, dated 3/2008, the hospice program provides eotional, physical, and spiritual care during the illness and continued support for the family during the bereavement period. 1.Patient #12 had a start of care date of 8/16/24, a death date of 11/7/24 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. A bereavement assessment post death form, dated 11/7/24, was completed and identified the daughter of Patient #14 as the bereaved. b. The social service assessment/reassessment, dated 12/10/25, revealed a call placed to the bereaved. c. The bereavement, dated 12/17/25, documented a choice for card mailing sent. d. Review of the clinical record lacked further contact with the bereaved. e. During an interview on 11/12/25 at 9:25 AM the Social Worker stated patinet #14’s bereaved declined further bereavement services. She further stated she failed to document the bereaved declinied in the clinical record. The hospice failed to complete further contact according to the plan/interventions with the bereaved following the death of the patient.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient’s needs for 2 of 5 sampled patients receiving hospice aide services (Patients #9 and #13). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner. Findings include: According to the hospice policy titled Home Care Aide (HCA) Supervision and HCA Duties, dated 2/2024, the Registered Nurse (RN) evaluates and updates, as necessary, the home care aide plan of care. During an interview on 11/10/25 at 10:23 AM, the Administrator stated the admission nurse is responsible for creating the aide care plan. 1.Patient #9 had a hospice admission date of 11/14/24, a death date of 12/22/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 11/14/24 to 2/11/25, identified the patient had a diagnosis of heart failure and include physician orders for skilled nurse and hospice aide services. b. The skilled nurse visit note, dated 11/22/25, completed by Staff B, RN, identified the patient was transferred to wheelchair with gait belt and two person assist. c. The aide care plan, dated 11/18/24, included aide instructions to assist with transfers. The assignment did not include specific instructions on what assistive device should be used when transferring the patient. The hospice RN failed to include what specific assistive device the aide should use when transferring the patient. 2.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. Review of the clinical record revealed: a. The POC, dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 1/27/25, included aide instructions to provide foot care per client request, provide skin care per client request and provide nail care per client request. The assignment did not include specific instructions on what foot care, nail care and skin care the aide should provide. The hospice RN failed to include specific instructions on what foot care, nail care and skin care the aide should provide to the patient. The above findings were reviewed with the Administrator.”

“Based on 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 2 of 5 sampled patients receiving hospice aide services (Patients #8 and #13). 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: 2. Patient #8 had a hospice admission date of 6/27/25, a death date of 8/7/25 and received hospice services while residing in a private residence. Review of the clinical record revealed: a. The POC, dated 6/27/25 to 9/24/25, identified the patient had a diagnosis of malignant neoplasm of the esophagus and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 6/27/25, included aide instructions to shower per client request and provide bed complete bed bath per client request. c. Hospice aide visits notes, dated 7/15/25, 7/18/25 7/25/25 and 7/29/25, completed by Staff E, Hospice Aide, documented completing both a shower and a bed bath. The hospice aide failed to accurately document completion of a shower or bed bath per RN instruction. The above findings reviewed with the Administrator/Clinical Manager. According to the hospice policy titled Home Care Aide (HCA) Supervision and HCA Duties, dated 2/2024, the Registered Nurse (RN) evaluates and updates, as necessary, the home care aide plan of care. The home care aide communicates any changes or need to revise the home care aide care plan to the RN. 1.Patient #13 had a hospice admission date of 1/21/25, a death date of 4/14/25 and received hospice services while residing in a private residence. Review of the clinical record revealed: a. The Plan of Care (POC), dated 1/21/25 to 4/20/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 1/27/25, included aide instructions to shower per client request and provide bed bath per client request. c. Hospice aide visits notes, dated 3/4/25 and 3/14/25, completed by Staff E, Hospice Aide, documented completing both a shower and a bed bath. The hospice aide failed to accurately document completion of a shower or bed bath per RN instruction.”

“Based on review of written hospice agreements for services under arrangements, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contractual components for 1 of 3 sampled services (Massage therapy 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 agency and Staff F, Massage Therapist, dated 7/5/2022, identified the contract lacked a signature by the massage therapist. The hospice failed to ensure the contractual agreement contained all required components. The above findings were reviewed with the Administrator.”

“Based on review of contracts for inpatient services, the hospice failed to ensure contracts with facilities providing inpatient level of care services to hospice patients included specifications of the requirement that staffing schedules included registered nurse shifts as required at 418.110 (b) and (f) regarding 24 hour nursing services and patient areas for 1 of 1 sampled inpatient facility contracts (hospital contract). Failure to ensure contractual agreements with inpatient providers included necessary provisions placed patients at risk of not having their needs met in a comfortable atmosphere. Findings include: Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, failed to include specifications regarding registered nurse staffing requirements and requirements for patient care areas. The above findings were reviewed with the Administrator.”

“Based on review of written contracts, the hospice failed to ensure written contractual agreements between the hospice and a hospital to provide respite inpatient care included a provision which specified the hospice patient would receive respite care in a facility which provided physical space for private patient and family visiting, accommodations for family members to remain with the patient throughout the night, physical space for family privacy after a patient’s death and the opportunity for patients to receive visitors at any hour. Failure to include this provision within the contractual agreement increased the potential of hospice and inpatient facility staff not meeting patient needs 24 hours a day. Findings include: Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, lacked a provision which required the inpatient facility to provide care in a home-like atmosphere and ensure that patient areas are designed to preserve dignity, comfort and privacy of patients. The above findings were reviewed with the Administrator.”

“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. 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: Review of the inpatient facility agreement between the hospice agency and the hospital, dated 9/29/2015, 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.”

“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 3 sampled patients (Patients #1 and #2) 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 #1 had a hospice admission date of 5/30/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/28/25 to 11/25/25, identified the patient had a diagnosis of cirrhosis of the liver, included orders for skilled nursing services and included physician orders for medications. b. Review of the patient’s nursing home MAR, dated 10/29/25, identified the following medication discrepancy with the hospice’s POC and Medication Profile for the patient: The nursing home MAR identified an order for Tums 500 mg oral chewable tablets with instructions to give 1 tablet by mouth every 6 hours as needed for indigestion. The nursing home’s MAR identified a start date for the medication, dated 9/24/25. The hospice IDG update to the POC, dated 10/23/25 lacked an order for this medication. Hospice staff failed to ensure the coordination of the patient’s medication with the patient’s nursing home. The above findings were reviewed with the Administrator. During an interview on 11/4/25 at 4:00 PM the Administrator/Clinical Manager stated the hospice current medications listed on the Medication Profile. 1.Patient #2 had a hospice admission date of 6/18/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 9/16/25 to 12/14/25, 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 11/2/25 to 11/30/25, identified the following medication discrepancy with the hospice’s POC and Medication Profile for patient #2: 1) Nursing home MAR included Salonpas pain releiving external patch 4%. Apply to right shoulder topically as needed for pain/discomfort, may apply daily as needed. Start date 10/11/23. The hospice failed to include orders for the medication Salonpas pain releiving patch. 2: Nursing home MAR included Artifical tears opthalmic solution 1-0.3%. Instil 1 drop in both eyes as needed for dry eyes, may administer up to 4 times a day. Start date of 6/26/25. The hospice included the following duplicate orders: Artificial tears opthalmic solution 1-0.3% 1 drop, administer in each eye 4 times a day as needed for dry eyes, artificial tears opthalmic sollution 1%, 1 drop in each eye 2 times a day as needed for dry eyes and tears naturale opthalmic solution appy 1 drop in each ey 4 times a day as needed for dry eyes. Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home.”

“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 3 sampled employees who began serving hospice patients since their last survey, dated 7/19/23. The hospice reported hiring 3 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 H, Volunteer, had a hire date of 1/17/25. Staff H’s personnel file included documentation of a completed criminal history background check, dated 2/6/25, 20 days after Staff H’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.”