Avera @ Home of Spencer Hospital

“Based on hospice staff Interview, hospice clinical record reviews, and hospice policу review, the hospice failed to ensure the documentation and correct Identification, in a prominent part of the patient’s record, any advance directives executed by the patient or patient’s representative for 1 of 14 sampled patients (Patients #3) with a record review. 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 Advance Directives, dated 5/20/25, the hospice recognizes that all adult persons have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. It is the policy of the hospice to encourage individuals and their family/caregivers to participate in decisions regarding care, treatment and services. 1. Patient #3 had a hospice admission date of 11/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following:a.The Plan of Care (POC), dated 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, revealed the patient had a primary diagnosis of congestive heart failure and identified the patient’s code status, do not intubate (DNI).b. The Iowa Physician Orders for Scope of Treatment (IPOST), dated 7/8/24, revealed the patient code status to provide cardiopulmonary resusitation (CPR)/attempt resusitation and limited additional interventions to do not use intubation or mechanical ventilation (DNI). May consider less invasive airway support. May use vasopressors. Transfer to hospital if indicated, may include critical care. c. The do not resuscitate (DNR) form, signed by the patient on 3/13/25, included patient directive to not attempt CPR.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, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 4 of 9 sampled patients with a wound (Patient #2, #3, #5, and #9). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients’ wound status and effectiveness of treatments and interventions. Findings include: 2. Patient #2 had a hospice admission date of 4/29/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/29/26 to 7/27/26, identified the patient had a primary diagnosis of malignant neoplasm of right ovary and included physician orders for skilled nurse to assess skin and measure wounds each week. b. The skilled nurse comprehensive assessment, dated 5/21/26, completed by Staff O, RN, identified wound care completed to left buttock and patient tolerated well. The hospice skilled nurse failed to assess and measure the patient’s wound to the left buttock as directed by the plan of care. 3. Patient #5 had a hospice admission date of 4/17/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/17/26 to 7/15/26, identified the patient had a primary diagnosis of malignant neoplasm of base of tongue and included physician orders for skilled nurse to assess skin and provide wound care. b. The skilled nurse visit note, dated 5/7/26, completed by Staff H, RN, identified the following wounds: 1) Jaw-Midline-Fistula measuring 2 centimeters (cm) by 0.8 cm by 3 cm. 2)Throat-Left-Tumor measuring 1 cm by 2 cm by 0.1 cm. c. The skilled nurse visit notes, dated 5/12/26 and 5/15/26, completed by Staff H, RN, failed to assess and measure the patient’s wound to the throat. d. The skilled nurse visit note, dated 5/19/26, completed by Staff J, RN, failed to assess and measure the patient’s wounds to jaw and throat. The hospice skilled nurse failed to assess and measure all of the patient’s wounds each week. 4. Patient #9 had a hospice admission date of 8/22/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/19/26 to 6/17/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse to assess skin. b. The skilled nurse comprehensive assessment, dated 5/14/26, completed by Staff E, RN, identified the patient had an excoriated area to the outer buttock. The hospice nurse failed to measure the patient’s excoriated area to the outer buttock. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner and Staff P, Quality Partner. According to the agency policy titled Pressure Injury and Wound, dated April, 2025, the wound assessment includes appearance of the wound (color, type, percentage of tissue involvement), wound size (length, depth, and width), presence fo tunneling (location and measurement), status of surrounding skin (color, moisture, integrity), amount of any drainage (color, consistency, odor), phase of healing, and undermining, if present.During an interview on 6/8/26 the Clinical manager stated staff expected to assess the wounds weekly and include wound measurements.1.Patient #3 had a hospice admission date of 11/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, identified the patient had a primary diagnosis of congestive heart failure and included the following physician orders for wound care to the left lateral 3rd toe: cleanse area with wound wash and pat dry. Apply bacitracin ointment and cover with bandaid daily until healed. b. The skilled nurse comprehensive assessment, dated 4/27/26, Staff H, RN, documented the patinet had a wound to the left lateral 3rd toe. The area cleansed with wound wash and pat dry, applied bacitracin ointment and covered with a bandaid daily. The wound assessment measured 1.3 cm length by 1.8 cm width. The note failed to include wound assessment or depth measurements.c. The skilled nurse comprehensive assessment, dated 4/30/25, Staff O, RN, documented the patient and a wound on the left 3rd toe. The wound ulcer irregular, tissue bed color pink with no drainage. The assessment failed to include wound measurements.The hospice skilled nurse failed to measure include complete wound measurements including wound depth.”

“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 14 of 14 sampled patients (Patients #1, #2, #3,#4, #5, #6, #7, #8, #9, #10, #11, #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: 2.Patient #8 had a hospice admission date of 5/19/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The POC, dated 5/19/26 to 8/16/26, included primary diagnosis of Senile degeneration of brain and 3 as needed (PRN) treatment orders for skilled nursing: may insert/reinsert Foley catheter 14-18 French/5 cubic centimeters (cc) as needed for comfort. Change Foley catheter PRN malfunction, leaking, hard sediment or frequent irrigation. May irrigate Foley catheter with sterile water as needed to maintain patency. May discontinue Foley catheter for malfunction or per patient/family request. b.The skilled nurse visit note, dated 5/21/26, completed by Staff E, Registered Nurse (RN), identified that the patient has a Foley catheter in place. The POC failed to identify that the patient had a Foley catheter and to include Foley catheter orders individualized to the patient. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner. According to the hospice policy titled Hospice Plan of Care, dated 1/30/26, a written individualized patient and care giver plan of care (POC) will be established and maintained for each individual admitted to the hospice program. The POC must state, in detail, the scope and frequency of services needed to meet the patients and family/caregiver’s needs and established patient goals and outcomes. During an interview on 6/8/26 at 12:03, the Clinical Manager reported that the physician is notified when a standing order is started, but an order is not obtained from the physician when a standing order is started. If a patient has a Foley catheter when they are admitted to hospice, no additional order related to the care of the Foley catheter is needed because the standing order is in place that provides the order to change the Foley catheter. 1. The routine standing orders signed off by a physician contained the following patient non-specific orders for Patients #1 through #14, on the patients’ POC. a. May insert/reinsert Foley catheter 14-28 F/5cc as needed for comfort. Change Foley catheter as needed for malfunction, leaking, hard sediment or frequent irrigation. May irrigate Foley catheter with sterile water as needed to maintain patency. May discontinue Foley catheter for malfunction per patient/family request.b. Hospice to provide additional nursing services, social worker services, volunteer services, music therapy, massage therapy, aide servicwes, bereavement services and coordination of care between patient, family, facility personal care provider and hospice acare team. c. May suction orally as needed for excess secretions and may teach caregivers.d. May use skin care products/interventions of choice to prevent or treat skin care problens. May consult wound care nurse for additinoal assessments and intervention.e. May set up medications in med planner device as needed. Automatic medication substitutions per pharmacy based on formulary and substitution policies. May change oral meds to liquids or suppositories and/or routes to IV, subsutaneous or rectal if patient unable to swallow.f. May implement home oxygen 1 to 5 liters per nasal cannula as needed for comfort-intermittent or continous. May add humidity.4. The as need dicipline orders signed off by a physician contained the following patient discipline orders for Patients #1 through #14, on the patients’ POC. a. Social Serivces, 10 visits as needed.b. Aide, 10 visits as needed.c. Spiritual counseling, 10 visits as needed.d. Nursing, 10 visits as needed.The hospice failed to include specific orders for the individual patient’s needs.”

“Based on clinical record review and hospice policy review, the hospice failed to ensure that hospice plan of care (POC) included orders for all medications to meet the needs of patient for 3 of 14 sampled patients (Patients #1, #11 and #13). Failure to ensure the POC included all medications placed the patients at risk to receive inappropriate treatment of symptoms and/or not meet the needs of the patients. Findings include: According to the hospice policy titled Hospice Interdisciplinary Group Meeting, dated 6/17/25, the patient’s plan of care will be updated by the interdisciplinary team based on changes in condition, response to treatment and progress toward targeted outcomes, which may include pharmacotherapeutic effectiveness of symptom management outcomes and presence of active infection. 1.Patient #1 had a hospice admission date of 2/10/26 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The plan of care (POC), dated 5/11/26 to 8/8/26, included the patient’s primary diagnosis of neurocognitive disorder with Lewy bodies and physician orders for skilled nurse visits and medications.b.The skilled nurse visit note, dated 5/14/26, completed by Staff E, Registered Nurse (RN), identified that nursing home staff has been treating the patient’s left inner arm for redness with nystatin powder.c.The interdisciplinary group (IDG) update to the POC, dated 5/19/26, did not include that the patient had new redness to the left inner arm or that the patient started a new medication.The hospice failed to include medication orders on the patient’s POC. 2.Patient #11 had a hospice admission date of 4/4/25 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The POC, dated 4/4/25 to 7/2/25, included the patient’s primary diagnosis of hypertensive heart and kidney disease and physician orders for skilled nurse visits and medications.a.The physician order, dated 4/26/25, included orders for nitrofurantoin macrocrystal 100 mg, oral capsule 1 Capsule two times a day:with urinary tract infection (UTI) as the purpose.b.The IDG update to the POC, dated 5/8/25, did not include that the patient had a UTI or that the patient started a new medication.The hospice failed to include medication orders on the patient’s POC. 3.Patient #13 had a hospice admission date of 1/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The POC, dated 4/3/25 to 7/1/56, included the patient’s primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for skilled nurse visits and medications.b.The physician order, dated 5/16/25, included a order for nystatin swish and swallow or spit 1-2 cubic centimeters (cc), 4 times per day (QID) for 7 days.c.The IDG update to the POC, date d 5/22/25, did not include that the patient started a new medication.The hospice failed to include medication orders on the patient’s POC. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner.”

“Based on clinical record reviews and hospice policy review, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 3 of 4 sampled patients with missed visits (Patients #6, #7 and #9). Failure of the hospice Interdisciplinary Group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care, increased the risk that patients did not receive services to meet assessed needs. Findings include: 3. Patient #6 had a hospice admission date of 12/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/11/26 to 6/9/26, identified the patient had a primary diagnosis of Alzheimer’s disease and included orders for skilled nurse, social worker, chaplain, music therapy, massage therapy, and hospice aide services 3 times per week. b. The hospice aide visit note, dated 4/30/26, identified 1 hospice aide service provided the week of 4/26/26 to 5/1/26. c. The hospice aide visit ntoes, dated 5/4/26 and 5/6/26, idenitified 2 hospice aide services were provided the week of 5/3/26 to 5/9/26. d. The IDG update to the POC, dated 5/5/26 and 5/19/26, failed to identify the missed hospice visits for the week of 4/26/26 through 5/1/26 and 5/3/26 to 5/9/26. The hospice failed to provide hospice aide visits as ordered per the POC. The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner. According to the hospice policy titled Hospice Interdisciplinary Group Meeting, dated 6/17/26, the patient’s plan of care will be updated by the IDG based on changes in condition, response to treatment and progress toward targeted outcomes, which may include increases or decreases in frequency of visits by team members and reason for the change. 1.Patient #7 had a hospice admission date of 5/22/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 5/22/26 to 8/19/26, identified the patient had a primary diagnosis of Parkinsonism and included orders for skilled nurse, social worker, chaplain, music therapy, massage therapy, volunteer and hospice aide services 4 times per week. b. The hospice aide visit notes, dated 5/27/26, 5/28/26 and 5/29/26 identified services were provided. c. The IDG update to the POC, dated 6/2/26, failed to identify the missed hospice visit for the week of 5/24/26 through 5/30/26. The hospice agency failed to provide hospice aide visits as ordered per the POC. 2. Patient #9 had a hospice admission date of 8/22/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/19/26 to 6/17/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social work, volunteer and hospice aide services 2 times per week. b. The hospice aide visit notes dated 5/5/26 and 5/15/26 identified services were provided. c. The IDG update to the POC, dated 5/19/26, failed to identify the missed hospice visits for the weeks of 5/3/26 through 5/9/26 and 5/10/26 through 5/16/26. d. The hospice aide visit note, dated 5/26/26 identified services were provided. e. The IDG update to the POC, dated 6/2/26, failed to identify the missed hospice hospice visit for the week of 5/24/26 through 5/30/26. The hospice agency failed to provide hospice aide 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 agency and sampled pharmacy provider, dated 7/1/20, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services, c. All services are authorized by the hospice, d. All services are furnished in a safe and effective manner by qualified personnel and e. All services are delivered in accordance with the patient’s plan of care. The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement. The above findings were reviewed with the Administrator.”

“Based on clinical record review, hospice policy review, nursing home medication administration records and hospice staff interview, 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 #1 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 patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: 2. Patient #3 had a hospice admission date of 11/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The POCs, dated 3/19/26 to 5/17/26 and 5/18/26 to 7/16/26, included the patient’s primary diagnosis of congestive heart disease and physician orders for medications.b. The POCs included order for calcium carbonate-vitamin D3 600 mg/200 micrograms (mcg) 2 times a day and a standing order for oxygen 1 to 5 liters.c.Review of the hospice medication list, dated 6/1/26, identified the order for calcuim carbonate-vitamin D3 600 mg/200 mcg 2 times a day, effective 11/19/25. The medication list failed to include an order for oxygen.d. Review of the nursing home MAR/TAR, dated June 2026, included order for calcuim carbonate 1 tablet, 2 times a day and oxygen 1 to 5 liters as needed.Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home.The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner. According to the hospice policy titled Hospice Provision of Care to Residents of skilled nursing facility/nursing facility (SNF/NF) or intermediate care facility/mental retardation (ICF/ MR), dated 1/30/26, hospice will assume responsibility for professional management of the SNF/NF or ICF/MR resident’s hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation (CoPs) and the organization will provide the SNF/NF/assisted living (AL) or ICF/MR hospice primary care provider and attending primary care provider (if any) orders. During an interview on 6/8/26 at 11:36 AM, Staff H, Registered Nurse (RN), reported that the medication administration record (MAR) is obtained from the nursing home once per week at the first visit of the week, and the medication administration record (MAR) is compared with the hospice medication list to make sure there are no discrepancies. 1.Patient #1 had a hospice admission date of 2/10/26 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The Plan of Care (POC), dated 5/11/26 to 8/8/26, included the patient’s primary diagnosis of neurocognitive disorder with Lewy bodies.b.The POC included physician order for sertraline 25 milligram (mg) 1 Tablet daily.c.Review of the patient’s nursing home MAR, dated May 2026, identified an order, dated 5/6/26, for sertraline 25 MG, 0.5 tablet by mouth one time per day.Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home.”

“Based on clinical record review, hospice policy review, nursing home clinical record review, and hospice staff interview, the hospice failed to ensure the nursing home received copies of all required documents including advance directives for 1 of 2 sampled patients (Patient #1) with observation visits in nursing homes.Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments as needed to meet the individual needs of the patient.Findings include: According to the hospice policy titled Hospice Provision of Care to Residents of skilled nursing facility/nursing facility (SNF/NF) or intermediate care facility/mental retardation (ICF/ MR), dated 1/30/26, the organization will provide the SNF/NF/assisted living (AL) or ICF/MR the following information specific to each patient’s advance directives.During an interview and nursing home record review on 6/2/26 at 1:10 PM, Staff H, Registered Nurse (RN), was not able to find the patient’s advance directive in the hospice binder (located at the nursing home) that contained hospice documents provided by hospice. Staff H reported that advance directives are obtained at the patient’s admission, sent to physician for signature, returned to the hospice office, and then delivered to the nursing home at the next visit where hospice staff place it in the patient’s hospice binder. Patient #1 had a hospice admission date of 2/10/26 and received hospice services while residing in a nursing home. Clinical record review revealed:a.The Plans of Care (POC), dated 2/10/26 to 5/10/26 and 5/11/26 to 8/8/26, included the patient’s primary diagnosis of neurocognitive disorder with Lewy bodies and physician orders for skilled nursing, hospice aide, social services, and spiritual counseling. b. An advance directive form that included a do not resuscitate (DNR) signed by a physician, dated 2/11/26. The hospice failed to provide a copy of the patient’s advance directive form to the nursing home.The above findings were reviewed with the Administrator, Clinical Manager, Social Worker, Vice President of Nursing, Director of Patient Care, Staff L, Quality Partner, and Staff P, Quality Partner.”