Hospice of Pella, the Comfort House

“Based on agency staff interview, clinical record review and policy review, the hospice failed to ensure the patient received information about the services covered under the hospice benefit for 1 of 1 sampled patients (Patient #13) requesting the information at the time of admission to hospice care. Failure of the hospice to ensure the patient received information about the services covered under the hospice benefit increased the risk that patients did not receive appropriate services to meet assessed needs. Findings include: According to the agency policy titled Patient Rights, dated 3/2024, patients have the right to be advised prior to initiation of cares of the extent to which payment may be required from the patient. Patient liability for payment will be given orally and in writing. During an interview with the Administrator on 3/11/25 at 2:30 PM, stated on the Medicare Hospice Election Form, completed at the time of admission to hospice services, there is a box to be checked whether the patient would like to receive the addendum with the itemized list of non covered items, services or drugs. The Administrator acknowledged if the patient or family checks the box indicating they wish to receive the addendum, the nursing staff are knowledgeable on how to complete the addendum. Administrator could not locate an addendum form or verify one had been completed for Patient #13. Patient #13 had a start of care date of 2/14/25 and a death date of 2/18/25 and received hospice services inpatient in the hospice house. Clinical record review revealed : a. The Hospice Benefit Form, dated 2/14/25, patient marked yes to receive the addendum listing conditions, items, services and drugs the hospice agency determined to be unrelated to the terminal illness and thus not covered by Medicare. b. The clinical record lacked evidence this form was completed and given to the patient at the start of care. The agency failed to provide the patient with the requested addendum for conditions, items, services and drugs that would not be covered financially by Medicare. The above findings were reviewed with the Administrator.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 1 of 2 sampled patients with wounds (Patient #14). Failure to follow the patient’s plan of care as directed by the Interdisciplinary Group (IDG) put the patients at risk of inconsistent care that may not meet the needs of the patient. Findings include: According to the agency policy, titled Care Planning Process, revised 3/2022, the hospice interdisciplinary group, in consultation with the attending physician will prepare a written plan of care for each patient. The primary care registered nurse will provide coordination of care and ensure continuous assessment of each patient and family’s needs and implementation of the interdisciplinary plan of care. All hospice care and services furnished to patients and their families will follow an individualized plan of care. During an interview on 3/5/25 at 11:00 AM, the Administrator stated wound assessments and measurements are to be completed weekly. Patient #14 had a hospice admission date of 4/23/24, a death date of 9/14/24 and received services while residing in a private residence. a. Plan of Care (POC), dated 7/22/24 to 10/19/24, identified the patient had diagnoses of Alzheimer’s disease, Nonrheumatic aortic valve stenosis and Type II diabetes mellitus without complications. The POC included orders for skilled nursing services to monitor and measure wounds weekly. b. The skilled nurse visit note, dated 8/5/24, completed by Staff C, Registered Nurse (RN), identified the patient had the following wounds: 1) Unstageable, circular pressure ulcer to right heel covered by eschar measuring 1 centimeters (cm) by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 2) Unstageable, circular pressure ulcer to left heel covered by eschar measuring 3 cm by 3 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 3) Unstageable pressure ulcer to right, lateral leg, 90% covered with slough measuring 4 cm by 1.8 cm by 0.1 cm. Wound edges are attached to wound bed, scant amount of bright red drainage and no signs or symptoms of infection. 4) Unstageable pressure ulcer to right, lateral leg below bigger wound, 100% slough covered measuring 1.5 cm by 0.8 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 5) Unstageable pressure ulcer to left calf, covered by eschar measuring 17 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 6) Unstageable pressure ulcer to sacrum-midline, 100% covered by slough measuring 3.5 cm by 1.5 cm by 0 cm. Wound edges are attached to wound bed, moderate amount of tan drainage and no signs or symptoms of infection. c. The skilled nurse visit note, dated 8/13/24, completed by Staff C, RN, identified the patient had the following wounds: 1) Unstageable, circular pressure ulcer to right heel covered by eschar measuring 1 cm by 1.3 cm by 0 cm. No drainage noted, tissue bed color black and no signs or symptoms of infection. 2) Stage 1 pressure ulcer to left heel improving, measuring 1.7 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage noted and no signs or symptoms of infection. 3) Stage 2 pressure ulcer to left calf, has three black areas in bottom half of wound that are eschar measuring 15 cm by 1 cm by 0 cm. Wound edges are attached to wound bed, no drainage and no signs or symptoms of infection. 4) Stage 2 pressure ulcer to right, lateral leg, 20% eschar measuring 8 cm by 3 cm by 0.1 cm. Wound edges are attached to wound bed, scant amount of light brown drainage and no signs or symptoms of infections. The agency failed to provide weekly wound assessments and measurements per the POC for the unstageable pressure ulcer to the right lateral leg below the bigger wound and for the unstageable pressure ulcer to the sacrum. The above findings were reviewed with the Administrator.”

“Based on home observation visits, staff and patient interviews, clinical record review and agency policy review, the agency failed to ensure the hospice plan of care, included all necessary medications and treatments and/or physicians orders for all medications and treatments to meet the needs of the patients in 3 of 3 sampled patients (Patient #1, #2 and #3) with home observation visits. Failure to update the plan of care with with medication changes and/or failure to obtain physicians orders for all medications the patient is taking, increased the potential for medications errors, possible adverse interactions and inaccurate provision of care. Findings include: According to the agency policy titled Care Planning Process, dated 3/2022, the hospice will develop an individualized Plan of Care for each patient. The Plan of Care will reflect patient and family goals and interventions based on the problems identified on the comprehensive and updated comprehensive assessments. These goals must have time frames and measurable outcomes. The Plan of Care must include all services necessary for management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the Plan of Care, medications and treatments necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #1 had a start of care date of 2/19/25 and received hospice services in a private home. Home observation visit and clinical record revealed the following: a. The Plan of Care (POC), dated 2/19/25 to 5/19/25, included physician orders for services, treatments and medications. b. During the home observation visit on 3/3/25, with Staff B, Registered Nurse (RN), the surveyor noted the bottle with the medication Zofran (used to help prevent nausea) had been refilled at the pharmacy on 2/18/25 with directions to take 8 milligrams (mg), every 8 hours as needed. The POC failed to include an updated order for the medication and indicated an order for 4mg every 8 hours as needed for nausea. The agency failed to update the POC with current physician orders for medication. 2. Patient #2 had a start of care date of 1/10/25, and received hospice services in a private home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/10/25 to 4/9/25 , included physician orders for services, treatments and medications. b. During a home observation visit on 3/3/25, with Staff B, RN, the patient stated that instead of taking aspirin 325 mg, when a new bottle was purchased patient started taking 3 tablets of aspirin with 81 mg in each tablet instead. The POC failed to include an updated order for the aspirin as patient indicated was self administering. The agency failed to update the POC with current physician orders for medication. 3. Patient #3 had a start of care date of 8/2/24 and received hospice services in the home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/29/25 to 3/29/25, included physician orders for services, treatments and medications. b. During a home observation visit on 3/4/25 with Staff C, RN, the surveyor noted patient was taking Mucinex (expectorant) one tablet every day, which the patient verified. The POC failed to include the medication Mucinex as a current medication order. Failure to update the POC with all current medications increased the potential for medication errors, possible adverse interactions and inaccurate provision of care. The above findings were reviewed with the Administrator.”

“Based on home observation visits, patient interviews, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 3 of 14 sampled patients. (Patient #1, #2 and #12) Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, supplies and/or treatments according to assessed needs and physician orders. 3. Patient #12 had a start of care date of 1/9/25, a revocation date of 1/31/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. POC, dated 1/9/25 to 4/8/25, identified the patient had a primary diagnosis of Chronic diastolic (congestive) heart failure and identified the patient required use of the following medical supplies and equipment: bedrail/bed cane, walker, portable heater, lifeline, elevated toilet seat, stair chair, shower bench, nebulizer, handheld shower and grab bars. b. The start of care assessment, completed by Staff C, Registered Nurse (RN), identified the patient’s medication is set up in a medication cassette. c. The IDG meeting note, dated 1/22/25 identified no additional medical supplies and equipment used by the patient. The POC and the IDG meeting notes to update the POC failed to identify all medical supplies and equipment used by the patient, including medication cassette. The above findings were reviewed with the Administrator. Findings include: According to the agency policy titled Care Planning Process, dated 3/2022, the hospice will develop an individualized Plan of Care for each patient. The Plan of Care will reflect patient and family goals and interventions based on the problems identified on the comprehensive and updated comprehensive assessments. These goals must have time frames and measurable outcomes. The Plan of Care must include all services necessary for management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, measurable outcomes anticipated from implementing and coordinating the Plan of Care, medications and treatments necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #1 had a start of care date of 2/19/25 and received hospice services in a private home. Home observation visit and clinical record revealed the following: a. The POC, dated 2/19/25 to 5/19/25 , identified the patient had the following medical equipment and supplies: Hospital bed and lift chair. b. During the home observation visit on 3/3/25, with Staff B, Registered Nurse (RN), the surveyor noted the patient was weighed by the nurse on a scale and the patient had gastrostomy tube supplies, and oral mouth swabs in the home. The patient did not have a hospital bed in the home. The POC failed to identify all the supplies the patient utilized in the home. c. The Interdisciplinary Group (IDG) meeting note dated 2/19/25 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meetings to update the POC, failed to identify the additional DME of weight scale, gastrostomy tube supplies, and oral mouth swabs as medical supplies used by the patient and incorrectly identified a hospital bed the patient did not have in the home. 2. Patient #2 had a start of care date of 1/10/25, and received hospice services in a private home. Home observation visit and clinical record review revealed the following: a. The POC, dated 1/10/25 to 4/9/25 , identified the patient had the following medical equipment and supplies: Hospital bed and lift chair, humidifier and oxygen equipment. b. During a home observation visit on 3/3/25, with Staff B, RN, the surveyor noted the patient did not have a hospital bed or a lift chair in the home. c. The Interdisciplinary Group (IDG) meeting notes dated 1/22/25, 2/5/25 and 2/19/25 identified no additional medical equipment and supplies used by the patient. The POC, and IDG meetings to update the POC, failed to identify the additional DME of weight scale, gastrostomy tube supplies, and oral mouth swabs as medical supplies used by the patient and incorrectly identified a hospital bed the patient did not have in the home.”

“Based on staff interview and clinical record review the hospice failed to ensure the hospice staff sent a copy of the patient’s discharge summary to the attending physician for 1 of 2 sampled discharged patients (Patient #12) who revoked the hospice benefit. Failure to ensure the hospice staff included the attending physician in the process of imminent discharge placed the patient at risk for not receiving ongoing medical care and services to meet the needs of the patient. Findings include: Patient #12 had a hospice admission date of 1/9/25, received hospice services while residing in a private residence and revoked hospice services on 1/31/25. a. Plan of Care (POC), dated 1/9/25 to 4/8/25, identified the patient had a primary diagnosis of Chronic diastolic (congestive) heart failure. The POC included orders for skilled nursing services. b. Clinical record review lacked documentation the discharge summary was completed or forwarded to the patient’s attending physician. c. During an interview on 3/11/25 at 3:00 PM, the Administrator stated the agency failed to send a discharge summary to the patient’s attending physician following the patient’s revocation from hospice services. The above findings were reviewed with the Administrator.”

“Based on record review and interview, the facility is not conducting fire drills at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code (Section-19.7.1.6), 2012 Edition. This deficient practice affects all residents, staff, and visitors as the lack of drills can affect the abilities of staff to respond in the event of an actual emergency. This facility has a capacity of 6 and a census of 3. Findings include: Observation and interview, on 2/2/14/25, at 09:15 a.m. that a 3rd quarter night shift fire drill had not been conducted. This was verified by the secretary and maintenance supervisor.”

“Based on observation and interview, the facility is not segregating empty and full cylinders in accordance with National Fire Protection Association (NFPA) 99, Healthcare Facilities Code (Section-11.6.5.2), 2012 Edition. This deficient practice affects all residents who require oxygen. This facility has a capacity of 6 and a census of 3. Observation and interview on 2/14/25 at 09:40 a.m., revealed that the upstairs oxygen storage room contained full oxygen cylinders that were intermingled with 1 partially used cylinder that were placed in an oxygen cart marked empty. The nursing staff and secretary verified this observation at the time of the survey process.”