Howard County Community Hospice

“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 6 sampled employees who began serving hospice patients since their last survey, dated 6/9/22. The hospice reported hiring 22 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. Findings include: Staff G, volunteer, had a start date of December 2024. Staff G’s personnel file included documentation of completed criminal history, dependent adult and child abuse record checks, dated 6/17/25, approximately 6 months after Staff G’s start 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 above findings were reviewed with the Administrator and Clinical Manager.”

“Based on hospice staff interview, clinical record review and hospice policy review, the hospice failed to have all members of the Interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 6 of 14 sampled patients (Patient #4, #6, #7, #8, #10 and #13). Failure to have all disciplines complete the comprehensive assessment within 5 calendar days of the election of hospice care put patients at risk for inconsistent care that may not meet the needs of the patient. 5.Patient #7 had a hospice admission date of 5/27/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/27/25 to 8/24/25, failed to include documentation the social worker was involved in completing the initial comprehensive assessment and development of the plan of care. b. The clinical record lacked a social work assessment or documentation of why a social work assessment was not completed. The social worker failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame. 6. Patient #10 had a hospice admission date of 5/12/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/12/25 to 8/9/25, included physician orders for Social work services 1-2 times per month. b. IDG meeting note, dated 5/14/25, included documentation Social work services were ordered on initial plan of care and for the next two weeks. c. Social work initial visit note, dated 5/23/25, completed by Staff H, Social Worker, 11 days after admission and 6 days late according to the required time frame. The social worker failed to completed an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: Review of the hospice policy, titled Clinical Record Documentation and Retention, dated 4/30/25, identified time frames for completion and transfer of documentation for admission assessment for registered nurses – initial assessment documentation completed by the 5th calendar day of the start of care, comprehensive assessment documentation completed by the 5th calendar day of the start of care. For social workers – by the 5th day of the start of care. Any other member of the Interdisciplinary group may participate in the initial or comprehensive assessment. Review of the hospice policy, titled Comprehensive Assessment Policy – Hospice, dated 4/30/25, identified the comprehensive assessment will be completed upon admission and will be documented within 5 days of admission. During an interview on 6/17/25 at 10:36 AM, Staff H, Social Worker, reported they are generally involved in all initial assessments, typically they get out there within 5 days to get assessment done. There may be a time when they don’t go within the 5 days if there was a scheduling conflict or they weren’t in the office. 1.Patient #4 had a hospice admission date of 2/14/25 and received services while residing in a private home. Clinical record review revealed the following: a. Plan of Care, dated 2/14/25 to 5/14/25, included physician orders for Social work services 1-2 times per month. b. Interdisciplinary Group (IDG) meeting note, dated 2/19/25, included documentation Social work services were ordered on initial plan of care and for the next two weeks. c. Communication note, dated 2/19/25, included documentation Social worker had not made a formal visit yet, spoke with patient extensively at time of consents and will start visits soon. d. Communication note, dated 3/5/25, included documentation social worker did not have an official visit after admission and will meet with patient this month. e. Communication note, dated 3/19/25, included documentation social worker has not seen patient since admit and patient is not sure they want social work support. Social work services will be discontinued per nurse recommendation. The social worker failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame. 2. Patient #6 had a hospice admission date of 3/31/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. Plan of Care, dated 3/31/25 to 5/29/25, included physician orders for Chaplain services 1-2 times a month. b. IDG meeting note, dated 4/2/25, included documentation Chaplain services were ordered on initial plan of care and for the next two weeks. c. Chaplain visit note, dated 4/13/25, included documentation a chaplain assessment was completed, 13 days after the admission date and 8 days after the 5 day window after election of hospice services. The Chaplain failed to complete an assessment no later than 5 calendar days after the election of hospice services or document why the assessment was not completed within the required time frame. 3. Patient #8 had a hospice admission date of 6/2/25 and received services while residing in an assisted living facility. Clinical record review revealed the following: a. Plan of Care, dated 6/2/25 to 8/30/25, included physician orders for Chaplain services 1-2 times a month. b. IDG meeting note, dated 6/11/25, included documentation Chaplain services were ordered on initial plan of care and for the next two weeks. c. Chaplain visit note, dated 6/9/25, included documentation a chaplain assessment was completed, 7 days after the admission date and 2 days after the 5 day window after election of hospice services. d. Clinical record lacked Social work assessment or documentation of why social work assessment was not completed. The Chaplain and social worker failed to complete assessments no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame. 4. Patient #13 had a hospice admission date of 11/14/24, a death date of 11/29/24 and received services while residing in a private home. Clinical record review revealed the following: a. Plan of Care, dated 11/14/24 to 2/11/25, included physician orders for Social work services 1-2 times per month. b. IDG meeting note, dated 11/27/24, included documentation Social work services were ordered on initial plan of care and for the next two weeks. c. Communication note, dated 11/27/24, included documentation social worker met with patient and caregiver prior to admission and no visits have taken place since admission. The social worker failed to complete assessments no later than 5 calendar days after the election of hospice services or document why the assessments were not completed within the required time frame.”

“Based on clinical record review and hospice policy review, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 6 of 14 sampled patients (Patients #1, #2, #5, #8, #10 and #14). Failure to follow the patient’s Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. 3.Patient #2 had a hospice admission date of 2/24/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/25/25 to 6/23/25, identified the patient had a diagnosis of Metachromatic leukodystrophy and included physician orders for skilled nursing services 1-2 times a week. b. Staff C, Skilled nurse, provided services on 4/28/25, 5/1/25, 5/1/25 (second visit of day) and 5/2/25; exceeding the ordered visit frequency for the week of 4/27/25 by two visits. c. The IDG meeting notes, dated 4/30/25 and 5/14/25, lacked documentation of variations to skilled nursing services ordered 1-2 times a week. The hospice failed to follow all orders as directed by the IDG. 4. Patient #5 had a hospice admission date of 4/22/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/22/25 to 7/20/25, identified the patient had a diagnosis of Senile degeneration of the brain and included physician orders for hospice aide services 2-3 times a week. b. Hospice aide provided services on 4/29/25, 4/29/25 (second visit of day), 4/30/25 and 5/1/25; exceeding the ordered visit frequency for the week of 4/27/25 by one visit. c. The IDG meeting notes, dated 4/30/25 and 5/14/25, lacked documentation of variations to aide services ordered 2-3 times a week. The hospice failed to follow all orders as directed by the IDG. 5. Patient #10 had a hospice admission date of 5/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/12/25 to 8/9/25, identified the patient had a diagnosis of Alzheimer’s disease and included physician orders for skilled nursing services 2-3 times a week. b. Skilled nurse visit note, dated 5/16/25, completed by Staff D, Registered Nurse (RN), identified a wound to patient’s midline inner buttocks, with an onset date of 5/16/25. Wound cleansed per plan of care. c. Skilled nurse visit note, dated 5/27/25, completed by Staff K, RN, identified wound was cleansed with soap and water, covered with Calmoseptine (moisture barrier cream) and left open to air. d. IDG meeting note, dated 5/28/25, lacked documentation of an interim physician for wound care to midline inner buttocks. The hospice provided wound care without an interim physician order and failed to update the plan of care to included needed wound care orders. 6. Patient #14 had a hospice admission date of 10/11/24, a death date of 10/16/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 10/11/24 to 1/8/25, identified the patient had a diagnosis of Neurocognitive disorder with lewy bodies and included physician orders for skilled nursing services 1-2 times a day. b. Skilled nurse, provided three separate visits on 10/11/25; exceeding the ordered visit frequency of 1-2 visits a day by one visits. c. The IDG meeting notes, dated 10/16/24, lacked documentation of variations to skilled nursing services ordered 1-2 times a day. The hospice failed to follow all orders as directed by the IDG. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: Review of the hospice policy, titled Hospice Plan of Care, dated 4/30/25, identified the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including 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 goals, and implementing and coordinating the plan of care; and drugs and treatment necessary to meet the needs of the patient. Changes in the plan of care will be communicated to the patient/family as they occur with communication being documented in the medical record. Review of the hospice policy, titled Wound Measurement and Documentation – Hospice, dated 5/29/24, identified wound care is only provided per order from Medical Director, primary care provider, or Wound clinic provider. 1.Patient #1 had a hospice admission date of 5/9/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. Plan of Care (POC), dated 5/14/21 to 7/21/21, included physician orders for volunteer services 1-2 times per month. b. Interdisciplinary Group (IDG) meeting note, dated 5/14/25, included documentation volunteer services were ordered on initial plan of care and for the next two weeks with a frequency of 1-2 times per month. c. IDG meeting note, dated 5/28/25, included documentation volunteer services were ordered at last IDG and for next two weeks with a frequency of 1-2 times per month. Clinical record lacked documentation of volunteer visits for the month of May or a reason why the services were not performed as ordered. The hospice failed to provide volunteer visits as ordered per the plan of care. 2. Patient #8 had a hospice admission date of 6/2/25 and received services while residing in an assisted living facility. Clinical record review revealed the following: a. Plan of Care, dated 6/2/25 to 8/30/25, included physician orders for skilled nursing services 3 times a week for 1 week then 2 times a week. b. Skilled nurse visit note, dated 6/6/25, identified a right lower arm skin tear, with an onset date of 6/6/25. Wound cleansed with soap and water and band-aid applied. c. IDG meeting note, dated 6/11/25, lacked documentation of an interim physician order for wound care to the right lower arm skin tear. The hospice provided wound care without an interim physician order and failed to update the plan of care to include needed wound care orders.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the hospice Interdisciplinary Group (IDG) developed patient plans of care that specified scope and frequency for all services required by and provided to patients for 2 of 2 sampled patients (Patient #9 and #14) who received respite services. Failure to identify scope and frequency for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. Findings include: 2. Patient #9 had a hospice admission date of 5/2/25, received hospice services while residing in a private home from 5/2/25 to 5/18/25 and 5/21/25 to 6/11/25 and residing at the hospital in respite care from 5/19/25 to 5/20/25. Clinical record review revealed the following: a. Plan of Care, dated 5/2/25 to 7/30/25, included physician orders to admit patient to hospice services with skilled nursing, hospice aide and social work services. b. Interdisciplinary Group (IDG) meeting note, dated 5/28/25, included documentation the social worker assisted the patient with respite services. c. Patient admission setting documentation, dated 5/2/25, identified the patient received routine home care services at home; dated 5/19/25, identified the patient received inpatient respite services at the hospital; and dated 5/21/25, identified the patient received routine home care services at home. Administrator emailed to surveyor on 6/18/25, Regional Health Services Hospice Protocol Orders, dated 5/19/25, identified admit to hospice respite level of care. The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite and respite to routine. The surveyor reviewed the above findings with the Administrator and Clinical Manager. According to the agency policy titled Hospice Plan of Care, dated 4/30/25, all hospice care and services furnished to patients and their families must follow and individualized written plan of care established by the hospice IDG in collaboration with the attending physician, the patient or representative and the primary caregiver in accordance with the patient’s needs. The hospice IDG will review, revise and document the individual POC as frequently as the patient condition requires. During an interview on 6/17/25 at 11:06 AM, the Clinical Manager reported there should be an order in the Electronic Medical Record (EMR) identifying when a patient is admitted for respite care. 1.Patient #14 had a hospice admission date of 10/11/24, a death date of 10/16/24, received hospice services while residing in a private residence from 10/11/24 to 10/12/24 and received hospice services while residing at the hospital in respite care from 10/12/24 to 10/16/24. Clinical record review revealed: a. The Plan of Care, dated 10/11/24 to 1/8/25, included physician orders to admit patient to hospice services with skilled nursing, hospice aide, social worker, healing touch and music therapy services. b. IDG meeting note, dated 10/16/24, included documentation aide services were increased while patient was on respite services. c. Patient admission setting documentation, dated 10/11/24, identified the patient received routine home care services at home; dated 10/11/24; identified the patient received inpatient respite services at the hospital; dated 10/12/24; and identified the patient expired at the hospital on 10/16/24. Administrator emailed to surveyor on 6/18/25, Regional Health Services Hospice Protocol Orders, dated 10/12/24, identified admit to hospice respite level of care. The hospice clinical record failed to identify interim physician orders to change level of care from routine to respite.”

“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 contract components for 3 of 3 sampled services (Medical equipment/supply provider, Pharmacy provider and 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: 1.Review of the contract between the hospice and sampled pharmacy provider, dated 9/30/14, 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 delivered in a safe and effective manner by qualified staff and d. All services are approved by hospice and delivered in accordance with the patient’s plan of care. 2.Review of the contract between the hospice and sampled medical equipment/supply provider, dated 5/26/20, 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 and c. All services are approved by hospice and delivered in accordance with the patient’s plan of care. 3.Review of the contract between the hospice and sampled massage therapy provider, dated 6/3/25, identified the contract lacked the following required components: a. The hospice retains administrative and financial management and b. 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 and Clinical Manager.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 6 of 14 sampled patients with ancillary services (Patients #2, #3, #6, #10, #13, #14). 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: 4. Patient #6 had a hospice start of care date of 3/31/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. Plan of Care, dated 3/31/25 to 5/29/25, included physician orders for Healing Touch services 1-2 times per month. b. Healing Touch paper visit note, dated 5/7/25, identified the note was scanned into the electronic medical record on 6/12/25, 36 days after the visit date, and 22 days late per hospice policy. c. Healing Touch paper visit note, dated 5/22/25, identified the note was scanned into the electronic medical record on 6/12/25, 21 days after the visit date, and 7 days late per hospice policy. The hospice failed to have all completed documentation for ancillary disciplines placed in the chart within the required time frame. 5. Patient #13 had a hospice admission date of 11/14/24, a death date of 11/29/24 and received services while residing in a private home. Clinical record review revealed the following: a. Plan of Care, dated 11/14/24 to 2/11/25, included physician orders for skilled nurse, Social work and Healing Touch services. b. Social Worker bereavement plan of care, dated 11/29/24, identified bereavement mailings would be sent at the following intervals: 2 weeks, 1, 3, 6, 9, 11 and 12 months. c. Bereavement communication note, dated 12/23/24, identified Social Worker sent bereaved a handwritten note and a thumbprint pendant. On 6/17/25, Staff H, Social Worker, emailed the following documents to the surveyor: i. Interdisciplinary Group (IDG) bereavement addendum minutes, dated February 2025, identified Patient #13 quarterly review 3 month, mailings continue to family members and no other needs identified. ii. IDG bereavement addendum minutes, dated May 2025, identified Patient #13 quarterly review 6 month, mailings continue to family members and no other needs identified. The hospice failed to document a mailing for the 2 week time frame or a reason why mailing was not sent as identified in bereavement plan of care. The hospice failed to include bereavement mailing information in the hospice clinical record as required by regulation. The surveyor reviewed the above findings with the Administrator and Clinical Manager. According to the hospice policy titled Clinical Record Documentation and Retention, dated 4/30/2025, routine visit notes for nursing, social workers and home care aides are to be completed within two business days of the date of the visit. All of disciplines are to have completed documentation placed in the chart within two weeks of the date of the visit. During an interview on 6/17/25 at 11:06 AM, the Clinical Manager identified disciplines completing paper documentation are expected to turn completed notes into the office per agency policy (within two weeks) and agency staff scan the notes into the electronic medical record (EMR). 1.Patient #2 had a hospice admission date of 2/24/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 4/25/25 to 6/23/25, identified the patient had a diagnosis of Metachromatic leukodystrophy and included orders for Healing Touch services 1-2 times per month. b. The healing touch paper visit note, dated 5/18/25, identified the note was scanned into the EMR on 6/12/25, 25 days after the visit and 11 days late (per agency policy). The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe. 2. Patient #3 had a hospice admission date of 1/31/23 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/21/25 to 5/19/25, identified the patient had a diagnosis of Heart failure and included orders for Healing Touch services 1-2 times a month. b. The healing touch paper visit note, dated 5/19/25, identified the note was scanned into the EMR on 6/12/25, 24 days after the visit and 10 days late (per agency policy). The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe. 3. Patient #10 had a hospice admission date of 5/12/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/12/25 to 8/9/25, identified the patient had a diagnosis of Alzheimer’s disease and included orders for Healing Touch services 1-2 times a month. b. The healing touch paper visit note, dated 5/22/25, identified the note was scanned into the EMR on 6/12/25, 21 days after the visit and 7 days late (per agency policy). c. The healing touch paper visit note, dated 5/28/25, identified the note was scanned into the EMR on 6/12/25, 15 days after the visit and 1 day late (per agency policy). The hospice failed to have all completed documentation for ancillary services placed in the EMR within the required timeframe.”

“Based on review of the written agreements between the hospice and nursing facilities providing respite care, the hospice failed to ensure the written agreements identified the nursing facilities 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 (Nursing home A and Nursing home B). Failure to ensure the nursing facilities provided the hospice with a discharge summary upon nursing facility 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 Nursing facility A, dated 1/1/25. The contractual agreement failed to specify the nursing facility would provide the hospice agency with a copy of the discharge summary at the time of discharge and failed to specify a copy of the patient’s facility clinical record is available to the hospice at the time of discharge. 2. The hospice had a contractual agreement with Nursing facility B, dated 11/10/22. The contractual agreement failed to specify the nursing facility would provide the agency hospice with a copy of the discharge summary at the time of discharge and failed to specify a copy of the patient’s facility clinical record is available to the hospice at the time of discharge. The above findings were reviewed with the Administrator and Clinical Manager.”

“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 6 sampled employees who began serving hospice patients since their last survey, dated 6/9/22. The hospice reported hiring 22 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 G, volunteer, had a start date of December 2024. Staff G’s personnel file included documentation of a completed criminal history background check, dated 6/17/25, approximately 6 months after Staff G’s start date. Hospice staff failed to complete a criminal history background check on all staff prior to hiring. The above findings were reviewed with the Administrator and Clinical Manager.”