Wesleylife 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 and staff interview, the hospice failed to ensure completion of a dependent adult abuse or child abuse record checks for 1 of 7 sampled employees (Staff H) who began serving hospice patients since their last survey, dated 3/21/22. The hospice reported hiring 46 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 staff who had direct patient contact. According to the hospice policy titled Background Screening of Contractors and Team Members, last revised 11/2022, after an offer of employment, but before hire of any applicant, the hospice will conduct a background record check including, where applicable, a check on criminal history, a check on dependent adult abuse background, a check on professional health care licensure status, and a check on nurse aide competency. Background checks will be conducted through the use of the State on-line single contact repository system established by the Iowa Department of Inspections. Appeals and Licensing. During an interview on 2/24/25 at 3:25 PM, Human Resource staff stated the hospice found no record of the results of the criminal background check for Staff H, RN. 1. Staff H, RN, had a hire date of 6/3/24. A criminal background check was completed using DCI and dated 5/10/24, and instructed the criminal background to await further information. The hospice failed to follow through to complete further information for the criminal background check for possible department of human services evaluation within 30 days prior to the date of hire. Hospice staff failed to complete possible Department of Human Services evaluation, 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, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.”

“Based on clinical record review and hospice policy review, the hospice failed to ensure the hospice Interdisciplinary Group developed patient plans of care which specified the scope and frequency for all services required by and provided to patients for 3 of 19 sampled patients (Patients #1, #15 and #17). Failure to identify a scope and frequencies for all ordered services increased the potential for hospice services to not adequately meet the needs of hospice patients and families. 3.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and IDG orders for skilled nursing twice weekly, hospice aide five times a week and chaplain service to evaluate. b. Chaplain visit note, dated 2/13/25, identified Chaplain will be visiting patient every other Wednesday. c. The IDG meeting note to update the POC, dated 2/5/25, lacked documentation to identify specific frequency and duration for chaplain services. The IDG failed to include a detailed scope and frequency of all services necessary to meet the patient/family needs. The above findings were reviewed with the Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. Findings include: Review of the hospice policy, titled Plan of Care, dated 05/2024, identified the written plan of care will contain frequency/amount/duration of services. 1.Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and Interdisciplinary Group (IDG) orders for skilled nursing, social work, chaplain, music therapy and hospice aide services. b. The IDG meeting note to update the POC, dated 3/13/24, included documentation massage therapy services was not applicable. c. The IDG meeting note to update the POC, dated 3/27/24, lacked documentation of IDG order for massage therapy. d. Massage therapy note, dated 3/29/24, identified massage therapy techniques were performed. e. Interim physician order, dated 4/12/24, included order for massage therapy services but lacked a visit frequency and duration. The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services. 2. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing twice a week, hospice aide 3 times a week, social work, chaplain, music therapy and massage therapy services to evaluate. b. The IDG meeting notes to update the POC, dated 10/16/24, 10/30/24, and 11/13/24, lacked documentation massage therapy services evaluation was completed or declined by patient and/or caregiver. The clinical record lacked massage therapy visit notes. The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services or documentation the service had been declined.”

“Based on staff interview, clinical record review and hospice policy review, the hospice failed to ensure coordination and collaboration among Interdisciplinary Group members occurred to ensure updates to the plan of care and the services provided to the patients were according to assessed needs and wound measurements were documented weekly for 5 of 6 sampled patients with wounds (Patients #5, #7, #8, #12 and #13). Failure of the hospice team members to accurately update the plan of care and collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. 4. Patient #8 had a hospice admission date of 11/29/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 11/29/24 to 2/26/25, included primary diagnosis of Emphysema and interim physician orders for skilled nursing services three times per week, chaplain and social work services. b.. Skilled nurse visit note, dated 11/30/24, Staff G, RN, included identification of a pressure ulcer on the left hip with measurements of length 1.9 cm by width 1.5 cm by depth 0 cm. c. Physician order dated 11/30/34, noted by Staff G, RN, for wound care to the left hip to include: cleanse the wound with cleanser of choice, pat dry, apply Mepilex dressing and change every 7 days or as needed if soiled or falls off. Follow up with treatment to monitor effectiveness or need to adjust. d. Skilled nurse visit note, dated 12/2/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. e. Skilled nurse visit note, dated 12/924, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. f. Skilled nurse visit note, dated 12/16/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. g. Skilled nurse visit note, dated 12/24/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. h. Skilled nurse visit note, dated 12/30/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. i. Skilled nurse visit note, dated 1/13/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. j. Skilled nurse visit note, dated 1/20/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. k. Skilled nurse visit note, dated 1/27/25, Staff G, RN documented wound care completed, but lacked documentation of wound description and measurements. l. Skilled nurse visit note, dated 2/3/24, Staff G, RN, documented wound care completed, but lacked documentation of wound description and measurements. m. Skilled nurse visit note, dated 2/11/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. n. Skilled nurse visit note, dated 2/17/25, Staff R, LPN, documented wound care completed, but lacked documentation of wound description and measurements. The hospice failed to assess the left hip wound and obtain weekly wound measurements. 5. Patient #12 had a start of care date of 2/7/25 and received hospice services in a private home. Clinical record review revealed the following: a. The POC, dated 2/7/25 to 5/7/25, included primary diagnosis of liver cancer and interim physician orders for skilled nursing services two times per week, chaplain and social work services. b. The skilled nurse visit note, dated 2/24/25, noted a new pressure ulcer documented as unstageable and measurements of length 1.75 cm by width 1.54 cm , but lacked a depth measurement. The hospice failed to assess and obtain weekly wound measurements including length by width by depth. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager 3. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included Interdisciplinary Group (IDG) orders for skilled nurse, social worker, hospice aide and chaplain services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nursing and hospice aide services twice a week. c. Skilled nurse visit note, dated 2/13/25, completed by Staff F, RN, included documentation of a wound to left ring finger. Documentation identified the wound to be covered and recently dressed measuring 1 cm by 2 cm with no tunneling. The skilled nurse failed to assess the wound and the wound measurement lacked a wound depth. The hospice failed to assess and obtain weekly wound measurements including length by width by depth. Findings include: According to the hospice policy, titled Skin Management, dated 02/2025, identified a comprehensive wound assessment will be completed at every admission visit to include measurements (length x width x depth). Wounds will be visualized at every visit and measured one time a week to include length x width x depth. A comprehensive wound assessment will be completed weekly and with every comprehensive assessment time point (admission, recertification, update to comprehensive assessment and live discharge). During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager, reported hospice expectation is wound assessment done weekly, measure length x width x depth. If patient resides in a nursing home, hospice staff schedule visits to visualize wounds and may take measurements from facility documentation. 1.Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services, social work and hospice aide services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nurse twice a week and hospice aide twice a week services. c. Skilled nurse visit note, dated 2/3/25, included documentation of a pressure ulcer (wound) to the intergluteal cleft (area between the buttocks), measured 0.3 centimeters (cm) by 0.2 cm. The wound measurements lacked a wound depth. d. Skilled nurse visit note, dated 2/10/25, included documentation no new skin lesions reported or observed. The note lacked wound measurements. e. RN (registered nurse) Update to Comprehensive Assessment, dated 2/14/25, included documentation no new skin lesions reported or observed. The note lacked wound measurements. The week of 2/2/25, the wound measurements lacked a depth and the week of 2/9/25, lacked wound measurements. The hospice failed to obtain weekly wound measurements. 2. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing, social work, chaplain, music therapy, massage therapy and hospice aide services. b. Start of Care comprehensive assessment note, dated 12/24/24, included documentation of left lower leg wound with drainage, abrasion to left ear, and right lower extremity with drainage, unable to assess wounds due to patient sleeping. c. Skilled nurse phone call note, dated 12/30/24, included documentation the caregiver called to discuss multiple topics, including patient wounds. d. Skilled nurse phone call note, dated 1/5/25, included documentation regarding update for caregiver. Bottom is pink but no open wounds, ear wound almost healed and patients legs have multiple small blisters and are weeping (fluid). e. RN Update to Comprehensive Assessment, dated 1/8/25, included documentation abdominal fold treated with nystatin but not healing and possible new butt wound, patient has current treatment for bottom. f. RN Update to Comprehensive Assessment, dated 1/13/25, included documentation nystatin was changed to miconazole (treatment for abdominal fold) and area on bottom being treated with calmoseptine. g. RN Update to Comprehensive Assessment, dated 1/21/25, included documentation red area on bottom being treated with calmoseptine. h. Skilled nurse phone call note, dated 2/2/25, included documentation patient has skin tear to right forearm and buttocks red and excoriated. i. Skilled nurse visit note, dated 2/10/25, included documentation right gluteal fold measured 4.5 cm x 5.5 cm but lacked a wound depth. j. Skilled nurse visit note, dated 2/14/25, included documentation left anterior forearm bleeding, measured 1 cm x 1 cm but lacked a wound depth. The hospice failed to obtain weekly wound measurements.”

“Based on staff interview, clinical record reviews and hospice policy reviews, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the Plan of Care for 6 of 19 sampled patients (Patients #1, #3, #11, #14, #17 and #19). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care, increased the risk that patients did not receive services to meet assessed needs. Findings include: 6. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing, hospice aide 3 times a week, social work, chaplain, music therapy and massage therapy services. b. The IDG meeting notes to update the POC, dated 10/16/24 and 10/30/24, included IDG direction to provide two hospice aide visits each week. c. Hospice aide visits were completed weekly, dated 10/28/24, 10/30/24 and 11/4/24. d. The week of 10/27/24 to 11/2/24 lacked documentation of a third completed hospice aide visit. e. The IDG meeting notes to update the POC, dated 10/30/24 and 11/13/24, lacked documentation the IDG was notified of the missed hospice aide visit for the week of 10/27/24. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 5.Patient #9 had a hospice admission date of 8/30/24, a death date of 9/6/24, and received hospice services while residing in an acute hospital. Clinical record review revealed: a. The POC, dated 8/30/24 to 9/6/24, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing daily, social work and chaplain services. b. Skilled Nurse visit notes were completed on 9/2/24, 9/3/24, 9/4/24, and 9/5/24. c. The clinical record lacked documentation of a skilled nurse visit on 9/1/24. d. The IDG meeting notes dated 9/11/24, lacked documentation the IDG was notified of the missed skilled nurse visit on 9/1/24. The hospice failed to skilled nurse visits as ordered per the POC. According to the agency policy, titled Missed Visits, revised 10/2020, missed visits will be communicated to the Interdisciplinary Group (IDG). If a visit is missed for any reason, the clinician should attempt to reschedule the visit for the same week so the physician ordered frequency is maintained. If the visit is not rescheduled, the clinician notifies the IDG and clinical supervisor of the missed visit and documents the clients name, date and type of visit missed, reason for missed visit, and description of any unmet needs. During an interview on 2/20/25 at 3:30 PM, the Hospice Medical Director stated missed visits are discussed at IDG. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse, social worker, hospice aide five times a week and chaplain services. b. The week of 1/26/25 to 2/1/25, hospice aide completed visits 1/28/25, 1/29/25 and 1/30/25. c. The IDG meeting notes to update the POC, dated 2/5/25 lacked documentation the IDG was notified of the missed hospice aide visits for the week of 1/26/25. The hospice failed to provide hospice aide visits as ordered per the POC. 2. Patient #3 had a hospice admission date of 2/7/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/7/25 to 5/7/25, identified patient had a diagnosis of Chronic obstructive pulmonary disease and IDG orders for skilled nursing services and hospice aide services two times a week. b. The week of 2/2/25 to 2/8/25 lacked documentation of completed hospice aide visits. c. The IDG meeting notes to update the POC, dated 2/19/25, lacked documentation the IDG was notified of the missed hospice aide visits for the week of 2/7/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. 3. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/23/25 to 4/22/25, identified patient had a diagnosis of Intrahepatic bile duct carcinoma and IDG orders for skilled nurse visits two times weekly and hospice aide visits two times weekly. b. The IDG meeting notes to update the POC, dated 2/5/25, included IDG direction to provide two skilled nurse visits weekly and two hospice aide visits weekly. c. The weeks of 1/19/25 to 1/25/25 and 1/26/25 to 2/1/25 lacked documentation of a second skilled nurse visit. d. The week of 1/19/25 to 1/25/25 lacked documentation of any hospice aide visits. e. The IDG meeting notes to update the POC, dated 2/5/25, lacked documentation the IDG was notified of the missed skilled nurse visits the weeks of 1/19/25 and 1/26/25 and of the missed hospice aide visits the week of 1/19/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC. 4. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide visits two times weekly, social worker and chaplain services. b. The IDG meeting notes to update the POC, dated 1/22/25, included IDG direction to provide two hospice aide visits each week. c. The week of 1/5/25 to 1/11/25 lacked documentation of any hospice aide visits. d. The IDG meeting notes to update the POC, dated 1/22/25, lacked documentation the IDG was notified of the missed hospice aide visits for the week of 1/5/25. The hospice failed to provide hospice aide visits as ordered per the IDG meeting notes to update the POC.”

“Based on observations, staff and agency interviews, clinical record review and agency policy review, the hospice failed to develop and maintain a system of communication and integration in accordance with hospice’s own policies and procedures as evidenced by failing to update the Plan of Care based on the patients assessments and needs for 3 of 19 sampled patients (Patients #6, #14 and #19). Failure to ensure hospice staff provide care and services in accordance with an updated Plan of Care developed by the interdisciplinary Group (IDG) placed the patient at risk for not receiving necessary care and services to meet the needs of the patient. 2. Patient #6 had a hospice admission date of 1/28/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/28/25 to 3/28/25, identified the patient had a diagnosis of Alzheimer’s disease with early onset and included orders for skilled nurse, social worker, hospice aide chaplain and music therapy services. b. Skilled nurse comprehensive assessment, dated 2/6/25, completed by Staff W, RN, identified staff at the nursing home have been utilizing a Hoyer lift to transfer the patient due to pain and stiffness. c. Hospice aide completed visits on 2/7/25 and 2/11/25 and hospice care plan continues to provide RN instruction for aide to transfer patient using EZ stand and assist of two. The RN failed to update the aide care plan based on assessment of the patient’s needs. 3. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. Chaplain visit note, dated 1/14/25, completed by Staff K, identified chaplain visits would increase to weekly. c. The IDG meeting notes to update the POC, dated 1/22/25 and 2/5/25 included orders for hospice chaplain services 2 times monthly. The IDG failed to update the patient’s POC based on assessed needs. The above information was reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. Findings include: According to the agency policy titled The Plan of Care, dated 5/2022, a written Plan of Care will be established and maintained for each individual admitted to the hospice program. The care provided to the client must be in accordance with the plan of care. The Plan of Care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but not less than every 15 days. 1.Patient #18 had a start of care date of 9/20/24 and a death date of 10/26/24, with a primary diagnosis of end stage Parkinson’s and received services in a long term care facility. a. The Plan of Care (POC), dated 8/30/24 to 11/27/24 and included physician orders for all services, medications and treatments. b. The skilled nurse service note, dated 9/30/24, Staff V, Registered Nurse (RN), included documentation that noted new onset of edema (fluid) in both legs that was weeping out. Documentation indicated the RN would contact the physician for orders to address the edema. c. Physician order, dated 9/30/24, noted by Staff V, RN, for the medication Lasix 40 milligrams (a medication that pulls fluid from the body) one tablet a day for three days was received. d. The skilled nurse service note, dated 10/11/24, indicated an order for wrapping the lower legs with gauze pads and kerlix wrap, however the clinical record lacks a specific treatment order for both of the lower legs. e. The skilled nurse service note, dated 10/15/24, Staff S, Licensed Practical Nurse (LPN), included documentation of both legs being wrapped by facility staff for weeping. f. The skilled nurse service note, dated 10/17/24, Staff V, RN, included documentation of facility staff wrapping both legs twice a day related to legs weeping fluid. g. The skilled nurse service note, dated 10/23/24, Staff S, LPN included documentation of patients lower legs being wrapped due to fluid weeping. The agency failed to obtain and update the POC with treatment orders for wrapping the patient’s lower legs.”

“Based on clinical record review, review of employee personnel files, and hospice staff interview, the hospice failed to ensure 2 of 6 hospice aides (Staff J and Staff L) demonstrated competency in the performance of any skills which exceed the level of basic hospice aide skills in the presence of a registered nurse with competency determined at a patient’s bedside or using a real person (pseudo-patient) prior to being assigned to perform the task independently for 2 of 11 sampled patients who required an extra skill to be performed (Patients #3 and #7). Failure to ensure hospice aides have a competent ability to perform all skills above and beyond basic hospice skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation direct that the hospice aide may not independently provide any patient cares beyond the basic required skills without successful instruction and demonstration of competency in extra skills assigned on the aide care plan. During an interview on 2/25/24 at 3:10 PM The Director of Clinical Quality stated the hospice had no further documentation of hospice aide competencies. 1. Patient #3 had a start of care date of 2/7/25, and received hospice services while residing in a nursing home. The aide care plan included Registered Nurse (RN) instructions to the aide to utilize the pivot disc for transfers. Review of the clinical record showed Staff J, Hospice Aide and Staff L, Hospice Aide, provided aide services independently for Patient #3. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff Fs personnel file lacked documentation RN had observed Staff J competently perform the task utilizing a pivot disc transfer. Staff L, Hospice Aide, had a hire date of 7/16/18. Staff Ls personnel file lacked documentation RN had observed Staff L competently perform the task utilizing a pivot disc transfer. 2. Patient #7 had a start of care date of 8/23/24, and received hospice services while residing in a private residence. The aide care plan included RN instructions to the aide to utilize the pivot disc for transfers, provide nectar thick liquids for intake and range of motion. Review of the clinical record showed Staff J and Staff L, Hospice Aide, provided aide services independently for Patient #3. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff Js personnel file lacked documentation RN had observed Staff J competently perform the task utilizing a pivot disc transfer, nectar thick liquids and range of motion. Staff L, Hospice Aide, had a hire date of 7/16/18. Staff Ls personnel file lacked documentation RN had observed Staff L competently perform the task utilizing a pivot disc transfer and nectar thick liquids. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager”

“Based on personnel file review and staff interview the agency failed to ensure a registered nurse, or other appropriate skilled professionals in consultation with a registered nurse as appropriate, performed direct observation of a performance aide’s performance of all required hospice aide skills on a hospice patient or pseudo-patient to determine satisfactory competency prior to allowing the hospice aide to provide care independently to hospice patients for 2 of 3 sampled hospice aides (Staff J and Staff M) hired since the last recertification survey (3/21/22). At the time of the survey, the agency employed 9 hospice aides and provided hospice aide services to 113 patients. Failure to ensure hospice aides successfully complete a competency evaluation in all basic home hospice aide skills on a patient and were competent in any assigned extra skills which exceed the level of basic hospice aide skills placed agency patients at risk to receive inadequate or unsafe hospice aide services. Findings include: The Medicare Conditions of Participation require hospices to ensure all newly hired hospice aides are competent in all of the basic hospice aide skills by successfully demonstrating competency in the performance of all of the “hands on” basic home health aide skills with a home health patient, exactly as these tasks will be performed with an actual home health patient, in the presence of a qualified Registered Nurse before being assigned to provide any patient care independently. The list of “hands on” basic home health aide tasks are: communication skills, reading and recording temperature, pulse, respirations, bed bath, sponge bath, tub bath and shower bath, shampoo in a sink, tub and bed, skin care, oral care, nail care, toileting and elimination, transfers/ambulation and range of motion and positioning. Basic hospice aide competencies may be demonstrated using a patient or pseudo-patient. During an interview on 2/25/24 at 3:10 PM The Director of Clinical Quality stated the hospice had no further documentation of hospice aide competencies. 1. Staff J, Hospice Aide, had a hire date of 8/19/24. Staff J’s personnel file included competency documentation on 12/20/24. The competency documentation lacked competency testing for sponge bath and shampoo in sink and a written basic skills test. Staff J provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. 2. Staff M, Hospice Aide, had a hire date of 8/19/24. Staff J’s personnel file included competency documentation on 8/27 and 8/28/24. The competency documentation lacked competency testing for sponge bath. Staff M provided care independently to agency patients without successfully demonstrating competency in the performance of all required basic skills. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.”

“Based on observations, staff and patient/family interviews, clinical record review and policy review, the hospice failed to ensure hospice aides provided care to the patients only as directed by the interdisciplinary group (IDG), and according to the hospice aide care plan for 10 of 14 sampled patients receiving hospice aide services (Patients #1, #2, #5, #7, #8, #11, #13, #14, #15 and #17). Failure to ensure that the 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. 7. Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated 2/5/25, included IDG orders for hospice aide services. c. The hospice aide task list, last reviewed on 1/28/25, included RN instructions to the hospice aide to perform the tasks assist with 1-2 person transfers to and from bed to wheelchair or recliner using gait belt, notify RN of changes to skin integrity, assist with using bedside commode, empty after use, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bedlinens on the first visit of the week or if appear soiled, empty trash, make bed, assist patient in wheelchair to meals if requested, feed patient with eating when present during meal or snack time, setup meal tray when present for meals, assist patient with shower, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, lotion to all extremities, provide bed bath, provide oral care using toothettes and shampoo hair. d. Hospice aide visit note, dated 2/5/25, identified the tasks of assist patient with a shower, assist with brushing teeth, assist with dressing, assist with undressing, lotion to all extremities, provide bed bath, provide oral cares using toothettes and shampoo hair as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. 8. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The IDG meeting notes to update the POC, dated 1/8/25, 1/22/25, and 2/5/25 included IDG orders for hospice aide services. c. The hospice aide task list, last reviewed on 1/22/25, included RN instructions to the hospice aide to perform the tasks assist with 2 person transfers to and from bed to wheelchair or recliner, reposition patient, transfer patient using mechanical lift (hoyer), notify RN of changes to skin integrity, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bed linens if appear soiled, empty trash, make bed, assist with dressing, assist with undressing, clean and file fingernails, comb or brush hair, lotion to all extremities, provide oral care using toothettes, provide shower and shampoo hair. d. Hospice aide visit note, dated 1/7/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient’s last bowel movement. e. Hospice aide visit note, dated 1/10/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. f. Hospice aide visit notes, dated 1/14/25 and 1/17/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient’s last bowel movement. g. Hospice aide visit notes, dated 1/21/25 and 1/24/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. h. Hospice aide visit notes, dated 1/28/25, 1/30/25 and 2/4/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient’s last bowel movement. i. Hospice aide visit note, dated 2/6/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. j. Hospice aide visit notes, dated 2/11/25 and 2/14/25, identified the tasks of provide shower and shampoo were not performed and identified the task identify date of last bowel movement as acknowledged and completed. The aide failed to include a comment on why the shower and shampoo were not performed and failed to include a date of patient’s last bowel movement. The hospice aide failed to provide services as instructed by the RN assignment. 9. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/23/25 to 4/22/25, identified the patient had a diagnosis of Intrahepatic bile duct carcinoma and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated 2/5/25 and 2/19/25, included orders for hospice aide services. c. The hospice aide task list, reviewed on 1/23/25, included RN instructions to the hospice aide to perform the tasks notify RN of changes to skin integrity, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, comb or brush hair, lotion to all extremities, provide shower, shampoo hair and identify date of last bowel movement. d. Hospice aide visit notes, dated 1/28/25, 1/31/25, 2/4/25, 2/7/25, 2/11/25, 2/14/25, 2/18/25 and 2/21/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. e. Hospice aide visit note, dated 2/11/25, identified the aide provided patient a sponge bath; however, lacked RN instruction for this. The hospice aide failed to provide services as instructed by the RN assignment. 10. Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. The IDG meeting notes to update the POC, dated 1/22/25, 2/5/25 and 2/19/25 included IDG orders for hospice aide services. c. The hospice aide task list, reviewed on 1/8/25, included RN instructions to the hospice aide to perform the tasks assist with two person transfers to and from bed to wheelchair or recliner, reposition patient, complete catheter care, empty catheter bag, measure urine output, report to facility staff, report changes in skin integrity to facility staff, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, change bed linens if appear soiled, empty trash, make bed, assist patient in wheelchair to meals if requested, feed patient with eating when present during meal or snack time, setup meal tray when present for meals, apply heel/elbow protectors-specify which one, assist with brushing teeth, assist with dressing, assist with undressing, clean and file fingernails on first visit of the week, comb or brush hair, lotion all extremities, provide bed bath, provide oral care, provide oral care using toothettes, provide sponge bath and shampoo hair. d. Hospice aide visit note, dated 1/14/25, identified the tasks provide oral care, provide oral care using toothettes and shampoo hair as acknowledged but not completed; and failed to include a comment on why tasks were not completed. e. Hospice aide visit note, dated 1/22/25, first visit of the week, identified the tasks clean and file fingernails on first visit of week and identify date of last bowel movement as acknowledged but not completed; and failed to include a comment on why the task was not completed. f. Hospice aide visit notes, dated 1/28/25 and 1/31/25 identified the task identify date of last bowel movement, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 3. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care when incontinent, provide pericare, assist with feeding, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor. d. Hospice aide visit notes, dated 10/9/24, first visit of the week, identified the tasks notify RN of changes to skin integrity, identify date of last bowel movement, provide pericare, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. e. Hospice aide visit notes, dated 10/11/24, second visit of the week, identified the tasks notify RN of changes to skin integrity, identify date of last bowel movement, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails on first visit of the week, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. f. Hospice aide visit note, dated 10/16/24, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. g. Hospice aide visit notes, dated 10/18/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with feeding, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. h. Hospice aide visit notes, dated 10/23/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor each visit, as acknowledged but not completed; and failed to include a comment on why the task was not completed. i. Hospice aide visit notes, dated 10/25/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, clean nails at each visit, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. j. Hospice aide visit notes, dated 10/28/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower, shampoo hair and shave with electric razor, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. k. Hospice aide visit notes, dated 10/28/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care, assist with feeding, encourage fluids, assist with brushing teeth, assist with dressing, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. l. Hospice aide visit notes, dated 11/4/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with dressing, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. m. Hospice aide visit notes, dated 11/6/24 and 11/8/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, assist with feeding, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. n. Hospice aide visit notes, dated 11/11/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, assist with brushing teeth, assist with dressing, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The task identify date of last bowel movement, was acknowledged and completed but failed to include a date. o. Hospice aide visit notes, dated 11/13/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, change brief when incontinent, identify date of last bowel movement, provide incontinent care, assist with undressing, clean nails at each visit, file fingernails as tolerated, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. p. Hospice aide visit notes, dated 11/15/24, identified the tasks notify RN of changes to skin integrity, bathroom assistance, identify date of last bowel movement, provide incontinent care, assist with feeding, assist with brushing teeth, clean nails at each visit, file fingernails as tolerated, lotion to all extremities, provide shower and shampoo hair, as acknowledged but not completed; and failed to include a comment on why the task was not completed. The hospice aide failed to provide services as instructed by the RN assignment. 4. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/8/25, 1/22/25 and 2/5/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included Registered Nurse (RN) instructions to the hospice aide to perform the tasks of brushing teeth, clean and file fingernails and nectar thick liquids per sipping cup. d. Hospice aide visit notes, dated 1/17/25 and 1/24/25, identified the tasks assist with brushing teeth and clean and file fingernails, as acknowledged but not completed; and failed to include a comment on why the task was not completed. e. Hospice aide visit note, dated 2/14/25, identified the tasks nectar thick liquids per sipping cup, assist with brushing teeth, as acknowledged but not completed; and failed to include a comment on why the tasks were not completed. The hospice aide failed to provide services as instructed by the RN assignment. 5. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/29/25 and 2/12/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the task identify date of last bowel movement. d. Hospice aide visit notes, dated 1/31/25, 2/3/25, 2/5/25, 2/7/25, 2/10/25, 2/11/25, 2/14/25, 2/17/25, 2/19/25 and 2/21/25, identified the task identify date of last bowel movement, as acknowledged and completed; but failed to include a date. The hospice aide failed to provide services as instructed by the RN assignment. 6. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 3/13/25 and 3/27/25, included IDG orders for hospice aide services. c. The undated hospice aide task list included RN instructions to the hospice aide to perform the tasks of brushing teeth, clean and file fingernails and nectar thick liquids per sipping cup. d. Hospice aide visit notes, dated 3/20/25 and 3/27/25, the second visits of the week, identified the task on first visit of the week, clean and file nails, as performed. The hospice aide failed to provide services as instructed by the RN assignment. Findings Include: According to the agency policy titled Interdisciplinary Group Membership and Responsibilities, dated 4/2024, the interdisciplinary group (IDG) will collaborate with the client’s attending physician to develop an individualized written plan of care. The IDG group has the responsibilities of establishing the plan of care (POC) for each client admitted to hospice services, updating the POC and for the provision and supervision of all hospice care and services as directed by the POC. 1.Patient #2, had a start of care date of 8/20/24, with a primary diagnosis of Senile Degeneration of the Brain and received hospice services in a long term care facility. Clinical record review revealed the following: a. The plan of care (POC), dated 11/18/24 to 2/15/24, included Registered Nurse (RN) instructions to the hospice aide to perform the following tasks: assist the patient to meals with a wheelchair if present during mealtime, regular diet, assist with ambulation using the walker, fall precautions including ensuring the patient has the fall pendent on at all times, notification to the RN of any changes in skin integrity, universal precautions, assist with dressing, undressing, toileting to include change adult brief and provide perineal cleansing if client is incontinent, shower and shampoo hair, clean and file nails, comb/brush hair, and to apply lotion to all extremities. b. The hospice aide note, dated 12/6/24, Staff O, Hospice Aide (HA), failed to document shower and oral cares completed and lacked reasons to why tasks could not be completed. c. The hospice aide note, dated 12/11/24, Staff O, HA, failed to document oral cares, lotion to extremities, clean and file nails, and adult brief change and lacked reasons as to why tasks could not be completed. d. The hospice aide note, dated 12/23/24, Staff O, HA, failed to document oral cares, and shampoo hair and lacked reasons as to why the tasks could not be completed. The hospice failed to ensure the hospice aide provided cares to the patients as directed by the IDG. 2. Patient #18 had a start of care date of 9/20/24 and a discharge date of 10/263/24, with a primary diagnosis of late effects of a cerebral vascular accident (stroke) and received hospice services in a long term care facility. Clinical record review revealed the following: a. The POC, dated 9/20/24 to 12/17/24, included Registered Nurse (RN) instructions to the hospice aide to perform the following tasks: provide a shower or bed bath, assist patient to ambulate with a walker and gait belt, have 2 people for all transfers out of bed into the wheelchair or recliner, assist to the bathroom and provide incontinency cares, identify the date of the last bowel movement, to assist with eating, dressing, and undressing, clean and file nails, brush or comb hair, reposition, and apply lotion to all extremities. b. The hospice aide note dated 9/20/24, Staff J, HA, failed to document the tasks of clean and file nails, and identify the date of the last bowel movement and lacked a reason to why the tasks could not be completed. c. The hospice aide note dated 9/25/24, Staff J, HA, failed to document the tasks of oral cares, clean and file nails and comb/brush hair and lacked a reason as to why the tasks could not be completed. d. The hospice aide note dated 9/26/24, Staff J, HA, failed to document the tasks of oral cares, bed bath, and identify the date of the last bowel movement, and lacked a reason as to why the tasks could not be completed. e. The hospice aide note dated 9/30/24, Staff J, HA, failed to document the tasks of reposition patient, oral cares, incontinency cares, clean and file nails, and apply lotion to all extremities, and lacked a reason as to why the tasks could not be completed. d. The hospice aide note, dated 10/25/24, Staff P, HA, failed to document the task of identify the date of the last bowel movement and lacked a reason as to why the task could not be completed. The hospice failed to ensure the hospice aide provided cares to the patients as directed by the IDG.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit at least once every 14 days for 5 of 13 sampled patients (Patients #7, #9, #14, #15 and #17) that required supervision. Failure to supervise hospice aides at least every 14 days placed patients at risk for a delay in identification of potential problems and/or patient needs and placed patient’s at risk for not receiving the services needed to meet the assessed patient needs. Findings include: 3. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and interdisciplinary group (IDG) orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 3/13/25 and 3/27/25, included IDG orders for hospice aide services. c. Hospice aide visit note, dated 3/12/25, identified aide services had been provided. d. Skilled nurse visit notes, dated 3/20/25, 3/22/25 and 3/28/25, lacked documentation hospice aide supervision had been provided. e. Skilled nurse visit note, dated 4/2/25, included documentation hospice aide supervision had been completed, 21 days after the start of aide services, 7 days late. The hospice failed to document aide supervision every 14 days. 4. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 11/7/24 and 11/25/24, included hospice aide supervision, 18 days apart, 4 days late. The hospice failed to document aide supervision every 14 days. 5. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/8/25, 1/22/25 and 2/5/25, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 1/30/25 and 2/14/25, included hospice aide supervision, 15 days apart, 1 day late. The hospice failed to document aide supervision every 14 days. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. According to the hospice policy, titled Clinical Field Team Member Supervision, revised 3/13/2019, a registered nurse must make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure services ordered by the hospice interdisciplinary group met the patient’s needs. The hospice aide does not have to be present during this visit. During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager stated the Registered Nurse (RN) Case Manager or the visiting RN complete aide supervision every 14 days. This is documented in the patient’s electronical medical record. 1.Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 10/19/24 to 1/16/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease and included orders for skilled nursing, hospice aide, music therapy and chaplain services. b. The skill nurse update to the comprehensive assessment, dated 12/27/24, signed completed by Staff F, RN, on 12/30/24 included hospice aide supervision. c. The skilled nurse visit notes, dated 12/31/24, 1/2/25, 1/7/25 and 1/9/25, failed to include hospice aide supervision. d. The skilled nurse update to the comprehensive assessment, signed completed by Staff F, RN, on 1/14/25 included hospice aide supervision (4 days late). The RN failed to supervise hospice aide services every 14 days. 2.Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/8/25 to 4/7/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing, hospice aide, social worker and chaplain services. b. The skilled nurse visit notes, dated 1/13/25, 1/22/25 and 1/30/25, failed to include hospice aide supervision. c. The skilled nurse update to the comprehensive assessment, signed completed by Staff F, RN, on 2/5/25 included hospice aide supervision (8 days late). The RN failed to supervise hospice aide services every 14 days.”

“Based on interviews, clinical record reviews and agency policy review, the hospice failed to document all required components of hospice aide supervision for 12 of 13 sampled patients (Patients #1, #2, #3, #5, #6, #7, #9, #11, #13, #14, #17 and #18) with aide services. Failure to ensure the supervision of hospice aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: 10. Patient #7 had a hospice admission date of 8/23/24 and received hospice services while residing in a private home. Clinical record review revealed: a. The POC, dated 8/23/24 to 11/21/24, included primary diagnosis of Parkinsons disease and interim physician orders for skilled nursing services, social work and hospice aide services. b. IDG meeting note to update the POC, dated 2/5/25, included interim physician orders for skilled nurse twice a week and hospice aide twice a week services. c. Skilled nurse visit notes, dated 12/19/24, 1/2/25, 1/16/25, 1/30/25 and 2/14/25, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 11. Patient #13 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 12/24/24 to 3/23/25, included primary diagnosis of Chronic Kidney Disease and interim physician orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 1/29/25 and 2/12/25, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 1/8/25, 1/21/25, 2/4/25 and 2/17/25, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 12. Patient #17 had a hospice admission date of 10/9/24, a death date of 11/27/24, and, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/9/24 to 1/6/25, included primary diagnosis of senile degeneration of brain and IDG orders for skilled nursing and hospice aide services. b. The IDG meeting notes to update the POC, dated, 10/16/24, 10/30/24 and 11/13/24, included IDG orders for hospice aide services. c. Skilled nurse visit notes, dated 10/24/24, 11/7/24 and 11/25/24, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. 8. Patient #2 had a hospice admission date of 8/20/24 and received hospice services while residing in a private long term care facility. Clinical record review revealed the following: a. The POC, dated 11/18/24 to 2/15/25, identified the patient had a diagnosis of Senile Degeneration of the Brain, and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 12/31/24, 1/14/25, 1/28/25, and 2/11/25, completed by Staff G, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 9. Patient #18 had a hospice admission date of 9/19/24 and a death date of 10/26/24 and received hospice services while residing in a long term care facility. Clinical record review revealed the following: a. The Plan of Care (POC), dated , identified the patient had a diagnosis of late effects following a cerebral vascular accident (stroke), and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 10/3/24 and 10/17/24, completed by Staff V, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. According to the hospice policy, titled Clinical Field Team Member Supervision, revised 3/13/2019, a registered nurse must make an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure services ordered by the hospice interdisciplinary group met the patient’s needs. The supervising nurse must assess an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to: Following the patient’s plan of care; creating successful interpersonal relationships with the patient and family; demonstrating competency with assigned tasks; complying with infection control policies and procedures; and reporting changes in the patient’s condition. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Interdisciplinary Group (IDG) meeting notes, dated 2/5/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/11/25, completed by Staff F, Registered Nurse (RN) included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 2. Patient #3 had a hospice admission date of 2/7/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 2/7/25 to 5/7/25, identified the patient had a diagnosis of Chronic obstructive pulmonary disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/17/25, completed by Staff U, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 3. Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/8/25, 1/22/25 and 2/5/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 1/21/25 and 2/3/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. c. Skilled nurse visit note, dated 2/13/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide followed the plan of care and demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 4. Patient #6 had a hospice admission date of 1/28/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/29/25 and 2/12/25, identified the patient had a diagnosis of Alzheimer’s disease with early onset and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 2/13/25, completed by Staff Q, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 5. Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The IDG notes, 12/18/24, 12/31/24, 1/15/25, 1/29/25 and 2/12/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit notes, dated 12/27/24 and 1/14/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. c. Skilled nurse visit note, dated 1/28/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide followed the plan of care and demonstrated competency with assigned tasks. d. Skilled nurse visit note, dated 2/10/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 6. Patient #11 had a hospice admission date of 1/23/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The IDG note, dated 2/5/25, identified the patient had a diagnosis of Intrahepatic bile duct carcinoma and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/11/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision. 7.Patient #14 had a hospice admission date of 1/8/25 and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The IDG notes, dated 1/22/25 and 2/5/25, identified the patient had a diagnosis of unspecified severe protein calorie malnutrition and included orders for skilled nursing and hospice aide services. b. Skilled nurse visit note, dated 2/5/25, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: aide followed plan of care, created successful interpersonal relationships with patient/family, complied with infection control and reported changes in patient condition. The skilled nurse visit note lacked documentation the aide demonstrated competency with assigned tasks. The hospice failed to document all required components of hospice aide supervision.”

“Based on staff interview and clinical record review the hospice failed to ensure all documentation was completed and appropriately authenticated in accordance with accepted standards of practice and agency standards for 4 of 19 sampled patients (Patients #1, #5, #9 and #15). Failure to ensure all documentation was completed, dated and signed in a timely manner decreased the ability of hospice staff to communicate and coordinate patient care effectively and to provide safe, effective hospice services to its patients. Findings include: 4. Patient #15 had a hospice admission date of 3/11/24, a revocation date of 4/3/24, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/11/24 to 6/8/24, included primary diagnosis of heart failure and chronic kidney disease and Interdisciplinary Group (IDG) orders for skilled nursing, social work, chaplain, music therapy and hospice aide services. b. The IDG meeting note to update the POC, dated 3/13/24, included documentation massage therapy services was not applicable. c. The IDG meeting note to update the POC, dated 3/27/24, lacked documentation of IDG order for massage therapy. d. Massage therapy visit note, dated 3/29/24, identified massage therapy techniques were performed. Note was marked as completed on 4/12/25, 14 days after the visit date, 11 days late. The hospice failed to ensure timely completion of all documentation. Findings reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager. During an interview on 2/20/25 at 9:00 AM, Staff C, Clinical Manager stated that agency goal is to have documentation completed the same day; however, staff have 72 hours to complete their documentation. Notes are authenticated with name, date, time and title of the clinician. 1.Patient #1 had a hospice admission date of 1/27/25 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/27/25 to 4/26/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The Chaplain initial assessment, dated 1/31/25, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. The hospice failed to ensure all completed documentation included appropriate authentication. 2.Patient #5 had a hospice admission date of 1/3/25 and received services while residing in a nursing home. Clinical record review revealed the following: a. The POC, dated 1/3/25 to 4/2/25, identified the patient had a diagnosis of Dementia due to Alzheimer’s disease and included orders for skilled nurse, social worker, hospice aide and chaplain services. b. The Chaplain initial assessment, dated 1/6/25, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. c. The skilled nurse start of care assessment, dated 1/3/25, signed completed by Staff E, Registered Nurse (RN) on 1/16/25 (7 days late). The hospice failed to ensure timely completion and appropriate authentication of all documentation. 3.Patient #9 had a hospice admission date of 10/19/24 and received hospice services while residing in a private residence. Clinical record review revealed the following: a. The POC, dated 10/19/24 to 1/16/24, identified the patient had a diagnosis of Chronic obstructive pulmonary disease and included orders for skilled nurse, hospice aide, social worker and chaplain services. b. The Chaplain initial assessment, dated 11/25/24, completed by Staff K, Chaplain, lacked a signature with name, date, time and title of clinician completing the assessment. The hospice failed to ensure all completed documentation included appropriate authentication.”

“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 and staff interview, the hospice failed to ensure completion of a criminal background check for 2 of 7 sampled employees (Staff H and I) who began serving hospice patients since their last survey, dated 3/21/22. The hospice reported hiring 46 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 employees who had direct patient contact. Findings include: According to the hospice policy titled Background Screening of Contractors and Team Members, last revised 11/2022, after an offer of employment, but before hire of any applicant, the hospice will conduct a background record check including, where applicable, a check on criminal history, a check on dependent adult abuse background, a check on professional health care licensure status, and a check on nurse aide competency. Background checks will be conducted through the use of the State on-line single contact repository system established by the Iowa Department of Inspections, Appeals and Licensing. During an interview on 2/24/25 at 3:25 PM, Human Resource staff stated the hospice found no record of the results of the criminal background check for Staff H, RN. 1. Staff I, Volunteer, had a hire date of 12/20/23. A SING criminal background check was completed using DCI and dated 1/26/24, 36 days after the hire date. The hospice failed to complete a criminal background check within 30 days prior to the date of hire. 2. Staff H, RN, had a hire date of 6/3/24. A criminal background check was completed using DCI and dated 5/10/24, and instructed the criminal background to await further information. The RN license verification, dated 7/24/24, was completed 51 days after the hire date. The hospice failed to follow through to complete further information for the criminal background check and check license verification within 30 days prior to the date of hire. Hospice staff failed to ensure the completion of a criminal history background check per Iowa law on personnel prior to allowing that person direct contact with hospice patients. The above findings were reviewed with the Administrator, Executive Director, Director of Clinical Quality and Staff C, Clinical Manager.”