Good Samaritan Society Home Care and Hospice

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to: 1) Ensure social worker member of the interdisciplinary group participated in all interdisciplinary group meetings. (L541) 2) Ensure physician orders were obtained and wrote for all treatments in the plan of care. (L549) 3) Ensure all medical equipment and supplies were included in the plan of care. (L550) 4) Ensure physician and IDG members were notified of missed visits. (L555) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure the Interdisciplinary Group meetings were attended by all core members and plans of care were updated as needed for hospice patients.”

“Based on hospice staff interview, hospice policy review, hospice personnel file review and clinical record review, the hospice failed to: 1) Ensure hospice aides are competency tested prior to providing extra skills. (L613) 2) Ensure hospice aides receive at least 12 hours of in-service training during each 12-month period. (L620) 3) Ensure hospice aide assignments are patient specific. (L625) 4) Ensure hospice aide performs tasks assigned. (L626) 5) Ensure registered nurse complete hospice aide supervision every 14 days. (L629) 6) Ensure registered nurse supervision of hospice aide services includes required elements. (L633) The cumulative effects of these systemic practices resulted in the failure of the hospice to ensure hospice aide services are provided by individuals who meet specified requirements, hospice aides follow patient specific assignments and registered nurses supervise hospice aide services to ensure care provided is appropriate and meets the needs of the hospice patient.”

“The lowa 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 lowa Single Information Repository (SING), or using both the lowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the lowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The lowa 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 6/8/23. The hospice reported hiring 17 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: According to the hospice policy titled Hiring and Screening, dated 3/28/25, in those states where state law requires an in-state agency check, state law will supersede. If the location’s state requires a state -specific background check, the location must fulfill the state’s requirements. Interview 3/31/26 at 2:58 PM, the Administrator reported that the central office human resources department performs background checks. Staff E, Licensed Practical Nurse (LPN), had a hire date of 1/8/25. Staff E’s personnel file included documentation of completed dependent adult and child abuse record checks, dated 12/6/24, 32 days prior to Staff E’s hire 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, Staff K, Clinical Quality Specialist, and Staff N, Administrative Assistant.”

“Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to have all members of the interdisciplinary group (IDG) complete the comprehensive assessment no later than 5 calendar days after the election of hospice care for 3 of 14 sampled patients (Patients #1, #4, and #13). Failure to have all disciplines complete the comprehensive assessment within 5 calendar days of the election of hospice care puts patients at risk for inconsistent care that may not meet the needs of the patient. Findings include: 3. Patient #4 had a hospice admission date of 2/18/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The Hospice Consent and Authorization for Treatment signed by the patient, dated 2/18/26, included an initial visit plan that included chaplain visits 2 times per month. b.The POC, dated 2/18/26 to 5/18/26, included orders for chaplain services 1 time a month for 1 month and then 2 times a month. c. The chaplain visit note, dated 2/24/26, occured 5 days after the start of care (1 day late per regulation). The clinical record failed to include the chaplain visit within 5 calendar days after the hospice consent and authorization was signed. The above findings reviewed with the Administrator and Clinical Manager. According to the hospice policy titled Assessments: Initial, Comprehensive and Ongoing Hospice, last reviewed/revised 1/27/25, the comprehensive assessment is completed within 5calendar days after the election of hospice care by the IDG, in consultation with the patient’s attending physician (if any). In an interview on 3/24/26 at 1:49 PM, the Administrator reported that the agency has been without a social worker on staff from 1/2/26 until March 2026 when the social worker started working for the agency. 1.Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The Hospice Consent and Authorization for Treatment signed by the patient’s representative on 3/16/26 included an initial visit plan that included social worker visits 1 per month. b.Plan of Care (POC), dated 3/16/26 to 6/13/26, included a primary diagnosis of Alzheimer’s disease and physician orders for social work services 1 visit per month for 3 months. The clinical record review failed to reveal that a social worker visited the patient within 5 calendar days after the election was signed. 2.Patient #13 had a hospice admission date of 2/5/26 and date of death on 3/20/26 and received hospice services while residing in a private home. Clinical record review revealed: a.The Hospice Consent and Authorization for Treatment signed by the patient’s representative on 2/5/26 included an initial visit plan that included 1 visit per month by the social worker. b.POC, dated 2/5/26 to 4/5/26, included physician orders for social work services 1 visit per month for 2 months. The clinical record failed to include that a social worker visited the patient within 5 calendar days after the election was signed.”

“Based on clinical record review, interdisciplinary group (IDG) meeting sign-in sheets, hospice policy review and staff interview, the hospice failed to ensure a social worker participated in each interdisciplinary group meeting held over a 3 month time frame (January 2026 through March 2026) and participated in the review and updating of the patient’s plan of care through the interdisciplinary team meeting. Failure of the hospice to ensure all 4 required core members of the interdisciplinary group (IDG) doctor of medicine or osteopathy, registered nurse, social worker and pastoral or other counselor, participated in each IDG meeting placed hospice patients at risk for not having all of their medical needs identified and met. Findings include: According to the hospice policy, titled Interdisciplinary Group Hospice, dated 4/8/25, the core members of the IDG are physician, registered nurse, social worker and pastoral or other counselor. Review of the hospice’s IDG meeting sign-in sheets for 2026, dated 1/13/26, 1/27/26, 2/10/26, 2/24/26, 3/10/26 and 3/24/26, identified a lack of signature of attendance for a social worker. During an interview on 3/24/26 at 1:49 PM, the Administrator reported the hospice social worker left at the beginning of the year and it took the hospice a while to find a replacement. No social worker attended IDG meetings since January 2026, a new social worker has been hired and will start seeing patients soon. The new social worker is a bachelor of social work and will be overseen by the masters of social work staff that work in the affiliated long term care facility. The Administrator received the above findings.”

“Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 5 of 14 sampled patients (Patients #4, #6, #7, #9 and #11). Failure to ensure the plan of care included complete and accurate physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. Findings include: 5. Patient #4 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/18/26 to 5/18/26, identified the patient had a primary diagnosis of interstitial pulmonary disease and included orders for skilled nurse and hospice aide services. The POC also included orders for the skilled nurse to educate the patinet/caregivers regarding care of Foley catheter including: cleaning perineal area properly, emptying catheter bag, placement drain tube for safety during ambulation, cleaning spout and closing drain and if foley isn’t draining to contact the facility to assess. b. The skilled nurse note, dated 2/19/26, included documentation the patinet had an indwelling suprapubic catheter #16. b. The physician’s order, dated 3/10/26, included orders for Foley change monthly and flush prn for occlusion. The order included a 16 French foley. The order lacked orders for balloon size. The hospice failed to include order for the Foley catheter balloon size. The above findings reviewed with the Administrator and Clinical Manager. 3. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services to educate caregivers in performing wound care. b. Initial comprehensive assessment, dated 2/18/26, completed by Staff F, RN, identified wound was cleaned, barrier cream applied, covered with mepilex (silicone foam dressing) and patient tolerated well. c. Interim physician order, dated 3/2/26, included physician direction to clean wound area with soap and water, apply barrier cream, cover with mepilex dressing and use skin prep (transparent film on intact skin to protect against adhesive trauma or friction) to keep mepilex in place. Family educated and will change dressing every 5-7 days or as needed. Hospice failed to obtain specific wound care order until 3/2/26, 13 days after wound care performed. During an interview on 3/31/26 at 11:16 AM, Administrator reported clinical record was reviewed and the initial plan of care lacked specific wound care orders, specific wound care order was obtained on 3/2/26. 4. Patient #11 had a hospice admission date of 1/9/26, a discharge date of 1/28/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 1/9/26 to 4/8/26, included a primary diagnosis of chronic hepatic (liver) failure and physician orders for skilled nurse services. b. IDG meeting notes, dated 1/13/26 and 1/27/26, lacked physician orders for massage therapy services. c. Massage therapy visit notes, dated 1/22/26 and 1/26/26, completed by Staff G, Massage Therapist, identified massage therapy services were provided. Hospice failed to obtain physician orders for massage therapy prior to massage therapy services being provided. During an interview on 3/31/26 at 11:20 AM, Administrator reported clinical record was reviewed and no massage therapy orders were in the clinical record. 2. Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. Massage therapy visit notes, dated 2/25/26 and 3/2/26, completed by Staff G, Massage Therapist, identified massage therapy services were performed. c. The IDG meeting notes, dated 2/24/26 and 3/10/26, lacked documentation of an IDG order for massage therapy. The IDG meeting notes to update the POC failed to identify specific frequency and duration for massage therapy services. According to hospice policy titled Plan of Care, Hospice, last reviewed/revised 7/30/25, hospice care follows a written Plan of Care (POC) established and reviewed by the Interdisciplinary Group (IDG) in collaboration with the patient’s attending provider, if any. Services are provided under this POC. Therapeutic orders are obtained from the attending physician or their designee, according to policy and applicable law and regulation. The review of and revisions to the POC by the IDG occurs at least every 15 days. The contents of the POC includes: interventions to manage pain and symptoms and drugs and treatments necessary to meet the needs of the patient. In an interview on 3/31/26 at 10:21 AM, the Administrator reported that this was an issue found during the first week in March 2026 where the issue with the missing orders was identified and the agency started working towards correcting this. 1.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a.POC, dated 2/5/26 to 4/5/26, identified the patient had a diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and included orders for skilled nurse and social work services. b.The Hospice IDG Comprehensive Assessment and Plan of Care Update Report, dated 2/24/26, identified a massage therapy evaluation to be completed for pain management. c. The patient’s clinical record included massage therapy visit notes, dated 3/4/26 and 3/9/26, by Staff G, massage therapist. d. IDG meeting notes for the patient on 3/10/26 or 3/24/26 lacked massage therapy orders. The patient’s clinical record failed to reveal orders for the massage therapy visits on 3/4/26 and 3/9/26. The hospice provided massage services without an order.”

“Based on home visit observation, patient interviews, clinical record reviews and agency policy review, the hospice failed to ensure the Plans of Care for 4 of 14 sampled patients (Patients #1, #2, #3 and #7) included all medical equipment and supplies necessary to meet identified patient needs. Failure to include all needed items of medical equipment and supplies the patient used on the Plans of Care placed the patients at risk of unanticipated decline or injury and of needs not met. Findings include: 4. Patient #3 had a hospice admission date of 2/3/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/3/26 to 5/3/26, identified the patient had a primary diagnosis of vascular dementia and identified the patient used the following medical equipment and supplies: shower/tub equipment. b. The skilled nurse initial assessment, dated 2/3/26, completed by Staff F, RN, identified the patient used the following medical equipment and supplies: shower chair. c. During a home observation visit on 3/24/26 at 2:00 PM with Staff F, RN, the surveyor observed a lift chair in the patient’s living room. An interview with the patient’s spouse during the same home observation visit revealed the patient has utilized the for greater than two months. The POC failed to identify all necessary medical equipment and supplies used by the patient, including BIPAP, diabetic supplies, raised toilet seat, shower chair and lift chair. The above findings were reviewed with the Administrator and Clinical Manager. 3. Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/16/26 to 6/13/26, identified the patient had a diagnosis of Alzheimer’s disease and did not include any supplies and equipment the patient used. b.Skilled nursing visit note, dated 3/16/26, by Staff D, RN, indicated the supplies and equipment used by the patient included chair lift, grab bars, hospital bed, wheelchair, and pommel cushion. b. During a home observation visit on 3/24/26 at 12:45 PM, with Staff D the surveyor observed the following supplies and equipment used by the patient and/or stored in the patient’s room for use: disposable overlay for incontinence, bedside table, urinal, wheelchair, pommel cushion, and hospital bed with a positioning rail. c.In an interview on 3/24/26 at 12:45 PM, Staff D reported that additional equipment supplies and equipment that is used by the patient includes: a sit to stand mechanical lift, incontinence briefs, and shower chair. d.The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 3/24/26, did not include supplies and equipment used by the patient. The hospice failed to include all medical equipment and supplies utilized by the patient including disposable overlay for incontinence, bedside table, urinal, wheelchair, pommel cushion, hospital bed with a positioning rail, sit to stand mechanical lift, incontinence briefs, and shower chair in the POC. Review of the hospice policy titled Plan of Care, last revised July 2025, identified the content of the Plan of Care (POC) includes medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #2 had a hospice admission date of 2/5/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/5/26 to 5/5/26, identified the patient had a primary diagnosis of pancreatic cancer and identified the patient used the following medical equipment and supplies: cane and commode. b. The skilled nurse initial assessment, dated 2/5/26, completed by Staff F, Registered Nurse (RN), identified the patient used the following medical equipment and supplies: bilevel positive airway pressure (BIPAP), diabetic supplies, raised toilet seat and shower chair. c. During a home observation visit on 3/24/26 at 9:15 AM with Staff E, Licensed Practical Nurse (LPN), the surveyor observed a lift chair in the patient’s living room. An interview with the patient during the same home observation visit revealed the patient has utilized the lift chair for greater than two months. The POC failed to identify all necessary medical equipment and supplies used by the patient, including BIPAP, diabetic supplies, raised toilet seat, shower chair and lift chair. 2. Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/22/25 to 2/19/26, identified the patient had a primary diagnosis of congestive heart failure and identified the patient used the following medical equipment and supplies: grab bars, walker and wheelchair. b. The skilled nurse initial assessment, dated 12/22/25, completed by Staff D, RN, identified the patient used the following medical equipment and supplies: commode and incontinence products. The POC failed to identify all necessary medical equipment and supplies used by the patient, including commode and incontinence products.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 3 of 14 sampled patients (Patients #6, #8 and #12). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. 3. Patient #8 had a hospice admission date of 9/13/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 12/12/25 to 3/12/26, identified the patient had a primary diagnosis of sarcopenia and included physician orders for skilled nursing services weekly and hospice aide services twice a week. b. The clinical record failed to include any aide visit notes the week of 2/22/26 to 2/28/26. c. The IDG update to the POC, dated 2/24/26 and 3/8/26, failed to identify any missed aide visits. The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC. The above findings reviewed with the Administrator and Clinical Manager. 2. Patient #12 had a hospice admission date of 4/15/25, a discharge date of 5/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 4/15/25 to 7/13/25, identified the patient had a primary diagnosis of malignant melanoma of right lower limb and included physician orders for skilled nursing services weekly and hospice aide services twice a week. b. The clinical record failed to include any aide visit notes. c. The IDG update to the POC, dated 4/22/25, failed to identify any missed aide visits. The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC. Findings include: Review of the hospice policy, titled Interdisciplinary Group, dated 4/8/25, the attending physician is informed of any changes to the plan of care (POC) by the IDG. 1. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services and hospice aide services effective 2/22/26 twice a week for twelve weeks. b. Hospice aide visit notes, dated 3/9, 3/12 and 3/18/26, completed by Staff I, Hospice Aide, identified services were provided. c. IDG update to the POC, dated 3/24/26, failed to identify missed hospice aide visit for the week of 3/15/26. Hospice failed to provide a second hospice aide visit the week of 3/15/26 or document a reason why a visit was not provided and notify the physician and IDG of the missed hospice aide visit. During an interview on 3/31/26 at 11:13 AM, Administrator reported the missed visit the week of 3/15/26 should have been reported at the IDG meeting on 3/24/26 but the agency failed to do that. Hospice failed to provide hospice aide services as ordered in the plan of care.”

“Based on review of bereavement documentation and staff interview, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved. The survey identified this concern with 1 of 2 sampled bereavement records (Patient #14). Failure to provide bereavement counseling according to identified needs, placed the bereaved at increased risk for worsening severe grief and increased the potential for self harm. Findings include: Review of the hospice policy, titled Bereavement, dated 4/8/25, bereavement services are provided based on the assessment of the family/caregiver needs, the presence of any risk factors associated with the patient’s death, and the ability of the family/caregiver to cope with grief. After death occurs, the Hospice Social Worker or Bereavement Coordinator initiates bereavement services. A bereavement plan of care is developed based on the findings of the hospice bereavement assessment and includes frequency and types of services offered. Bereavement documentation is included in the patient’s medical record. During an interview on 3/31/26 at 3:07 PM, Administrator reported bereavement mailings are sent after a patient’s death to the primary contact. Patient #14 had a hospice admission date of 8/7/25, a death date of 8/10/25 and received services while residing in a private residence. During an interview on 3/30/26 at 2:30 PM, Staff N, Administrative Assistant, reported she sends out the bereavement mailings and confirmed Patient #14’s primary caregiver should receive bereavement mailings. Clinical record review revealed no documentation of a bereavement assessment or bereavement plan of care. Administrator and Clinical Manager received the above findings.”

“Based on staff interview, clinical record reviews, review of employee personnel files and agency policy review, the hospice failed to ensure 1 of 2 sampled hospice aides (Staff I) demonstrated competency in the performance of any skills which exceeded 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 6 sampled patients (Patient #1 and #9) who required an extra skill be performed. 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: 1. Patient #1 had a hospice admission date of 3/16/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/16/26 to 6/13/26, identified the patient had a diagnosis of Alzheimer’s disease and orders for skilled nursing and hospice aide (HA) services. b. The Aide Care Plan Report, dated 3/17/26, by Staff B, Clinical Manager, included Registered Nurse (RN) instructions for the aide to assist the patient with feeding. c. Review of the clinical record showed Staff I, HA, provided aide services independently for Patient #1. d. Staff I had a hire date of 1/5/26. Staff I’s personnel file lacked documentation that a RN observed Staff I competently perform the task of assisting the patient with feeding. In an interview on 3/31/26 at 1:49 PM, the Administrator reported that they do not understand why feeding was not part of the training that Staff I had during orientation, they thought this skill was a line item on the competency checklist. 2.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a.The Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 1/27/26, included orders for skilled nursing and aide services. b.The Aide Care Plan Report, dated 2/2/26, by the Administrator, included instructions for the aide to trim the patient’s nails. c.Review of the clinical record showed that Staff I provided aide services independently for Patient #9. d. Staff I had a hire date of 1/5/26. Staff I’s personnel file lacked documentation that a RN had observed Staff I competently perform the task of trimming nails. The above findings were reviewed with the Administrator, Staff K, Clinical Quality Specialist, and Staff N, Administrative Assistant. The Medicare Conditions of Participation direct 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. According to the agency’s policy titled Aide Training Program, last revised in July 2025, the hospice agency is responsible for training aides in skills not covered in the basic checklist.”

“Based on staff interview, in- service education training documentation, and hospice policy review, the hospice failed to maintain documentation that 1 of 1 sampled hospice aides, employed for more than 1 year, completed a minimum of 12 hours of in- service educational training annually (Staff C). The agency employed 2 hospice aides at the time of the survey. Failure to have hospice aides receive 12 hours of in-service training annually increased the potential that hospice aides lacked updated and current information related to the care provided by the hospice aides. Findings include: According to hospice policy titled Aide Hiring Requirements, Home Health and Hospice, updated 7/30/25, the aide must receive at least 12 hours of in-service training during each 12 month period. In an interview on 3/31/26 at 10:08 AM, the Administrator reported that Staff C, Hospice Aid (HA), should have at least 12 hours of in service for 2024 and 2025. Staff C, Hospice Aide, had a hire date of 2/16/21. Staff C’s personnel file contained documentation of more than 12 in-service hours in 2025 and only 6.67 in-service hours in 2024. The above findings were reviewed with the Administrator, Staff K and Clinical Quality Specialist.”

“Based on hospice staff interview, clinical record review, and hospice policy review, the hospice failed to ensure registered nurses (RN) developed and updated individualized patient specific written instructions directing the care provided by each hospice aide for 1 of 8 patients receiving hospice aide services (Patient #9. Failure to provide patient specific written instructions for hospice aides directing them which tasks to perform and how frequently and update those instructions with changes for each patient increased the risk that hospice patients did not receive the services to meet each patient’s assessed needs. Findings include: According to hospice policy titled Aide Services, Hospice, dated 1/27/25, the RN arranges the aide services, assigns the care, and supervises the aide, which are completed per regulation. Written instructions for the aide are prepared by the RN. In an interview on 3/31/26 at 10:08 AM, Administrator reported the task to trim the nails included both fingernails and toenails. Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a.The Plan of Care (POC) dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services. b. The IDG meeting notes to update the POC, dated 2/24/26, 3/10/26, and 3/24/26, included IDG orders for hospice aide services. c.Hospice Aide Care Plan, dated 2/2/26, included RN instruction to the hospice aide to complete the task for trimming the nails however it did not specify if fingernails and/or toenails were to be trimmed. The hospice RN failed to ensure a hospice aide care plan specified to which nails were to be trimmed and filed. The above findings were reviewed with the Administrator, Staff K, Clinical Quality Specialist and Staff N, Administrative Assistant.”

“Based on staff interview, clinical record reviews and hospice agency policy review, the hospice failed to ensure hospice aides provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 1 of 8 sampled patients receiving hospice aide services (Patient #7). Failure to ensure that hospice aide services are provided only as ordered by the physician and according to the hospice aide care plan increased the risk that patients’ personal care needs were not adequately met. Findings include: According to the agency policy titled Aide Services, dated July 2025, the hospice aide provides care according to the established Plan of Care and documents all care in the medical record. During an interview on 3/24/26 at 1:49 PM, Staff A, Administrator, stated the aide contacts the registered nurse (RN) if a patient requests an unassigned task be completed and the RN adds the task to the aide care plan if appropriate. Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 12/22/25 to 2/19/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 12/22/25, included aide instructions to provide a bed bath. c. Hospice aide visit note, dated 2/3/26, completed by Staff I, Hospice Aide, documented the task as completed and documented she applied lotion to the patient. The hospice aide failed to provide services only as ordered and according to the hospice aide care plan. The above findings were reviewed with the Administrator and Staff K, Clinical Quality Specialist.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure registered nurses performed a hospice aide supervisory visit at least once every 14 days for 3 of 8 sampled patients (Patients #6, #7 and #9) 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 patients at risk for not receiving the services needed to meet the assessed patient needs. Findings include: 3. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 3/2/26 and 3/18/26, completed by Staff F, RN, included documentation the nurse supervised the hospice aide, 16 days apart, 2 days late per regulation and policy. During an interview on 3/31/26 at 11:20 AM, Administrator reported clinical record review was completed and she agreed the supervision was late. The hospice failed to document aide supervision every 14 days. Administrator and Clinical Quality Specialist received the above findings 2.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a.The Plan of Care dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services. b.Skilled nurse visit note, dated 3/3/26, by Staff D, RN, included documentation hospice aide supervision had been completed. c. Skilled nurse visit note, dated 3/18/26, by Staff F included documentation the nurse supervised the hospice aide, 15 days apart, 1 day late per regulation and policy. The hospice failed to document aide supervision every 14 days. According to the hospice policy titled Aide Services, last revised January 2025, the Registered Nurse (RN) arranges the aide services, assigns the care and supervises the aide, which are completed per regulation. An on-site supervisory visit will be done by an RN at least every 14 days. During an interview on 3/31/26 at 11:54 AM, Staff A, Administrator, confirmed aide supervision is required every 14 days and stated there should be documentation in the clinical record if the RN was unable to complete the supervision timely. 1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care, dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. The skilled nurse visit note, dated 2/24/26, signed completed on 2/24/26 by Staff F, RN, included hospice aide supervision. c. The skilled nurse visit note, dated 3/12/26, signed completed on 3/12/26 by Staff F, RN, included hospice aide supervision (2 days late per regulation). The RN failed to supervise hospice aide services every 14 days.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to document all required components of hospice aide supervision for 6 of 8 sampled patients with aide services (Patients #6, #7, #8, #9, #10 and #13). 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: 6. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 3/2/26 and 3/18/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. Hospice failed to document all required elements of aide supervision Administrator and Clinical Quality Specialist received the above findings. 4.Patient #9 had a hospice admission date of 8/13/25 and received hospice services while residing in a private home. Clinical record review revealed the following: a.POC dated 2/23/26 to 4/23/26 included a primary diagnosis of prostate cancer and orders for skilled nursing and aide services. b.Skilled nurse visit notes by Staff D, RN, on 1/28/26, 2/11/26, 2/17/26, 2/25/26, and 3/3/26 included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. c.Skilled nursing note on 3/18/26 by Staff F, RN, included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. The hospice failed to document all required elements of aide supervision. 5.Patient #13 had a hospice admission date of 2/5/26 and date of death of 3/20/26 and received hospice services while residing in a private home. Clinical record review revealed: a.POC dated 2/5/26 to 4/5/26 included a primary diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and orders for skilled nursing and aide services and orders for skilled nursing and aide services. b.Skilled nursing visit notes by Staff D, RN, on 2/17/26, 3/3/26, and 3/17/26 included supervision of the hospice aide: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. The hospice failed to document all required elements of aide supervision. 2. Patient #8 had a hospice admission date of 9/13/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/12/26 to 5/10/26, included a primary diagnosis of sarcopenia and physician orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 3/17/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. The hospice failed to document all required elements of aide supervision. 3. Patient #10 had a hospice admission date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/20/26 to 4/19/26, included a primary diagnosis of colon cancer and physician orders for skilled nurse and hospice aide services. b. Skilled nurse visit notes, dated 3/17/26, completed by Staff F, RN, included aide supervision: aide followed plan of care, aide competent with assigned tasks and follows infection control protocols, but lacks documentation of creating successful interpersonal relationships with patient and family and reports changes in patient’s condition. The hospice failed to document all required elements of aide supervision. According to the hospice policy titled Aide Services, last revised January 2025, the Registered Nurse (RN) arranges the aide services, assigns the care and supervises the aide, which are completed per regulation. During an interview on 3/31/2026 at 11:54 AM, Staff A, Administrator, confirmed the electronic medical record does not capture all required components of aide supervision. 1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plans of Care (POCs), dated 12/22/25 to 2/19/26 and 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. Skilled nurse visit note, dated 1/19/26, completed by Staff D, RN, included documentation the hospice nurse provided aide supervision: followed the patient’s plan of care, demonstrated competency with assigned tasks and complied with infection control policies and procedures. The skilled nurse visit note lacked documentation the aide created successful interpersonal relationships with the patient and family and reported changes in the patient’s condition. c. Skilled nurse visit note, dated 2/2/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient’s plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures. The skilled nurse visit note lacked documentation the aide reported changes in the patient’s condition. d. Skilled nurse visit note, dated 2/10/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient’s plan of care, demonstrated competency with assigned tasks and complied with infection control policies and procedures. The skilled nurse visit note lacked documentation the aide created successful interpersonal relationships with the patient and family and reported changes in the patient’s condition. e. Skilled nurse visit note, dated 2/24/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient’s plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures. The skilled nurse visit note lacked documentation the aide reported changes in the patient’s condition. f. Skilled nurse visit note, dated 3/12/26, completed by Staff F, RN, included documentation the hospice nurse provided aide supervision: followed the patient’s plan of care, created successful interpersonal relationships with the patient and family, demonstrated competency with assigned tasks and complied with infection control policies and procedures. The skilled nurse visit note lacked documentation the aide reported changes in the patient’s condition. The hospice failed to document all required components of hospice aide supervision.”

“Based on review of written hospice agreements for services under arrangement and agency policy review, the hospice failed to ensure the written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 3 sampled services (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: According to the agency policy titled Contractual Agreements, last revised February 2026, the agency provides oversight for all contractual agreements which provide patient care, treatment and services. The agency retains Quality Improvement responsibility for evaluating services, maintaining professional management responsibility and ensuring continuity of care in its settings. Review of the contract between the hospice and sampled massage therapy provider, dated 12/1/2024, identified the contract lacked the following required components: a. The hospice retains administrative and financial management, b. The hospice retains oversight of staff and services, c. All services are authorized by the hospice and d) All services are delivered in accordance with the patient’s plan of care. The hospice failed to include all required contract components in written agreements between the hospice agency and agencies providing services under arrangement. The above findings were reviewed with the Administrator.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure all documentation was completed timely and appropriately authenticated in accordance with accepted standards of practice and agency standards for 7 of 14 sampled patients (Patients #3, #6, #7, #8, #9, #11 and #14). 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 it’s patients. Findings include: 5. Patient #6 had a hospice admission date of 2/18/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/18/26 to 5/18/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse and hospice aide services. b. Handwritten paper massage therapy visit notes, dated 3/2/26 and 3/9/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature. 6. Patient #11 had a hospice admission date of 1/9/26, a discharge date of 1/28/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 1/9/26 to 4/8/26, included a primary diagnosis of chronic hepatic (liver) failure and physician orders for skilled nurse services. b. Handwritten paper massage therapy visit notes, dated 1/22/26 and 1/26/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature. 7. Patient #14 had a hospice admission date of 8/7/25, a death date of 8/10/25 and received services while residing in a private residence. a. Plan of Care, dated 8/7/25 to 11/4/25, included primary diagnosis of myelodysplastic syndrome (bone marrow disorder causing insufficient healthy blood cell production) and physician orders for skilled nurse and hospice aide services. b. Initial comprehensive assessment, dated 8/8/25, completed by Staff A, Administrator/RN, included electronic signature and date but lacked staff credentials with signature. c. Skilled nurse visit note, dated 8/9/25 and 8/10/25, completed by Staff R, RN, included electronic signature and date but lacked staff credentials with signature. d. Hospice aide visit note, dated 8/8/25, completed by Staff C, Administrative Assistant/Hospice aide, included electronic signature and date but lacked staff credentials with signature. Administrator and Clinical Quality Specialist received the above findings. 4. Patient #9 had a hospice admission date of 8/13/25 and received services while residing in a private home. Clinical record review revealed: a. The POC, dated 2/5/26 to 4/5/26, identified the patient had a diagnosis of malignant neoplasm of upper lobe, left bronchus or lung and included orders for skilled nurse and social work services. b.Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report, dated 2/24/26, identified a massage therapy evaluation to be completed for pain management. c. Massage therapy visit notes, dated 3/4/26 and 3/9/26, completed by Staff G, massage therapist, lacked a signature with title of individual completing the visit notes. In an interview on 3/31/26 at 10:17 AM, the Administrator reported that during the current survey, they have talked with the massage therapist about this finding. The massage therapist will start to add credentials to their signature. The hospice failed to ensure appropriate authentication of all documentation. 2. Patient #3 had a hospice admission date of 2/3/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. Plan of Care, dated 2/3/26 to 5/3/26, included a primary diagnosis of lung cancer and physician orders for skilled nurse services. b. Handwritten paper massage therapy visit notes, dated 2/11/26 and 3/2/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature. 3. Patient #8 had a hospice admission date of 9/13/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 12/12/25 to 3/11/26 and 5/10/26, included a primary diagnosis of lung sarcopenia and physician orders for skilled nurse and hospice aide services. b. The handwritten paper massage therapy visit notes, dated 3/9/26, completed by Staff G, Massage Therapist, included handwritten signature and date but lacked staff credentials with signature. According to the agency policy titled Documentation in the Electronic Medical Record (EMR), last revised October 2024, documentation for all care, services, observations, assessments and communication are done within 24 hours of the contact. Entries are documented by the full given name, full surname and initials or licensing credentials. During an interview on 3/24/26 at 1:49 PM, Staff A, Administrator, stated staff are expected to complete documentation in the EMR within 24 hours of contact. 1.Patient #7 had a hospice admission date of 12/22/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 2/20/26 to 4/20/26, identified the patient had a primary diagnosis of congestive heart failure and included orders for skilled nurse and hospice aide services. b. The massage therapy visit notes, dated 2/25/26 and 3/2/26, completed by Staff G, Massage Therapist, lacked a signature with title of individual completing the visit notes. The hospice failed to ensure appropriate authentication of all documentation.”

“Based on staff interview and clinical record review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #8 and #10). Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for who the medication was prescribed. Findings include: According to the hospice policy titled Disposal of Controlled Medications, Hospice-Enterprise, dated 3/18/25, the patient/family/caregiver are educated regarding proper storage, management, and disposal of controlled medications when ordered for a patient. During an interview on 4/22/25 at 11:10 AM, the Administrator stated the hospice did not have documentation of patient education on the disposal of controlled medications policy at the time when controlled medications ordered. 1.Patient #8 had a start of care date of 9/13/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial plan of care (POC), dated 9/13/25 to 12/11/25, included physician orders for medications, but no controlled medications. The POC identified the patient had a diagnosis of sarcopenia. b. A skilled nurse visit note, dated 2/16/25, completed by the Administrator, identified the physician ordered Morphine and Ativan that would be delivered later on this date. c. A physicians order, dated 2/24/25, identified new orders including morphine and lorazepam (controlled medications). d. An Interdisciplinary Group (IDG) meeting note, dated 3/10/26, included physician orders (effective 2/24/26) for morphine and lorazepam; controlled medications. The clinical record lacked documentation hospice staff reviewed with patient #8 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. 2. Patient #10 had a start of care date of 1/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial POC, dated 1/20/26 to 4/19/26, included physician orders for medications, but no controlled medications. The POC identified the patient had a diagnosis of colon cancer. b. A physicians order, dated 2/5/26, identified new orders including lorazepam (controlled medication). d. An IDG meeting note, dated 2/10/26, included physician orders (effective 2/5/26) for lorazepam; controlled medication. The clinical record lacked documentation hospice staff reviewed with patient #10 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. The hospice failed to review the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. The above findings reviewed with the Administrator and Clinical Manager.”

“The lowa 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 lowa Single Information Repository (SING), or using both the lowa Department of Criminal Investigation (DCI) to conduct the criminal background check, and using the lowa Department of Human Services to conduct the dependent adult abuse and child abuse background checks. The lowa 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 staff interview, review of employee personnel files, and hospice policy review, 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 6/8/23. The hospice reported hiring 17 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 employees who had direct patient contact. Findings include: According to the hospice policy titled Hiring and Screening, dated 3/28/25, in those states where state law requires an in-state agency check, state law will supersede. Interview on 3/31/26 at 2:58 PM, the Administrator reported that the central office human resources department performs background checks and monitors the timeliness of background checks with the employee’s date of hire. Staff E, Licensed Practical Nurse (LPN), had a hire date of 1/8/25. Staff E’s personnel file included documentation of a completed criminal history background check, dated 12/6/24, 32 days prior to Staff E’s hire date. Hospice staff failed to complete a criminal history background check within 30 days prior to the date of hire on all staff prior to hiring. The above findings were reviewed with the Administrator and Staff K, Clinical Quality Specialist.”