Care Initiatives Hospice - Cedar Falls

“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 dependent adult abuse or child abuse record checks for 1 of 2 contracted employees who began serving hospice patients since their last survey, dated 7/6/23. The hospice reported hiring 2 contracted 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 Contract Management, Approval, and Initiation of Services, dated 7/31/24, all contracted services will have the required background checks. Once the legal department prepares the draft contract, the appropriate initial background checks are conducted by the legal department. Contractors must clear all the following searches: cleared criminal background check Single Contact Repository (SING). In Iowa criminal background check is completed through SING which provides authorized agencies access to Iowa Criminal History and Sex Offender (SOR), information held by the department of Public Safety/Division of Criminal Investigation (DCI), Department of Human Services’ (DHS) Central Abuse Registry for Dependent Adult and Child Abuse, and Professional License Information. Interview on 4/21/26 at 8:03 AM, the Administrator reported they thought that the contract company should have provided Staff FF’s, Medical Director, background check to the agency when it was requested. Staff FF, Medical Director, had a hire date of 9/8/25. A criminal background check, dated 12/14/24, was completed using a third party background check company. The hospice failed to complete adult abuse and child abuse checks with Iowa SING or the Iowa Department of health within 30 days prior to the date of hire. 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 Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager.”

“Based on home visit observation, patient interview, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 4 sampled patients with home observation visits (Patients #2 and #4). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency’s policy titled Medication-Drug Regimen Review, dated 3/23/26, an initial drug regimen review (DRR) is completed within five days of admission and ongoing with medication changes, changes in patient condition and/or at a minimum of every 15 days. The DRR includes a review of the patient’s medications for side effects of drug therapy, lab monitoring for associated drug therapy, actual or potential drug interactions, duplicate drug therapy and effectiveness of drug therapy. During an interview on 4/15/2026 at 11:49 AM, Staff L, Clinical Manager, stated DRR’s are completed on admission, anytime a new medication is started and at every Interdisciplinary Group (IDG) meeting. 1.Patient #2 had a hospice admission date of 3/6/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/6/26 to 6/3/26, identified the patient had a primary diagnosis of hypertensive heart and chronic kidney disease and included physician orders for medication and skilled nursing services. b. Skilled nurse comprehensive assessment, dated 4/9/26, completed by Staff N, Registered Nurse (RN), included documentation a DRR was completed and the medication profile updated. c. During a home observation visit on 4/14/26 at 12:00 PM with Staff N, RN, the surveyor observed Staff N set up the patient’s medication in a medication planner. The following medication discrepancy was identified: The medication profile, dated 4/13/26, identified acetaminophen 325 milligram (mg) oral tablets with instructions to take 2 tablets orally every 4 hours for elevated temperature and/or pain. The bottle in the home identified acetaminophen 500 mg tablets. During an interview at the same home observation visit, Staff N, RN confirmed she utilized the patient’s bottle of acetaminophen 500 mg tablets and placed 2 tablets daily in the patient’s medication planner. The patient identified they only take the 2 tablets set up by the nurse in the medication planner and denied having any other bottles of acetaminophen in the home. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #4 had a hospice admission date of 6/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/22/26 to 4/22/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and included physician orders for medication and skilled nursing services. b. Skilled nurse comprehensive assessment, dated 4/10/26, completed by Staff CC, RN, included documentation a DRR was completed and no changes since last review. c. During a home observation visit on 4/14/26 at 9:00 AM with Staff CC, RN, interview with the patient stated they take scheduled medication from the medication planner set up by the RN in addition to using cough suppressants daily. The following medication discrepancy was identified: The medication profile, dated 4/13/26, identified acetaminophen 500 milligram (mg) tablets with instructions to take 2 tablets orally 2 times a day and acetaminophen 325 mg oral tablets with instructions to take 2 tablets orally every 4 hours for elevated temperature and/or pain. The patient stated they only take the acetaminophen 500 mg tablets set up in the med planner and they do not have acetaminophen 325 mg tablets in the home. The medication profile lacked an order for cough suppressants utilized by the patient daily. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager and Staff EE, Clinical Manager.”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient condition regarding wound descriptions and measurements for 1 of 6 sampled patients with a wound (Patient #18). Failure by the IDG registered nurses (RN) to update the comprehensive assessment with complete wound descriptions and measurements placed the patients at risk for ineffective staff collaboration and communication regarding patients’ wound status and effectiveness of treatments and interventions. Findings include: According to the agency policy titled Palliative Wound Care Management and Treatment, dated 9/5/24, wound assessment is performed by the RN Case Manager during the initial assessment and by a hospice nurse a minimum of every 7 days and as necessary to meet patient needs. The wound assessment is documented in the electronic medical record and includes length, width, depth and a description of the wound. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager stated hospice staff are expected to assess and measure (length, width, depth) wounds every 7 days. Patient #18 had a hospice admission date of 3/27/25, a death date of 5/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/27/25 to 6/24/25, identified the patient had a primary diagnosis of congestive heart failure and included physician orders for skilled nursing, social worker, chaplain, hospice aide, volunteer and music therapy services. b. The skilled nurse comprehensive assessment, dated 4/15/25, Staff CC, RN, documented she reviewed the patient’s nursing home clinical record that identified the patient had an abrasion to the dorsal aspect of left calf which is almost healed and a small circular abrasion to right shin that continues to be cleansed with wound cleanser, covered with xeroform and wrapped with gauze. c. The skilled nurse comprehensive assessment, dated 4/18/25, Staff CC, RN, documented the patient has scattered open areas and scabbed lesions to bilateral lower extremities. The hospice skilled nurse failed to assess and measure the patient’s wounds. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager and Staff EE, Clinical Manager.”

“Based on home visit observations, patient interviews, clinical record reviews and agency policy review, the hospice failed to ensure the Plans of Care for 7 of 19 sampled patients (Patients #1, #2, #4, #5, #9, #12 and #13) 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: 5.Patient #1 had a hospice admission date of 2/6/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The POC, dated 2/6/26 to 5/6/26, identified the patient had a primary diagnosis of malignant neoplasm of pancreas and identified the patient used the following medical equipment and supplies: overbed table, adult diapers, bluepads/chux, moisture barrier cream/ointment, wheelchair, pressure release mattress, wheelchair cushion, shower chair, grab bars/safety rails, hospital bed, non sterile gloves, sit to stand mechanical lift, off load boots, and Mepilex. b.The IDG meeting notes, dated 3/4/26, included orders for DuoNeb on 3/2/26. c.During a home observation visit on 4/13/26 at 10:00 AM with Staff B, Registered Nurse (RN), the surveyor observed the patient had a nebulizer machine and a fall mat in the room. The patient was wearing an arm protector on their lower right arm. d.IDG meeting notes, dated 3/4/26, 3/18/26, and 4/1/26, failed to identify the nebulizer machine needed in order to administer DuoNeb medication. e.During an interview on 4/13/26 at 10:00 AM, Staff B, RN, reported that the patient started using the right arm protector before the patient’s start of care with the hospice agency. The POC failed to identify all necessary medical equipment and supplies used by the patient, including nebulizer machine, fall mat, and arm protector. 6. Patient #5 had a hospice admission date of 2/19/26 and received hospice services while residing in a private residence. Clinical record review revealed: a.The POC, dated 2/19/26 to 5/19/26, identified the patient had a primary diagnosis of malignant neoplasm of pancreas and Type 2 diabetes mellitus and identified the patient used the following medical equipment and supplies: adult diapers, blue pads/chux, moisture barrier cream/ointment, male urinal, cane, shower chair, hand held shower, raised toilet seat, and wipes. b. The skilled nurse visit note, dated 2/19/26, completed by Staff Y, RN, identified that the patient used a blood glucose monitor. The POC failed to identify all necessary medical equipment and supplies used by the patient, including a blood glucose monitor, lancets, test strips, cotton balls, alcohol pads, and adhesive bandages. 7. Patient #9 had a hospice admission date of 11/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 11/17/25 to 2/14/26 and 2/15/26 to 5/15/26, identified the patient had a primary diagnosis of hemiplegia following cerebral infarct affecting left nondominant side and identified the patient used the following medical equipment and supplies: overbed table, adult diapers, blue pads/chux, non sterile gloves, shower chair, hand held shower, grab bars/safety rails, Mepilex, glucometer, lancets, alcohol pads, test strips, cotton balls, bandaids, left leg immobilizer, hospital bed, wheelchair, wheelchair cushion, arm sling, tilt in space positioning wheelchair, and mechanical sling lift. b.The skilled nurse initial assessment, dated 11/17/25, completed by Staff D, RN, identified that the patient had sleep apnea and used CPAP (continuous positive airway pressure) or BiPAP (bilevel positive airway pressure) treatment. The POC failed to identify all necessary medical equipment and supplies used by the patient, including CPAP/BiPAP. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager. According to the hospice policy titled Plan of Care, dated 2/1/23, the content of the plan of care includes, but is not limited to interventions to facilitate the management of pain and symptoms, a detailed statement of the scope and frequency of services necessary to meet the needs of the patient, drugs and treatment necessary to meet the needs of the patient and medical supplies and appliances necessary to meet the needs of the patient. 1.Patient #2 had a hospice admission date of 3/6/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/6/26 to 6/3/26, identified the patient had a primary diagnosis of hypertensive heart and chronic kidney disease and identified the patient used the following medical equipment and supplies: overbed table, adult diapers, moisture barrier cream, wheelchair, wheelchair cushion, rolling walker, gait/transfer belt, shower chair, foley catheter, bedside drainage bag and leg straps, hand held shower, grab bars/safety rails and hospital bed. b. The skilled nurse visit note, dated 3/24/26, completed by Staff N, Registered Nurse (RN), identified the patient used elasticated tubular bandages (for edema). c. During a home observation visit on 4/14/26 at 12:00 PM with Staff N, RN, the surveyor observed elasticated tubular bandages next to the patient’s chair. An interview with the patient during the same home visit revealed the patient wears the elasticated tubular bandages, they had not put them on for the day. d. The hospice Interdisciplinary Group (IDG) meeting notes, dated 3/25/26 and 4/8/26, failed to identify elasticated tubular bandages as additional medical supplies utilized by the patient. The POC failed to identify all necessary medical equipment and supplies used by the patient, including elasticated tubular bandages. 2. Patient #4 had a hospice admission date of 6/27/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 2/22/26 to 4/22/26, identified the patient had a primary diagnosis of chronic obstructive pulmonary disease and identified the patient used the following medical equipment and supplies: overbed table, adult diapers, raised toilet seat, disposable bed pads, non-sterile gloves, oxygen, pressure relief mattress, shower chair, electric scooter, hand held shower, grab bars, hospital bed and four wheeled walker. b. During a home observation visit on 4/14/26 at 9:00 AM with Staff CC, RN, the surveyor observed a life alert button, oximeter, diabetic supplies and weight scale in the home. An interview with the patient during the same home visit revealed the patient has utilized the additional medical equipment and supplies for greater than one year. The POC failed to identify all necessary medical equipment and supplies used by the patient, including life alert button, oximeter, diabetic supplies and weight scale. 3. Patient #12 had a hospice admission date of 3/17/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 3/17/26 to 6/14/26, identified the patient had a primary diagnosis of hypertensive chronic kidney disease and identified the patient used the following medical equipment and supplies: adult diapers, raised toilet seat, disposable bed pads, non-sterile gloves, walker, wheelchair, bed rails, shower chair, hand held shower, grab bars and personal care wipes. b. The skilled nurse initial assessment, dated 3/17/26, completed by Staff Z, RN, identified the patient used a weight scale. The POC failed to identify all necessary medical equipment and supplies used by the patient, including weight scale. 4. Patient #13 had a hospice admission date of 1/8/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 1/8/26 to 4/7/26, identified the patient had a primary diagnosis of progressive supranuclear palsy and identified the patient used the following medical equipment and supplies: bedside commode, walk in shower with grab bars and four wheeled walker. b. The skilled nurse initial assessment, dated 1/8/26, completed by Staff M, RN, identified the patient used a lift chair. The POC failed to identify all necessary medical equipment and supplies used by the patient, including lift chair.”

“Based on clinical record reviews, review of employee personnel files and agency policy reviews, the hospice failed to ensure 4 of 6 sampled hospice aides (Staff BB, Staff Q, Staff I and Staff S) 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 3 of 8 sampled patients (Patients #12, #15 and #18) 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: 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 Hospice Aide Services, dated 11/15/23, hospice aide services are provided under the supervision of a registered nurse by individuals who meet training requirements and who have successfully completed a competency evaluation program. All assigned duties are only as specified in the hospice aide care plan and only as permitted by facility policy, regulatory requirement and/or training. According to the agency’s policy titled Competency Evaluation, dated 2/23/24, hospice aides have additional competencies in any task the agency chooses to have the aide perform (within the scope of service). 1.Patient #12 had a hospice admission date of 3/17/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The aide care plan included Registered Nurse (RN) instructions to the aide to apply medicated topical ointment to perineum and labia after shower and place moleskin between the 4th and 5th toes on right foot when patient requests. b. Review of the clinical record showed Staff I, Hospice Aide, provided aide services independently for Patient #12. c. Staff I, Hospice Aide, had a hire date of 3/6/26. Staff I’s personnel file lacked documentation an RN had observed Staff I competently perform the tasks of applying medicated ointment to perineum and labia and placing moleskin between toes. 2. Patient #15 had a hospice admission date of 2/23/26 and received services while residing at home. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to transfer the patient with left lower extremity leg brace on. b. Review of the clinical record showed Staff Q, Staff S and Staff BB, Hospice Aides, provided aide services independently for Patient #15. c. Staff Q, Hospice Aide, had a hire date of 1/30/2012. Staff Q’s personnel file lacked documentation an RN had observed Staff Q competently perform the task of transferring the patient with the leg brace on. d. Staff S, Hospice Aide, had a hire date of 8/9/22. Staff S’s personnel file lacked documentation an RN had observed Staff S competently perform the task of transferring the patient with the leg brace on. e. Staff BB, Hospice Aide, had a hire date of 7/22/25. Staff BB’s personnel file lacked documentation an RN had observed Staff BB competently perform the task of transferring the patient with the leg brace on. 3. Patient #18 had a hospice admission date of 3/27/25, a death date of 5/13/25 and received hospice services while residing in a nursing home. a. The aide care plan included RN instructions to the aide to perform oxygen precautions. b. Review of the clinical record showed Staff Q provided aide services independently for Patient #18. c. Staff Q, Hospice Aide, had a hire date of 1/30/2012. Staff Q’s personnel file lacked documentation an RN had observed Staff Q competently perform the task of oxygen precautions. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager and Staff EE, Clinical Manager.”

“Based on hospice staff interview, clinical record review and policy review, the hospice failed to ensure the registered nurses developed individualized patient specific written instructions directing the care provided by each hospice aide for 4 of 16 sampled patients receiving hospice aide services. (Patients #6, #7, #17 and #19). Failure to provide patient specific, written instructions for hospice aides, directing them which tasks to perform and how frequently, for each patient; increased the risk hospice patients did not receive the services as ordered by the patient’s physician and by the Interdisciplinary Group (IDG) Care Plan, to meet each patient’s needs. 1. Patient #6 had a hospice admission date of 3/4/26 and received hospice services while residing in a private home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/4/26 to 6/1/26, included primary diagnosis of senile degeneration of the brain and included physicians orders for hospice aide services one time per week. b. The undated hospice aide care plan included the one visit per week hospice aide service frequency and instructions completed by Staff D, Registered Nurse (RN), to the hospice aide to perform the task of a shower two times per week. c.The IDG meeting notes, dated 3/18/26, included physicians orders for hospice aide services one time per week. d.The IDG meeting notes, dated 4/1/26, included physicians orders for hospice aide services one time per week. The hospice RN failed to identify that the hospice aide was able to provide a shower to the patient one time per week. 2. Patient #7 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The POC, dated 12/22/25 to 3/21/26, included primary diagnosis of chronic obstructive pulmonary disease and physicians orders for hospice aide services two times per week. The POC identified that the patient used a gait/transfer belt. b. The undated hospice aide care plan completed by Staff HH, RN, instructed the hospice aide to ambulate the patient using an assistive device, walker, oxygen, and wheelchair. Patient walks minimally, with assist x1. c.The hospice aide visit notes, dated 3/24/26, 3/27/26, 3/31/26, and 4/7/26, completed by Staff F, Hospice Aide, documented that Staff F, Hospice Aide performed that task to ambulate the patient using an assistive device, walker, oxygen, and wheelchair. d.Interview on 4/20/26 at 2:30 PM, Staff F, Hospice Aide reported that a gait belt is used with the patient to assist with transfers. The hospice RN failed to identify that the hospice aide should use a gait belt to assist with transfers. 3. Patient #11 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.The IDG meeting note, dated 2/26/26, included primary diagnosis of parkinson’s disease without dyskinesia and included physicians orders for hospice aide services two times per week. b.The undated hospice aide care plan completed by Staff Z, RN, instructed the hospice aide to complete range of motion (ROM) exercises as tolerated. c.The hospice aide visit notes, dated 4/1/26, 4/8/26, and 4/9/26, documented that ROM exercises were completed. d.During an interview on 4/21/26 at 8:47 AM with Staff I, Hospice Aide, when they see ROM on a task to perform with a patient, they know to move the patient’s arms and legs. Staff I, Hospice Aide, reported that she has not received any instruction while working at this hospice on passive ROM or active ROM. The hospice RN failed to identify what kind of ROM the aide should perform, passive ROM or active ROM. 4. Patient #17 had a hospice admission date of 12/16/25, a death date of 1/8/26, and received hospice services while residing in a private home. Clinical record review revealed: a.The IDG meeting note, dated 12/31/25, included primary diagnosis of malignant neoplasm of head of pancreas and included physicians orders for hospice aide services two times per week. b. The undated hospice aide care plan completed by Staff EE, Clinical Manager, included RN instructions to the hospice aide to apply lotion after bath. c. The hospice aide visit notes, dated 12/30/25, 1/2/26, and 1/6/26, completed by Staff O, Hospice Aide, documented that the aide applied lotion after bath. The hospice RN failed to include patient specific instructions for the hospice aide to apply lotion. 5.Patient #19 had a hospice admission date of 5/21/25, a death date of 6/29/25, and received hospice services while residing in a nursing home. Clinical record review revealed: a.The POC, dated 5/21/25 to 8/18/25, included primary diagnosis of white matter disease and physicians orders for hospice aide services two times per week. The POC identified that the patient used a mechanical sling lift b.The undated hospice aide care plan completed by Staff U, RN, included RN instructions to assist with transfers as needed assist of 1 with 2 pivot. c.The hospice aide visit note, dated 6/12/25, documented the task to assist with transfers as needed; assist of 1 with 2 pivot was completed. d.The hospice aide visit, notes dated 5/29/25, 6/3/25, and 6/10/25, documented the task to assist with transfers as needed; assist of 1 with 2 pivot was refused by the patient, patient caregiver, or responsible party. The hospice RN failed to include patient specific instructions for the hospice aide to transfer the patient. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager. Findings include: According to the hospice policy titled, Hospice Aide Services, dated 11/15/23, the registered nurse (RN) case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager, reported the Registered Nurse case manager is responsible for creating the aide care plan.”

“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 12 of 16 sampled patients receiving hospice aide services (Patients #1, #2, #6, #7, #8, #9, #10, #11, #14, #17, #18 and #19). 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: 12. Patient #10 had a hospice admission date of 3/5/26 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. Plan of Care, dated 3/5/26 to 6/2/26, included primary diagnosis of cerebral infarction and physician orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 3/9/26, included Registered Nurse (RN) instructions to the hospice aide to perform the task of hygiene – bath – shower chair. c. Hospice aide visit note, dated 3/13/26, completed by Staff BB, Hospice aide, included documentation the patient refused shower today so gave a partial bed bath. The clinical record lacked documentation the hospice aide contacted the RN to get approval to perform the partial bed bath and partial bed bath was not added to the hospice aide care plan. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager. According to the hospice policy titled Hospice Aide Services, dated 11/15/23, the Registered Nurse (RN) Case Manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services. Staff L also identified the aide notifies the RN Case Manager of tasks not completed. 1.Patient #2 had a hospice admission date of 3/6/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/6/26 to 6/3/26, identified the patient had a primary diagnosis of hypertensive heart and chronic kidney disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 3/9/26, included aide instructions to provide bath-shower chair and hand held shower weekly, shampoo patient’s hair, apply lotion to extremities each visit and obtain a monthly weight. c. Hospice aide visit note, dated 3/12/26, completed by Staff R, Hospice Aide, documented tasks provide bath-shower chair and hand held shower weekly, shampoo patient’s hair and obtain a monthly weight not required today. d. Hospice aide visit note, dated 3/18/26, completed by Staff E, Hospice Aide, documented task obtain a monthly weight not required today. e. Hospice aide visit note, dated 3/20/26, completed by Staff BB, Hospice Aide, documented task obtain a monthly weight not required today. f. Hospice aide visit notes, dated 3/23/26 and 3/25/26, completed by Staff BB, Hospice Aide, documented the tasks provide bath-shower chair and hand held shower weekly, shampoo patient’s hair, apply lotion to extremities each visit and obtain a monthly weight not required today. g. Hospice aide visit notes, dated 3/27/26, 3/30/26, 4/6/26 and 4/10/26, completed by Staff BB, Hospice Aide, documented the task obtain a monthly weight not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 2. Patient #8 had a hospice admission date of 9/30/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/29/25 to 3/28/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 12/29/25, included aide instructions to provide bath-shower as patient allows. c. Hospice Aide visit note, dated 3/4/26, completed by Staff GG, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment. 3. Patient #18 had a hospice admission date of 3/27/25, a death date of 5/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/27/25 to 6/24/25, 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 4/3/25, included aide instructions to obtain patient’s weight the first week of each month and document in the electronic medical record. c. Hospice Aide visit notes, dated 4/3/25 and 5/1/25, completed by Staff V, Hospice Aide, documented task not required today. The hospice aide failed to complete the task as instructed by the RN assignment. 4.Patient #1 had a hospice admission date of 2/6/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 2/6/26 to 5/6/26, included primary diagnosis of malignant neoplasm of pancreas and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/11/26, included RN instructions to the hospice aide to perform the task of hygiene – bath – shower chair, 2 times a week and weight biweekly and chart in electronic medical record (EMR). c.Hospice aide visit note, dated 2/27/26, completed by Staff E, Hospice aide, documented the task of hygiene – bath – shower chair, 2 times a week and weight biweekly and chart in electronic medical record (EMR) not required today. d.Hospice aide visit notes, dated 3/31/26, 4/3/26, 4/7/26, and 4/10/26, completed by Staff E, Hospice aide, documented the task weight biweekly and chart in electronic medical record (EMR) not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 5.Patient #6 had a hospice admission date of 3/4/26 and received hospice services while residing in a private home. Clinical record review revealed: a.POC, dated 3/4/26 to 6/1/26, included primary diagnosis of senile degeneration of the brain and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 3/9/26, included RN instructions to the hospice aide to perform the task of hygiene – bath – shower 2 times per week and weight biweekly. c.Hospice aide visit note, dated 3/18/26, completed by Staff GG, Hospice aide, included documentation the task of hygiene – bath – shower 2 times per week and weight biweekly not required today. d.Hospice aide visit note, dated 3/23/26, completed by Staff GG, Hospice aide, included documentation the task of weight biweekly refused by patient/caregiver/responsible party. e.Hospice aide visit note, dated 3/31/26, completed by Staff GG, Hospice aide, included documentation of the task of weight biweekly as already performed by patient caregiver. f.Hospice aide visit note, dated 4/6/26 and 4/13/26, completed by Staff GG, Hospice aide, included documentation of the patient’s weight. The hospice aide failed to complete the tasks as instructed by the RN assignment. 6.Patient #7 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POCs, dated 9/23/25 to 12/21/25, 12/22/5 to 3/21/26, and 3/22/26 to 5/20/26, included primary diagnosis of chronic obstructive pulmonary disease and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 9/23/25, included RN instructions to the hospice aide to perform the task of hygiene – bath – shower chair and hygiene - shampoo. c.The hospice aide care plan, dated 11/17/25, included RN instructions to the hospice aide to perform the task of monthly weight. d.Hospice aide visit notes, dated 3/3/26, 3/17/26, 3/20/26, 3/27/26, 3/31/26, and 4/7/26, completed by Staff F, Hospice aide, included documentation the tasks of hygiene – bath – shower chair, hygiene - shampoo, and monthly weight not required today. e.Hospice aide visit notes, dated 3/6/26 and 3/13/26, completed by Staff F, Hospice aide, included documentation the task of monthly weight not required today. f.Hospice aide visit note, dated 3/24/26, by Staff F, Hospice aide, included documentation the task of monthly weight already performed by patient caregiver. g.Hospice aide visit note, dated 3/10/26, by Staff E, Hospice aide, included documentation the task of monthly weight not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 7.Patient #9 had a hospice admission date of 11/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 3/5/26 to 6/2/26, included primary diagnosis of hemiplegia following cerebral infarct affecting left nondominant side and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 11/20/25, included RN instructions to the hospice aide to perform the task of weight biweekly. c.Hospice aide visit note, dated 3/11/26, completed by Staff GG, Hospice aide, included documentation the task of monthly weight not required today. d.Hospice aide visit note, dated 3/18/26, by Staff GG, Hospice aide, included documentation the task of monthly weight already performed by patient caregiver. e.Hospice aide visit notes, dated 3/25/26, 4/1/26, and 4/8/26, completed by Staff GG, Hospice aide, included documentation of the patient’s weight. The hospice aide failed to complete the tasks as instructed by the RN assignment. 8.Patient #11 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.IDG meeting notes, dated 3/26/26 and 4/9/26, included primary diagnosis of parkinson’s disease without dykinesia and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/27/26, included RN instructions to the hospice aide to perform the task of provide bed bath and complete range of motion (ROM) exercises as tolerated. c.Hospice aide visit notes, dated 3/27/26, 3/30/26, and 3/31/26, completed by Staff I, Hospice aide, included documentation the tasks of provide bed bath and complete range of motion (ROM) exercises as tolerated not required today. d.Hospice aide visit notes, dated 4/1/26, 4/8/26, and 4/9/26, completed by Staff I, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 9.Patient #14 had a hospice admission date of 2/23/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 2/23/26 to 5/23/26, included primary diagnosis of endocarditis and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/26/26, included RN instructions to the hospice aide to perform the task of facility staff provides showers 2 times per week, provide bed bath. c.Hospice aide visit note, dated 3/27/26, completed by Staff I, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 10.Patient #17 had a hospice admission date of 12/16/25, a death date of 1/8/26, and received hospice services while residing in a private home. Clinical record review revealed: a.IDG meeting note, dated 12/31/25, included primary diagnosis of malignant neoplasm of head of pancreas and included physicians orders for hospice aide services two times per week. b.The hospice aide care plan, dated 12/29/25, included RN instructions to the hospice aide to perform the task of hygiene – shampoo, wash hair, dry, and style. c.Hospice aide visit note, dated 1/2/26, completed by Staff O, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 11.Patient #19 had a hospice admission date of 5/21/25, a death date of 6/29/26, and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 5/21/25 to 8/18/25, included primary diagnosis of white matter disease and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 5/23/25, included RN instructions to the hospice aide to perform the task of weight once monthly on first week of the month. c.Hospice aide visit note, dated 6/2/25, completed by Staff Q, Hospice aide, included documentation not required today for the task of weight once monthly on first week of the month. The hospice aide failed to complete the tasks as instructed by the RN assignment. According to the hospice policy titled Hospice Aide Services, dated 11/15/23, the Registered Nurse (RN) Case Manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services. Staff L also identified the aide notifies the RN Case Manager of tasks not completed. 1.Patient #2 had a hospice admission date of 3/6/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 3/6/26 to 6/3/26, identified the patient had a primary diagnosis of hypertensive heart and chronic kidney disease and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 3/9/26, included aide instructions to provide bath-shower chair and hand held shower weekly, shampoo patient’s hair, apply lotion to extremities each visit and obtain a monthly weight. c. Hospice aide visit note, dated 3/12/26, completed by Staff R, Hospice Aide, documented tasks provide bath-shower chair and hand held shower weekly, shampoo patient’s hair and obtain a monthly weight not required today. d. Hospice aide visit note, dated 3/18/26, completed by Staff E, Hospice Aide, documented task obtain a monthly weight not required today. e. Hospice aide visit note, dated 3/20/26, completed by Staff BB, Hospice Aide, documented task obtain a monthly weight not required today. f. Hospice aide visit notes, dated 3/23/26 and 3/25/26, completed by Staff BB, Hospice Aide, documented the tasks provide bath-shower chair and hand held shower weekly, shampoo patient’s hair, apply lotion to extremities each visit and obtain a monthly weight not required today. g. Hospice aide visit notes, dated 3/27/26, 3/30/26, 4/6/26 and 4/10/26, completed by Staff BB, Hospice Aide, documented the task obtain a monthly weight not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 2. Patient #8 had a hospice admission date of 9/30/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 12/29/25 to 3/28/26, identified the patient had a primary diagnosis of pulmonary fibrosis and included orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 12/29/25, included aide instructions to provide bath-shower as patient allows. c. Hospice Aide visit note, dated 3/4/26, completed by Staff GG, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment. 3. Patient #18 had a hospice admission date of 3/27/25, a death date of 5/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/27/25 to 6/24/25, 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 4/3/25, included aide instructions to obtain patient’s weight the first week of each month and document in the electronic medical record. c. Hospice Aide visit notes, dated 4/3/25 and 5/1/25, completed by Staff V, Hospice Aide, documented task not required today. The hospice aide failed to complete the task as instructed by the RN assignment. 4.Patient #1 had a hospice admission date of 2/6/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/6/26 to 5/6/26, included primary diagnosis of malignant neoplasm of pancreas and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/11/26, included RN instructions to the hospice aide to perform the task of bath – shower chair, 2 times a week, weight biweekly and document in electronic medical record (EMR). c. Hospice Aide visit note, dated 2/27/26, completed by Staff E, Hospice Aide, documented task not required today. d. Hospice Aide visit note, dated 3/31/26, 4/3/26, 4/7/26, and 4/10/26, completed by Staff E, Hospice Aide, documented task not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 5.Patient #6 had a hospice admission date of 3/4/26 and received hospice services while residing in a private home. Clinical record review revealed: a. POC, dated 3/4/26 to 6/1/26, included primary diagnosis of senile degeneration of the brain and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 3/9/26, included RN instructions to the hospice aide to perform the task of bath – shower 2 times per week and weight biweekly. c. Hospice Aide visit note, dated 3/18/26, completed by Staff GG, Hospice Aide, documented task not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 6.Patient #7 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POCs, dated 9/23/25 to 12/21/25, 12/22/5 to 3/21/26, and 3/22/26 to 5/20/26, included primary diagnosis of chronic obstructive pulmonary disease and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 9/23/25, included RN instructions to the hospice aide to perform the task of hygiene – bath – shower chair and hygiene - shampoo. c.The hospice aide care plan, dated 11/17/25, included RN instructions to the hospice aide to perform the task of monthly weight. d.Hospice aide visit notes, dated 3/3/26, 3/17/26, 3/20/26, 3/27/26, 3/31/26, and 4/7/26, completed by Staff F, Hospice aide, included documentation the tasks of hygiene – bath – shower chair, hygiene - shampoo, and monthly weight not required today. e.Hospice aide visit notes, dated 3/6/26 and 3/13/26, completed by Staff F, Hospice aide, included documentation the task of monthly weight not required today. f.Hospice aide visit note, dated 3/24/26, by Staff F, Hospice aide, included documentation the task of monthly weight already performed by patient caregiver. g.Hospice aide visit note, dated 3/10/26, by Staff E, Hospice aide, included documentation the task of monthly weight not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 7.Patient #9 had a hospice admission date of 11/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 3/5/26 to 6/2/26, included primary diagnosis of hemiplegia following cerebral infarct affecting left nondominant side and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 11/20/25, included RN instructions to the hospice aide to perform the task of weight biweekly. c.Hospice aide visit note, dated 3/11/26, completed by Staff GG, Hospice aide, included documentation the task of monthly weight not required today. d.Hospice aide visit note, dated 3/18/26, by Staff GG, Hospice aide, included documentation the task of monthly weight already performed by patient caregiver. e.Hospice aide visit notes, dated 3/25/26, 4/1/26, and 4/8/26, completed by Staff GG, Hospice aide, included documentation of the patient’s weight. The hospice aide failed to complete the tasks as instructed by the RN assignment. 8.Patient #11 had a hospice admission date of 2/12/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.IDG meeting notes, dated 3/26/26 and 4/9/26, included primary diagnosis of parkinson’s disease without dykinesia and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/27/26, included RN instructions to the hospice aide to perform the task of provide bed bath and complete range of motion (ROM) exercises as tolerated. c.Hospice aide visit notes, dated 3/27/26, 3/30/26, and 3/31/26, completed by Staff I, Hospice aide, included documentation the tasks of provide bed bath and complete range of motion (ROM) exercises as tolerated not required today. d.Hospice aide visit notes, dated 4/1/26, 4/8/26, and 4/9/26, completed by Staff I, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 9.Patient #14 had a hospice admission date of 2/23/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 2/23/26 to 5/23/26, included primary diagnosis of endocarditis and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 2/26/26, included RN instructions to the hospice aide to perform the task of facility staff provides showers 2 times per week, provide bed bath. c.Hospice aide visit note, dated 3/27/26, completed by Staff I, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 10.Patient #17 had a hospice admission date of 12/16/25, a death date of 1/8/26, and received hospice services while residing in a private home. Clinical record review revealed: a.IDG meeting note, dated 12/31/25, included primary diagnosis of malignant neoplasm of head of pancreas and included physicians orders for hospice aide services two times per week. b.The hospice aide care plan, dated 12/29/25, included RN instructions to the hospice aide to perform the task of hygiene – shampoo, wash hair, dry, and style. c.Hospice aide visit note, dated 1/2/26, completed by Staff O, Hospice aide, included documentation the task of provide bed bath not required today. The hospice aide failed to complete the tasks as instructed by the RN assignment. 11.Patient #19 had a hospice admission date of 5/21/25, a death date of 6/29/26, and received hospice services while residing in a nursing home. Clinical record review revealed: a.POC, dated 5/21/25 to 8/18/25, included primary diagnosis of white matter disease and physician orders for skilled nursing and hospice aide services. b.The hospice aide care plan, dated 5/23/25, included RN instructions to the hospice aide to perform the task of weight once monthly on first week of the month. c.Hospice aide visit note, dated 6/2/25, completed by Staff Q, Hospice aide, included documentation not required today for the task of weight once monthly on first week of the month. The hospice aide failed to complete the tasks as instructed by the RN assignment. 12. Patient #10 had a hospice admission date of 3/5/26 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. Plan of Care, dated 3/5/26 to 6/2/26, included primary diagnosis of cerebral infarction and physician orders for skilled nursing and hospice aide services. b. The hospice aide care plan, dated 3/9/26, included Registered Nurse (RN) instructions to the hospice aide to perform the task of hygiene – bath – shower chair. c. Hospice aide visit note, dated 3/13/26, completed by Staff BB, Hospice aide, included documentation the patient refused shower today so gave a partial bed bath. The clinical record lacked documentation the hospice aide contacted the RN to get approval to perform the partial bed bath and partial bed bath was not added to the hospice aide care plan. The hospice aide failed to provide services as instructed by the RN assignment. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date and complete information in a timely manner for 2 of 19 sampled patients (Patients #18 and #19). Failure to maintain accurate clinical records with current patient information increased the risk that hospice staff provided services without up-to-date information related to the patient’s condition and decreased the ability of hospice staff to communicate effectively in order to coordinate patient care. Findings include: 2.Patient #19 had a hospice admission date of 5/21/25, a death date of 6/29/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 5/21/25 to 8/18/25, identified the patient had a primary diagnosis of white matter disease and included orders for music therapy services 3 times per month effective 6/1/25. b. The IDG meeting notes, dated 6/5/25, 6/19/25 and 7/3/25, identified music therapy services provided. c. Review of the patient’s electronic medical record lacks music therapy notes. The hospice failed to include completed music therapy visit notes in the electronic medical record. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager. 1.Patient #18 had a hospice admission date of 3/27/25, a death date of 5/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 3/27/25 to 6/24/25, identified the patient had a primary diagnosis of congestive heart failure and included orders for music therapy services 3 times per month effective 4/1/25. b. The Interdisciplinary Group (IDG) meeting notes, dated 4/10/24, 4/24/24 and 5/8/24, identified music therapy services provided. c. Review of the patient’s electronic medical record lacked music therapy notes. The hospice failed to include completed music therapy visit notes in the electronic medical record. According to the hospice policy, titled Clinical Records, dated 2/1/23, entries are made in the clinical record for all services provided (both those services provided directly and through contracted providers) in a standardized format and are signed by the person providing the services. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager, reported staff have up to one week to complete documentation.”

“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 4 of 19 sampled patients (Patients #3, #13, #14 and #16). 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. 3. Patient #13 had a hospice admission date of 1/8/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 1/8/26 to 4/7/26 and 4/8/26 to 7/6/26, identified the patient had a primary diagnosis of progressive supranuclear palsy and included orders for massage therapy services. b. The massage therapy visit notes, dated 2/16/26, 2/26/26, 3/5/26, 3/12/26, 3/30/26 and 4/8/26, completed by Staff K, Massage Therapist, included staff initials, month and date of visit but lacked a signature, staff credentials and the year of the visit. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. 4. Patient #16 had a hospice admission date of 12/20/24, a discharge date of 4/18/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 2/18/26 to 4/18/26, identified the patient had a primary diagnosis of multiple sclerosis and included orders for massage therapy services. b. The massage therapy visit notes, dated 2/20/26, 2/27/26, 3/6/26 and 4/7/26, completed by Staff K, Massage Therapist, included staff initials, month and date of visit but lacked a signature, staff credentials and the year of the visit. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. The above findings were reviewed with Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager and Staff EE, Clinical Manager. 2.Patient #14 had a start of care date of 2/23/26 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Interdisciplinary Group (IDG) update to the POC, dated 3/12/26, included a primary diagnosis of endocarditis and physician orders for music therapy services. b. The music therapy visit note, dated 3/19/26, completed by Staff W, Music Therapist, lacked a signature, staff credentials, and the date of the visit. The Music Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice. Findings include: According to the hospice policy titled, Clinical Records, dated 2/1/23, all entries into the clinical record must be legible, clear, complete and appropriately authenticated and dated in accordance with hospice policy and accepted standards of practice. According to the hospice policy titled, Patient Record Integrity, dated 12/5/23, all visit information, including notes and visit documentation, is ideally completed/locked down during the patient visit but no later than one week from the date of service. During an interview on 4/15/26 at 11:49 AM, Staff L, Clinical Manager, identified agency staff are to sign every visit note, include credentials and date. Staff have up to one week to complete documentation. 1.Patient # 3 had a start of care date of 12/12/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plans of Care (POC), dated 12/12/25 to 3/11/26 and 3/12/26 to 6/9/26, included a primary diagnosis of hypertensive heart disease with heart failure and physician orders for massage therapy services. b. The massage therapy visit notes, dated 2/12/26, 2/24/26, 3/19/26 and 3/31/26, completed by Staff K, Massage Therapist, included staff initials, month and date of visit but lacked a signature, staff credentials and the year of the visit. The Massage Therapist failed to appropriately authenticate the visit notes per hospice policy and accepted standards of practice.”

“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 2 contracted employees who began serving hospice patients since their last survey, dated 7/6/23. The hospice reported hiring 2 contracted 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 Contract Management, Approval, and Initiation of Services, dated 7/31/24, all contracted services will have the required background checks. Once the legal department prepares the draft contract, the appropriate initial background checks are conducted by the legal department. Contractors must clear all the following searches: cleared criminal background check Single Contact Repository (SING). In Iowa criminal background check is completed through SING which provides authorized agencies access to Iowa Criminal History and Sex Offender (SOR), information held by the department of Public Safety/Division of Criminal Investigation (DCI), Department of Human Services’ (DHS) Central Abuse Registry for Dependent Adult and Child Abuse, and Professional License Information. Interview on 4/21/26 at 8:03 AM, the Administrator reported they thought that the contract company should have provided Staff FF’s, Medical Director, SING background check to the agency when it was requested. Staff FF, Medical Director, had a hire date of 9/8/25. A criminal background check was completed using a third party background check company and dated 12/14/24. The hospice failed to complete a criminal background check with the Iowa SING or the Iowa DCI 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 Staff A, Administrator, Staff DD, Executive Director, Staff L, Clinical Manager, Staff AA, Clinical Manager, and Staff EE, Clinical Manager.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 2 of 4 sampled patients with wounds (Patients #1 and #3). Failure to follow the patient’s Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. Findings include: 2. Patient #1 had a hospice admission date of 7/29/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 7/29/25 to 10/26/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing services. b. Skilled nurse visit note, dated 10/12/25, completed by Staff F, Licensed Practical Nurse (LPN), included documentation the patient had a small cut to the right ear and cheek measuring about 1/2 centimeter (cm). The measurement lacked an accurate length, width and depth in centimeters per agency policy. c. Skilled nurse visit note, dated 10/19/25, completed by Staff E, RN, included documentation the patient had an open wound to midline anterior head nose measuring 0.56 cm X 0.52 cm X 0.0 cm. The measurements lacked an accurate depth measurement for the open wound. d. Skilled nurse visit note, dated 10/20/25, completed by Staff B, RN, included documentation the patient had an open wound to midline anterior head nose measuring 0.7 cm X 0.1 cm X 0.0 cm. The measurements lacked an accurate depth measurement for the open wound. The clinical record lacked accurate wound measurements including length, width and depth in centimeters. The above findings were reviewed with the Clinical Manager and Clinical Documentation Coordinator. Review of the hospice policy, titled Palliative Wound Care Management and Treatment, dated 9/5/24, identified the wound care is administered as ordered by the patient’s attending physician, physician designee or nurse practitioner. Wound assessment is documented in the electronic health record and includes location, length, width, depth and description. Description includes color, odor, exudate, and appearance of wound/peri-wound area. Wound care orders include date, location, cleaning solution, medication (if applicable), dressing type/securement, frequency and delineation of care. Review of the hospice policy, titled Physician Orders, dated 2/2/2020, identified verbal orders or written order are obtained from physicians in order to provide the following: a. new medication, change in medication or discontinuation of medication; b. dressing changes/wound care; or c. any procedures or interventions not included in rules, regulations, or standards of practice in the state in which they reside for any healthcare provider that requires a physician order. During an interview on 10/21/25 at 11:26 AM, Staff B, Clinical Manager East, reported wound measurements include length, width and depth and are done t time every 7 days. 1. Patient #3 had a hospice admission date of 8/29/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 8/29/25 to 11/26/25, included primary diagnosis of chronic kidney disease and orders for skilled nursing services. b. IDG update to the Plan of Care, dated 9/11/25, included physician order for wound care to coccyx pressure ulcer: clean with soap and water, with start date of 9/3/25. c. Skilled nurse visit note, dated 9/17/25, included documentation the wound was cleansed with wound cleanser, not soap and water as ordered. d. IDG update to the Plan of Care, dated 9/25/25, included physician order for wound care to coccyx pressure ulcer: pack with mupirocin coated gauze, apply mupirocin ointment to wound bed and triad paste to peri wound area, with start date 9/24/25. e. Skilled nurse visit note, dated 9/24/25, included documentation apply medihoney to the wound, not mupirocin as ordered. f. IDG update to the Plan of Care, dated 9/25/25, included physician order for wound care for skin tear to right knee: clean with wound wash, apply triple antibiotic ointment and cover with band aid, with start date of 9/24/25. g. Skilled nurse visit note, dated 10/1/25, included documentation skin tear to right knee was covered with foam dressing, not band aid as ordered. h. Skilled nurse visit note, dated 10/1/25, included documentation left knee abrasion was cleaned with wound cleanser and covered with foam dressing. The clinical record lacked documentation of an interim physician order for wound care to the left knee abrasion. The hospice nurse failed to provide wound care as ordered.”

“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 1 of 1 sampled patients with massage therapy (Patient #3). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice policy, titled Interdisciplinary Care Plan Process, dated 7/19/23, identified the Plan of Care, consists of Problems, Goals and Interventions Care Plan, medications, treatments, supplies, durable medical equipment, frequencies of team services and other elements of the care plan; and updates to the Plan of Care from IDG meeting minutes includes changes to the medications, treatments, supplies, durable medical equipment, problems, interventions, goals, changes in frequencies of team services, prep notes, discussion notes and other elements of the care plan. During an interview on 10/21/25 at 1:36 PM, Staff C, Clinical Documentation Coordinator, was asked about agency expectations for missed visits. In an email later that day, Staff C, reported the agency is in the process of creating a policy, agency expectation is if we can reschedule the visit we will. If we cannot reschedule, we document the missed visit and reason for missing and report that in IDG for discussion. Patient #3 had a hospice admission date of 8/29/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care, dated 8/29/25 to 11/26/25, included primary diagnosis of chronic kidney disease and orders for complimentary (massage therapy) services twice a month for 3 months. b. Massage therapy referral form, dated 9/2/25, included frequency of twice a month. c. IDG updates to the Plan of Care, dated 9/11/25, 9/25/25 and 10/9/25, include physician orders for massage therapy twice a month for 3 months. During an interview on 10/22/25 at 9:15 AM, Staff C and Staff K, Clinical Documentation Coordinators reported they had no additional information. The clinical record failed to include documentation of massage therapy visits for the months of September and October. The above findings were reviewed with the Clinical Manager and Clinical Documentation Coordinator.”