Care Initiatives Hospice - West Des Moines

“Based on review of emergency preparedness training rosters, review of the emergency preparedness plan and staff interview, the hospice failed to ensure training in emergency preparedness for 1 of 1 contracted staff consistent with their expected roles for the calendar years of 2023 and 2024. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. During interview on 11/4/25 at 9:20 AM, Staff A, Administrator, gave the surveyor the most current emergency preparedness training documentation for contracted Staff J, massage therapist. The Emergency preparedness training was dated 3/30/2020.. The agency failed to provide emergency preparedness training to their contracted staff every 2 years. The above findings were reviewed with the Quality and Education Coordinator and Administrator.”

“Based on hospice staff interview and clinical record review, the hospice failed to ensure the documentation and correct identification, in a prominent part of the patient’s clinical record, any advance directives executed by the patient for 1 of 19 sampled patients (Patient #18). Failure to ensure the hospice documented and correctly identified any executed advance directives in a prominent part of the record placed patients at risk for their advance directives not being correctly carried out. Findings include: Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 11/22/24 to 2/19/25, identified the patient’s advance directive information as do not resuscitate. b. The resuscitation instruction form, signed by the patient’s medical power of attorney on 11/22/24, identified resuscitation measures. On 10/30/25 at 8:52 AM, the Administrator confirmed the discrepancy with the patient’s code status. The hospice agency failed to include accurate advance directive information on the patient’s plan of care. The above findings were reviewed with the Administrator and Vice President of Clinical Services.”

“Based on home visit observation, patient interview, staff interview, clinical record reviews and agency policy reviews, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 1 of 4 sampled patients with home observation visits (Patient #1). 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 policy titled Medication-Drug Regimen Review, an initial drug regimen review (DRR) is completed on admission and ongoing with medication changes, changes in patient condition and/or at a minimum of every 14 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 10/28/25 at 10:00 AM, Staff C, Registered Nurse (RN), stated DRR’s are completed a minimum of every 14 days. Patient #1 had a hospice admission date of 11/29/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 9/19/25 to 11/17/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for medication and skilled nursing services. b. The recertification comprehensive assessment, dated 9/9/25, completed by Staff C, RN, included documentation a DRR was completed and no discrepancies were identified. c. During a home observation visit on 10/28/25 at 8:55 AM with Staff C, RN, interview with the patient stated he/she takes medication independently from the bottles. The following medication discrepancies were identified: 1) The IDG POC, dated 10/15/25, identified patient takes milk of magnesia 8% oral suspension as needed for constipation. The patient reported he/she does not take milk of magnesia and he/she does not have the medication in the home. 2) The IDG POC, dated 10/15/25, identified the patient takes hexylresorcinol 2.4 milligram (mg) mucous membrane lozenges (relieves sore throat). The patient reported he/she has not used these lozenges for a long time and he/she does not have any in the home. 3) The IDG POC, dated 10/15/25, identified the patient utilizes fluticasone 50 micrograms (mcg)/inhalation nasal spray with instructions to administer 1 spray in each nostril 1 time a day. The bottle in the home identifies fluticasone 50 mcg/inhalation spray with instructions to administer 2 sprays in each nostril 1 time a day, last filled on 9/29/25. The patient reported he/she sprays 2 sprays in each nostril 1 time a day per the instructions on the bottle. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator and Vice President of Clinical Services.”

“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 7 sampled patients (Patients #2 and #3) with wounds. 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: Review of the hospice policy, titled Palliative Wound Care Management and Treatment, dated 9/5/24, identified the hospice nurse collaborates with the patient’s provider to determine wound care treatment and wound care is administered as ordered by the patient’s attending physician, physician designee or nurse practitioner. 1. Patient #2 had a hospice admission date of 4/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The recert Plan of Care (POC), dated 7/23/25 to 10/20/25, included primary diagnosis of osteomyelitis of vertebra thoracic region, and identified skilled nurse to provide wound care per physician orders. b. The IDG (Interdisciplinary Group) update to the POC, dated 10/1/25, included orders for skilled nursing services one time per week and midline upper posterior superior buttocks coccyx pressure ulcer, apply foam dressing to open area and change every 3 days and as needed, apply calmoseptine to rest of moisture-associated skin damage 3 times a day. c. Skilled nurse visit note, dated 10/11/25, included documentation of an open wound to the midline upper posterior superior buttocks coccyx and wound cleansed with soap and water. d. The clinical record failed to identify an interim physician order to cleanse the wound. The hospice nurse failed to obtain an order to cleanse the wound prior to cleansing the wound on 10/11/25. 2. Patient #3 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 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney; identified right posterior foot heel pressure ulcer, clean with wound cleanser and leave open to air; left lower distal leg shin abrasion, clean with soap and water and leave open to air. b. Skilled nurse comprehensive assessment, dated 9/23/25, included wound care to right posterior foot heel pressure ulcer, cleaned with soap and water; and left lower distal leg shin abrasion, cleaned with wound cleanser. The hospice nurse failed to clean the wounds as ordered by the plan of care. The above findings were reviewed with the Quality and Education Coordinator and Administrator.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure interventions completed by hospice staff included in the patient’s plan of care for 1 of 2 sampled patients with home observation visits in a nursing home (Patient #4). Failure to follow the interventions in 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: Review of 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, drugs and treatment necessary to meet the needs of the patient and documentation from the IDG of the patient and/or caregiver’s understanding, involvement, and agreement with the care plan. Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 10/13/25 to 12/11/25, included primary diagnosis of hemiplegia post cerebral vascular accident, and identified skilled nursing services per physician orders. b. The IDG update to the POC, dated 10/15/25, included orders for skilled nursing services one time per week to provide assessment of pain management, fatigue and response, falls, neurological status, nutritional status, speech, and equipment and assistive device needs. c. The home visit on 10/28/25 at 9:30 AM with Staff H, Registered Nurse (RN), the surveyor observed Staff H received medication in a medication cup, mixed in applesauce, from the nursing home RN. During an interview at the same observation home visit, Staff H stated the nursing home RN identified the patient’s pain medication hydrocodone was mixed in the applesauce. Staff H administered the medication and later identified the applesauce contained additional medication and must have been the morning medications, that included the hydrocodone and all of patient # 4’s scheduled morning medications. d. The clinical record failed to identify a physician order for the hospice nurse to administer medications. The hospice nurse failed to obtain an order to administer medications prior to 10/28/25. The above findings were reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services.”

“Based on clinical record review, hospice policy review, home visit observation and hospice staff interview, the hospice failed to ensure the Plan of Care (POC) for 3 of 19 sampled patients (Patient #2, #4 and #8) 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: 2. Patient #4 had a start of care date of 12/17/24. Record review revealed the following: a. The plans of care (POCs), dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25, included the following medical supplies and appliances: adult diapers, blue pads, wheelchair, wheelchair cushion, gait/transfer belt, shower chair, hand-held shower, grab bars/safety rails, nebulizer tubing/supplies, wipes, and lift chair. b. During a home observation visit on 10/28/25 at 9:30 AM, with Staff H, RN, the patient had a reacher on the table next to the lift chair. The patient stated the reacher required at times. The hospice failed to list all medical supplies and appliances required by the patient on the POC. 3. Patient #8 had a start of care date of 8/14/25. Record review revealed the following: a. The POC, dated 8/14/25 to 11/11/25, identified the patient had a diagnosis of Myelodysplastic syndrome and included the following medical supplies and appliances: Moisture barrier, scooter/power chair, shower chair, hand-held shower, cane, gloves, rolling walker and grab bars/safety rails. b. The comprehensive skilled nurse visit at start of care, dated 8/14/25, identified the patient required use of a medication planner to set up medications. The hospice failed to list all medical supplies and appliances required by the patient on the POC. The above findings were reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services. Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified the content of the POC includes medical supplies and appliances necessary to meet the needs of the patient. 1. Patient #2 had a hospice admission date of 4/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/24/25 to 7/22/25, included primary diagnosis of osteomyelitis of vertebra thoracic region, and identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, bedside drainage bag, adult diapers, blue pads/chux, hoyer lift, gloves, wheelchair, pressure release mattress, wheelchair cushion, shower chair, foley catheter, hand-held shower, and long handled sponge. b. The recert POC, dated 7/23/25 to 10/20/25, identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, bedside drainage bag, adult diapers, blue pads/chux, hoyer lift, gloves, wheelchair, pressure release mattress, wheelchair cushion, shower chair, foley catheter, hand-held shower, and long handled sponge. c. The recert POC, dated 10/21/25 to 12/19/25, identified the patient used the following medical equipment and supplies: hospital bed with bed rails, overbed table, adult diapers, blue pads/chux, hoyer lift, wheelchair, pressure release mattress, wheelchair cushion, shower chair, hand-held shower, and long handled sponge. d. During a home visit observation with Staff F, RN (Registered Nurse) on 10/28/25 at 9:40 AM, the surveyor observed Patient #2 resting in bed with waffle boots (heel protectors to prevent pressure ulcers) on bilateral feet. Staff F reported the patient had been wearing waffle boots “for a while now”. The waffle boots were added to the plan of care, dated 10/27/25, one day prior to the home visit observation. The Plans of Care failed to identify all necessary medical equipment and supplies used by the patient, including the waffle boots.”

“Based on home observations, staff interviews, record review, and policy review, the agency failed to maintain and develop a system of communication and integration in accordance with the hospices’ own policy to ensure the interdisciplinary group maintains responsibility for directing coordination and supervising the care and services provided for 2 of 7 with wounds. (Patient #4 and #9). Failure of the interdisciplinary team to collaborate and communicate effectively increased the risk that patients did not receive services to meet assessed needs. Findings include: 2. Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nursing services. b. Skilled nurse visit note, dated 9/7/25, completed by Staff F, RN, included documentation the patient had a new wound to the left anterior foot, 2nd toe. Staff F, described the wound bed as clean, dry and red, normal peri wound skin, noted a small amount of sanguineous/bloody drainage and identified the wound measured 1.3 cm X 0.1 cm X 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 Administrator and Vice President of Clinical Services. According to the policy titled Interdisciplinary Team Meetings, dated 7/28/2021, Interdisciplinary team (IDT) members review each patinet care plan at least every 15 days, or more frequently if needed, to continually monitor care and services and continued eligibility for hospice care. During IDT meetings patinet care plans are reviewed and updated and changes are communicated to primary (attending) physicians with requests for new orders as needed, IDT documentation reflects team discussion and changes in the care plan. According to the hospice policy titled Palliative Wound Care Management and Treatment, dated 9/5/24,wound assessment is performed by the Registered Nurse (RN) Case Manager during initial assessment and by a hospice nurse a minimum of every 7 days and as necessary to meet patient needs. The wound assessment documented in the electronic health record and includes location, length, sidth, depth and description. Description includes color, odor, exudate and appearance of wound/peri-wound area. During an interview on 10/29/25 at 10:40 AM, the Clinical Manager stated the expectation for wound assessment completed every 7 days and to include length, width and depth, drainage, odor, tunneling and pain. 1.Patient #4 had a start of care date of 12/17/24. Clinical record revealed the following: a. The Plan of Care (POC), dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25 included a diagnosis of hemiplegia post cerebral vascular accident. The POC included physician orders for skilled nurse visits 1 time a week. The POC included orders for the skilled nurse to appy triad ointment to the abrasion on the left buttock every shift until healed. b. The skilled nurse note, dated 10/23/25, Staff H, RN, documented the patient had a wound on the upper left buttock. The wound bed described clean and granulating and pink in color. The wound measurements documented length 0.69 centimeters (cm) by width 1 cm and depth 0 cm. c. During an home visit on 10/28/25 at 9:00 AM, Staff H, RN stated the abraision had been a superficial open wound. The IDG team failed to maintain responsibility for coordinating and supervising the care and services provided to meet the individualized needs of the patient.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure the registered nurse (RN) developed hospice aide instructions for patient care that were specific and individualized to the patient’s needs for 5 of 19 sampled patients receiving hospice aide services (Patients #9, #11, #12, #16 and #18). Failure to identify specific tasks for the hospice aide to perform or a specific frequency for the task increases the potential risk that patients may fail to receive necessary services ordered on the plan of care in a safe and effective manner. Findings include: 4. Patient #12 had a hospice admission date of 6/20/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 6/20/25 to 9/17/25 and 9/18/25 to 12/16/25, identified the patient had a diagnosis of hypoxic ischemic encephalopathy and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 6/26/25, included aide instructions to provide the following: file fingernails, file toe nails and nail care. The hospice RN failed to include specific instructions to provide patient nail care. 5. Patient #16 had a hospice admission date of 2/20/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 2/20/25 to 5/20/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services. The POC included medical supplies and appliances for Hoyer lift, gait belt and EZ stand lift. b. The comprehensive assessment at start of care, dated 2/20/25, identified the patient chair bound/bed bound and required the use of an EZ stand to transfer. c. Hospice aide care plan, dated 2/24/25, provide included aide instructions to assist with transfers and transfer to bed/chair with assistance. The care plan did not identify equipment to be used for transfer. The hospice RN failed to include specific instructions to use equipment to transfer the patient. The above findings reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services. According to the hospice policy titled Hospice Aide Services, last revised November 2023, hospice aide services are provided under the supervision of a Registered Nurse (RN). The RN case manager develops a written hospice aide care plan that provides instructions to the hospice aide of the care to be provided. The hospice aide care plan is reviewed as often as necessary and at a minimum every 14 days by the RN case manager. 1.Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services. b. The skilled nurse initial assessment, dated 8/19/25, completed by Staff C, RN, identified the patient requires the use of a gait belt during transfers. c. Hospice aide care plan, dated 8/21/25, included aide instructions to assist with transfers x 2 assist and assist to toilet. The assignment did not include specific instruction on what assistive device should be used when transferring the patient. During an interview on 10/29/25 at 8:52 AM, Staff D, Hospice Aide, reported the patient is a pivot transfer and he does not use a gait belt when transferring the patient. During an interview on 10/29/25 at 9:25 AM, Nursing home Administrator reported the patient requires the assistance of 1 for a stand pivot transfer using a gait belt and front wheeled walker. The hospice RN failed to include what specific assistive device the aide should use when transferring the patient. 2.Patient #11 had a hospice admission date of 10/2/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/2/25 to 11/30/25, identified the patient had a diagnosis of pancreatic cancer and included physician orders for skilled nurse and hospice aide services. b. The skilled nurse initial assessment, dated 10/2/25, completed by Staff G, RN, identified the patient requires the use of a gait belt during transfers. c. Hospice aide care plan, dated 10/7/25, included aide instructions to ambulate patient using rollator. The assignment failed to include the patient required the use of a gait belt. During an interview on 10/29/25 at 8:53 AM, Staff D, Home Health Aide, reported he has not transferred the patient due to patient being in bed at the time of visit. During an interview on 10/29/25 at 9:18 AM, Nursing home RN reported the patient requires the assistance of 1 using a gait belt. The hospice RN failed to include all specific assistive devices the aide should use when transferring the patient. 3.Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/22/24 to 2/19/25, identified the patient had a diagnosis of hypertensive heart disease with heart failure and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 11/27/24, included aide instructions to provide skin care. The assignment did not include specific instructions on what skin care the aide should provide. The hospice RN failed to include specific skin care instructions for the patient.”

“Based on hospice staff interview, clinical record reviews and hospice 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 6 of 17 sampled patients receiving hospice aide services (Patients #1, #4, #8, #9, #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: 6. Patient #19 had a hospice admission date of 11/4/24, a death date of 2/15/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 11/4/24 to 2/1/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services. Hospice aide intervention included the task vital signs: weight. b. IDG updates to the POC, dated 1/29/25 and 2/12/25, included the hospice aide intervention: vital signs: weight. c. Hospice aide visit notes, dated 12/17/24, 19, 23, 26, 30, 1/2/25, 7, 10, 14, 15, 16, 20, 22, 23, 27, 29, 30, 2/3, 5, 7, 11, 12 and 2/13/25, identified the task vital signs: weight “not required today”. The hospice aide failed to obtain a weight as ordered. The above findings were reviewed with the Administrator, Clinical Manager, Vice President of Clinical Services and Quality and Education Coordinator. 4. Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 8/14/25 to 10/12/25 and 10/13/25 to 12/11/25, identified the patient had a diagnosis of hemiplegia post cerebral vascular accident and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 12/20/2024, identified the task to provide a shower. On 3/10/25, the aide care plan updated to include the task to provide a whirlpool bath. c. Hospice aide visit note, dated 9/9/25, completed by Staff D, Hospice Aide, identified the task of both a shower and whirlpool provided during the visit. The hospice aide failed to identify which bath provided per RN instruction. 5. Patient #8 had a hospice admission date of 8/14/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 8/14/25 to 11/11/25, identified the patient had a diagnosis of Myelodysplastic syndrom and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 8/15/2025, identified the following tasks: ambulate using a cane, clean bathroom, patinet laundry, shower chair built into walk in shower, file long or uneven finger nails once a week, file long or uneven toe nails once a month, apply polish, oral care, shampoo with showers, lotion to extremities, fall precautions and standard precautions. c. The hospice aide note, dated 8/29/25 and 9/15/25, identified the patinet refusedd all tasks assigned to the hospice aide. The clinical record lacked documentation the hospice aide notified the case manager. The hospice aide failed to notify the case manager of lack of completion of the task per RN instruction. According to the hospice policy titled Hospice Aide Services, last revised in November 2023, 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. 1.Patient #1 had a hospice admission date of 11/29/23 and received hospice services while residing in a private residence. Clinical record review revealed: a. IDG update to the Plan of Care (POC), dated 9/17/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 9/19/2025, identified the task of weigh patient by the 7th of each month. c. Hospice aide visit note, dated 9/4/25, completed by Staff D, Hospice Aide, identified the task weigh patient by the 7th of the month as not required today. The hospice aide failed to complete the task of obtaining the patient’s weight by the 7th of the month per RN instruction. 2. Patient #9 had a hospice admission date of 8/19/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/19/25 to 10/17/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 8/21/25, identified the following tasks: assist with transfers x2 assist, companionship, assist with meal set up, offer snacks and fluids between meals, assist to toilet, change adult diapers, provide incontinent care, change patient linen when soiled, assist patient with dressing, file any long or uneven fingernails and toenails and weigh patient between the 1st and 7th of each month. c. Hospice aide visit note, dated 9/3/25, completed by Staff D, Hospice Aide, identified the task weigh patient by the 7th of the month as not required today. d. Hospice aide visit note, dated 10/1/25, completed by Staff D, Hospice Aide, identified the hospice aide shaved the patient. The hospice aide failed to complete the task of obtaining the patient’s weight by the 7th of the month and failed to provided services only as ordered on the plan of care. 3. Patient #18 had a hospice admission date of 11/22/24, a death date of 2/1/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 11/22/24 to 2/19/25, identified the patient had a diagnosis of hypertensive heart disease with heart failure and included physician orders for skilled nurse and hospice aide services. b. Hospice aide care plan, dated 11/27/24, included aide instructions to shampoo the patient and shower the patient. c. Hospice aide visit note, dated 1/27/25, completed by Staff D, Hospice Aide, documented the tasks of shampoo and shower not required today. d. Hospice aide visit note, dated 1/31/25, completed by Staff I, Hospice Aide, documented the tasks of shampoo and shower not required today. The hospice aides failed to complete tasks of shampoo patient and shower patient per RN instruction.”

“Based on review of written hospice agreements for services under arrangement, the hospice failed to ensure written agreements between the hospice agency and agencies providing services under arrangement included all required contract components for 1 of 2 sampled services (Medical supply and equipment 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. Review of the contract between the hospice and sampled medical supply and equipment provider, dated 10/23/25, identified the contract lacked the following required components: a. The hospice retains administrative management, b. The hospice retains financial management and c. The hospice retains oversight of staff and services. The hospice failed to include all required contract components in written agreements between the hospice agency and agency providing services under arrangement. The above findings were reviewed with the Quality and Education Coordinator and Administrator.”

“Based on hospice staff interview and clinical record reviews the hospice failed to ensure the hospice staff sent a copy of the patient’s transfer summary to the receiving facility for 1 of 1 sampled, live transferred patients (Patients #16). Failure to ensure the hospice staff included the receiving facility in the process of transfer placed the patients at risk for not receiving ongoing medical care and services to meet the needs of the patient. Findings include: According to the hospice policy titled Discharge Summary, dated 2/1/23, the discharge summary is completed for any hospice discharge, patient revocation of services, or patient transfer to another hospice or care provider, by the registered nurse case manager or designee by adding the discharge summary form, clinical document discharge summary identifying a transfer in the electronic health record. Patient #16 had a start of care date of 2/20/25, a discharge date of 4/28/25 and received hospice services while residing in a private residence. a. The Plan of Care (POC), dated 2/20/25 to 5/20/25, identified the patient had a primary diagnosis of senile degeneration of the brain. The POC included orders for skilled nursing services. b. The physicians order dated 4/28/25, included an order to transfer the patient to another hospice. The communication note note, dated 4/30/25, identified a discharge summary forwarded to the Medical Director and the personal care Physician. c. The transfer summary, dated 4/30/25, included a summary of hospice services and a list of the patient’s current medications. d. Clinical record review lacked documentation the transfer summary was forwarded to the receiving hospice. The hospice failed to forward the transfer summary to the receiving hospice. The above findings reviewed with the Administrator, Clinical Manager and Vice President of Clinical Services.”

“Based on staff interview, clinical record reviews and review of nursing home medication administration records, the hospice failed to ensure hospice staff provided overall coordination of the hospice care in regards to the patient’s medications with the nursing home for 2 of 3 sampled patients (Patients #3 and #4) with a nursing home medication review. Failure to ensure the hospice staff provided overall coordination of the patient’s medications with the nursing home placed the patients at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: 2. Patient #3 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 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney, orders for skilled nursing services and medications: Protonix 40 milligrams (mg) 1 tablet once a day, Sertraline 25 mg 1 tablet once a day, Miconazole Nitrate topical cream 2 times a day left breast. b. IDG updates to the POC, dated 10/1/25 and 10/15/25, include medication orders Protonix 40 mg 1 tablet once a day, Sertraline 25 mg 1 tablet once a day, Miconazole Nitrate topical cream 2 times a day left breast. c. Review of the nursing facility MAR revealed: i. Protonix 40 mg 1 tablet by mouth two times a day with a start date of 8/29/25; ii. Sertraline 25 mg discontinued 10/23/25; and iii. Miconazole Nitrate topical cream discontinued on 10/1/25. Hospice skilled nurse failed to accurately update the POC with medication orders on the nursing facility MAR. The above findings were reviewed with the Quality and Education Coordinator and Administrator. Review of the hospice policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 4/2/25, identified registered nurse case managers for patients are responsible for coordinating and implementing patient care plans in collaboration with members of the IDG, facility representatives and the attending physician. All care provided to facility patients must be in accordance with a written care plan that includes the patient’s current medical, physical, social, emotional, and spiritual needs. 1.Patient #4 had a hospice admission date of 12/17/24 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 10/13/25 to 12/11/25, included Interdisciplinary Group (IDG) orders for skilled nursing services 1 time per week and included physician orders for medications. b. Review of the patient’s nursing home Medication Administration Record (MAR), dated 10/1/25, identified the following medication discrepancy with the hospice’s POC and Medication Profile for patient #4:1) The hospice POC had an order for Ondanstron 4 milligram (mg) tablet with instructions to take 4 mg by mouth every 8 hours as needed for agitation or anxiety. The hospice’s Medication Profile identified a start date for the medication, dated 7/14/25. The nursing home’s MAR had an order for Ativan (Lorazepam) 4 mg oral tablet with instructions to give 4 mg by mouth every 6 hours as needed for nausea”. The nursing home MAR identified a start date for the medication, dated 7/14/25. 2) The nursing home’s MAR had an order for Senna 8.6 mg every 12 hours as needed for constipation. The hospice POC and medication list failed to include orders for Senna.3) The hospice had an order for Gieaofemeson 100 mg/5 milliliters (ML) 10 ml every 8 hours. The nurisng home’s MAR failed to include an order for Gueaifenesin.3) The hospice POV had an order for Escitaloprm 20n mg daily. The nursing home’s MAR had an order for Escitalopram 30 mg daily.4) The hospice POC and medication list included an order for Tylenol HR arthritis pain give 650 mg oral tablet 2 times a day. The POC and medication list also included a duplicate order for Acetaminophen 650 mg 2 times a day. Hospice staff failed to ensure the coordination of the patient’s medications with the patient’s nursing home.”

“Based on clinical record review, nursing home clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the nursing home received copies of the physician certification of terminal illness and the physician recertification of terminal illness for 1 of 3 sampled patients (Patient #3) with home visit observations in nursing homes. Failure to ensure the hospice staff provided the required documentation to the nursing home staff placed the patient at risk for receiving inadequate care and/or treatments needed to meet the individual needs of the patient. Findings include: Review of the hospice’s policy, titled Nursing Facility Care Plan, Coordination and Communication, dated 4/2/25, revealed when the CTI (Certification of Terminal Illness) and POC (Plan of Care) have all of the required signatures, within 3 business days, the business office manager is responsible for patients with access to the EHR (electronic health record), create a PDF (portable document format) of the completed CTI and POC and upload them into the patient’s nursing facility clinical record according to the Scanned Documents Crosswalk. Patient #3 had a hospice admission date of 9/23/25 and received hospice services while residing in a nursing home. Clinical record review revealed the POC, dated 9/23/25 to 12/210/25, included primary diagnosis of malignant neoplasm of left kidney and orders for skilled nursing services. Before a home visit observation on 10/28/25 at 9:40 AM, Staff F, RN (registered nurse), reported the business office manager is responsible for uploading completed CTIs and POCs to the nursing facility EHR. Staff F reviewed the nursing facility EHR and was unable to find the CTI and POC for Patient #3, she was unsure why documents had not been uploaded yet. The above findings were reviewed with the Quality and Education Coordinator and Administrator.”