Care Initiatives Hospice - Cedar Rapids

“Based on staff interview, clinical record reviews and agency policy reviews, the hospice failed to ensure the completion of a drug regimen review with the comprehensive assessment, within the first 5 days after election of the hospice benefit and at least every 15 days with the update to the comprehensive assessment for 4 of 6 sampled patients (Patients #1, #2, #4 and #5). Failure to ensure the Interdisciplinary Group (IDG) members involved in the assessment of patient needs completed all components of the drug regimen review (DRR) with each update to the comprehensive assessment increased the risk of unidentified ineffective medications, side effects and actual or potential drug interactions. Findings include: 2. Patient #2 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home setting. Clinical record review revealed: a. IDG meeting note, dated 1/8/26, included documentation a DRR completed. b. IDG meeting notes, dated 1/22/26 and 2/5/26, included documentation any new medications that would require DRR: no. The notes failed to include a DRR. IDG meeting notes failed to include a DRR every 15 days as required. 3. Patient #4 had a hospice admission date of 10/24/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time. b. IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none. The notes failed to include a DRR. IDG meeting notes failed to include a DRR every 15 days as required. 4. Patient #5 had a hospice admission date of 4/14/25 and received hospice services while residing in a nursing home setting. Clinical record review revealed: a. IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time. b. IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none. The notes failed to include a DRR. IDG meeting notes failed to include a DRR every 15 days as required. The above findings were reviewed with the Administrator, Interim Administrator, Clinical Manager, Interim Clinical Manager, Vice President (VP) of Hospice and VP of Clinical Services for Hospice. According to the hospice policy, titled Medication – Drug Regimen Review – Initial and Ongoing, dated 12/29/08, identified on admission a nurse documents all medications in the patient’s electronic health record medication profile. The registered nurse (RN) case manager is responsible to review the patient medications with medication changes, changes in patient condition or at a minimum of every 14 days. Medications are reviewed for side effects of drug therapy; lab monitoring for associated drug therapies; interactions of drug therapy, actual or potential; duplicate drug therapy and effectiveness of drug therapy. The RN at a minimum reviews findings of the drug review with the IDG at least every 14 days. Documentation of the drug regimen discussion is captured in the IDG note. During an interview on 3/3/26 at 3:43 PM, Interim Clinical Manager reported the DRR is typically done with new patients, new medications, recertifications and every 14 days. The DRR is documented under the visit note or a prep note (communication note), the notes are pulled into the IDG notes and discussed at IDG meeting. 1. Patient #1 had a hospice admission date of 12/24/24 and received hospice services while residing in a nursing home setting. Clinical record review revealed: a. IDG meeting note, dated 12/24/25, included documentation diagnoses/medication relatedness reviewed and DRR discussed with physician, no suggested changes at this time. b. IDG meeting notes, dated 1/8/26 and 1/22/26, included documentation any new medications that would require DRR: none. The notes failed to include a DRR. IDG meeting notes failed to include a DRR every 15 days as required.”

“Based on clinical record review and agency policy review, the hospice failed to ensure the hospice completed a comprehensive spiritual assessment on admission for 1 of 19 sampled patients (Patient #7). Failure to complete an initial comprehensive spiritual assessment increased the risk patient’s spiritual needs would not be identified and/or addressed appropriately. Findings include: Patient # 7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/21/25 to 11/18/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse and social work services. b. Registered Nurse (RN) initial comprehensive assessment, dated 8/21/25, completed by Staff D, RN, documented spiritual assessment: not assessed. c. Social Worker (SW) initial assessment, dated 8/26/25, completed by Staff J, SW, documented spiritual assessment: not assessed. The hospice team failed to complete a comprehensive assessment within 5 days of the hospice admission that assessed spiritual needs. The above findings were reviewed with the Clinical Documentation Coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services. According to the hospice policy titled Comprehensive Assessment, dated 7/19/23, the hospice conducts and documents a patient specific initial assessment within 48 hours after the election of hospice care unless the physician, patient or representative requests the initial assessment be completed in less than 48 hours. This initial assessment may be combined with a comprehensive assessment that identifies the patient’s and caregiver’s needs for hospice care, including medical nursing, psychosocial, emotional and spiritual care. The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elects the hospice benefit (admission to hospice).”

“Based on staff interview, clinical record reviews and hospice policy review, the hospice failed to perform an initial bereavement assessment within 5 days of the patient’s election of the hospice benefit as part of the initial comprehensive assessment in order to determine patient and/or family bereavement needs, goals and interventions to be identified on the Plan of Care for 2 of 19 sampled patients (Patients #12 and #18) receiving hospice services for more than 5 days. Failure to complete an initial bereavement assessment increased the risk that patient’s or family’s/caregiver’s grieving and bereavement needs would not be addressed appropriately, leading to prolonged or dysfunctional grieving and potentially increased the risk of self harm for hospice patients or survivors. Findings include: According to the hospice policy titled Comprehensive Assessment, dated 7/19/23, the hospice conducts and documents a patient specific initial assessment within 48 hours after the election of hospice care unless the physician, patient, or representative requests that the initial assessment be completed in less than 48 hours. This initial assessment may be combined with a comprehensive assessment that identifies the patient’s and caregiver’s needs for hospice care, including medical nursing, psychosocial, emotional and spiritual care. The comprehensive assessment of the patient is completed by members of the interdisciplinary team in consultation with the patient’s attending physician no later than five (5) calendar days after the patient elects the hospice benefit (admission to hospice). The comprehensive assessment of the patient consists of at least the following assessment tools: the nursing assessment, with psychosocial, spiritual and bereavement components or the components assessed separately. 1.Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 10/24/25 to 1/21/25, identified the patient had a diagnosis of idiopathic pulmonary fibrosis and included orders for skilled nurse, social work, chaplain and hospice aide services. b. Skilled nurse initial comprehensive assessment, dated 10/24/25, completed by Staff H, Registered Nurse, (RN) lacked an initial bereavement risk assessment. c. Chaplain initial comprehensive assessment, dated 10/27/25, lacked an initial bereavement risk assessment. d. Social work initial comprehensive assessment, dated 10/28/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment. 2. Patient #18 had a hospice admission date of 4/11/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 6/28/25 to 9/25/25, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social work, chaplain and hospice aide services. b. Skilled nurse initial comprehensive assessment, dated 4/11/25, completed by Staff H, RN, lacked an initial bereavement risk assessment. c. Social work initial comprehensive assessment, dated 4/14/25, lacked an initial bereavement risk assessment. d. Chaplain initial comprehensive assessment, dated 4/16/25, lacked an initial bereavement risk assessment. The hospice failed to complete an initial bereavement risk assessment. The above findings reviewed with the Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice 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 1 of 3 sampled patients (Patient #14) 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 wound care is performed by the Registered Nurse Case Manager (RNCM) during the initial assessment, and by a hospice nurse a minimum of every 7 days and as necessary to meet patient needs. Wound care is administered as ordered by the patient’s attending physician, physician designee or nurse practitioner. Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified the patient’s plan of car specifies the care and services necessary to meet the needs of the patient, caregiver and family as identified in the comprehensive assessment and reassessments of the patient. The content of the plan of care incudes interventions to facilitate the management of pain and symptoms; and a detailed statement of the scope and frequency of services necessary to meet the needs of the patient, caregiver and family. Patient #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The IDG meeting notes, dated 9/18/25, 10/2/25, 10/16/25 and 10/30/25, included physician orders decubitus/pressure ulcer/midline inner buttocks gluteal fold: facility nurse to apply mepilex dressing to wound and change every 72 hours and as needed if soiled or dislodged. Hospice RN to assess every 7 days. b. Skilled nurse visit notes, completed by Staff H, RN, dated 9/25/25, 10/6/25, included documentation of an open wound with wound treatment and measurements. The visits were 11 days apart, 4 days greater than the required 7 days. c. Skilled nurse visit notes, completed by Staff H, RN, dated 10/9/25, 10/20/25, included documentation of an open wound with wound treatment and measurements. The visits were 11 days apart, 4 days greater than the required 7 days. The hospice nurse failed to assess patient wounds every 7 days as ordered and per hospice policy. Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services.”

“Based on hospice staff interview, home visit observation, clinical record review and hospice policy review, the hospice failed to ensure the hospice plan of care included all necessary medications and treatments to meet the needs of the patient for 4 of 18 sampled patients (Patients #3, #4, #7 and #12). Failure to ensure the plan of care included physician orders for all necessary medications and treatments placed patients at risk to receive inappropriate treatment of symptoms. Findings include: 3. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included orders for skilled nurse visits and included physician orders for medications and treatments. b. Skilled nurse visit note, dated 10/18/25, completed by Staff E, RN, identified the patient utilized 2 liters of oxygen via nasal cannula, continuously. c. The IDG update to the POC, dated 10/30/25, lacked physician orders for oxygen therapy. The hospice failed to include all physician orders for necessary drugs and treatment including oxygen therapy on the patient’s plan of care. 4. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/21/25 to 11/15/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse visits and included physician orders for medications and treatments. b. The RN comprehensive assessment, dated 8/21/25, completed by Staff D, RN, identified the patient had a catheter. c. The IDG update to the POC, dated 9/4/25, lacked orders for catheter type, size and balloon volume. The hospice failed to include all physician orders for necessary drugs and treatment including catheter orders on the patient’s plan of care. The above findings were reviewed with the Clinical Documentation Coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services. 2. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/24/25 to 1/21/25, identified the patient had a diagnosis of idiopathic pulmonary fibrosis, and included orders for skilled nurse visits and included physician orders for medications and treatments. b. The comprehensive skilled nurse visit note, dated 10/24/25, completed by Staff H, Registered Nurse (RN), identified the patient utilized oxygen at 2 liters at hours of sleep. c. The IDG update to the POC, dated 10/30/25, lacked physician orders for oxygen therapy. The hospice failed to include all physician orders for necessary drugs and treatment including oxygen therapy on the patient’s plan of care. According to the hospice policy, titled Plan of Care, dated 2/1/23, identified the content of the plan of care includes drugs and treatment necessary to meet the needs of the patient. 1. Patient #4 had a hospice admission date of 11/3/25 and received hospice services in a private home. a. During a home visit observation on 11/17/25 at 3:40 PM, with Staff A, Administrator, the surveyor reviewed the patient’s medications with Staff A. The current medication profile provided to the surveyor included duplication of medications and medications the patient was no longer taking. Staff A reported the medications patient was no longer taking and the duplicate medications had been discontinued and was unsure why these medications printed on the current medication profile. b. Medication Profile, printed date 11/17/25, provided to surveyor for home visit observation, included current medications: aspirin 81 mg, Novolog (insulin), torsemide 20 mg daily, all with a start date of 11/3/25, and medications identified as discontinued by Staff A: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine, all with a start date of 11/3/25. Clinical record review revealed: c. Plan of Care, dated 11/3/25 to 1/31/26, included primary diagnosis of heart failure and medications: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine. d. Interdisciplinary Group (IDG) meeting note, dated 11/13/25, included medications: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine. e. Medication Profile, printed date 11/18/25, , included current medications: aspirin 81 mg, Novolog (insulin), torsemide 20 mg daily, all with a start date of 11/3/25, and medications identified as discontinued by Staff A: aspirin 325 mg, insulin aspart, insulin glargine solostar, torsemide 20 mg twice a day, cefadroxil, fluorouracil topical cream, gabapentin, klor-con and meclizine, all with a start date of 11/3/25.; arnica topical cream with a start date of 11/10/25; and lorazepam with a start date of 11/4/25 and discontinued date of 11/10/25. During an interview on 11/10/25 at 11:38 AM, Staff M, Quality and Education Coordinator, reported the discontinued medications noted above were marked as discontinued but the order to discontinue was marked in error which removed the discontinuation of the medications. The hospice nurse failed to update the Plan of Care and IDG meeting note with an accurate list of medications.”

“Based on hospice staff interview, clinical record review and hospice policy review, 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 2 of 4 sampled patients with missed visits (Patients #4 and #9). 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 Group Meetings, dated 7/28/21, identified IDG documentation reflects team discussion and changes in the plan of care. Review of the hospice policy, titled Plan of Care, dated 2/1/23, identified reviews of and changes to the plan of care are documented and communicated to members of the IDG. 1. Patient #4 had a hospice admission date of 11/3/25, and received hospice services while residing in a private home. Clinical record review revealed: a. Plan of Care (POC), dated 11/3/25 to 1/31/26, included primary diagnosis of heart failure and orders for skilled nursing services weekly and hospice aide services twice a week. b. Hospice aide visit note, dated 11/7/25, included documentation patient refused visit today. c. The IDG update to the POC, dated 11/13/25, included documentation missed visits: none. The hospice failed to provide hospice aide visits as ordered per the POC and IDG update to the POC. 2. Patient #9 had a hospice admission date of 7/17/25, and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 7/17/25 to 10/14/25 and 10/15/25 to 1/12/26, identified the patient had a diagnosis of congestive heart failure and included orders for skilled nurse, social worker, hospice aide, and volunteer services. b. The IDG updates to the POC, dated 8/7, 8/21/25, 9/4 and 9/18/25, include orders for volunteer services 4 times a month. The notes lacked documentation of missed volunteer visits. c. The clinical record lacked documentation of volunteer notes for the month of August. d. The clinical record, dated 9/2/25 and 9/21/25, included documentation of 2 visits volunteer visits completed for the month of September. The hospice failed to provide volunteer services as ordered per the POC. The above findings were reviewed with the Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to follow a bereavement plan of care to ensure the hospice provided bereavement counseling according to identified needs and risks of the bereaved for 3 of 3 sampled bereavement records (Patients #17, #18 and #19). Failure to provide bereavement counseling according to identified needs placed the bereaved at an increased risk for worsening or unresolved issues related to grief. Findings include: 3. Patient #19 had a hospice admission date of 9/25/24, a death date of 11/8/24 and received services while residing in a nursing home. Clinical record review revealed no bereavement plan of care completed. During an interview on 11/19/25 at 11:38 AM, Staff M, Quality and Education Coordinator, confirmed the clinical record failed to include a bereavement care plan however the bereaved is receiving bereavement mailings. Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services. 2. Patient #18 had a start of care date of 4/11/25, a death date of 5/21/25 and received hospice services while residing in a nursing home. Review of the clinical record revealed: a. A bereavement initial visit/assessent, dated 6/10/25, idenitfied the bereaved would like monthly follow-up concerning grief. b. The bereavement care plan, dated 7/1/25, idneitified the following planned interventions: contact by phone or face to face, facilitate life review and teach coping strategies for dealing with grief. The goal target date identified 7/1/26. c. The bereavement note, dated 7/7/25, documented bereavement visit made. d. The bereavement note, dated 8/7/25, documented the bereaved contacted and would like a follow-up call next month. e. The bereavement note, dated 9/10/25, documented the bereaved contacted and plan a follow up call next month. f. The bereavement communication note, dated 10/3/25, documented no further phone contact required. Continue monthly mailings. g. Clinical record review lacked documentation of mailings to the bereaved. The hospice failed to complete documentation of mailings sent to the bereaved. According to the hospice policy titled Bereavement Services, dated 6/29/23, at the first Interdisciplinary Group (IDG) following the death of a patient, risk factors and needs of family members, caregivers and significant others are considered when identifying bereavement services. The Spiritual Counselor or Social Worker updates the electronic health record (EHR) and develops the bereavement plan of care noting the kind of bereavement services required. The Spiritual Counselor or Social Worker initiates contact with the bereaved by telephone within 2-4 weeks of the patient’s death; attempting a minimum of two phone calls. The initial bereavement assessment is completed at the first contact with the bereaved. Monthly bereavement mailings are provided for all identified bereavement parties unless specifically declined. 1. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. IDG update to the plan of care, dated 8/21/25, identified the patient died but lacked a bereavement plan of care. b. Clinical record review lacked documentation of any monthly bereavement mailings sent to the bereaved. The hospice failed to complete documentation of mailings sent to the bereaved.”

“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 18 sampled patients receiving hospice aide services (Patients #1, #3, #5, #12 and #17). 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: 5. Patient #5 had a hospice admission date of 9/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. Plan of Care, dated 9/24/25 to 12/22/25, included primary diagnosis of Alzheimer’s disease and physician orders for hospice aide services twice a week. b. The hospice aide care plan, dated 9/29/25 included Registered Nurse (RN) instructions to the hospice aide to perform the task of Medication: Other. c. The hospice aide visit notes, completed by Staff I, Hospice Aide, dated 9/30, 10/3, 10/7, 10/10, 10/14, 10/21, 10/22, 10/24, 10/28, 11/4 and 11/7/25, included documentation the task Medications: Other: was completed. The hospice aide care plan failed to provide specific instructions to the hospice aide on what Medications: Other was to be completed by the hospice aide. Findings reviewed with Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services. 4. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/24/25 to 1/21/26, identified the patient had a diagnosis of ideopathic fibrosis and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 11/12/25, included aide instructions to ambulate with assistance using assistive devise cane, crutches, walker and oxygen. The care plan failed to specify which assistive devise the patient required. The hospice RN failed to include specific instructions on what assistive device the aide should provide for the patient. 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. Hospice aide services are assigned based on the RN Case Manager’s comprehensive assessment and reassessment of the patient’s personal care needs and ability to perform activities of daily living. During an interview on 11/18/25 at 8:15 AM, Staff A, Administrator stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services. 1.Patient #1 had a hospice admission date of 10/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 10/10/25 to 1/7/26, identified the patient had a diagnosis of malignant neoplasm of tongue and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 10/10/25, 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 instructions on what skin care the aide should provide to the patient. 2. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma, included physician orders for skilled nurse and hospice aide services and identified a gait/transfer belt as durable medical equipment the patient uses. b. The hospice aide care plan, dated 10/20/25, included aide instructions to assist with transfers. The assignment did not include specific instructions on what assistive device should be used when transferring the patient. The hospice RN failed to include what specific assistive device the aide should use when transferring the patient. 3. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 6/3/25 to 8/1/25 and 8/2/25 to 9/30/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, effective 4/8/25 to 8/11/25, included aide instructions to assist with transfers, provide skin care, and weight. The assignment did not include specific instructions on what assistive device should be used when transferring patient, what skin care the aide should provide the patient and how often the aide should obtain a weight on the patient. The hospice RN failed to include specific instructions to the hospice aide regarding all tasks assigned.”

“Based on staff interview, clinical record reviews and hospice agency policy review, the hospice failed to ensure hospice hospices provided care to patients only as directed by the Interdisciplinary Group (IDG) and according to the hospice aide care plan for 13 of 18 sampled patients receiving hospice aide services (Patients #1, #3, #6, #7, #8, #9, #10, #12, #14, #16, #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 #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The interdisciplinary group (IDG) updates to the POC, dated 9/18/25, 10/2/25, 10/16/25 and 10/30/25, included physician orders for hospice aide services twice a week. b. The hospice aide care plan, dated 6/19/25, included Registered Nurse (RN) instructions to the hospice aide to perform the task nail care, clean under nail beds one time weekly and as needed for hygiene. c. Hospice aide visit notes, completed by Staff I, Hospice Aide (HA), dated 9/19, 9/22, 9/25, 9/29, 10/2, 10/7, 10/13, 10/14, 10/21, 10/24, 10/28, 10/31, 11/4 and 11/7/25, included documentation the task nail care, clean under nail beds one time weekly and as needed for hygiene was completed. The hospice aide failed to follow the hospice aide care plan. 13. Patient #19 had a hospice admission date of 9/25/24, a death date of 11/8/24 and received services while residing in a nursing home. Clinical record review revealed: a. The IDG updates to the POC, dated 10/3/24, 10/17/24 and 10/31/24, included physician orders for hospice aide services twice a week and identified hospice aide task to weight patient with a start date of 9/30/24. b. Hospice aide visit notes, completed by Staff L, HA, dated 10/1, 10/2, 10/4, 10/17, 10/23, 10/29 and 11/1/24, included documentation the task weight was not required today. c. Hospice aide visit notes, completed by Staff L, HA, dated 10/16 and 11/6/24, failed to include tasks completed or not completed. Hospice aide failed to follow the hospice aide care plan. Findings reviewed with Clinical documentation coordinator, Vice President of Clinical Services, Quality Education Coordinator and Vice President of Hospice Services. 6. Patient #6 had a hospice admission date of 10/17/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of peripheral vascular disease and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 10/30/25, included aide instructions to clean under the patient’s fingernails 1 time weekly. c. Hospice aide visit notes, dated 10/30/25, 11/3, 11/6, and 11/10/25, completed by Staff I, Hospice Aide, documented task completed every visi (2 times per week). The hospice aide failed to complete the task of clean under the fingernails 1 time weekly as instructed by the RN assignment. 7. Patient #8 had a hospice admission date of 5/7/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/15/25 to 11/2/25 and 11/3/25 to 1/1/26, identified the patient had a diagnosis of Alzheimer’s disease and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 5/9/25, included aide instructions to provide bath: shower. c. Hospice aide visit note, dated 10/3, 10/7, 10/10/25 and 11/7/25, completed by Staff C, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment. 8. Patient #9 had a hospice admission date of 7/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 7/17/25 to 10/14/25 and 10/15/25 to 1/12/26, identified the patient had a diagnosis of congestive heart failure and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 11/5/25, included aide instructions to provide bath: shave and shower. c. Hospice aide visit note, dated 9/9, 9/12, 9/16/25 and 10/24/25 completed by Staff F, Hospice Aide, documented task not required today. The hospice aide failed to complete the shave and shower task as instructed by the RN assignment. 9. Patient #12 had a hospice admission date of 10/24/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/24/25 to 1/21/26, identified the patient had a diagnosis of ideopathic pulmonary fibrosis and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 11/12/25, included aide instructions to provide bath: clean under fingernails 1 time weekly. c. Hospice aide visit notes, dated 10/30/25 and 11/3/25, completed by Staff I, Hospice Aide, documented the task completed every visit (2 times a week). The hospice aide failed to complete the task to clean under the fingernails 1 time weekly as instructed by the RN assignment. 10. Patient #16 had a hospice admission date of 3/25/25 and discharge date of 8/9/25 received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 3/25/25 to 6/22/25 and 6/23/25 to 9/20/25, identified the patient had a diagnosis of sequelae of cerebral infarction and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 5/9/25, included aide instructions to provide bath: weight the first week of every month and bed bath and shampoo every visit. c. Hospice aide visit note, dated 7/2, 7/3, 7/8/25 and 8/1 and 8/5/25 completed by Staff C, Hospice Aide, documented task of weight the fist week of every month not applicable this visit. d. Hospice aide visit notes, dated 7/28 and 7/29/25, completed by Staff C, Hospice Aide documented the task of bed bath and shampoo not required today. The hospice aide failed to complete the weight, bed bath and shampoo task as instructed by the RN assignment. 11. Patient #18 had a hospice admission date of 4/11/25 and date of death of 5/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 4/11/25 to 7/9/25, identified the patient had a diagnosis of congestive heart failure and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 4/24/25, included aide instructions to provide bath: shower. c. The hospice aide visit notes, dated 4/18/25 and 4/22/25, failed to include documentation of any tasks completed by the hospice aide. d. Hospice aide visit note, dated 5/2, 5/6, 5/13 and 5/19/25, completed by Staff I, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task 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 11/18/25 at 8:15 AM, Staff A, Administrator stated the RN Case Manager develops the hospice aide care plan and supervises the hospice aide services. Staff A also identified the hospice aide notifies the case manager of tasks not completed. 1.Patient #1 had a hospice admission date of 10/10/25 and received hospice services while residing in a private residence. Clinical record review revealed: a. The Plan of Care (POC), dated 10/10/25 to 1/7/26, identified the patient had a diagnosis of malignant neoplasm of tongue and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 10/10/25, included aide instructions to provide bath: shower. c. Hospice aide visit note, dated 10/23/25, completed by Staff C, Hospice Aide, documented task not required today. The hospice aide failed to complete the shower task as instructed by the RN assignment. 2. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 10/20/25, included aide instructions to provide bath: bed and bath: shower chair. c. Hospice aide visit note, dated 10/24/25, completed by Staff F, Hospice Aide, documented tasks as not applicable this visit. The hospice aide failed to complete the bath tasks as instructed by the RN assignment. 3. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/21/25 to 11/18/25, identified the patient had a diagnosis of parkinsonism and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 8/26/25, included aide instructions to assist patient with dressing, shampoo, bath: shower chair and weigh patient by the 15th of every month. c. Hospice aide visit note, dated 9/25/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair as not applicable this visit. d. Hospice aide visit note, dated 10/2/25, completed by Staff C, Hospice Aide, documented tasks of bath: shower chair, shampoo and obtain weight by the 15th of every month as not required today. e. Hospice aide visit note, dated 10/10/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair not required today and task of obtain weight by the 15th of every month as unable to document: other reason. f. Hospice aide visit note, dated 10/15/25, completed by Staff F, Hospice Aide, documented task of obtain weight by the 15th of every month as not applicable this visit. g. Hospice aide visit note, dated 10/16/25, completed by Staff C, Hospice Aide, documented task of bath: shower chair as not applicable this visit and the task of shampoo as not required today. h. Hospice aide visit note, dated 10/28/25, completed by Staff C, Hospice Aide, documented tasks of bath: shower chair and shampoo as not applicable this visit. The hospice aides failed to complete all tasks as instructed by the RN assignment. 4. Patient #10 had a hospice admission date of 6/3/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The POC, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of hypertensive chronic kidney disease and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, dated 7/7/25, included aide instructions to apply immobilizer to patient’s right arm as patient allows. c. Hospice aide visit notes, dated 9/8/25, 9/15/25 and 9/18/25, completed by Staff F, Hospice Aide, documented the task of apply immobilizer to right arm as patient allows as not required today. d. Hospice aide visit note, dated 9/11/25, completed by Staff C, Hospice Aide, documented the task of apply immobilizer to right arm as patient allows as not required today. Hospice aides failed to complete tasks as instructed by the RN assignment. 5. Patient #17 had a hospice admission date of 4/4/25, a death date of 8/11/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POCs, dated 6/3/25 to 8/1/25 and 8/2/25 to 9/30/25, identified the patient had a diagnosis of senile degeneration of the brain and included physician orders for skilled nurse and hospice aide services. b. The hospice aide care plan, effective 4/8/25 to 8/11/25, included aide instructions to provide bed bath and obtain weight. c. Hospice aide visit notes, dated 6/17/25 and 6/18/25, completed by Staff I, Hospice Aide, documented the task of bed bath as not required today. d. Hospice aide visit note, dated 6/24/25, completed by Staff L, Hospice Aide, documented the tasks of bed bath and obtain weight as not required today. e. Hospice aide visit notes, dated 7/2/25 and 7/8/25, completed by Staff I, Hospice Aide, documented the tasks of bed bath and obtain weight as not required today. Hospice aides failed to complete tasks as instructed by the RN assignment.”

“Based on staff interview, clinical record reviews and agency policy review, the hospice failed to ensure clinical records contained pertinent, up-to-date, accurate and complete information in a timely manner for 7 of 19 sampled patients (Patients #3, #7, #8, #10, #13, #14 and #15). 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: 7. Patient #14 had a hospice admission date of 6/13/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 9/11/25 to 12/9/25, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, chaplain, hospice aide and volunteer services. b. IDG meeting note, dated 10/2/25, included order for massage therapy services. c. The EMR included documentation of a volunteer visit note, dated 9/26/25, signed completed on 10/22/25, by Staff S, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 9/26/25, signed completed by Staff S, Hospice Volunteer on 9/26/25. d. The EMR included documentation of a volunteer visit note, dated 10/14/25, signed completed on 10/27/25, by Staff S, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 10/14/25, signed completed by Staff S, Hospice Volunteer on 10/14/25. e. The EMR included documentation of a volunteer visit note, dated 10/21/25, signed completed on 10/27/25, by Staff S, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 10/21/25, signed completed by Staff S, Hospice Volunteer on 10/27/25. f. The EMR included documentation of a volunteer visit note, dated 11/4/25, signed completed on 11/18/25, by Staff S, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 11/4/25, signed completed by Staff S, Hospice Volunteer on 11/4/25. g. The EMR included documentation of a massage therapy visit note, dated 10/29/25, signed completed on 11/7/25, by Staff G, Massage Therapist. The clinical record included paper documentation of the same massage therapy visit, dated 10/29/25, signed completed by Staff G, Massage Therapist on 10/29/25. The hospice failed to ensure all documentation in the clinical record was accurate. Findings reviewed with Clinical documentation coordinator, Vice President (VP) of Clinical Services, Quality Education Coordinator and VP of Hospice Services. 3. Patient #3 had a hospice admission date of 10/17/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 10/17/25 to 1/14/26, identified the patient had a diagnosis of chronic hepatic failure without coma and included orders for skilled nurse, social work, chaplain, hospice aide and massage therapy services. b. The skilled nurse visit, dated 10/21/25, completed by Staff A, Administrator, identified aide supervision completed; however, aide services had not been implemented yet. The hospice nurse failed to document accurate information in the patient’s clinical record. 4. Patient #7 had a hospice admission date of 8/21/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 8/21/25 to 11/15/25, identified the patient had a diagnosis of parkinsonism and included orders for skilled nurse, social work, chaplain, hospice aide, volunteer and massage therapy services. b. The EMR included documentation of a volunteer visit note, dated 10/2/25, signed completed on 10/13/25, by Staff R, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit note, dated 10/2/25, signed completed by Staff R, Hospice Volunteer on 10/8/25. c. The EMR included documentation of a volunteer visit note, dated 10/15/25, signed completed on 11/3/25, by Staff R, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit note, dated 10/15/25, signed completed by Staff R, Hospice Volunteer on 10/17/25. The hospice failed to include accurate, timely and appropriately authenticated documentation in the patient’s clinical record of volunteer services provided 5.Patient #10 had a hospice admission date of 6/3/25 and received hospice services while residing in an assisted living facility. Clinical record review revealed: a. The POC, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of hypertensive chronic kidney disease and included orders for skilled nurse, social work, chaplain, hospice aide and volunteer services. b. The EMR included documentation of a volunteer visit note, dated 9/16/25, signed completed on 9/30/25, by Staff K, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit note, dated 9/16/25, signed completed by Staff K, Hospice Volunteer on 10/6/25. The hospice failed to include accurate, timely and appropriately authenticated documentation in the patient’s clinical record of volunteer services provided. 6. Patient #13 had a hospice admission date of 9/3/25 and received hospice services while residing in a nursing home. Clinical record review revealed: a. The POC, dated 9/3/25 to 12/1/25, identified the patient had a diagnosis of metabolic encephalopathy and included orders for skilled nurse, social work, chaplain, hospice aide and music therapy services. b. The skilled nurse visit, dated 9/4/25, completed by Staff H, RN, identified aide supervision completed; however, aide services had not been implemented yet. The hospice nurse failed to document accurate information in the patient’s clinical 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 servies. All entries into the clinical record must be legible, clear, complete and appropriately authenticated and dated in accordance with the hospice policy and accepted standards of practice. During an interview on 11/19/25 at AM the Quality and Education Coordinator stated the administration staff entered the narrative completed by the volunteers in the electronic clinical record. She further stated the practice not allowed and a perfrmance improvement plan put in place as of 11/19/25 and will continue to be monitored. 1.Patient #8 had a hospice admission date of 5/7/25 and received services while residing in a nursing home. Clinical record review revealed: a. The Plan of Care (POC), dated 8/5/25 to 11/2/25 and 11/3/25 to 1/1/26, identified the patient had a diagnosis of Alzheimer’s disease and included orders for skilled nurse, social work, chaplain, hospice aide, music therapy and volunteer services. b. The electronic medical Record (EMR) included documentation of a volunteer visit note, dated 9/16/25, signed completed on 9/28/25, by Staff O, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 9/16/25, signed completed by Staff R, Hospice Volunteer on 9/16/25. c. The EMR included documentation of a volunteer visit note, dated 9/24/25, signed completed on 10/20/25, by Staff Q, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 10/20/25, signed completed by Staff P, Hospice Volunteer on 10/20/25. d. The EMR included documentation of a volunteer visit note, dated 10/9/25, signed completed on 9/28/25, by Staff O, Hospice Volunteer. The clinical record included paper documentation of the same volunteer visit, dated 9/16/25, signed completed by Staff R, Hospice Volunteer on 9/16/25. The hospice failed to ensure all documentation completed only by the provider who completed the service. 2. Patient #15 had a hospice admission date of 10/21/25 and discharge date of 3/22/25 and received services while residing in a private residence. Clinical record review revealed: a. The POCs, dated 10/21/24 to 1/18/25 and 1/9/25 to 4/18/26, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nurse, social work and chaplain services. b. The POCs included assignment of wound care to the long term care facility nurse c. The Interdisciplinary Group (IDG) notes, dated 1/23/25, 2/6, 2/20/25, 3/6 and 3/20/25, include interventions the nursing facility staff will be primary caregiver providing activities of daily living, administering medications/treatments as weell as providing a safe environment. During an interview on 11/19/25 at 11:20 AM the Quality Education Coordinator stated the patient discharged from the nursing home on 11/18/24 and the documentation failed to change to reflect the appropriate interventions. The hospice failed to ensure all documentation complete and reflect correct services provided.”