Hospice of the Midwest, LLC

“Based on staff interview, policy review and clinical record review, the hospice failed to maintain documentation in the patient clinical records as evidence patients received a copy of the hospice policy concerning the disposal of controlled medications and hospice staff discussed this policy with the patient/caregiver for 2 of 2 sampled patients who received routine home care while living in a private residence and received orders for controlled medications after the start of care (Patients #3 and #4). Failure to ensure patients and/or caregivers received adequate education on the use and disposal of controlled substances increased the risk of inappropriate use of narcotics and other controlled substances by individuals other than the patient for who the medication was prescribed. Findings include: According to the hospice policy titled Disposal of Controlled Medications, Hospice-Enterprise, dated 3/18/25, the patient/family/caregiver are educated regarding proper storage, management, and disposal of controlled medications when ordered for a patient. During an interview on 7/1/26 at 12:30 PM, Staff C, Clinical Manager stated the hospice did not have documentation of patient education on the disposal of controlled medications policy at the time when controlled medications ordered. 1.Patient #3 had a start of care date of 6/16/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial plan of care (POC), dated 6/16/26 to 9/13/26, included physician orders for medications, but no controlled medications. The POC identified the patient had a diagnosis of hypertensive heart disease. b. A skilled nurse visit note, dated 6/16/26, completed by the Administrator, identified the physician ordered Morphine and Ativan that would be delivered later on this date. c. A physicians order, dated 6/17/26, identified new orders including morphine and lorazepam (controlled medications). The clinical record lacked documentation hospice staff reviewed with patient #3 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. 2. Patient #4 had a start of care date of 3/20/26 and received hospice services while residing in a private residence. Clinical record review revealed: a. The initial POC, dated 3/20/26 to 6/3/26, included physician orders for medications, but no controlled medications. The POC identified the patient had a diagnosis of hypertensive heart disease with heart failure. b. A physicians order, dated 3/22/26, identified new orders including tramadol (controlled medication). The clinical record lacked documentation hospice staff reviewed with Patient #4 the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. The hospice failed to review the policy for the disposal of controlled medications at the time when the physician first ordered the controlled medications. The above findings reviewed with the Administrator.”

“Based on observation, interview, record review and review of the Iowa Department of Health and Human Services (DHS) website, the agency failed to comply with mandatory reporting requirements for suspicions of neglect for a vulnerable patient living at home alone, while on hospice services, for one patient (Patient (P) 4) whose records were reviewed out of a total sample of 14. The failure placed the patient at risk of serious injury or harm. Findings include: Review of P4’s “Patient Profile” located in the “Patient Information” tab of the electronic medical record (EMR) revealed P4 had a “Start of Care (SOC)” date of 04/12/24 with a terminal diagnosis of severe protein-calorie malnutrition. Review of a 12/08/25 letter between the hospice agency and P4, provided by the Clinical Supervisor (CS) revealed, “…This letter is to document current safety concerns related to [P4] who is enrolled in hospice services with [agency name]. The patient is bed-bound and requires assistance with activities of daily living, including repositioning, hygiene needs, nutrition, hydration, toileting, and accessing medications. At this time, [P4] remains alert, oriented, and capable of making their own decisions regarding care and living arrangements. The patient has expressed the desire to remain in the current home setting despite the physical limitations associated with being bed-bound without regular hands-on support, the patient is at increased risk for: Skin breakdown, Inadequate food, fluids, or medications. Delayed emergency response, Infection or medical complications. These risks have been discussed with the patient, who understands and chooses to remain at home at this time. Hospice services are intermittent and cannot replace full-time caregiving.” P4 signed the letter. Review of an 01/03/25 “Social Services Visit Care Note” provided by the CS revealed, “…Completed joint visit with RNCM [Registered Nurse Case Manager]. This SW [Social Worker] used to be in the home visiting P4 but at the time [he/she] didn’t want a SW in [his/her] home. RNCM called this SW to complete a joint visit with RNCM today. There have been some recent concerns with P4 being left saturated, [he/she] is aware that [he/she] needs to be changed but there is nothing [he/she] can do about it, [he/she] states. P4 admits [he/she] just waits and [he/she] is fine with that. Patient is bed bound and doesn’t leave [his/her] bed, [he/she] is pale in color-Patient is alert and oriented x3 with some confusion, [he/she] is very open about staying in [his/her] home. [He/She] doesn’t think it’s necessary to have extra visitors in [his/her] home. Patient says [he/she] is fine; [he/she] has plenty to eat and drink, patient leans to the left-hand side, [he/she] is weak, fraile [sic], very thin appearance, patient appears clean though, with hair brushed and clean clothes on. [Family] will come and check on [him/her] but not there 24/7. [He/She] gets [his/her] meals from the community center three days a week. The meals are so big [he/she] divides them up…” In addition, “…[Family] was present for visit and agrees that [his/her] mother needs more care and support at home as [he/she] stated none of them [family] are dependable and can care for [him/her] at home. All of them are in the understanding that they want [him/her] to be at home, but they need more help…Patient is reluctant of letting others into [his/her] home, [he/she] doesn’t think [he/she] needs extra care…Patient where’s [sic] a life-line button around [his/her] neck…Patient is very blunt about not contacting other family members to let them know what is going on. Plans moving forward and [him/her] staying in [his/her] room, home health agencies were brought up to help check and change her throughout the day that [he/she] would have to pay privately. Patient can afford some private home health, but right now [he/she] is not accepting of this. [He/she] is very adamant about staying in [his/her] home and believing that [he/she] doesn’t need the extra care…” During a home visit with Certified Nurse Aide (CNA)1 on 05/20/26 at 2:12 PM, P4 was observed lying in bed, bed rails in the up position. [His/her] legs were contracted, no pressure ulcers or other skin issues were identified during incontinent care provided by CNA1. P4 was alert and oriented during the visit and answered questions accordingly. P4 was asked if [he/she] lived alone. P4 stated, “Yes.” P4 revealed the life-line alert necklace that [he/she] wore and stated, “When I push the button, it goes to hospice.” P4 further stated that [he/she] had hospice aides coming out two times per day for toileting, incontinent care, repositioning and conversation. P4 stated, “Hospice provides everything for me, medications, supplies, nurses, aides, a social worker, chaplain, music therapy and massage therapy.” During an interview on 05/21/26 at 8:10 AM, the Director of Clinical Operations (DCO) and the CS were asked if they had reported to DHS that P4, a vulnerable adult, was living alone at home. The DCO stated, “No, we haven’t.” The CS stated, “We increased the skilled nursing visits to three times a week, and the aide visits to two times per day, in addition to other staff members’ visits.” During an interview on 05/21/26 at 10:27 AM, SW2, whom the CS stated had previously worked at DHS prior to coming to work at this hospice agency stated, “When we do an investigation [at DHS] , we would get medical records, and if [he/she] was able to make their own decisions, and chooses to stay, despite the risk, we typically do not follow [with an investigation] any further.” Review of the “Iowa Department of Health and Human Services Employee Manual provided by SW2 revealed, “Finding a dependent adult responsible for denial of critical care due to the adult’s own actions: A pattern of the dependent adult being denied essential food, shelter, clothing, supervision, physical or mental health care, or other care necessary for the dependent adult’s health and welfare…A dependent adult, who has no cognitive impairments and is able to rationalize the consequences of their decisions, has the right to make unhealthy choices…Founded, Unfounded, Confirmed, Not Registered Reports: Founded means that a preponderance of the evidence [greater than 50%] that abuse has occurred…Unfounded means that a preponderance of the evidence is [less than 50%] that dependent adult abuse has not occurred.””

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed, the organization did not ensure that the comprehensive assessment included a drug profile that contained the patient’s current drugs. Clinical Record 1/Home Visit 1: The patient was admitted to hospice services on 06/07/2023 with the diagnoses of malignant neoplasm of the unspecified part of the bronchus or lung and chronic obstructive pulmonary disease (COPD). During the home visit on 07/23/2024, the patient stated that they had been having ongoing stomach pain that had gotten worse over the past month. The patient reported “I take a Tylenol Arthritis pill daily by mouth, which is effective unless eating. The pain is most noticeable when eating...My doctor has ordered a diagnostic X-ray to see if my cancer has spread.” During a joint record review on 07/23/2024, the Director of Clinical Services confirmed that the “Tylenol Arthritis pill” was not included in the patient’s current drug profile and had not been reviewed for actual or potential interactions with the patient’s other medications. Clinical Record 8: The patient was admitted to hospice services on 05/08/2023 with the diagnoses of unspecified severe protein-calorie malnutrition, Multiple Sclerosis, and abnormal weight loss. On 06/17/2024, a Nurse Practitioner performed a face-to-face visit and documented that the patient “takes Ibuprofen to relieve pain that she has in her shoulder.” During a joint record review on 07/25/2024, the Director of Clinical Services confirmed that Ibuprofen was not included in the patient’s current drug profile and had not been reviewed for actual or potential interactions with the patient’s other medications.”

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient’s plan of care (POC) included the drugs and treatments necessary to meet the patient’s needs. Clinical Record 1/Home Visit 1: The patient was admitted to hospice services on 06/07/2023 with the diagnoses of malignant neoplasm of the unspecified part of the bronchus or lung and chronic obstructive pulmonary disease (COPD). During the home visit on 07/23/2024, the patient stated that they had been having ongoing stomach pain that had gotten worse over the past month. The patient reported that they “ Take a Tylenol Arthritis pill daily by mouth, which is effective unless eating. The pain is most noticeable when eating...My doctor has ordered a diagnostic X-ray to see if my cancer has spread.” During a joint record review on 07/23/2024, the Director of Clinical Services confirmed that the Tylenol Arthritis was not documented in the patient’s POC effective 06/01/2024 or POC updates. Clinical Record 8: The patient was admitted to hospice services on 05/08/2023 with the diagnoses of unspecified severe protein-calorie malnutrition, Multiple Sclerosis, and abnormal weight loss. On 06/17/2024, a Nurse Practitioner performed a face-to-face visit and documented that the patient “takes Ibuprofen to relieve pain that she has in her shoulder.” During a joint record review on 07/25/2024, the Director of Clinical Services confirmed that Ibuprofen was not documented in the patient’s POC effective 07/01/2024 or POC updates.”

“It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 17 (6%) clinical records reviewed that included Hospice Aide (HA) services, the organization did not ensure that the HA provided services included in the aide plan of care. Clinical Record 1/Home Visit 1: The patient elected hospice care on 06/07/2023 with the diagnoses of malignant neoplasm of the unspecified part of the bronchus or lung and chronic pulmonary disease (COPD). During the home visit with the Hospice Aide (HA) [Personnel Record 1] on 07/23/2024, the HA stated that following the patient’s shower they always placed a band-aid on the patient’s left lower back wound. The left lower back wound was documented by the RN during the comprehensive assessment dated 06/14/2024, and the RN obtained the physician’s order: ‘Wash (left lower back wound) with soap and water and cover with a band-aid. Change every 3 days.” During a joint clinical record review and interview, the Director of Clinical Services confirmed that the HA care plan effective 06/21/2024 did not include instructions for the HA to place a band-aid on the patient’s left lower back wound.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by document review and interview. In 1 of 1 (100%) clinical record review of a patient with a live discharge, the hospice did not ensure that the patient’s clinical record contained a copy of a Notice of Medicare Non-Coverage signed at least two calendar days before Medicare-covered services ended. Document 2: The organization’s written Patient Rights and Responsibilities in the patient admission booklet (revision date of 03/2024) stated in part, “You have the right to be given five days’ oral and written notice before the hospice program terminates your services. ...” The admission booklet also contained a blank copy of the form CMS 10123-NOMNC (approved 12/31/2011), “Notice of Medicare Non-Coverage.” Clinical Record 16: The patient elected hospice care on 10/31/2023, and the “failure to decline” discharge was dated 04/27/2024. The patient resided in an SNF. A review of the clinical record revealed no evidence of that a NOMNC had been given to the patient’s durable power of attorney (DPOA). The clinical record contained evidence that the patient’s DPOA was verbally notified of discharge from hospice services on 04/25/2024, at two (2) days before the patient’s discharge. There was no evidence that the DPOA had been provided with written notice of the patient’s discharge, a NOMNC. During an interview, the Director of Clinical Services stated, “Our discharge policy doesn’t indicate specifically that the NOMNC form is the document required to be given to the patient as written notice of discharge, but that is our process.””

“It is required that each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the patient’s record included physician orders for all care and services. Clinical Record 2: The patient was admitted to hospice services on 12/30/2024 with a primary diagnosis of senile degeneration of the brain. During a joint record review on 07/23/2024, the Director of Clinical Services stated that the patient had a fall and landed on her right hip on 06/28/2024. The RN assessed the patient on 06/29/2024 and documented in the fall report, “No order changes needed. Advised the facility staff to use an ice pack as needed for patient comfort.” The Director of Clinical Services (DCS) stated that applying an ice pack to mitigate pain would require a doctor’s order. The DCS acknowledged that the patient’s record and plan of care did not contain an order for an ice pack.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy “Revocation of Hospice Benefit” (revision date October 2019) stated in part, “The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician....” In 1 of 1 (100%) clinical record review of a patient with a revocation, the agency did not ensure that a copy of the discharge summary was sent to the patient’s attending physician. Clinical Record 15: The patient was admitted to hospice services on 5/26/2023 and resided in a skilled nursing facility (SNF). The patient revoked hospice services on 01/05/2024 to seek aggressive treatment at the hospital for a bowel obstruction and an emergent sigmoidectomy and colostomy. During a joint clinical record review on 07/25/2024, the Director of Clinical Services (DCS) confirmed the patient’s attending physician, who is the SNF physician, was not sent a copy of the hospice discharge summary and stated, “We would only send a discharge summary if an order were written for patient discharge. The attending physician sent the patient to the hospital for aggressive treatment, resulting in the revocation, so we did not realize it was necessary to send the attending physician a discharge summary.””