Inspection Reports for Everystep
3000 Easton Blvd, Des Moines, IA, 503173124
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 24, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a pattern of standard level deficiencies primarily related to care planning and coordination, including failures to review and update individualized plans of care and to provide services according to updated physician orders. Complaint investigations were mostly unsubstantiated, with the exception of several substantiated findings involving interdisciplinary group care planning and coordination issues. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The trend suggests some improvement over time, with the most recent inspection showing no cited deficiencies after previous citations for care planning and coordination.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
160 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
The Department of Inspections, Appeals and Licensing conducted a complaint investigation for complaint #115237-I from 2025-06-17 to 2025-06-24 related to 42 CFR 418.56 IDG, Care Planning, Coordination.
Complaint Details
Complaint #115237-I was investigated and found to have no conditional or standard level deficiencies.
Findings
No conditional level or standard level deficiencies were identified during the investigation.
Report Facts
Census: 160
Inspection Report
Complaint Investigation
Census: 188
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The Department of Inspections, Appeals & Licensing conducted a complaint survey for complaint #110033-C from 10/21/24 to 10/23/24 as directed by CMS Kansas City location.
Complaint Details
Complaint #110033-C was investigated; no condition level deficiencies were found, but one standard level deficiency was identified related to care planning. The complaint was substantiated by findings.
Findings
The hospice failed to ensure the individualized plan of care was reviewed and revised at least every 15 days for one of six sampled patients, placing patients at risk of not receiving appropriate care. No condition level deficiencies were identified; one standard level deficiency (L552) was cited related to care planning.
Deficiencies (1)
Failure of the interdisciplinary group to review and update the individualized plan of care at least every 15 days for one sampled patient.
Report Facts
Census: 188
Patients per branch: 60
Patients per branch: 48
Patients per branch: 37
Patients per branch: 21
Patients per branch: 11
Patients per branch: 11
Days between IDG meetings: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Vice President of Clinical Services | Identified missed IDG meeting due to patient transfer to skilled nursing facility |
| B. Rasmussen | Agency representative who deemed no plan of correction required |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 14, 2024
Visit Reason
The Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #104045-I from 2/12/24 to 2/15/24, investigating compliance with Conditions of Participation related to Care Planning and Coordination of Services and Drugs and Biologicals.
Complaint Details
Complaint #104045-I was investigated with no condition level deficiencies identified but one standard level deficiency related to coordination of services was found.
Findings
The hospice failed to ensure care and services were provided in accordance with the plan of care for 1 of 4 sampled patients, specifically failing to update the plan of care with new physician orders for Morphine Sulfate, placing patients at risk of not receiving services and medications according to assessed needs and physician orders.
Deficiencies (1)
Failure to ensure care and services were provided in accordance with the plan of care for 1 of 4 sampled patients due to failure to update plan of care with new physician orders for Morphine Sulfate.
Report Facts
Complaint investigation dates: 4
Sampled patients: 4
Morphine Sulfate dosage frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Failed to enter verbal order into patient record and update plan of care |
| B. Rasmussen | Agency Representative | Signed statement that agency is deemed and no plan of correction is required |
Inspection Report
Complaint Investigation
Census: 194
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
The Department of Inspections and Appeals conducted a complaint investigation for complaint #100053-C and #100404-C from 8/6/23 to 9/5/23.
Complaint Details
The complaint investigation was substantiated for the allegation related to 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services with standard level deficiencies. Other allegations were unsubstantiated with no deficiencies.
Findings
The allegation related to Interdisciplinary Group, Care Planning, and Coordination of Services was substantiated with standard level deficiencies. Allegations related to Patient rights, Licensed Professional Services, and Discharge or Transfer of care were unsubstantiated with no deficiencies. The hospice failed to ensure the Interdisciplinary Group reviewed and revised the patient's plan of care based on updates to the comprehensive assessment for 3 of 6 sampled patients.
Deficiencies (1)
Failure of the hospice to ensure the Interdisciplinary Group reviewed and revised the patient's plan of care based on updates to the comprehensive assessment and included patients' progress towards outcomes and goals for care and services provided.
Report Facts
Census: 194
Branch census: 61
Branch census: 49
Branch census: 42
Branch census: 34
Branch census: 8
Sampled patients: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
The Department of Inspections and Appeals conducted a complaint investigation for complaint #97456-C from 2023-05-30 to 2023-06-01.
Complaint Details
Complaint #97456-C was investigated and found unsubstantiated with no deficiencies related to 42 CFR 418.52 Patient rights, 42 CFR 418.54 Initial and Comprehensive Assessment of the Patient, and 42 CFR 418.56 Interdisciplinary Group, Care Planning, and Coordination of Services.
Findings
The allegations related to patient rights, initial and comprehensive assessment of the patient, and interdisciplinary group care planning and coordination of services were all unsubstantiated with no deficiencies found.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The Iowa Department of Inspections and Appeals conducted an onsite complaint investigation from 2/28/23 to 3/6/23 related to complaint #96393-C.
Complaint Details
Complaint #96393-C was investigated and found unsubstantiated in all cited areas: patient rights, interdisciplinary group care planning, and inpatient hospice care.
Findings
The complaint survey found that the allegations regarding patient rights, interdisciplinary group care planning, and inpatient hospice care were unsubstantiated without any related or unrelated deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 10, 2020
Visit Reason
The complaint survey was conducted on 02/10/2020 for complaint #89171-C to investigate compliance with infection control regulations.
Complaint Details
Complaint #89171-C was investigated and found to be unsubstantiated with no deficient practices identified.
Findings
The hospice was found to be operating in compliance with CFR 418.60 Infection Control with no deficient practices identified.
Inspection Report
Complaint Investigation
Census: 146
Deficiencies: 1
Date: Jun 12, 2019
Visit Reason
The inspection was a 45-day revisit complaint investigation conducted from 6/10 through 6/12/19 to determine compliance with previously cited conditions related to the Condition of Participation of Interdisciplinary Group, Care Planning and Coordination.
Complaint Details
This was a 45-day revisit complaint investigation. The hospice was found in compliance with previously cited conditions but still had deficiencies related to wound care for one patient. The complaint was partially substantiated based on the findings.
Findings
The hospice was found to be in compliance with the previously cited Condition of Participation of Interdisciplinary Group, Care Planning and Coordination but still had standard level deficiencies related to the same condition. The deficient practice involved failure to ensure hospice nursing staff provided wound care in accordance with the patient's plan of care for one sampled patient.
Deficiencies (1)
Failure to follow the patient's Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk of inconsistent care that may not meet the needs of the patient, specifically related to wound care orders and documentation.
Report Facts
Census: 146
Patients receiving wound care: 13
Patients receiving services from Des Moines parent office: 28
Patients receiving services from West Des Moines hospice house: 9
Patients receiving services from hospice house in Creston: 3
Patients receiving services from Centerville office: 34
Patients receiving services from Osceola office: 28
Patients receiving services from Mount Ayr office: 19
Patients receiving services from Perry office: 8
Patients receiving services from Knoxville office: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| B. Rasmussen | Signed approval of plan of correction on 4/20/19 | |
| Medical Director | Reported awareness of patient's wounds and provided orders for wound care | |
| Hospice Administrator | Interviewed regarding wound care documentation and staff knowledge | |
| Team Director | Discussed wound care documentation issues and provided patient's MAR |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 11
Date: Apr 11, 2019
Visit Reason
The inspection was a complaint investigation survey (#82331) conducted from 4/9/19 to 4/11/19 to assess compliance with Medicare Conditions of Participation related to interdisciplinary group, care planning, coordination, and patient rights.
Complaint Details
The complaint investigation survey was triggered by complaint #82331. The complaint was not substantiated with a related deficiency for patient rights but identified other non-related standard level deficiencies.
Findings
The hospice was found out of compliance with Medicare Conditions of Participation, including failure to ensure patient rights were respected, inadequate interdisciplinary group coordination, and failure to follow individualized plans of care for patients. Several deficiencies were identified related to patient care, documentation, and communication.
Deficiencies (11)
Failure to ensure the legal representative designated by the patient exercised the patient's rights, increasing the risk hospice patients' choices might not be acknowledged and honored at the end of life.
Failure to ensure the hospice provided care and services to patients and their families that followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician.
Failure to ensure the use of patient-specific routine orders increased the potential for hospice services to not adequately meet the needs of hospice patients and families.
Failure to ensure coordination and collaboration among interdisciplinary group members to ensure updates to the plan of care and services provided to the patients were according to assessed needs and team decisions.
Failure to ensure each hospice patient has an individualized plan of care specific to their needs, and all hospice care and services follow the individualized plan of care.
Failure to include all needed items of medical equipment and supplies the patient used on the plans of care, placing patients at risk of unanticipated decline or injury.
Failure to ensure hospice staff followed a written physician order for wound care.
Failure to ensure hospice staff followed a written physician order for content of plan of care including scope and frequency of services.
Failure to ensure hospice staff followed physician orders for oxygen and morphine administration and follow-up oxygen saturation levels after nebulizer treatment.
Failure to ensure hospice staff followed physician orders for spiritual care services and volunteer services as ordered.
Failure to ensure hospice staff followed physician orders for wound care and documentation of wounds.
Report Facts
Census: 140
Deficiency correction due date: May 24, 2019
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 27, 2019
Visit Reason
An investigation of complaint #81639-C was conducted from 2/26/19 through 2/27/19 regarding intake allegations related to Conditions of Participation.
Complaint Details
Complaint #81639-C was investigated and found unsubstantiated with no deficiencies identified related to patient rights or licensed professional services.
Findings
The investigation found that 42 CFR 418.52 Patient Rights and 42 CFR 418.62 Licensed Professional Services were unsubstantiated with no related or unrelated deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 14, 2013
Visit Reason
The investigation was conducted in response to complaint #43174-C on 5/13/13 and 5/14/13, focusing on patient rights, interdisciplinary group coordination, and hospice inpatient care.
Complaint Details
Complaint #43174-C was investigated; patient rights and hospice inpatient care allegations were unsubstantiated, but interdisciplinary group coordination was substantiated with deficient practices identified.
Findings
The complaint investigation found patient rights and hospice inpatient care allegations unsubstantiated, but identified deficient practices in interdisciplinary group coordination related to patient care and safety, including failure to supervise and coordinate care leading to patient falls and medication administration issues.
Deficiencies (2)
Failure of the interdisciplinary group to supervise and coordinate delivery of patient care, placing patients at risk for unmet needs and injury.
Failure to provide medications as ordered on the plan of care, placing the patient at risk for unmet needs and adverse side effects.
Report Facts
Patient falls reported: 11
Patients receiving hospice services: 10
Audit compliance threshold: 10
Audit compliance period: 8
Audit minimum quarterly percentage: 5
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2012
Visit Reason
The inspection was conducted as a complaint survey concerning medication administration and controlled substance management at the hospice inpatient units of H C I Care Services.
Complaint Details
The complaint survey identified concerns with 2 of 4 sampled patients who received services at the hospice inpatient units. The hospice failed to accurately document medication administration and controlled substance management for these patients. The complaint was substantiated based on clinical record review, staff interviews, and hospice policy review.
Findings
The hospice failed to accurately document medication administration and controlled substance disposal for hospice patients, with issues identified in medication administration records (MAR), controlled medication records, and discrepancies in narcotic counts. The hospice also lacked consistent nursing staff initials on MARs and had inadequate documentation of medication wastage.
Deficiencies (3)
Hospice failed to accurately document administration of medications to hospice patients in inpatient units.
Hospice failed to maintain accurate records and documentation of controlled substances including disposal and wastage.
Discrepancies in dispensing, administration, and storage of controlled drugs were not properly investigated or documented.
Report Facts
Patients sampled: 4
Patients with concerns: 2
Patients receiving inpatient services: 12
Medication administration times: 4
Medication doses missed: 3
Roxanol bottle volume: 31
Roxanol concentration: 20
Roxanol remaining discrepancy: 0.25
Roxanol remaining discrepancy: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Registered Nurse | Documented patient care activities and medication administration; involved in controlled medication record discrepancies |
| Staff B | Team Director | Team Director for hospice inpatient units; provided statements on medication documentation and nursing staff practices |
| Staff C | Vice-President of Patient Services | Provided statements on hospice aide instructions and reviewed medication records |
| Staff A | Nurse Supervisor | Nurse Supervisor for inpatient unit; reported on medication record discrepancies and controlled substance management |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2010
Visit Reason
The investigation was conducted due to complaint #30161-C on 8/17/10 and 8/18/10 regarding allegations related to 42 CFR 418.110 Hospices That Provide Inpatient Care Directly, specifically concerning one of the two inpatient facilities operated by the hospice.
Complaint Details
Complaint #30161-C was investigated and found unsubstantiated with no deficiencies identified.
Findings
The complaint allegations related to 42 CFR 418.110 Hospices That Provide Inpatient Care Directly were found to be unsubstantiated, and no deficient practices were identified during the complaint investigation.
Inspection Report
Complaint Investigation
Census: 276
Deficiencies: 11
Date: Jun 29, 2010
Visit Reason
The survey was conducted as an investigation for complaint #28770-C and a recertification survey concurrently from 6/21/10 through 6/29/10. The complaint allegations related to Conditions of Participation were investigated.
Complaint Details
The complaint investigation was conducted concurrently with the recertification survey from 6/21/10 to 6/29/10. Some complaint allegations were unsubstantiated, while others were substantiated resulting in cited deficiencies.
Findings
The survey found some allegations unsubstantiated, but substantiated deficiencies related to drugs and biologicals, and inpatient care practices. Additional deficiencies were found related to comprehensive assessments, infection control, competency evaluations, in-service training, supervision of hospice aides, medication storage, physical environment, meal service, and regulatory compliance.
Deficiencies (11)
Failure to complete a review of all patient medications including prescription and over-the-counter drugs, herbal remedies, and alternative treatments for 25 sampled patients.
Failure to maintain a coordinated agency-wide infection control program integrated into the Quality Assessment and Performance Improvement (QAPI) program.
Failure to ensure hospice aide competency evaluations included all required components for 18 sampled hospice aides.
Failure to ensure all contracted hospice aides received at least 12 hours of in-service training during each 12-month period for 3 of 4 sampled aides.
Failure to complete annual on-site supervisory visits by registered nurses for 13 of 31 sampled hospice aides employed over 12 months.
Failure to maintain secure drug storage areas and proper documentation of controlled drug administration in inpatient hospice facilities.
Failure to maintain a governing body that assumes full legal authority and responsibility for hospice management and quality assessment.
Failure to maintain policies and procedures for physical environment safety and maintenance, including temperature control and hazardous materials.
Failure to maintain safe food storage, preparation, and sanitation practices in hospice kitchens.
Failure to ensure hospice medication information and documentation for patients residing in nursing homes.
Failure to complete required criminal background checks for newly hired employees prior to hire.
Report Facts
Patient census: 276
Hospice aides employed/contracted: 71
Hospice aides employed/contracted: 29
Sampled patients: 25
Sampled hospice aides: 18
Sampled hospice aides for in-service training: 4
Sampled hospice aides for supervisory visits: 31
Sampled employees for background checks: 16
Number of deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Norene Mostkoff | President and CEO | Named as President and CEO in notification to CMS and policy approval. |
| R. Kirlin | Signed acceptance of Plan of Correction on 9/15/10. |
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