Every finding on record at Alternative Hospice of Western Missouri LLC

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 13 (8%) clinical records that included oxygen orders, the agency did not ensure that the patient and primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. CLINICAL RECORD 2/Home Visit 2: The patient was admitted on 12/20/2024 with a diagnosis of pancreatic cancer and initial orders included oxygen as needed for shortness of breath. During a home visit on 01/09/2024, with the Social Worker (Personnel Record 2), the home smelled of cigarette smoke. The caregiver was observed walking to the sliding glass door of the kitchen to smoke. The patient was not currently using oxygen, but did have it available in the home. There was no documented evidence that the patient or caregiver's home was assessed for oxygen safety, including smoke alarms, fire extinguishers, or oxygen in-use signs. The Administrator and Clinical Director on 01/09/2025 stated that the patient and caregivers did receive oxygen safety education, but the assessment only allowed them to check a box for oxygen safety. The Social Worker assessment included a home safety assessment, but the oxygen safety items were not addressed.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient was admitted on 10/18/2024 with a diagnosis of Alzheimer's Disease. The patient's progress notes from (facility) dated 09/30/2024 noted that the patient had a history of seizures and was admitted to hospice with an order for Keppra 750mg at bedtime. The Plan of Care for the certification period of 12/31/2024 to 03/30/2025 did not include seizure precautions. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 2: The hospital referral dated 12/18/2024 and comprehensive assessment dated 12/24/2024 identified the following allergies: Latex, Naproxen, Meclizine, Quinolones, Statins, yellow dye, ciprofloxacin, lisinopril, prednisone, and latanoprost. The plan of care for the certification period 12/24/2024 to 03/19/2025 included only the latex allergy. The Administrator and Clinical Director stated in an interview on 01/09/2025, after a review of the record, that the allergies did not flow from the comprehensive assessment to the Plan of Care due to a computer glitch. CLINICAL RECORD 3: The patient was admitted on 12/19/2024 with a diagnosis of Cardiac Disease requiring Oxygen (as needed) and a walker due to weakness with fall risk. Eliquis (anticoagulant) 5mg twice daily was included in the Plan of Care (POC). Bleeding precautions were not included in the POC. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 5: The patient was admitted on 11/30/2024 with a diagnosis of Alzheimer's Disease and Type Two Diabetes Mellitus. The patient was actively being treated for Diabetes with Jardiance 25mg and Januvia 100mg daily. The Plan of Care for the certification period of 11/30/2024 to 02/27/2025 did not include interventions and goals for the Diabetes. The Administrator and Clinical Director stated in an interview on 01/10/2025, after a review of the clinical record, that the interventions and goals should have been included. Still, they agreed they were missing from the POC due to oversight.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 13 (15%) clinical records reviewed, of patients that accepted aide services, it was revealed that the agency did not ensure the Registered Nurse (RN) provided written patient care instructions for the hospice aide that included precautions to take when providing care. CLINICAL RECORD 1: The patient was admitted on 10/18/2024 with a diagnosis of Alzheimer's Disease. The patient's progress notes from (facility) dated 09/30/2024 noted that the patient has a history of seizures and was admitted to hospice with an order for Keppra 750mg at bedtime. The aide care plan dated 01/02/2025 for the certification period 12/31/2024 to 03/30/2025 did not include seizure precautions. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight. CLINICAL RECORD 3: The patient was admitted on 12/19/2025 with a diagnosis of Atrial Fibrillation and was on Eliquis, an anticoagulant. The patient was at high risk for falls and utilized a walker. Bleeding precautions were not included in the aide care plan. The Administrator and Clinical Director stated in an interview on 01/09/2025 that the precaution should have been included but was an oversight.

It is required that each patient’s individualized written plan of care reflects patient, and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 4 of 15 (27%) clinical records reviewed it was revealed that the agency did not ensure that each individualized plan of care reflected the planned interventions and family goals. Clinical Record 4: The patient was admitted to hospice on 07/25/2024 with a primary diagnosis of heart failure and a secondary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Oxygen was ordered on admission for 2L/min per NC PRN (2 liters per minute, per nasal cannula, as needed). The plan of care dated 07/25/2024 -10/22/2024 did not include any interventions or goals related to oxygen use or respiratory status. Oxygen safety was identified in the plan of care. Clinical Record 5: The patient was admitted on 09/22/2024 with a diagnosis of Multiple Myeloma. Skilled Nurse (SN) assessment on 09/22/2024 revealed that the patient was experiencing some shortness of breath and oxygen was ordered at 2 L/min PRN. The plan of care dated 09/22/2024 to 12/20/2024 did not include any interventions or goals related to the respiratory status or the use of oxygen. Oxygen safety was identified on the plan of care. Clinical Record 6: The patient was admitted on 05/09/2024 with a diagnosis of acute and chronic congestive heart failure. The SN assessment on 05/09/2024 described the need the patient to utilize continuous oxygen. Oxygen was ordered and placed on medication profile but the care plan dated 05/09/2024 -08/06/2024 did not include any interventions or goals related to the patient respiratory status or the use of oxygen. Oxygen safety was noted on the plan of care under safety measures. Clinical Record 12: The patient was admitted on 05/14/2024 with a diagnosis of breast cancer. Oxygen 2 L/min per NC PRN was ordered and oxygen safety was included on the plan of care. There were no respiratory goals or interventions on the plan of care. On 12/04/2024 after a joint review of the clinical record, the administrator stated, "OK" and confirmed the finding.

It is required that each patient’s individualized written plan of care includes medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed, in which medical supplies were required for the patient's care reviewed revealed that the agency did not ensure that all medical supplies were included on the plan of care. Clinical Record 15: The patient was admitted on 11/04/2024 with a diagnosis of multiple sclerosis with a suprapubic catheter in place. Catheter supplies were not included on the plan of care. In an interview on 12/06/2024 the administrator stated, "I understand. I am creating an in-service as we speak,” and confirmed the finding.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 5 of 13 (38%) clinical records reviewed, with a hospice aide ordered, it was revealed that the agency did not ensure that a Registered Nurse (RN) created a plan of care with specific instructions for the aide to follow. Clinical Record 4: The patient was admitted on 07/25/2024 with a diagnosis of heart failure and Chronic Obstructive Pulmonary Disease (COPD). Oxygen 2 L per NC PRN (2 liters per minute, per nasal cannula, as needed) was ordered for the patient on 07/25/2025. The hospice aide care plan, initiated by the RN on 07/25/2024, did not include instructions to the aide related to oxygen safety or patient oxygen use. Clinical Record 5: The patient was admitted on 09/22/2024 with a diagnosis of multiple myeloma. Oxygen was ordered for the patient on 09/22/2024. The hospice aide care plan, initiated by the RN on 09/22/2024 did not include instructions to the aide related to oxygen safety or patient oxygen use. Clinical Record 6: The patient was admitted on 05/09/2024 with a diagnosis of chronic heart failure. The Skilled Nurse assessment on 05/09/2024 described the need the patient to utilize continuous oxygen. An aide care plan was developed on 05/09/2024 for aide services 1 time per week. The aide care plan did not identify oxygen precautions or the patient use of oxygen. Clinical Record 10: The patient was admitted 03/11/2024 with a diagnosis of unspecified protein malnutrition. Upon admission oxygen was ordered as well as aide visits. The aide plan of care, developed on 03/11/2024, did not include any information to the aide related to the use of oxygen. Clinical Record 15: The patient was admitted on 11/04/2024 with a diagnosis of multiple sclerosis and a suprapubic catheter in place. The aide plan of care developed 11/04/2024 did not include any information to the aide related to the suprapubic catheter. After joint clinical record review, Administrator confirmed finding on 12/04/2024 and stated, " I have sent a note to the EMR company for enhancements to the aide care plan.”

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION of participation was not met as evidenced by personnel record reviews, interviews, and review of the findings with the Administrator which revealed issues with the hospice organizing, managing and administering its resources to provide the hospice care and services to patients, families, and caregivers in the following area: Failed to ensure that the hospice assessed the skills and competencies of all individuals providing care, including volunteers providing services {HSRM.14.I/L663}. The cumulative effect of these deficiencies has resulted in the hospice organization’s inability to ensure the provision of quality of care for the Condition of Participation CFR 418.100: Organization and Administration of Services. The collective deficient practice illustrated systemic process failures that had the potential to affect all patients receiving hospice care and services from the agency.

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by interview and personnel record review. In 8 of 8 (100%) personnel files reviewed revealed that the agency did not ensure that all individuals providing care were assessed for competency of skills. Personnel Record 1: The Director of Clinical Services/ Registered Nurse (RN) was hired on 11/07/2023. The personnel file did not include evidence of a competency assessment, or skills check for any role including RN or Director of Clinical Services. Personnel Record 2: The Volunteer was hired on 07/15/2024. The personnel file did not include evidence of a competency assessment, or skills check for the volunteer role. Personnel Record 3: The Social Worker was hired on 11/27/2024. The personnel file did not include evidence of a competency assessment, or skills check for the social work role. Personnel Record 4: The Medical Director was contracted on 12/05/2024. The personnel file did not include evidence of a competency assessment, or skills check. Personnel Record 5: The Massage Therapist was hired on 11/14/2024. The personnel file did not include evidence of a competency assessment, or skills check. Personnel Record 6: The Chaplain/ Bereavement Coordinator was hired on 12/13/2023. The personnel file did not include evidence of a competency assessment, or skills check for a Chaplain or Bereavement Coordinator role. Personnel Record 7: The Hospice Aide/ intake coordinator was hired on 10/09/2023. The personnel file did not include any evidence of a competency assessment, or skills check for the aide role or the intake coordinator role. Personnel Record 8: The Administrator/ Volunteer Coordinator was hired on 09/20/2023. The personnel file did not include evidence of a competency assessment, or skills check. In an interview on 12/05/2024, the administrator stated, "No, you won't find competency checklists in any of the personnel files. We have not done them and that's on me."

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 15 (20%) clinical records reviewed revealed that the agency did not ensure that documentation was completed consistent with agency policy. Agency policy titled, "Timely submission of patient documentation" No. 11.6.1( revised June 2019), read in part, “Procedure.2. Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days.” Clinical Record 3: A massage therapy visit was conducted on 11/5/2024, however, the documentation for the massage therapy visit was completed and signed on 11/18/2024 (9 business days). Clinical Record 7: A hospice aide visit was conducted on 07/02/2024. Documentation for the hospice aide visit was not completed and placed in the clinical record until 07/12/2024 (7 business days). Clinical Record 15: The chaplain assessment was conducted on 11/05/2024. The documentation for the chaplain encounter was not completed until 11/12/2024 (5 business days). A massage therapy visit was conducted on 11/05/2024 but the documentation for the encounter was not completed until 11/18/2024 (9 business days). The administrator stated in an interview on 12/05/2024, "Oh, that is too long and not acceptable. I will be speaking to all staff about timeliness.