Every finding on record at Appl Orchard Hospice of Missouri Inc

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment and reassessment identified the patient's need for hospice care and services. On review of RRNHV#7 the patient was admitted to service with a chronic wound to the heel. There was no documentation of a comprehensive wound assessment noted on the admission visit. There was mention of the wound but no documentation of a description of the size, character, odor, drainage, or surrounding skin as required. On the follow up visit two days later the LVN did not assess the wound. The first wound assessment documented was noted 5 days after admission. This observation was reviewed with the Hospice Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the hospice interdisciplinary group update the comprehensive assessment no less frequently than every 15 days. In review of RRNHV#6 there was a 17 day gap in the RN comprehensive assessment visits from March to April and no documentation of an update of the comprehensive assessment by the RN in corresponding IDG meeting for that time period. This observation was reviewed with the DON, and Administrator.

Observed in Record Review. In 6 of 10 patient records reviewed, organization failed to ensure the plan of care reflect the patient and family goals that were specific, measurable, and time bound. On review of RRNHV#10 the goals established were not noted to be specific, measurable and time bound. For example a goal was Wound healing will be optimal. The goals were established on admission in February and had the same target dates in June. In RRNHV#9 an example was Maintenance of respiratory baseline s as evidenced by breathing at optimal level within disease parameters. In RRNHV#8 there were interventions for medication management and urinary elimination yet no goals established. In RRNHV#7 the goals were not individualized as all nursing goals had the same target date at the end of July. In RRNHV#6 a goal read Patient’s cardiovascular status is stable as disease progression allows. In RRNHV#5 the goal of Patient/caregiver verbalize demonstrate proper catheter care was established on admission in April with a target date in October. These observations were reviewed with the DON and Administrator. Observed in Patient Home. In 3 of 3 patient records reviewed, the organization failed to ensure the plan of care reflect the patient and family goals that were specific, measurable and time bound. On review of RRHV#3 the goal was Optimal activity level achieved and maintained within base line respiratory and energy parameters; TargetDate:6/30/2026 On review of RRHV#3 the Patient's nutritional needs will be met as patient's condition/comfort allows; TargetDate:6/30/2026 On review of RRHV#2 the goal Patient will demonstrate ability to cope with limitations;TargetDate:4/15/2026 On review of RRHV#1 the goal Pt/caregiver will demonstrate use of mechanical respiratory device(s);TargetDate:3/23/2026 This was reviewed with the DON, Administrator and Executive Director.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care (POC) include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#10 there was documentation of the patient will issues of pain and decreased appetite yet no care plans established to guide the care. There was documentation the patient/family was seeking respite yet the issue was not reflected in the care plans. Further the patient was on Lantus and Insulin daily and that the family was monitoring blood glucose but no care plan for diabetes management. There were antibiotics for an infection in March yet the infection was not reflected in the POC. IN RRNHV#5 there was documentation of weight loss, UTI, Nausea, and issues with orthostatic hypotension yet there were no care plans established to guide the care for the issues. In RRNHV#7 the Certificate of Terminal Illness noted issues with weight loss, poor appetite, and dysphagia yet no care plan established to address the issues. In RRNHV#6 the was documentation of multiple UTI's and a fall but no care plans established to address the infections or fall safety. These observations were reviewed with the Administrator, Executive Director, and DON.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the plan of care (POC) include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#6 there was documentation of an assessment of 2 wounds on admission yet there were no orders for the treatment of the wounds nor a care plan opened to guide the care of the wounds noted on the record. This observation was reviewed with the DON, Administrator, and Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services, the organization failed to ensure the bereavement plan of care note the kind of bereavement services to be offered and the frequency of the service delivery. On review of RRBR#1, and RRBR#2 there was a bereavement plan of care established yet the care plan did not specify the kind of bereavement services nor the frequency of the service delivery. This observation was reviewed with the Bereavement Coordinator , DON and Executive Director.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization failed to maintain documentation that demonstrated staff competence was assessed and documented annually per policy. On review of HR#3 for the Medical Director (MD) there was no documentation of competency assessment annually as required. For the MD there was no competency assessment for 2024, and 2025. This observation was reviewed with the HR Staff and Administrator.

Observed in Record Review. In 3 of 9 patient records reviewed, receiving aide services, the organization failed to ensure written patient care instructions for the hospice aide were prepared by the registered nurse. On review of RRNHV#10 the documentation noted the patient with multiple wounds with wound treatments yet the aide plan of care there were no specific instructions for how the aide was to handle the patient's wounds/treatments while providing care. In RRNHV#7 the patient had a wound with wound treatment yet there were no instructions for the aide regarding the wound. In RRNHV#6 the aide plan of care noted to give bath each visit but did not specify what type of bath was to be given. These observations were reviewed with the DON, Executive Director, and Administrator. Observed in Record Review. In 1 of 10 patient records reviewed, the hospice surveyor noted during the home visit that patient had a Peg Tube, Foley and Tracheostomy, however; the aide POC did not provide specific instruction regarding how the Aide was to handle the Peg Tube, Foley and Tracheostomy while care was provided. This was discussed and reviewed with the DON administrator and Executive Director..

Observed in Record Review. In 1 of 9 patient records reviewed, with hospice aide services provided, the organization failed to ensure the RN supervise the hospice aide during an on-site visit to the patient's home no less frequently than every 14 days. On review of RRNHV#6 there was a 17 day gap in aide supervisory visits documented between March and April. There was 22 day gap from April to May. These observations were reviewed with the DON, and Administrator.

Observed in Tracer Activities. During the volunteer program session and review it was noted the organization failed to provide day to day administrative and/or direct patient care services in an amount that, at a minimum equal 5% of the total patient care hours of all paid hospice employees and contract staff. Documentation showed the organization providing less than 4% volunteer time for 2024, less than 1% for 2025 and no volunteer hours logged so far for 2026. This observation was reviewed with the Volunteer Coordinator, and Leadership.

Observed in Competency Session. In 1 of 3 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice included all required areas. The contract for DME failed to include a stipulation that services were to be provided only with the authorization of the hospice and delivered in accordance with the patient's plan. This observation was reviewed with the DON, and Administrator.

Observed in Record Review. the hospice surveyor noted that there was incomplete documentation regarding the PRN medication for pain—it was missing the scale for why the medication should be administered. For example: On RRDC#2 0237CJ acetaminophen500mgoral tablet; Take2tab(s) orally every 8hours as needed [Comments: Do not exceed more than 4,000mg in 24 hours TOTAL (with Percocet)] StartDate:05/08/2026 In addition, On RRDC#2 0237CJ Pain Percocet 325mg-5mgoral tablet; Take1-2tab(s) orally every4hours as needed [Comments: Pain] Start Date: 05/07/2026 This finding was reviewed and discuss with the Director of Clinical Services.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice surveyor noted during the RRDC#1 0223 CN, the organization did not provide summary of care to receiving facility when patient was transferred to the receiving facility as required by the organization's policy and procedure No 2-070.1 Revision dated April 2019. This finding was discussed with the director of clinical services.

Observed in Competency Session. In 1 of 3 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice include all required areas. On review of the contract for DME there was no stipulation that hospice contracts require that all contracted entities obtain criminal background checks on contracted employees who have direct patient access or access to patient records. This observation was reviewed with the DON and Administrator.

Observed in Record Review. The surveyor observed on one patient record of patient with wound that the initial wound assessment had not been measured initially , nor in the following two weeks as required by HCO policy. This issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 8 of 11 patient records reviewed, the surveyor observed that the Initial bereavement assessment had not been completed and on 11/11 patient records reviewed the surveyor observed that the need for volunteer services had not been assessed. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 9 of 11 patient records reviewed, the surveyor observed that the majority of patient goals had goal achieved by end of cert period. The surveyor discussed and confirmed with organization leadership.

Observed in Individual Tracer. The surveyor observed the hospice nurse go in and out of nursing bag multiple times without cleaning hands. The issue was discussed and confirmed with organization leadership. Observed in Individual Tracer. The surveyor observed the hospice nurse providing care to patient ,cleaned her equipment used during assessment of patient and immediately return to nursing bag without waiting the appropriate wait time for the product used to clean equipment. This was discussed and confirmed with leadership.

Observed in HR File Review. There was no documented evidence of annual competence assessment of the volunteers as required by the organization policy.

Observed in Record Review. In 2 of 11 patient records reviewed, The surveyor observed that the discharge summary only indicated the patient revoked and went to hospital to seek aggressive treatment . There was no summary of the care, treatment and services provided to the patient in the discharge summary.