Every finding on record at Beacon of Hope Hospice of Missouri, Inc.

Upon patient record review, 2 of 14 (Patient #5,6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #5 On 1/10/25 patient has orders for oxygen with no oxygen listed on the medication profile. Patient #6 On 12/20/24 patient has orders for oxygen with no oxygen listed on the medication profile.

Upon patient record review, 5 of 14 (Patient #4,5,7,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #4 Patient on Xarelto daily as of 1/20/25, no evidence of bleeding or anti-coagulant precautions on plan of care. Patient #5 On 1/10/25 patient has orders for Oxygen, no evidence of oxygen precautions on plan of care. Patient #7 Patient on Aspirin daily as of 1/11/25, no evidence of bleeding or anti-coagulant precautions on plan of care. Patient #9 Patient on Aspirin daily as of 1/9/25, no evidence of bleeding or anti-coagulant precautions on plan of care. Patient #10 Patient on Aspirin daily as of 1/14/25, no evidence of bleeding or anti-coagulant precautions on plan of care.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #9 On 1/9/25 patient has plan of care orders for Voltaren 1% gel, instructions do not specify location to apply gel.

Upon patient record review, 2 of 14 (Patient #5,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #5 On 1/10/25 patient has plan of care orders for oxygen with no oxygen DME listed on the plan of care. Patient #6 On 12/30/24 patient has plan of care orders for oxygen with no oxygen DME listed on the plan of care.

Upon patient record review 2 of 14 (Patient #3,6) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3 Aide visit 1/21/25 Aide documented "N/A this visit" for Cleaning and trimming fingernails without documentation that the task was refused by patient or caregiver. Patient #6 Aide visit 1/21/25 Aide documented "N/A this visit" for Activity and elimination without documentation that the task was refused by patient or caregiver.

Upon patient record review 1 of 14 (Patient #3) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures Patient #3 Aide documented "Patient no longer using walker and is now using wheelchair" on 1/7/25 and 1/14/25, there is no evidence that it was reported to the nurse and it remains on the aide care plan.

Based on policy review, record review, and interview the hospice provider failed to develop an individualized plan of care (POC) in, but not limited to, one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, ";The Plan of Care," revised November 2020, showed that: - The plan of care (POC) will be established and maintained for each individual admitted to the hospice program; - The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG); - This POC will focus on identified problems, goals and interventions and will ill include all services necessary for the palliation and management of the terminal illness and related conditions; and - The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the POC. RECORD/PATIENT #1: The patient was admitted to hospice services on 01/28/2022, with a terminal diagnosis of severe protein-calorie malnutrition. Other pertinent diagnosis included history of an unruptured cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain), hypertension (high blood pressure), and cerebrovascular disease (conditions that affect blood flow to the brain). Review of the interdisciplinary care plan, dated 05/08/2023, showed compromised cardiovascular (relating to heart and blood vessels) status and the interventions included to assess the cardiovascular status for signs and symptoms of cardiac complications. The cardiovascular status problem showed resolved on 05/16/2023. Review of the skilled nursing note, dated 05/18/2023 at 1:02 PM, showed that: - The patients blood pressure was 175/100 (the top number is the systolic blood pressure [amount of pressure when your heart pushes blood out] and normal systolic is less than 120. The bottom number is the diastolic blood pressure [the pressure when the heart rests between beats] and normal diastolic is less than 80); - The patient has been more hypertensive (high blood pressure) over the last two months, the patients blood pressure was 175/100 and he/she already had his/her blood pressure medication; - Three plus pitting edema (occurs when excess fluid builds up in the body, causing swelling and when pressure is applied to a swollen area, an indentation will remain) to bilateral extremities; and - The plan of care failed to include problems, interventions, and goals regarding the elevated blood pressure and pitting edema. Review of the skilled nursing note, dated 05/23/2023 at 1:41 PM, showed that: - At 2:30 PM, the patient had not taken his/her morning medications and his/her blood pressure was high at 184/99; - Three plus pitting edema to bilateral extremities; and - The plan of care failed to include problems, interventions and goals regarding the elevated blood pressure and pitting edema. Review of the skilled nursing note, dated 06/06/2023 at 11:42 AM, showed that: - He/she did not have his/her morning medications and his/her blood pressure was 185/106; - Three plus pitting edema in both lower extremities, the patient had been receiving furosemide (diuretic) daily and will speak to the physician to see if he/she wants to add a second dose of Lasix (furosemide) or add spirolactone (diuretic); and - The plan of care failed to include problems, interventions and goals regarding the elevated blood pressure and pitting edema. During an interview on 08/01/2023 at 2:50 PM, registered nurse (RN) A stated that: - He/she was the patients primary nurse, the patient lived with his/her significant other who was his/her primary caregiver; - The people that lived next door brought the patients medication over on a daily basis at different times; - The patient was prescribed three different blood pressure pills; - The patients blood pressure was frequently high he/she did not ";approach anyone" because the patient had medication and he/she was not taking the medication, as he/she should; - He/she did not notify the physician of the high blood pressure due to non-compliance with the medication; - The blood pressures might not been discussed during IDG due to the blood pressures being erratic and the patients caregiver did not want to be responsible for the medication; and - He/she did not include the next-door neighbor gave the patient his/her medication or the patient was non-compliant with his/her medication on the plan of care. During an interview on 08/02/2023 at 9:38 AM, the administrator stated the following: - There was no specific policy on blood pressure parameters but if the readings were outside normal parameters, they would turn red in the EMR; - The individualized interventions would indicate expectations if the physician should be notified; - The plan of care is updated during the IDG meeting; - There was a cardiac plan of care opened on 05/18/2023 and changed to inactive on 05/23/2023, there was no information to show why it was inactive; and - There was no information on the plan of care addressing the patients blood pressure or edema (swelling).

Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) maintained communication and responsibility for coordinating the care and services provided to the hospice patient in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect the individualized care received by all the agency's patients. --- Findings included: Review of the provider's policy titled, "Interdisciplinary Group Meeting," revised November 2020, showed that: - The interdisciplinary group (IDG) will collaborate with the patients attending physician to develop an individualized written plan of care; and - The IDG will take a proactive approach in developing/revising the plan of care (POC) by planning for anticipated patient changes and needs. RECORD/PATIENT #1: The patient was admitted to hospice services on 01/28/2022, with a terminal diagnosis of severe protein-calorie malnutrition. Other pertinent diagnosis were hypertension (high blood pressure), unruptured cerebral aneurysm (a bulge or ballooning in a blood vessel in the brain), and cerebrovascular disease (conditions that affect blood flow to the brain). Review of the skilled nursing note, dated 05/18/2023 at 1:02 PM, showed that: - The patients blood pressure was 175/100 (the top number is the systolic blood pressure [amount of pressure when your heart pushes blood out] and normal systolic is less than 120. The bottom number is the diastolic blood pressure [the pressure when the heart rests between beats] and normal diastolic is less than 80); - The patient has been more hypertensive (high blood pressure) over the last two months, the patients blood pressure was 175/100 and he/she already had his/her blood pressure medication; - Three plus pitting edema (occurs when excess fluid builds up in the body, causing swelling and when pressure is applied to a swollen area, an indentation will remain) to bilateral extremities; and - The documentation failed to include coordination with the physician regarding the elevated blood pressure. Review of the skilled nursing note, dated 05/23/2023 at 1:41 PM, showed that: - At 2:30 PM, the patient had not taken his/her morning medications and his/her blood pressure was high at 184/99; - Three plus pitting edema to bilateral extremities; - The patient took his/her medications during the visit; and - The documentation failed to include coordination with the physician regarding the elevated blood pressure. Review of the skilled nursing note, dated 06/06/2023 at 11:42 AM, showed that: - He/she did not have his/her morning medications and his/her blood pressure was 185/106; - The patients niece brought his/her medications half way through the visit - Three plus pitting edema in both lower extremities, the patient had been receiving furosemide (diuretic) daily and will speak to the physician to see if he/she wants to add a second dose of Lasix (furosemide) or add spirolactone (diuretic); and - The documentation failed to include coordination with the physician regarding the elevated blood pressure or pitting edema. Review of the hospital records, dated 06/08/2023, showed that: - Chief complaint: Hypertension and dehydration; - Past medical history included, but not limited to, hypertension (high blood pressure), and chronic kidney disease who presents to the emergency department (ED) from home with multiple complaints for hypertension, lower extremity edema and dehydration; - The patients family member stated the patient had lower extremity edema for ";a while" and was on Lasix (diuretic) daily; - The patient lives with a roommate and has ";home health" coming in; - The family member was communicating with the patients primary care physician who advised to get blood work; there was mild issues in getting the blood work done so ";they" recommended the patient ";dropping in the ED (emergency department) first"; - The patients family member stated the patient started complaining of chest pain and headache while in the ED; - The patients initial blood pressure was 239/76; - The patient was admitted for hypertensive urgency, acute renal (kidneys) failure, and elevated troponin (indicates damage to the heart); and - The plan: Hypertension appears to be significant and apparently had difficulty controlling this at home, and the blood pressure needs to come down. Review of the interdisciplinary group (IDG) meeting dated 06/09/2023 (one day after the patient went to the hospital), showed a prep note by RN A dated 06/08/2023, the note consisted of the skilled nursing visit note from 06/06/2023. The documentation from the IDG showed the RN, chaplain, and social worker attended and no evidence to show the physician attended. There was a note to show a beta-blocker (lowers blood pressure) was increased due to high blood pressure. During an interview on 08/01/2023 at 2:50 PM, registered nurse (RN) A stated that: - He/she was the patients primary nursed and the patient lived with his/her significant other who was his/her primary caregiver; - The people that lived next door brought the patients medication over on a daily basis at different times; - The patient was prescribed three different blood pressure pills; - He/she talked to the primary caregiver about the patients medications, he/she contacted the patients son who was the power of attorney three or four times but not about the medication; - The patients blood pressure was frequently high he/she did not ";approach anyone" because the patient had medication and he/she was not taking the medication, as he/she should; - The patients carvedilol (can treat high blood pressure and heart failure) was increased on 06/08/2023; - He/she did not notify the physician of the high blood pressure due to non-compliance with the medication; - He/she did not notify the physician of the blood pressure being 185/106 on the 06/06/2023 visit because the patients caregiver said the patient did not have his/her medication, RN A told the caregiver he/she needed the medication; - There was no parameters on the POC and he/she did not recheck the patients blood pressure before leaving his/her home; - The physician was not notified of the blood pressure readings due to the patient had blood pressure medication and was not taking the medication, as he/she should; - The blood pressures might not been discussed during IDG due to the blood pressures being erratic; - He/she was notified by the previous administrator the patient went to the hospital, RN A notified the hospital that the patient was a hospice patient, asked if they needed medical records and, he/she could not recall what the hospital staff said; and - He/she kept in touch while the patient was in the hospital. During an interview on 08/02/2023 at 9:38 AM, the administrator stated the following: - The blood pressure readings on 05/18/2023, 05/23/2023, and 06/06/2023 where in red a font color in the electronic medical record (EMR), the red font color indicated the blood pressure was higher than deemed normal; - There was no specific policy on blood pressure parameters but if the readings were outside normal parameters, they would turn red in the EMR; - The individualized interventions would indicate expectations if the physician should be notified; - There was a prep note dated 05/18/2023 and 05/23/2023 which showed what was to be communicated in the interdisciplinary group (IDG) and this was not discussed in IDG until 05/26/2023, the plan of care is updated during the IDG meeting; - There was a cardiac plan of care opened on 05/18/2023 and changed to inactive on 05/23/2023 and there was no information to show why it was made inactive; - There was no information on the plan of care addressing the patients blood pressure or edema (swelling); - There was no communication with the physician regarding the blood pressure reading on 06/06/2023; - The documentation failed to include if there was coordination with the hospital; - He/she would have expected a nurse to go to or call the emergency room (ER) and coordinate with the ER and ask if they wanted medical records from the hospice; and - The patients carvedilol was increased on 06/09/2023 (the patient went to the emergency room on 06/08/2023).

Based on review of the agencys patient rights and responsibilities provided to patients at the start of care, record review, home visit observation, and administrative interview, the agency failed to ensure that the patients received accurate and current information in three (Records/Patients #1, #2, and #3) of three patient records reviewed. The deficient practice has the potential to affect the protection of patient rights for all patients served by the hospice. --- RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 11/18/2021 with a diagnosis of unspecified protein-deficient malnutrition. . Observation on 12/20/2022 at 12:15 PM, during the patient's home visit showed the patients signed patient and responsibilities, dated 11/18/2021 in the patient's home folder failed to include: -The patient has the right to be informed of his or her rights; -The hospice must protect and promote the exercise of these rights; -If a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patients behalf; -If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patients right to the extent allowed by state law; and -Ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the administrator. Findings included: Review of the patient rights and responsibilities, used by staff and reviewed with the patient and families, showed the agencys patient bill and responsibilities failed to include the following: - The patient has the right to be informed of his/her rights, and the hospice must protect and promote the exercise of these rights; - If a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patients behalf; - If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patients right to the extent allowed by state law; and - Ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the administrator. RECORD/PATIENT #2 Review of the clinical record showed the patient was admitted to hospice services on 09/06/2022 with a diagnosis of hypertensive heart disease with heart failure. Review of the patients signed patient and responsibilities, dated 09/06/2022, failed to include the following: - If a patient has been adjudged incompetent under state law by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed pursuant to state law to act on the patients behalf; - If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patients right to the extent allowed by state law; and - Ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice, are reported immediately by hospice employees and contracted staff to the administrator. During an interview on 12/19/2022 at 11:20 AM, the administrator stated he/she agreed with the above findings. The patient rights and responsibilities was the agencys policy. He/she would update the agencys current patient rights.

Based on review of the agency's patient admission packet and interview, the agency failed to include required information in the written notice of patient rights for patients admitted to hospice services in, but not limited to, one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- During an interview on 12/20/2022 at 11:30 AM, the administrator stated the patient rights were not in the patients home unless the patient request a copy. He/she referred the process to the regional director of clinical services on how the patient would know the contact the Division of health and Senior Services to file a complaint or questions about local hospices. During an interview on 12/20/2022 at 11:47 AM, the director of clinical services stated that staff read and review the patient rights and responsibilities with the patient on admission. The team assistant prints out all signed forms, including the patient rights and copies are sent to the patient. During an interview on 12/20/2022 at 11:53 AM, the team assistant stated that he/she does not print out patients signed patient rights. The central intake registered nurse in Iowa gets all patients paperwork. During an interview on 12/20/2022 at 12:00 PM, the central intake registered nurse stated that he/she does not print patient rights and send to the patient, that was left up to the branch. Findings included: Review of the Patient Rights and Responsibilities section of the agency's admission paper work showed in part that as a patient you have the right to, be fully informed of your rights and responsibilities and receive this notice before the initiation of care. The information failed to include that the patient has the right to receive verbal and written notice of rights in advance of providing care in a language and manner the patient understands. RECORD/PATIENT #1: During record review on 12/19/2022, the patient rights and responsibilities information signed by the patient 11/07/2022 was reviewed. The information failed to include that the patient has the right to receive verbal and written notice of rights in advance of providing care in a language and manner the patient understands. During interview on 2/19/2022 at 11:50 AM, the administrator stated admissions are done with docu sign and copies offered at the visit. A lot of patients request them to be emailed to them and if not, and they want a copy it is printed at the office and taken the next day because they are admitted and then a visit is made the next day. During interview on 12/20/2022 at 11:48 AM, the regional director of clinical services stated admission packets are left in the home. The agency can provide patient rights if patient request. Everything is signed and if copy requested, it is taken out next visit usually within 48 hours. The findings were reviewed with the regional director of clinical services on 12/20/2022, at 11:30 AM. The regional director of clinical services acknowledged the findings. No further information was provided. During interview on 12/20/2022 at 1:40 PM, the patient stated he/she never received a patient rights folder and never asked for one.

Upon patient record review, 1 of 11 (Patient #2) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #2: There is a verbal order on 7/12/21 for Oxygen 2-4L via NC as needed to keep 02 above 88%. Oxygen is not listed on the medication profile.

Upon patient record review, 4 of 11 (Patient #1, #2, #7, #9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- Orders on admission 11/30/21 and to date for medication: Lactaid 1 tab as needed PO, does not include a reason for the PRN. Patient #2- Order 1/8/22 for Tramadol 50mg PO PRN with no reason for the PRN. Patient #7- Medication order dated 5/6/21 for Nitroglycerin 0.4mg every 5 minutes PO, repeat every 5 min x 15 min. This order is not written as a PRN order as it should be. Patient #9- Orders entered on 6/16/21 read Acetaminophen 500mg PO every 6 hours as needed with no reason for the PRN. Hydrocortisone cream 1% 1 GR 3 times a day PRN with no site of application indicated.

Upon patient record review, 6 of 11 (Patient #3, #6, #7, #8, #10, #11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #3, The patient has orders on 6/7/21 for oxygen and uses oxygen in the home (as witnessed by surveyor), but oxygen is not listed as part of the DME on the patients record. Patient #6, The patient has evidence in the chart since admission on 1/28/22 of use of a rolling walker in the home, but a rolling walker is not listed as part of the DME on the patients record. Patient #7 The patient has evidence in the chart upon admission on 5/6/21 and witnessed by surveyor in the home, of use of a cane and/or walker in the home, but a walker or cane is not listed as part of the DME on the patients record. There are orders on the chart dated 1/25/2022 for oxygen, but there is no oxygen listed as part of the DME. Patient #8 The patient has evidence in the admission assessment on 1/6/22 of the use of cane/walker for ambulating but items are not listed as part of the DME on the patient record. Patient #10 Orders on 9/28/21 for oxygen 2-4L per min NC as needed for dyspnea, no oxygen is listed on the DME profile. Patient #11 Orders upon record review, orders received on 5/10/21 for oxygen 1-4L as needed, not listed on the DME profile.

Upon client record review, 1 of 11 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11 Medical Social Worker documented tasks and interventions via clinical notes on 10/21, 10/22 and 10/26 with no orders for visits entered into the plan of care.

Upon patient record review, 3 of 9 applicable (Patient #1, #3, #4) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be performed and the frequency of those tasks. Patient #1 - The POC for Aide services effective 1/30/22 is for 1x per week. The aide task assignment for bed bath, nail care, dressing, shampoo and oral care is ordered for 2x per week. Patient #3 - Patients current POC includes orders for Aide services 3 x per week. The patient tasks for patient needs are ordered for 2 x per week, the PCG for this patient verifies that visits are received 2x week. Patient #4 - Aide documentation on all visits from 1/3 to 2/11 indicated that the patient refused his shower and shampoo services and from 1/3 - 2/4 the patient refused his clothing/dressing changes. There was no evidence that the plan of care wasreviewed or updated by the RNCM to determine if the tasks should remain on the aide assignment.

Upon client record review, 1 of 1 applicable (Patient #4) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #4 As of 1/3/2022 and to present, there is missing evidence of a coordinated care plan between the hospice and the SNF.