Every finding on record at Brighton Hospice Missouri, LLC

It is required that the hospice Interdisciplinary Group completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected the hospice benefit on 05/17/2025. The initial Social Work Assessment visit was performed on 05/23/2025, six days after the patient's election of the hospice benefit. A clinical record review revealed no evidence of communication notes or documentation in the first or second Interdisciplinary Group Meetings, dated 05/21/2025 or 06/04/2025, indicating a reason for the visit being conducted after the required five-day timeline. Clinical Record 9: The patient elected the hospice benefit on 05/02/2025. The initial Social Work Assessment visit was performed on 05/09/2025, nine days after the patient's election of the hospice benefit. A clinical record review revealed no evidence of communication notes or documentation in the first or second Interdisciplinary Group Meetings, dated 05/07/2025 or 05/21/2025, indicating a reason for the visit being conducted after the required five-day timeline. During a joint clinical record review and interview on 06/18/2025, the Senior Director of Clinical Quality confirmed the initial social work assessments were completed late, stating that the previous Social Worker (SW) left the agency abruptly on 05/02/2025 with very short notice, so another Social Worker had to cover all visits, including admissions, until the new Social Worker, who begins on Monday, 06/23/2025, completes orientation.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. For the year 2024, the percentage of volunteer hours was 3.67%. During an interview and joint review of the QAPI Performance Improvement Projects (PIPs), and volunteer recruitment and retention activities on 06/18/2025, the Administrator and the Senior Director of Clinical Quality confirmed the volunteer hour percentage for 2024 was 3.67%. During a review of the annual volunteer percentage hours for the year 2024, the QAPI Performance Improvement Projects (PIPs), and volunteer recruitment and retention activities - along with interviews with the Volunteer Coordinator (Personnel Record 4), Administrator (Personnel Record 2), and the Senior Director of Clinical Quality on 06/18/2024, it was revealed and confirmed the volunteer hour percentage from 2024 was 3.67%. A volunteer QAPI PIP was identified and initiated on 05/29/2024 for a less than 5% volunteer percentage. The QAPI PIP and percentages have been reviewed quarterly beginning September 2024 through April 2025, with documented initiatives to recruit new volunteers through Social Work internship programs, local senior centers/activities, and word of mouth. The Volunteer Coordinator was hired on 04/30/2024 but did not assume the Volunteer Coordinator role until 05/14/2025, as this was a small program with an active census of only 24 patients at the time of the site visit. The Volunteer Coordinator was brought in to assume the duties and provide more focused attention to the volunteer program due to the agency's struggle with a low volunteer percentage. The retention activities recorded included face-to-face encounters and phone calls, as the new Volunteer Coordinator made a point to introduce himself and get to know the current volunteers.

Based on policy review, clinical record review, and interview the hospice provider failed to forward to the receiving facility, a copy of the hospice discharge summary in one of three records reviewed (Record/Patient #2). This deficient practice has to potential to affect all discharged patients served by the provider. --- Findings included: Review of the providers policy titled, ";Transfer of a Hospice Patient to Another Agency," dated 10/25/2021, showed in part, the following: - Continuity of care is maintained when a hospice patient is transferred to another treatment setting or provider; and - If the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 07/02/2024, with a terminal diagnosis of senile degeneration of the brain. He/she lived at home in a long-term care facility (LTCF). On 08/26/2024, the patients family wanted the patient sent to the hospital to seek aggressive treatment. The hospice failed to send a discharge summary to the receiving facility (hospital). During an interview on 08/09/2024 at 2:43 PM, the administrator assistant stated that he/she had sent the discharge summary to the patients physician at the LTCF and not to the receiving facility. If the patient resided in a LTCF they send the discharge summary to the patient's primary physician and not the receiving facility.

Based on policy review, record review, and interview, the hospice provider failed to document a transfer summary that included a summary of the patient's stay including treatments, symptoms, and pain management, current plan of care, and latest physician orders in two of three records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Discharge for reasons other than death," dated 12/01/2021, showed in part, the following: - This discharge summary is filed in the clinical record and includes: * A summary of the patients stay including treatment, symptoms, and pain management * The patients current plan of care * The patients latest physician orders; and * Ay other documentation that will assist in post-discharge continuity of care. RECORD/PATIENT #1:Review of a discharge summary dated 08/08/2024, showed the patient was a live discharge (when a patient leaves hospice care before they die), he/she ";moved out of the service area" to pursue treatment at a medical center for nausea, vomiting, and diarrhea for three days. Review of the discharge summary that was sent to the receiving facility failed to show a summary of the patient's stay including treatments, symptoms, and pain management, the patients current plan of care, and the latest physician orders. RECORD/PATIENT #3:Review of a discharge summary dated 07/05/2024, showed the patient was a live discharge under the primary terminal diagnosis of psychomotor deficit following a cerebral vascular accident (stroke) due to extended prognosis/no longer terminally ill. Review of the discharge summary failed to show a summary of the patient's stay including treatments, symptoms, and pain management, the patients current plan of care, and the latest physician orders. During an interview on 08/09/2024 at 2:43 PM, the administrator assistant stated that they he/she was responsible to send the discharge summary once the patient was discharged. The diagnosis, medication list and visit frequency were sent to the physician or receiving facility. The discharge summary did not include treatment, symptoms, and pain management, current plan of care, and the latest physician orders. During an interview on 09/10/2024 at 12:22 PM, the director of nursing stated that he/she reviewed the discharge summary coordination notes for the physician and interdisciplinary group notification.

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. The medication review process includes the identification of the following: The effectiveness of drug therapy, drug side effects, actual or potential drug interactions and duplicate drug therapy. 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. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 8 (50%) records reviewed they revealed that the medication profiles were not updated to reflect the current Physician Orders. Clinical Record 1 - Review was completed for the Election of Benefit beginning 7/15/2022 through 9/10/2022. On the Hospice The Plan of Care, in the section titled, “DME/Supplies”, there was documented, “Oxygen Concentrator start effective 7/15/2022.” Documentation in the area designated for medications did not include an entry for use of oxygen by the patient at 2-4 liters per nasal cannula. Clinical Record 4 - Review was completed for the Election of Benefit beginning 7/17/2022. The Hospice Plan of Care, under the section titled, “DME/Supplies”, listed “Oxygen Concentrator start effective 7/17/2022.” Under the Medication section, there were no documented instructions to include the amount of oxygen use, expressed as a liter flow or a percentage, and the duration of use, such as continuous administration or PRN. The delivery device/modality of administration was also absent. Clinical Record 6 - Review was completed for the Election of Benefits beginning 8/10/2022. The Hospice Plan of Care, under the section titled, DME/Supplies listed "Oxygen Concentrator Hospice Start Effective Date: 8/10/2022.” In addition, under the section titled, “Safety Measures”, listed, "O2 Precautions Start Effective Date: 8/10/2022". The Medication section did not include documented instructions that included the liter flow or percentage of oxygen to be administered, the duration and frequency of use, and the delivery device/modality. The nursing visit notes dated 8/10/2022 and 8/12/2022 documented the patient's use of oxygen.“ Clinical Record 0 - Review was completed for the Election of Benefits beginning 7/28/2022. The Hospice Plan of Care, under the section titled, “DME/Supplies” listed “Oxygen Concentrator start effective 7/28/2022.” Under the Medication section to be completed by the RN, there were no documented instructions to include the liter flow or a percentage, duration and frequency of oxygen use, or the delivery device/modality. In an interview on 8/25/2022 with the Director of Clinical Services (Staff ID: 11) they stated that they will, ”Provide a Plan of Correction to ensure compliance."

It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes: Information on the patient’s progress toward desired outcomes; and reassessment of the patient’s response to care. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 3 (33%) records reviewed of patients who received wound care, documentation on Skilled Nurse visit notes was missing evidence of updated assessments of the patient's wound status. Clinical Record 1 - Election of Hospice Benefit: 7/15/2022 through 9/10/2022. The client, a 67-year-old female, resides at home and was admitted to hospice with diagnoses including Cortico-Basal Syndrome, Parkinson’s, Unspecified Caloric Malnutrition, and CVA. The nursing assessment dated 8/11/2020, documented, ”Wound Left Buttock, measured at 4 CM X 2.5 CM, red in appearance”, and was followed by the Hospice Physician Order, “Monitor Wound on Left Buttock, Start Date 8/11/2022, Zinc Cream to Stage 2 on Buttock BID and PRN.” In addition, documentation also stated: “Patient has chronic drooling, and the result is severe moisture and is at high risk for breakdown. Large site of excoriation under chin onto chest, Wound care right face, cleanse with wound cleanser and apply zinc oxide BID.” The Nursing visit note dated, 8/16/2022, did not include documentation that described the patient's wound and chest excoriation status under the section titled, “Integumentary”. On 8/17/2022, the nurse visit note documented: “New orders received for wound care for Buttock Stage 2, Cleanse with wound cleanser, apply small amount Medi honey, cover with adhesive dressing BID and PRN. Zinc has been applied to face per order and 4 X 4 to buttock is clean dry and intact.” There was evidence of wound care being provided during the visit, but the visit note did not document a description or measurement of the wound or chest excoriation. The nursing visit note documentation on 8/23/2022 included the following: “Integumentary: Wound, documented #1, Location: Left Gluteal, Type Pressure Ulcer/Injury Stage2, wound bed healthy.” Areas on the visit note to document the wound's length, width, skin surrounding tissue, and other descriptors were left blank. The narrative only stated that, ”4 X 4 applied to buttock and Zinc applied for face". In an interview on 8/25/2022, the Director of Clinical Services (Staff ID: 11), stated, "The agency will be providing in-services to ensure staff compliance with standards of practice."

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene, and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by interviews and observations. In 1 of 3 (33%) home visits, the Chaplain was observed not following infection control protocols. Clinical Record 4 - During a home visit, the chaplain was observed not washing his hands upon entrance to the patient's home. The Chaplain was also observed placing his notebook on the floor after taking a seat following introducing himself to the client’s caregiver. In an interview on 8/25/2022, the Director of Clinical Services (Staff ID: 11), stated, "The agency will be providing in-services to ensure staff compliance to infection control."

It is required that the hospice obtains a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. In 2 of 5 (40%) contracts reviewed, it was revealed that the DME and OT/PT/ST contracts did not include written verbiage that described the provision that requires the completion of Criminal Background Checks . An interview was conducted on 8/25/2022 with the Director of Clinical Services (Staff ID: 11) who stated that the organization ”Will provide an addendum to ensure compliance” for the requirement that all contractors who either have access to patient records, provide direct patient care, or both, have had Criminal background Checks performed and documented.