Every finding on record at Care Alternatives of Missouri, LLC

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. Document 1: The review of the 2024 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked for January 2024 through December 2024 was 0.85%. The review of the 2025 Hospice Volunteer Requirement Report revealed that the volunteer percentage of hours worked for January 2025 through July 2025 was 1.41%. In an interview with the Volunteer Supervisor on 07/31/2025, she agreed that the 5% minimum was not met for the year of 2024. She stated, "They have a lot more volunteers available now and should be close to the percentages by the end of the year."

It is required that 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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed, of a patient that was transferred, it was revealed that the agency did not ensure that a discharge summary was provided to the facility upon discharge POLICY: Policy #PC. T10, titled, Transfer of a Hospice Patient, stated in part: "Transfer procedures are initiated when a patient requests or needs admission to an inpatient facility, skilled nursing facility, assisted living facility, a hospice residence, or another hospice or health care provider. A written discharge summary is prepared for the receiving provider that includes, at a minimum: the reason for the transfer: a summary of the patient's stay including treatments, symptoms and pain management: a copy of the patient's current plan of care; the patient's latest physician orders; documentation related to a face-to-face encounter with the patient if the patient is in his/her third or later benefit period and is transferring to a different hospice program; and any other documentation that will assist in post-transfer continuity of care." CLINICAL RECORD 19: The patient elected the hospice benefit on 09/11/2024. The patient requested a revocation on 10/06/2024 to be admitted to the hospital for additional care. The patient was seen by the registered nurse on 10/06/2024 for a discharge visit. The record lacked evidence that a discharge summary being sent to the facility where the patient was receiving care. During joint clinical record reviews and an interview on 07/29/2025 with the Clinical Director (PR 11), she agreed that the record lacked evidence that the discharge summary was sent to the facility after discharge from hospice. She stated, "This happened on a weekend, and they did not communicate this to the office, so the discharge could be sent to the facility".

Based on review of the agencys current patient rights information in the ";Patient/Family Orientation for Hospice Care" handbook provided to each patient at the start of care, and interview, the hospice failed to ensure that the patient received accurate and current information related to his/her patient rights. This deficient practice has the potential to adversely affect all patients served by the agency. --- Findings included: Review of the ";Patient/Family Orientation for Hospice Care" handbook provided to each patient at the start of care showed: - On page 12 (twelve), as a hospice provider, we have an obligation to protect your rights and to provide these rights to you or your representative verbally and in writing in a language and manner you can understand, during the initial assessment visit before care is provided and on an ongoing basis, as needed; and - It failed to contain that the hospice must promote the exercise of these rights. During an interview on 11/09/2022 9:05 AM, after reviewing the patients rights in the handbook, the clinical director stated that: - All of the verbiage in our patients rights is in the patients perspective; and - Promote isnt included. During an interview on 11/09/2022 9:30 AM, the clinical director and the VP (vice president) of business development each stated that the patients rights does not include the part that the hospice must promote the rights of the patient.

Based on review of the agencys current patient rights information in the ";Patient/Family Orientation for Hospice Care" handbook provided to each patient at the start of care, and interview, the hospice failed to ensure the required information was provided to patients. This deficient practice has the potential to adversely affect all patients served by the agency. --- Findings included: Review of the agencys current patient rights information in the ";Patient/Family Orientation for Hospice Care" handbook provided to each patient at the start of care showed the following on page 14, you also have the right to: - All mistreatment, abuse neglect, injury and exploitation complaints by anyone furnishing care service on behalf of hospice are reported immediately by our staff to the hospice administrator; - All reports will be promptly investigated and immediate action taken to prevent potential violations during our investigation; and - Hospice will take appropriate corrective action in accordance with state law. Further review of the patients rights failed to include "as soon as possible, but not to exceed 24 (twenty four) hours". During an interview on 11/09/2022 at 9:05 AM, the clinical director stated that he/she did not see that we (the agency) have 24 (twenty four) hours in our patient rights for the administrator being made aware of a complaint. During an interview on 11/09/2022 at 9:30 AM, the clinical director and the VP of business development stated that the rights did not include the hospice administrator being made aware of complaint grievance within 24 (twenty four) hours of discovery of incident.

Based on policy review, record review, home visit observation, and interview the agency failed to maintain an accurate/updated medication profile in, but not limited to, two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's undated policy titled, "Medication Profile," Policy No. H:2-055.1, showed in part: - Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record; - The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications; - A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication; - The review will identify ineffective drug therapy and noncompliance with drug therapy; - During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: * Using the medication profile to evaluate the use of the drugs in the home setting; * Using the medication profile as a communication tool for other clinicians involved in care; - Based on review of the medication profile as well as the written material, changes in the plan of care may be required; - Any conclusions and findings of patient medication use or monitoring should be communicated to the pharmacist, when appropriate, and other clinicians; and - Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or other authorized independent practitioner) will be notified. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 10/07/2022 with a terminal diagnosis of senile degeneration of the brain (decrease in cognitive abilities or mental decline). The patient resided in a long term care facility (LTCF). Observation on 11/08/2022 beginning at 10:30 AM, during the patient's home visit, showed the following discrepancies between the hospice physicians plan of care (POC) medication profile (provided by the agency) dated 12/06/2022 through 02/03/2023, and the medication administration record (MARs) and treatment administration record (TARs) in the LTCF, dated 11/01/022 through 11/30/2022: -The hospice medication profile showed an order for hydrocodone-acetaminophen (hydrocodone 5 milligram (mg)-acetaminophen 325 mg tablet) (combination medication used to relieve moderate to severe pain) by mouth two times a day as needed, the facility PRN (as needed) administration record showed Norco 2.5 mg by mouth twice a day as needed; - The hospice medication profile showed no order for skin barrier cream (provide protection from irritants and prevent skin from drying out), the facility TAR showed skin barrier cream after each incontinence episode; and - The hospice medication profile showed Humalog (brand name) (fast-acting insulin to control high blood sugars) U-100 Insulin (100 unit/milliliter (ml) solution) inject 12 units subcutaneously at breakfast and 6 units at lunch, the facility insulin MAR showed Insulin lispro 10 units with breakfast and 4 units with lunch. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 08/25/2022 with a terminal diagnosis of Parkinsons disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) with Lewy Body dementia (dementia targeting problem-solving and reasoning). The patient resided in his/her own home with spouse and full time caregiver. Observation on 11/08/2022 beginning at 12:56 PM, during the patient's home visit, showed the following discrepancies between the hospice physicians POC medication profile (provided by the agency) dated 10/24/2022 through 12/22/2022, and the medication in the patients home: - The hospice medication profile showed morphine concentrate (100mg/5ml (20mg/ml (solution) take 5 mg by mouth every three hours as needed, the patient had morphine concentrate take 0.25-0.5 mg every two hours as needed (from the previous hospice agency he/she had received services from prior to the admission with the present hospice agency; - The hospice medication profile showed memantine 10 mg by mouth two times a day, the patient was taking 10 mg once a day (not two times a day); - The hospice medication profile showed vitamin B12-folic acid (vitamin B12 1,000mcg-folic acid 400mcg lozenge) place one lozenge under the tongue one time daily, the patient was taking Vitamin B12 daily crushed (not under his/her tongue); - The hospice medication profile showed Seroquel 25 mg tablet by mouth at bedtime, the patient was not taking Seroquel; - The hospice medication profile showed gabapentin (600 mg tablet) take 0.25 mg by mouth at bedtime, the patient was not taking gabapentin; - The hospice medication profile had no albuterol listed on the medication profile, the patient had albuterol treatments he/she took as needed; - The hospice medication profile showed no Tylenol, the patient was taking 500 mg one time a day; and - All the medications were crushed per the caregiver. Medication review was verified with the patients spouse and fulltime caregiver. During an interview on 11/09/2022 at 02:34 PM and 03:56 PM, the clinical director and clinical quality educator stated that they expected the medication profile to be reconciled at least monthly and as the patient is doing the medications. MARs and TARs should also be looked at to reconcile medications.

Based on policy review, record review, observation and interview, the agency failed to ensure all disciplines were informed of changes/updates regarding patients care and services in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to adversely affect all patients served by the agency. --- Findings included: Review of the agencys undated policy titled ";ON OF CARE Policy No. H:2-035.1", showed in part: - ";Named Hospice" will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers serviced by the hospice; - It will be the responsibility of the clinical supervisor to assign a case manager who is a registered nurse (RN); - The case manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge; - It will be the responsibility of the case manager to facilitate communication about changes in the patients status between interdisciplinary group members and the patients attending physician; - ";Named Hospice" personnel will communicate changes in a timely manner via telephone, one-to-one meetings, interdisciplinary group meetings and home visits; - Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group form, and/or clinical note; - Documentation will include the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication; and - Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record, and will involve the hospice patients attending physician. RECORD/PATIENT #3: Review of the physicians plan of care e-signed by the RN 10/19/2022 and the physician on 11/02/2022 showed, in part, the following: - The patient was admitted to hospice on 10/19/2022 with a primary diagnosis of senile degeneration of the brain, unspecified protein-calorie malnutrition, repeated falls and weakness: and - Orders for skilled nursing for symptom management and Chaplain and massage therapist to evaluate and treat. Review of the clinical record showed: - A clinical narrative note dated 11/01/2022 09:35 (thirteen days later) signed by the LMT (licensed massage therapist) that failed to include documentation of notification to the case manager and/or physician with a plan for further care; - An IDG (interdisciplinary group) report dated 11/07/2022 that failed to include the massage therapist; - A Clinical narrative note e-signed by the LPN (licensed practical nurse) 11/01/2022 21:21 that showed the patients child reported that last night the patient was found in their room with the lights off and in their wheelchair with their pants around their ankles. The patient has started to confuse the child with their (the patients) spouse. Child reports this started a few days ago. (This note failed to contain documentation of this increased confusion to the case manager and/or the physician); and - A clinical narrative note e-signed by the Chaplain that showed the patient was scratching their torso and stated they were itching and the facility staff was summonsed who applied triamcinolone cream at bedside. (This note failed to contain documentation that the patient was having itching or about the noted triamcinolone cream at the bedside). Review of both the facility current physician order sheet (provided to the surveyor by the facility administrator) as well as the hospice plan of care failed to contain an order for triamcinolone cream. Observation on 11/08/2022 at 10:00 AM, during the patient's home visit in the ALF (assisted living facility), showed the patient patient complained of itching and was scratching their torso. A jar of triamcinolone cream was noted at bedside. The chaplain summosned the facility staff regarding the patients itching. The staff member stated that the patient would be taken care of as they needed to get him/her ready for Christmas pictures. During an interview on 11/09/2022 at 2:30 PM, the Spiritual Counselor reviewed the chart for communication regarding the massage therapist evaluation and visit, and stated that the RN case manager is who puts the order in for the massage therapist and they had gone on vacation. During an interview on 11/09/2022 at 2:59 PM, the clinical manager stated that: - The patients itching should be reported to the case manager unless it was their baseline; and - A change in the patients condition should be reported to the RN case manager.

Based on policy review, record review and interview the agency failed to ensure the hospice aide followed the plan of care (POC) assignment in two (Records/Patients #2 and #3) of four records reviewed that received aide services. This deficient practice has the potential to affect all patients receiving aide services. --- RECORD/PATIENT #3: Review of the Physicians plan of care, e signed (electronically signed) by the RN (registered nurse) on 10/19/2022 and e signed by the physician on 11/02/2022, with a start date of 10/19/2022 and an end date of 11/02/2022 showed under the Medical Treatment Orders section: ";Home Health Aide: HHA (home health aide), Start: 10/19/22, End 10/22/22, 1 x wk x 1 weeks (one time a week for one week)." Further review of the clinical record showed: - The first aide visit documented on 10/25/2022 (week two, which started 10/23/2022); and - There failed to be any communication documented regarding why an aide visit was not completed on week one (which ended 10/22/2022). During an interview on 11/09/2022 at 2:59 PM, the clinical director stated that: - The aides are expected to follow the plan of care; - We have a plan for missed visits; and - We have a PIP (performance improvement plan) for it (missed visits). Findings included: Review of the agency's undated policy titled, "Plan of Care," showed in part: - A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program; - The care provided to the patient must be in accordance with the plan of care; - The case manager will complete the initial assessment and will initiate the development of the plan of care; - The plan of care will identify the patients needs and services to meet those needs and it must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs; - The written plan of care will contain, but will not be limited to the frequency of services; and - Care provided to the patient will be in accordance with the plan of care. RECORD/PATIENT #2: Review of the physicians plan of care dated 10/24/2022 through 12/22/2022, showed the RN assigned the aide to visit twice a week. The clinical record contained one documented visit for the time period between 10/16/2022 and 10/22/2022 when assigned twice a week visits. During an interview on 11/09/2022 beginning at 2:53 AM, the clinical director and clinical quality educator stated that there was no documentation for the missed visit for the week of 10/16/2022 through 10/22/2022 and they would expect visits to be made as ordered on plan of care.

Based on nationally-recognized standards, record review, and interview, the agency failed to provide services in accordance with current clinical practice guidelines and accepted standards of practice in one (Record/Patient #7) of one respite record reviewed when they failed to follow the Medicare Benefit Policy Manual regarding admission of a patient to respite care. --- Findings included: Review of the CMS Medicare Benefit Policy Manual, Chapter 9, Section 40.1.5- Short-Term-Inpatient Care 40.1.5 - Short-Term Inpatient Care (Rev. 10437, Issued: 11-06-20, Effective: 10-01-20, Implementation: 12-09-20) showed the following: - Respite care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons who normally care for the individual at home; - Respite care may be provided only on an occasional basis and may not be reimbursed for more than 5 consecutive days at a time; - Payment for the sixth and any subsequent day of respite care is made at the routine home care rate, and the patient would be liable for room and board; and - Respite care cannot be provided to hospice patients who reside in a facility (such as a long term care nursing facility). RECORD/PATIENT #7: Review of an IDG (interdisciplinary group) Report dated 10/05/2022 13:00 showed the following: - The patient was admitted on 9/29/2022 as an emergency admit with hospice diagnosis of malignant of unspecified breast (breast cancer); - Patient (Pt) was admitted to ";Named Facility" on 09/17/2022 for rehab after hospital stay; - Pt did not thrive in rehab- refused therapies and over last five days per staff refused medications and food/fluids was reduced to only bites and sips; - Pt was found to be minimally responsive on 09/29/2022 (at the rehab facility); - Emergency admit, symptom management completed and admitted on vigil cares; - Pt passed away peacefully on 09/30/2022 at 0452 AM with hospice RN at bedside; - Admit date was 09/29/2022 and level of care showed respite. During an interview on 11/08/2022 at 10:35 AM with the clinical director and the clinical quality educator, they stated that: - The facility the patient was at, was for a rehab stay; - The family was unable to care for the patient on the day of the planned discharge; and - The patient was admitted to hospice on respite and expired before the family was able to care for the patient at home. During an interview on 11/09/2022 at 3:10 PM the clinical quality educator stated that: - He/she read the Medicare guidelines and did the best he/she could, but it was confusing; - He/she did what he/she thought was best for the patient; - It was an unusual situation; and - We will back out the billing for that patient.

Based on policy review, record review, and interview, the agency failed to maintain a complete clinical record for each patient to include timely documentation of all visits completed by the registered nurse (RN) in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to adversely affect the quality and continuity of care provided to all patients served by the hospice. --- Findings included: Review of the agencys undated policy titled ";Clinical/Service Data Collection Policy No. C:2-033.1 showed, in part: - Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided; - A clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies found in this manual and will include at a minimum: * Dates, times, and types of interventions, assessments, and coordination of care/service; * Patient response to care and services is analyzed and documented as measurable goals; * Current patient status and progress toward goals; and * Outcomes of care/service. - Entries to the clinical service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization; - Entries into the clinical/service record will be clear, concise, and specific statements of fact; - Entries into the clinical/service record will be made on the day care/service is provided to the patient; and - All documentation will turned into the office at the end of the workday. RECORD/PATIENT #4: Review of the clinical record showed, in part, the patient was admitted to hospice on 04/29/2021with a primary diagnosis of heart failure, with orders for SN (skilled nurse) to visit two times a week, beginning the week of 05/02/2021 for symptom management. Review of a progress report showed the following information: - Visit information with a visit date of Wednesday, November 2 2022, discipline: RN, Visit time: 11:20-12:20, Sub Type: Routine in person, and made by ";named employee"; - Clinical assessments showed a covid screening was performed; and - There failed to be any other documentation from the RN visit. During an interview on 11/09/2020 at 3:30 PM the clinical director stated that: - I think its incomplete documentation, but the visit was made; and - Documentation is expected to be completed within 24 (twenty four) hours of the visit.

Based on policy review, record review, and interview, the agency failed to ensure physicians orders were obtained in, one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to adversely affect the quality of care provided to all patients served by the agency. --- Findings included: Review of the agencys undated policy titled ";Verification of Physician Orders Policy No. H:2-032.1" showed, in part: - Orders will be obtained from a license physician (or other authorized independent practitioner) for care and services to be provided to hospice patients; - Verbal orders will be spoken to, taken and documented only by professional, licensed hospice personnel; and - A qualified individual will review each order or prescription before care is provided. RECORD/PATIENT #4: Review of an SN (skilled nurse) visit note dated 10/26/2022, 10:30 to 11:30, showed pt. (patient) has a new area to RFA (right forearm) where another raised skin area was accidentally removed by patient pulling sleeve of t-shirt up, small amount of dried blood noted with small raised skin area underneath, area cleansed with wound cleanser, abx (antibiotic) ointment applied with dressing covering, instructions given for CG (caregiver) to remove old dressing, cleanse area with wound cleanser, apply small amount of abx ointment and cover with band aid or island dressing (absorbent pad with adhesive backing) left in the home. Review of the clinical record failed to show documentation of physician communication or a physician order for the treatment provided and instructed on. During an interview on 11/09/2022 the clinical director stated that: - He/she would expect the clinician to get physician orders for wound care; - We already have a PIP (performance improvement plan); and - A wound nurse is doing audits.

Based on policy review, record review, and interview, the agency failed to ensure that the discharge summary was sent to the attending physician in one (Record/Patient #8) of two live records reviewed. This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the agency. --- Findings included: Review of the agencys policy titled ";Discharge Summary Policy No. H:2-086.1", dated revised April 2018 showed: - All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; - Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: * The date of discharge, the date the physician and patient informed of discharge; * The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable; * The status of problems identified at admission and during the provision of care; * The resolution of identified problems; * Continuing symptom management needs; * The overall status of the patient; * A summary of the care or services provided; * The patients current plan of care; and * The patients latest physician orders. - The discharge summary and other relevant clinical record documents will be completed and submitted within 72 (seventy two) hours of discharge from service; and - A copy of the discharge summary will be provided to the patients attending physician. RECORD/PATIENT #8: Review of the clinical record showed: - The patient was admitted to hospice on 03/24/2022; - A clinical narrative note e-signed by the social worker on 05/22/2022 18:02 that showed the patient chose to revoke the hospice benefit to seek more aggressive treatment on 05/22/2022; - A telephone contact note e-signed by the RN dated 05/22/2022 15:11 that showed, in part, the patient and spouse have decided for aggressive treatment and that the patient will revoke from hospice services and go to ";named hospital" for aggressive treatment; - A revocation statement form signed by the patients legal representative (spouse) date 05/22/2022; - An IDG (interdisciplinary group) report note dated 05/31/2022, e-signed by the patients attending physician that showed on 5/22/2022 patient revocates hospice services to seek aggressive treatment. Patient transferred to ";named hospital" for aggressive treatment; - A discharge summary and checklist form with in part, the following items marked no: * Discussed discharge plans with patient and family; * Print final IDT (interdisciplinary team) report for attending physician; * Obtained discharge order from Medical Director; * Discussed/arranged for alternative services; * Notified IDT staff involved in care; * Notified volunteer; and * Notified equipment company. - Documentation failed to show that a discharge summary was sent to the attending physician. During an interview on 11/05/2022 at 10:15 AM the clinical manager stated that: - The medical director was the attending physician; and - The physician was informed of the patient revoking on 05/31/2022 during the IDG meeting. During an interview on 11/08/2022 at 10:55 AM the clinical director stated that no was answered to the items on the discharge summary and checklist form because the social worker completed it all on the day of revocation.

Based on policy review, record review, and interview, the agency failed to ensure a complete discharge summary containing all the components required by this regulation was completed in one (Record/Patient #8) of two live records reviewed. This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the agency. --- Findings included: Review of the agencys policy titled ";Discharge Summary Policy No. H:2-086.1", dated revised April 2018 showed: - All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record; - Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued, which may include, as appropriate: * The date of discharge, the date the physician and patient informed of discharge; * The reason for discharge, including the name of the organization to which the patient is being transferred, if applicable; * The status of problems identified at admission and during the provision of care; * The resolution of identified problems; * Continuing symptom management needs; * The overall status of the patient; * A summary of the care or services provided; * The patients current plan of care; and * The patients latest physician orders. - The discharge summary and other relevant clinical record documents will be completed and submitted within 72 (seventy two) hours of discharge from service; and - A copy of the discharge summary will be provided to the patients attending physician. RECORD/PATIENT #8: Review of the clinical record showed: - The patient was admitted to hospice on 03/24/2022; - A clinical narrative note e-signed by the social worker on 05/22/2022 18:02 that showed the patient chose to revoke the hospice benefit to seek more aggressive treatment on 05/22/2022; - A telephone contact note e-signed by the RN dated 05/22/2022 15:11 that showed, in part, the patient and spouse have decided for aggressive treatment and that the patient will revoke from hospice services and go to ";named hospital" for aggressive treatment; - A revocation statement form signed by the patients legal representative (spouse) date 05/22/2022; - An IDG (interdisciplinary group) report note dated 05/31/2022, e-signed by the patients attending physician that showed on 5/22/2022 patient revocates hospice services to seek aggressive treatment. Patient transferred to ";named hospital" for aggressive treatment; and - A discharge summary and checklist form with in part, the following items marked no: * Discussed discharge plans with patient and family; * Print final IDT (interdisciplinary team) report for attending physician; * Obtained discharge order from Medical Director; * Discussed/arranged for alternative services; * Notified IDT staff involved in care; * Notified volunteer; and * Notified equipment company. Further review of the clinical record failed to show a discharge summary containing the following required information: - A summary of the patients stay including treatments, symptoms and pain management; - The patients current plan of care; and - The patients latest physician orders. During an interview on 11/05/2022 at 10:15 AM the clinical manager stated that: - The medical director was the attending physician; and - The physician was informed of the patient revoking on 05/31/2022 during the IDG meeting.

Based on review of the agencys general inpatient (GIP) and respite contracts, and interview, the agency failed to ensure the contracts specified the provision that hospice must report 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 unrelated to the hospice to the administrator within 24 (twenty four) hours of becoming aware of the alleged violation. This deficient practice has the potential to adversely affect the care of any patient that receives GIP or respite care. --- Findings included: Review of the signed GIP agreement dated by the hospice regional executive director on December 13, 2021 and dated by the hospital president and CEO (chief executive officer) on January 20, 2022 failed to include the provision stating that the hospice would notify the administrator of alleged violations within 24 hours. Review of the signed respite contract dated by the hospice executive director 11/29/17 and signed by the respite facility regional executive director on 12/01/17 (this date is difficult to read, it could possibly show 2/07/17) failed to include the provision stating that the hospice would notify the administrator of alleged violations within 24 hours. During an interview on 11/09/2022 at 09:05 AM, the clinical director acknowledged that the contracts were missing the part about the facility administrator being notified within 24 hours of becoming aware of alleged violations.

Based on Federal and Missouri state law review, employee and volunteer file review and interview, the agency failed to: - Check the EDL (employee disqualification list) prior to hire on one (Volunteer #1) of one volunteer file reviewed; and - Provide Alzheimers and related dementia education at orientation on, but not limited to, two (Employees #2 and #3) of six employee files reviewed. This deficient practice has the potential to adversely affect all patients served by the agency. --- Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of 19 CSR 30-35.010 (2) (M) 1. B. (xiii) requires: "Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. (a) At a minimum, the training required shall address the following areas: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; and E. Understanding and dealing with family issues. (b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; and B. Communicating with persons with dementia. (c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed. " Review of volunteer and employee files showed the following: - Volunteer #1: * Hire date 10/26/2021; and * EDL completion date of 11/05/2021. - Employee #2: * Hire date 06/10/2021; and * Alzheimers and related dementia education date of 10/31/2022 (over a year later); and - Employee #3: * Hire date of 09/06/2021; and * Alzheimers and related dementia education date of 10/25/2022 (over a year later). During an interview on 11/09/2022 at 11:55 AM the volunteer coordinator stated that he/she was not aware that the EDL had to be done prior to hire. During an interview on 11/09/2022 at 10:15 AM the office manager stated that: - He/she was unable to find where employee #2 had completed the Alzheimers training on hire; and - He/she did not find where employee #3 had done Alzheimers training on hire.

Based on agency admission booklet on patient rights, the agency's complaint log, record review, and interview, the agency failed to immediately investigate alleged violations and take action to prevent further potential violations for one patient (Record/Patient #1) of three records reviewed. This deficient practice has the potential to adversely affect the rights of all the agency's patients. Findings included: Review of the agency's policy titled, "Assessment of Possible Abuse/Neglect," dated revised April 2018, failed to show that the agency would immediately investigate alleged violations and take immediate action to prevent further potential violations. Review of the agency's admission booklet, dated revised April 2021, showed the following: -The patient has the right to be free from mistreatment, neglect, verbal, mental, sexual, and physical abuse, corporal punishment, injuries of unknown source, and misappropriation of patient property; -All mistreatment, abuse, neglect, injury and exploitation complaints by anyone furnishing service on behalf of hospice are reported immediately by agency staff to the hospice administrator; and -All reports will be promptly investigated and immediate action taken to prevent potential violations during the agency investigation. Review of the agency's complaint log, dated 12/16/2021, showed LPN (licensed practical nurse) A, reported to the agency regional manager that Patient #1 had alleged that agency staff member hospice aide B had been rough with him/her in the shower and hit him/her in the mouth and was argumentative with him/her at the dining room table. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 08/20/2019. The terminal diagnosis was senile degeneration of the brain (dementia that is characterized by a decrease in cognitive abilities or mental decline). The patient lived in an assisted living facility and was 106 years old. The hospice aide was to visit twice weekly and the hospice nurse was to visit weekly. During an interview on 12/27/2021 at 12:50 PM, the executive director stated that: -He/she was aware of the allegation; -That hospice aide B would not be allowed to care for Patient #1; -Did not immediately interview any other patient's that hospice aide B had cared for; and -Hospice aide B was allowed to continue to care for all other patients. The agency failed to complete an immediate investigation and take immediate action to prevent potential violations.