Every finding on record at Cox Hps of the Ozarks, Inc.

Upon patient record review, 5 of 19 (Patient #3, #4, #5, #7, #10) 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 #3: There is evidence on the medication record that the route for Atropine drops was ophthalmic rather than oral. In addition, there was no reason indicated for PRN medication Atropine. corrected on site Patient #4: There is evidence on the medication record that Sustain eye drops every 4 hours as needed did not indicate which eye or eye(s). corrected on site Patient #5: There is evidence in the medication record that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. corrected on site Patient #7: There is evidence in the medication record that Acetaminophen suppository PRN, did not include a reason for use. In Addition, Carvedilol hold for hypotension did not identify a blood pressure reading for hold. corrected on site Patient #10: There is evidence in the medication record that Acetaminophen suppository PRN one every 6 months as needed, this PRN did not include a reason for use. In addition, Atropine 1% eye was written as ointment rather than drops and the route was ophthalmic rather than oral.

Upon patient record review, 6 of 19 (Patient #3, #4, #5, #7, #10, #12) 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 #3: There is evidence on the plan of care that the route for Atropine drops was ophthalmic rather than oral. In addition, there was no reason indicated for PRN medication Atropine. corrected on site Patient #4: There is evidence on the plan of care that Sustain eye drops every 4 hours as needed did not indicate which eye or eye(s). corrected on site Patient #5: There is evidence in the plan of care that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. corrected on site Patient #7: There is evidence in the plan of care that Acetaminophen suppository PRN, Haldol, PRN and Bisacodyl suppository PRN did not include a reason for use. In Addition, Carvedilol hold for hypotension did not identify a blood pressure reading for hole. corrected on site Patient #10: There is evidence in the medication record that Acetaminophen suppository PRN one every 6 months as needed. In addition, this PRN did not include a reason for use. In addition, Atropine 1% eye was written as ointment rather than drops and the route was ophthalmic rather than oral. corrected on site Patient #12: There is evidence in the medication record that Acetaminophen suppository PRN and Bisacodyl suppository PRN did not include a reason for use. In addition, Nitroglycerine 0.4 mg SL q 5 min as needed for chest pain, did not include a total dose. In addition, Oxygen indicated the route was oral. corrected on site

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #7: There is evidence of an order for foley catheter on 6/30/24. The plan of care was not updated to include risk for infection/discomfort due to foley catheter insertion. (Corrected on site.)

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. Patient 10: On 6/1/24, it was noted the patient had a urinary tract infection that required medication to treat. However, these infections were not recorded in the hospice's log for tracking and trending of QAPI data.

Upon patient record review, 3 of 19 (Patient #1, #6, #7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There is evidence in the Plan of Care that the patient is at risk for bleeding. The HHA plan of care did not include bleeding precautions. corrected on site Patient #6: There is evidence in the Plan of Care that the patient is using Oxygen. The HHA plan of care did not include Oxygen precautions. corrected on site Patient #7: There is evidence in the Plan of Care that the patient had a foley catheter inserted on 6/30/24. On 7/8/24, the HHA plan of care continued to state incontinence care and was not updated to foley care. corrected on site

Upon patient record review 2 of 19 (Patient #3, #7) 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: There is evidence in the record that the HHA plan of care ordered shampoo 1Xweek. The week of 7/14/24, the HHA completed a shampoo 2X. Patient #7: There is evidence in the record that the HHA plan of care ordered 2 visits per week. The week of 6/30/24 there was one HHA visit.

Upon patient client record review, 14 of 19 (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #16, #17, #18, #19) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1-#10 and #16-#19: There is evidence in the record that when agency staff sign the Election of Benefits, credentials are not included.

Based on review of the hospice provider's admission booklet, clinical record review, and interviews, the hospice provider failed to ensure the patient received effective pain management and symptom control from the hospice for conditions related to the terminal illness in one of three records reviewed (Record/Patient #1). This deficient practice has the potential to affect the rights of all the hospice provider's patients. Findings included: --- On 06/06/2023 at 12:30 PM, review of the hospice providers admission booklet that is provided to all patients at start of care showed that the patient had the right to receive effective pain management and symptom control from the hospice for conditions related to the terminal illness. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted on 02/18/2023 to hospice services with a terminal diagnosis of diastolic congestive heart failure (a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body). The patient resided in a private residence with their adult child and the childs significant other. Review of the clinical record showed that: - On 03/24/2023: * An as needed registered nurse visit was performed at 10:36 AM to evaluate post fall pain (the patient had fallen at home on 03/23/2023); * The patient had an area on the lumbar spine that seemed to be painful with palpitation. * The physician was notified; * Physician orders were received for a portable x-ray to left hip, pelvis, and lumbar spine; and * A requisition for portable service for stat (as soon as possible) x-rays was signed by the patients physician on 03/24/2023. - On 03/27/2023: * At 09:37 AM, the x-ray technician reported that the patients adult child had refused to have the portable x-ray performed; and - The clinical record failed to contain documentation that the physician was notified that the stat x-ray had not been performed. During an interview on 06/06/2023 at 10:45 AM the administrator and the quality assurance nurses stated that: - It is not standard practice to send patients to the emergency room for evaluation following a fall. We will send patients to the emergency room if the family requests, but if the family doesnt want the patient sent to the emergency room, we have made arrangements for an x-ray to be obtained at home. We expect the x-ray to be obtained by the next day. During an interview on 06/08/2023 at 1:00 PM, the administrator stated that they would expect the physician to be notified of a delay in obtaining a stat mobile x-ray, and the clinical record failed to contain documentation that the physician was notified in a timely manner that the x-ray had been delayed and refused.

Based on policy review, clinical record review, home visit observation, and interview, the agency failed to ensure that coordination of care with the long term care facility (LTCF) was effective when the hospice failed to: - Ensure that the agency assumed responsibility for professional management of the resident's hospice services (L762); and - Ensure that the plan of care identified the care and services that were needed and specifically identified which provider was responsible for performing the respective functions (L774). --- The cumulative effect of these systemic practices resulted in the agency's inability to effectively provide care and services to hospice patients that reside in a LTCF.

Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure that the hospice assumed responsibility for professional management of the long-term care facility (LTCF) resident's hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation in two (Records/Patients #3 and #5) of four records reviewed. This deficient practice has the potential to affect the professional management of all of the agency's patients. --- Findings included: Review of the agency's policy titled, "CHAH (Cox Health at Home) Hospice Interdisciplinary Team Plan of Care," and dated 11/21/2022 showed that: - At the time of admission, a written Plan of Care is initiated in collaboration with the patient and/or family, which includes: * The scope and frequency of services needed to meet the patient and familys needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care; and * The Interdisciplinary Team provides for the sharing of information with other team members as well as other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. CHAH Hospice must ensure that the Interdisciplinary team maintains responsibility for directing, coordinating and supervising the care and services provided. RECORD/PATIENT #3:Review of the plan of care (POC) dated 12/19/2022, showed in part diagnoses that included cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and vascular dementia. Nursing interventions included to assess for pain and comfort and instruct in symptom control measures as needed with condition changes. Review of a chaplain note dated 12/21/2022 showed the patient complained of severe pain on the left side of his/her abdomen. The chaplain contacted the RNCM (registered nurse case manager) who will talk to the long term care facility (LTCF) nurse. Review of the record showed no documentation of follow up with the LTCF nurse by the RNCM regarding the patients pain. Review of the LTCF nursing notes showed no documentation on 12/21/2022. Review of the LTCF medication administration record (MAR) dated 12/01/2022 through 12/31/2022 showed:- An order for Norco (a narcotic pain medication that contains Tylenol) 5-325 milligrams (mg), give 0.5 (half) tablet as needed daily for pain;- An order for Tylenol 325 mg two tablets by mouth every four hours as needed for pain; and- No documentation of administration of Norco or Tylenol for pain. Review of the RN hospice visit note dated 12/22/2022 showed FLACC (a behavioral pain assessment scale used for people who are unable to rate their pain on a pain scale) score was zero. Bowel sounds were active times four quadrants. The patient had a medium bowel movement on 12/20/2022. There was no documentation regarding the chaplains report on 12/21/2022. Review of a case communication note dated 01/29/2023 showed the LTCF nurse called to let the hospice know that the patient was somewhat distended (swollen, usually refers to the abdomen). The patient stated ";It hurts," The patient was having bowel movements daily. The LTCF declined a visit but wanted to make the hospice aware. RNCM please follow up on Monday. There was no documented discussion regarding the patients pain medications. Review of the record showed no documentation of follow up with the facility regarding the patients pain and distention. Review of the LTCF nursing note dated 01/29/2023 showed the resident complained of pain on the left side of his/her abdomen. The left side of the abdomen appeared distended and non-tender to touch and palpate (palpation, touch). The resident stated, ";It just hurts." The resident had bowel movements charted daily and did not feel the urge to have a bowel movement. Bowel sounds present times four quadrants. The nurse called the hospice to notify of condition change. The hospice nurse stated to monitor and if anything worsens to call hospice again and they will come to facility. The hospice nurse stated the next scheduled visit was Tuesday or Wednesday but they would come sooner if needed. There was no documented discussion regarding the patients pain medications. Review of the LTCF MAR dated 01/01/2023 through 01/31/2023 showed no documentation of Norco or Tylenol being administered on 01/29/2023. Per interview conducted during observation on 02/01/2023, beginning at 9:30 AM, the hospice nurse talked with the LTCF charge nurse. The charge nurse stated that the patient had a large and medium bowel movement the previous day. There was no discussion regarding the phone call on 01/29/2023 of the patient being distended and having pain. Observation showed the patient sat in his/her room in a specialized wheelchair. The patient slept throughout the nurses assessment. During an interview on 02/01/2023 beginning at 10:00 AM, the LTCF charge nurse stated that the patient rarely had pain. The patient used to have problems with constipation but not recently. His/her bowel medications were working. The patient had a medium and a large bowel movement the previous day. During an interview on 02/02/2023, beginning at 10:00 AM, the administrator stated that when staff reported a concern to the RNCM, he/she would expect the nurse to follow up and document the follow up. He/she would have expected the nurse to call the facility when he/she received the phone call from the chaplain. He/she would have expected the nurse to make a visit on Monday after the call from the LTCF on 01/29/2023. RECORD/PATIENT #5:Review of the hospice RN evaluation visit dated 11/28/2022, showed the patient had presented to his/her physician office for a left inguinal (groin) lump that had been present approximately two months. The patient underwent a surgical excision of the mass and pathology (testing) showed the mass to be cancerous. The patient was discharged to a LTCF. The patient had a large edematous (swollen) area to the right (should be left) groin/pubic area with discoloration noted. The incision appeared healed and skin is intact and approximated. There was no documented discussion regarding wound care for the patient or clarification regarding wound care orders. Review of the POC dated 11/28/2022 showed no wound care orders for the left groin area. Review of the RN visits showed:- On 11/30/2022 the patient denied pain to the left groin area. The FLACC (a behavioral pain assessment scale used for people who are unable to rate their pain on a pain scale pain scale) assessment was zero. The facility staff reported the physician drained the site of infection earlier in the day, no drainage noted at this time. The patient was started on an antibiotic. No documented discussion regarding whether the patient needed wound care to the site or whether Mepilex was used;- On 12/06/2022 the wound assessment showed the anterior (front) suprapubic abscess had a depth of 0.1 centimeters (cm) with 100% epithelial tissue (healing), no drainage, surrounding skin was intact with edema (swelling) and erythema (redness). The physician drained the area on 11/30/2022. The area was now closed and healing appropriately per the physician. The patient finished his/her antibiotic. No wound care needed; and- On 12/08/2022 the patient denied pain to the left groin area. FLACC scale was zero. The area had discoloration without warmth. Review of a case communication note dated 12/09/2022 showed the social worker received a call from the patients family member who reported concerns about the patient aspirating. He/she called the LTCF to check on the patient and was told that the patient ate well at breakfast and lunch. The family member reported the patient had been very lethargic the night before and did not think the patient would be awake enough to eat. He/she thought they were going to stop feeding the patient due to this. The social worker called the patients nurse and informed him/her of the concerns. Review of the record showed no documentation of follow up with the LTCF regarding the family members concerns. During an interview on 02/02/2023, beginning at 10:00 AM, the administrator stated that the nurse should have followed up and documented their follow up with the LTCF after they received the call from the social worker.

Based on agency policy, record review, home visit observation, and interview, the agency failed to ensure that the hospice plan of care identified the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care in three (Records/Patients #1, #5 and #6) of four records reviewed. This deficient practice has the potential to affect the coordination of care for all of the agency's patients. Findings included: --- Review of the agency's policy titled, "CHAH (Cox Health at Home) Hospice Interdisciplinary Team Plan of Care," and dated 11/21/2022 showed that: - At the time of admission, a written Plan of Care is initiated in collaboration with the patient and/or family, which includes the scope and frequency of services needed to meet the patient and familys needs and by whom the services will be provided, prescribed and required medical equipment, supplies, medications, treatments and the level of care. Review of the document titled, "Long-Term Care/Hospice Coordination of Care Form," and dated 07/20/2022 showed that the coordination of care form will contain signatures of the LTC (Long-Term Care) representatives informed of the changes [in the plan of care]. RECORD/PATIENT #6: Review of the clinical record showed the patient was admitted to hospice services on 11/15/2022 with a terminal diagnosis of sepsis (life threatening infection) and encephalopathy (a disease of the brain that alters brain function or structure). The patient resided in a long-term care facility (LTCF). Review of the plan of treatment dated 11/15/2022 showed the patient had:- Wounds on their right upper abdomen, right heel, right rib cage, and sacrum (tail bone); and * The sacral wound order stated to cleanse the wound with soap and water, apply Triad (wound cream) cream to wound bed, change every three days; * The right heel wound order stated to cleanse the heel with normal saline, and apply a foam dressing; - A urinary catheter that was to be changed monthly; and- Hospice aide services for personal care and bathing. Review of the document titled, "Hospice/LTC Coordinated Task Plan of Care," and dated 11/15/2022 failed to contain:- A schedule for wound care to identify who was responsible for the provision of care and oversight;- Identification of who would be responsible for catheter changes; and- The frequency and days that hospice aide services would be provided. Review of the document titled, ";Order Summary Report," printed 02/01/2023 showed that the facility received orders:- For the sacral wound: * On 11/17/2022 to cleanse sacral wound with wound cleanser, apply hydroconductive dressing to wound bed and cover with optifoam (a foam dressing) dressing, change every three days; * On 12/07/2022 to cleanse sacral wound with facility choice wound cleanser, apply Santyl (a medication used to dissolve dead tissue in wounds) to wound bed, then pack with gauze dampened with VASHE (a wound cleansing solution) for wet to dry dressing to wound bed and cover with silicone boarder gauze dressing two times per day; - For the right heel wound: * On 11/17/2022 to apply skin prep to the right heel daily; Review of the hospice clinical record showed the hospice plan of care failed to contain the updated orders for care of the sacral wound and the right heel wound until 12/26/2022. RECORD/PATIENT #5:Review of the coordinated task plan of care (a form that shows coordination of care between the hospice and LTCF staff for patients that reside in a LTCF dated (unable to read date) showed:-The patient had a wound to the left suprapubic (above the pelvic area) area;-The hospice nurse wound care schedule was Tuesday and Thursday and the LTCF would be responsible for all other days;-Wound-Mepilex (foam dressing); -Signed by the hospice nurse; and-No signature by the LTCF staff. Review of the hospice RN evaluation visit dated 11/28/2022, showed the patient had presented to his/her physician office for a left inguinal (groin) lump that had been present approximately two months. The patient underwent a surgical excision of the mass and pathology (testing) showed the mass to be cancerous. The patient was discharged to a LTCF). The patient had a large edematous (swollen) area to the right (should be left) groin/pubic area with discoloration noted. The incision appeared healed and skin is intact and approximated. There was no documented discussion regarding wound care for the patient or clarification regarding wound care orders.Review of the POC dated 11/28/2022 showed no wound care orders for the left groin area. Review of the RN visits showed:- On 11/30/2022 the patient denied pain to the left groin area. The FLACC (a behavioral pain assessment scale used for people who are unable to rate their pain on a pain scale pain scale) assessment was zero. The facility staff reported the physician drained the site of infection earlier in the day, no drainage noted at this time. The patient was started on an antibiotic. No documented discussion regarding whether the patient needed wound care to the site or whether Mepilex was used;- On 12/06/2022 the wound assessment showed the anterior (front) suprapubic abscess had a depth of 0.1 centimeters (cm) with 100% epithelial tissue (healing), no drainage, surrounding skin was intact with edema (swelling) and erythema (redness). The physician drained the area on 11/30/2022. The area was now closed and healing appropriately per the physician. The patient finished his/her antibiotic. No wound care needed; and- On 12/08/2022 the patient denied pain to the left groin area. FLACC scale was zero. The area had discoloration without warmth. During an interview on 02/02/2023, beginning at 10:00 AM, the administrator stated that he/she was not sure about the date on the coordinated task POC. The hospice nurse should have the LTCF facility staff sign the coordinated task POC. Staff should document they reviewed the wound care with the LTCF or clarify if wound care was needed. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a LTCF. Review of the undated document titled, ";Long-Term Care/Hospice Coordination of Care Form," showed the document failed to contain signatures of the hospice staff or the LTCF staff. During an interview on 02/01/2023 the hospice nurse stated that the form was not signed and that the form had been at the facility since 01/30/2023.