Every finding on record at Crown Hospice of Poplar Bluff, LLC

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 reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed it was revealed that the agency did not ensure that the comprehensive assessment was updated based on changes that had taken place since the initial assessment. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/25/2025. At admission, the patient had an extensive right foot wound exposing tendons. Although the wound was photographed at admission, measurements were not obtained. Nursing documentation throughout care was vague, with entries such as ‘wound present’ and ‘wound improving.’ The wound was photographed during the healing process, and wound care treatment was discontinued on 11/23/2025 following complete healing. However, while the wound was assessed, required elements of a comprehensive wound assessment—such as measurements, evaluation of tissue characteristics, general appearance, drainage, and signs or symptoms of infection—were not documented. CLINICAL RECORD 5: The patient elected the benefit on 03/13/2025. On 06/19/2025, the patient developed a coccyx wound requiring daily wound care orders. At the time of onset, no wound measurements or photographs were documented. As of 12/01/2025, the wound remains present, though noted as improving. Documentation examples include: 07/07/2025 – ‘wound to coccyx remains present’; 09/02/2025 – ‘wound continues to show improvement’; and 12/01/2025 – ‘small open area on coccyx with continued improvement.’ While the wound was being assessed, required elements of a comprehensive wound assessment—such as measurements, general appearance, evaluation of tissue characteristics, signs and symptoms of infection, and photographic evidence have not been documented. CLINICAL RECORD 6: The patient elected the benefit on 06/04/2025. On 08/11/2025 the patient developed a wound on the right upper buttocks requiring daily wound care orders. The nursing documentation has only vague statements regarding the wound that it is improving and wound still present. While the wound was being assessed, required elements of a comprehensive wound assessment—such as measurements, evaluation of tissue characteristics, signs and symptoms of infection, and photographic evidence have not been documented. Following a joint record review and an interview with the Program Director and Director of Clinical Services on 12/11/2025, both confirmed that the agency’s expectation is for wound assessments to be completed weekly. These assessments must include measurements and evaluation of wound characteristics, such as drainage and signs or symptoms of infection, for all patients, including those in facilities. horrible right foot wound opens down to the tendons. Wound-healing treatment was discontinued on 11/23/2025. Not consistent wound assessments vague comments like wound continues to improve. few measurements noted.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following interventions to manage pain and symptoms. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed the agency did not ensure that the patient's individualized written plan of care includes all services necessary for the palliation and management of the terminal illness including planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/01/2025. A review of the clinical record revealed that the initial plan of care dated 04/02/2025 did not include specific interventions or instructions for managing the patient’s PleurX chest tube drain. On 04/02/2025, the registered nurse documented cleansing the drain site and applying a new border gauze; however, the plan of care lacked any guidance or interventions related to drain management. Although the assessment noted the patient was independent in draining the tube, this was not reflected in the plan of care. The drain was subsequently removed by the physician on 05/22/2025. During a joint record review and interview on 12/10/2025, the Program Director (Personnel Record 1) and Director of Clinical Services (Personnel Record 2) acknowledged that the plan of care lacked specific interventions addressing an identified and assessed problem.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient and must include physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed revealed the agency did not ensure that orders were obtained for all necessary services. CLINICAL RECORD 3: The patient elected the hospice benefit on 04/01/2025. At that time, standing orders included oxygen at 2 liters via nasal cannula as needed, with instructions to increase to 3 liters as needed. However, nursing documentation on 11/24/2025, 11/26/2025, and 12/08/2025 reflected the patient utilizing oxygen at 4–5 liters via nasal cannula as needed. These changes in oxygen usage were not reflected in the plan of care and were not supported by updated physician orders. During a joint record review and interview on 12/10/2025, both the Program Director (Personnel Record 1) and the Director of Clinical Services (Personnel Record 2) acknowledged that an updated physician order was required to reflect the increased oxygen usage documented in the clinical record.

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 7 (14%) clinical records reviewed of patients residing in a facility it was revealed that the agency did not identify which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 6: The patient elected the benefit on 06/04/2025. On 08/11/2025 wound care orders were initiated for a coccyx wound: cleanse with wound cleanser, apply calcium alginate, and cover with Optifoam gentle/silicone border dressing daily. On 10/07/2025, new orders were issued: cleanse with wound cleanser, apply Medihoney and Flagyl, then pack with packing strip daily and as needed. On 10/22/2025, the order was revised to remove Medihoney, continuing Flagyl and packing. There was no documented evidence to delineate responsibility for dressing changes between facility staff and hospice staff. Following a joint record review and an interview with the Program Director (Personnel Record 1) and Director of Clinical Services (Personnel Record 2) on 12/11/2025, both confirmed that the physician’s order did not specify whether dressing changes were to be performed by hospice staff or facility staff.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), 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 a review of clinical records, document reviews and interviews. In 3 of 13 (23%) clinical records reviewed it was revealed that the agency did not complete an initial bereavement risk assessment as part of the comprehensive assessment no later than five calendar days after the election of hospice care. Agency policy, "1-021 Bereavement Assessment, Revised September 2020", stated in part: "On admission, the social worker or registered nurse will complete a bereavement risk assessment that is given to the bereavement coordinator. At a minimum, it will include: patient and family/caregiver loss issues, survivor needs, grief risk factors and potential for pathological grief reactions." Clinical Record 1 - The patient elected their hospice benefit on 9/15/22. The Chaplain/Bereavement Coordinator completed the initial bereavement risk assessment on 9/28/22, which was 13 days after election of hospice care. Clinical Record 4 - The patient elected their hospice benefit on 9/5/22. The Chaplain/Bereavement Coordinator completed the initial bereavement risk assessment on 9/15/22, which was10 days after election of hospice care. Clinical Record 13 - The patient elected their hospice benefit on 8/12/22. The Medical Social Worker completed the initial bereavement risk assessment on 8/25/22, which was 13 days after election of hospice care. In an interview on 1/19/23, the Administrator (Staff 1) stated that the nurse or social worker should have conducted the initial bereavement risk assessment upon admission if the Chaplain/Bereavement Coordinator was not able to.

It is required that each patient’s individualized written plan of care: Reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 13 (23%) clinical records reviewed it was revealed that the agency did not ensure the written plans of care included documentation of all of the care and services necessary based on the problems identified in the comprehensive assessments. Clinical Record 2 - The patient elected their hospice benefit on 1/11/23. The "RN (registered nurse) Initial Assessment" dated 1/11/23 documented: "Is pain an active problem for the patient: Yes." The assessment also documented: "Did the screening indicate the patient had shortness of breath: Yes", and "Was treatment for shortness of breath initiated: Yes", with "types of treatment for shortness of breath: opioids, other medications, oxygen, and non-medications." The Plan of Care Order dated 1/11/23 for benefit period dates of 1/11/23 - 3/11/23 did not contain documentation that described patient and/or family goals or planned interventions to address the patient's pain or dyspnea. Clinical Record 3 - The patient elected their hospice benefit on 11/25/22. The "RN Initial Assessment" dated 11/25/22 documented: "Did the screening indicate the patient had shortness of breath: Yes", and "Was treatment for shortness of breath initiated: Yes", with "types of treatment of shortness of breath: opioids, other medications, oxygen, non-medications." The assessment also documented: "Difficulty swallowing foods and fluids, difficulty chewing... dysphagia reported... nutrition screening score: 12, risk high. For High risk (7 or greater) coordinate with IDG about how to best address individual/family needs. Reassess nutritional status and educate based on plan of care." The Plan of Care dated 11/25/22 for the benefit period of 11/25/22 to 1/23/23 did not contain documentation that described patient and/or family goals or planned interventions to address the patient's dyspnea, nutrition, or dysphagia. Clinical Record 4 - The patient elected their hospice benefit on 9/5/22. A Physician order dated 10/28/22 ordered, "Cefuroxime Axetil oral tablet 500mg, one tablet by mouth twice a day for 10 days. Indication: UTI (urinary tract infection)." The Nurse Practitioner assessment on 10/28/22 documented "UTI." Plan of care dated 10/25/22 for benefit period 9/5/22 to 11/4/22, which was reviewed during the Interdisciplinary Group Meeting on 11/1/22, did not contain documented evidence that the plan was updated and described patient and/or family goals or planned interventions to address the patient's urinary tract infection. In an interview on 1/19/23, the Director of Nursing (Staff 2) confirmed the plan of care did not address the problems identified in the initial and updated comprehensive assessments.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: The types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 2 of 2 (100%) clinical records reviewed in which bereavement services were being provided following the death of the patient, it was revealed that the agency did not have documentation of a bereavement plan of care that included a description of the types of bereavement services to be offered and the frequency of services being provided. Agency policy, "9-023 Bereavement Services, Revised April 2019", stated in part: "A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: a bereavement plan of care." Clinical Record 12 - The patient elected hospice benefit on 7/19/22 and died on 10/18/22. The IDG (interdisciplinary group) meeting documentation dated 10/21/22 included evidence of a bereavement plan of care that was identified and initiated on 7/19/22 and then documented as resolved on the date of death on 10/18/22. Following the death of the patient, the Bereavement Coordinator conducted a condolence call via phone and began sending bereavement mailings to the bereaved. There was no documentation of a bereavement plan of care in place after the death of the patient on 10/19/22. Clinical Record 13 - The patient elected hospice benefit on 8/12/22 and died on 10/8/22. The Plan of Care Order dated 10/8/22 included a bereavement plan of care that was identified and initiated on 8/12/22 and then documented as resolved on the date of death on 10/8/22. Following the patient's death, the Bereavement Coordinator conducted a condolence call via phone and began sending bereavement mailings to the bereaved. There was no documentation of a bereavement plan of care in place after the death of the patient on 10/8/22. In an interview on 1/20/23, the Director or Nursing (Staff 2) stated: "The Bereavement Coordinator keeps an Excel tracking sheet on his computer of all of the bereaved that includes their phone calls, mailings and other bereavement activity, along with when each item is due to be completed." The Director or Nursing also stated: "When we document the patient's death in the clinical record, our EMR automatically puts an end date on the open plans of care, and we did not initiate another bereavement plan of care on those two patients."

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 13 (7%) clinical records reviewed it was revealed that the agency did not ensure that all physician orders were included in the patient's clinical record. Clinical Record 12 - The patient elected their hospice benefit on 7/19/22. The RN (registered nurse) skilled nursing visit note dated 10/14/22 documented: "wound number 7 location: left food pad by toes, status: open, length 7.2cm, width 5.5cm, apply Betadine to dry gangrene areas and Medihoney to wet gangrene, cover with foam, abd pad and wrap 3 times weekly and PRN". The clinical record did not contain documentation of a physician order for wound care to the left food pad. The Director of Nursing (Staff 2) was interviewed on 1/20/23 and reported they were unable to locate documentation of the physician order.

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 and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 3 (33%) clinical records reviewed in which the patient was a live discharge from the hospice agency and care was transferred to a Medicare/Medicaid certified facility, it was revealed that the agency did not forward a copy of a discharge summary to the receiving facility. Agency policy, "1-025: Discharge From Hospice Program, Revised September 2020", stated in part: "When a patient is discharged, transferred, or referred to another organization, relevant information will include: reason for discharge, physical and psychosocial status at the time of transfer or discharge, including specific medical, psychosocial, or other problems requiring intervention or follow up, summary of the care provided and progress towards achieving goals, a copy of the current plan of care, a copy of the medication profile including discontinued medications, the latest physician orders... Documentation will be filed in the clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours". Clinical Record 10 - The patient elected their hospice benefit on 7/15/22. Documentation on "SN (skilled nurse) Revocation Statement", dated 12/7/22, stated: "Hospice services revocated 12/7/22 to seek aggressive treatment. Patient was transferred to (hospital name) via (emergency ambulance service name) for aggressive treatment." There was no documented evidence that a discharge summary was forwarded to the receiving hospital. In an interview on 1/20/23, the Director of Nursing (Staff 2) stated they were not aware of the need to send a copy of a discharge summary to a receiving hospital if the patient and/or family requested to revoke the hospice election of benefit.