Every finding on record at Faith Health Holding, Inc

Based on policy review, record review, and interview, the hospice provider failed to ensure:- The interdisciplinary group (IDG) met the needs of the patient and family (L0539); and- An individualized POC was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments (L0545).

Based on policy review, record review, and interview, the hospice provider failed to ensure that the interdisciplinary group (IDG) provided care in its entirety to meet the needs of the patient, in one of three records reviewed (Record/Patient #3). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Interdisciplinary Group Coordination of Care," dated May 2024, showed in part:- The hospice interdisciplinary group will retain professional management responsibilities for the provision of services and will ensure services are furnished in a safe and effective manner;- The case manager will be responsible for coordination of services with the IDG from admission to discharge;- The type and scope of services provided by the IDG will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care (POC) that defines patient and family/caregiver problems, goals, and interventions;- The exact combination of services and the level of care will be unique to each patient and family/caregiver unit and will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice;- It will be the responsibility of the case manager to facilitate communication about changes in the patient’s status between IDG members and the patient’s attending physician;- Hospice personnel will communicate changes in a timely manner, documentation of all communication will be documented in the clinical record;- Written evidence of care coordination will be found in the POC and/or IDG meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician; and- The IDG (in collaboration with the patient’s attending physician, if any) will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 days. Review of the provider's policy titled, "Interdisciplinary Group Meeting," dated May 2024, showed in part:- The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC; and- An IDG meeting POC update form will note changes, response to treatment, and progresses toward targeted outcomes, which may include, but not (be) limited to nutritional status, pain management, and plan for changes in treatment or procedures. Review of the provider's policy titled, "PEG (Gastrostomy)/Eternal Tube Management-Hospice," dated 08/01/2025, showed in part:- Enteral Tube: PEG, G-tube, J-tube, GJ-tube used for nutrition, hydration, and/or medication delivery (PEG, G-tube, J-tube, enteral tube - a tube placed surgically through the abdominal wall into the stomach or intestine for the administration of food, fluids, and medication) ;- To establish safe, patient-centered, comfort-focused standards for assessment, care, medication administration, feeding, troubleshooting, and documentation for patients with percutaneous endoscopic gastrostomy (PEG) or other enteral access (G-tube, J-tube, GJ-tube) receiving hospice services;- Care aligns with goals of care (comfort/quality of life) and the hospice plan of care; - New tube placement after hospice admission is generally not pursued; any exception requires MD (medical doctor) approval, IDG review, and documentation that the intended benefit is palliative (comfort) rather than life-prolonging; - Care is provided per manufacturer IFU (instructions for use), evidence-based practice, and state nurse practice standards;- RN (registered nurse): Initial/ongoing assessment, education, competency validation, tube/skin care, feeding/med admin protocols, troubleshooting, documentation, escalation;- LPN (licensed practical nurse): Performs care within scope under RN supervision;- Medical Director/Attending: Orders, risk–benefit review, decisions on initiation/continuation/taper/discontinuation; and- IDG: Reviews goals, outcomes, complications, and POC at least every 15 days or with change in condition. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 12/06/2023 with a terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood).  Other pertinent diagnosis included malignant neoplasm (a cancerous tumor) of the lower right bronchus (major air passages of the lung) or lung, malignant neoplasm of the larynx (the hollow muscular organ forming an air passage to the lungs and holding the vocal cords), presence of automatic cardiac defibrillator (a battery-powered device that monitors and treats abnormal heart rhythms with electrical impulses), and tracheostomy (trach) tube (a surgical opening in the airway in the windpipe to facilitate breathing). The patient resided at home with his/her spouse who was the primary caregiver. The patient revoked services on 06/04/2025 due to issues with the G-Tube that were not addressed during the hospice nurse visits. Review of the nurse’s note dated 05/08/2025 at 2:12 PM, showed the following:- The patient was short of air (SOA) and anxious;- The patient had a fall one week ago and had a skin tear on the left forearm and right eye;- The patient was complaining of pain in his/her back and rated the pain at a seven (7) on a pain scale of zero to 10 (zero representing no pain and 10 representing the worst pain possible);- The patient requested the nurse to apply Aspercreme (a topical pain reliever used for minor aches and pains in muscles and joints) patches to his/her back for relief;- The patient was hypertensive (had elevated blood pressure) 118/96 and one (1) plus edema (swelling of tissues) in the bilateral lower extremities (BLE);- The patches helped alleviate some pain and the patient rated the pain five out of six (5/6);- The patient denied chest pain but stated that he/she took a nitroglycerin tablet (used to treat certain heart conditions and to widen the opening in blood vessels) about a week ago for chest pain; - Wound care was provided to the skin tear on the right eye and left forearm; and- Shortness of breath, anxiety, chest pain, edema, hypertension, and SOA were secondary to decreased cardiac output.  (The clinical record failed to show physician notification of the patient’s fall with injuries, use of Aspercreme, elevated blood pressure, edema, and chest pain.)   Review of the nurse’s note dated 05/08/2025 at 9:39 PM, showed the following:- The patient was short of air (SOA) at rest and it took him three to five minutes to recover, wore oxygen as needed and mostly at night; and- The patient stated that he/she had chest pain over the weekend and had to take one nitroglycerin tablet. (The clinical record failed to show the physician was notified of the patient's SOA and chest pain.) Review of the nurse’s note dated 05/15/2025 at 1:05 PM, showed the following:- The patient was sitting outside on his/her golf cart, was hunched over, and appeared weak and in pain;- The patient complained of pain in his/her back and rated the pain a nine (9);- The patient took an as-needed Norco (used to treat moderate to moderately severe pain) one hour prior to the nurse’s arrival;- The patient reported having chest pain yesterday that “came and went” but did not take anything for the pain, education was provided on utilizing nitroglycerin for chest pain;- The patient had three (3) plus edema in the lower left extremity and two (2) plus edema in the right lower extremity;- The patient forgot to take his/her furosemide (diuretic) that morning and education was provided on taking medications as prescribed;- Wound care was provided on the left arm laceration;- Education was provided on conserving energy and not over exerting self to prevent fall; and- The patient reported the pain had decreased to a tolerable level of 7. (The clinical record failed to show physician notification of the pain rated at a 9 despite taking Norco an hour prior to the nurse’s arrival, chest pain, increase in edema, and the fall with injuries.) Review of the nurse’s note dated 05/19/2025 at 2:55 PM, showed the following:- The patient’s spouse reported the patient had a varicose vein (a condition in which a vein becomes permanently enlarged, twisted, and painful) rupture a few days ago in the left leg. The patient had Tubigrips (brand, an elastic, tubular bandage) on and had increased edema for the last week. The spouse had to gently cut off the Tubigrip to get it off of the patient’s leg;- The patient had a pool of blood in his/her shoe and on the deck, where he/she had been sitting when this happened;- The patient's toes were a bluish color on both feet with 2 plus edema to both lower extremities and feet;- The patient stated his/her tube feedings came back up last night, “it” (the feeding) came up into his/her throat and nose for approximately 2 hours after the feeding was finished;- He/she had difficulty catching his/her breath during that time; and- The nurse educated on the possible need to split tube feedings up into smaller amounts with more frequent feedings and the patient stated that he/she would do this if it kept happening. (The clinical record failed to show physician notification of the ruptured varicose vein, toes a bluish color, edema, the tube feeding coming up into his/her throat, and the patient's difficulty catching his/her breath.  The documentation failed to show whether the nurse checked the tube for placement). Review of the nurse’s note dated 05/26/2025 at 2:08 PM, showed the following:- The patient complained of 9/10 pain; - He/she took a Norco not long before this visit;- The patient stated that pain was worse, lately, and he/she was not getting much relief even with using the lidocaine patch (a topical pain medication) on his/her back;- The physician was notified to switch Norco to Oxycodone (used to treat moderate to severe pain), as needed (11 days after the patient’s pain had increased); and- The patient had conversational dyspnea (shortness of breath) and dyspnea with ambulation (walking), patient had oxygen as needed at 2 to 10 liters via trach. Trach care was performed per the patient’s request.(The documentation failed to show physician notification of the dyspnea.  The nurse failed to offer education to the patient regarding adjustment of the flow rate (the physician orders failed to include specific adjustment of flow rate), and how to administer the oxygen (i.e. higher flow rate nasal cannula or mask) and if a humidifier was needed with use of a higher flow rate.) Review of the nurse’s note dated 05/29/2025 at 12:52 PM, showed the following:- The patient had still been having some tube feeding come up into his/her throat and was trying to split the feeding up in smaller amounts at a time;- Bowel sounds were hypoactive (decreased intestinal activity);- Trach care was completed per the patient’s request;- The patient had 3 plus edema to BLE and his/her toes were light purple in color;- The patient was SOA with ambulation and conversation and had oxygen and nebulizer as needed; and- He/she was standing at the kitchen sink today and the next thing he/she knew he/she felt a sharp pain in his/her chest, he/she stated that he/she was not sure if his/her defibrillator went off or what it was, but he/she stated it hurt. (The documentation failed to show physician notification of the tube feeding coming up into the patient’s throat, edema and toes purple, SOA, and sharp chest pain. The documentation failed to show whether the nurse checked the feeding tube placement).Review of the nurse’s note dated 06/04/2025 at 8:30 AM, showed the following:- The patient went to the emergency room (ER) after having tube feeding come up his/her esophagus (the tube connecting the throat to the stomach) into his/her nose and trach;- The patient stated that he/she felt like he/she was drowning;- This was the second time during the night that this happened;- The patient’s spouse notified the nurse and stated that he/she thought the patient would be admitted; and- The nurse met the patient in the ER and had him/her sign a revocation (a patient or representative must provide a signed written statement to the hospice agency with the effective date of the revocation, revoking hospice means the patient is no longer covered under Medicare for hospice care but can resume coverage for other Medicare benefits) form.Review of the hospice revocation statement dated 06/04/2025 at 4:50 PM, showed the reason for revocation was “Tube feeding came up esophagus and patient felt” (the documentation was incomplete). The clinical record failed to include documentation that showed IDG coordination to meet the needs of the patient and family. During an interview on 10/08/2025 at 12:18 PM, RN-A stated that:- He/she was the case manager for the patient;- The patient’s caregiver called RN-A and reported that the patient threw up and felt like his/her “trach was clogged”, he was aspirating (to accidentally inhale a substance into the lungs), and they were at the hospital emergency room (ER);- The patient signed the hospice revocation in the ER and the patient kept throwing up;- RN-A cleaned the trach at each visit unless the patient cleaned it;- There was a disposable inner cannula (single-use, sterile tube that fits inside a tracheostomy tube’s outer tube to keep the airway open and clean) and he/she would change this at times;- The patient’s pulmonologist (a medical doctor who specializes in treating diseases of the respiratory system) changed the whole trach every three months; and- The patient was very independent, and he/she could clean and suction his/her trach. During an interview on 10/08/2025 at 12:55 PM, the administrator stated that:- There was no further documentation regarding the G-Tube feeding coming back up into the patient’s throat, whether the nurse checked for feeding tube placement, and physician notification;- Active issues with the G-Tube should be on the plan of care; and- The clinician should have reached out to the physician who inserted the feeding tube with any issues (this was not on the POC).  During an interview on 10/08/2025 at 2:32 PM and 2:45 PM, the registered nurse coordinator, known by the provider as the clinical director, stated that:- There was no further documentation to show physician notification or coordination with IDG;- He/she received the patient’s defibrillator report and the patient was not "shocked". There was no further follow up;- The patient’s chest pain was managed with nitroglycerin;- The patient had not complained of chest pain until the hospice provider talked about discharge due to the patient not having enough of a decline;- The patient had a cardiologist (a medical doctor who specializes in treating diseases of the heart and circulatory system) who was not listed on the POC;- The patient also had a pulmonologist who was not listed on the POC; and- He/she would have expected staff to notify the gastrointestinal (GI) clinic specialist with any problems/complications with the feeding tube.

Based on policy review, record review, and interview, the hospice provider failed to ensure an individualized plan of care (POC) was developed to reflect the patient and family goals and interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in one of three records reviewed (Record/Patient #3). This deficient practice has the potential to affect the provision of care to all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Interdisciplinary Group Coordination of Care," dated May 2024, showed in part:- The type and scope of services provided by the IDG (interdisciplinary group) will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions;- Written evidence of care coordination will be found in the POC and/or IDG meeting forms in the patient’s clinical record, and will involve the hospice patient’s attending physician; and- The IDG (in collaboration with the patient’s attending physician, if any) will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 days. Review of the provider's policy titled, "Interdisciplinary Group Meeting," dated May 2024, showed in part:- The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the POC; and- An IDG meeting POC update form and will note changes, response to treatment and progresses toward targeted outcomes, which may include, but not (be) limited to nutritional status, pain management and plan for changes in treatment or procedures.  Review of the provider's policy titled, "PEG (Gastrostomy)/Eternal Tube Management-Hospice," dated 08/01/2025, showed in part:- Enteral Tube: PEG, G-tube, J-tube, GJ-tube used for nutrition, hydration, and/or medication delivery (PEG, G-tube, J-tube, enteral tube - a tube placed surgically through the abdominal wall into the stomach or intestine for the administration of food, fluids, and medication;- To establish safe, patient-centered, comfort-focused standards for assessment, care, medication administration, feeding, troubleshooting, and documentation for patients with percutaneous endoscopic gastrostomy (PEG) or other enteral access (G-tube, J-tube, GJ-tube) receiving hospice services; and- IDG: Reviews goals, outcomes, complications, and POC at least every 15 days or with change in condition.RECORD/PATIENT #3: Review of the clinical record showed the following:- The patient was admitted to hospice services on 12/06/2023 with a terminal diagnosis of unspecified combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood);- The patient had an automatic cardiac defibrillator (a battery-powered device that monitors and treats abnormal heart rhythms with electrical impulses);- Tracheostomy tube (trach, a surgical opening in the airway in the windpipe to facilitate breathing); and- The patient resided at home with his/her spouse who was the primary caregiver. The POC failed to show specific interventions for cardiac defibrillator and trach care.  Review of the nurse’s note dated 05/08/2025 at 2:12 PM, showed the following:- The patient had a fall one week ago and had a skin tear on the left forearm and right eye;- The patient was complaining of chest pain in his/her back and rated the patient seven (7) on a pain scale of zero to 10 (zero representing no pain and 10 representing the worst pain possible);- The patient requested the nurse to apply Aspercreme (a topical pain reliever used for minor aches and pains in muscles and joints) patches to his/her back for relief;- The patient was hypertensive (had elevated blood pressure) 118/96 and one (1) plus edema (swelling of the tissues) in bilateral lower extremities (BLE); and- Wound care was provided to the skin tear on the right eye and left forearm.The POC failed to include the fall with injury, chest pain with interventions and edema.  Review of the nurse’s note dated 05/08/2025 at 9:39 PM, showed the following:- The patient was short of air (SOA) at rest and took him three to five minutes to recover, wore oxygen as needed and mostly at night; and- The patient stated that he/she had chest pain over the weekend and had to take one nitroglycerin (used to treat certain heart conditions and to widen the opening in blood vessels) tablet. (The clinical record failed to show the physician was notified of the patient's SOA and chest pain.)The POC failed to include the SOA and chest pain.  Review of the nurse’s note dated 05/19/2025 at 2:55 PM, showed the following:- The patient’s spouse reported the patient had a varicose vein (a condition in which a vein becomes permanently enlarged, twisted, and painful) rupture a few days ago in the left leg;- The patient had a pool of blood in his/her shoe and on the deck, where he/she had been sitting when this happened; and- The patient stated his/her tube feedings came back up last night and came up into his/her throat and nose for approximately two hours after finishing the feeding.The POC failed to include interventions for the ruptured varicose vein (treatment) and revised interventions to address intolerance of the tube feeding. Review of the nurse’s note dated 05/26/2025 at 2:08 PM, showed the following:- The patient complained of nine (9)/10 pain;- He/she took a Norco (used to treat moderate to moderately severe pain) not long before this visit;- The patient stated that pain had been worse lately and was not getting much relief even with using the lidocaine patch on his/her back;- The physician was notified to switch Norco to Oxycodone (used to treat moderate to severe pain) as needed (11 days after the patient’s pain had increased); and- The patient had conversational dyspnea (shortness of breath) and dyspnea with ambulation (walking), patient had oxygen as needed at two (2) to 10 liters via trach, trach care was completed per the patient’s request.The POC failed to include specific adjustment of flow rate, and how to administer the oxygen (i.e. higher flow rate nasal cannula or mask) and if a humidifier was needed with use of a higher flow rate, and revised interventions to address the increased pain. During an interview on 10/08/2025 at 12:18 PM, registered nurse (RN)-A stated the following:- He/she was the case manager for the patient;- RN-A cleaned the trach at each visit unless the patient cleaned it;- There was a disposable inner cannula (single-use, sterile tube that fits inside a tracheostomy tube’s outer tube to keep the airway open and clean) and he/she would change this at times;- The patient’s pulmonologist (a medical doctor who specializes in treating diseases of the respiratory system) changed the whole trach every three months; and- The patient was very independent, and he/she could clean and suction his/her trach.  The POC failed to include the RN cleaned the trach and specific interventions how this was done, changing the disposable inner cannula, suctioning, and the pulmonologist. During an interview on 10/08/2025 at 12:55 PM, the administrator stated that:- Active issues with the G-Tube should be on the plan of care; and- The clinician should have reached out to the physician who inserted the feeding tube with any issues (this was not on the POC). During an interview on 10/08/2025 at 2:32 PM and 2:45 PM, the registered nurse coordinator, known by the provider as the clinical director,  stated that:- The patient’s chest pain was managed with nitroglycerin (used to treat certain heart conditions and to widen the opening in the blood vessels);- The patient had a cardiologist (a medical doctor who specializes in the treatment of diseases of the heart and circulatory system) who was not listed on the POC;- The patient also had a pulmonologist who was not listed on the POC; - He/she would have expected staff to notify the gastrointestinal (GI) clinic specialist with any problems/complications with the feeding tube; and- The POC did not include this information.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was completed within 5 calendar days after the start of care. Clinical Record 9: The patient was 102 years old and resided at home. The Start of Care and Election of Benefits was dated 8/21/23. There were no documented attempts from the Social Worker to reach the patient/family until 8/25/2023. The social worker documented two (2) unanswered calls. There were no documented attempts to reach the patient/family by the social worker on day five (5) 8/26/2023. The next attempt from the social worker to contact family was dated 8/30/23. On 9/14/2023 in interview, the Director of Nursing confirmed that the comprehensive assessment including social work was not completed within 5 days. 1 of 14 (7%) of records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was completed within 5 calendar days after the start of care.

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 a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 1 of 14 (7%) clinical records reviewed revealed that the agency did not ensure that the plan of care included a detailed scope and frequency for all disciplines on the plan of care. Clinical Record 1: The recertification plan of care dated 7/19/2023- 9/16/2023 included interventions and goals for chaplain and social work. It did not include a visit frequency and duration for social work and chaplain. The Director of Nursing confirmed the finding during an interview on 9/13/2023, stating, "The visit frequency and duration for Social Work and Chaplain are not on there." 1 of 14 (7%) of clinical records reviewed revealed that the agency did not ensure that the plan of care included a detailed scope and frequency for all disciplines on the plan of care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 3 of 8 (38%) records reviewed of patients receiving Home Health Aide (HHA) services, revealed that the agency did not ensure that the aide care plan was developed to provide clear patient specific information and task details. Clinical Record 7: The start of care (SOC) assessment dated 8/28/23 revealed that the patient has a pressure ulcer on the right heel requiring treatment and dressings. The HHA care plan dated 8/28/2023 did not include any information or instruction to the HHA related to the wound or dressing or information to report to the nurse. Clinical Record 9: The SOC assessment dated 8/21/23 revealed that the patient had four (4) pressure ulcers including a stage 4 pressure ulcer on the coccyx, and an indwelling catheter. The HHA visit frequency was ordered 2xwk effective 8/21/23. The HHA care plan did not inform the HHA of the patient's wounds and dressing and did not provide direction of how to manage the wounds when providing personal care. Additionally, the plan did not include catheter care. Clinical Record 13: The patient was admitted on 7/7/2023 with a pluerex drain in place. HHA services were added effective 7/11/2023. The HHA care plan did not include any information related to the pluerex drain. A physician order was obtained dated 7/11/2023 for an 18 French/10ml silicone indwelling catheter. The HHA care plan did not include any information related to the indwelling catheter care and catheter care. During an interview on 9/12/2023, the Director of Nursing (DON) confirmed that the care plan did not include individualized patient care as identified through the assessment. The DON stated in part, "It makes complete sense to include patient specific conditions on the aide care plan. 3 of 8 (38%) of records reviewed with a HHA revealed that the agency did not ensure that the aide care plan was developed to provide clear patient specific information and task details.

It is required that the hospice has written policies and procedures for the management and disposal of controlled drugs in the patient’s home. The policies and procedures address the circumstances under which controlled drugs are disposed of (e.g., the patient’s death, a change in drug regimen, etc.) and the method to be used in accordance with the state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review and interview. 2 of 4 (50%) records reviewed of patients that were no longer receiving hospice services revealed that the agency did not ensure that all patients were provided with consistent written policies and processes for the disposal of controlled drugs in the patient's home. Document 1: Agency policy, "Care of the Terminally Ill Patient" Section: Provision of Care, Treatment and Services, PC 24 read, "Controlled drugs to be disposed by the hospice nurse upon death of the patient, after the family has given consent. Nurse to have a witness even if it's family present and a signature required." Document 2: Agency policy, "Controlled Drug Disposal" Section Medication Management MM:12 read, "When a patient no longer requires the controlled drug, the nurse will inform the family of the need to destroy the remaining medication. The RN will instruct the patient or responsible party on proper methods of disposing medications. RN may watch the patient or responsible party dispose of the medication and document this in the patient record. Documentation reflecting the name and amount of the drug, method of disposal and witnesses will become part of the medical record." Document 3: The Patient Handbook provided on admission stated in part, Page 10, "Staff or volunteers cannot destroy or dispose of medications. A member of the household will need to dispose of medications and the nurse will document." Clinical Record 13: The LPN attended the patient's death and provided post-mortem care on 7/19/2023. The LPN documented the medications Lorazepam and Morphine were disposed. The documentation did not include the amount disposed of and who was a witness to the disposal of the medication. Clinical Record 14: The medication profile included Morphine concentrate ordered on 2/22/2023 and alprazolam ordered on 3/6/2023. The death visit note was dated 3/8/2023. The medication name and amount disposed was left blank. The witness of medication disposal was left blank. On 9/12/2023, during interview, the Director of Clinical Services confirmed that the policies and patient handbook had conflicting statements related to who was to destroy medications when they were no longer needed or upon the death of the patient. The Director of Nursing and Director of Clinical Services confirmed that the policy and procedure was not consistent and were not followed. The agency did not ensure that they had consistent policies and procedures for the management and disposal of controlled drugs in the patient home. The patient handbook and 2 seperate policies all included conflicting information related to the procedure to dispose of medications.

Based on record review and interviews, the hospice failed to ensure the administrator was responsible for the day-to-day operation of the hospice. The administrator failed to follow hospice policy for patient grievences (Example #1), and the hospice had an unclear chain of command (Example #2). The deficient practice has the potential to affect all patients on service with the hospice. Findings included: Review of the undated hospice policy titled "Patient Conflicts, Grievences, or Concerns" showed in part the following: - The administration/Clinical Director is responsible for investigating all patient complaints and for giving feedback to the patient"; - The investigation shall be completed within 14 days; and - "All actions and follow-up performed will be documented on the complaint form". Example #1: Review of the hospice complaint log and files showed the hospice had received two patient complaints during the previous six months. Review of the complaint form showed areas for the hospice to document "investigation findings", "corrective actions made", and "resolution". Complaint #1 showed it was called in by Patient #1 on 06/20/2022. The complaint form sections to document "investigation findings", "corrective actions made", and "resolution" were left blank. During an interview with Patient #1 on 08/09/2022 showed he/she could not recall any hospice administration getting back to him/her regarding the complaint. Complaint #2 showed a patient filed a complaint on 03/17/2022. The complaint form sections to document "investigation findings", "corrective actions made", and "resolution" were left blank. Example #2: During staff interviews of the interdisciplinary group on 08/09/2022 three hospice core service staff were interviewed. When asked who specifically in administration was the hospice administrator that was responsible for the day-to-day operation of the hospice, all three staff stated that RN-B was the administrator. It should be noted that registered nurse (RN-B) is not the administrator on file for the hospice provider. During an interview with registered nurse (RN-C), a RN case manager, on 08/09/2022 showed that he/she stated "There are frequent changes in peoples titles (in administration), there is no consistency with leadership". The nurse identified RN-B as the current administrator. It should be noted that RN-B is not the administrator on file with the hospice provider. Three hospice care policys were reviewed, "RI:8, PC:3, and PC:10". The "clinical director" and/or "clinical supervisor" are responsible for oversight and implementation of the policies. Review of the hospice organizational chart showed no listing for a "clinical director" or "clinical supervisor".

Based on record review and interviews the hospice failed to ensure nursing services were routinely available on a 24-hour 7 days a week basis for one of three sampled patients (Record/Patient #1). The deficient practice has the ability to affect all patients on service with the hospice provider. Findings included: Review of the undated hospice policy titled "Provision of Care, Treatment, and Services-On Call After Hours", showed in part the following: - "To ensure patients' needs are met after hours. On call answering service is available 24 hours a day, 7 days a week"; and - "The answering service will take the call, they will then call the nurse on call, if no call back within 15 minutes, and they will call again, if no call the answering service will call the administrator on call". Record/Patient #1: Review of the plan of care showed that the patient was admitted to hospice service on 08/27/2021 with a terminal diagnosis of heart failure. Review of the hospice complaint file showed that the patient called in a complaint on 06/20/2022 regarding the on-call nursing availability on 06/19/2022. The patient reported that he/she had called multiple times after hours on 06/19/2022 for chest pain, and received no return calls from the hospice. Review of the on-call records and hospice investigation notes showed that the patient had called the hospice on 06/19/2022 at 2:53 AM, 3:19 AM, and 4:46 AM to ask about medication use for chest pain without any call back from hospice staff. The hospice returned the patient's call the next morning. Review of the patient's primary nurse written statement showed that the patient reported to him/her that the on-call nurse or administrator on-call did not return his/her calls on 06/19/2022 at 2:53 AM, 3:19 AM, and 4:46 AM. The patient fell in his/her apartment on 06/19/2022 in attempts to get alternative numbers for the hospice when the hospice would not return his/her calls. The patient called his/her apartment staff for help and emergency medical services (EMS) had to assist him/her off the floor. The patient had no apparent injuries from the fall. Review of the on-call schedule on 06/19/2022 showed licensed practical nurse (LPN-A) was the nurse on-call, and that registered nurse (RN-A) was the administrator on call. During an interview with the hospice administrator on 08/09/2022 at 1:45 PM, he/she stated the following: - The nurse on-call should respond and call the patient back within 15 minutes of notification from the on-call service; - The on-call service will call the administration on-call if they receive no response from the on-call nurse; and - He/she expects the administrator on-call to call the patient back and conduct a home visit if required, if the administrator on-call is a nurse. During an interview with RN-A on 08/09/2022 at 11:05 AM, he/she stated that on 06/19/2022 that he/she was the administrator on call. When asked if he/she called the patient back or conducted a home visit, he/she stated that the administration on-call does not see patients. Review of an email dated 06/28/2022 from RN-A to the previous hospice clinical manager, that was investigating the 06/20/2022 patient complaint showed: "I received calls from (the call service) on 06/19/2022 at 0318, 0352, and 0510 with messages they were holding for the MO office". The email failed to show that RN-A called the patient or visited the patient, or the actions he/she took as the administrator on call on 06/19/2022. Review of the employee file of LPN-A showed that he/she was terminated from hospice employment on 07/06/2022 for not responding to on-call after hours patient calls on 05/02/2022 and 06/19/2022.

Based on policy review, record review, state regulation review, and interviews, the hospice failed to meet the requirements for the Condition of Participation: Core Services when the hospice failed to ensure the spiritual counseling bereavement program reflected the individualized needs of the bereaved (L596). The effect of this systemic practice resulted in the inability of the hospice to provide effective core services to meet the individualized needs of the bereaved.

Based on policy review, record review, state regulation review, and interviews, the hospice failed to ensure the bereavement counseling program and bereavement plan of care reflected the individualized needs of the bereaved as identified in bereavement risk assessments in three of three sampled records reviewed for bereavement. (Record/Patients #4, #5 and #6). The deficient practice has the potential to affect all the bereaved families/caregivers of hospice patients. Findings included: Review of the agency policy titled "Bereavement Services", last revised in 2020 showed in part the following: - The hospice will provide bereavement services to families/caregivers both before and after a patient's death; - An initial bereavement assessment will be performed as part of the comprehensive assessment; - The IDG (interdisciplinary group) will recommend bereavement based on severity of grief; A bereavement plan will be initiated, will note kind of bereavement services; - It should be noted that the agency policy does not include interventions specific to low, medium, and high risk bereaved. The policy fails to include the Missouri regulation requirement for a second bereavement assessment 60 days after death of the patient. Review of Missouri program operations regulation 19 CSR-30-35.010-F(5B) shows "Within two months following the patient's death, there shall be an assessment of risk of the bereaved individual and a plan of care that extends for one year appropriate to the level of risk assessed." Review of Missouri Missouri program operations regulation 19 CSR-30-35.010-F(5C) shows "In addition to the assessment, at least one bereavement visit (other than funeral attendance/visitation) shall occur within six months after the death of the patient". RECORD/PATIENT #4: Review of the patient's comprehensive assessment showed that the patient was admitted to hospice service on 09/10/2021. Review of the initial comprehensive assessment and all subsequent chaplain and social worker visits showed no bereavement risk assessment was completed. Review of all available visit and case communication notes showed no refusal of any visits or assessments. RECORD/PATIENT #5: Review of the patient's comprehensive assessment showed that the patient was admitted to hospice service on 12/08/2020. Review of the death visit documentation showed that the patient passed away on 01/04/2021. The patient's family (adult child) was identified at moderate risk for bereavement by the hospice social worker on the initial comprehensive assessment dated 12/14/2020. Review of the bereavement plan of care from 12/14/2020 showed a letter would be mailed to the bereaved at one month, two months, four months, six months, nine months, 12 months and 13 months after the patient expired. The plan showed no listing for phone calls or attempts of an in-person visit attempt of the bereaved. A social worker phone note, dated 04/13/2021 showed that the bereaved spoke with the hospice social worker and stated that he/she was not doing well, "stressed out" about the (patient's) passing and declining health of other family members. Review of the bereavement plan of care showed no changes after this information was received. During an interview on 11/03/2021 at 4:34 PM, the clinical manager stated that the bereavement plan of care are the same for all patient families/caregivers regardless of the bereavement risk assessment. The clinical manager was unaware that a 60 day follow-up bereavement assessment was required. RECORD/PATIENT #6: Review of the patient's comprehensive assessment showed that the patient was admitted to hospice service on 08/30/2021. Review of the death visit documentation showed that the patient passed away on 08/30/2021. The patient's family was identified at low risk for bereavement on the initial comprehensive assessment. Review of the bereavement plan of care showed a letter would be mailed to the bereaved at one month, two months, four months, six months, nine months, 12 months and 13 months after the patient expired. The plan showed no listing for phone calls or attempts of an in-person visit attempt of the bereaved. During an interview on 11/03/2021 at 4:34 PM, the clinical manager stated that the bereavement plan of care are the same for all patient families/caregivers regardless of the bereavement risk assessment. The clinical manager was unaware that a 60 day follow-up bereavement assessment was required. During an interview with the hospice chaplain on 11/03/2021 at 1:16 PM, he/she stated the following: - He/she started employment with the hospice September of 2020; - He/she is now in charge of the hospice bereavement program, took over from a social worker that is no longer employed at the hospice provider; - He/she did not get trained in bereavement program; - He/she is concerned that all bereavement plans of care are "cookie cutter", and are not individualized based on the risk assessment; - He/she is unfamiliar on the specifics in the agency policy, but plans to make changes to the policy and procedure for bereavement; - Currently no follow-up risk assessment 60 days after the patient's death is being completed, was unaware of specific Missouri bereavement requirements.