Every finding on record at Faith Hospice of the Ozarks, LLC

Based on policy review, personnel record review, and interview, the hospice provider failed to provide initial emergency preparedness (EP) training to new employees in one of five personnel records reviewed (Employee #4) and failed to provide employees with ongoing EP training at least every two years in two of five personnel records reviewed (Employees #4 and #5). This deficient practice has the potential to affect the safety of all patients served by the provider. --- Findings included: Review of the providers undated policy titled, ";Emergency Preparedness Program – Training and Testing," showed in part, the hospices EP training program provides for the following: - Initial training in EP policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their roles; - EP training at least every two years; and - Documentation of all EP training. EMPLOYEE #4: Review of Employee #4s personnel record showed the following: - A hire date of 09/08/2022; - The employees position was medical director; - The record failed to show EP training was completed upon hire; and - The record failed to show EP training was completed every two years. EMPLOYEE #5: Review of Employee #5s personnel record showed the following: - A hire date of 03/01/2016; - The employees position was hospice aide; and - The record failed to show EP training was completed every two years. During an interview on 12/11/2024 at 10:50 AM, the administrator stated that he/she was not aware the medical director was required to do the EP training and he/she would expect the hospice aide to complete the required training.

Based on policy review, review of the providers emergency preparedness (EP) information, and interview, the hospice provider failed to maintain records that showed they performed full scale or functional exercises to test their emergency plan. This deficient practice has the potential to affect the safety of all patients served by the provider. --- Findings included: Review of the providers undated policy titled, ";Emergency Preparedness Program – Training and Testing," showed in part, the hospice conducts exercises to test the emergency plan at least every two years. EP testing includes: - Participation in a full-scale community- based exercise or when a community-based exercise is not accessible, an individual facility-based exercise; - If the hospice experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in a community-based or individual facility-based full-scale exercise for one year following the onset of the actual event; - Conducting an additional exercise that may include a second full-scale community-based or facility-based exercise, or a tabletop exercise; and - The hospice will analyze their response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospices emergency plan, as needed. Review of the providers EP binder showed the provider performed one tabletop exercise dated 10/30/2024. The provider failed to maintain documentation of any full-scale exercises, functional exercises, or activation of the emergency plan. During an interview on 12/10/2024 at 2:30 PM, the administrator stated that they only had documentation of the tabletop exercise they did that year.

Based on policy review, record review, and interview, the hospice provider failed to ensure that patients received a complete pain assessment in two of five records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Pain Management," effective 10/15/2015, showed in part:- The skilled nurse will perform a pain assessment during each home visit. The pain assessment will be documented; and- Pain assessment should include a thorough history of the pain and pain relief methods used to date. A pain scale will be utilized. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/08/2024 with a terminal diagnosis of malignant neoplasm of the endometrium (cancer of the lining of the uterus). The patient had secondary diagnoses of Alzheimers disease; diabetes mellitus (a group of diseases that results in too much sugar in the blood); adult failure to thrive; and moderate protein calorie malnutrition (a condition in which the body doesn't get enough nutrients to meet its needs). The patient resided in a long-term care facility (LTCF) and required staff assistance with all personal care and grooming needs. Review of the document titled, ";Plan of Care Order," dated 11/27/2024, showed in part:- An identified problem of alteration in comfort; - Patient goals that stated that the patient would achieve their desired level of comfort;- Interventions to assess pain using comprehensive pain assessment; - Updates to the plan of care on: * 03/12/2024 showed the patient reported occasional left hip and leg pain; * 09/24/2024 showed the patient reported occasional lower extremity neuropathy and coccyx pain; and * The care plan updates on 03/26/2024, 04/10/2024, 04/30/2024, 05/21/2024, 06/11/2024, 07/02/2024, 07/23/2024, 08/12/2024, 08/20/2024, 09/10/2024, 10/01/2024, and 11/19/2024 failed to identify the location or severity of the patients pain, however included documentation that the patient was satisfied with pain control; and - Orders for Norco (an opioid pain medication) as needed for pain, Tramadol (an opioid pain medication as needed for pain, and acetaminophen (a non-opioid pain medication) as needed for pain. Review of the document titled, ";Skilled Nursing SOAP Visit (Subjective, objective, assessment, and plan)," dated 11/30/2024, showed the visit documentation failed to include a thorough history of the patients pain. Review of the document titled, ";Skilled Nursing Visit," dated 12/03/2024, showed in part:- The patient rated pain in their coccyx a 0 (zero) on a 0 to10 high scale; - The visit documentation failed to include a thorough assessment of the patients pain that included a history of the patients pain, the location of the historical pain, and pain relief methods used to date including non-pharmacological pain management interventions. Review of the LTCF medication administration records for November and December 2024, showed in part:- The patient had received acetaminophen for pain location unknown: * Rated at a 3 (three) on a 0 to10 high scale on 11/01/2024, 11/22/2024, and 12/07/2024; * Rated at a 4 (four) on a 0 to10 high scale on 11/26/2024; and * Rated at a 6 (six) on a 0 to 10 high scale on 11/25/2024; and- The patient had received Norco for pain location unknown: * Rated at a 4 on a 0 to10 high scale on 11/13/2024 and 11/30/2024; * Rated at a 5 (five) on a 0 to10 high scale on 11/27/2024; * Rated at a 6 on a 0 to 10 high scale on 11/11/2024; and * Rated at a 7 (seven) on a 0 to 10 high scale on 11/11/2024; - The facility documentation indicated the patient had reported and received treatment for pain. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/03/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a buildup of plaque in the arteries of the heart resulting in chest pain). The patient had secondary diagnoses of vascular dementia with behavioral disturbance (dementia caused by changes in the blood vessels in the brain); severe protein-calorie nutrition (a condition in which the body doesn't get enough nutrients to meet its needs); anxiety disorder; pain in right knee and lower back; and a history of falling. The patient required moderate assistance with personal care and activities of daily living. The patient resided alone in their own home with the assistance of their adult child. The adult child was the primary caregiver for the patient. Review of the documents titled, ";RN Skilled Nursing Visit (Registered nurse)," dated 11/27/2024 and 12/05/2024, showed the clinician failed to document a pain assessment that included:- A thorough history of the patients pain; - Documentation of the patients right knee pain as listed on the plan of care; and- Pain relief methods used up to the date of the visit including non-pharmacological interventions. Review of the document titled, ";MSW Visit (Medical social work)," dated 12/10/2024, showed in part:- A PAINAD score (Pain in advanced dementia) of 0 on a 0 to 10 scale; - The patient had no non-verbal pain indicators; - Pain in the shoulder that came and went; and- The visit documentation failed to contain an assessment of the patients knee pain as listed on the plan of care. During an interview on 12/11/2024 at 10:15 AM, the administrator stated that:- They would expect a complete pain assessment to be completed; and- They had no further comments or documentation to provide at that time.

Based on policy review, clinical record review, observation, and interview, the hospice provider failed to ensure that each patient received an individualized initial or revised plan of care (POC), in three of five full records reviewed (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. --- Record/Patient #3: Review of the clinical record showed the patient was admitted to hospice services on 03/08/2024 with a terminal diagnosis of malignant neoplasm of the endometrium (cancer of the lining of the uterus). The patient had secondary diagnoses of Alzheimers disease; diabetes mellitus (a group of diseases that results in too much sugar in the blood); adult failure to thrive; and moderate protein calorie malnutrition (a condition in which the body doesn't get enough nutrients to meet its needs). The patient resided in a long-term care facility (LTCF) and required staff assistance with all personal care and grooming needs. Review of the LTCF document titled, ";Order Summary Report," dated 12/10/2024 showed in part the patient had orders for a regular diet, with thin texture, and a protein supplement in the morning. Review of the document titled, ";IDG Meeting (Interdisciplinary group)," dated 12/04/2024 showed in part that the provider had identified:- Alteration in comfort as a problem for this patient: * With a goal that the patient will achieve their desired level of comfort: * Interventions that the provider would provide education to the patient/primary caregiver/ family (P/PCG/F) non-pharmacological techniques to manage pain; and * An intervention to, ";see standing orders plan of care for treatment of pain;"- Decreased caloric intake resulting in unintentional weight loss as a problem for this patient: * With a goal that the patient would maintain weight within the limits of the disease process, and maintenance of current body mass index (BMI) within the limits of the disease process; * Interventions that the provider would provide education to the P/PCG/F on decreasing appetite and decreased nutritional needs at the end of life using the providers handbook; - The plan of care failed to contain individualized and patient specific interventions and goals related to: * Identification of the location of the patients pain; * The patient specific goal for the pain control using a pain scale; * The standing orders for pain control; * The non-pharmacological interventions to alleviate the patients pain; and * The patients diet and protein supplementation. Record/Patient #4Review of the clinical record showed the patient was admitted to hospice services on 10/03/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (a buildup of plaque in the arteries of the heart resulting in chest pain). The patient had secondary diagnoses of vascular dementia with behavioral disturbance (dementia caused by changes in the blood vessels in the brain); severe protein-calorie nutrition (a condition in which the body doesn't get enough nutrients to meet its needs); anxiety disorder; pain in right knee and lower back; and a history of falling. The patient required moderate assistance with personal care and activities of daily living. The patient resided alone in their own home with the assistance of their adult child. The adult child was the primary caregiver for the patient. Review of the document titled, ";Plan of Care Order," dated 12/04/2024 showed in part that the provider had identified:- Alteration in comfort as a problem for this patient: * With a goal that the patient would remain free from pain as their disease progressed; and * An intervention that the provider would provide education to the patient/primary caregiver/ family (P/PCG/F) non-pharmacological techniques to manage pain; - The POC update failed to contain: * Documentation that the patient used a PAINAD scale for pain assessment; * The patient specific goal for the pain control using a pain scale; and * The non-pharmacological interventions to alleviate the patients pain. During an interview on 12/11/2024 at 10:15 AM, the administrator stated that:- They would expect the plan of care to be individualized for the patient; and- They had no further documentation to submit related to the plan of care. Findings included: Review of the provider's policy titled," Plan of Care" dated 03/07/2022 showed: -All hospice care and services furnished to patients and their families must follow an individualized written comprehensive plan of care established by the interdisciplinary team in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; and - [named hospice] must ensure that each patient and the primary caregiver(s) receive education and training provided by the hospice provider as appropriate to their responsibilities for the care and services identified in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice care on 06/08/2023 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnoses which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), diabetes, (a chronic disease that occurs when the body can't produce enough insulin or use insulin properly), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a private residence alone with assistance of a primary caregiver (PCG). Review of the Patient Medication Record, dated 12/09/2024, showed the patients medications included Toujeo SoloStar, (a prefilled pen that contains insulin glargine, a long-acting insulin to treat diabetes) inject 18 units subcutaneously every evening. Observation during the home visit on 12/10/2024 at 2:30 PM showed a glucometer and supplies in the patients home. During an interview during the home visit on 12/10/2024 at 2:30 PM, the patient stated that he/she had not taken a blood sugar yet that day. Review of the interdisciplinary group (IDG) meeting note dated 12/04/2024 showed the patients DME included accu- check glucometer (a device used to measure blood sugar levels) and supplies. Review of the POC revised 12/09/2024 failed to include individualized interventions regarding diabetes care. During an interview conducted on 12/11/2014 at 10:49 AM, the administrator and clinical manager stated diabetes should be included in the patients POC.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) necessary to meet the needs of the patients in one of five full records reviewed (Record/Patient #1).This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Plan of Care," dated 03/07/2022, showed the POC will include all services necessary for the palliation and management of the terminal illness and related conditions, including medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/08/2023 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnoses which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood),diabetes, (a group of diseases that results in too much sugar in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a private residence alone with assistance of a primary care giver (PCG). Review of the interdisciplinary group (IDG) meeting note dated 12/04/2024, showed the patients DME included a portable ";E" (reference on the size of the tank) oxygen tank, which contained the educational intervention of instruction on the use of oxygen and oxygen supplies. Review of the patients POC dated 12/04/2024, showed the patients DME included a portable ";E" size oxygen tank, which contained the educational intervention of instruction on the use of oxygen and oxygen supplies. Observation during the home visit on 12/10/2024 at 2:30 PM, showed two portable ";E" size oxygen tanks which did not have an oxygen regulator (a device used to display the amount within the tank and used to deliver the amount of oxygen to the patient) attached. Additionally, one tank was observed unsecured, leaning against a wall in the bedroom. During an interview during the home visit on 12/10/2024 at 2:30 PM, the patient stated that he/she was not sure where or if he/she had an oxygen regulator since the tanks were delivered. The patient stated he/she usually used the oxygen concentrator (which was also in the home). The patient stated his/her daughter (PCG) may know more about the oxygen regulator. During a telephone interview conducted on 12/11/2024 at 8:30 AM, the PCG stated the patient had both an oxygen concentrator and two portable tanks. The PCG was unsure of the location of the oxygen regulator or if there was an oxygen regulator in the home. The PCG also stated that they were unaware if any additional cart/stand was delivered with each tank as part of the DME. The PCG stated that he/she had not received education regarding operation of the portable oxygen tanks. During an interview conducted on 12/11/2024 at 9:00 AM, the registered nurse (RN) coordinator stated the patients POC should include an oxygen regulator installed on one of the tanks, a method to safely store all portable tanks as part of the DME, and education for patients and/or PCG in use of the portable oxygen tanks as listed on the POC.

Based on record review and interview the hospice provider failed to ensure all visits were completed as ordered by the physician, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 09/30/2024 with a terminal diagnosis of end stage heart failure, and secondary diagnosis which included chronic kidney disease,(a condition where the kidneys gradually lose the ability to filter waste products from the blood),and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided in a private residence alone. Review of the plan of care (POC), dated 09/30/2024, showed the physician order for hospice aide two visits each week for 12 weeks. Review of aide care visit notes showed: -The week of 11/03/2024, one visit was made on 11/04/2024; -The provider failed to perform a second aide visit the week of 11/03/2024; and -The provider failed to notify the physician of the missed visit. During an interview on 12/11/2024 beginning at 10:45 AM, the administrator stated that the visit was not documented as missed and there was no documentation that the physician was notified.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure the ongoing sharing of information between all disciplines providing care and services in one of three applicable records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Pain Management," effective 10/15/2015 showed in part:- The skilled nurse will perform a pain assessment during each home visit. The pain assessment will be documented; and- All other interdisciplinary members will ask the patient whether they are experiencing pain and will document positive results. The skilled nurse will be contacted with reports of pain that are not consistent with the patients history and any report of pain over a pain scale of five. The skilled nurse will also be contacted by the members of the IDG if the patient is not satisfied with their current pain level regardless of the pain level number. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/08/2024 with a terminal diagnosis of malignant neoplasm of the endometrium (cancer of the lining of the uterus). The patient had secondary diagnoses of Alzheimers disease; diabetes mellitus (a group of diseases that results in too much sugar in the blood); adult failure to thrive; and moderate protein calorie malnutrition (a condition in which the body doesn't get enough nutrients to meet its needs). The patient resided in a long-term care facility (LTCF) and required staff assistance with all personal care and grooming needs. Observation on 12/10/2024 at 2:00 PM, in the presence of the hospice chaplain, the state agent (SA) observed:- The patient: * Complaining of pain and discomfort in their buttocks; * Actively repositioning themselves in the recliner multiple times; * Lifting themselves off their buttocks using the arms of the recliner; * Raising and lowering the foot of the recliner multiple times, and * Repeatedly pushing and holding down the button of the recliner, causing the seat to jump, in an effort to reposition themselves; and- The chaplain performing a spiritual assessment. The chaplain failed to report the pain to the RN (registered nurse) coordinator. During an interview on 12/10/2024 at 2:30 PM, the facility nurse stated that: - The patient had developed open areas on their buttocks; and- Had been complaining about buttock pain. Observation on 12/10/2024 at 2:40 PM, the SA observed the patients skin integrity. The patient had open areas of shearing on both buttocks covering an area of approximately three centimeters on each buttock. The patients buttocks were covered in white cream or ointment. During an interview on 12/11/2024 at 10:00 AM, the RN coordinator stated that he/she had not received report from the chaplain about the patients increased buttock pain or open areas.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the hospice nurse performed hand hygiene, disinfected electronic devices, and disinfected equipment, in one of four home visit observations (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Cleaning Home Equipment and Supplies," dated 10/15/2015, showed in part to wipe stethoscope diaphragms with 70% isopropyl alcohol solution or disinfectant between each patient use. Review of the providers policy titled, ";Hand Hygiene," dated 07/15/2015, showed in part: Hand hygiene is to occur: - Before and after direct patient contact; - After contact with inanimate objects or medical equipment close to patient; - When there has been a potential exposure to spore-forming organisms; - After blowing nose, sneezing and coughing; - After contact with a patient's intact skin; and - After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. The provider failed to provide a policy regarding the cleaning guidelines for electronic charting tablets/computers and cellular phones. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/08/2023 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnoses which included chronic kidney disease (a condition where the kidneys gradually lose the ability to filter waste products from the blood), diabetes (a group of diseases that results in too much sugar in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a private residence alone with assistance of a primary caregiver (PCG). Observation on 12/09/2024 at 2:30 PM, showed Registered Nurse (RN)-A was performing the patients assessment and failed to wash or sanitize an electronic charting tablet, and cell phone during the assessment. Additionally, RN-A failed to wash or sanitize hands after using a tissue for self-use during the provision of care and failed to sanitize equipment used from the patients personal bin prior to use on the patient. During an interview on 12/09/2024 at 3:30 PM, RN-A stated that he/she sometimes forgot to disinfect the electronic charting tablet and cell phone before using. RN-A stated that this should be done as handwashing/hand sanitizing would be performed between each patient home visit. During an interview on 12/11/2024 at 10:45 AM, the administrator stated that staff should follow policies with regard to handwashing and disinfecting equipment between patients.

Based on policy review, record review, and interview, the hospice provider failed to ensure the registered nurse (RN) followed policies and procedures for standing orders in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the clinical record showed the patient was admitted to hospice services on 09/17/2024 with a terminal diagnosis of malignant melanoma (a type of skin cancer that has spread to other parts of the body). The patient had additional diagnoses of metastasis (spreading of cancer) to the rectum, brain, bone, and lymph nodes. He/she lived at home and his/her spouse assisted the patient with care. Review of the providers policy titled, ";FHO (abbreviation of named provider) Standing Orders," updated 07/10/2024, showed in part: - Patient specific standing orders will be utilized to allow the hospice nurse to intervene immediately when symptoms occur; - When implementing a standing order, the first step will be initiated first. To implement the next step, document the patients response to the previous step, d/c (discontinue) the previous medication/order, then progress to the next step in numerical order. If the patient is unable to take a medication, document the reason and implement the next step; and - All patients requiring opioid therapy will have a bowel regimen initiated upon admission or at the start of opioid use. This regimen will include a stimulant laxative with or without a stool softener. Alternatives will be considered in the presence of allergy or intolerance to stimulant laxatives. RECORD/PATIENT #5: Review of the plan of care (POC), dated 09/17/2024, showed in part: - The patient had a problem with constipation and the goal was to have a bowel movement (bm) every three days; - Standing orders for constipation included the following steps; * Step one – Senna-docusate (a combination laxative and stool softener) one tab by mouth twice daily (bid) as needed if no bm in two days, increase to one by mouth three times daily as needed; * Step two – Senna-docusate two tablets by mouth bid as needed if no bm in two days, increase to two by mouth three times daily as needed; * Step three – Senna-docusate three tablets by mouth bid as needed if no bm in two days, increase to three tablets by mouth three times daily; * Step four – Bisacodyl (a stimulant laxative) 10 milligrams (mg) suppository rectally bid as needed; * Step five – If no bm for two days, may give pre-packaged sodium phosphate (Fleets)(brand) or mineral oil enema as needed; * Step six – If impacted, may manually, gently remove as needed, may follow with enema as per step five above; and - A skilled nurse (SN) entry that showed, on 09/17/2024, standing orders for Senna-S (senna-docusate) initiated due to opioid use (step one of the standing orders). Patient/patient caregiver instructed on dose, route, administration, and possible side effects. Patient/patient caregiver verbalized understanding of teaching provided. Review of the SN visit notes showed in part: - On 09/24/2024, the patient reported no bm since 09/16/2024, standing orders initiated for Dulcolax (bisacodyl) suppository 10 mg rectally bid as needed (step four of the standing order) and Fleets enema rectally daily as needed for constipation (step five of the standing order); - The SN skipped the remainder of step one and steps two and three and initiated steps four and five and the SN failed to document a reason the standing order was not followed numerically; - On 09/27/2024, the SN documented the patient reported his/her bowels moved several times yesterday with Dulcolax tablets as directed; - On 10/15/2024, the SN documented no bm was reported since 10/09/2024. Teaching was provided on medications prescribed for constipation and Senna-S was increased to two tablets bid per standing orders (step two of the standing order); and - The SNs failed to follow the standing order steps in numerical order as outlined in the providers policy. Review of the physician order, dated 09/24/2024, showed: - Fleet enema 7-19 grams (gm) in 118 milliliters (ml), give one enema rectally daily as needed; - Dulcolax rectal suppository 10mg, insert one suppository rectally twice a day as needed; -Dulcolax oral tablet delayed release 5 mg take two tablets by mouth twice a day as needed (this medication was not part of the standing order); - The order was digitally signed by the physician on 10/01/2024; - An addendum note that showed ";Standing orders initiated as written above. Pt/PCG (patient/patient caregiver) instructed on dose, route, administration, and possible side effects. Verbalized understanding of teaching provided"; - The SN failed to document the reason the steps in the standing order were not followed in numerical order as outlined in the providers policy; and - The SN failed to correctly initiate the standing orders per provider policy when he/she added Dulcolax tablets to the order. Review of the physician order, dated 10/15/2024, showed: An order to discontinue Senna S 8.6-50 mg one tablet bid and start Senna S 8.6-50 mg two tablets bid for constipation (this skipped the instructions in step one to increase Senna-S to one tablet three times daily as needed); - A narrative entry that showed the physician was notified of initiation of the standing orders; - The order was digitally signed by the physician on 10/23/2024; and - The order failed to follow the standing order steps in numerical order as outlined in the providers policy. The record failed to include documentation that showed the reasons the clinicians bypassed the sequential steps for alternative steps in the protocol. During an interview on 12/11/2024 at 10:50 AM, the administrator stated that he/she expected the clinician to call the physician and get an order if they needed to bypass steps in the standing order and document the reason the steps needed to be bypassed. Otherwise, they should follow the steps as they are written.

Based on policy review, personnel record review, and interview, the hospice provider failed to ensure the hospice aide completed 12 hours of in-service training annually in one of one hospice aide record reviewed (Employee #5). This deficient practice has the potential to affect the quality of care provided to all patients receiving hospice aide services from the provider. --- Findings included: Review of the hospice providers policy titled, ";Coordination of Services – Hospice Aide Training and Competency," dated 10/15/2015, showed in part; - A hospice aide must receive at least 12 hours of in-service training during each 12-month period; and - (Named hospice) must maintain documentation that demonstrates the requirements of this standard are met. EMPLOYEE #5: Review of Employee #5s personnel record showed: - A hire date of 03/01/2016; - The employees position was hospice aide; and - The record failed to show any documentation that the employee received 12 hours of in-service training annually. During an interview on 12/11/2024 at 10:50 AM, the administrator stated that he/she would expect the hospice aide to complete the required in-service training.

Based on policy review, record review, and interview, the hospice provider failed to ensure the hospice aide followed the aide care plan orders as prepared by the registered nurse (RN) in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Review of the provider's policy titled, "Hospice Aide – Supervisory Visits," dated 03/07/2022, showed a supervisory registered nurse must assess an aides ability to demonstrate following the patients plan of care for completion of tasks assigned to the aide. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/08/2023 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnoses which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), diabetes (a group of diseases that results in too much sugar in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a private residence alone with assistance of a primary caregiver (PCG). Review of the hospice aide care plan dated 10/11/2024, showed section, ";vital sign notification", which directed the aide to obtain and document the patients vital signs which included: blood pressure, pulse, respirations, temperature, oxygen, saturation, weight, urine output, and bowel movement. Review of the hospice aide visits ranging from 10/11/2024 to 12/05/2024 failed to show documentation of vital signs obtained and documented by the hospice aide. During an interview on 12/11/2024 at 10:50 AM, the RN Coordinator stated that the aide should only take vitals if ordered by the RN for each individual visit. The RN Coordinator then stated that the aide care plan assignment to take vitals every visit was an error in assignment.

Based on policy review, record review, and interview, the provider failed to ensure the registered nurse (RN) made a hospice aide on-site supervisory visit every 14 days in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect patients with aide services through the provider. --- Findings included: Review of the provider's policy titled, ";Hospice Aide – Supervisory Visits," dated 03/07/2022, showed a RN must make an on-site visit to the patients home no less frequently than every 14 days to assess the quality of care and services provided by hospice provider. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/08/2023 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), diabetes (a group of diseases that results in too much sugar in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body). The patient resided in a private residence alone with assistance of a primary caregiver (PCG). Review of the clinical record showed: - A missed aide supervisory visit on 10/22/2024; - An aide supervisory visit on 11/06/2024 (2 days late); - A missed aide supervisory visit 11/20/2024; and - A missed aide supervisory visit on 12/02/2024. The provider failed to ensure an aide supervisory visit was completed every 14 days. During an interview on 12/11/2024 at 10:45 AM, the administrator and RN coordinator stated that the aide supervisory visits should be completed every 14 days, and there was no documentation regarding the missed aide supervisory visits.

Based on policy review, personnel record review, and interview, the hospice provider failed to ensure the registered nurse (RN) performed an annual on-site visit to evaluate the patient care performance of the hospice aide in one of one hospice aide record reviewed (Employee #5). This deficient practice has the potential to affect the quality of care provided to all patients receiving hospice aide services from the provider. --- Findings included: Review of the providers policy titled, ";Hospice Aide – Supervisory Visits," revised 03/07/2022, showed in part, ";a registered nurse must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care". EMPLOYEE #5: Review of Employee #5s personnel record showed: - A hire date of 03/01/2016; - The employees position was hospice aide; and - The file failed to show documentation that an annual on-site visit was completed by the RN. During an interview on 12/11/2024 at 9:21 AM, the administrator stated that he/she was not aware the hospice aide needed an annual on-site supervisory visit by the RN.

Based on survey findings and interview, the hospice provider failed to ensure the administrator was responsible for the day-to-day operations of the hospice. This deficient practice has the potential to affect all the patients served by the provider. --- The current survey findings showed the hospice administrator failed to effectively manage the overall day-to-day operations of the provider resulting in citations: -He/she failed to ensure emergency preparedness training was completed upon hire and every two years; -He/she failed to conduct exercises to test the emergency plan at least annually; -He/she failed to ensure staff completed comprehensive assessments on their patients; -He/she failed to ensure each patient received an individualized or revised plan of care; -He/she failed to ensure the patient's plan of care contained all durable medical equipment; -He/she failed to ensure staff made all visits as ordered by the physician; -He/she failed to ensure staff shared all patient information among all disciplines; -He/she failed to ensure staff followed standards of practice to prevent the transmission of infections and communicable diseases; -He/she failed to ensure licensed professionals followed the hospice's policies and procedures regarding standing orders; -He/she failed to ensure hospice aides received at least 12 hours of in-service training during each 12-month period; -He/she failed to ensure the hospice aide followed the aide care plan orders; -He/she failed to ensure a registered nurse made an on-site visit to the patient's home, no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide; -He/she failed to ensure a registered nurse made an annual on-site visit to the location where a patient was receiving care in order to observe and assess each aide while that aide was performing care; -He/she failed to ensure that a discharge summary was sent to the patient's attending physician upon a live discharge; -He/she failed to ensure supervision of patient assessments by a bachelor prepared social worker was completed by a Master prepared social worker; and -He/she failed to ensure criminal background checks were performed prior to patient contact. During an interview on 12/11/2024 at 9:21 AM, the administrator stated that he/she was not aware the hospice aide needed an annual on-site supervisory visit by the registered nurse. During an interview on 12/11/2024 at 10:50 AM, the administrator stated that he/she was not aware the medical director was required to do the emergency preparedness training.

Based on record review and interview, the hospice provider failed to send a discharge summary to the patients attending physician upon discharge in one of three live discharge records reviewed (Record/Patient #9). This deficient practice has the potential to affect the continuity of care for all live discharge patients served by the provider. --- Findings included: RECORD/PATIENT #9: Review of the clinical record showed in part: - A face to face visit by the nurse practitioner, dated 12/29/2023, that showed the patient wanted to discontinue hospice care due to his/her condition had improved. The nurse practitioner recommended discontinuing hospice care; - A discharge note, dated 01/10/2024, that showed the patient was discharged and provided with prescriptions for medication and oxygen and the patient declined the offer made by hospice nurse to schedule an appointment with the patients primary physician; and - The record failed to show that a discharge summary was sent to the patients primary physician. During an interview on 12/11/2024 at 9:35 AM, the administrator stated that they did not have documentation to show a discharge summary was sent to the patients primary physician.

Based on record review and interview, the provider failed to ensure supervision of patient assessments by a bachelor prepared social worker (BSW) was completed by a Master prepared social worker (MSW) as required by federal and state regulations, in one of five full records reviewed (Record/Patient #1).This deficient practice has the potential to affect all patients served by the provider. --- Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/08/2024 with a terminal diagnosis of malignant neoplasm of the prostate (prostate cancer), and secondary diagnosis which included chronic kidney disease, (a condition where the kidneys gradually lose the ability to filter waste products from the blood), diabetes (a group of diseases that results in too much sugar in the blood), and anemia (a blood disorder that occurs when the body doesn't have enough red blood cells to carry oxygen throughout the body).The patient resided in a private residence alone with assistance of a primary care giver (PCG). Review of the patients initial MSW social work assessment, dated 10/03/2024, showed the assessment was completed by a BSW. Review of the clinical record showed: - A social worker visit dated 10/30/2024 completed by a BSW; and - A social worker visit dated11/13/2024 completed by a BSW. During an interview on 12/11/2024 at 10:45 AM, the administrator stated that the MSW should review and provide supervision for all social work visits. The administrator stated there was no documentation of MSW oversight for patient #1.

Based on review of Missouri regulation, policy review, personnel record review, and interview, the hospice provider failed to ensure a criminal background check (CBC) was performed prior to patient contact in two of five personnel records reviewed (Employees #2 and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the providers duty to conduct employee criminal background checks pursuant to this section..." Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest). Review of the providers policy titled, ";Criminal Background Checks," revised 05/08/2019, showed the hospice will complete all required state and federal criminal background checks on all employees, volunteers, and contracted staff who have direct patient contact or access to patient records at a minimum. EMPLOYEE #2: Review of sampled patient records showed a chaplain visit note, dated 11/22/2024, in which Employee #2 had patient contact. Review of Employee #2s personnel record showed: - A hire date of 11/07/2024; - The employees position was chaplain; - The provider failed to document the date of the employees first patient contact; and - The date of the CBC was 12/03/2024 (11 days after the sampled patients chaplain visit). EMPLOYEE #4: Review of Employee #4s personnel record showed: - A hire date of 09/08/2022; - The employees position was medical director; - The provider failed to document the date of first patient contact; and - The date of the CBC was 12/11/2024 (Two years and three months after Employee #4s hire date). During an interview on 12/11/2024 at 10:50 AM, the administrator stated that he/she would expect the CBC to be checked prior to patient contact and understands that Employees #2 and #4 were checked after patient contact.

Based on policy review, record review, 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 policy titled, "Medication - Administration and Management," dated 10/15/2015, showed in part: - The skilled nurse will obtain during the first patient contact and/or update information on the medications, the patient is currently taking; - This information is documented in a medication list or profile. The information will be updated when the patient's medications change; and - The skilled nurse will compare the medication information the patient is currently taking with the medications ordered in order to identify and resolve discrepancies including omissions, duplications, contraindications, unclear information, and changes. Review of the agency's policy titled, "Medication Regimen Review," dated 10/15/2015, showed in part: - A licensed nurse must review all prescription and non-prescription medications of a client/patient on an ongoing basis; - At the time of admission an accurate, current, and complete list of all prescription and over-the-counter medications including sample medication/drugs taken by the patient will be maintained on the medication profile; and - A licensed nurse must review all prescription and non-prescription medications on an ongoing basis. RECORD/PATIENT #1: Review of the long term care facility (LTCF) physician order sheet dated March, 2022 showed the following discrepancies with the agency's medication profile: - The agency medication profile showed an order for Zofran (anti-nausea) 4 milligrams (mg) one tablet every six hours as needed. The LTCF orders did not include an order for Zofran; - The agency medication profile showed an order for oxygen per nasal cannula two to four liters as needed for shortness of breath. The LTCF orders did not include an order for oxygen; and - The agency medication profile showed an order for Two cal HN 2.0 (high calorie supplement) 60 milliliters (ml) three times a day. The LTCF orders showed an order for Two cal 90 ml three times a day. RECORD/PATIENT #2: Review of the LTCF physician order sheet dated March, 2022 showed the following discrepancies with the agency's medication profile: - The agency's medication profile showed an order for Senna S (laxative) 8.6-50 mg one tablet two times daily. The LTCF orders showed an order dated 03/07/2022 for Senna S 8.6 mg-50 mg two tablets two times daily; and - The agency's medication profile showed an order for antioxidant capsules two capsules daily. The LTCF orders showed an order dated 03/07/2022 for antioxidant capsules two capsules two times daily. During an interview on 03/29/2022, beginning at 4:45 PM, the administrator stated that the nurse takes the medication record to the facility every two weeks to compare it with the facility orders. If there are discrepancies, the nurse discusses it with the charge nurse. The medications are reconciled anytime there is a medication changed or discontinued. The nurse updates the medication profile with changes.

Based on policy review, record review, and interview, the agency failed to ensure an individualized plan of care (POC) was developed in, but not limited to, three (Records/Patients #1, #2 and #5) 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 policy titled, "Plan of Care," revised 03/07/2022, showed in part: - It is the policy that a written individualized comprehensive interdisciplinary team (IDG) care plan be established and maintained for each individual admitted to hospice and the care provided will be in accordance with the care plan; - The agency will have a written comprehensive POC established within five days of admission; - The POC will be reviewed and updated, at least every 14 days by the medical director and the IDG and will be documented in the record in coordination with the attending physician (if any); - Documentation on the POC shall reflect the changing needs of the patient/family and the services required to meet those needs; and - The agency will develop an individualized written comprehensive POC for each patient which will reflect patient and family goals and interventions based on the problems identified in the initial and updated comprehensive assessments RECORD/PATIENT #1: Review of the record showed the patient resided in a long term care facility (LTCF). Review of the skilled nurse (SN) visits showed: - From 02/15/2022 through 03/24/2022, the nurse documented the patient had 1+ edema/fluid (swelling) (edema is graded on a scale of 1-4 with 1 being the least and 4 being the most - to determine the extent of the edema. The depth of the edema depends on the indentation in the skin when pressed), to the bilateral lower extremities (legs); - On 02/15/2022, the nurse documented the patient had bruising and an abrasion to the right forehead from a fall on 02/12/2022; and - On 02/21/2022, the LTCF was awaiting results of a urinalysis (a test of the urine to see if infection is present). Review of a communication note dated 02/27/2022, showed the LTCF charge nurse called to report the patient fell at 5:00 AM with no apparent injuries noted. Review of the SN visits showed: - On 02/28/2022, the patient was on an antibiotic for a urinary tract infection (UTI). A new order for Lasix (helps rid the body of fluid) 20 milligrams (mg) daily was verified with the physician; - On 03/21/2022, the patient had a traumatic wound to the left eyebrow with an onset date of 03/19/2022. The nurse documented under the psychosocial assessment the patient had a three centimeter laceration (cut) to the left eyebrow. Steri strips (wound dressing) intact. Cause unknown. The nurse failed to document any information regarding how the patient sustained the laceration. The section for plan of care problems for alteration in safety identified 02/07/2022 showed the goal included that the patient would not sustain injury from a fall. The assessment failed to show the patient had an actual fall and the POC was not updated due to an actual fall. Review of the IDG meeting notes dated 03/23/2022 showed no documented discussion regarding the patient's edema, having been placed on an antibiotic for a UTI or discussion of the injury sustained to the left eyebrow. Review of the POC dated 03/23/2022 showed no interventions and goals related to the patient's edema, UTI or update related to the injury to the left eyebrow. During an interview on 03/30/2022 at approximately 10:30 AM, the administrator acknowledged the findings, no further information was provided. RECORD/PATIENT #2: Review of the POC dated 03/23/2022 showed: - Alteration in respiratory function - oxygen needed; - Interventions included standing orders for oxygen at two liters (measurement) per nasal cannula as needed or continuous. May increase in one liter increments every five minutes up to four liters until respiratory distress is relieved and sodium chloride 0.9% for inhalation three milliliters (ml) every four hours as needed per nebulizer (a small machine that turns liquid medicine into a mist) for excessive or thick secretions; -The activities section of the POC showed on 01/05/2022 and 03/21/2022, the patient used oxygen continuously at five liters per nasal cannula for symptom management and comfort; and - The POC failed to include the current interventions that the patient's oxygen may be increased to six liters per nasal cannula as needed and the order for nebulizer treatment for excess secretions. Review of the current medication profile showed: - An order dated 01/03/2022 that the patient's oxygen may be increased to six liters per nasal cannula as needed; - An order dated 01/05/2022 for oxygen five liters continuous per nasal cannula; and - No order for oxygen at two liters per nasal cannula as needed or continuous. May increase in one liter increments every five minutes up to four liters until respiratory distress is relieved and sodium chloride 0.9% for inhalation three milliliters (ml) every four hours as needed per nebulizer for excessive or thick secretions. Review of the SN visits from 02/28/2022 through 03/07/2022, showed the nurse documented the patient was on four liters of oxygen (No order for this). Review of the IDG meeting notes dated 03/23/2022, showed new orders that included the patient was on a pureed diet with nectar thickened liquids. Review of the POC dated 03/23/2022, showed the patient had dysphagia (difficulty swallowing). The POC was not updated to include that the patient was on a pureed diet with nectar thickened liquids. During an interview on 03/30/2022 beginning at 12:20 PM, the administrator stated that the standing orders are on the POC for the nurses to choose from. If they are not using something on the standing orders, they do not put it on the medication list unless it was something the patient started using and they had an order for it. The orders for a pureed diet with nectar thick liquids should be part of the POC. RECORD/PATIENT #5: Review of the POC dated 03/22/2022, showed in part: - A problem identified as alteration in cardiac status - edema; and - Interventions included to assess edema, instruct the patient/caregiver/family on the importance of elevating bilateral lower extremities to decrease edema, use of medications/treatments for edema, and give medications as ordered on the medication profile. Review of the SN visits showed: - On 02/21/2022 and 03/07/2022, the patient had 1+ pitting edema lower extremities; - On 03/18/2022, the patient had 2+ pitting edema in both lower extremities. The nurse documented he/she coordinated with the director of nursing (DON) but failed to document he/she notified the physician of the increased edema; and - On 03/24/2022, the patient had 2+ pitting edema in the lower right extremity and 3+ pitting edema in the left lower extremity. The nurse documented he/she coordinated with the DON but failed to document he/she notified the physician of the increased edema. During an interview on 03/30/2022 beginning at 12:50 PM, the administrator stated that the increased edema should have been reported to the physician and the POC should have been updated.

Based on policy review, record review, and interview, the agency failed to ensure all disciplines were informed of changes/updates regarding patients' care and services in, but not limited to, one (Record/Patient #1) 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 policy titled, "Interdisciplinary Team Group (IDT/IDG) Conferences," dated 10/15/2015, showed in part, each staff member will be responsible for discussing appropriate issues/concerns with other disciplines involved in the patients care. RECORD/PATIENT #1: Review of the record showed the patient was admitted to hospice services on 11/19/2021, with the terminal diagnosis of end stage heart failure. On 03/25/2022, the social worker documented the patient had a pain level of five (pain is rated on a scale of 0-10 with 0 meaning no pain and 10 meaning the worst pain) but his/her facial expressions and movements were indicative of pain. The social worker failed to document this was communicated to the registered nurse (RN) case manager. During an interview on 03/30/2022 beginning at 12:50 PM, the administrator stated that the pain should have been reported to the nurse.

Based on record review and interview, the agency failed to ensure the nursing needs of the patient were assessed and met in, but not limited to, three (Records/Patients #1, #2 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the skilled nurse (SN) visits from 02/15/2022 through 03/24/2022, showed: - Respiratory assessment showed within normal limits but further assessment showed the lung sounds were CTA (clear to auscultation) and diminished bilaterally with shortness of breath and a productive cough; and - The patient's pupils were unequal but no documentation in the medical record that this is normal for the patient. During an interview on 03/30/2022 at approximately 10:30 AM, the clinical manager stated that assessments should clarify baseline for the patients. The clinical manager stated that for most of the patients their assessment would not be within normal limits due to their disease process. RECORD/PATIENT #2: Review of the plan of care (POC) dated 03/23/2022, showed in part: - Alteration in bowel elimination-constipation; - Interventions included: *Teach patient/caregiver/family to report all bowel movements (BM) and call the agency if no BM in three days; and *Included standing orders for constipation; - Activities included: *On 01/20/2022 teaching provided on constipation. Patient to be given Dulcolax (laxative) suppository today; *On 02/10/2022 no BM reported. The patient refused MOM (milk of magnesia). Instructed charge nurse to give a Dulcolax suppository; *On 02/15/2022 reported to charge nurse no recorded BM in the last 15 days. To follow up with staff. Teaching provided on prevention of constipation including administering suppository as directed. Verbalized understanding; and *On 03/07/2022 teaching provided on prevention of constipation. Staff to give Dulcolax suppository today. Review of the skilled nurse (SN) visits showed: - On 01/14/2022, the last BM was 01/09/2022 (five days). Lax/enema use - Dulcolax (unclear whether this was given this day or what was available to give the patient). Bowel sounds normal. Taking sips of liquids and a few bites of lunch but refused breakfast No documentation whether the patient's constipation was discussed with the LTCF staff; - On 01/18/2022, the last BM was 01/09/2022 (nine days). Dulcolax (unclear whether this was given this day or what was available to give the patient). Bowel sounds normal. Sleeping most of the time. Refused food and liquids for breakfast. No documentation whether the patient's constipation was discussed with the LTCF staff; - On 01/20/2022, the last BM was 01/09/2022 (11 days). Bowel sounds normal. Refused food and liquids for breakfast. Teaching provided on constipation. To be given Dulcolax suppository today. Verbalized understanding; - No documentation of follow up of results of the Dulcolax suppository until 01/24/2022; - On 01/24/2022, the last BM was 01/20/2022 (four days). Bowel sounds normal. Refused food and liquids for breakfast and lunch. No documentation the patient's constipation was discussed with the LTCF staff; - On 01/27/2022, the last BM was 01/22/2022 (five days, conflicts with the previous visit on 01/24/2022). Bowel sounds normal. Sleeping most of the time. Refused food and liquids for breakfast and lunch. Lax/enema use - Dulcolax. No documentation that the patient's constipation was discussed with the LTCF staff; - On 02/07/2022, the last BM was 01/22/2022 (15 days). Bowel sounds normal. Ate 25% of breakfast and lunch today with 240 cc (cubic centimeters) of fluid intake. Lax/enema use - Dulcolax. No documentation whether the patient's constipation was discussed with LTCF staff; - On 02/10/2022 last BM 01/31/2022 (conflicts with the previous visit). Bowel sounds normal. Refused breakfast today. Patient refused MOM (milk of magnesia). No BM reported in eight days (it was actually ten days). Instructed the charge nurse to administer a Dulcolax suppository. He/she agreed; - No documentation of follow up of results from the Dulcolax suppository until 02/15/2022; - On 02/15/2022, the last BM was 01/31/2022 (15 days). Bowel sounds normal. Patient continues with poor intake. Lax/enema use - Dulcolax. Reported to charge nurse no recorded BM in the last 15 days. The nurse practitioner and Charge nurse was notified to check with staff on the last Dulcolax suppository. Abdomen soft, round non-tender, bowel sounds active times four quadrant. To follow up with staff. Teaching provided on prevention of constipation including administering suppository as directed; and - No follow up of results of the Dulcolax suppository until 02/18/2022. Last BM 02/16/2022; - On 03/07/2022 last BM 03/02/2022 (five days). Bowel sounds normal. Continues with poor intake. Staff report refused breakfast and lunch. Teaching provided on prevention of constipation. Charge nurse placed patient on the laxative list; - On 03/10/2022 last BM 03/07/2022; - On 03/14/2022, the last BM was 03/07/2022 (seven days). Bowel sounds normal. Lax/enema use - Dulcolax. Patient continues with poor intake. Refused breakfast and lunch today. No documentation the patient's constipation was discussed with the LTCF staff; - On 03/17/2022 last BM 03/08/2022 (nine days). Bowel sounds normal. Lax/enema use - Dulcolax. Continues with poor intake. Ate eight bites of cereal and drank 2 cal (high calorie supplement). Teaching provided on prevention of constipation. Staff to give Dulcolax suppository today; - No documentation of follow up of results of the Dulcolax suppository until 03/21/2022; and - On 03/21/2022 last BM 03/19/2022. During an interview on 03/30/2022 beginning at 11:20 AM, the administrator stated that he/she expected the nurse to assess bowel function each visit. They are not supposed to go over three days without a documented BM. They should go to the charge nurse to see when the last BM was. The nurse should call the next day to see if the interventions for constipation worked. RECORD/PATIENT #5: Review of the patient communication notes (no indication of who the communication notes went to) showed: - On 03/05/2022 the aide documented the patient complained of pain again about three small toes and some pain on the bottom of the right foot. The patient's pain level was 5 (pain is rated on a scale of 0-10 with zero meaning no pain and 10 meaning the worst pain); and - On 03/05/2022 RN A received a call from the patient's caregiver that the patient had pain in his/her feet and would like the patient's nurse (RN B) to check with the physician this week to see about a clonidine compound (certain formulations can be used to treat pain) for him/her. RN A notified RN B. Review of the SN visits showed no visit or call made to the patient until 03/07/2022. During an interview on 03/30/2022 beginning at 12:50 PM, the administrator stated that the communication notes go to all staff. A nursing visit should have been made when the caregiver reported the pain.

Based on record review, and interview, the agency failed to ensure the hospice aide reported changes in the patient's condition to the registered nurse (RN) in two (Records/Patients #2 and #5) of two records reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: RECORD/PATIENT #2: Review of the aide care plan dated 01/05/2022, showed that pain must be addressed and documented on every aide visit. The aide is to document complaints of pain in the aide comment section every visit, noting the RN (registered nurse) was notified of pain; Review of the aide visits on 01/10/2022, 01/14/2022, 01/21/2022, 01/24/2022, 02/07/2022, and 02/11/2022 showed the aide documented the patient had pain, but failed to document he/she notified the RN of the pain. Review of the RN aide supervisory visits dated 02/15/2022 and 02/21/2022, showed the RN provided teaching on reporting the patient's pain level and care provided to the facility charge nurse. Review of the aide visits on 03/07/2022, 03/14/2022, 03/21/2022, 03/25/2022, and 03/28/2022 showed the aide documented the patient had pain but failed to document he/she notified the RN of the pain. During an interview on 03/30/2022 beginning at 11:20 AM, the administrator stated that he/she expected the aide to report and document he/she reported the pain to the RN. RECORD/PATIENT #5: Review of the aide care plan dated 02/16/2022 showed: - Pain must be addressed and documented on every aide visit. The aide is to document complaints of pain in the aide comment section every visit, noting the RN was notified of pain; - Notify the RN if the patient is unable to complete/tolerate any assigned tasks; and - Notify RN if the care plan needs to be reassessed due to patient decline or if patient/caregiver/family refuses the aide visit or any assigned tasks. Review of the aide visits showed: - On 02/16/2022 and 02/19/2022 the patient declined the assigned tasks of changing linens and making bed; - From 03/02/2022 through 03/09/2022 the aide documented the patient had pain; and - The aide failed to document he/she notified the RN of the pain and the patient's declination of the assigned tasks. During an interview on 03/30/2022 beginning at 12:50 PM, the administrator stated that the patient's pain should have been reported to the nurse. If a patient declined an assigned task three times they were to report to the nurse. The declined tasks should have been removed from the aide care plan.

Based on policy review, record review, and interview, the agency failed to ensure the registered nurse (RN) adequately evaluated the aides completed the tasks assigned by the RN in two (Records/Patients #2 and #5) of two records reviewed that received aide services. This deficient practice has the potential to affect all patients that receive aide services. Findings included: Review of the agency's policy titled, "Hospice Aide - Supervisory Visits," revised 03/07/2022, showed the supervising RN must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that includes, but not limited to, following the patient's plan of care for completion of assigned tasks by the RN and reporting changes in the patient's condition. RECORD/PATIENT #2: Review of the aide care plan dated 01/05/2022, showed that pain must be addressed and documented on every aide visit. The aide is to document complaints of pain in the aide comment section every visit, noting the RN was notified of pain; Review of the aide visits on 03/07/2022, 03/14/2022, 03/21/2022, 03/25/2022, and 03/28/2022 showed the aide documented the patient had pain, but failed to document he/she notified the RN of the pain. Review of the aide supervisory visits dated 03/07/2022 and 03/21/2022, showed that the aide satisfactorily followed the aide care plan as instructed and provided excellent timely notification to the supervisor of client's needs or changes in condition. The supervisory visits failed to address documentation of reporting the pain to the RN. During an interview on 03/30/2022 beginning at 11:20 AM, the administrator stated that the nurse should inform the aide that they want to know if the patient is having pain. RECORD/PATIENT #5: Review of the aide care plan dated 02/16/2022, showed that pain must be addressed and documented on every aide visit. The aide is to document complaints of pain in the aide comment section every visit, noting the RN was notified of pain; - Notify the RN if the patient is unable to complete/tolerate any assigned tasks; and - Notify RN if the POC needs to be reassessed due to patient decline or if patient/caregiver/family refuses the aide visit or any assigned tasks. Review of the aide visits showed: - On 02/16/2022 and 02/19/2022, the patient declined the assigned tasks of changing linen and making bed; - From 03/02/2022 through 03/09/2022, the aide documented the patient had pain; and - The aide failed to document he/she notified the RN of the patient's pain and declination of assigned tasks. Review of the aide supervisory visits dated 02/21/2022, 03/07/2022, 03/14/2022 and 03/28/2022 showed that the aide satisfactorily followed the aide care plan as instructed and provided excellent timely notification to the supervisor of client's needs or changes in condition. The supervisory visits failed to address/update the aide assignment regarding the patient's declined tasks and documentation of reporting the patient's pain to the RN.. During an interview on 03/30/2022 beginning at 12:50 PM, the administrator stated that the pain should have been reported to the RN. If a patient declined an assigned task three times they were to report to the nurse. The declined tasks should have been removed from the aide care plan.

Based on policy review, record review, and home visit observation, the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in, but not limited to, one (Record/Patient #1) of two applicable records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled, "Hospice Care to Residents at a SNF/NF (long term care facilities (LTCF) or ICF/IID (intermediate care facilities)," revised 03/07/2022, showed the agency would provide the following to the SNF/NF: - Hospice election form and any advance directive specific to the patient; and - The physician certification/recertification of the terminal illness. RECORD/PATIENT #1: Review of the hospice record maintained at the LTCF, during a home visit observation on 03/28/2022 beginning at 11:55 AM, showed it failed to contain the following required information: - Hospice election form; - Advance directive; and - Physician certification and recertification. The findings were reviewed with the administrator on 03/30/2022, beginning at 12:50 PM. No further information was provided.

Based on review of Missouri state law, policy review, personnel file review, and interview, the hospice failed to obtain the results of a criminal background check prior to patient contact in two (Employees #1 and #3) of four personnel files reviewed; and failed to obtain the employee disqualification list (EDL) check prior to hire in two (Employees #1 and #4) of four personnel files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." Review of Section 192.2495.3, RSMo states: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540, RSMo." Review of the agency's policy titled, "Employee Personnel Files," dated 10/15/2015, showed a criminal background check will be kept in each employee file. EMPLOYEE #1: - Date of hire: 10/10/2020, and date of first patient contact 10/12/2020; - Family Care Safety Registry (criminal background check) obtained 10/20/20 (eight days after first patient contact); and - EDL obtained 10/20/20 (10 days after hire). EMPLOYEE #3: - Date of hire: 08/31/2020, and date of first patient contact 09/01/2020; and - Family Care Safety Registry obtained 05/10/2021 (almost nine months after hire). EMPLOYEE #4: - Date of hire: 10/15/2015; and - EDL obtained 10/28/2015 (nine days after hire). During an interview on 03/30/2022, at 3:10 PM, the human resource director stated that it was difficult to obtain the criminal background check. When they called to obtain an FCSR they tell you that they are backed up.