Every finding on record at Generations Care, LLC

Based on employee file review and interview the agency failed to ensure emergency preparedness training was provided during employee orientation in four (Employees #3, #4, #5, and #6) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #3: Review of the employee file showed: - Date of hire 01/08/2023; and - No evidence of emergency preparedness training at orientation. Employee #4: Review of the employee file showed: - Date of hire 05/10/2022; and - No evidence of emergency preparedness training at orientation. Employee #5: Review of the employee file showed: -Date of hire 01/09/2023; and -No evidence of emergency preparedness training at orientation. Employee #6: Review of the employee file showed: -Date of hire 01/03/2023; and -No evidence of emergency preparedness training at orientation. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that they did not provide emergency preparedness training at orientation for these employees.

Based on review of the agencys admission packet, home visit observation, and interview the agency failed to ensure that the patients received accurate and current written information related to his/her patient rights in, but not limited to, one (Record/Patient #1) of three full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the patient bill of rights section of the agency's admission packet showed that upon admission, the patient must be informed of the rights and responsibilities in receiving care. The information failed to include that the agency must provide the patient or representative with verbal and written notice of the patients rights and responsibilities in a language and manner the patient understands. RECORD/PATIENT #1:Observation on 02/07/2023 beginning at 09:55 AM, during the patient's home visit, showed the patient rights written information was not found in the home. Per interview conducted during observation, the patient and caregiver denied receiving any information at the time of admission on patients rights or responsibilities. The findings were reviewed with the clinical director on 08/03/2022, at 10:40 AM. The clinical director acknowledged the findings. No further information was provided. During an interview with the RN Director of Care Transitions on 02/07/2023 at 11:55 AM, he/she stated the admission paperwork and consents are signed with the patient and then staff brings the signed paperwork back to the office and scan it into the chart. They only provide copies of signed documents or admission paperwork to home patients on request. They do not provide written patient rights to home patients.

Based on review of the patient admission packet and interview, the agency failed to ensure advance directive information provided to patients on admission, included information regarding applicable Missouri case law as set forth in Cruzan v. Director Mo. Dept. of Health, 497 U.S. 261, 110 S. ct 2841, 11L.ED.2nd224(1990). This case identified that advance directives that do not meet the formal requirements of either a living will or durable power of attorney for health care can be established by "clear and convincing evidence" of the patient's wishes as to the withdrawal of life-sustaining treatment. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Per 42 CFR 489.102(a)(1)(i) the agency failed to "Provide written information to such individuals concerning – (i) An individuals rights under State law (whether statutory or recognized by courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives." The agency failed to provide the patient with information regarding applicable Missouri case law as set forth in Cruzan v. Director, Mo. Dept. of Health, 497 U.S. 261, 110 S.Ct. 2841, 111 L.Ed.2d 224 (1990). This case identified that advance directives that do not meet the formal requirements of either a living will or durable power of attorney for health care can be established by "clear and convincing evidence" of the patient's wishes as to the withdrawal of life-sustaining treatment. Review of the patient admission packet provided by the agency on 02/06/2023, failed to include information regarding the applicable Missouri state law with the advance directive information. During an interview on 02/08/2023, beginning at 11:05 AM, the administrator stated that the information would now be included with the patient information.

Based on policy review, record review, and interview, the agency failed to ensure the social worker's (MSW) comprehensive assessment was completed within five days of election of hospice care in one (Record/Patient #1) of five 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, "Comprehensive Assessment," dated/revised November 2020, showed in part, a comprehensive assessment will be performed by the IDG (interdisciplinary group) no later than five calendar days after the election of hospice care in consultation with the attending physician. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 12/21/2022 with a terminal diagnosis of Congestive Heart Failure (CHF -a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body). The patient resided in his/her home with a caregiver. Review of the hospice election statement showed the effective date of election was 12/21/2022. Review of the initial MSW evaluation visit showed a date of 12/28/2022 (7 days after election of hospice care). During an interview on 02/08/2023, at 9:30 AM, the Registered Nurse Director of Care Transitions stated that he/she would expect all disciplines to complete the assessment within five days.

Based on policy review, record review, home visit observation, and interview the agency failed to maintain an accurate/updated medication profile in, but not limited to, 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, "Initial Assessment/Comprehensive Assessment," undated, showed in part:- Each patient's comprehensive assessment includes a review of all medications the patient is currently taking. Review of agency's policy "Reassessments/Update to the Comprehensive Assessment," undated, showed in part: -Each patient will be reassessed when: -A significant change in condition, status, diagnosis, care, environment or support system occurs; and -Response to care needs to reassessed. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 12/21/2022 with a terminal diagnosis of Congestive Heart Failure (CHF -a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body). The patient resided in his/her home with a caregiver. Per interview conducted during a home visit observation on 02/07/2023 beginning at 09:55 AM, a review of the patient's medications with the RN A showed:-Fish oil (supplement) 1000mg capsules two daily; -AERDS vision health (supplement) one tab daily; -Calcium (supplement) 500 mg one tab daily; -Zyrtec (allergy relief) 10 mg one tab daily; -Volfenac Gel 2.32% (topical pain relief) apply to desired area up to four times daily; and -The hospice medication profile failed to show the over the counter medications. During an interview on 02/08/2023 at 10:50 PM, the RN Director of Care Transitions stated that he/she expected the medication bottles to be reviewed at admission and with each nursing visit to ensure medication profile accuracy.

Based on policy review, record review, and interview the agency failed to ensure the skilled nurse (SN) and hospice aide followed the visit frequency as assigned on the plan of care (POC) in, but not limited to, one (Record/Patient #3) 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, "The Plan of Care," revised November, 2020, showed in part that the care provided to the patient will be in accordance with the POC. RECORD/PATIENT #3: Review of the IDG (interdisciplinary group) comprehensive assessments dated 12/20/2022 and 01/03/2023 showed the visit frequency assignments for the SN (skilled nurse) and hospice aide visits were two times a week. Review of the SN visits showed the SN visited once the week of 12/18/2022. Review of the hospice aide visits showed the aide visited once the week of 01/01/2023. During an interview on 02/08/2023 beginning at 8:55 AM, the RN (registered nurse) director of care transitions stated that the RNs were supposed to let the clinical director know of missed visits. They should try and rearrange visits for another time. They should document why there were missed visits and notify the patient and/or facilities if the nurse or aide was not coming.

Based on policy review, record review, and interview the agency failed to ensure a complete individualized written plan of care (POC) was developed that was based on the problems identified in the patient's comprehensive assessment, in one (Record/Patient #2) record 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, ";The Plan of Care," revised November 2020, showed in part that a written individualized patient and family POC will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be accordance with the POC. The POC will be based on the initial, comprehensive, and ongoing assessments. This plan will focus on identified problems, goals, and interventions. RECORD/PATIENT #2: Review of the registered nurse (RN) recertification visit note dated 01/03/2023, showed the patient was at risk for falls. Review of the skilled nurse (SN) visits showed: - On 01/14/2023, the patient was a high fall risk and had the bed in the lowest position with a fall mat on the floor; - On 01/24/2023, the patient was at increased risk for falls related to weakness, fatigue, incontinence, cognition, and mobility. The patient tried to get out of bed; and - On 1/26/2023 and 02/06/2023 the patient was at increased risk for falls related to weakness, fatigue, incontinence, cognition, and mobility. Review of the interdisciplinary group (IDG) comprehensive assessment dated 01/31/2023, included the SN visit notes that showed the patient was at risk for falls. Review of the POC dated 02/06/2023, failed to include the patients fall risk with interventions and goals to address the fall risk. During an interview on 02/08/2023, at 10:35 AM, the administrator stated he/she would expect the POC to include interventions and goals to address the fall risk.

Based on policy review, record review, and interview the agency failed to ensure the plan of care (POC) included pain interventions and goals related to pain management in one (Record/Patient #3) 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, "The Plan of Care," revised November, 2020, showed in part that the POC will include pain and symptom management interventions. RECORD/PATIENT #3: Review of a skilled nurse (SN) visit note dated 01/12/2023, showed the nurse observed the LTCF certified nursing aide (CNA) caring for the patient. The patient had his/her arms held tight to his/her torso and legs seemed rigid. The CNA stated that he/she struggled to get the patient to relax his/her body. The hospice nurse spoke with the LTCF nurse and agreed that the patient was probably having some pain. The LTCF nurse was going to give Tylenol (acetaminophen) to the patient, and also stated that he/she thought it was time for something stronger for pain. The hospice nurse agreed and would give the information to the RNCM (registered nurse case manager) and the physician. Review of the IDG (interdisciplinary group) comprehensive assessments showed: - On 01/17/2023, there was documentation of the SN visit note dated 01/12/2023 and a new order for morphine (narcotic pain medication) 20 milligrams (mg)/milliliter (ml) 0.25 ml every four hours as needed for shortness of air and/or pain. Will continue to monitor for pain and symptom management. The care plan problem interventions showed to assess pain/symptoms and intervene as necessary to bring to a level of comfort. There were no further individualized interventions or goals related to pain; and - On 01/31/2023, showed no issues with pain during visits from 01/16/2023 through 01/27/2023. Current medications included morphine concentrate 20 mg/ml 0.25 ml sublingual every four hours as needed for pain. The medication list failed to include the order for acetaminophen. The care plan problems failed to include pain as a problem with interventions and goals related to pain. Review of the current POC dated 02/03/2023, failed to include pain with interventions and goals to manage pain. During an interview on 02/08/2023 at 10:30 AM, the administrator stated that the POC should include interventions and goals to manage pain.

Based on employee file review and interview the agency failed to ensure an evaluation of the competency of certified nursing assistants (CNA) to provide services to hospice patients was conducted in two (Employee #5 and #6) of two hospice aide files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #5: Review of the employee file showed: - Date of hire 01/09/2023; and - No evidence of a competency evaluation completed by the agency. Employee #6: Review of the employee file showed: - Date of hire 01/03/2023, and - No evidence of a competency evaluation completed by the agency. During an interview on 02/08/2023 beginning at 11:27 AM the administrator stated that Employee #5 was a contract CNA and did not have a competency evaluation on the employee. He/she did not do a competency evaluation on Employee #6.

Based on policy review, record review, and interview the agency failed to ensure the registered nurse (RN) documented aide supervisory visits at least every 14 days in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients that received aide services. --- Findings included: Review of the agency's policy titled, "Hospice Aide Supervisory Visits," revised November, 2020, showed in part that the frequency of supervisory visits will be based upon the needs of the patient after the plan of care (POC) is established. They must be conducted no less frequently than every 14 days. RECORD/PATIENT #2: Review of the record showed no documentation of an aide supervisory visit between 01/05/2023 and 01/24/2023 (19 days). During an interview on 02/08/2023 at 10:45 AM, the RN director of care transitions stated that the supervisory visits should be documented every two weeks. He/she could not find documentation of an aide supervisory visit between 01/05/202 and 01/24/2023.

Based on policy review, record review, and interview the agency failed to ensure the hospice aide supervisory visits included all the required components in, but not limited to, three (Records/Patients #1, #4, and #5) of five full records reviewed; failed to ensure the hospice aide provided care as assigned and failed to ensure the RN (registered nurse) adequately supervised the hospice aides, in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients that received aide services. --- Findings included: Review of the agency's undated policy titled, "Hospice Aide Supervision," showed in part that the supervising registered nurse (RN) assesses an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria in, but not limited to:- Following the patient's plan of care (POC) for completion of assigned tasks;- Creating successful interpersonal relationships with the patient and family;- Demonstrating competency with assigned tasks;- Complying with infection control practices; and- Reporting changes in the patient's condition. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 12/21/2022 with a terminal diagnosis of Congestive Heart Failure (CHF).-a decrease in the ability of the heart to pump blood, resulting in an accumulation of fluid in the lungs and other areas of the body. The patient resided in his/her home with a caregiver. Review of the aide supervision notes from 12/27/2022 through 02/06/2023 failed to address the components of creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control practices; and reporting changes in the patient's condition. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice on 06/16/2022 with a terminal diagnosis of Alzheimer's disease-a disease marked by progressive loss of mental capacity. The patient resided in a skilled nursing facility (SNF).Review of the aide supervision notes from 12/05/2022 through 02/06/2023 failed to address the components of creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control practices; and reporting changes in the patient's condition. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 01/27/2023 with a terminal diagnosis of Hemiplegia-paralysis affecting one side of the body, and Hemiparesis-muscular weakness on one side of the body. The patient resided in a skilled nursing facility (SNF). Review of the aide supervision note from 010/30/2023 through 02/06/2023 failed to address the components of creating successful interpersonal relationships with the patient and family, demonstrating competency with assigned tasks, complying with infection control practices; and reporting changes in the patient's condition. During an interview on 0208/2023, beginning at 9:30 AM, the director of care transitions stated that the aide supervisory visits did not include all the required information. Findings included: Review of the agencys undated policy titled, ";Hospice Aide Documentation," showed in part that the hospice aide will document services rendered to the patient as directed in the aide care plan/assignment. The manager of patient services or designated RN is responsible for reviewing the aides charting. Review of the agencys policy titled, ";Hospice Aide Supervisory Visits," dated November, 2020, showed in part that the case manager will be responsible for supervision of all services provided for in the plan of care. RECORD/PATIENT #2: Review of the hospice aide visit notes showed: - On 12/27/2022, the aide shaved the patient; and - On 12/29/2022, the aide provided feeding assistance. Review of the IDG (interdisciplinary group) comprehensive assessment dated 12/20/2022 showed the aide care assigned tasks did not include shaving or feeding assistance for the patient. Review of the RN aide supervisory note dated 01/03/2023 showed that follow through on the plan of care had been good. The RN failed to address that shaving and feeding assistance had been provided without being assigned. During an interview on 02/08/2023 at 10:35 AM, the RN director of care transitions stated that the aides should not do anything that was not on the care plan. If something was needed that wasnt assigned, they should discuss it with the RN case manager so he/she could update the care plan. The nurse should have looked back at the aide notes and addressed the shaving and feeding assistance.

Based on employee file review and interview the agency failed to provide documented proof of orientation that included hospice philosophy for two (Employee #4 and #5) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #4: Review of the employee file showed: - Date of hire 05/10/2022, and - No evidence of hospice orientation that included hospice philosophy. Employee #5: Review of the employee file showed: - Date of hire 01/09/2023; and - No evidence of hospice orientation that included hospice philosophy. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that he/she did not have evidence of orientation for Employee #4. Employee #5 was contracted through an agency, and they did not do orientation with him/her.

Based on employee file review and interview the agency failed to provide/document initial orientation that addressed the employee's specific job duties in two (Employee #4 and #5) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #4: -Date of hire 05/10/2022; and -No evidence of hospice orientation that addressed specific job duties. Employee #5: -Date of hire 01/09/2023; and -No evidence of hospice orientation that addressed specific job duties. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that he/she did not have evidence of orientation for Employee #4. Employee #5 was contracted through an agency, and they did not do orientation with him/her.

Based on employee file review and interview the agency failed to assess/document the skills and competency of staff furnishing care as part of the orientation process in one (Employee #4) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #4: Review of the employee file showed: - Date of hire 05/10/2022; and - No evidence of a skills/competency evaluation. During an interview on 02/08/2027 beginning at 11:27 AM, the administrator stated that he/she could not provide this information.

Based on review of the agency's patient admission packet and interview the agency failed to ensure the patients received the agency's policy for disposal of controlled medications. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's patient admission packet provided by the agency on 02/06/2023 failed to include the agency's policy and procedure for disposal of controlled medications. During an interview on 02/08/2023, at 11:05 AM, the administrator stated that he/she would expect the policy to be in the admission paperwork. The agency's policy for disposal of controlled medications was not provided by the time of the survey exit.

Based on review of the written agreement for respite services, record review, and interview the agency failed to obtain a discharge summary from the skilled nursing facility (SNF) that provided respite services (inpatient care for caregiver relief) for one (Record/Patient #10) of one patient record reviewed for respite care. This deficient practice has the potential to affect coordination of care for hospice patients who receive respite care. --- Findings included: Review of the agency's respite care agreement with the SNF dated 01/01/2023, showed the contract failed to include that there be a copy of the discharge summary provided at discharge. RECORD/PATENT #10:Review of the clinical chart failed to show a discharge summary from the SNF included in the clinical documentation at the time of discharge from respite care back to home care. During an interview on 02/08/2023 at 10:47 AM, the administrator stated that he/she would expect the contract to meet the regulation requirements.

Based on contract review and interview, the agency general inpatient (GIP) contract failed to specify all of the required components, including that if one patient in the hospice facility is receiving general inpatient care, then each shift must include a registered nurse who provides direct patient care, in one of one in-patient contract reviewed. The deficient practice has the potential to affect care of any patient that receives general inpatient care for symptom control. --- Findings included: Review of the agency's contract with Skilled nursing facility (SNF) dated 01/01/2023 failed to specify all of the required components, including that if one patient in the hospice facility is receiving general inpatient care, then each shift must include a registered nurse who provides direct patient care. During an interview on 02/08/2023 at 10:47 AM, the administrator stated that he/she would expect the contract to meet the regulation requirement and no additional information was provided.

Based on policy review, record review, observation, and interview the agency failed to coordinate/ follow-up on an assessment of pain and ensure medications were updated with the long term care facility (LTCF) in two (Records/Patients #2 and #3) of four records reviewed of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that reside in a LTCF. --- Findings included: Review of the agency's undated policy titled, "Care to Residents of a SNF (skilled nursing facility, long term care facility (LTCF)/NF (nursing facility) or ICF (intermediate care facility)," showed in part that the hospice is responsible for providing all hospice services including ongoing assessment, care planning, monitoring, coordination, and provision of care by the hospice IDG (interdisciplinary group), coordination by the hospice RN (registered nurse) for the implementation of the plan of care (POC) for the patient, the designated IDG member is responsible for providing overall coordination of hospice care of the SNF/NF representatives, communicating with the SNF representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. Review of the agencys policy titled, ";Ongoing Assessments," revised November, 2020, showed in part: - During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment; - The nurse will assess each patient on each visit for pain, patient's response to medications and other interventions, current treatment related to the identified symptoms and the patient's response, progress toward hospice goals and patient needs and problems, compliance with treatments and medication regimen; - Ongoing comprehensive assessments should focus on the patient's response to care and changes in patient condition; and - Based on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. Review of the agencys undated policy titled, ";Medication Reconciliation," showed in part that medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication RECORD/PATIENT #2: Review of the agency's current medication profile and current LTCF physician orders showed the following discrepancies: -The agency's medication profile showed an order for atorvastatin calcium (reduces cholesterol) 20 mg one time a day. The LTCF physician orders did not include this medication; -The agency's medication profile showed an order for atropine sulfate 1% 3 solution sublingual as needed for secretions. The LTCF physician orders did not include this medication; -The agency's medication profile showed an order for lorazepam (for anxiety) intensol 2 mg/ml 0.25 ml orally. The order failed to include the dosage frequency. The LTCF physician orders did not include this order; -The agency's medication profile showed an order for memantine (used to treat symptoms of Alzheimer's disease) 10 mg one tablet two times a day. The LTCF physician orders did not include this medication; and -The agency's medication profile showed an order for morphine concentrate 20 mg/ml 0.25 ml sublingual every three hours as needed for anxiety/dyspnea (difficulty breathing), and pain. The LTCF physician orders did not include this medication. RECORD/PATIENT #3: Review of a skilled nurse (SN) visit note dated 01/12/2023, showed the nurse observed the LTCF certified nursing aide (CNA) caring for the patient. The patient had his/her arms held tight to his/her torso and legs seemed rigid. The CNA stated that he/she struggled to get the patient to relax his/her body. The hospice nurse spoke with the LTCF nurse and agreed that the patient was probably having some pain. The LTCF nurse was going to give Tylenol (acetaminophen) to the patient, and also stated that he/she thought it was time for something stronger for pain. The hospice nurse agreed and would give the information to the RNCM (registered nurse case manager) and the physician. Review of an email to the clinical team dated 01/13/2023 showed that the patients extremities were rigid and brought into the torso when the CNA provided perineal (cleansing of the genitalia area) care. The LTCF nurse asked about getting the patient something stronger than Tylenol, and asked if it could be scheduled due to the patients dementia. Review of the record showed no documentation of follow-up to the email on 01/13/2023. Review of an SN visit note dated 01/15/2023 showed the patients FLACC (a behavioral pain assessment scale used for patients who are unable to report their level of pain) score zero. The patient denied pain but a FLACC assessment was completed as well due to low verbal communication. The patients roommate reported no known pain. The patients current pain medication was Tylenol. The facility nurse reported the patient had enough medications. No documented discussion of the visit on 01/12/2023 regarding the request of getting the patient something stronger for pain. Review of the IDG (interdisciplinary group) comprehensive assessments showed: - On 01/17/2023, there was documentation of the SN visit note dated 01/12/2023 and a new order for morphine (narcotic pain medication) 20 milligrams (mg)/milliliter (ml) 0.25 ml every four hours as needed for shortness of air and/or pain. Will continue to monitor for pain and symptom management. The care plan problem interventions showed to assess pain/symptoms and intervene as necessary to bring to a level of comfort. There were no further individualized interventions or goals related to pain; and - On 01/31/2023, showed no issues with pain during visits from 01/16/2023 through 01/27/2023. Current medications included morphine concentrate 20 mg/ml 0.25 ml sublingual every four hours as needed for pain. The medication list failed to include the order for acetaminophen. The care plan problems failed to include pain as a problem with interventions and goals related to pain. Observation on 02/07/2023 beginning at 8:10 AM, during the patient's home visit, showed the registered nurse (RN) asked the patient if he/she had pain. The patient spoke in a very low tone. The RN put his/her ear by the patients mouth. The patient said no, just hungry. The facility nurse and CNA stated that the patient did not have pain. The facility director of nursing stated that the patient had been doing well and never seemed to be in any pain. The RN failed to review the patients medication orders. Review of the agencys current medication profile and current LTCF orders showed the following discrepancies: -The agencys medication profile showed an order for acetaminophen 325 mg two tablets orally three times a day for pain. The LTCF physician orders showed an order dated 12/16/2022 for Tylenol 500 mg three times a day for pain; and -The agencys medication profile showed an order dated 01/17/2023 for morphine concentrate 20 mg/milliliters (ml) 0.25 ml sublingual (under the tongue) every four hours as needed for pain and shortness of breath. The LTCF orders did not include this medication. During an interview on 02/08/2022, at 9:25 AM, the administrator stated that the LPN (licensed practical nurse) sent an email to the RNCM on 01/13/2023. The RNCM should have addressed and followed up on the information when he/she received the email. During an interview on 02/08/2022, at approximately 10:00 AM, the administrator stated that the nurse should check medications at every visit. During the first visit of the week, the nurse should check the agency and facility medication profiles for any changes.

Based on policy review, record review, and interview the agency failed to ensure the hospice binder maintained at the long term care facility (LTCF) included all the required information in, but not limited to, one (Record/Patient #2) of two home visits observations of patients that resided in a LTCF. This deficient practice has the potential to affect all patient that reside in a LTCF. --- Findings included Review of the agency's undated policy titled, "Care to Resident of a SNF (skilled nursing facility/LTCF (long term care facility) showed in part that the agency would provide the LTCF the physician certification and recertification of the terminal illness specific to each patient. RECORD/PATIENT #2: Review of the recertification of terminal illness was signed by the medical director on 01/15/2023. Review of the hospice binder maintained at the LTCF failed to include the physician recertification of terminal illness. During an interview on 02/08/2023 at approximately 11 :15 AM, the registered nurse (RN) director of care transitions stated that they had not been putting the recertification in the hospice binders at the LTCF.

Based on employee file review and interview the agency failed to document evidence that two of two registered nurse (RN) employee's nursing licenses were valid and in good standing at the time of hire. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Employee #1: Review of the employee file showed: - Date of hire 04/16/2022; and - Failed to include documentation that the employee's nursing license was valid and in good standing.. Employee #2: Review of the employee file showed: - Date of hire 01/08/2023; and - Failed to include documentation that the employee's nursing license was valid and in good standing. During an interview on 02/08/2023, beginning at 11:27 AM, the administrator stated that he/she could not find evidence that the nursing licenses were checked.

Based on review of Missouri state law, employee file review and interview, the hospice failed to obtain and document the results of a criminal background check in three (Employee #1, #3 and #4) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: 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." Employee #1: Review of the employee file showed: - Date of hire 04/16/2022; and - No evidence of a criminal background check. Employee #3: Review of the employee file showed: - Date of hire 01/08/2023; - Date of first patient contact 01/09/2023; and - Criminal background check 02/06/2023. Employee #4: Review of the employee file showed: - Date of hire 05/10/2022; - Date of first patient contact not known; and - Criminal background check 06/10/2022. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that staff were supposed to have a criminal background check at orientation. He/she had an office manager hired and was starting tomorrow.

Based on review of Missouri state law, employee file review, and interview the agency failed to obtain and/or document the results of an employee disqualification list (EDL) prior to hire in four (Employee #1, #2, #3 and #4) of six employee 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: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Employee #1: - Date of hire 04/16/2022; and - No evidence of an EDL check. Employee #2: - Date of hire 08/24/2022; and - EDL check 08/25/2022. Employee #3; - Date of hire 01/08/2023; and - EDL check 02/06/2023. Employee #4: - Date of hire 05/10/2022 and - EDL check 06/10/2022. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that he/she had someone hired to take care of the employee files.

Based on federal law review, Missouri state law, employee file review and interview the agency failed to ensure Alzheimer's training was provided at orientation in three (Employee #3, #4, and #5) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of 19 CSR 30-35.010 (2) (M) 1. B. (xiii) requires: "Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. (a) At a minimum, the training required shall address the following areas: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; and E. Understanding and dealing with family issues. (b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; and B. Communicating with persons with dementia. (c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed." Employee #3: Review of the employee file showed: - Date of hire 01/08/2023; and - No documentation of Alzheimer's disease training at orientation. Employee #4: Review of the employee file showed: - Date of hire 05/10/2022; and - No documentation of Alzheimer's disease training at orientation. Employee #5: Review of the employee file showed: - Date of hire 01/09/2023; and - No documentation of Alzheimers disease training at orientation. During an interview on 02/08/2023 beginning at 11:27 AM, the administrator stated that he/she could not provide evidence of Alzheimers disease training at orientation. Employee #5 was a contracted employee and he/she did not have Alzheimer's disease training when hired.

Based on policy review, record review, "Patients Bill of Rights and Responsibilities," grievance file review, and interview, the agency failed to promote and protect the following patient rights: -To be informed of his or her rights, and the hospice must protect and promote the exercise of these rights (L501); -To have an immediate investigation to prevent further violations (L509); -To receive effective pain management and symptom control from the hospice for conditions related to the terminal illness (L512); -To receive information about services covered under the hospice benefit (L518); and -To receive information on services that will be provided and limitations (L519). The cumulative effect of these deficient practices resulted in a finding of immediate jeopardy for two patients (Records/Patients #1 and #3) and has the potential to affect all patients served by the agency. --- .

Based on review of the agency's admission packet and written information provided to each patient at the start of care, the hospice failed to ensure the patient received accurate and current information related to his/her patient rights. This deficient practice has the potential to affect all patients served by the hospice. --- Findings included: Review of the admission folder used by staff during the admission of a patient and reviewed with the patient and families, showed the agency's ";Patient Bill of Rights and Responsibilities" failed to include the following patient's rights as defined in regulation:-To refuse care or treatment;-To choose his/her attending physician; and-To a confidential clinical record, and access to or release of patient information and clinical records is permitted in accordance with 45 CFR Parts 160 and 164, During an interview on 12/06/2022 at 3:57 PM, the executive director stated: -He/she agreed the Patient Bill of Rights and Responsibilities document failed to include the missing items; and-The document would be fixed immediately.

Based on review of "Patient Bill of Rights and Responsibilities" information provided to patients and interview, the hospice agency failed to immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice, and take immediate action to prevent further potential violations while the alleged violation is being verified. The agency did not immediately investigate a family complaint to prevent further violations in one (Record/Patient #3) of one complaint records reviewed. This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: Review of the agency's "Patients Bill of Rights and Responsibilities," dated 10/30/2020, and provided to patients on admission showed all alleged violations are immediately investigated involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Investigations and/or documentation of all alleged violations must be conducted in accordance to established procedures. During an interview on 12/07/2022 at 9:05 AM, the registered nurse (RN) A stated that the patients family member complained to him/her the patient had not received any narcotics, the patient was left uncovered, had no pillow, and the patients room floor was filthy. He/she had looked at the long-term care facility (LTCF) medication administration record (MAR) and found the facility had not given the patient his/her narcotics. He/she had reported this to the executive director (ED). During an interview on 12/07/2022 at 10:20 AM, the ED stated that RN A reported to him/her the patient did not receive narcotics and he/she did not write a grievance or investigate. Normally whoever takes a complaint does the following: Writes a description, who is making the complaint, and notifies the ED in person or through e-mail. The ED then investigates and finds out what happened and then notifies the complainant. The ED stated that he/she was new in his/her position and thought the complaint was against the LTCF and not the hospice agency. He/she now understood the importance of documenting complaints.

Based on policy review, "Patient Rights and Responsibilities" information provided to patients, clinical record review, and interviews, the agency failed to ensure that patients received effective pain management and symptom control for conditions related to the terminal illness and related conditions in three (Records/Patients #1, #2, and #3) of three records reviewed. This deficient practice has the potential to affect the pain and symptom management of all the agency's patients. --- Findings included: Review of the agencys policy titled, ";Pain Assessment," dated revised November 2020, showed the following:-Purpose: To provide guidelines for the appropriate identification and assessment of patients who may experience pain;-All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patients condition;-During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data;-When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible:• Pain intensity using a rating scale (on a scale of 0 to 10; 0 = no pain, 10 = unbearable pain). Pain intensity should include current pain, worst pain, and least pain using the scale. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain;• Pain location;• Pain quality, patterns of radiation and character. Use the patients own words whenever possible;• Pain onset, duration, variations, and pattern;• Alleviating and aggravating factors;• Present pain management regimen and effectiveness;• Pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain;• Effects of pain. These include impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, ect. (et cetera; used to show that a list of at least two items is incomplete);• The patients/familys pain goal and satisfaction with goal, including pain intensity and goals related to function, activities, and quality of life;• Physical exam or observation of the site of pain; • Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise;-If patient is unable to communicate pain using the rating scale, is cognitively impaired, the clinician will assess behavioral factors that signal pain or discomfort and include this information in the assessment;-The patients preference for pain management will be reflected in the pain control measures selected;-Nonpharmacological interventions will be considered for the treatment of pain; and-Patient and family/caregiver education will focus on the use and side effects of analgesic and/or adjuvant medications, expected responses to therapy, and the importance of administering medications according to prescribed dosage and frequency. Review of the agencys policy titled, ";Identification, Prevention, and Treatment of Secondary Symptoms," dated revised November 2020, showed the following:-Purpose: To provide direction for symptom control;-Symptom control is the foundation of good hospice care. Symptom control is best achieved in the context of the interdisciplinary group care. Supporting and educating the patient and family/caregiver is an essential part of symptom control; and -Care will be directed to optimize the patients comfort and dignity through appropriate treatment and secondary symptoms as well as aggressively managing these symptoms. Review of the agencys policy titled, ";The Plan of Care," dated revised November 2020, showed the following:-Purpose: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues;-A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis. This plan of care must be initiated at the start of care;-The plan of care will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals and outcome achievement; -The hospice must assume responsibility for professional management of the residents hospice services, in accordance with the hospice plan of care and the hospice conditions of participation;-An agreement that it is the hospices responsibility to provide services at the same level and to the same extent as those services would be provided in the residents own home;-The goal is for all care to be delivered by personnel who are hospice-oriented and hospice-trained; and -Facility staff should be trained on pain and symptom management in palliative care and patient rights. Review of the agencys policy titled, ";Hospice Nursing Care," dated revised November 2020, showed the following:-The hospice nurse will play a key role in easing physical and psychosocial symptoms and initiating communication with the interdisciplinary group to establish the plan of care;-The hospice nurse will manage discomfort and provide symptom relief; and-Provide specialized hospice training to other staff, family/caregivers to ensure adequate care. RECORD/PATIENT #3: Review of the hospital discharge summary dated 11/23/2022, showed the following:-Patient was admitted 11/09/2022;-Diagnoses included: Sepsis (a life-threatening complication of an infection), infected decubitus ulcer (infected injury to the skin and underlying tissue resulting from prolonged pressure on the skin), infected right upper extremity (arm) PICC (peripherally inserted central catheter) line, bilateral (both) lower extremity (leg/foot) cellulitis (a common and potentially serious bacterial skin infection), paraplegia (paralysis of the legs and lower body, neurogenic bladder (lacks bladder control due to a brain, spinal cord, or nerve condition), spastic disorder (a condition in which there is an abnormal increase in muscle tome or stiffness of muscle, which might interfere with movement, speech, or be associated with discomfort or pain), seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), unspecified mood disorder (applies to presentations in which symptoms predominate that are characteristic of a depressive disorder and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning), and TBI (traumatic brain injury: brain dysfunction caused by outside force);-Patient was on comfort level of care since 11/20/2022, and case management was arranging for facility placement. In meantime, continue with comfort medications (meds). Prognosis remains guarded and poor;-Continue these meds: • Alprazolam (sedative) 0.5 milligram (mg) TID (three times a day);• Baclofen (muscle relaxant) 20 mg TID;• Flexeril (muscle relaxant) 10 mg every 8 hours;• Gabapentin (anticonvulsant and nerve pain medication) 600 mg TID;• Norco (opioid pain reliever) 7.5/325 mg one every four hours as needed for pain 7-10 (Severe);• Tylenol (analgesic) 325 mg two tabs every six hours as needed for pain 4-6 (Moderate);• Zinc Oxide (barrier cream)- apply topical BID (twice a day) as needed for skin protectant;-Skin: Multiple wounds, unstageable to coccyx with tracking into scrotum, bilateral heels/feet (covered with dressing (yet had no discharge order for a dressing); and-Psych: Appears calm. Review of hospital records showed the patient had a suprapubic catheter (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow), yet there were no discharge orders regarding the catheter. Review of the long-term care facility (LTCF) note, dated 11/23/2022 at 6:39 PM, showed it was noted upon the patient's arrival to the facility, the patient had a bowel movement. The resident was situated in the room/bed, cleaned up and a head to toe assessment was completed (however, the facility did not document a head to toe assessment in their records). Also, there was no documentation regarding the patient's pain, cognition ability, or psychosocial issues. Review of the facility medication list showed:-Alprazolam 0.5 mg TID;-Baclofen 20 mg TID;-Flexeril 10 mg every 8 hours;-Gabapentin 600 mg TID;-Norco 7.5/325 one every four hours as needed for pain 7-10 (Severe); and-Tylenol 325 mg two tabs every six hours as needed for pain 4-6 (Moderate). Review of the hospice election statement, dated 11/23/2022, showed the terminal diagnosis was bacterial infection (a disease caused by microorganisms that invade tissue) and secondary diagnosis was resistance to other single specified antibiotic (antimicrobial resistance happens when germs like bacteria or fungi no longer respond to the drugs designed to kill them. That means these germs are not killed and continue to grow). Review of the hospice registered nurse (RN) A admission/comprehensive assessment, dated 11/23/2022, showed:-In at 7:50 PM and out at 8:30 PM;-Incontinent of bowel and bladder. Uses brief/pull ups. Has a suprapubic catheter;-Skin: unstageable necrotic pressure injuries (full thickness tissue loss in which actual depth of the ulcer is completely obscured by eschar (tan, brown, or black) in the wound bed) to bilateral heels, large Stage 4 pressure ulcer injury (most severe form of bedsore, a deep wound reaching the muscle, ligaments, or bones. They often cause extreme pain, infection, invasive surgeries, or even death) to left ischial tuberosity (IT: lower part of pelvis, sometimes referred to as your sit bones)/sacrum (a shield-shaped bony structure that is located at the base of the lower back and that is connected to the pelvis);-Max assist for feeding, dressing, and bathing;-Complete assist for toileting, ambulation, and transfers;-Bedbound;-Incomplete quadriplegic (may still retain some function and/or sensation in their arms or legs);-Oriented times two;-Mild agitation;-Chronic pain. Active problem for patient. Pain present- rated ";1, best pain has been ";0", worst pain has been ";8", acceptable level of pain ";2". Patient uncomfortable because of pain. Pain in bilateral lower extremities. Characteristics of pain- aching and shooting. Frequency of pain- occasional. Pain is relieved by meds, positioning, and rest. Pain is worsened by activity. Pain effects function/quality of life;-Comorbidities included: incomplete quadriplegic, neurogenic bladder, spastic disorder, seizure disorder, unspecified mood disorder, and TBI;-Patient has history of refusing care;-Patient and facility caregiver taught about pain medication, disease process, pain management, symptom management of anxiety (intense, excessive, and persistent worry and fear about everyday situations; fast heart rate, rapid breathing, sweating, and feeling tired may occur), and positioning. Review of the LTCF medication administration record (MAR) showed:-Alprazolam 0.5 mg TID at 8:00 AM, 2:00 PM, and 8:00 PM;-Gabapentin 600 mg one tab TID at 8:00 AM, 2:00 PM, and 8:00 PM;-Norco 7.5/325 mg one tablet every four hours as needed for pain;-Tylenol 325 mg two tablets every six hours as needed for general discomfort/pain;-Alprazolam on 11/23/2022 at 8:00 PM showed a ";9" (which according to chart codes meant other/see progress notes);-Alprazolam on 11/24/2022 at 8:00 AM, 2:00 PM, and 8:00 PM, all showed a ";9";-Gabapentin on 11/23/2022 at 8:00 PM showed an ";X" (not given);-Gabapentin on 11/24/2022 at 8:00 AM showed a ";9"; and-Norco and Tylenol showed the patient did not receive any doses of either while at the LTCF. Review of the LTCF notes dated 11/23/2022 at 11:52 PM, 11/24/2022 at 10:45 AM, 1:25 PM, and 7:03 PM showed Alprazolam awaiting arrival from the pharmacy. Review of the LTCF notes dated 11/24/2022 at 10:46 AM showed Gabapentin 600 mg awaiting arrival from the pharmacy. There were no facility assessments or notes regarding the patient besides the admission note on 11/23/2022. Review of hospice note dated 11/24/2022, showed the following:-In at 7:00 PM and out at 9:20 PM;-Follow up visit completed to assess the patients needs; and- Upon arrival the patients sister and her husband were at the bedside. They were visibly upset because the patients floor was dirty from the roommate. Also upset that the patient did not have a pillow under his/her head, this nurse explained that she had tried to get the patient to use a pillow and he/she refused. She also said that she had tried to get him/her to use a pillow between his/her legs and he/she refused. The patient had told the sister that his/her suprapubic catheter was pulled out by staff, the nurse assessed and the catheter was in place and draining amber urine with minimal blood tinge. The patient refused further assessment and the sister called an ambulance and the patient was transported back to the hospital that he/she was discharged from. Spoke to the nurse at the hospital on 11/25/2022 at 12:05 AM and the patient had been admitted for hematuria (blood in urine) and his/her wounds.Review of the facility note, dated 11/24/2022 at 8:30 PM, showed the facility nurse was called to the patient's room by the hospice nurse. The hospice nurse reported the family that was present at bedside was wanting to move the patient back to the hospital due to the patient and their expectations were not being met and the family had called 911. The patient was transported via EMS (Emergency Medical Services) back to the hospital. Review of the ambulance EMS trip sheet, dated 11/24/2022, showed:-Primary impression: Pain;-Chief complaint: Difficulty managing severe chronic pain;-Pulse 109 (normal= 60 to 100);-Patient had a urinary catheter, showing blood in the urine; and-The patients sister who was the DPOA stated she did not feel the patients pain was under control and wanted the patient to be evaluated at the hospital. The patient was transported to the hospital. Review of Emergency Room Department note, dated 11/24/2022, showed:-Physical exam: Distress moderate, dehydration moderate, ill appearing/not toxic, in pain, delusional, confused, mucous membranes are dry, and severe spasticity of lower extremities;-Oral medications were begun sublingually, the patient continued to escalate with delusions, confusion, and appeared to be in pain;-Medications given for symptoms:• Roxanol (narcotic used to treat moderate to severe pain) 2.5 mg was given at 9:44 PM;• Lorazepam (sedative) 0.5 mg was given at 9:45 PM;• Scopolamine (antimuscarinic, used to help decrease secretions and prevent nausea and vomiting) 1mg transdermal patch applied at 10:50 PM; • Lorazepam 1 mg was given at 10:51 PM;• Roxanol 5 mg was given at 10:51 PM; and-Clinical impression at 11:14 PM showed pain exacerbation. During an interview on 12/06/2022 at 10:05 AM, the director of nursing at the LTCF stated that he/she did not have a narcotic sheet for the patient as they had not received any narcotics in for that patient prior to his/her discharge. During an interview on 12/06/2022 at 2:00 PM, the administrator of the agency stated that he/she expected a new patients meds to be available prior to the hospice nurse leaving the patient. During an interview on 12/07/2022 at 7:50 AM, the patients sister stated the following:-She arrived to the facility to see her sibling on 11/24/2022 at about 7:00 PM and the patient was laying naked and the door was open to his/her room, her husband went in and covered him/her up before she went in;-The patient informed her that he/she was hurting and he/she looked miserable was frowning with a scowl look on his/her face. The patient said he/she was so glad to see her;-The patient had blood all over his/her hands from pounding on the wall to try and get help;-The roommate stated to her that at one time, he/she was going to call the ambulance because the patient was hollering out in pain;-She asked the facility staff why the patient was not getting his/her pain meds or anxiety meds and the staff said they did not have those medications to give;-The hospice nurse showed up after they had been at the facility awhile, and she asked him/her why he/she couldnt give the pain and anxiety medications. She was informed by the hospice nurse that he/she didnt do that;-She denied being explained the hospice philosophy; -She called 911 and waited for ambulance to arrive before she left the LTCF; and-Her sibling passed away on 11/29/2022. During an interview on 12/07/2022 at 9:00 AM, the patients admitting hospice nurse RN A stated the following:-He/she admitted the patient the evening of 11/23/2022;-He/she usually works from 5:00 PM to 8:00 AM;-The patient was admitted to the facility earlier that day, but was unsure what time he/she arrived;-The facility had the hospital discharge orders and he/she reviewed those;-The facility physician was the primary care physician for this patient and that was who wrote the orders for the patient;-He/she was informed by email that the facility would use their pharmacy to get the patients meds;-He/she did not ensure the facility had all the patients medications before leaving the LTCF, as he/she was informed the LTCF would take care of that;-He/she was unable to complete the admission assessment first of all because of computer problems, and then the patient was discharged and was unable to complete the assessment prior to the discharge;-He/she went back on 11/24/2022 in the evening for a follow up visit and the patients sister and husband were present and upset with the facility and the fact that the patient had not received his/her pain or anxiety medication;-He/she spoke to the facility nurse and the facility nurse informed him/her at that time that the LTCF needed a script for the Norco and alprazolam before they could be sent from their pharmacy; -The sister insisted on sending the patient back to the hospital because her expectation of hospice was not met; -The patients legs were spastic, but he/she denied pain and per her RN assessment she did not feel he/she was in pain prior to being sent to the hospital on 11/24/2022; and-He/she reported the family being unhappy regarding the medications being unavailable to the agency administrator. During an interview on 12/07/2022 at 10:40 AM, the director of care transitions RN B for the hospice agency stated the following:-He/she went and peeked in on the patient while in the hospital on 11/23/2022 and the patient was due to be sent to the LTCF at around 2 PM that day. The patient was not very coherent and no family was present at that time. The patient stated that he/she was not feeling very good that day, but no specifics;-Denied talking to DPOA (Durable Power of Attorney) about the hospice philosophy;-Called the LTCF and spoke with the nurse regarding the patient's meds and told them to go ahead and order the patients meds from their pharmacy and if any issues to call hospice;-Was not called when the patient was discharged from the hospital, so the evening agency nurse did the admission assessment; and-He/she usually goes over the medications with the facilities and ensures that they have available before leaving and if not then will contact the hospice medical director to order the medications. RECORD/PATIENT #1: Review of the clinical record showed:-The patient was admitted to hospice services on 05/16/2022;- The patient had a terminal diagnosis of chronic obstructive pulmonary disease (a condition that causes obstructed air flow from the lungs); and-The patient resided in a skilled nursing facility. Observation on 12/06/2022 beginning at 9:00 AM, during the patients home visit at the LTCF showed:-The LTCF nurse reported to RN B that the patient had not received any scheduled Tramadol for over 24 hours;-The LTCF controlled drug record was last dated 12/04/2022 at 5:00pm for the last dose of medication signed out with a remaining balance of zero;-The LTCF MAR showed ";medication not available" for the scheduled 8:00 AM and 5:00 PM doses on 12/05/2022; and-The facility was administering as needed morphine (narcotic pain medication) per physicians order. During an interview on 12/06/2022 at approximately 9:45 AM, the patient stated he/she was in pain, in his/her low back and stomach. He/she stated did not want morphine because he/she did not like it. He/she said he/she did not feel his/her pain was controlled. During an interview on 12/06/2022 at approximately 9:55 AM, the LTCF nurse stated that the patient does well with Tramadol (narcotic pain medication). He/she was waiting for a paper prescription to be signed and that was the hold up on the medication being available for the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice care on 10/04/2022 with a diagnosis of hydrocephalus (a build-up of fluid in the cavities deep within the brain). The patient's family member signed the patient's bill of rights and responsibilities due to the patient's cognitive delay. Review of the plan of care (POC) dated 10/19/2022 showed to assess pain/symptoms and intervene as necessary to bring to level of patient comfort. There was no individualized interventions. Review of the chaplains visit note, dated 10/06/2022 at 4:00 PM, showed the ";chaplain listened as staff reflected on changing the patient and patient yelling along with making a lot of noise crying during other times." The record failed to show if the yelling and crying was due to pain and the case manager notification. Review of the skilled nurse general visit note, dated 10/17/2022 at 9:10 AM, showed the patient ";had infrequent moans and may be having some pain". There was no further assessment/interventions/follow-up or interventions regarding the patients pain. During an interview on 12/06/2022, the chaplain stated that he/she was no sure if the patient was in pain during his/her visit on 10/06/2022, the patient was a new admission, and a certified nursing assistant reported the patient yelling and that was the patients normal behavior. He/she did not report this information to the hospice case manager but reported this information to the long-term care facility staff. During an interview on 12/07/2022 at 10:20 AM, the executive director stated that he/she reviewed the staff notes regarding the patients pain, agreed with the above findings, and will speak to the nurse about not following up on pain.

Based on review of "Patient Bill of Rights and Responsibilities" information provided to patients and interview the hospice agency failed to ensure the Patient Bill of Rights included the requirement for the hospice to inform the patient of the right to receive information about the services covered under the hospice benefit. This deficient practice has the potential to affect all patients admitted to the agency for hospice services. --- Findings included: Review of the agency's ";Patient Bill of Rights and Responsibilities," dated 10/30/2020, and provided to patients on admission showed the hospice agency failed to include the patient has the right to receive information about the services covered under the hospice benefit. During an interview on 12/06/2022 at 3:57 PM, Executive director stated:-He/she agreed the Patient Rights and Responsibilities document failed to include the missing items; and-The document would be fixed immediately.

Based on review of "Patient Bill of Rights and Responsibilities" information provided to patients and interview the hospice agency failed to include in the Patient Bill or Rights the requirement for the hospice to inform the patient of the right to receive information about the scope of services that the hospice will provide and specific limitations on those services. This deficient practice has the potential to affect all patients admitted to the agency for hospice services. --- Findings included: Review of the agency's ";Patient Bill of Rights and Responsibilities," dated 10/30/2020, and provided to patients on admission, the hospice agency failed to include the patient has the right to receive information about the scope of services that the hospice will provide and specific limitations of those services. During an interview on 12/06/2022 at 3:57 PM, Executive director stated:-He/she agreed the Patient Rights and Responsibilities document failed to include the missing items; and-The document would be fixed immediately.