Every finding on record at Good Shepherd Hospice of Springfield, LLC

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the hospice plan of care (POC) included written coordination with the long-term care facility (LTCF) that identified which provider was responsible for wound care management in one of three records reviewed of patients that resided in a LTCF (Records/Patient #1). This deficient practice has the potential to affect the coordination of care for all hospice patients who reside in a LTCF. Findings included: --- Review of the hospice provider's policy, titled "Hospice Care for Nursing Facility Resident - Coordination of Care," revised 06/01/2020, showed in part, the provider ensures mechanisms are in place to provide for coordination of all hospice services to patients residing in facilities. The hospice designates an individual for each interdisciplinary team that is responsible for a patient who is a resident of a facility.  The designated interdisciplinary group member is responsible for:  providing overall coordination of hospice care for the resident with facility representatives; and communicating with facility 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.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice on 10/20/2025 with a terminal diagnosis of malignant neoplasm of the aortic body and other paraganglia (rare, often slow-growing, cancerous tumors in the chest, neck, or skull base).  He/she lived in a LTCF and required assistance with personal care. Review of the physician’s order, dated 01/07/2026, showed:- Wound care to lipoma (a noncancerous tumor of the fatty tissue) on patient’s low back – cleanse with wound cleanser, pat dry with 4x4 gauze and apply skin prep every day shift;- Wound care to coccyx (tailbone) wound and surrounding area with cleanser, pat dry with 4x4 gauze, apply calcium alginate Ag (silver, antimicrobial wound dressing), cover with bordered dressing daily and as needed for soiling.  May apply barrier cream on "surround";- Triad (Brand) wound paste (for wound healing) – apply to buttocks topically every 12 hours as needed;- Triad wound paste – apply to buttocks topically two times a day; and- Wound care left hip – keep dressing to left hip clean and dry.  Change only if soiled in morning.  Observation on 01/20/2026 at 1:40 PM, showed the LTCF’s hospice binder (located at the nurses’ station), contained a long-term care/hospice coordination of care form that showed the following:- Cleanse coccyx WC (wound care), apply triad paste;- WC to lipoma on low back – WC pat dry with 4x4, apply skin prep every day;- Sacrum (bone that forms part of the pelvis) WC - every day 4x4, apply triad, foam dressing every day and prn (as needed); and- The provider failed to specify on the coordinated plan of care, which wounds/dressings the hospice RN would care for/change and on what days the hospice RN would complete the wound care.  During an interview on 01/20/2026 at 1:45 PM, the long-term care facility charge nurse stated the hospice registered nurse (RN) changed the patient’s dressing when he/she came in.  The hospice RN stated he/she checked with the LTCF to see if the wound care had been done when he/she arrived for each visit, and usually completed the wound care when he/she was there for a visit.  The hospice RN stated he/she did not do the dressing change on the lipoma as the facility staff always completed it. Both the LTCF charge nurse and the hospice nurse agreed the schedule for who was completing the wound care, and on what days, was not written down. During an interview on 01/22/2026 at 10:00 AM, the registered nurse coordinator (RNC) stated the expectation was for the hospice RN and the LTCF to coordinate wound care, complete the coordination of care plan form, and to specify what days the hospice RN would complete the wound care.

Based on policy review, record review, observation, and interview the agency failed to ensure that all medications were documented in the plan of care in one (Record/Patient #1) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Medication Management," dated 07/14/2014, showed in part that: - A drug profile is maintained for every patient and includes a listing of the current medication orders for each patient; and - The drug profile is reviewed and updated with each medication change or at a minimum of every recertification. RECORD/PATIENT #1: Review of the clinical record showed: - The agency's medication report showed the following medications: * Vitamin D3 (a medication supplement that helps the body absorb calcium) 25 micrograms (mcg) one tablet daily; * Hydrocortisone 2.5% topical cream (a medication used for skin irritation) apply a thin layer to affected area twice per day; and * Probiotic (a medication supplement that helps to improve gastrointestinal health) 250 milligram (mg) four capsules daily. Observation on 02/06/2023 beginning at 2 PM, during the patient's long term care facility home visit, showed that the facility's physician's orders dated 02/01/2023 to 02/28/2023 failed to include Vitamin D3, Hydrocortisone, and Probiotic. During an interview on 02/08/2023 beginning at 1:10 PM, the administrator stated that he/she would expect that the agency and facility would have the same medications on the drug profiles.

Based on nationally-recognized standards, policy review, observation, and interview the agency failed to ensure that infection control prevention practices were followed in one (Record/Patient #2) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the agency's policy titled, "Infection Control- Bag Technique," dated 06/01/2020, showed in part that: - Upon arrival at the patient's home, the bag is placed on a clean surface utilizing newspaper, paper towels, and/or a liner as a barrier. Alternatively, the bag may be hung on a doorknob if no liner is available. Review of the agency's policy titled, "Infection Control- Standard Precautions," dated 06/01/2020, showed in part that employees should: - Wash hands after touching blood, body fluids, secretions, and contaminated items, whether or not gloves are worn; - Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments; - Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites; - Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms; and - Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients and environments. RECORD/PATIENT #2: Observation on 02/06/2023 beginning at 3:40 PM, during the patient's long term care facility home visit, showed the following: - Upon entering the room, RN B placed his/her bag, dressing supplies, and tablet in the patient's wheelchair without a barrier; - During a skin assessment patient was found to be incontinent of urine; - RN B provided peri-care (cleaning of the private areas of the patient), failed to remove his/her gloves and touched the patient's clothing, bedding, and other clean items; - RN B then removed his/her soiled gloves and failed to complete hand hygiene, donned another pair of gloves, and applied ointment to the patient's coccyx and buttocks; and - RN B failed to remove gloves or complete hand hygiene and redressed the patient. After completing hand hygiene RN B continued the visit and: - Picked up the barrier that had been placed on a side table without gloves; - Failed to complete hand hygiene; - Touched his/her computer for documentation; and - Touched the patient's cup to provide a drink of water. During an interview on 02/08/2023 beginning at 1:10 PM, the administrator stated that he/she would expect gloves to be changed, hand hygiene to be completed, and a barrier to be used according to policy.

Based on policy review, record review, observation, and interview the agency failed to ensure that the needs of the patient were met in, but not limited to, one (Record/Patient #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, "Nursing Services," dated 06/01/2020, showed in part: - Nursing services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient's comprehensive and updated assessments; and - Nursing services are provided in accordance with accepted standards of practice. Review of the agency's policy titled, "Applicable Standards: Wound Care and Skin Integrity Assessments," dated 06/05/2019 showed in part: - Skin inspections will be completed on admission and during each skilled nursing visit; - The presence of skin breakdown/abnormal skin appearance, i.e. abrasion, blister, bruising- due to pressure, burn, denuded, erythema, hematoma, laceration, rash, skin tear and wound will be documented in the patient's medical record upon admission and during skilled nurse visits in accordance with established guidelines; and - Upon identification of a wound, a full wound assessment, including its location, size, and description of the tissue involved, will be completed in accordance with established guidelines. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 01/13/2023; - Review of the initial comprehensive assessment dated 01/13/2023 showed that the patient had psoriasis (a condition in which skin cells build up and form scales and itchy, dry patches) to the body; - Review of the skilled nurse note (SN) dated 02/02/2023 showed that the patient had pale skin and poor skin turgor; - Review of the SN dated 02/06/2023 showed that the patient had redness to his/her coccyx; and - Review of the facility's current physician's orders showed that the facility had received orders for dressing changes and assessments for one acquired Stage II pressure area (a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough and/or may also present as an intact or open/ruptured blister) to the right buttock and one acquired Stage II pressure area to the left buttock. Observation on 02/6/2023 beginning at 3:40 PM, showed that: - RN B completed a skin assessment; - During the skin assessment open areas were noted to the right and left buttocks and excoriation (wearing off of the skin) was noted to the coccyx area; - RN B failed to measure the open areas to the buttocks; and - RN B failed to document a full wound assessment of the open areas. During an interview on 02/8/2023 beginning at 1:10 PM, the administrator stated that he/she would expect that the open areas would be measured according to policy and that the wounds would be documented per policy.

Based on policy review, record review, and interview, the agency failed to ensure that the aide was following the written instructions in, but not limited to, two (Records/Patients #4 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, "Hospice Aide/Homemaker Assignments and Duties," dated 01/15/2020 showed a hospice aide/homemaker provides services that are included on the plan of care. RECORD/PATIENT #4: -Review of the Aide Care Plan Report dated 02/03/2023 showed that a pain level over five should be reported to the physician; and -Review of the aide visit notes show that the aide failed to document pain levels for the patient. RECORD/PATIENT #5: -Review of the Aide Care Plan Report dated 11/29/2022 showed that a pain level over five should be reported to the physician; and -Review of the aide visit notes show that the aide failed to document pain levels for the patient. During an interview on 02/08/2023 at 10:00 AM, the executive director stated that he/she would expect the aide to document a pain level for the patient and any pain levels over the parameters to be reported to the physician as ordered.

Based on policy review, contract review, and interview the agency failed to ensure that the general inpatient (GIP) contract contained a provision that each shift must include a registered nurse (RN) in one (Contract #1) of one contract reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Written Agreements," dated 12/2009, showed in part that: - Contracted or arranged services may include general inpatient care; - No services are provided or arranged unless a written agreement or contract is signed and in effect; and - The written agreement or contract includes, as appropriate to the contractor, availability of services or supplies 24/7. Contract #1: During contract review the agency provided a signed contract for GIP dated 05/31/2019 that failed to contain the provision that each shift must include an RN to provide direct patient care. During an interview on 02/08/2023 beginning at 1:10 PM, the administrator stated that a new contract had been written up to include that information in 2020, however, the contract had not been signed as of 02/08/2023.

Based on Missouri state statutes, employee file review, and interview the agency failed to ensure that an Employee Disqualification List (EDL) check was completed on one (Employee #1) of seven 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: 08/30/2021; and -Date of EDL: 05/03/2022. During an interview on 02/08/2023 at 10:00 AM, the executive director stated that he/she would expect the EDL of a new employee to be checked prior to their hire.