Every finding on record at Harrison County Hospice

Based on record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Observation and interview on 10/28/2025 showed the following discrepancies between the provider’s current medication profile, dated 09/25/2025 to 11/232025, and the patient’s home medication bottles:- The patient was taking Vitamin B12 (supplement) 500 mcg take one daily. The provider’s profile failed to include this medication. The patient’s spouse stated the patient had been taking the medication for about five months.  During an interview on 10/29/2025 beginning at 3:17 PM, RNC stated that he/she expected the clinicians to ask if any med changes at every visit and would expect it to be on the medication profile.    Findings included:The provider failed to provide a Drug Regimen Review (start of care and on-going) policy prior to exit.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child.Observation and interview on 10/27/2025 at 3:00 PM, showed the following discrepancies between the provider’s medication profile and the patient’s home medications:- The provider’s profile showed loratadine (antihistamine) 10 milligrams (mg), one tablet daily as needed. The patient failed to have the medication;- The provider’s profile showed pantoprazole sodium (acid reflux) 40 mg, one tablet twice a day. The patient failed to have the medication;- The provider’s profile failed to show the following medications:* Famotidine (stomach acid) 20 mg, one tablet, two times per day * Black seed oil (supplement), ½ teaspoon, once a day     * Selenium (supplement) 200 micrograms (mcg), one tablet per day* Vitamin E (supplement) 180 mg, one softgel per day* Vitamin C (supplement) 1000 mg, one tablet per day* Milk thistle (supplement) 150 mg, two capsules per day* Cat’s claw (supplement) 500 mg, two capsules per day. Patient stated that he/she took one per day* Quercetin-LipoMicel (supplement) 250 mg, one softgel per day* Zinc (supplement) 50 mg, one capsule per day * Turmeric (supplement) 500 mg, one capsule per day - The patient stated that he/she took the above medications daily. He/She was not aware if the hospice nurse knew it or not.During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that the nurse asked about medication at every visit and updated the medication list.

Based on policy review, record review, and interview, the bereavement assessment failed to identify the bereaved in, but not limited to, five of seven records reviewed for bereavement (Records/Patients #1, #2, #3, #5, and #10) and the hospice provider failed to incorporate the needs of the bereaved in the bereavement plan of care in one of seven records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Bereavement Services,” revised 06/2024, showed in part the following:- The program provided bereavement services to the families and caregivers of hospice patients both before and up to 13 months after the patient’s death in accordance with the plan of care;- On admission, the registered nurse (RN) completed the “pre-bereavement” section of the assessment; and- The social worker did a more extensive grief assessment during his/her visit within five days. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Review of the initial bereavement assessment dated 01/28/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/17/2025 with a terminal diagnosis of end stage renal disease (ESRD) (a severe condition where the kidneys have permanently lost most of their ability to function). The patient resided at a long-term care facility (LTCF). Review of the initial bereavement assessment dated 09/17/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. During an interview on 10/29/2025 at 3:08 PM, the registered nurse coordinator, stated that the assessment does not have a name documented of who the bereavement assessment was completed on.    RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child. Review of the admission assessment dated 09/30/2025, showed the family was not available for the pre-bereavement assessment. Review of the social services assessment dated 10/01/2025, showed the following: - The adult child lived with the patient and was the primary caregiver; and - The patient believed the situation was having an emotional impact on him/her.Review of the spiritual care assessment dated 10/02/2025, showed the following: - The adult son was not available; - The patient shared that family was well prepared for his/her approaching death; - The patient did not feel that there was a high degree of bereavement risk for the family; and - The assessment failed to identify the caregiver for the bereavement risk.Review of the nursing note dated 10/23/2025, showed the following: - The adult child/primary caregiver was present for the visit; and - The RN failed to complete a bereavement risk assessment. During an interview on 10/29/2025 at 11:55 AM, RNC stated that since the caregiver was not present during the admission visit, he/she would have expected the RN to complete the bereavement risk assessment during the visit on 10/23/2025. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia(a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at his/her parent’s home with the patient’s parents. Review of the chaplain patient missed visit on 03/13/2025, showed the initial evaluation was delayed due to inability to contact the patient.Review of the spiritual care assessment dated 03/19/2025, showed the following:- Some anger and pain was evident in the caregivers’ lives;- The patient was blocking access to his/her parents/caregivers; and- The assessment failed to identify the caregiver for the bereavement risk.RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and significant other had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; - The patient and family were in denial of the severity of the diagnosis;- The patient and family were not able to openly discuss the pending death; - Possible grief process complications due to dependency; - Bereavement risk factors with children/adolescents in the home; and - The bereavement assessment failed to include the children in the home and the bereaved family member identified on the bereavement plan of care dated 07/06/2025.Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter (previously identified as significant other); - Moderate risk level; and - Spiritual care visit would be offered monthly for the next two months.Review of the bereavement plan of care updated 09/05/2025, failed to show a plan to offer spiritual care visits in October and November.During an interview on 10/29/2025 at 11:55 AM, RNC stated that the social worker completes the initial bereavement assessment at the time of admission. He/She would expect the person that was assessed to be identified. If the social worker was not available, then the nurse would complete the bereavement assessment. He/She would expect the bereavement plan of care to be updated and it would be put on a different form. During an interview on 10/29/2025 at 3:10 PM, RNC stated that the caregivers received the initial bereavement assessment and caregivers in the home. If there are several children or other family members, they would receive mailings about bereavement services after the death of the loved one. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/30/2025 with a terminal diagnosis of pancreatic cancer. The patient resided at his/her home shared by an adult child. Review of the admission assessment dated 09/30/2025, showed the family was not available for the pre-bereavement assessment. Review of the social services assessment dated 10/01/2025, showed the following: - The adult child lived with the patient and was the primary caregiver; and - The patient believed the situation was having an emotional impact on him/her.Review of the spiritual care assessment dated 10/02/2025, showed the following: - The adult son was not available; - The patient shared that family was well prepared for his/her approaching death; - The patient did not feel that there was a high degree of bereavement risk for the family; and - The assessment failed to identify the caregiver for the bereavement risk.Review of the nursing note dated 10/23/2025, showed the following: - The adult child/primary caregiver was present for the visit; and - The RN failed to complete a bereavement risk assessment. During an interview on 10/29/2025 at 11:55 AM, RNC stated that since the caregiver was not present during the admission visit, he/she would have expected the RN to complete the bereavement risk assessment during the visit on 10/23/2025. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks requiring treatment.  The patient resided in a LTCF. Review of the initial bereavement assessment (known to the provider as the pre-bereavement assessment) dated 10/20/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/28/2025 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity). The patient resided at his/her own home with spouse. Review of the initial bereavement assessment dated 01/28/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 08/21/2025 with a terminal diagnosis of acute exacerbation (a sudden worsening) of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of the initial bereavement assessment dated 10/20/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 09/17/2025 with a terminal diagnosis of end stage renal disease (ESRD) (a severe condition where the kidneys have permanently lost most of their ability to function). The patient resided at a long-term care facility (LTCF). Review of the initial bereavement assessment dated 09/17/2025, showed the assessment failed to identify the name of the bereaved survivor and if the bereaved was a low, medium or high risk. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia(a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at his/her parent’s home with the patient’s parents. Review of the chaplain patient missed visit on 03/13/2025, showed the initial evaluation was delayed due to inability to contact the patient.Review of the spiritual care assessment dated 03/19/2025, showed the following:- Some anger and pain was evident in the caregivers’ lives;- The patient was blocking access to his/her parents/caregivers; and- The assessment failed to identify the caregiver for the bereavement risk. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and significant other had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; - The patient and family were in denial of the severity of the diagnosis;- The patient and family were not able to openly discuss the pending death; - Possible grief process complications due to dependency; - Bereavement risk factors with children/adolescents in the home; and - The bereavement assessment failed to include the children in the home and the bereaved family member identified on the bereavement plan of care dated 07/06/2025.Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter (previously identified as significant other); - Moderate risk level; and - Spiritual care visit would be offered monthly for the next two months.Review of the bereavement plan of care updated 09/05/2025, failed to show a plan to offer spiritual care visits in October and November. During an interview on 10/29/2025 at 11:55 AM, registered nurse coordinator (RNC) stated that the social worker completes the initial bereavement assessment at the time of admission. He/She would expect the person that was assessed to be identified. If the social worker was not available, then the nurse would complete the bereavement assessment. He/She would expect the bereavement plan of care to be updated and it would be put on a different form.  During an interview on 10/29/2025 at 3:10 PM, RNC stated that the caregivers received the initial bereavement assessment and caregivers in the home. If there are several children or other family members, they would receive mailings about bereavement services after the death of the loved one.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure all care and services furnished to patients and their families follow an individualized, written plan of care (POC) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the care of all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “Plan of Care,” last revised “06/24,” showed in part: - Hospice care and services furnished to patients and their families were to follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient’s needs; and- Care provided to the patient would be in accordance with the plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment.  The patient resided in a long-term care facility (LTCF). Review of the hospice POC with a start of care (SOC) date of 10/16/2025 showed under the integumentary (skin) section: Integumentary interventions: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/perineal area (peri area - the area on the body between the genitals and anus) daily, start effective date: 10/16/2025. Review of the document titled, "Interdisciplinary Group (IDG) Meeting Review," dated 10/23/2025, showed, under the integumentary (skin) section: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/peri area daily, start effective date: 10/16/2025. Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed he/she:- Cleansed the patient’s buttock and peri area with disposable cleansing wipes; and- Applied 1.5% dimethicone cream; and- Failed to follow the POC treatment to the buttock/peri area.Review of a skilled nursing note dated 10/28/2025 showed redness/shearing (a mechanical force where layers of tissue move in opposite directions, causing damage beneath the skins surface) was noted to bilateral outer gluteal cleft (the natural groove or fold between the buttocks). Moisture ointment applied to buttock following peri care; - Moisturizing ointment applied to the patient buttock as patient stated that he/she was allergic to zinc. New order placed. (The RN failed to contact the physician during the observation visit for new orders prior to applying the dimethicone). During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that he/she knew the staff were supposed to follow the POC.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) updated/revised the plan of care (POC) with new assessment findings/orders, in two of five full records reviewed (Records/Patients #2, and #4).  This deficient practice has the potential to adversely affect coordination of care for all patients served by the provider. --- Findings included:Review of the provider's policy titled, "Plan of Care," last revised “06/24,” showed in part:-The POC was reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; and-Review of the POC was to be documented in the clinical record. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (a condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks requiring treatment.  The patient resided in a long-term care facility (LTCF). Review of the hospice POC dated 10/16/2025, showed chaplain visits one time a week for one week starting 10/16/2025. Review of the spiritual assessment dated 10/16/2025 showed plan for next visit/contact: two times per month and as needed. Review of a physician’s order dated 10/17/2025 showed chaplain visits two times a month for three months starting 10/17/2025, and three as needed visits starting 10/17/2025 for emotional support. Review of the document titled, "Interdisciplinary Group (IDG) Meeting Review," dated 10/23/2025, showed the POC update failed to include the chaplain services and their visit frequency. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that the chaplain discipline and visit frequency should have been on the IDG meeting note dated 10/23/2025. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 08/21/2025 with a terminal diagnosis of acute exacerbation (a sudden worsening) of chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). The patient lived at home with their spouse. Review of a skilled nurse (SN) visit note dated 09/11/2025, showed:- An assessment of the back revealed an area at the site of a previous skin graft, with scar tissue noted. The area had rolled edges from shear (a mechanical force where layers of tissue move in opposite directions, causing damage beneath the skin's surface) due to prolonged recliner use, with a small open area present; and- The patient’s physician was notified and orders were received. Duoderm (brand, an adhesive dressing) was applied as ordered to the area for protection and to promote healing. Review of a physician’s order dated 09/11/2025 showed apply hydrocolloid (Duoderm) dressing to previous skin graft site on mid back. Change every seven days. Review of an interdisciplinary group (IDG) meeting note dated 09/12/2025 showed the IDG failed to update the individualized plan of care to include the new open area to the mid back and the new treatment orders. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that the back wound and new treatment should have been addressed on the POC/IDG meeting note.

Based on policy review, record review, and interview, the hospice provider failed to:- Provide medical social services (L0594); and- Provide an organized bereavement program for the provision of bereavement services (L0596). --- The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the provider failed to ensure medical social services were available in one of seven records reviewed (Record/Patient #10). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, ‘Plan of Care,” reviewed 06/2024, showed in part the following: - The registered nurse (RN) was to complete the initial assessment and initiate the development of the plan of care after the consent forms were signed; - The admitting RN was to notify the attending physician and a core member of the interdisciplinary group (IDG) of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs; and - The plan of care was to identify the patient’s needs and services to meet those needs.Review of the provider’s policy titled, “Suicide Threat,” reviewed 01/2020, showed in part the following:  - When a patient was assessed to be suicidal (whether through behaviors or verbal statements) the patient would be placed on suicide precautions to promote safety and decrease/prevent the risk of self-inflicted injury; - Any patient who verbalized ideation involving thoughts of self-harm or suicide would be placed on suicide precautions as reviewed and ordered by the attending physician; - If verbalizations were given to or behaviors observed by hospice employees who were not registered nurses, the case manager or nursing supervisor would be notified immediately;- Suicide precautions were to be based on level of apparent risk of self-harm;- Nursing considerations for all levels included:* Remove from the environment anything the patient may use to inflict injury* Check the patient’s belongings for any unsafe items* One to one constant observation with well-defined documentation as per policy - Low risk-minimal danger of attempting suicide* Notify hospice interdisciplinary group (IDG) members, including on-call nurse* A referral would be made to the individual’s spiritual mentor, if there was a spiritual connection identified; and* Hospice social worker would make a support visit and a referral to local professional counseling, if patient was agreeable. --- RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at home with his/her parents. Review of the admission assessment dated 03/10/2025, showed in part the following:- Other diagnoses included depression, anxiety disorder, nicotine dependence, and long term (current) use of opiate analgesics (a drug to relieve pain); - The patient was trying to protect his/her parents and did not let them listen to the hospice conversation; - Bereavement risk factors included a history of substance abuse and concern for teenage child;- Pain level was an eight (on a numerical pain scale where zero equals no pain and 10 equals the worst pain imaginable) due to the patient's fall off the roof of their house a “few” days ago; and - The IDG members failed to include a medical social worker (The provider failed to have a social worker from 12/2024 to 05/2025).Review of the plan of care dated 03/17/2025, failed to show medical social services.Review of the nursing note dated 04/01/2025, showed the patient called the office requesting a visit related to anxiety. The patient talked with the RN about his/her spiritual turmoil and distress. The patient verbalized constant thoughts of suicide with no plan. The patient cried during the visit and was tearful discussing depression, end of life, suicide, and spiritual distress. The patient reported he/she had no plan or intentions to commit suicide which was why he/she made the phone call to the office for the visit. The patient reported decreased anxiety toward the end of the visit. The chaplain and physician were notified. The nurse failed to document notification of the medical social worker or the reason why medical social services were not notified.Review of the spiritual care note dated 04/02/2025, showed the chaplain phoned the patient at 7:30 PM. The patient discussed his/her thoughts and emotions.Review of the chaplain missed visit notes, dated 04/10/2025 and 04/17/2025, showed the patient postponed the visits.Review of the spiritual care visit note dated 04/23/2025 at 3:00 PM, showed the patient was intoxicated and was deeply emotional, expressed many negative feelings, and expressed thoughts about ending his/her life. The patient expressed a desire to become sober and not to do anything self-destructive. The patient admitted that he/she was having a mental health crisis and agreed to go to the hospital. The chaplain transported the patient to the emergency department and the patient checked himself/herself in.Review of the emergency department note from an outside hospital (OH)-1 dated 04/23/2025, showed the patient was treated for psychiatric symptoms of depression. The patient was discharged on 04/23/2025 with recommendations to follow up with psychiatry and an outpatient order for “Psych” (psychiatry) follow up was written and placed.Review of the spiritual care note dated 04/24/2025, showed the following spiritual issues:- Anxious about the future;- Isolation/withdrawal;- Depression;- Concern with death and dying;- Spiritual questioning;- Suicidal; and- The chaplain failed to notify the social worker (the provider failed to have a social worker at this time).Review of the hospice discharge summary dated 04/28/2025, showed in part the following:- The patient was hospitalized for facial fractures that occurred during an altercation with his/her family; - The patient was transferred from OH-2 to OH-3 for facial fractures and surgical procedures;- The patient was out of the hospice covered area;- The patient’s stay length was unknown to the patient and current caregivers; and- The patient verbalized to the RN his/her understanding of the reason for the discharge and agreed to discharge from current hospice services.Review of the care summary, on the hospice discharge summary, dated 04/28/2025, showed the patient struggled with pain control during hospice [services] and "compliance" (unspecified) was "unknown". The RN was unable to enter the patient’s home and review the medications with the patient while on hospice [services]. The patient cancelled scheduled visits multiple times and verbalized alcohol use and increased depression. The patient refused therapy services and depression management that were offered to him/her. The patient agreed to discharge from current hospice services related to being out of the coverage area and his/her unknown course of upcoming treatment.During an interview on 10/29/2025 at 2:00 PM, the administrator stated that the provider advertised the (social worker) position via the local newspaper on 11/26/2024, social media on 11/30/2024, at a local college 12/09/2024, and on an employment website on 01/21/2025. The last day of employment for the social worker (MSW -master's of social work) was 12/06/2024.During an interview on 10/29/2025 at 3:45 PM, registered nurse coordinator (RNC) stated that the provider did not have a social worker for about six months. If a patient needed social services, the chaplain or a registered nurse would fill in. The new social worker (BSW- bachelor's of social work) started on 05/12/2025 and a contract with a MSW was dated 05/14/2025. Based on the diagnoses documented on the admission assessment, the RNC would have expected social services to be included in the plan of care.

Based on policy review, record review, and interview, the hospice provider failed to have an organized program for bereavement services and failed to ensure the needs of the bereaved and bereavement services provided were included in the bereavement plan of care (POC), in one of seven records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Bereavement Services,” revised 06/2024, showed in part the following: - The provider was to have an organized program for the provision of bereavement services under the supervision of a qualified professional; - Services were to be provided by personnel who had received training and had experience in dealing with grief; - The program was to provide bereavement services to the families and caregivers of hospice patients both before and up to 13 months after the patient’s death in accordance with the plan of care; - On admission, the registered nurse (RN) would complete the “pre-bereavement” section of the assessment; - The social worker did a more extensive grief assessment during his/her visit within five days; - Within two months after the patient’s death, a face-to-face visit would be made in which a bereavement risk assessment of the family and caregiver was completed; - The risk assessment would rate the bereavement risk as low, moderate, and high; - After the risk assessment was completed, a plan would be developed to address bereavement/grief issues and would be implemented as needed; - At six months after the death of a patient, the bereaved would be called and offered a visit; - Persons deemed to have been experiencing moderate or severe grief would be followed with increased services and contact offered as noted in the plan of care; and - If any time during bereavement services grieving was perceived as acute, the bereavement coordinator would attempt to reassess what additional professional services were necessary and appropriate referrals were indicated and documented the referral. --- RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 04/21/2025 with a terminal diagnosis of liver cancer. The patient resided at home prior to moving to a long-term care facility (LTCF) on 07/01/2025. Review of the admission assessment dated 04/21/2025, showed the following: - The patient and an adopted daughter (originally identified as a significant other) had not come to terms with the patient diagnosis; - Bereavement referral for anticipatory grief concerns; -  The patient and family were in denial of the severity of the diagnosis; - The patient and family were not able to openly discuss the pending death; -  There were possible grief process complications due to dependency; and-  Bereavement risk factors included children/adolescents in the home.  Review of the spiritual care assessment dated 04/22/2025, showed a planned visit schedule of one time per week and as needed.Review of the medical social services assessment dated 07/01/2025, showed a plan for contact once a month. Review of the bereavement plan of care dated 07/06/2025, identified a significant other and a family member as the bereaved. Review of the bereavement note dated 07/10/2025, showed in part, an adopted daughter welcomed the chaplain’s invitation to attend the bereavement support group held on Mondays.Review of the document titled, “Bereavement Initial Assessment/Care Plan,” dated 09/02/2025, showed the following: - Identified the bereaved as an adopted daughter; - The bereaved was assessed at a moderate risk level; - A spiritual care visit would be offered monthly for the next two months; and - The bereavement POC failed to include the type of interventions/services offered and the frequency of all services being delivered (bereavement support group, social services).Review of the bereavement plan of care updated 09/05/2025, failed to show the following: - Spiritual care visits planned for October and November; - Social services visits once a month; and - The bereaved's attendance at the bereavement support groups.During an interview on 10/29/2025 at 11:55 AM, registered nurse coordinator (RNC) stated that he/she would expect the bereavement plan of care to be updated. The RNC stated that the program needed to be reorganized.

Based on policy review, record review, and interview, the hospice provider failed to forward the discharge summary to the patient's attending physician, in one of one live discharge records reviewed (Record/Patient #10). This deficient practice has the potential to affect all live discharge patients served by the provider.Findings included:Review of the provider’s policy titled, “Discharge Summary,” reviewed 06/2024, showed in part the following:- The discharge summary and other relevant clinical record documents were to be completed and submitted within 72 hours of discharge of service; and- A copy of the discharge summary was to be provided to the patient’s attending physician. --- RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at home with his/her parents. Review of the discharge summary dated 04/25/2025, showed the provider failed to forward a copy of the patient's discharge summary to the patient's receiving care provider. During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that normally, the hospice provider sent the discharge summary to the receiving provider.

Based on policy review, record review, and interview, the discharge summary failed to include the plan of care and physician orders, in one of one live discharge record reviewed (Record/Patient #10). This deficient practice has the potential to affect all the live discharge patients served by the provider.Findings included:Review of the provider’s policy titled, “Discharge Summary,” reviewed 06/2024, showed in part that the discharge summary would include the patient’s current plan of care and latest physician orders. --- RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/10/2025 with a terminal diagnosis of chronic myeloid leukemia (a type of blood cancer that originates in the bone marrow and produces abnormal white blood cells). The patient resided at  home with his/her parents. Review of the discharge summary dated 04/25/2025, showed the provider failed to forward a discharge summary that included the plan of care and physician orders to the patient's receiving care provider. During an interview on 10/29/2025 at 11:55 AM, the registered nurse coordinator (RNC) stated that normally, the hospice provider sent the discharge summary to the receiving provider.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure coordination of responsibility for daily wound care between the hospice and the long-term care facility (LTCF) in one of one record reviewed of patients that resided in a LTCF (Record/Patient #2).  This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. --- Findings included:Review of the provider's policy titled, " Provision of Care to Residents of Nursing, Intermediate Care, and Mental Retardation Facilities," last reviewed “06/25”, showed in part:- Purpose: to ensure the coordination of care provided to residents of skilled nursing facilities/nursing facilities (SNF/NF); and- A written plan of care (POC) must be established and maintained in consultation with the SNF/NF. All hospice care provided must be in accordance with this POC. The POC must identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (A condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment.  The patient resided in a LTCF.Review of the initial plan of care, dated 10/16/2025 to 01/13/2026, failed to show who was responsible (the hospice provider or the LTCF) for daily care to the buttock/perineal area (peri area - the area of the body between the anus and the genitals). Review of the document titled, "Interdisciplinary Group (IDG) Meeting Review," dated 10/23/2025, showed under the integumentary (skin) section: Cleanse with soap and water, dress with zinc ointment. Responsible for wound care: patient, caregiver, facility, nurse, hospice nurse. Wound care to buttock/peri area daily, start effective date: 10/16/2025. The IDG failed to specify when the hospice nurse was to perform wound care and when the LTCF staff would be responsible for wound care.Review of the LTCF’s current physician order sheet dated printed on 10/28/2025, failed to show who was responsible for zinc oxide treatment to the buttock/peri area (the LTCF or the hospice provider). Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed:- He/she provided care to the buttock/peri area; and- The LTCF hospice binder failed to contain any information for this patient.During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that:- "We (the hospice provider) sent that information" (all the required documents for the facility binder). "I know it (all the required documents for the facility binder) was taken there"; and- That was their most difficult facility to get along with.

Based on policy review, record review, home visit observation, and interview, the provider failed to provide the long-term care facility (LTCF) with all the required hospice documentation in one of one LTCF patient records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients residing in a LTCF served by the provider. --- Findings included:Review of the provider's policy titled, " Provision of Care to Residents of Nursing, Intermediate Care, and Mental Retardation Facilities", last reviewed “06/25,” showed in part, the hospice provided the LTCF the following information:- The most recent plan of care (POC);- Hospice election form and advance directives;- Physician certification and recertification of terminal illness;- Names and contact information for hospice personnel involved in hospice care;- Instructions on how to access the hospice’s 24-hour on-call system;- Hospice medication information; and - Hospice physician and attending physician (if any) orders. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of hypertensive heart disease with heart failure (A condition where chronic high blood pressure causes structural and functional changes to the heart, ultimately leading to heart failure). The patient also had an area to his/her buttocks that required treatment.  The patient resided in a LTCF.Observation on 10/28/2025 at 1:28 PM with registered nurse (RN) - A, showed the hospice binder at the LTCF failed to include the following documentation:- Physician certification and recertification; - Hospice physician and attending physician orders;- Hospice election form and advance directives; and- The most recent POC. During an interview on 10/29/2025 at 3:09 PM, the registered nurse coordinator stated that:- "We (the hospice provider) sent that information" (all the required documents for the facility binder). "I know it (all the required documents for the facility binder) was taken there"; and- That was their most difficult facility to get along with.

Based on review of the agencys policy, record review, and interview, the agency failed to ensure the medical social worker's (MSW) comprehensive assessment was completed within five days of election of hospice care, in one (Record/Patient #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, "Comprehensive Assessment," revised 04/20, showed, in part, an initial social work and spiritual assessment and care plan will be completed and documented within 5 (five) days after admission, unless visits are needed sooner. RECORD/PATIENT #5: Review of the hospice admission records, showed, the patient was admitted on 07/25/2022. Review of the initial MSW evaluation visit showed a date of 08/04/2022 (9 days after admission). During an interview on 10/26/2022, at 9:32 AM, the nursing coordinator stated that: - The initial MSW assessment visit was late; - No documentation of why visit was late; and - He/she would expect the MSW to visit the patient within five days to complete the comprehensive assessment.

Based on review of the agencys policy, record review, and interview, the agency failed to provide a complete comprehensive assessment including all physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process, in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the care provided to all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Comprehensive Assessment," revised 04/20, showed, in part: -The initial/comprehensive assessment will be performed within 2 (two) calendar days or 48 (forty-eight) hours after the election of hospice care in consultation with attending physician; - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: * An assessment of pain, including the origin, location, duration, severity, and relief measures; * Alleviating and exacerbating factors for physical symptoms; and * Patients past and present medical and psychosocial history, including, pertinent diagnosis and any co-morbid conditions. RECORD/PATIENT #1: Review of the clinical record showed, the patient was admitted to hospice on 08/01/2022. Review of the initial/comprehensive assessment, dated, 08/01/2022, showed, - Patient with severe pain during admission visit; - Patient rated pain a 9 for pain severity (pain level severity, 1-3 = mild, 4-6 = moderate, and 7-10 = severe); - Patient taking hydrocodone-acetaminophen (combination medication of an opioid pain reliever and a non-opioid pain reliever used to treat moderate to severe pain) 10/325mg (10 milligram of hydrocodone and 325 milligrams of acetaminophen) pain, without relief; - No documentation of pain history prior to admission; and - No documentation of pain management history. During an interview, on 10/25/2022, at 3:25 PM, the nursing coordinator stated that, the pain assessment was incomplete and no documentation found for follow up on pain.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain a complete/accurate medication profile in three (Records/Patients #1, #2 and #3) of three home visit observations conducted. This deficient practice has the potential to adversely affect the agencys ability to ensure safe and effective use of medication for all patients served by the agency. --- RECORD/PATIENT #3:Review of clinical record showed:-The patient was admitted to hospice on 09/22/2022 with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should); and-He/she lived at home with spouse as caregiver. A home visit observation on 10/25/2022 beginning at 4:05 PM, showed the following discrepancy with the medication profile, the caregiver stated that the patient took Glycopyrrolate (anticholinergic) 1 milligram (mg) twice a day and the agency medication profile showed Glycopyrrolate 1 mg once daily. Findings included: Review of the agencys policy with a most recently reviewed/revision date of 01/22, titled, ";Medication Reconciliation/Profile", showed the following: - Hospice will complete a review of all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy; - A complete and current drug regimen review will be performed at the time of initial and comprehensive assessment and at recertification; - Any major/sever drug interactions will be reported to physician within 48 (forty eight) hours of review; - On admission, the medication list will be checked using the EMR (electronic medical record) for review and must be completed within 5 (five) days. The review will identify: * Effectiveness of drug therapy; * Drug side effects; * Actual or potential drug interaction; * Duplicate drug therapy. - During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: * Using the medication profile to evaluate the use of the drugs in the home setting; * Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications; * Using the medication profile as a communication tool for other clinicians involved in care. - The medication profiles will be reviewed every 14 (fourteen) days and for each change to reflect current medications and new or discontinued medications based on review of the medication profile as well as the written material, changes in the plan of care may be required; - Any medication concerns should be discussed with a pharmacist, when appropriate, and the primary physician as soon as the nurse becomes aware. This communication shall be maintained in the clinical record; and - Deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified. RECORD/PATIENT #2: Review of the local hospital discharge referral orders with a date and time faxed of Oct. 13, 2022 9:18 AM showed, in part, the following: - Gabapentin cap 100 mg (milligram) oral, 1 x daily at bedtime, Special Instructions: 1 or 2 at bedtime (medication that can be used to treat nerve pain); - Docusate sodium capsule 100 mg oral 2 times daily (medication to soften bowels); and - Cholecalciferol capsule 10,000 units oral every 1 week (vitamin D supplement). Review of the plan of care dated 10/13/2022 showed, in part, the following: - Triad cream topically ";lirally" (possibly meaning liberally) twice per day (it failed to include where to apply the cream) (a zinc oxide based sterile coating designed to manage low and moderately draining wounds, while providing a moist wound healing environment); - Gabapentin 100 mg cap oral 2 caps every night at bedtime (referral showed 1 time daily at bedtime with special instructions for 1 or 2 at bedtime); - Docusate sodium 100 mg cap oral 1 cap daily (referral showed twice daily); and - Cholecalciferol 5,000 units oral 2 tablets weekly. Review of the long term care facility MAR (medication administration record) showed, in part, the following: - Cholecalciferol failed to be listed; - Gabapentin 100 mg 1 capsule at bedtime (plan of care showed 2 capsules at bedtime); and - Docusate 100mg 1 oral twice daily (plan of care showed 1 capsule daily). Further review of the clinical record failed to include documentation clarifying the medication discrepancies/incomplete medication orders. During an interview on 10/25/2022 at 3:30 PM the nursing coordinator stated that: - The facility MAR and plan of care medications should match; and - Here is does say 1 or 2 at bedtime (while pointing to the special instructions listed for the gabapentin on the referral. RECORD/PATIENT #1: Observation on 10/25/2022 at 10:28 AM, during the patients home visit, showed: - On 10/13/2022, Patient was started on Paxlovid 300mg/100mg (300 milligram nirmatrelvir with 100 milligram ritonavir- combination of two antiviral medications to treat for a respiratory virus called, coronavirus), take 400mg by mouth two times daily; - Patient reported taking Nyguil (over the counter cough medicine) PRN (as needed) for the last two weeks; and - Paxlovid and Nyquil were not on the patients medication profile list and/or plan of care. During an interview on 10/25/2022, at 3:25 PM, the nursing coordinator stated that: - The medication profile and plan of care were not updated to reflect medication changes; and - New medications should have been added to the medication profile and plan of care.

Based on review of the agencys policies, record review, and interview, the agency failed to: - Develop an individualized plan of care specific to the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions (L538); - Develop an individualized plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire (L543); - Develop an individualized plan of care based on problems identified in the initial, comprehensive and updated comprehensive assessments, that included all services necessary for the management of the terminal illness (L545); - Provide drugs and treatments necessary to meet the needs of the patient (L549); - Provide medical supplies and appliances necessary to meet the needs of the patient (L550); and - Ensure that the care and services provided are based on all assessments of the patient and family needs (L556). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency. --- .

Based on review of the agencys policy, record review, and interview, the hospice provider failed to ensure that the plan of care specified the hospice care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessments in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. --- Findings included: Review of the agency's policy titled, "Plan of Care," revised 01/22, showed, in part: -The registered nurse will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed; - 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; - The plan must state, in detail, the scope and frequency of services needed to meet the patients and family/caregiver needs; and - Each patient will be monitored for his/her outcomes of care. RECORD/PATIENT #1: Review of the clinical record showed, the patient was admitted to hospice on 08/01/2022. Review of the initial/comprehensive assessment, dated, 08/01/2022, showed, ";heat," listed for pain relief use. Review of the plan of care, dated, 08/01/2022, failed to show, heat listed as an intervention for pain. During an interview, on 10/25/2022, at 3:25 PM, the nursing coordinator stated that, he/she would expect heat to be on the plan of care for pain interventions.

Based on policy review, clinical record review, and interview, the agency failed to ensure each patient would receive services that follow an individualized written plan of care, established by the interdisciplinary team (IDT) in collaboration with the attending physician and patient/caregiver in two (Records/Patients #2 and #4) of five applicable records reviewed. This deficient practice has the potential to affect all patients receiving hospice services. --- Findings included: Review of the agencys policy titled, "Plan of Care," dated reviewed/revised 01/2022, showed in part, the following: -Purpose: To ensure that an individualized plan of care (POC) is completed that complies with accepted standards of care and regulatory issues within five days of admission; -Hospice care and services furnished to the patient and their families must follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire; -The POC will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. The plan must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs; and -Care provided to the patient will be in accordance with the POC. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services, with a primary diagnosis of heart failure, on 10/13/2022; and - The patient resided in a long term care facility at the time of admission. Review of the POC dated 10/13/2022 showed HHA (home health aide) 2 x week for 13 weeks (two times a week for thirteen weeks) starting 10/14/2022 (week 1) Start Date: 10/14/2022 End Date: 01/08/2023. Review of the hospice aide visit notes showed: - The first visit note was dated 10/17/2022 (week two); and - There were no hospice aide visits documented week one. Further review of the clinical record failed to show any missed visit documentation regarding no aide visits during week one and/or no notification to the physician of the missed aide visits. During an interview on 10/25/2022 at 3:30 PM, when discussing the aide frequency on the plan of care that showed two times a week starting 10/14/2022, the nursing coordinator stated that: - That should have been the next week; and - Starting on 10/17/2022. RECORD/PATIENT #4: Review of the clinical record showed:-The patient was admitted to hospice services, with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should); and-The patient initially lived at home, but then transferred to long-term care facility (LTCF) on 07/15/2022. Review of the POC, dated 09/22/2022 showed the chaplain to visit four times a month starting 10/01/2022. Review of the IDG meeting review notes, dated 09/27/2022, showed the chaplain was to start weekly visits on 10/01/2022. Review of the clinical record failed to show any documentation for a chaplain visit for the week of 10/02/2022 to 10/09/2022. During an interview on 10/26/2022 at 1:55 PM, the nursing coordinator stated the following:-He/she could not find any documentation of a chaplain visit for the week of 10/02/2022 to 10/09/2022; and -He/she could not find any documentation of a missed chaplain visit for the week of 10/02/2022 to 10/09/2022.

Based on review of the agencys policy, record review, and interview, the agency failed to develop an individualized plan of care (POC) in, but not limited to, three (Records/Patients #2, #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, "Plan of Care," revised 01/22, showed, in part: - Hospice care and services furnished to patient and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire; - The registered nurse will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed; - 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; - The written plan of care will contain, but will not be limited to, the following; * Diagnosis; * All services necessary for the palliation/management of the terminal illness and related conditions; * Identification of patient and family/caregiver problems and needs; * Scope and frequency of services needed to meet patient/family needs; * Who will provide the services; * Prescribed and required medical equipment, supplies, medications and treatments; * Level of care; * Realistic and achievable goals; * All physicians orders; * Interventions to manage pain and symptoms; and * Measurable outcomes anticipated from implementing/coordinating the plan of care. RECORD/PATIENT #5: Review of the clinical record showed, showed: - The patient was admitted on 07/25/2022, with a terminal diagnosis of left temporal brain mass; - Initial comprehensive admission assessment, dated, 07/25/2022, showed, patient with port-a-cath (a device placed under the skin that is used to draw blood and give treatments) on the left side of anterior chest; - No documentation of port-a-cath on POC; - No documentation of port-a cath being discussed in IDG (interdisciplinary group) meeting; - Nursing visit note, dated, 08/09/2022, showed, RN (registered nurse) delivered a pill box and filled it with the patients medications; - POC failed to include interventions for SN (skilled nurse) to fill pill box; - Nursing visit note, dated, 08/19/2022, showed, RN spoke with the physician's nurse regarding the patients port-a-cath and per [named nurse] the port did not need to be flushed; - No documentation of port-a-cath on POC to include port not needing to be flushed; - No documentation of port-a cath being discussed in IDG meeting; - Nursing visit note, dated, 10/07/2022, showed, bedbound selected in musculoskeletal/activities section, and patient walked with 2x (times 2) assist (people to help the patient walk) to the toilet; - Review of the IDG meeting, dated, 10/12/2022, showed: * Patient in bed most of time sleeping; * Oriented to self only; * Patient is max [maximum] assist; - Review of the updated plan of care, failed to show, bedbound and max assist; - Nursing visit note, dated, 10/21/2022, showed, in part: * Assistive devices used, wheelchair, hospital bed, and heel protectors bilaterally; * Psychological/Mental/Emotional/Behavioral assessment section, showed, patient oriented to person, lethargic, confused, disoriented, and decreased level of consciousness; * Integumentary (skin) comments section, showed, patient wears bilateral heel protectors to keep heels off of bed; - Review of the updated plan of care, showed: * DME/Supplies (durable medical equipment and supplies) with heel protectors (effective 10/21/2022); * Patient continues to be oriented to self only; * Patient remains generally weak, requiring assist to transfer to WC (wheelchair); * Patient is 100% dependent for bathing and toileting; - Review of the updated POC, failed to show: * Patient status to include, lethargic, confused, disoriented, with decreased level of consciousness; * Patient requiring 2 people to assist with walking to the toilet; * Interventions for heel protectors; and * DME/Supplies for hospital bed. During an interview on 10/26/2022, at 9:32 AM, the nursing coordinator, stated that: - Heel protectors were added to the DME/supplies list section of the POC on 10/21/2022; - No record of port-a-cath found on POC and IDG meeting; - He/she would expect port-a-cath to be on the poc at the start of care and discontinued when orders received; - Not all of the patients equipment are listed on POC and should be; and - Nursing interventions should include filling the patients pill box. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 10/13/2022 with a primary diagnosis of heart failure; and - The patient resided in a long term care facility (LTCF) at the time of admission. Review of the hospice initial comprehensive assessment, dated 10/13/2022 showed Wound #1 with the following documentation: - Location: Coccyx; - Type: Pressure ulcer/injury; - Stage: II (partial-thickness skin loss of dermis, presenting as a shallow open ulcer) superficial; - Length: 1cm (centimeter) open/5cm reddened; - Width: 1 cm open/5cm reddened; - Depth: Left blank; - Wound bed: Color-red, Tissue- Other blanchable; - Drainage: Amount- none, Odor- none; - Wound care provided by: Facility staff; - Cleansed with: Soap and water; - Dressed with: Barrier cream; - Covered with: Triad (a zinc oxide based sterile coating designed to manage low and moderately draining wounds, while providing a moist wound healing environment), wound dressing; and -Secure with: left blank. Review of the hospice initial comprehensive assessment, dated 10/13/2022 showed Wound #2 with the following documentation: - Location: Left calf area; - Type: Other, abrasion; - Stage: II Broken skin, superficial; - Length: 1.5cm; - Width: 1.5cm; - Depth: Left blank; - Wound bed: Color-pink, Tissue- Healthy; - Drainage: Amount- none, Odor- none; - Wound care provided by: Facility staff; - Cleansed with: Soap and water; - Dressed with: None; - Covered with: None; and -Secure with: left blank. Additional integumentary comments on the hospice initial comprehensive assessment dated 10/13/2022 showed the patient has a 1.5cm elongated area on left heel. The patient is wearing heel protector booties. Summary of problems on the hospice initial comprehensive assessment dated 10/13/2022 showed the patient has reddened area on coccyx bone with quarter size open area on right buttock. Left heel is soft and discolored without open area. Left calf area has a round abrasion about the size of a nickel. Review of the hospice plan of care dated 10/13/2022 showed: - Triad cream topically ";lirally" (possibly meaning liberally) twice per day hospice covers (failed to include where to apply); - Integumentary summary of problems: Patient has redden area on coccyx bone with quarter size open area on right buttock. Left heel is soft and discolored without open area. Left calf area has a round abrasion about the size of a quarter; and -Integumentary Interventions: Cleanse with soap and water (failed to include which area), dress with triad wound care (again failed to include which area), responsible for wound care: facility, nurse, hospice nurse (failed to include what days/times the hospice vs the facility was responsible for the wound care), wound care to be completed twice a day as ordered (again failed to specify location wound care to be provided to). The plan of care failed to address all skin areas of concern identified on on the comprehensive assessment. RECORD/PATIENT #4: Review of hospice clinical record, showed:-The patient was admitted to hospice on 06/24/2022 with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should); and-The patient initially lived at home, but then transferred to long-term care facility (LTCF) on 07/15/2022. Review of comprehensive assessment, dated 09/20/2022, showed in part, the following:-Alert to person only, pleasantly confused and occasional restlessness;-Genitourinary (urinary system): no deficits, the patient wears disposable briefs and LTCF staff reports the patient uses a bedside commode;-Non-pitting edema to bilateral lower extremities (BLE);-The patient required extensive assist for bed mobility, transfer, toileting, dressing, and bathing; --Used a wheelchair; and-The patient was unable to walk. Review of the POC, dated 09/22/2022, failed to show the following:-No documentation or interventions regarding the patient alert to self only;-No documentation the patient wore disposable briefs;-No documentation the patient required extensive assist for bed mobility, transfer, toileting, dressing, and bathing; and-No documentation the patient was unable to walk. Review of SN visit, dated 09/23/2022, showed:-1 + edema (swelling) to BLE; and-The caregiver wants the patient to stay in bed for safety reasons. Review of SN visit, dated 09/26/2022, showed:-1 + edema to BLE; and-Occasional incontinence, wears disposable brief, and uses a bedside commode. Review of the IDG meeting notes for 09/29/2022 meeting, failed to show:-Updated or revised interventions for the increase in edema;-Documentation or interventions for the caregivers request for the patient to stay in bed; and-Documentation the patient had occasional incontinence and wore disposable briefs. Review of SN visit, dated 10/11/2022, showed:-Incontinent, wears disposable brief;-Difficulty swallowing pills, new onset per LTCF staff;-When transferring patient today, he/she complained of pain to his/her right knee, was holding knee and moaning, had LTCF nurse give pain medication;-Gets anxious with transfers;-Patient doesnt stand during transfers, he/she is maximum assist, and is high risk for falls; and-New wound to right lower leg. Wound bed- bloody, drainage- serosanguinous (thin watery fluid that is pink in color), cleaned with soap and water and applied a border gauze absorbent dressing that is sticky around edges). Review of the IDG meeting notes for 10/13/2022 meeting, failed to show:-Any interventions for the patients incontinence;-Any interventions for the difficulty swallowing;-Updated or revised interventions regarding the right knee pain; and -Any interventions regarding the new wound. Review of the IDG notes for 10/13/2022 meeting, did show the agency changed the patient to a bed bath, but failed to address what staff should do regarding other transfers. During an interview on 10/26/2022 that started at 12:05 PM, the nursing coordinator stated that:-The POC should be individualized;-The POC should be updated and revised when changes were made; and -He/she agreed with the above findings.

Based on the agencys policy review, record review, and interview, the agency failed to ensure that the plan of care (POC) included all physicians orders for medications and treatments in, but not limited to, one (Record/Patient #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 01/22, showed, in part: - 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; - The written plan of care will contain, but will not be limited to, the following; * Prescribed and required medical equipment, supplies, medications and treatments; and * All physicians orders. RECORD/PATIENT #5: Review of the clinical record showed, showed: - Hospice aide visit note, dated, 10/07/2022, showed; * RN present during bed bath; * Patient with open spot on bottom of left foot and one on the bottom of right foot; * RN shown open areas on patients feet by the aide; - Nursing visit note, dated, 10/07/2022, integumentary (skin) assessment section, showed; * Open wound to left lateral heel with dry cracked skin; * Closed wound to right medial heel with dry cracked skin; * RN applied lotion to moisten and remove dry skin to heels; * After removing dry skin patient found to have 1 open area from cracked dryness to the left lateral heel, and another closed crack to right medial heel; * RN applied a Band-Aid to cover each; - Review of physician order, dated 10/13/2022, at 10:20 AM, showed, apply lotion to dry skin, cover skin breakage with Band-Aid to left and right heel PRN (as needed) with effective start date of 10/07/2022; and - No documentation of physician orders for wound care on 10/07/2022. During an interview on 10/26/2022, at 9:32 AM, the nursing coordinator, stated that: - Charts were being audited and the order may have been added late after being discovered during audit; and - He/she would expect orders to be received on time; and - Wound care orders were received late.

Based on review of the agencys policy review, record review, and interview, the agency failed to ensure a complete, individualized written plan of care (POC) when the POC failed to include medical supplies and appliances necessary to meet the needs of the patient in, but not limited to, one (Record/Patients #5) of five complete record reviews. This deficient practice has the potential to adversely affect the care provided to all the agency's patients. --- Findings included: Review of the agency's policy, titled, "Plan of Care," revised 01/22, showed, in part: - Hospice care and services furnished to patient and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire; - 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; - The written plan of care will contain, but will not be limited to, the following; * Identification of patient and family/caregiver problems and needs; and * Prescribed and required medical equipment, supplies, medications and treatments; RECORD/PATIENT/ #5: Review of nursing visit note, dated, 10/21/2022, showed, assistive devices included; wheelchair, hospital bed, and heel protectors bilaterally. Review of the updated plan of care, showed: * DME/Supplies (durable medical equipment and supplies) with heel protectors (effective 10/21/2022); * Patient remains generally weak, requiring assist to transfer to WC (wheelchair); * Patient is 100% dependent for bathing and toileting; and * Hospital bed not listed on POC. During an interview on 10/26/2022, at 9:32 AM, the nursing coordinator, stated that, not all of the patients equipment are listed on the POC and should be.

Based on the agencys policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) discussed/documented changes regarding the patient's status and updated the plan of care (POC), 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, "Plan of Care," revised 01/22, showed, in part: - Hospice care and services furnished to patient and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician, the patient or representative, and the primary caregiver in accordance with the patients needs if any of them so desire; - The registered nurse will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed; - 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; - The written plan of care will contain, but will not be limited to, the following; * Diagnosis; * All services necessary for the palliation/management of the terminal illness and related conditions; * Identification of patient and family/caregiver problems and needs; * Scope and frequency of services needed to meet patient/family needs; * Who will provide the services; * Prescribed and required medical equipment, supplies, medications and treatments; * Level of care; * Realistic and achievable goals; * All physicians orders; * Interventions to manage pain and symptoms; and * Measurable outcomes anticipated from implementing/coordinating the plan of care. RECORD/PATIENT #5: Review of the clinical record showed, showed: - The patient was admitted on 07/25/2022, with a terminal diagnosis of left temporal brain mass; - Initial comprehensive admission assessment, dated, 07/25/2022, showed, patient with port-a-cath (a device placed under the skin that is used to draw blood and give treatments) on the left side of anterior chest; - No documentation of port-a-cath on POC; - No documentation of port-a cath being discussed in IDG (interdisciplinary group) meeting; - Nursing visit note, dated, 08/09/2022, showed, RN (registered nurse) delivered a pill box and filled it with the patients medications; - POC failed to include interventions for SN (skilled nurse) to fill pill box; - Nursing visit note, dated, 08/19/2022, showed, RN spoke with the physicians nurse regarding the patients port-a-cath and per [named nurse] the port did not need to be flushed; - No documentation of port-a-cath on POC to include port not needing to be flushed; - No documentation of port-a cath being discussed in IDG meeting; - Nursing visit note, dated, 10/07/2022, showed, bedbound selected in musculoskeletal/activities section, and patient walked with 2x (times 2) assist (people to help the patient walk) to the toilet; - Review of the IDG meeting, dated, 10/12/2022, showed: * Patient in bed most of time sleeping; * Oriented to self only; * Patient is max [maximum] assist; - Review of the updated plan of care, failed to show, bedbound and max assist; - Nursing visit note, dated, 10/21/2022, showed, in part: * Assistive devices used, wheelchair, hospital bed, and heel protectors bilaterally; * Psychological/Mental/Emotional/Behavioral assessment section, showed, patient oriented to person, lethargic, confused, disoriented, and decreased level of consciousness; * Integumentary (skin) comments section, showed, patient wears bilateral heel protectors to keep heels off of bed; - Review of the updated plan of care, showed: * DME/Supplies (durable medical equipment and supplies) with heel protectors (effective 10/21/2022); * Patient continues to be oriented to self only; * Patient remains generally weak, requiring assist to transfer to WC (wheelchair); * Patient is 100% dependent for bathing and toileting; - Review of the updated POC, failed to show: * Patient status to include, lethargic, confused, disoriented, with decreased level of consciousness; * Patient requiring 2 people to assist with walking to the toilet; * Interventions for heel protectors; and * DME/Supplies for hospital bed. During an interview on 10/26/2022, at 9:32 AM, the nursing coordinator, stated that: - Heel protectors were added to the DME/supplies list section of the POC on 10/21/2022; - No record of port-a-cath found on POC and IDG meeting; - He/she would expect port-a-cath to be on the poc at the start of care and discontinued when orders received; - Not all of the patients equipment are listed on POC and should be; and - Nursing interventions should include filling the patients pill box.

Based on the agencys policy review, record review, and interview, the designated registered nurse that is a member of the interdisciplinary group to provide coordination of care, failed to ensure that the care and services provided are based on all assessments of the patient and family needs in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. --- Findings included: Review of the agency's policy titled, "Comprehensive Assessment," revised 04/20, showed, in part: - During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: * An assessment of pain, including the origin, location, duration, severity, and relief measures; * Alleviating and exacerbating factors for physical symptoms; and * Current treatment and patient response to that treatment. Review of the agency's policy titled, "Hospice Nursing Services," revised 12/21, showed, in part: - The nurse will be responsible for coordination of care and fostering communication between the patient and the IDG (interdisciplinary group); - The hospice registered nurse performs the initial assessment and participates in the comprehensive assessment and ongoing assessments to assess the impact of the terminal diagnosis on the patients physical, functional, psychosocial, and environmental needs and activities of daily living; - The hospice nurse will: * Manage discomfort and provide symptom relief; * Initiate appropriate preventative and rehabilitative nursing procedures; * Coordinate all patient and family/caregiver services and prioritization of needs with the interdisciplinary group; and * Provide an ongoing evaluation of the patient and family/caregiver response to care. Review of the agency's policy titled, "Hospice Staff Nurse/Case Manager Job," revised 04/20, showed, in part: - The Registered Nurse formulates a nursing care plan based on the identified needs of the client and caregiver; - Coordinates the patients care between nursing services and other entities through data in the clinical record, conferences and team meetings; and - Evaluates the effects of care given and regularly re-evaluates the clients and caregivers needs, and informs the physician and other personnel of any significant changes; and then makes changes in the treatment plan with patient/family, and hospice team input and documents these changes on the care plans. RECORD/PATIENT #1: Review of the initial/comprehensive assessment, dated, 08/01/2022, showed, in part: - Patient with severe pain during admission visit; - Patient rated pain a 9 for pain severity (pain level severity, 1-3 = mild, 4-6 = moderate, and 7-10 = severe); - Patient taking hydrocodone-acetaminophen (combination medication of an opioid pain reliever and a non-opioid pain reliever used to treat moderate to severe pain) 10/325mg (10 milligram of hydrocodone and 325 milligrams of acetaminophen) pain, without relief; - Patients physician contacted and ";received orders to increase hydrocodone to QID [four times daily]," was noted in the comments section of the pain assessment; and - No documentation of pain and/or pain management history. Review of the nursing visit note, dated, 08/02/2022, showed, in part: - Patient continues to report pain at a 9; and - Patient ";currently taking Hydrocodone 10/325 QID [four times daily], using heat and is frequently changing seating locations for pain relief. Writer to obtain orders for Gabapentin for pain relief," noted in the summary section. Review of the MSW (medical social work) visit note, dated, 08/03/2022, showed, in part: - Patient reported current pain rated at 8 with pain intensity worse at a 10; and - The patients ";pain and discomfort has increased," noted in the summary of problems section. Review of the chaplain missed visit note, dated, 08/03/2022, showed, spouse asked to wait because the patient was not feeling well. Review of the spiritual visit note, dated, 08/08/2022, showed, ";Pt [patient] did not assign a number, but just said [he/she] hurts all the time," noted in pain assessment section. Review of the nursing visit note, dated, 08/09/2022, showed, in part: - Pain assessment question, pain level now, answered with a 7; - Pain assessment question, worse pain level experienced, was left blank; - ";Pt [patient] reports today that [his/her] pain is currently a 7/10 [7 out of 10] improved with the hydrocodone increase," and ";Pt believes Gabapentin to not be working for relief," was noted in the nursing summary; and - Nursing to increase visit frequency to 2x [two times] weekly to control pain, noted in the summary. Review of the nursing visit note, dated, 08/11/2022, showed, in part: - Pain assessment question, pain level now, answered with a 7; - Patient taking ";hydrocodone BID [two times daily] out of habit rather than the newly instructed and educated 4 times daily," and ";pt [patient] reports not taking Gabapentin PRN as well," noted in the pain summary; - Patient to start Aleve (over the counter medication to relieve pain) 220mg PO [by mouth] BID PRN for bone pain; - Patient reported that Aleve does not settle well with patient but could not explain further; and - Patient was educated to take Aleve PM (over the counter pain reliever with a combination of medications used to treat pain and help with sleep) nightly until next visit and hospice could adjust medications if needed at that time. Review of the nursing visit note, dated, 08/16/2022, showed, in part: - Pain improved from last skilled nurse visit (08/11/2022) with pain rated at a 4; - Patient ";not able to take hydrocodone 4 times per day, 3 times per day knocks [him/her] out through the day," noted in additional pain information section; and - Patient denied taking Aleve PM. Review of the clinical record, failed to show: - Follow up visits being conducted to assess patients pain and medication effectiveness for patient with severe pain; - Documentation of follow up on severe pain; and - Documentation of follow up related to medication effectiveness. During an interview, on 10/25/2022, at 3:30 PM, the nursing coordinator stated that: - He/she would expect the skilled nurse to follow up and document pain; and - No follow up on pain and medication effectiveness is an issue.

Based on policy review, clinical record review, and interview, the agency failed to ensure that the licensed professional services delivered by their health care professionals was practiced under the hospices policies and procedures when the agency nursing staff failed to document weekly wound measurements in but not limited to, two (Records/Patients #2 and #5) of five applicable records reviewed. This deficient practice has the potential to adversely affect the quality of care provided to all the agencys patients. --- Findings included: Review of the agencys undated policy titled ";Wound Care" showed: - A qualified agency Registered Nurse will assess wound(s) as part of the comprehensive initial assessment and will document all clinical findings as per agency policy; - The admitting clinician will document each wound status including, location and etiology, measurement of length, width, depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition; - At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present; and - Each wound will be numbered and documentation associated with each numbered wound will be completed on each visit. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 10/13/2022; and - The patient resided in a long term care facility at the time of admission. Review of the hospice initial comprehensive assessment, dated 10/13/2022 showed Wound #1 with the following documentation: - Location: Coccyx; - Type: Pressure ulcer/injury; - Stage: II Broken skin, superficial; - Length: 1cm (centimeter) open/5cm reddened; - Width: 1 cm open/5cm reddened; - Depth: Left blank; - Wound bed: Color-red, Tissue- Other blanchable; - Drainage: Amount- none, Odor- none; - Wound care provided by: Facility staff; - Cleansed with: Soap and water; - Dressed with: Barrier cream; - Covered with: Triad, wound dressing; and -Secure with: left blank. Review of the hospice initial comprehensive assessment, dated 10/13/2022 showed Wound #2 with the following documentation: - Location: Left calf area; - Type: Other, abrasion; - Stage: II Broken skin, superficial; - Length: 1.5cm; - Width: 1.5cm; - Depth: Left blank; - Wound bed: Color-pink, Tissue- Healthy; - Drainage: Amount- none, Odor- none; - Wound care provided by: Facility staff; - Cleansed with: Soap and water; - Dressed with: None; - Covered with: None; and -Secure with: left blank. Additional integumentary comments on the hospice initial comprehensive assessment dated 10/13/2022 showed pt. has a 1.5cm elongated area on left heel. Pt is wearing heel protector booties. Summary of problems on the hospice initial comprehensive assessment dated 10/13/2022 showed Pt. has reddened area on coccyx bone with quarter size open area on right buttock. Left heel is soft and discolored without open area. Left calf area has a round abrasion about the size of a nickel. Review of the hospice plan of care dated 10/13/2022 showed: - Triad cream topically ";lirally" (possibly meaning liberally) twice per day hospice covers; - Integumentary summary of problems: Patient has redden area on coccyx bone with quarter size open area on right buttock. Left heel is soft and discolored without open area. Left calf area has a round abrasion about the size of a quarter. Review of the hospice nursing clinical note dated 10/14/2022 showed Wound #1 with the following documentation: - Location: Coccyx; - Type: Pressure ulcer/injury; - Stage: I; - Length: left blank; - Width: left blank; - Depth: left blank; - Tunneling: left blank; - Wound bed: Tissue- Other; - Skin surrounding wound: Normal - Drainage: Type- none, amount- none; - Wound care provided by: Facility; - Cleansed with: left blank; - Dressed with: left blank; and - Covered with: left blank. Review of the hospice nursing clinical note dated 10/14/2022 showed Wound #2 with the following documentation: - Location: Left calf area; - Type: Trauma wound; - Stage: I; - Length: left blank; - Width: left blank; - Depth: left blank; - Tunneling: left blank - Wound bed: Tissue- Other; - Skin surrounding wound: Normal - Drainage: Type- none, amount- none; - Wound care provided by: Facility; - Cleansed with: left blank; - Dressed with: left blank; and - Covered with: left blank. Further review of the hospice nursing clinical note dated 10/14/2022 showed: - Additional integumentary information: See wound addendum box left unmarked; and - No documentation regarding the skin status of the left heel or the right buttock. Review of the hospice nursing clinical note dated 10/17/2022 showed Wound #1 with the following documentation: - Location: Right coccyx; - Type: Pressure ulcer/injury; - Stage: 2; - Length: left blank; - Width: left blank; - Depth: left blank; - Tunneling: left blank; - Wound bed: left blank; - Skin surrounding wound: left blank; - Drainage: Type- left blank, amount- left blank; - Wound care provided by: Facility nurse ";named nurse"; - Cleansed with: soap and water; - Dressed with: Triad cream; and - Covered with: left blank. Review of the hospice nursing clinical note dated 10/17/2022 showed Wound #2 with the following documentation: - Location: Left calf; - Type: left blank; - Stage: 2; - Length: 1.5cm; - Width: 1.5cm; - Depth: left blank; - Tunneling: left blank - Wound bed: Tissue- Healthy; - Skin surrounding wound: Normal; - Drainage: Type- none, amount- none; - Wound care provided by: Hospice nurse; - Cleansed with: soap and water; - Dressed with: open to air; and - Covered with: open to air. Further review of the hospice nursing clinical note dated 10/17/2022 showed: - Additional integumentary information: See wound addendum box left unmarked; and - No documentation regarding the skin status of the left heel or the right buttock. Review of the hospice nursing clinical note dated 10/20/2022 showed Wound #1 with the following documentation: - Location: coccyx; - Type: Pressure ulcer/injury; - Stage: left blank; - Length: left blank; - Width: left blank; - Depth: left blank; - Tunneling: left blank; - Wound bed: left blank; - Skin surrounding wound: left blank; - Drainage: Type- left blank, amount- left blank; - Wound care provided by: facility; - Cleansed with: left blank; - Dressed with: left blank; and - Covered with: left blank. Review of the hospice nursing clinical note dated 10/20/2022 showed Wound #2 with the following documentation: - Location: Left calf area; - Type: left blank; - Stage: left blank; - Length: left blank; - Width: left blank; - Depth: left blank; - Tunneling: left blank - Wound bed: Tissue- left blank; - Skin surrounding wound: left blank; - Drainage: Type- left blank, amount- left blank; - Wound care provided by: facility; - Cleansed with: left blank; - Dressed with: left blank; and - Covered with: left blank. Further review of the hospice nursing clinical note dated 10/20/2022 showed: - Additional integumentary information: See wound addendum box left unmarked; and - No documentation regarding the skin status of the left heel or the right buttock. During an interview on 10/25/2022 at 3:30 PM, the nursing coordinator stated that wounds are measured weekly.

Based on policy review, record review, and interview, the agency failed to ensure nursing needs of the patient were met when an on-call agency nurse failed to follow the agency policy and procedure and go assess a patient with a significant change in condition for over five hours and nursing staff failed to document notification of changes to the physician when patient had changes in condition (L591). This deficient practice has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview, the agency failed to ensure nursing needs of the patient were met when an on-call agency nurse failed to follow the agency policy and procedure and go assess a patient with a significant change in condition for over five hours, and nursing staff failed to document notification of changes to physician when the patient had changes in condition for one patient (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to adversely affect the provision of care to all patients served by the agency. --- Findings included: Review of the agencys policy titled, ";Hospice Staff Nurse/Case Manager Job," with a most recently review/revision date of 4/20 showed the following duties: - After making the initial assessment, the Registered Nurse formulates a nursing care plan based on the identified needs of the client and care giver; - Provides skilled nursing services in the clients home in accordance with a plan of treatment authorized by the attending physician and interdisciplinary team; - Evaluates the effects of care given and regularly reevaluates the clients and care givers needs; - Informs the physician and other personnel of any significant changes, and then makes changes in the treatment plan with patient/family, and hospice team input and documents these changes on the care plan; and - Assumes responsibility for managing the care and ensuring all needs are being met to assigned patients. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 10/13/2022; and - The patient resided in a long term care facility at the time of admission. Review of the plan of care dated 10/13/2022 showed oxygen NC (nasal cannula) 2L (liters) QHS/PRN (every night/as needed) SOA (shortness of air). Review of the hospice initial comprehensive admission assessment dated 10/13/2022 showed the following under the respiratory portion of the assessment: - Shortness of breath improved by: oxygen at 2L/min (liters per minute) was marked; - PRN was marked; - Nasal Cannula was marked; and - Other: at HS (bedtime) and PRN for SOB (shortness of breath) (differing from the plan of care that showed every night as needed. Review of a hospice nursing clinical note, dated 10/14/2022, with a time in of 9:15 AM and a time out of 10:30 AM, showed: - O2 SAT (blood oxygen level) 90%; - Oxygen use: Pt (patient) placed on 2L/NC; - Pt oxygen sat (saturation) increased to 93% after placing on 2L/NC; - Care coordination with SN and facility staff each marked and physician left blank; and - Updated ";Named LTC (long term care) facility" charge nurse, ";named charge nurse", on pts assessment. No further needs/concerns voiced at this time. Review of a hospice nursing clinical note, dated 10/17/2022, with a time in of 10:15 AM and a time out of 11:15 AM, showed - A note under the respiratory portion: Following bathing with the hospice aide the pt. noted to have fine crackles in right mid and bilateral lower lobes. Upper lobes clear. Found pt. with cool fingers somewhat difficulty to obtain SPO2 (blood oxygen level). Writer applied 2L of oxygen, found at 83% RA (room air), increased to 93% on 2L; - O2 SAT (blood oxygen level) 93%; - Oxygen use: 2L; - Care coordination with SN, HA (hospice aide) and facility staff each marked and physician left blank; and - Discussed assessment with patient and ";named LPN (licensed practical nurse), both deny needing anything further at this time. Educated to call hospice with any changes or concerns. Review of a hospice nursing clinical note, dated 10/20/2022, with a time in of 9:45 AM and a time out of 10:15 AM, showed - A note under the respiratory portion: Patient denies SOA, currently on room air without notable respiratory distress. Pt. requires oxygen at night or while lying in bed to keep sats >92%; - O2 SAT (blood oxygen level) 95%; - Oxygen use: room air; and - Care coordination with SN, and facility staff each marked and physician left blank. Further review of the clinical record failed to show any communication with the physician regarding the need for oxygen through the day as well as at night. During an interview on 10/25/2022 at 3:30 PM, the nursing coordinator stated that the initial plan of care should have said QHS (every bedtime) and prn. Findings included: Review of the agencys policy titled, ";After Hours Services," dated reviewed/revised 11/2021, showed in part the following:-Purpose: To establish the process by which patients have access to hospice services 24 hours per day, seven days a week;-Patient care needs are the agencies highest priority. A nurse will be on-call 24 hours per day, seven days a week. Clinical personnel are expected to perform visits on an as-needed basis, including weekends. There will be an on-call nurse available after office hours, Monday through Friday, and 24 hours a day on weekends and holidays;-On-call staff will respond to an answering service call within 15 minutes and must be able to reach a patient within 90 minutes from the time the need is identified in emergent visits and three hours from the time the need is identified for non-emergent visits;-The registered nurse (RN) will use his/her best judgement between an emergent and non-emergent call. The on-call nurse will report his/her evening and/or weekend patient care activities to the Clinical Director and staff on first working day back to the office; and-Guidelines: The following list is meant to guide the on-call nurse. It is not exhaustive list, but includes many problems that may require a visit from the hospice nurse:*Unusual, severe, or uncontrolled pain;*Increased anxiety and/or confusion;*Duplicate calls regarding the same problem; and*Patient/family/caregiver perceives a problem and requests a visit. Review of the agencys policy titled, ";Hospice Service Area and Response Time," dated reviewed/revised 03/2022, showed in part the following:-In accordance to state and federal regulation, hospice staff must be able to respond within 90 minutes of an emergency call or need of a hospice patient. For non-emergent calls, hospice staff must be able to respond within three hours; and-Emergent examples: changes in behaviors, substantial condition changes, severe anxiety of patient and caregiver (hospice related), etc (et cetera; so forth). Review of the agencys policy titled, ";Hospice Nursing Services," dated reviewed/revised 12/2021, showed in part the following:-Nursing services will be provided in accordance with accepted standards of practice by or under the supervision of a registered nurse;-The hospice nurse will participate in developing and implementing the plan of care (POC) and will report the condition of the patient and family/caregiver to the attending physician, medical director, and interdisciplinary group (IDG) on a regular basis, as well as changes in the POC. Review of the hospice staff nurse job description, dated reviewed/revised 04/2020, showed the following:-Provides skilled nursing services in the clients home in accordance with a plan of treatment authorized by the attending physician and IDG;-Evaluates the effects of care given and regularly re-evaluates the clients and caregivers needs, and informs the physician and other personnel of any significant changes, and then makes changes in the treatment plan with patient/family and the hospice team input and documents these changes on the care plans; and-Assumes responsibility for evening, weekend, and holidays on-call duty as scheduled and consistent with hospice policies and procedures. RECORD/PATIENT #4: Review of hospice clinical record, showed that the patient was admitted to hospice on 06/24/2022 with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should). Patient initially lived at home, but then transferred to long-term care facility (LTCF) on 07/15/2022. Review of skilled nurse (SN) note, dated 10/11/2022, showed the following:-The patient had trouble swallowing pills during visit, the LTCF staff stated that was new for the patient;-The patient had open area to his/her right lower leg and the wound had serosanguineous (thin watery fluid that is pink in color) drainage. The wound was cleansed in the shower with soap and water, then dressed with a bordered gauze (absorbent dressing that is sticky around edges); and-The agency failed to document notification to the patients physician regarding the new difficulty swallowing and the new open area. Review of the clinical record failed to show an order for the dressing. Review of skilled nurse SN note, dated 10/22/2022, showed the following:-At 5:34 AM, the on-call agency registered nurse (RN) received a call from the answering service from the LTCF regarding the patient and requesting order clarifications. Facility nurse (FN) stated that the patient had orders for Hydromorphone (narcotic used to treat moderate to severe pain) but no Roxanol (narcotic used to treat moderate to severe pain) and the FN wondered if he/she needed to give Hydromorphone. The agency RN asked if the patient was having pain or SOA (shortness of air) and the FN stated the patient was restless. The FN stated the patient had been restless most of the night but possibly from being uncomfortable. The agency RN informed the FN that he/she could give the Hydromorphone, but that the patient also had orders for Seroquel (antipsychotic) or Haldol (antipsychotic) that could be given for agitation/restlessness. The FN was agreeable; -At 6:50 AM, the on-call agency RN received a call from the answering service from the LTCF. The FN stated the Hydromorphone was not working, the agency RN asked how long ago it was given, and the FN reported 15-20 minutes ago. The agency RN explained that the facility needed to give it more time to work. The agency RN also explained to the FN that the patient could have two milligram (mg) instead of one mg of Hydromorphone. The FN stated the patient took the Hydromorphone without difficulty but did not want the Haldol. The agency RN suggested crushing the Haldol and putting it in pudding or applesauce. The FN stated that the patients caregiver was upset that the patient did not have Roxanol and requested the agency RN bring in Roxanol soon as the facility had none in their Ekit (emergency kit). The agency RN explained to the FN that the agency would need a physicians order for the Roxanol. The agency RN explained that the Roxanol was for pain/SOA and if the patient was restless or agitated, to give the Seroquel or Haldol as the patient had orders for them and they had not been given. The FN agreed and stated he/she would try to give them. The agency nurse explained to give the medications and he/she would call the on-call physician regarding the patients medications in the next hour; -At 7:41 AM, the on-call agency RN received a call from the answering service this time from the patients nurse practitioner (NP). The NP stated that the patients caregiver had been texting/calling him/her last night and that morning. They discussed the patients assessment (yet the agency nurse had not been to assess the patient). New orders were received for Atropine (involuntary nervous system blocker used to decrease saliva) and Haldol concentrate (liquid). The NP was going to get ahold of the back-up Medical Director for hospice for the Roxanol script and then call the medications into the pharmacy. The agency RN called the LTCF and informed the FN of the new orders and that when the pharmacy opened at 9:00 AM, he/she would call and see when the medications would be ready;-At 9:05 AM, the agency RN spoke with the pharmacy and the medications would not be ready until 10:30-11:00AM. The agency RN notified the FN of this; -At 10:30 AM, the agency RN arrived to the pharmacy to pick up the medications and was informed the LTCF had already picked the medications up. The Atropine and Haldol concentrate were not going to be available from the pharmacy until Monday/Tuesday. The patient had Haldol tablets and Levsin (anticholinergic used to decrease saliva) tablets on hand. The NP was informed regarding the medications not being available; and -At 10:55 AM, the agency RN arrived to the LTCF to assess the patient (5 hours and 21 minutes after receiving the first call). Review of the LTCFs progress notes, dated 10/22/2022, showed the following:-At 5:40 AM, FN walked by the residents room and noted the resident to be very anxious. As FN entered the patients room, the patient was yelling, ";Help me, help me, I cant breathe." ";I want a doctor, just get it done, just get it done. Im done here on earth." The patient was not wanting to keep his/her oxygen on, the FN attempted to calm the patient down without success. FN contacted the hospice on-call RN due to possible medication change. The agency nurse stated to give one milliliter (ml) of Hydromorphone and to give Haldol if the patient would take it;-At 6:15 AM, The patient refused the Haldol and remained anxious, one on one provided by FN. FN called the patients family member/caregiver, who went into the LTCF to sit with the patient;-AT 7:00 AM, The patient continued to be anxious, complained it was hard to breathe, and begging ";to go home to John" FN notified the hospice on-call nurse again and was told to go ahead and give another one ml of Hydromorphone. The agency nurse was going to see the patient and the family/caregiver was going to notify the NP later that morning to get an order for Roxanol and a refill on Levsin; and-At 7:20 AM, NP called LTCF and spoke with FN and gave new orders for Roxanol 0.25 ml to 1.0 ml sublingual (SL) every one hour as needed for air hunger/pain. Atropine drops- give two drops every two hours as needed for excessive secretions. The NP stated that the hospice nurse would get the medications from the pharmacy and deliver to the facility later that morning. During an interview on 10/26/2022 at 12:05 PM, the nursing coordinator stated the following:-The physician should have been notified regarding the new onset of difficulty swallowing and the new open area;-He/she could not find an order for the wound care or that the physician had been notified of the new onset of difficulty swallowing or the new open area; and-He/she would have expected the on-call nurse to go assess the patient on 10/22/2022 within 90 minutes of the first call at 5:34 AM.

Based on review of the Missouri Home Health Aide/Hospice Aide Competency Evaluation form, policy review, personnel file review, and interview, the agency failed to ensure the required Missouri Home Health Aide/Hospice Aide written test was completed prior to providing aide services to hospice patients, in one (Employee #2) of one aide employee file reviewed. This deficient practice has the potential to adversely affect all patients who receive aide services from the agency. --- Findings included: Review of the current Missouri approved Home Health Aide/Hospice Aide Competency Evaluation form shows it includes two parts, written aide competency evaluation (test) and basic skills test. The written competency test needs to have each section of the exam numbered with the correct answers written by score. A passing score for each section is to have at least three of the five questions answered correctly. An aide is not considered to have a satisfactory score for this written exam if there is more than one section not passed. Both the skills and the written competency test must be completed and passed before the aide is considered qualified and can provide care independently. Review of the agencys policy titled ";Hospice aide training", dated most recently reviewed/revised 4/20, showed: - CNA (certified nursing assistant) will complete and pass Missouri State Competency and Skills test; - Any new assigned task must be passed off before the CNA can perform it independently; - All hospice aide applicants will complete a written/verbal basic knowledge/skills test; and - Competencies and skills will be assessed prior to delivery of services Employee #2: Review of the aides (employee #2) employee file showed the following: - The aide was hired 10/04/2021; - Date of first patient contact was 10/12/2021; - His/her CNA certificate was current as of 03/16/2020; - Basic skills test was completed 10/12/2021; - Add. (additional) skills were completed 10/12/2021; and - A written competency exam failed to be present. During an interview on 10/25/2022 at 1:30 PM the nursing coordinator stated that: - The hospice aide written competency test was not done due to waiver; and - He/she was unaware that the waiver was only related to the on-site evaluation of skills.

Based on policy review, pharmacy contract/agreement, and interview, the agency administration failed to ensure pharmacy services were routinely available on a 24-hour basis seven days a week to meet the needs of the hospice patients (L653). The potential effect of this identified deficiency creates inability to effectively manage pain and symptom control of all hospice patients after normal pharmacy business hours.

Based on policy review, pharmacy agreement/contract, record review, and interview the hospice governing body failed to ensure drugs and biologicals, were available on a 24-hour basis seven days a week, in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: Review of the agencys policy titled, ";Pharmacy Services," dated reviewed/revised 10/2022, showed in part the following:-Purpose: To ensure that pharmacy services are available 24 hours per day;-Pharmacy services needed by hospice patients/families/caregivers and hospice personnel will be available 24 hours a day. Medications will be available through contracts between specific pharmacies and hospice. Controlled substances and other medications will be available through these pharmacy contracts for patients and for those unexpected situations requiring pain and symptom management after normal business hours;-The nurse will contract the patients attending physician (or other authorized independent practitioner) for medication orders;-The attending physician (or other authorized independent practitioner) must submit a verbal or written order to the pharmacy for the medication;-The nurse will contract the pharmacist and inform them of the need for medications and meet the pharmacist to pick up the medications; -The pharmacy will dispense a quantity of medication (15 day supply) as well as appropriate dosage and frequency of the medication;-The pharmacy will provide to the patient and family/caregiver education on drug use and adverse effects; and-If the nurse has any problems reaching the pharmacist they will contact the hospice supervisor or administrator. Review of the agencys undated pharmacy agreement, showed in part the following:-The hospice provider provides palliative and supportive care to terminally ill patients and their family members. A plan of care formulated by the hospice interdisciplinary team and the attending physician outlines services and supplies needed to enhance the quality of the patients life. The hospice philosophy focuses on pain and symptom management, not curative measures;-The pharmacy (supplier) provides prescription service 24 hours per day, seven days per week under the laws of Missouri, by a registered pharmacist;-The supplier agrees to provide the following:*Prescription services are accessible 24 hours per day, seven days per week. Prescriptions shall be filled by a registered pharmacist; and*Medication shall be picked up and delivered by the hospice agency staff or patient family;-This agreement shall be in force and effect from the time of signing this agreement until it has terminated by either party by giving at least a 30 day written notice to the other party;-Each party shall review this agreement yearly and if necessary changes are needed, be agreed upon and changed by hospice provider and a new agreement will be signed at that time;-Hospice administrators signature and dated 10/18/2021; and-The agreement failed to have pharmacist signature. RECORD/PATIENT #4: Review of hospice clinical record, showed that the patient was admitted to hospice on 06/24/2022 with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should). Patient initially lived at home, but then transferred to long-term care facility (LTCF) on 07/15/2022. Review of skilled nurse (SN) note, dated 10/22/2022, showed the following:-At 5:34 AM, the on-call agency registered nurse (RN) received a call from the answering service from the LTCF regarding the patient and requesting order clarifications. Facility nurse (FN) stated that the patient had orders for Hydromorphone (narcotic used to treat moderate to severe pain) but no Roxanol (narcotic used to treat moderate to severe pain) and the FN wondered if he/she needed to give Hydromorphone. The agency RN asked if the patient was having pain or SOA (shortness of air) and the FN stated the patient was restless. The FN stated the patient had been restless most of the night but possibly from being uncomfortable. The agency RN informed the FN that he/she could give the Hydromorphone, but that the patient also had orders for Seroquel (antipsychotic) or Haldol (antipsychotic) that could be given for agitation/restlessness. The FN was agreeable; -At 6:50 AM, the on-call agency RN received a call from the answering service from the LTCF. The FN stated the Hydromorphone was not working, the agency RN asked how long ago it was given, and the FN reported 15-20 minutes ago. The agency RN explained that the facility needed to give it more time to work. The agency RN also explained to the FN that the patient could have two milligram (mg) instead of one mg of Hydromorphone. The FN stated the patient took the Hydromorphone without difficulty but did not want the Haldol. The agency RN suggested crushing the Haldol and putting it in pudding or applesauce. The FN stated that the patients caregiver was upset that the patient did not have Roxanol and requested the agency RN bring in Roxanol soon as the facility had none in their Ekit (emergency kit). The agency RN explained to the FN that the agency would need a physicians order for the Roxanol. The agency RN explained that the Roxanol was for pain/SOA and if the patient was restless or agitated, to give the Seroquel or Haldol as the patient had orders for them and they had not been given. The FN agreed and stated he/she would try to give them. The agency nurse explained to give the medications and he/she would call the on-call physician regarding the patients medications in the next hour; -At 7:41 AM, the on-call agency RN received a call from the answering service this time from the patients nurse practitioner (NP). The NP stated that the patients caregiver had been texting/calling him/her last night and that morning. They discussed the patients assessment (yet the agency nurse had not been to assess the patient). New orders were received for Atropine (involuntary nervous system blocker used to decrease saliva) and Haldol concentrate (liquid). The NP was going to get ahold of the back-up Medical Director for hospice for the Roxanol script and then call the medications into the pharmacy. The agency RN called the LTCF and informed the FN of the new orders and that when the pharmacy opened at 9:00 AM, he/she would call and see when the medications would be ready;-At 9:05 AM, the agency RN spoke with the pharmacy and the medications would not be ready until 10:30-11:00AM. The agency RN notified the FN of this; and-At 10:30 AM, the agency RN arrived to the pharmacy to pick up the medications and was informed the LTCF had already picked the medications up. The Atropine and Haldol concentrate were not going to be available from the pharmacy until Monday/Tuesday. The patient had Haldol tablets and Levsin (anticholinergic used to decrease saliva) tablets on hand. The NP was informed regarding the medications not being available. Discussed assessment and new orders with the FN. Review of SN note, dated 10/24/2022, showed the following:-At 6:30 AM, the RN on-call received a call from the LTCF that the patients oxygen saturation levels had dropped and the FN had given Roxanol and turned oxygen up to three liters. The agency RN informed the FN that he/she would be in to see patient that morning; and-At 7:30 AM, the RN arrived to the LTCF and the FN reported that he/she was able to pull the Atropine from the Ekit and administer to the patient and it had helped with the patients secretions. During an interview on 10/26/2022 at 9:50 AM, the pharmacist from the contracted pharmacy, stated the following:-That he/she did not know until that morning that the pharmacy needed to be available 24 hours a day, seven days a week; and-That he/she had just signed the agreement/contract that morning.

Based on review of policy review, clinical record review, and interview, the agency failed to ensure physician orders were obtained for two (Records/Patients #2, and #4 ) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agencys policy titled, ";Physicians Orders," dated reviewed/revised 12/2021, showed in part, the following:-Purpose: To ensure accurate physician orders are obtained in accordance with applicable law and regulation; and-Orders will be obtained from a licensed physician or other authorized practitioner for care and services to be provided to hospice patients. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 10/13/2022; and - The patient resided in a long term care facility (LTCF) at the time of admission. Review of the plan of care dated 10/13/2022 showed oxygen NC (nasal cannula) 2L (liters) QHS/PRN (every night/as needed) SOA (shortness of air). Review of the hospice initial comprehensive admission assessment dated 10/13/2022 showed the following under the respiratory portion of the assessment: - Shortness of breath improved by: oxygen at 2L/min (liters per minute) was marked; - PRN was marked; - Nasal Cannula was marked; and - Other: at HS (bedtime) and PRN for SOB (shortness of breath) (differing from the plan of care that showed every night as needed. Review of a hospice nursing clinical note, dated 10/14/2022, with a time in of 9:15 AM and a time out of 10:30 AM, showed: - O2 SAT (blood oxygen level) 90%; - Oxygen use: Pt (patient) placed on 2L/NC; - Pt oxygen sat (saturation) increased to 93% after placing on 2L/NC; - Care coordination with SN and facility staff each marked and physician left blank; and - Updated ";Named LTC (long term care) facility" charge nurse, ";named charge nurse", on pts assessment. No further needs/concerns voiced at this time. Review of a hospice nursing clinical note, dated 10/17/2022, with a time in of 10:15 AM and a time out of 11:15 AM, showed - A note under the respiratory portion: Following bathing with the hospice aide the pt. noted to have fine crackles in right mid and bilateral lower lobes. Upper lobes clear. Found pt. with cool fingers somewhat difficulty to obtain SPO2 (blood oxygen level). Writer applied 2L of oxygen, found at 83% RA (room air), increased to 93% on 2L; - O2 SAT (blood oxygen level) 93%; - Oxygen use: 2L; - Care coordination with SN, HA (hospice aide) and facility staff each marked and physician left blank; and - Discussed assessment with patient and ";named LPN (licensed practical nurse), both deny needing anything further at this time. Educated to call hospice with any changes or concerns. Review of a hospice nursing clinical note, dated 10/20/2022, with a time in of 9:45 AM and a time out of 10:15 AM, showed - A note under the respiratory portion: Patient denies SOA, currently on room air without notable respiratory distress. Pt. requires oxygen at night or while lying in bed to keep sats >92%; - O2 SAT (blood oxygen level) 95%; - Oxygen use: room air; and - Care coordination with SN, and facility staff each marked and physician left blank. Further review of the clinical record failed to show any communication with the physician regarding the need for oxygen through the day as well as at night nor an order for oxygen use PRN. During an interview on 10/25/2022 at 3:30 PM, the nursing coordinator stated that the initial plan of care should have said QHS (every bedtime) and PRN. RECORD/PATIENT #4: Review of the clinical record showed:-The patient was admitted to hospice services, with a terminal diagnosis of congestive heart failure (CHF; a chronic condition in which the heart does not pump blood as well as it should); and-The patient initially lived at home, but then transferred to long-term care facility (LTCF) on 07/15/2022. Review of skilled nurse (SN) note, dated 10/11/2022, showed the patient had open area to his/her right lower leg and the wound had serosanguineous (thin watery fluid that is pink in color) drainage. The wound was cleansed in the shower with soap and water, then dressed with a bordered gauze (absorbent dressing that is sticky around edges). Review of SN note, dated 10/14/2022, showed wound to right lower leg, cleansed with soap and water and dressed with border gauze. Review of SN note, dated 10/17/2022, showed wound to right lower leg, cleansed with soap and water and dressed with border gauze. Review of SN note, dated 10/20/2022, showed wound to right lower leg, LTCF changed dressing on 10/19/2022 and covered with two by two opsite (transparent, adhesive dressing). Review of the plan of care failed to show an order for the wound care. During an interview on 10/26/2022 at 12:05 PM, the nursing coordinator stated that he/she would expect a physician order for the wound care and he/she could not find an order.

Based on Missouri law review, policy review, employee file review and interview, the agency failed to ensure criminal background checks were performed in one (Employee #1) of six employee files reviewed. This deficient practice has the potential to adversely affect services provided to all hospice patients. --- 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 agencys undated policy titled ";Background Checks," showed: - Policy: To assure all employees who have contact with clients are cleared of criminal history; - Criminal history, background checks, employee disqualification list, and family care safety registry will be checked prior to employment; - If there is any evidence of the applicant being on any of these lists, they shall not be eligible for employment; - Applicants will be informed that it is required the above mentioned checks will be done prior to hire, as well as checks for professional registration or certification status; and - The administrator/designee will be responsible to ensure this is implemented. Employee #1: Review of the MSWs (Master of Social Work) (E-1) employee file showed the following: - Date of hire 03/08/2022; - Date of first patient contact 03/30/2022; and - Criminal background check was completed 07/07/2022. During an interview on 10/25/2022 at 1:43 PM the nursing coordinator stated that: - He/she was unsure what happened to employee #1s FCSR (family care safety registry) (which contains criminal background history) and EDL prior to hire; - They were found missing during file audits; and - They were re-ran in July.

Based on review of Missouri state law, policy review, employee file review and interview, the agency failed to provide services in compliance with all applicable State laws and regulations when the agency failed to obtain the results of the employee disqualification list (EDL) prior to hire in one (Employee #1) of six employee files reviewed. This deficient practice has the potential to adversely 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." Review of the agencys undated policy titled ";Background Checks," showed: - Policy: To assure all employees who have contact with clients are cleared of criminal history; - Criminal history, background checks, employee disqualification list, and family care safety registry will be checked prior to employment; - If there is any evidence of the applicant being on any of these lists, they shall not be eligible for employment; - Applicants will be informed that it is required the above mentioned checks will be done prior to hire, as well as checks for professional registration or certification status; and - The administrator/designee will be responsible to ensure this is implemented. Employee #1: Review of the MSWs (Master of Social Work) (E-1) employee file showed the following: - Date of hire 03/08/2022; - Date of first patient contact 03/30/2022; and - EDL check was completed 07/07/2022. During an interview on 10/25/2022 at 1:43 PM the nursing coordinator stated that: - He/she was unsure what happened to Employee #1s FCSR (family care safety registry) and EDL prior to hire; - They were found missing during file audits; and - They were re-ran in July.