Every finding on record at Hospice of the Ozarks

Based on a review of clinical records and staff interviews, it was determined that the Agency failed to complete a Spiritual Needs Assessment as part of the Initial Comprehensive Assessment within five (5) days following the election of hospice services for 1 of 19 patients reviewed (Patient #3). This failed practice had the potential to affect all hospice admissions, as it may delay the identification of patient and family spiritual and psychosocial needs. Such delays could place patients and/or families at increased risk for inadequate coping with end-of-life issues, lack of appropriate spiritual resources, and insufficient emotional or familial support. --- A review of clinical record #3, with a Start of Care (SOC) date of 07/28/25, revealed a patient diagnosed with Heart Failure. A document titled “Chaplain Visit Note”, dated 07/31/25, indicated that the Chaplain contacted the patient’s caregiver to schedule the initial spiritual assessment visit. The caregiver declined the visit. The Chaplain noted he spoke with the Social Worker and requested that she complete the spiritual assessment during her psychosocial assessment. A review of a the “Medical Social Worker Visit Note” dated 08/01/25 documented that the “Spiritual Assessment [was] not assessed.” There was no documentation indicating coordination of care between the Chaplain and the Social Worker to ensure completion of the spiritual assessment.  During an interview conducted on 08/14/25 at 2:00 PM, Agency Personnel #1and #2 confirmed that the Spiritual Assessment had not been completed within the required five (5) calendar days from the SOC, as required by the Medicare Hospice Conditions of Participation as part of the comprehensive assessment.

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to install twelve of twelve alcohol-based hand-rub (ABHR) dispensers at a safe distance from hazardous locations as required by NFPA 101. The failed practice created a fire hazard in all Patient Rooms in the In-patient Unit. Findings follow: A. Review of NFPA 101 2012 Edition: 19.3.2.6 (8) showed ABHR dispensers shall not be installed above an ignition source within a 1-inch horizontal distance from each side of the ignition source. B. Observation on 9/13/22 from 1:45 PM to 2:10 PM of the In-Patient Unit showed an ABHR dispenser was installed in all twelve Patient Rooms (Rooms 1201 - 1212) directly above a light switch in every room. This finding was verified with the Director of Maintenance at the time of observation. .

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition, it was determined the facility failed to use portable space heaters in accordance with Life Safety standards in that there was no process in place to ensure the space heaters in the facility would not exceed 212 degrees Fahrenheit. The failed practice created a fire hazard in the In-Patient Unit. Findings follow: A. Review of NFPA 101 2012 Edition: 19.7.8 showed portable space heating devices shall be prohibited in all health care occupancies unless such devices are used in non-sleeping staff areas and the heating elements of such devices do not exceed 212 degrees Fahrenheit. B. Observation on 9/13/22 from 1:45 PM to 2:10 PM of the In-Patient Unit showed a portable space heater was present in the Volunteer Coordinator office. This finding was verified with the Director of Maintenance at the time of observation. C. In an interview with the Director of Maintenance on 9/14/22 at 9:00 AM it was confirmed the facility did not have any process in place to ensure the heating element of portable space heating devices did not exceed 212 degrees Fahrenheit. .

Based on observation, interview, and review of National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 99 Health Care Facilities Code 2012 Edition, it was determined the facility failed to store portable oxygen cylinders in accordance with NFPA standards. The failed practice had the likelihood to affect all patients relying on oxygen in that in the event of an emergency an empty portable oxygen tank could be mistaken as full and result in delayed care for the patient in need of oxygen. Findings follow: A. Review of NFPA 101: 19.3.2.4 showed medical gas storage and administration shall be in accordance with section 8.7 and NFPA 99. B. Review of NFPA 99: 11.6.5.2 showed if empty and full portable oxygen cylinders are stored together, full cylinders shall be segregated from empty cylinders. Further review of NFPA 99: 11.6.5.3 showed empty portable oxygen cylinders shall be marked to avoid confusion. C. Observation on 9/13/22 at 2:25 PM of the Laundry area showed a single rack was present with 6 full portable oxygen cylinders stored in it. This finding was verified with the Director of Maintenance at the time of observation. D. In an interview with the Director of Maintenance on 9/13/22 at 2:30 PM it was verified that nursing staff were instructed to store empty portable oxygen cylinders in the rack with the full portable oxygen cylinders until the empty cylinders are picked up by Maintenance and there was not a process for marking the empty cylinders.

Based on review of Clinical Records and staff interview, the Skilled Nurse (SN) failed to include Oxygen on the patients "Medications" list (a section of the Agency's Care Plan containing the medication profile) in 3 (#2, #4, #13) of 3 Clinical Records reviewed. This deficient practice presented a potential risk to patients currently requiring Oxygen therapy by delaying pertinent information to the attending Physician regarding the patients individualized medication regimen. This failed practice had the likelihood to affect all patients receiving oxygen. Findings follow: 1. Review of Clinical Record #2 revealed the following: A. A patient with a start of care of 08/07/22 and a diagnosis of Lung Cancer. B. A document titled, "Hospice Plan of Care" with a certification period of 08/07/22 through 11/04/22 contained orders for Oxygen. C. A form titled, "Skilled Nurse Visit" and dated 08/07/22 (patient's start of care date), the SN documented the patient was currently utilizing Oxygen. D. A form titled, "Medication profile" (the form the agency used to document medications the patient was taking), failed to include the medication Oxygen. E. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. 2. Review of Clinical Record #4 revealed the following: A. A patient with a start of care of 08/25/22 and a diagnosis of Head and Neck Cancer. B. A document titled, "Hospice Plan of Care" with a certification period of 08/25/22 through 11/22/22 contained orders for Oxygen. C. On a form titled, "Skilled Nurse Visit" and dated 08/25/22 the SN documented the patient was currently utilizing Oxygen. D. A form titled, "Medication profile" (the form the agency used to document medications the patient was taking), failed to include the medication Oxygen. E. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. 4. Review of Clinical Record #13 revealed the following: A. A patient with a start of care date of 03/05/20 and a diagnosis of Chronic Obstructive Pulmonary Disease. B. A document titled, "Hospice Plan of Care" with a certification period of 08/22/22 through 10/20/22 contained orders for Oxygen. C. On a form titled, "Skilled Nurse Visit" and dated 08/24/22, the SN documented the patient was currently utilizing Oxygen. D. A form titled, "Medication profile" (the form the agency used to document medications the patient was taking), failed to include the medication Oxygen. E. There was no documentation in the chart to indicate that Oxygen had been checked for actual or potential drug interactions. 5. During an interview on 09/14/22 at 3:30 PM, Agency Personnel #1 confirmed that Oxygen was not included on the medication profile and not checked for actual or potential drug interactions for patients #2, #4, and #13. .

Based on observation of Interdisciplinary Group (IDG) meeting, staff interview, IDG meeting minutes and clinical record review, it was determined the Agency did not initiate a Plan of Care (POC) utilizing the core component of Physician in 13 (#1 - #13) of 13 clinical records reviewed. This failed practice had the likelihood to affect all patients on census in that, it inhibited the patient's physician from participating in developing and updating the patient's plan of care. Findings follow: 1. Observation of the IDG meeting on 09/14/22 at 9:00 AM, revealed no Physician was present for the development or update of the patient's POC. 2. Review of weekly IDG meeting minutes for July and August 2022 indicated the Physician was not in attendance during the IDG meetings. 3. Review of 13 Clinical Records (#1 - #13) revealed no evidence the Physician attended the IDG meetings and actively participated in the update or development of the patient's POC. 4. On 09/14/22 at 3:30 PM, Agency Personnel #1 confirmed the findings and reported the Physician reviewed the IDG summary from each discipline a day after the IDG meeting. .

Based on clinical record review and staff interview it was determined the Agency failed to develop an individualized Plan of Care (POC) which included patient specific scope and frequency of visits to be made by the Hospice Chaplain in 1 (#6) of 13 (#1 - #13) clinical records reviewed. This lack of individualized POC specific scope and frequency of visits could potentially result in a failure to meet the patient and/or families specific spiritual needs for all patients on current census. Findings follow: Review of clinical record #6 revealed the following: 1 A patient with a start of care date of 05/13/22 and a diagnosis of Multiple Myeloma. 2. A form titled "Hospice Plan of Care" with a certification period of 08/11/22 through 11/08/22 did not include an order for a scope or frequency of visits for Hospice Chaplain services. 3. A form titled "Chaplain Visit Note" and dated, 09/08/22 showed documentation the Hospice Chaplain made a visit with the patient. 4. A form titled, "Interdiscplinary Group Meeting" and dated 08/17/22 and 08/31/22, showed no evidence of a frequency of visits for the Hospice Chaplain. 5. During a staff interview on 09/14/22 at 3:30 PM Agency Personnel #3 confirmed the above findings. .

Based on clinical record review and staff interviews, it was determined the agency did not individualize standing or routine orders in 2 of 2 (#3 and #4) clinical records reviewed. This failed practice could result in potential harm for all patients on census in that, the agency did not obtain individual and specific orders to address the patient's specific needs. Findings follow: 1. Review of clinical record #3 revealed the following: A. A patient with a start of care of 08/9/22 and a diagnosis of Liver Cancer. B. A document titled, "Hospice Plan of Care" with a certification date of 08/09/22 through 11/06/22 showed orders for a urinary catheter, " ...Insert Foley catheter as needed for urinary retention or patient comfort ..." And an order "...Flush Foley catheter PRN (as needed)...". C. There was no evidence of individualized orders for Foley Catheter to include the size of catheter to be inserted or balloon size and there was no evidence of amount of irrigating solution to be used to flush the catheter. 2. Review of clinical record #4 revealed the following: A. A patient with a start of care of 08/25/22 and a diagnosis of Head & Neck Cancer. B. A document titled, "Hospice Plan of Care" with a certification period of 08/25/22 through 11/22/22 showed orders for a urinary catheter, " ...Insert Foley catheter as needed for urinary retention or patient comfort ..." and an order " ...Flush Foley catheter PRN (as needed) ...". C. There was no evidence of individualized orders for Foley Catheter to include the size of catheter to be inserted or balloon size and there was no evidence of amount of irrigating solution to be used to flush the catheter. D. A document titled, "Hospice Plan of Care" with a certification period of 08/25/22 through 11/22/22 showed orders, "Nurse to change tracheostomy...". E. There were no orders to include size and frequency of tracheostomy care. F. A document titled, "Skilled Nursing Visit Note" and dated 08/25/22 (patient's start of care) showed the nurse noted the patient had a tracheostomy, "Tracheostomy site WNL" (within normal limits). G. A document titled, "Hospice Plan of Care" with a certification period of 08/25/22 through 11/22/22 showed orders, "Perform wound care/Dressing change". H. There were no orders to include individualized and specific wound care treatment and frequency. I. A document titled, "Skilled Nursing Visit Note" and dated 08/25/22 (patient's start of care) showed the nurse noted the patient had a wound, "Graft site (A skin graft is a section of epidermis and dermis which has been completely separated from its blood supply in one part of the body, the donor site, before being transplanted to another area of the body, its recipient site) and surgical incision. Incision site Neck." 3. During an interview on 09/14/22 at 3:30 PM, Agency Personnel #1 and #2 confirmed the orders were not individualized and specific for each patient. .

Based on clinical record review and interview with Agency staff, it was determined the Agency failed to facilitate visits by local clergy, pastoral counselors, or other individuals to support the patient's/family's spiritual needs in 2 (#3, #7) of 13 (#1 - #13) clinical records reviewed. This failed practice had the likelihood to affect all patients on census from obtaining relief from spiritual and/or emotional conflict in order to improve the quality of life for the patient and/or family. Findings follow: 1. Review of clinical record #3 with a start of care date of 08/09/22 and a diagnosis of Liver Cancer, on a document titled "Chaplain Visit Note", record entry states patient was a member of, and receiving support from his local church. There was no evidence of contact made by Hospice Chaplain to local clergy to facilitate visits or support the patient's/family's spiritual needs. 2. Review of Clinical Record #7 with a start of care date of 08/22/22 and a diagnosis of Heart Failure, on a document titled "Chaplain Visit Note", record entry states patient was a member of a local church, and asked Chaplain to call and ask her local clergy to visit. Chaplain documented he called the church and relayed the patient's request to the church secretary. There was no evidence of follow-up of this phone call, or any other contact with local clergy to facilitate visits or support the patient's/family's spiritual needs. 3. During an interview on 09/14/22 at 3:30 PM, Agency Personnel #3 confirmed the Chaplain did not facilitate visits or coordinate care with the patient's local faith community.