Every finding on record at Intrepid of Missouri, Inc.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 4: The medication profile contains two PRN medications Ipratropium Albuterol and Oxygen with a PRN reason of "respiratory". There is no symptom reason listed. Corrected on site.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 4: The POC contains two PRN medications Ipratropium Albuterol and Oxygen with a PRN reason of "respiratory". There is no symptom reason listed. Corrected on site.

Upon patient record review, 3 of 5 (Patient #3,4,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patients 3,4,5: The POC does not contain DME orders. There is evidence in the RN comprehensive assessment that all 3 patients have DME however, these are not on the POC for orders. Corrected on site for patients 3 and 4.

Upon patient client record review, 2 of 5(Patient #1,5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The Chaplain documents on 11/22/23 "Coordinator visited with pig about his grief". ADN states it may have auto corrected from pcg. Patient 5: The SN documented on 12/21/23 comprehensive assessment "Do not place the individual on his/her hip or directly on the wound". The pt does not have a wound.

Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1, Patient admitted on 9/10/21, MSW assess completed on 9/17/23 not meeting within 5 calendar days.

Upon patient record review, 2 of 14 (Patient #4,5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4, No bereavement assessment completed. Patient #5, No bereavement assessment completed.

Upon patient record review, 12 of 14 (Patient #1,2,3,4,5,7,8,9,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patients #1,2,3,4,5,7,8,9,10,11,12,13,14, No evidence of aide service discussed during IDG and no reassessment of response to aide care.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient #14, No evidence of pain care plan upon admission.

Upon client record review, 12 of 14 (Patient #2,3,4,5,7,8,9,10,11,12,13,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2, SC frequency 1x/mon and 2 PRN, patient was seen, 4/10/23, 4/21/23 as a PRN visit, 4/25/23 as a PRN visit, 5/8/23, 5/15/23 as a PRN visit, 5/22/23 as a PRN visit. Patient #3, SN frequency 1x/week for 2 weeks on 06/22/23 then no frequency order until 9/5/23 for 1x/week visits completed 6/22/23, 6/23/23, 6/26/23, 6/30/23, 7/7/23, 7/14/23, 7/21/23. SC 1x/month increased to 2x/month on 9/5/23, SC visits on 9/11/23, 9/19/23, 9/26/23, 10/2/23, 10/9/23, 10/23/23. Patient #4, SN frequency 1w1,2w1, then 2x/week. Patient seen on 7/13/23, 714/23. Patient was seen 2 times in the first week. SW frequency 1x/month, patient seen 7/17/23, 8/17/23 documented as missed visit. No evidence of visit for Sept and Oct. Patient #5, SW frequency 2x/week for 2 weeks. Visits made 10/23/23, 11/9/23. Volunteer frequency 1x/month and 2 PRN visits. No evidence of visits completed. Patient # 7, SN frequency 1w1, 2w1 then no orders until 9/19/23 1x/week and 2 PRN. Patient seen 8/9/23, 8/10/23, 8/15/23, 8/18/23, 8/22/23, 8/25/23, 9/29/23, 9/1/23, 9/6/23, 9/8/23, 9/12/23, 9/15/23, 9/19/23. SC frequency 2x/month, visits 8/10/23, 9/7/23, 9/12/23, 9/14/23, on 9/19/23 frequency changed to 3x/month. Patient #8, SN frequency 1w1, 2w1, no nursing orders after the second week. Visits made on 7/28/23, 7/29/23, 7/31/23, 8/3/23, 8/8/23, 8/10/23, 8/16/23, 8/18/23, 8/21/23, 8/23/23, 8/28/23, 9/1/23, 0/6/23, 9/8/23. 9/12/23. SC frequency 2x/month, visits made 7/28/23, 8/2/23, 8/23/23, 9/7/23, 9/20/23. Patient #9, SN frequency 1-2xw1, 2w1, no further orders for SN. Visits made 9/26/23, 9/27/23, 9/29/23, 10/4/23, 10/6/23, 10/11/23, 10/18/23, 10/20/23, 10/25/23, 10/27/23,11/1/23, 11/3/23, 11/8/23, 11/10/23. Patient #10, SN frequency 1w1,2w1, no further orders for SN. Visits made 8/11/23, 8/12/23, 8/15/23, 8/18/23, 8/30/23, 9/1/23, 9/6/23, 9/8/23,9/13/23, 9/15/23, 9/20/23, 9/22/23, 9/27/23, Patient #11, SN frequency 1w2 and 2 PRN, no further orders for SN. Visits made 7/6/23, 7/7/23, 7/12/23, 7/17/23, 7/19/23, 7/22/23, 7/26/23. SC frequency 1x/mon, visits made 7/10/23, 7/25/23. Patient #12, SC frequency 1x/month. Visits made 3/23/23, 3/31/23 as PRN tele visit. No orders for tele visit to be completed. Patient #13, SN frequency 2w2, visits made on 7/29/23, 7/30/23, 7/31/23, 8/1/23. Patient #14, SN frequency 1w1,2w1, visits made 7/15/2/3, 7/16/23, 7/18/23, 7/20/23, 7/24/23,7/25/23.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. Agency has a long term nursing contract with one RN without evidence of being unable to fill the position with direct employee.

Upon patient record review, 2 of 14 (Patient #13, 14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13,14, No updated bereavement plan of care after death.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Personnel #11, 12, no employee record. Agency unable to obtain files due to no OT or ST available at this time through contracted agency.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon patient record review, 2 of 14 (Patient #8,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #8, No evidence of care plan for need for Aide. Patient #10, No evidence of care plan for need for Aide.

Upon patient record review 8 of 14 (Patient #2,3,7,8,9,10,11,13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2, Aide frequency 0w1, 1w1, then 2x/week, Visits made 4/12/23, 4/19/23, 4/26/23, 5/3/23, 5/10/23, 5/17/23, 5/24/23, 5/31/23. Patient #3, Aide frequency 0w1,2w1, no further orders. Visits made 6/26/23, 6/29/23, 7/3/23, 7/6/23, 7/10/23, 7/13/23, 7/17/23, 7/20/23, 7/24/23, 7/27/23, 7/31/23, 8/3/23. Patient #7, Aide frequency 1w1,2w1, no further orders. Visits made 10/9/23, 10/12/23, 10/16/23, 10/19/23, 10/23/23, 10/26/23, 10/30/23, 11/2/23, 11/6/23, 11/9/23, 11/13/23. Patient #8, Aide frequency 1w1,2w1, no further orders. Visits made 7/31/23, 8/3/23, 8/8/23, 8/11/23, 8/14/23, 8/17/23, 8/22/23, 8/24/23, 8/29/23, through 11/2/23, 11/7/23, 11/9/23. Patient #9, Aide frequency 1w1,2w1, no further orders. Visits made 9/29/23, 10/4/23, 10/6/23, 10/11/23, 10/13/23, 10/18/23,10/20/23, 10/25/23, 10/27/23, 11/1/23, 11/3/23, 11/8/23, 11/20/23. In addition, Aide care plan directed foot care every visit, shampoo hair every visit, oral hygiene every visit, shower every visit. No evidence this was completed on 9/29/23, 10/4/23 Patient #10, Aide frequency 0w1,1w1, no further orders. Visits made 8/15/23, 8/18/23, 8/22,23, 8/25/23, 8/30/23, 9/1/23, 9/6/23, 9/8/23, through 11/1/23, 11/8/23. Patient #11, Aide frequency 0w1,2w1, no further orders. Visits made 7/10/23, 7/13/23, 7/17/23, 7/20/23, 7/24/23, 7/27/23, 7/31/23, 8/3/23, 8/7/23. In addition, Aide care plan directed shampoo every visit. No evidence completed on 7/13/23. Patient #13, Aide frequency 2w2, no visits made.

Upon patient record review 1 of 14 (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #3, Sup visits completed 7/14/23 and not again until 8/4/23 greater than 14 days.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #11,12, No evidence of discharge summary was forward to attending physician.