Every finding on record at John Knox Village

Based on policy review, orientation and training document review, employee file review, and interview, the provider failed to ensure all staff were provided emergency preparedness (EP) training in one of five employee files reviewed (E-1). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Orientation Program,” revised 05/2022, showed in part, contract personnel receive orientation to hospice by the provider’s policies regarding confidentiality, the hospice philosophy of care, including levels of care and Alzheimer’s / Dementia training, and the contract personnel’s specific job duties, as appropriate and delineated in the written agreement.The provider’s policy failed to include emergency preparedness training for contract personnel.Review of the provider’s undated document titled, “Hospice Contracted Partner/Volunteer Orientation and Training,” showed in part, training on the procedures to follow: - When an emergency is declared; and- After the emergency. --- EMPLOYEE #1:Review of E-1’s file showed he/she was a contracted employee with a hire date of 04/01/2024. The employee file failed to show emergency preparedness training was completed during orientation.Review of the document titled, “Hospice Contracted Partner/Volunteer Orientation and Training,” signed 06/23/2025, showed the document failed to be completed during E-1’s orientation period.During an interview on 06/24/2025 at 3:50 PM, the administrator stated that E-1 was not trained on emergency preparedness during new employee orientation and it should have been completed before 06/23/2025.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/18/2025 with a terminal diagnosis of malignant neoplasm of endometrium (type of cancer that begins in the lining of the uterus). The patient resided at home alone.  Review of the initial comprehensive assessment, dated 04/18/2025, showed:- The patient’s medication box was filled by the daughter in-law; and- All routine medication bottles were kept at the patient’s son and daughter in-laws home due to the patient’s memory issues. Review of the initial POC, dated 04/18/2025, showed:- Skilled nurse to educate patient/caregiver on all medications including side effects, importance of taking medications as ordered, and effects to report immediately to health care provider;  - The patient’s medication box was filled by the daughter in-law; and- All routine medication bottles were kept at the patient’s son and daughter in-laws home due to the patient’s memory issues. Review of the skilled nurse (SN) visit note, dated 06/13/2025, showed:- The registered nurse case manager (RN CM) filled the patient’s pillbox for the upcoming week;- The patient was previously assisted with medications by his/her son, but the patient expressed a strong desire to manage his/her own medications independently; - The RN assured the patient’s son that at each SN visit medication compliance and pillbox review/refill would be completed; - Patient able to take medication as prescribed;- No new or changed orders to IDG plan of care required; and- Narrative note sent to IDG summary.  Review of the clinical record failed to show an updated POC that included interventions for the skilled nurse to review and/or fill the patient’s pillbox at each visit.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 05/19/2025 with a terminal diagnosis of squamous cell carcinoma of skin of scalp and neck (a type of skin cancer that arises from squamous cells, which are found in the outer layer of the skin). The patient lived at home with adult family members.  Review of the initial comprehensive assessment, dated 05/19/2025, showed:- Long term (current) use of anticoagulants (a medication that helps prevent blood clots from forming or growing larger);- Wound care was done to 3rd toe on left foot as per patient/caregiver instructions, but wound care would change when orders from “named podiatrist” were received; and- The caregiver requested the pillbox/med planner to be filled. Review of the initial POC dated 05/19/2025, showed:- A diagnosis of long-term current use of anticoagulants;- The patient was taking Warfarin Sodium (an anticoagulant medication that requires monitoring of the patient’s International Normalized Ratio (INR- a blood test that measures how long it takes for your blood to clot); - The patient was at risk for bleeding due to anticoagulant therapy;- The POC failed to:   * Include orders for skilled nursing (SN) to obtain INRs or the method to obtain the INRs (venipuncture- the process of collecting blood from a vein or fingerstick- a minimally invasive method of collecting blood samples from the fingertip);  * Include orders for SN to fill the pillbox/med planner and the frequency; and   * Include orders to identify the physician managing the foot wound. Review of a faxed wound care order dated 05/20/2025 showed the physician as “named podiatrist”.  Review of the SN visit note, dated 05/20/2025, showed:- The patient’s INR was 1.8; and - The “med planner” was filled. Review of the SN visit note, dated 05/27/2025, showed:- The patient’s INR was 2.4; and - The “med planner” was filled. Review of the SN visit note, dated 06/03/2025, showed “med planner filled”. Review of the SN visit note, dated 06/11/2025, showed the patient’s INR was 1.8. Review of the SN visit note, dated 06/17/2025, showed the patient’s INR was 1.9. Review of the SN visit note, dated 06/24/2025, showed:- The patient’s INR was 1.7; and- It failed to be documented that the pillbox/med planner was filled during the visit. Observation on 06/24/2025 at 10:50 AM, showed RN-A:- Performed a fingerstick to obtain an INR on the patient; and- Filled the pillbox/med planner.  Review of the clinical record failed to show an updated POC that included interventions for:- The skilled nurse to fill the patient’s pillbox/med planner or the frequency;- The physician managing the patient’s wound; and- The method or frequency to obtain the patient’s INRs.  During an interview on 06/25/2025 at 10:24 AM, the Registered Nurse Coordinator stated that:- The provider did not routinely add to fill the med planner to the plan of care because they routinely had the same nurse visiting;- The attending position was probably now managing the wound; and- The provider’s baseline standard was that all INRs were fingerstick so the method of obtaining the INRs was not put on the POC.

Based on policy review, record review, and interview, the hospice provider failed to maintain a system of communication to ensure the provision of care and services, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Interdisciplinary Team (IDT),” reviewed 02/2019, showed in part the following:- The IDT assess, plan, provide, and evaluate the care and services provided to hospice patients and caregivers; - The IDT is responsible for establishing, implementing, reviewing, and revising the patient's plan of care; and - The registered nurse (RN) is responsible for coordinating the care and services provided by the IDT, ensuring continuous assessment of patient/caregiver needs, and implementing the interdisciplinary plan of care. --- RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of senile degeneration of the brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior). The patient resided at a long-term care facility (LTCF).Review of the initial plan of care, dated 06/02/2025, showed the following:- At risk for skin breakdown related to bedbound;- Incontinence of bowel related to terminal diagnosis; and- Aide visit frequency of two times per week.Review of the aide visit notes, dated 06/06/2025, 06/17/2025, 06/19/2025, 06/24/2025, showed the bedbath was refused.Review of the aide visit notes dated 06/06/2025 and 06/24/2025, showed the aide notified the registered nurse of the refusal of care.Review of the aide visit notes, dated 06/17/202 and 06/19/2025, showed the aide failed to notify the registered nurse of the refusal of care.Review of the interdisciplinary group (IDG) summary and comprehensive assessment update, dated 06/10/2025, showed in part, on 06/09/2025, nystatin cream (used to treat fungal infections) was ordered to be applied to peri-area (region of the body between the anus and the vulva) and buttocks.Review of the interdisciplinary group (IDG) summary and comprehensive assessment update, dated 06/24/2025, showed in part the following:- On 06/13/2025, hydrocortisone cream (used to relieve inflammation, redness, itching, and swelling associated with various skin conditions) was ordered to be applied to peri-area, abdomen, and buttocks;- On 06/16/2025, patient continued to receive nystatin cream and hydrocortisone cream to peri-area and buttocks and patient no longer used brief and was on chux (disposable, absorbent underpads used to protect incontinence on the bed); and- On 06/23/2025, a mixture of nystatin cream, hydrocortisone cream, and Eucerin cream (used to treat dry and sensitive skin) was ordered to be applied to abdomen, peri-area, buttocks, and upper legs.Review of the IDG discussion, dated 06/24/2025, showed the following:- Anxious turning in bed;- Skin rash treated with nystatin and hydrocortisone cream;- Stopped brief and used chux;- Started oral steroids; and- Failed to show the patient/caregiver refused bedbaths.During an interview on 06/25/2025 at 9:50 AM, the registered nurse coordinator (RNC) stated that he/she would expect the IDG to talk about what had changed with the patient at the IDG meeting. The RNC stated that he/she would expect the refusal of care to be reported to the registered nurse case manager (RNCM) and for the RNCM then to report to the IDG. He/She stated that he/she would want to know that the condition of the patient was worsening. The RNC stated that there was discussion about the treatment of the rash and other interventions. The RNC stated that there was failure to discuss the refusal of bedbaths and would expect notes to be in the IDG summary.

Based on record review, home visit observation, and interview, the hospice provider failed to ensure that all procedures had physician orders in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 05/19/2025 with a terminal diagnosis of squamous cell carcinoma of skin of scalp and neck (a type of skin cancer that arises from squamous cells, which are found in the outer layer of the skin). The patient lived at home with adult family members.Review of the initial plan of care (POC) dated 05/19/2025 to 08/16/2025 showed:- A diagnosis of long-term current use of anticoagulants (a medication that helps prevent blood clots from forming or growing larger);- The patient was taking warfarin sodium (an anticoagulant medication that requires monitoring of the patient’s International Normalized Ratio (INR- a blood test that measures how long it takes for your blood to clot); - The patient was at risk for bleeding due to anticoagulant therapy; and- The POC failed to include orders for INRs.  Review of the skilled nurse (SN) visit noted dated 05/20/2025 showed: “INR 1.8 - coordinated with “named physician” with no change in Coumadin (warfarin) dose at this time, and to check INR next week on Tuesday 05/27/25 and then 2 weeks from then on Wednesday, 06/11/2025.” Review of the SN visit noted dated 06/24/2025 showed: “INR 1.7- new order received to increase coumadin to 3 mg MON/WED/FRI and 6 mg SUN/TUES/THUR/SAT” (3 mg (milligram) Monday, Wednesday and Friday and 6 mg on Sunday, Tuesday, Thursday and Saturday). Observation on 06/24/2025 at 10:50 AM, showed RN-A performed a fingerstick to obtain an INR on the patient.  Further review of the clinical record failed to show physician orders for the INRs obtained on 05/20/2025 and 06/24/2025. During an interview on 06/25/2025 at 10:24 AM, the registered nurse coordinator stated that:- The nurse had documented in the nurses notes and they were sent in teams (an instant messaging system that is currently not part of the hospice’s chart or signed by the physician);- The 06/17/2025 SN visit note did show a new order was received, but did not show when to repeat the INR; and- He/she was unable to find written orders for the INRs obtained on 05/20/2025 and 06/24/2025.

Based on policy review, respite facility contract review, record review, and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite discharge in one of one respite record review (Record/Patient #6). This deficient practice has the potential to affect the coordination of respite care for all the provider’s patients. --- Findings included: Review of the provider’s policy titled, “Levels of Care- Inpatient Respite Care,” revised December 2022, failed to show that the hospice provider would ensure a copy of the discharge summary would be provided to the hospice at the time of respite discharge. Review of the provider’s respite facility contract, dated September 9th 2021, showed that a copy of the inpatient clinical record shall be available to hospice at the time of discharge. RECORD/PATIENT #6:Review of the clinical record showed, in part:- The patient was admitted to hospice services on 02/25/2025 with a terminal diagnosis of malignant neoplasm of the rectum (cancer that develops in the rectum, the last section of the large intestine); - The patient resided at home with his/her spouse; - The patient began inpatient respite services on 03/10/2025 for caregiver relief (The spouse had a scheduled procedure and passed away from a heart attack during the patient’s respite stay);- The patient completed five consecutive days of respite care;- The patient was discharged from inpatient respite on 03/15/2025; and- The clinical record failed to contain a discharge summary from the respite facility.  During an interview on 06/25/2025 at 10:11 AM, the administrator stated that:- They (hospice provider) did not obtain a copy of the discharge summary from the inpatient respite provider; and- He/she was aware that a copy of the discharge summary should have been obtained.

Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure the long-term care facility (LTCF) patient record contained a copy of all required hospice documents in one of two home visit observations of patients that resided in a LTCF (Record/Patient #3). This deficient practice has the potential to affect all the provider's patients who reside in a LTCF. --- Findings included: Review of the hospice provider's policy titled, "Hospice Care for Nursing Facility Residents-Coordination of Services," reviewed “August 2022”, showed in part, the following information is provided to the facility:- The Hospice election form;- The instructions how to access the hospice’s 24 hour on-call system; and- Any advance directives specific to each patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/04/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided in a LTCF. Observation on 06/24/2025 at 3:00 PM, when reviewing the facility binder with the facility’s charge nurse showed the binder failed to contain:- The hospice election form;- The instructions how to access the hospice’s 24-hour on-call system; and- The advance directives specific to the patient.   During an interview on 06/25/2025, at 10:15 AM, the administrator stated that he/she:- Would expect the hospice election form, the instructions how to access the hospice’s 24-hour on-call system, and the advance directives specific to the patient to be included in the binder; and- The binders had just been cleaned out, “and apparently too well”.

Based on review of Missouri state statutes, policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was performed prior to first patient contact, in one of five employee files reviewed (E-1). This deficient practice has the potential to affect all the patients served by the provider. 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 provider’s duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence.  If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states.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 provider’s policy titled, “Criminal Background Checks,” dated 07/2019, showed in part the following:- Criminal background checks are required for all associates (including volunteers) and contracted staff who provide direct patient care or who have access to patient records; - Written agreements with contracted entities include a provision that a criminal background check must be provided for any contracted staff providing services for the hospice or having access to patient records; - Offers of employment contain a written statement that employment is conditional upon acceptable results from the criminal background check; and - The criminal background check is obtained prior to the date of employment for all States that the individual has lived or worked in for the past years required by state and federal regulations. --- EMPLOYEE #1:Review of the employee file showed the following:- Date of hire: 04/01/2024; and- The employee file failed to include a CBC as of 06/24/2025. During an interview on 06/24/2025 at 3:50 PM, the administrator stated that the provider failed to complete a CBC prior to E-1’s date of hire.  The administrator corrected the CBC onsite on 06/24/2025.

Based on policy review and record review the agency failed to ensure complete nursing pain assessments were performed and/or documented in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential for unmet pain management needs. Findings included: Review of the agency's policy titled "Pain and Symptom Management" (policy number: REG.P02) dated revised May 2022, showed: -The IDT (interdisciplinary team) ensures that patients receive effective pain management and symptom control from the hospice for the terminal illness and its related conditions; -The patient's pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the RN (registered nurse) Case Manager or designee; -The comprehensive assessment includes standardized tools to assess patient pain; -Pain is reassessed during every home visit, any time a patient states their pain level has changed, and whenever pain medications or dosages are changed; and -This information (pain assessment) is documented in the patient's clinical record. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 07/27/2022, under respite level of care (temporary care provided in a professional care facility such as a hospital, hospice inpatient care facility, or nursing home. This allows the caregiver to get rest), with an admitting terminal diagnosis of CHF (Congestive heart failure- a chronic condition in which the heart doesn't pump blood as well as it should). Review of the SN (skilled nurse) visit note pain assessment dated 7/29/2022 showed: -Nonverbal pain cues with restlessness marked; -Narcotic pain medication necessary marked yes; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; and -Comments showed a FLACC score (pain score assessment utilized for nonverbal patients) of 1 (the FLACC score ranges from 0-10 in severity). Review of the SN visit note pain assessment dated 8/01/2022 showed: -Narcotic pain medication necessary with responses yes and no each left blank; and -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day. Review of the SN visit note pain assessment dated 8/02/2022 showed: -Narcotic pain medication necessary with responses yes and no each left blank; and -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day. Review of the SN visit note pain assessment dated 8/03/2022 showed: -Nonverbal pain cues with moaning, crying and restlessness marked; -Narcotic pain medication necessary marked no; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; and -Comments showed denies pain (although previously had been using FLACC score for nonverbal pain assessment). Review of the SN visit note pain assessment dated 8/04/2022 showed: -Narcotic pain medication necessary with responses yes and no each left blank, although did answer this question under comments; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; and -Comments showed resting in his/her chair, facility staff nurse has not had to give him/her pain meds today and FLACC score of 0. Review of the SN visit note pain assessment dated 8/05/2022 showed: -Narcotic pain medication necessary marked yes; and -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day. Review of the SN visit note pain assessment dated 8/06/2022 showed: -Narcotic pain medication necessary marked yes; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; and -Is patient satisfied with pain control marked yes (although previously had been using FLACC score for nonverbal pain assessment). Review of the SN visit note pain assessment dated 8/08/2022 showed: -Nonverbal pain cues with grimacing and guarding marked; -Narcotic pain medication necessary marked yes; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; -Comments left blank; and -A FLACC score failed to be documented. Review of the SN visit note pain assessment dated 8/09/2022 showed: -Nonverbal pain cues with restlessness marked; -Narcotic pain medication necessary with responses yes and no each left blank; -How often is medication needed with all of the following options left unmarked: never, less than daily, at least daily and multiples times per day; -Comments showed facility staff nurse administered morphine (narcotic pain medication) around 1330 and encouraged to use Zyprexa (medication used to improve mood, thoughts, and behaviors) if he/she continues to be restless and thrashing; and -A FLACC score failed to be documented. The agency failed to ensure the patient's above pain assessments were completed and/or documented.

Based on agency policy review, record review, and interview, the agency failed to ensure that each patient and the primary caregiver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in two (Records/Patients #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care," revised November 2021, showed that: - The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient; and - Each patient and their primary caregiver(s) receive education and training from the hospice as appropriate to their responsibilities for the care and services provided in the plan of care. RECORD/PATIENT #2: Review of clinical record showed that the patient was admitted to hospice services on 05/04/2022 with a terminal diagnosis of Congestive Heart Failure (a disorder where the heart muscle doesn't pump blood as well as it should), and an open wound on the coccyx. Review of Physician orders on 05/04/22 showed: -Oxygen at 1-5 liters per minute (LPM) for comfort as needed (PRN); and -Wound care to coccyx skin care- cleanse with foam perineal cleanser, pat dry, apply small amount of aloe vista skin protective ointment, then mepilex (absorbant foam dressing) sacral boarder dressing. Change every 2-3 days and as needed. Review of the initial nursing assessment dated 05/04/2022, showed: -Indwelling urinary catheter (a tube inserted into the bladder to allow the bladder to drain), size 16 French inserted on 05/04/2022; -The patient has an oxygen concentrator (a device that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream) in his/her room to use as needed for shortness of air (SOA); -The patient does have a pressure ulcer (wound caused by pressure) 0.4 centimeter (cm) by 0.4 cm by 0.1 cm to his/her coccyx as noted per hospital record; and -The patient has a mepilex dressing intact on his/her coccyx that was placed on 08/03/2022 in the hospital and that dressing was not removed during the visit. The initial nursing assessment dated 05/04/2022, failed to show: -Documentation that education was provided regarding urinary catheter, care of catheter, or when to call agency with concerns; -Documentation of oxygen concentrator or portable tank safety and precautions; and -Documentation of coccyx wound care and when to call hospice agency with concerns. Review of the nursing visits failed to show teaching to the family/caregiver regarding catheter care, oxygen use and safety, and no teaching related to wound concerns. During an interview on 08/16/2022 at 2:50 PM, the clinical manager stated that the expectation is for the patient and caregiver education to be documented at each visit until competency is established. RECORD/PATIENT #3: Review of the care plan dated 05/24/2022 to 08/15/2022, showed: - Patient admitted to hospice with diagnoses of chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breath), dependence on supplemental oxygen (oxygen therapy used to help keep organs and tissues oxygenated), abnormal weight loss (losing more weight than is considered healthy), and edema (swelling caused by excess fluid trapped in the body's tissues); - Registered Nurse to provide instruction to patient and/or caregiver regarding dyspnea treatment plan, and signs and symptoms of dyspnea; - Registered Nurse to provide instruction to patient and/or caregiver regarding treatment plan for poor appetite and expected disease related loss of appetite; - Registered Nurse to provide instruction to patient and/or caregiver regarding edema treatment plan and signs and symptoms of edema concerns; and - Registered Nurse, Medical Social Worker, and Chaplain/Spiritual Counselor, to provide instruction to patient and/or caregiver regarding signs and symptoms of imminent death and treatment to ensure comfort during the dying process; Review of the clinical record failed to show documentation of education provided to the patient and/or caregiver. During an interview on 08/17/2022 at 11:30 AM, the clinical manager stated that he/she was unable to find documentation of education provided.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care (POC) in, but not limited to, one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care", dated revised November 2021 showed: -The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDT in collaboration with the patient's attending physician (if any), and, if appropriate, the patient and/or their representative; and -The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial comprehensive assessment and updated assessments of the patient. Review of the agency's policy titled, "Comprehensive Assessment - Content," revised 2022, showed in part "the IDT uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver". Review of agency's policy titled, "Comprehensive Assessment- Patient Outcome Measures," revised 2022, showed: -The data elements related to selected outcome measures are an integral part of the comprehensive assessment and reassessment tools and are documented in a systematic and retrievable manner for each patient; and -The data collected from the patient's comprehensive assessment is used to provide individualized care planning, appropriate interventions and for the coordination of services for each patient. RECORD/PATIENT #2: Review of clinical record showed that the patient was admitted to hospice services on 05/04/2022 with a terminal diagnosis of Congestive Heart Failure (a disorder where the heart muscle doesn't pump blood as well as it should) and an open wound on the coccyx. Review of the skilled nurse comprehensive assessment dated 05/04/2022 showed a narrative note stating the patient had a 16 French indwelling urinary catheter (a tube inserted into the bladder to allow the bladder to drain) placed at the hospital. Review of skilled nurse assessment on 05/06/2022 showed patient had pain at a ten of ten [zero being no pain, ten being the worst] on the numeric pain scale. Review of physician order dated 08/5/2022 showed Coumadin (blood thinning medication) 6 mg (milligram) daily. Review of Medication profile dated 08/16/22 showed the following as needed pain medications: -Acetaminophen (pain reliever/fever reducer) tab 325 mg give 1-2 tabs every 6 hours for pain as needed; -Hydrocodone/Acetaminophen (Narcotic pain reliever) 5/325 mg give 1 tab every 6 hours as needed for pain; -Oxycodone Concentrate (narcotic pain reliever) 100mg/5ML (milliliters) give 0.25 ml sublingual every 4 hours for pain as needed; -Bio freeze gel 4% (topical pain reliever) apply to affected area every six hours as needed; and -Jantoven (blood thinning medication) 5.5 mg daily. Review of the POC and the care plan failed to show: -The patient was on Coumadin and Jantoven and what signs and symptoms to watch for and what to do if bleeding occurred; -The patient's as needed medications of Bio freeze, Acetaminophen, Hydrocodone-Acetaminophen, or Oxycodone, or any non-pharmacological interventions that would benefit the patient; -An acceptable level of pain; and -Documentation of catheter size, insertion or change date, or reason for catheter use. During an interview on 08/17/2022 at approximately 4:25 PM, the administrator stated that he/she would expect the documentation of interventions to be documented in the skilled nurse note as well as the updated POC in a narrative note to reflect any changes needed when asked what the expectations for an individualized care plan documentation was for the agency.

Based on record review and interview, the hospice failed to ensure the plan of care included, medical supplies and appliances necessary to meet the needs of the patient in one (Record/Patient #2) of five full records reviewed. The deficient practice has the potential to affect all patients on service with the hospice. Findings included: RECORD/PATIENT #2: Review of clinical record showed that the patient was admitted to hospice services on 05/04/2022 with a terminal diagnosis of Congestive Heart Failure (a disorder where the heart muscle doesn't pump blood as well as it should), and an open wound on the coccyx. Review of physician order dated 05/04/22 showed for wound care to the coccyx- cleanse with perineal cleanser, pat dry, apply small amount of aloe vista skin protective ointment, then mepilex (absorbent foam dressing) sacral boarder dressing. Change every 2-3 days and as needed. Review of signed plan of care dated 05/04/22 shows current problem urinary catheter (a tube inserted into the bladder to allow the bladder to drain). Review initial/comprehensive dated 05/04/2022 showed indwelling urinary catheter size 16 French inserted on 05/04/2022. Review of the Initial Plan of Care (POC) dated 05/04/2022 and subsequent updated POCs dated between 05/04/2022-08/15/2022 showed: -No documentation hospice provided catheter supplies; and -No documentation hospice provided wound care supplies. During an interview on 08/16/22 at 9:55 AM, the administrator stated it was the expectation that any supplies hospice provides are to be included on the POC. When asked how the hospice determined what supplies are provided by the hospice he/she stated "We supply it, no matter what."

Based on policy review and clinical record review, the hospice failed to ensure the interdisciplinary team (IDT) updated/revised the POC (plan of care), discussed/documented all changes in the patient/family needs or concerns, and assessed/documented progress toward goals/outcomes in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to adversely affect coordination of care for all patients served by the agency. Findings included: Review of the agency's policy titled, "Comprehensive assessment of the Patient" (Policy Number: REG.C45), dated revised February 2022 showed: -"Named Hospice" conducts and documents a patient specific comprehensive assessment that identifies the patient's need for hospice care, including medical, nursing, psychosocial, emotional and spiritual care; and -The patient's comprehensive assessment is updated at a minimum every 15 days of more frequently if needed by the patient. Review of the agency's policy titled, "Comprehensive assessment-Content" (Policy Number: REG.C50), dated revised February 2022 showed the IDT uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver. Review of the agency's policy titled, "Comprehensive assessment - Updates" (Policy Number: REG.C65), dated reviewed February 2022 showed "Named Hospice's" IDT updates the comprehensive assessment and reassess the patient's response to care on a regular basis. Review of the agency's policy titled, "Plan of Care" (Policy Number: REG.P25), dated revised November 2021 showed: -The care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDT in collaboration with the patient's attending physician (if any), and, if appropriate, the patient and/or their representative; -The patient's plan of care specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial comprehensive assessment and updated assessments of the patient; -Efforts to involve the patient's attending physician (if there is one) in the development and updating of the hospice plan of care and the results of those efforts are documented in the patient's clinical record; -The plan of care is reviewed and updated by the IDT every 14 days or more frequently if needed; -Revisions to the plan of care are based on information from the patient's updated comprehensive assessment and the patient's progress toward outcomes specified in the plan; and -Reviews and changes to the plan of care are documented and communicated to members of the IDT team. Review of the agency's policy titled, "Plan of Care- Content" (Policy Number: REG.P30), dated reviewed November 2021 showed: -The plan of care reflects patient and family goals and interventions that are based on the problems identified in the initial comprehensive and updated assessments; -The plan of care includes, but is not limited to: * Interventions to manage pain and symptoms; * A detailed statement of the scope and frequency of services necessary to meet the specific needs of the patient; * Measurable outcomes and anticipated from implementing and coordinating the plan of care; * Drugs and treatment necessary to meet the needs of the patient; and * Medical supplies, equipment, and appliances necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 07/27/2022, under respite level of care (temporary care provided in a professional care facility such as a hospital, hospice inpatient care facility, or nursing home. This allows the caregiver to get rest), with an admitting terminal diagnosis of CHF (Congestive heart failure- a chronic condition in which the heart doesn't pump blood as well as it should). Review of the Physician Certification of Terminal Illness, dated 07/27/2022, showed the patient sustained a fall leading to an ER (emergency room) visit on 7/20/2022 resulting in a pubic rami fracture (broken pelvis). The patient appears to have had multiple hospitalization episodes due to congestive heart failure recently and worsening generalized weakness. Review of the Initial POC dated 7/27/2022 to 10/24/2022 showed: - Edema (swelling caused by excess fluid trapped in the body's tissue), weakness and change in level of consciousness marked under worsening symptoms; - Palliative Performance Scale (is a tool to assess performance status) marked PPS Score 30% with totally bedbound marked, unable to do any activity; - Narrative note showed he/she is to remain on bedrest due to extreme pain and anxiety with movement; and - Problem/Current Issues with urinary catheter (a tube inserted into the bladder to allow the bladder to drain) marked. Review of the SN (skilled nurse) visit note dated 07/27/2022 showed: -Catheter marked yes, type marked indwelling, size and date inserted left blank, and comments: date of insertion unknown; -Edema scale section with assessment detail options were all left blank/unmarked; -Activity level sections all left blank/unmarked; and -Medical equipment needs section, with hospital bed with specialty mattress and bedside table marked. Review of the SN visit note date 08/01/2022 showed: -Activity level section marked with up as tolerated; -Narrative note showed foley catheter in place, per NP (nurse practitioner) ok to remove and do a voiding trial. POA (power of attorney) said the patient failed (a voiding trial) in the hospital and they had a difficult time replacing catheter so the POA would like to leave it in until it needs to be changed in a couple weeks; -Edema scale section with assessment detail options were all left blank/unmarked; and -Medical equipment needs section showed wheelchair marked. Review of the SN visit note date 08/04/2022 showed: -Activity level left blank/unmarked; -Edema scale showed right and left foot with 3+, right and left ankle with 2+, right and left calf with 1+ edema; and -Narrative showed up in chair in the common area sleeping. Increased edema, feet elevated. Dependent in all ADLs (activities of daily living- daily self-care activities). Further review of the clinical record failed to show any physician notification in changes in edema or any physician orders for change in level of activity (to go from bedrest to up as tolerated). Review of the Interdisciplinary POC update summary dated 8/09/2022 showed: -Foley to remain in place per request because it was difficult to replace in hospital and the patient was unable to void (urinate) on their own, but failed to clarify if this was a permanent decision or if just until the catheter was due to be changed; -Up in BRODA chair (special reclining wheelchair) for meals (although had already been up in chair on 8/04/2022 without a physician order and/or updated POC to include change in level of activity; and -Interventions for, or mention of, increasing edema as noted in, but not limited to, SN visit note 08/04/2022 failed to be documented.

Based on agency policy review, record review, and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care in two (Records/Patients #1 and #3) in 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, "Physician Orders," revised April 2021, showed that: - Physician orders are obtained as needed and received from the physician within the time frames required by laws and regulations; and - Reason orders are obtained from physicians include, but are not limited to, change in visit frequency if not within the range specified in the patient's plan of care. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 07/27/2022, under respite level of care (temporary care provided in a professional care facility such as a hospital, hospice inpatient care facility, or nursing home. This allows the caregiver to get rest), with an admitting terminal diagnosis of CHF (Congestive heart failure- a chronic condition in which the heart doesn't pump blood as well as it should). Review of the initial plan of care dated 7/27/2022 to 10/24/2022 showed skilled nurse visits were to be daily and as needed. Review of the interdisciplinary plan of care update summary dated 08/09/2022 showed skilled nurse frequency one to two times weekly and as needed. Review of the clinical record showed: -The agency provided documented skilled nurse (SN) visits for 7/27/2022, 7/28/2022, 7/29/2022, 8/01/2022, 8/02/2022, 8/3/2022, 8/04/2022, 8/05/2022, 8/06/2022, 8/07/2022. 8/08/2022, 8/9/2022 and 8/12/2022; -The record failed to show documentation of skilled nurse visits on 7/30/2022 and 7/31/2022; and -The IDG (interdisciplinary group) failed to ensure skilled nurse visits were provided as ordered: daily from 7/27/2022 to 8/09/2022. During an interview on 08/17/2022 at 2:45 PM, after requesting SN visit notes for 7/30/2022 and 7/31/2022, the administrator stated that: -"Those are missing"; and -"I've given you everything we have". RECORD/PATIENT #3: Review of the IDG plan of care update, dated 07/05/2022, showed that: -SN visit frequency of 2 to 3 times per week and PRN (as needed); and -Concerns and plan interventions section had skilled nursing visits to increase to 3x (3 times) a week. Review of the clinical record showed: -SN visit was made on 07/06/2022; and -No other documentation of SN visits made. During an interview on 08/17/2022 at 11:30 AM, the clinical manager stated that: -SN visit made on 07/06/2022 at 1:16 PM; -No other SN visits were made in that week; -No documentation for missed visits; and -The patient was transitioning to a new case manager and may have been missed.

Based on agency policy review, home visit observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmissions of infections and communicable diseases were followed in one (Record/Patient #3) of three home visits conducted. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Infection Control-Hand Hygiene," reviewed April 2019, showed that: -Hand hygiene guidelines recommended by the Centers for Disease Control and the World Health Organization; -Hospices associates must wash hands: * Before touching a patient; * After any activity involving physical contact with a patient's immediate environment; and -Hands must be washed/sanitized regardless of whether or not gloves are used. RECORD/PATIENT #3: Observation on 08/16/2022, beginning at 10:45 AM, during the patient's home visit, showed the medical social worker (MSW): -Entered the home with only a laptop to chart visit note on; -No hand hygiene performed; -Sat on the patient's couch and completed an assessment of patient's social and emotional status; -Completed a medication review (touching the patient's medication bottles); -Handed the laptop to the patient to electronically sign for the visit being made; -No hand hygiene performed; and -Laptop not cleaned prior to leaving the patient's apartment. During an interview on 08/16/2022 at 11:30 AM, the MSW stated that: -He/she will use a barrier mat if a bag is taken into the visit; -If no bag is taken into the visit then the laptop and the patient's face sheet are the only items taken in; and -He/she did not take hand sanitizer into the visit but would disinfect at the car. During an interview on 08/17/2022 at 11:50 AM, the administrator stated that hand hygiene and equipment cleansing is expected to be done at the visit.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the registered nurse (RN) prepared complete written care instructions for the hospice aide in two (Records/Patients #1 and #2) of five full records with aide services. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of the agency's policy titled, "Hospice Aide Assignments and Duties," revised April 2019, showed the hospice aide must follow the patient's plan of care for completion of tasks assigned to the aide by the registered nurse. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 07/27/2022, under respite level of care (temporary care provided in a professional care facility such as a hospital, hospice inpatient care facility, or nursing home. This allows the caregiver to get rest), with an admitting terminal diagnosis of CHF (Congestive heart failure- a chronic condition in which the heart doesn't pump blood as well as it should). Review of the Hospice Aide/Homemaker assignment form dated 7/27/2022 failed to show the patient's level of activity participation (how much physical assistance was required) to complete personal care tasks assigned, such as bathing (bed bath was marked), dressing, oral hygiene etc.. Furthermore, the aide assignment sheet failed to list any instructions/safety precautions for activity tasks. All tasks listed: positioning, transfer, ambulation, exercise, gait belt and feeding were not marked (left blank). Observation on 08/16/2022 at 1:36 PM, during the home visit at the skilled nursing facility in which the patient resides, the patient was noted up in a wheelchair that offered reclining capabilities with a transfer sling (used when utilizing a mechanical lift for transfers) underneath the patient. RECORD/PATIENT #2: Review of clinical record showed that the patient was admitted to hospice services on 05/04/2022 with a terminal diagnosis of CHF and an open wound on the coccyx. Review of the Hospice Aide care plan dated 05/09/2020 failed to show guidance and tasks associated with the open wound on the coccyx, methods to assure the integrity of the dressing during personal care and bathing, or the actions needed to coordinate the patient's wound care after the personal care and bathing process was competed. Additionally, the care plan failed to instruct the aide on necessary precautions for safety for patients on medications (Jantoven,Coumadin), used in CHF, that thins blood, putting this patient at increased risk for bleeding or injury. During an interview on 08/16/22 at 12:08 PM, the administrator stated that it was his/her expectation for the aide care plan to address safety precautions for any patient on blood thinning medications. He/She also expects the patient's activity level would be listed on the care plan to identify any equipment they may need for safe ambulation and transfer.

Based on policy review, record review, and interview, the agency failed to provide services in accordance with current clinical practice guidelines and accepted standards of practice when they failed to follow their established policy regarding the provision of respite care services in one (Record/Patient #1) of 2 respite records reviewed. This deficient practice has the potential to adversely affect all the patients served by the hospice. Review of the policy titled "Levels of Care- Inpatient Respite Care" (Policy number REG.L35), dated revised January 2021 showed short-term inpatient respite care is available to patients and is provided in a contracted facility on an occasional basis for not more than 5 (five) consecutive days at a time. The inpatient respite level of care is not available to patients who reside in facilities. RECORD/PATIENT#1: Review of a recurring charges report supplied to the surveyor by the agency dated and printed on 8/15/2022 at 2:50:59 PM showed the patient: -Received respite care starting on 07/28/2022 and ending on 07/31/2022; -Received respite care again starting on 08/01/2022 and ending on 08/02/2022; and -Received respite care again starting on 08/02/2022 and ending on 08/06/2022. Review of the initial plan of care dated 07/27/2022-10/24/2022 showed level of care with respite care as the option marked. Review of a physician order dated 7/28/22 at 08:44 AM showed an order clarification: At time of admission patient's LOC (level of care) is respite for caregiver breakdown. Review of a physician order dated 8/02/22 at 4:00 PM showed an order for level of care change from routine home care to respite due to caregiver burnout. Review of the long term care facility's August 2022 physician order sheet provided to this surveyor by the facility's clinical manager of the unit the patient resided showed an admission date of 7/13/2022. Review of the "named hospital" general discharge note, dated 7/27/2022 showed: -The finalized discharge selection destination as a nursing facility and also included their address (the facility the patient was still residing in when the home visit observation was made on 08/16/2022); and -Home medical care- "Named hospice" (the same hospice providing care during the survey starting 08/15/2022 through 08/17/2022. During an interview on 08/17/2022 at 2:45 PM, when discussing respite and that you can't put a respite level of care on a patient who resides in a LTC (long term care) facility, the administrator stated "He/She didn't know this."

Based on record review, and interview, the agency failed to document a discharge summary in one (Record/Patient #6) of one revoked (Medicare beneficiary/representative chooses to no longer receive Medicare covered hospice benefits) record reviewed. This deficient practice has the potential to affect the post-hospice medical care of all the agency's live discharged patients. Findings included: RECORD/PATIENT #6: Review of the record showed the patient revoked hospice care on 08/01/2022, to return to Oklahoma with his/her family member. The record failed to include a discharge summary. During an interview on 08/17/2022 at approximately 2:45 PM, the clinical manager stated that no discharge summary was sent to a provider in Oklahoma. A discharge summary was sent to the hospice medical director who was the patient's attending physician.

Based on review of the written agreement for respite services, record review, and interview, the agency failed to obtain a discharge summary from the skilled nursing facility (SNF) that provided respite services (inpatient care for caregiver relief) for one (Record/Patient #8) of one patient record reviewed for respite care. This deficient practice has the potential to affect coordination of care for hospice patients who receive respite care. Findings included: Review of the written agreement for respite services with the SNF that provided Patient #8's respite care, showed the facility will make a copy of the inpatient clinical record available to the hospice at time of discharge. RECORD/PATIENT #8: Record review showed the patient received respite care from 05/18/2022 to 05/22/2022. The record failed to include a discharge summary for the respite stay. During an interview on 08/17/2022 at 11:15 AM, the administrator stated that they did not have a discharge summary from the facility. He/she agreed that the contract failed to state the discharge summary must be supplied to the hospice at discharge.

Based on contract review and interview, the agency failed to ensure the agreement with the Hospital included the requirement that they provide a home like atmosphere, space for private and family visiting, accommodations for family members to remain with patient throughout the night, space for family privacy after a patient's death, and for visitors at any hour, including infants and small children in one (Contract A) of one inpatient contract reviewed. This deficient practice has the potential to affect the inpatient needs for all patients served by the agency. Findings included: CONTRACT A: Review of the agency's contract for inpatient services with a contracted hospital dated 10/24/2019 failed to include: -The provision that the inpatient provider would provide a home like atmosphere; and -The provision to allow visitation at any hour including infants and small children. During an interview on 08/17/2022 at 11:15 AM, the administrator stated that he/she could not find the missing items.

Based on policy review, record review and interview the hospice failed to ensure coordination of responsibility for a foley catheter (a tube placed in the bladder to allow urine to drain) change between the hospice agency and the LTCF (long term care facility) as well as communicate a fluid restriction and a KerraFoam dressing (a gentle foam dressing used to treat wounds or add extra protection to prevent wounds from occurring) order in one (Record/Patient #1) of one record reviewed of patients that resided in a LTCF. This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. Review of the agency's policy titled, "Continuity of Care" (Policy Number: REG.C75), dated reviewed February 2022 showed: - "Named hospice" assures the continuity of care for the patient and caregiver(s) in the home, outpatient and inpatient settings; - All disciplines providing services to the patient/caregiver follow established communication mechanisms to ensure that services continue without interruption whenever there are changes to the patient's level of care or care setting; and - The clinical records of patients transferring to a different level of care or care setting contain detailed information that promotes continuity of care. Review of the agency's policy titled "Levels of Care-Inpatient Respite Care" (Policy Number REG.I.35 or REG.L (difficult to read printed copy), dated revised January 2021 showed: - The documentation of the patient's condition provided to the facility staff includes, but is not limited to, the following: *Hospice diagnosis, current med (medication), and treatment orders; * DNR (do not resuscitate) and advance directives if any; and * Current plan of care; and - The IDT (interdisciplinary team) continues to provide services to the patient/caregiver during the period of respite and re-evaluates and updates the comprehensive assessment and the plan of care at the time of discharge for the inpatient respite. RECORD/PATIENT #1: Review of the initial plan of care, dated 07/27/2022 to 10/24/2022, failed to show who was responsible (the hospice agency or the facility) for the monthly foley catheter changes and failed to show any orders for KerraFoam dressings to heels or any fluid restrictions. Review of the interdisciplinary plan of care update summary, dated 08/09/2022, failed to show who was responsible (the hospice agency or the facility) for the monthly foley catheter changes or any orders for KerraFoam dressing to heels or any fluid restriction. Review of the nursing facility's August physician order sheet: - Failed to show who was responsible for the foley catheter changes (the facility or the hospice agency); - A fluid restriction of 1800ml (milliliter) in 24 hours (that failed to be listed on the initial or updated plan of care); and - Apply KerraFoam dressing to bilateral heels every day (that failed to be listed on the initial or updated plan of care). Per interview conducted during observation, on 08/16/2022 at 2:30 PM the nursing facility clinical manager of the unit the patient resided in stated that: -The nursing facility staff communicate directly with the hospice staff to coordinate wound care, foley catheter changes, or other treatments related to the terminal illness; -We (the nursing facility staff) can see all the hospice information on the EMR (electronic medical record); and -This (the EMR) is difficult for me to navigate.