Every finding on record at Kansas City Hospice, Inc

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in one of three community patient records reviewed (Record/Patient #6). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed in part that:- The POC is based on the identified and expressed values, goals and needs of the patient/caregiver and is developed with professional guidance and support from the interdisciplinary team (IDT) while taking into consideration risk versus benefit and best evidence; and- The POC includes, but is not limited to, an initial and comprehensive, interdisciplinary assessment of the patient and caregiver; and the needs and goals expressed or identified by the patient/caregiver and developed with the guidance of the IDT. --- RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the updated POC, dated 02/17/2026, showed in part that:- The patient:  * Had steps in his/her home and needed assistance at times with ambulation;   * Had difficulty finding his/her words, forming words, when he/she tried to speak, the words made no sense and he/she could not find the correct pronunciation;   * Had a decreased appetite and was trying to eat two meals per day;   * Needed lots of continuing education on his/her pain medications, specifically when to take them. The nurse had educated the patient at every visit and with every phone call on how to take his/her pain medications; - The POC contained interventions related to pain management including:   * Collaboration with attending physician regarding pain medications, treatment, and care needs;   * Educate family in nonverbal expressions of pain;   * Instruct patient/caregivers on provider’s 24-hour contact numbers; and  * Teach medication  actions, side effects, and interactions; and- The POC contained, in part, the following medication orders:   * Dexamethasone (a medication used to reduce inflammation) daily;   * MS (morphine sulfate) Contin (an opioid pain medication) every 12 hours;  * Pepcid (used to treat itching) daily;   * Hydroxyzine (used to treat itching) as needed for itching; and  * Oxycodone (an opioid pain medication) as needed for pain. Observation and interview on 02/24/2026 at 1:00 PM: - This state agent (SA) asked the patient for his/her current medication list. The patient stated that he/she would like to have a list of his/her medications, and he/she had asked for a list on more than one occasion;- This SA then asked to look at the patient’s medication bottles, the patient’s spouse stated that he/she would be very happy to have someone look at the patient’s medications, and that he/she had not seen anyone look at the patient’s medication bottles for a long time; - The patient stated that he/she kept his/her daily medications in the hall closet, escorted this SA to the closet, and showed this SA bottles containing oxycodone, hydroxyzine, and MS Contin. The patient stated that he/she took one pill from each of the three bottles one time per day; - The patient stated that he/she kept all of his/her as needed medications in the bathroom medicine cabinet;  - The patient escorted this SA to the bathroom, and this SA observed the medication bottles in the bathroom medicine cabinet, and noted that prescription bottles for Pepcid and Dexamethasone were in the medicine cabinet in the patient’s bathroom; - This SA then asked the patient where he/she kept the comfort kit medications; - The patient stated that he/she kept them in the refrigerator, the patient escorted this SA to the kitchen and retrieved the comfort kit medication bag from the refrigerator;- The patient stated that he/she would like to get a medication list so he/she would know what medications he/she should be taking; and- He/she would be willing to use a medication planner, and no one had offered to assist him/her with one. During an interview on 02/25/2026 at 9:20 AM, registered nurse (RN)-2 stated that:- The patient and his/her spouse were both extremely confused at times; - He/she had taken and left two medication lists to the patient’s home; - He/she physically checked the patient’s medication bottles every visit;- The patient would move the bottles around his/her home between visits; they were never in the same place; - He/she sat with the patient on several occasions and explained the purpose of the medications to the patient; - The patient had a history of noncompliance with his/her medication regimen; - The patient had refused to use a medication planner in the past; - He/she thought they had discussed the patient’s noncompliance with his/her medication regimen at interdisciplinary group (IDG) meetings; - He/she was not worried about the patient’s safety with his/her medications because the patient had an adult child who checked on the patient. Review of the updated POC documentation for the dates of 01/13/2026, 01/20/2026, 01/31/2026, 02/03/2026, and 02/17/2026, showed in part that the POC failed to contain goals and interventions related to the patient’s ongoing noncompliance with his/her medication regimen including, but not limited to, the patient’s:- Refusal to use the medication planner offered by the skilled nurse;- Retain multiple medication lists;- Frequent relocation of his/her medication bottles; and - The adult child providing oversight for the patient’s medications. During an interview on 02/25/2026 at 11:02 AM, governing body appointee-1 and the RN coordinator stated that they would expect clinicians to check the patient’s medications at least weekly, modify the patient’s POC to reflect interventions and goals related to noncompliance, and the patient’s POC failed to contain goals and interventions related to the patient’s noncompliance with his/her medication regimen.

Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) contained measurable outcomes in three of three community patient records reviewed (Records/Patients #5, #6, and #7). This deficient practice has the potential to affect all the patients served by the provider.Findings included: Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed that goals for immediate needs will be identified and individualized. The policy failed to contain the verbiage that the patient goals would be measurable. --- RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 05/06/2024 with a terminal diagnosis of sequelae (aftereffects) of cerebral infarction (stroke). The patient had secondary diagnoses of dementia (decline in mental capacity), severe malnutrition, and abnormal weight loss. The patient resided in the private residence of his/her adult child. Review of the POC last updated 02/18/2026 showed in part the following patient goals:  - For patient and family, primary caregiver, maintain safe home environment, the goal failed to identify what elements evidenced a safe home environment; - For patient and family, increase quality of life, the goal failed to identify what elements evidenced quality of life; and- For the patient and family, primary caregiver, adjust to changing nutritional needs, the goal failed to identify what elements evidenced adjustment to changing nutritional needs. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the POC last updated 02/17/2026 showed in part the following patient goals:  - For minor child, patient, and family, increase quality of life, the goal failed to identify what elements evidenced increased quality of life; and - For patient and family, maintain desired nutrition/hydration level, the goal failed to identify what elements to evidenced the patient’s desired nutrition/hydration level. RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2023 with a terminal diagnosis of Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had secondary diagnoses of dementia (decline in mental capacity), history of falling. The patient resided in a skilled nursing facility (SNF). Review of the POC last updated 02/10/2026, showed in part the following patient goals: - For patient and family, facility staff, maintain optimal airway patency, the goal failed to identify what elements evidenced optimal airway patency; - For patient and family, facility staff achieve optimal fluid/electrolyte balance, the goal failed to identify what elements evidenced optimal fluid/electrolyte balance; and- Mental function will be managed effectively while on hospice, the goal failed to identify what elements evidenced effective management.  During an interview on 02/25/2026 at 11:39 AM, governing body appointee-1 and the registered nurse coordinator stated that the software allows for numerical rating of progress toward goals, and they were unable to locate measurable elements in the identified goals.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the drugs and treatments necessary to meet the needs of the patient in two of three community patient records reviewed (Records/Patients #6 and #7). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Care Planning Process,” dated 06/26/2024, showed that the POC would include the scope and frequency of services, medical equipment, supplies, medications and treatments needed to meet the patient/caregiver needs. --- RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 01/08/2026 with a terminal diagnosis of cancer of the pancreas. The patient had secondary diagnoses of anemia , nicotine dependence, and itching. The patient resided in his/her private residence with his/her spouse. Review of the interdisciplinary group (IDG) notes, dated 02/03/2026, showed that the registered dietician (RD) had made recommendations for the patient’s care and gave the skilled nurse written literature for the patient. Review of the updated POC and IDG notes, dated 02/17/2026, showed the document failed to contain information on the RD’s information and treatment recommendations for the patient’s care. During an interview on 02/25/2026 at 11:02 AM, governing body appointee (GBA)-1 and the registered nurse coordinator (RNC) stated that they would expect the POC to contain the drugs and treatments necessary to meet the needs of the patient, and they were unable to locate the RD’s recommendations in the patient’s POC.RECORD/PATIENT #7: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2023 with a terminal diagnosis of Parkinson’s disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient had secondary diagnoses of dementia (decline in mental capacity), history of falling. The patient resided in a skilled nursing facility (SNF). Observation on 02/24/2026 at 1:00 PM, review of the facility POC showed the patient had orders for: - Heat to right shoulder PRN (as needed) for pain; - A regular diet, thin consistency, fruit with all meals, a Super Donut (a donut that provides meaningful amounts of vitamins, minerals and protein)  with breakfast, Vanilla Thrive ice cream (a complete nutritional supplement) with lunch, and a house supplement (a dietary supplement) three times per day; - Elevate the head of bed/chair 30-45 degrees; and- TED (thrombo-embolic deterrent; support hose used to reduce the occurrence of blood clots) hose on bilateral lower extremities PRN. Review of the updated POC IDG notes, dated 02/10/2026, showed that the documentation failed to contain drugs and interventions to address the patient’s facility orders for heat to the right shoulder, fruit with all meals, Super Donut with breakfast, Vanilla Thrive ice cream  with lunch, house supplement  three times per day, elevation of the head of bed/chair 30-45 degrees, and the use of TED hose PRN. During an interview on 02/25/2026 at 11:30 AM, GBA-1 and the RNC stated that they would expect the hospice POC to reflect the drugs and treatments used at the SNF, and they were unable to locate the identified items on the hospice POC.

Based on policy review, record review, and interview, the hospice provider failed to ensure that care and services were provided in accordance with the plan of care (POC) when they failed to administer medication timely, in one of seven full records reviewed (Record/Patient #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, "Care Planning Process," revised 06/26/2024, showed in part: - The interdisciplinary team (IDT) establishes and maintains an individualized POC for each patient/caregiver admitted;- The POC includes but is not limited to medications needed to meet the patient/caregiver needs; and- Care Is provided in accordance with the POC. Review of the provider's policy titled, "Medication Administration," revised 08/23/2011, showed in part, medications must be given within one hour before or after the designated time. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 10/25/2025 with a terminal diagnosis of extranodal marginal zone B-cell lymphoma of mucosa associated with lymphoid tissue also known as MALT lymphoma (a rare, slow growing type of non-Hodgkin lymphoma (a blood cancer of the lymphatic system) that originates in B cells within mucosal tissues most commonly of the stomach but also in the lungs, thyroid or skin). The patient was admitted to inpatient hospice house B under general inpatient care (GIP- short term, Medicare covered level of care for managing acute pain or severe symptoms that cannot be treated at home or in other settings) care on 02/15/2026. Review of the physician’s POC signed by the physician 01/29/2026 showed:-  Assess medication effectiveness, duplication, interactions, side effects and regimen adherence; and-  Collaborate with the attending physician regarding pain medications, treatment and care needs. Review of the current medication profile showed methadone (an opioid used to treat chronic pain) 15 milligrams (mg) every eight hours at 5:00 AM, 1:00 PM, and 9:00 PM. Observation on 02/23/2026 at 5:48 PM, showed registered nurse (RN)-1 administered methadone 15 mg (more than three hours before it was scheduled to be administered). Per interview conducted during observation, RN-1 stated that:- The methadone should not have been given until 9:00 PM;- He/she had to notify the attending physician, the supervisor, and the patient’s power of attorney of the error; and- He/she had to write up an incident report. During an interview on 02/25/2026 at 9:25 AM, inpatient manager (IM)-1 stated that medications were to be given within one hour either before or after the time the medication was ordered to be given.

Based on policy review, record review, and interview, the hospice provider failed to ensure the written agreement specified how the skilled nursing facility/nursing facility (SNF/NF) or intermediate care facility of individuals with intellectual disabilities (ICF/IID) and the hospice would communicate with each other, and document such communications, to meet patient needs 24 hours a day. --- Findings included: Review of the provider's policy titled, “Written Agreements for Contracted Services,” updated 10/18/2024, showed the written agreement would address the following:- The role, if any, of the organization and the contracted individual in coordination, supervision, and evaluation of patient care provided; and - What documentation the provider required and the time frame for completing and submitting the documentation to the provider.  Review of the hospice contract titled, “Agreement for the Provision of Hospice Home Health Care Services to Residents of Nursing Home,” dated 06/28/2024, showed:- The facility would promptly notify the hospice in the event of changes in the patient’s condition; and- The facility would communicate with the hospice to ensure the needs of the patient are addressed and met 24 hours a day.The hospice contract failed to indicate how the facility and the Hospice would communicate with each other regarding patient care to ensure prompt communication.   During an interview, on 02/25/2026 at 1:30 PM, the hospice governing body appointee (GBA)-2 stated that the way they communicate with the nursing facilities had never been specified. It was assumed the nursing facility would call the phone numbers in the patient’s hospice files. GBA-2 stated the nursing facility also utilizes a documentation sheet in the patient file to let the hospice nurse know about the patient's needs.

Based on nationally recognized standards, observation, and interview the hospice inpatient provider failed to maintain a safe physical environment free of hazards. This deficient practice has the potential to affect all patients, staff, and visitors. --- Findings included:Review of  the National Fire Protection Association (NFPA) 1 Fire Code, 2012 edition showed 11.1.2: All electrical appliances, fixtures, equipment, or wiring shall be installed and maintained in accordance with NFPA 70, National Electrical Code. Review of the NFPA 70, 2011 edition showed 210.8 (B): Other Than Dwelling Units. All 125-volt, single phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel.(1) Bathrooms(2) Kitchens(3) Rooftops(4) Outdoors(5) Sinks - where receptacles are installed within 1.8 meters (6 ft) of the outside edge of the sink.(6) Indoor wet locations(7) Locker rooms with associated showering facilities(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used.*NFPA 70, 2011 edition - Definition of Dwelling Unit: Dwelling Unit. A single unit, providing complete and independent living facilities for one or more persons, including permanent provisions for living, sleeping, cooking, and sanitation. Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The manager’s office contained a small fish tank full of water plugged into a wall outlet that failed to be a ground fault circuit interrupter (GFCI) outlet (a GFCI outlet must be installed within six feet of water sources to prevent shock hazards);- The kitchen hallway contained a water and ice machine plugged into a wall outlet that failed to be a GFCI outlet;- The pod C nurse’s station contained an apartment sized refrigerator that was plugged into a power strip (power strips are not allowed for heavy electrical use items in patient care areas due to fire hazards); and- The pod D storage room contained a blanket warmer plugged into an extension cord (extension cords are not allowed for heavy electrical use items due to fire hazards). During an interview on 02/24/2026 at 10:08 AM, the maintenance supervisor confirmed that the fish tank and water and ice machine were not on GFCI outlets. During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect any electrical items with water to be on GFCI outlets and that power strips and extension cords should not be used for refrigerators and towel warmers.

Based on nationally-recognized standards, observation, record review, and interview the inpatient hospice provider failed to ensure that the sprinkler system was maintained according to National Fire Protection Association (NFPA) standards, that minimum clearance for sprinklers was maintained, and that the fire alarm system was tested semi-annually.  This deficient practice has the potential to affect all patients, staff, and visitors. --- Findings included: Review of the NFPA 25, 2011 edition, showed 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage (2) Corrosion (a sprinkler head that has experienced degradation due to a chemical reaction with the environment) (3) Physical damage (4) Loss of fluid in the glass bulb heat responsive element (5)*Loading (a sprinkler head that has an accumulation of dust, debris, paint, or other foreign materials on its surface) (6) Painting unless painted by the sprinkler manufacturer. Review of the NFPA 25, 2011 edition, showed 5.2.1.2 The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.Review of the NFPA 72, 2002 edition, showed 10.4 Testing. 10.4.2 Test Methods. 10.4.3 Testing Frequency. Testing shall be performed in accordance with the schedules in Table 10.4.3, except as modified in other paragraphs of 10.4.3, or more often if required by the authority having jurisdiction. 10.5 Maintenance. 10.5.1 Fire alarm system equipment shall be maintained in accordance with the manufacturer's instructions. 10.6.2 Maintenance, Inspection, and Testing Records. 10.6.2.1 Records shall be retained until the next test and for 1 year thereafter. Review of NFPA 72, 2010 edition, showed 14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter. Observation on 02/24/2026, beginning at 9:30 AM, at inpatient house-A, showed the following:- Room number six had a ¼-inch opening around the sprinkler head escutcheon creating an opening into the ceiling in the closet;- The outdoor seating area off B pod had one corroded sprinkler head and one sprinkler cover with rust that had water damage marks in the wood surrounding the sprinkler;- The supply closet on B pod had a sprinkler cover hanging down out of the ceiling tile;- The A pod courtyard (across from room number one) had two sprinkler covers hanging down one-inch on one side;- Room 17 had a missing escutcheon on one sprinkler head that created a 2-inch opening into the ceiling around the sprinkler;- The C pod hallway had a missing escutcheon on one sprinkler head outside of the manager’s office;- The manager’s office had a missing escutcheon on a sprinkler head;- Room 20 had a sprinkler head cover hanging down ¼-inch creating a 1/8-inch opening into the ceiling;- The closet between rooms 23 and 24 had a missing escutcheon on one sprinkler;- The C pod courtyard was missing three escutcheons from sprinkler heads;- The oxygen storage area had a loaded sprinkler head cover;- The D pod locker room had one missing escutcheon from a sprinkler head;- The D pod courtyard had one missing escutcheon from a sprinkler head;- Room 28 had 10 pillows in the closet shelf obstructing the sprinkler head;- Outside the front door was missing an escutcheon on one sprinkler head;- Between rooms seven and eight on the outside of the building the sprinkler head was loaded;- Between rooms nine and 10 on the outside of the building the sprinkler head was loaded;- Between rooms 11 and 12 on the outside of the building the sprinkler head was loaded;- Between rooms 14 and 15 on the outside of the building the sprinkler head was loaded;- Between rooms 16 and 17 on the outside of the building the sprinkler head was loaded;- Between rooms 22 and 23 on the outside of the building the escutcheon was missing from the sprinkler head; and- Between rooms 24 and 25 on the outside of the building the sprinkler head was loaded. Record review showed that a fire alarm inspection was completed on 05/08/2025 and no other inspections had been completed in 2025 or 2026 (fire alarm inspections are to be completed semi-annually). During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect sprinkler heads to be clean, covered, and in good working order.  Also stated that the sprinkler heads should not be blocked and that a minimum of 18-inches of clearance for the sprinkler head should be maintained at all times.  He/she would expect that the fire alarm system would be inspected twice per year.

Based on observation, record review, and interview the inpatient hospice provider failed to ensure that water temperatures were maintained at a safe level.  This deficient practice has the potential to affect all patients, staff, and visitors. --- Findings included: Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The water temperature in the bathroom sink in room four (Pod A) was 115 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 11 (Pod B) was 113 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 17 (Pod C) was 112.5 degrees Fahrenheit after running the hot water for three minutes;- The water temperature in the bathroom sink in room 27 (Pod D) was 113.5 degrees Fahrenheit after running the hot water for three minutes;- The water mixer for the facility was located in the mechanical room and was observed to be set to 118 degrees Fahrenheit at 11 AM; and- The recommended water temperature at plumbing fixtures should be maintained at or below 110 degrees Fahrenheit. Record review showed that water temperatures were tested weekly in various rooms in the facility and that the water temperatures for 2026 were as follows:- The water temperature on 01/08/2026 in room number one was 114.5 degrees Fahrenheit;- The water temperature on 01/15/2026 in room number 14 was 115.5 degrees Fahrenheit;- The water temperature on 01/23/2026 in room number eight was 115.0 degrees Fahrenheit;- The water temperature on 01/28/2026 in the spa was 117.5 degrees Fahrenheit;- The water temperature on 02/05/2026 in room number 25 was 114.5 degrees Fahrenheit;- The water temperature on 02/13/2026 in the Pod A kitchenette was 115.5 degrees Fahrenheit; and- The water temperature on 02/20/2026 in room number four was 115.5 degrees Fahrenheit. During an interview on 02/24/2026 at 11 AM, the maintenance supervisor stated that the water mixing valve is set to 118 degrees Fahrenheit and that he/she usually checks water temperatures in the afternoon.  He/she stated that he/she was unaware that water temperatures should be 110 degrees Fahrenheit or lower.

Based on policy review, observation, and interview the inpatient hospice provider failed to ensure that infection control standards were met while giving medications, that all intake and exhaust air ducts were maintained to prevent the entrance of dust, dirt, and other contaminating material into the facility, that all ceiling tiles were free of stains, and that all floors were free of dust.  This deficient practice has the potential to affect all patients, staff, and visitors. --- Findings included: Review of the provider’s policy titled, “Infusion,” revised 07/01/2011, showed in part,:- The named provider will follow the procedures that are recommended by the Infusion Nursing Society;- All other infusion procedures are referenced in the “Policies and Procedure for Infusion Nursing 3rd Edition” which is available in all office locations; and- Nursing staff are to review and follow these procedures when caring for patients with infusion therapy. Observation on 02/23/2026 at 5:00 PM, at inpatient house-A, showed the following:- Patient #13 received Haldol (a medication used for anxiety) 1 milligram (mg), diazepam (a medication used for anxiety) 5 mg, and morphine (a medication used for pain) 5 mg by an internal jugular (IJ) intravenous (IV) site (an IV site placed in the right side of the large vein of the neck for administering medications and IV fluids);- Licensed practical nurse (LPN)-C washed his/her hands, donned gloves, cleaned the IJ IV port with an alcohol pad and administered Haldol, administered a normal saline flush (a medication used to maintain the patency of an IJ or SQ (subcutaneous-given under the skin layers) IV catheter), administered morphine, administered a normal saline flush, administered diazepam, and administered a normal saline flush; and- LPN-C failed to clean the IJ IV port before administering the normal saline flushes or the Morphine and Diazepam. Observation on 02/23/2026 at 5:30 PM, at inpatient house-A, showed the following:- Patient #14 received morphine 10 mg by mouth and diazepam 2.5 mg by SQ infusion;- LPN-C washed his/her hands, donned gloves, administered the morphine by mouth, cleaned the SQ port with an alcohol wipe, administered a normal saline flush, administered the diazepam, and then administered a normal saline flush;- During the administration of the medications the patient’s SQ port laid on his/her shirt between medication administrations; and- LPN-C failed to clean the SQ port before administering the diazepam and the second normal saline flush. Observation on 02/24/2026 beginning at 9:30 AM, at inpatient house-A, showed the following:- The electrical closet in pod A had a thick covering of dust on the floor;- The conference room in pod A had two ceiling tiles with three dark colored stained areas;- The vent in the wall of the pod A kitchenette had a build-up of dust;- The family laundry room had a build-up of dust on the ceiling and on the water valves located in the wall behind the washer and dryer;- The electrical closet in pod C had a thick covering of dust on the floor;- The manager’s office had four ceiling tiles with dark colored stained areas;- The mechanical room had a thick covering of dust on the floor;- The public bathroom across from room 18 had a build-up of dust in the vent;- Room 21 had a build-up of dust in the vent in the bathroom;- Room 25 had one ceiling tile with a dark colored stain;- The dirty utility room was missing an electrical receptacle cover;- The staff breakroom had two ceiling tiles with dark colored stained areas and the lights, ceiling, and vent had dust build-up;- The kitchen hallway had two ceiling tiles with dark colored stained areas;- The volunteer office had two ceiling tiles with dark colored stained areas inside the room and two ceiling tiles with dark colored stained areas outside the room in the hallway; and- The paper storage area had one ceiling tile with a dark colored stained area. During an interview on 02/25/2026 beginning at 9:45 AM, the maintenance supervisor stated that he/she would expect that floors, vents, and ceiling tiles would be clean and stain free at all times.During an interview on 02/25/2026 beginning at 1:35 PM, the inpatient house-A director stated that he/she would expect the IJ and SQ ports to be cleaned with alcohol in between each medication and if the port touched the patient’s shirt.

Based on policy review, observation, and interview the hospice inpatient houses, A and B, failed to store food under sanitary conditions in the refrigerator in the kitchenettes.  The deficient practice has the potential to affect all patients/families/visitors at the inpatient houses. Findings included:Review of the provider's policy titled, "Hospice House Kitchenette," dated revised 03/02/2021, showed in part the following:-The hospice house provides kitchenettes which may be used by patients and/or visitors;-A microwave and refrigerator/freezer are provided for the patient and their visitors to use; and-Written instructions are on the refrigerator:  *All items placed in the refrigerator or freezer must be labeled and dated; and     * Items left in the refrigerator longer than one week or not labeled/dated will be disposed of by staff or volunteers.     Review of undated instructions posted on the kitchenette refrigerator showed:- All food must be stored in an enclosed container (such as a to-go box);- Containers must be bagged and tied, or folded closed in grocery or food delivery bag;- Bags must be labeled with the date. Labels are provided in the family kitchen; and- Outdated and unlabeled food will be removed and discarded per the normal routine. --- Observation on 02/24/2026 at 4:15 PM, at inpatient house-A, showed that the refrigerator in the pod C kitchenette at the hospice house contained a fast-food container labeled room 14 with a date of 02/17/2026 and multiple unlabeled and undated condiments.  The freezer contained homemade freezer pops without a label identifying a patient or visitor name or date.Observation on 02/24/2026 at 4:20 PM, at inpatient house-A, showed that the refrigerator in the pod B kitchenette at the hospice house contained a plastic container labeled as ham salad without a label identifying a patient or visitor name or date and a sandwich wrapped in aluminum foil without a label identifying a patient or visitor name or date.  The freezer contained a frozen drink without a label identifying a patient or visitor name or date. During an interview on 02/25/2026 beginning at 1:35 PM, the inpatient house-A director stated that:- He/she would expect that all items in the refrigerator and freezer would be labeled with a patient or visitor name as well as the date;- The refrigerator should be checked periodically; and- Items should be thrown away as necessary.  Observation on 02/23/26 at 2:20 PM, of the kitchenette located across from the living room area in inpatient house B during facility rounds, showed a clear plastic container containing lettuce and two plastic tubs inside of it with white gel-like substance (similar to ranch salad dressing) in the refrigerator. The container was not labeled with a patient’s or visitor name and was not dated. Observation on 02/24/2026 at 2:00 PM, of the kitchenette located across from the living room area in inpatient house B, showed the same plastic container in the refrigerator without a label identifying patient or visitor name and date. Observation on 02/25/2026 at 9:10 AM, of the kitchenette located across from the living room area in inpatient house B, showed the same plastic container in the refrigerator without a label identifying patient or visitor name and date. During an interview on 02/25/2026 at 9:15 AM, the Inpatient Manager (IM1), stated that:- He/she would have expected the salad to have been labeled and dated;- The families knew they were supposed to date and label their items;- The hospital staff (not the staff of the North inpatient hospice) are who cleaned the family kitchen (kitchenette); and- He/she knew the hospital environmental staff cleaned the kitchenette every day.

Based on policy review, record review, and interview, the hospice provider failed to ensure the nursing needs of the patient were met in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the hospice providers policy titled, "Nursing Services," revised 07/26/2011, showed: - All nursing care and services are provided by or under the supervision of a registered nurse; - Nursing services are offered to every patient/family/significant other/primary caregiver. These services include assessment of disease progression, related physical symptoms, prevention of symptoms, patient/family end-of life goals, psychosocial and spiritual adaptation; - A thorough nursing assessment is completed for all patients by a registered nurse; and - The RN (registered nurse) delegates duties according to the established plan of care (POC) when a LPN (license practical nurse) provides nursing care. An RN is always available to the LPN. Review of the hospice provider's policy titled, "Assessment Policy," dated 08/09/2011, showed: - To provide guidelines for the initial assessment of patients admitted to service and for reassessments of patients during ongoing care; - During each home visit, the clinician will re-evaluate the patient according to problems identified during the admission assessment and on the plan of care. Re-assessments should focus on the patient's response to care, changes in patient condition, and changes in the patient's care environment or support systems; and - Based on each re-assessment, the plan of care, including problems, interventions, and outcomes, will be reviewed and revised accordingly. RECORD/PATIENT #1: Review of the hospice providers answering service call log, dated 04/29/2023 at 11:01 AM, showed the long-term care facility (LTCF) messaged the hospice provider that the patient was having a rapid decline and needed someone there. Review of the LTCF nurses note, dated 04/29/2023 at 11:09 AM, showed the patient was having a rapid decline, acute changes in mental status; the patient was restless and moaning in pain. The patient cannot make his/her needs known. Pain medication was administered and not effective. The family and hospice was notified of the decline and hospice assured the LTCF that they would send someone to come and evaluate. Review of hospice provider's document titled, "clients comments", dated 04/29/23 at 12:07 PM, showed the registered nurse (RN) documented the LTCF nurse called and requested a visit related to end of life. Family at bedside and would like hospice to assess. The visit was assigned to a LPN at 11:15 AM. Review of the LPN clinical assessment note, dated 04/29/2023 at 1:44 PM (two hours and 43 minutes after the answering service received the call) showed the RN asked the LPN to visit the patient for a change in condition. The patients caregiver stated the patients speech was slower, the patients oxygen saturation (measured how much oxygen is carried by the hemoglobin in the blood) was at 74% (ideal blood oxygen level is between 95% and 100%) and the LPN placed oxygen at 2 liters/minute on the patient and the oxygen saturation increased to 94%. The patient had stage 5 kidney disease (kidneys are getting very close to failure or already have failed) and just finished an antibiotic for a urinary tract infection (UTI). The patients caregiver wanted to know what the patients confusion was from, and the LPN stated that he/she could not make a diagnosis, and it could be from just having an off day, and it could possibly be from kidney disease, urinary tract infection, and ";etcetera". The LPN met with the LCTF nurse and the patients caregiver, and suggested watching the patient closely, and if there was more of a decline to call the hospice provider back. Plan/follow-up action was; the family or daughter will call back if theres any more decline. Review of the documentation showed the LPN failed to assess the patients urinary system, mental/emotional/neurological status, and the hospice provider failed to ensure that a supervising registered nurse met the nursing needs of the patient. Review of the LTCF nurses note, dated 04/29/2023 at 9:52 PM, showed, at 3:30 PM the resident became agitated with air hunger and kept removing oxygen. The hospice was notified and the nurse (LPN) who had spent time with the patient earlier this day (04/29/2023) returned the call. The nurse (LPN) stated that he/she did not feel it was appropriate to increase the frequency of the lorazepam (anti-anxiety) .05 milligrams (mg) every four hours to every two hours and the hospice LPN stated that the hospice would be there tomorrow to do a visit. The patients family member came and witnessed the patients distress and called hospice as well, the LTCF nurse called hospice again after the patient had emesis while changing his/her brief. Review of the hospice providers answering service call log, dated 04/29/2023 at 3:46 PM, showed the LTCF would like to up the lorazepam, it is ordered for every four hours and the caller would like to give more frequently, caller would like to keep the patient more comfortable. Review of the hospice provider's document titled, ";update timesheet", dated 04/29/2023 at 3:49 PM to 3:56 PM, showed the LPN spoke to the nurse at the LTCF who was under the impression from the day shift nurse the patient was end of life and wondering if comfort medications could be increased for comfort. The LPN clarified that it is ";too early to tell" and asked the LTCF if the medications needed to be increased due to symptoms and he/she said, ";not necessarily I just gave him/her some dilaudid (used to treat moderate to severe pain) for pain". The LPN told the LTCF nurse if the medication needs adjusted for symptom control, the hospice would gladly take care of that. The LTCF said, ";fair enough, we will call if we need that." The LPN failed to assess the patient. Review of hospice provider's document titled, "clients comments", dated 04/29/2023 at 5:12 PM, showed the RN documented the LTCF nurse called and wanted to speak to the LPN who did the visit earlier today, the LPN was notified and will return call. The clinical record failed to show documentation of LPN contact to the LTCF related to this request. Review of the hospice providers answering service call log, dated 04/29/2023 at 5:56 PM, showed a message from the patients family member. The patient has not been comfortable at all and he/she is requesting medication, please call as soon as possible. Review of the hospice providers answering service call log, dated 04/29/2023 at 6:11 PM, showed the long-term care facility messaged; the patient is having increased emesis (the action or process of vomiting) and restlessness. Review of the hospice provider's document titled, "clients comments", dated 04/29/2023 at 7:10 PM, showed the RN documented the phone call from the patients family member asking if the hospice provider can reassess the patient. He/she feels the patient remains uncomfortable and continues to have restlessness; the RN assured him/her they were happy to do so, and a RN was assigned at 6:09 PM. Review of the clinical assessment, dated 04/29/2023 at 10:16 PM, (the RN visit was from 6:31 PM to 11:31 PM) showed RN A documented the patients immediate needs were to assess the patient for possible terminal restlessness, pain, anxiety, and near death awareness. Imminent death assessment showed irregular breathing patterns, minimally responsive, mottled/cool extremities, terminal congestion, terminal restlessness, and no oral intake. Pain ad (pain assessment in advanced dementia scale, a reliable assessment tool for dementia patients) five (moderate pain). The patient was having possible terminal restlessness, patients family member arrived with current nurse, patient is very restless, delirium, and hallucination. Started Haldol (used to treat terminal delirium, severe agitation in end-stage dementia), and Ativan (lorazepam). Telephone contact with the physician and received order for scheduled dilaudid, Haldol, and Ativan in addition to PRN (as needed). The medication was ordered stat to hospice pharmacy for stat delivery. The patients family member requested to have patient comfortable and is okay with hospice going up with comfort medications. Review of the hospice provider's document titled, "Quality Monitor", dated 05/05/2023, showed the patient's family member called to complain about his/her hospice experience. The patient was sitting up eating on 04/28/2023 and doing well and on Saturday (04/29/2023) something changed. The LTCF called the hospice provider and they made a visit. The patient was having terminal restlessness and his/her hospice provider's nurse gave the patient comfort medication and directions to the LTCF staff and left. The patient's terminal restlessness continued and the LTCF called the hospice again to get increased orders for comfort medications, the LTCF nurse let the family member know that he/she was denied the increase in orders. The patient's family member decided to call the hospice and beg for an increase in orders, again he/she was denied orders but the hospice provider sent a nurse out. The RN that was sent out, it took him/her three hours to get the patient comfortable. The investigation showed: The nurse was called out that day (04/29/2023) for a change in condition visit made at 12:37 PM. The writer (LPN) was asked to visit the patient for a change in condition by the RN. The patient was comfortable, when spoke to answered questions, and the patient's daughter stated the patient's speech is slower. The vital signs were within normal range, with the exception of the oxygen which was at 74 percent, so the writer put oxygen on at two liters and patient's oxygen increased to 94 percent. The patient has stage 5 kidney disease and just finished an antibiotic for UTI. The patient's family member wanted to know what the confusion was from but the writer let the family member know he/she could not make a diagnosis and it could have been from an off day. It could be from the kidney disease, UTI, etcetera. The patient was not eating or drinking much. The writer spoke with the LTCF nurse and the patient's family member and suggested just watching the patient closely and if there was more decline to call the hospice back, and the LTCF nurse agreed. At 3:57 PM, the LTCF called to speak to the nurse that made the visit and he/she was asked to call the LTCF back and there was no phone note related to this conversation. At 6:00 PM, the patient's family member called and wanted the patient reassessed and the RN was sent out and spent three hours with the patient and got the patient comfortable. During an interview on 06/06/2023 at 9:30 AM, the patients family member stated that on Saturday (04/29/2023) the patient was restless, slurring words, and confused. The LTCF called hospice and a nurse (LPN) arrived and gave him/her some comfort medication. A little later that afternoon the LTCF nurse on duty felt the comfort medications were not enough for the patient and called hospice to get them increased and his/her request was denied. The LTCF nurse was upset and could not provide the appropriate care the patient deserved. The family member had to call hospice him/herself to get someone else out to the LTCF to change the medication orders. The RN that came out had to spend approximately two to three hours to get the patient to a calm and restful place. The patient passed after just a few hours, on Sunday morning (04/30/2023). If he/she had not called hospice Saturday they would not have returned that day. He/she thought hospices main job was to provide comfort medication and care while dying. During an interview on 06/07/2023 at 12:07 PM, RN A stated that he/she arrived at the LTCF at 6:30 PM and the patient was ";totally distressed" and the main issue was respiratory distress. The patient had a death rattle and was almost unresponsive. The LTCF nurse was giving the patient Lorazepam (Ativan) 0.5 mg (milligram) and hydromorphone (dilaudid). RN A had added the Haldol, a medication for secretions, and increased the Ativan to 1 mg. The oxygen was not helping the patient. When the patient had a change in condition, the LTCF was good about calling the hospice provider. The patient's condition started approximately two hours prior to his/her visit and that is why the LTCF called the hospice provider to reassess the patient. The patient struggled to breath and it took the RN two hours to get the patient comfortable. During an interview on 06/07/2023 at 12:45 PM, the LTCF LPN stated that he/she received report from the LTCF day shift nurse who stated that the patient was already in distress and hospice had already been out earlier. He/she went to assess the patient (04/29/2023 at 3:30 PM), the patient was agitated and kept removing his/her oxygen, the patient was distressed and thrashing and he/she couldnt let the patient and patients daughter suffer. He/she talked to the hospice LPN on the phone and asked to increase the Ativan to every hour. He/she felt the LPN ";blew him/her off and didnt think the patient was actively dying". The LPN would not increase the medication or make a visit. The daughter had to end up calling the hospice provider. During an interview on 06/07/2023 beginning at 11:00 AM, the director of quality and regulatory compliance stated that the LPN did not need to follow up with the RN on 04/29/2023 at 1:44 PM due to the patient not having issues with comfort. He/she expects the LPN to practice within the LPN scope of practice for the state of Missouri. During an interview on 06/07/2023 at 11:00 AM, the director of clinical services (director of nursing) stated the LPN would call the RN if collaboration is needed. They try to send a nurse, chaplain or social worker if the patient has a change in condition.

Based on policy review and record review, the agency failed to maintain an accurate/updated medication profile in one (Record/Patient #9) of 12 patient 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, "Medication monitoring," revised date 04/18/17 showed: Ongoing patient medication monitoring will use a collaborative approach between the clinicians, physicians, pharmacists and patient/families/caregivers; The results of patient medication monitoring will be used to improve the patient's medication regimen; and The ongoing monitoring will occur in accordance with the established goals of therapy and be used to evaluate the continued use of a medication in this current regimen. RECORD/PATIENT #9: Review of the long term care facility (LTCF) physician order sheet dated February, 2023, during LTCF home visit beginning at 8:30 AM, showed the following discrepancies with the agency's medication profile: The agency's medication profile showed an order for Zoloft (to treat depression) 50 milligram (mg) daily, the LTCF medication profile showed this medication discontinued on 02/17/2023; The agency's medication profile failed to show Zoloft 100 mg daily, the LTCF medication profile showed Zoloft 100 mg, added on 02/17/2023; The agency's medication profile failed to show Thera tears (to treat dry eyes) four times a day as needed; and The LTCF's medication profile showed Thera tears for dry eye therapy four times a day as needed, may keep at bedside added on 02/17/2023. The findings were reviewed with the community registered nurse (RN) on 02/28/2023 ay 11:30 AM, during a nursing home visit, and the community RN concurred with the medication findings.

Based on policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in, but not limited to, four (Records/Patients #3, #5, #6 and #7) of twelve full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #3: Review of the comprehensive assessment, dated 02/23/2023 at 5:50 PM, showed: - The patient is uncomfortable because of pain and the pain is in the right side of abdomen; - Pain rated a three and pain scale used is zero to ten (zero representing no pain and ten representing the worst pain possible); - The pain occurs frequently and intermittently. The pain described as deep and aching, and dull and worst in the ";N/A", the suspected type of pain is visceral (pain related to the internal organs in the midline of the body); - The patient has facial grimacing, guarded movement, and wincing on movement; - The patient has a Foley catheter (a flexible tube that passes through the urethra and into the bladder to drain); - General inpatient admission to have continuous bladder irrigation (a medical procedure that flushes the bladder with sterile liquid); - The patient had four plus pitting edema (occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, an indentation will remain) to the ankles, calf and feet, and - A wound to the back right thigh and the wound type was a tear. The wound measured 1.5 centimeters (cm) in length, 1.0 cm in width, and 0.1 cm in depth. Review of the POC dated 02/25/2022, failed to show: - Specific interventions and goals related to abdominal pain; - Size of the Foley catheter; - Interventions and goals related to the wound to the back of the right thigh; and - Interventions and goals for pitting edema. During an interview on 03/01/2023 at 1:00 PM, the inpatient supervisor/registered nurse (RN) D stated that he/she would expect the POC to be individualized. No additional information was provided. Findings included: Review of the agency's policy titled, ";Clinical Documentation," dated 01/29/2016, showed the following: -Each patient/family served have a medical record, which reflects the patients physical, spiritual, and psychosocial status, physician orders and care provided from admission to discharge. The record should reflect observation/assessment and be objective/non-judgmental; -The inpatient house utilizes problem-oriented documentation, which supports the interdisciplinary team (same as interdisciplinary group; IDG) to create a problem list and formulate goals and interventions for these problems; and -Assessment is the analysis made based upon the information received through subjective and objective data. Review of the agency's policy titled, ";Care Planning Process," revised 12/01/2007, showed the following: - Care is provided in accordance with the plan; - The care plan starts upon referral, incorporating information available up to and at the time of admission and it on going throughout care of the patient/family. It is based on the identified and expressed values, goals and needs of the patient/family and his developed with professional guidance and support for decision making. It is reflected in the electronic record via documentation in the assessment forms and on the plan of care screen for the patient. The plan of care will be reviewed routinely by staff in relation to changes in the patient's/family's needs and at the IDT meetings; - The plan of care includes but is not limited to: *Prescribed and required medical equipment, supplies, medications, treatments and a level of care; *Doctor's orders demonstrating new, changed or d/c orders; - Each problem (PIO – problem, issue, opportunity) statement will be entered and modified (individualized) as necessary to make it patient specific; - Goals for immediate needs will be identified and modified (individualized) as well as setting whom the goal is intended for; - The interventions performed at the admission visit and any that need to be addressed at the next visit or ongoing will be indicated. Interventions performed and results of the intervention will be documented; - Care plans will be reviewed at each visit; and - Care plan changes are based on the evolving needs and preferences of the patient and family overtime. Treatment decisions are based on goals of care, assessment or risk and benefit, best evidence and patient/family preferences. RECORD/PATIENT #5: Review of the hospice initial certification showed the patient was admitted to hospice on 11/10/2022 for malignant neoplasm of left kidney, except renal pelvis. The disease is metastatic to bones. Review of the hospice recertification dated 02/08/2023 through 05/08/2023 showed: - Primary diagnosis of malignant neoplasm of left kidney (cancer of the kidney), except renal pelvis; - Coexisting diagnosis of cutaneous abscess (localized collection of pus in the skin and may occur on any skin surface) of groin, neoplasm related pain (acute) (chronic); and - The brief narrative statement documentation included he/she required a recent stay in inpatient hospice for pain crisis and has a Dilaudid (narcotic used to treat moderate to severe pain) patient controlled analgesic (PCA) in addition to fentanyl (narcotic for severe pain) patch and methadone (narcotic used to treat moderate to severe pain). He/she is unable to stand and bear weight to pivot to the bedside commode. He/she has a urinary catheter (a sterile tube placed in the bladder to drain urine) and colostomy (piece of colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) so that he/she does not have to turn to change disposable briefs. He/she has become more forgetful, with no recall of significant conversations and events. He/she has a draining cutaneous abscess in his/her left groin that is foul-smelling and requires daily dressing changes. Review of the physicians plan of care (POC), dated 02/08/2023 to 05/08/2023 showed in part, the following: - Pain: Fentanyl (narcotic for severe pain) patch every 72 hours, hydromorphone (narcotic to treat moderate to severe pain) via IV (intravenous therapy – soft, flexible tube placed inside a vein) pump every hour and every 15 minutes as needed, Methadone every eight hours, and Ibuprofen four times a day as needed; -Foley catheter: May insert Foley catheter (a sterile tube placed in the bladder to drain urine) as needed for retention, skin integrity impairment, or patient request. May use lidocaine jelly (numbing agent). Change every 30 days and as needed; - Ostomy/Ileostomy care: Change ostomy appliance weekly on Wednesday and as needed for leaking; - Other wound care orders daily as needed: Use adhesive remover to help with tape removal. Cleanse left lower quadrant (LLQ) drain site with wound cleaning spray and gauze. Use Cavilon advanced skin protectant. Place a split drain sponge around catheter, then pack gauze and ABD (abdominal gauze pad used to absorb discharges from abdominal and other heavily draining wounds) pad around the catheter to stabilize the tube and absorb leakage. Tape drain tube to secure it, and tape the gauze to hold in place. [LLQ drain site]; - The POC failed to be individualized as evidenced by no interventions for Foley catheter size or care, ostomy system as to one piece or two piece, no instructions to pre medicate with pain medication prior to care and no instructions to talk to the patient with each move/step to be performed with the patient, and no directions as to when to drain the LLQ drain site. During interview on 02/28/2023 at 12:05 PM, certified nurse assistant (CNA) A stated that the staff manage the patient pain by giving him/her medication before they turn him/her. This information was not on the plan of care (POC) but the charting shows what care CNA A is to provide. The nurse passes report in the morning to the CNA about everything he/she needs to know about the patient. The patient has a PICC line so they give the pain medications five minutes before care. The patient has a pump so the pain relief is quick. They turn the patient with two staff so it does not hurt as bad. The patient needs constant reassurance he/she will not fall when turned and explanation of everything you are doing before doing it. During interview on 02/28/2023 at 12:05 PM, registered nurse (RN) E was helping CNA A turn the patient and stated that the patients entire left side hurt, so they start with the right side. During observation on 02/28/2023 at 12:05 PM, CNA A raised the patients left leg (without explaining what he/she was doing) and the patient said ";ow" and the rest of the observation showed CNA A explaining everything he/she was going to do to the patient prior to doing it and the patient showed no evidence of pain. CNA A kept reassuring the patient would not fall when they turned her to her side. During an interview on 03/01/2023 at 3:05 PM, the inpatient supervisor/registered nurse (RN) D stated that he/she would expect the POC to be individualized including the catheter size, instructions to pre medicate the patient prior to cares, care regarding the colostomy and the drain in the left groin. RECORD/PATIENT #6: The patient was admitted to the hospice inpatient house from the hospital on 02/07/2023 with a terminal diagnosis of acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs cant get enough oxygen into the blood) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). The initial assessment, dated 02/07/2023, showed in part, the following: -The patient is covered in psoriasis (a condition in which skin cells build up and form scales and itchy, dry patches) type of rash; -Mental: Alert, oriented, restless, confused, slow thought process; -Respiratory: Cough, oxygen at 6 liters per nasal cannula, oxygen saturation 87% (normal = greater than 90%); -Incontinent of bowel and bladder; -Foley catheter connected to bedside drainage- draining urine; -Cardiovascular: diaphoresis (sweating), dyspnea (shortness of breath) at rest, orthopnea (cant breathe lying down), restlessness, and weakness; and -Edema pitting/severe to left ankle, left calf, left foot, hands, left leg, scrotum, right thigh, left thigh, and right thigh marked AKA (above the knee amputation). Review of the POC, dated 02/07/2023 showed in part, the following: -May insert Foley catheter (a sterile tube placed in the bladder to drain urine) as needed for retention, skin integrity impairment, or patient request. May use lidocaine jelly (numbing agent). Change every 30 days and as needed; -Oxygen at 2 liters per nasal cannula, titrate for comfort as needed for dyspnea; and -The POC failed to be individualized as evidenced by: no Foley catheter type or size, the liters of oxygen, no goals and interventions for the cardiovascular signs and symptoms (diaphoresis, dyspnea, orthopnea), no goals or interventions for the edema, and no goals or interventions for the psoriasis. During an interview on 02/28/2023 at 3:20 PM, the inpatient director stated that the POC should be individualized and agreed with the findings of the POC not being individualized.

Based on policy review, clinical record review, and interview, the provider failed to ensure the interdisciplinary group (IDG) reviewed, revised, and documented the individualized plan of care as frequently as the patients condition required in one (Record/Patient #2) of 12 clinical records reviewed. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the agency's policy titled, ";Care Planning Process," revised 12/01/2007, showed the following: - Care is provided in accordance with the plan; - The care plan starts upon referral, incorporating information available up to and at the time of admission and it on going throughout care of the patient/family. It is based on the identified and expressed values, goals and needs of the patient/family and his developed with professional guidance and support for decision making. It is reflected in the electronic record via documentation in the assessment forms and on the plan of care screen for the patient. The plan of care will be reviewed routinely by staff in relation to changes in the patient's/family's needs and at the interdisciplinary team meetings; - The plan of care includes but is not limited to: *Prescribed and required medical equipment, supplies, medications, treatments and a level of care; *Doctor's orders demonstrating new, changed or d/c orders; - Each problem (PIO-problem.issue,opportunity) statement will be entered and modified (individualized) as necessary to make it patient specific; - Goals for immediate needs will be identified and modified (individualized) as well as setting whom the goal is intended for; - The interventions performed at the admission visit and any that need to be addressed at the next visit or ongoing will be indicated. Interventions performed and results of the intervention will be documented; - Care plans will be reviewed at each visit; and - Care plan changes are based on the evolving needs and preferences of the patient and family overtime. Treatment decisions are based on goals of care, assessment or risk and benefit, best evidence and patient/family preferences. Review of the Plan of Care (POC) dated 02/14/2023 through 04/14/2023 showed, in part, the following: - May insert Foley catheter (a flexible tube that a clinician inserts into the bladder to drain urine) as needed for urinary retention, skin integrity impairment or patient request. Change every 30 days and PRN (as needed); - Clean left lower extremity with soap and water, pat dry. Apply skin prep to area covered with bandage, place a foam bandage with adhesive boarders. Change when bandage is wet from weeping; - Cleanse wound (order does not specify the wound location) with normal saline or wound cleanser, then apply hydrocolloid dressing; - Cleanse wound (order does not specify the wound location) with normal saline or wound cleanser, then apply hydrogel dressing; - The licensed practical nurse (LPN A) stated that the patient is no longer receiving any dressing changes; and - The POC failed to specify the size of catheter and the size of bulb that should be used. During an interview on 03/01/2023 at 2:02 PM, the nursing supervisor stated that the POC should have included the order for the size of the catheter and the bulb. He/she stated that the hydrocolloid and hydrogel dressing are a type of standing order. The dressing order should have stated a wound location if the dressings were needed but they should not be on the POC because the patient had not been receiving dressing changes. The POC should also have been updated to discontinue the left leg dressings since the patient was not receiving them.

Based on policy review, observation, and interview, the agency failed to ensure that accepted standards of practice to prevent the transmission of infections was followed in two (Records/Patients #8 and #9) 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," revised date 06/17/11 showed home care staff will consistently implement principles for maintaining clean equipment to prevent cross-contamination and assure asepsis (means clean). When staff use a computer laptop or IPAD, staff are to keep it on their lap or on a visibly clean, hard surface. If staff put it down, place it on a surface barrier. Staff are to clean the laptop or IPAD after each patient visit with disinfectant wipes. Review of the agency's undated standard of practice titled, "Hand Hygiene in Healthcare Settings," showed staff are to keep natural nail tips less than 1/4 inch long. RECORD/PATIENT #8: Observation on 02/27/2023 beginning at 3:30 PM, during the patient's home visit, showed the community medical social worker (MSW) D placed his/her laptop, tablet and phone on the patient's table. MSW D failed to use a barrier under this equipment. MSW D failed to use disinfectant wipes after the home visit to clean his/her equipment. During an interview immediately following the home visit, MSW D stated that he/she failed to use a barrier and failed to clean his/her equipment with disinfectant wipes. MSW D stated that he/she just used alcohol gel to clean the equipment. During an interview on 02/27/2023 at 4:15 PM, the director of clinical services/supervising registered nurse (RN) stated that he/she would expect the MSW to use a barrier to protect his/her equipment and would expect that the equipment be cleaned with disinfectant wipes. RECORD/PATIENT #9 Observation on 02/28/2023 at 8:30 AM, during a the patient's home visit at a long term care facility (LTCF), showed community RN with long (greater than 1/4 inch in length), uneven nails. During an interview immediately following the LTC visit, the community RN concurred that his/her nails were probably longer than a 1/4 inch and stated that he/she was unaware of the hospice policy and would do better with his/her nails. During an interview on 02/28/2023 at approximately 2:30 PM, the director of clinical services/supervising RN provided the agency policy for nails and no further information was provided.

Based on policy review, record review, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the long term care facility (LTCF) included the frequency of visits for the volunteer and failed to show accurate days of visit for the registered nurse (RN) and the hospice aide in one (Record/Patient #9) of one LTCF patient visit. This deficient practice has the potential to affect all patients residing in a LTCF. --- Findings included: Review of the agency's policy titled, "Coordinating Care with Nursing Facilities," revised date of 07/01/09, showed: Hospice agency staff members will collaborate and coordinate services with each LTCF provider; Hospice agency will utilize the Coordinated Task Plan as the tool to communicate services, frequency, changes and collaboration with the LTCF; The hospice agency case manager is responsible for ongoing coordination of the POC; The hospice staff member who initiates changes to POC is responsible for updating the coordinated task plan, getting it signed by the LTCF representative, and providing a copy of the updated document for hospice chart; Task plan instructions included: update any on-going schedule changes ; Circle the days of the week the hospice aide plans to visit; and List the frequency of visits planned for the volunteer or other staff. RECORD/PATIENT #9: Review of the clinical record, during LTCF home visit on 02/28/2023 beginning at 8:30 AM, showed the patient was admitted to hospice on 08/31/2021 with a terminal diagnosis of senile degeneration (decline) of brain. The patient resided in a LTCF. Review of the coordinated task POC failed to show the following: Hospice volunteer visits - community registered nurse (RN) stated that patient had been receiving weekly volunteer visit for over a month; Days of the week for the RN visits; and Days of the week for the hospice aide visits. During an interview at time of the LTCF visit, with the community RN, the RN concurred with the findings. During an interview on 02/28/2023 late afternoon, the administrator and the director of clinical services/supervising RN both concurred that the coordinated task plan needed to be completed in full, to coordinate hospice and LTCF patient care.

Based on policy review, record review, and home visit observation, the agency failed to ensure that the long term care facility (LTCF)'s hospice patient record contained a copy of all required hospice documents, in one (Record/Patient #9) of one LTCF record reviewed. This deficient practice has the potential to affect all patients that resided in a LTCF. --- Findings included: Review of the agency's policy titled, "LTCF - Hospice Admissions," revised 10/01/07, showed the agency would provide the following to the LTCF: A copy of the Consent Forms (Election form, Authorization to Release Information); A copy of the Initial Hospice Plan of Care (Hospice Orders); A copy of the Hospice medication sheet, indicating the medications that are covered by the agency; The do not resuscitate (DNR) order, if applicable; The Advanced Directive (DPOA);, if applicable; The most current physician order sheet; The most recent history and physical; The most recent lab/x-ray reports; The face sheet; and A list of all current medications. RECORD/PATIENT #9: Observation on 02/28/2023 beginning at 8:30 AM, during the patient's home visit, showed the hospice record maintained at the LTCF failed to contain the following required information: Current Plan of Care (POC); Advance directive; Physician certification and recertification; Current medication profile; and Hospice physician and attending physician orders. During an interview on 02/28/2023 at 11:25 AM, the director of clinical services/supervising registered nurse (RN) stated that all of those papers should be in the hospice binder.

Based on health standards, policy review, record review, observation, and interview, the agency failed to ensure accepted standards of practice to prevent the transmission of infections was followed in three (Records/Patients #2, #5 and #6) of seven inpatient records reviewed, and one additional inpatient (Record/Patient #13); and the agency failed to track and monitor urinary tract infections for one (Record/Patient #6) of seven inpatients records reviewed, . The deficient practice has the potential to affect all patients served by the inpatient setting. --- Findings included: Review of official reference: [Centers for Disease Control and Prevention] CDC (2022). Guidelines for Hand Hygiene in Healthcare Settings; Clinical indications for hand hygiene include:-Immediately before touching a patient;-After touching a patient or the patients immediate environment;-After contact with blood, body fluid, or contaminated surfaces; and-Immediately after gloves removed. Review of the agencys policy titled, ";Hand Hygiene," dated revised 03/11/2011, showed in part, the following:-All staff should perform frequent and appropriate hand hygiene as the most important practice for the prevention of transmission of infection to themselves or between patients; and-Hand hygiene should be done at the following times and whenever obviously soiled:• Before and after contact with a patient;• After contact with used or soiled material or equipment; and• After removing gloves. RECORD/PATIENT #6:Record review showed the patient was admitted to the hospice inpatient house on 02/07/2023 from the hospital. The patients start of care date was 02/07/2023 with a terminal diagnosis of acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. Develops when the lungs cant get enough oxygen into the blood) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). Review of physician order, dated 02/26/2023, showed: Start Cipro (antibiotic) 500 milligram (mg) by mouth twice a day for seven days for UTI. Observation on 02/28/2023, beginning at approximately 9:19 AM, RN C administered the patient Cipro 500 milligram by mouth. RN C informed the patient he/she was on the Cipro for a UTI. During an interview on 02/28/2023 at 11:30 AM, the director of quality and regulatory compliance stated that they could not find the patients name on the infection control log and wanted to know where SA had found information regarding the infection. SA informed of where he/she had found out about the infection. Observation on 02/28/2023, beginning at approximately 1:53 PM, during the inpatient care, showed the inpatient Registered Nurse (RN) C:-Entered the inpatients room to assist other staff with care, with gloved hands he/she held the patients right thigh area that had visible psoriatic lesions, some of which had been draining serous (clear or slightly yellow thin plasma) fluid;-RN C removed gloves in the patient room and failed to wash hands before leaving the room to retrieve more help and medication for the patient;-Upon reentering the patient room, RN C failed to wash hands before putting on gloves, he/she then went to the patients left side so he/she could administer medication via subcutaneous (SC-just beneath the skin) port;-RN C laid two syringes on top of sheet on top of patient as he/she wiped the SC port with an alcohol pad, he/she then administered the medication from the syringes;-RN C then removed those gloves and without washing or using hand sanitizer, put on a new pair of gloves and went to right side of bed and he/she went back to holding the patients right thigh; and-One of the other staff members asked for some barrier cream and RN C with same gloved hands that had been touching draining psoriatic lesions opened drawer to right of patient and reached into drawer and grabbed barrier cream and opened package for the other staff member. RECORD/PATIENT #13:Observation on 02/27/2023, beginning at approximately 4:50 PM, during a medication pass, showed the inpatient RN C:-In the medication room, draw up three medications and lay them down on the counter top. The syringes were not capped and did not have a barrier between them and the counter. RN B informed RN C he/she should put a cap on the syringes, so RN C capped the syringes prior to leaving the medication room;-RN C then went to computer cart in hall and grabbed a pair of gloves and put them on prior to going into the patients room. RN C failed to wash his/her hands prior to entering the patients room and prior to putting on gloves;-RN C laid the syringes on top of the patients blanket and then wipe intravenous (IV- in the vein) port with alcohol wipe, he/she then administered medications; and-RN C left room with same gloved hands and removed his/her gloves after exiting the room. During an interview on 02/28/2023 at 2:35 PM, RN C stated that he/she would wash hands after touching a contaminated surface and before and after gloving. During an interview on 02/28/2023 at 3:20 PM, the inpatient director stated the following:-Infection control training is conducted on general orientation, but doesnt go in depth;-He/she expects hand hygiene to be done before and after patient care, in between clean and dirty processes with patient care;-He/she would expect gloves to be removed and hands washed after touching psoriatic lesions and new gloves to be put on prior to reaching into a patients drawer to get supplies; -He/she would expect supplies to be placed on a clean surface or a barrier to be put down prior to placing supplies on them; and-He/she expected all inpatient infections to be logged and monitored. RECORD/PATIENT #5: Observation on 02/28/2023 beginning at 12:05 PM, showed certified nurse assistant (CNA) providing peri-care (cleaning the patients private areas around the genitals and anus), after the peri-care was completed, CNA A removed his/her gloves and donned new gloves, without washing his/her hands. He/she proceeded to pick up the Foley catheter tubing (a flexible tube that is passed through the urethra and into the bladder to drain urine) without washing his/her hands. During an interview immediately after the observation, CNA A said he/she should have washed his/her hands after providing peri-care and before touching the Foley catheter tubing. During an interview on 03/01/2023 at 1:00 PM, the inpatient supervisor/registered nurse (RN) D stated that he/she would expect staff to wash his/her hands after providing peri-care and before touching the Foley catheter tubing. RECORD/PATIENT #2: Observation of care performed by the certified nursing assistant showed the following: - He/she was observed in the hallway wearing gloves; - Wearing the gloves from the hallway, the C.N.A: * Entered the patients room and informed the patient and family that they were going to turn and reposition the patient; * Removed positioning pillows and blankets from patients bed; * Picked up the urinary catheter and placed it in the bed with the patient; * Turned and repositioned the patient with the RN; a * Opened cabinets in the room and removed a pillowcase and extra pillows and placed them under the patients head and arm. During an interview on 02/28/2023 at 11:44 AM, the clinical manager stated that he/she would expect the C.N.A to not wear gloves in the hallways. He/she stated that the expectation is to enter patient room, perform hand hygiene, then don gloves. The expectation is also to change gloves and perform hand hygiene between patient care tasks so the C.N.A should have removed gloves and performed hand hygiene prior to opening the cabinets in the room. Observation during lunch meal pass on 02/28/2023 at 12:00 PM showed the dietary employee: - Delivered a meal tray to a patients room; - Entered the kitchen and grabbed a towel; - Cleaned a water spill in the hallway floor; - Re-entered kitchen and failed to wash hands; - Picked up plate warming trays, touched plates, and warming table with soiled hands. During an interview on 02/28/2023 at 2:50 PM, the nursing supervisor stated that she would expect the dietary employee to wash their hands after delivering food trays and cleaning a spill on the floor prior to touching anything in the kitchen that would go to a patient.

Based on policy review, observation, and interview the hospice inpatient house failed to store food under sanitary conditions in the refrigerator in the kitchenette of the inpatient hospice house. The deficient practice has the potential to affect all patients/families/visitors at the inpatient house. --- Findings included: Review of the agency's policy titled, "Hospice House Kitchenette," dated revised 03/02/2021, showed in part, the following: -The hospice house provides kitchenettes which may be used by patients and/or visitors; -A microwave and refrigerator/freezer are provided for the patient and their visitors to use; -Written instructions are on the refrigerator: All items placed in the refrigerator or freezer must be labeled and dated; and Items left in the refrigerator longer than one week or not labeled/dated will be disposed of by staff or volunteers; and -Temperature of the refrigerator/freezer will be monitored by hospice house staff or volunteers. Observation on 02/27/2023 at 2:05 PM, showed the kitchenette refrigerator to be dirty with food spills, the temperature log for February was blank with no recorded refrigerator temperatures or freezer temperatures, and the food that was in the refrigerator was unlabeled and undated. During an interview on 02/27/2023 at 4:35 PM, the inpatient director stated that the temperature log should have been filled out for February, but that the person that usually completed that had been off and that all food in the refrigerator should have been labeled and dated. She stated that the agency was going to order a temperature stick for that refrigerator so the temperatures could be checked and monitored daily. Observation of kitchenette located adjacent to main entrance in south hospice house, during facility rounds, on 02/27/2023 at 3:00 PM showed a clear glass bowl containing a white gel-like substance in the refrigerator. The bowl was covered with clear plastic cling wrap. The bowl was not labeled with a patients or visitor name and was not dated. Observation of kitchenette located adjacent to main entrance on 02/28/2023 at 11:00 AM and at 4:30 PM showed the same bowl in the refrigerator without a label identifying patient or visitor name and date. During an interview on 02/28/2023 at 10:30 AM, the dietary employee stated that the provider informs patient visitors and family that food brought in from outside the facility may be stored in the kitchenettes and must be labeled with the patients name and the date. He/she stated that he/she checks all of the kitchenette refrigerators daily to ensure food is stored safely.

Based on policy review, record review, and interviews, the hospice failed to ensure care and services furnished to patients and their families followed an individualized plan of care in collaboration with primary caregiver in accordance with the patient's needs in one of three sampled cases (Record/Patient #1). The deficient practice has the potential to affect all hospice patients on service. --- Findings included: Review of the hospice policy titled "Care Planning Process", dated 12/01/2007 showed in part the following: Care plan changes are based on the evolving needs and preferences of the patient and family over time. Treatment decisions are based on goals of care, assessment of risk and benefit, and patient/family preferences; and All members of the Interdisciplinary Team can make changes to the plan of care based on the evolving needs (of the patient). RECORD/PATIENT #1: Review of the comprehensive assessment of the patient showed the following: The patient was 95 years old and was admitted to hospice on 07/08/22; and The patient had a terminal diagnosis of senile degeneration of the brain. Review of the updated nursing assessment from the patient's case manager, RN-A, dated 09/27/2022 showed: The patient had limited perception, was occasional moist, had occasional urinary incontinence, limited mobility, had fragile skin, and skin shear/friction as a possible problem; and The patient was alert, confused, had memory deficits, unsteady gait, and was dependent on others for all instrumental activities of daily living (IADLs) such as bathing dressing, and toileting. Review of the inpatient hospice nursing notes dated 09/28/2022 showed the following: The patient arrived to the hospice inpatient facility for a respite stay on 09/28/2022; The patient was confused, forgetful, required considerable assistance, and had fragile skin; The patient had a personal bed alarm to alert staff when he/she was mobile; and The patient refused to allow staff to assist with toileting, the patient was wearing an adult incontinence brief. Review of the inpatient hospice aide notes dated 09/29/2022 showed the patient was provided a new adult incontinence brief by hospice Aide-A. No bath or shower was documented. Review of the inpatient hospice nursing notes and hospice aide notes dated 09/30/2022, 10/01/2022 and 10/02/2022 showed the following: The patient refused to allow staff to provide hygiene care, bathing/showering, change his/her adult incontinence brief, or assist in the restroom with toileting; There was no documented communication from the hospice team with the family/primary caregiver during the 5 day respite stay regarding the problem that the patient refused to allow staff to provide hygiene care, change the adult incontinence brief, or assist with toileting. During interview with hospice Aide-A on 10/06/2022 at 12:59 PM, showed he/she stated the following: He/she worked at the inpatient hospice as an agency hospice aide, cared for the patient on one shift; The patient was in the inpatient facility for a respite stay; The patient was very modest, had dementia, Alzheimers, and had to be "firmly encouraged" to change his/her adult incontinence brief; He/she provided the patient a new brief, the brief in the patient bathroom supply was obviously too small "at least one size too small"; The brief was a "pull-up" type that had an elastic top; He/she passed along to the nurse that the patient needed larger briefs from the supply (it should be noted that this small brief remained on the patient for four days from 09/29/2022 through 10/02/2022) and He/she did not see or assess the condition of the patient's skin. During interviews on 10/06/2022 with all the nursing staff (11 staff members) that were assigned to care for the patient in the inpatient facility during the five day respite stay showed: The patient was confused, forgetful, required considerable assistance, and had fragile skin; The patient refused to allow staff to assist with toileting; The patient refused to have the his/her adult incontinence brief to changed; Did not assess or visualize the patient's skin, buttocks, or perineum; and Did not call the patient's family or caregiver to discuss the problem that the patient was refusing hygiene care, bathing, toileting assistance, or to have his/her adult brief changed. Review of time/date stamped photographs provided by the patient's primary caregiver showed on 10/02/2022 that the patient had red marks and open areas around his/her waist in the areas where an adult pull-up style brief elastic would be. During an interview with the patient's primary caregiver (PCG) on 10/07/2022 at 10:12 AM, he/she stated the following: The patient was placed into the inpatient facility for a five day respite stay from 09/28/2022 through 10/02/2022; The patient was wearing the same blouse when she was picked up and when she was admitted. The patient had six days or clothes on admission to the inpatient facility; When the patient was picked up on 10/02/2022 from the inpatient facility and back at home, it was found that the patient had odor, open areas and red marks around his/her waist "where the elastic had rolled up into a rope, the diaper was disintegrated and fell apart"; and The hospice did not call or contact her to inform or discuss the problem that the patient was refusing hygiene care, bathing, toileting assistance, or to have his/her adult brief changed.