Every finding on record at Lhcg Cxl VIII

Based on employee file review and interview, the hospice provider failed to ensure all new and existing staff received emergency preparedness (EP) training upon hire and every two years in, but not limited to, one of five employee files reviewed (Employee #4- (E-4)). This deficient practice has the potential to affect the safety of all the patients served by the provider. Findings included: --- EMPLOYEE #4: Review of the medical director’s personnel file showed the following:- The employee was hired on 06/01/2019; - There failed to be EP training documented upon hire; and- The provider failed to ensure E-4 received emergency preparedness training every two years thereafter.   During an interview on 04/30/2026 at 2:05 PM, LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator) stated that:- The last EP training documented on E-4 was in 2021 (five years ago); - He/she was unable to provide the state agent (SA) with the documentation of EP training on hire; and- EP training was completed on hire and every two years at a minimum.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider.Findings included:Review of the provider’s policy titled, “Monitoring Medications,” revised 11/01/2017, showed in part the following: - A drug regimen review was to be performed on all patients in conjunction with all comprehensive assessments; - All nurses were to participate in medication review and reconciliation throughout the benefit period; - The physician was to be contacted immediately if any discrepancies between agency (provider) information and patient medications were found; - All nurses who participated in the patient's care were responsible to assist in maintenance of accurate patient medication information throughout the tenure of care;  - Through a collaborative process the care team were to:*Compare medication information patients were currently taking with medications ordered for the patient in order to identify and resolve discrepancies; and*Have access to information about each patient in order to facilitate continuity of care. At a minimum, this information included; age, sex, current medications, diagnoses, co-morbidities, laboratory values, allergies, past sensitivities and as appropriate weight, height, or any other information for safe medication management. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice service on 04/10/2026 with a terminal diagnosis of moderate protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), abnormal weight loss, and dementia (decline in mental capacity). The patient resided in his/her home.Observation and interview, on 04/28/2026 at 11:55 AM, showed the following discrepancies between the provider’s medication profile provided on 04/27/2026 and the medications in the patient’s home: - Docusate sodium 100 milligrams (mg) oral capsule, two capsules once a day for constipation. The patient’s adult child (PAC) stated that he/she was not aware of the medication and it was not with the patient’s medications; - Haloperidol (used to treat nervous, emotional, and mental conditions) 1 mg tablet, once daily for nausea. The PAC stated that the patient did not need it and was not taking it;- Lisinopril 10 mg, once daily for hypertension. The PAC stated that the patient did not need it and was not taking it; - Lorazepam 0.5 mg, three times daily for anxiety. The PAC stated that the nurse told him/her to give the patient ½ a tablet (0.25 mg). He/she believed the patient did better when the patient took one tablet per day; - Metoprolol tartrate (used to treat high blood pressure) 25 mg, one tablet daily. The PAC stated that the nurse told them not to give it to the patient anymore; - Hyoscyamine 0.125 mg sublingual (under the tongue) one tablet, every two hours as needed for secretions. The PAC stated that the patient took one tablet at bedtime; and - The following supplements were in the home and were not listed on the provider’s medication list: *Fish Oil (used to support heart health) 1000 mg, once daily *Vitamin supplement (eye vitamin), once daily containing: Vitamins A,C,E, zinc and copper*Vitamin B-12 (used to support healthy nerve cells), 5000 micrograms (mcg), once daily. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice service on 01/07/2026 with a terminal diagnosis of chronic kidney disease, stage four (severe kidney damage). The patient resided in an assisted living facility (ALF).Observation on 04/28/2026 2:00 PM, showed a discrepancy between the provider’s medication profile provided to the state agent on 04/28/2026 and the medication administration record (MAR) provided by the ALF for Paroxetine (an antidepressant used to treat depression and anxiety disorder) 20 mg, one tablet at bedtime. The ALF's MAR listed the medication and the provider’s medication profile failed to show the medication.During an interview on 04/30/2026 at 11:05 AM, the administrator (known by the provider as executive director) stated that the registered nurses were to review the medications during every visit. He/she would have expected the nurse to realize the discrepancies in the medication list. He/she would expect the nurses to provide education to the patient and caregiver regarding medication administration.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice service on 02/25/2026 with a terminal diagnosis of malignant neoplasm of the duodenum (cancer of the intestines). The patient resided in a long-term care facility (LTCF).Observation on 04/29/2026 at 10:20 AM,  showed the following discrepancies between the provider’s current medication profile and the LTCF current medication orders:The LTCF's active April medication orders showed: - Tums, give two tablets by mouth four times a day for gastritis (irritation of the stomach’s lining) with an order date of 04/12/2026; and- Voltaren external gel 1%, apply to knee, and hip every 12 hours as needed for hip and knee related pain with an order date of 03/02/2026. The current provider’s medication list, dated printed 04/28/2026, failed to show the Tums or Voltaren gel.  During an interview on 04/30/2026, starting at 11:05 AM, the hospice administrator stated that:- Medication reconciliation was done weekly at a minimum;- The provider "taught it (medication reconciliation) to be done at every registered nurse (RN) visit"; and- All medications the patient was taking should be on the provider’s medication list. During an interview on 04/30/2026 at 11:30 AM, LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator)  stated that the provider preferred for facilities to print their medication list every visit.

Based on policy review, review of the bereavement coordinator manual, record review, and interview, the bereavement assessment results failed to be incorporated into the plan of care in one of six records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Bereavement Counseling,” revised 02/01/2022, showed in part the following:- After the initial bereavement risk assessment is completed, a bereavement plan of care was to be developed to address anticipatory bereavement/grief issues and implemented as needed;- Depending on the patient and family/caregiver needs identified in the bereavement risk assessment, the bereavement coordinator may have a need to contact and/or visit the patient and family/caregiver prior to death; and- The bereavement plan of care was to include specific goals and interventions that indicate the kind of bereavement services to be offered and the frequency of service delivery. Review of the provider's bereavement coordinator manual, dated January 2015, showed the program failed to include responses to the bereaved at moderate and high risk levels identified on the initial bereavement assessments (known to the provider as the pre-death risk assessment). --- RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 10/31/2025 with a terminal diagnosis of severe protein-calorie malnutrition and dementia (a decline in mental status). The patient resided in his/her adult child’s home. Review of the initial bereavement assessment, dated 10/31/2025, showed the bereaved as the adult child and a bereavement risk assessment level of 10 (based on the provider’s bereavement risk score guidance where zero to two = (equals) low, three to four = moderate, and five or greater = high). Review of the chaplain spiritual assessment, dated 11/04/2025, showed the patient yelled at the adult child for inviting the chaplain to the home. The adult child had a Christian faith and desired that his/her parent/patient would come to “know the Lord.” The chaplain and adult child agreed to not have the chaplain visit the home and to be available by phone. The chaplain would reevaluate later. Review of the record showed the provider failed to document attempts to follow-up with the adult child via phone. The provider failed to incorporate the high risk needs of the bereaved into the plan of care. During an interview on 04/29/2026 at 10:20 AM, the medical social worker (MSW) stated that if the bereavement risk assessment prior to death showed a high risk then the provider would offer more visits. The adult child declined social work and chaplain services. The provider did not have a protocol for high and moderate bereavement risk levels prior to the patient’s death. He/she stated that the chaplain sends out mailings and he/she did not mail the bereaved any materials. During an interview on 04/29/2026 at 11:45 AM, LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator) stated that he/she would expect the bereaved to be referred to the bereavement coordinator. The patient’s record failed to show interventions to address the bereaved adult child’s high bereavement risk assessment. During an interview on 04/302026 at 11:00 AM, the administrator stated that high risk bereavement prior to death would include ongoing assessment by nursing, offering outside resources, and utilizing the booklet titled, “Gone from Sight,” included in the admission packet.

Based on policy review, contract review, record review, on call message review, observation, and interview, the hospice provider failed to ensure:- The individualized written plan of care (POC)  was followed (L0543); -The POC included interventions to manage pain and symptoms (L0546); - A 24-hour pharmacy was in place to have timely access to medications 24 hours a day, seven days a week (L0549); - The interdisciplinary group (IDG) reviewed and revised the POC in response to changes in the patient's condition (L0552); and-  A system of communication and integration was developed and maintained, in accordance with the hospice’s own policies and procedures, to ensure that the IDG maintained responsibility for directing, coordinating, and supervising the care and services of a patient residing in a long-term care facility (LTCF) (L0554).The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, observation, and interview, the hospice provider failed to follow the individualized written plan of care (POC) in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all patients served by the provider.Findings included:Review of the provider’s policy titled, “Plan of Care,” revised 10/01/2024, showed in part, the POC included the following: - An individualized POC that included the specific needs, goals and desires of the patient; - The revised POC was to include the patient's progress toward outcomes and goals specified in the POC;- Services necessary for the palliation and management of the terminal illness and related conditions;- Interventions to manage pain and symptoms; - Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs;- Measurable outcomes anticipated from implementing and coordinating the POC;- It was the expectation that POC goals without specified time frames were to be accomplished throughout the course of care; - Drugs, biologicals and treatments necessary to meet the needs of the patient;- Durable medical equipment, medical supplies and appliances necessary to meet the needs of the patient; - Patient/family understanding, agreement and involvement with the POC;- Recognition of the patient/family's psychosocial, religious, and cultural variables and values;- Safety measures to protect against injury;- Nutritional requirements; and- Coordination of care. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice service on 04/10/2026 with a terminal diagnosis of moderate protein-calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), abnormal weight loss, and dementia (decline in mental capacity). The patient resided in his/her home.Review of the coordination notes skilled nurse entry, dated 04/15/2026, showed the following:- The adult child/caregiver was concerned with constipation (a problem passing stool); - Patient was not taking Colace (a brand-name stool softener that contains the active ingredient docusate sodium used to treat constipation); - The caregiver was educated on taking the Colace two capsules, two times a day as ordered and Miralax (a brand-name laxative that contains the active ingredient polyethylene glycol to treat constipation) two times a day; - An order was received to add senna (used to relieve occasional constipation) 8.6 milligrams (mg), two tablets two times a day; - Instructed patient to increase fluid and water intake; and - Caregiver verbalized understanding.Review of the interdisciplinary group (IDG) notes, dated 04/16/2026, showed a physician order to add bisacodyl suppository (used to treat constipation) 10 mg inserted rectally daily as needed for constipation. Administer if no bowel movement for three days.Review of the POC dated 04/16/2026, showed the patient’s problem of constipation with a goal to have relief from constipation within three days. Review of the skilled nurse (SN) visit note, dated 04/16/2026, showed the last date for a bowel movement was 04/15/2026.Review of the aide visit notes, dated 04/17/2026, 04/20/2026, 04/22/2026, and 04/24/2026 failed to show the aide asked the date of the patient’s last bowel movement.Review of the SN visit notes, dated 04/21/2026 and 04/24/2026, showed the last date for a bowel movement was not known (last recorded bowel movement was 04/15/2026, nine days prior to the 04/24/2026 visit).The nurse failed to ensure the POC was followed to monitor the patient’s bowel movements and to ensure the medication regimen for constipation was followed when a bowel movement had not occurred within three days.During an interview on 04/30/2026 at 11:00 AM, the administrator stated that the skilled nurse was to ask the patient/caregiver at each visit the date of the patient’s last bowel movement. The aide was to ask the date of the patient’s last bowel movement. The bowel movements were to be documented by the nurse and aide. The family sometimes documented patient information in a spiral notebook. He/she was not aware if the patient’s family kept a notebook. The documentation for the monitoring of the bowel movements was to be on the plan of care.RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice service on 02/18/2026 with a terminal diagnosis of interstitial pulmonary disease (An umbrella term for over 200 chronic lung conditions causing progressive scarring or inflammation of the lung tissue, making it difficult to breathe and transfer oxygen to the bloodstream). The patient resided in their home with their spouse.Review of the initial POC dated 02/18/2026 to 04/18/2026 showed:- Using aseptic (procedure used to reduce the number of microorganisms and prevent their spread) technique, insert 16 Fr (French) 10ML (milliliter) balloon Foley catheter (a sterile tube placed in the bladder to drain urine) to continuous bedside drainage related to retention. Catheter to be changed as needed for complications; and- The POC failed to include orders for nursing to fill the patient's medication planner. Review of a skilled nursing visit note dated 03/02/2026, showed the nurse filled the patient's medication planner for the next week. Review of a skilled nursing note dated 03/07/2026, showed the Foley catheter was changed and a 18 Fr coude (A specialized urinary catheter with a bent or curved tip designed to navigate obstructions in the urethra, such as strictures, false passages, or an enlarged prostate) was used. Further review of the clinical record failed to show:- A POC update or interim order for nursing to fill the medication planner; and- An order for an 18 Fr coude catheter. During an interview on 04/30/2026 at 12:20 PM, LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator), stated that there was no order for an 18 Fr coude catheter in the clinical record and he/she would expect the plan of care to be followed.

Based on policy review, record review, observation, and interview, the plan of care  failed to include interventions to manage pain and symptoms in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider.Findings included:Review of the provider’s policy titled, “Plan of Care (POC),” revised 10/01/2024, showed in part the POC included the following services necessary for the palliation and management of the terminal illness and related conditions:- Interventions to manage pain and symptoms; - A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs;- Measurable outcomes anticipated from implementing and coordinating the plan of care;- It is the expectation that plan of care goals without specified time frames will be accomplished throughout the course of care; and- Drugs, biologicals and treatments necessary to meet the needs of the patient. --- RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice service on 01/07/2026 with a terminal diagnosis of chronic kidney disease, stage four (severe kidney damage. The patient resided in an assisted living facility (ALF).Review of the skilled nurse (SN) initial assessment, dated 01/07/2026, showed the patient with 4 (four) plus (+) (most severe pitting) edema (swelling of the tissue) in bilateral (both sides of the body) feet and ankles.Review of the recertification clinical note, dated 03/16/2026, showed a need for hospice services due in part, to 4+ edema below the knees.Review of the recertification SN assessment, dated 03/16/2026, showed 3 (three) + pitting edema in feet and ankles.Review of the recertification POC, updated 03/25/2026, showed a goal for the patient to have decrease in edema as evidenced by less swelling within one week.Review of the SN visit notes, dated 04/02/2026, 04/08/2026, 04/16/2026, showed 4+ edema to both feet.Review of the SN visit note, dated 04/13/2026, showed unspecified pitting edema to ankles and feet.Review of the aide visit note, dated 04/16/2026, showed the patient was not in pain and the patient’s feet were “so swollen.” The registered nurse was made aware.Review of the SN visit note, dated 04/20/2026, showed 3+ edema to feet and ankles. Review of the SN visit note, dated 04/23/2026, showed unspecified bilateral edema pitting.Review of the SN visit note, dated 04/27/2026, failed to show status of bilateral feet and ankles.The POC failed to include interventions to reduce the patient’s edema.Observation on 04/28/2026 at 2:00 PM, showed the patient with his/her feet propped up sitting in a recliner. The patient’s feet had noticeable swelling.During an interview on 04/30/2026 at 11:30 AM, the administrator stated that he/she would have expected interventions to address the patient’s edema would be included in the plan of care.Prior to the survey exit on 04/30/2026, LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator) provided the state agent with a care plan, updated 04/30/2026, that showed a goal for the patient to have his/her edema assessed weekly and an intervention for the nurse to assess and monitor edema weekly with a goal of no greater than 2 (two)+.

Based on policy review, contract review, and interview, the hospice provider failed to have a 24-hour pharmacy in place to have timely access to medications 24 hours a day, seven days a week. This failure has a high potential for unmanaged symptoms. This deficient practice has the potential to affect all patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Pharmacy Services,” dated most recently revised 04/01/2015, showed in part, pharmacy services and pharmaceutical supplies will be made available 24 hours per day for hospice patients through direct purchase.Review of the hospice’s contracted pharmacy agreement showed the provider failed to have a 24-hour pharmacy contract/agreement.During an interview on 04/27/2026 at 11:37AM the administrator (known at the provider as the Executive Director) stated that:- The provider did not have a 24-hour pharmacy at that time;- The provider tried to be proactive in obtaining medications and “so far” it (the failure of having a 24-hour pharmacy)  had not presented a problem; and- He/she would be checking into what was available.

Based on policy review, record review, and interview, the hospice failed to ensure the interdisciplinary group (IDG) reviewed and revised the plan of care (POC) in response to changes in the patient's condition, including wound healing, in one of five full records reviewed (Record/Patient #3).  This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s titled policy, “Plan of Care,” dated most recently revised  10/01/2024, showed in part:- The IDG, in collaboration with the patient's attending physician, if any, will review, revise, and document the plan of care as frequently as the patient's condition changes, but no less frequently than every 15 calendar days; and- The revised POC must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the POC. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of arthritis due to other bacteria (septic arthritis of the vertebrae, is a rare but severe bacterial infection causing rapid joint destruction, intense back pain, and fever), and secondary sepsis (a life threatening infection in the blood stream) due to methicillin susceptible staphylococcus aureus (a bacteria). The patient currently resided in a long-term care facility (LTCF) with their spouse.Review of an updated IDG POCs dated 03/12/2026 and 03/26/2026 showed: perform wound care to right buttocks. Cleanse wound with wound cleanser, pat dry, and apply barrier cream. Wound care to be performed three times a week and as needed in conjunction with facility staff.Review of skilled nursing (SN) visit notes dated 03/17/2026, 03/20/2026, 03/25/2026, 03/31/2026, and 04/04/2026  showed the SN failed to document wound care. During an interview on 04/30/2026 at 2:27 PM, the administrator (known at the provider as the Executive Director) stated that:- The wound had healed on 11/12/2025 (the state agent (SA) was shown documentation on the computer to verify this); - The IDG failed to update the POC to reflect the change in the patient's wound; and- He/she would expect the POC to be updated when a wound heals.

Based on policy review, record review, on-call message review, and interview, the hospice provider failed to maintain a system of communication and integration, in accordance with the hospice’s own policies and procedures, to ensure that the interdisciplinary group maintained responsibility for directing, coordinating, and supervising the care and services provided in one of one focused on-call patient record reviewed (Record/Patient #10), and failed to maintain a contract with a pharmacy for the provision of medications 24 hours a day per the hospice's policy. This deficient practice has the potential to affect all patients served by the provider.Findings included:Review of the hospice policy titled, “Plan of Care (POC),” revised 10/01/2024, showed in part the following:- The POC must include all services necessary for the palliation and management of the terminal illness and related conditions including drugs, biologicals and treatments necessary to meet the needs of the patients; and- The registered nurse (RN) would coordinate the implementation of the initial POC for each patient.Review of the hospice policy titled, “Pharmacy Services,” revised 04/01/2015, showed that pharmacy services and supplies would be made available 24 hours per day for hospice patients through direct purchase. --- RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 04/14/2026 with a terminal diagnosis of unspecified severe protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in a long-term care facility (LTCF).Review of the hospice RN start of care note dated 04/14/2026, from 2:41 PM to 4:39 PM, showed:- The patient had facial grimacing with repositioning, pain was relieved with positioning, and no pain relief measures were performed during the visit;- Comfort medications were ordered at admission; and- The POC was reviewed with a named facility staff.Review of the hospice on-call messages for 04/14/2026 showed:- 8:59 PM, the LTCF nurse called the hospice provider and reported; no comfort meds in place yet, patient had increased respirations to 26 (breaths per minute), appeared uncomfortable when repositioned, no fever, not really verbal, please call with medication availability;- 9:04 PM, the information was relayed to the hospice on-call triage nurse; and- 9:04 PM the hospice on-call triage nurse stated that he/she would follow up and address the patient’s needs.Review of a late entry hospice coordination note, for 04/14/2026, dated 04/28/2026 (after the start of the survey) showed:- Late entry for 04/14/2026 regarding the on-call message received;- The hospice on-call nurse explained that the hospice admission nurse was still placing the patient into their system;- The hospice on-call nurse had confirmed with the hospice admission nurse that comfort medications of morphine (a strong narcotic medication used to treat severe pain and respiratory distress) 0.25 cubic centimeters (cc) every three (3) hours and lorazepam (medication used to treat anxiety and respiratory distress) 0.5 milligrams (mg) as needed every six (6) hours had been ordered and the hospice on-call nurse provided instructions for the LTCF nurse to pull (obtain) the necessary medication from the e-kit (emergency medication supply kit) at the LTCF; and- No additional information/documentation was found in the clinical record regarding coordination of the effectiveness of the interventions to manage the patient’s symptoms.Review of the hospice RN visit note, dated 04/15/2026, showed:- The patient grimaced and started breathing fast when touched or repositioned;- A narrative note that showed the facility had just received morphine and other comfort medications and a PRN (as needed) dose of morphine was given at 5:17 PM; and- New orders were obtained to change the morphine from as needed to a scheduled dose every 4 (four) hours.Review of the medication administration report (MAR) from the LTCF, printed 04/28/2026, showed:- An order, start date- 04/14/2026 at 9:15 PM, for morphine sulfate 20 mg/5 milliliters (ml) give 0.25 ml every two  hours as needed for severe pain/restlessness;- An order, start date- 04/14/2026 at 10:30 PM, for lorazepam 0.5 mg give 1 tablet every two hours as needed for anxiety; and- The MAR failed to show that any medications were administered to the patient on 04/14/2026, and the first dose documented for administration of morphine was 04/15/2026 at 5:17 PM.During an interview on 04/28/2026 at 3:45 PM, the LTCF administrator stated that morphine and lorazepam are medications that were available and could be removed and administered from the LTCF emergency medications.During an interview on 04/30/2026 at 2:15 PM, the hospice administrator (known at the provider as the Executive Director) agreed that the hospice on-call nurse should have followed up on 04/14/2026 to ensure the patient’s symptoms were managed.

Based on policy review, employee file review, and interview, the hospice provider failed to complete a timely initial skills competency, per their policy, in one of five employee files reviewed (E-2). This deficient practice has the potential to affect the provision of competent services for all the provider’s patients. Findings included: --- Review of the provider’s policy titled, “Evaluation and Competency Assessment,” dated most recently revised 11/01/2022, showed in part: - Purpose: to establish a procedure for staff performance evaluations and verification of competency, to provide excellent patient care, and to provide guidance for licensed staff performing clinical skills procedures in the home setting; and- All clinicians will demonstrate core competency skills before performing patient care independently and annually thereafter.  EMPLOYEE #2:Review of the spiritual counselor (chaplain) employee file showed the following:- Date of hire was 01/30/2024;- First patient contact was 03/05/2024 and- Initial skills competency was completed 04/04/2024 (30 days after the first patient contact). During an interview on 04/30/2026 at 2:05 PM,  LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator)  confirmed that the spiritual counselor’s initial skills competency was not done until 04/04/2024, and the first patient contact was 03/05/2024 (30 days prior).

Based on policy review, record review, and interview, the hospice provider failed to ensure the accuracy of documentation in, but not limited to, one of five full records reviewed (Record/Patients #3). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Hospice Medical Records,” dated most recently revised 10/01/2024 showed in part the following:-Purpose: to define the contents and requirements of the hospice medical record;- The hospice medical record shall contain any specific notes on care, treatment, or services; and- All entries recorded in the hospice record must be legible and accurate. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/30/2025 with a terminal diagnosis of arthritis due to other bacteria (septic arthritis of the vertebrae, is a rare but severe bacterial infection causing rapid joint destruction, intense back pain, and fever), and secondary sepsis (a life threatening infection in the blood stream) due to methicillin susceptible staphylococcus aureus (a bacteria). The patient currently resided in a long-term care facility (LTCF) with their spouse.Review of plan of care (POC) updates dated 03/12/2026, 03/26/2026, 04/09/2026 and 04/26/2026 each showed skilled nurse (SN) using aseptic (procedure used to reduce the number of microorganisms and prevent their spread) technique, insert 18 French (Fr) 30 milliliter (ml) balloon Foley catheter (a sterile tube placed in the bladder to drain urine) . Catheter to be changed every 30 days and as needed for complications. Review of a SN visit note dated 03/17/2026 showed indwelling Foley catheter, size 16 Fr, insertion date of 03/12/2026 (POC showed the size was 18 Fr).Review of a SN visit note dated 03/20/2026 showed indwelling Foley catheter, size 18 Fr, insertion date of 03/12/2026 (SN note dated 03/17/2026 showed the size was 16 Fr)Review of a SN visit note dated 03/25/2026 showed indwelling Foley catheter, size 18 Fr, insertion date of 03/12/2026.Review of a SN visit note dated 03/31/2026 showed indwelling Foley catheter, size 16 Fr, insertion date of 03/12/2026. (SN visit note dated 03/25/2026 showed 18Fr).Review of a SN visit note dated 04/08/2026 showed indwelling Foley catheter, size 16 Fr, insertion date of 03/12/2026.During an interview on 04/30/2026 at 12:15 PM, the administrator (known at the provider as the Executive Director) stated that:- It must have been documented wrong; and- He/she would expect accurate documentation.

Based on Missouri law review, employee file review, and interview, the hospice provider failed to ensure criminal background checks were performed in, but not limited to, one of five employee files reviewed (Employee #2 (E-2)).  This deficient practice has the potential to adversely affect services provided to all the hospice's patients. Findings included:Review of Section 192.2495.3, RSMo: 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). --- EMPLOYEE #2:Review of the spiritual counselor (chaplain) employee file showed the following:- Date of hire was 01/30/2024;- First patient contact was 03/05/2024 and- Criminal background check was completed 07/02/2024 (119 days after first patient contact). During an interview on 04/30/2026 at 2:05 PM,  LPN-A (licensed practical nurse; known at the provider as High Impact Quality Coordinator)  stated that criminal background checks should be done prior to first patient contact.

Based on policy review, volunteer tracking documentation review, and interview, the provider failed to ensure that volunteer services were provided in an amount that, at a minimum, equaled 5 percent of the total patient care hours of all paid hospice employees and contract staff. This deficient practice has the potential to affect volunteer services for all the provider's patients. --- Findings included: Review of the provider’s policy titled, "Volunteer Roles and Responsibilities," revised 11/01/2022, showed the hospice provider must maintain a volunteer staff sufficient to provide day to day administrative or direct patient care to a minimum of 5 percent of total patient care hours for paid hospice employees or contract staff.Review of the volunteer tracking documentation for 12 months (from August 2024 through August 2025), showed that the provider's administrative and direct patient care hours equaled 2.71 percent of the provider's total patient care hours of paid and contracted staff. The provider failed to meet the 5 percent requirement.During an interview on 09/03/2025 at 3:55 PM, the administrator (known by the provider as the executive director) stated that:- They did not have a volunteer coordinator;-They had one volunteer that worked two days a month in the office doing paperwork;- They were aware they fell short of meeting the 5 percent requirement;- The last time he/she saw the office volunteer was a few weeks ago; and- The provider had been actively recruiting volunteers.

Based on policy review, review of the hospice provider's admission packet, and interview the provider failed to ensure that all patients received verbal and written notice of their rights in a language that the patient understands. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Patient Rights and Responsibilities," revised 10/01/2020, showed in part, that the provider will make every attempt to present the information on rights and responsibilities in a language or through a medium that the patient or representative will understand. Review of the provider's admission packet failed to include the verbiage that the patient will receive verbal and written notice of their rights in advance of providing care in a language the patient understands. During an interview on 07/19/2023 beginning at 3:15 PM, the administrator stated that he/she would expect the correct information to be in the patient rights.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure that the medication profiles were accurate in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #4: Review of the hospice provider's medication report showed the patient was taking the following medications: -Hyoscyamine 0.125 mg/ml oral drops- take 1 drop every four hours as needed for terminal secretions; and -Morphine concentrate 100mg/5 ml- give 0.5ml for pain 5 or less and 1ml for pain above 5 every hour as needed. Review of the SNF medication report showed the patient was taking the following medications: -Hyoscyamine 0.125mg/ml- take 1 ml by mouth every four hours as needed for increased secretions; and -Morphine concentrate 20mg/ml- give 0.5 ml every hour as needed for pain, give 0.75 ml every hour as needed for pain, and give 1ml by mouth every hour as needed for pain. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated that he/she would expect the medications to match what was being given to the patient by the facility. Findings included: Review of the provider's policy titled, "Monitoring Medications," revised 11/01/2017, showed in part that: - A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments; - A Comprehensive Medication Review will be completed on admit and at every Interdisciplinary Group (IDG) meeting in conjunction with all comprehensive assessments; - Compare medication list to actual medications patient is taking. If the patient resides in a facility, compare medication list to the facility's medication administration record (MAR) rather than reviewing actual medications; - Review over-the-counter (OTC) medications, vitamins, herbs and herbal products, and creams and topical ointments and medical marijuana (in states where legalized) to identify issues such as: * Potential adverse effects and drug reactions; * Ineffective drug therapy; * Significant side effects; * Significant drug interactions; * Duplicate drug therapy; * Noncompliance with drug therapy; * Dosage errors; * Drug omissions; - All nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care; and - Compare medication information patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 03/28/2023 and resided in a long-term care facility (LTCF). Review of the LTCF's MAR dated 07/18/2023, showed the following: - On 05/16/2023 an order was received for Miralax (a medication used for constipation) 17 grams/scoop give one scoop by mouth every 24 hours as needed for constipation prevention. The hospice provider failed to include this medication on the client medication report for the patient; and - On 06/21/2023 an order was received for Zyrtec (a medication used for allergies) 10 milligrams (mg) one time per day for allergies/nasal drainage. The hospice provider failed to include this medication on the client medication report for the patient. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated that he/she would expect the medications to match what was being given to the patient by the facility. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 07/08/2022 and resided at home with a family member. Observation on 07/17/2023 beginning at 2:40 PM, showed the following discrepancies with the hospice client medication report: - The patient's caregiver stated that the patient had not been taking medical Marijuana (a medication used for pain and sleep) for two weeks. The hospice medication report showed that the patient was taking the medication scheduled at bedtime; - The patient's caregiver stated that the patient was taking Lorazepam (a medication used for anxiety) 0.5 mg every night at bedtime. The hospice medication report showed that the patient was taking the medication every 4 hours as needed; and - The patient's caregiver stated that the patient was taking Ipratropium 0.5 mg/Albuterol 3 mg (a medication used for shortness of breath and excessive secretions) one vial in the morning and one vial at bedtime. The hospice medication report showed that the patient was taking the medication every 4 hours as needed to keep secretions down. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated that the medications for this patient, "should continue to follow the as needed instructions and not be updated as they are being given due to the changing of the medication by the family."

Based on policy review, record review, and interview the provider failed to follow the plan of care in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #3: Review of the patient's medication profile within the POC dated prior to 06/14/2023 showed an order for oxygen at 5 liters per minute (lpm) continuously. Review of SN notes showed the following: -On 06/01/2023, the patient was on 6 lpm; -On 06/05/2023, the patient was on 7 lpm; -On 06/08/2023, the patient was on 6 lpm; and -On 06/12/2023, the patient was on 6 lpm. During an interview on 07/19/2023 at 3:30 PM, the hospice administrator stated that he/she would expect the order to be updated regarding the patient's needs. Findings included: Review of the provider's policy titled, "Physician Orders," revised 11/01/2021, showed in part, that services are provided according to the most recent orders updating the patient's plan of care. RECORD/PATIENT #2: - Review of the start of care dated 07/08/2022, showed that a suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder) change was ordered to be completed every 30 days and as needed; - Review of the skilled nurse's (SN) note dated 05/31/2023, showed that the suprapubic catheter was changed on 05/24/2023; and - Review of the SN note dated 07/12/2023, showed that the suprapubic catheter was changed on 07/12/2023 (49 days after the last change). During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated that he/she would expect the plan of care to be followed.

Based on nationally recognized standards, policy review, observation, and interview the hospice provider failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in one of four home visits completed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the provider's policy titled, "Hand Hygiene," dated 03/01/2021, showed: -Staff performs hand hygiene by handwashing with soap and water or using an alcohol based hand sanitizer before and after removing personal protective equipment (PPE) such as gloves, gowns, etc.; and -Staff are to change gloves during patient care if moving from a contaminated body site to a clean body site. Review of the provider's policy titled, "Home Care Bag Protocol Job Aid," dated 08/13/2015, showed after entering the patient's home, staff are to place the bag on a clean, dry surface and a barrier placed between the bag and the surface. Do not hang bag on doorknobs. RECORD/PATIENT #4: Observation on 07/18/2023 at 10:00 AM, during the patient's home visit, showed Registered Nurse (RN) A entered the patient's room and hung his/her bag off the patient's wheelchair. RN A then set the bag on a barrier on the patients bedside table. RN A put on gloves and removed patient's soiled brief and discarded it. RN A then opened a new brief and put it under the patient. RN A then cleaned the peri-area and discarded the wipe used to clean. RN A then put a medicated cream on the patient's peri-area and fastened the new brief. RN A then removed and discarded his/her gloves. RN A failed to change gloves when switching from a soiled to clean site. During an interview on 07/19/2023 at 3:30 PM, the hospice administrator stated that he/she would expect gloves to be changed between soiled and clean body sites.

Based on policy review, record review, and interview the hospice provider failed to ensure that the physician was notified of changes in patient condition in three of five full records reviewed (Records/Patients #1, #2, and #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the hospice provider's policy titled, "Patient Reassessments," revised 07/01/2012, showed in part, that: - The nurse and other disciplines, as appropriate, and within their scope of practice will complete an assessment of the patient on each visit according to the patient's plan of care (POC); - Reassessment should focus on changes in patient condition; and - The hospice Medical Director and attending physician, if any, will be notified regarding any changes in medications, including over-the-counter medications, and/or any treatment/interventions that require physician approval. RECORD/PATIENT #1: Review of the clinical record showed the following: - The skilled nurse's (SN) note dated 06/20/2023, showed that the patient had a cough and abnormal lung sounds described as diminished (absent or decreased air sounds). A new medication order was received for Guaifenesin (a medication used for cough) 100 milligrams (mg) per 5 milliliters (mL) give 10 mL by mouth every 6 hours as needed for cough; - The SN note dated 06/30/2023, showed that the patient continued with a cough and abnormal lung sounds described as diminished; - The SN note dated 07/05/2023, showed that the patient continued with a cough with a small amount of tan and yellow sputum (the mucus that settles in the lower airways of the lungs when an infection or a chronic illness may be present) noted. No lung sounds were documented; - The SN note dated 07/11/2023, showed that the patient continued with a cough and abnormal lung sounds described as diminished; and - The hospice provider failed to notify the physician of continued changes in the patient's respiratory status. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated, "a new order for Guaifenesin was obtained on 06/20/2023 and the patient was discussed in interdisciplinary group (IDG) meeting on 06/30/2023 with the physician and no other notification was needed as the patient was getting better." RECORD/PATIENT #2: Review of the clinical record showed the following: - The SN note dated 06/07/2023, showed that the patient had a cough and abnormal lung sounds described as crackles (lung sounds that occur when the small air sacks in the lungs fill with fluid). The physician was notified and no new orders were received; - The SN note dated 06/14/2023, showed that the patient continued with a cough and abnormal lung sounds described as crackles, shortness of breath at rest was noted, and increased secretions. The patient's urine color was noted to be abnormal (described as straw colored) and cloudy (normal urine is pale yellow to amber in color and clear). The hospice provider failed to notify the physician of changes in the patient's condition; - The SN note dated 06/21/2023, showed the patient continued with a cough. No lung sounds were documented. The patient's urine was noted to contain sediment (normal urine does not contain sediment); - The SN note dated 06/28/2023, showed that the patient had clear lung sounds and no issues with his/her urine; - The IDG meeting note dated 06/30/2023, showed that the physician was notified that the patient had, "more coughing with food and fluid intake and coarse lung sounds and loose cough," and the changes in the patient's urine failed to be documented as discussed; - The SN note dated 07/06/2023, showed that the patient had a cough with a scant amount of sputum, cloudy urine, and a small fluid filled blister on the left side of the neck. The hospice provider failed to notify the physician of changes in the patient's condition; and - The SN note dated 07/12/2023, showed that the patient had abnormal lung sounds described as crackles and was using intermittent oxygen and inhalation treatments. The patient's urine was noted to be abnormal and described as straw colored and blood tinged and cloudy. The hospice provider failed to notify the physician of changes in the patient's respiratory status and urine description. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated that he/she would expect the physician to be notified of changes and, "the physician had been notified in IDG meetings." RECORD/PATIENT #5: Review of the clinical record showed the following: - The SN note dated 06/15/2023, showed that the patient had 2+ (a measurement of the amount of swelling) edema (swelling caused by excess fluid trapped in the body's tissues) in the bilateral legs, abnormal breath sounds described as diminished, and used his/her accessory muscles (an abnormal or labored breathing pattern) when breathing and an open area noted to the coccyx (tailbone) area of the body; - The SN note dated 06/19/2023, showed that the patient had a cough, dyspnea (difficult or labored breathing), abnormal lung sounds described as crackles, and used his/her accessory muscles when breathing; - The SN note dated 06/22/2023, showed that the patient had a cough, dyspnea, used his/her accessory muscles when breathing, and had abnormal lung sounds described as rhonchi (lung sounds that occur when there are secretions or an obstruction in the larger airway); - The SN note dated 06/26/2023, showed that the patient had a cough, dyspnea, used his/her accessory muscles when breathing, had abnormal lung sounds described as diminished, and had 2+ edema to the bilateral legs; and - The hospice provider failed to notify the physician of changes in the patient's condition. During an interview on 07/19/2023 beginning at 3:15 PM, the clinical manager stated, "he/she would expect that the physician would be notified of changes in the patient's condition, but this particular patient has conditions that require comfort medications for those conditions described and the patient does have frequent infections."

Based on policy review, record review, and interview the hospice provider failed to ensure all entries for the clinical record were complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice in two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Hospice Medical Record," dated 11/01/2021, showed for point of care users, clinical notes for all services the patient received shall be synchronized within 24 hours from the visit. RECORD/PATIENT #3: Review of the clinical record showed a social work visit completed on 06/12/2023 and documented on 06/16/2023. RECORD/PATIENT #4: Review of the clinical record showed: -A skilled nurse visit completed on 07/08/2023 and documented on 07/16/2023; -An aide visit completed on 07/07/2023 and documented on 07/19/2023; and -A coordination note for two missed aide visits the week of 06/04/2023-06/10/2023 documented on 07/19/2023. During an interview on 07/19/2023 at 3:30 PM, the hospice administrator stated that he/she would expect visit noted to be documented within 24 hours of the visit.

Based on policy review, observation, and interview the hospice provider failed to provide the long-term care facility (LTCF) with the most recent hospice plan of care (POC), advance directives specific to the patient, and the physician certification of the terminal illness in one of two skilled nursing facility (SNF) visits made (Record/Patient #4). This deficient practice has the potential to affect all patients residing in a LTCF served by the provider. --- Findings included: Review of the provider's policy titled, "Hospice Care in the Nursing Home/Skilled Nursing Facility Setting," dated 06/01/2018, showed: -The Hospice Agency will provide the Nursing Home/Skilled Nursing Facility with the following information on each Hospice patient: *The most recent Hospice plan of care; *Hospice election form and any advance directives; and *Physician certification and recertification of the terminal illness. RECORD/PATIENT #4: Observation on 07/18/2023 at 10:30 AM, during the patient's home visit, showed the hospice binder placed at the facility failed to contain the most recent hospice POC, the patient's advance directives, and the physician certification of terminal illness. During an interview on 07/19/2023 at 3:30 PM, the hospice administrator stated that these elements should be placed in the facility binders.