Every finding on record at Lhcg Lxix, LLC

Based on policy review, record review, and interview, the hospice provider failed to ensure that emergency preparedness training was provided to all staff in one of five employee files reviewed (Employee #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Emergency Preparedness/Operational Plan,” revised 08/01/2024, showed the administrator shall ensure that all staff are trained in their emergency roles and provisions of the plan.EMPLOYEE #4:Review of the employee file showed the employee was hired on 11/01/2025.The file showed the provider failed to ensure the employee received emergency preparedness training during orientation.During an interview on 06/03/2026 at 11:10 AM, the business office manager stated that the employee did not have emergency preparedness training on file with the provider.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that the advance directive status was documented accurately in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's policy titled, "Advance Directives," revised 09/01/2023, showed:- On admission, the patient/representative makes known the patient's wishes regarding advance directives, and this is documented in the patient's record; and- Changes to the advance directives would be documented in the patient's medical record. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of non-Hodgkin lymphoma (cancer of the blood). The patient resided at home alone on 02/27/2026 and then transferred to a skilled nursing facility (SNF) on 03/06/2026. The plan of care (POC) dated 02/27/2026 showed the patient's advance directive wishes were to be a full code (patient would be resuscitated-lifesaving measures to restore heartbeat or breathing). Review of the Allow Natural Death (A.N.D.) Request/Do Not Resuscitate (DNR) form in the patient's clinical record, dated 03/06/2026, showed:-The patient signed the DNR form on 03/06/2026 and changed the full code status to A.N.D./DNR status; and-The physician/hospice medical director signed the form 03/06/2026. Review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Report, dated 06/02/2026, showed the patient's advance directive status was still listed as full code. Observation of the SNF's documentation during a home visit on 06/03/2026 at 2:30 PM, showed the patient's advance directive status was a DNR effective 03/06/2026. During an interview on 06/04/2026 at 11:50 AM, the hospice administrator confirmed that the patient's code status was DNR and that the patient's documentation should show that. The administrator stated the code status would be fixed immediately.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider's policy titled, "Medication Management," revised 11/01/2017, showed that all nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of non-Hodgkin lymphoma (cancer of the blood). The patient resided at home alone on 02/27/2026 and then transferred to a skilled nursing facility (SNF) on 03/06/2026. Observation of the facilities medication profile (FMP), printed 06/03/2026 at 2:30 PM during the home visit, showed the following medication discrepancies:- FMP showed an order, dated 05/27/2026, for albuterol sulfate nebulizer solution every four hours as needed for dyspnea (shortness of breath). The provider's medication profile (PMP), dated 06/02/2026, failed to include this medication;- FMP showed an order, start date 05/12/2026 and discontinue date 05/19/2026, for polytrim ophthalmic solution (antibiotic eye drop). The PMP failed to include this medication on the list of current or discontinued medications; and- FMP showed an order, dated 05/25/2026, for barrier cream (skin protectant). The PMP failed to include this medication/treatment. During an interview on 06/04/2026 at 11:50 AM, the hospice administrator agreed that the medications should match and stated that he/she was unable to find the orders for those medications. He/she stated that there was documentation of the albuterol, and the eye drops in the nurse's notes, but there were no orders.

Based on policy review, record review, and interview, the hospice provider failed to ensure a bereavement assessment was completed in one of five full records reviewed (Record/Patient #5). 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 Assessment," revised 03/01/2021, showed the social worker or designee would complete a bereavement risk assessment within five days of admission to hospice.  RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/18/2026 with a terminal diagnosis of multiple sclerosis (MS-an autoimmune disease).  The patient resided in a skilled nursing facility (SNF). Review of the registered nurse (RN) admission visit, dated 05/18/2026, showed the patient stated it would be ok for a social worker (SW) to contact him/her. Further review of the clinical record, date range 05/18/2026 through 06/03/2026, showed the SW never contacted the patient or patient's family and there was no bereavement assessment completed by the SW or a designee. During an interview on 06/04/2026 at 09:15 AM, the hospice administrator stated that the patient had refused services from the SW and chaplain. The RN documented an incorrect response to the SW question, and the RN did not know he/she was responsible for completing the bereavement assessment.

Based on policy review, record review, and interview, the hospice provider failed to ensure that each patient had an individualized plan of care (POC) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled,” Plan of Care,” dated 10/01/2024, showed the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions including measurable outcomes anticipated from implementing and coordinating the plan of care.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/10/2025 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (a dangerous cycle where high blood pressure strains the heart) and secondary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at home with a family caregiver.Review of the POC dated 04/06/2026-06/04/2026 showed a goal that patient’s capillary blood glucose (CBG) will be maintained within prescribed therapeutic range. The POC failed to specify a range for the CBG of the patient.During an interview on 06/04/2026 at 9:00 AM, the administrator stated that he/she would expect the POC to include a range for all vital signs for the patients.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the skilled nurse followed the plan of care (POC) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Physician Orders,” revised 10/01/2024, showed services are provided according to the most recent orders updating the patient’s plan of care.Review of the clinical record showed the patient was admitted to hospice services on 06/10/2025 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure (a dangerous cycle where high blood pressure strains the heart) and secondary diagnosis of type 2 diabetes mellitus (a chronic disease that affects how the body uses sugar for energy). The patient lived at home with a family caregiver.Review of the POC dated 04/06/2026 - 06/04/2026 showed a skilled nursing intervention that the nurse will monitor the patient's blood sugar at every visit.Review of skilled nurse visits dated 04/22/2026 – 06/01/2026, showed the nurse failed to document the patient’s blood sugar levels.During an interview on 06/04/2026 at 9:00 AM, the administrator stated that he/she would expect the nurse to follow the POC orders and the nurse should have documented the patient’s blood sugar levels.

Based on job description review, employee file review, and interview, the hospice provider failed to ensure that all hospice aides completed a competency evaluation program in one of five employee files reviewed (Employee #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated hospice aide job description, showed a job qualification that the employee would have a successful completion of a competency evaluation prior to patient care.EMPLOYEE #5:Review of the employee file showed:-Date of hire: 07/07/2025; and-Date of written competency exam: 04/19/2026 (286 days after the date of hire).During an interview on 06/04/2026 at 12:30 PM, the business office manager stated that the aide began seeing patients in the middle of July 2025.During an interview on 06/04/2026 at 12:30 PM, the administrator stated that the aide had completed the exam prior to April of 2026, but the provider moved office buildings in November of 2025, and the original competency exam could not be located. He/she also stated that they had discovered the missing exam after the move, and they had the aide take a new exam for the employee file.

Based on job description review, policy review, record review, observation, and interview, the hospice provider failed to ensure that the registered nurse (RN) updated the aide care plan when the needs of the patient changed in two of four records reviewed with aide services (Records/Patients #1 and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated aide job description showed, (care provided) under the direction and ongoing supervision of an RN, personal direct patient care services provided as established and delegated in the plan of care on a daily basis.Review of the provider’s policy titled, “Physician Orders,” revised 10/01/2024, showed services were provided according to the most recent orders updating the patient’s plan of care. Review of the provider’s policy titled, “Hospice Aide Supervision,” revised 11/01/2022, showed aides were assigned to patients based on the assessment made by the staff RN. --- RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/13/2023 with a terminal diagnosis of Alzheimer’s Disease (a disease marked by progressive loss of mental capacity). The patient lived in a skilled nursing facility.Review of the aide care plan report, dated 10/13/2023, showed the aide was to assist the patient to the toilet every visit due to the patient’s risk of falling.Review of the aide visits dated 04/21/2026-05/26/2026, showed the aide did not complete the task of assisting the patient to the toilet due to the patient being incontinent. Aide also documented that the registered nurse case manager was aware of the task not being completed each visit.During an interview on 06/04/2026 at 9:00 AM, the administrator stated that he/she would have expected the aide care plan to be updated to reflect the care the patient was receiving. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of Non-Hodgkin Lymphoma (cancer of the blood). The patient resided at home alone on 02/27/2026 and then transferred to a skilled nursing facility (SNF) on 03/06/2026. Review of the aide care plan report dated 02/27/2026 showed:-The patient was a full code (code status changed to DNR 03/06/2026); and-The patient was to ambulate with the use of a walker (wheelchair was not listed on the aide care plan). Review of the recertification plan of care (POC) dated 05/28/2026 showed the patient had the following durable medical equipment, a walker, wheelchair, and shower/tub equipment. The goals of care included that the patient and caregiver would verbalize and demonstrate understanding of fall precautions within 48 hours of identified potential fall risk. Observation of the patient on 06/03/2026 at 3:00 PM showed the patient was sitting in his/her wheelchair watching a movie with other residents in the common area. The patient propelled the wheelchair with his/her feet back to his/her room to visit with the chaplain.  During an interview on 06/04/2026 at 11:50 AM, the hospice administrator stated that the aide care plan should be updated when the patient had changes. The only aide care plan in the clinical record was the one dated 02/27/2026, and the code status and addition of the wheelchair should be added to an updated aide care plan.

Based on policy review, volunteer hour review, and interview, the hospice provider failed to ensure that volunteers provided care services that equaled 5% of the total patient care hours. This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Volunteer Program Reporting Process,” revised 03/17/2010 showed an action plan will be developed if volunteer hours are less than 5% of all total direct patient care hours of all paid employees and contract staff.Review of the provider’s volunteer hours for the past year showed volunteers hours equaled 4.2675% of all direct patient care hours for the provider.During an interview on 06/02/2026 at 2:30 PM, the administrator stated that he/she was working on building up the volunteer program and recruiting/training more volunteers.

Based on policy review, record review, and interview, the hospice provider failed to ensure that a discharge summary that included treatments, symptoms, and pain management was sent to the attending physician in three of six discharge records reviewed (Records/Patients #6, #9 and #10). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Live Discharge/Transfer of the Hospice Patient,” revised 05/01/2026, showed when a patient is discharged, transferred or referred to another agency, relevant information for discharge is documented in the medical record, typically in the form of a discharge summary and sent to the patient’s physician and receiving agency.RECORD/PATIENT #6:Review of the clinical record showed the patient was discharged from the provider on 01/16/2026.The record failed to show a discharge summary for the patient.RECORD/PATIENT #9:Review of the clinical record showed the patient was discharged from the provider on 03/28/2025.The record failed to show a discharge summary for the patient.RECORD/PATIENT #10:Review of the clinical record showed the patient was discharged from the provider on 08/14/2025.The record failed to show a discharge summary for the patient.During an interview on 06/04/2026 at 9:30 AM, the administrator stated that he/she was not aware that sending discharge summaries was a requirement and there were no discharge summaries for those records.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that the document used to coordinate care with the facility, the Hospice/Nursing Home Coordinated Task Plan of Care, was accurate and updated in one of one facility visit record 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, "Hospice Care in the Nursing Home/Skilled Nursing Facility Setting," revised 06/01/2018, showed that the hospice provider and the facility must define the manner in which the facility and the hospice would communicate and document communications to ensure that the needs of (the) patient were addressed and met. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of non-Hodgkin lymphoma (cancer of the blood). The patient resided at home alone on 02/27/2026 and then transferred to a skilled nursing facility (SNF) on 03/06/2026. Review of the document titled, "Hospice/Nursing Home Coordinated Task Plan of Care," dated 03/06/2026, provided with the patient's clinical record showed the document failed to include the hospice chaplain or the hospice social worker visit frequency.  During the home observation at the SNF on 06/03/2026 at 2:30 PM, the facility charge nurse (FCN) provided a hospice binder and stated that all of the paperwork that hospice provided was in that binder, including the coordinated task plan. Review of the Hospice/Nursing Home Coordinated Task Plan of Care form, dated 03/06/2026, in the hospice binder failed to include the hospice chaplain or the hospice social worker visit frequency. The coordination form showed the aide visits were on Monday and Thursday. The clinical record showed the aide visited Wednesday and Friday and the FCN stated that the aide usually visited on Wednesday and Friday.  During an interview on 06/04/2026 at 11:50 AM, the hospice administrator stated that the coordination form should have been updated and signed off by the hospice and facility staff.

Based on policy review, record review, observation, and interview, the hospice provider failed to provide the skilled nursing facility (SNF) all the required information in one of one facility visit record 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, "Hospice Care in the Nursing Home/Skilled Nursing Facility Setting," revised 06/01/2018, showed that the hospice provider would provide the SNF with the hospice election form and the physician certification/recertification of the terminal illness forms. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 02/27/2026 with a terminal diagnosis of non-Hodgkin lymphoma (cancer of the blood). The patient resided at home alone on 02/27/2026 and then transferred to a SNF on 03/06/2026. During the home observation at the SNF on 06/03/2026 at 2:30 PM, the facility charge nurse (FCN) provided a hospice binder and stated that all of the paperwork that hospice provided was in that binder. Review of the binder showed that the binder failed to contain the hospice election form and the physician certification/recertification of the terminal illness form. The FCN stated that the information was thinned and scanned into the facility electronic medical record (EMR) when the binder was too full. The FCN searched the EMR and was unable to find the documents. During an interview on 06/04/2026 at 11:50 AM, the hospice administrator stated that the hospice election form and the physician certification and recertification forms should have been in the binder.

Based on review of Missouri Statutes, policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was performed on all staff prior to first patient contact in one of five employee files reviewed (Employee #4). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the provider’s duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence.  If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states. Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest). Review of the provider’s policy titled, “Background Checks,” revised 10/01/2025, showed all applicants who are offered employment with [named company] must have a criminal background check successfully completed in order to remain with the company.EMPLOYEE #4:Review of the employee file showed the employee was hired on 11/01/2025.The file showed the provider failed to obtain a criminal background check on the employee.During an interview on 06/04/2026 at 10:00 AM, the administrator stated that the corporate office performed all other CBC checks and he/she was unaware that they did not do the CBC check on the employee.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure an accurate/updated medication profile/plan of care (POC) was maintained for each patient in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers 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. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period. The physician is contacted immediately if any discrepancies between the hospice provider information and patient medications are found. A comprehensive medication review will be completed on admit and at every IDG (interdisciplinary group) meeting, in conjunction with all comprehensive assessments. Compare medication list to actual medications the patient is taking. If the patient resides in a facility, compare the medication list to the facilitys medication administration record (MAR) rather than reviewing the actual medications. Review over the counter (OTC) medications, vitamins, herbs and herbal products. Notify the physician of any identified issues/discrepancies. All nurses participating in the patients care are responsible to assist in maintenance of accurate patient medication information through the tenure of care. Through a collaborative process the care team will compare medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies. RECORD/PATIENT #2: Observation on 08/15/2023, beginning at 9:00 AM, during the patients home visit, the nurse reviewed the patients medications. The nurse did not ask if there were any other medications the patient took. Per interview conducted during observation on 08/15/2023, after the nurse left, the patient stated that he/she took two regular Tylenol about two or three times a week. This was not included on the providers current medication profile/POC. The findings were reviewed with the administrator on 08/16/2023 beginning at 11:50 AM. No further information was provided. RECORD/PATIENT #4: Review of the record showed the patient was admitted to hospice on 05/20/2023, with a diagnosis of COPD (chronic obstructive pulmonary disease, a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). The patient resided in a long-term care facility (LTCF). Review of RN (registered nurse) As visit note dated 06/02/2023, showed the patient wanted to stop all PO (by mouth) medications except for pain medications. Discussed at IDG today. The physician gave an order to discontinue all PO medications. The order was given to the LTCF staff. Review of the current hospice medication profile/POC and current LTCF medication administration record (MAR) showed the following discrepancies: - The hospice providers current medication profile and POC continued to show the patient took diltiazem (heart medication) ER (extended release), Eliquis (blood thinner) 5 milligrams (mg), iron (supplement) 325 mg, Miralax (laxative) 17 grams, potassium chloride (supplement), Seroquel (antipsychotic) 25 mg, and Xtandi (for prostate cancer). The current LTCF MAR did not include these medications; - The hospice providers current medication profile/POC showed an order for Dexamethasone (steroid medication) 2 mg two times a day. The current LTCF MAR did not include this medication; and -The hospice providers current medication profile/POC showed an order for morphine (narcotic pain medication) concentrate 100 mg/5 ml (20 mg/ml) take 0.25 ml (milliliter) every four hours. The current LTCF MAR did not include this dosage of medication. During an interview on 08/16/2023, at 11:50 AM, the administrator stated that the nurses do a medication reconciliation when they go to the facilities. They ask for the facility chart and compare to what they have on their tablets. When a new order is received, they call and talk to the facility nurse or if they get an order while in the facility they verbally give them the order and document this communication in their notes. During an interview on 08/17/2023 beginning at 9:03 AM, with RN A and the administrator, RN A stated that when he/she received a new order, he/she gave the facility a written order. When asked about the Dexamethasone order, he/she stated that they used to have a chart he/she could look at but now everything is computerized. He/she always asks if the patient has the same medications and reviews it verbally with the staff from his/her tablet and they look at their list and say it is the same. When he/she asks for their medication sheets, they say they dont have time to print it out and he/she cannot get into their computer to look. He/she gave the Dexamethasone order to the facility. The morphine order for every four hours was also given to the facility. He/she does not make copies when he/she gives them the orders. RN A stated that from now on, he/she would stand there until they gave him/her a copy of the medication sheets. The administrator stated that he/she is going to have a meeting with the administrator and director of nursing. During an interview on 08/17/2023 at 10:00 AM, the administrator stated that he/she was going to get the facility medication record to ensure the medications were fixed.

Based on policy review, record review, observation, and interview the hospice provider failed to develop an individualized plan of care (POC) in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Plan of Care," revised 11/01/2021, showed in part 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 patient. The IDG (interdisciplinary group) in collaboration with the patients attending physician, if any, will review, revise and document the POC as frequently as the patients condition changes. The revised POC must include information from the patients updated comprehensive assessment and must note the patients progress toward outcomes and goals specified in the POC. Review of the hospice providers policy titled, ";Interdisciplinary Group Membership and Responsibilities," revised 11/01/2021, showed in part that the IDG responsibilities include participating in the establishment in an individualized POC for each patient, reviewing, revising, and documenting the individualized POC as frequently as the patients condition requires. RECORD/PATIENT #2: Review of the RN (registered nurse) start of care assessment dated 02/28/2023, showed the patient had a diagnosis of Type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). The question, can the patient manage insulin (medication to lower blood sugar that comes in an injectable form) or non-insulin anti-diabetic dosage (draw up or use pen and self-inject) was answered yes. No information regarding how often or whether the patient checked his/her blood sugars. Review of the POC dated 02/28/2023, showed diagnoses that included Type 2 DM and the patient was insulin dependent. The POC failed to include monitoring of the patients diabetes/blood sugars, problems, interventions, and goals related to his/her diabetes, and failed to include the patients insulin order. Review of the recertification assessment dated 05/18/2023, showed the patient had Type 2 DM, took insulin, and was able to manage his/her own insulin. Review of the hospice IDG comprehensive assessment and plan of care update report dated 05/19/2023, showed diagnoses that included Type 2 DM. The POC failed to include problems, interventions, and goals related to DM and failed to include the patients insulin order. Review of the recertification orders dated 05/19/2023, showed an order for Norco (narcotic pain medication that contains Tylenol) 10-325 milligrams (mg) one tablet every four hours as needed. Review of the hospice IDG comprehensive assessment and plan of care update dated 06/02/2023, failed to include the patients insulin order and the order for Norco 10/325 mg one tablet every four hours as needed. Review of an RN visit dated 06/08/2023, showed the nurse documented that Lantus (insulin) and Norco were added to the medication list. These were not new orders. The medication list was updated from already existing orders. Review of a physician order dated 06/08/2023, showed an order for medication list update for Lantus insulin 100 units/ml (milliliter) 60 units at bedtime and hydrocodone 10 mg-acetaminophen (Norco) 325 mg one tablet every four hours as needed. Per interview conducted during observation on 08/15/2023, beginning at 9:00 AM, the patient stated that he/she checked his/her blood sugar at least once a day. His/her blood sugar had gotten a little low a couple of times. The nurse failed to ask what his/her blood sugars had been running. After the nurse left, the patient stated that he/she knew when his/her blood sugar was low because he/she would feel shaky and sweaty. He/she would get something to drink or eat if it got too low. One time in the middle of the night his/her blood sugar was 50 and another time the blood sugar was 62. During an interview on 08/16/2023, beginning at 11:50 AM, the administrator stated that he/she would think the POC should include interventions and monitoring of the patients diabetes. RECORD/PATIENT #4: Review of the SN visits on 06/27/2023, 06/29/2023, 07/06/2023, 07/13/2023, 07/27/2023, and 08/10/2023 showed the patient had wounds to the heels and/or coccyx (tailbone). Review of the IDG comprehensive assessment and plan of care update report showed from 06/30/2023 through 08/11/2023 the POC failed to include treatment orders, interventions and goals related to the patient's wounds. The findings were reviewed with the administrator on 08/16/2023 beginning at 11:50 AM. The administrator stated that he/she would expect the nurse to document wound care orders and coordinate with the facility.

Based on contract review, clinical record review, and interview, the hospice provider failed to develop and maintain a system of communication and integration to ensure the ongoing sharing of information between all disciplines providing care and services in all settings when it failed to obtain a discharge summary from the long-term care facility (LTCF) providing respite care in one of one respite record reviewed (Record/Patient #6). This deficient practice has the potential to affect the coordination of care for all of the providers patients receiving respite care. --- Findings included: On 08/15/2023 at approximately 9:30 AM, the administrator provided a nursing facility contract with a respite addendum for review. Per an interview immediately after providing the contract, the administrator stated that all of the LTCF contracts contained the respite addendum. The contract showed the facility shall provide the hospice with a copy of the discharge summary at the time of discharge. RECORD/PATIENT #6: Review of the clinical record showed the following: - The patients start of care date was 05/27/2022; - The patient was in the LTCF for respite care from 03/10/2023 through 03/14/2023; and - The record failed to include the discharge summary from the LTCF. During an interview on 08/15/2023 at 4:10 PM, the administrator stated that they could not find a discharge summary for this patients respite stay because the facility did not send one to them. He/she was not aware the nursing facility was required to send the hospice a discharge summary.

Based on policy review, home visit observation, and interview, the hospice provider failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, in one of four home visit observations conducted (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Hand Hygiene," revised 03/01/2021, showed in part: - Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer; - Wear gloves when contact with blood or other potentially infectious materials, mucous membranes and non-intact skin could occur; - Change gloves during patient care if moving from a contaminated body site to a clean body site. - Staff performs hand hygiene; * Before direct contact with patients; * At the conclusion of the visit after contact with a patients intact skin; * After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings; * If moving from a contaminated body site to a clean body site during patient care; * After contact with inanimate objects in the immediate vicinity of the patient; and * Before and after removing personal protective equipment such as gloves and gowns; RECORD/PATIENT #3: Observation on 08/15/2023 at 10:00 AM, during the patients home visit at the long-term care facility (LTCF), showed registered nurse C (RN-C): - Checked the patients brief for incontinence with a gloved hand; - Removed and discarded gloves; - Failed to perform hand hygiene; - With soiled hands, opened drawers in patients nightstand and dresser and looked for cleansing wipes; - With soiled hands, opened the patients door and went down the hallway to find incontinence supplies; - Returned to room, failed to perform hand hygiene and donned another pair of gloves; - Removed the patients wet and soiled brief; - Using cleansing wipes, wiped the perineal area approximately eight to 10 times (going over the same areas repeatedly), with each side of the wipe before discarding; - Rolled the patient onto his/her side and cleaned the buttocks and rectal area, wiping approximately eight to 10 times with each side of the wipe before discarding; - With the same soiled gloves, picked up the clean adult brief and placed it on the patient; - With the same soiled gloves, pulled up the patients pants over the brief; - Removed and discarded gloves and washed hands; - Donned gloves; - Entered the patients bathroom and prepared wet soapy washcloths; - Removed old drain sponge (a dry dressing cut to fit around feeding tubes); - Wearing same soiled gloves, washed area around gastric tube (a tube that is surgically inserted through the skin into the stomach, used to receive liquid nutrition and medications in patients with difficulty swallowing) with the soapy washcloths; - With same soiled gloves, patted area dry with a dry washcloth; - With same soiled gloves, picked up a medicine cup containing antibiotic ointment and a cotton-tipped applicator and placed it on the patients bed; - Removed and discarded gloves; - Failed to perform hand hygiene; - Donned gloves; - Picked up the medicine cup with antibiotic ointment and applied ointment with cotton-tipped applicator; - Applied a new drain sponge; - Removed and discarded gloves; - Failed to perform hand hygiene; - With soiled hands, used the patients bed control pad to lower the patients bed; - With soiled hands, opened the door and exited room to find a facility nurse aide; - Returned to the patients room; - Failed to perform hand hygiene; - Donned gloves; - Picked up trash bags containing soiled brief, dressing and washcloths; - Placed the patients fall mat onto the floor; - With gloves on, opened the patients door and took trash bags to the utility room; - Returned to the room with ungloved hands; - Failed to perform hand hygiene; - Donned gloves; - Cleaned vital signs equipment and placed equipment back into the nursing bag; - Wiped down tablet; - Removed and discarded gloves; - Failed to perform hand hygiene; and - Left patients room. During an interview, immediately following the home visit, RN-C stated that he/she did not think about glove changes between dirty and clean tasks or hand hygiene. He/she could see how going from dirty to clean tasks without performing hand hygiene and donning new gloves could cause a problem with the spread of microorganisms. He/she could have used hand sanitizer in between glove changes. During an interview on 08/15/2023 at 1:00 PM, the administrator stated that he/she would expect hand hygiene to be performed before and after care and after glove removal and would expect gloves to be changed when going from a dirty task to a clean task.

Based on policy review, record review, and interview the hospice provider failed to ensure the nursing needs of the patient's were met in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Wound Assessment, Documentation, and Photography," revised 03/01/2023, showed in part that all wounds will be assessed with appropriate documentation within the medical record. Wound care will be performed according to the physician orders specified in the patients POC (plan of care). Documentation in the medical record included treatment and condition of the wound each visit, appearance of the wound bed, wound measurements weekly including the length, depth, and width of the wound, surrounding tissue, color, odor and estimated amount of drainage, stage (wounds are staged by a number rating of 1-4 depending on the appearance/condition of the wound) the wound weekly, patient/representative/caregiver instructions on wound care and compliance with wound management, including ability to change dressing, other pertinent findings such as wound ulcer classification, wound care and dressing change procedure, client symptoms and response to the procedure, and redress the wound using appropriate wound care dressing procedure following physician orders. Review of the hospice provider's policy titled, "Patient Reassessments," revised 07/01/2012, showed in part that a pain assessment will be completed every visit. Reassessments should focus on the patient's response to care. RECORD/PATIENT #4: Review of the RN (registered nurse) start of care assessment dated 05/20/2023, showed the patient resided in a LTCF (long term-care facility). Diagnoses included COPD (chronic obstructive pulmonary disease, a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). Review of RN A's visit dated 06/13/2023 showed, the patient rated his/her pain at a level of ten (pain is rated on a scale of zero to 10 with zero meaning no pain and 10 meaning the worst pain). In another section of the pain assessment the pain was rated at a level of eight. The patients pain level at the end of the visit was eight. The patients pain goal was four. The MSIR (morphine sulfate immediate release, narcotic pain medication) was increased to 0.05 (unsure if this was to be 0.25 or 0.5) ml (milliliter) every hour as needed. Spoke with the (LTCF) staff nurse to inform of the changes. The patient asked for pain medication every hour. Informed facility nurse to call the hospice if the increase in pain medication does not help. Review of a physician order dated 06/14/2023, showed an order for dexamethasone two milligrams (mg) two times a day for bone pain. No documentation of coordination with the LTCF regarding this order. Review of the SN (skilled nurse) visits showed: - On 06/15/2023, two sections of the pain assessment showed the patient rated his/her pain level at five. The end of the visit showed a pain level of eight. The narrative section showed the patient reported poor pain control at a nine and down to a six after pain medication. Instructed to put on call light to request pain medication when needed. He/she verbalized understanding. Interventions provided, showed instructions to patient/caregiver on the cause(s) of pain in the terminally ill. The patient verbalized understanding. Instructed patient/caregiver to coordinate administration of pain control medications with activity, types of pain, signs and symptoms of pain, and how to describe pain. The nurse documented a medication reconciliation (the hospice medication orders are compared with the LTCF orders to ensure the orders are the same and up to date) was performed (it should be noted that the order for dexamethasone was not on the LTCF's current medication administration record (MAR), this indicated the medication reconciliation by the hospice nurse was not effective). (It should be noted that the hospice failed to follow-up on the patient's pain or effectiveness of the dexamethasone until 06/23/2023 - 8 days later). - On 06/23/2023, the patient denied pain. Nonverbal pain indicators included nonverbal complaints observed with movement and facial grimace/winces observed with movement. Prescription medications for pain control showed morphine (did not include the dexamethasone). Pain relief measures provide an acceptable level of pain relief. Pain post treatment showed zero nonverbal pain indicators; - On 06/27/2023, the LPN (licensed practical nurse) documented a pain score of eight that was continuous. Relieved with prescription pain medication, rest, and relaxation. Breakthrough medication needed greater than three times a day. The question, did you assess patients pain post treatment was answered no. Medications reconciled and current medications met the patients needs. The patients pain rating at the end of the visit was zero. The integumentary (pertaining to the skin) findings showed wound(s). The bilateral heels were bruised and soft (could indicate tissue damage). The heels were floated on pillows and skin prep (used to toughen the skin) applied. Care coordination showed would discuss in IDG. The note failed to show if the physician, hospice RN, or facility staff were notified of the wounds; and - On 06/29/2023, the patient's pain level was five with a goal of four. Assessment post treatment showed a level of four (no documentation what treatment or medication was provided). Facility (LTCF) nurse instructed on safe medication disposal. A medication reconciliation was performed (the current facility MAR did not include the dexamethasone order which indicated the medication reconciliation was not effective). Interventions provided included instructing patient/caregiver to coordinate administration of pain control medications with activity. The integumentary findings showed wounds. The note failed to show an assessment of the wounds or wound care orders. Review of a physician order dated 06/29/2023, showed an order to discontinue Percocet 10-325 mg one tablet every four hours while awake and add Percocet 10-325 mg two tablets every four hours for pain. Review of the IDG (hospice interdisciplinary group) comprehensive assessment and plan of care update report dated 06/30/2023 showed an order dated 06/29/2023 for Percocet 10-325 mg take two tablets every four hours for pain. The hospice physician documented the patients pain was a lot worse. The Percocet and liquid morphine was increased. Wounds on both heels breaking down. Coccyx (tailbone) wound stage 2 (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). The hospice SN visit note failed to contain an assessment of a wound to the patient's coccyx. Review of RN A's visits showed: - On 07/06/2023, the patient's pain level was a level of five. Post treatment the pain level was three. The pain goal was four. The integumentary findings showed wounds. There was no documented wound assessment or information regarding wound care orders. Care coordination showed IDG (not LTCF). The note failed to include documentation of what was coordinated with the IDG, and failed to show documentation of coordination with facility staff regarding wound care; - On 07/11/2023, the patient's pain level was five. Post treatment the pain level was three. Post treatment the patient rated his/her pain at a zero. The end of visit level showed five (unsure of this documentation since post treatment level was zero). The integumentary findings showed wounds. The note failed to contain further information regarding wounds; and - On 07/13/2023, the integumentary assessment by the hospice nurse showed wounds. The pressure ulcers to the left buttock was healing without signs and symptoms of infection. The nurse cleansed the wound with normal saline (salt solution with healing properties) and covered with Optifoam (foam dressing, there were no physician orders found for this treatment). The note failed to show information regarding the patients heels. The pain level was rated a level of six. Post treatment the level was zero. At the end of the visit the level was four (unsure of this documentation since post treatment was zero) with a pain goal of four. The patient reported his/her pain was better controlled. Discussed with the medication nurse whether the patient had enough pain medications. Care coordination showed, IDG, but the note failed to show specific information of what was coordinated with the IDG and failed to include documentation of coordination of wound care with the facility staff. Review of the hospice physician recertification narrative dated 07/14/2023, showed in part that the patient was admitted to hospice services for COPD (chronic obstructive pulmonary disease, a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). Likely has lung cancer that has spread to the bone requiring dexamethasone. Using the morphine and Percocet regularly. The patient had developed stage 2 pressure ulcers to both heels and the right buttock. Review of RN A's visits showed: -On 07/18/2023, the patient's pain level was five. Post treatment level was four with a pain goal of four. A medication reconciliation was performed (the current LTCF MAR did not include the order for dexamethasone and MSIR 0.25 ml every four hours, which indicated the medication reconciliation was ineffective). The integumentary findings showed within normal limits. Reviewed hospice POC with facility staff. There was no specific information documented whether the wounds had healed; -On 07/21/2023, the patient's pain level was four. Post treatment the patient reported a level of zero. The end of visit showed a level of four with a goal of four (unsure of this since the patient reported a level of zero post treatment). A medication reconciliation was performed and current medications met the patient's needs (the current LTCF MAR did not include the order for dexamethasone and MSIR 0.25 ml every four hours which indicated the medication reconciliation was ineffective). The integumentary findings showed within normal limits; - On 07/25/2023,the pain level was four and zero at the end of the visit. The integumentary findings showed within normal limits. There was no specific information documented regarding whether the wounds had healed or any wound measurements; and - On 07/27/2023, the patient was not uncomfortable due to pain. The right heel wound was open and draining small amounts of S/S (unsure if this meant serosanguineous which is a thin, watery, pink colored fluid). The wound bed was covered with black eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed). The assessment failed to include measurements of the wound. Dressing changed per aseptic technique. Cleaned with normal saline and covered with Optifoam (There were no physician orders found for this treatment). The note failed to show documentation regarding the patients left heel or coccyx. Review of the IDG comprehensive assessment and plan of care update dated 07/28/2023, showed new wounds to bilateral heels stage 2 (the SN assessment on 07/27/2023 showed the right heel wound was covered with eschar which would make the wound unstageable). The POC failed to include an update with problems, interventions, and goals related to the patients heels. Review of RN A's visits showed: - On 08/01/2023, the integumentary findings showed within normal limits. The wounds to the bilateral heels were closed with no drainage noted. The note failed to show further assessment of the heels, and failed to include documentation regarding the coccyx; - On 08/03/2023, the integumentary findings showed within normal limits; - On 08/08/2023, pain level was five. Post treatment level was zero. The patient took Percocet every four hours and alternates with morphine every four hours. A medication reconciliation was performed (the current LTCF MAR did not include the dexamethasone order and MSIR every four hours order which indicated the medication reconciliation was not effective). The integumentary findings showed pale. The note failed to show additional assessments for the wounds; - On 08/10/2023, the patient had redness to the buttocks. Calmoseptine (no order found for this, an ointment that provides a moisture barrier that prevents and helps heal skin irritations) applied. Heel wound dressing (did not indicate left or right, RN visits 08/03/2023 through 08/08/2023 showed no information regarding dressings to the heel) was intact and changed earlier today; and - On 08/15/2023, the wound assessment (this was the first documented complete wound assessment) showed the right heel measured 3.0 x 3.0 x 3.0 centimeters (cm, wounds are measured length x width x depth). The top section of the assessment showed it was a stage 2 pressure ulcer and the body of the assessment showed suspected deep tissue injury (purple or maroon colored area of discolored intact skin or blood filled blister due to damage of underlying soft tissue), small amount of serosanguineous drainage, surrounding skin normal, no odor, slough (yellow colored dead tissue which can be stringy or thick and adherent to the wound bed) 26-50%, eschar 0-25%, no undermining (a separation of wound edges), epithelialization (healing tissue) 75- less than 100%. Wound care included cleansing with normal saline and applying Optifoam (no order found for this treatment). The left heel measured 2.0 x 2.0 x 0.0 cm, the top section of the assessment showed stage 2 pressure ulcer and another section of the assessment showed suspected deep tissue injury, small amount of serosanguineous drainage, slough and eschar 0-25%, surrounding skin bright red, no undermining, epithelialization 75- less than 100%. Wound care included cleansing with normal saline and applying Optifoam. The nurse documented the heels were now open with S/S drainage. Cleaned wounds with normal saline, applied Optifoam and heel protectors on. Instructed to keep feet elevated. (The SN failed to provide a full assessment with measurements, per agency policy (measure wounds weekly), from 06/27/23 when wounds were identified until the date of this visit 08/15/2023.) During an interview on 08/16/2023 at 11:50 AM, the administrator stated that it is their policy to document a wound assessment at least once a week. They should open the integumentary system in their assessments and document measurements and assessments. He/she would expect the nurse to document wound care orders and coordinate with the (LTCF) facility. During an interview on 08/17/2023 beginning at 9:03 AM, with RN-A and the administrator, RN A stated that the patients heels sometimes look bruised and reddish in color. Last week it was draining and he/she got an order for Optifoam and to clean with normal saline. The facility staff said they had been putting on heel protectors and applying skin prep. They are putting Calmoseptine on the coccyx area. He/she did have Stage 1 (a persistent are of skin redness without a break in the skin that does not disappear when pressure is relieved) redness and they were applying Calmoseptine. It was all healed this week. RN-A stated that he/she did wound assessments when a patient had a wound. He/she did not remember his/her documentation about the patients wounds. When asked about the pain assessments on 06/13/2023 and 06/15/2023, RN-A stated that the first pain rating is what the patient told him/her and the second entry rating was the rating at the end of the visit. When asked about the other section that showed a rating of eight at the end of the visit, he/she stated that he/she obviously did not pay attention when he/she entered the information. The administrator stated that if a patients pain is not at the patient's stated goal, after provided pain medication, he/she expected the nurse to wait for about 30 minutes to ensure the pain is under control.

Based on policy review, record review, observation and interview the hospice provider failed to ensure the registered nurse (RN) developed a complete/updated aide care plan in one of three records reviewed that received aide services (Record/Patient #4). This deficient practice has the potential to affect all patients that received aide services. --- Findings included: Review of the hospice providers policy titled, ";Hospice Aide Supervision," revised 11/01/2022, showed in part that aides are assigned to patients based on the assessment made by the staff RN (registered nurse). RECORD/PATIENT #4: Clinical record review showed, beginning on 06/27/2023, nursing staff documented the patient had wounds to his/her heels. Review of the interdisciplinary group (IDG) comprehensive assessment and plan of care update, dated 06/30/2023, showed the patient had a wound to the coccyx (tailbone). Review of the current aide care plan report established 05/20/2023, showed no updates to include instructions for the aide regarding the patients wounds. Per observation and interview on 08/15/2023, beginning at 11:30 AM, during the patients home visit, showed the aide/LPN (licensed practical nurse) set up for the patients bath. The patient wore pressure relief booties on his/her heels. The aide/LPN stated that he/she did not know of any special precautions to take with the patient. When asked if the patient had wounds on his/her feet, he/she stated yes but he/she did not touch the dressings. The nurse would do that. When asked if the patient had any other areas, he/she asked the patient if there was a spot on his/her bottom that they put dressings on. The patient responded yes. During an interview on 08/16/2023, beginning at 11:50 AM, the administrator stated that the aide care plan should be updated with information about the patients wounds.

Based on policy review, clinical record review, and interview, the hospice provider failed to forward, to the receiving Medicare/Medicaid-certified facility, a copy of the hospice discharge summary in one of one patient transfer record reviewed (Record/Patient #10). This deficient practice has the potential to affect all patients discharged or transferred by the provider. --- Findings included: Review of the providers policy titled, ";Live Discharge/Transfer of the Hospice Patient," revised 04/01/2022, showed when a patient is discharged, transferred, or referred to another agency, relevant information for discharge is documented in the medical record. Documentation sent to the patients physician and receiving agency may include: - Reason for transfer or discharge and date of transfer or discharge; - Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions and follow-up; - Summary of the care provided, and progress toward achieving goals, including both positive and adverse patient responses to treatment or services; - Copy of the current medication profile; - Copy of the current plan of care (POC); - Copy of current physician orders; - Continuing symptom management needs, e.g. (exempli gratia, for example) pain, nausea, dyspnea (shortness of breath); - All pertinent lab data; - Existence of an advance directive, if applicable; - Date of discharge; - Patient diagnoses; and - Notification of any current infections. RECORD/PATIENT #10: Review of the clinical record showed: - The patient was admitted to hospice on 02/16/2023; - The admitting diagnosis was lung cancer; - A visit note dated 03/09/2023, that showed the patient was transferred to another hospice and the transfer was initiated by family; - A hospice transfer form/change statement from the receiving hospice that showed the patients mothers signature, dated 03/09/2023; - A discharge summary with a fax cover letter addressed to the providers medical director; and - The provider failed to provide a copy of the discharge summary to the receiving hospice. During an interview on 08/16/2023 at 9:30 AM, the administrator stated that the discharge summary was sent to the attending physician but he/she could not find where it was sent to the receiving hospice. He/she stated that they will keep looking. During an interview on 08/16/2023 at 12:05 PM, the administrator stated that he/she could not find where they sent the discharge summary to the receiving hospice. They have a new computer system and it has been difficult to find some of the records. He/ she was not able to find any evidence that the discharge summary was sent to the receiving hospice.

Based on policy review, clinical record review, and interview, the hospice provider failed to forward, to the patients attending physician, a copy of the hospice discharge summary in one of two patient revocation records reviewed (Record/Patient #8). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the hospice providers policy titled, ";Revocation of Hospice Benefit," revised 04/01/2022, showed the hospice agency will provide the attending physician, if any, a copy of the hospice discharge summary and patient clinical record, if requested. The hospice discharge summary must include: - A summary of the patients stay including treatments, symptoms, and pain management; - The patients current plan of care; - The patients latest physician orders; and - Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. RECORD/PATIENT #8: Review of the medical record showed the following: - The patient was admitted to hospice services on 10/13/2022; - A document titled, ";Missouri Department of Social Services MO (Missouri) Healthnet Division Notification of Termination of Hospice Benefits," that showed the patients guardian signed the revocation of hospice benefits on 05/25/2023; - A document titled, ";Discharge from Hospice Program," and the reason was the physician gave an order to be sent to the emergency room (ER) and that it was at the guardians request; - A visit note that showed the hospice discharge/revocation from the provider and stated that the long-term care facility called the hospice provider to inform them the patient had a decline in condition, the physician gave the order to send the patient to the ER, and the guardian wished to revoke hospice to seek further treatment; - The record failed to include a discharge summary; and - The record failed to show that the discharge summary was sent to the attending physician. On 08/15/2023 at 4:30 PM, documentation was requested to show the discharge summary was completed and sent to the attending physician. The administrator provided a physicians certification of terminal illness but failed to provide a discharge summary. The administrator stated that he/she provided all the information they had.

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to: - Ensure the hospice plan of care identified the care and services that were needed and specifically identify which provider was responsible for performing the respective functions that were agreed upon and included in the hospice plan of care (L0774); - Communicate with the skilled nursing facility/nursing facility/long-term care facility (SNF/NF/LTCF) representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family (L0779); and - Provide the SNF/NF/LTCF with the following information: * The most recent hospice plan of care specific to each patient; * The hospice election form and any advance directives specific to each patient; * Physician certification and recertification of the terminal illness specific to each patient; * Names and contact information for hospice personnel involved in hospice care of each patient; * Instructions on how to access the hospices 24-hour on-call system; * Hospice medication information specific to each patient; and * Hospice physician and attending physician (if any) orders specific to each patient (L0781). The cumulative effect of these deficient practices has the potential to affect all SNF/NF/LTCF patients receiving services from the hospice provider. --- .

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the coordinated task plan of care (POC) with the long-term care facility (LTCF) included the name of the hospice aide, schedule of hospice nurse visits, schedule of hospice aide visits, or the frequency of social work and chaplain visits and failed to show coordination of wound care management and/or management of a surgically inserted feeding tube in two of three records reviewed of patients that resided in a LTCF (Records/Patients #3 and #4). This deficient practice has the potential to affect the coordination of care for all hospice patients who reside in a LTCF. --- Findings included: Review of the hospice providers policy titled, ";Hospice Care in the Nursing Home/Skilled Nursing Facility Setting", revised 06/01/2018, showed in part that a written hospice POC must be established and maintained in consultation with the nursing home/skilled nursing facility representatives. All hospice care must be in accordance with this hospice POC. RECORD/PATIENT #4: Review of SN (skilled nurse) visits showed from 06/27/2023 through 08/10/2023 showed the patient had wounds to the heels and/or buttocks with no documentation of coordination with facility staff regarding wound care. Review of the Hospice/Nursing Home Coordinated Task Plan of Care dated 05/20/2023 located at the facility on 08/15/2023, failed to indicate the name of the hospice aide, schedule of hospice nurse visits, schedule of hospice aide visits, or social work and chaplain frequency. There were no updates since 05/20/2023 to include wound care orders and wound care schedule. During an interview on 08/15/2023, at 11:50 AM, the facility charge nurse stated that the hospice nurse verbally gave them new orders. The hospice nurse usually did the treatments when he/she came. The director of nursing stated that the hospice had not coordinated wound care with them. He/she stated that they never knew when hospice was coming. During an interview on 08/16/2023 at 11:50 AM, the administrator stated that he/she wound expect the nurse to document wound care orders and coordinate with the facility. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice with a terminal diagnosis of esophageal (The tube connecting the mouth to the stomach) cancer with metastasis (spreading of the cancer from its initial site to a new site) to the liver. The patient had a history of a cerebrovascular accident (CVA, Stroke) in April 2023 and had a right above the knee amputation (surgical removal of the leg above the knee) approximately two years ago. He/she had an esophageal tumor which impaired his/her ability to speak and swallow food. He/she had a tube surgically inserted through the skin into the stomach (PEG tube, percutaneous endoscopic gastrostomy) and received nutrition through the tube every night from 7:00 PM to 7:00 AM. The patient lived in a long-term care facility (LTCF) and required maximum assistance with his/her activities of daily living (ADLs). Review of the plan of care (POC), dated 07/31/2023, showed the following: - The patient received skilled nursing (SN) visits two times a week and as needed; - The patient received hospice aide visits two times a week; - The patient received social worker visits one time a month; - The patient received chaplain visits one time a month; and - The hospice nurse was to coordinate POC with the facility staff. Review of the physician order, dated 07/31/2023, showed; - PEG site: Cleanse area around tube with soap and water then place a drain sponge around the tube and secure with tape; - Flush PEG tube with 200 milliliters of water every four hours and check residual (fluid content that remains in the stomach) every four hours; - The order failed to include the frequency for the PEG tube cleansing and dressing change; and - The order failed to contain information regarding what days the hospice nurse would perform the dressing change to the PEG site. Review of the chaplain visit note, dated 08/03/2023, showed, the patient expressed a desire for no chaplain visits. Observation on 08/15/2023 at 10:45 AM, during the patients home visit, showed the long-term care facilitys records, provided by the hospice (located in a three-ring binder at the nurses station), contained a coordinated task plan of care that showed: - Hospice nurse visits had a start date of 07/31/2023; - The provider failed to complete the hospice nurse visit schedule; - Hospice aide visits had a start date of 07/31/2023; - The provider failed to complete the hospice aide visit schedule; - The provider failed to complete the social worker visit schedule; - The provider failed to include the chaplain visit on 08/03/2023 and that no further visits would be made per patient request; - The provider failed to include hospice wound care (the PEG site cleansing and dressing change, the dressing change was completed by the hospice nurse during this home visit observation); and - The provider failed to specify what days the hospice nurse would complete the wound care. Per an interview conducted immediately following the home visit observation, the LTCFs charge nurse stated that he/she did not recall seeing the hospice binder before this week. He/she has not had a lot of contact with the hospice nurses and they do not usually give or get report before or after seeing the patient. He/she said the hospice aide is good about communicating with them after the visit but they do not know what days the aide is coming, they just show up. The charge nurse also stated that they do not know what tasks the hospice nurse or the hospice aide will be doing when they get to the facility. They are not able to coordinate the delivery of their care around the hospices care because they usually do not know what they will be doing but he/she did not think the nurses usually did any treatments or dressing changes when they came for a visit. During an interview on 08/16/2023 at 12:10 PM, the administrator stated that the facilities complain that the hospice staff doesnt communicate with them and the hospice staff complains that the facilities wont communicate with them. They complain about each other and he/she thinks the facilities have their favorite hospices and dont want to work with the others.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure coordination of care with the long-term care facility (LTCF) in two of three records reviewed of patients that resided in LTCF (Records/Patients #3 and #4) This deficient practice has the potential to affect all patients that reside in a LTCF. --- Findings included: Review of the hospice providers policy titled, ";Hospice Care in the Nursing Home/Skilled Nursing Facility Setting", revised 06/01/2018, showed in part that the agency must assume responsibility for professional management of the residents hospice services, in accordance with the hospice plan of care (POC, directs staff how to care for a patient) and the hospice conditions of participation. A written hospice POC must be established and maintained in consultation with the nursing home/skilled nursing facility representatives. All hospice care must be in accordance with this hospice POC. The hospice agencys responsibilities include, but are not limited to providing medical direction and management of the patient and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions. These services will be included in the patient POC. Review of the hospice provider's policy titled, "Physician Orders", revised 11/01/2021, showed in part that medications and treatments will not be administered without the written order of a qualified physician, physician designee, physician assistant or nurse practitioner. Medication orders must include the name and dose of the medication. RECORD/PATIENT #4: Review of the RN start of care assessment dated 05/20/2023 showed the patient resided in a LTCF. The patients chronic pain was being treated with Percocet (narcotic pain medication) 10/325 milligrams (mg) every six hours. The patient stated he/she needed it more frequently. The nurse received an order from the physician to increase the Percocet to every four hours while awake. Caregiver aware and understanding of medication schedule, dosage, indication for use and side effects. Review of RN (registered nurse) A's visits showed: - On 06/02/2023 the patients pain was controlled with morphine. The patient wanted to stop all PO (by mouth) medications except for pain medications. Discussed at IDG (interdisciplinary group) today. The physician gave an order to discontinue all PO medications. The order was given to the LTCF staff; and - On 06/13/2023 the patient rated his/her pain a level of ten. In another section of the pain assessment the pain was rated at a level of eight. The patients pain level at the end of the visit was eight. The patients pain goal was four. The MSIR (morphine sulfate immediate release, narcotic pain medication) was increased to 0.05 (unsure if this was to be 0.25 or 0.5) ml (milliliter) every hour as needed. Spoke with the staff nurse to inform of the changes. The patient asked for pain medication every hour. Informed facility nurse to call the hospice if the increase in pain medication does not help. Review of a physician order dated 06/13/2023 showed an order to increase MSIR (dose not documented) to every 12 hours and every one hour as needed. Review of the IDG comprehensive assessment and Plan of Care Update Report dated 06/16/2023 showed a hospice physician order on 06/14/2023 for Dexamethasone (steroid medication) two mg two times a day. The hospice physician documented opiates (pain medications) were increased for pain. The POC showed a problem of uncontrolled pain. Intervention included to teach facility staff pain medication times and amounts and to give pain medications as ordered and as needed. The goal was that the patients pain would be controlled by 06/30/2023. Review of a physician order dated 06/14/2023 showed an order for Dexamethasone two mg two times a day for bone pain. No documentation of coordination with the facility regarding this order. Review of the LTCF physician orders and medication administration record dated August, 2023 showed no order for Dexamethasone two mg two times a day. Review of the skilled nurse (SN) visits showed: - On 06/15/2023 two sections of the pain assessment showed the patient rated his/her pain level at five. The end of the visit showed a pain level of eight. The narrative section showed the patient reported poor pain control at a nine and down to a six after pain medication. Instructed to put on call light to request pain medication when needed. He/she verbalized understanding. Interventions provided included showed instruction to patient/caregiver the cause of pain in the terminally ill. The patient verbalized understanding. Instructed patient/caregiver to coordinate administration of pain control medications with activity, types of pain, signs and symptoms of pain, and how to describe pain. Goals not met included patient/caregivers need to report changes in pain level to hospice RN, understands the cause (s) of pain, administration and side effects of pain medication, and understand the pain scale and how to manage pain ad report changes to the hospice RN. Left hospice folder with phone number visible to call hospice when needed (unsure if this was given to patient or facility). Coordination showed IDG. No documentation of what was coordinated with the IDG or coordination with the facility; - On 06/23/2023 the patient denied pain. Nonverbal pain indicators included nonverbal complaints observed with movement and facial grimace/winces observed with movement. Prescription medications for pain control showed morphine (did not include the Dexamethasone). Pain relief measures provide an acceptable level of pain relief. Pain post treatment showed zero nonverbal pain indicators; - On 06/27/2023 showed LPN (licensed practical nurse) B documented a pain score of eight that was continuous. Relieved with prescription pain medication, rest, and relaxation. Breakthrough medication needed greater than three times a day. The question did you assess patients pain post treatment was answered no. Medications reconciled and current medications met the patients needs. The patients pain rating at the end of the visit was zero. The integumentary (pertaining to the skin) findings showed wound (s). The bilateral heels were bruised and soft (could indicate tissue damage). The heels were floated on pillows and skin prep applied. Care coordination showed would discuss in IDG. No documentation of coordination with the physician, hospice RN, or facility staff; and - On 06/29/2023 the patient's pain level was five with a pain goal of four. Assessment post treatment showed a level of four (no documentation of what treatment was given). Facility nurse instructed on safe medication disposal. A medication reconciliation was performed. Interventions provided included instructing patient/caregiver to coordinate administration of pain control medications with activity. The integumentary findings showed wounds. No documented assessment of the wounds or wound care orders. Care coordination showed IDG. No documentation what was coordinated with IDG or that wound care was coordinated with facility staff. Review of a physician order dated 06/29/2023 showed an order to discontinue Percocet 10-325 mg one tablet every four hours while awake and add Percocet 10-325 mg two tablets every four hours for pain. Review of the IDG comprehensive assessment and plan of care update report dated 06/30/2023 showed an order dated 06/29/2023 for Percocet 10-325 mg take two tablets every four hours for pain. The hospice physician documented the patients pain was a lot worse. The Percocet and liquid morphine was increased. Wounds on both heels breaking down. Coccyx (tailbone) wound stage 2 (a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater). There was no documentation in the SN visits of a wound to the coccyx. There was no update to the POC regarding treatments, interventions, and goals for the wounds. Review of RN A's visits showed: - On 07/06/2023 the patient's pain level was a level of five. Post treatment the pain level was three.. The pain goal was four. The integumentary assessment showed wounds. There was no documented wound assessment or information regarding wound care orders. Care coordination showed IDG. No documentation what was coordinated with the IDG and no documentation of coordination with facility staff; - On 07/11/2023 the patient's pain level was five. Post treatment the pain level was three. Post treatment the patient rated his/her pain at a zero. The end of visit level showed five (unsure of this documentation since post treatment level was zero). The integrity assessment showed wounds. No further information documented regarding wounds. - On 07/13/2023 the integumentary assessment showed wounds. The pressure ulcers to the left buttock was healing without signs and symptoms of infection. The nurse cleansed the wound with normal saline (salt solution with healing properties) and covered with Optifoam (foam dressing, there were no physician orders found for this treatment). No information documented regarding the patients heels. The pain level was rated a level of six. Post treatment the level was zero. At the end of the visit the level was four (unsure of this documentation since post treatment was zero) with a pain goal of four. The patient reported his/her pain was better controlled. Discussed with the medication nurse whether the patient had enough pain medications. Care coordination showed IDG but no specific information what was coordinated with the IDG and no documentation of coordination of wound care with the facility staff. Review of the IDG comprehensive assessment and plan of care update report dated 07/14/2023 showed an order for MSIR 20 mg/ml give 0.25 ml every four hours. The plan of care identified a problem of increased skin breakdown to the coccyx area. Interventions included to teach the caregiver preventions of skin breakdown, keep skin clean and dry, and change position every two hours with a goal the wound to the coccyx would heal without complications. There was no documentation regarding treatment orders and there was no update with interventions and goals regarding the patients heels. The hospice physician documented the patient status was expected disease trajectory as evidenced by worsened status over time. Continued to decline. See recertification narrative for details. Review of the hospice physician recertification narrative dated 07/14/2023 showed the patient was admitted to hospice services for COPD (chronic obstructive pulmonary lung disease, a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). Likely has lung cancer that has spread to the bone. Increased bone pain requiring Dexamethasone. Lots more air hunger and pain than before and using the morphine and Percocet regularly. The patient has developed stage 2 pressure ulcers to both heels and the right buttock. Review of a physician order dated 07/14/2023 showed an order for MSIR 20 mg/ml give 0.25 ml every four hours. No documentation of coordination with the facility regarding this order. Review of the LTCF physician orders and medication administration record dated August, 2023 showed no order for MSIR 0.25 ml every four hours. Review of RN A's visits showed: - On 07/18/2023 the patient's pain level was five. Post treatment level was four. Pain goal was four. The integumentary assessment showed within normal limits. There was no specific information documented regarding whether the wounds had healed; - On 07/25/2023 the patient was not uncomfortable due to pain. Pain level was four. Post treatment level was zero. The integumentary assessment showed wounds. No further information was documented regarding the wounds; and - On 07/27/2023 the pain level was five. Post treatment was zero. The right heel wound was open and draining small amounts of S/S (unsure if this meant serosanguineous which is a thin, watery, pink colored fluid). The wound bed was covered with black eschar (dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed). Dressing changed per aseptic technique. Cleaned with normal saline and covered with Optifoam (There were no physician orders found for this treatment). Instructed patient to keep feet off the sheets and propped up with a pillow. Pain is controlled with current pain medications. No information regarding the patients left heel or coccyx. Care coordination showed IDG but no specific information what was coordinated with the IDG or coordination with facility staff. Review of the IDG comprehensive assessment and plan of care update dated 07/28/2023 showed an order dated 07/14/2023 for MSIR 20 mg/ml give 0.25 ml every four hours. The hospice physician documented that the morphine was increased and has Percocet to utilize. New wounds to bilateral heels stage 2 (the SN assessment on 07/27/2023 showed the right heel wound was covered with eschar which would make the wound unstageable). The plan of care showed no update with problems, interventions, and goals related to the patients heels. Review of RN A's visits showed: - On 08/01/2023 the patient's pain level was six. Post treatment level was three. The integumentary assessment showed within normal limits. The wounds to the bilateral heels were closed with no drainage noted. No further documented assessment and no information regarding the coccyx. Coordination showed IDG but no specific information what was coordinated; - On 08/03/2023 the patient's pain level was four. Post treatment level was zero. Pain level at end of visit was four. Pain goal was four. - On 08/08/2023 the pain level was five. Post treatment level was zero. no information regarding wounds. The patient took two Percocet 10/325 mg every four hours and alternates with morphine every four hours (the LTCF MAR did not include the order for morphine every four hours). No information regarding wounds; and - On 08/10/2023 the patient's pain level was six. Post treatment level was four. The patient reported pain level at an eight an hour ago and had morphine about an hour ago and alternates with morphine and Percocet. The patients pain was a level of four at the end of the visit with a pain goal of five. Will discuss with physician at IDG about a change in pain medication. The patient had redness to the buttocks. Calmoseptine (no order found for this, an ointment that provides a moisture barrier that prevents and helps heal skin irritations) applied. Heel wound dressing was intact and changed earlier today. Review of the hospice IDG comprehensive assessment and plan of care update dated 08/11/2023 showed pain not controlled. Add Fentanyl (narcotic pain medication) patch 25 mcg (micrograms) every 72 hours. No information regarding the patients wounds. Observation during the patients home visit on 08/15/2023 beginning at 11:30 AM, showed the aide/LPN set up for the patients bath. The patient wore pressure relief booties on his/her heels. The aide/LPN stated he/she did not know of any special precautions to take with the patient. When asked if the patient had wounds on his/her foot, he/she stated yes but he/she did not touch the dressings. The nurse would do that. When asked if the patient had any areas to his/her bottom, the aide asked the patient if there was a spot on his/her bottom that they put dressings on? The patient responded yes. The patient washed his/her face. The patient was calm, pleasant, and conversed appropriately with the hospice aide/LPN. Review of the LTCF physician orders and treatment administration record dated August, 2023 showed no wound care orders for the patient. Review of RN A's visit dated 08/15/2023 showed the patient started Fentanyl patches 25 mcg on Friday. The patient reported the pain was a little better but taking morphine every hour. The nurse called the physician and obtained an order to increase the Fentanyl patch to 50 mcg. Discussed increase with facility nurse. Prescription written. The wound assessment (this was the first documented complete wound assessment) showed the right heel measured 3.0 x 3.0 x 3.0 centimeters (cm). The top section of the assessment showed it was a stage 2 pressure ulcer and the body of the assessment showed suspected deep tissue injury (purple or maroon colored area of discolored intact skin or blood filled blister due to damage of underlying soft tissue), small amount of serosanguineous drainage, surrounding skin normal, no odor, slough (yellow colored dead tissue which can be stringy or thick and adherent to the wound bed) 26-50%, eschar 0-25%, no undermining (a separation of wound edges), epithelialization (healing tissue) 75- less than 100%. Wound care included cleansing with normal saline and applying Optifoam. The left heel measured 2.0 x 2.0 x 0.0 cm, the top section of the assessment showed stage 2 pressure ulcer and another section of the assessment showed suspected deep tissue injury, small amount of serosanguineous drainage, slough and eschar 0-25%, surrounding skin bright red, no undermining, epithelialization 75- less than 100%. Wound care included cleansing with normal saline and applying Optifoam. The nurse documented the heels were now open with S/S drainage. Cleaned wounds with normal saline, applied Optifoam and heel protectors on. Instructed to keep feet elevated. Review of the Hospice/Nursing Home Coordinated Task Plan of Care showed no updates since 05/20/2023 to include wound care schedule. During an interview on 08/15/2023, at 11:50 AM, the facility charge nurse stated that the hospice nurse verbally gave them new orders. They started the patient on a Fentanyl patch last Friday (08/11/2023) but did not think the patient really needed it. The charge nurse stated that the hospice nurse usually did the treatments when he/she came. The charge nurse had done the treatment once or twice. He/she thought they cleaned the bottom and applied Allevyn (foam dressing), used skin prep on the left heel, and hydrofera blue (antibacterial dressing) on the right heel. He/she could not find these orders in their electronic system. The director of nursing stated that the patient had wounds on both heels and bottom. They could never get hospice orders. The hospice had not coordinated wound care with them. They never knew when hospice was coming. During an interview on 08/16/2023 at 11:50 AM, the administrator stated that the nurses do a medication reconciliation when they go to the facilities. They ask for the facility chart and compare to what they have on their tablets. When a new order is received, they call and talk to the facility nurse or if they get an order while in the facility they verbally give them the order and document this communication in their notes. If they give pain medication or have the facility give pain medication they should document that. It is their policy to document a wound assessment at least once a week. They should open the integrity system in their assessments and document measurements and assessments. He/she would expect the nurse to document wound care orders and coordinate with the facility. During an interview on 08/17/2023 beginning at 9:03 AM, with RN A and the administrator, RN A stated that the patient would rate his/her pain a ten even if just laying there. He/she has had to do education with the patient regarding his/her pain ratings. Last week, they started him/her on a Fentanyl patch that seemed to help but the LTCF nurses stated he/she asked for morphine every two to three hours and sometimes every one hour. Yesterday, the pain was much better. When he/she sees the patient, he will be watching TV. He/she doesnt seem restless or have any grimacing. When he/she received a new order, he/she gave the facility a written order. When asked about the Dexamethasone order, he/she stated that they used to have a chart he/she could look at but now everything is computerized. He/she always asks if he/she has the same medications and reviews it verbally with the staff from his/her tablet and they look at their list and say it is the same. When he/she asks for their medication sheets, they say they dont have time to print it out and he/she cannot get into their computer to look. He/she gave the Dexamethasone order to the facility. The morphine order for every four hours was also given to the facility. He/she does not make a copy when he/she gives them the orders. The patients heels sometimes look bruised and reddish in color. Last week it was draining and he/she got an order for Optifoam (foam dressing) and to clean with normal saline. The facility staff said they had been putting on heel protectors and applying skin prep. They are putting Calmoseptine on the coccyx area. He/she did have Stage 1 (a persistent are of skin redness without a break in the skin that does not disappear when pressure is relieved) redness and they were applying Calmoseptine. It was all healed this week. RN A stated that he/she did wound assessments when a patient had a wound. He/she did not remember his/her documentation about the patients wounds. He/she cleaned with normal saline and applied Optifoam. The administrator stated that he/she would expect the order to increase the MSIR to include a dosage. RN A stated that from now on, he/she would stand there until they gave him/her a copy of the medication sheets. The administrator stated that he/she is going to have a meeting with the administrator and director of nursing. When asked about the pain assessments on 06/13/2023 and 06/15/2023, RN A stated that the first pain rating is what the patient told him/her and the second entry rating of was the rating at the end of the visit. When asked about the other section that showed a rating of eight at the end of the visit, he/she stated that he/she obviously did not pay attention when he/she entered the information. The administrator stated that if a patients pain is not at their goal and they have given pain medication, he/she expected the nurse to wait for about 30 minutes to ensure the pain is under control. During an interview on 08/17/2023 at 10:00 AM, the administrator stated that he/she did not find any more wound assessments or treatment orders. He/she was going to get the facility medication record to ensure the medications were fixed. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice with a terminal diagnosis of esophageal (The tube connecting the mouth to the stomach) cancer with metastasis (spreading of the cancer from its initial site to a new site) to the liver. The patient had a history of a cerebrovascular accident (CVA, Stroke) in April 2023 and had a right above the knee amputation (surgical removal of the leg above the knee) approximately two years ago. He/she had an esophageal tumor which impaired his/her ability to speak and swallow food. He/she had a tube surgically inserted through the skin into the stomach (PEG tube, percutaneous endoscopic gastrostomy) and received nutrition through the tube every night from 7:00 PM to 7:00 AM. The patient lived in a long-term care facility (LTCF) and required maximum assistance with his/her activities of daily living (ADLs). Review of the plan of care (POC), dated 07/31/2023, showed the following: - The patient received skilled nursing (SN) visits two times a week and as needed; - The patient received hospice aide visits two times a week; - The patient received social worker visits one time a month; - The patient received chaplain visits one time a month; and - The hospice nurse was to coordinate POC with the facility staff. Review of the physician order, dated 07/31/2023, showed; - PEG site: Cleanse area around tube with soap and water the cover with drain sponge around tube, secure with tape; - Flush PEG tube with 200 milliliters of water every four hours and check residual (fluid content that remains in the stomach) every four hours; - The order failed to include the frequency for the PEG tube cleansing and dressing change; and - The order failed to contain information regarding what days the hospice nurse would perform the dressing change to the PEG site. Review of SN visit notes showed: - On 07/31/2023, the registered nurse (RN) documented care coordination took place in the development of the POC with the long-term care facility (LTCF) director of nursing (DON). The note failed to specify what was contributed by the DON; - On 08/01/2023, the RN documented that care coordination took place with the hospices interdisciplinary team (IDT) and that the facility charge nurse was educated that narcotics will be destroyed when the patient expires; - On 08/04/2023, the RN documented that care coordination took place with the hospices IDT and the hospices social worker; - On 08/07/2023, the RN documented that care coordination took place with the hospices IDT and that he/she spoke with a nurse at the LTCF and no needs were voiced at that time; and - On 08/10/2023, the RN documented that he/she discussed the POC with the IDT and the LTCF nurse. The note failed to include specific information about what was discussed. Review of the chaplain visit note, dated 08/03/2023, showed, the patient expressed a desire for no chaplain visits. Observation on 08/15/2023 at 10:45 AM, during the patients home visit, showed the long-term care facilitys records, provided by the hospice (located in a three-ring binder at the nurses station), contained a coordinated task plan of care that showed: - Hospice nurse visits had a start date of 07/31/2023; - The provider failed to complete the hospice nurse visit schedule; - Hospice aide visits had a start date of 07/31/2023; - The provider failed to complete the hospice aide visit schedule; - The provider failed to complete the social worker visit schedule; - The provider failed to include the chaplain visit on 08/03/2023 and that no further visits would be made per patient request; - The provider failed to include hospice wound care (the PEG site cleansing and dressing change, the dressing change was completed by the hospice nurse during this home visit observation); and - The provider failed to specify what days the hospice nurse would complete the wound care. Per an interview conducted immediately following the home visit observation, the LTCFs charge nurse stated that he/she did not recall seeing the hospice binder before this week. He/she has not had a lot of contact with the hospice nurses and they do not usually give or get report before or after seeing the patient. He/she said the hospice aide is good about communicating with them after the visit but they do not know what days the aide is coming, they just show up. The charge nurse also stated that they do not know what tasks the hospice nurse or the hospice aide will be doing when they get to the facility. They are not able to coordinate the delivery of their care around the hospices care because they usually do not know what they will be doing but he/she did not think the nurses usually did any treatments or dressing changes when they came for a visit. During an interview on 08/16/2023 at 12:10 PM, the administrator stated that the facilities complain that the hospice staff doesnt communicate with them and the hospice staff complains that the facilities wont communicate with them. They complain about each other and he/she thinks the facilities have their favorite hospices and dont want to work with the others.

Based on policy review, observation, and interview the hospice provider failed to ensure the long-term care facility (LTCF) patient record contained a copy of all required hospice documents in one of two home visit observations of patients that resided in a LTCF (Record/Patient #4). This deficient practice has the potential to affect all of the provider's patients who reside in a LTCF. --- Findings included: Review of the hospice provider's policy titled, "Hospice Care in the Nursing Home/Skilled Nursing Facility Setting," revised 06/01/2018, showed in part that the hospice provider would provide in the nursing home/skilled nursing facility with the most recent hospice plan of care, hospice election form (shows when a patient elects to begin hospice services), physician certification and recertification of the terminal illness (this is signed by the physician at the start of care and at different intervals to certify the patient has a terminal illness with a life expectancy of six months or less), hospice medication information, and hospice physician orders. RECORD/PATIENT #4: Review of the record showed the patient resided in a LTCF and received hospice services beginning on 05/20/2023. During an interview on 08/15/2023, beginning at 11:50 AM, during a home visit observation, the LTCF director of nursing stated that they did not have hard charts anymore. He/she looked in the patients paper chart and their electronic record. He/she could not find a current hospice plan of care (POC), hospice election form, physician certification and recertification, current medication profile, and hospice physician orders. The findings were reviewed with the administrator on 08/16/2023 beginning at 11:50 AM. No additional information was provided.