Every finding on record at Loving Hands Hospice, LLC

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the social workers comprehensive assessments were completed within five days of election of hospice care in one of five records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";PC.30 Plan of Care Process," last reviewed 09/01/2024, showed in part: - A comprehensive assessment will be completed by the Hospice Interdisciplinary Group/Team (IDG/IDT) no later than five calendar days after the election of hospice care and consultation with attending physician; and - The contents of the comprehensive assessment will identify the patients physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the hospice patients well-being, comfort and dignity throughout the dying process. RECORD/PATIENT #5: Review of the hospice election statement showed the effective date of election was 07/26/2023. Review of the record failed to show an initial MSW evaluation visit within five days of hospice election. During an interview on 10/23/2024, at 4:17 PM, the administrator stated that there was no initial assessment completed by the MSW for July 2023. He/she expects it to be completed within five days after the admission.

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to ensure clinicians maintained an accurate/updated medication profile/POC (plan of care) in, but not limited to, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the providers patients. --- Findings included: Review of the providers policy titled, ";PC.85 Medication List and Monitoring," last reviewed 09/01/2024, showed in part: - A medication/drug profile will be maintained on all patients; - Medication monitoring will include appropriate data/information to develop an accurate patient medication history and a current, complete medication profile; - The Hospice will review, monitor and maintain a current, accurate list of all prescription and over the counter medications, herbal remedies and other alternative treatments that could affect drug therapy taken by patient; - The medication will be documented on the medication/drug profile; - Changes in the medication/drug regimen will be documented in the medical record either on the medication profile, or a verbal order plan of care, as well as communicated to the patient and/or caregiver; and - The medication/drug profile will be updated as frequently as necessary to reflect changes in the medication regimen, keeping the profile accurate. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/25/2024 with a primary diagnosis of Alzheimers disease (a disease marked by progressive loss of mental capacity). The patient resided in a long-term care facility (LTCF). Observation on 10/22/2024, starting at 10:00 AM, the patients medications were reconciled utilizing the current medication profile report supplied to the surveyor by the provider and the 10/01/2024 through 10/22/2024 physician order report provided by the LTCF. The following discrepancies were noted: - The physician order report showed the patient took melatonin (needed for insomnia) 5 milligrams (mg) take one tablet by mouth at bedtime as needed. The current medication profile report failed to include melatonin; - The physician order report showed the patient took polyethylene glycol (needed for constipation) mix 17 gram (gm) in eight ounces (oz) liquid daily as needed for constipation. The current medication profile report failed to include polyethylene glycol; - The physician order report showed the patient took acetaminophen (treats minor aches and pains) tablets 325 mg take two every four hours as needed. The current medication profile report failed to include acetaminophen; - The physician order report showed the patient took Norvasc (treats high blood pressure) 10 mg take one tablet by mouth daily. The current medication profile report failed to include Norvasc; - The physician order report showed the patient took mirtazapine (antidepressant) 45 mg take one tablet at bedtime. The current medication profile report failed to include mirtazapine; - The physician order report showed the patient took paxil (antidepressant) 10 mg take one tablet by mouth daily. The current medication profile report failed to include paxil; and - The physician order report showed the patient took acetaminophen tablet, chewable 325 mg take one by mouth two times a day. The current medication profile report failed to include acetaminophen. During an interview on 10/24/2024 at 12:10 PM, the administrator stated that he/she would expect medications to be reconciled every visit and in the interdisciplinary team meetings and expected all medications the patient was taking to be on the medication profile.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an individualized plan of care (POC) when it included interventions for a Macy catheter (a rectally inserted catheter for medication administration) and the patients did not have a Macy catheter in, but not limited to, two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect the individualized care of all patients served by the provider. Findings included: Review of the providers policy titled, ";Plan of Care Process," last reviewed 09/01/2024, showed in part: - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the hospice interdisciplinary group (IDG) in collaboration with the attending physician, the patient or representative, and the primary caregiver, in accordance with the patients needs; - The hospice will develop an individualized written POC for each patient; and - The POC must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. --- RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice on 09/16/2024, with a terminal diagnosis of sepsis (a life-threatening infection in the bloodstream) and a secondary diagnosis of urinary tract infection. The patient lived in an assisted living facility and his/her adult children were involved in his/her care. Review of the initial comprehensive assessment dated 09/06/2024, showed the patient was alert and oriented to person, place, and situation. He/she did not have any trouble swallowing and was on a regular diet. He/she required maximum assistance with feeding and total assistance with dressing, bathing, and toileting. The patient did not have a Macy catheter for medication administration and medications were ordered to be administered orally. Review of the POC, dated 09/16/2024, showed in part the following interventions: - SN will collaborate with MD for order for and utilize Macy catheter for medication and the date the intervention was updated was 09/17/2024; and - SN will educate family/patient/facility RN in regard to usage of Macy catheter with return demonstration and the date the intervention was updated was 09/17/2024. Review of IDG meeting notes showed in part: - On 10/01/2024, the IDG noted the patient lived in a facility, the facility managed all medications, continue current POC and goals; and - On 10/15/2024, the IDG noted the patient fed himself/herself finger foods but did cough with thin liquids. The facility requested an order to crush medications as needed. The current POC problems included SN will educate the family/patient/facility RN in regard to usage of Macy catheter with return demonstration and the outcome was documented as ";effective" and the patient/family engagement was documented as ";engaged". Per an interview conducted prior to home visit observation on 10/22/2024 at 10:00 AM, RN – A stated that the patient did not have a Macy catheter. The nurse who develops the POC chooses the interventions in the computer based on the patients diagnoses and this was one of the canned interventions that come up as a choice. The admitting nurse usually selects all the interventions associated with that particular diagnosis. He/she stated that the POC should be individualized, and the Macy catheter should not be on the patients POC. During an interview on 10/24/2024 at 11:45 AM, the administrator and governing body appointee A stated that the Macy catheter is an optional intervention that shows up in their system and it sounded like some of their staff did not know to not choose those options on every patient. Both the administrator and governing body appointee - A stated that the POC interventions should be individualized. Record/Patient #1: Review of the clinical record showed the patient elected hospice on 06/25/2024, with a terminal diagnosis of Alzheimers (a disease marked by progressive loss of mental capacity). The patient lived in a long-term care facility (LTCF). Review of the initial comprehensive assessment dated 06/25/2024, showed the patient was oriented to self only and disoriented. He/she did not have any trouble swallowing and was on a diet as tolerated. He/she required maximum to extensive assistance with feeding, dressing, bathing, toileting, ambulation, and transfers. The patient did not have a Macy catheter for medication administration and medications were ordered to be administered orally. Review of the POC, dated 07/08/2024, showed in part the following interventions: - Skilled nurse (SN) will collaborate with MD (Doctor of Medicine) for order for and utilize Macy catheter for medication and the date the intervention was updated was 07/11/2024; and - SN will educate family/patient/facility registered nurse (RN) in regard to usage of Macy catheter with return demonstration and the date the intervention was updated was 07/11/2024. Review of IDG meeting notes showed in part: - On 10/15/2024, the IDG noted the patient lived in a LTCF, the facility managed all medications, no changes in POC; and - On 10/01/2024, the IDG noted the patient lived in a LTCF, the facility provides primary care and administers medications, patient on pureed diet; and - On 09/17/2024, the IDG noted the patient lived in a LTCF, the facility administers medications and provides 24/7 care. Observation on 10/22/2024, starting at 10:00 AM, showed the patient had no Macy catheter present during his/her total bed bath by the hospice aide

Based on provider policy review, clinical record review, and interview, the hospice provider failed to ensure that care and services were provided in accordance with the plan of care in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";PC.30 Plan of Care Process," last reviewed 09/01/2024, showed in part: - To ensure that the care provided is in accordance with the written Plan of Care (POC), appropriately planned, and delivered in a timely manner to meet the patients and familys special needs; and - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice Interdisciplinary Group/Team (IDG/IDT) in collaboration with the attending physician, the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs. RECORD/PATIENT #1: Review of the clinical record showed that the patient was admitted to hospice services on 06/25/2024, with an admitting terminal diagnosis of Alzheimers (a disease marked by progressive loss of mental capacity). Review of the initial plan of care dated 07/08/2024, showed skilled nurse (SN) visits were to be once weekly and three as needed visits every 14 days. Review of the clinical record showed: -The record failed to show documentation of a SN visit for the week of 09/29/2024 through 10/05/2024; and -The IDG/IDT failed to ensure SN visits were provided as ordered. During an interview on 10/24/2024 at 10:57 AM, after requesting SN visit notes for 09/29/2024 through 10/05/2024, the governing body appointee A stated that there was no visit completed, and he/she would expect it to be completed.

Based on policy review, record review, and interview, the hospice provider failed to ensure all disciplines were informed of the patients complaint of painful urination during a chaplain visit in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Coordination of Care," last reviewed 09/01/2024, showed the hospice will develop and maintain a system of communication and integration to ensure that the care and services provided are based on all assessments of the patient and family needs and to provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice on 09/16/2024, with a terminal diagnosis of sepsis (a life-threatening infection in the bloodstream) and a secondary diagnosis of urinary tract infection. The patient lived in an assisted living facility and his/her adult children were involved in his/her care. Review of the skilled nurse (SN) note, dated 10/07/2024, showed the SN received a telephone call notification that the patient was started on amoxicillin (an antibiotic) 500 milligrams (mg) twice daily for five days on 10/05/2024 for a urinary tract infection. Review of the chaplain visit note, dated 10/10/2024, showed: - The patient complained of pain with urination (five days after the antibiotic was started); - Coordination of care was documented as ";Facility nurse denied concerns"; and - The visit note failed to show the chaplain notified the facility care team, the interdisciplinary group (IDG), or the registered nurse (RN) case manager of the patients continued complaint of painful urination. Review of the IDG meeting notes, dated 10/15/2024, showed the chaplain failed to inform the RN case manager or IDG members of the patients complaint of painful urination on 10/10/2024. During an interview on 10/23/2024 at 4:40 PM, the administrator stated that he/she spoke with the chaplain, and he/she stated that it was discussed in the ";stand up meeting" but there was no documentation that showed the patients complaint was reported to the RN case manager or the IDG. The administrator stated that he/she expected the chaplain to have documented their communication with the nurse.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the bereavement services reflect the needs of the bereaved in one of one bereavement record reviewed (Record/Patient #11). This deficient practice has the potential to affect all the bereaved served by the provider. --- Findings included: Review of the providers policy titled, ";Bereavement Coordinator Job Description," last reviewed 06/01/2020, showed in part, the bereavement coordinator provided continued bereavement support to hospice families evidenced by documentation. Review of the providers policy titled, ";Administrative Policy Manual: Bereavement," last reviewed 09/01/2024, showed in part, the bereavement services will reflect the needs of the bereaved and the provider will make bereavement services available to the family for up to one year following the death of the patient. RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 05/31/2024 with a principal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient passed on 06/05/2024. Review of the skilled nurse (SN) comprehensive assessment dated 05/31/2024 showed ";moderate risk" level of complications to normal grief process. Review of the Bereavement Care Plan, dated 06/08/2024 failed to show a completion date for the following interventions with timeline dates: -By 07/05/2024 complete 30-day phone call for follow up and to set up bereavement visit; - -By 07/20/2024 complete bereavement visit to assess risk; - - By 08/09/2024 complete Hospice Survey notice letter; - - By 09/03/2024 complete three-month letter with grief support information; and - - By 10/03/2024 complete additional bereavement encounter. Review of the social workers notes dated 07/22/2024 showed the bereavement coordinator left a voice mail message offering support and did not offer to visit because the bereaved lived out of state. The social worker failed to follow the timeline of the care plan and document attempts to offer bereavement support and services. During an interview on 10/24/2024 at 12:00 PM, the registered nurse coordinator (RNC) stated that the social worker was expected to document in the plan of care the efforts to provide bereavement services and limitations to bereaved family members that were out of state.

Based on policy review, record review, and interview, the hospice provider failed to ensure the hospice aide provided patient visits as ordered by the interdisciplinary group (IDG) in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients receiving aide services from the hospice provider. --- Findings included: Review of the providers policy titled, ";Hospice Aide," last reviewed 10/01/2024, showed in part: - A hospice aide care plan is completed by the registered nurse (RN). This identifies the patients care needs and the hospice aide can only perform the tasks that are checked; - It is very important to check the care plan every visit as the RN may have updated and changed the plan; - A hospice aide note is completed for each visit; - Notify the RN if the patient refuses care or the visit; - A communication note, or similar electronic format is used if a visit is attempted and not completed; and - Notify the RN and the office if the patient declines care or if it is discovered that a visit was missed and document the specifics on a communication note. RECORD/PATIENT #2: Review of the plan of care (POC), dated 09/16/2024, showed an order for hospice aide visits two times weekly. Review of the IDG meeting notes, with dates ranging from 09/17/2024 through 10/15/2024, showed the hospice aide visits were increased to three times weekly effective 10/02/2024. Review of the hospice aide visit notes showed: - A hospice aide visit on 10/01/2024; - A missing aide visit for the week of 09/29/2024 through 10/05/2024 (this is the week the visit frequency increased to three times weekly); and - The visit notes failed to include missed visit notes or communication notes explaining the reason for the missed visit. During an interview on 10/23/2024 at 3:06 PM, the administrator stated that they reached out to the hospice aide, and he/she was currently dealing with a family emergency, so they were not able to reach him/her. They did not have any information about the missed visit. The system showed the visit was scheduled, but they did not have any documentation about why the visit was missed. The administrator and governing body appointee A both stated that the expectation was for the aide to fill out a missed visit form, then it would be forwarded to the nurse, and the nurse would notify the physician.

Based on policy review, record review, and interview, the hospice provider failed to forward a discharge summary to the patients attending physician in one of one revocation record reviewed (Record/Patient #8). This deficient practice has the potential to affect the coordination of care of all patients who revoke the hospice benefit. --- Findings included: Review of the hospice providers policy titled, ";Patient Discharge," last reviewed 09/01/2024, showed in part: - The hospice will follow federal, state, and local regulations related to patient discharge; and - The hospice will forward, upon revocation and discharge, copies of a summary of the patients care, the patients current plan of care (POC) including the current medication profile, the latest physician orders, and any other documentation requested or that may assist with the patients post-discharge continuity of care. RECORD/PATIENT #8: Review of the clinical record showed in part, the following: - The patient elected hospice on 01/31/2024; - The patient made the decision to revoke hospice because he/she felt he/she no longer needed hospice; - The patient revoked hospice on 06/21/2024; and - The provider failed to send a summary of the patients stay, the patients POC, current medication list or the latest physician orders to the patients attending physician. During an interview on 10/23/2024 at 1:00 PM, the administrator stated that they did not have evidence that a discharge summary was sent to the attending physician because that doctor did not want the hospice provider to send anything to his/her office. The administrator stated that they did not have any documentation that showed the physicians request.

Based on policy review, record review, and interview, the hospice provider failed to ensure safe disposition of narcotics upon discharge in one of three discharge records reviewed (Record/Patient #10). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the hospice providers policy titled, ";Disposal of Controlled Substances," last reviewed 09/01/2024, showed in part the following: - The disposal of controlled substances is at the discretion of the patient and/or caregivers; - The hospice will follow all applicable state and local regulations regarding disposal of controlled substances. The more stringent regulations will be followed; - After disposal by the hospice staff and/or assistance with disposal, the hospice staff will document the occurrence in the clinical record; and - Documentation in the patients record should include the type of controlled substance, dosage, route of administration, quantity disposed, and the time, date, and way the disposal occurred. RECORD/PATIENT #10: Review of the clinical record showed in part, the following: - The patient elected hospice on 04/02/2024 with a terminal diagnosis of dementia due to Alzheimers disease (a disease marked by progressive loss of mental capacity); - The patient lived in an assisted living facility (ALF); - Patients medications included hydrocodone – acetaminophen (a narcotic pain reliever), lorazepam concentrate (a narcotic used for anxiety/agitation), and morphine sulfate concentrate (a narcotic medication used for severe pain); - On 08/07/2024, the hospice nurse documented the hospice was notified on 08/06/2024 that the patients power of attorney took the patient out of the ALF for a visit and did not bring the patient back to the ALF. The POA moved the patient to Arizona without notification to the ALF or the hospice provider (this occurred ";last Friday" which was 08/02/2024); - The patient was discharged on 08/06/2024 for moving out of the service area; and - The record failed to show the disposition of the patients narcotic medication. During an interview on 10/23/2024 at 1:00 PM, the administrator stated that he/she called the ALF and asked about the disposition of the patients narcotics. The ALF told him/her that the patients POA told them they were only going to be out for a ";few days" and the ALF sent a ";few days" of the patients medications with the POA. When the ALF discovered the POA moved the patient to Arizona, the ALF destroyed the medications left behind by the patient. The ALF told the administrator that they could not send the hospice proof of the medication destruction because it was too long ago, and those records were sent to a storage location. The administrator stated that since the patient lived in an ALF and not in a contracted skilled nursing facility, the hospices policy on narcotic destruction would apply to this patient.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the long-term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one of one applicable records of patients that resided in a LTCF (Record/Patient #1). This deficient practice has the potential to affect all patients that resided in a LTCF. --- Findings included: Review of the providers policy titled, ";PC.125 Hospice Care in a SNF/NF or ICF/ID," last reviewed 09/01/2024, showed in part: - A Hospice plan of care (POC) will be developed based on the patient/familys needs. The POC will be written in collaboration with the Interdisciplinary Group/Team (IDG/IDT), facility staff, patient and/or the family, and the attending physician. A copy of the POC, which includes services furnished, will be provided to the facility; - The Hospice will provide the facility with the following hospice information/documentation on admission and on-going: * The most recent Hospice POC specific to each patient; * The Hospice election form and any advance directives specific to each patient; * The physician certification and recertification of the terminal illness specific to each patient; * The Hospice medication information specific to each patient; * The Hospice physician and attending physician orders specific to each patient; * The manner in which communication will occur to ensure that the needs of the patients are addressed and 24 hours a day, with specific instructions on how to access the Hospice's 24-hour on-call system; and * Names and contact information for the Hospice personnel involved in the care of each patient. Review of the providers policy titled, ";PC.125-MO Hospice Care in a SNF/NF or ICF/ID," last reviewed 10/20/2023, showed in part: - There will be a coordinated single plan of care (POC) in the nursing facility which may be multiple documents, that: * Reflects coordination and input from both the Hospice and the nursing facility; * Identifies the care and services which each will provide; * Is updated to reflect changes in patient/family condition, needs, and care; - A registered nurse (RN) is designated from the Hospice to: * Coordinate the implementation of the POC; and * Respond to questions and concerns from the nursing facility. RECORD/PATIENT #1: Review of the hospice record maintained at the long-term care facility (LTCF), during a home visit observation on 10/22/2024 beginning at approximately 10:00 AM, showed the hospice binder failed to contain: - The current hospice POC; - The hospice election form; - The physician certification and re-certification; - The name of the case manager involved in the patients care; - The current medication profile; - The hospice and attending physician orders; and - Complete written coordination that identified the care and services required. During an interview on 10/24/2024 at 10:59 AM, the registered nurse coordinator stated that: - The hospice staff did not use the LTCFs computer system; and - The binder in the LTCF should have been completed and include the missing documents.

Based on policy review, review of the providers patient roster and facility in-service records, and interview, the hospice provider failed to ensure facility staff were offered education on the hospice philosophy in 11 of 11 skilled nursing/long-term care facilities (SNF/LTCF) providing care to hospice patients. This deficient practice has the potential to affect the care provided to all SNF/LTCF patients served by the hospice provider. --- Findings included: Review of the hospice providers policy titled, ";Hospice Care in a SNF/NF (Nursing Facility) or ICF/IID (Intermediate Care Facility/Individuals with Intellectual Disabilities)," last reviewed 09/01/2024, showed the hospice will ";assure the orientation of staff who provides that care, in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements". Review of the providers current patient list showed 23 of 74 patients lived in a SNF/LTCF. On 10/24/2024, the administrator provided a three-ring binder titled, ";Facility Inservice 2024" that showed: - A sign-up sheet for (named assisted living facility) for ";Death and Dying," dated 01/15/2024; - A sign-up sheet for (named memory care assisted living facility), ";Hospice 101," dated 01/15/2024; - A sign-up sheet for (named assisted living facility) for ";Hospice 101," dated 02/02/2024; and - The provider failed to maintain documentation that education was offered to any SNFs/LTCFs On 10/24/2024 at 9:45 AM, the administrator stated that they did not have documentation to show education on the hospice philosophy was offered to the SNFs.

Based on policy review, employee file review, and interviews the hospice provider failed to ensure initial orientation was completed for an clinical employee who had patient and family contact in one of three employee files reviewed (Employee-A). The deficient practice has the potential to affect all patients served by the hospice. Findings included: Review of the agency's policy, last revised in 2019, titled "Employee Orientation HR.8" showed in part the following: The agency orientation for each employee will include but not be limited to: - Hospice philosophy; - Personnel issues and requirements; - Policies and procedures specific to the discipline; - Patient care issues; - Patient rights and responsibilities; - Safety issues; and - Job specific tasks. Employee - A: Review of the current employee list showed a medical director listed, the medical director is identified as employee-A. Review of the employee file of employee-A showed the following: - He/she was contracted as the medical director on 05/25/2022; - The skills checklist form of the employee was blank; - The competency checklist form of the employee was blank; - The "orientation checklist" form for contract employees which included hospice philosophy, compliance program, emergency preparedness, scheduling, supplies, patient rights, clinical policies and procedures, patient care issues, patient rights, abuse and neglect, safety issues; and job specific tasks was blank. During an interview with the medical director (Employee-A) on 09/22/2022 at 9:47 AM, he/she stated the following: - He/she was the medical director of the hospice for approximately three months; - He/she turned in his/her resignation notice on 09/20/2022 because his/her private medical practice was busy, the onboarding process with the hospice was disappointing, there were delays in getting him/her access to the electronic medical record and electronic prescription ordering; - When asked if he/she had received orientation regarding hospice philosophy, the hospice compliance program, the emergency preparedness program, patient rights, clinical policies and procedures, patient care issues, patient rights, abuse and neglect, safety issues; and job specific tasks he/she responded "No..none of that"; and - His/her last day as the hospice medical director will be 10/31/2022. During a review of the finding with the hospice administrator on 09/20/25022 at 3:32 PM, he/she stated that there is no evidence that the medical director had received orientation.

Based on policy review, record review and interviews, the agency failed to provide accurate education for the caregiver regarding the plan of care (L544). The effect of this deficient practice has the potential to affect all patients served by the agency.

Based on policy review, record review, and interviews the hospice failed to ensure that the primary caregiver received appropriate education by the hospice nurse as identified in the plan of care in, but not limited to, one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect all hospice patients. Findings included: Review of the agency's policy titled, "Plan of Care Process," dated 05/01/2020, showed in part that agency staff will ensure that the primary caregiver (PCG) receives education as appropriate for the care and services in the plan of care. RECORD/PATIENT #1: Review of the hospice plan of care showed the following: - The patient was admitted on 07/28/2022 with a terminal diagnosis of congestive heart failure; - The patient resided in an assisted living living facility (ALF-A); - On 08/12/2022 and 08/13/2022 the patient's physician orders for morphine were to give 0.25 milliliters (100 mg/5 ml), every four hours as needed (PRN) for dyspnea or pain, Review of a telephone visit note from hospice registered nurse (RN-B) on 08/12/2022 at 9:30 PM showed that the nurse documented the following: - The phone visit occurred on 08/12/2022 at 9:30 PM; - The patient fell on 08/12/2022 and complained of hip and shoulder pain; and - The ALF staff (level 1 medication aide) LIMA-A was informed about morphine dosing "standing order permits up to 1 ml (milliliter) as needed for pain" (it should be noted that the hospice has no standing orders to increase morphine dosing). Review of a hospice text communication note from RN-B to the hospice administrator and office manager showed "The facility is cool. I know (L1MA-A) well. (L1MA-A) gave me (the patient's family) number, but (he/she) dont answer. I texted (him/her) asking (him/her) to call me. (L1MA-A) is fine with giving Morphine and gave 0.25 and I told (L1MA-A) to double it and if necessary triple it till pt is comfortable". Review of the hospice complaint log showed an investigation from an incident on 08/12/2022 regarding (Patient #1). During the investigation the administrator and office manager interviewed RN-B in regarding to instructing the ALF staff to increase the morphine dosing. The interview notes showed RN-B stated that the comfort kit orders in Texas (the state where RN-B resides and works for the hospice corporation) "contain range of up to 1 ml (milliliter) Morphine". During a interview with the hospice administrator on 08/22/20022 at 1:57 PM, he/she stated that the hospice has no standing orders, and the nurse from Texas (RN-B) that gave the ALF staff directive to increase the PRN Morphine made an error informing the ALF staff to increase the morphine dosing. Review of a communication note written by the hospice medical director on 08/14/2022 showed he/she documented the following: - On 08/12/2022, the RN (RN-B), advised (the ALF) to increase (the patient's) morphine up to "1 ml" every four hours as needed. The order was for 0.25 ml every four hours; - "The physician was not notified of this event and was not discussed by (RN-B) or the ALF staff regarding a medication change"; and - After the diagnosis of fractures on 08/14/2022, he/she ordered a indwelling urinary catheter, a non-weight bearing status, an increase in morphine to 0.5 ml (10 mg) every four hours, dexamethasone (a steroid) for pain control twice daily, a Broda chair for comfort, and change hospice nurse visits to daily. During a interview with the hospice medical director on 08/22/20022 at 6:00 PM, he/she stated: - The hospice has no standing orders, or range orders for morphine; and - He/she did not authorize an increase in morphine for (Patient #1) until 08/14/2022, after the patient was diagnosed with pelvic fractures and possible sternal fracture. During an interview with RN-B on 08/25/2022 at 11:41 AM, he/she stated the following: - Was contacted by the hospice office manager on 08/12/2022 to follow-up with a nursing facility regarding a patient fall; - Patient #1 fell at an assisted living facility, I encouraged them to call emergency medical services, they stated the patient refused (it should be noted that all ALF three ALF staff interviewed stated the patient was confused and could not make his/her decisions); - I told him/her (L1MA-A) to give up to 1 ml per hour of morphine (100 mg/5 ml) for pain out of the comfort kit per standing orders; - He/she was unaware that the hospice provider did not have standing orders, he/she works for a provider in Texas where standing orders are available; and -"This (morphine education to the ALF primary caregiver) was a mistake on my part, an error". (It should be noted that RN-B had an employee file with orientation and training on file with the provider).

Based on policy review, record review, and interviews, the agency failed to ensure nursing core services were available and provided in a manner consistent with agency policy (L588). The effect of this deficient practice has the potential to affect all patients served by the agency.

Based on policy review, record review, and interviews the hospice failed to ensure core services (nursing services) were available and provided in a manner consistent with agency policy in, but not limited to, one (Record/Patient #1) of three records reviewed. This deficient practice has the potential to affect hospice patients. Findings included: Review of the agency's policy titled, "On-call for Patient Care," dated 10/01/2021, showed in part the following: - The on-call system is to ensure that patient care needs are safely met and appropriately after hospice office hours, during weekends and on holidays; and - The hospice ensures that a Registered nurse (RN) is available 24 hours a day, 7 days a week to respond to calls. RECORD/PATIENT #1: Review of the hospice plan of care showed the following: - The patient was admitted on 07/28/2022 with a terminal diagnosis of congestive heart failure; and - The patient resided in an assisted living living facility (ALF-A). Review of a telephone visit note from, licensed practical nurse (LPN-A) on 08/12/2022 at 8:50 PM showed he/she documented the following: - Received a call from the hospice administrator at 8:49 PM that (Patient #1) fell and is "hurt and we can't get a hold of the on-call nurse"; - The patient was having shoulder and hip pain; - LPN-A informed the assisted living facility (ALF-A) staff that the hospice on-call nurse was "likely with another patient and temporarily unavailable"; and - LPN-A informed ALF staff that "the on-call nurse for Three Oaks Hospice would be in to assess the patient as soon as possible". Review of a telephone visit note from hospice registered nurse (RN-B) on 08/12/2022 at 9:30 PM showed that the nurse documented the following: - The phone visit occurred on 08/12/2022 at 9:30 PM; - The patient fell on 08/12/2022 and complained of hip and shoulder pain; - The ALF staff (level 1 medication aide) LIMA-A was reminded about morphine that "standing order permits up to 1 ml as needed for pain" (it should be noted that the hospice has no standing orders to increase Morphine dosing); and - "called twice after conversation to (the patient's family) with no reply". Review of a nurse "phone" visit on 08/13/2022 at 2:41 PM showed RN-A documented the following: - Spoke with the ALF staff regarding the patient's fall the previous night, the ALF staff "felt it can wait until tomorrow"; and - The patient was having intermittent pain and has been provided morphine solution. Review of the ALF "controlled substance record" showed that the ALF staff administered the patient 5 doses of morphine 5 mg (milligram) from 08/12/2022 at 8:30 PM through 08/14/2022 at 2:00 PM for pain. Review of a written statement from the ALF staff, L1MA-C, that worked 08/12/22 at 7:00 PM through 08/13/22 at 7:00 AM showed he/she documented the following: - The hospice LPN called him/her on 08/12/2022 at around 9:00 PM, and said the hospice nurse would be out to do an assessment, but the hospice nurse was with another patient; and - "The hospice nurse never showed to do an assessment on the patient before I left at 7:30 AM on 08/13/2022". Review of a nurse visit note from 08/14/2022 at 4:00 PM showed RN-A documented the following: - The visit occurred on 08/14/2022 at 4:00 PM; - Type of visit was "weekend on call visit"; - Reason for visit was "s/p fall"; - The patient was confused; - The pain assessment showed the patient had a frown, was tense/fidgeting, occasional moan or groan, occasional labored breathing; - The patient was in sharp, severe pain to right shoulder; - "Patient was medicated with morphine on 08/14/2022 @10:00 AM and 2:15 PM; and - Physician was called to inform of fall and possible injury, orders obtained to send the patient out via ambulance for evaluation. Review of a nurse phone visit entry from RN-A on 08/14/2022 at 10:22 PM showed the nurse documented the following: - The patient was sent back to the ALF from the hospital after being diagnosed with "possible sternal fracture and pelvic fractures x2"; - The patient is now non-ambulatory, required a urinary drainage catheter insertion; - Morphine dose was increased to 10 mg every four hours as needed for pain; and - Dexamethasone (a steroid that assists in inflammation/pain control) was added for 10 days. Review of hospital physician records showed on 08/14/2022 the patient had right superior and inferior pubic rami fractures (pelvic fractures) displaced bone fragment and possible scapular body and sternal fracture. During an interview on 08/22/2022 at 3:06 PM, the assisted living facility (ALF-A) director of nursing stated: - The patient (Patient #1) was alert and confused before the fall on 08/12/2022; - The ALF level 1 medication aide (L1MA-A) called the hospice after the patient fell on 08/12/2022 at approximately 7:30 PM, after no response in 30 minutes he/she called the on-call service back; - The (hospice office manager) called the L1MA-A back at 8:30 PM and was told by L1MA-A that the patient fell and was having pain, the (hospice office manager) assured the L1MA-A that a nurse was son his/her way; - After 9:30 PM, there was still no hospice nurse, the L1MA-A had provided the patient PRN (as needed) morphine, the patient's pain was "better", the hospice nurse was messaged directly by the L1MA; - A hospice nurse (RN-B) called back around 9:30 PM and reassured the ALF staff (L1MA-A) that a hospice nurse was on their way, and the L1MA-A could double the morphine dose if the patient had any more pain; - At least three times on 08/13/2022 the assisted living facility L1MA-B called the hospice staff on-call service and private phones to ask for a nurse assessment, the patient was still in intermittent pain in the shoulder and hip; - The hospice nurse (RN-A) called "the morning of 08/13/2022" and told L1MA-B that he/she was "on the way". RN-A never came to the ALF to assess the patient on 08/13/2022; - We (the ALF staff) were blowing up their phones trying to get a nurse out"; - After another call to the hospice staff the morning of 08/14/2022, the hospice nurse arrived in the afternoon. The patient was having shoulder and hip pain, was transported to the hospital where two pelvic fractures and sternal fracture were identified. During an interview with RN-B on 08/25/2022 at 11:41 AM, he/she stated the following: - Was contacted by the hospice office manager on 08/12/2022 to follow-up with a nursing facility regarding a patient fall; - Patient #1 fell at an assisted living facility, I encouraged them to call emergency medical services, they stated the patient refused (it should be noted that all ALF three ALF staff interviewed stated the patient was confused and could not make his/her decisions); and - I told him/her (L1MA-A) to give up to 1 ml per hour of morphine (100 mg/5 ml) for pain out of the comfort kit per standing orders. Review of the last RN assessment before the 08/12/2022 fall showed that on 08/11/2022 at 11:00 AM that the hospice nurse, RN-A, assessed the patient to be confused, forgetful, and with a poor memory. This indicates that the patient's refusal of EMS [emergency medical staff] as described by RN-B on the 08/25/2022 interview would be contradicted by the reasonable person standard. During an interview with the ALF staff L1MA-A on 08/22/2022 at 3:57 PM, showed that he/she stated: - Worked 7:00 AM to 7:00 PM at ALF-A on 08/12/2022 and 08/13/2022; - He/she called the on hospice on-call service, or the hospice staff private phones at least twice on 08/12/2022 and twice on 08/13/2022 in attempts to get a hospice nurse to assess the patient; - The patient was confused and could not reliably make his/her own decisions; - When RN-B asked me if the patient needed a hospice nurse visit, I responded "yes"; - "(RN-B) told me I could give morphine every hour". (it should be noted the patient's morphine order was 5 mg every four hours PRN); and - I called at least twice more on 08/13/2022 and could not get anyone form the hospice to come out. Could not recall if he/she used the on-call service or called the hospice staff directly. During an interview with the ALF staff L1MA-C on 08/22/2022 at 6:35 PM, showed that he/she stated: - Worked 7:00 AM to 7:00 PM at ALF-A on 08/13/2022 and 08/14/2022; - He/she called the on hospice on-call service, or the hospice staff private phones at "several times" on 08/13/2022 and 08/14/2022 in attempts to get a hospice nurse to assess the patient, LIMA-A also tried; - The patient was confused and (the family) made the decisions; - The patient moaned with turning and repositioning after the fall, he/she gave a couple doses of morphine during his/her shifts; and - I called twice more on 08/13/2022 and could not get anyone form the hospice to come out. Could not recall if he/she used the on-call service or called the hospice staff directly. During an interview with hospice RN-A on 08/23/2022 at 10:27 AM, he/she stated the following: - He/she was the on-call nurse for after hours and the weekend beginning on 08/12/2022; - The evening of 08/12/2022 received multiple calls from the on-call service and hospice administrator, but was fatigued, asleep and did not hear the calls; - He/she was "exhausted" because has worked without a day off since 07/05/2022, was" just over being sick myself"; - There was no other registered nurse available to visit patients that weekend (weekend of 08/12/2022), since the hospice only has two nurses available, and the other nurse was out of town on a boat; - When I called the ALF on 08/13/2022, I asked them if I could wait to see the patient on Sunday, was exhausted. In hindsight, "I should have visited the patient myself on Saturday (08/13/2022)"; - When assessing the patient on Sunday (08/14/2022), He/she was having some pain, especially in the shoulder; and - He/she called the medical director, sent the patient to the emergency room where it was determined that the patient had pelvic fractures. During a interview with the hospice medical director on 08/22/20022 at 6:00 PM, he/she stated: - He/she was not aware of the patient's increase in pain or range of motion limitations from the 08/12/2022 fall until evening of 08/14/2022; and - He/she would have made order changes sooner such as non-weight bearing, steroids, and increase in pain medication dose if he/she would have been made aware the patient's injuries when they occurred.

Based on policy review, review of the agency's emergency plan, and interview, the agency failed to conduct testing of their emergency plan at least annually with a full scale community based exercise every two years or an additional exercise every two years opposite the full scale exercise. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Emergency Preparedness and Response Plan," revised 07/01/2020, showed in part: - The agency will conduct exercises to test the emergency plan at least annually; and - The agency will participate in a full scale exercise that is community based every two years and conduct an additional exercise every two years opposite the year the full scale or functional exercise is conducted. Review of the agency's emergency preparedness plan showed the agency failed to document they conducted exercises to test the emergency plan for the years of 2020 and 2021. During an interview on 05/25/2022 at 9:00 AM, the director of clinical services stated that he/she could not provide any documentation regarding exercises for the year of 2020 or 2021.

Based on policy review, record review, and interview, the agency failed to ensure the hospice registered nurse (RN) completed the initial assessment within 48 hours after the election of hospice care in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Assessments," revised 01/01/2021, showed in part that the hospice RN will complete an initial assessment within 48 hours after the election of hospice care. The initial assessment includes evaluating the patient's physical, psychosocial and emotional status related to the terminal illness and related conditions. RECORD/PATIENT #1: Review of the hospice election statement showed the effective date of election was 03/21/2022. Review of the initial RN visit showed a visit date of 04/13/2022 (23 days after hospice election). During an interview on 05/24/2022, beginning at 11:45 AM, the director of clinical services stated that he/she could not show evidence that the initial assessment had been completed prior to 04/13/2022.

Based on policy review, record review, and interview, the agency failed to ensure the social worker's (MSW) comprehensive assessment and the spiritual assessment were completed within five days of election of hospice care in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Assessments," revised 01/02/2021, showed in part that: - The hospice RN will complete an initial assessment within 48 hours after the election of hospice care. The initial assessment includes evaluating the patient's physical, psychosocial and emotional status related to the terminal illness and related conditions, and - The hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotional, and spiritual care. The interdisciplinary group (IDG) in consultation with the patient's attending physician (if any), will complete the comprehensive assessment no later than five calendar days after the election of the hospice benefit. RECORD/PATIENT #1: Review of the hospice election statement showed the effective date of election was 03/21/2022. Review of the registered nurse (RN) evaluation visit showed a date of 04/13/2022 (23 days after the election of hospice care). Review of the initial MSW evaluation visit showed a date of 04/28/2022 (38 days after election of hospice care). Review of initial spiritual assessment evaluation visit showed a date of 05/03/2022 (43 days after the election of hospice care). During an interview on 05/24/2022, at 2:50 PM, the director of clinical services stated that he/she could not find documentation of a comprehensive assessment.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile in four (Records/Patients #1, #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Medication List and Monitoring," revised 01/01/2021, showed in part: - A hospice registered nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen; - The RN will monitor medications including drug therapy associated with laboratory monitoring; - The hospice will maintain a current, accurate medication profile of all prescription and over-the-counter medications taken by the patient; - Changes in the medication regimen will be documented in the medical record on the medication profile, verbal order, and in the plan of care (POC); and - Changes in the medication regimen will be updated as frequently as necessary to keep the profile accurate. Review of the agency's policy titled, "Patient Assessments," revised 01/01/2021, showed in part the comprehensive assessment will review all of the patient's prescription and over-the-counter drugs, herbal regimen and other alternative treatments that could affect drug therapy. RECORD/PATIENT #1: Observation on 05/23/2022 at approximately 3:15 PM, during the patient's home visit, showed the following discrepancies with the hospice medication profile: - The patient had Ativan (treatment for anxiety) 0.5 milligram (mg) one every four hours as needed. This was not included on the hospice medication profile; and - Wal-flu (used to treat flu-like symptoms) 1/2 packet in the home. This was not included on the hospice medication profile. During an interview on 05/24/2022, at 2:45 PM, the director of clinical services (DCS) reviewed the patient's medical record and was unable to find the missing medications. RECORD/PATIENT #2: Observation on 05/23/2022, at approximately 2:30 PM, during the patient's home visit, showed the following discrepancy with the long term care facility (LTCF) medication record. The LTCF record showed Tylenol (pain and./or temperature), take every AM. The agency medication record showed Tylenol 500 mg give as needed every four hours. Neither medication profile listed a reason for the medication. During an interview on 05/23/2022 at 3:00 PM, the administrator concurred with the findings. RECORD/PATIENT #3: Observation on 05/23/2022, at approximately 2:30 PM, during the patient's home visit, showed the following discrepancy with the hospice medication profile: - The hospice medication profile showed an order for lidocaine (pain reliever) patch 4% one patch topical every 12 hours as needed (the order failed to include the reason for using the patch). The LTCF medication orders showed an order for lidocaine pain relief 4% patch, apply one patch to lower back once daily as needed for pain, on two hours, off 12 hours. During an interview on 05/25/2022 at 11:50 AM, the DCS stated that he/she expected the hospice and LTCF orders to match. RECORD/PATIENT #4: Review of the record showed the patient resided in an assisted living facility Review of the hospice medication profile showed: - The agency failed to enter reasons for taking the medications; and - The agency failed to record any laboratory monitoring that should occur as a result of taking these medications. During an interview on 05/25/2022 at 11:00 AM, the DCS stated that he/she would expect the medication profile to have the reasons for taking the medications and any laboratory monitoring required as a result of taking these medications.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the patient/caregiver received education and training as appropriate to their responsibilities for care in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care Process," revised 05/01/2020, showed in part: - The agency will ensure that each patient and primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the POC; - Medical supplies, equipment and appliances necessary to meet the needs of the patient; and - Drugs and treatments necessary to meet the needs of the patient. RECORD/PATIENT #1: Review of the initial nursing visit dated 04/28/2022, showed: - No documentation that education was provided regarding G-tube feedings (a feeding tube inserted through the stomach), flushing, or care of the insertion site; - No documentation of flow of tube feedings, amount of water to flush tube, and who is responsible for tube care; and - No documentation of assessment or education regarding covid (public health emergency) screenings. Review of nursing visits failed to show teaching to the family/caregiver regarding G-tube care, and no teaching related to covid screening. Per interview conducted during observation, on 05/24/2022 at 4:15 PM, the patient's caregiver stated that patient was symptomatic for covid. The medical social worker (MSW) stated that he/she was not aware of patient's covid status. During an interview on 05/24/2022 at 2:50 PM, the director of clinical services reviewed the clinical record and found no additional education.

Based on policy review, record review, home visit observation, and interview, the agency failed to develop and/or revise an individualized plan of care (POC) in, but not limited to, two (Records/Patients #2 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Plan of Care Process," revised 05/01/2020, showed in part: - The agency will ensure that each patient and primary caregiver receive education and training as appropriate to their responsibilities for the care and services identified in the POC; - Medical supplies, equipment and appliances necessary to meet the needs of the patient; - Drugs and treatments necessary to meet the needs of the patient; - The interdisciplinary group (IDG) POC will be developed by the IDG, upon completion of the comprehensive assessment, within fifteen (15)days of the start of care; - A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs, including level of care; and - Medical supplies, equipment and appliances necessary to meet the needs of the patient. RECORD/PATIENT #2: Review of the registered nurse (RN) assessment dated 04/15/2022, showed: - The patient resided in a long term care facility (LTCF); - Diagnoses included Atherosclerotic (when arteries (blood vessels) become hard and lose their supple, elastic quality) and vascular dementia (confusion); - Patient's right ankle broken, due to a recent fall; - Patient right ankle placed in ankle brace; - Agency requested to provide an ankle brace; and - Review of IDG notes 04/21/2022 orders/equipment failed to list right ankle brace. Observation on 05/23/2022 at 2:00 PM, during the patient's home visit, failed to show patient's right leg in an ankle brace. During an interview on 05/25/2022 at 3:00 PM, the director of clinical services specialist (DCS) stated that the POC should have been updated with the ankle brace. The DCS had a receipt for the agency's purchase of the ankle brace. The DCS was unable to explain the absence of the brace during the visit. RECORD/PATIENT #5: Review of the clinical record showed that the POC directed the RN to make patient visits two times a week. POC also directed home health aide (HHA) visits two times a week. Review of the RN visits for the week of March 6th through March 12th showed a missed RN visit. Review of the visits for March 20th through March 26 showed a missed RN visit. Review of the HHA visits for the week of February 20th through 26th showed two missed visits. March 13 through 19 showed a missed visit. During an interview on 05/25/2022 at 3:15 PM, the DCS concurred with the missing visits and no further information was provided.

Based on policy review, record review, and interview, the agency failed to ensure the nursing needs of the patients were met in two (Records/Patients #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Assessments," revised 01/01/2020, showed in part: - Nursing services must ensure that the nursing needs of the patient are identified in the patient's initial assessment, comprehensive assessments, and updated assessments; and - Pertinent data/information will be communicated within the interdisciplinary group (IDG), as well as to the patient's identified attending physician, verbally and/or in writing. RECORD/PATIENT #3: Review of the IDG (interdisciplinary group)/POC (plan of care) dated 05/05/2022, showed: - Diagnoses that included chronic systolic heart failure (a condition where the heart does not pump efficiently); - Interventions included that the skilled nurse (SN) would perform a cardiovascular assessment (includes assessment of heart and lung sounds) every 14 days and as needed; and - Care plan interventions included that the SN will contact the physician for medications and treatments to achieve/maintain the patient's pain goal. Review of the SN visits from 04/14/2022 through 05/18/2022 showed no documentation of lung sounds under the section for respiratory findings. Review of the SN visit dated 05/17/2022, showed the patient had moderate pain at a level of five (pain is rated on a scale of 0-10 with 0 (zero) meaning no pain and 10 meaning the worst pain) that was tingling/burning and constant in both feet. The patient was uncomfortable because of the pain. The patient's acceptable level of pain was 0. The narrative note showed the patient complained of nerve pain in both feet and lower legs. The patient did not know he/she took medication for nerve pain. The documentation failed to show that the physician was notified of the patient's pain level. During an interview on 05/25/2022, beginning at 10:12 AM, the chief compliance and clinical officer stated that he/she would expect the nurse to contact the physician of the patient's pain. He/she would expect lung sounds to be documented at least every 14 days. During an interview on 05/25/2022, at 11:50 AM, the director of clinical services (DCS) stated that he/she did not find any documented interventions for the patient's pain on 05/17/2022. During an interview on 05/25/2022, at 4:55 PM, the chief compliance and clinical officer stated that they did not have a policy that showed lung sounds are included with the respiratory assessments. RECORD/PATIENT #4: Review of the SN visits showed: - On 04/19/2022, the patient had new edema (swelling) to right knee, slightly pitting (when the skin is pressed an indentation is left), no visible change in the shape of the extremity; depth of indentation 0 to 1/4 of an inch; disappears rapidly. The documentation failed to show that the physician was notified; - On 05/11/2022, the patient had edema to bilateral (both) feet, noticeably deep pitting, swollen extremity; depth of pitting 1/2 of an inch to 1 inch; duration 1 to 2 minutes. The documentation failed to show that the physician was notified; and - On 05/17/2022, the patient had edema to bilateral feet, noticeably deep pitting, swollen extremity; depth of pitting 1/2 of an inch to 1 inch; duration 1 to 2 minutes. The documentation failed to show that the physician was notified. During an interview on 05/25/2022 at 11:50 AM, the DCS stated that he/she could not provide proof that the physician was notified of these changes in the patient's condition.

Based on policy review, record review, and interview, the agency failed to ensure a bereavement plan of care (POC) was developed for one year after the patient's death in one (Record/Patient #7) of two bereavement records reviewed. This deficient practice has the potential to affect the bereavement needs of all patients/families/caregivers served by the agency. Findings included: Review of the agency's policy titled, "Bereavement," revised 12/01/2019, showed in part: - The agency will make bereavement services available to the family and other individuals in the bereavement POC before, and up to one year following the death of the patient; and - The bereavement coordinator will complete a follow-up assessment and develop a POC for bereavement services based on the reassessment and the family/caregiver's willingness to receive services. RECORD/PATIENT #7: Review of the record showed: - Date of death: 04/21/2021; - A form that listed interventions showed a check mark beside "Send sympathy card" with a date of 04/28/2021; and - Another form that listed interventions showed no further interventions had been completed until 08/25/2021. During an interview on 05/24/2022, at 1:20 PM, the chief compliance and clinical officer stated that he/she expected the bereavement POC to be initiated for the bereaved after death and developed for one year. He/she agreed the POC was not completed until August of 2021, but would expect the POC to be developed for one year right after the date of the patient's death.

Based on record review and interview, the agency failed to ensure staff documented the patient's reason for transfer to another hospice in two (Records/Patients #8 and #11) of two transfer records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Transfer," revised 01/01/2020, failed to include that the clinical record would include documentation regarding the reason for the transfer. Findings included: RECORD/PATIENT #8: Review of the record showed: - The hospice transferred the patient on 04/08/2022; and - No documentation to include where the patient was transferred to or the reason for the transfer. During an interview on 05/25/2022 at 9:30 AM, evidence was requested regarding the patient's reason for transfer. The director of clinical services (DCS) stated that he/she could not provide the missing information. RECORD/PATIENT #11: Review of the record showed the patient transferred to another hospice on 03/30/2022. The record failed to include documentation of the reason for the transfer. During an interview on 05/25/2022 at 9:52 AM, the DCS stated that he/she could not find documentation of the reason for the transfer.

Based on policy review, record review and interview, the agency failed to provide accurate patient documentation of the patient's advance directive (right to make and direct decisions concerning medical care to accept and/or refuse care) for one (Record/Patient #1) of five patient records reviewed, and failed to ensure the clinical record contained accurate information for one (Record/Patient #3) patient of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Advance Directives," revised 05/01/2019, showed in part that agency staff will distribute to and review with the patient or their legal representative written information relating to the patent's right to refuse medical or surgical treatment and the right to formulate advance directives, as well as agency policies relating to advance directives at the time of the initial assessment, prior to the provision of care to the patient. RECORD/PATIENT #1: Review of the general patient details at start of care showed Code Status - Full code [wants all medical interventions at time of heart and/or lung arrest (stop)]. Outside the hospital code status showed patient a Do-Not-Resuscitate (DNR), which stated that in the event that the patient suffered cardiac or respiratory arrest, the DNR will take effect and no medical procedure to restart breathing or heart functioning will be instituted. During an interview on 05/24/2022 at 2:50 PM, with the director of clinical services (DCS), the DCS concurred with the findings and acknowledged the directives were in direct conflict and required clarification. RECORD/PATIENT #3: Review of an indicator data/LCD (local coverage determination) worksheet form attached to the IDG (interdisciplinary group) notes dated 04/21/2022, 05/05/2022, and 05/19/2022, showed the narrative portion contained another patient's information. During an interview on 05/24/2022, at 5:00 PM, the DCS stated that the other information on the form was the right patient, but the narrative portion was the wrong patient. At the IDG meetings they look more at the staff narratives and not the LCD worksheet. They discuss the visits for the previous two weeks.

Based on policy review, record review, and interview, the agency failed to ensure that when a patient was transferred to another Medicare/Medicaid certified agency, the receiving agency would receive a copy of the hospice transfer/discharge summary in two (Records/Patients #8 and #11) of two transfer records reviewed. This deficient practice has the potential to affect all patients transferred from the hospice agency. Findings included: Review of the agency's policy titled, "Patient Transfer," revised 01/01/2020, showed in part if the care of a patient is transferred to another Medicare/Medicaid certified facility, the agency will forward a copy of the discharge summary to the receiving facility. RECORD/PATIENT #8: Review of the record showed the patient was transferred from the agency's service on 04/08/2022. The record failed to include where the patient was transferred to. The record failed to show the discharge summary had been sent to the receiving provider or attending physician. During an interview on 05/25/2022 at 9:30 AM, the director of clinical services (DCS) stated that he/she could not provide the missing information. RECORD/PATIENT #11: Review of the record showed the patient transferred to another agency on 03/30/2022. The record failed to show staff sent the discharge summary or a copy of the patient's advance directive to the receiving provider. During an interview on 05/25/2022 at 9:52 AM, the DCS stated that he/she could not find evidence the discharge summary or a copy of the advance directive had been sent.

Based on review of an agency general inpatient (GIP) contract and interview, the agency failed to ensure the contract included all the required components in one of one GIP contract reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the GIP contract signed 11/29/2017, failed to include that a copy of a discharge summary and/or clinical record would be supplied to the hospice at the time of discharge. During an interview on 05/24/2022, at 4:15 PM, the chief compliance and clinical officer stated that he/she could not find that verbiage in the contract.

Based on policy review, record review, and interview, the agency failed to ensure staff updated the coordinated task plan of care (a form used by the agency to coordinate care for a patient in a long term care facility (LTCF)) in a timely manner to reflect a change in visit frequency, in one (Record/Patient #3) of two records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled, "Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Immediate Care Facility for the Developmentally Disabled)," revised 10/01/2019, showed in part: - A hospice plan of care (POC) will be developed based on the patient/family's needs; - The POC will be written in collaboration with the facility staff, the family, and the patient; and - A copy of the POC, which includes services furnished, will be provided to the facility. RECORD/PATIENT #3: Review of the hospice record at the LTCF showed: -A a physician order dated 04/07/2022, to decrease the skilled nurse (SN) visits from twice a week to one time a week; and - The coordinated task POC showed the visit frequency was updated on 05/12/2022 (over a month later). During an interview on 05/25/2022, beginning at 10:12 AM, the chief compliance and clinical officer stated that when changes are made, the coordinated task POC should be updated at the next visit. No further information was provided.

Based on policy review, record review, home visit observation, and interview, the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in two (Record/Patient #2 and #3) of two records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled, "Hospice Care in a SNF/NF (Skilled Nursing Facility/Nursing Facility) or ICF/IID (Intermediate Care Facility/Immediate Care Facility for the Developmentally Disabled)," revised 10/01/2019, showed in part that the agency will provide the facility with the following hospice information/documentation on admission and ongoing: -The hospice election form and advance directive. RECORD/PATIENT #2: Review of the hospice record maintained at the LTCF, during a home visit observation on 05/23/2022, at 2:00 PM, showed no patient advance directive information. During an interview on 05/25/2022, beginning at 3:00 PM, the director of clinical services (DCS) stated that he/she expected the correct patient forms to be placed in the hospice records at the LTCF's. RECORD/PATIENT #3: Review of the hospice record maintained at the LTCF, during a home visit observation on 05/23/2022, beginning at 2:30 PM, showed it contained the wrong patient's election form. During an interview on 05/25/2022, beginning at 10:12 AM, the DCS stated that he/she expected the correct patient forms to be placed in the hospice records at the LTCF's.

Based on policy review and interview, the agency failed to ensure orientation of long-term care facility (LTCF) staff caring for hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled "Hospice Care in a Skilled Nursing Facility/Nursing Facility (SNF/NF) or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)" showed in part: - The agency will assure the orientation of staff who provides that care, in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements; and - The agency will provide inservices/education to the facility staff on hospice topics, to increase awareness of the hospices concept of care and to promote a good working relationship. During the survey entrance on 05/23/2022 at 11:30 AM, evidence of inservice training for nursing facilities was requested from the agency administrator and the director of clinical services. The agency failed to provide evidence of inservices by the survey exit. During an interview on 05/23/2022, at 3:30 PM, the director of clinical services stated that they had not yet began offering inservices to facilities.

Based on review of Missouri state law, agency employee handbook, personnel file review, and interview, the agency failed to obtain the results of the employee disqualification list (EDL) check prior to hire in one (Employee #1) of one personnel file reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." Review of the agency's employee handbook revised 04/26/2022, showed all employment offers area contingent upon clear results of a thorough background check prior the start date. All Missouri new hires will follow the Missouri Department of Health and Senior Services employee background check requirements. Background checks will include the EDL. EMPLOYEE #1: - Date of hire: 05/23/2022; and - EDL check 05/23/2022. During an interview on 05/25/2022, at 9:10 AM, the business office manager stated that he/she did the criminal background check when he/she got the employee information. No further information was provided.

Based on policy review, employee record review, and interview, the agency failed to ensure that all staff were fully vaccinated for COVID-19 or had been granted an exemption to the vaccination requirement in one (Employee #5) of six employee records reviewed for vaccination status. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled "Staff Vaccination Requirements for COVID-19," revised 02/22/2022, showed in part: - Phase 2 requirements: All applicable staff are fully vaccinated for COVID-19, except for those staff who have been granted exemptions from COVID-19 vaccination or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; and - The Hospice will track and securely document information provided by those staff who have requested, and for whom the Hospice has granted, an exemption from the COVID-19 vaccination requirements. Review of Employee #5's employee record showed: - No proof of vaccination for COVID-19; and - No documentation of a granted exemption. During an interview on 05/25/2022 at 11:00 AM, with the chief compliance and clinical officer and the business office manager, the business office manager stated that he/she was unaware that the employee did not have proof of vaccination status on file. He/she could not provide proof of vaccination status or an exemption for the employee.

Based on policy review, record reviews, and interviews, the hospice provider's governing body failed to: - Manage and administer its resources for the day-to-day provision of hospice services when given two weeks notice failed to have an effective plan for onsite registered nurse (RN) availability (L649); - Ensure nursing services was made routinely available on a 24-hour basis 7 days a week (L653); - Ensure an initial hospice provider specific orientation was completed for new nurses prior to patient care (L662); and - Ensure the skills and competence of nurses furnishing care were completed by the provider prior to patient care. (L663). The cumulative effect of these deficient practices has the potential to affect nursing services for all patients on service with the hospice provider.

Based on interviews, employee file information, and electronic communication review, the hospice governing body failed to manage and administer its resources for the day-to-day provision of hospice services. The hospice provider's corporation was aware two weeks in advance, and failed to have an effective plan for onsite registered nurse (RN) availability. Findings included: During an interview on 04/05/2022 at 12:09 PM with the hospice administrator, he/she stated the following: - On 03/31/2022 was the last day of employment for all hospice nurses, the hospice had two RN's up to 03/31/2022 (these are identified as the previous administrator and previous RN-F); - The previous administrator was a RN and he/she provided 9 days notice of resignation (this contradicts electronic communication showing the previous administrator gave 14 days notice of resignation to corporate staff); - The other RN (previous RN-F), gave notice of resignation "a month ago" to the best of his/her knowledge; and - The hospice had no RN available to physically assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. The RNs taking on-call during that time were four or five hours away, if patients would have needed a onsite RN during that time, they would have been sent to the emergency room. During an interview on 04/05/2022 at 12:09 PM with the interim clinical manager on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she works remotely as the interim clinical manager; - He/she lives 4-5 hours away; - Has never been physically to the hospice, only by teleconference; and - The hospice had no RN available to assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. He/she instructed the RNs taking on-call from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM to call 911 or send the patients to the hospital if emergent registered nurse intervention or assessment was indicated. Review of electronic communications showed on 03/17/2022 that the previous administrator gave notice of resignation of employment to the corporate operations management. This notice was 14 days before his/her last day of employment. Review of the employee file for previous RN-F showed that he/she submitted a signed "two week resignation" letter on 03/14/2022. The effective resignation date was 03/31/2022. During an interview with previous administrator (no longer employed at the provider), RN-F, on 04/06/2022 at 10:26 AM, he/she stated the following: - He/she resigned from the hospice provider on 03/31/2022, he/she provided notice of resignation two weeks in advance, on 03/17/2022, by electronic communication to to the corporate operations management; - When asked why patients were still being admitted to the hospice between 03/17/2022 and 03/31/2022 after knowing the hospice would no longer have an onsite RN after 03/31/2022, she/she replied that the corporate operations manager assured him/her that there was a plan in place to care for the patients; - When asked if he/she ever withdrew his/her intent to resign after 03/17/2022, he/she stated "no"; and - When asked if he/she provided any type of hand-off or report on the existing hospice patients before her planned resignation on 03/31/2022 to any other RN, he/she stated "No". During an interview with previous RN-F (no longer employed at the provider), on 04/06/2022 at 1:52 PM, he/she stated the following: - He/she resigned form the hospice provider on on 03/31/2022, she provided a letter of resignation two weeks in advance; - He/she resigned for health reasons; - When asked if he/she ever withdrew his/her intent to resign, he/she stated "no"; and - When asked if he/she provided any type of hand-off or report on the existing hospice patients on or before 03/31/2022 to any other RN, he/she stated "No". Review of the census list showed four patients were admitted after 03/17/2022 when the hospice corporate management and administration were aware that there would be no onsite RN availability after 03/31/2022. Two patients were admitted on 3/21/2022, the other patients were admitted on 03/25/2022 and 03/29/2022.

Based on policy review, record review, home visit observation, and interviews the hospice governing body failed to ensure nursing services, were available on a 24-hour basis 7 days a week in, but not limited to, three of four sampled patients (Patient/Records #1, #2, and #4.) The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency policy titled "Plan of Care Process", revised 05/01/2020, showed in part that all hospice care and services furnished to patients and their families will follow an individualized written plan of care established by the interdisciplinary group (IDG), in collaboration with the attending physician, the patient, and primary caregiver in accordance with the patient's needs. Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were currently employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on-call schedule showed three RNs were on call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs for new hire orientation, competency, and background checks. During an interview on 04/05/2022 at 12:09 PM with the hospice administrator, he/she stated the following: - On 03/31/2022 was the last day of employment for all hospice nurses, the hospice had two RN's up to 03/31/2022 (these are identified as the previous administrator and previous RN-F); and - The hospice had no RN available to physically assess patients from 5:00 PM on 03/31/2022 through 04/04/2022 at 8:00 AM. The RNs taking on-call during that time were four or five hours away, if patients would have needed a onsite RN during that time, they would have been sent to the emergency room. On 04/05/2022 at 3:14 PM the administrator stated that there was no employee file information on RN-A, RN-B, RN-C, RN-D, or RN-E for new hire orientation, competency, or background checks. Any information rearguing orientation and competency would come from another hospice provider in Texas or Kansas City. He/she stated that background checks were in process. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM.; - When asked if he/she received any type of verbal report, hand-off from the nurses that resigned on 03/31/2022, he/she stated "no", had to review what was in the EMR; and - When asked if he/she had any specific orientation to duties, he/she responded "no", was provided a binder by the office manager with patient names, face sheets, and a visit schedule, and started immediately visiting patients. During an interview with (registered nurse) RN-B on 04/05/2022 at 4:22 PM, he/she stated the following: - He/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022; - He/she worked for a hospice in Texas that is owned by the same corporation that "recently bought this hospice"; - When asked if he/she received orientation to the hospice provider, he/she stated she was provided a binder by the office manager and visited patients with RN-A that morning; and - She is unaware of the medical directors name or the location of the GIP (general inpatient acute) facility, has met the chaplain. Review of the informational binder provided to RN-A and RN-B in lieu of orientation showed the provider provided the nurses a list of patients including a face sheet, and a visit schedule of the hospice patients. Review of the visit schedule provided to RN-A and RN-B showed that 13 patients are scheduled to receive visits on Tuesday and Fridays. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated the following: - Works for a hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No", but he/she worked for the corporation at another location in Kansas City, MO and was familiar with the clinical software; - He/she lived approximately four hours away from Three Oaks hospice in Warrenton; and - He/she was informed by the director of clinical services to send hospice patients to the hospital emergency room if they need any RN intervention or physical assessment. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated the following: - Works for another hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received new hire orientation to the Three Oaks hospice in Warrenton, he she responded "No"; - He/she lived approximately four hours away from the Three Oaks hospice Warrenton location; - When asked if he/she was provided access to the electronic medical record, he/she responded "I think so"; and - He/she was informed by the director of clinical services to send hospice patients to the hospital emergency room if they need any RN intervention or physical assessment. During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated the following: - Works for a different hospice provider in Kansas City Missouri, was asked to take call on 04/03/2022 for the Three Oaks hospice in Warrenton; - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No". He/she stated that she asked for a list of IDG (interdisciplinary group), the GIP (general inpatient acute) location, and hospice pharmacy from the director of clinical services and it was not provided; and - He/she lived approximately five hours away from Three Oaks hospice in Warrenton. Patient/Record #1: The hospice recently adopted new clinical software when the hospice provider was purchased. The records that were requested were unable to be clearly printed for timeline of visit dates and times. The medical record was reviewed in the electronic Medical record (EMR) with the office manager. Review of the RN recertification assessment on 03/08/2022 showed that the RN educated the patient to a visit frequency change to twice weekly. Review of nurse visit notes showed a RN visited the patient: - On 03/09/2022 for (PRN) as needed visit because the patient "passed out" twice; and - On 03/11/2022 (Friday), 03/15/2022 Tuesday), 03/18/2022 (Friday), 03/21/2022 (Monday), 03/25/2022 (Friday), and 03/29/2022 (Wednesday) for a routine visits. Review of the visit schedule posted in the hospice conference room showed the patient was to receive visits on Tuesdays and Fridays. Review of the visit schedule provided to RN-A and RN-B showed the patient was to be visited on Tuesdays and Fridays. During interview with RN-A on 04/05/2022 at 3:59 PM, he/she stated the following: - When asked if any routine visits or needed visits were missed on 04/01/2022, he/she stated that Patient #1 and Patient #2 should of had skilled nurse visits; and - Patient #1 had a worsening wound that was from a cat scratch. Review of all available documentation showed that the patient was only assessed once (on 03/30/2022) by a hospice nurse the week of 03/20/2022 through 03/26/2022 when the patient required two visits. Patient/Record #2: The hospice recently adopted new clinical software when the hospice provider was purchased. The records that were requested were unable to be clearly printed for timeline of visit dates and times. The medical record was reviewed in the electronic Medical record (EMR) with the office manager. Review of the plan of care showed that the patient was to be visited twice weekly. Review of the visit schedule posted in the conference room, nurse orientation binders, showed the patient was to receive visits on Tuesdays and Fridays. Review of all available nurse visit notes showed the patient had routine visits on 03/16/2022, 03/28/2022, 03/30/2022, 03/31/2022, and 04/04/2022. During interview with RN-A on 04/05/2022 at 3:59 PM, he/she stated the following: - When asked if any routine visits or needed visits were missed on 04/01/2022, he/she stated that Patient #2 "definitely" should of had skilled nurse visits; - Patient #2 had a worsening wound with dressing from a spider bite; - The caregivers work, have disabilities, and are a limited help to care for the patient; and - The patient has an approximately one inch deep wound that requires it to be packed with antibiotic ointment and gauze. This dressing needs changed daily. Review of the nurse visit note, dated 03/31/2022 showed the nurse provided wound care to the patient's left foot with Betadine and calcium alginate. The medication list showed orders Santyl dressing was ordered on 01/27/2022. Review of the 04/04/2022 nurse visit showed the nurse measure the patient's wound as 2.0 CM(centimeters) by 3.0 CM, with a depth of "1.5-2CM". The left foot wound was coated with Santyl and covered with gauze and Kerlix. Review of all available interim orders showed no changes in wound care between 01/27/2022 and 04/04/2022. Patient/Record #4: Review of the electronic medical record (EMR) with the office manager showed: - Effective 02/05/2022 that the patient was to receive three visits a week by the hospice nurse; - A care plan identified problem that the patient has at risk for alteration in skin integrity; - A care plan identified problem that the patient had a skin deficit related to wounds; - A plan of care intervention that the patient's wounds would be assessed and measured at least every two weeks by the hospice nurse; and - The visit "general details" dated 03/18/2022, 03/21/2022, 03/25/2022, and 03/30/2022 show that the patient is ordered to be visited by a hospice nurse three times a week. Review of the nurse visits from 08/18/2022 through 04/03/2022 showed no assessment or measurements of the patients wounds. Review of the nurse visit note, dated 03/25/2022 showed in the narrative section that the "Facility nurse changes wound dressings". (This indicates the hospice plan of care was not followed regarding the patient's wound management). Review of the visit schedule provided to RN-A and RN-B, and posted in the hospice conference room showed the patient is scheduled to receive visits twice weekly on Mondays and Fridays (this contradicts the EMR order for visits three times a week by a hospice nurse). Further review of the electronic medical record with the office manager showed: - During the week of 03/13/2022 through 03/19/2022 that the patient had a two visits by a hospice nurse on Monday and Friday. (This indicates the hospice plan of care was not followed regarding the nurse visit frequency); - During the week of 03/20/2022 through 03/26/2022 that the patient had a two visits by a hospice nurse on Monday and Friday. (This indicates the hospice plan of care was not followed regarding the nurse visit frequency); and - During the week of 03/27/2022 through 04/02/2022 that the patient had only one visit by a hospice nurse on Wednesday (03/30/2022). This shows the plan of care was not followed on this patient. Review of the EMR showed no missed visit notifications to the physician or (interdisciplinary care group) IDG regarding the two missed hospice nurse visits. During a home visit to the skilled nursing facility (SNF) where the patient resided on 04/06/2022, the written coordinated plan of care could not be located by the charge nurse, director of nursing, the SNF administrator or the hospice office manager. During a joint interview with the SNF charge nurse and SNF director of nursing, on 04/06/2022 at 10:40 AM, the following was stated: - When asked if the hospice coordinated what days the SNF staff would be responsible for the patient's wound care and what days the hospice would be responsible, they said "No"; and - The charge nurse and director of nursing were unaware the name of the hospice nurse that is responsible for care of the patient, were unaware what days the hospice nurse visits, the nurse visit frequency, or when the hospice would need to assess or change the patient's dressings. It should be noted that two of the hospice provider's patients resided in this facility (SNF). There was no written coordination, no hospice plan of care, no advance directive from the hospice, no physician certification of terminal illness, no hospice medication profile, or contact information of hospice personnel involved in care of the patient available to SNF staff. During interview with RN-A on 04/05/2022 at 3:59 PM, when asked if any routine visits or needed visits were missed on Friday 04/01/2022, he/she stated that Patient #4 had dressing changes, lives in a long-term care facility so the facility staff should change it.

Based on employee records review and interviews, the hospice provider failed to ensure a specific initial orientation for nurses was completed prior to the nurses being assigned care to patients. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on call schedule showed three RNs were on call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs for new hire orientation, competency, and background checks. On 04/05/2022 at 3:14 PM the administrator stated that there was currently no employee file information on RN-A, RN-B, RN-C, RN-D, or RN-E for new hire orientation to Three Oaks hospice in Warrenton. Employee files have been started, but any information regarding orientation would be from the hospice provider in Texas and the Hospice provider in Kansas City, MO where the nurses worked. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated the following: - He/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM.; - When asked if he/she received orientation to the hospice provider, he/she stated that he was familiar with the corporations procedures since he/she worked for another corporate provider in Texas; and - When asked if he/she had any specific orientation to duties, he/she responded "no", was provided a binder by the office manager with patient names and visit schedule, and started immediately visiting patients. During an interview with (registered nurse) RN-B on 04/05/2022 at 4:22 PM, he/she stated the following: - He/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022; - He/she worked for a hospice in Texas that is owned by the same corporation that "recently bought this hospice"; - When asked if he/she received orientation to the hospice provider, he/she stated she was provided a binder by the office manager and visited patients with RN-A that morning; and - She is unaware of the medical directors name or the location of the GIP (general inpatient acute) facility, has met the chaplain. Review of the informational binder provided to RN-A and RN-B in lieu of orientation showed the provider provided the nurses a list of patients including a face sheet, and a visit schedule of the hospice patients. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated the following: - Works for a hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No", but he/she worked for the corporation at another location in Kansas City, MO and was familiar with the clinical software. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated the following: - Works for another hospice provider in Kansas City Missouri, was asked to take call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received new hire orientation to the Three Oaks hospice in Warrenton, he she responded "No". During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated the following: - Works for a different hospice provider in Kansas City Missouri, was asked to take call on 04/03/2022 for the Three Oaks hospice in Warrenton; and - When asked if he/she received orientation to the Three Oaks hospice in Warrenton, he she responded "No". He/she stated that she asked for a list of IDG (interdisciplinary group), the GIP (general inpatient acute) location, and hospice pharmacy from the director of clinical services and it was not provided. It should be noted that RN-C, RN-D, and RN-E were not identified as hospice employees on the hospice employee list.

Based on employee records review and interviews, the hospice provider failed to ensure the skills and competence of all individuals furnishing care, were assessed by the provider prior to being assigned care to patients. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the hospice staff employee list provided by the hospice administration, showed two registered nurses (RNs) were employed at the hospice provider. These nurses were identified as RN-A and RN-B. The start date of RN-A was listed as "04/04/2022" and RN-B's start date was listed as "04/05/2022". Review of the on-call schedule showed three RNs were on-call for the provider from 03/31/2022 at 5:00 PM through 04/04/2022 at 8:00 AM. These nurses are identified as (registered nurses) RN-C, RN-D, and RN-E. On 04/05/2022 at 12:09 PM, the hospice administrator was asked to provide employee file information on all hospice RNs regarding the assessment of nursing skills and competence. On 04/05/2022 at 3:14 PM the administrator stated that there was currently no employee file information from this specific hospice provider on RN-A, RN-B, RN-C, RN-D, or RN-E for assessment of skills and competence. Employee files have been started, but any information regarding skills and competence would be from the hospice provider in Texas and the Hospice provider in Kansas City, MO. RN-A and RN-B were brought in from the corporation in an emergency manner since the hospice had no RN's left after 03/31/2022 at 5:00 PM. During an interview with (registered nurse) RN-A on 04/05/2022 at 3:39 PM, he/she stated that he/she started with the provider on 04/04/2022 at 8:00 AM, and started seeing patients on 04/04/2022 at approximately 9:00 AM. During an interview with RN-B on 04/05/2022 at 4:22 PM, he/she stated that he/she started with the hospice provider on 04/05/2022, and started seeing patients on 04/05/2022. During an interview with RN-C on 04/06/2022 at 3:02 PM, he/she stated that he/she works for a hospice provider in Kansas City Missouri (another provider number), was asked to take primary call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton. During an interview with RN-D on 04/06/2022 at 3:15 PM, he/she stated that he/she works for hospice provider in Kansas City Missouri (another provider number), took secondary call on the weekend of 04/01/2022 for the Three Oaks hospice in Warrenton. During an interview with RN-E on 04/06/2022 at 12:00 PM, he/she stated that he/she works for a different hospice provider in Kansas City Missouri (another provider number), took call on 04/03/2022 for the Three Oaks hospice in Warrenton.