Every finding on record at Lutheran Home for the Aged

Based on policy review, record review, and interview, the hospice provider failed to complete a fall assessment during the initial comprehensive assessment in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Comprehensive Assessment,” dated 10/2025, showed during the comprehensive patient assessment, all baseline data and other relevant information was to be documented in the patient’s clinical record including: - A physical assessment that included relevant data related to pertinent physical findings and the patient’s terminal illness; - The patient’s functional status that included, but was not limited to, the degree of self-care and the amount and level of assistance needed; and - Complications and risk factors that affect care planning. --- RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a long-term care facility (LTCF). Review of the initial comprehensive assessment, dated 10/16/2025, showed the patient was admitted to a LTCF for a rehabilitation stay for hip repair, due to a fall, that resulted in a fracture in the right femur (thigh bone). The registered nurse (RN) failed to complete a fall assessment.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that they would expect a fall assessment to be completed on a patient who had recovered from a hip fracture that was due to a fall.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure staff maintained an accurate and updated medication profile in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Profile,” updated 07/2024, showed in part: - A drug regimen review would be performed by a registered nurse at the time of the initial assessment, when updates to the comprehensive assessments are performed, and with the addition of a new medication; - During subsequent home visits, the medication profile would be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians understood the medication regimen. This includes, but will not be limited to:    * Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, dates prescribed, name and medication, dose, frequency, drug classification, and date discontinued; -  Based on review of the medication profile as well as the written material, changes in the plan of care may be required; and - Deviations from taking medications as ordered would be documented in clinical notes, and the physician (or other authorized independent practitioner) would be notified. --- RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/15/2025 with a terminal diagnosis of chronic combined systolic and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood). The patient resided at his/her own home with their spouse. Observation and interview on 11/12/2025 showed the following discrepancies between the provider’s current medication profile, dated 09/15/2025 to 12/13/2025, and the patient’s home medication bottles:- The provider’s profile showed levothyroxine (thyroid hormone) 75 micrograms (mcg) take one daily (order received 09/23/2025). The patient was taking 50 mcg daily;- The provider’s profile showed Mucus Relief 400 milligram (mg) take one every four hours as needed for congestion (order received 10/01/2025). The patient was not taking the medication and did not have it in the home;- The provider’s profile showed aspirin, chewable, 81 mg take one daily for clot prevention (order received 09/23/2025). The patient stated that he/she was not taking the aspirin and that he/she never received the medication;- The provider’s profile showed vitamin D3 (supplement) 25 mcg take one daily. The patient was taking 125 mcg (5,000 international units) daily;  - The patient was taking Eliquis 5 mg, take one twice a day (order to discontinue on 09/23/2025). He/she stated he/she never stopped taking the Eliquis. The provider’s profile failed to include Eliquis; and - The patient was using over the counter (OTC) CBD (topical cannabidiol is a natural compound derived from the hemp plant) cream for lower back pain with good results (noted on skilled nurse note 10/02/2025 and interdisciplinary group meeting 10/14/2025). The provider’s profile failed to include the OTC CBD cream.   During an interview on 11/13/2025 beginning at 2:02 PM, the administrator stated that the medications in the home should match the medication profile

Based on policy review, record review, and interview, the plan of care (POC) failed to include measurable outcomes in, but not limited to, two of five full records reviewed (Records/Patients #3 and #4). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “The Plan of Care,” dated 10/2025, showed, in part, the POC was to contain measurable outcomes anticipated from implementing and coordinating the POC. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/07/2025 with a terminal diagnosis of stage 4 (four) chronic kidney disease (a serious condition where kidneys are moderately to severely damaged). The patient resided in a long-term care facility (LTCF). Review of the POC, dated 11/11/2025, showed the following goals/interventions: - Patient’s pain was to be maintained at a comfortable level throughout the end of life; - Skin integrity was to be maintained during care; - Patient/caregiver were to receive optimal teaching and support as cardiac functions changed during care; and - The POC failed to include measurable outcomes anticipated from implementing and coordinating the POC.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a LTCF. Review of the plan of care, dated 11/11/2025, showed the following goals/interventions: - Patient’s pain was to remain at a comfortable level during care; - Patient was to receive optimal level of pain and/or symptom management on a short-term basis; - Patient/caregiver was to receive optimal teaching and support as cardiac functions change during care; - Skin integrity was to be maintained during care; and - The POC failed to include measurable outcomes anticipated from implementing and coordinating the POC.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that they would expect the goals on the POC to be measurable.

Based on policy review, record review, and interview, the hospice provider failed to ensure a complete, individualized written plan of care (POC) was developed that included all of the patient’s medical equipment 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 provider's policy titled, “The Plan of Care,” revised 10/2025, showed in part: - The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every 15 days;- The POC will include all services necessary for the palliation and management of the terminal illness and related conditions;- The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the POC; and- The written plan of care may contain, but not be limited to, the durable medical equipment (DME) and medical supplies necessary to meet the patient’s needs.  Review of the provider’s undated policy titled, “Comprehensive Assessment,” showed in part, during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including but not limited to, equipment presently in home and potentially needed by (the) patient. Review of the provider’s undated policy titled, “Interdisciplinary Group Plan of Care,” showed in part, the interdisciplinary group, (in collaboration with the attending physician, if any) will conduct assessments, develop and update the POC. --- RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 09/15/2025 with a terminal diagnosis of chronic combined systolic (congestive) and diastolic (congestive) heart failure (a decrease in the ability of the heart to pump blood) and obstructive sleep apnea (OSA) (sleep-related breathing disorder). The patient resided at his/her own home with their spouse. Review of the referral history and physical (H&P), dated 08/25/2025, showed:- The patient’s past medical history included OSA and used a continuous positive airway pressure (CPAP) machine (a machine that uses mild air pressure to keep the airway open while sleeping) with oxygen at 3 (three) liters per a minute (lpm); and- The assessment/plan included obstructive sleep apnea syndrome (OSAS) using CPAP.   Review of the initial POC (IPOC) dated 09/15/2025, showed the following interventions under the shortness of breath problem:- Administer supplemental oxygen as ordered; and- Educate patient and/or caregiver on oxygen safety and equipment maintenance. Review of the clinical record failed to show oxygen and CPAP listed on the DME section on the initial POC (IPOC) dated 09/15/2025 and the POC dated 09/16/2025.   During an interview on 11/13/2025 beginning at 2:09 PM, the administrator stated that the POC should be completed within five days of admission and should include the DME.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the interdisciplinary group (IDG) updated/revised the plan of care (POC) with new assessment findings/orders in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Review of the provider’s policy titled, “The Plan of Care,” dated/revised 10/2025, showed, in part: - Purpose: To ensure that an individualized POC is completed that complies with accepted standards of care and regulatory issues;- A written individualized patient and family/caregiver POC will be established and maintained for each individual admitted to the hospice program;-  The POC will meet the documentation requirements of the physician-directed medical orders and the care planning process;-  The POC will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group (IDG) and will be reviewed on a regular basis but no less than every 15 days;- The POC will include all services necessary for the palliation and management of the terminal illness and related conditions;- The POC will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort, and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregivers needs, goals and outcome achievement;- The POC will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the IDG, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver; - Review of the POC will be documented in the clinical record; and- Revision dates will be noted on the plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/25/2025 with a terminal diagnosis of chronic diastolic, congestive heart failure (a decrease in the ability of the heart to pump blood). He/she resided in a long-term care facility (LTCF).Review of the registered nurse (RN) initial assessment visit note dated 09/25/2025, showed “right foot pinky toe- 1.2 by 1.8 (failed to specify the unit of measurement) wound, treatment in place skin tear LFA (left forearm), buttocks with shearing (a skin injury that occurs when skin and underlying tissues are pulled in the opposite direction) area- tx (treatment) in place”. Review of the POC dated 09/25/2025 to 12/23/2025 showed:- Provide/educate on wound care as ordered; and- The POC failed to contain specific wound care orders. Review of a physician order dated 09/25/2025, showed:- Buttocks: cleanse, apply hydrogel/collagen to wound and cover with foam dressing daily until healed;- Right foot pinky toe: cleanse, apply betadine to wound and cover with dry dressing daily until healed; and- Left forearm skin tear: contact layer every seven (7) days until healed.  Review of the IDG meeting/updated POCs dated 09/30/2025,10/14/2025, 10/28/2025, and 11/11/2025, showed;- Provide/educate on wound care as ordered; and- The IDG/POC updates failed to identify the specific wound care orders for the pinky toe. During an interview on 11/12/2025 at 11:15 AM, the administrator designee stated that he/she:- Thought the initial plan of care order, dated 09/25/2025, followed throughout the patient’s stay;- Thought the “provide/educate on wound care as ordered” was sufficient for updating the POCs since there was an order; and- Voiced understanding that the POCs needed to be individualized with the patient’s specific orders.

Based on standards of practice, record review, observation, and interview, the hospice provider failed to ensure nursing care and services were provided to meet the nursing needs of the patient as identified in the patient’s initial assessment, comprehensive assessment, and updated assessment in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included:Review of the provider's policies showed the provider failed to have a wound care/measurement policy.Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, "Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses," showed the following: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin, wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes." (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 09/25/2025 with a terminal diagnosis of chronic diastolic, congestive heart failure (a decrease in the ability of the heart to pump blood). He/she resided in a long-term care facility (LTCF).Review of the registered nurse (RN) initial assessment visit note dated 09/25/2025 showed “right foot pinky toe- 1.2 by 1.8 wound (failed to specify the unit of measurement), treatment in place skin tear LFA (left forearm), buttocks with shearing area (a skin injury that occurs when skin and underlying tissues are pulled in the opposite direction) - tx (treatment) in place”. Review of the subsequent skilled nurse (SN) visit notes, dated 09/26/2025, 09/30/2025, 10/02/2025, 10/07/2025, 10/09/2025, 10/14/2025, 10/16/2025, 10/21/2025, 10/23/2025, 10/28/2025, 10/30/2025, 11/04/2025, 11/06/2025, and 11/11/2025, showed the SN failed to document measurements of the right pinky toe.Observation on 11/12/2025 at 10:22 AM showed the patient continued to have a measurable black scabbed area on the top of the right pinky toe.During an interview on 11/13/2025 at 10:26 AM, the administrator stated that:- He/she could find no further measurements of the pinky toe wound in the clinical record;- He/she would expect the RN to assess wounds every visit and measure wounds weekly; and- The RN had told her that “you really couldn’t measure that wound”.

Based on policy review, record review, and interview, the hospice provider failed to forward the discharge summary to the patient's attending physician, in but not limited to, one of four applicable records reviewed (Record/Patient #8). This deficient practice has the potential to affect all live discharge patients served by the provider. --- Findings included:Review of the provider’s policy titled, “Discharge Summary,” dated/updated 07/2024, showed all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical records.Review of the provider’s undated policy titled, “Discharge from Hospice Program,” showed a copy of the discharge summary will be sent to the attending physician.RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 07/03/2025. The patient revoked the hospice benefit and was discharged 07/31/2025.Further review of the clinical record showed the record failed to include a discharge summary.During an interview on 11/12/2025 at 3:35 PM, the administrator stated that, unfortunately, he/she did not have a written discharge summary, therefore it was not sent to the attending physician.

Based on policy review, record review, and interview, the provider failed to ensure the long-term care facility (LTCF) had the necessary information to assure the patient received the necessary care and services in, but not limited to, two of three home visits conducted in a LTCF (Records/Patients #3 and #4). This deficient practice has the potential to affect all patients served by the provider who reside in a LTCF.Findings included:Review of the provider’s policy titled, “Provision of Care to Residents of Skilled Nursing Facility (SNF)/Nursing facility (NF) or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID),” dated 07/2024, showed the [provider] was to provide the SNF/NF and ICF/IID the following information: - The most recent plan of care; - Hospice election form and advance directives; - Physician certification and recertification of the terminal illness; - Names and contact information for the hospice personnel involved in hospice care; - Instruction on how to access the hospice 24-hour on-call system; - Hospice medication information; and - Hospice physician and attending physician (if any) orders. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/07/2025 with a terminal diagnosis of stage 4 (four) chronic kidney disease (a serious condition where kidneys are moderately to severely damaged). The patient resided in a LTCF. Review of the hospice binder located in the LTCF failed to include the following: - Current hospice plan of care; - Hospice election form; - Current medication profile; and - Hospice physician and attending physician orders.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 10/16/2025 with a terminal diagnosis of stage 3a (three) chronic kidney disease (a condition where kidneys are mildly to moderately damaged). The patient resided in a LTCF. Review of the hospice binder located in the LTCF failed to include the following: - Current hospice plan of care; - Hospice election form; - Advance directive; - Physician certification and recertification; - Current medication profile; and - Hospice physician and attending physician orders.During an interview on 11/11/2025 at 2:45 PM, the hospice care unit manager, at the LTCF, stated that the provider always provided the necessary documents in the binder. The information had never been missing in the binder and he/she did not know why it was not there.During an interview on 11/13/2025 at 10:00 AM, the administrator and administrator designee stated that once the documents were created, they were printed and set aside for a volunteer to insert in the binder when he/she volunteered on the following Saturday. The provider was not aware that the volunteer did not come. The provider changed their process during the survey and the hospice aides were directed to file the documents in the hospice binders in the LTCF.

Based on policy review, record review, and interview the agency failed to ensure that all necessary services were provided to the patient 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 undated policy titled, "Interdisciplinary Plan of Care," showed in part: -A written plan of care will be established and maintained for each patient, the care provided to the patient will be in accordance with the plan; - Each plan is individualized to meet the specific needs of the patient and care givers; - The plan is based on the identification of services needed, including the management of discomfort and symptom relief; and - The scope (each discipline is identified) and frequency of services. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to hospice services on 04/15/2022 with a primary diagnosis of Gastrointestinal Hemorrhage, unspecified (bleeding in the gastrointestinal tract of unknown cause); - The patient resided in a long term care facility (LTCF); - The patient was to receive social worker (BSW) visits one time per week and as needed; and - A physician's order dated 06/30/2022 stated, omit BSW visits for the following dates: 06/01/2022, 06/08/2022, 06/15/2022, and 06/22/2022- no reason given. - The patient was to receive aide visits two times per week; and - A physician's order dated 09/22/2022 stated: Decrease frequency of aide visits to one time per week due to availability of aide effective week of 08/28/2022; Omit one hospice aide visit week of 08/07/2022- no reason given; Omit one hospice aide visit week of 09/04/2022- no reason given; and Omit one hospice aide visit week of 09/11/2022- no reason given. Review of interdisciplinary meeting notes dated 10/18/2022 showed social worker visits were to be made one time per month and as needed and aide visits were to be made two times per week on Monday and Thursday. The agency failed to provide services according to the plan of care. During an interview on 11/16/2022 beginning at 9:30 AM, the administrator stated that he/she would expect to be able to provide all necessary services to patients according to the plan of care.

Based on policy review, record review, and interview the agency failed to perform a review of all of the patient's prescribed medications and treatments in, but not limited to, one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's undated policy titled, " Review of Patients Drug Regimen," showed, in part, the following: -Drug regimen review was to be completed by the nurse upon admission and on resumption of care; and -The pharmacist will review the patient's drug regimen within 1-2 days of admission and report any concerns to the Hospice nurse. RECORD/PATIENT #2: Review of the clinical record showed: -Patient was admitted to hospice on 10/18/2022 with a terminal diagnosis of Chronic Obstructive Pulmonary Disorder (a group of diseases that cause airflow blockage and breathing-related problems). The patient resided in a skilled nursing facility; -Patient's hospice medication record showed an order for Bisacodyl Rectal Suppositories 10 milligrams (mg) daily as needed (PRN) for constipation; -Patient's facility medication record failed to contain an order for Bisacodyl Rectal Suppositories; and -Patient's clinical record failed to show any medication reviews for the patient. During an interview on 11/16/2022 at 10:00 AM, the administrator stated that he/she would expect the medications to be reviewed and documented in the clinical record.

Based on record review and interview the agency failed to ensure that a comprehensive assessment that includes information on the patient's progress towards desired outcomes and the patient's response to care was performed at least every fifteen days in, but not limited to, five (Records/Patients #1, #2, #3, #4, and #5) of five full records reviewed . This deficient practice has the potential to affect all patient's served by the agency. --- Findings included: RECORD/PATIENT #2: Review of the clinical record showed the following: -Patient was admitted to hospice on 10/18/2022 with a terminal diagnosis of Chronic Obstructive Pulmonary Disorder; -Patient had an initial assessment completed on 10/18/2022; and -Patient had no comprehensive assessments in their clinical record since admission. RECORD/PATIENT #4: Review of the clinical record showed the following: -Patient was admitted to hospice on 08/17/2022 with a terminal diagnosis of Malignant Neoplasm of the Left Kidney; -Patient had an initial assessment completed on 08/17/2022; -Patient had a comprehensive assessment completed on 11/07/2022 for recertification; and -Patient had no other comprehensive assessments documented in their clinical record. During an interview on 11/16/2022 at 10:00 AM, the administrator stated that he/she would educate the staff regarding completing the comprehensive assessment and documenting the assessment at least every fifteen days. .

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care in, but not limited to, three (Records/Patients #1, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Finding included: Review of the agency's undated policy titled, "Interdisciplinary Plan of Care," showed in part: - A written plan of care will be established and maintained for each patient, the care provided to the patient will be in accordance with the plan; - Each plan is individualized to meet the specific needs of the patient and care givers; - The plan is based on the: Patient's diagnosis and prognosis; Assessment of nursing, medical, functional, psychosocial, and spiritual needs; Identification of services needed, including the management of discomfort and symptom relief; Scope (each discipline is identified) and frequency of services; Equipment; Physician's orders; and - The plan of care is routinely reviewed by the Interdisciplinary Group (IDG) every two weeks and whenever there is a change in level of care. RECORD/PATIENT #1: Review of the clinical record showed: - The patient was admitted to hospice services on 04/15/2022 with a diagnosis of Gastrointestinal Hemorrhage, unspecified (bleeding in the gastrointestinal tract of unknown cause); - The patient resided in a long term care facility (LTCF); - IDG meeting notes dated 10/18/2022 showed the patient's blood sugar level will be maintained at optimal level for patient's illness within 72 hours. Interventions included: assess, perform, and instruct on diabetic care and assess, perform and instruct on glucometer testing. - Patient's co-morbidities failed to include a diabetic diagnosis; and - LTCF diagnoses failed to include a diabetic diagnosis. - IDG meeting notes dated 10/18/2022 showed an intervention under maintaining skin integrity for heel boots on while in bed; and - A physician's order dated 05/03/2022 showed that the heel boots were discontinued due to patient refusal to wear boots. - IDG meeting notes dated 10/18/2022 showed that patient's seizures will be controlled within three hours and patient will remain safe from injury during seizure activity. - Patient's co-morbidities failed to include a seizure diagnosis; and - LTCF diagnoses failed to include a seizure diagnosis. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to hospice services on 10/11/2022 with a diagnosis of Dementia (a loss of mental function that is severe enough to affect daily life and activities); - The patient resided at home; - The Registered Nurse (RN) Initial Assessment dated 10/11/2022 showed: - The patient was a fall risk due to a history of a fall on 09/27/2022 resulting in a fracture and a total score of eight on the fall risk scale with a notation that a score of four or greater is considered at risk for falling; and - The plan of care dated 11/15/2022 failed to include a problem or interventions for falls. - The RN Initial Assessment dated 10/11/2022 showed: - During the visit the patient had hard stool noted that he/she could not pass, a rectal suppository was administered, and the nurse assisted the patient in passing the stool by digitally removing hard stool; and - The plan of care dated 11/15/2022 failed to include a problem or interventions for constipation. RECORD/PATIENT #5: Review of the clinical record showed: - The patient was admitted to hospice services on 09/17/2022 with a diagnosis of congestive heart failure (a chronic condition that effects the ability of the heart to pump blood adequately); - The patient resided in a LTCF; - The RN Initial Assessment dated 09/17/2022 showed: - The patient was a fall risk due to a history of falls and a score of eight on the fall risk scale with a notation that a score of four or greater is considered at risk for falling; and - The plan of care dated 10/01/2022 failed to contain a problem or interventions for falls. -The Medication List dated 09/17/2022 to 12/15/2022 showed: -The patient was receiving Coumadin (a blood thinner) one milligram (mg) daily for a prosthetic heart valve; and - The plan of care dated 10/01/2022 failed to contain a problem for monitoring bleeding complications or interventions for safety related to bleeding complications. During an interview on 11/16/2022 beginning at 9:30 AM, the administrator stated that he/she would expect the plan of care to be individualized and updated as needed.

Based on nationally-recognized standards, policy review, observation, and interview the agency failed to ensure that accepted standards of practice to prevent transmission of infections and communicable diseases were followed in two (Records/Patients #1 and #3) of three home visit observations conducted. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2020, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the agency's undated policy titled, "Standard Precautions," showed in part: - Hands should be washed immediately after gloves are removed; - Between patient contacts; and - When otherwise indicated to avoid transfer of microorganisms to other patients or environments. RECORD/PATIENT #1: Observation on 11/15/2022 beginning at 9:40 AM, during the patient's home visit in a long term care facility, showed social worker A: - Entered the facility and failed to perform hand hygiene prior to patient contact; - Touched the patient several times after touching his/her face mask; - Left the visitor area to go to the dining room for a requested item for the patient; - Returned the patient to the common room and touched other patients in the common room without performing hand hygiene between patient #1 and other patients; - Wheeled another patient down a hallway to a common area; and - Left the facility at approximately 10:20 AM without performing hand hygiene. RECORD/PATIENT #3: Observation on 11/15/2022 beginning at 12:00 PM, during the patient's home visit, showed RN B: - Donned gloves to complete patient's vitals signs; - Removed gloves and failed to perform hand hygiene; - Donned gloves to complete patient's assessment including checking patient's mouth and skin; - Removed gloves and failed to perform hand hygiene; - Donned gloves, scratched his/her forehead, cleaned equipment used for patient vital signs and assessment; and - Removed gloves and performed hand hygiene. During an interview on 11/16/2022 at 9:30 AM, the administrator stated that he/she would expect handwashing to be done according to the policy.

Based on policy review, contract review, and interview the agency failed to ensure that inpatient contract (#1) of two contracts reviewed included that the agency retains the responsibility for ensuring that the training of personnel has been provided and that training has been documented. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's undated policy titled, " Admission for Inpatient Services in a Contract Inpatient Bed," showed in part, the hospice shall provide appropriate hospice care and training to the hospital personnel who will be providing inpatient care to hospice patients pursuant to this agreement. CONTRACT #1: Review of contract #1 titled, "Agreement Between Hospital and Hospice," dated 12/22/2003, showed on 11/15/2022, that the contract failed to include that the agency is responsible for the training of inpatient personnel and documentation of that training. During an interview on 11/16/2022 at 9:30 AM, the administrator stated that a new contract had been drafted but had not been signed by the hospital as of 11/16/2022 date.

Based on policy review, record review, and interview, the agency failed to ensure that the Skilled Nursing Facility binder contained the required documents in, but not limited to, one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's undated policy titled, "Patient Care in a Nursing Home," showed that a photocopy of the signed Hospice care plan will remain at the facility for their records. RECORD/PATIENT #2: Review of the patient's hospice binder at the skilled nursing facility on 11/15/2022 at 10:30 AM showed that the binder failed to contain: -The patient's current plan of care (Plan of care in binder was from 10/18/2022); -The patient's advanced directive; and -The certification of terminal illness. During an interview on 11/16/2022 at 10:00 AM, the administrator stated that he/she would would expect these documents to be in the facility binder per regulation.

Based on Missouri state statute, policy review, employee file review, and interview, the agency failed to ensure that the Employee Disqualification List (EDL) was checked prior to employee hire in, but not limited to, three (Employees #3, #4, and #5) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the providers duty to conduct employee criminal background checks pursuant to this section..." Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest). Review of the agency's undated policy titled "Procedure for Employment," showed that prior to employment, each prospective employee will complete an application either by paper or online. The agency will decide whether or not to interview the applicant based on qualifications, work history, education, certifications, and background. If the applicant is desired after the interview, the pre-employment process will begin. This consists of: a drug/alcohol screening, Tuberculosis Testing, background check, preliminary job offer, and the Family Care Safety Registry. The applicant will also be checked against the Employee Disqualification List, CNA/Nurse registries, office of the inspector general, and degree audits. EMPLOYEE #3: Review of the employee files showed the following: -Date of Hire: 11/02/2022; and -Date of EDL: 11/02/2022. EMPLOYEE #4: Review of the employee files showed the following: -Date of Hire: 10/04/2022; and -Date of EDL: 10/04/2022. EMPLOYEE #5: Review of the employee files showed the following: -Date of Hire: 09/21/2022; and -Date of EDL: 09/22/2022. During an interview on 11/16/2022 at 10:00 AM, the administrator stated that the agency will be updating the hiring process to ensure that the EDL is completed prior to hire of an employee.