Every finding on record at Missouri Caris Healthcare, LLC

Based on policy, record review and interview the hospice provider failed to ensure an accurate/updated medication profile was maintained in four of five full records reviewed (Records/Patients #1, #2, #3 and #4). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current active medication orders, printed 06/09/2026, showed the following discrepancies:- The hospice provider’s medication report showed Milk of Magnesia (a medication for constipation) 400 mg/5ml oral suspension, tree (3) ml daily as needed.  The LTCF’s medication orders showed Milk of Magnesia suspension 400 mg/5ml, 30 ml once a day as needed; - The hospice provider’s medication report showed Insulin Aspart (injectable medication used to lower blood sugar)  100 unit/ml subcutaneous as needed three times daily per sliding scale instructions for blood sugar levels.  The LTCF’s medication orders failed to include the sliding scale insulin; and - The LTCF’s medication orders showed oxygen (O2) at 2 liters/minute via nasal cannula to maintain O2 sats greater than 92% as needed every shift.  The hospice provider’s medication report failed to include the oxygen. The hospice provider failed to maintain an accurate drug profile.  RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks).  The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current medication administration record (MAR), printed 06/10/2026, showed the following discrepancies: - The hospice provider’s medication report showed Insulin Glargine 100 unit/ml subcutaneous 10 units daily at bedtime.  The LTCF’s MAR failed to include the Glargine insulin; and - The hospice provider’s medication report showed Insulin Lispro (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous as needed four times daily per sliding scale instructions for blood sugar levels.  The LTCF’s MAR failed to include the sliding scale insulin; and - The LTCF’s MAR showed glipizide (a medication used to lower blood sugar) 5 mg one tablet once a day.  The hospice provider’s medication report failed to include the glipizide.  The hospice provider failed to maintain an accurate drug profile.      Findings included:Review of the provider's policy titled, "Medication Management," dated 04/28/2026, showed in part, that a medication profile is maintained for every patient and includes a listing of the current medication orders for each patient and specifies whether the medication is or is not related to the patient's terminal illness.  The profiles is updated at the time of each comprehensive assessment at a minimum and/or when new medication is added or changes are made to existing medications.  Review of the provider's policy titled, "Medication Assessment and Reconciliation," dated 07/05/2021, showed in part, on every skilled nursing visit, perform medication reconciliation to ensure all medications are correctly documented in the electronic record (EMR).  Medication reconciliation for patients residing in the long-term care facility (LTCF) includes the following:- Review facility medication administration record (MAR) and confirm against what is in the medication profile of the EMR.  If discrepancies noted, make changes in the EMR; and- Review each medication's strength/dosage/frequency. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with the terminal diagnosis of cerebral atherosclerosis (ICAD; the buildup of fatty plaque in the arteries that supply blood to the brain), hemiplegia following cerebral infaaction affecting left non-dominate side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere) and aphasia (language impairment) and dysphagia (difficulty swallowing) following cerebral infarction. The patient resided in a LTCF.Review of the LTCF MAR on 06/09/2026 beginning at 11:18 AM, showed the following discrepancy: -The hospice provider's client medication report, printed on 06/08/2025, showed the patient was ordered Duloxetine (an antidepressant) 20 milligrams (mg) tablet by mouth (PO) once a day; and -The LTCF MAR did not show this medication was being given. The hospice providers chronological list of medications and equipment, printed on 06/08/2026, included duloxetine.The hospice provider failed to maintain an accurate drug profile.   RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis. The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current MAR, printed 06/09/2026, showed the following discrepancies:- The hospice provider’s medication report showed Milk of Magnesia (a medication for constipation) 400 mg/5ml oral suspension, three (3) milliliters (ml) daily as needed.  The LTCF’s medication orders showed Milk of Magnesia suspension 400 mg/5ml, 30 ml once a day as needed; - The hospice provider’s medication report showed Insulin Aspart (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous as needed three times daily per sliding scale instructions for blood sugar levels.  The LTCF’s medication orders failed to include the sliding scale insulin; and - The LTCF’s current MAR showed oxygen (O2) at 2 liters/minute via nasal cannula to maintain O2 sats greater than 92% as needed every shift.  The hospice provider’s medication report failed to include the oxygen. The hospice provider failed to maintain an accurate drug profile.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer's disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the left non-dominant side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere). The patient resided in a long-term care facility (LTCF).Review of the LTCF MAR on 06/09/2026 beginning at 10:08 AM, showed the following discrepancies:-Bisacodyl suppository to be given once daily; -Chloraseptic throat spray to be give twice daily;-Glucerna meal shake to be given twice daily; -Juven collagen packets to be give twice daily; and-ProTGold protein supplement and collagen supplement to be given twice daily. The hospice provider's client medication report did not include the following: Bisacodyl suppository, Chloraseptic throat spray, Glucerna (or any other brand) of meal shake, Juven collagen packets or ProTGold protein supplements.The hospice provider failed to maintain an accurate drug profile.   RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks).  The patient resided in a LTCF. Review of the hospice provider’s client medication report, printed 06/09/2026, and the LTCF’s current MAR, printed 06/10/2026, showed the following discrepancies: - The hospice provider’s medication report showed Insulin Glargine (injectable medication used to lower blood sugar) 100 unit/ml subcutaneous 10 units daily at bedtime.  The LTCF’s MAR failed to include the Glargine insulin; and - The hospice provider’s medication report showed Insulin Lispro 100 unit/ml subcutaneous as needed four times daily per sliding scale instructions for blood sugar levels.  The LTCF’s MAR failed to include the sliding scale insulin; and - The LTCF’s MAR showed glipizide (a medication used to lower blood sugar) 5 mg one tablet once a day.  The hospice provider’s medication report failed to include the glipizide.  The hospice provider failed to maintain an accurate drug profile.  During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; known at the provider as the regional vice president of clinical care), stated that he/she would expect the medication reconciliation to be done at least weekly, and would expect the profile to reflect what the patient was taking in the home.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) necessary to meet the needs of the patient in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Review of the provider’s policy titled, “Plan of Care – Content,” dated 04/28/2025, showed in part, the patient’s plan of care includes all services necessary for the palliation and management of the primary terminal illness and related diagnoses and conditions.  The plan of care includes, but is not limited to medical supplies, DME, and appliances necessary to meet the needs of the patient.  RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the recertification updated POC, dated 05/19/2026, and the POC update report, dated 06/02/2026, showed, in part: - DME included a wheelchair, low air loss mattress, and electric bed; and- The POC failed to include a Broda chair (a type of specialty wheeled chair) and fall mat, necessary to meet the needs of the patient.    RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks).  The patient resided in a LTCF. Review of the POC, dated 04/04/2026, showed, in part: - No DME or supplies listed; - Activities Permitted included, up as tolerated with walker; and- The POC failed to include a walker, necessary to meet the needs of the patient.   RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity).  The patient resided in a LTCF.  Review of the POC, dated 05/04/2026, showed, in part, no DME or supplies listed. Review of the POC Update Report, dated 06/02/2026, showed, in part:- No DME or supplies listed;- The POC failed to include an oxygen concentrator and supplies, for oxygen ordered on 05/15/2026, necessary to meet the needs of the patient.   Review of the provider’s policy titled, “Plan of Care – Content,” dated 04/28/2025, showed in part, the patient’s plan of care includes all services necessary for the palliation and management of the primary terminal illness and related diagnoses and conditions.  The plan of care includes, but is not limited to medical supplies, DME, and appliances necessary to meet the needs of the patient.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 04/01/2025 with the terminal diagnosis of cerebral atherosclerosis (ICAD; the buildup of fatty plaque in the arteries that supply blood to the brain), hemiplegia following cerebral infraction affecting left non-dominate side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere) and aphasia (language impairment) and dysphagia (difficulty swallowing) following cerebral infarction. The patient resided in a long-term care facility (LTCF).Review of the Plan of Care (POC) dated 04/03/2025, showed, in part, the following: The patient would use a wheelchair for activities.The POC failed to list a Broda chair (a type of specialty wheeled chair) necessary to meet the needs of the patient. The hospice provider failed to maintain an accurate list of DME. Observation on 06/09/2026 beginning at 11:20 AM, showed the patient was sitting in a Broda chair (a rolling reclining chair the is pushed by a second person) sleeping in his/her room.   RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the recertification updated POC, dated 05/19/2026, and the POC update report, dated 06/02/2026, showed, in part: - DME included a wheelchair, low air loss mattress, and electric bed; and- The POC failed to include a Broda chair (a type of specialty wheeled chair) and fall mat, necessary to meet the needs of the patient.    RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer's disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the left non-dominant side (total paralysis on the left side of the body due to a stroke in the right brain hemisphere). The patient resided in a long-term care facility (LTCF).Review of the POC dated 05/07/2026, showed, in part the following: The patient would use a wheelchair for activities.-The POC failed to list a Broda chair necessary to meet the needs of the patient. Observation on 06/09/2026 at approximately 10:15 AM, showed Patient #3 sitting in a Broda chair in the SNF religious program. The hospice provider failed to maintain an accurate list of DME.   RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks).  The patient resided in a LTCF. Review of the POC, dated 04/04/2026, showed, in part: - No DME or supplies listed; - Activities Permitted included, up as tolerated with walker; and- The POC failed to include a walker, necessary to meet the needs of the patient.   RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity).  The patient resided in a LTCF.  Review of the POC, dated 05/04/2026, showed, in part, no DME or supplies listed. Review of the POC Update Report, dated 06/02/2026, showed, in part:- No DME or supplies listed;- The POC failed to include an oxygen concentrator and supplies, for oxygen ordered on 05/15/2026, necessary to meet the needs of the patient.    During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care), stated that the durable medical equipment (DME) should be updated whenever equipment is added, it should be in the nurse's narrative as well.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure the nursing needs of the patients were met in two of five full records reviewed (Records/Patients #2 and #5). This deficient practice has the potential to adversely affect all patients served by the hospice provider. --- Findings included:Review of the provider’s policy titled, “Wound Care Treatment,” dated 12/02/2022, showed in part the following:- The nurse will perform a complete head-to-toe assessment of the patient’s skin integrity on a weekly basis and document the findings in the electronic medical record (EMR);- If a wound/pressure injury is present, the documented findings include location, appearance, measurements, drainage, odor, and treatment orders as well as the education provided to the patient/caregiver.  The plan of care will include wound orders, interventions, and the measurable outcomes;- If the patient resides in a long-term care facility (LTCF) and the facility prefers to continue treating with their wound protocol, the hospice nurse still needs to visualize the wound weekly and document findings in the EMR.  As the Hospice Case Manager, the hospice nurse must collaborate with the facility nurse to ensure the treatment to resolve the wound/pressure injury is appropriate.  If the hospice nurse removes the dressing to visualize the wound, the hospice nurse must re-dress the wound correctly unless the facility nurse indicates otherwise.   RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a LTCF. Review of the provider’s Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Reports, dated 03/10/2026. 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, showed in part the following:- The patient had a diagnosis of unstageable pressure ulcer of sacral region; and- Skilled nurse (SN) to provide wound care per orders, cleanse area with wound cleanser, then apply collagen powder into wound, use Dakins solution to moisten non-woven gauze, pack wound bed, apply dry gauze then cover with an island dressing twice a day and as needed.   Review of the hospice provider’s registered nurses’ (RN) notes from 04/14/2026 through 06/022026 showed in part the following:- The hospice RN failed to assess the sacral wound on 4/14/2026, 04/23/2026, 04/30/2026, 05/06/2026, 05/11/2026, 05/19/2026, 05/28/2026, and 06/02/2026; and- The RN discussed the wound with the LTCF’s nurse on 04/23/2026 and 04/30/2026, recorded the LTCF’s measurements of the sacral wound, but failed to visualize and assess the wound. During observation of RN-A’s visit with the patient on 06/09/2026, beginning at 9:00 AM, RN-A failed to observe the patient’s sacral wound or remove or change the wound dressing.  In an interview on 06/09/2026 at 09:45 AM, RN-A stated that he/she did not change the sacral wound dressing, and it was done by the LTCF on the evening shift.   RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity).  The patient resided in a LTCF.  Review of the initial hospice certification and POC, dated 05/04/2026, showed in part the following:- Diagnosis of abrasion right ankle;- SN visits two times per week; and- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount.   Review of physician’s narrative statement and orders, dated 05/06/2026, showed in part, the patient had multiple skin irritation areas and blisters on the right side of the back and a stage two wound on the lateral aspect of the right ankle.   Review of the hospice RN visit notes from 05/04/2026 through 06/08/2026, showed in part the following:- On 05/04/2026, the RN assessment  showed right lateral ankle wound identified, measuring 2 cm x 1.5 cm x 0 cm, irregular shape, no odor or drainage¸ wound care and dressing change completed;- On 05/06/2026, the RN failed to assess wound;- On 05/14/2026, the RN failed to assess the wound and stated “caregiver completed”;- On 05/15/2026, the RN failed to assess wound and stated “caregiver completed”;- On 05/16/2026, the RN failed to assess wound;- On 05/21/2026, the RN failed to assess the wound and stated “caregiver completed”;- On 05/22/2026, the RN assessed the right ankle wound, measured wound at 0.2 cm x 0.5 cm x 0 cm, and changed the dressing;- On 05/22/2026 during the second RN visit, the RN failed to assess the ankle  wound.   LTCF staff reported redness to coccyx but RN failed to visualize coccyx;- On 05/26/2026, the RN failed to assess wound;- On 05/28/2026, the RN assessed the coccyx area for redness and applied barrier cream.  The RN failed to assess the ankle wound;- On 06/01/2026, the RN failed to assess wound;- On 06/04/2026, the RN failed to assess wound; and- On 06/08/2026, the RN failed to assess wound.    During an interview on 06/11/2026 at 10:12 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care), stated that he/she would expect the medication reconciliation to be done at least weekly, and would expect the profile to reflect what the patient was taking in the home or LTCF.

Based on policy review, record review, observation, and interview the hospice provider failed to ensure the hospice aide followed the aide plan of care (POC) in two of five full records reviewed (Record/Patient #3 and #4). This deficient practice has the potential to adversely affect all patients receiving aide services. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 05/07/2026 with the terminal diagnosis of Alzheimer's disease (a progressive, irreversible disorder that destroys memory, thinking skill and the ability to perform simple tasks), hemiplegia following cerebral infarction affecting the non-dominant side. The patient resided at skilled nursing facility (SNF) and the SNF staff were the primary caregivers.  Review of the hospice aide POC, dated 05/07/2026, showed, in part, the following aide services were to be provided on every visit:- Bathing – shower;- Shampoo;- Hair Care;- Oral Care; and- Perineal Care. Review of the “Visit Note Report,” showed, in part, the aide tasks marked as refused, or not required as the following:- Shower/ bath, refused 05/13/2026, not required 05/22/2026, not required 05/26/2026, not required 05/28/2026, not required 06/02/2026;-Oral care/ mouth care, already completed 05/13/2026, not required 05/22/2026, not required 05/28/2026;- Shampoo/ hair care, refused 05/13/2026, not required 05/22/2026, not required 05/26/2026, not required 05/28/2026, not required 06/02/2026; and- Perineal care, refused 05/13/2026, not required 05/22/2026, 2026, not required 05/26/2026, not required 05/28/2026. During an interview on 06/11/2026 at 10:32 AM, TM stated that an action plan was put in place during a quality improvement meeting due to the number of missed and refused visits.  Aides should contact the director of nurses to plan another visit, or additional actions needed.  Findings included: Review of the job description titled “Hospice Aide Assignments and Duties”, dated 05/14/2025, showed the hospice aide provides services that are ordered by the interdisciplinary group and included in the POC.   RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 04/04/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related loss of brain tissue and cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks).  The patient resided in a long term care facility. Review of the hospice aide POC, dated 04/04/2026, showed, in part, the following aide services were to be provided on every visit:- Bathing – shower;- Shampoo;- Hair Care;- Oral Care;- Skin care; - Ear Care;- Nail Care;- Foot Care;- Perineal Care;- Dressing;- Assistance with ambulation;- Offer fluids;- Empty trash;- Change linens;- Make bed;- Straighten patient’s area; and- Three most important things. Observation of the aide visit on 06/10/2026, beginning at 9:00 AM, showed the aide failed to complete or offer the following:- Bathing – Shower was offered but patient declined;- Shampoo was offered but patient declined;- Oral care;- Foot care;- Perineal care was offered but patient declined;- Fluids;- Empty trash;- Change linens; and- Three most important things.

Based on contract review, policy review, record review, observation and interview the hospice provider failed to ensure coordination of responsibility for wound care and foley catheter (a thin flexible tube inserted through the urethra into the bladder to drain urine) care between the hospice and the long-term care facility (LTCF) in two of five records reviewed of patients that resided in a LTCF (Records/Patients #2 and #5).  This deficient practice has the potential to adversely affect all hospice patients residing in a LTCF. Findings included: --- Findings included: Review of the hospice provider’s policy titled, “Hospice Care for Nursing Facility Residents,” dated 04/28/2025, showed in part the following:- The hospice assumes full responsibility for the professional management of the facility patient’s hospice care and routinely provides all core services including nursing, medical social services and counseling; and- The hospice may use the facility’s nursing personnel to assist in the administration prescribed therapies included in the patient’s POC only to the extent that the hospice would routinely utilize the services of a hospice patient’s family in implementing the POC.  Review of the agreement between the hospice provider and the LTCF titled, “Hospice Nursing Facility Services Agreement,” dated 2013, showed in part the following:- In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a hospice POC for each hospice patient that is consistent with the hospice philosophy and is responsive to the unique needs of each hospice patient and his or her expressed desires for hospice care;- Hospice retains primary responsibility for determining each hospice patient’s appropriate hospice POC in accordance with its applicable regulations; and- The hospice plan of care (POC) will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice POC.     RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted for hospice services on 03/05/2026 with a terminal diagnosis of cerebral atherosclerosis (an abnormal collection of calcium and cholesterol on the artery walls of the brain, also known as plaque buildup). The patient resided in a long-term care facility (LTCF). Review of the provider’s POC and POC Update Reports, dated 03/10/2026. 03/24/2026, 04/07/2026, 04/21/2026, 05/05/2026, 05/19/2026, 06/02/2026, showed in part the following:- The patient had a diagnosis of unstageable pressure ulcer of sacral region; - Skilled nurse (SN) to provide wound care per orders, cleanse area with wound cleanser, then apply collagen powder into wound, use Dakins solution to moisten non-woven gauze, pack wound bed, apply dry gauze then cover with an island dressing twice a day and as needed;- Skilled nurse to insert/change indwelling 16 French(FR)/30 cubic centimeters (cc) balloon foley catheter every 30 days using sterile technique; and- Skilled nurse to complete irrigation of urinary catheter using 30 to 60 cc acetic acid daily on Tuesday and Thursday with return.    Observation and interview on 06/08/2026 at 9:45 AM, during the patient’s home visit in the LTCF, the LTCF RN assigned to the patient  stated that all of the hospice paperwork was scanned into the electronic medical record (EMR), but the recent coordination notes (titled, “Hospice Coordinated Plan of Care) were kept in a folder.  He/She stated that they do not have a coordinated task plan or plan of care, just the coordination notes.  Review of the Hospice Coordinated Plan of Care notes completed by the hospice RNs, dated 04/06/2026, 04/23/2026, 04/30/2026, 05/06/2026, 05/11/2026, 05/17/2026, 05, 28, 2026, and 06/02/2026, showed in part the following:- The RN visits were marked with one day per week under “visit frequency” but had inconsistent days of the week documented including two Mondays, one Tuesday, one Tuesday/Wednesday, one Wednesday/Thursday, two Thursday and one not marked;- The RN recorded wound care by “facility staff” on five out of eight records, and one record was not documented; and- The RN failed to record the foley catheter and when care and changes were to be made and which staff (hospice or facility) were to complete the care on eight out of eight records.During an interview on 06/08/2026, RN-A stated that the Hospice Coordinated Plan of Care notes were completed after each visit and shared with the hospice nurse assigned to the patient.  The provider failed to have a coordinated plan of care which indicated coordination of responsibility and identified which provider would be responsible for specific task (wound dressing changes, foley catheter changes, and foley catheter flushes).  The provider also failed to provide the schedule for hospice staff (days of the week and times of day) for patient visits in the coordinated POC.  In an interview on 06/08/2026, at 10:15 AM, the LTCF Assistant Director of Nursing stated that the facility did the foley catheter changes and flushes for all of the hospice patients.  He/She also stated the LTCF wound nurse did the dressing changes for Patient #2.   RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 05/04/2026 with a terminal diagnosis of Alzheimer’s disease (a disease marked by progressive loss of mental capacity).  The patient resided in a LTCF.  Review of the initial hospice certification and POC, dated 05/04/2026, showed in part the following:- Diagnosis of abrasion right ankle;- SN visits two times per week; and- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount.   Review of physician’s narrative statement and orders, dated 05/06/2026, showed in part, the patient had multiple skin irritation areas and blisters on the right side of the back and a stage two wound on the lateral aspect of the right ankle.   Review of the POC Update Reports, dated 05/05/2026, 05/19/2026, and 05/02/2026, showed in part the following:- Diagnosis of abrasion right ankle;- Iodosorb 0.9% topical gel, apply to right outer ankle area at bedtime, small pea size amount;- POC failed to mention dressing change instructions or who was responsible for changing the dressing (hospice of the LTCF).    Review of the Hospice Coordinated POC notes completed by the Registered nurse (RN) showed in part the following:- On 0/26/2026, the RN documented wound care right ankle per facility;- On 05/2028, the RN failed to document the wound care or party responsible;- On both 05/26/2026 and 05/28/2026, the RN failed to document visit frequency or day/time of scheduled visit.    During an interview on 06/11/2026 at 10:15 AM, the governing body appointee (GBA; know at the provider as the regional vice president of clinical care) stated that wounds should be assessed weekly.  He/she stated that the nurse should see the wound, assess the wound, and measure the wound.  The GBA also stated that the foley catheter care should be done as ordered by the doctor, with no delineation of care.

Based on review of personnel files and interview, the hospice provider failed to furnish initial training in emergency preparedness policies and procedures to all new and existing hospice employees consistent with their expected roles and failed to maintain documentation of all emergency preparedness training in two of five personnel files reviewed (Employee/Record #2 and #3). This deficient practice has the potential to affect the safety of all patients served by the provider. --- Findings included: EMPLOYEE #2: Review of Employee #2s personnel file showed: - The employee was a contractor; - The employees hire date was 01/01/2022; and - The file failed to contain evidence that emergency preparedness training was provided upon orientation; EMPLOYEE #3: Review of Employee #3s personnel file showed: - The employees hire date was 09/07/2021; and - The file failed to contain evidence that emergency preparedness training was provided upon orientation; During an interview on 07/13/2023 at 8:50 AM, the administrator stated that he/she would expect the emergency preparedness training to be completed on orientation and recorded in the employees personnel file for employee #3 and that employee #2 is a contractor and the contract states that the provider is not responsible for training and the contractor should have had initial orientation. He/she stated corporate is now aware of the oversight and will work to fix it.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the patients terminal illness when it failed to perform a comprehensive pain assessment in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Assessment – Content of the Comprehensive Assessment," dated/reviewed 02/25/2020, showed in part: - The comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs of the patient related to the terminal illness that must be addressed to promote the patients well-being, comfort and dignity throughout the dying process; - The comprehensive assessment of the patient consists of assessment tools that address the nature and condition causing admission, complications and risk factors that affect care planning, severity of symptoms, and a review of all the patients medications; and - Each assessment tool is designed to obtain information related to the patients history, current status, problems, and needs. Review of the providers policy titled, ";Pain and Symptom Management," dated/reviewed 02/25/2020, showed in part: - The patients pain and other symptoms related to the terminal condition are thoroughly assessed during the comprehensive assessment of the patient by the registered nurse (RN) case manager; and - Pain is re-assessed during every visit, any time a patient indicates that his/her pain level has changed, and whenever pain medication or dosage is changed. This information is documented in the clinical record. RECORD/PATIENT #4: Review of the document titled, ";Client Medication Report," showed the patient had a terminal diagnosis of esophageal (the hollow muscular tube that carries food and liquids from the throat to the stomach) cancer and was taking scheduled oxycodone (a narcotic opioid pain reliever used to treat moderate to severe pain) 5 milligrams (mg) four times daily. The patient also had orders for the oxycodone to be administered every four hours as needed (PRN- Pro re nata) for breakthrough pain. Review of the comprehensive recertification assessment, dated 04/05/2023, showed: - The patient lived in a long-term care facility; - The patient had a recent decline in functional status; - The patient had difficulty speaking; - The pain assessment question ";Are you uncomfortable because of pain," was documented as ";No"; - The pain assessment question, ";Pain reported by," was documented as ";Health Professional - Assisted"; - The patient was unable to verbalize an answer to the assessment; - The pain assessment question, ";Was a detailed pain assessment completed," was answered as ";No"; - The pain assessment question, ";Indicate why pain/comfort was not assessed," was answered as ";N/A" (not applicable); - The pain assessment question, ";Is patient receiving opioid medication," was answered as ";No" (the patient has been taking scheduled oxycodone since admission on 01/12/2023); - Interventions provided were documented as ";Evaluated effectiveness of pain control measures" (no evaluation was documented in the visit note); - Details/comments showed ";See physical assessment pain section for detailed description"; - The recertification assessment failed to include the patients history of pain, the characteristics and prior severity of the pain, or the scheduled and PRN narcotic pain medication. During an interview on 07/12/2023 at 1:50 PM, the administrator stated that he/she would expect the recertification assessment of a patient with cancer to include a thorough comprehensive pain assessment.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in, but not limited to, 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, ";Medication – Management", reviewed 02/25/2020, showed in part that a medication profile is maintained for every patient and includes a listing of the current medication orders for each patient. The hospice monitors the medications dispensed to and used by the patient. RECORD/PATIENT #1: Observation on 07/11/2023 beginning at 1:18 PM, during the patients home visit, showed the following medication discrepancies with the current LTCF (long term care facility) medication orders and the hospice providers updated POC dated 07/04/2023 and current medication profile: - The LTCF orders showed an order for vitamin D3 (supplement) 25 mcg (micrograms) one tablet once a day. This order was not included on the hospice updated POC and medication profile; - The LTCF orders showed an order for artificial tears (used for dry eyes) one drop in each eye two times a day and an order for one drop in both eyes two times a day as needed. The hospice updated POC and hospice medication profile failed to include the routine order for one drop in each eye two times a day; - The LTCF orders showed an order for Senokot-S (laxative plus stool softener) 8.6 mg (milligrams)-50 mg one tablet two times a day as needed. This order was not included on the hospice updated POC and medication profile; -The LTCF orders showed an order for alprazolam (anti-anxiety) 0.25 mg at bedtime. This order was not included on the hospice updated POC and medication profile; and -The hospice updated POC and medication profile showed an order for atropine 1% two to four drops every four hours as needed. The LTCF orders did not include this order. During an interview on 07/12/2023 at 1:50 PM, the administrator stated that he/she expected a drug regimen review to be performed with the nursing visits. He/she could not remember if their policy stated with every visit but expected it to be frequently enough so the medications stayed current.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure a complete individualized written plan of care (POC) was developed that was based on the problems identified in the patient's comprehensive 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 providers policy titled, ";Plan of Care," reviewed 02/25/2020, showed in part that the hospice care and services provided to patients and their families are in accordance with an individualized, written POC established by the hospice IDT (interdisciplinary team/group). The POC specifies the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient. Revisions to the POC are based on information from the patients updated comprehensive assessment. Review of the providers policy titled," Plan of Care – Content," reviewed 02/25/2020, showed in part that the POC reflects patient and family goals and interventions that are based on the problems identified in the initial, comprehensive and updated assessments. RECORD/PATIENT #2: Review of information faxed from the long-term care facility (LTCF) where the patient resided dated 03/23/2023 showed the patient had a history of suicidal ideation in June, 2022 and a history of falls. Review of the RN (registered nurse) start of care assessment dated 03/30/2023 showed: - Falls assessed; - Fall precautions implemented included low bed, fall mat, call light within reach, assistance with ADLs (activities of daily living), and frequent rounding; - Alert to person; - The patient was not at risk for suicide; and - Resided in a LTCF Review of the nursing admission narrative coordination note dated 03/30/2023 showed the patient had a significant decline over the last few months. Prior to illness the patient was alert and oriented times two. Currently alert and oriented times one and had increased confusion. The patient had a history of hospitalization related to suicidal ideation. Review of the POC dated 03/30/2023 showed: - Diagnoses included history of falling and bipolar disorder; - Hospice nurse for assessment of patient safety and instruct on safety measures as applicable; - The POC failed to include specific interventions such as low bed, fall mat, call light in reach and making frequent rounds on the patient; - Medical social worker to evaluate social and emotional factors related to the patients illness; and - The POC failed to include specific nursing interventions related to the patients history of suicidal ideation. Review of the RN recertification assessment dated 06/21/2023 showed: - No skin issues identified; - The patient was at risk for falls; - The patient was not at risk for suicide; and - No abnormal psychiatric symptoms identified. Review of the hospice recertification POC update dated 06/21/2023 showed: - An order for the hospice nurse to provide wound care to the left forehead (the wound had healed on 04/12/2023); - Hospice nurse for assessment of patient safety, instruct safety measures as applicable; - The POC failed to include specific interventions related to the patients fall risk such as low bed, fall mat, call light in reach, and making frequent rounds on the patient; - Medical social worker to evaluate social and emotional factors related to the patients illness and to assess the patient for thoughts of suicidal homicidal ideation; and - The POC failed to include nursing interventions related to assessment of the patients history of suicidal ideation. Observation showed on 07/11/2023, at 1:45 PM, during the patient's home visit at the LTCF, the patient lay in a low bed with a fall mat beside the bed. The patient was alert and spoke softly. The patient agreed to a shower with the hospice aide. During an interview on 07/12/2023 at 2:25 PM, the administrator stated that if nursing was supposed to assess suicide risk per policy then he/she would expect that to be on the POC. Usually, the social worker took the lead with suicide risk assessments. He/she would expect staff to follow what their POC policy said to do related to fall prevention interventions.

Based on record review, home visit observation, and interview, the hospice provider failed to ensure that the plan of care included all medical supplies and appliances necessary to meet the needs of the patient in, but not limited to, one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the care plans of all the providers patients. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/02/2022 with a terminal diagnosis of Malignant Neoplasm of the Right Breast. The patient resided at home. Observation on 07/12/2023 beginning at 1:15 PM, showed the patient's durable medical equipment (DME) included an oxygen concentrator, wheelchair, gait belt, portable oxygen tanks, and incontinence supplies. Review of the document titled, "Hospice Certification and Plan of Care" (POC) dated 08/02/2022 showed that the patient's DME needs were ";none". Review of clinical record failed to show:- A physician order for the DME in the patients home; and- DME needs documented in the visit notes dated 06/01/2023 through 07/12/2023. During an interview on 07/12/2023 at 4:15 PM, the administrator stated that, the DME should be listed on the POC and it was not documented in the new software.

Based on policy review, record review and interview the hospice provider failed to ensure the nursing needs of the patient were met in one of five full records reviewed (Record/Patient #2) and failed to ensure the RN (registered nurse) performed LPN (licensed practical nurse) supervisory visits per policy in, but not limited to, 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, ";Nursing Services," reviewed 02/25/2020, showed in part that nursing care and services are provided under the supervision of an RN. In the state of Missouri, LPNs are supervised by an RN at least every 30 days. Review of the providers hospice LPN job description revised/reviewed 09/20/2018, showed in part that the LPN reports to the patient care manager. The LPN observes, records and reports all observation of the patients mental and physical care provided in progress notes and submits notes daily to the patient care manager. The LPN notifies the patient care manager or physician immediately of any changes in the patients condition that warrant attention. Review of the providers policy titled, ";Documentation Requirements", reviewed 02/25/2020, showed in part that real time documentation is performed at the bedside and completed shortly after the visit using the electronic charting system. RECORD/PATIENT #2: Review of the RN visits from 04/20/2023 through 07/05/2023 failed to show documentation of LPN supervisory visits. Review of a SN (skilled nurse) visit note dated 06/28/2023 showed the LPN documented the patient had abnormal breath sounds with crackles (congestion) in the lower right and lower left lobe of the lungs. The patients current respiratory status was deteriorating. The LPN documented he/she communicated with the RN, SN (skilled nurse), hospice aide, social worker, chaplain, facility staff, volunteer coordinator and bereavement coordinator. The LPN failed to document what he/she communicated to the hospice staff. The section that asked; was a narrative coordination note completed indicating communication of all disciplines regarding the patients plan of care was answered- yes. Review of a coordination note provided by the administrator on 07/12/2023 at 12:08 PM, showed the narrative note for the visit of 06/28/2023 was dated 07/05/2023 (seven days later). The patient sat comfortably in a wheelchair. The patient became anxious and began pedaling the wheelchair into the hall then back into his/her room. The facility nurse reported the patients anxiety comes and goes. The patient continued on routine anxiety medications as well as as needed lorazepam (anti-anxiety medication) in place. No concerns or questions at this time. The note failed to show documentation that the patients abnormal lung sounds was discussed with the facility nurse, hospice RN case manager or the hospice clinical manager. Review of the IDG (interdisciplinary group) meeting note dated 07/04/2023 showed the RN documented there were no new changes noted or reported. The medication list showed the patient had been on Augmentin (antibiotic) from 06/25/2023 through 07/01/2023 for pneumonia. Review of an RN visit note dated 07/05/2023 showed there was no change in respiratory status. The nurse did not document the patients lung sounds. The facility nurse reported the patient continued to have intermittent anxiety and Ativan (anti-anxiety medication) was effective. No other issues reported by staff. No symptoms of distress. No shortness of breath or edema. The patient finished an antibiotic for pneumonia on 07/01/2023. During an interview on 07/12/2023 at 12:08 PM, the administrator stated that he/she expected staff to have their documentation in as soon as possible. When asked if he/she expected the LPN to report the change in lung sounds to the RNCM (RN case manager), he/she stated that he/she would check on that. During an interview on 07/12/2023 at 12:30 PM, the administrator stated that he/she talked with the regional nurse, and they would expect the nurse to talk with the hospice RN about any changes. They are trained to document those discussions in the general comment section. They have stand-up meetings every morning and afternoon and they typically talk about any changes or things that have occurred. He/she looked at the stand-up notes for that day (06/28/2023) and stated that there was nothing specifically documented regarding the patients lung sounds. During an interview on 07/13/2023 at 9:00 AM, the administrator stated that he/she was not sure what to expect for timely documentation if there is not a policy. Per policy, charting is to be completed in real time.

Based on policy review, record review, observation and interview the hospice provider failed to ensure the RN (registered nurse) developed a complete aide care plan (CP) in one of four full records reviewed that received aide services (Record/Patient #2). This deficient practice has the potential to affect all patients that received aide services by the provider. --- Findings included: Review of the providers policy titled, ";Hospice Aide Assignment and Duties", reviewed 02/25/2020, showed in part that the hospice aides are assigned to specific patients by a hospice RN and follow written patient care instructions in providing care to assigned patients. Review of the providers policy titled, Hospice Aide Services," reviewed 02/25/2020, showed in part that the RN case manager develops a written hospice aide CP that provides instructions to the hospice aide of the care to be provided. RECORD/PATIENT #2: Review of the RN start of care assessment dated 03/30/2023 showed the patient transferred from chair to bed with maximum assistance (did not indicate whether this meant using two staff to transfer or use of a mechanical lift). Review of the plan of care (POC) dated 03/30/2023 showed diagnoses included long term use of anticoagulants (blood thinning medications). The medication list included an order for Eliquis (blood thinner) 2.5 mg (milligrams) two times a day. Safety measures included anticoagulant precautions (precautions to prevent bleeding such as avoiding sharp objects, using a soft toothbrush, electric razor, and care with using nail clippers). Review of the aide CP report dated 03/30/2023 failed to include anticoagulant precautions. The aide services included oral care, nail care, and shaving every visit but no instructions regarding precautions to take when providing these services. The aide was also to transfer the patient from the bed to chair and from the chair to bed (no specific instructions regarding maximum assistance or use of a mechanical lift). Per interview conducted during observation on 07/11/2023 beginning at 1:45 PM, the hospice aide stated that he/she did not know of any special precautions with the patient. The hospice aide and facility staff transferred the patient with a mechanical lift. During an interview on 07/12/2023 beginning at 2:25 PM, the administrator stated that he/she would expect Hoyer lift (mechanical lift) transfers to be on the aide CP. He/she had not seen anticoagulant precautions for the aide CP in their electronic medical record system. He/she would expect the RNs to follow their policy for the aide CP.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure a registered nurse (RN) made on-site visits to the patients home every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group (IDG) meet the patients needs in, but not limited to, one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Hospice Aide Supervision," dated/reviewed 02/25/2020, showed: - A RN makes an on-site visit to the patients home no less frequently than every 14 days to ensure that the services ordered by the interdisciplinary group (IDG) and provided by the aide are meeting the patients needs; - If an area of concern is noted by the RN case manager, the hospice RN case manager makes an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he/she is performing care; - The RN case manager assesses an aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to; *Following the patients plan of care (POC) for completion of tasks assigned to the hospice aide by the RN; and *Reporting changes in the patients condition. RECORD/PATIENT #4: Review of the POC, dated 04/05/2023, showed: - Orders for skilled nursing (SN) visits one time a week for 13 weeks effective 04/12/2023; and - Orders for hospice aide visits one time a week for one week, then two times a week for 12 weeks, then one time a week for one week effective 04/12/2023. Review of the hospice aide visit notes showed: - The aide performed one visit between 04/12/2023 and 04/15/2023; and - The aide performed two visits per week from 04/16/2023 to 07/07/2023. Review of the SN notes with dates ranging from 04/05/2023 to 07/01/2023 showed: - The RN performed a supervisory visit with the recertification assessment on 04/05/2023; - On 04/12/2023 through 06/28/2023, the RN visit type was identified as, ";RN10H – RN Hospice Subsequent W/Sup (with supervisory) Visit"; - The assessment question, ";Were supervisory functions performed," was answered ";No"; and - The note showed it was not applicable to the visit or not appropriate at time of evaluation as the reason supervisory functions were not performed. During an interview on 07/12/2023 at 1:50 PM, the administrator stated that it is the hospice providers policy for the RN to perform a supervisory visit of the hospice aide every 14 days. He/she stated the RNs know they are supposed to do these visits. They recently switched to a new software system so he/she will ask the nurse if they could have documented the supervisory visit elsewhere. During an interview on 07/13/2023 at 9:15 AM, the administrator stated that he/she questioned the RN about the supervisory visits and the nurse was confused about how to document with the software and thought that marking the visit type as a supervisory visit was all that needed to be done. They do not have any documentation to show that supervisory visits were performed since 04/05/2023.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure the supervising registered nurse (RN) assessed whether the hospice aide demonstrated satisfactory performance in following the patients plan of care (POC) in, but not limited to, one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all patients served by the hospice provider. --- Findings included: Review of the providers policy titled, ";Hospice Aide Assignments and Duties," dated/reviewed 02/25/2020, showed in part: - A hospice aide provides services that are; * Ordered by the interdisciplinary group (IDG); * Included in the POC; * Under the supervision of an RN; and - Hospice aides must report changes in the patients medical, nursing, rehabilitative, and social needs to a RN, as the changes relate to the POC and quality assessment and improvement activities. Review of the providers policy titled, ";Hospice Aide Supervision," dated/reviewed 02/25/2020, showed in part: - A RN makes an on-site visit to the patients home no less frequently than every 14 days to ensure that the services ordered by the IDG and provided by the aide are meeting the patients needs; - If an area of concern is noted by the RN case manager (supervising nurse), the hospice RN case manager makes an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he/she is performing care; - The RN case manager assesses an aides ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to; * Following the patients POC for completion of tasks assigned to the hospice aide by the RN; * Demonstrating competency with assigned tasks; and * Reporting changes in the patients condition. RECORD/PATIENT #4: Review of the hospice aide POC, dated 04/12/2023, showed: - A visit frequency of two times a week for 12 weeks then one time a week for one week; - The following tasks were assigned for every visit; * Bathing/shower; * Shampoo; * Hair care; * Oral care; * Skin care; * Ear care; * Nail care; * Foot care; * Perineal care; * Assist to toilet; * Dressing; * Turn and position in bed; *Transfer client from bed/chair; * Transfer client from chair/bed; * Assist with feeding; * Offer fluids; * Empty trash; * Change linens; * Make bed; and * Straighten patients area. Review of the hospice aide visit notes with dates ranging from 04/12/2023 to 07/07/2023, showed the aide: - Failed to complete bathing 21 of 25 visits; - Failed to complete shampoo 22 of 25 visits; - Failed to perform hair care 16 of 25 visits; - Failed to complete oral care nine of 25 visits; - Failed to complete skin care seven of 25 visits; - Failed to complete ear care seven of 25 visits; - Failed to complete nail care eight of 25 visits; - Failed to complete foot care eight of 25 visits; - Failed to complete perineal care 10 of 25 visits; - Failed to assist with toileting 16 of 25 visits; - Failed to assist the patient with dressing 12 of 25 visits; - Failed to turn and position the patient in bed 11 of 25 visits; - Failed to transfer the patient from bed to chair 12 of 25 visits; - Failed to transfer the patient from chair to bed 12 of 25 visits; - Failed to assist the patient with feeding 24 of 25 visits; - Failed to change bed linens seven of 25 visits; - Failed to make bed three of 25 visits; and - Failed to notify the RN supervising nurse that tasks were not being completed. Review of the RN visit notes, with dates ranging from 04/12/2023 to 06/28/2023, showed the supervising nurse failed to assess the hospice aides performance in the completion of tasks assigned in the POC. During an interview on 07/12/2023, at 1:50 PM, the administrator stated he/she would expect the hospice aide to communicate to the RN if they are not doing the tasks in the POC and he/she would expect the RN to perform supervisory visits on the hospice aides every 14 days.

Based on employment contract review, employee file review, and interview the hospice provider failed to ensure initial orientation was completed for a clinical employee who had patient and family contact in one of five employee files reviewed (Employee/Record # 2). This deficient practice has the potential to affect all patients served by the hospice. --- Findings included: Review of the employment contract signed 02/10/2015, between the provider and employment group A showed in part: - Employee #2 shall comply with the ethics and professional standards of the medical profession, applicable federal, state and local laws, rules and regulations, including those related to the health and safety of patients, hospice policies and procedures, and the rules and regulations that are applicable to hospice, including accreditation and certification requirements; and- Employee #2 is to attend orientation about hospice philosophy and job duties and in-service training programs, including education on infection control, patient rights and reporting caregiver misconduct. Review of the employee record #2 showed the following:- He/she was contracted as the medical director on 01/01/2022;- There was no documentation of a skills checklist;- There was no documentation of a competency checklist; and- There was no documentation of a 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 on 07/13/2023 at 8:50 AM with the administrator, he/she stated that there is no evidence that the medical director had received orientation and that per the contract it was the responsibility of the employment group.

Based on policy review, contract review, and interview, the hospice providers nursing facility contract failed to specify the provision that hospice must report alleged violations within 24 hours to the facility administrator. This deficient practice has the potential to affect care of any patient that receives hospice services from the provider in a nursing facility. --- Findings included: Review of the hospice policy titled, ";Abuse, Neglect, Mistreatment, and Exploitation", dated 02/25/2020, showed in part that the hospice provider: - Follow all Federal and State requirements regarding alleged violations involving mistreatment, neglect, or verbal, mental, sexual and physical abuse; - Take appropriate corrective action in accordance with State laws; and- Ensure that violations are reported to State and local bodies having jurisdiction within designated reporting period and of becoming aware of the violation. Review of the signed nursing facility agreement dated 05/09/2014, showed the contract failed to include provision stating that the hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the nursing facility administrator within 24 hours of the hospice becoming aware of the alleged violation. During interviews on 07/12/2023 at 2:50 PM, the administrator agreed the 24 hour reporting window was missing from the contract and that he/she would expect the staff to report immediately to supervisor and that the appropriate parties would be notified immediately.

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to ensure the coordinated plan of care (POC) between a long-term care facility (LTCF) and the hospice was updated to include what hospice services were provided, when services were provided and which hospice staff was to provide services in, but not limited to, one of three cases sampled where the patient resided in a LTCF (Record/Patient #4). This deficient practice has the potential to affect the coordination of care for all of the hospice providers patients who reside in a LTCF. --- Findings included: Review of the hospice providers policy titled, ";Hospice Care for Nursing Facility Residents – Coordination of Care," dated/reviewed 02/25/2020, showed in part: - The hospice designates a registered nurse (RN) case manager for each interdisciplinary group (IDG) that is responsible for patients residing in a LTCF. The RN case manager is responsible for providing overall coordination of the hospice care of the patients with the facility representatives; - The hospice will provide; * The names and contact information of hospice personnel involved in hospice care of each patient; * Hospice medication information specific to each patient; and - Documentation of each patient visit in the facility is reported on the two-part coordinated POC form, with one page left in the facility and the other in the hospice chart. Review of the hospice providers policy titled, ";Hospice Care for Nursing Facility Residents – Hospice Plan of Care," dated/reviewed 02/25/2020, showed in part: - The RN case manager assigned to the facility patient is responsible for coordinating and implementing the patients POC in collaboration with members of the hospice IDG and with representatives from the facility; - All care provided to the facility patient must be in accordance with the written POC that includes the patients current medical, physical, social, emotional, and spiritual needs; - The POC for the facility patients identifies the care and services that are needed and specifically identifies which provider is responsible for performing the respective functions that have been agreed upon and included in the POC; and - The POC reflects the participation of the hospice, the facility and the patient and his/her family to the extent possible. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 01/12/2023 with a terminal diagnosis of esophageal (the hollow muscular tube that carries food and liquids from the throat to the stomach) cancer. The patient resided in a LTCF. Review of the document titled, ";Hospice Recertification Plan of Care Update," dated 04/12/2023, showed, in part, the following orders: - Skilled nurse (SN) to visit one time a week for 13 weeks; - Hospice aide to visit one time a week for one week, then two times a week for 12 weeks, then one time a week for one week; - Hospice nurse to provide treatment related to urinary incontinence; - For urinary incontinence care, cleanse skin with Aloe Vesta (brand) perineal/skin cleanser, pat dry, moisturize with Aloe Vesta daily moisturizer and protect skin with Aloe Vesta protective ointment; and - Hospice aide service for assistance with personal care, hygiene, and activities of daily living (ADL). Review of the document titled, ";Aide Care Plan Report," dated 04/12/2023, showed the hospice aide to provide the following ADL services at every visit: - Bathing; - Shampoo; - Hair care; - Oral care; - Skin care; - Ear care; - Nail care; - Foot care; - Perineal care; - Assist to toilet; - Dressing; - Turn and position in bed; - Transfer client from bed/chair; - Transfer client from chair/bed; - Assist with feeding; - Offer fluids; - Empty trash; - Change linens; - Make bed; and - Straighten patients area During a home visit observation at the LTCF on 07/12/2023 at 09:30 AM, the LTCF charge nurse showed this surveyor the hospice binder maintained by the facility. The binder contained numerous carbon copies of the hospice coordinated plan of care for all patients on services with the hospice provider, in no particular order. During the home visit, the hospice RN case manager provided this surveyor with a copy of the hospice coordinated POC completed with this visit. Review of the document showed the coordinated POC failed to identify the patient care and services required and specifically which hospice staff was to provide those services. During an interview immediately following the home visit, the LTCF charge nurse stated that the hospice communicates what days each discipline visits the patients but he/she did not know what approximate time the hospice staff comes or what tasks they will do when they arrive. The hospice nurses do not really communicate what treatments, wound care, catheter care they are responsible for performing and the facility staff does not know what ADLs the hospice aide will do when they arrive at the LTCF. During an interview on 07/12/2023 at 1:50 PM, the administrator stated that they send in a task plan to the medical records employee at the LTCF and that employee is supposed to upload the information in the electronic medical record for the facility staff. He/she will have to address the issue with the LTCF because not all of the information is getting uploaded.

Based on policy review, clinical record review, home visit observation, and interview, the hospice provider failed to provide the skilled nursing facility (SNF) with the names and contact information for hospice personnel involved in hospice care of each patient, the hospice medication information specific to each patient, and hospice physician and attending physician orders specific to each patient in, but not limited to, one of three sampled cases in which the patient resided in a long-term care facility (LTCF) (Record/Patient #4). This deficient practice has the potential to affect the coordination of care for all of the hospice providers patients who reside in a LTCF. --- Findings included: Review of the providers policy titled, ";Hospice Care for Nursing Facility Residents – Coordination of Care," dated/reviewed 02/25/2020, showed the following information is provided to the facility: - The most recent hospice plan of care (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 names and contact information for hospice personnel involved in hospice care of each patient; - Instructions on how to access the hospices 24-hour on-call system; - Hospice medication information specific to each patient; and - Hospice physician and attending physician (if any) orders specific to each patient. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 01/12/2023 with a terminal diagnosis of esophageal (the hollow muscular tube that carries food and liquids from the throat to the stomach) cancer. The patient resided in a LTCF. Review of the hospice records maintained in the electronic medical record (EMR) at the LTCF, during a home visit observation on 07/12/2023 beginning at 9:30 AM, showed the EMR failed to contain: - The names and contact information for hospice personnel involved in the care of the patient; - A current hospice medication profile; and - The hospice physician and attending physician orders. During an interview on 07/12/2023 at 1:50 PM, the administrator stated that they send the LTCF updated information after every interdisciplinary group (IDG) meeting. The information is sent to the facilitys medical records staff and they are supposed to upload the information into the facilitys EMR but it is obviously something he/she is going to have to address because not all of the information is being uploaded.