Every finding on record at Preferred Hospice of Missouri (Central), LLC

Based on policy review, record review, and interview, the hospice provider failed to ensure that staff followed up on the management of pain and symptoms in, but not limited to, 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 providers policy titled, "Hospice Information and Patient Rights and Responsibilities," updated 10/2024, showed that the patient has the right to receive effective pain management and symptom control from hospice. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient resided in a long-term care facility (LTCF).Review of the hospice skilled nurse visit (SNV) note, dated 02/07/2026, showed the nurse documented that the patient had not "pooped" in a few days. The nurse provided instruction to the LTCF staff to begin administering Miralax (medication used to treat constipation).Review of the hospice SNV note, dated 02/10/2026, showed the nurse documented the patient had a bowel movement on 02/09/2026. The nurse failed to follow up on the effectiveness of the medication for constipation until three days later.Review of the hospice chaplain visit note, dated 02/09/2026, showed the chaplain documented the patient reported that his/her feet were really hurting, and that the patient seemed distracted by the pain. The chaplain reported the pain to the facility nurse, and he/she informed the chaplain that they were working on the medications and eventually administered the medications. The note failed to show if the medication was effective.Review of the hospice SNV note, dated 02/13/2026, showed the nurse documented the patient had moderate pain, and the LTCF staff gave the patient a dose of oral pain medication. The SN failed to document if the medication was effective.During an interview on 3/05/2026 at 1:50 PM, the administrator designee stated that reported pain and symptoms should have follow-up within 24 hours.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in one of five full records reviewed (Record/Patient #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, "Medication Profile," dated 08/13/2021, showed the registered nurse (RN) will compile an individualized profile of medications for each patient which will contain, at least, the following for each medication; start date, dosage, route, and frequency. The policy failed to show that any PRN (pro re nata - as needed) medication should include the reason for use.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient resided in a long-term care facility (LTCF).Observation on 03/03/2026 at 10:30 AM showed the following medication discrepancies between the LTCF medication list (LTCF list) printed 03/03/2026, and the hospice medication (HM) list printed 03/03/2026:- The LTCF list showed fentanyl (a strong opioid pain medication) 25 micrograms/hour (mcg/hr) patch every three days with a start date of 02/10/2026; the HM list showed fentanyl 12 mcg/hr patch apply every three days with a start date of 01/29/2026;- The LTCF showed ferrous sulfate (iron supplement) 325 milligram (mg) tablet every Monday, Wednesday, and Friday; the HM list showed ferrous sulfate 325 mg tablet daily;- The LTCF showed hydrocodone-acetaminophen (an opioid pain medication) 5/325 mg tablet, one (1) to two (2) tablets every four hours PRN for pain scale of four - seven (rating scale used to measure pain intensity from zero - no pain to 10 - worst imaginable pain); the HM list showed the same instructions. Both lists failed to indicate when to give one tablet and/or when to give two tablets;- The LTCF list showed lorazepam (antianxiety) 0.5 mg 1 tablet every six (6) hours PRN; the HM list showed the same instructions. Both lists failed to include the PRN reason for administration;- The LTCF list showed melatonin (sleep hormone) 3 mg daily PRN; the HM list showed the same instructions. Both lists failed to include the PRN reason for administration;- The LTCF list showed naloxone (used to reverse opioid overdose) 4 mg/0.1 milliliter (ml) inhalation daily PRN; the HM list showed the same instructions. Both lists failed to include the PRN reason for administration;- The LTCF list showed Tums (used for heartburn or calcium supplement) 200 mg chewable every 6 hours PRN; the HM list showed Tums chewable 500 mg every 6 hours PRN. Both lists failed to include the PRN reason for administration;- The LTCF list showed a multivitamin give 1 tablet daily; the HM list failed to include this medication; and- The HM list showed an order for Hydrofera Blue (brand) foam dressing (bacteriostatic, moisture retentive dressing) daily to wound. The order failed to show who was responsible for the treatment and where the wound was located. During an interview on 03/05/2026 at 12:10 PM, the governing body appointee stated that the medications should be the same, and agreed that PRN medications should include the reason for use.

Based on policy review, bereavement document review, record review, and interview, the hospice provider failed to ensure the initial bereavement assessment identified the social, spiritual, and cultural factors that may impact the bereaved in four of six records reviewed for bereavement (Records/Patients #1, #2, #3, and #11) and failed to identify the family and other individuals that may experience difficulty coping with the patient's death in two of six records reviewed for bereavement (Records/Patients #1 and #11). This deficient practice has the potential to affect the bereaved of all the patients served by the provider.  Findings included: Review of the provider’s policy titled, “Scope of Services,” approved 03/24/2021, showed in part that hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment. Review of the provider's undated document titled, "Areas Covered in Post-Death Bereavement Assessments," showed the following considerations the clinician should evaluate when assessing bereavement risk: - Dependent members in the house; - Other significant or multiple losses; - Severe symptoms of depression, withdrawal, anger, anxiety, or grief; - Social isolation/lack of support system; - Highly complicated relationship with the patient (excessive anger, guilt, resentment); - Multiple life stresses (housing problems, illness, need for employment); - History of mental illness and/or substance abuse (drugs, alcohol) for family member or patient; - Financial status; - Abuse/neglect/domestic violence; - Complicated anticipatory grief;- Caregiver was dependent on patient; - Caregiver stress; - Concurrent life stressors; - Living arrangement change; and - Loss of long term relationship. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/13/2025 with a terminal diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities). The patient resided at a long term care facility (LTCF).  Review of the initial bereavement assessment (known to the provider as the pre-bereavement assessment), dated 03/18/2025, showed the survivor to be the public administrator with conflicting risk information of low moderate risk and low risk. The initial bereavement assessment failed to include the patient’s spouse and his/her adult children. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/25/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and diabetes (a chronic disease that results in too much sugar in the blood). The patient resided at a LTCF. Review of the initial bereavement assessment, dated 03/27/2025, showed the survivor to be the patient’s sibling with conflicting risk information of low moderate risk and low risk. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 07/26/2025 with a terminal diagnosis of malignant neoplasm (cancer) of the lung. The patient resided at home with his/her spouse and family friends.  Review of the initial bereavement, dated 07/31/2025, showed the bereaved survivor at low risk. The initial bereavement assessment failed to identify the name of the bereaved survivor. During an interview on 03/03/2026 at 9:25 AM, social worker (BSW) stated that Patient #1 had a spouse and also adult children. The spouse used to come and visit the patient and was experiencing health issues so he/she did not come as often. The initial bereavement assessment was completed on the daughter and the spouse would have been a candidate. Record review showed the bereaved was the public administrator. During an interview on 03/03/2026 at 12:20 PM, bereavement coordinator (BC) stated that the bereavement program included specific questions used during bereavement assessments conducted pre-death and post death. Those answers are given a numeric value and then based on the results the bereaved were considered low, medium, or high risk. Bereavement services were provided based on the provider's bereavement protocol. During an interview on 03/04/2026 at 3:30 PM, BSW stated that during the initial bereavement assessment he/she would gauge how the person was coping by the feelings that the person was expressing. He/She would offer resources if the person needed financial help or help with funeral arrangements. The amount of resources and type of services would depend on if the patient was in a facility or at home. He/she did not have specific questions that he/she asked during the assessment.  He/She was trained to include the following comment in on the bereavement assessment, “Survivor/Bereavement is low moderate risk.” He/She considered a person high risk if the person had thoughts of suicide, they did not know how to deal with the loved one’s death, and did not want to be near the loved one. Moderate risk would be if the person was emotional and dealing with the loss appropriately. The provider failed to provide evidence that the bereavement assessment considered factors related to bereavement other than identified feelings and the expression of those feelings. During an interview on 03/05/2026 at 11:50 AM, governing body appointee (GBA)-A stated that the social worker had access to the bereavement assessment questions and would expect the social worker to use them. He/She would not expect a public administrator (PA) to be considered the bereaved and would not expect PA to be assessed. He/She would expect the spouse to be assessed. All patients should be treated the same whether they resided in a facility or at home. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/03/2026 with a terminal diagnosis of malignant neoplasm of liver (liver cancer).   The patient resided at the home of his/her sibling.Review of the initial bereavement assessment, dated 02/06/2026, showed the survivor to be the patient’s sibling with conflicting risk information of low moderate risk and low risk.

Based on policy review, record review, observation, and interview, the hospice provider failed to ensure that each patient received a plan of care (POC) that included interventions based on problems identified in two of five full records reviewed (Records/Patients #2, 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, “Scope of Services,” approved 03/24/2021, showed in part the following:- The POC will identify the care and services the hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care;- The hospice will provide a copy of the patient’s POC to the family/caregiver or nursing facility where the patient resides;- The POC will be reviewed and/or revised at a minimum every fourteen days by the interdisciplinary group;- Any changes to the POC will be coordinated with the family/caregiver and or nursing facility;- The nursing facility and the hospice are responsible for performing each of their respective functions as agreed upon and included in the POC; and- The POC will include directives for managing pain and other symptoms and physician standing orders. --- RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/25/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and diabetes (a chronic disease that results in too much sugar in the blood). The patient resided at a LTCF. Review of the POC, dated 02/24/2026, showed a goal to monitor the patient’s blood sugar per physician orders. The POC failed to show orders for blood sugar monitoring and failed to show who would complete the monitoring. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient lived in a long-term care facility (LTCF).Review of the LTCF wound management form printed 03/04/2026 showed that the patient had four current wounds; a right heel wound that was identified on 02/23/2026, a right pinky toe/right lateral foot fifth metatarsal wound identified 02/16/2026, a left bottom of foot/lateral next to fifth distal wound identified on 01/26/2026, and a right sacrum wound identified on 12/16/2025. Review of the LTCF list of active orders printed on 03/03/2026 showed:- A treatment order, dated 02/24/2026, for the right heel wound - cleanse with wound cleanser, pat dry, apply Santyl (used to remove necrotic tissue from wounds) to wound base, then apply Hydrofera Blue (bacteriostatic, moisture-retentive dressing) when available to base of wound and secure with a silicone border gauze daily and as needed;- A treatment order, dated 02/18/2026, for the right lateral fifth metatarsal wound – cleanse with wound cleanser, pat dry, apply skin prep to wound and peri-wound daily;- A treatment order, dated 02/18/2026, for the left foot, lateral next to fifth digit wound – cleanse with wound cleanser, pat dry, and apply skin prep daily; and- A treatment order, dated 02/24/2026, for the right sacral wound – cleanse with wound cleanser, pat dry, apply skin prep to peri-wound, apply Santyl nickel thick to wound base, cover with Hydrofera Blue, secure with silicone bordered gauze daily and as needed; and - A catheter order (patient had a foley catheter (a sterile tube placed in the bladder to drain urine): Change catheter monthly on the first day of the month and as needed.Review of the hospice POC, effective 02/24/2026, showed the POC failed to include:- Treatment orders for the right heel wound and who is responsible for the treatment;- Treatment orders for the right lateral fifth metatarsal wound and who is responsible for the treatment;- Treatment orders for the left foot, lateral next to fifth digit wound and who is responsible for the treatment;- The current treatment orders for the right sacral wound and who is responsible for the treatment; and- An order to change the foley catheter monthly and who is responsible for changing.During an interview on 03/05/2026 at 1:55 PM, the hospice administrator stated that he/she would expect orders for all wounds, treatments, and monitoring of patient needs.

Based on policy review, clinical record review, and interview, the hospice provider failed to ensure a copy of the hospice plan of care was provided to the facility providing respite at the time of respite admission or during the patient’s stay for one of one respite records reviewed (Record/Patient #6). This deficient practice has the potential to affect the coordination of respite for all of the provider’s patients. Findings included: --- Review of the provider's policy titled, "Levels of Care - Inpatient Respite Care," dated 03/30/2023, showed in part the following:- Arrangements with the attending physician and the care facility must be coordinated by the provider and should include the most recent patient plan of care; and- The hospice plan of care will accompany the patient and be followed by the facility staff.   RECORD/PATIENT #6:Review of the clinical record showed in part that:- The patient began inpatient respite services on 02/21/2026;- The patient completed four consecutive days of respite care;- The family privately paid for inpatient care on day five and six; - The provider resumed inpatient respite care on day seven; - The patient was discharged from inpatient respite on 03/03/2026; and- The hospice provider failed to ensure coordination of services when the clinical record failed to include documentation that the patient’s hospice plan of care was placed in the respite facility.  During an interview on 03/05/2026 at 11:30 AM, the governing body appointee stated that they did not have documentation showing the hospice plan of care was provided to the inpatient respite provider,

Based on policy review, record review, observation, and interview, the provider failed to use proper hand hygiene and bag technique in one of four home visit observations conducted (Record/Patient #4). This deficient practice has the potential to affect the health and safety of all the patients served by the provider. --- Findings included:Review of the provider's undated policy titled, "PPE (Personal Protective Equipment), Supplies, and Bag Technique," showed in part the following bag technique:- The interior of the bag is regarded as clean and shall not be re-entered after patient care has begun without sanitizing hands;- Put bag on a clean hard surface, when possible, on a disposable barrier;- Remove necessary items from bag and lay them on a clean disposable barrier, reclose bag and apply PPE. Keep bag closed during visit; and- Clean reusable equipment after patient care and do not put them back in the bag prior to cleaning.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient resided in a long-term care facility (LTCF).Observation on 03/03/2026 beginning at 10:00 AM, showed the registered nurse (RN) placed a barrier on the cushion in the patient’s wheelchair and then set his/her nursing bag on top of the barrier. He/she removed assessment tools from the bag, set them on the barrier, and failed to close the nursing bag. The RN put his/her clipboard into the open front pocket (where the clean assessment tools had been) while he/she assessed the vital signs. The RN completed the vital sign assessment, removed the clipboard and wrote on the paper on the clipboard and returned the clipboard to the front pocket again.  The nurse reached into the open nursing bag rear pocket and removed gloves to conduct the head to toe assessment. The nurse failed to sanitize his/her hands before reaching into the nursing bag.  The blood pressure (BP) cuff was in a plastic outer case and the nurse removed the BP cuff from the case, used it, and returned it to the plastic outer case. The RN cleaned the equipment and returned it to the open nursing bag. When cleaning the BP cuff, the nurse removed it from the plastic outer case, wiped it, and returned it to the case. The nurse failed to wipe the inside of the plastic case before putting the BP cuff back in. The RN zipped up the nursing bag, picked up the barrier underneath, folded it in half, and carried the bag and the barrier out of the room. The RN walked into the soiled linen room, then to the nurse’s station and still had the barrier in his/her hand. The RN began to fold up the barrier and placed it on a counter at the nurse’s station, with his/her nursing bag. The nurse failed to dispose of the barrier in the patient’s room.During an interview conducted immediately after observation, the RN was questioned about removing the barrier from the patient's room and the open nursing bag. The RN stated that he/she was not aware the barrier should have been discarded and, after the interview, he/she discarded the barrier at the nurses station. The RN also stated that he/she was not aware the nursing bag should have remained closed during the nursing visit.

Based on review of the social worker (SW) job description, record review, and interview, the provider failed to ensure social worker services included a complete assessment of patient and family needs for two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: --- Review of the provider’s job description for social workers, dated 09/2022, showed in part the following responsibilities of the social worker:- Provide palliative and supportive casework geared to resolving patients’/families’ financial and emotional issues related to the terminal phase of life;- Assists the patient, family and caregiver in coping with issues related to death and dying;- Assists patients and their families with personal and environmental difficulties which interfere with them obtaining maximum benefits for medical care;- Consults with the physician and other members of the interdisciplinary team for the purpose of assisting them to understand significant social, emotional and environmental factors related to the patient’s status; and- Assists in the development and revision of the hospice plan of care;   RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/03/2026 with a terminal diagnosis of malignant neoplasm of liver (liver cancer).   The patient resided at the home of his/her sibling. Review of the social work initial assessment dated 02/10/2026 failed to be completed in a timely manner due to patient request to postpone.  The social work initial assessment failed to identify the patient's adjustment to moving from the state of California to sibling's home and the patient's history of substance abuse and its psychosocial effect on adjustment, medication management and pain control.   Review of the registered nurse (RN) visit note, dated 02/10/2026 at 10:35 AM, showed the patient had not taken his/her ordered pain medicine very often because he/she had a history of substance abuse and did not want to take a lot of narcotics.  He/she reported sleep was interrupted by pain, he/she started taking hydrocodone on 02/06/2026, and stated this helps his/her pain but it takes a while to notice a difference and wears off quickly.   Review of the plan of care, dated 02/04/2026, showed problem of risk of poor coping issues related to death and dying prior to patient death, risk level “Edit—low/medium/high”.   During an interview on 03/04/2026, the social worker (BSW) stated the bereavement risk level was auto generated on the plan of care and he/she was supposed to choose a risk level and delete the others.  The BSW stated he/she failed to do this.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/13/2025 with a terminal diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities). The patient resided at a long term care facility (LTCF).  Review of the social work initial assessment dated 03/18/2025 failed to mention the patient’s spouse, failed to show the family’s adjustment to the terminal illness, and failed to identify the family support systems. During an interview on 03/05/2026 at 11:50 AM, the governing body appointee stated that he/she would expect the psycho-social assessment to include a conversation regarding Patient #3's move from California and his/her history of substance use. He/She would also expect Patient #1's assessment to include information regarding the patient's family. Resources offered to the family would be the same whether the patient was living at home or in a facility.

Based on policy review, record review, and interview, the hospice provider failed to ensure that the registered nurse (RN) prepared an aide assignment sheet that was patient specific with tasks that were appropriate for an aide to complete in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the provider's patients with aide services. --- Findings included:Review of the provider's policy titled, "Nursing Services," dated 08/13/2021, showed that the RN is responsible for the coordination of all hospice services. The hospice aides may provide hands-on care to the patient, as needed, and as directed by the plan of care and under the direction of the RN.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient resided in a long-term care facility (LTCF).Review of the hospice aide visit task template, last reviewed 02/02/2026, showed the RN assigned the following:- Under the elimination section, the RN assigned; barrier products in use, Calazime (zinc-oxide cream used to protect skin in the perineal area). The treatment/medication failed to be listed on the plan of care or medication list; and- Under the wound care section, the RN assigned; change simple dressing as instructed by RN - Santyl ointment (a medicated ointment used to remove necrotic (dead or dying) tissue from wounds) with Mepilex dressing (brand; highly absorbent foam dressing) on sacral region (patient had a stage three sacral pressure ulcer; a full thickness loss of skin near the tailbone).During an interview on 03/04/2026 at 2:50 PM, the hospice administrator stated that the provision of wound care to a stage three pressure ulcer would be out of the scope of practice for an aide.During an interview on 03/04/2026 at 2:55 PM, the RN coordinator stated that it would not be appropriate for an aide to change the dressing, and that it was an error that the RN assigned this task to the aide.

Based on policy review, record review, and interview, the hospice provider failed to ensure the registered nurse (RN) provided aide supervision in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all the patients with aide services served by the provider. --- Findings included:Review of the provider's policy titled, "Hospice Home Health Aide," dated 08/13/2021, showed that hospice aide services will be supervised by the RN.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient resided in a long-term care facility (LTCF).Review of the hospice plan of care, dated 01/30/2026, showed an order for hospice aide services. Review of the hospice skilled nurse visit notes with a date range of 01/30/2026 through 02/27/2026, (28 days since aide services were ordered) showed that the documentation contained a section titled supervisory visit. The section further showed supervisory visit general details and who completed the form. The section/form failed to contain an assessment of the aide's services.During an interview on 03/05/2026 at 12:45 PM, the governing body appointee stated that the nurses checked the box and that showed the aide supervision was completed but they did not answer the questions, and the form was incomplete.

Based on policy review, record review, and interview, the hospice provider failed to ensure documentation was accurate, complete, and timely in three of five full records reviewed (Records/Patients #1, #2, 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, "Hospice Documentation within 24-48 hours,” approved 04/2025, showed in part the following: - All hospice staff are to complete, finalize, and submit documentation within 24 hours whenever possible and no later than 48 hours after the visit or service; - Documentation accurately reflects the patient’s condition, interventions provided, change in status, caregiver needs, and alignment with the individualized plan of care (POC); - Failure to meet documentation timelines may result in corrective action, as delayed documentation jeopardizes patient safety, regulatory compliance, and claim integrity; and - Immediate documentation requirements include the following:  *Any change in condition  *Falls, injuries, or safety concerns; and - Late entries are to:  *Be clearly labeled "Late Entry"  *Include the actual date/time of the event  *Include the date/time the entry was made  *Explain the reason for the delay  *Never alter or obscure original documentation. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/13/2025 with a terminal diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities). The patient resided at a long term care facility (LTCF).  Review of the aide visits showed the following visits: - Visit date on 02/23/2026, recorded date on 03/02/2026; and- Visit date on 02/23/2026, recorded date on 03/02/2026.  RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/25/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and diabetes (a chronic disease that results in too much sugar in the blood). The patient resided at a LTCF. Review of the aide visits showed the following visits: - Visit date on 01/21/2026, recorded date on 01/25/2026; - Visit date on 01/28/2026, recorded date on 02/01/2026; - Visit date on 02/06/2026, recorded date on 02/16/2026; - Visit date on 02/13/2026, recorded date on 02/16/2026; and  - Visit date on 02/20/2026, recorded date on 03/02/2026. Review of the skilled nurse visits showed the following visits: - Visit date on 01/15/2026, recorded date on 01/19/2026; - Visit date on 01/20/2026, recorded date on 01/23/2026; - Visit date on 01/29/2026, recorded date on 02/02/2026; - Visit date on 02/03/2026, recorded date on 0/08/2026; - Visit date on 02/18/2026, recorded date on 02/22/2026; and - Visit date on 02/19/2026, recorded date on 02/23/2026. During an interview on 03/05/2026 at 12:00 PM, the administrator designee (AD) stated that he/she would expect all staff to complete documentation according to the provider’s policy. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient lived in a long-term care facility (LTCF).Review of the hospice aide visit note dated 02/03/2026 showed that the aide marked acknowledged and completed to wound care task; change simple dressing as directed by RN (Santyl ointment (used to remove necrotic tissue from wounds) with Mepilex dressing (highly absorbent foam dressing) on sacral region.Review of the hospice aide visit note dated 02/06/2026 showed that the aide marked all tasks on the aide assignment sheet, including the wound care task, bed bath every visit, perineal care every visit, and shampoo every visit as acknowledged and completed even though the aide had documented that the patient refused the bath. During an interview on 03/04/2026 at 3:30 PM, the hospice aide was interviewed regarding documentation of tasks, specifically wound care to the patient's sacral area. The aide denied providing wound care and states he/she never does wound care for patients. He/she stated this was an error in documentation and states the software will not allow a user to close their documentation until they have checked all the boxes. He/she agreed that the documentation was not accurate.

Based on policy review, record review, and interview, the hospice provider failed to forward the discharge summary to the patients’ attending physicians, in but not limited to, three of three revocation records reviewed (Records/Patients #8, #9, and #10). This deficient practice has the potential to affect all live discharge patients served by the provider. Findings included: --- Review of the provider’s undated policy titled, “Death, Discharge or Revocation of the Hospice Patient,” showed the responsibilities for live discharge procedures included sending a discharge summary to the attending physician.  RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 09/22/2025 and revoked the hospice benefit and was discharged 10/27/2025.Further review of the clinical record showed the hospice provider failed to ensure the clinical record contained documentation that a discharge summary was sent to the patient's attending physician. RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 10/10/2025 and revoked the hospice benefit and was discharged 10/27/2025.Further review of the clinical record showed the hospice provider failed to ensure the clinical record contained documentation that a discharge summary was sent to the patient's attending physician. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 11/19/2024 and revoked the hospice benefit and was discharged 11/20/2025.Further review of the clinical record showed the hospice provider failed to ensure the clinical record contained documentation that a discharge summary was sent to the patient's attending physician. During an interview on 03/05/2026 at 11:30 AM, the governing body appointee stated that they did not have documentation to show that the discharge summaries were sent to the attending physicians.

Based on policy review, contract review, record review, and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite and general inpatient discharge in two of two inpatient records reviewed (Records/Patients #6 and #7). This deficient practice has the potential to affect the coordination of respite and general inpatient care for all of the provider’s patients.  Findings included: --- Review of the provider's policy titled, "Levels of Care - Inpatient Respite Care," dated 03/30/2023, showed in part that, upon discharge from respite to routine home care, a discharge summary must be obtained from the facility and signed by the facility nurse to include any changes within the medication or plan of care that has the potential to impact the patient. Review of the provider’s contract agreement with the named hospital, titled “Inpatient Hospice Services Agreement,” dated 10/01/2025, showed in part, at the time of discharge, the hospital shall provide the hospice with a copy of the discharge summary, and if requested by the hospice, a copy of its clinical records regarding the Inpatient Services, Respite Care and Contracted Physician Visits provided.      RECORD/PATIENT #6:Review of the clinical record showed in part:- The patient began inpatient respite services on 02/21/2026;- The patient completed four consecutive days of respite care;- The family privately paid for inpatient respite care on day five and six; - The provider resumed inpatient respite care on day seven; - The patient was discharged from inpatient respite on 03/03/2026; and- The clinical record failed to contain a discharge summary from the respite facility.  RECORD/PATIENT #7:Review of the clinical record showed in part:- The patient began general inpatient services on 02/11/2026;- The patient completed two consecutive days of inpatient care;- The patient was discharged from the inpatient facility on 02/12/2026 due to death; and- The clinical record failed to contain a discharge summary from the inpatient facility.  During an interview on 03/05/2026 at 11:30 AM, the governing body appointee stated that:- They did not have a copy of the discharge summary from the inpatient respite provider, - They did not have a copy of the discharge summary from the general inpatient provider; and - They would expect to receive a discharge summary from the respite and inpatient providers at the time of discharge.

Based on policy review, record review, and interview the hospice plan of care (POC) failed to identify the care and services that are needed and failed to identify who was responsible for providing the care and services in three of five records reviewed (Records/Patients #1, #2, 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, “Paperwork for Facility Charts,” approved 07/18/2022, showed in part the coordinated task sheet (coordinated care plan):  - Is to be updated to show what is provided by the hospice and what is provided by the facility; - The durable medical equipment, wound care, catheter care, and etcetera are up-to-date; - All applicable areas are to be properly filled out on the sheet and a copy is made for the chart in the hospice office; and - Is updated at least every two weeks and with all new orders/changes, and is required to be signed by the facility and hospice nurse. --- RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 01/30/2026 with a terminal diagnosis of abnormal weight loss. The patient lived in a long-term care facility (LTCF).Review of the coordinated care plan, last reviewed 02/27/2026, failed to identify the following:- Who was responsible for changing the foley catheter, what was the balloon size, and the date(s) the catheter was changed;- Date, location, orders, and who was the responsible party for the care to the wounds on the right heel, right lateral fifth metatarsal, and left foot lateral next to fifth digit; and- Date, order, and who was the responsible party for the care to the sacral wound.   RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 03/13/2025 with a terminal diagnosis of senile degeneration of the brain (a decline in an individual's memory, behavior, and cognitive abilities). The patient resided at a long term care facility (LTCF).  Review of the coordinated care plan, last reviewed 02/24/2026, failed to identify the following:- Date of wound care treatment;- Location of the wound(s);- Who was responsible for the care; and- Who was responsible for the supplies. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 03/25/2025 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood) and diabetes (a chronic disease that results in too much sugar in the blood). The patient resided at a LTCF. Review of the coordinated care plan, updated 02/12/2026, failed to show who would monitor the patient’s blood sugar levels. During an interview on 3/05/2026 at 11:50 AM, the governing body appointee stated that he/she would expect the coordinated task plan to be updated as changes were made. Details about the patients’ wounds and blood sugar should have been included on the task plan.

Based on Missouri law review, policy review, employee file review, and interview, the hospice provider failed to ensure criminal background checks were performed in two of six employee files reviewed (Employees #2 and #6).  This deficient practice has the potential to adversely affect services provided to all the hospice's patients.  Findings included: --- Review of Section 192.2495.3, RSMo: Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the provider’s duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence. If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states. Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest). Review of the provider's policy titled, “Human Resources - Hiring,” dated 06/2022, showed:- Reference checks and background checks will be conducted on each individual before the hiring is confirmed; and- Checking on the preferred candidate will include criminal history (Employee Disqualification List and Family Care Safety Registry).  Employee #2:Review of the medical director’s employee file showed the following:- Date of hire was 08/01/2008; and- Criminal background check was completed 12/30/2025. Employee #6:Review of the hospice aide’s employee file showed the following:- Date of hire was 01/04/2023; and- The employee file failed to contain a record of a criminal background check for the employee. During an interview on 03/05/2026 at 11:30 AM the governing body appointee stated that:- He/she was unsure what happened to employee #2’s original criminal background check documentation prior to hire, but they had completed one recently on 12/30/2025;- He/she was unable to find a criminal background check for employee #6; and- Criminal background checks should be done prior to hire.

Based on emergency plan review and interview, the agency failed to comply with all federal, state, and local emergency preparedness requirements when the agency failed to establish and maintain a program that conducted two exercises per year to test the emergency plan. This deficient practice has the potential to affect the health, safety, and well-being of all patients and staff of the agency. --- Findings included: Review of the Emergency Preparedness program documentation showed only a fire drill exercise was completed in February 2023. There was no documentation of who participated or what was done during the drill. During an interview on 03/08/2023 at 4:14 PM, the administrator stated that they had discussed emergency planning at a staff meeting, but they had not documented the agency's response or revisions to the emergency plan. The administrator failed to show documentation of a tabletop exercise or a full-scale exercise.

Based on record review, and interview, the agency failed to ensure the social worker's comprehensive assessment was completed within five days of election of hospice care in two (Records/Patients #1 and #2) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2: Review of the clinical record showed the patient admitted to hospice services on 11/18/2022 with a terminal diagnosis of Chronic Obstructive Pulmonary Disorder (a group of diseases that cause airflow blockage and breathing-related problems). The patient resided at home. Review of the document titled "Master of Social Work (MSW) Assessment," 12/05/2023 showed, in part, the following: -MSW initial assessment was completed on 12/05/2022, 17 days after admission. During an interview on 03/08/2023, the administrator stated that he/she would expect the initial assessments to be completed within the proper time frame. RECORD/PATIENT #1:Review of the patients clinical record showed that the patient was admitted to hospice services on 11/22/2022 for terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD)-a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing and the patient resided in a skilled nursing facility (SNF). Review of the document titled "Master of Social Work (MSW) Assessment," 11/29/2023 showed, in part, the following: - MSW initial assessment was completed on 11/29/2022, 7 days after admission. During an interview on 03/08/2023, the administrator stated that he/she would expect the initial assessments to be completed within the proper time frame.

Based on policy review, record review, observation, and interview, the agency failed to complete a review of all of the patient's prescription and over the counter drugs in, but not limited to, two (Records/Patients #2 & #3) 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, "Drug Regimen Review," showed, in part, the following: -The contracted pharmacy benefit manager (PBM) will provide regimen upon admission and throughout the patient's time on hospice services. The pharmacist will review medications per hospice protocols regarding drug interaction, duplication of therapy, and pill burden; and -If PBM services are unavailable or the hospice physician requests an updated drug review, the registered nurse can run the medication reconciliation task in the hospice electronic medical record (EMR) to check for drug interactions and duplication of therapy. Review of the agency's policy titled, "Paperwork for Facility Charts," dated 07/18/2022, showed, in part, the following: -Most current hospice medication list-- this list must mirror the facility medication list. Medication reconciliation should be done in [named EMR system] and then a good copy printed for the facility chart. RECORD/PATIENT #2: Review of the patient's medication profile dated 03/06/2023 showed the following order: -Wellbutrin 150 milligrams (mg)- take 150 mg daily for depression. Observation on 03/06/2023 beginning at 12:30 PM, during the patient's home visit, showed the patient was taking the following medications: -Wellbutrin 300 mg- take 300 mg daily for depression; -Oxygen 3 liters per minute (lpm) via nasal cannula (NC) continuous; and -Tylenol 650 mg- take two tablets three times a day as needed. The agency failed to include these orders on the medication profile for the patient. RECORD/PATIENT #3: Review of the agency's medication record dated 02/13/2023 showed the following: -Trazodone (used to treat depression) 50 mg tablet take half a tab (25 mg) twice a day. Review of the facility's medication record dated 03/07/2023 showed the following: -Acetaminophen 650 mg-take two tablets every 6 hours for pain or fever; -Diltiazem (a medication used to treat high blood pressure and chest pain) 120 mg-take one tablet daily; -Lasix (a medication used to treat fluid retention and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 mg twice daily; -Haloperidol (used to treat nervous, emotional, and mental conditions) 1 milliliter (mL) per 5 mg- inject 1 mL once daily as needed; -Lisinopril (used to treat high blood pressure and heart failure) 10 mg daily; -Lorazepam (used to treat anxiety) 0.5 mg twice daily as needed; -Melatonin (used for insomnia and improving sleep) 6 mg at bedtime; -Trazodone 50 mg at bedtime; -Nystatin powder (used to treat fungal or yeast infections of the skin) 1 application daily under bilateral breasts; and -Skin prep wipes (liquid film-forming dressing that forms a protective film to help reduce friction during removal of tapes and films) apply to bilateral heels twice daily. The agency failed to ensure that the medication lists for the agency and facility contained the same medications. During an interview on 03/08/2023 at 2:40 PM, the quality assurance nurse stated that he/she would expect the medication lists to match between the facility and the agency.

Based on policy review, clinical record review, and interview, the hospice provider failed to collaborate with the patient's attending physician to ensure the patient's individualized plan of care was accurate and included all current hospice orders in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect the care provided to all of the agency's patients. --- Findings included: Review of agency's policy dated 08/13/2021 and titled, "Palliative Care Services," showed, in part, the following: - The medical director acts as a liaison with physicians; - The medical director reviews interdisciplinary group (IDG) information and has oversight over all care planning processes; - Encourages participation by the patients attending physician in coordinating the medical care of the patient through ongoing communication between the attending physician and the IDG; and - The attending physician provides at least the following to the IDG: -Admitting diagnosis and prognosis, current medical findings, orders for medications, treatments, symptom management, direction for medical management of other conditions not related to the terminal illness, designation of an alternative physician to contact regarding emergency care of the patient when the attending physician is not available. RECORD/PATIENT #1: Review of the patients clinical record showed the patient was admitted to hospice services on 11/22/2022 for terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing). The patient resided in a skilled nursing facility (SNF). The SNF clinical record contained the following orders all signed by the patients attending physician (that the hospice agency failed to include in the hospice clinical record): - Oxygen at three liters per minute continuously dated 02/08/2023; - Oxycodone (narcotic pain medication) 5 milligrams (mg) every four hours for pain dated 02/28/2023; - Hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg two tablets every four hours for pain, discontinued on 02/27/2023; - Wound care order to cleanse open area to right groin pat dry then apply zinc paste twice daily and as needed until healed, signed 11/20/2022; - Wound care order to cleanse bilateral lower extremities (BLE) with wound cleanser apply Xeroform (medicated gauze) apply ABD pads (absorbent dressing) and wrap with Kerlix (rolled gauze) everyday, dated 02/03/2023; and - Symbicort Inhaler (inhaled steroid and bronchodilator to help with gas exchange) 160/4.5 mg one puff as needed once daily at least four hours after scheduled dose, dated 10/10/2022. The hospice clinical record showed the following orders signed by the medical director that contradict the SNF clinical record: - Hydrocodone-acetaminophen 5/325 mg two tablets every four hours, signed 01/19/2023; and - Wound care order to cleanse BLE with wound cleanser pat dry apply betadine to entire lower extremities from knees to tip toes, allow to air dry, cover with ABD pads, wrap loosely with Kerlix then wrap loosely with coban (elastic rolled bandage), daily and as needed dated 02/23/2023 per the plan of care and on provider order signed 01/12/2023; During an interview on 03/08/2023 at 11:15 AM, the quality assurance nurse stated that the attending physician should be called for orders. If the attending declines to manage hospice care that should be documented in the clinical record.

Based on policy review, record review, and interview, the agency failed to develop an individualized plan of care for each patient in, but not limited to, two (Records/Patients #2 & #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021 showed, in part, the following: -When a patient or family member/caregiver has elected the Medicare hospice benefit, the hospice, physician, facility, patient and/or family/caregiver will communicate, establish and agree upon a coordinated plan of care for all providers which reflects the hospice philosophy, and is based on an assessment of the individual's needs and unique living situation in the home or facility; and -The plan of care will identify the care and services to which the hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 11/18/2022 with a terminal diagnosis of Chronic Obstructive Pulmonary Disorder (a group of diseases that cause airflow blockage and breathing-related problems). The patient resides at home. Review of the document titled "IDG (interdisciplinary group) Meeting," dated 12/01/2022 showed the following: -The plan of care contained one identified problem of "Alteration of Respiratory Status"; -The plan of care contained the interventions to assess for dyspnea or respiratory changes, educate on anticipated changes in respiratory symptoms as disease progresses, and evaluate the effectiveness of respiratory medications; and -The 12/01/2022 plan of care failed to contain other individualized problems and interventions for the patient Review of the document titled "IDG Meeting," dated 02/23/2023 failed to show the following: -Patient drinks Boost supplements, the plan of care does not contain an intervention for these supplements; -Patient uses oxygen continuously, the plan of care does not contain an intervention for oxygen use; -Patient has a wheelchair and walker, the plan of care does not specify any education regarding these items of medical equipment; and -Patient is at a risk for skin breakdown, the plan of care does not contain interventions for skin breakdown. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice on 02/09/2023 with a terminal diagnosis of Cerebrovascular Accident (damage to the brain from interruption of its blood supply). The patient resides in a facility. Review of the document titled "IDG Meeting," dated 02/23/2023 failed to show the following: -Patient is getting legs wrapped with ace wraps per physician's written certification, the plan of care does not contain this intervention; -Patient has a facility order for pressure relief devices, the plan of care does not contain this intervention; and -Patient is at risk for skin breakdown, the plan of care does not contain interventions regarding skin breakdown. During an interview on 03/08/2023 at 2:50 PM, the quality assurance nurse stated that he/she would expect the plan of care to contain interventions that are individualized to each individual patient.

Based on policy review, observation, and interview, the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases in, but not limited to, two (Records/Patients #2 & #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled "Infection Control," dated 03/31/2020, showed in part, the following: -All health care workers who perform or assist in invasive procedures shall wear gloves when touching mucous membranes or non-intact skin of all patients. Review of the agency's policy titled "PPE (personal protective equipment), Supplies, and Bag Technique," dated 03/31/2020, showed, in part, the following: -In the client's home, put bag on a clean, hard surface when possible, and on top of a disposable barrier. Also place any notebooks etc. on a disposable barrier; -Never put dirty equipment or dressing into nursing bag; and -Clean/wash hands. Ensure bag is closed before leaving. Review of the agency's policy titled "COVID-19 Update," dated 01/03/2023, showed, in part, the following: -Hospice staff must utilize face masks and any additional PPE deemed necessary before entering the patients home and remove PPE and properly dispose of PPE after exiting the patient's home. RECORD/PATIENT #2: Observation on 03/06/2023 at 12:30 PM, during the patients home visit, showed Social Worker A failed to do the following: -Social Worker A failed to perform hand hygiene prior to entering patient's home; -Social Worker A failed to don a mask prior to entering patient's home; -Social Worker A failed to don a mask at any point during the visit to the patient's home; and -Social Worker A failed to perform hand hygiene after exiting the patient's home. During an interview on 03/08/2023 at 3:00 PM, the quality assurance nurse stated that he/she would expect employees to follow the agency's policies and procedures regarding infection control. RECORD/PATIENT #3: Observation on 03/07/2023 at 10:00 AM, during the patient's home visit showed Chaplain A failed to do the following: -Chaplain A entered the patient's room and set his bag on the patient's floor, there was no barrier present; -Chaplain A obtained his bible from his bag and set it on the patient's bedside table, there was no barrier present; and -Chaplain A failed to disinfect his bible prior to placing it back into his bag. During an interview on 03/08/2023 at 3:00 PM, the quality assurance nurse stated that he/she would expect the employee to follow the bag technique policies and procedures.

Based on policy review, record review, and interview, the agency failed to create a plan of care that reflected the individualized needs of the patient in, but not limited to, one (Record/Patient #9) of two bereavement records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled "Scope of Services," dated 08/13/2021 showed, in part, the following: -Following the death of the patient, families will be offered support, which follows an individualized bereavement care plan; and -Bereavement services address such issues as family grief and loss issues, survivor needs, social, religious, and cultural issues, risk factors, and potential for complicated grief reactions. RECORD/PATIENT #9: Review of the clinical record showed the following: -The agency failed to offer/make home visits; -The agency failed to make phone contacts; -The agency failed to document proof of printed materials being sent; -The agency failed to perform a bereavement risk assessment within two months after death; and -The agency failed to offer information regarding bereavement support groups. During an interview on 03/08/2023 at 3:00 PM, the administrator stated that he/she would expect to see these services and information offered to all bereaved individuals served by the agency.

Based on policy review, employee file review, and interview the agency failed to assure the hospice aide competency evaluation was performed by a registered nurse in one (Aide 2) of two hospice aide employee files reviewed. This deficient practice has the potential to affect all patients with services provided by the hospice aide. --- Findings included: Review of the agency's policy dated 08/21/2021 titled, "Hospice Home Health Aide," showed in part: - Competency evaluations will be completed prior to delivering patient care; and- Documentation of training will be maintained in the personnel file. Aide #2:Review of the employee file showed the following:- Date of hire: 11/01/2021;- The employee was a current direct clinical staff of the hospice provider; and- No evidence that the employee had skills and competence assessed. The findings were reviewed with the agency administrator on 03/08/2023, beginning at 2:40 PM. The administrator stated that the employee files were missing the required components and he/she would expect the business manager to have the records.

Based on clinical record review and interview, the hospice provider failed to ensure the aide care plan was appropriate for individual patient needs in, but not limited to, one (Patient/Record #1) of five full records reviewed. This deficient practice has the potential to affect all patients with aide services provided by the hospice provider. --- RECORD/PATIENT #1:Review of the patients clinical record showed:- Patient was admitted to hospice services on 11/22/2022 for terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing); -Patient resided in a skilled nursing facility (SNF); and- Patient was being treated for circulatory concerns in bilateral lower extremities. Review of aide care plan updated 02/20/2022 showed: -Patient was diabetic; and - Nail care was to be performed at each visit. Review of hospice aide visit documentation at each visit showed patient was a diabetic and nail care was provided during visits conducted on 01/25/2023, 01/27/2023, 02/01/2023, 02/03/2023, 02/08/2023, 02/10/2023, 02/15/2023, 02/17/2023, 02/22/2023 and 02/24/2023. Review of admission orders dated 11/22/2022 showed nail care on a diabetic patient with circulatory issues should only be performed by a registered nurse under direction of the physician. During an interview on 03/08/2023 at 11:15 AM, the administrator stated that they would expect the aide care plan to be specific as to what the aide was responsible for with nail care and that the registered nurse would obtain an order to trim/file nails from the provider if appropriate.

Based on employee file review and interview, the hospice provider failed to provide written policies and procedures upon request, and failed to ensure that the skills and competence were assessed of all staff furnishing care/services to hospice patients in one (Registered Nurse A) of three employee files reviewed. This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings included: REGISTERED NURSE A:Review of the employee file showed the following:- Date of hire: 11/23/2022;- The employee was a current direct clinical staff of the hospice provider; and- No evidence that the agency assessed their skills and competence. The findings were reviewed with the agency's administrator on 03/08/2023 beginning at 2:40 PM. The administrator stated that the employee files were missing the required components and he/she would expect the business manager to have the records. No policy was provided for nursing training expectations.

Based on policy review, record review, and interview, the agency failed to ensure that all physician orders were obtained in, but not limited to, two (Records/Patients #1 & #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 policy titled "Scope of Services," dated 08/31/2021, showed that the attending physician provides the admitting diagnosis and prognosis, current medical findings, orders for medications, treatments, and symptom management to the interdisciplinary team. RECORD/PATIENT #2: Review of clinical record showed the following: -The skilled nursing (SN) notes dated 01/23/2023, 01/27/2023, 01/31/2023, 02/03/2023, 02/07/2023, 02/10/2023, 02/11/2023, 02/14/2023, 02/17/2023 and 03/03/2023 showed the patient was on oxygen at 2 liters per minute (lpm); -The SN notes dated 02/21/2023 and 02/27/2023 showed the patient was on oxygen at 3 lpm; -The SN notes dated 02/24/2023 showed the patient was on oxygen at 2.5 lpm; -The SN notes dated 03/04/2023 showed the patient was on oxygen at 4 lpm; The agency failed to obtain a physician order for the patient's oxygen. During an interview on 03/08/2023 at 3:00 PM, the quality assurance nurse stated that he/she would expect for there to be a physician order for oxygen, if the patient needs oxygen.

Based on clinical record review and interview, the hospice agency failed to document they supplied the inpatient provider with a copy of the patient's plan of care, which included the inpatient services to be furnished by the inpatient facility, in one (Record/Patient #8) of one inpatient acute records reviewed. This deficient practice has the potential to affect all patients admitted for inpatient care while receiving hospice services from the agency. --- Findings included: RECORD/PATIENT #9:Review of the clinical record showed:- The patient was admitted to hospice services on 07/26/2021 for terminal diagnosis of Senile Degeneration of the Brain - a disease marked by progressive loss of mental capacity; and- The patient received inpatient care in a contracted facility 01/04/2023-01/06/2023. The hospice staff failed to document they furnished the contracted facility a current hospice plan of care that included the inpatient services to be provided. During an interview on 03/08/2023 at 2:00 PM, the administrator stated there was no documentation to show the patient's care plan was provided or that it included the inpatient services to be furnished during inpatient care.

Based on review of a written agreement for respite (inpatient care for caregiver relief) and inpatient services, clinical record review and interview, the agency failed to ensure the agreement with the inpatient facility included the requirement that a copy of the discharge summary be provided to the hospice at the time of discharge in two (Patients/Records #6 and #8) in eleven records reviewed. This deficient practice has the potential to affect patients receiving respite or inpatient services in a contracted facility. --- Findings included: Review of the agency's Contract A dated 10/12/2020, showed the contract failed to include that there be a copy of the discharge summary provided at discharge. RECORD/PATIENT #6:Review of the clinical record showed:- The patient was admitted to hospice services on 01/19/2023 for terminal diagnosis of Multiple Sclerosis – a disabling disease of the brain and spinal cord central nervous system;- The patient received respite care in a contracted facility 02/3/2023-02/07/2023; and- The clinical record failed to include a discharge summary at the completion of the respite stay. RECORD/PATIENT #8:Review of the clinical record showed:- The patient was admitted to hospice services on 07/26/2021 for terminal diagnosis of Senile Degeneration of the Brain - a disease marked by progressive loss of mental capacity;- The patient received inpatient care in a contracted facility 01/04/2023-01/06/2023; and- The clinical record failed to include a discharge summary at the completion of the inpatient stay. During an interview on 03/08/2023 at 2:00 PM, the administrator stated that there was no documentation of the patients discharge summary being provided to the agency after discharging from respite or inpatient care.

Based on policy review, review of a written agreement for general inpatient care (GIP, short-term care for symptom management) and interview, the agency failed to ensure the agreement with the hospital included the requirement that the inpatient provider has identified an individual within the facility who is responsible for the implementation of the provisions of the agreement. This deficient practice has the potential to affect all inpatient/respite patients served by the agency. --- Findings included: Review of the agency's Contract A dated 10/12/2020, showed the contract failed to include the provision that the inpatient provider has identified an individual within the facility who is responsible for the provisions of the agreement. During an interview on 03/08/2023 at 3:15 PM, the administrator stated that he/she could not find the missing information and agreed with the findings. He/she stated that the agency had updated the inpatient acute care agreement, but failed to provide it prior to exit.

Based on policy review, record review, and interview, the agency failed to ensure that a coordinated plan of care was placed in the facility binder in, but not limited to, one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled "Paperwork for Facility Charts," dated 07/18/2022 showed, in part, the following: -Page 1- coordinated task sheet- must be updated to show what is provided by [named agency] and what is provided by the facility-- DME [durable medical equipment], wound care, Foley [indwelling urinary catheter], etc. must be up-to-date. Also includes the name of the case manager and attending physician. All applicable areas should be properly filled out on this page and a copy made for the chart in the hospice office. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 02/09/2023 with a terminal diagnosis of cerebrovascular accident. The patient resided in a facility. Review of the facility binder showed the following: -The agency failed to place a coordinated plan of care in the facility binder. During an interview on 03/08/2023 at 3:00 PM, the administrator stated that he/she would expect all of the required components to be in the facility binder.

Based on policy review, record review, and interview, the agency failed to ensure that the facility binders contained all of the required components in, but not limited to, two (Records/Patients #1 & #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Paperwork for Facility Charts," dated 07/18/2022 showed, in part, the following: -Facility binders must include the certified nurses aide care plan and be kept updated; -Facility binders must include most recent plan of care (POC) and problems list-- should have 3 months' worth of interdisciplinary team (IDT) notes; -Facility binders should include the original physician's Medicaid and Medicare certification as well as the initial POC. This sleeve will also contain the most recent recertifications; -Facility binders should include the names and contact information for hospice personnel involved in care of each patient; -Facility binders should include most current hospice medication list -- this list must mirror the facility med list. Medication Reconciliation should be done in [named EMR system] and then a good copy printed for the facility chart; and -Facility should have orders from the last 3 months. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 02/09/2023 with a terminal diagnosis of cerebrovascular accident. The patient resided in a facility. Review of the facility binder failed to show the following: -The names and contact information for hospice personnel involved in care of patient; and -Hospice physician and attending physician orders. During an interview on 03/08/2023 at 3:00 PM, the administrator stated that he/she would expect the facility binder to contain the required elements. Findings included: RECORD/PATIENT #1:Review of the patients clinical record showed that the patient was admitted to hospice services on 11/22/2022 for terminal diagnosis of Chronic Obstructive Pulmonary Disease (COPD)-a term referring to chronic bronchitis and emphysema, characterized by obstruction of air flow that interferes with normal breathing and the patient resided in a skilled nursing facility (SNF); Review of the facility binder failed to show the following: - The most recent plan of care (POC) and problems list; - The physician's Medicaid and Medicare certification ; - The certified nurses aide care plan; -The names and contact information for hospice personnel involved in care of patient; and -Any hospice physician or attending physician orders following the admission orders dated 11/22/2022. During an interview on 03/08/2023 at 3:00 PM, the administrator stated that he/she would expect the facility binder to contain the required elements.

Based on contract review and interview, the agency's inpatient contract failed to include all required components, including that if one patient in the facility is receiving inpatient care, then each shift must include a registered nurse who provides direct patient care, in one (Contract A) of one inpatient contract reviewed. This deficient practice has the potential to affect care of any patient that receives inpatient care for symptom control. --- Findings included: Review of the agency's Contract A dated 10/12/2022 failed to include all of the required components, including that if one patient in the facility is receiving inpatient care, then each shift must include a registered nurse who provides direct patient care. During an interview on 03/08/2023 at 3:15 PM, the administrator stated that he/she could not find the missing information and agreed with the findings. He/she stated that the agency had updated the inpatient acute care agreement, but failed to provide it prior to exit.

Based on clinical record review and interview, the agency failed to assure that documents in the clinical record were accurate in one (Record/Patient #2) of three clinical records reviewed. This deficient practice has the potential to affect the clinical documentation for all of the agency patients. Findings included: RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 06/29/21 with a terminal diagnosis of worsening Alzheimer's disease, and secondary diagnoses of constipation, unspecified respiratory disorder, and nutritional deficiency. The patient resided in a skilled nursing facility. Review of skilled nursing visit dated 06/30/21 showed documentation that the patient, "had 90 CC's (cubic centimeters) drained from the foley catheter (a tube inserted into the bladder through the urethra to facilitate urinary drainage) since last night." During an interview on 11/17/21 the facility nurse stated that the patient did not have a foley catheter in place. He/she also reported that the nursing notes dated 06/30/21 addressed the patients lack of control of his/her bowel and bladder. During an interview on 11/17/21 at 4:30 PM the administrator stated that there were no records of the patient having a foley catheter, and that the documentation in the client's record was in error.

Based on clinical record review, and interview, the agency failed to assure that the patient's plan of care identified the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care in one (Patient/Record #1) of three records reviewed. This deficient practice has the potential to affect the care and services of all the agency patients. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 10/23/21 with a terminal diagnosis of multiple sclerosis (a disabling disease of the brain and spinal cord where the immune system attacks the protective sheath that covers nerve fibers). And secondary diagnoses of congestive heart failure (a condition in which the hearts doesn't pump a sufficient amount of blood to meet the body's metabolic needs), small bowel obstruction (a blockage in the upper section of the bowel), and neurogenic bladder (a condition in which problems with the nervous system affect the bladder and ability to urinate). The patient lived in a skilled nursing facility. Review of the initial nursing assessment, performed on 10/25/21, showed the patient: - Had a suprapubic catheter (a tube inserted through a surgical opening in the area just above the pubic bone to create an access the bladder and facilitate urinary drainage); - Had a colostomy (a surgical opening on the abdomen that allows fecal matter to collect in a bag) for bowel evacuation; - Wore Unna boots to keep the heels off the bed; - Had a wound on the right foot just below the fourth and fifth toes; and - Had a wound on the left upper inner thigh. Review of the interdisciplinary group meeting, dated November 4, 2021, showed: - The colostomy had been identified as a problem for the patient, and: * The plan failed to contain individualized goals and interventions for the patient's care, stating, "Patient will have adequate care of catheter/ostomy/nephrostomy tube;" and * Failed to identify which provider would be responsible for provision of care to the colostomy. - A Foley (a urinary catheter inserted through the urethra to access the bladder to collect urine) was incorrectly identified as a problem for the patient, when the patient had a suprapubic catheter, and: * The plan failed to contain individualized goals and interventions for the patient's care, stating, "Patient will have adequate care of catheter/ostomy/nephrostomy tube;" and * Failed to identify which provider would be responsible for provision of care to the catheter. - The plan of care/IDG documentation did not contain interventions or goals for the Unna boot and wounds to right foot and left thigh. During an interview on November 17, 2021 at 2:31 PM the administrator stated that the nursing facility staff provided the Unna boot wound care for the right foot and left thigh, and catheter care. The administrator showed this surveyor the coordinated task plan and nursing facility orders. The administrator stated that they were unable to provide documentation that the coordinated task plan was discussed during the IDG meeting or included in the hospice plan of care.