Every finding on record at Preferred Hospice of Missouri LLC

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure:- The plan of care contained measurable outcomes (L0548); and- The plan of care was revised and included information from the patient's updated comprehensive assessment and noted the patient's progress towards outcomes and goals (L0553). --- The cumulative effect of these deficient practices has the potential to affect all the patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) contained individualized goals with measurable outcomes 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. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the updated plans of care document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 06/17/2025, 07/01/2025, and 07/15/2025 showed that: - The patient had the goals of:  * Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal;” and  * Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate.”RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the updated plans of care document titled, “IDG Comprehensive Assessment Details,” dated 06/19/2025, 07/03/2025, and 07/17/2025 showed that: - The patient had the goals of:  * Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal;” and  * Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate.”During an interview on 07/23/2025 at 2:26 PM, the administrator stated they would expect the patient’s goals to be measurable within the confines of the patient’s disease process.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (inability to move the right side of the body, due to stroke). The patient had secondary diagnoses of hypertension (high blood pressure), and arthrosclerosis (hardening of the arteries). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/23/2025, showed that the patient had the problems and goals of:-The patient and caregiver will report an improvement in confusion and sleep. The goal failed to define “improvement”.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility.Review of the updated plans of care / IDG dated 07/17/2025, showed that the patient had the problems and goals of:-The patient would tolerate all treatments with minimum discomfort or alteration to daily routines. The goal failed to define “minimum discomfort”. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/20/2025, showed that the patient had the problems and goals of:-Dyspnea (shortness of breath), edema, hypertension (high blood pressure), and chest pain to be managed at an “acceptable level”. The goal failed to define “acceptable level”. Findings included:Review of the provider’s undated policy titled, “Physician Plan of Care Summary,” showed in part:- The physician plan of care summary will be completed by the admitting nurse using information gathered and assessed from the patient; and- The goals, scope, and frequency of service and recommended interventions must be documented on the physician plan of care summary form. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the updated plans of care document titled, “Interdisciplinary Group (IDG) Comprehensive Assessment Details,” dated 06/17/2025, 07/01/2025, and 07/15/2025 showed the patient had the following goals: - Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal”; and- Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate”.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the updated plans of care documents titled, “IDG Comprehensive Assessment Details,” dated 06/19/2025, 07/03/2025, and 07/17/2025 showed the patient had the following goals: - Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal”; and- Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate”.During an interview on 07/23/2025 at 2:26 PM, the administrator stated that they would expect the patient’s goals to be measurable within the confines of the patient’s disease process.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (muscular weakness on one side of the body). The patient had secondary diagnoses of hypertension (high blood pressure) and arthrosclerosis (an abnormal collection of calcium and cholesterol on the artery walls, also known as plaque buildup). The patient resided in their own home.Review of the updated plans of care/IDG dated 07/23/2025, showed that the patient had the problems and goals of:-The patient and caregiver will report an improvement in confusion and sleep; and-The goal failed to define “improvement”. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility. Review of the updated plans of care/IDG dated 07/17/2025, showed that the patient had the problems and goals of:-The patient would tolerate all treatments with minimum discomfort or alteration to daily routines. The goal failed to define “minimum discomfort”. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/20/2025, showed that the patient had the problems and goals of:-Dyspnea (shortness of breath), edema, hypertension (high blood pressure), and chest pain to be managed at an “acceptable level”. The goal failed to define “acceptable level”.During an interview on 07/23/2025 at 2:26 PM, the administrator stated they would expect the patient’s goals to be measurable within the confines of the patient’s disease process.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the plan of care was revised and updated based on the patient's updated comprehensive assessment and failed to note the patient's progress toward outcomes and goals 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.Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 03/24/2021 showed in part:- 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; - The plan of care will be reviewed and/or revised a minimum of every fourteen days by the interdisciplinary group (IDG); and - The plan of care includes directives for managing pain and other symptoms and physician standing orders. --- TAG: 553 RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 06/17/2025 showed that the patient had a decline in skin integrity, redness noted on his/her left heel, and bilateral heels were soft and mushy (an indication of pressure injury on a boney prominence).Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/15/2025, showed that the patient’s skin integrity had continued to decline, both heels remained soft and mushy, and the redness on the patient’s left heel was treated with skin preparation pads (moistened pads used to protect skin).Observation on 07/22/2025 at 10:45 AM, showed that: - The patient was sitting in a high-backed wheelchair and leaning toward the right side; - Was frequently coughing while facility staff members fed him/her; - Had a bump in the roof of his/her mouth measuring approximately one inch in diameter that:  * Had appeared about two weeks prior;   * Was vascular in nature; and  * Was most likely interfering with the patient’s ability to swallow; and- Had redness to bilateral heels. Review of the document titled, “Plan of Care,” dated 07/21/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - The patient’s coughing on food and fluids while staff members fed him/her; - The bump on the roof of the patient’s mouth; and- The redness to the patient’s bilateral heels. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had a pressure injury on his/her right heel. The patient resided in an assisted living facility. Review of the physician’s order dated 06/16/2025 showed that:- The nurses were to cleanse the wound on the patient’s right heel with wound cleanser then; - Apply alginate (a fabric like material used in wound care) cut to the size of the wound; - Cover with foam dressing; and- secure with tape. Review of the physician’s order dated 07/08/2025 showed that the patient had started on Bactrim DS (a sulfa based antibiotic) following a positive urine dipstick indicating a urinary tract infection. Review of the document titled, “Plan of Care,” dated 07/23/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to the change in wound care and the urinary tract infection. During an interview on 07/23/2025 at 2:26 PM, the administrator stated that they would expect the plan of care to be updated to include changes to the plan of care and progress toward goals.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (inability to move the right side of the body, due to stroke). The patient had secondary diagnoses of hypertension (high blood pressure), and arthrosclerosis (hardening of the arteries). The patient resided in their own home.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/20/2025, showed that the patient was assessed with problems which included knowledge deficit (memory issues), and comfort alteration due to pain (generalized physical pain). The goal listed as these problems to be managed at an “understandable” and "optimal" levels.Review of the document titled, “Plan of Care,” dated 07/23/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for knowledge deficit; and- Quantitative measurable goals for pain level. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/17/2025, showed that the patient was assessed with problems which included confusion (memory impairment), and irregular heart rate. The goal list did not address these problems to be managed.Review of the document titled, “Plan of Care,” dated 07/21/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for confusion and forgetfulness; and- Quantitative measurable goals for irregular heart rate. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/20/2025, showed that the patient was assessed with problems which included dyspnea (shortness of breath) during moderate exertion, hypertension (high blood pressure). The goal listed as these problems to be managed at an “acceptable level”.Review of the document titled, “Plan of Care,” dated 07/20/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for hypertension; and- Quantitative measurable goals for dyspnea.

Based on policy review, home visit observation, and interview, the hospice provider failed to ensure clinicians followed accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in two of four home visit observations conducted (Records/Patients #1 and 2). This deficient practice has the potential to affect all of the patients served by the provider. --- Findings included: Review of the provider’s clinical protocol titled, “Bag Technique Checklist,” dated 07/18/2022, showed in part that the clinician must:- Sanitize his/her hands; and - Wipe down reusable equipment with Sani-wipes or alcohol wipes. Wear gloves, place on clean barrier, let dry before placing back in bag. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Observation on 07/22/2025 at 10:30 AM, showed the registered nurse: - Performed hand hygiene; - Retrieved a blood pressure cuff, pulse oximeter, stethoscope, and thermometer from his/her nursing bag; - Performed hand hygiene; - Assessed the patient’s blood pressure, pulse oximetry, and temperature;- Cleansed the equipment;- Placed the equipment into the bag;- Then performed hand hygiene; and- The clinician failed to perform hand hygiene before cleansing his/her soiled equipment. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Observation on 07/21/2025 at 1130 AM, showed the registered nurse: - Performed hand hygiene; - Retrieved a blood pressure cuff, pulse oximeter, stethoscope, and thermometer from his/her nursing bag; - Performed hand hygiene; - Put on his/her gloves; - Assessed the patient’s blood pressure, pulse oximetry, and temperature;- Cleansed the equipment while still wearing the gloves:- Placed the equipment into the bag;- He/she then removed his/her soiled gloves;- Then performed hand hygiene; and- The clinician failed to remove his/her gloves and perform hand hygiene before cleansing his/her soiled equipment. During an interview on 07/23/2025 at 10:00 AM, the administrator stated that they would expect clinicians to perform hand hygiene prior to cleansing his/her soiled equipment.

Based on record review and interview, the hospice provider failed to ensure clinicians completed accurate, complete and timely documentation in five of fifteen records reviewed (Records/Patients #2, #6, #7, #8, and #10). This deficient practice has the potential to affect all patients served by the provider. --- RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient resided at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following: - The patient transferred to a long term care facility (LTCF) for respite care; and - The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025.The RNC failed to sign and record the order in a timely manner.Review of the registered nurse (RN) visit dated 05/03/2025, showed the following: - The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- Hospice team was notified.Review of the client’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025. The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the client died on 03/22/2025 at 1:50 PM.  The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the client’s physician orders dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025. The RN failed to sign and record the orders in a timely manner.RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the client’s general visit note dated 05/13/2025, showed the patient did the following:- Discharged on 05/04/2025;- Discharged to LTCF-2; and - RNC signed and recorded the event on 05/13/2025.The RNC failed to sign and record the event in a timely manner.Review of the interdisciplinary group (IDG) meeting dated 05/15/2025, showed the patient was discharged to LTCF-2.The IDG failed to document accurate information.During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient.During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information.  Findings included:RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the hospice aide visit documentation showed that the aide signed his/her visit documentation for:- 07/01/2025 on 07/09/2025;- 07/02/2025 on 07/14/2025;  - 07/03/2025 on 07/14/2025;- 07/16/2025 on 07/21/2025; and - The aide signed his/her documentation visits after an extended period of time. Review of the nursing visit dated 06/26/2025 showed in part that the visit narrative contained the documentation of assessment and interventions performed on a patient with a heart condition and not the patient of record Findings included:Findings included:Review of the provider's nursing services approved 03/24/2021, showed the following: RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the hospice aide visit documentation showed that the aide signed his/her visit documentation for:- 07/01/2025 on 07/09/2025;- 07/02/2025 on 07/14/2025;  - 07/03/2025 on 07/14/2025;- 07/16/2025 on 07/21/2025; and - The aide signed his/her documentation visits after an extended period of time. Review of the nursing visit dated 06/26/2025 showed in part that the visit narrative contained the documentation of assessment and interventions performed on a patient with a heart condition and not the patient of record. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient resided at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following: - The patient transferred to a long term care facility (LTCF) for respite care; and - The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025.The RNC failed to sign and record the order in a timely manner.Review of the registered nurse (RN) visit dated 05/03/2025, showed the following: - The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- Hospice team was notified.Review of the client’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025. The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the client died on 03/22/2025 at 1:50 PM.  The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the client’s physician orders dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025. The RN failed to sign and record the orders in a timely manner. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the client’s general visit note dated 05/13/2025, showed the patient did the following:- Discharged on 05/04/2025;- Discharged to LTCF-2; and - RNC signed and recorded the event on 05/13/2025.The RNC failed to sign and record the event in a timely manner.Review of the interdisciplinary group (IDG) meeting dated 05/15/2025, showed the patient was discharged to LTCF-2.The IDG failed to document accurate information.During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient.During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information.

Based on policy review, bereavement protocol review, record review, and interview, the hospice provider failed to have an organized program for the provision of bereavement services under a qualified bereavement care supervisor, ensure bereavement services reflected the needs of the bereaved, and develop a bereavement plan of care that included the kind of bereavement services to be offered and the frequency of service delivery (L0596). --- The cumulative effect of this deficient practice has the potential to affect the ability of the hospice to provide effective core services to meet the individualized needs of the bereaved.

Based on policy review, bereavement protocol review, record review, and interview the hospice provider failed to have an organized program for bereavement services under a qualified bereavement care supervisor (BCS) and failed to ensure bereavement services reflect the needs of the bereaved in one of five bereavement records reviewed (Record/Patient #11) and failed to develop a bereavement care plan (BCP) in four of four additional bereavement records reviewed (Records/Patients #12, #13, #14, and #15). This deficient practice has the potential to affect all the bereaved families/caregivers of hospice patients.Findings included:Review of the provider's policy titled, "Scope of Services," dated approved 03/24/2021, showed the following:- Hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment and continue through 13 months of the bereavement period. The goal is to help the patient/family cope with death related to grief and loss issues; - Following the death of the patient, families will he offered support, which follows an individualized BCP; and - Bereavement services address such issues as family grief and loss issues, survivor(s) needs, social, religious, and cultural issues, risk factors and potential for complicated grief reactions. Review of the provider’s bereavement protocol, dated approved 01/2021, showed the following:-The basic framework for bereavement interventions is based on the risk assessment;-All services provided should be tailored to the specific needs of each bereaved person;-Low, medium, and high-risk interventions include the following:*Attend the visitation or funeral if at all possible;*Staff sign a sympathy card and mail it as soon as possible;*Discuss the bereaved at the first interdisciplinary group (IDG) meeting after the patient’s death;*Complete a bereavement assessment within two weeks of the IDG meeting (preferably face-to-face);*Send a bereavement introduction letter;*Provide the bereaved with the book, “My Friend, I Care”;*Send a letter around the three-month mark;*Before the sixth-month mark, make every attempt to do a face-to-face visit per regulations, with a phone call at a minimum;*Send a hand-written card at the 12-month anniversary;*Send a bereavement discharge letter and bereavement services survey at the 13-month mark;- Medium and high-risk interventions include the following:*A bereavement assessment may need to be completed prior to the first IDG meeting after the patient’s death;*Increase calls and visits in the first three months;*Send a letter around the nine-month mark; and-High risk interventions include the following:*Provide the bereaved with a list of community resources for more support;*Provide monthly contact via phone calls and/or visits. --- RECORD/PATIENT #11:Review of the patient’s BCP dated 07/18/2024, showed in part the following: - On 07/18/2024 (the date of the patient’s death) the following interventions were completed:*Performed the bereavement assessment*Discussed the bereaved at the first IDG meeting after the death and IDG approved the plan of care - On 07/22/2024, the following interventions were completed:*Offered community grief support groups*Sent a sympathy card signed by the staff* Provided the bereaved with the book, “My Friend, I Care”*Performed calls and visits per risk assessment and bereavement protocol*Sent bereavement introduction letter*Completed condolence call following the patient’s death*Affirmed feelings associated with the loss - On 07/23/2024, the visitation/funeral service was attended; - On 02/05/2025, the social worker (MSW) sent an invitation to the annual hospice memorial service; and- On 07/17/2025, the MSW (who was no longer employed) sent a hand-written card at the 12-month anniversary.The BCP failed to show the bereavement risk assessment level. Review of the MSW phone call note dated 07/22/2024 at 10:00 AM, showed:-The bereaved said that the family was coping fairly well; and-The bereavement risk assessment was completed with a low-risk score. Review of the chaplain’s visit note dated 07/23/2024 at 12:00 PM, showed:- The visit occurred at the funeral home; and  - The family was grieving appropriately. Review of the chaplain’s visit note dated 08/30/2024 at 10:45 AM, showed the following:- The visit occurred at the home of the bereaved;- The bereaved was at a moderate risk level; - The bereaved was dealing with anger; - The chaplain mentioned support group and offered to attend with the bereaved; - The chaplain communicated with the social worker that the bereaved struggled and requested a follow-up call to the bereaved; and - The chaplain would check back with the bereaved in a couple of weeks regarding interest in the support group. Review of the chaplain’s phone call note dated 09/12/2024 at 9:45 AM, showed the bereaved was doing better, denied bereavement services, and was discharged from bereavement services. (This entry was signed and recorded on 07/21/2025, the date the state agents arrived for the recertification survey) The BCS failed to provide an organized program for the provision of bereavement services as evidenced in the following: - Allowed an intervention (from 07/17/2025) entry on the BCP that was falsely documented by the MSW who was no longer employed; - Had discrepancy in the bereavement protocol risk levels and the bereavement assessment levels; - The MSW failed to follow-up contact with the bereaved per the chaplain’s request on 08/30/2024; and- The bereavement protocol was not followed for a medium risk assessment (as per the chaplain bereavement risk assessment 08/30/2024). RECORD/PATIENT #12:Review of the patient’s BCP created 02/14/2025, showed the date of death was 02/11/2025 and failed to show any interventions were completed.Review of the chaplain’s visit note dated 02/25/2025, showed the bereaved was a low risk according to the assessment.The provider failed to develop a BCP to reflect a low risk assessment. Review of the chaplain’s visit note dated 03/25/2025, showed the bereaved was a moderate risk according to the assessment.The provider failed to update the BCP to reflect a moderate risk assessment. RECORDS/PATIENTS #13:Review of the patient’s bereavement record showed the date of death was 04/26/2025.Review of the bereavement assessment dated 05/12/2025, showed the bereaved was a low risk and bereavement services were declined. The provider failed to develop a BCP. RECORD/PATIENT #14:Review of the patient’s bereavement record showed the date of death was 04/07/2025.Review of the bereavement assessment dated 05/01/2025, showed the bereaved was a low risk and bereavement services were declined.The provider failed to develop a BCP. RECORD/PATIENT #15:Review of the patient’s bereavement record showed the date of death was 04/05/2025.The provider failed to: - Develop a BCP; - Complete a risk assessment within the first two months after death; and - Follow their bereavement protocol. During an interview on 07/22/2025 at 2:35 PM, the registered nurse coordinator (RNC) stated that he/she would expect a BCP to be created and followed according to the bereavement protocol even when services had been declined. He/She stated that the correct contact date should be entered to reflect the bereavement intervention timeline. Once the intervention was completed the date was entered and the person that completed the intervention. He/She stated that the MSW had not worked for the provider since the beginning of 2025 and he/she could not explain why the MSW’s name was on the BCP.During an interview on 07/23/2025 at 2:25 PM, the administrator stated that he/she:- Expected the bereavement assessment be completed within the two weeks following a patient’s death;- The staff were trained to wait a few days and to complete the bereavement assessment; - The day of the funeral was not appropriate to complete the bereavement assessment; - The current BCS should have corrected the error in the entry of the former BCS’s name on the BCP; - The expectation was for full bereavement services to be provided; - The services were to be offered and documented if services were refused;  - Expected the bereavement protocol to be followed based on the risk assessment;  - The BCP should have been updated when the risk level changed;   - A BCP should have been created, regardless, if services were refused; and- Would have expected the bereavement staff to have had an encounter with the bereaved to reassess the situation for new challenges and would have expected encounters at six months and 13 months after the patient’s death.

Based on policy review, record review, and interview, the hospice provider failed to ensure clinicians completed accurate, complete, and timely documentation in five of fifteen records reviewed (Records/Patients #2, #6, #7, #8, and #10). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: During the Medicare recertification survey, policies regarding documentation accuracy and completion timelines were requested for nursing, hospice aides, social workers, chaplains, volunteers, and any other staff responsible for documenting in the clinical record. The provider was unable to produce the requested policies for all disciplines except licensed nursing. Review of the provider's policy titled, "Scope of Services," dated as approved 03/24/2021, showed in part the following:A registered nurse (RN) is responsible for the coordination of all hospice services. Scope and frequency of services are based on initial and ongoing assessments of the patient's needs. Nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care. Hospice nursing provides: Registered Nurse •    Documentation of problems and appropriate goals and intervention entered into the current EMR (electronic medical record) within 24-48 hours;•    Documentation of patient/family participation in and response to the plan of care (POC); and•    Coordination of all patient/family hospice services.Licensed Practical Nurse (LPN)•    Documentation of problems and appropriate goals and intervention;•    Documentation of patient/family participation in and response to the plan of care entered into the current EMR within 24-48 hours;•    Coordination of all patient/family hospice services; and•    The LPN functions under the supervision of the RNCM (RN case manager) and communicates to the RNCM following a developed POC by the IDG/IDT (interdisciplinary group/interdisciplinary team). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the nursing visit, dated 06/26/2025, showed the visit narrative contained the documentation of the assessment and interventions performed on a patient with a heart condition and not the patient of record. The nurse failed to accurately document on the patient. Review of the hospice aide visits documentation showed the aide failed to sign his/her visits documentation in a timely manner:- On 07/01/2025 was signed on 07/09/2025 (eight days after the visit);- On 07/02/2025 was signed on 07/14/2025 (12 days after the visit);  - On 07/03/2025 was signed on 07/14/2025 (11 days after the visit); and- On 07/16/2025 was signed on 07/21/2025 (five days after the visit). RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe).  The patient resided at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following:- The patient transferred to a long-term care facility (LTCF) for respite care; and- The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025 (81 days later and on the day the state agents entered for the recertification survey).The RNC failed to sign and record the order within the timeframe identified in the provider's policy. Review of the registered nurse (RN) visit dated 05/03/2025, showed the following:- The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- The hospice team was notified.Review of the patient’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025.The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the patient died on 03/22/2025 at 1:50 PM (three days prior to the SN visit).  The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the physician orders, dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025 (The day the state agents arrived for the recertification survey and 116 days after the order was received). The RN failed to sign and record the orders within the timeframe identified in the provider's policy. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the patient’s general visit note dated 05/13/2025, showed the following:- The patient was discharged on 05/04/2025 to LTCF-2; and-  The RNC signed and recorded the event on 05/13/2025 (nine days after the patient discharged).The RNC failed to sign and record the event within the timeframe identified in the provider's policy. Review of the IDG meeting dated 05/15/2025, showed the patient was discharged to LTCF-2 (the patient discharged to LTCF-1) .The IDG failed to document accurate information. During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient. During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information.

Based on record review and interview, the hospice provider failed to forward a copy of the discharge summary to the patient’s attending physician in one of two revocation record reviews (Record/Patient #9) and in one of one live discharge record review (Record/Patient #10). This deficient practice has the potential to affect all the discharged patients served by the provider.Findings included:The provider was not able to provide a policy for the discharge of patients. --- RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 10/23/2024 with a terminal diagnosis of cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle coordination) with abnormal weight loss. The patient resided at his/her home with his/her family. The patient was discharged from services on 03/12/2025 to seek aggressive treatment.Review of the patient’s undated discharge summary failed to include the following: - A summary of the patient’s treatments, symptoms, and pain management; - Current plan of care;  - Latest physician’s orders; - Other documentation that would assist in post-discharge continuity of care.RECORD/PATIENT # 10: Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at a long term care facility (LTCF). The patient's condition was not consistent with a terminal prognosis of six months or less and was discharged from services on 05/04/2025.The provider failed to provide a discharge summary to the attending physician that included the following: - A summary of the patient’s stay including treatments, symptoms, and pain management; - The patient’s latest physician orders; - Other documentation that would assist in post-discharge continuity of care.During an interview on 07/22/2025 at 2:05 PM, the administrator stated that a discharge summary was provided to the receiving attending physician. During an interview on 07/23/2025 at 11:15 AM, the alternate administrator (AA) stated that the provider did not have a discharge policy. He/She stated that they implemented a new process on 05/13/2025 that included elements of the discharge summary.

Based on agency policy and clinical record review, the agency failed to ensure that the comprehensive assessment identify the physical needs (specifically pain) related to the terminal illness, that must be addressed in order to promote the hospice patient's well-being in three (Records/Patients #2, #3, and #5) of five full records reviewed. This deficient practice has the potential to affect the pain management of all the agency's patients. Findings included: Review of the agency's undated policy titled, "Pain Management," showed that: - Assessment of pain upon admission and throughout hospice service to include: * Location (generalized, specific, at the site or origin or referred); * Onset and duration (when, were there precipitating factors, what makes it worse, how long does it last); * Quality (patient description of what the pain feels like, such as stabbing, burning, searing, sharp, shooting, shock-like, pins and needles); * Intensity (use a standardized scale to objectify the subject of intensity, use a scale that makes sense to the patient, use the same scale each time, and specify the parameters of the scale; * Distress (is the pain interfering with the patient's life and/or activities of daily living); and * Relief factors (what makes the pain go away, or gives partial relief, how long does the relief last, helps assess patient/patient caregiver understanding of pain treatment plan. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the clinical record showed: - On 08/16/2022 the registered nurse (RN) assessed the patient, documentation showed that: * The patient was alert and oriented to person, who had slurred speech; * The nurse evaluated the patient's pain using the FLACC scale (FLACC is a behavioral pain assessment scale used for nonverbal or preverbal patients who are unable to self-report their level of pain. Pain is assessed through observation of 5 categories including face, legs, activity, cry, and consolability.); and * The nurse failed to document a complete pain assessment including a description of the quality of the patient's pain, onset and duration of the pain, what factors provide pain relief; - On 08/19/2022 and 08/26/2022 the licensed practical nurse (LPN) assessed the patient, the documentation showed that: * The patient remained oriented to person and place, and was forgetful; * The nurse evaluated the patient's pain using a numeric pain scale; * The nurse failed to document the onset, duration, and quality of the patient's pain, and factors that provide relief from pain; - On 08/23/2022 the RN assessed the patient, documentation showed that: * The patient was oriented to person and place and was forgetful, and had slurred speech; and * The nurse failed to document the onset, duration, and quality of the patient's pain, and factors that provide relief from pain. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). The patient resided in a skilled nursing facility. Review of the clinical visits showed that on 08/09/2022, 08/12/2022, 08/16/2022, and 08/19/2022 the patient received nursing visits. Visit documentation showed that: * The patient was oriented to person, disoriented, and forgetful, with a speech impairment; and * The nurses failed to document the onset, duration, and factors that provide relief from pain. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the clinical visits showed that on 08/16/2022 and 08/25/2022 the patient received nursing visits. Visit documentation showed that the nurses failed to document the onset, duration, and factors that provide relief from pain. The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM, no further evidence was provided prior to the survey exit.

Based on policy review, record review, observation, and interview, the agency failed to: - Develop an individualized plan of care (L545); - Develop an individualized written plan of care for each patient that included interventions to manage pain and symptoms (L546); - Implement plans of care that included anticipated measurable outcomes (L548); - Ensure that the plan of care included all physicians orders for medications and treatments (L549); and - Ensure that the revised plan of care included information from the patient's updated comprehensive assessment and noted the patient's progress toward outcomes and goals specified in the plan of care (L553). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on agency policy and clinical record review, the agency failed to ensure that plans of care reflect the patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments in five (Records/Patients #1, #2, #3, #4, and #5) of five records reviewed. This deficient practice has the potential to affect the care planning for all of the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021, showed that 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 #1: Review of the clinical record showed the patient was admitted to hospice with a terminal diagnosis of Emphysema. The patient resided at home. Review of the clinical record showed: - Review of the document titled "IDG [Interdisciplinary Group] Meeting", dated 08/02/2022 showed a goal under the Plan of Care problem of "Treatments" that the patient will receive lab draws, tuberculosis tests, etc. per facility protocol. The patient lived at home; - Review of the Skilled Nursing notes throughout care showed that the patient was on oxygen. The agency failed to include oxygen on the medication list or plan of care with flow rate and order; - Review of the medication profile dated 07/26/2022-10/23/2022 showed an order for Aspirin. The POC failed to show interventions related to Aspirin order; and -Review of the Registered Nurse Initial Assessment, dated 07/26/2022 showed that the patient was at a risk for falls. The POC failed to show any fall risk interventions. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that the plan of care contained interventions and goals that failed to reflect the unique needs of the patient including an intervention for the nurse to change central line dressing/port-a-cath needle and dressing weekly and as needed. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that the plan of care contained interventions and goals that failed to reflect the unique needs of the patient including an intervention for the nurse to change central line dressing/port-a-cath needle and dressing weekly and as needed. RECORD/PATIENT #4: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of Sepsis. The patient resided in a skilled nursing facility. Review of the document titled "IDG Meeting", dated 07/12/2022 failed to show a visit frequency to the Skilled Nursing visits and the Hospice Aide visits. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/16/2022 showed that the plan of care contained interventions and goals that failed to reflect the unique needs of the patient including an intervention for the nurse to change central line dressing/port-a-cath needle and dressing weekly and as needed. The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM, no further evidence was provided prior to the survey exit.

Based on agency policy and clinical record review, the agency failed to ensure that plans of care included all services necessary for the palliation and management of the terminal illness including interventions to manage pain and symptoms in three (Records/Patients #2, #3, and #5) of five records reviewed. This deficient practice has the potential to affect the pain management for all of the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021 showed that: - 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; and - The plan of care includes directives for managing pain and other symptoms. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the clinical visits showed that: - On 08/11/2022 the chaplain documented that the patient was constantly in pain, but she was making it; - On 08/12/2022 the social worker documented that the patient talked about pain in his/her hip and asked for pain medications; - On 08/12/2022 the licensed practical nurse (LPN) documented that: * The patient had pain in the neck and back daily, but not constantly; and * Was taking Percocet on a routine schedule (a narcotic pain medication); - On 08/16/2022 the registered nurse (RN) documented that: * The patient had pain in the neck and back daily, but not constantly; and * Was taking scheduled Percocet and using acetaminophen (a non-narcotic pain reliever) for breakthrough pain. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that the patient: - Had pain in the legs/back/shoulder, but failed to address the pain in the patient's neck or hip; - Failed to identify the specific non-pharmacological measures used to mitigate the patient's pain; and - Failed to identify the patient's pain management regimen, specifically the medications used to manage pain. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). The patient resided in a skilled nursing facility. Review of the clinical visits showed that: - On 08/09/2022 the LPN documented that the patient: * Had pain daily, but not constantly; and * Was taking tramadol for pain management; - On 08/12/2022 the RN documented that the patient: * Had pain less often than daily; and * Was taking regularly scheduled acetaminophen for pain management with Tramadol (a narcotic pain medication) available on an as needed basis for breakthrough pain; - On 08/16/2022, the LPN documented that the patient had pain daily but not constantly; - On 08/19/2022 the RN documented that the patient: * Had pain in his/her legs; and * Continued to take regularly scheduled acetaminophen for pain management with Tramadol available on an as needed basis for breakthrough pain. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that care plan failed to contain goals and interventions for the management of the patient's pain. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the clinical visits showed that: - On 08/15/2022 the RN documented that the patient: - Had pain daily but not constantly; - Pain managed with pain medications and rest; - Movement and activity made the patient's pain worse; - The patient used a Duragesic patch (a narcotic pain medication applied to the skin by a patch); and - Other pain medications for use with breakthrough pain; Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/16/2022 showed that the updated plan of care failed to: - Identify the location of the patient's pain; - Failed to identify the specific non-pharmacological measures used to mitigate the patient's pain; and - Failed to identify the patient's pain management regimen, specifically the medications used to manage pain. The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM, no further evidence was provided prior to the survey exit.

Based on agency policy and clinical record review, the agency failed to ensure that plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care in, but not limited to, three (Records/Patients #2, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect the care planning process for all of the agency's patients. Findings included: Review of the agency's policy titled, "Physician Plan of Care Summary," dated 08/13/2021 showed that: - The plan of care summary becomes part of the IDG (Interdisciplinary Group) plan of care; and - The goals, scope, and frequency of service and recommended interventions must be documented on the physician plan of care summary form. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that the care plan failed to contain measurable goals or outcomes as evidenced by the goal for pain management failed to identify the patient's acceptable level of pain. RECORD/PATIENT #4: Review of the document titled "Plan of Care Order" dated 07/08/2022, showed a goal that patient will report pain at acceptable level on 0 to 10 scale [0 being no pain and 10 being worst pain]. The agency failed to care plan a specific level of pain that the patient was comfortable at. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/16/2022 showed that the care plan failed to contain measurable goals or outcomes as evidenced by: - The goal for pain management failed to identify the patient's acceptable level of pain; and - The problem of impaired skin integrity failed to contain a goal addressing the patient's decubitus ulcer (bed sore). The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM, no further evidence was provided prior to the survey exit.

Based on agency policy and clinical record review, the agency failed to ensure that plans of care included drugs and treatments necessary to meet the needs of the patient in, but not limited to, one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the care planning process for all of the agency's patients. Findings included: Review of the agency's policy titled, "Physician Plan of Care Summary," dated 08/13/2021 showed that: - The plan of care summary becomes part of the IDG (Interdisciplinary Group) plan of care; and - The goals, scope, and frequency of service and recommended interventions must be documented on the physician plan of care summary form. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/16/2022 showed that the care plan failed to contain drugs and treatments necessary to manage the patient's decubitus ulcer (bed sore). The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM, no further evidence was provided prior to the survey exit.

Based on agency policy and clinical record review, the agency failed to ensure that the revised plans of care included information from the patient's updated comprehensive assessment, and must note the patient's progress toward outcomes and goals specified in the plan of care in five (Records/Patients #1, #2, #2, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect the care planning for all of the agency's patients. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021 showed that the plan of care will be reviewed and/or revised at a minimum [of] every fourteen days by the interdisciplinary group (IDG). RECORD/PATIENT # 1: Review of the clinical record showed the following: -Review of the Chaplain visit note dated 08/08/2022, the narrative noted states that the patient has declined further chaplain services at this time; -Review of the IDG Meeting dated 08/09/2022, the chaplain is still scheduled to visit twice a month; and -The agency failed to update the plan of care to contain patient's wishes for declining chaplain services. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that progress toward outcomes for the patients identified problems were, "0%," or, "N/A,"; and the updated care plan failed to contain narrative updates for all of the problems identified for the patient. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/23/2022 showed that progress toward outcomes for the patients identified problems were, "0%," or, "N/A,"; and the updated care plan failed to contain narrative updates for all of the problems identified for the patient. RECORD/PATIENT #4: Review of the clinical record showed the following: -Review of the initial comprehensive assessment dated 07/26/2022 showed that the patient was admitted with a Foley catheter (a tube placed in the bladder to drain urine); -Review of the Skilled Nursing note dated 07/11/2022 showed that the Foley catheter was discontinued and removed; -Review of the plan of cares dated from 07/12/2022-08/23/2022 showed that the Foley catheter was still care planned for patient and -The agency failed to update the plan of care to remove the Foley catheter after it was discontinued. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting, "the agency's updated care plan, dated 08/16/2022 showed that progress toward outcomes for the patients identified problems were, "0%," or, "N/A,"; and the updated care plan failed to contain narrative updates for all of the problems identified for the patient. The findings were reviewed with the quality assurance nurse on 09/01/2022 at 10:00 AM. No further evidence was provided prior to the survey exit.

Based on review of Missouri Home Health Aide/Hospice Aide Competency Exam form, personnel file review, and interview, the agency failed to ensure completion of the required Missouri competency evaluations prior to providing aide services to patients, in one (Aide A) of one aide employee file reviewed. This deficient practice has the potential to affect all patients who receive aide services from the agency. Findings included: Review of the current Missouri approved Home Health Aide/Hospice Aide competency exam instructs the agency to have the qualified registered nurse (RN) observe the aide performing all tasks listed while providing care to a patient. The exam must be completed prior to providing aide services to patients. Aide A: Review of Aide A's personnel file showed the following: - Aide was hired 07/26/2022; - The agency had a copy of the passed written competency exam; and - The agency failed to ensure that the exam was dated when it was taken. During interview on 08/31/2022 at 3:30 PM, the quality assurance nurse stated that he/she would expect the exam to be dated when it is taken by the aide.

Based on agency policy, clinical record review, and interview the agency failed to ensure the registered nurse prepared accurate written patient care instructions for the hospice aide assignment in, but not limited to, two (Records/Patients #2 and #3) of five applicable records reviewed. This deficient practice has the potential to affect the aide assignments for all of the agency's patients. Findings included: Review of the agency's policy titled, "Hospice Home Health," dated 08/13/2021 showed that the aide provides hands-on care of the patient as needed and directed by the plan of care and under the direction of the registered nurse. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of abnormal weight loss and malnutrition. The patient resided in a skilled nursing facility. Review of the document titled, "Aide Care Plan," dated 07/25/2022 showed the aide was to perform the following: - Complete bed bath prn (as needed) if pt [patient] unable to tolerate and a complete shower q (every) visit if tolerated; - Nail care prn hands only; - Assist in ambulation and range of motion prn; and - The assignment failed to contain specific and individualized criteria for bathing requiring the aide to determine whether to complete a bed bath or perform a complete shower, specific criteria on when the aide should perform nail care, assist in ambulation, and perform range of motion. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services with a terminal diagnosis of senile degeneration of the brain (a decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). The patient resided in a skilled nursing facility. Review of the document titled, "Aide Care Plan," dated 06/06/2022 showed the aide was to perform the following: - Apply barrier cream as ordered; and - The assignment failed to contain specific and individualized criteria for the application of the barrier cream including, but not limited to, the location and frequency of use. During an interview on 08/31/2022 at 04:30 PM the quality assurance nurse stated that they would expect the aide assignment sheets to contain individualized and specific interventions for the aide that do not allow for the aide to make choices about the care that is provided.

Based on policy review, record review, and interview, the agency failed to ensure that the physicians orders were being followed in, but not limited to, one (Record/Patient #1) or 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 "Nursing Services" dated 08/13/2021, showed, in part, the following: -Scope and frequency of services are based on initial and ongoing assessments of the patient's needs. Nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care; and -Hospice nursing provides coordination of all patient/family hospice services. Review of the agency's policy titled "Hospice Aide/Homemaker Support Services" dated 08/13/2021, showed that hospice aides may provide hands-on care of the patient as needed and directed by the plan of care and under the direction of the registered nurse. RECORD/PATIENT #1: Review of the clinical record showed the following: -Patient was admitted to hospice on 07/26/2022; -Review of the Interdisciplinary Group (IDG) meeting dated 08/02/2022 showed an aide visit frequency of two times a week; -Review of the aide care plan dated 07/26/2022 showed a visit frequency of one time a week; -The agency failed to have any aide visit completed during the first week of 07/26/2022-07/30/2022; and -The agency failed to follow the physician order of aide visits two times a week. During an interview on 08/31/2022 beginning at 03:30 PM, the quality assurance nurse stated that he/she would expect the physician orders to be followed.

Based on agency policy and clinical record review the agency failed to ensure that the hospice plan of care identify 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 (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect the coordination of care for all of the agency's patients who reside in nursing facilities. Findings included: Review of the agency's policy titled, "Plan of Care," dated 08/13/2021 showed that the nursing facility and the hospice are responsible for performing each of their respective functions as agreed upon and included in the plan of care. RECORD/PATIENT #5: Review of the patient record showed the patient was admitted to hospice services with a terminal diagnosis of breast cancer. The patient resided in a skilled nursing facility. Review of the document titled, "IDG Meeting," (Interdisciplinary Group) dated 07/19/2022 showed that the patient had a wound on his/her right buttock and was receiving wound care. Review of the document titled, "Coordinated Task Plan," updated 05/16/2022 showed the document failed to contain information related to the patient's wound care and identification of which provider was responsible for performing care of the wound on the right buttock.

Based on review of Missouri state law, employee file review, and interview the agency failed to obtain the results of the employee disqualification list (EDL) checks prior to hire in five (Employees #1, #3, #4, #5, and #8) of eight employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo showed the statement, "No person, corporation, organization or association who received the employee list under subdivisions (1) to (5) of subsection 11 "of this section shall knowingly employee any person who is on the employee disqualification list." EMPLOYEE #1: -Date of hire: 08/15/2022; and -EDL check completed: 08/17/2022. EMPLOYEE #3: -Date of hire: 05/02/2022; and EDL check completed: 05/02/2022. EMPLOYEE #4: -Date of hire: 12/02/2019; and -EDL check completed: 02/21/2020. EMPLOYEE #5: -Date of hire: 12/28/2021; and -EDL check completed: 01/04/2022. EMPLOYEE #8: -Date of hire: 03/16/2022; and -EDL check completed: 03/16/2022. During an interview on 09/01/2022, beginning at 11:00 AM, the director of operations stated that he/she would expect the EDL to be checked prior to hire.

Based on state law, Alzheimer's and Dementia training, and interview, the agency failed to ensure that the Alzheimer's and Dementia training contained all of the required components. This deficient practice had the potential to affect all patients served by the agency. Findings included: Review of the Missouri state law, the training required shall address the following areas: - An overview of Alzheimer's disease and related dementias; - Communicating with persons with dementia; - Behavior management; - Promoting independence in activities of daily living; and - Understanding and dealing with family issues. Review of the Alzheimer's and Dementia training given to employees upon hire and annually showed that the training failed to contain elements regarding understanding and dealing with family issues. During an interview on 08/31/2022 starting at 3:30 PM, the quality assurance nurse stated that he/she could not find elements regarding understanding and dealing with family issues. He/she also stated that they would expect these elements to be included in the training.

Based on clinical record review, policy review, and staff interviews, the hospice provider failed to ensure that a registered nurse (RN) gathered the critical information necessary on the initial assessment to treat the patient's immediate care needs. The single deficiency example was identified at an condition level due to substantial risk to adversely affect health and safety to hospice patients (L522). The effect of this deficient practice has the potential to affect nursing services for all patients on service with the agency.

Based on policy review, record review, observation, and interviews, the hospice provider failed to ensure that the registered nurse (RN) completed an initial assessment within 48 hours after the election of hospice care, to assess the patient's immediate physical status related to the terminal illness, for an effective plan of care in two of three patients sampled (Records/Patients #1 and #2). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: On survey entrance the hospice initial and comprehensive assessment policy was requested. Review of the provided "clinical services procedures" policies showed no mention of frequency for wound measurements, or wound assessments by a registered nurse. Review of a hospice policy, undated, titled "Wound Monitoring and Measurements" states in part that home patients' wounds will be assessed with each visit for changes or signs of worsening, Measure wounds from the farthest outer edges in length and width. The skin should be assessed at a minimum weekly. Review of the hospice policy titled "Nursing Services" dated 08/2021, showed in part that the registered nurse was responsible for "initial and ongoing assessment of the patient's physical symptoms". "Scope and frequency of services are based on initial and ongoing assessments of the patient's needs". "The registered nurse shall make at least monthly on-site visits and document that the licensed practical nurse (LPN) is routinely providing nursing services in accordance to the plan of care". Review of the hospice policy titled "Telehealth", dated 03/2020, states in part that "The hospice will conduct telehealth visits only when in-person visits are limited /denied due to lack of access to our patients from an outside source such as a pandemic". "LPN or RN utilizing a competent CNA (certified nursing assistant) or nurse on the in-person assessment or RN utilizing an LPN for an initial assessment as per the 1135 waiver". "The hospice team will perform telehealth admissions only when required by the facility or when no RN is available and the patient is ready for admission" RECORD/PATIENT #1: Review of the hospice initial plan of care showed the following: - The patient was admitted on 03/11/2022 with a terminal diagnosis of senile degeneration of the brain; - The patient had identified problems of advance directives, knowledge deficit, self care deficit, alteration on neurological status, alteration in nutrition, alteration in discomfort, alteration in respiratory system and impaired skin integrity; and -The interventions listed for alteration in skin integrity included education of the caregiver, pressure relieving devices as needed, assessment for changes in skin integrity, provide wound care as ordered, and to encourage patient to reposition every two hours as tolerated. Review of the hospice initial assessment dated 03/11/2022 showed the following: - The document was signed by a registered nurse and titled "RNIA Telehealth"; - The patient was admitted on 03/11/2022 with a terminal diagnosis of senile degeneration of the brain; - The patient resided in a private residence, the patient's spouse and in-home care aide were the primary caregivers; - The patient had mild pain; - The patient's integumentary status was "poor"; - The patient was at moderate risk of developing pressure sores (it should be noted that the patient already had pressure sores on admission); - The patient had five wounds; - The patient had a stage III pressure sore (Stage III Pressure sore-a full thickness of skin loss, exposing the subcutaneous tissues, presents as a deep crater with or without undermining adjacent tissue) to the left heel identified as wound #1. The length or width of the wound was not documented; - The patient had a stage III pressure sore to the outer left foot. There were no measurements of the wound identified as "wound #2"; - The patient had a stage III pressure sore to the right heel. There were no measurements of the wound identified as "wound #3"; - The patient had an unstagable black eschar (Eschar-dead skin that is usually dry, tough, leathery, and black in color, tightly attached to a wound bed) area to the coccyx. There were no measurements of the area. The wound was identified as "wound #4"; - The patient had a stage II pressure sore (Stage II Pressure Sore-a partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater) to the left buttock. There were no measurements of the wound identified as wound #5; - The narrative section showed "admission completed with LPN (LPN-A) at pt's [patient's] bedside"; and - It should be noted that the wound to the patient's left hand/forearm from an infiltrated intravenous (IV) site that the hospice LPNs were dressing with hydrogel and a non-adhering dressing since admission was not assessed or documented. Review of the plan of care, provided on 03/14/2022, showed wound care orders for four wound sites as follows: - Cleanse left gluteal area with wound cleanser, apply calcium alginate and cover with Optifoam twice weekly; - Cleanse coccyx with wound cleanser, and cover with Optifoam twice weekly; - Cleanse area apply skin prep and heel protector. This order was incomplete for location/site; - Cleanse left heel with wound cleanser, pat dry, and apply a calcium alginate dressing covered with non-adhering dressing and kerlix gauze; and - It should be noted that there were no wound care orders for the patient's left forearm infiltrated intravenous (IV) site that the hospice LPNs were dressing with hydrogel and a non-adhering dressing since admission. During an interview with RN-A on 03/15/2022 at 10:20 AM, he/she stated the following: - Admission with Patient #1 was completed in person by a licensed practical nurse (LPN-A), and he/she phoned the patient for telehealth assessment while LPN was physically assessing the patient; - The COVID waiver allowed for a telehealth initial assessment; - When asked if the LPN should have measured all of the patient's wounds he/she responded "yes"; and - When asked if all of patient #1's wounds should have been assessed on the initial assessment, he/she responded "yes". During an interview with LPN-A on 03/15/2022 at 10:57 AM and 03/16/2022 at 11:15 AM, he/she stated the following: - Admission with Patient #1 was completed in person by him/herself, with RN-A on the phone for telehealth assessment; - The COVID waiver allowed for telehealth initial assessment according to corporate management; - When asked if the he/she measured the patient #1's wounds on the initial assessment, he/she responded "no"; - Patient #1 had the open wound on the left forearm since admission. The wound was from an infiltrated intravenous (IV) site from the last hospitalization; - The patient was provided pain medication 30 minutes before the dressings were changed on 03/16/2022; and - Patient #1 has not been physically assessed by a RN since the admission. During a home visit observation on 03/16/2022 at 9:20 AM through 11:15 AM, the following was observed: - The patient was lying in a standard hospital bed in a private residence living room; - The patient had systemic visible edema; - The patient was on a standard hospital mattress, no pressure relieving mattress; - LPN- A changed dressings to the patient's left hand and left forearm, right heel, left heel, and coccyx area; - The patient's left heel had an open wound that had a foul odor, the nurse removed and re-applied a calcium aginiate dressing after cleaning the wound; - The patient's coccyx wound was irregular large eschar tissue, the nurse removed and reapplied a foam dressing after cleaning the wound; - The patient's left forearm wound had skin slough and was reddened throughout, the nurse removed and reapplied a hydrogel and non-adhering dressing after cleaning the wound. (it should be noted that this wound had not been identified on the initial assessment, and no treatment orders on the plan of care for this wound); - After the dressings were changed the patient was lifted into a sling by a mechanical lift, and a new pressure relieving mattress was applied to the patient bed; and - The patient was log rolled multiple times for the dressing changes, and to be placed on the mechanical lift sling. The patient was grimacing and moaning during these movements. Review of the LPN visit note from 03/16/2022 showed LPN-A documented the following: - A low air loss mattress was delivered during the visit; - Edema was noted to all extremities; - Patient with a new area to left inner foot and and blister to left upper thigh; - Wound #1 left heel pressure ulcer was now a stage IV. The wound was a stage III on admission which indicates worsening of the wound since admission. This wound measured 2cm (centimeters) x 2cm x 0.5cm (length by width by depth). A stage IV pressure sore is a full thickness skin loss with extensive destruction, tissue death or damage to muscle tissue; - Wound #2 to the right heel pressure ulcer "suspected deep tissue injury" was 2cm x 2cm x 0cm; - Wound #3 pressure ulcer to the patient's coccyx was documented as "unstagable" measuring 6.5cm x 6cm x 0cm; - Wound #4 to the left buttock stage III pressure ulcer was 2cm x 2cm x 0.3cm; - Wound #5 to the left hand was 7cm x 6.5cm x 0.0cm; - Wound #6 to the left inner foot 1cm x 2.5 cm (no depth was documented); - Wound #7 to the left upper thigh blister was 5cm x 1.5cm; - Wound #8 to the left upper thigh abrasion was 4cm by 0.4cm; - It should be noted that wound site location identifiers I.E. "wound #2, #3, #4, etc." had changed site locations from the initial assessment visit; and - It should be noted that the pressure relief device (low-air loss mattress) should have been been placed at admission due to the patient's pressure sores and physical condition. Review of all available nurse visit records from 03/11/2022, 03/12/2022, 03/13/2022 and 03/16/2022 showed that no registered nurse physically assessed the patient. All visits were completed in person by a LPN. RECORD/PATIENT #2: Review of the initial assessment dated 03/03/2022 showed that the patient was admitted to hospice for terminal heart failure; - The patient resides in a skilled nursing facility (SNF); - The initial assessment document was signed by a registered nurse (RN-A) and titled "RNIA Telehealth", there was no co-signature by the LPN; - The narrative section showed "admission completed with LPN (LPN-A) at pt's bedside". Review of all available nurse visit records from 03/03/2022, 03/07/2022, and 03/10/2022 showed that no registered nurse physically assessed the patient. All visits were completed in person by a LPN. During an interview with RN-A on 03/15/2022 at 10:20 AM, he/she stated the following: - Admission with Patient #2 was completed in person by a licensed practical nurse (LPN-A), and he/she phoned the patient for telehealth assessment while LPN was physically assessed the patient; - The COVID waiver allowed for telehealth initial assessment; and - No hospice RN has physically assessed the patient. During an interview with LPN-A on 03/15/2022 at 10:57 AM and 03/16/2022 at 11:15 AM, he/she stated the following: - Admission with Patient #2 was completed in person by him/herself, with RN-A on the phone for telehealth assessment; - The COVID waiver allowed for telehealth initial assessment according to corporate management; and - Patient #2 has not been physically assessed by a RN since their admission.