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

Based on policy review, the provider’s bereavement protocol review, record review, and interview, the bereavement assessment failed to assess social, spiritual, and cultural factors that may impact the bereaved in three of six records reviewed for bereavement (Records/Patients #3, #4, and #11) and the hospice provider failed to incorporate the needs of the bereaved in the bereavement plan of care in one of six records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s undated policy titled, “Death, Discharge or Revocation of the Hospice Patient,” showed, in part, the interdisciplinary team (group) would implement the following:- Discuss and assess family member(s) who may need bereavement care;- The bereavement assessment completed by the bereavement coordinator and updated as necessary; and- Complete a bereavement plan of care in the patient’s electronic medical record.Review of the provider’s bereavement protocol, approved 01/2021, showed, in part, the following:- The basic framework for bereavement interventions (are) based on the risk assessment;- All services provided should be tailored to the specific needs of each bereaved person; and- For Moderate risk increase calls and visits in the first three months.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. --- RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/05/2025 with a terminal diagnosis of acute congestive heart failure (a decrease in the ability of the heart to pump blood). 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 08/05/2025, showed the bereaved survivor at low risk. The initial bereavement assessment failed to identify the name of the bereaved survivor.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/25/2025 with a terminal diagnosis of sarcopenia (loss of muscle mass and strength) and dementia (decline in mental capacity). The patient resided at a LTCF. Review of the initial bereavement assessment dated 04/28/2025, showed the bereaved survivor at low risk. The initial bereavement assessment failed to identify the name of the bereaved survivor.RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 01/26/2025 with a terminal diagnosis of sarcopenia and dementia. The patient resided at a LTCF and his/her spouse visited regularly.Review of the social worker’s initial assessment dated 01/27/2025 showed the patient lived at a LTCF, his/her spouse visited regularly through the week, the spouse came in the morning, and stayed through lunch.Review of the initial bereavement assessment dated 01/27/2025, showed the assessment was completed on the patient’s adult child with a low risk assessment. The provider failed to complete an initial bereavement assessment for the spouse.Review of the clinical record showed the patient's date of death was 03/04/2025.Review of the chaplain note dated 03/04/2025, showed the following:- The patient’s spouse accepted bereavement services;- There was no funeral; and- The bereavement coordinator (BC) would follow-up according to the care plan.Review of the bereavement care plan dated 03/05/2025, showed the following:- Medium risk; and- Bereaved requested extra visits.Review of the post bereavement assessment (known to the provider as the initial bereavement assessment) dated 03/19/2025, showed the following:- Low risk;- The spouse indicated that he/she would like more visits;- The spouse’s adult son (who lived out of state) would like his/her parent to have more visits;- The spouse appeared to be grieving appropriately;- The spouse wanted to receive bereavement services; and- The BC planned to make more visits.The bereavement care plan interventions showed the BC failed to:-  Provide a visit to the bereaved spouse in April; and- Include plans for bereavement services for September and October.During an interview on 09/16/2025 at 11:00 AM, the social worker with a bachelor’s degree (BSW) stated that he/she did not use a set of questions to complete the bereavement assessments. The BSW stated that the risk level was determined by conversations and interactions with the family members. The BSW rated the person as low if he/she was accepting, understood the dying process, and knew what to expect during the dying process. The BSW rated the person as medium, if during the conversation, there were tons and tons of tears and the high risk would be indicated by more intense emotions. He/She stated that the primary contact was considered the bereaved and other family members would not be assessed.During an interview on 09/17/2025 at 9:45 AM, the social worker with a master’s degree (MSW) stated that he/she oversaw the pre-bereavement assessment performed by the BSW and MSW staff. The MSW stated that this assessment was subjective and was based on interview(s) of the patient, caretaker(s), and family members of the hospice patient. The MSW stated that there was no formal objective assessment tool to assess risk levels of grief/ bereavement.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that they had a bereavement assessment tool that asked questions and then generated a risk assessment score. He/She stated that they would implement the tool again to guide the team in determining a risk level for the bereaved.During an interview on 09/17/025 at 12:30 PM, the BC stated that, since he/she contacted the bereaved spouse at the end of March, he/she did not provide services in April. Since the spouse was getting better, then the visits would be less. The spouse wanted frequent visits. The primary focus of the visits was socialization, and that socialization would fall under bereavement services. Monthly visits would be beneficial to the bereaved spouse, but they would usually wait until it was time for the next letter. If the bereaved were low risk, they would not get as many visits as this bereaved had received.  For moderate risk,  extra visits would be one time per month and for low risk the extra visits would be about the same at one time per month.

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained individualized goals with measurable outcomes in three of five full records reviewed (Records/Patients #1, #2, and #5). This deficient practice has the potential to affect all the patients served by the provider. --- Review of the provider's policy titled, "Registered Nurse (RN) Coordination of Care," dated 08/13/2025, showed in part the following:- A RN is responsible for the coordination of all hospice services; and- Documentation of problems and appropriate goals and interventions.  RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of cardiovascular disease (CVD - a group of conditions which affects the heart and blood vessels). The patient resided in a skilled nursing facility with total care.  Review of the updated plans of care/IDG note, dated 09/15/2025, showed the patient had the following goals:- Patient to report a decrease in shortness of breath, with the intervention to encourage optimal activity with frequent rest periods. The goal failed to define, “optimal”;- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- Patient will have adequate urine output as disease process allows. The goal failed to define, “adequate”;- 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 #5:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses which included hypertension (high blood pressure), acute renal failure (a condition in which the kidneys fail to effectively remove waste products from the body), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a skilled nursing facility with total care.  Review of the plans of care/IDG Comprehensive Assessment Details, dated 08/19/2025, showed the patient had the following goals:- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- 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 09/17/2025 At 11:45 AM, the administrator and director of operations stated they were aware of the issue of the POCs not being individualized with measurable goals for the referenced patients and were in the process of correcting the problem prior to the survey.  RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer, and additional diagnoses of restrictive lung disease (a group of conditions that limit the lungs' ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the form titled, "IDG (Interdisciplinary Group) Comprehensive Assessment Details," dated 09/10/2025, showed in part:- Patient does have orthopnea (difficulty breathing when lying flat); - Continues to use PRN (as needed) oxygen at 2-5 liters; and- The current medication section showed the oxygen was ordered at 2-4 liters PRN for comfort use.Review of the POC dated 09/15/2025 showed the following:- An order for oxygen 2-4 liters PRN for comfort;- An order for morphine sulfate (an opioid medication used to treat pain or shortness of breath) 0.5 ml every 30 minutes as needed for discomfort, dyspnea (difficulty breathing), and pain; and - The POC failed to contain a respiratory care plan with individualized goals and interventions related to the patient's respiratory diagnoses and symptoms.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters. During an interview on 09/17/2025 at 11:45 AM, the hospice administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters.    Findings included:Review of the provider's policy titled, "Registered Nurse (RN) Coordination of Care," dated 08/13/2025, showed, in part, the RN had the following responsibilities: - The coordination of all hospice services; and- Documentation of problems and appropriate goals and interventions. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs' ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document titled, "IDG (Interdisciplinary Group) Comprehensive Assessment Details," dated 09/10/2025, showed in part:- "Patient does have orthopnea (difficulty breathing when lying flat)"; - "Continues to use PRN (as needed) oxygen at 2-5 (two-five) liters"; and- The current medication section showed the oxygen was ordered at 2-4 (four) liters PRN for comfort use.Review of the POC dated 09/15/2025 showed the following:- An order for oxygen 2-4 liters PRN for comfort;- An order for morphine sulfate (an opioid medication used to treat pain or shortness of breath) 0.5 ml every 30 minutes as needed for discomfort, dyspnea (difficulty breathing), and pain; and - The POC failed to contain a respiratory care plan with individualized goals and interventions related to the patient's respiratory diagnoses and symptoms.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters. During an interview on 09/17/2025 at 11:45 AM, the hospice administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of cardiovascular disease (CVD - a group of conditions which affects the heart and blood vessels). The patient resided in a skilled nursing facility with total care.  Review of the updated plans of care/IDG note, dated 09/15/2025, showed the patient had the following goals:- Patient to report a decrease in shortness of breath, with the intervention to encourage optimal activity with frequent rest periods. The goal failed to define, “optimal”;- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- Patient will have adequate urine output as disease process allows. The goal failed to define, “adequate”;- 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 #5:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses which included hypertension (high blood pressure), acute renal failure (a condition in which the kidneys fail to effectively remove waste products from the body), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a skilled nursing facility with total care.  Review of the plans of care/IDG Comprehensive Assessment Details, dated 08/19/2025, showed the patient had the following goals:- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- 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 09/17/2025 At 11:45 AM, the administrator and director of operations stated that they were aware of the issue of the POCs not being individualized with measurable goals for the referenced patients and were in the process of correcting the problem prior to the survey.

Based on policy review, record review, home visit observation, and interview, the provider failed to ensure staff provided services as ordered in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy titled, "Nursing Services," dated 08/13/2025, showed nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs' ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document titled, "IDG (Interdisciplinary Group) Comprehensive Assessment Details," dated 09/10/2025, showed in part:- (Patient) "Continues to use PRN (as needed) oxygen at 2-5 (two-five) liters"; and- The current medication section showed the oxygen was ordered at 2-4 (four) liters PRN for comfort use.Review of a skilled nurse visit note, dated 09/11/2025, showed in the narrative section; (patient) "continues PRN oxygen at 2-5 liters for comfort".Review of the plan of care (POC), dated 09/15/2025, showed an order for oxygen 2-4 liters PRN for comfort. The POC failed to contain an order for oxygen at the rate the patient was using.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula (a tube that facilitates oxygen delivery via the nostrils) that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters.

Based on policy review, record review, and interview, the hospice aide failed to follow the aide care plan in one of five reviewed records of patients receiving aide services (Record/Patient #1). This deficient practice has the potential to affect all the patients receiving hospice aide services. --- Findings included:Review of the provider's policy titled, "Hospice Home Health Aide," dated 08/13/2025, showed the home health (and/or hospice) aide will follow an individualized assignment for each patient provided in the plan of care.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer, and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs' ability to expand and take in air, resulting in difficulty breathing) and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document that reflected the aide tasks, last reviewed by the registered nurse on 09/12/2025 showed the aide was assigned the following tasks:- Weigh weekly;- Document date of last BM (bowel movement);- Document output; and- Personal care (PC) items and homemaker chore items were also assigned (the patient was independent and refused personal care at this time). Review of seven aide visit notes with a date range of 08/19/2025 through 09/12/2025 showed the aide failed to document/obtain a weight weekly for five of the seven visits provided and failed to document the date of the last BM or output in all seven visits.During an interview on 09/16/2025 at 8:05 AM, the administrator stated that he/she would prefer for the aide care plan to include PC items in case the patient allows the care. If the patient was in a facility, he/she would expect the aide care plan to be updated sooner. The expectation is that the aide keeps the case manager updated.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that he/she would expect the aide to obtain weights and ask about BM's and other items each visit.

Based on policy review, record review, and interview the agency failed to ensure that the medication profiles were updated and accurate in three (Records/Patients #2, #3, and #4) of five full records reviewed; and failed to ensure the comprehensive medication review was completed with the comprehensive assessment within five days of the election of hospice care in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, " Medication Administration Record," dated 08/13/2021, showed: -A medication administration record, which is an exact duplicate of the medication profile in the hospice office, will be kept in the patient's chart in the home or nursing facility; and -The licensed nurse will assure that all changes are reflected in both the medication profile and the office patient chart medication profile. Changes will be updated as new orders are received and filed into the patient record. RECORD/PATIENT #3: Review of the clinical record showed: -The current medication list, dated 05/31/2022 through 08/28/2022, and verified by the administrator on 10/11/2022 and 10/13/2022 as current, failed to include the following medications that were being administered by the skilled nursing facility: -Famotidine (a medication for gastric ulcers) 10 milligrams (mg) at bedtime; -Zyrtec (a medication for rash) 10 mg daily; and -Tums tablets (a medication for stomach upset) 200 mg two tablets every four hours as needed. During an interview on 10/13/2022 beginning at 11 AM the administrator stated that he/she would expect the medications to match and the medications should be checked before each scheduled interdisciplinary team meeting (IDT) for the patient. Findings included: Review of the agency's policy titled, "Medication Administration Record," dated 08/13/2021, showed in part: - A medication administration record (MAR), which is an exact duplicate of the medication profile in the hospice office, will be kept in the patient's chart in the home or nursing facility; and - The licensed nurse will assure that all changes are reflected in both the medication profile and the office patient chart medication profile. Changes will be updated as new orders are received and filed into the patient record. RECORD/PATIENT #2: Review of the clinical record showed the patient elected hospice care on 06/20/2022. Review of the record showed the medication comprehensive assessment was not completed within five days of the comprehensive assessment. The comprehensive medication assessment was completed on 06/28/2022. Review of the medication profile dated 06/20/2022 through 09/17/2022, showed an order dated 06/20/2022, for oxygen two liters per minute, may increase in 0.5 liter increments up to five liters (this order did not specify whether this was continuous or as needed). Review of the skilled nursing facility (SNF) physician order report dated 09/01/2022 through 10/31/2022 showed an order dated 06/20/2022, for oxygen two to six liters per minute per nasal cannula as needed for shortness of breath. Review of the IDG (interdisciplinary group) meeting/plan of care (POC) notes from 08/25/2022 through 10/04/2022 showed in part: -The patient had an order for oxygen two to six liters per minute per nasal cannula as needed for shortness of breath; and -The patient utilized oxygen at three liters per minute per nasal cannula during the day and a simple mask during the night as needed. During an interview on 10/12/2022, at 12:25 PM, the administrator stated that on 06/25/2022, the pharmacy sent a notification that there was insufficient data on the medication list. He/she did not know why there was insufficient data. The first pharmacy review was on 06/28/2022. RECORD/PATIENT #4: Review of the medication profile dated 08/12/2022 through 11/09/2022, showed an order for oxygen two liters per minute per nasal cannula, may increase in 0.5 liter increments up to five liters (this order did not specify whether the oxygen was continuous or as needed). Review of the IDG/POC dated 08/17/2022 through 09/07/2022 showed an order for oxygen two liters per minute per nasal cannula as needed for shortness of breath. The IDG/POC notes from 09/21/2022 through 10/05/2022 did not address oxygen orders. During an interview on 10/13/2022, beginning at 11:00 AM, the administrator stated that they print a medication list and reconcile the medications/orders at every IDG meeting. During an interview on 10/13/2022, at 2:45 PM, the administrator stated that they could not find a comprehensive assessment policy.

Based on policy review, record review, and interview the agency failed to ensure all hospice care and services on the plan of care (POC) were followed, when visits were not completed as ordered in one (Record/Patient #5) out 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: -The POC will identify the care and services to which hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care; -The POC will be reviewed and/or revised at a minimum every 14 days by the interdisciplinary group (IDG); and -Any changes to the POC will be conducted with the family/caregiver. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice service on 08/12/2022 with a terminal diagnosis of colon cancer. The patient resided at a long-term care facility (LTCF). Review of the clinical record showed the following: -The IDG meeting on 09/09/2022 showed the skilled nursing visit frequency to be two times a week. Complete skilled nursing visits and assess patient for emotional/spiritual/and additional needs. The patient has a lower abdominal wound that measured 7.5 centimeter (cm) by 3.5 cm. Dressing changed three times weekly; -A missed visit form dated 09/13/2022 documented by the skilled nurse showed the patient was not at the LTCF, he/she was on a visit with a family member and would not be back until later that evening; and -The skilled nurse failed to make up the missed visit during the week of 09/11/2022 through 09/17/2022. During an interview on 10/13/2022 at 11:40 AM, the administrator stated that he/she would have expected the skilled nurse visit to have been made up another day that week.

Based on job description, record review, and interview the agency failed to provide/document education and training to the patient regarding interventions from his/her plan of care and wound care when patient was transferred from long-term care facility (LTCF) to home in one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's job description titled, "Registered Nurse," dated 02/2020, showed in part the following: -Develops a comprehensive nursing care plan for all patients and coordinates with the interdisciplinary team (IDT); -Provides service to patients and families based on the plan of care (POC) approved; and -Provides teaching to patient, families and care givers for appropriate technique of care. Review of the agency's job description titled, "Licensed Practical Nurse," dated 02/2020, showed in part the following: -Follows through with the comprehensive nursing care plan for all patients and coordinates with the IDT; -Provides service to patients and families based on the POC approved; and -Provides teaching to patient, families and care givers for appropriate technique of care. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice service on 08/12/2022 with a terminal diagnosis of colon cancer. The patient resided at a LTCF. Review of interdisciplinary group (IDG) meeting, dated 09/22/2022, showed the following: -A potential for increased pain as disease progresses, interventions included: *Educate and/or implement nonpharmacological measures to reduce pain (ice, heat, massage, relaxation, meditation); *Educate patient and/or caregiver(s) on pain reduction and prevention technique; and *Educate patient and/or caregiver(s) on pain medication regimen; -A potential for increased respiratory distress as disease progresses, interventions included: *Educate on anticipated changes in respiratory symptoms as disease progresses; *Educate on measures to reduce respiratory distress; *Educate patient and/or caregiver(s) on oxygen safety and equipment (patient had no order for oxygen); *Educate patient and/or caregiver(s) on aspiration (a condition in which food, liquids, saliva or vomit is breathed into the airways) precautions; *Instruct patient and/or caregiver(s) on energy conservation technique; and *Provide/educate on use of suction (patient had no order for suction); -A potential for decrease in neurological status system function as disease progresses, interventions included: *Instruct patient and/or caregiver(s) on seizure (sudden uncontrolled electrical disturbance in the brain) precautions/management; and *Educate on anticipated decline in neurological status as disease progresses; -A potential for alteration in gastrointestinal (GI) system function as disease progresses, interventions included: *Educate on nutritional intake and needs as disease progresses; *Educate patient and/or caregiver(s) on PEG (percutaneous endoscopic gastrostomy; feeding tube inserted through the skin and the stomach wall and goes directly into the stomach) tube use and/or maintenance (patient had no orders for PEG tube); *Educate patient and/or caregiver(s)on effects of ascites (abdominal swelling caused by accumulation of fluid) on GI function/appetite; *Educate patient and/or caregiver(s) on aspiration precautions; *Educate patient and/or caregiver(s) on smaller, frequent meals; and *Educate patient and/or caregiver(s) on proper oral hygiene; -A potential for decreasing nutritional status/adequate caloric-protein intake as disease progresses, interventions included: *Educate patient and/or caregiver(s) on aspiration precautions; and *Educate patient and/or caregiver(s) on smaller, frequent meals; -A potential for decreased function of urinary system as disease progresses, interventions included: *Educate patient and/or caregiver(s) on cleaning and/or irrigating urinary drainage device as ordered (patient had no urinary drainage device); *Instruct caregiver(s) on urinary incontinence care; and *Provide and/or educate patient and/or caregiver(s) on proper cleaning of peri area (diamond shaped area that is found between the tail bone and the pubic arch); -A potential for alteration in skin integrity related to disease progression, interventions included: *Educate and/or assess for signs and/or symptoms of infection; *Instruct patient and/or caregiver(s) on infection control techniques; *Teach and/or demonstrate good preventive skin care; *Provide/educate on wound care as ordered; and *Teach and/or encourage repositioning every two hours as tolerated by the patient; -A potential for decreased colon function as disease progresses, interventions included: *Teach/review importance of compliance with bowel regimen; *Teach/encourage fluids, mobility and/or dietary changes as tolerated; and *Instruct patient and/or caregiver(s) in monitoring and recording bowel frequency/characteristics; and -Staff failed to document any potential that the patient might go home from the LTCF. Review of Registered Nurse (RN) recertification visit, dated 09/30/2022, showed the following: - Patient lives alone; - Requires occasional assistance, but is able to care for most of his/her personal needs; - His/her functional limitations were, ambulation, bathing, and dressing; - Alert and oriented times three; - Patient slept 12 plus hours a day; - Patient had a chronic abdominal wound; - Patient never short of breath; - No oxygen; - Appetite good; - Able to eat normal diet, no difficulty swallowing; - Bowel incontinence; - Eats alone most of the time; - Not always physically able to shop, cook, and/or feed self; - Urinary incontinence; - At risk for falls; - Durable medical equipment (DME) the patient had: cane, grab bars (tub/shower/toilet), wheelchair, and wheelchair cushion; - Did not need any DME; - Patient was transferred home on 09/30/2022. Abdominal wound measured 7 centimeters (cm) by 3 cm. Dressing changes three times a week. Patient educated on use of medications and need to contact hospice agency with any questions or concerns; - No mention of a caregiver(s); and - Staff failed to provide/document education and training on the interventions from the latest IDG meeting (09/22/2022) and how to care for his/her wound and/or what to do if the dressing became soiled or fell off. During an interview on 10/13/2022 at 11:40 AM, the administrator stated that he/she would expect the patient to be educated/instructed on the interventions from his/her plan of care and how to care for the wound if it became soiled or fell off between visits.

Based on policy review, record review, and interview the agency failed to ensure patients have an individualized plan of care (POC) in five (Records/Patients #1, #2, #3, #4, and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the policy titled, "Nursing Services: Plan of Care," dated 08/13/2021 showed in part: - 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; - 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 will be reviewed and/or revised at minimum every fourteen days by the interdisciplinary group (IDG) (physician, social worker, registered nurse, chaplain, volunteer coordinator). Review of the policy titled, "Nursing Services," dated 08/13/2021 showed in part: - The hospice registered nurse will monitor, initiate and evaluate the plan of care as needed; and - The hospice registered nurse in agreement with the IDG team will make changes to the resident's plan of care, or assign a designee. RECORD/PATIENT #3: Review of the clinical record showed: - The initial assessment dated 03/02/2022 showed: - The patient verbally expressed pain involving his/her back, knees, and neck; - The intensity of the pain was rated five medium on a pain scale of zero to 10 with zero being no pain and 10 being the worst pain ever experienced by the patient; - The pain was described as ache/dull, sharp/stabbing, radiating, burning, and continuous; - The pain was increased by movement and doing own activities of daily living; - The pain was relieved by rest, positioning, and medication; - The pain interfered with rest, movement, and activity; - The patient's target pain goal was two on the pain scale; and - A level of six on the pain scale warranted further attention by staff. Review of the initial plan of care dated 03/02/2022 showed: - A goal that the patient would report pain at acceptable level on 0 to 10 scale; and - The patient will report decreased pain. Review of the current plan of care dated 10/11/2022 showed: - A goal that the patient would report pain at acceptable level on 0 to 10 scale; and - The patient will report decreased pain. The agency failed to care plan the patient's acceptable pain level and what pain level warranted further attention by staff for follow-up. During an interview on 10/13/2022 beginning at 11 AM, the administrator stated that he/she would expect an acceptable pain level to be on the plan of care for a patient having pain. RECORD/P/ATIENT #2: Review of the registered nurse (RN) recertification assessment dated 09/02/2022 showed: - The patient resided in a skilled nursing facility (SNF); and - Weight loss of 10.8 pounds in the past three months. Review of the SNF physician order report dated 09/01/2022 to 10/31/2022 showed an order dated 08/22/2022 for an easy to chew fortified diet (providing foods higher in nutrition and calories). Review of the IDG/POC notes dated 09/09/2022 and 09/22/2022, showed in part a problem identified with nutrition due to dysphagia (difficulty swallowing). Interventions included to assess for signs of dysphagia and modify the consistency of liquids as ordered and monitor and/or instruct on dietary modifications due to disease progress. The interventions did not include the patients diet order for an easy to chew fortified diet. During an interview on 10/13/2022, beginning at 11:00 AM, the administrator stated that he/she would expect the diet order to be included with the nutrition POC. RECORD/PATIENT #4: Review of the physician written certification for the certification period 08/12/2022 – 11/09/2022, showed in part that the patient had a terminal diagnosis of cerebrovascular disease (conditions that affect blood vessels and blood flow to the brain). The patient also had recent falls with multiple lacerations. Review of the RN initial assessment dated 08/12/2022 showed: - Terminal diagnosis of cerebrovascular disease, other diagnoses included repeated falls; - Resided in a skilled nursing facility (SNF); - The patient was at risk for falls and had a fall that morning and sustained bruising and a cut to the right eye area; - The patient was not cognizant of safety issues and need for assistance; - The nurse recommended and ordered a fall mattress to be placed next to the patients bed; - The nurse reviewed all durable medical equipment and supplies; and - No documented discussion with the facility staff regarding use of a fall mat for the patient, what fall interventions the facility had in place for the patient, or whether education was provided regarding fall interventions/safety issues. Review of a skilled nurse (SN) visit dated 08/16/2022, showed the patient was able to transfer him/herself from the bed to a wheelchair and was able to self- propel the wheelchair. The patient had a recent fall on 08/12/2022 and since this was the first time seeing the patient, the nurse asked the facility if they would like a fall mat. The facility declined, stating it might be more of a hazard since the patient transferred him/herself. No further documentation regarding fall interventions for the patient. Review of the POC dated 08/17/2022, showed: - A problem identified as musculoskeletal with potential for decline in strength and increasing weakness as his/her disease progressed with goal that the patient would remain safe in his/her current environment; and - Interventions included to educate on ways to reduce fall risk, identify safety issues and educate on safety precautions to prevent falls/injury, assess for weakness and fatigue and for signs of muscle wasting but did not include what specific fall interventions/safety measures were in place. Review of an SN visit dated 09/20/2022, showed the patient had two new skin tears with steri strips (helps to seal wounds by pulling the two sides of the skin together) from a fall on 09/17/2022. The nurse reviewed the POC, communicated changes to the IDG, certified nursing assistant and facility nurse. There was no specific documented discussion regarding the patients fall, what interventions were in place, or whether further interventions needed to be implemented. Review of the IDG meeting notes/POC dated 09/21/2022, showed a problem identified with fall safety. The patient had an unwitnessed fall when he/she fell out of his/her wheelchair in the dining room and sustained a laceration to the right finger. Interventions included to educate the patient and/or caregiver on ways to reduce fall risk, identify safety issues and educate on safety precautions to prevent falls and/or injury and assess for weakness and/or fatigue. The POC continued to show a fall mat listed as durable medical equipment even though the facility declined the use of the fall mat on 08/16/2022. No documented discussion regarding what fall interventions were in place or whether further interventions needed to be implemented. During an interview on 10/13/2022 beginning at 11:00 AM, the administrator stated that he/she would expect specific fall interventions to be included on the POC and be updated regarding the use/nonuse of the fall mat. RECORD/PATIENT #1: Review of the registered nurse (RN) initial assessment, dated 07/01/2022 showed in part the following: -Primary terminal diagnosis: Atherosclerotic heart disease (a build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow. Plaques may rupture causing acute occlusion of the artery by clot); -Comorbidities included: Hypertension (elevated blood pressure), atrial fibrillation (irregular rapid heart rate that commonly causes poor blood flow), diabetes mellitus (high blood glucose/sugar), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to various regions of the brain, depriving them of oxygen and nutrients), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs); -Lived with spouse, who was primary caregiver (PCG); -Denied pain; -Used Tylenol (pain reliever) for occasional pain; -Target pain goal: three; -Pain greater than a four warrants further attention; -Required considerable assistance and frequent medical care; -Required assistance several times during the day and night from the PCG; -Confused during the day and evening, but not constantly; -Slept four to six hours per day and used a sleep aide nightly; -Short of breath with minimal exertion; and -Edema (swelling) to bilateral feet two plus and pitting (when pressure applied to swollen area, an indentation, will remain). Review of the medication profile, showed in part the following: -Gabapentin (anticonvulsant) 100 milligram (mg) give one tablet at bedtime for diabetic neuropathy (a type of nerve damage that can occur with diabetes); -Aspirin 325 mg give one tablet daily for anticoagulant (blood thinner); and -Metformin 500 mg give one tablet daily for diabetes. Review of IDG/POC notes dated 07/14/2022 showed that the POC failed to be individualized and include interventions specific to the patient's unique needs, such as no interventions for diabetes, diabetic neuropathy, and vascular dementia. The plan of care had pre-generated interventions for specific problems that were not individualized, for example, under the problem respiratory one of the interventions was to educate on the use of inhaler(s) and/or nebulizer(s), which the patient had no order for. Under the problem of skin, one of the interventions was provide/educate on wound care as ordered, yet the patient did not have a wound. Under the problem cardiovascular, one of the interventions was to assess blood pressure and pulse, but failed to be specific to what to do if out of range or what the range should be. Another intervention under cardiovascular was to assess for signs/symptoms of fluid overload, but failed to be specific as to what to do for the fluid overload. Under the problem pain, it was not specific to what was an acceptable level of pain for the patient or when the patient needed further attention. During an interview on 10/13/2022 at 11:30 AM, the administrator stated that the POC should be individualized and he/she agreed that the POC was not individualized to the patient's unique needs. RECORD/PATIENT #5: Review of the RN initial assessment, dated 08/12/2022 showed in part the following: -Primary terminal diagnosis: Colon (bowel) cancer; -Comorbidities included: Chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a condition in which air sacs of the lungs are damaged and enlarged, causing breathlessness), hypertension (elevated blood pressure), benign prostatic hyperplasia (BPH; age-associated prostate gland enlargement that can cause urination difficulty), and nutritional deficiency (deficiency of one or more essential vitamins); -Had generalized pain; -Rated pain a two on a scale of zero to ten with ten being the most severe pain; -Current pain medication: Tylenol, Mobic (non-steroidal anti-inflammatory), and morphine (narcotic analgesic); -Target pain goal: three; -Pain greater than a four warrants further attention; -Lived in a long-term care facility (LTCF); -Required considerable assistance and frequent medical care; -Received assistance from the LTCF staff several times during the day and night; -Alert to person, place, and time; -Had a long-standing abdominal wound related to bowel resection. Wound not infected. Dressing adequate. Dressing change every three days. Slight bleeding with dressing changes; -Had shortness of breath with moderate exertion; -No oxygen; -Used nebulizer as needed for shortness of breath; -Bowel incontinence; -Bladder incontinence; -Used a nutritional supplement; and -At risk for falls. Review of initial POC dated 08/17/2022 showed that the POC failed to be individualized and include interventions specific to the patient's unique needs, such as under the problem pain, it was not specific to what was an acceptable level of pain for the patient or when the patient needed further attention, under the problem of respiratory, one of the interventions was to administer supplemental oxygen as ordered, yet the patient did not have an order for oxygen. Under the problem of gastrointestinal, one of the interventions was to educate patient and/or caregiver(s) on PEG (percutaneous endoscopic gastrostomy; feeding tube inserted through the skin and the stomach wall and goes directly into the stomach) tube use and/or maintenance, yet the patient did not have a PEG tube. Under the problem of urinary elimination, interventions included: educate patient and/or caregiver(s) on cleaning and/or irrigating urinary drainage device as ordered, monitor urinary drainage device for patency and function, and change urinary drainage device as ordered, yet the patient had no urinary drainage device. Under the problem skin, it showed the patient had the potential for alteration in skin integrity, but failed to show the patient had an actual long-standing wound and included specifics related to the actual wound. During an interview on 10/13/2022 at 11:40 AM, the administrator stated that the POC was not individualized and specific to the unique needs of the patient.

Based on policy review, record review, and interview the agency failed to ensure a plan of care included information from the patient's updated assessments in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "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; -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 will be reviewed and/or revised at minimum every 14 days by the interdisciplinary group (IDG). Review of the agency's policy titled, "IDG," dated 08/13/2021 showed in part the following: -The IDG team will meet at minimum every two weeks to evaluate, review and update the patient's plan of care; and -Responsibilities of the IDG team include: Review, assess, and recommend changes in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 07/01/2022 with a terminal diagnosis of Atherosclerotic heart disease (a build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow. Plaques may rupture causing acute occlusion of the artery by clot). The patient resided at home with his/her spouse. Review of the registered nurse (RN) skilled nurse (SN) assessment on 08/23/2022, showed the nurse was informed of the patient having an episode of elopement over the weekend. The patient was found in the front yard under a tree. The primary caregiver (PCG) had difficulty redirecting and getting the patient back into the home. Review of the IDG meeting notes, dated 09/06/2022, showed the patient had an elopement from the home on 08/22/2022 and was up the street, agitated and difficult to redirect. Review of the plan of care failed to show an update to the plan of care or interventions for the patient's elopement. Review of the RN recertification assessment, dated 09/16/2022, showed the patient had fluctuating edema (swelling caused by excess fluid trapped in the body's tissue) from a trace to two plus in bilateral lower extremities (legs, ankle, feet), trace to bilateral upper extremities (arms and hands), and periorbital (area around eye). Periorbital edema worsening over last 30 days. Review of the RN SN assessment on 09/20/2022, showed the patient and PCG reported the patient fell from his/her recliner to the floor over the weekend, requiring the local fire department to assist getting the patient off the floor. Review of IDG meeting notes, dated 09/23/2022, showed: -The patient had fluctuating edema from a trace to two plus in bilateral lower extremities, trace to bilateral upper extremities, and periorbital. Periorbital edema worsening over last 30 days; and -Denied any recent falls. Review of the plan of care failed to show an update to the plan of care or interventions for the patient's edema and fall. During an interview on 10/13/2022 at 11:30 AM, the administrator stated that he/she would expect the patient's plan of care to be revised and include interventions for the patient's edema, elopement, and fall.

Based on policy review, record review, and interview the agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided to the hospice patient in one (Record/Patient #5) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy titled, "IDG and Hospice Staff Communication," dated 08/13/2021, showed in part the following: -Hospice IDG members and all staff will participate in effective communication within the hospice team and with all parties involved in the patient's care present or absent; -IDG members and all staff members will communicate effectively and timely with each other regarding patient status and changes in condition; and -All communication will be documented in the patient's electronic medical record (EMR) listing who was communicated with and when. RECORD/PATIENT #5: Review of the clinical record showed the following: -The patient was admitted to hospice on 08/12/2022; -The terminal diagnosis was colon cancer; -The patient resided in a long-term care facility (LTCF) from 08/12/2022 until 09/30/2022; and -The patient transferred home on 09/30/2022. Review of skilled nurse (SN) visit dated 10/03/2022, showed the patient lived alone and the nurse coordinated plan with the clinical nurse regarding meals on wheels. Requested social worker to do a visit. Review of the patient's clinical record failed to show any communication note to the social worker following the 10/03/2022 visit and failed to show any visit from the social worker after 10/03/2022. During an interview on 10/13/2022 at 1:55 PM, the administrator stated that he/she did not find a note from the social worker after 10/03/2022. He/she would have expected communication to have taken place and a visit made by the social worker.

Based on policy review, record review, and interview the agency failed to ensure the nursing needs of the patients were met in three (Records/Patients #1, #4 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 07/01/2022 with a terminal diagnosis of Atherosclerotic heart disease (a build up of cholesterol plaque in the walls of arteries causing obstruction of blood flow. Plaques may rupture causing acute occlusion of the artery by clot). The patient's co-morbidity was hypertension (elevated blood pressure). The patient resided at home with his/her spouse. Review of the medication profile, showed in part the following: -Losartan (antihypertensive) 100 milligram (MG) one tablet daily; -Sotalol (beta blocker) 120 MG twice a day; -Hydrochlorothiazide (diuretic)25 MG once daily; and -Amlodipine besylate (calcium channel blocker) 10 MG once daily. Review of skilled nurse (SN) visit, dated 08/23/2022 showed the registered nurse (RN) was informed the patient eloped (left a designated area without permission) over the weekend. The patient was found outside under a tree and the primary caregiver (PCG) had difficulty redirecting and getting patient back in the home. Documentation failed to show the physician was notified of the patient's elopement. Review of SN visit, dated 09/09/2022 showed the patient's blood pressure was 95/61 (normal= 120/60). Documentation failed to show the physician was notified of the low blood pressure reading. Review of SN visit, dated 10/11/2022 showed the patient's blood pressure was 135/110. Documentation failed to show the physician was notified of the elevated blood pressure reading. During an interview on 10/13/2022 at 11:30 AM, the administrator stated that he/she would have expected the nurse to notify the physician in regards to the elopement and blood pressure readings. He/she would have expected that notification to be documented in the clinical record. RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice services on 08/12/2022 with a terminal diagnosis of colon cancer. The patient's co-morbidity was chronic obstructive pulmonary disease (COPD; a group of lung diseased that block airflow and make it difficult to breathe). The patient resided in a long-term care facility (LTCF). Review of SN visit, dated 08/13/2022 showed the patient's heart rate 48 (normal= 60-100). Documentation failed to show the physician was notified of the low heart rate. During an interview on 10/13/2022 at 11:40 AM, the administrator stated that he/she would have expected the nurse to notify the physician of the heart rate. He/she would have expected that notification to be documented in the clinical record. Findings included: Review of the agency's policy titled, "Nursing Services," dated 08/13/2021, showed in part: - A registered nurse (RN) is responsible for the coordination of all hospice services. Nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care (POC); - The hospice RN supervises and communicates the coordination of all services to the patient, nursing facility, and family/caregiver; and - Hospice nursing provides initial and ongoing assessment of the patient's physical symptoms and coordination of all patient/family hospice services. RECORD/PATIENT #4: Review of the physician certification of terminal illness showed the patient has a terminal diagnosis of cerebrovascular disease (conditions that affect blood vessels and blood flow to the brain) and abnormal weight loss. Diagnoses also included anemia, epilepsy (seizures), hypertension, atherosclerotic heart disease (hardening of the arteries) and chronic kidney disease. Review of the registered nurse (RN) initial assessment dated 08/12/2022, showed: - The patient resided in a skilled nursing facility (SNF); - Weight 141.6. Review of a skilled nurse (SN) visit note dated 08/16/2022, showed the patients weight was 146.6 (a five pound gain since the previous visit). Review of the plan of care (POC) dated 08/17/2022, showed the patient had potential for cardiovascular compromise as disease progresses. Interventions included to monitor and instruct on changes due to disease progression and assess for signs and symptoms of fluid overload such as peripheral edema (swelling), increased weight, and ascites (fluid in the abdomen). Review of the SN visit notes showed: - On 08/24/2022, the patients weight was 147.6; and - On 08/30/2022, the patients weight was 158.6 on 08/29/2022 (a gain of 11 pounds since the previous visit). The SN documented he/she reviewed the plan of care and communicated changes to the IDG members, certified nursing assistant and facility nurse but failed to document whether he/she discussed the patients weight gain or a plan for continued follow-up of the patients weight. Review of the SN visits showed no further weight documented until 09/30/2022. The patients weight was 151.6 During an interview on 10/13/2022, beginning at 11:00 AM, the administrator stated that there should have been discussion and follow-up with the facility staff and physician regarding the patients weight gain.

Based on policy review, record review, and interview the agency failed to ensure that all documentation was completed in a timely manner in three (Records/Patients #1, #2, and #3) of five full records reviewed and that documentation was accurate in two (Records/Patients #1 and #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the policy titled, "Content and Format of the Patient Record-Control of Information," dated 10/2020, showed in part: -The records shall be updated and documented promptly and accurate and systematically organized to facilitate retrieval; and -Clinical documentation the patient record is complete and done timely. RECORD/PATIENT #3 Review of the clinical record showed: -Aide care visit dated 09/06/2022 digitally signed on 09/12/2022 (four days later); -Aide care visit date 09/08/2022 digitally signed on 09/12/2022 (four days later); -Aide care visit date 09/12/2022 digitally signed on 09/19/2022 (seven days later); -Aide care visit dated 09/14/2022 digitally signed on 09/19/2022 (five days later); -Aide care visit dated 09/26/2022 digitally signed on 09/29/2022 (three days later); -Volunteer note dated 09/17/2022 digitally signed on 10/11/2022 (twenty four days later); and -Volunteer noted dated 09/24/2022 digitally signed on 10/11/2022 (seventeen days later). During an interview on 10/13/2022 beginning at 11 AM the administrator stated that he/she expects that notes will be signed within 24 to 48 hours of completion of care. RECORD/PATIENT #2: Review of the hospice aide visit notes showed: - Visit date 09/06/2022. The hospice aide digitally signed the visit note on 09/11/2022 (five days later); - Visit date 09/08/2022. The hospice aide digitally signed the visit note on 09/11/2022 (three days later); - Visit date 09/12/2022. The hospice aide digitally signed the visit note on 09/15/2022 (three days later; - Visit date 09/19/2022. The hospice aide digitally signed the visit note on 09/22/2022 (three days later); - Visit date 09/22/2022. The hospice aide digitally signed the visit note on 09/26/2022 (four days later); and -Visit note 10/05/2022. The hospice aide digitally signed the visit note on 10/09/2022 (four days later). RECORD/PATIENT #1: Review of the medication profile showed, apply oxygen via nasal (nose) cannula (tubing) at 2 liters per minute. May titrate up 1 liter at a time to 5 liters to maintain oxygen saturation above 90%. Use as needed. Review of the skilled nurse (SN) visit, dated 08/16/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. Review of aide visit, dated 08/18/2022 was digitally signed 08/24/2022 (six days later). Review of SN visit, dated 08/19/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. This visit was digitally signed 08/22/2022 (three days later). Review of aide visit, dated 08/22/2022 was digitally signed on 08/28/2022 (six days later). Review of SN visit dated 09/02/2022 was digitally signed 09/06/2022 (four days later). Review of SN visit, dated 09/06/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. Review of aide visit, dated 09/08/2022 was digitally signed 09/13/2022 (five days later). Review of SN visit, dated 09/09/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. This visit was digitally signed 09/12/2022 (three days later). Review of aide visit, dated 09/15/2022 was digitally signed 09/21/2022 (six days later). Review of SN visit dated 09/16/2022 was digitally signed 09/19/2022 (three days later). Review of SN visit, dated 09/20/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. Patient/primary caregiver (PCG) stated oxygen use was sporadic, that the patient did not wear oxygen at bedtime nor when outside. Review of SN visit, dated 09/23/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. Patient/PCG stated oxygen use was sporadic, that the patient did not wear oxygen at bedtime nor when outside. Review of SN visit, dated 09/27/2022 showed patient denied oxygen use that day. Oxygen saturation was 96% on room air. Patient/PCG stated oxygen used that day at 2 liters per nasal cannula, with oxygen saturation at 96%. Review of SN visit, dated 09/30/2022 showed oxygen frequency: Continuous, yet narrative showed the patient did not have oxygen on upon the nurse arriving for the visit. Patient/PCG stated oxygen use was sporadic, that the patient did not wear oxygen at bedtime nor when outside. Review of aide visit, dated 10/03/2022 was digitally signed 10/10/2022 (seven days later). Review of SN visit, dated 10/04/2022 showed the patient's oxygen saturation was 65% on room air and the patient wore his/her oxygen continuous. The narrative showed the patient was wearing his/her oxygen at 2 liters per nasal cannula upon the nurse arrival and his/her oxygen saturation was 98%. During an interview on 10/13/2022 at 11:30 AM, the administrator stated that he/she expected documentation to be accurate and timely. He/she agreed the documentation was not accurate and was not timely. RECORD/PATIENT #5: Review of the initial registered nurse (RN) assessment, dated 08/12/2022 showed the patient had a long standing abdominal wound related to bowel resection (removal of part of bowel/intestines). No measurements were documented. Review of SN visit, dated 08/13/2022 showed the abdominal wound measured 3 centimeter (cm) by 2 cm. Review of SN visit, dated 08/18/2022 showed the abdominal wound measured 8.6 cm by 5 cm. Review of SN visit, dated 08/23/2022 showed the following; -Abdominal wound measured 3 cm by 2 cm; and -Colostomy (a surgical operation in which a piece of colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon) had a beefy red stoma (opening). Review of SN visit, dated 08/25/2022 showed the abdominal wound measured 8.5 cm by 5 cm. Review of SN visit, dated 08/30/2022 showed the following: -Abdominal wound 3 cm by 2 cm; and -Colostomy had a beefy red stoma. During an interview on 10/13/2022 at 11:40 AM, the administrator stated that the wound measurements on 08/23/2022 and 08/30/2022 was not accurate and he/she denied the patient having a colostomy.

Based on review of an agency respite contract and interview, the agency failed to ensure the contract included all the required components in one of one respite contract reviewed. This deficient practice has the potential to affect all respite patients served by the agency. --- Findings included: Review of the respite contract signed 07/02/2008, failed to include that a copy of a discharge summary and/or clinical record would be supplied to the hospice at the time of discharge. During an interview on 10/13/2022, at 9:05 AM, the administrator stated that he/she could not find that verbiage in the contract.

Based on policy review, record review, observation, and interview, the agency failed to ensure the coordinated task plan of care (POC) with the skilled nursing facility (SNF) included the frequency of visits for all disciplines in two (Records/Patients #2 and #4) of three records reviewed of patients that resided in a SNF. --- Findings included: Review of the agency's policy titled, "Nursing Services," dated 08/13/2021, showed in part that the hospice registered nurse (RN) supervises and communicates the coordination of all services to the patient, nursing facility, and family/caregiver. RECORD/PATIENT #2: Review of the coordinated task POC maintained in the SNF hospice record failed to include the frequency of visits for the social worker, chaplain, and volunteer. The frequency of visits and days of the week for the home health aide visits were not marked. Per interview conducted during observation on 10/12/2022 beginning at 9:00 AM, the social worker looked at the coordinated POC and stated that he/she thought the social worker and chaplain frequency were on the coordinated POC but did not think the volunteer frequency was included. RECORD/PATIENT #4: Review of the coordinated task POC failed to include the frequency of visits for the social worker and chaplain. During an interview on 10/13/2022 beginning at 11:00 AM, the administrator stated that he/she expected the frequency of visits to be included on the coordinated task POC.

Based on observation and interview the agency failed to ensure that the long term care facility (LTCF) had access to names and contact information for hospice staff members and instructions on how to access the hospice's 24-hour on-call system in one (Record/Patient #3) of three home observations. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #3: Observation on 10/12/2022 beginning at 9:00 AM, during the patient's LTCF home visit, showed the patient's hospice binder failed to contain information regarding the team members responsible for the patient's care, or the 24-hour access number for the agency. During an interview with a licensed practical nurse (LPN) from the LTCF on 10/12/2022 at approximately 9:40 AM, he/she stated that he/she often just looks at the face sheet to be sure of what hospice is being used by the patient and that's where the hospice number can be found. During an interview with the administrator on 10/13/2022 beginning at 11:00 AM, he/she stated that he/she would expect a blue page with the hospice team members listed and the 24-hour on-call directions to be present in the binder at the LTCF.