Every finding on record at Remembrance Hospice, LLC

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but at a minimum, at the time of each comprehensive assessment and/or when a new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure an accurate review of medications the patient was currently using to identify any potential adverse effects and drug reactions was documented. HOME VISIT 1 / CLINICAL RECORD 1: The patient elected the hospice benefit on 01/15/2026 with a terminal diagnosis of combined systolic and diastolic heart failure. During the home visit observation on 03/04/2026, with the Hospice Aide (HA) (Personnel Record 1) and the Clinical Director (Personnel Record 7) present, the hospice drug profile was reconciled with the assisted living facility medication administration record. The following medications were on the ALF medication administration record but were not on the hospice drug profile: ascorbic acid oral wafer 500mg one tablet daily, cholecalciferol tablet 1000-unit one tablet daily by mouth, and Ferrett's oral tablet 325 mg one tablet daily by mouth. In an interview with the Clinical Manager on 03/05/2026, she stated that the ALF medication administration record did not match the hospice drug profile.

It is required that the hospice follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene as required by agency policy. DOCUMENT 1: Agency Policy No. 7-009 titled, Hand Hygiene stated, in part: " 3. Hand decontamination using an alcohol-based rub should be performed...after contact with a patient's intact skin." HOME VISIT 1/CLINICAL RECORD1: This patient elected the hospice benefit on 01/15/2026 with a terminal diagnosis of combined systolic and diastolic heart failure. During the home visit observation on 03/04/2026 with the Hospice Aide (HA) (Personnel Record 1) and the Clinical Director (Personnel Record 7) present, the HA was observed to assist the patient to the toilet, go to the patient's bedroom, and pull out clean clothes without removing gloves and sanitizing hands. The Clinical Manager was interviewed on 03/4/2026 and stated that the Hospice Aide did not follow the agency policy for hand hygiene.

It is required that hospice aides be assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 14 (7%) clinical records reviewed of patients who received Hospice Aide Services (HA), the agency did not ensure that all written patient care instructions were included in the hospice aide care plan. CLINICAL RECORD 2/HOME VISIT 2: This patient elected the hospice benefit on 09/25/2024 with a terminal diagnosis of hypertensive heart disease with congestive heart failure. The plan of care dated 09/25/2024-12/24/2024 ordered: "Insert indwelling urinary catheter per physician order 22 French (FR) with 10ml balloon" and "Aide 2x/week." The HA care plan dated 09/25/2024 did not include instructions addressing the care and maintenance of the Foley catheter during personal care. The hospice plan of care for the dates of 01/18/2026-03/18/2026 included orders for the use of a Hoyer lift, oxygen prn, and Aide 2x/week. The hospice aide care plan was reviewed for the dates of 01/18/2026-03/04/2026. The hospice aide care plan did not include instructions for the use of the Hoyer lift and Oxygen. During the home visit observation on 03/04/2026, with the Registered Nurse (RN) (Personnel Record 2) and the Clinical Director (Personnel Record 7) present, a Hoyer lift and an oxygen concentrator were present in the patient's room. The RN stated that the staff utilized the Hoyer lift daily. During an interview and joint review of records on 03/04/2025, the Clinical Director stated that the hospice aide care plan was not complete and that there would be continued education for the case managers to ensure the care plans included all the necessary instructions.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met, as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed in which hospice aide services were provided, the agency did not ensure the Hospice Aide reported a change in the patient’s needs to the Registered Nurse. CLINICAL RECORD 6: This patient elected the hospice benefit on 12/04/2025 with a terminal diagnosis of Alzheimer's Disease. The hospice plan of care reviewed for the dates of 12/04/2025-03/04/2026 included orders for hospice aide visits 1XW. The hospice aide's visit note dated 12/11/2025 documented that the patient refused the bed bath. The clinical record was reviewed with no evidence that the RN was notified of the change. During an interview and joint review of records on 03/04/2025, the Clinical Director stated that there was no documentation present in the clinical record that the Hospice Aide had notified the RN that the patient refused a bed bath.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met, as evidenced by document review and interview. In 1 of 14 (7%) clinical records reviewed, the agency did not ensure that volunteer services were offered to the patient. CLINICAL RECORD 3: This patient elected the hospice benefit on 08/19/2025 with a terminal diagnosis of Alzheimer's Disease. A review of the clinical record, admission forms, and the IDG notes for the dates of 08/19/2025-03/042026 did not include documentation that volunteer services were offered. During an interview and joint clinical record review on 03/04/2026, the Clinical Director stated that the admitting Registered Nurse was the person responsible for assessing the patient's request for volunteer services and there was no documentation in the clinical records that the volunteer services were offered to the patient.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles. This standard was not met as evidenced by document review, interview, and record review. Review of 10 of 10 (100%) personnel records revealed the agency did not ensure all new hospice employees, and those providing services under arrangement, received initial training in the agency's EP program [Staff 1 (Date of Hire (DOH), 2/6/23); Staff 2 (DOH. 2/9/23); Staff 3 (DOH, 11/28/23); Staff 4 (DOH, 4/12/23); Staff 5 (DOH, 4/17/23); Staff 6 (DOH, 2/27/23); Staff 7 (DOH, 12/6/22); Staff 8 (DOH, 1/23/23); Staff 9 (DOH, 2/1/23); and Staff 10 (DOH, 2/14/23)]. The agency's policy, "Emergency Management Plan Policy No. 4-001 (CHAP Hospice Operations/Revised November 2022)", which stated in relevant parts: "Training: 1. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable." In an interview conducted on 4/25/23, the Administrator stated that they had not provided Emergency Preparedness Training to staff upon hire. Emergency Management Plan Policy No. 4-001 (CHAP Hospice Operations/Revised November 2022) which stated in relevant parts, " Training: 1. The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable. " Personnel records reviewed lacked evidence of emergency preparedness training on hire. Staff 1 [Date of Hire (DOH): 2/6/23], Staff 2 [DOH: 2/9/23], Staff 3 [DOH: 11/28/23], Staff 4 [DOH: 4/12/23], Staff 5 [DOH: 4/17/23], Staff6 [DOH: 2/27/23], Staff 7 [DOH: 12/6/22], Staff 8 [DOH: 1/23/23, Staff 9 [DOH: 2/1/23], Staff 10 [DOH: 2/14/23] In an interview conducted on 4/25/23, the Administrator stated that they had not provided Emergency Preparedness Training to staff upon hire.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: Actual or potential drug interactions. This standard was not met as evidenced by clinical record review and interview. In 2 of 9 (22%) clinical records reviewed it was revealed that the agency did not ensure that the patients' drug profiles contained documentation of all prescribed drugs for inclusion in the drug regimen review to identify actual or potential drug interactions. Clinical Record 5: The patient's date of hospice election was 4/5/23 with a primary diagnosis of CHF. The comprehensive nursing assessment completed by the Registered Nurse (RN) on 4/5/23 stated that the patient was "oxygen dependent", and documentation on subsequent nursing visit notes stated that the patient remained oxygen dependent. The medication profile dated for the period of 4/5/23 to 4/27/23 did not contain a documented entry for oxygen, which prevented oxygen from being included in the comprehensive review of the drug regimen to identify actual or potential interactions. Clinical Record 8: The patient's date of hospice election was 3/23/23 with a primary diagnosis of COPD. The comprehensive nursing assessment completed by the RN on 3/23/23 stated that the patient was "oxygen dependent", and documentation on subsequent nursing visit notes stated that the patient remained oxygen dependent. The medication profile dated for the period of 3/23/23 to 4/27/23 did not contain a documented entry for oxygen, which prevented oxygen from being included in the comprehensive review of the drug regimen to identify actual or potential interactions. During an interview on 4/27/23, the Administrator stated that oxygen was not entered into the drug profiles for these patients and should have been.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). The hospice governing body is responsible for ensuring that the program: Includes defined data detail and frequency of collection and approves such. This standard was not met as evidenced by document review and interview. Review of the governing body meeting minutes dated 3/15/23, 3/16/23, 3/22/23, and 4/1/23 revealed they did not contain documented evidence of the governing body's review of the agency's QAPI program, as described in the agency's policy, to ensure the review included defined detail and frequency of data collection to be completed. The agency's policy, "Improving Organizational Performance, Policy No. 3-001 (CHAP Hospice Operations/Revised November 2022)", stated in relevant parts: "The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, and maintained, and is evaluated annually. " During an interview conducted on 4/25/23, the Administrator stated that the elements of the QAPI program had not been reviewed or discussed with the Governing Body. This standard was not met as evidenced by a review of the Improving Organizational Performance policy, governing body minutes and interview which revealed that the agency did not ensure that the QAPI program data detail and frequency of collection were approved by the governing body.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 8 of 9 (89%) clinical records reviewed it was revealed that the agency did not ensure that hospice aide plans of care contained a description of all care and services required to meet the patient's assessed needs. Clinical Record 2: The patient's date of hospice election was 4/22/23 with a primary diagnosis of Alzheimer's Disease. The initial comprehensive nursing assessment was performed by the Registered Nurse (RN) on 4/22/23 and the patient was assessed for fall risk using the Missouri Alliance for Home Care tool (MAHC-10). The patient was determined to have a fall risk score of "8" and the electronic medical record (EMR) stated that the patient was "At risk for falls" with this score. Also, the certificate of terminal illness (CTI) narrative dated 4/22/23 stated, "The patient has been experiencing falls over the last two to three weeks." There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated 4/22/23. Clinical Record 3: The patient's date of hospice election was 3/29/23 with a primary diagnosis of Parkinson's Disease. The initial comprehensive nursing assessment was performed by the RN on 3/29/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "7" and the EMR stated that the patient was "At risk for falls" with this score. There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated 3/29/23. Clinical Record 4: The patient's date of hospice election was 3/28/23 with a primary diagnosis of Protein-Calorie Malnutrition. The initial comprehensive nursing assessment was performed by the RN on 3/28/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "4" and the EMR stated that the patient was "At risk for falls" with this score. There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated 3/28/23. Clinical Record 5: The patient's date of hospice election was 4/5/23 with a primary diagnosis of Congestive Heart Failure. The initial comprehensive assessment was performed by the RN on 4/5/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "4" and the EMR stated that the patient was "At risk for falls" with this score. No fall precautions or safety measures were specifically included in the aide care plan dated 4/5/23. Clinical Record 6: The patient's date of hospice election was 4/14/23 with a primary diagnosis of Alzheimer's Disease. The initial comprehensive assessment was performed by the RN on 4/14/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "6" and the EMR stated that the patient was "At risk for falls" with this score. There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated 4/14/23. Clinical Record 7: The patient's date of hospice election was 2/24/23 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. The initial comprehensive assessment was performed by the RN on 2/24/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "4" and the EMR stated that the patient was "At risk for falls" with this score. In addition, documentation on the comprehensive assessment stated that the patient was "oxygen dependent". There was no documentation that specifically addressed fall precautions or safety measures related to falls or the use of oxygen with the patient during the assigned shower present on the aide plan of care dated 2/24/23. Clinical Record 8: The patient's date of hospice election was 3/23/23 with a primary diagnosis of Atherosclerotic Heart Disease. The initial comprehensive assessment was performed by the RN on 3/23/23 and the patient was assessed for falls using the MAHC-10 tool. The patient was determined to have a fall risk score of "8" and the EMR stated that the patient was "At risk for falls" with this score. There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated 3/23/23. Clinical Record 9: The patient's date of hospice election was 4/5/23 with a primary diagnosis of Alzheimer's Disease. The initial comprehensive assessment was performed by the RN on 4/5/23 and the patient was assessed for fall risk using the MAHC-10 tool. The patient was determined to have a fall risk score of "8" and the paper medical record stated that the patient was "At risk for falls" with this score. There was no documentation that specifically addressed fall precautions or safety measures related to falls present on the aide plan of care dated from 4/5/23 until his death on 4/20/23. During interviews on 4/26/23 and 4/27/23, the Administrator confirmed that the fall precautions, safety measures, and oxygen instructions were not included in the aide plans of care and should have been.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed it was revealed that the agency did not ensure that the aide provided services as assigned on the hospice aide plan of care. Clinical Record 9: The patient's date of hospice election was 4/4/23 with a primary diagnosis of Alzheimer's Disease. The Registered Nurse (RN) developed an aide care plan on 4/5/23 and the care plan was dated as updated on 4/11/23, 4/18/23, 4/20/23, and 4/21/23. All of the aide plans assigned the aide to assist the patient with ADL services and provide a shower bath during every visit. Documentation on the aide visit notes dated 4/18/23 and 4/20/23 stated that the assigned shower was not completed as assigned, and a complete bed bath was given. The clinical record did not contain documented evidence that the aide had contacted the RN regarding the type of bath to provide to the patient. On 4/27/23, the Administrator stated during interview that the aide did not follow the care plan as written.

Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by interview and record review. In 1 of 10 (10%) personnel records reviewed of staff, volunteers and contractors it was revealed that the agency did not ensure a criminal background check was completed for all applicable hospice staff. Personnel Record 9: Review of the record revealed there was no evidence that a criminal background check was completed for the contracted Medical Director, who was hired on 2/1/23. The was provided the opportunity to retrieve the missing evidence, however the agency was not able to present any additional evidence prior to the end of the site visit review. In an interview on 4/27/23 the Office Manage stated that they had not obtained a criminal background report for this contracted employee.

It is required that the hospice demonstrates the vaccination status of each individual eligible to be fully vaccinated for COVID-19. At a minimum, the hospice has evidence of an individual having received a single-dose of COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the hospice and/or its patients/families. Or there is evidence of an individual having a pending request for, or having been granted a medical or spiritual vaccination exemption, or a job responsibility exception, or a temporary COVID-19 vaccination delay due to clinical precautions and considerations per policy and procedure. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 10 (10%) personnel records reviewed it was revealed that the agency did not ensure the presence of evidence to confirm the COVID-19 vaccination status of all individuals eligible to be fully vaccinated for COVID-19 prior to providing hospice services to patients and families. The agency's policy, "COVID-19 Vaccination Policy No. 1-046, (CHAP Hospice Human Resources/ Revised November 2022)", stated in relevant parts: "Hospice will ensure all staff, who provide any care, treatment or other services for the organization and/or its patients are vaccinated against COVID-19. Staff includes A) Hospice employees B) Licensed Practitioners C) Students, Trainees and Volunteers D) Individuals who provide care, treatment or other services for the organization and/or its patients under contract or by other arrangement. " Personnel Record 9: Review of the personnel record for the contracted Medical Director, hired on 2/1/23, revealed there was no evidence of COVID-19 vaccination status present for this direct care provider. The agency was provided the opportunity to present evidence to confirm the individual's vaccination status prior to the end of the site visit review, but no additional evidence was provided by the agency. During interview on 4/27/23, the Office Manager stated that they did not have the COVID-19 vaccination card in the personnel record, and it should have been.