Every finding on record at Residential Hospice of Missouri, LLC

Based on policy review, record review, and interview, the hospice provider failed to ensure:- The hospice designated a registered nurse that is a member of the interdisciplinary group (IDG) to coordinate care and ensure ongoing, comprehensive assessment of each patient's and family's needs and the implementation of the interdisciplinary plan of care (POC) (L0540);  - The hospice care and services furnished to patients and their families followed an individualized written POC established by the hospice IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, that reflected and addressed the patient’s needs (L0543); and- An individualized written POC was developed for each patient (L0545).The cumulative effect of these deficient practices has the potential to affect all the patients serviced by the provider.

Based on policy review, record review, and interview, the hospice failed to ensure the development, timely implementation, and ongoing revision of individualized plans of care in responses to changes in patient condition and symptom escalation.  The hospice failed to provide timely nursing assessments and implement appropriate hospice interventions when patients experienced significant changes in condition, resulting in delayed or insufficient care planning and coordination.  The deficient practice occurred in three of three patient records reviewed (Records/Patients #1, #2, and #3).  This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s policy titled, “On-Call/Weekend Services,” revised May 2023, showed the hospice had established processes to ensure 24-hour availability and timely response to patient needs including: - Patient care needs are the highest priority, including evenings and weekends;- Clinical staff are expected to perform visits as needed, including weekends;- Triage nurses are responsible for follow- up which may include:* Telephonic assessment* Dispatching on-call nurse for a visit, if necessary* Obtaining physician orders* Arranging additional hospice services; and- Situations requiring visits include, but are not limited to:* Uncontrolled pain* Respiratory difficulty* Increased anxiety or confusion* Significant changes in condition.The policy further required timely documentation, maintenance of on-call logs and reporting of patient care activities. RECORD/PATIENT #1:Review of the medical record showed the patient was admitted to hospice on 10/06/2025 with a terminal diagnosis of malignant neoplasm (cancerous tumor) of bone and articular cartilage (rare aggressive cancer), with secondary malignant neoplasm of right lung and pleural effusion (the buildup of excess fluid between the lungs and chest wall, often causing shortness of breath, chest pain, and cough) and resided in a long-term care facility (LTCF).Review of the plan of care (POC) dated 10/06/2025 through 01/03/2026, included routine skilled nursing visits and general interventions for pain, anxiety and shortness of breath (SOB).Review of the patient information report dated 11/23/2025, showed LTCF staff contacted hospice multiple times to report escalating respiratory distress and anxiety, including lack of available morphine (used to treat severe pain) at the facility.  Hospice provided telephonic recommendations only.  At 10:27 PM, the patient was transferred to the emergency department via ambulance due to worsening symptoms.The provider failed to revise the POC to reflect the patient’s acute respiratory decline or need for enhanced interventions prior to transfer.  A nursing assessment and medication changes did not occur until 11/24/2025, approximately 17 hours after the initial report.  New PRN orders were later added following the emergency room (ER) visit; however, the POC failed to demonstrate timely implementation of individualized interventions to manage escalating symptoms. RECORD/PATIENT #2:Review of the medical record showed the patient was admitted to hospice on 09/17/2025, with a terminal diagnosis of hypertensive heart with chronic kidney disease and resided in a LTCF.Review of the POC dated 09/17/2025 through 12/15/2025, included routine monitoring and general pain and anxiety management.Review of a patient information note, dated 10/19/2025, showed the LTCF staff reported the patient was experiencing extreme pain, refusing care, and exhibiting behavioral distress, requiring hospice assessment.  The hospice staff addressed the concern telephonically, and new medication orders were obtained; however, no timely nursing visit occurred.Review of the nurse's note showed the hospice nurse made a visit on 10/21/2025 at 3:28 PM, more than two days after the initial report of uncontrolled pain. The hospice failed to implement timely, individualized POC interventions to address the patient’s escalating pain and behavioral symptoms.RECORD/PATIENT #3:Review of the medical record showed the patient was admitted to hospice on 07/10/2025 with a terminal diagnosis of moderate protein-calorie malnutrition and resided in a LTCF.Review of the plan of care dated 10/08/2025 through 01/05/2026, showed routine nursing visits and general monitoring for decline.Review of the on call/triage note, dated 11/21/2025 at 5:35 PM, showed the LTCF nurse reported a significant change in condition, the patient was non-responsive and exhibiting open mouth breathing, almost gasping, and low blood pressure.On 11/23/2025 at 1:46 PM, the LTCF nurse reported the patient had no oral intake and was unresponsive.Review of the nurses notes showed the hospice RN made a visit on 11/24/2025 at 4:03 PM, more than two days after the initial report.  Review of the hospice IDG meeting notes dated 11/25/2025, showed the IDG failed to incorporate the documented change in condition into the POC.  The hospice failed to revise the POC to reflect the patient’s decline or changing care needs. During an interview on 01/05/2026 at 1:09 PM, the registered nurse case manager (RNCM) A stated that patient #2 had an accepted visit on 10/19/2025 at 12:36 PM with no further documentation until 9:33 PM. During an interview on 01/06/2026 at 11:30 AM, the RN compliance nurse stated that:- Symptom management was often handled over the phone;- Visits were offered but declined by the LTCF; and- Triage nurses document coordination notes but do not update the plan of care.

Based on policy review, record review, and interview, the provider failed to ensure effective coordination of care by not consistently providing timely access to hospice services and/or ensuring timely follow-up in response to changes in patient's condition, in three of three patient records reviewed (Records/Patients #1, #2, and #3).  This deficient practice has the potential to affect all the patients served by the provider. --- Findings included: Review of the provider’s policy titled, “The Plan of Care,” reviewed April 2024, showed in part:- The plan of care (POC) is based on the initial, comprehensive, and ongoing comprehensive assessments;- The POC must be reviewed and revised at least every 15 days;- The POC must be revised as frequently as the patient’s condition warrants;- Any change in the patient’s condition must result in a change in the plan of care prior to implementation of new services;- Documentation of plan of care review and revisions must be maintained in the clinical record; and- The POC must include individualized interventions for pain, symptom management, and changing patient needs. RECORD/PATIENT #1:Review of the medical record showed the patient was admitted to hospice on 10/06/2025 with a terminal diagnosis of malignant neoplasm (cancerous tumor) of bone and articular cartilage (rare aggressive cancer), with secondary malignant neoplasm of right lung and pleural effusion (the buildup of excess fluid between the lungs and chest wall, often causing shortness of breath, chest pain, and cough). The patient resided in a long-term care facility (LTCF).Review of the plan of care dated 10/06/2025 through 01/03/2025, showed in part:- Skilled nursing visits two times per week with as needed (PRN) visits;- Hospice nurse to assess and manage cardiopulmonary symptoms, anxiety, and terminal agitation; and- Morphine and lorazepam ordered for pain, shortness of breath, and anxiety. Review of the patient information report dated 11/23/2025, showed multiple calls reporting worsening shortness of breath, lack of available morphine, and ineffective symptom management. The record showed escalation occurred and a hospice nurse visit was accepted; however, the patient was transported to the emergency room prior to the hospice nurse arrival.Review of the clinical record showed no hospice nursing visit occurred prior to the patient’s transfer to the emergency room.Review of the nurse note dated 11/24/2025 at 12:53 PM, showed an assessment and new interventions for the POC were completed after the emergency room visit.Review of the hospice interdisciplinary group (IDG) dated 11/25/2025, showed an emergent PRN visit for 11/23/2025; however, record review showed no visit occurred on that date. RECORD/PATIENT #2:Review of the medical record showed the patient was admitted on 09/17/2025, with a terminal diagnosis of hypertensive heart disease with chronic kidney disease. The patient resided in a LTCF.Review of the plan of care dated 09/17/2025 through 12/15/2025, showed hospice responsibility for assessment and management of pain, anxiety, and signs of decline.Review of coordination notes dated 10/19/2025, showed the LTCF reported extreme pain and requested hospice assessment. Hospice acknowledged the need for a follow-up.Review of the nurse note dated 10/19/2025, showed hospice responded by phone only, and no in-person assessment was completed for ongoing reports of uncontrolled pain. RECORD/PATIENT #3:Review of the medical record showed the patient was admitted on 07/10/2025 with a terminal diagnosis of moderate protein-calorie malnutrition. The patient resided in an LTCF. Review of the plan of care dated 10/08/2025 through 01/05/2026, showed hospice responsibility for monitoring neurological status, nutrition, signs of decline, and coordination of care.Review of the triage/on-call records showed a significant change in condition was reported on 11/21/2025. Record review failed to show a follow-up nursing assessment until 11/24/2025.Review of the hospice IDG dated 11/25/2025 failed to include or address the significant change in condition reported on 11/21/2025. During an interview on 01/05/2026 at 1:09 PM, the registered nurse case manager (RNCM) A stated that the triage nurses do not update the plan of care and updates occur after a nurse visit the following day. During an interview on 01/05/2026 beginning at 1:24 PM, the administrator stated that Patient #1 complained of shortness of breath and anxiety on 11/22/2025, with nomorphine, PRN lorazepam, or oxygen available. During an interview on 01/06/2026 at 11:30 AM, the RN compliance nurse stated that triage nurses do not update the plan of care and updates occur after a nurse visit the following day.

Based on policy review and record review, the provider failed to ensure the plan of care included individualized, patient-specific interventions sufficient to guide hospice staff in response to patient needs and changes in condition. This deficient practice occurred in three of three patient records reviewed (Records/Patients #1, #2, and #3) and had the potential to affect all patients served by the provider. --- Findings included: Review of the provider’s policy titled, “The Plan of Care,” reviewed April 2024, showed in part:- The plan of care (POC) will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days;- This plan will focus on identified problems, goals, and interventions;- The plan of care will identify the patient needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient s and family/caregiver needs, goals and outcome achievement;- Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes;- The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care; and- Any change in the patient s condition must result in a change in the plan of care, prior to implementation of the new service. RECORD/PATIENT #1:Review of the medical record showed the patient was admitted to hospice on 10/06/2025 with a terminal diagnosis of malignant neoplasm  (cancerous tumor) of bone and articular cartilage (rare aggressive cancer), with secondary malignant neoplasm of right lung and pleural effusion (the buildup of excess fluid between the lungs and chest wall, often causing shortness of breath, chest pain, and cough) and resided in a long-term care facility (LTCF).Review of the plan of care dated 10/06/2025 through 01/03/2026, showed generic interventions for pain, anxiety, and shortness of breath, and included statements to “monitor symptoms” and “provide PRN medications”. The POC failed to include specific guidance for escalation, frequency of reassessment, or actions to be taken in response to worsening symptoms.Despite multiple reports of worsening shortness of breath, ineffective symptom management, and lack of available morphine (used for severe pain) on 11/23/2025, the provider failed to revise the POC to include individualized interventions addressing symptom escalation, urgent nursing response, and coordination with the long-term care facility to ensure timely implementation of hospice services. RECORD/PATIENT #2:Review of the medical record showed the patient was admitted to hospice on 09/17/2025, with al terminal diagnosis of hypertensive heart with chronic kidney disease and resided in a LTCF.Review of the plan of care dated 09/17/2025 through 12/15/2025, showed hospice responsibility for pain and anxiety management; however, the plan lacked specific, measurable interventions to address reports of extreme and uncontrolled pain.Following reports from the long-term care facility on 10/19/2025 of extreme pain, the provider failed to revise the plan of care to include individualized interventions for pain management, reassessment parameters, and criteria for in-person nursing evaluation. RECORD/PATIENT #3:Review of the medical record showed the patient was admitted to hospice on 07/10/2025 with a terminal diagnosis of moderate protein-calorie malnutrition and resided in a LTCF.Review of the plan of care dated 10/08/2025 through 01/05/2026, showed generalized interventions for monitoring neurological status, nutrition, and signs of decline. The POC failed to include patient-specific actions or timelines for reassessment.Following a reported significant change in condition on 11/21/2025, the provider failed to update the POC to reflect individualized interventions addressing the reported decline or to guide hospice staff in timely response.The provider failed to develop and maintain individualized plans of care with sufficient detail to guide hospice staff in managing patient symptoms and responding to changes in condition, resulting in plans of care that were inadequate to direct appropriate hospice services.During an interview on 01/05/2026 at 1:09 PM, registered nurse case manager (RNCM) A stated that he/she made the nurse visit on patient #1 the day after he/she returned from the emergency room (ER), the POC was not updated because the patient symptoms were more anxiety-related, and he/she would have increased the lorazepam (antianxiety) if notified.During an interview on 01/06/2026 at 11:30 AM, the RN compliance nurse stated that he/she would expect the POC to be individualized.During an interview on 01/06/2026 at 8:38 AM, the administrator stated that triage determined when nurses were contacted, and the administrator was not aware of the situation until the following morning.

Upon patient record review, 3 of 11 (Patient #1,#4,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile includes an entry on 1/25/24 for MiraLAX 17 grams po daily PRN for constipation. There is no evidence that the profile includes the type and amount of diluent needed for administration. Patient 4: The medication profile includes an entry on admission for MiraLAX 17 grams po daily PRN and Oxygen 2-4 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the entries include a type and amount of diluent for administration of MiraLAX and titration instructions for oxygen. Patient 9: The medical record includes an order 1/15/24 to discontinue insulin. The insulin order remains on the the medication profile until discharge on 1/24/24.

Upon patient record review, 2 of 11 (Patient #1,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record includes an order on 1/25/24 for MiraLAX 17 grams po daily PRN. There is no evidence that the order includes a type and amount of diluent for administration. COS Patient 4: The medical record includes orders on admission for MiraLAX 17 grams po daily PRN and Oxygen 2-4 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the orders include a type and amount of diluent for administration of MiraLAX and titration instructions for oxygen.

Upon patient record review, 3 of 11 (Patient #1,#3,#9) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 1: The medical record includes nursing documentation on 1/25/24 of the problem statement of altered Neuro due to the patients diagnosis of Alzheimer's. There is no evidence of goals associated with altered Neuro. Patient 3: The medical record contains nursing documentation of symptoms of a urinary tract infection with an order obtained from the physician to treat with Bactrim DS BID x 3 days. There is no evidence of an update to the plan of care to include problems goals and interventions for an active infection. Patient 9:The medical record contains nursing documentation of symptoms of a wound infection with an order obtained from the physician to treat with doxycycline x 10 days. There is no evidence of an update to the plan of care to include problems goals and interventions for an active infection.

Upon patient record review 2 of 11 (Patient #2,#7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 2:The aide plan of care with task of nail care assigned weekly. There is documentation to support that nail care was completed every visit from 10/20/23 to 1/3/24. Patient 7:The aide plan of care with the task of catheter care ordered to be performed weekly. There is documentation that catheter care was completed twice during the week of 10/15/23.