Every finding on record at Southeast Missouri Hospital Association

Based on policy review, record review, home visit observation, and interview, the hospice provider failed to maintain an accurate, updated medication profile in two of four home visit observations conducted (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider’s undated policy titled, “Medication Administration Policy,” showed in part “a medication regime review will occur at the time of the initial comprehensive assessment on admission. The medication profile will include all prescribed and over-the-counter (OTC) medications.”Review of the provider's undated policy titled, " Comprehensive Assessment," showed in part the patient's drug profile is a review of all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 06/16/2025 with a terminal diagnosis of senile degeneration (cognitive decline in older adults, often associated with dementia) of the brain. The patient resided in a skilled nursing facility (SNF). Observation on 07/07/2025 at 3:00 PM, showed the following discrepancies between the provider’s medication profile and the SNF’s medication list:-    The provider’s profile showed the patient took amlodipine (used to treat high blood pressure) 5 milligrams (mg) by mouth daily. The SNF medication list failed to contain this medication; -    The provider’s profile showed the patient took olanzapine (used to treat schizophrenia and bipolar disorder) 10 mg injected intramuscularly one time for aggressive behavior. The SNF medication list failed to contain this medication; -    The provider’s profile showed the patient took rosuvastatin (used to treat high cholesterol) 10 mg by mouth daily. The SNF medication list failed to contain this medication; -    The provider’s profile showed the patient took risperidone (used to treat schizophrenia and bipolar disorder) 0.5 mg by mouth two times daily. The SNF medication list showed the patient took risperidone 0.5 mg by mouth daily in the morning and 1 mg by mouth daily in the evening; -    The SNF medication list showed the patient took sodium phosphate, mono-dibasic (saline laxative used to treat constipation) give one enema rectally daily as needed. The provider’s profile failed to contain this medication; and-    The SNF medication list showed the patient took acetaminophen (used to treat mild pain) 650 mg by mouth daily as needed. The provider’s profile failed to contain this medication. During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator stated that he/she would expect the medications to match between the SNF and the hospice provider.  RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on July 21, 2022 with Alzheimer's disease (a disease marked by progressive loss of mental capacity). The patient resided in a SNF.Observation on 07/08/2025 at 4:45 PM, showed the following discrepancies between the provider's medication profile and the SNF's medication list:The provider's profile showed the patient took famotidine (for stomach upset) two times daily. The SNF medication profile showed the patient took famotidine one time a day;The provider's profile showed the patient took Lasix (swelling lower extremities) 40 milligram(mg) daily. The SNF medication profile showed the patient took Lasix 40 mg two times a day;The provider's profile failed to show Morphine Sulfate oral every two hours for pain, Remeron 15 mg at bedtime to increase appetite, and Zofran as needed for nausea, every eight hours. These medications were on the SNF medication profile.During an interview on 07/09/2025 at 10:45 AM, the registered nurse coordinator (RNC) stated that the skilled nurse (SN) was to compare the provider's medication list to the SNF's medication list during each SNF visit.

Based on record review and interview, the hospice provider failed to ensure all visits were completed as ordered by the physician in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all the patients served by the provider. --- RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 06/16/2025 with a terminal diagnosis of senile degeneration (cognitive decline in older adults, often associated with dementia) of the brain. The patient resided in a skilled nursing facility (SNF).Review of the Hospice Plan of Care Update, dated 06/26/2025 – 07/10/2025, showed a hospice aide visit schedule of two visits every week for 12 weeks beginning 06/22/2025.Review of the clinician visit notes failed to show a second visit for the week of 06/29/2025 – 07/05/2025.Review of the Hospice Plan of Care Update, dated 07/10/2025 – 07/24/2025, failed to show physician notification of the missed aide visit.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/10/2025 with a terminal diagnosis of malignant neoplasm (a disease in which abnormal cells divide uncontrollably and destroy body tissue) of the colon. The patient resided at home alone.Review of the Hospice Plan of Care Update, dated 06/10/2025 – 06/19/2025, showed a hospice aide visit schedule of one visit every week for 12 weeks beginning 06/15/2025.Review of the clinician visit notes failed to show:-            A visit for the week of 06/15/2025 – 06/21/2025; and-            A visit for the week of 06/22/2025 – 06/28/2025.Review of the Hospice Plan of Care Update, dated 07/03/2025 - 07/17/2025, failed to show physician notification of the missed aide visits.During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator stated that he/she would expect documentation as to why the aide visits were missed and the physician to be notified of the missed visits.  RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 12/28/2024 with a terminal diagnosis of Congestive Heart Failure (CHF; - a decrease in the ability of the heart to pump blood),and secondary diagnosis which included chronic kidney disease,(a condition where the kidneys gradually lose the ability to filter waste products from the blood).The patient resided in a skilled nursing facility.Review of the POC, dated 07/03/2025 to 07/17/2025, showed the physician’s order for pastoral care, two visits each month, for 12 weeks.Review of pastoral care visit notes showed:-The provider staff documented one missed pastoral visit on 04/11/2025, for the month of April 2025, due to schedule change; -The provider failed to reschedule the visit for another day in the month of April 2025; and-The staff failed notify the physician, and supervisory staff of the missed pastoral visit on 04/11/2025.Review of the Hospice Plan of Care Update, dated 07/03/2025 to 07/17/2025, failed to show physician notification of the missed pastoral visit.During an interview on 07/09/2025 beginning at 9:20 AM, the Registered Nurse Coordinator (RNC) stated that the visit was missed and was not re-scheduled. The RNC stated that there was no documentation that the physician, or supervisory staff were notified. The RNC also stated that there was not a policy regarding the issue of missed visits.

Based  on policy review, record review, and interview, the hospice provider failed to ensure the ongoing sharing of information between all disciplines providing care and services in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all the patients served by the provider. --- Findings included:Review of the provider's policy, titled, "CAPE HOSPICE Hospice Interdisciplinary Group Policy," dated 07/08/2025,howed in part, the hospice will provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, where the care and services are provided directly or under arrangement. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 06/17/2025 with a primary diagnosis of cancer of the right lung. Patient resided at home with family support. Review of the skilled nurse (SN) visit note, dated 06/30/2025, showed that the patient stated that he/she was not pleased with the medicine that he/she started taking on Friday. The patient stated that he/she felt weak ever since he/she started on the medication and that he/she could not even make it to the bathroom.Review of the record failed to show communication to the physician, nurse practitioner, and/or other patient care providers. During an interview on 07/09/2025 at 10:30 AM, the registered nurse coordinator (RNC) stated that he/she would expect the nurse to notify the physician related to the medication complaints.       Showed

Based on policy review, review of the agency's patient admission packet, and interview the agency failed to ensure the information provided to the patient included the requirement for the hospice to ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice agency are reported immediately by hospice employees and contracted staff to the hospice administrator. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice- Rights and Responsibilities," reviewed/revised 03/08/2022, showed in part: - The hospice informs the patient of his/her rights prior to beginning care, treatment, services or during the initial evaluation visit before beginning care; - Patients/caregivers will receive the booklet "Patient Bill of Rights and Responsibilities"; and - The hospice will ensure that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice agency are reported immediately by hospice employees and contracted staff to the hospice administrator Review of the agency's admission packet provided to patients on admission and the hospice patient's bill of rights and responsibilities booklet failed to include the information that all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice agency are reported immediately by hospice employees and contracted staff to the hospice administrator. During an interview on 08/16/2022 at 2:30 PM, the administrator stated that this information was included in their policy, but the policy is not included in the patient rights booklet.

Based on policy review, review of the agency's patient admission packet, and interview the agency failed to ensure the information provided to the patient included the requirement for the hospice to immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. This deficient practice has the potential to affect all patient served by the agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice-Rights and Responsibilities," showed in part: - The hospice informs the patient of his/her rights prior to beginning care, treatment, services or during the initial evaluation visit before beginning care; - Patients/caregivers will receive the booklet "Patient Bill of Rights and Responsibilities"; and - The hospice administrator will immediately investigate any alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. Review of the agency's admission packet provided to patients on admission and the hospice patient's bill of rights and responsibilities booklet failed to include the information that the hospice to immediately investigate all alleged violations involving anyone furnishing services on behalf of the hospice and immediately take action to prevent further potential violations while the alleged violation is being verified. During an interview on 08/16/2022 at 2:30 PM, the administrator stated that this information was included in their policy, but the policy is not included in the patient rights booklet.

Based on policy review, review of the agency's patient admission packet, and interview the agency failed to ensure the information provided to the patient included the requirement that the hospice must take appropriate corrective action in accordance with State law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction such as the State survey agency or local law enforcement agency. This deficient practice has the potential to affect all patient served by the agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice-Rights and Responsibilities," showed in part: - The hospice informs the patient of his/her rights prior to beginning care, treatment, services or during the initial evaluation visit before beginning care; - Patients/caregivers will receive the booklet "Patient Bill of Rights and Responsibilities"; and - Corrective action will be taken in accordance with state law if the alleged violation is verified by the hospice administrator or to an outside body having jurisdiction, such as the State survey agency or local law enforcement agency. Review of the agency's admission packet provided to patients on admission and the hospice patient's bill of rights and responsibilities booklet failed to include the information that the hospice must take appropriate corrective action in accordance with State law if the alleged violation is verified by the hospice administration or an outside body having jurisdiction such as the State survey agency or local law enforcement agency. During an interview on 08/16/2022 at 2:30 PM, the administrator stated that this information was included in their policy, but the policy is not included in the patient rights booklet.

Based on policy review, review of the agency's patient admission packet, and interview the agency failed to ensure the information provided to the patient included that the hospice must ensure that verified violations are reported to the state and local bodies having jurisdiction (including to the State survey and certification agency) within five working days of becoming aware of the violation. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice-Rights and Responsibilities," showed in part: - The hospice informs the patient of his/her rights prior to beginning care, treatment, services or during the initial evaluation visit before beginning care; - Patients/caregivers will receive the booklet "Patient Bill of Rights and Responsibilities"; and - Verified violations will be reported to State and local bodies having jurisdiction (including State survey and certification agency) within five working days of becoming aware of the violation. Review of the agency's admission packet provided to patients on admission and the hospice patient's bill of rights and responsibilities booklet failed to include the information that the hospice must ensure that verified violations are reported to the state and local bodies having jurisdiction (including to the State survey and certification agency) within five working days of becoming aware of the violation. During an interview on 08/16/2022 at 2:30 PM, the administrator stated that this information was included in their policy, but the policy is not included in the patient rights booklet.

Based on policy review, record review, and interview, the agency failed to maintain an accurate/updated medication list in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the the potential to affect all patients served by the agency. Findings included: Review of the agency's policy, "Hospice- Medication Administration and Review," revised 06/21/2021, showed in part: - To be used on all hospice patients both in the home setting and in the facility setting; - The medication list is updated with any medication changes; - The patient's medication list will be reviewed prior to each nursing visit; and - The patient's medication sheet will be updated with any medication changes and then reviewed by the primary nurse at the time of the monthly chart review. RECORD/PATIENT #1: Review of the agency's medication list during a home observation visit on 08/15/2022 beginning at 1:25 PM, showed that the agency failed to include the following medications: - Melatonin (a medication used for sleep) three milligrams (mg) two tablets by mouth at bedtime; - Bisacodyl (a medication used for constipation) rectal suppository 10 mg one suppository per rectum every 24 hours as needed for constipation; - Milk of Magnesia (a medication used for constipation) 400 mg/5 milliliters (ml) give 30 ml by mouth every 24 hours as needed for constipation; and - Senna-S (a medication used for constipation) 8.6-50 mg give two tablets by mouth three times per day. During an interview on 08/17/2022 beginning at 12:00 PM, the administrator stated that medication reconciliation is usually done on each visit and a new medication list is taken to the facility on the first visit of the month.

Based on policy review, record review, and interview the agency failed to develop an individualized plan of care in three (Records/Patients #2, #3, and #4) 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 "Homecare: Hospice Plan of Care (POC) - Interdisciplinary - Coordination of Services" dated 11/20/2021, showed in part: - All hospice care an services furnished to patients and their families will follow an individualized written plan of care established by the hospice interdisciplinary group (IDG); - An individualized POC will be developed for each patient; - The POC will reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments; and - The POC will include measurable outcomes anticipated from implementing and coordinating the POC, drugs and treatment necessary to meet the needs of the patient, and medical supplies and appliances necessary to meet the needs of the patient. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted on 03/01/2022 with a terminal diagnosis of congestive heart failure. The patient lived at home. Review of the recertification POC dated 05/26/2022, showed: - A goal that facility staff is knowledgeable and involved in the hospice POC for patient; and - A goal that facility staff is able to verbalize/demonstrate the nursing facility's role in hospice patient's POC. Review of the skilled nurse visit notes dating from 03/01/2022 to 08/12/2022 showed: - Patient has Aspira drain (long-term catheter used to drain accumulated fluid from the pleural cavity) in place to left side of chest; - Patient's daughter empties drainage bag and changes dressing to catheter site; - Hospice delivered new drainage kits and dressing kits; and - The patient's POC failed to include the Aspira drain and its care. RECORD/PATIENT #3: Review of the recertification POC dated 06/23/2022 showed in part: - An order for warfarin (blood thinning medication) 2 milligrams (mg) one half tablet daily; and - No interventions and goals related to the use of warfarin. During an interview on 08/17/2022 beginning at 8:30 AM, the patient care coordinator stated that if a patient took an anticoagulant they tried to either get them off the medication or maintain a low dose. They would monitor the patient for safety including bruising and falls. He/she updated the POC today to include the warfarin. The administrator stated that the POC should include medication teaching and bleeding precautions. RECORD/PATIENT #4: Review of the clinical record showed the following: -The patient was admitted on 07/08/2022 with a terminal diagnosis of atherosclerotic heart disease. The patient lived in a skilled nursing facility. Review of the hospice certification and POC document dated 07/08/2022, showed: - A goal of a nursing POC will be established that meets the patient's needs; and - A goal that the patient will have safety needs met; and - The agency failed to include specific interventions that related to the patient and the diagnosis. During an interview on 08/17/2022 at 8:30 AM, the administrator stated that they would expect the POC to be individualized for each patient.

Based on policy review, record review, and interview, the agency failed to ensure that care and services were provided based on all assessments of the patient and family needs for one (Record/Patient #3) of five full records reviewed . This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice Plan of Care-Interdisciplinary-Coordination of Services," reviewed/revised 11/20/2021, showed in part the plan of care and comprehensive assessment is reassessed and reviewed on each patient a minimum of every two weeks at the hospice IDG (interdisciplinary group) meeting. Problems as well as progress toward outcomes and goals specified in the plan of care will be addressed by each discipline and recorded along with additional interventions for each patient being discussed. RECORD/PATIENT #3: Review of the skilled nurse (SN) visit notes showed: - On 06/28/2022, the patient had blanchable (when pressure is applied the skin turns white) redness to the heels and a Stage 1 (intact skin that is not blanchable when pressure is applied) pressure ulcer to the right outer ankle. The appearance was a small purple area. No measurement of the area. Initiated a change in medication per physician orders as follows: Heels, right outer ankle, skin prep (skin protectant) and float off pillow; and - On 07/01/2022 the integumentary (skin) assessment portion of the assessment showed not assessed and not applicable. The caregiver reported the patient's skin was improved and were not using the heel boots anymore. The heels showed no signs of redness. The SN failed to document an assessment of the right outer ankle; Review of the hospice IDG and plan of care update report dated 07/07/2022, showed a hospice physician order dated 06/28/2022, for heels, right outer ankle - apply skin prep daily and float off pillow. The problem list included a need for observation and assessment of skin and wound care but failed to include a goal related to the patient's wound. There was no documentation under the section for wound progression including what the wound looked like or if it was healing or deteriorating. Review of the SN visit notes showed: - On 07/12/2022 the patient had a Stage 2 (shallow open wound) pressure ulcer to the right ankle that was scabbed. No further assessment of the wound including surrounding skin or if drainage was present No measurement of the wound. Wound care provided per orders showed no, even though the interventions provided section showed wound care per orders, heels, right outer ankle skin prep and float off pillow; - On 07/15/2022 no skin problems identified. The wound on the right ankle was healing well. No documented assessment of the wound; and - On 07/19/2022 no skin problems identified. Interventions provided showed wound care per orders to heels, right outer ankle skin prep and float off pillows. No documentation of an assessment of the right outer ankle wound or whether the wound had healed. Review of the hospice IDG and plan of care update report dated 07/21/2022, showed no documentation under the section for wound progression including what the wound looked like or if it was healing or deteriorating. During an interview on 08/17/2022, beginning at 8:30 AM, the administrator stated that the IDG note should show the healing and progression of wounds.

Based on policy review, record review, and interview, the agency failed to ensure the nursing needs of the patient were met in two (Records/Patients #3 and #4) 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 "Home Care - Prescription/orders: Requirements of a Medication/Physician Order/Signatures" dated 11/18/2021, showed, in part, drugs services and treatments are administered only as ordered by a physician. Review of the article by Karen S. Clay, RN, BSN, CWCN Copyright 2008 titled, "Evidence-Based Pressure Ulcer Prevention: A Study Guide for Nurses," showed the following: "The standard of practice requires at least weekly measurement of the wound. In addition, every time you change the dressing, assess peri-wound skin (surrounding skin), wound margins, wound tissue, drainage, odor, pain, and any other relevant issues. On a weekly basis, assess those macroscopic (i.e., visible to the naked eye) indices, measure the wound, assess the effectiveness of the treatment, and determine any treatment plan changes." (http://www.hcpro.com/content/76944.pdf Chapter 9-Wound Healing-Page 95) Review of the agency's policy titled, "Homecare: Hospice Skin Care Guidelines," reviewed/revised 01/07/2022, showed in part: - A skin assessment will be done upon admission and weekly thereafter. When breakdown is present, the wound will be descried in the electronic medical record (EMR). For stage 1 or 2 wounds, skin tears, or lesions, this is documented in a coordination note and hospice wound care and treatment provided is documented under the appropriate intervention; - Stage 1 and 2 wounds will be described in the nurses' documentation in the EMR, measurement of stage 1 and 2 is not necessary; and - Wounds will be assessed weekly on the first visit of the week RECORD/PATIENT #3: Review of the skilled nurse (SN) visit notes showed: - On 06/28/2022, the patient had blanchable (when pressure is applied the skin turns white) and a Stage 1 (intact skin that is not blanchable when pressure is applied) pressure ulcer to the right outer ankle. The appearance was a small purple area. No measurement of the area. Initiated a change in medication per physician orders as follows: Heels, right outer ankle, skin prep (skin protectant) and float off pillow; - On 07/01/2022 the integumentary (skin) assessment portion of the assessment showed not assessed and not applicable. The caregiver reported the patient's skin had improved and were not using the heel boots anymore. They were floating the patient's heels which showed no signs of redness. The SN failed to document an assessment of the right outer ankle; - On 07/12/2022 the patient had a Stage 2 (shallow open wound) pressure ulcer to the right ankle that was scabbed. No further assessment of the wound including surrounding skin or if drainage was present No measurement of the wound. Wound care provided per orders showed no, even though the interventions provided section showed wound care per orders, heels, right outer ankle skin prep and float off pillow; - On 07/15/2022 no skin problems identified. The wound on the right ankle was healing well. No documented assessment of the wound; - On 07/19/2022 no skin problems identified. Interventions provided showed wound care per orders to heels, right outer ankle skin prep and float off pillows. No documentation of an assessment of the right outer ankle wound or whether the wound had healed; - On 08/05/2022 the caregiver requested SN assess right outer ankle area that they stated "popped up" overnight. A small blistered area approximately one centimeter in diameter noted to ankle bone with redness also noted in the region. A medium Allevyn (foam) dressing applied for protection and cushioning. No documentation that the physician was notified or a physician order obtained for this treatment; - On 08/09/2022 the patient had redness to the right outer ankle. Right ankle scabbed with a scant amount of red drainage on the bandage. Interventions provided included wound care per orders. Right outer ankle, apply medium Allevyn to protect area and provide cushioning. Change every five to seven days and as needed (no physician order found for this); - On 08/12/2022 interventions provided included wound care per orders. Right outer ankle apply medium Allevyn to protect area and provide cushioning. Change every five to seven days and as needed. No documented assessment of the right outer ankle; and - On 08/16/2022 the patient had a small wound on the outside of the right ankle that was treated per orders and healing well. Observation on 08/16/2022 beginning at 10:55 AM, during the patient's home visit, showed a dark purple intact area over the right ankle bone with surrounding redness and an area above that appeared shiny (unsure if this was due to the antibiotic ointment being applied) with pink tissue. The SN failed to measure or provide any treatment to the wound. The caregiver stated that they thought the dressing may have irritated the area, and the previous nurse on Friday (08/12/2022) had told them to leave the dressing off and apply triple antibiotic ointment and cover with gauze (no documentation of this in the 08/12/2022 nurse note or physician order found for this treatment). During an interview on 08/17/2022 beginning at 08:30 AM, the patient care coordinator stated that there should be a coordination note that includes what the wound treatment was. He/she would expect there to be wound care orders for the treatments. If there was a change in a wound, he/she would expect the physician to be notified. The administrator stated that he/she would expect there to be a physician order for wound care. The wound assessment should include a description of the wound and surrounding skin. The IDG note should include the healing progression of the wound. He/she would expect to be able to follow the progression of wounds and documentation if a wound had healed. During an interview on 08/17/2022, at 11:20 AM, the patient care coordinator agreed that their wound documentation was lacking. Wound assessments should be documented on subsequent visits. He/she could not find a physician order for the Allevyn dressing. RECORD/PATIENT #4: Review of the clinical record showed: -The patient's physician orders had an order for oxygen 4 liters per minute (lpm) via nasal cannula continuously; - Skilled nursing documentation dating from 07/11/2022 to 08/15/2022 showed the patient wore oxygen inconsistently to the physician's order; and -The agency failed to report that the patient was not following the order to the physician. During an interview on 08/17/2022 at 11:00 AM, the adminstrator states that he/she would expect the physcian to be notified of any needed changes to the order and patient noncompliance with current orders.

Based on policy review, record review, and interview, the agency failed to ensure that when a patient was transferred to another Medicare/Medicaid certified agency, the receiving agency would receive a copy of the hospice transfer/discharge summary in one (Record/Patient #7) of two transfer record reviewed. This deficient practice has the potential to affect all patients transferred from the hospice agency. Findings included: Review of the agency's policy titled, "Homecare: Hospice Discharge-Transfer Summary," revised 06/25/2021, showed in part that at the time of a patient's transfer the organization informs the other service providers who will provide care, treatment, or services to the patient about a summary of care, treatment, or services it provided to the patient and patient care provider and any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility. RECORD/PATIENT #7: Review of the record showed the patient was transferred from the agency's service on 06/20/2022. The record failed to show that the discharge summary, medication report, hospice certification, plan of care, and do not resuscitate order had been sent to the receiving provider. During an interview on 08/17/2022 at 12:00 PM the administrator stated that he/she could not provide the missing information.

Based on policy review, record review, home visit observation, and interview the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #1) of one applicable record of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled, "Hospice Plan of Care- Nursing Home," revised 11/2021 showed in part, all hospice patients residing in a nursing home will have a plan of care and a coordinated task plan developed and maintained in consultation with the skilled nursing facility/nursing facility, all hospice care provided must be in accordance with this hospice plan of care (POC), and the hospice interdisciplinary group (IDG) will review the plan of care at a minimum of every 15 days. RECORD/PATIENT #1: Review of the hospice record maintained at the long term care facility (LTCF), during a home visit observation on 08/15/2022 beginning at 1:25 PM, showed the hospice binder failed to contain an updated POC for the patient. The POC available in the hospice binder at the LTCF was dated 02/11/2022 to 05/11/2022. Review of the agency's records showed that the last POC update was dated 08/11/2022 during an IDG review. During an interview on 08/17/2022 beginning at 12:00 PM, the administrator stated that a copy of the updated POC should be available to the LTCF staff.