Every finding on record at Ssm Health Business

Observed in Tracer Activities. The organization failed to address patient decisions about care, treatment, or services received at the end of life. During tracer activities for leadership and policy review, the Hospice Nurse Surveyor #1 observed the organization had not provided written information about its policies on advance directives. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 6 patient records reviewed, the Hospice Surveyor #2 noted an initial spiritual assessment had not been completed within the 5 days post election of Hospice Benefits (EOHB). In HOSRRNHV #11, there had been no spiritual care assessment by day 8 post EOHB. This was validated with the Hospice Branch Director.

Observed in Record Review. In 18 of 23 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRHV#5, RRHV#6, RRNHV#1- RRNHV#6, Hospice Nurse Surveyor #1 observed the organization failed to document the need for volunteer services in order to offer support or respite to the patient, family, or other caregivers. During record review for RRHV#1, RRHV#2, RRHV#3, RRHV#6, RRNHV#1-RRNHV#3, the Hospice Nurse Surveyor #1 observed the organization failed to document an initial bereavement assessment. During conversation with the Hospice Team, it was noted due to a change in an EMR about a year prior to survey the organization was doing the bereavement assessment but there was no documentation of the activities. This was validated with the Hospice Branch Manager. The Hospice Surveyor #2 noted the initial bereavement assessment and the need for volunteer services had not been documented as completed in the electronic medical record (EMR). This had been evident in HOSRRNHV #7, HOSRRNHV #8, HOSRRNHV #9, HOSRRNHV #10, HOSRRNHV #11, and HOSRRNHV #12. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 11 of 23 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRHV#5, RRHV#6, RRNHV#1, RRNHV#3- RRNHV#6, the comprehensive assessments did not include documentation of progress towards desired outcomes. Upon conversation with the Hospice Team, it was noted that progress was being documented as progressing which was not measurable. This was discussed and reviewed with the Hospice Team. Observed in Record Review. In 1 of 1 patient records reviewed, where the patient had a planned discharge, the Hospice surveyor #2 noted no documentation present in the Interdisciplinary group (IDG) to support the discharge. For example, in HOSRRDC #2, the patient had been deemed no longer terminally ill and was to be discharged. The IDG 2 weeks prior and the day before the discharge had not contained discussion related to the pending discharge. Of note, the IDG 1 day prior still had documentation that the patient had 6 months or less to live. This was validated with the Hospice Branch Manager.

Observed in Record Review. During the Bereavement Tracer/Record Review the surveyor noted that in 3 of 3 patient records reviewed, the initial Plan of Care contained a standard statement and goal intended to identify and address bereavement needs during the care of the patient. However, in each of the 3 patients the results of the initial bereavement risk assessment performed indicating low, medium or high risk had not been documented in the Plan of Care to provide a baseline level to enhance monitoring related to this goal. This was discussed with the Bereavement Coordinators and hospice leadership who also described that results of reassessments of bereavement risk would also not be documented in subsequent, updated Plans of Care.

Observed in Record Review. In 3 of 23 patient records reviewed, In 3 of 23 patient records reviewed, the PRN medications did not include indications for use. HOSRRNHV #8 had both Morphine and Oxycodone ordered every 4 hours as needed for severe pain. HOSRRNHV #9 the patient had Oxycodone 2 tabs every 4 hours and Morphine 20mg/ml every 2 hours both ordered as needed for pain without clear indications for which to use first. HOSRRNHV #10 had Morphine ordered for every 2 hours and Tylenol ordered every 4 hour according to PAINAD scale. This was validated with the Hospice Branch Manager. Observed in Record Review. In 5 of 23 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#4, RRHV#6, RRNHV#4, RRNHV#5, and RRNHV#6, PRN medications did not include indications for use. All five patients had Acetaminophen and Morphine for pain with no indication for when to take which medication according to organizational policy. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 2 of 6 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During home visits for RRHV#4 and RRHV#5, the Hospice Nurse Surveyor #1 observed that staff failed to perform hand hygiene consistent with policy. For example in RRHV#4, the staff did not wash hands before touching the patient and she placed her hand soap inside her front pocket which caused her to reach in with contaminated hands. In RRHV#6, the staff did not change gloves or complete hand hygiene after cleaning genitals and cleaning stool from the patient. She continued on with care, providing a clean towel which she used to dry the patient and then used lotion on the patient body. Also in RRHV#6, the staff member went into bag several times without completing hand hygiene. This was discussed and reviewed with the Hospice Team. Observed in Patient Home. In 1 of 6 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During home visits for RRHV#4 the Hospice Nurse Surveyor #1 observed the staff failed to follow the organizational policy for bag technique. For example in RRHV#4, the staff member left her outside pocket unzipped while walking through the facility and left the middle pocket unzipped throughout her whole visit. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. During the Bereavement Tracer/Record Review, the surveyor noted that in an individual identified by the organization as at high bereavement risk after the death of their partner/spouse, the bereavement care plan did not include specific, individualized interventions. Organization policy states, Standard bereavement includes, but is not limited to: followed by a list of tasks and actions to be performed with no differences or designations identified based upon level of risk assessed. Identification of high risk designation in the bereaved individual required a clear and specific description of interventions included in the post-death, bereavement Plan of Care which were in addition to standard bereavement. This was discussed with the Bereavement Coordinators and hospice leadership.

Observed in Record Review. In 6 of 15 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#4, RRHV#5, RRHV#6, RRNHV#2, RRNHV#3, and RRNHV#6, the aide care plan failed to document safety precautions. For example in RRHV#4, the aide care plan failed to include oxygen on the care plan. In RRHV#5, the aide care plan failed to include oxygen and bleeding precautions. In RRHV#6, the aide care plan failed to include aspiration precautions. In RRNHV#2, the aide care plan failed to include fall risk, oxygen and aspiration precautions. In RRNHV#3, oxygen was not addressed on the aide care plan. And in RRNHV#6, the aide care plan did not include aspiration risk. In RRHV#4 the aide care plan written instructions were not accurate. For example in RRHV#4, the patient had catheter care on the aide care plan but the patient did not have a catheter. This was discussed and reviewed with the hospice team.

Observed in Record Review. In 1 of 15 patient records reviewed, of patients with aide services, the organization failed to provide care, treatment, or services in accordance with orders. During record review for RRHV#6, Hospice Nurse Surveyor #1 observed the aide care plan stated bath but the aide gave a shower. And the aide shaved the patient's face but shave was not on the aide care plan. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 3 of 15 patient records reviewed, where aide services were ordered, the organization failed to supervise effectively. During record review for RRHV#3, RRNHV#2, and RRNHV#3, Hospice Nurse Surveyor #1 observed the organization failed to document Hospice Aide Supervision at least every 14 days. For example in RRHV#3, the Home Health Aide supervision was documented 21 days apart. In RRNHV#2, the supervision was documented at 19 days and 21 days. And in RRNHV#3, the supervision was documented at 21 days. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 1 of 1 patient records reviewed, where the patient revoked hospice the Hospice Surveyor #2 noted no documented communication/collaboration between the Hospice and the Emergency Department to facilitate the transition of care. HOSRRDC #1 the patient revoked to go to the emergency department. There had been no documentation that the hospice communicated with the hospital about the patient plan of care. Validated with the Hospice Branch manager.

Based on policy review, record review, and interview, the agency failed to ensure that: - Aide visits were assigned and/or completed as ordered and failed to document concerns from the patient's family regarding the lack of services provided (505); and - The patient received effective pain management and symptom control (512). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview, the agency failed to ensure that aide visits were assigned and/or completed as ordered and failed to document concerns from the patient's family regarding the lack of services provided in, but not limited to, one (Patient/Record #9) of eleven records reviewed. The deficiency has the potential to affect all patients on service with the agency. --- Findings included: Review of the agency's policy titled, "Patient Rights and Responsibilities," reviewed 05/24/2021, showed, in part: - The patient has the right to: * Participate in the development and periodic revision of the plan of care; and * Receive effective pain management and symptom control for conditions related to terminal illness(s). Review of the agency's informed consent document titled, "Hospice Patient/Family Informed Consent and Patient/Client Rights and Responsibilities," provided to the patients on admission, showed, in part: - The patient and/or family/caregiver has the right: * To exercise his or her rights as a patient of the hospice; * To have his or her property and person treated with respect, consideration, and recognition of patient dignity and individuality; * To voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; and * Have grievances/complaints regarding treatment or care that is (or fails to be) furnished and the lack of respect for property investigated. RECORD/PATIENT #9: Review of the clinical record showed, the patient was admitted to hospice services on, 01/04/2023, with a past medical history of hypertension (the force of blood against the artery wall is too high), atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots), right adrenal mass (a tumor that forms in the adrenal glands) and IVC (Inferior vena cava, a large vein in the abdomen that carries blood from the lower to the upper half of the body to the heart) thrombus (a blood clot formed within the vascular system of the body and impeding blood flow). Review of the POC (plan of care), dated 01/04/2023 to 01/18/2023, showed, home health aide [hospice aide], 2 visits every week for 13 weeks with dates of 01/04/2023 to 04/01/2023. Review of the clinical record, showed, document titled, "Telephone Encounter," dated, 01/06/2023, showed, in part: - Caregiver unhappy about HHA [hospice aide] visit not happening and he/she called the office to voice his/her disappointment; - Visits were scheduled but not assigned; - RN (registered nurse) A, apologized and attempted to rectify the situation; - Follow up: [RN A] Spoke with [named employee] at the office who stated orders had not been signed so the aide visits were not assigned; and - Note: Clinical record failed to show documentation of a follow up telephone call or visit being made on 01/08/2023. Review of the clinical record, showed, document titled, "Telephone Encounter,"dated, 01/07/2023, showed, in part: - Call received from patients [spouse] regarding lack of visits; - Only seen by one person since 01/04/2023 (The admission visit and the second day follow up visit were done by RN A); - The CNA [certified nurse aide] and the MSW are on the schedule for Monday 01/09/2023; - [Spouse] reported visit not needed today but may want one tomorrow if possible; - [Spouse] was asked if an urgent visit is needed this weekend and reported they [patient and spouse] can wait until Monday; - Message sent to the care team to follow up on Monday 01/09/2023; and - ";RNCM [Registered nurse case manager]: Please ensure at least a follow up call is completed on Monday 1/9/23, and also complete some education with patient and [spouse] about frequency of visits in the future. [Spouse] has stated that with [his/her] mother, ";hospice was showing up every other day at least!" I [RN F] did discuss with [spouse] that each patient will need a different frequency of visits depending on how they are doing, but please discuss expectations." During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - The patient wanted to revoke hospice because [he/she] was not getting the aide visits; - There was an issue with the aide visits getting assigned because of issues with the new electronic charting system; - He/she was made aware of the complaint made by the patients caregiver on 01/06/2023 regarding the lack of aide visits but no complaints were recorded in the complaint log; - He/she probably should have recorded the complaints made by family in the complaint book; and - He/she did reach out to the family regarding the complaint but he/she did not document it.

Based on policy review, record review, and interview, the agency failed to ensure that the patient received effective pain management and symptom control from the hospice in, but not limited to, one (Patient/Record #9) of eleven records reviewed. The deficiency has the potential to affect all patients on service with the agency. --- Findings included: Review of the agency's policy titled, "Patient Rights and Responsibilities," reviewed 05/24/2021, showed, the patient has the right to receive effective pain management and symptom control for conditions related to terminal illness(s). Review of the agency's policy titled, "Hospice Coordination of Care," reviewed 06/15/2021, showed, in part: - On-going verbal or written communication regarding care or services which includes significant changes in the patients overall care, patients needs, goals, care or services to be provided, and/or physicians orders will occur between members of the IDT and on-call services by means of IDT meeting; - On-going communication, when indicated, will occur between hospice staff and the patients physician, or between the IDT and the patients physician as appropriate to the care of the patient; - Communication will occur: * When there are changes in the patients condition; * When changes occur in the patients expected response to treatment or medication; and * When changes occur in caregiver support or environment of care. RECORD/PATIENT #9: Review of the clinical record showed, the patient was admitted to hospice services on 01/04/2023, with a past medical history of hypertension (the force of blood against the artery wall is too high), atrial fibrillation (an irregular and often rapid heart rhythm that can lead to blood clots), right adrenal mass (a tumor that forms in the adrenal glands) and IVC (Inferior vena cava, a large vein in the abdomen that carries blood from the lower to the upper half of the body to the heart) thrombus (a blood clot formed within the vascular system of the body and impeding blood flow). Review of the SOC (start of care) comprehensive assessment, dated, 01/04/2023, with a start time of 1:45 PM, showed, in part: - Cardiovascular (relating to heart and blood vessels) assessment with dyspnea (shortness of breath) on exertion (physical effort), fatigues easily, palpitations a (sensation that the heart is racing, pounding, fluttering, or skipping a beat), decreased pulses (difficulty feeling a pulse); - Edema (swelling caused by excess fluid trapped in the bodys tissues) section was left blank; - Respiratory assessment with shortness of breath; - Respiratory effort is normal; - Breath sounds with decreased sounds in RUF [right upper field], RMF [right middle field], RLF [right lower field], and LUF [left upper field]; - Oxygen saturation (the amount of oxygen circulating in the blood) of 94% (normal range is 95 to 100%); - Pulse of 72 beats per minute (normal for healthy adults ranges from 60 to 100); - Intermittent (occurring at irregular intervals, not continuous or steady), sharp, abdomen pain rated 6/10 (0 being no pain and 10 being the worst pain); - Was physician aware or notified of the pain? Was marked with ";aware;" and - Patient will need ongoing support to encourage use for adequate pain control and relief of side effects. Review of the skilled nurse visit note, dated, 01/05/2023, with a start time of 1:30 PM, showed, in part: - Cardiovascular assessment with dyspnea on exertion , fatigues easily, palpitations, edema, and decreased pulses; - Edema +3 (Edema scale measured by applying pressure on the affected area and then measuring the depth of the pit and how long it lasts to rebound or return. Grade +3 is 5-6mm (millimeters) depression and rebounding in 60 seconds) pitting (when pressure is applied to the swollen area, a pit or indentation will remain) to right foot, +3 pitting edema to left foot, +3 edema to right ankle, +3 edema to left ankle, +2 (3-4mm of depression, rebounding in 15 seconds or less) edema to left thigh and +2 edema to right thigh; - Respiratory assessment with cough and shortness of breath (Cough is a new symptom since previous visit); - Respiratory effort with increased effort (Increased effort is a new symptom); - Breath sounds with decreased sounds and rhonchi (Continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation) noted in RUF, RMF, RLF, LLF [left lower field], and LUF (Rhonchi is a new symptom since previous visit); - Oxygen saturation of 90% (this is a decrease from 94% the previous day); - Pulse of 140 beats per minute (this is an increase from 72 beats per minute the day before); - Constant, sharp, abdomen pain rated 7/10 (Pain was intermittent the day before and now constant); and - No documentation of physician notification. Review of the telephone encounter note, dated, 01/05/2023, with a time of 8:18 PM, showed, in part: - Granddaughter calls into on-call to report new onset of RLE (right lower extremity) swelling and deep purple discoloration; - Granddaughter reports the pt [patient] did lay down on [his/her] couch all afternoon with both legs elevated without any decrease in swelling; - Denies any current or prior use of compression stockings; - Reports currently sitting up in [his/her] WC [wheelchair] and writer (RN D) strongly recommended laying down with elevation of BLE [bilateral lower extremities] again to reduce swelling; - Educated on common s/s [signs and symptoms] of CHF [congestive heart failure] and fluid retention; - Granddaughter reports that pt RLE has an increase in deep purple color and are ";ice cold" to touch; - Pt denies pain or chest pain and reports that family administered Morphine [narcotic pain medication] 15 min [minutes] ago; - Granddaughter reports that pt is taking all of [his/her] medications as ordered including todays [01/05/2023] dose of Furosemide [Diuretic medication to reduce swelling caused by fluid retention]; - Both patient and granddaughter request nursing visit this evening to assess d/t [due to] above concerns; and - Writer [RN D] contacted on-call RN (registered nurse) and report provided. Review of an email from the on-call RN, to the agency administration, dated, 01/05/2023, at 9:57 PM, showed, in part: - RN received a call from the on-call afterhours stating this patient is requesting a nurse visit due to swelling and [his/her] bil [bilateral-both] feet turning purple; - RN called pt cg [caregiver] who voiced [he/she] has swelling to [his/her] BLE [bilateral lower extremities] but the right leg is worse than the left; - He/she also voiced [his/her] left foot was feeling numb prior to RN retuning [his/her] call; -Patient voiced the numbness has resolved; - The granddaughter voiced the patient has been sitting up all day with legs elevated; - Patient got in the bed 20 minutes prior to RN calling; - Granddaughter voiced feet are no longer purple; - RN asked if the patient was having any pain and patient stated [his/her] left knee was hurting; - Per granddaughter, pt refused [his/her] 30 mg (milligrams) MSER (morphine sulfate extended release) earlier but did take evening dose; Patient took 1 dose of MSIR (morphine sulfate immediate release) 15 MG early this AM (morning); - RN encouraged patient to take the MEIR [MSIR] 15 MG now as it is more of an instant release; - Patient voiced [his/her] pain is not the issue; - ";So we focused back on the swelling;" - The granddaughter voiced the patients Lasix [furosemide] was increased today and the patient is scheduled to take a double dose in the AM (No documentation of physician being notified and medication dose increase); - The RN discussed ";possibly some ace wraps to aide in edema management also;" - Pt agreed and RN will place an order for the ace wrap; - The granddaughter voiced her feet are no longer purple since the patient laid down; - The RN discussed the plan for tonight to stay in bed with elevation, take Lasix in the AM, and order the ace wrap to aide in edema management; - CM [case manager] please follow up with a telephone call on 01/06/2023; - No in person visit needed at this time; - CG [caregiver] instructed to call hospice back if pt feet turn purple, pain increase, pt develops SOB [shortness of breath] or any other concerns; - Granddaughter voiced understanding; and - Ace wraps ordered (No order was placed and no documentation of physician notification to obtain an order or report new symptoms). Review of the clinical record, showed, document titled, "Telephone Encounter," dated, 01/06/2023, showed, in part: - RN A spoke with the patients [caregiver] who stated the edema and purpling of toes and knees has ";resolved somewhat" with increased dosage of Lasix and elevation; - RN called pharmacy to resolve medication misunderstanding (Documented in the note but no explanation of what the medication misunderstanding was); - Caregiver purchased over the counter guaifenesin (used to relieve chest congestion) as pharmacy did not have in supply; - Other medication issue was a moot point (No documentation of what the medication issue was); - Lasix dosage was doubled but caregiver had plenty in home; and - Caregiver thought [he/she] was picking up Lasix at the pharmacy. Review of the skilled nurse visit note, dated, 01/09/2023, with a start time of 11:30 AM, showed, in part: - Cardiovascular assessment with dyspnea on exertion, fatigues easily, palpitations, edema, mottling, lower extremity pain, and decreased pulses (Mottling and lower extremity pain is a new symptom since SN visit 4 days prior); - Edema to +4 (8mm of depression, rebounding in 2-3 minutes) pitting edema to right foot, +4 pitting edema to left foot, +3 edema to right ankle, +3 edema left ankle, +1 edema to left thigh and +1 edema to right thigh (Right and left foot edema increased from +3 edema since last SN visit 4 days prior); - Respiratory assessment with cough and shortness of breath; - Respiratory effort with increased effort; - Breath sounds with decreased sounds with rhonchi noted in RUF, RMF, RLF, LLF, and LUF; - Integumentary assessment with pale, mottling listed for color and purple discoloration to soles of feet noted in comments (new assessment findings since last SN visit 4 days prior); - Caregiver assessment section with caregiver name and relationship of daughter; - Stress factors include lack of caregivers and lack of knowledge; - [Caregiver] is supportive and has many questions regarding care, does not seem to be completely on hospice page at this time; and - A wound assessment was completed for a stage 2 wound to buttocks measuring 1.6 CM (centimeters) in length, 1 cm in width (wound is new since last SN visit 4 days prior on 01/05/2023). Review of the clinical record failed to show: - Documentation of coordination of care regarding significant changes in condition; - Physician notification regarding significant changes in condition with each skilled nurse visit; and - An updated plan of care to include interventions specific to the patient and family needs after significant change in condition. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - The on call nurse should have made a visit to assess the patient; - No documentation of physician notification regarding changes in condition; - No orders received for ace wraps; - The patients past medical history did include a history of blood clots and no visit was made by the nurse to assess the patient prior to recommending ace wraps to lower extremities; - The on call nurse should have made a visit to assess the patient and then contacted the physician to obtain orders prior to recommending the patient wrap legs with ace wraps; - He/she would expect the on call nurse to make a visit anytime a patient or family requests a visit; and - The patient should have received a follow up visit at least on 01/06/2023 or 01/07/2023 to assess the patients condition instead of the patient going 4 days between visits after having a significant change in condition.

Based on policy review, record review, and interview, the agency failed to ensure that the comprehensive assessment identified the physical needs of the patient were addressed in order to promote the patients well-being throughout the dying process in, but not limited to, two (Records/Patients #2 and #4) of eight applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agencys policy titled, ";Assessment of Patient and Client," dated 06/21/2021, showed, in part, the following: -The comprehensive assessment includes, but is not limited to: *The physical health component: **Head to toe assessment; -Common physical symptoms other than pain that are assessed at the time of admission and on an ongoing basis based on policies and procedures/protocols for symptom identification and management. Common symptoms include: *Skin breakdown. Review of the agencys policy titled, ";Equipment Supplies and Solutions," dated 05/08/2021, showed, in part, the following: -Wound Assessment: *Wound should be evaluated for sign of infection: **redness, **swelling, and **purulent drainage. RECORD/PATIENT #2: Review of the initial hospice plan of care (POC) dated 01/05/2023 showed, in part, the following: -The patient had a small skin tear to the left hip from a tab brief; and -A stage one pressure ulcer (a reddened, painful area on the skin that does not turn white (blanch) when pressed) developing on the buttocks. Review of the initial comprehensive assessment showed, in part, the following: -The integumentary assessment was within defined limits; and -The initial comprehensive assessment failed to show any measurements for the skin tear or the stage one pressure ulcer. RECORD/PATIENT #4: Review of the document titled, ";Patient Information Facesheet," dated 01/23/2023 showed, in part, the following: -Skin integrity: stage 1 to coccyx on admission. Review of the initial comprehensive assessment failed to show any wound measurements. During an interview on 01/24/2023 at 12:50 PM, the administrators stated that he/she would expect wound measurements to be completed on admission if the patient had a wound that needed interventions.

Based on policy review, record review, observation, and interview the agency failed to ensure that the medication profile included all medications prescribed by the physician for two (Records/Patients #2 and #3) of eight applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #2: Review of the clinical record showed, in part, the following: -Review of the patient's written medication list posted in the home showed the following medications: *Eliquis 5 milligrams (mg) take one tablet twice daily; and *Lactulose 30 milliliters (mL) every 4 hours until a successful bowel movement, then 30 mL daily for maintenance -Review of the patient's medication list showed that the agency failed to include these medication on their medication profile. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect the medication list to be reconciled and match what is ordered and in place in the home. Findings included: Review of the agencys policy titled, ";Medication Reconciliation," dated 09/27/2021, showed in part that: - On admitting patient to hospice services clinician must review all of the patients prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy; - Meds are reconciled with every home visit, transition of care in which meds ordered or existing orders are rewritten. Reconcile meds by comparing the list in the home, assessing all meds in the home, and compare to med profile (these must match at all times). Any changes to medications or new meds initiated must be added to med profile and list in the home and confirmed with physician; and - If a patient is in a facility the clinician must collaborate with the facility staff at admission and every visit to reconcile meds. RECORD/PATIENT #3: Observation on 01/24/2023 beginning at 9:30 AM, during the patients long term care facility (LTCF) visit, showed the medication profile dated 11/21/2022 and provided to the facility by the agency failed to include the following medications: - Glucagon Emergency Kit (a medication used to raise blood glucose) one milligram (mg) inject one application intramuscularly every 15 minutes as needed for diabetes use if unable to swallow (start date 11/09/2022); and - Proventil HFA Aerosol Solution (a medication used for shortness of breath) 108 (90 base) micrograms (MCG)/ACT two puffs inhale orally every four hours as needed for shortness of breath (start date 11/09/2022). Further observation showed that the following medications on the agencys profile had directions that failed to match the facilitys profile: - Hydrocodone/Acetaminophen (a medication used for pain control) 5/325 mg ½ tablet every six hours as needed for pain was changed to one tablet three times per day and one tablet every four hours as needed on 01/10/2023; - Senna Plus (a medication used for constipation) 8.6/50 mg one tablet two times per day as needed for constipation was ordered on 11/09/2022 as one tablet two times per day scheduled; and - The agency profile included a notation that patient was receiving Novolog insulin (a medication used to lower blood sugar) on a sliding scale- this medication had been discontinued by the physician on 12/23/2022. During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect the medications to be updated with the facility on each visit and to match what the facility had.

Based on policy review, record review, observation, and interview, the agency failed to: - Ensure that each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care (L544); - Develop an individualized plan of care based on problems identified in the initial, comprehensive and updated comprehensive assessments, that included all services necessary for the management of the terminal illness (L545); - Provide medical supplies and appliances necessary to meet the needs of the patient (L550); - Ensure the interdisciplinary group (IDG) reviewed, revised and documented the individualized plan of care as frequently as the patients condition required (L552); and - Ensure that the interdisciplinary group directed, coordinated, and supervised the care and services provided (L554). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview the agency failed to ensure that the patient and primary caregiver received education and training related to safely administering medications in the home in, but not limited to, one (Record/Patient #1) of eight applicable 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 06/17/2021, showed in part, that the hospice will ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care and focused on outcome achievement measures. RECORD/PATIENT #1: Review of the clinical record showed the following: - Patient was admitted to hospice services on 09/16/2022; - The initial skilled nurse (SN) visit dated 09/16/2022 showed that the patient was alert, oriented and forgetful at times; - The designated primary caregiver on the initial SN visit was the patient's daughter; - The initial SN visit showed that the family would manage patient's medications including regimen, capability, and medication reconciliation; - The initial SN visit failed to include that the patient, family, or primary caregiver were instructed on medication regimen, medication side effects, contraindications, and compliance; - The initial SN visit failed to include that the patient, family, or primary caregiver were evaluated for proficiency of medication administration by return demonstration; and - The initial SN visit failed to include that the patient, family, or primary caregiver were instructed on proper storage, special directions and precautions for preparation, self administration, missed doses, and use of medications by the patient in the home. Review of a SN visit dated 01/19/2023 showed under medication management that the daughter or son of the patient set up the medication planner and prefilled syringes of Morphine (a medication used for pain control) and that the patient "was forgetting a lot to take meds." During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect caregiver and patient education to be done on admission and ongoing.

Based on policy review, record review, observation, and interview the agency failed to ensure that the hospice developed an individualized written plan of care for each patient in, but not limited to, two (Records/Patients #2 and #4) of eight applicable records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the policy titled, "Plan of Care," dated 06/17/2021, showed, in part, the following: -The outcome of the policy is to provide individualized, planned, appropriate, and coordinated care in accordance with physician's orders; -Standardized plans of care are not accepted unless each plan is individualized to meet specific needs of the patient and caregiver; -All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the interdisciplinary group (IDG) with the attending physician, if any, the patient or representative and the primary care giver in accordance with the patient's needs; and -The hospice plan of care (POC) must reflect patient and family goals and interventions based on the problems identified in the assessments. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 01/05/2023 with a terminal diagnosis of Alzheimer's Disease and Advanced Dementia. The patient has been bedridden since admission. The patient lived at home with their spouse. Review of the document titled, "Hospice Plan of Care Update," dated 01/05/2023, showed, in part, the following: -An intervention for the hospice aide to change the bed linens every visit; -The patient had Eliquis(an anticoagulant medication used to treat, prevent blood clots and to prevent strokes) listed as a medication; -The patient had an intervention to initiate oxygen and obtain an oxygen order; -The POC failed to contain interventions relating to the Eliquis order; and -The agency failed to obtain an oxygen order for the patient. During an observation on 01/23/2023 beginning at 2:00 PM during at the patient's home, the following was observed: -The patient's spouse had a list left by the agency stating that the bed linens would be changed every Friday rather than every visit; and -The patient's spouse stated that the hospice staff changes the bed linens every Friday as the in-home list states. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect the POC to be individualized for each patient. RECORD/PATIENT #4: Review of the clinical record showed that the patient was admitted to hospice services on 12/17/2022 with a terminal diagnosis of Alzheimer's Disease with Dementia. The patient lived at home. -Review of the hospice aide POC showed that the patient had an intervention to assist the patient with a facial shave every visit; and -Review of hospice aide visit notes show that the intervention was not performed because the patient did not have facial hair. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that the patient was a woman who did not have facial hair. The administrator stated that he/she would expect the plan of care to be individualized to each patient.

Based on policy review, record review, and interview, the agency failed to ensure the POC (plan of care) included medical supplies and appliances necessary to meet the needs of the patient in, but not limited to, one (Record/Patients #8) of eleven record reviews. This deficient practice has the potential to adversely affect the care provided to all the agency's patients. --- Findings included: Review of the agency's policy titled, "Plan of Care," revised 06/17/2021, showed, in part: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the IDT (interdisciplinary team) group with the attending physician, if any, the patient or representative and the primary caregiver in accordance with the patients needs; - The hospice will ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care and focused on outcome achievement and measures; - The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions including the following: * Orders for specific hospice services and disciplines, treatments, procedures (specify amount/frequency/duration); * Interventions to manage pain and symptoms; * Equipment and supply needs; * Family needs; * Safety measures; and - The IDT group must review, revise and document the individualized plan as frequently as the patients condition requires but no less frequently than every 15 calendar days, or in accordance with state regulations (14 days in Missouri). A revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress toward outcomes and goals specified in the plan of care. RECORD/PATIENT #8: Review of the Patient Information Facesheet, dated, 12/30/2022 to 03/29/2023, showed, in part: - Mobility on admission: Requires max [maximum] assist with transfers; PT [patient] able to stand for short time with gait belt and walker. Able to move self in bed; - Patient with history of falls; - Pt very weak and requires maximum assist with ADLs [activities of daily living] and transfers; and - SN [skilled nurse] may assess and order equipment and supplies as needed for safety and control. Review of the SOC (start of care) comprehensive assessment, dated, 12/30/2022, showed, in part: - Concerns expressed by CG (caregiver), had, ";CG elderly and has assist of granddaughter and son but cannot lift PT or assist with transfers," noted; - Musculoskeletal mobility with ";chair bound" listed; - Patient requires complete assistance of two people to transfer; - Equipment required for wheelchair mobility with BRODA [a type of wheelchair that offers tilt, recline, and leg rest adjustments for people with long-term assistance needs] listed; and - DME (durable medical equipment) of gait belt, hospital bed, side rails, over-bed table, walker, and BRODA chair were listed as DME the patient had in the home. Review of the telephone visit note, dated, 01/03/2023, showed, in part: - RN (registered nurse) received a page from the hospice office that family were requesting help with a lift ASAP [as soon as possible]; - The bath aide was present but not able to safely transfer the patient; - [Named DME company] coming in 1 [one] hour to switch the bed but the patient could not get out of bed; - RN called [named company] and they [DME company] said the Hoyer lift [an assistive device that allows patients to be transferred between a bed and a chair by the use of electrical or hydraulic power] delivery was canceled in the morning by the office [hospice]; - RN said that tomorrow RN could instruct family and use the Hoyer lift to get pt out of bed into broda [a type of wheelchair that offers tilt, recline, and leg rest adjustments for people with long-term assistance needs] chair; and - Note: No documentation of visit being made on 01/03/2023, as requested by the family. Review of the clinical record showed a need for a hoyer lift and no documentation in the record to show a hoyer lift being ordered and/or delivered. Review of the POC (plan of care), dated 12/30/2022 to 03/29/2023, showed N/A [not applicable], for DME [durable medical equipment] and supplies. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - Equipment is ordered prior to patient discharge from the hospital so it is in the home upon patient arrival; - The hoyer lift was not listed as DME in the patients home on admission and not on the plan of care; - All DME should be listed on the patients plan of care; and - He/she was unaware of the hoyer lift delivery being canceled.

Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary group (IDG) reviewed, revised and documented the individualized plan of care as frequently as the patients condition required in, but not limited to, one (Record/Patient #9) of eleven 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, "Hospice Coordination of Care," reviewed 06/15/2021, showed, in part: - On-going verbal or written communication regarding care or services which includes significant changes in the patients overall care, patients needs, goals, care or services to be provided, and/or physicians orders will occur between members of the IDT (interdisciplinary team) and on-call services by means of IDT meeting; - On-going communication, when indicated, will occur between hospice staff and the patients physician, or between the IDT and the patients physician as appropriate to the care of the patient; - Communication will occur: * When there are changes in the patients condition; * When changes occur in the patients expected response to treatment or medication; * When changes occur in caregiver support or environment of care; and - The organization will coordinate referral/transfer as appropriate to meet patient/family needs. Review of the agency's policy titled, "Plan of Care," revised 06/17/2021, showed, in part: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the IDT group with the attending physician, if any, the patient or representative and the primary caregiver in accordance with the patients needs; - The hospice will ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care and focused on outcome achievement and measures; - The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions; and - The IDT group must review, revise and document the individualized plan as frequently as the patients condition requires but no less frequently than every 15 calendar days, or in accordance with state regulations (14 days in Missouri). A revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress toward outcomes and goals specified in the plan of care. RECORD/PATIENT #9: Review of the skilled nurse visit note, dated, 01/05/2023, with a start time of 1:30 PM, showed, in part: - Cardiovascular assessment with dyspnea on exertion, fatigues easily, palpitations, edema, and decreased pulses (Edema is a new symptom since SN visit the previous day); - Respiratory assessment with cough and shortness of breath (Cough is a new symptom since previous visit); - Respiratory effort with increased effort (Increased effort is a new symptom since previous visit); - Breath sounds with decreased sounds with rhonchi (Continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation) noted in RUF, RMF, RLF, LLF [left lower field], and LUF (Rhonchi is a new symptom since SN visit the previous day); - Oxygen saturation of 90% (decreased from 94% the previous day); - Pulse of 140 beats per minute (Increased from 72 beats per minute the day before); - Constant, sharp, abdomen pain rated 7/10 (Pain was intermittent the day before and now constant); and - No documentation of physician notification. Review of the clinical record showed, a document titled, "Telephone Encounter," dated, 01/05/2023, with a time of 8:18 PM, showed, in part: - Granddaughter calls into on-call to report new onset of RLE (right lower extremity) swelling and deep purple discoloration; - Granddaughter reports that pt RLE has an increase in deep purple color and are ";ice cold" to touch; and - Both patient and granddaughter request nursing visit this evening to assess d/t [due to] above concerns. Review of an email from the On-call RN, to the agency administration, dated, 01/05/2023, at 9:57 PM, showed, in part: - RN received a call from the on-call afterhours stating this patient is requesting a nurse visit due to swelling and [his/her] bil [bilateral-both] feet turning purple; - RN called pt cg [caregiver] who voiced [he/she] has swelling to [his/her] BLE [bilateral lower extremities] but the right leg is worse than the left; - Granddaughter voiced feet are no longer purple; - RN asked if the patient was having any pain and patient stated [his/her] left knee was hurting; - The granddaughter voiced the patients Lasix [furosemide] was increased today and the patient is scheduled to take a double dose in the AM (No documentation of a physician order found in the record); - The RN discussed ";possibly some ace wraps to aide in edema management also;" - The RN discussed the plan for tonight to stay in bed with elevation, take Lasix in the AM, and order the ace wrap to aide in edema management; and - Ace wraps ordered (No physician orders for ace wraps). Review of the skilled nurse visit note, dated, 01/09/2023, with a start time of 11:30 AM, showed, in part: - Cardiovascular assessment with dyspnea on exertion, fatigues easily, palpitations, edema, mottling, lower extremity pain, and decreased pulses (Mottling and lower extremity pain is a new symptom since SN visit 4 days prior); - Edema to +4 (8mm of depression, rebounding in 2-3 minutes) pitting edema to right foot, +4 pitting edema to left foot, +3 edema to right ankle, +3 edema left ankle, +1 edema to left thigh and +1 edema to right thigh (Right and left foot edema increased from +3 edema since last SN visit 4 days prior); - Respiratory assessment with cough and shortness of breath; - Respiratory effort with increased effort; - Breath sounds with decreased sounds with rhonchi noted in RUF, RMF, RLF, LLF, and LUF; - Integumentary assessment with pale, mottling listed for color and purple discoloration to soles of feet noted in comments; - Caregiver assessment section with caregiver name and relationship; - Stress factors included lack of caregivers and lack of knowledge; - [Caregiver] is supportive and has many questions regarding care, does not seem to be completely on hospice page at this time; and - A wound assessment was completed for a stage 2 wound to buttocks measuring 1.6 CM (centimeters) in length, 1 cm in width (wound is new since last SN visit 4 days prior). Review of the clinical record failed to show: - Coordination of care regarding significant changes in condition; - Orders for ace wraps; and - An updated plan of care to include interventions specific to the patient and family needs after significant changes in condition. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - The on call nurse should have made a visit to assess the patient; - No documentation of physician notification regarding change in condition to include increased edema, deep purple discoloration, and extremity ";ice cold" to touch; - No orders received for ace wraps; - The patients past medical history did include a history of blood clots and no visit was made by the nurse to assess the patient prior to recommending ace wraps to lower extremities; - The on call nurse should have made a visit to assess the patient and then contacted the physician to obtain orders prior to recommending the patient wrap legs with ace wraps; - He/she would expect the on call nurse to make a visit anytime a patient or family requests a visit; and - The patient should have received a follow up visit at least on 01/06/2023 or 01/07/2023 to assess the patients condition instead of the patient going 4 days between visits after having a significant change in condition.

Based on policy review, record review, and interview, the agency failed to ensure that the interdisciplinary group (IDG) directed, coordinated, and supervised the care and services provided in, but not limited to, one (Record/Patient #10) of eleven records reviewed. This deficient practice has the potential to affect the care provided to all patients on service with the hospice provider. --- Findings included: Review of the agency's policy titled, "Hospice Coordination of Care," reviewed 06/15/2021, showed, in part: - Coordination and scheduling care or services will include efforts to minimize staff changes in providing care; - On-going verbal or written communication regarding care or services which includes significant changes in the patients overall care, patients needs, goals, care or services to be provided, and/or physicians orders will occur between members of the IDT (interdisciplinary team) and on-call services by means of IDT meeting; - On-going communication, when indicated, will occur between hospice staff and the patients physician, or between the IDT and the patients physician as appropriate to the care of the patient; - Communication will occur: * When there are changes in the patients condition; * When changes occur in the patients expected response to treatment or medication; * When changes occur in caregiver support or environment of care; and - The organization will coordinate referral/transfer as appropriate to meet patient/family needs. Review of the agency's policy titled, "Physician Orders," reviewed 06/11/2021, showed, in part: - Agencies will obtain physician orders for all patient care services including treatments, procedures and equipment before such services are furnished; - The ordering physician will be contacted when there is a change in patient condition or response to care requiring new or modified orders for care or service; - Every telephone or verbal order requires a live person interaction between the ordering physician (or responsible physician office staff member) and the person receiving the order(s) so that clarification may be requested when necessary; and - The agency will provide care and services in accordance with the most recent physician orders. Review of the agency's policy titled, "Discharge Criteria, Process, ABN, HHCCN, and Notice to Patients," revised 06/16/2021, showed, in part: - A patient will be discharged when one or more of the following conditions exist: * When it is discovered that the patient is not terminally ill; * When a patient revokes their hospice benefit; and * When a patient moves out of the service area or transfers to another hospice including when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract, and the hospice is unable to access the patient to provide hospice services; - If a patient will be discharged from the hospice program, whenever possible, the patient will be notified at least three (3) working days in advance (preferably two (2) weeks in advance) of the reason for and date of discharge; - When discharging all services to a patient receiving traditional Medicare and Medicare Advantage covered services, at least 2 day notice is required. Communication of pending discharge plans will be documented in the clinical record. When indicated, a plan will be developed or a referral made for any required continuing care; - Services shall not be terminated until such time as disciplines providing care and the patients physician, if applicable, deem it appropriate and arrangements are made for continuing care, if necessary; - A discharge summary is to be completed when a patient is discharged from services. It is the responsibility of the case manager/supervisor to ensure that the clinical record is complete including the discharge summary; - The discharge summary will be sent to the physician when it is a live discharge (i.e. revoke, transfer to another hospice, discharge due to no longer meeting criteria) and incorporated into the medical record; - Patients requiring continuing care will receive assistance in arranging for such services before home/hospice services are discontinued; and - Hospice will notify the physician in all instances of discontinuance of hospice care and such notification shall be documented in the patient record. Review of the agency's policy titled, "Plan of Care," revised 06/17/2021, showed, in part: - All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the IDT group with the attending physician, if any, the patient or representative and the primary caregiver in accordance with the patients needs; - The hospice will ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care and focused on outcome achievement and measures; and - The IDT group must review, revise and document the individualized plan as frequently as the patients condition requires but no less frequently than every 15 calendar days, or in accordance with state regulations (14 days in Missouri). A revised plan of care must include information from the patients updated comprehensive assessment and must note the patients progress toward outcomes and goals specified in the plan of care. RECORD/PATIENT #10: Review of the most recent Hospice Certification of Terminal Illness, dated 11/09/2022, showed, in part: - Terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a chronic condition in which the heart doesnt pump blood as well as it should); - Other past medical history includes: End stage heart failure, ischemic cardiomyopathy and dementia; - Since last recertification the patient had worsening dementia; - Developed covid-19 in August and still short of breath; and - Dyspnea (shortness of breath) at rest and with minimal activity with need to wear oxygen at 3 LPM via nasal cannula intermittently since covid-19. Review of the hospice face to face encounter, dated, 12/29/2022, showed, in part: - Patient alert and oriented x2; - Unable to answer questions regarding month, day, year, or where [he/she] was at; - Respirations 24 pausing after 6 to 8 words to catch [his/her] breathe; - A few audible crackles in both upper lobes, breathe sounds diminished in bases; - Patient able to ambulate slowly with assistance; - 1+ (up to 2mm of depression, rebounding immediately) edema on left foot; - Diagnoses: Hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a chronic condition in which the heart doesnt pump blood as well as it should); - Other past medical history includes: End stage heart failure, ischemic cardiomyopathy (heart can no longer pump enough blood to the rest of the body due to narrowing of the small blood vessels) and dementia (general term for loss of memory, problem-solving and other thinking abilities that are sever enough to interfere with daily living); - Continue hospice service and ensure comfort measures; - Follow up with primary care nurse to obtain weight; - The Nurse Practitioner attested to the face to face encounter with the patient on 12/29/2022; and - Addendum: January 4, 2022- Follow up conversation with [named physician] and the patients primary care nurse. We [agency staff] discussed [patient] recent health changes which included clear lungs, ability to go grocery shopping with [his/her] daughter in law, and increased participation in activities of daily living. It was decided that [he/she] was no longer appropriate for hospice services and discharge planning would commence (Assessment by SN on 01/03/2023 showed decreased lung sounds and rhonchi noted. No documentation in SN visit regarding increased activity tolerance and/or shopping with daughter in law). Review of the Home Care Update from the IDT (interdisciplinary team) meeting on 01/04/2023, showed, in part: - ";Discussed patient care, all in agreement with POC," was noted in the additional note section, on 01/04/2023 at 4:41 PM, by the administrator designee; - Medical director notes section had no notes created for current plan; - RN A entered a late entry note on 01/24/2023 at 10:36 AM with, ";Patient planned to be discharged on 01/10/2023. Reviewed plan of care with IDT team. All in agreement. Pt is no longer terminally ill. Patient denies pain, shortness of breath at time of recent visits. Plan to reach out to [named physician] to arrange post-discharge patient care. Patient medications reordered for 2 week period. DME will be scheduled to be picked up post discharge" (Late entry was made 14 days after patient was discharged); - MSW entered a late entry note on 01/24/2023 at 12:12 PM, with, ";Per CM [RN A], PT will likely discharge from hospice in the next 1-2 weeks. MSW is working with family and CM to ensure continuity of care for PT. Pts son to contact PCP [primary care provider] to re-establish care. PT has prepaid funeral plans. PT is a veteran. No further MSW follow up planned. However, MSW will remain available to PTs son if he has needs/concerns after PT discharge. PTs son has MSWs contact info [information];" - Chaplain entered a late entry note on 01/24/2023 at 10:44 AM, with, ";Patient was discussed in IDT for having met goals and is now stable. Patient will be discharged as hospice services are no longer needed at this time. Chaplain services had been declined. 1/4/23;" and - All notes regarding patient discharge were entered after the start of survey. Review of the clinical record failed to show: - Physician order for discharge; - Notice of termination of hospice benefits signed by the physician decertifying the terminal illness (Administrator designee obtained a copy from the hospice physician on 01/26/2023); - No documentation of IDG (interdisciplinary group) coordination of care that included the hospice attending provider; - No documentation of coordination of care with a primary care provider who would be responsible for providing care and services to the patient after discharge. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - All communications should be documented in the medical record; - He/she would expect the nurse to assist the patient and family with all post-discharge needs; and - He/she is able to see the primary care providers records in the system and there is no record of the nurse contacting the PCP [primary care provider] to arrange post-discharge needs of the patient. During an interview, with the medical assistant for the primary care provider, on 01/26/2023, beginning at 4:18 PM, the medical assistant stated that: - No documentation of calls or faxes received from the agency [hospice] regarding the patient; - The patients son sent a fax to the office [PCP office] on 01/16/2023 asking if the doctor would pick the patient back up since [he/she] is no longer on hospice and patient needing oxygen (6 days after hospice discharge); - The doctor agreed to restart care and sent a referral to pulmonology for oxygen supplies; and - The patient has an appointment with the doctor on 01/31/2022 to re-establish care (3 weeks after hospice discharge).

Based on policy review, record review, and interview the agency failed to ensure that the nursing needs of the patient were met in five (Records/Patients #1, #3, #5, #8, and #9) of 11 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, "Skilled Nursing Services" dated 05/21/2021, showed in part: - The skilled nurse evaluates and regularly reevaluates the patient's nursing care needs; and - The skilled nurse observes signs and symptoms, records, and reports reactions to treatments to the physician. This includes drugs as well as changes in the patient's physical or emotional condition. RECORD/PATIENT #1: Review of the clinical record showed: - Skilled Nurse (SN) visit dated 01/02/2023 showed the following respiratory assessment: * Patient complained of shortness of breath after ambulating less than 10 feet and while speaking; * Lung sounds were diminished to no airflow; * No edema (swelling) was noted; and * Patient was using supplemental oxygen at three liters per minute. - SN visit dated 01/05/2023 showed the patient continued to be short of breath after ambulating and no respiratory assessment was completed. - SN visit dated 01/09/2023 showed the following respiratory assessment: * Patient complained of shortness of breath and non-productive cough; * Patient was tachypneic (breathing that is abnormally rapid and often shallow); * Lung sounds were decreased and with crackles (lung sounds that indicate air sacs in the lungs contain fluid) in all fields and patient had trace edema; and * Patient was using supplemental oxygen at three liters per minute. - Review of the interdisciplinary group (IDG) notes dated 01/05/2023 to 01/18/2023 failed to show changes in lung sounds, new onset of edema, or changes in respiratory pattern. - The agency failed to provide any updated IDG notes after 01/09/2023, a physician's order, or SN that showed that the physician was notified of changes in patient's condition. During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect the physician to be notified of changes in the patient's condition. RECORD/PATIENT #3: Review of the clinical record showed: - The SN initial assessment, dated 11/21/2022, showed that the patient had a Foley catheter (a tube inserted into the bladder to drain urine) draining hazy, tea colored and occasionally bloody urine. - Review of the SN, dated 01/10/2023, showed that: * The patient's Foley catheter was draining cloudy, orange colored urine with blood clots, sediment, and red flecks and that the urine was malodorous; * The patient requested an increase in his/her pain medication; * The patient was complaining of lower abdominal tenderness; and * The patient had a blood pressure of 90/50. - Review of the IDG notes, dated 01/12/2023 to 01/25/2023, failed to show the changes in the appearance and odor of the patient's urine and the complaint of lower abdominal tenderness. - The agency failed to provide a physician's order or SN that showed that the physician was notified of changes in the patient's condition. During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect the physician to be notified of changes in the patient's condition. Findings included: Review of the agency's policy titled, "On-Call Services," revised 05/24/2021, showed, in part: - All on-call personnel will be instructed in procedures prior to being on-call and will be provided with necessary patient information and equipment for use while on-call; - The on-call nurse will complete documentation in the patients record regarding each after hours clinical call including the time the call was received and the outcome; - For hospice non-emergent calls visits will be made within three hours from the time the need is identified; - Upon returning a patients call, the on-call nurse will: * Make an inquiry regarding the nature of the problem; * Review the patients orders/plan of care; and * Make a clinical judgment regarding the immediate plan of treatment. Review of the agency's policy titled, "Assessment of Patient and Client," reviewed 06/21/2021, showed, in part: - A comprehensive assessment update must be accomplished as frequently as the patients condition requires, but no less frequently than every 14 days, or in accordance with applicable state regulations; - There is evidence of communication to the physician regarding the patients condition; - The revised plan of care must note the patients progress toward outcomes and goals specified in the plan of care; - If new or revised patient treatment goals are indicated, they must be reflected in a revised plan of care; and - Revised plans of care are approved by the patients physician. RECORD/PATIENT #5: Review of the updated POC (plan of care), dated, 01/05/2023, showed, in part: - Alt [alterations] in cardio/pulm cardiopulmonary] goal: adequate ventilation and cardiac output based on disease process. - Medication profile goal: Patient/family/caregiver/facility will be knowledgeable and compliant with medication regimen. Daughter is caregiver and managing medications. She is an RN [registered nurse], competent and compliant with medications; and - Medications were reviewed for hospice appropriateness in collaboration with hospice medical director, nurse practitioner, and or pharmacist. Review of the POC, dated, 01/01/2023, showed, in part: - Alt in cardio/pulm goal: adequate ventilation and cardiac output based on disease process. - Medication profile goal: Patient/family/caregiver/facility will be knowledgeable and compliant with medication regimen. Daughter is caregiver and managing medications. She is an RN, competent and compliant with medications; and - Medications were reviewed for hospice appropriateness in collaboration with hospice medical director, nurse practitioner, and or pharmacist. Review of the skilled nurse visit note, dated, 01/18/2023, showed, in part: - Blood pressure 173/115; - Caregiver had not given AM [morning] medication; and - No documentation of physician notification for high blood pressure. Review of the skilled nurse visit note, dated, 01/11/2023, showed, in part: - Blood pressure 175/116; - Daughter manages medications; - Medication management WNL [within normal limits], takes medications as ordered, knows purpose, basic side effects and adverse reactions. Knows how to reorder medications without need of lab test for medication monitoring, and without new meds [medications] within past month; and - No documentation of physician notification for high blood pressure. Review of the skilled nurse visit note, dated, 01/04/2023, showed, in part: - Blood pressure 170/111; - Daughter manages medications; - Medication management WNL [within normal limits], takes medications as ordered, knows purpose, basic side effects and adverse reactions. Knows how to reorder medications without need of lab test for medication monitoring, and without new meds [medications] within past month; and - No documentation of physician notification for high blood pressure. Review of the skilled nurse visit note, dated, 01/02/2023, showed, in part: - Blood pressure 154/108; - Daughter manages medications; and - No documentation of physician notification for high blood pressure. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - He/she would expect to see documentation of education provided; - He/she would expect to see the blood pressures discussed in the IDG (interdisciplinary group) meetings; and - Usually the physicians will wait until 3 (three) or 4 (four) high blood pressure readings before making adjustments. RECORD/PATIENT #8: Review of the Patient Information Facesheet, dated, 12/30/2022 to 03/29/2023, showed, in part: - Mobility on admission: Requires max [maximum] assist with transfers; PT [patient] able to stand for short tine with gait belt and walker. Able to move self in bed; - Patient with history of falls; - Pt very weak and requires maximum assist with ADLs [activities of daily living] and transfers; and - SN [skilled nurse] may assess and order equipment and supplies as needed for safety and control. Review of POC (plan of care), dated 12/30/2022 to 03/29/2023, showed N/A [not applicable], for DME [durable medical equipment] and supplies. Review of the SOC (start of care) comprehensive assessment, dated, 12/30/2022, showed, in part: - Concerns expressed by CG (caregiver) had, ";CG elderly and has assist of granddaughter and son but cannot lift PT or assist with transfers," noted; - Musculoskeletal mobility with ";chair bound" listed; - Patient requires complete assistance of two people to transfer; - Equipment required for wheelchair mobility with BRODA [a type of wheelchair that offers tilt, recline, and leg rest adjustments for people with long-term assistance needs] listed; - DME (durable medical equipment) of gait belt, hospital bed, side rails, over-bed table, walker, and BRODA chair were listed as DME the patient had in the home; and - Referral initiated for hospice social worker services with a comment of ";Wife/CG needs further assist in home with daily care. Please follow up with possible paid CG resources and Thank you." Review of the clinical record failed to show a 48 (forty-eight) hour follow up visit being made. Review of the skilled nurse visit note, dated, 01/01/2023, showed, in part: - Vital signs were obtained; - Pain was assessed; - No documentation of full assessment, interventions, and/or education provided to patient and/or caregiver during the visit. Review of the skilled nurse visit note, dated, 01/02/2023, showed, in part: - The RN (registered nurse) made a visit upon family request due to catheter drainage bag clamp being broke; - Visit encounter notes with, ";CG had questions about the patients insulin. RN educated on use of insulin pump [small device that delivers insulin through a thin tube under the skin] decreasing blood sugar because of the basal rate [the rate at which an insulin pump infuses small doses of short-acting insulin], and that pts [patients] appetite may change day to day. CG verbalized understanding. CG was concerned BG [blood glucose-amount of sugar in the blood] had been high, which it had been >300 [over 300] in the last two days. RN referred to the endocrinologists Novolog (fast acting insulin) sliding scale (the dose of insulin based on the blood glucose level) instructions and asked family to follow it as well as keep a log of what is eaten so that carb [carbohydrates] intake is recorded. RN said the log would be relayed to endocrinologist. CG verbalized understanding," noted in the nurses summary; and - No documentation of follow up with an endocrinologist. Review the telephone visit note, dated, 01/03/2023, showed, in part: - RN received a page from the hospice office that family were requesting help with a lift ASAP [as soon as possible]; - The bath aide was present but not able to safely transfer the patient; - [Named DME company] were coming in 1 [one] hour to switch the bed but the patient could not get out of bed; - RN called [named company] and they said the Hoyer lift [an assistive device that allows patients to be transferred between a bed and a chair by the use of electrical or hydraulic power] delivery was canceled in the morning by the office [hospice]; - RN said that tomorrow RN could instruct family and use the Hoyer lift to get pt out of bed into broda chair; and - No documentation of visit being made on 01/03/2023, as requested by the family. Review the skilled nurse hospice discharge note, dated, 01/04/2023, showed, in part: - CG notified hospice that pt would be transferred to another hospice service; - Office notified equipment company; - [Named hospice agency] called office to say equipment would be delivered today [01/04/2023] and that [named company] should come this afternoon to pick up their equipment; - Office contacted [named DME company] to let them know; and - Reason for discharge had, transferred to another hospice, listed. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - Equipment is ordered prior to patient discharge from the hospital so it is in the home upon patient arrival; - The hoyer lift was not listed as DME in the patients home and not on the plan of care; - All dme should be listed on the patients plan of care; - He/she was unaware of the hoyer lift delivery being canceled; - He/she would expect a nurse to be present when DME is delivered and the CG is unable to assist with transferring the patient; - The patient did not receive a 48 hour follow up and she have at least received a telephone visit; - He/she is unsure why the patient did not receive a follow up visit; and - He/she would expect the nurse to make a visit anytime a visit is requested by the patient or family. RECORD/PATIENT #9: Review of the SOC (start of care) comprehensive assessment, dated, 01/04/2023, with a start time of 1:45 PM, showed, in part: - Cardiovascular assessment with dyspnea (shortness of breath) on exertion, fatigues easily, palpitations, decreased pulses; - Edema (swelling caused by excess fluid trapped in the bodys tissues) section was left blank; - Respiratory assessment with shortness of bre ath; - Respiratory effort is normal; - Breath sounds with decreased sounds in RUF [right upper field], RMF [right middle field], RLF [right lower field], and LUF [left upper field]; - Daughter is both competent and very supportive. [Spouse] has dementia; - Oxygen saturation (the amount of oxygen circulating in the blood) of 94% (normal range is 95 to 100%); - Pulse of 72 beats per minute (normal for healthy adults ranges from 60 to 100); - Intermittent (occurring at irregular intervals, not continuous or steady), sharp, abdomen pain rated 6/10 (0 being no pain and 10 being the worst pain); - Was physician aware or notified of the pain? Was marked with ";aware;" and - Patient will need ongoing support to encourage use for adequate pain control and relief of side effects. Review of the skilled nurse visit note, dated, 01/05/2023, with a start time of 1:30 PM, showed, in part: - Cardiovascular assessment with dyspnea on exertion, fatigues easily, palpitations, edema, and decreased pulses (Edema is a new symptom since SN visit the previous day); - Edema +3 (Edema scale measured by applying pressure on the affected area and then measuring the depth of the pit and how long it lasts to rebound or return. Grade +3 is 5-6mm (millimeters) depression and rebounding in 60 seconds) pitting (when pressure is applied to the swollen area, a pit or indentation will remain) to right foot, +3 pitting edema to left foot, +3 edema to right ankle, +3 edema left ankle, +2 (3-4mm of depression, rebounding in 15 seconds or less) edema to left thigh and +2 edema to right thigh; - Respiratory assessment with cough and shortness of breath (Cough is a new symptom since previous visit); - Respiratory effort with increased effort (Increased effort is a new symptom); - Breath sounds with decreased sounds with rhonchi (Continuous gurgling or bubbling sounds typically heard during both inhalation and exhalation) noted in RUF, RMF, RLF, LLF [left lower field], and LUF (Rhonchi and LLF is new since last visit); - Oxygen saturation of 90% (decreased from 94% the previous day); - Pulse of 140 beats per minute (Increased from 72 beats per minute the day before); - Constant, sharp, abdomen pain rated 7/10 (Pain was intermittent the day before and now constant); and - No documentation of physician notification. Review the telephone encounter note, dated, 01/05/2023, with a time of 8:18 PM, showed, in part: - Granddaughter calls into on-call to report new onset of RLE (right lower extremity) swelling and deep purple discoloration; - Granddaughter reports the pt [patient] did lay down on [his/her] couch all afternoon with both legs elevated without any decrease in swelling; - Denies any current or prior use of compression stockings; - Reports currently sitting up in [his/her] WC [wheelchair] and writer (RN D) strongly recommended laying down with elevation of BLE [bilateral lower extremities] again to reduce swelling; - Educated on common s/s [signs and symptoms] of CHF [congestive heart failure] and fluid retention; - Granddaughter reports that pt RLE has an increase in deep purple color and are ";ice cold" to touch; - Pt denies pain or chest pain and reports that family administered Morphine [narcotic pain medication] 15 min [minutes] ago; - Granddaughter reports that pt is taking all of [his/her] medications as ordering including todays [01/05/2023] dose of Furosemide [Diuretic medication to reduce swelling caused by fluid retention]; - Both patient and granddaughter request nursing visit this evening to assess d/t [due to] above concerns; and - Writer [RN D] contacted on-call RN (registered nurse) and report provided. Review of an email from the on-call RN, to the agency administration, dated, 01/05/2023, at 9:57 PM, showed, in part: - RN received a call from the on-call afterhours stating this patient is requesting a nurse visit due to swelling and [his/her] bil [bilateral] feet turning purple; - RN called pt cg who voiced [he/she] has swelling to [his/her] BLE but the right leg is worse than the left; - He/she also voiced [his/her] left foot was feeling numb prior to RN retuning [his/her] call; -Patient voiced the numbness has resolved; - The granddaughter voiced the patient has been sitting up all day with legs elevated; - Patient got in the bed 20 minutes prior to RN calling; - Granddaughter voiced feet are no longer purple; - RN asked if the patient was having any pain and patient stated [his/her] left knee was hurting; - Per granddaughter, pt refused [his/her] 30 mg (milligrams) MSER (morphine sulfate extended release) earlier but did take evening dose; Patient took 1 dose of MSIR (morphine sulfate immediate release) 15 MG early this AM (morning); - RN encouraged patient to take the MEIR [MSIR] 15 MG now as it is more of an instant release; - Patient voiced [his/her] pain is not the issue; - ";So we focused back on the swelling;" - The granddaughter voiced the patients Lasix [furosemide] was increased today and the patient is scheduled to take a double dose in the AM (No documentation of physician being notified and medication dose increase); - The RN discussed ";possibly some ace wraps to aide in edema management also;" - Pt agreed and RN will place an order for the ace wrap; - The granddaughter voiced her feet are no longer purple since the patient laid down; - The RN discussed the plan for tonight to stay in bed with elevation, take Lasix in the AM, and order the ace wrap to aide in edema management; - CM please follow up with a telephone call on 01/06/2023; - No in person visit needed at this time; - CG instructed to call hospice back if pt feet turn purple, pain increase, pt develops SOB [shortness of breath] or any other concerns; - Granddaughter voiced understanding; and - Ace wraps ordered (No order was place and no documentation of physician notification to obtain an order). Review the telephone visit note, dated, 01/06/2023, showed, in part: - RN spoke with the patients daughter who stated the edema and purpling of toes and knees has ";resolved somewhat" with increased dosage of Lasix and elevation; - Caregiver unhappy about HHA [hospice aide] visit not happening and she called the office to voice her disappointment; - Visits were scheduled but not assigned; - RN apologized and attempted to rectify the situation; - RN called pharmacy to resolve medication misunderstanding; - Caregiver purchased over the counter guaifenesin (used to relieve chest congestion) as pharmacy did not have in supply; - Other medication issue was a moot point (No documentation of what the other medication issue was); - Lasix dosage was doubled but caregiver had plenty in home; - Caregiver thought she was picking up Lasix at the pharmacy; and - Follow up: Spoke with [named employee] at the office who stated orders had not been signed so the aide visits were not assigned. Review of the telephone communication note, dated, 01/07/2023, showed, in part: - Call received from patients [spouse] regarding lack of visits; - Only seen by one person since 01/04/2023 (The admission visit and the second day follow up visit were done by the same RN); - The CNA [certified nurse aide] and the MSW [medical social worker] are on the schedule for Monday 01/09/2023; - [Spouse] reported visit not needed today but may want one tomorrow if possible; - [Spouse] was asked if an urgent visit is needed this weekend and reported they [patient and spouse] can wait until Monday; - Message sent to the care team to follow up on Monday 01/09/2023; and - RNCM [Registered nurse case manager]: Please ensure at least a follow up call is completed on Monday 1/9/23, and also complete some education with patient and [spouse] about frequency of visits in the future. [Spouse] has stated that with [his/her] mother, ";hospice was showing up every other day at least!" I [RN F] did discuss with [spouse] that each patient will need a different frequency of visits depending on how they are doing, but please discuss expectations." Review of the skilled nurse visit note, dated, 01/09/2023, with a start time of 11:30 AM, showed, in part: - Cardiovascular assessment with dyspnea on exertion, fatigues easily, palpitations, edema, mottling, lower extremity pain, and decreased pulses (Mottling and lower extremity pain is a new symptom since SN visit 4 days prior); - Edema to +4 (8mm of depression, rebounding in 2-3 minutes) pitting edema to right foot, +4 pitting edema to left foot, +3 edema to right ankle, +3 edema left ankle, +1 edema to left thigh and +1 edema to right thigh (Right and left foot edema increased from +3 edema since last SN visit 4 days prior); - Respiratory assessment with cough and shortness of breath; - Respiratory effort with increased effort; - Breath sounds with decreased sounds with rhonchi noted in RUF, RMF, RLF, LLF, and LUF; - Integumentary assessment with pale, mottling listed for color and purple discoloration to soles of feet noted in comments (new assessment findings since last SN visit 4 days prior); - Caregiver assessment section with caregiver name and relationship of daughter; - Stress factors include lack of caregivers and lack of knowledge; - Daughter is supportive and has many questions regarding care, does not seem to be completely on hospice page at this time; and - A wound assessment was completed for a stage 2 wound to buttocks measuring 1.6 CM (centimeters) in length, 1 cm in width (wound is new since last SN visit 4 days prior). Review of the clinical record failed to show: - Coordination of care regarding significant change in condition; - Physician notification regarding significant change in condition with each skilled nurse visit; and - An updated plan of care to include interventions specific to the patient and family needs after significant change in condition. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - The on call nurse should have made a visit to assess the patient; - No documentation of physician notification regarding change in condition to include increased edema, deep purple discoloration, and extremity ";ice cold" to touch; - No orders received for ace wraps; - The patients past medical history did include a history of blood clots and no visit was made by the nurse to assess the patient prior to recommending ace wraps to lower extremities; - The on call nurse should have made a visit to assess the patient and then contacted the physician to obtain orders prior to recommending the patient wrap legs with ace wraps; - He/she would expect the on call nurse to make a visit anytime a patient or family requests a visit; and - The patient should have received a follow up visit on 01/06/2023 or 01/07/2023 to assess the patients condition instead of the patient going 4 days between visits after having a significant change in condition.

Based on policy review, record review, and interview, the agency failed to ensure that the hospice aide provided services that were ordered by the Interdisciplinary Group (IDG) and included in the plan of care in, but not limited to, two (Records/Patients #2 and #9) of eleven 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, "Certified Nursing Assistant, Post Acute," dated 12/15/2022 showed, in part, the following: -Receives patient care assignment from the registered nurse (RN) in charge. Initiates delegated tasks based on demonstrated competence in performing nursing activities for specific patient age group served; and -Answers patient's calls for help, takes their vital signs, and monitors their behavior and physical condition for progress or deterioration. RECORD/PATIENT #2: Review of the clinical record showed that the patient was admitted to hospice services on 01/05/2023 with a terminal diagnosis of Alzheimer's Disease. The patient lived at home. -Review of the hospice aide plan of care showed that that aide was to change the bed linens of the patient every visit. During an observation on 01/23/2023 beginning at 2:00 PM during at the patient's home, the following was observed:-The patient's spouse had a list left by the agency stating that the bed linens would be changed every Friday rather than every visit; and-The patient's spouse stated that the hospice staff changes the bed linens every Friday as the in-home list states. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect for the aide care plan to be followed as ordered. RECORD/PATIENT #9: Review of POC (plan of care), dated 01/04/2023 to 01/18/2023, showed, in part: - Home Health Aide [hospice aide], 2 visits every week for 13 weeks with dates of 01/04/2023 to 04/01/2023; - Not currently on O2 [oxygen]; - Dyspnea (shortness of breath) with activity was mild on admission with 1 or 2 minutes recovery time; - Patient is continent of bowel and bladder; - Home Health Aide (Hospice Aide) to: * Assist patient with personal cares as directed; * Assist repositioning; * Change bed linens; * Tidy patient area; * Aide to assist patient with elimination needs as directed; * Catheter (a flexible tune inserted into the bladder through the urethra and used to drain urine from the bladder) care- cleanse skin and catheter tuning with soap and water, empty bag, and measure and record output; * Observe urine and patient, and * Record observations and report any observations or patient-reported concerns to the RN; * Assist with personal cares as directed; * Assist with bath. Acceptable location(s): bed and chair; * Assist with upper and lower clothes; * Assist with lotion; * Perform hair care using comb or brush; and - All disciplines to involve patient and caregiver in the development of the plan of care. Review the telephone visit note, dated, 01/06/2023, showed, in part: - Caregiver unhappy about HHA [hospice aide] visit not happening and she called the office to voice her disappointment; - Visits were scheduled but not assigned; - RN apologized and attempted to rectify the situation; and - Follow up: Spoke with [named employee] at the office who stated orders had not been signed so the aide visits were not assigned. Review of the telephone communication note, dated, 01/07/2023, showed, in part: - Call received from patients [spouse] regarding lack of visits; - Only seen by one person since 01/04/2023 (The admission visit and the second day follow up visit were done by the same RN); - The CNA [certified nurse aide] and the MSW [medical social worker] are on the schedule for Monday 01/09/2023; - Message sent to the care team to follow up on Monday 01/09/2023; and - RNCM [Registered nurse case manager]: Please ensure at least a follow up call is completed on Monday 1/9/23, and also complete some education with patient and [spouse] about frequency of visits in the future. [Spouse] has stated that with [his/her] mother, ";hospice was showing up every other day at least!" I [RN F] did discuss with [spouse] that each patient will need a different frequency of visits depending on how they are doing, but please discuss expectations." Review of the clinical record failed to show: - Hospice aide visits completed as ordered in the plan of care; - Missed visit documentation for the hospice aide visits ordered 2 times weekly beginning on 01/04/2023 and not provided; - Aide plan of care to include interventions specific to the patient and family needs (aide care plan includes catheter care and patient does not have a catheter). During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - The patient wanted to revoke hospice because [he/she] was not getting the aide visits; - There was an issue with the aide visits getting assigned because of issues with the new electronic charting system; - He/she was made aware of the complaint made by the patients daughter on 01/06/2023 regarding the lack of aide visits but no complaints were recorded in the complaint log; - He/she probably should have recorded the complaints made by family in the complaint book; and - He/she did reach out to the family regarding the complaint but he/she did not document it.

Based on policy review, record review, and interview, the agency failed to ensure that: - The clinical records contained physician orders (678); - All entries were legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice (679); and - The discharge summary included all the components required by this regulation (684). The cumulative effect of these deficient practices has the potential to affect all patients served by the agency.

Based on policy review, record review, and interview, the agency failed to ensure physicians orders were obtained in, but not limited to, two (Records/Patients #9 and #10) of eleven records reviewed. This deficient practice has the potential to adversely affect the quality of care provided to all patients served by the agency. --- Findings included: Review of the agency's policy titled, "Physician Orders," reviewed 06/11/2021, showed, in part: - Agencies will obtain physician orders for all patient care services including treatments, procedures and equipment before such services are furnished; - The ordering physician will be contacted when there is a change in patient condition or response to care requiring new or modified orders for care or service; - Verbal orders may be accepted and put in writing by personnel authorized to do so by state and federal law (RN, LPN, or qualified therapist); - Orders will be signed and dated with the date and time of receipt by the RN or qualified therapist (PT, OT, ST, MSW) responsible for the furnishing or supervising the ordered services; - Every telephone or verbal order requires a live person interaction between the ordering physician (or responsible physician office staff member) and the person receiving the order(s) so that clarification may be requested when necessary; and - The agency will provide care and services in accordance with the most recent physician orders. RECORD/PATIENT #9: Review of the telephone encounter note, dated, 01/05/2023, with a time of 8:18 PM, showed, in part: - Granddaughter calls into on-call to report new onset of RLE (right lower extremity) swelling and deep purple discoloration; - Granddaughter reports the pt [patient] did lay down on [his/her] couch all afternoon with both legs elevated without any decrease in swelling; - Denies any current or prior use of compression stockings; - Reports currently sitting up in [his/her] WC [wheelchair] and writer (RN D) strongly recommended laying down with elevation of BLE [bilateral lower extremities] again to reduce swelling; - Educated on common s/s [signs and symptoms] of CHF [congestive heart failure] and fluid retention; - Granddaughter reports that pt RLE has an increase in deep purple color and are ";ice cold" to touch; - Pt denies pain or chest pain and reports that family administered Morphine [pain medication] 15 min [minutes] ago; - Granddaughter reports that pt is taking all of [his/her] medications as ordered including todays [01/05/2023] dose of Furosemide [Diuretic medication to reduce swelling caused by fluid retention]; - Both patient and granddaughter request nursing visit this evening to assess d/t [due to] above concerns; and - Writer [RN D] contacted on-call RN and report provided. Review of an email from the on-call RN, to the agency administration, dated, 01/05/2023, at 9:57 PM, showed, in part: - RN received a call from the on-call afterhours stating this patient is requesting a nurse visit due to swelling and [his/her] bil [bilateral] feet turning purple; - RN called pt cg who voiced [he/she] has swelling to [his/her] BLE but the right leg is worse than the left; - He/she also voiced [his/her] left foot was feeling numb prior to RN retuning [his/her] call; -Patient voiced the numbness has resolved; - The granddaughter voiced the patient has been sitting up all day with legs elevated; - Patient got in the bed 20 min [minutes] prior to RN calling; - Granddaughter voiced feet are no longer purple; - RN asked if the patient was having any pain and patient stated [his/her] left knee was hurting; - Per granddaughter, pt refused [his/her] 30 mg (milligrams) MSER [morphine sulfate extended release] earlier but did take evening dose; Patient took 1 dose of MSIR [morphine sulfate immediate release] 15 MG early this AM [morning]; - RN encouraged patient to take the MEIR 15 MG now as it is more of an instant release; - Patient voiced [his/her] pain is not the issue; - ";So we focused back on the swelling;" - The granddaughter voiced the patients Lasix [furosemide] was increased today and the patient is scheduled to take a double dose in the AM (No documentation of physician orders); - The RN discussed ";possibly some ace wraps to aide in edema management also;" - Pt agreed and RN will place an order for the ace wrap; - The granddaughter voiced her feet are no longer purple since the patient laid down; - The RN discussed the plan for tonight to stay in bed with elevation, take Lasix in the AM, and order the ace wrap to aide in edema management; - CM please follow up with a telephone call on 01/06/2023; - No in person visit needed at this time; - CG instructed to call hospice back if pt feet turn purple, pain increase, pt develops SOB [shortness of breath] or any other concerns; - Granddaughter voiced understanding; and - Ace wraps ordered. RECORD/PATIENT #10: Review of the clinical record showed, in part: - Skilled nurse completed a hospice discharge visit on 01/10/2023; - Reason for discharge listed as, no longer terminally ill; and - The clinical record failed to show a physician order for discharge. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - No orders received for ace wraps; - The patients past medical history did include a history of blood clots and no visit was made by the nurse to assess the patient prior to recommending ace wraps to lower extremities; - The on call nurse should have made a visit to assess the patient and then contacted the physician to obtain orders prior to recommending the patient wrap legs with ace wraps; and - No record of physician orders for discharge (for record/patient 10) so orders were entered late.

Based on record review, policy review, and interview the agency failed to ensure that documentation was complete, completed in a timely manner, accurate, and/or authenticated by the person giving care in, but not limited to, four (Records/Patients #1, #3, #4, and #10) of eleven records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- RECORD/PATIENT #4: Review of the clinical record showed the following: -The skilled nurses note on 12/18/2022 was a follow-up visit from the initial comprehensive assessment; *Pain level was documented on this visit; *The agency failed to document anything else that occurred during this visit; -The skilled nurses note on 12/20/2022 was a routine visit; *Pain level was documented; *Last bowel movement was documented; *The agency failed to document anything else that occurred during this visit; -The skilled nurses note on 12/22/2022 was a phone visit; and *The agency failed to document anything that occurred during this visit. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect all documentation to be completed and detailed. Findings included: Review of the agency's policy titled, "Clinical Records," dated 06/17/2021, showed in part, that the outcome of the policy is to: - Ensure timely, accurate documentation of all care and services provided; - Comply with applicable regulations and standards of care; - Comply with the required content of the patient record; and - All entries are legible, clear, complete, and appropriately authenticated and dated in accordance with policies and procedures and currently accepted standards of practice. RECORD/PATIENT #1: Review of the clinical record showed: - Hospice skilled nurse (SN) initial visit dated 09/16/2022, was created on 09/16/2022 and signed as complete on 09/20/2022 (four days later); - SN note dated 01/05/2023 was created on 01/05/2023 and signed as complete on 01/09/2023 (four days later); - Aide visit dated 01/03/2023 was created by the aide on 01/03/2023 and signed as complete by "Home health, Admin" on 01/06/2023 (three days later); - Aide visit dated 01/06/2023 was created by the aide on 01/06/2023 and signed as complete by "Home health, Admin" on 01/09/2023 (three days later); - Aide visit dated 01/10/2023 was created by the aide on 01/10/2023 and signed as complete by "Home health, Admin" on 01/13/2023 (three days later); - Aide visit dated 01/13/2023 was created by the aide on 01/13/2023 and signed as complete by "Home health, Admin" on 01/16/2023 (three days later); - Aide visit dated 01/17/2023 was created by the aide on 01/17/2023 and signed as complete by "Home health, Admin" on 01/20/2023 (three days later); and - Aide visit dated 01/20/2023 was created by the aide on 01/20/2023 and signed as complete by "Home health, Admin" on 01/23/2023 (three days later). During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect documentation to be signed by the person completing the documentation and that the documentation would be completed in a timely manner. RECORD/PATIENT #3: Review of the clinical record showed: - Hospice SN initial visit dated 11/21/2022, was created on 11/21/2022 and signed as complete on 11/29/2022 (eight days later); - Aide visit dated 01/03/2023 was created by the aide on 01/03/2023 and signed as complete by "Home health, Admin" on 01/13/2023 (10 days later); - Aide visit dated 01/05/2023 was created by the aide on 01/05/2023 and signed as complete by "Home health, Admin" on 01/13/2023 (eight days later); - Aide visit dated 01/10/2023 was created by the aide on 01/10/2023 and signed as complete by "Home health, Admin" on 01/13/2023 (three days later); - Aide visit dated 01/12/2023 was created by the aide on 01/12/2023 and signed complete by "Home health, Admin" on 01/15/2023 (three days later); - Aide visit dated 01/17/2023 was created by the aide on 01/17/2023 and signed complete by "Home health, Admin" on 01/20/2023 (three days later); and - Aide visit dated 01/19/2023 was created by the aide on 01/19/2023 and was noted as "not closed" as of 01/24/2023 (five days later). During an interview on 01/24/2023 beginning at 2:10 PM, the administrator stated that he/she would expect documentation to be signed by the person completing the documentation and that the documentation would be completed in a timely manner. RECORD/PATIENT #9: Review of an email from the RN on-call, to the agency administration, dated, 01/05/2023, at 9:57 PM, showed, in part: - RN received a call from the on-call afterhours stating this patient is requesting a nurse visit due to swelling and [his/her] bil [bilateral] feet turning purple; - RN called pt cg who voiced [he/she] has swelling to [his/her] BLE but the right leg is worse than the left; - He/she also voiced [his/her] left foot was feeling numb prior to RN retuning [his/her] call; -Patient voiced the numbness has resolved; - The granddaughter voiced the patient has been sitting up all day with legs elevated; - Patient got in the bed 20 min [minutes] prior to RN calling; - Granddaughter voiced feet are no longer purple; - RN asked if the patient was having any pain and patient stated [his/her] left knee was hurting; - Per granddaughter, pt refused [his/her] 30 mg (milligrams) MSER [morphine sulfate extended release] earlier but did take evening dose; Patient took 1 dose of MSIR [morphine sulfate immediate release] 15 MG early this AM [morning]; - RN encouraged patient to take the MEIR 15 MG now as it is more of an instant release; - Patient voiced [his/her] pain is not the issue; - ";So we focused back on the swelling;" - The granddaughter voiced the patients Lasix [furosemide] was increased today and the patient is scheduled to take a double dose in the AM; - The RN discussed ";possibly some ace wraps to aide in edema management also;" - Pt agreed and RN will place an order for the ace wrap; - The granddaughter voiced her feet are no longer purple since the patient laid down; - The RN discussed the plan for tonight to stay in bed with elevation, take Lasix in the AM, and order the ace wrap to aide in edema management; - CM please follow up with a telephone call on 01/06/2023; - No in person visit needed at this time; - CG instructed to call hospice back if pt feet turn purple, pain increase, pt develops SOB [shortness of breath] or any other concerns; - Granddaughter voiced understanding; and - Ace wraps ordered. Review of the clinical record failed to show documentation from the on-call RN regarding the afterhours call. Review of a late entry telephone communication note, showed, in part: - Late entry was made on 01/24/2023 at 11:48 AM; and - The addendum included the summary from the on-call RN that was in the email communication note regarding the afterhours call on 01/05/2023. On 01/24/2023, at 12:00 PM, the administrator designee stated that: - Late addendum note was added to the patients record due to it only showing up in an email; and - It was charted as a sensitive note by mistake and was unavailable to be reviewed by the other employees. RECORD/PATIENT #10: Review of the skilled nurse hospice discharge note, dated, 01/10/2023, in part: - Visit made on 01/10/2023, started at 12:10 PM, and ended at 12:40 PM; - Discharge remarks entered by RN A, on 01/13/2023 at 3:45 PM, showed, ";Explained equipment p/u [pick up] with son [name], [Named DME company] to give family 1 week grace. Reordered duoneb chamber + 1. Reordered medications. Encouraged family to contact [named] hospice with any future needs;" - Encounter notes section had a note that was created on 01/13/2023 at 3:46 PM by RN A with the following comment, ";Presented pt caregiver [son named] with discharge paperwork for his signature. Explained equipment p/u [Named DME company] giving family 1 week to decide on equipment they are keeping. Ordered medications. Said goodbye to pt and family;" and - No documentation to clarify why entries were made 3 (three) days after the discharge visit. Review of late entry clinical records, provided by the administrator designee, showed: - A discharge order that showed: * Discharge patient from home health services because discharged to home/self-care. Conversations with caregiver and patient over the last month related to stability of patient and discharging from hospice. Patient has been consistently stable with vital signs, no falls or injury, no pain issues, no oxygen requirements since covid-19 diagnosis and recovery period following. Caregiver (son [name]) agrees that his [parent] is currently stable but states the [he/she] is appreciative of the social interaction that his [parent] receives during [hospice agency] visits and that his [parent] will miss those. Patient discussions during IDT meetings and patient stable condition prompted decision to discharge to home/self-care; * Order date of 01/10/2023 at 10:37 AM; and * Order received and electronically signed by, RN A, on 01/25/2023 at 2:10 PM. - Review of the Home Care Update, dated, 01/01/2023, showed, in part: * Effective from 01/01/2023 to 01/04/2023; * RN A entered a late entry note on 01/24/2023 at 10:36 AM with, ";Patient planned to be discharged on 01/10/2023. Reviewed plan of care with IDT team. All in agreement. Pt is no longer terminally ill. Patient denies pain, shortness of breath at time of recent visits. Plan to reach out to [named physician] to arrange post-discharge patient care. Patient medications reordered for 2 week period. DME will be scheduled to be picked up post discharge;" * MSW entered a late entry note on 01/24/2023 at 12:12 PM, with, ";Per CM [RN A], PT will likely discharge from hospice in the next 1-2 weeks. MSW is working with family and CM to ensure continuity of care for PT. Pts son to contact PCP [primary care provider] to re-establish care. PT has prepaid funeral plans. PT is a veteran. No further MSW follow up planned. However, MSW will remain available to PTs son if he has needs/concerns after PT discharge. PTs son has MSWs contact info [information];" * Chaplain entered a late entry note on 01/24/2023 at 10:44 AM, with, ";Patient was discussed in IDT for having met goals and is now stable. Patient will be discharged as hospice services are no longer needed at this time. Chaplain services had been declined. 1/4/23;" * Medical director notes section had no notes created for current plan; * Additional discipline notes section, ";Discussed patient care, all in agreement with POC," was entered on 01/04/2023 at 4:41 PM by the administrator designee; and * No documentation in the updated plan of care to include discharge planning and/or orders. During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - All documentation and communications should be in the medical record; - Since switching to a new electronic medical record system on the January 1st [01/01/2023], there have been issues with documentation; - Some of the records are not showing up correctly for some reason; and - Unsure why some of the documentation is not showing up in the system correctly.

Based on policy review, record review, and interview, the agency failed to ensure a complete discharge summary containing all the components required by this regulation was completed in, but not limited to, two (Records/Patients #9 and #10) of three applicable records reviewed. This deficient practice has the potential to adversely affect the post discharge continuity of care for all the live patients discharged by the agency. --- Findings included: Review of the agency's policy titled, "Discharge Criteria, Process, ABN [Advance Beneficiary Notice of Non-coverage], HHCCN [Home Health Change of Care Notice], and Notice to Patients," revised 06/16/2021, showed, in part: - A patient will be discharged when one or more of the following conditions exist: * When it is discovered that the patient is not terminally ill; * When a patient revokes their hospice benefit; and * When a patient moves out of the service area or transfers to another hospice including when a hospice patient is receiving treatment for a condition unrelated to the terminal illness or related conditions in a facility with which the hospice does not have a contract, and the hospice is unable to access the patient to provide hospice services; - If a patient will be discharged from the hospice program, whenever possible, the patient will be notified at least three (3) working days in advance (preferably two (2) weeks in advance) of the reason for and date of discharge; - When discharging all services to a patient receiving traditional Medicare and Medicare Advantage covered services, at least 2 day notice is required. Communication of pending discharge plans will be documented in the clinical record. When indicated, a plan will be developed or a referral made for any required continuing care; - Services shall not be terminated until such time as disciplines providing care and the patients physician, if applicable, deem it appropriate and arrangements are made for continuing care, if necessary; - All disciplines are to communicate pending discharge dates to other staff involved in the patients care; - A discharge summary is to be completed when a patient is discharged from services. It is the responsibility of the case manager/supervisor to ensure that the clinical record is complete including the discharge summary; - The discharge summary will be sent to the physician when it is a live discharge (i.e. revoke, transfer to another hospice, discharge due to no longer meeting criteria) and incorporated into the medical record; - The discharge summary must include, in part: * Brief description of services provided and ongoing needs that cannot be met; * Instructions or referral information given to the patient or family; * Discharge orders, instructions, medication profile, and allergies, if discharge is other than patient death; * A summary of the patients stay, including treatments, symptoms and pain management; * The patients current plan of care; * The patients latest physician orders; and * Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility; - Patients requiring continuing care will receive assistance in arranging for such services before home/hospice services are discontinued; - Upon discharge from the agency, the patient and/or his representative shall be provided oral and/or written instructions for his/her future care, if applicable. Documentation of instruction will be made in the clinical record; - Hospice will notify the physician in all instances of discontinuance of hospice care and such notification shall be documented in the patient record; and - Notice of Termination (Discharge, Revocation, or Transfer to another hospice) will be provided to CMS within 5 calendar days. RECORD/PATIENT #9: Review of the skilled nurse hospice discharge note, dated, 01/11/2023, with a time of 5:15 PM showed, in part: - Hospice discharge encounter signed by RN B on 01/11/2023 at 10:31 PM; - Reason for discharge with revoked hospice; - Discharge summary scan on 01/18/2023 at 9:34 AM by clinical secretary with hospice revoke letter; and - Discharge remarks signed by RN B on 01/11/2023 at 10:31 PM with ";pt revoked hospice." Review of the faxed discharge record, dated, 01/17/2023, with a time of 5:15 PM showed, in part: - Hospice discharge note on 01/11/2023 at 10:31 PM with revoked listed on reason for discharge; and - Discharge summary failed to include: * A summary of patients treatments, symptoms and pain management; * The patients current plan of care; * The patients physician orders; and * Any other documentation that would assist in post-discharge continuity of care. RECORD/PATIENT #10: Review of the skilled nurse hospice discharge note, dated, 01/10/2023, in part: - Visit started at 12:10 PM and ended at 12:40 PM (30 minutes); - Reason for discharge with no longer terminally ill; - Discharge remarks entered by RN A, on 01/13/2023 at 3:45 PM, showed, ";Explained equipment p/u [pick up] with son [name], [Named DME company] to give family 1 week grace. Reordered duoneb chamber + 1. Reordered medications. Encouraged family to contact [named] hospice with any future needs;" - Encounter notes section had a note that was created on 01/13/2023 at 3:46 PM by RN A with the following comment, ";Presented pt caregiver [son named] with discharge paperwork for his signature. Explained equipment p/u [Named DME company] giving family 1 week to decide on equipment they are keeping. Ordered medications. Said goodbye to pt and family;" and - No documentation of education provided for patient/family post-discharge continuing care needs. Review of a clinical record document with, ";D/C Summary," handwritten at the top of the record, showed a discharge summary section with the following information: - Current patient demographics and info [information]; - Primary caregiver contact information; - Patient diagnoses; - Patients race/ethnicity; - Patients language; - Patients hospice provider and the patients primary care provider; - Discharge information with date of 01/10/2023, discharged to home or self-care, and patient no longer terminally ill; - Discharge remarks entered by RN A, on 01/13/2023 at 3:45 PM, showed, ";Explained equipment p/u [pick up] with son [name], [Named DME company] to give family 1 week grace. Reordered duoneb chamber + 1. Reordered medications. Encouraged family to contact [named] hospice with any future needs;" - Patient status with ";Alive" listed; - No other information included in the discharge summary section; and - The section following the discharge summary section, had a title of, ";Hospice Plan of care 11/22/22 effective from 11/22/2022 to 01/20/2023" and included the IDG plan of care as of 12/29/2022 (A face to face encounter on 12/29/2022 had "continue hospice service and ensure comfort measures" noted by the nurse practitioner). Review of a discharge order, provided by the administrator designee, showed: - Discharge patient from home health services because discharged to home/self-care. Conversations with caregiver and patient over the last month related to stability of patient and discharging from hospice. Patient has been consistently stable with vital signs, no falls or injury, no pain issues, no oxygen requirements since covid-19 diagnosis and recovery period following. Caregiver (son [name]) agrees that his [parent] is currently stable but states the [he/she] is appreciative of the social interaction that his [parent] receives during [hospice agency] visits and that his [parent] will miss those. Patient discussions during IDT meetings and patient stable condition prompted decision to discharge to home/self-care; and - Order received and electronically signed by, RN A, on 01/25/2023 at 2:10 PM (15 days after patient was discharged). During an interview, on 01/26/2023, beginning at 1:30 PM, the administrator designee stated that: - All documentation and communications should be in the medical record; - Since switching to a new electronic medical record system on the January 1st [01/01/2023], there have been issues with documentation; - The Notice of Termination of Hospice Benefits signed by the physician decertifying the terminal illness was not in the patients record for some reason so he/she requested a copy from the physician; - Some of the records are not showing up correctly for some reason; and - Unsure why some of the documentation is not showing up in the system correctly.

Based on employee file review and interview, the agency failed to ensure that a Criminal Background Check (CBC) was run prior to first patient contact in, but not limited to, two (Employees #1 and #2) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- EMPLOYEE #1: -Date of hire: 05/23/2022; -Date of CBC: 08/30/2022; and -Agency could not provide proof of first patient contact date. EMPLOYEE #2: -Date of hire: 03/14/2022; -Date of CBC: 05/12/2022; and Agency could not provide proof of first patient contact date. During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect the CBCs to be run prior to first patient contact.

Based on Missouri state statutes, employee file review, and interview, the agency failed to ensure that the employee disqualification list (EDL) was checked prior to hire in, but not limited to, four (Employees #1, #3, #4, and #5) of six employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, organization, or association who received the employee disqualification list under subdivisions (1) to (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." EMPLOYEE #1: -Date of hire: 05/23/2022 -Date of EDL: 08/30/2022 EMPLOYEE #2: -Date of hire: 03/14/2022 -Date of EDL: 05/05/2022 EMPLOYEE #3: -Date of hire: 01/11/2021 -Date of EDL: 06/09/2022 EMPLOYEE #4: -Date of hire: 03/17/2022 -Date of EDL: 01/24/2023 During an interview on 01/24/2023 at 12:50 PM, the administrator stated that he/she would expect the EDL to be checked prior to hire for all employees.