Every finding on record at Traditions Hospice of Blue Springs, LLC

Observed in Patient Home. In 2 of 2 home visits conducted, visits in single family homes, the organization failed to inform the patient of and provide the patient with written information about its policies on advance directives, including a description of any state law concerning the advance directives. During home visits for RRHV#2 and RRHV#3, the Hospice Nurse Surveyor observed the patients had organizational folders in the home which did not contain all required elements provided to the patients. Specifically neither patient received information about advance directives. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 21 of 21 patient records reviewed, the organization failed to assess the patient's needs. During record review all records,all required assessments were not completed. For example in all records the need for volunteer services was not assessed. In RRHV#1 the patient bereavement assessments were not completed. The patient had revoked and when she returned to service a new bereavement was not completed. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 2 of 21 patient records reviewed, the organization failed to assess according to defined time frames. In RRNHV#1 and RRNHV#3 the comprehensive psychosocial assessments were not completed timely. For example in RRNHV#1, the SW assessment was completed on day 6. In RRNHV#3, the SW assessment was completed on day 11. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 14 of 21 patient records reviewed, the organization failed to plan the patient's care. During record review for RRNHV#1, RRNHV#2, RRHV#1, RRHV#2, RRHV#3, RRHV#4, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6,RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#10, The Hospice Nurse Surveyor observed the timeframes to achieve goals were absent or were not updated and measurable. For example in RRNHV#1, the patient had a goal of caregiver will verbalize/ demonstrate measures to prevent/manager yeast infection by adjusting anti-fungal cream to powder and add barrier cream to buttocks by 2/22 and that date had passed. The patient also had a goal of Pt/ CG verbalize and demonstrate understanding of how to correct safety hazards in the home started 7/13/22 at SOC with no goal timeframe and almost two years later had not been updated. In RRNHV#2, the patient had a goal of pt/CG will demonstrate ability to administer meds via planner device with no goal timeframe. In RRHV#1, the patient had a goal of pt/ CG verablize understanding to report any altered mental status or incidence of confusion with no goal timeframe. In RRHV#2 had a goal of pt/cg verbalize demonstrate understanding of oxygen safety with no goal timeframe and the start date was 1 1/2 years prior to survey. In RRHV#3 the patient had a goal of pt/ CG verbalizes/ demonstrates understanding of how to correct safety hazards in the home with no goal timeframe. In RRHV#4 the patient had a goal of pt/cg verbalizes/ demonstrates understanding of proper safety measures related to fall prevention started 7/21 with no goal timeframe. In RRNHV#3, the patient had a goal of pt/ CG verbalized/ demonstrates understanding of how to correct safety hazards in the home which had a start date 8 months prior to survey and no goal timeframe. In RRNHV#4, the patient had a goal of patient/ cg verbalize/ demonstrate understanding of oxygen safety with a begin date 3 months prior to survey and no goal timeframe. For RRNHV#5 and RRNHV#6, the patients had a goal of CG/ facility will be knowledgeable and involved in hospice plan of care for patient by (enter date) and the target date was never entered. In RRNHV#7, the patient had a goal of pt/ CG verbalizes/ demonstrates understanding of applicable safety measures with no goal timeframe and it had been started 2 years earlier at SOC. In RRNHV#8, the MSW had a goal for problems concerning patient's personal affairs would be identified and a plan established to resolve issues but there was no goal timeframe and the patient had recently been placed on daily visits. In RRNHV#9, the patient had a goal of facility staff is knowledgeable and involved in hospice plan of care for patient be(enter date) and the goal timeframe was not filled in. In RRNHV#10, the patient had a goal of Pt/CG verbalize understanding of when to utilize PRN medications and to document each use. The goal was started one year prior to survey with no target date. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 10 of 21 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#3, RRNHV#1, RRNHV#2, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV10, the plan of care did not contain all required elements. In RRHV#3, RRNHV#1, RRNHV#2, RRNHV#6, RRNHV#7, the patient had more than one medication for the same symptom, the medication POC orders did not contain an indication for when to use which medication. In RRNHV#1, the patient had a urinary tract infection one month prior to survey but it was not addressed on the POC. In RRNHV#4, the patient had multiple narrative notes and goals on the POC related to Oxygen but there were no orders for the oxygen including route, dose, etc. In RRNHV#5, the patient had a new wound on her upper calf and coccyx with new wound orders and it was not added to the POC. She also had a goal of code status resolved with patient started 7 months prior to survey with no target date but did have documentation in the EMR that a DNR is in place. The goal was never updated. In RRNHV#6, the patient had a recent fall but the care plan was not updated to include falls. In RRNHV#7, the patient had an order for Acetaminophen PRN with no reason when to take it. The patient also had a recent fall with skin tear and wound care orders related to the skin tear that was not addressed on the POC. In RRNHV#8, the patient had a recent diagnosis of cellulitis with antibiotic ordered but the POC was not updated. In RRNHV#9, the patient had a recent PRN visit with medication changes for anxiety but the POC was not updated. In RRNHV#10, the patient had a new order for nectar thick diet but it was not added to the POC. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 1 of 4 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During home visit for RRHV#1, the Home Health Aide failed to follow the organizational policy on hand hygiene. The aide cleansed the patient's genitals while on the toilet, changed her gloves to move patient into the shower but did not perform hand hygiene. This was verified with the Hospice Director and discussed with the Team.

Observed in Tracer Activities. The organization failed to provide all services to meet the patient needs. During tracer activities for Volunteer Services, the Hospice Nurse Surveyor observed the organization had not met the 5% of total patient care hours for volunteer services. During conversation with the Administrator/Volunteer Coordinator Designee stated they had only one office volunteer, with a recent recruit wanting to do patient visits and they had hired a new volunteer coordinator the same month as survey. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 2 of 21 patient records reviewed, the patient record did not reflect the patient's care, treatment, or services. During record reviews for RRHV#2 and RRNHV#4, the Hospice Nurse Surveyor observed the medication orders were not correct. For example in RRHV#2, Carafate and Protonix were listed as sub-lingual but the patient was taking the medications orally and the pharmacy sent oral. For RRNHV#4, the patient meds (acetaminophen, albuterol, calcium, praluent, calcium carbonate) all had a alternate route listed as sub-lingual which crossed over to the 485/POC as the primary route. This was discussed and reviewed with the Hospice Team.

Observed in Patient Home. In 2 of 2 home visits conducted, visits in single family homes, the organization failed to plan for providing patient care and clinical support during an emergency. During home visits for RRHV#2 and RRHV#3, the Hospice Nurse Surveyor observed the organization had not provided the patient with an individualized emergency plan for the home which included education related to that plan. This was verified with the Hospice Director and discussed with the Hospice Team.

Observed in Tracer Activities. In 1 of 10 HR files reviewed, the organization failed to verify staff qualifications. During tracer activities for HR, the Hospice Nurse Surveyor observed the initial back ground check for HR#4 was not able to be found. Upon conversation with the hospice team, it was reported that systems had changed and that they had no record of the initial check ( as it is in the old system). They do have record of an annual check. This was discussed and reviewed with the Hospice Team.

Based on review of the agency's Emergency Preparedness (EP) binder, Administrative Policy Manual, and interview, the agency failed to ensure the names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers were included in the EP plan. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder did not include names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers. Review of the agency's Administrative Policy Manual titled, "EP and Response Plan," revised 07/01/2020 showed: - The agency will maintain a current listing of staff, contract staff, and volunteers, and all applicable contact numbers for use as a communication/disaster calling tree; and - Clinical staff are responsible to make sure the agency has an emergency phone list of names and numbers. Findings were reviewed with the administrator and the clinical manager on 05/19/2022 at 10:55 AM and they stated there was no contact information in the binder, and the EP binder was not individualized for the Missouri office. The EP binder contained Kansas and Texas information.

Based on review of the agency's Emergency Preparedness (EP) binder, Administrative Policy Manual, and interview, the agency failed to ensure contact information was included and updated for state, tribal, regional, or local emergency preparedness staff and other sources of assistance. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder showed no contact information for state, tribal, regional EP staff, and no updated information for local EP staff or other sources of assistance. Findings were reviewed with the administrator and the clinical manager on 05/19/2022 at 10:55 AM and they stated there was no contact information in the binder, and the EP binder was not individualized for the Missouri office. The EP binder contained Kansas and Texas information.

Based on policy review, clinical record review, and interview the agency failed to assure that patients received effective pain management and symptom control by the hospice, in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect the pain management of all patients served by the agency. Findings included: Review of agency's policy revised 03/01/2021 titled, "Patient's Rights and Responsibilities," showed: - Purpose - To ensure the patient, their representative (if any), and the hospice staff acknowledge, protect, observe and implement the patient's rights and responsibilities; and - The hospice staff will be responsible for knowing, observing, and implementing the patient's rights and patient responsibilities on an ongoing basis. The staff will also be responsible for protecting and promoting these rights. Review of agency's policy titled, "Implementing Care and Treatment," dated 04/2022, showed: - Purpose - To ensure patient care and treatment are provided as identified in the care planning process; - The assigned discipline(s) will be provided with information needed to provide patient care/treatment including, but not limited to, the plan of care (POC); and - When the provision of care/treatment cannot be implemented as established on the care planning document(s), the patient's physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline or clinical manager. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice services on 11/19/2021, with a terminal diagnosis of senile degeneration of the brain (decrease in cognitive abilities or mental decline) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). The patient resides in his or her own home with their spouse as primary care giver. Review of the Hospice Certification and Plan of Care (POC), dated 11/19/2021 to 02/16/2022, showed the following: - The hospice nurse to perform wound care to left leg utilizing clean technique - cleanse, cover and change three times per week and as needed; - Instruct the caregiver in wound care; - Hospice nurse to monitor patient's pain level and report ineffective pain control to the physician; - Goal: Pain will be managed at a level acceptable to the patient; - Acetaminophen Extra Strength (pain medication) 500 milligram (mg) take two tablets every six hours as needed; - Lidocaine Plus 4% topical cream (pain relief cream) apply 1 inch topically as needed daily for dressing change; - Lorazepam 2 mg/milliliter (ml) administer .25-1 ml orally every hour as needed for anxiety; and - Morphine 20 mg/5 ml administer .25 to 1 ml every hour as needed for pain or shortness of air. Observation on 05/17/2022 at 11:14 AM, during the patient's home visit showed: - Registered nurse (RN) A gathered dressing supplies for a wound dressing change to the left leg and placed supplies on a barrier; - RN A asked patient's caregiver if patient had taken any pain medication and he/she replied "no"; - RN A asked caregiver to give patient medication and he/she returned to the room with liquid Tylenol (pain reliever) stating his/her daughter had brought it to them for use and administered the liquid Tylenol; - RN A moved the patient's leg to perform dressing change and patient withdrew knee up slightly and had a grimace on his/her face; - RN A continued to remove old dressing and sprayed wound cleanser on the old dressing foam to soak due to it was sticking to patient's wound bed; - RN A put away equipment to let dressing sponge soak and then tried to remove old sponge and patient slightly jerked his/her knee; - RN A asked the patient if he/she was okay and the caregiver said the patient would let you know if he/she wasn't; - RN A removed old dressing and then applied 2x2 gauze to soak any drainage and the patient jerked left knee slightly; and - RN A applied new dressing and the patient moaned and pulled knee back with application of optifoam (foam dressing that has a silicone adhesive border) dressing and RN A said sorry to the patient and that he/she was done with the dressing change; and - RN A stated that he/she would talk to the caregiver, family and physician about starting a routine pain medication twice a day to help alleviate patient's pain. Caregiver is reluctant to give her any strong medication because it knocks her out all the next day. RN A did not use the Lidocaine Plus 4% topical cream as needed daily for dressing changes as ordered per physician. During an interview on 05/19/2022 at 01:58 PM, the administrator stated that he/she would expect the staff to use lidocaine cream as ordered.

Based on policy review, record review, and interview, the hospice registered nurse failed to complete an adequate initial assessment in one (Record/Patient #3) of three patients sampled. The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the agency's policy titled, "Patient Assessments - PE05," showed in part, that the initial assessment should include the patient's physical, psychosocial and emotional status related to the terminal illness and related conditions. RECORD/PATIENT #3: The patient was admitted on 05/13/2022 with the terminal diagnosis of protein calorie malnutrition. The patient was orientated and lived in a residential setting. He/she had a primary caregiver (niece). Review of the initial nursing visit dated 05/13/2022, showed in part: - Coccyx stage II pressure ulcer (partial thickness skin loss involving epidermis, dermis, or both) - onset 05/01/2022; - Wound assessed - no, caregiver completed care; - Wound care provided - wound care not provided: caregiver completed care; - No documentation of assessment or education regarding wound care for the Stage 2 pressure ulcer on coccyx; and - Skin: pressure ulcer to coccyx, almost healed. Unable to measure due to new dressing in place. Daughter showed this nurse a picture of it. The findings were reviewed on 05/19/2022 at 12:01 PM and the administrator stated that he/she was going to send nursing out that day to measure wounds and educate primary caregiver on dressing changes.

Based on policy review, record review, home visit observation, and interview, the agency failed to maintain an accurate/updated medication profile in two (Records/Patients #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Plan of Care - PC30," dated April 2022, showed in part the following: -Purpose: To ensure that the care provided is in accordance with the written [plan of care] POC, appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs; - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice [interdisplinary group] IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs; and - The comprehensive assessment will take into consideration the following factors but is not limited to: drug profile, including a review of all of the patient's prescription and over-the-counter drugs, herbal remedies, and other alternative treatments that could affect drug therapy, which includes, but is not limited to, identification of the following: effectiveness of drug therapy, drug side effects, actual or potential drug interactions, allergies, duplicate drug therapy, drug therapy currently associated with laboratory monitoring, and determine the ability of the patient and/or family to safely self-administer drugs and biologicals in the home. RECORD/PATIENT #1: Observation on 05/17/2022 beginning at 11:30 AM, during the patient's home visit, showed the following discrepancies with the hospice medication profile: -The patient's primary caregiver (CG) (spouse) stated that he/she took Advil PM (for mild pain relief and sleep aid) two every night at bedtime (HS) and that he/she had been on this for a couple months. This was not included on the hospice medication profile; -Tylenol dissolve pack 500 milligrams (mg) take one as needed (PRN). This was not on the hospice medication profile; -Calcium 600 + D(3) 600 mg Calcium-200 unit capsule, take one capsule daily. CG stated that the patient is not taking; and -Lidocaine Plus 4% topical cream, apply one inch daily PRN for dressing change. CG stated that this was not in the patient's home. During an interview on 05/19/2022, at 2:12 PM, the administrator stated that medication reconciliation's are to be done every visit. RECORD/PATIENT #2: Review of the long term care facility (LTCF) medication administration record (MAR) order summary report as of 05/01/2022, showed the following discrepancies with the hospice medication profile: -The LTCF MAR showed an order for Remeron (depression) 15 mg, one by mouth every HS, with an order date of 11/04/2021; and -Imodium (anti-diarrhea) 2 mg, one every eight hours PRN. With an order date of 04/20/2022. These were not included on the hospice medication profile. During record review and interview on 05/19/2022 at 12:05 PM, the administrator provided no additional information.

Based on agency policy, clinical record review, home visit observation, and interview, the agency failed to ensure that: - All hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire (L543); - Each patient and the primary care giver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care (L544); - The plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including the following: (1) Interventions to manage pain and symptoms (L546); - A revised plan of care included information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care (L553); - The hospice developed and maintained a system of communication and integration, in accordance with the hospice's own policies and procedures to ensure that the interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided (L554); and - The hospice developed and maintained a system of communication and integration, in accordance with the hospice's own policies and procedures, to ensure that the care and services are provided in accordance with the plan of care (L555). The cumulative effect of these systematic practices resulted in the agency's inability to ensure the patient's care needs were met.

Based on policy review, record review, and interview, the agency failed to ensure the plan of care (POC) was followed with the current visit frequency when visits were not completed as ordered on the POC in one (Record/Patient #1) of five full record reviews 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 04/2022, showed in part: - To ensure that the care provided is in accordance with the written POC; and - All hospice care and services furnished to patients and their families will follow an individualized written POC in accordance with the patient's needs. RECORD/PATIENT #1: Review of the recertication POC dated 02/17/2022 through 05/17/2022 showed the patient was admitted to hospice service on 11/19/2021. The patient's terminal diagnosis was senile degeneration of the brain (decrease in cognitive abilities or mental decline) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). The patient resides in his or her own home with spouse as primary care giver and the hospice aide was to visit seven days a week. Review of the record showed the following missed aide visits: - 02/17/2022 for inclement weather; - 04/09/2022 no documentation for missed visit; and - 04/10/2022 no documentation for missed visit. During an interview on 05/19/2022 at 1:54 PM, the administrator stated that he/she expects visits to be made as ordered.

Based on record review, and interview, the agency failed to provide/document education and training for the caregiver as appropriate to their responsibilities in one (Record/Patient #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #4: Review of the plan of care dated 05/13/2022 to 08/10/2022, showed: - SN (skilled nurse) to perform wound care to stage II (Partial thickness skin loss involving, epidermis, dermis, or both) pressure ulcer on coccyx; - Utilizing clean technique - cleanse with wound cleanser, apply venelex (reduces odors) ointment, cover with optifoam (absorbent foam dressing) dressing and change every three days and as needed; and - Instruct caregiver in wound care. Review of the initial nursing visit dated 05/13/2022, showed: - Coccyx stage II pressure ulcer - onset 05/01/2022; - Wound assessed - no, caregiver completed care; - Wound care provided - wound care not provided: caregiver completed care; and - No documentation of assessment or education regarding wound care for the Stage 2 pressure ulcer on coccyx. The findings were reviewed on 05/19/2022 at 12:01 PM and the administrator stated that he/she was going to send nursing out that day to measure wounds and educate primary caregiver on dressing changes.

Based on policy review, record review, and interview the interdisciplinary group (IDG) failed to ensure the plan of care (POC) included the interventions necessary to manage blood sugars (BS) levels of the patient on sliding scale insulin in, but not limited to, one (Record/Patient #5) of five complete records reviewed. This deficient practice has the potential to affect the services of all the agency's patients. Findings included: Review of the agency's policy titled "Inter-Disciplinary Group Meeting," dated March 2022, showed in part the following: - The hospice must designate an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement; - The IDG group, in consultation with the patient's attending physician, must prepare a written plan of care (POC); -The hospice IDG must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services; - The hospice must designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary POC; and - The POC must include all services necessary for the alleviation, treatment and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. Review of the agency's policy titled "Plan of Care - PC30," dated April 2022, showed in part the following: -Purpose: To ensure that the care provided is in accordance with the written POC, appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs; - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs; - A comprehensive assessment will be completed by the IDG and the contents will identify patient demographic information, along with physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process; and - The comprehensive assessment will take into consideration the following factors but is not limited to: severity of symptoms (complete assessment of pain and any other symptoms), and effectiveness of drug therapy. RECORD/PATIENT #5: Review of the initial comprehensive assessment completed by the hospice Registered nurse (RN) F on 03/30/2022 showed the following: -Admitted with a terminal diagnosis of protein calorie malnutrition and cirrhosis of the liver (late stage liver disease); -Abnormal immunologic findings: Diabetes; -Is the patient taking insulin: Yes; -How frequently are blood sugars checked: before meals (AC) and at bedtime (HS); -What are the patient's usual BS readings: Unknown; -Interventions provided: Communicated with interdisciplinary team to coordinate patient's care; -Medication: Novolog (rapid acting insulin) Flexpen U-100 insulin aspart 100 unit/milliliter (3 ML) subcutaneous per instructions; and -Tresiba (long acting insulin) flextouch U-100 insulin 100 unit/ml (3ML) subcutaneous pen, 85 units. Review of the POC, dated 03/30/2022 to 06/27/2022 showed the following: -Hospice RN to evaluate patient and develop a nursing POC; -Novolog Flexpen U-100 insulin aspart 100 Unit/ML (3 ML) subcutaneous as directed. Instructions: Give 25 units at breakfast, 30 units at lunch, 25 units at dinner, Sliding scale: 101-150 = 2 units, 151-200 = 4 units, 201-250 = 6 units, 251-300 = 8 units, 301-350 = 10 units, 351-400 = 12 units, greater than 400 = 14 units; -Tresiba Flextouch U-100 insulin 100 Unit/ML (3ML) subcutaneous pen, 85 units at HS; and -New order 05/06/2022 to discontinue Tresiba and start Semglee (long acting insulin) 85 units at HS. The POC had no intervention listed to monitor the BS. Review of a RN visit on 04/05/2022 showed a random BS of 147. That was the only BS documented for 03/30/2022 thru 05/12/2022. During an interview on 05/19/2022 at 12:10 PM, the administrator stated that they could not find any additional information regarding the blood sugar intervention.

Based on policy review, record review, and interview, the agency failed to ensure the interdisciplinary team/group (IDT/IDG) discussed/documented changes regarding the patient's status and updated the plan of care (POC) in one (Record/Patient #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Inter-Disciplinary Group Meeting," dated 03/2022 showed in part: -The hospice must designate an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement; - The hospice patient's POC will be updated and revised as indicated but not less than every 15 days, or as indicated by State regulations, to ensure the changing needs of the terminally ill patient, including the goals of care and appropriate interventions are identified and included in the POC; and - Active patients: review to include update on previous two weeks response to POC and Do-Not-Resuscitate (DNR) status. RECORD/PATIENT #1: Review of the initial POC dated 11/19/2021 to 02/16/2022 showed the patient as a full code. Review of the patient's "Outside the Hospital Do-Not-Resuscitate (OHDNR) Order" signed and dated 11/26/2021 by the physician and durable power of attorney, showed the patient as a DNR. Review of the updated POC report dated 05/13/2022 showed the patient as a full code. During an interview on 05/19/2022 at 1:58 PM, the administrator stated that he/she would expect the POC and OHDNR paperwork code status to match.

Based on agency policy review, clinical record review, and interviews, the agency failed to ensure the interdisciplinary group (IDG) maintained responsibility for directing, coordinating, and supervising the care and services provided to the hospice patient in one (Record/Patient #5) of five records reviewed. This patient had a pain level of seven and no follow up for five days. This deficient practice has the potential to affect all patients served by the hospice provider. Findings included: Review of the agency's policy titled "Inter-Disciplinary Group Meeting," dated March 2022, showed in part the following: - The hospice must designate an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement; - The IDG group, in consultation with the patient's attending physician, must prepare a written plan of care (POC); -The hospice IDG must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services; - The hospice must designate a registered nurse that is a member of the IDG to provide coordination of care and to ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary POC; and - The POC must include all services necessary for the alleviation, treatment and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. Review of the agency's policy titled "Plan of Care - PC30," dated April 2022, showed in part the following: -Purpose: To ensure that the care provided is in accordance with the written POC, appropriately planned, and delivered in a timely manner to meet the patient's and family's specific needs; and - All hospice care and services furnished to patients and their families will follow an individualized written POC established by the Hospice IDG in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver, if any of them so desire, and in accordance with the patient's needs; - A comprehensive assessment will be completed by the IDG and the contents will identify patient demographic information, along with physical, psychosocial, emotional, and spiritual needs related to the terminal illness that will be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process; and - The comprehensive assessment will take into consideration the following factors but is not limited to: severity of symptoms (complete assessment of pain and any other symptoms), and effectiveness of drug therapy. RECORD/PATIENT #5: Review of the patient's start of care assessment, documented by admission hospice nurse F, dated 03/30/2022, showed the following: -Was admitted from his/her home; -Had clinical evidence of advancing illness; -Had protein calorie malnutrition and cirrhosis of the liver (late stage liver disease); -Had Fentanyl (synthetic opioid typically used to treat patients with chronic severe pain) patches and hydrocodone (used to treat moderate to severe pain) 5/325 milligrams (mg) for pain medications; -Pain assessment: Pain severity was: Severe. Pain tool used: Verbal descriptor. Location of pain: Generalized. Character of pain: Aching. Duration of pain: Continuous. Frequency of pain interfering with patient's activity or movement: All of the time. Is pain an active problem for the patient: Yes; and -Recommendations: Weekly nurse visits, may need increased for medication education for pain management. Spouse is overwhelmed with tasks for caring patient. Review of the POC, dated 03/30/2022 to 06/27/2022 showed the following: -Hospice nurse to monitor patient's pain level and report ineffective pain control to the physician; -Goal: Pain will be managed at a level acceptable to the patient by end of care; -Fentanyl 25 [micrograms/hour] mcg/hr transdermal patch, one patch every 72 hours; -Hydrocodone 5 mg-Acetaminophen 325 mg tablet, two tablets every eight hours as needed. Review of the Nurse's note dated 03/31/2022, showed the following: -Current pain was a 7 (on a numeric pain scale of 0-10, with 0 no pain and 10 the worst pain); -Location of pain: Body ached all over; -Character of pain: Aching; -Frequency of pain: Constant; -What relieves pain: Prescription pain medication; -What exacerbates pain: All activity; -Pain medication used and number of as needed (PRN) doses for each over the past 24 hours: Fentanyl 25 micrograms/hour (mcg/hr) transdermal patch, one patch, transdermal every 72 hours, started 03/30/2022; and -Nurse's documented: Spouse is patient's caregiver which is overwhelming for her/him. Review of the Nurse's note dated 04/05/2022, showed the following: -Current pain was a 6; -Worst pain in level in 24 hours: 8; -Location of pain: General, all over; -Character of pain: Aching; -Frequency of pain: Constant; -How long does pain last: Constant. Patient has a Fentanyl 25 mg, one patch, transdermal every 72 hours. Decreases with hydrocodone 5 mg-Acetaminophen 325 mg tablet, take two tablets every 8 hours; -What relieves pain: Prescription pain medication; -What exacerbates pain: All activity; -Pain medication used and number of as needed (PRN) doses for each over the past 24 hours: Fentanyl 25 mcg/hr transdermal patch, one patch, transdermal every 72 hours and six hydrocodone 5 mg /Acetaminophen 325 mg, take two tablets every eight hours as needed; and -Nurse's documented: Spouse is patient's caregiver which is overwhelming for her/him. Spouse stated that he/she is tired and doesn't know how much longer he/she could keep this up. The hospice staff did not follow up with the patient for five days when his/her pain was rated a seven and documentation showed the spouse was overwhelmed. During an interview on 05/19/2022 at 12:10 PM, the administrator stated that they could not find any additional information regarding the follow-up on pain.

Based on agency policy, clinical record review, and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care in one (Record/Patient #11) of 1 applicable record(s) reviewed. The cumulative effect of these deficient practice has the potential to affect the care and services provided to all of the agency's patients. Findings included: Review of the agency's policy titled, "Transfer & Discharge," dated 02/2022 showed that: - Discharge when a patient is no longer terminally ill should never be a last-minute event for the interdisciplinary group (IDG). When the hospice provider observes indications of disease plateau, there should be discussion with the patient and family about the possibility of discharge if the plateau continues; - Hospice will provide discharge planning prior to discharge and information should be reviewed wit the patient and family at the start of care and at various intervals throughout the service period; - Discharge planning may include, but not limited to, the following: * Referral to appropriate community resources for ongoing support to the patient and family; * The hospice will ensure that the patient has enough medications and supplies for the notice period and until other care may resume; and * Confirmation that the attending physician will resume medical care of the patient. RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 09/14/2020 with a terminal diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). The patient resided in his/her own home, used oxygen continuously, and used morphine (an opioid medication used to help with difficulty breathing) and lorazepam (a medication used to treat anxiety associated with difficulty breathing). Review of the interdisciplinary group (IDG) comprehensive assessment and plan of care update dated 04/21/2022 showed that: - On 04/08/2022: * The patient no longer qualified for hospice care and was more appropriate for palliative care; * The IDG wanted to get things arranged for him/her so he/she would not be left without some kind of coverage by nursing or aides before his/her next recertification period; * Arrangements were being made for palliative consultation , and if appropriate, discharge planning world assure he/she had physician, medication, nursing, durable medical equipment, medical social services, and chaplain coverage by that time; and * They believed that the patient needed a higher level of care than his/her current living arrangements; - On 04/21/2022, review of the hospice physician note showed that: * The patient's life expectancy was greater than six months, and he/she no longer qualified for hospice services; * A referral was given to a palliative heath care agency and she has been accepted after discharge planning arranges for durable medical equipment, medication needs, and appointing a primary care physician for him/her; * The planned discharge date was 05/05/2022. Review of the medical social services visit performed on 04/27/2022 showed that a referral was made for placement to a durable medical equipment company that would provide equipment to the patient after discharge from hospice; Review of the hospice nursing discharge visit dated 05/05/2022 showed that: - The patient continued to use continuous oxygen; - The patient had all refills available and plenty of medications to last until palliative care could take over care; and - Supplies were ordered and delivered to the patient's home. Review of the agency's call log showed on 05/06/2022: - The patient called the agency to report that he/she had not received a call from the palliative care agency; - The receptionist called the palliative care agency and received information that the palliative care agency had not received a referral for the patient, the patient was on their (the palliative care agency's) do not admit list, and they would be unable to provide services for the patient; and - The receptionist then sent referral information to other palliative care agencies and was told that the patient would not receive services because he/she did not have a primary care physician. Review of the agency's call log showed on 05/10/2022, the had patient called the agency to report that he/she was still not on palliative care, and did not receive the correct medications or supplies. During an interview on 05/17/2022 at 08:54 AM, Patient #11 stated that: - The hospice durable medical equipment (DME) provider called to make arrangements to pick up their equipment (the oxygen concentrator and nebulizer on 05/11/2022 pr 05/12/2022; - He/she had not heard from the DME company that was taking over from hospice; - He/she stated that he/she was afraid that the hospice contracted DME company would leave her without oxygen; - He/she did not have a primary care physician and that he/she would soon be without medications (morphine and lorazepam); and - Still did not have palliative care in the home. Review of the fax sent to the DME company for home equipment following hospice discharge, showed the fax for the DME was sent on 05/10/2022, five days after the patient was discharged from hospice. During an interview on 05/19/2022 at 12:36 PM, Palliative Care intake personnel (PC)1 stated, "We have no records of the patient or any record of any referrals for the patient [from the agency]." During an interview on 05/19/2022 at 3:30 PM, the administrator stated that they did not, and would not, leave any patient without oxygen in the home, the patient did not have palliative care, and had an appointment with his/her pulmonologist (lung doctor) this week. Review of the clinical record showed that the record failed to contain documentation that the agency had addressed the following issues with the IDG prior to discharging the patient, as ordered in the updated plan of care dated 04/21/2022: - The referral for palliative care was accepted by the receiving agency; - The referral to a non-contracted DME company to provide equipment after discharge; and - The appointing of a primary care physician.

Based on policy review and clinical record review, the agency failed to forward, to the receiving facility, a copy of the hospice discharge summary in five (Records/Patients # 10, #11, #14, #16, and #17) of nine applicable records reviewed. This deficient practice has to potential to affect all discharged patients served by the agency. Findings included: Review of the agency's policy titled, "Transfer & Discharge," dated 02/2022, showed that the agency must fax a copy of the discharge summary to the attending physician (or the receiving Medicare/Medicaid certified facility) and document the coordination of care in the clinical record. RECORD/PATIENT #10: Review of the clinical record showed the patient was admitted to hospice services on 01/05/2021 with a terminal diagnosis of cerebral infarction (a stroke). The patient was discharged from hospice services on 05/01/2022, and the record failed to contain documentation that the discharge summary had been faxed to the patient's primary care physician. RECORD/PATIENT #11: Review of the clinical record showed the patient was admitted to hospice services on 09/14/2021 with a terminal diagnosis of chronic obstructive pulmonary disease (a disease with chronic inflammation of the lungs). The patient was discharged from hospice services on 05/05/2022, and the record failed to contain documentation that the discharge summary had been faxed to the patient's primary care practitioner. RECORD/PATIENT #14: Review of the clinical record showed the patient was admitted to hospice services on 02/09/2022 with a terminal diagnosis of senile degeneration of the brain (a form of dementia). The patient was discharged on 04/23/2022, and the record failed to contain documentation that the discharge summary had been faxed to the receiving provider. RECORD/PATIENT #16: Review of the clinical record showed that the patient was admitted to hospice services on 01/08/2022 with a terminal diagnosis of protein calorie malnutrition. The patient was discharged from hospice services on 05/06/2022, and the record failed to contain documentation that the discharge summary had been faxed to the patient's primary care physician. RECORD/PATIENT #17: Review of the clinical record showed that the patient was admitted to hospice services on 01/13/2022 with a terminal diagnosis of cancer of the colon. The patient was discharged from hospice care when he/she was admitted to the hospital. The record failed to contain documentation that the discharge summary had been faxed to the receiving facility. The findings were reviewed with the administrator on 05/19/2022 at 4:49 PM. No further documentation was provided prior to the survey exit.

Based on policy review, record review and home visit observation, the agency failed to ensure the long term care facility (LTCF) hospice patient record contained a copy of all required hospice documents in one (Record/Patient #2) of one applicable records of patients that resided in a LTCF. This deficient practice has the potential to affect all patients that resided in a LTCF. Findings included: Review of the agency's policy titled, "Advance Directives," revised 05/01/2019, showed in part: -- The purpose was to ensure that adult patients and their legal representatives are informed of patient rights under federal and state law to make and direct decisions concerning medical care; including the right to formulate advance directives such as a "Do-Not-Resuscitate" (DNR); and - To provide for education of staff and the community on issues concerning advance directives and related advance care documents. RECORD/PATIENT #2: Review of the hospice record maintained at the long term care facility (LTCF), during a home visit observation on 05/18/2022 beginning at approximately 09:40 AM, showed it failed to contain the advance directive information. (The only place found to show the patient's code status was on the interdisciplinary group (IDG) updated form.) The patient was a full code. The findings were reviewed with the administrator on 05/19/2022 at 12:05 PM. No further additional information was provided.

Based on agency policy and employee file review, the agency failed to obtain a criminal background check, prior to patient contact, on all hospice employees who have direct patient contact or access to patient records in two (Employee #4 and #7) of eight records reviewed. This deficient practice has the potential to affect the safety of all the agency's patients. Findings included: Review of the agency's policy titled, "Background Checks," dated 02/01/2021 showed that staff would not have direct contact with patients or access to records until the agency has obtained the results of the criminal history record information and has verified employability. EMPLOYEE #4: Review of the employee file showed that the employee's date of hire was 02/21/2022, and first patient contact was 02/28/2022. The employee file failed to contain a criminal background check. EMPLOYEE #7: Review of the employee file showed that the employee's date of hire was 07/06/2021, and first patient contact was 07/10/2021. The criminal background check was performed on 09/01/2021. The findings were reviewed with the regional director of operations on 05/18/2022 at 02:49 PM. No further documentation was provided before the survey exit.

Based on review of Missouri state law and employee file review, the agency failed to obtain the employee disqualification list (EDL) prior to hire, in one (Employee #4) of eight 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 showed the statement, "No person, corporation, organization or association who received the employee disqualification list under subdivisions (1) to (5) of subsection 11 of this section shall knowingly employ any person who is on the employee qualification list." EMPLOYEE #4: Review of the personnel file showed that the date of hire was 02/21/2022. There was no evidence of an EDL prior to hire. The findings were reviewed with the regional director of operations on 05/18/2022 at 02:49 PM. No further documentation was provided before the survey exit.

Based on federal law and Missouri state law review, personnel file review, and interview, the agency failed to assure Alzheimer's training was provided at orientation to four employees (Employee #1/Aide B, Employee #2/Registered Nurse (RN)) C, Employee #3/RN D, and Employee #4/Chaplain E) of seven personnel files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of 19 CSR 30-35.010 (2) (M) 1. B. (xiii) requires: "Alzheimer's disease and related dementias. Hospice agencies shall provide dementia-specific training about Alzheimer's disease and related dementias to their employees and those persons working as independent contractors who provide direct care to or may have daily contact with residents, patients, clients or consumers with Alzheimer's disease or related dementias. (a) At a minimum, the training required shall address the following areas: A. An overview of Alzheimer's disease and related dementias; B. Communicating with persons with dementia; C. Behavior management; D. Promoting independence in activities of daily living; and E. Understanding and dealing with family issues. (b) Employees or independent contractors who do not provide direct care for, but may have daily contact with, persons with Alzheimer's disease or related dementias shall receive dementia-specific training that includes, at a minimum: A. An overview of Alzheimer's disease and related dementias; and B. Communicating with persons with dementia. (c) Dementia-specific training about Alzheimer's disease and related dementias shall be incorporated into orientation for new employees with direct patient contact and independent contractors with direct patient contact. The training shall be provided annually and updated as needed." EMPLOYEE #1: - Date of hire: 12/06/2021; and - No evidence of Alzheimer's dementia training during orientation. EMPLOYEE #2: - Date of hire: 04/04/2022; and - No evidence of Alzheimer's dementia training during orientation. EMPLOYEE #3: - Date of hire: 04/18/2022; and - No evidence of Alzheimer's dementia training during orientation. EMPLOYEE #4: - Date of hire: 02/21/2022 and - No evidence of Alzheimer's dementia training during orientation. During an interview on 05/18/2022 at 2:54 PM, the administrator stated that the employee who teaches the Alzheimer's training had been out on maternity leave, and some new employees haven't had the training.

Based on clinical record review, policy review, and staff interviews, the hospice provider failed to ensure that registered nurse gathered the critical information necessary on the initial assessment to treat the patient's immediate care needs. The single deficiency example was identified at an condition level due to substantial risk to adversely affect health and safety to hospice patients (L522). The effect of this deficient practice has the potential to affect nursing services for all patients on service with the agency.

Based on policy review, record review, and interview, the hospice registered nurse failed to complete an adequate initial assessment in one of three patients sampled (Record/Patient #3). The deficient practice has the potential to affect all patients on service with the hospice provider. Findings included: Review of the undated Traditions Health hospice policy titled, "Patient Assessments PE.1" showed in part, that the initial assessment should include the "patient's physical, psychosocial and emotional status related to the terminal illness and related conditions". RECORD/PATIENT #3: The patient was admitted on 01/28/2022 with the terminal diagnosis of respiratory failure. The patient had dementia and lived in a memory care unit at Autumn Terrace long-term care facility (LTCF). The patient expired on 01/29/2022. Review of LTCF documentation where the patient resided, dated 01/28/2022, showed that the patient had just arrived back to the facility from a hospitalization of COVID-19. The staff documented two sacral pressure ulcers, with no measurements, description, or stage. No orders to treat the pressure ulcers were identified in the LTCF documentation. During the initial hospice assessment visit on 01/28/2022, that lasted from 7:09 PM to 9:50 PM, showed the registered nurse, RN-A, assessed the patient with "no skin breakdown to heels". No additional integumentary or skin assessment was documented. The patient was having dyspnea (labored breathing - a possible sign of pain). During a "as needed " hospice nurse visit on 01/29/2022, from 12:50 AM through 6:20 AM, showed the hospice registered nurse, RN-B, documented the following: - The patient's pain was as assessed at 7 (scale where 10 is most severe); - The patient had an unstaged mid-sacral wound, identified as wound #1. The integumentary section of the assessment failed to include description, or measurements of wound #1; - The narrative section of the assessment showed "This nurse noted when turning patient that two sacral wounds existed that are currently covered with dressing that partially came off, reapplied, area of wound assessed revealed brown and black necrotic eschar very strong foul odor"; - The patient had "IV access to right anterior forearm"; and - The nurse called RN-A and RN-A informed him/her that "I didn't know he/she had an IV or any wounds". During an interview with RN-A on 02/23/2022 at 11:49 AM, the nurse stated that during the initial assessment visit, that "I did not look at the patient's skin, more concerned with the patient's breathing".