Every finding on record at Vitas Healthcare Corporation Midwest

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, interview, and observation. In 4 of 19 (21%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a medication profile that contained the patient's current medications. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/29/2024. On 03/29/2024, the physician ordered, "monitor use and effectiveness of Aleve, Flexeril, Biofreeze, and heating pad. Biofreeze was not documented on the patient's medication profile. During the home visit with the Social Worker (SW) [Personnel Record 4] on 06/19/2024, the patient reported that they prefer herbal remedies, and the hospice staff is aware. The patient reported that smoking "Mullein" (an herbal remedy used for asthma, bronchitis, pneumonia, colds, and cough) as needed for respiratory relief. A large glass jar with dried plant material labeled "Mullein" was on the table. The patient reported that Mullein is primarily for breathing but also helps with the digestive system. The patient reported taking Turmeric (a dietary supplement used for disorders of the skin, upper respiratory tract, joints, and digestive system) for inflammation. The patient stated that they held off on taking their pain medication, but that could change at any time as their pain was becoming worse. Mullein and Turmeric were not documented on the patient's medication profile. There was no evidence that Biofreeze, Mullein, and Turmeric were reviewed with the patient's medication regimen. The SW confirmed that the staff was aware that the patient prefers herbal remedies. The patient's pain has increased over the last three (3) weeks, and the patient is aware that they may need to supplement herbal remedies soon. Clinical Record 9: The patient elected hospice care on 06/12/2023. A review of the clinical record revealed that the Registered Nurse (RN) plan of care review and updated comprehensive assessment dated 05/28/2024 documented, "Has started marijuana gummies." The patient's medication profile created on 05/06/2024 was not updated to document the marijuana gummies. There was no evidence that marijuana gummies were reviewed with the patient's medication regimen. Clinical Record 10: The patient elected hospice care on 05/24/2024 with a history of chronic obstructive pulmonary disease (COPD) and lung cancer. The Skilled Nursing (SN) visit note dated 05/25/2024 documented, "Oxygen (O2) and breathing treatment available for patient and effective." Oxygen was not documented on the patient's medication profile. Clinical Record 14: The patient elected hospice care on 05/25/2024. The plan of care dated 05/25/2024 ordered: "Oxygen 2 liters (L) per nasal cannula (NC) as needed (PRN) for dyspnea. The medication profile dated 05/27/2024 and updated 06/17/2024 documented oxygen via nasal cannula as needed for dyspnea. The medication profile did not document a flow rate for the oxygen. During an interview and a joint clinical record review on 06/19/2024, the Patient Care Administrator confirmed that medications, supplements, herbal treatments, and oxygen were not included in the medication profiles.

It is required that the hospice ensures that each patient and the primary caregiver(s) receive education and training, provided by the hospice, as appropriate to their responsibilities for care as stated in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the patient and the primary caregiver(s) received education and training. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/02/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 01/02/2024 documented that the patient smoked. The plan of care ordered: "Oxygen 4 liters per minute (LPM) per nasal cannula (NC)" continuously with an oxygen concentrator. The plan of care dated 01/02/2024 did not include interventions related to the patient's smoking and use of oxygen. The bi-weekly interdisciplinary group (IDG) notes dated through 06/12/2024 indicated that the patient continued to smoke. The plan of care did not include interventions or education after the initial visit related to safety concerns. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 06/18/2024, a single cigarette and lighter were observed on patient's the bedside table. The house did not smell of cigarette smoke, and the patient's daughter confirmed that the patient did not smoke in the home. The patient, who was alert and oriented, stated that they smoke outside and not around the oxygen. The patient stated that they do not stay outside too long because they cannot use oxygen. The patient had a sign on the front door that read "oxygen was in use." The patient stated that the agency provided education and safety information at the initiation of care. The patient safety information was observed in the home with the home folder.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, observation, and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/02/2024. The initial comprehensive assessment completed by the Registered Nurse (RN) on 01/02/2024 documented that the patient smoked. The plan of care ordered: "Oxygen 4 liters per minute (LPM) per nasal cannula (NC)" continuously with an oxygen concentrator. The plan of care dated 01/02/2024 did not include interventions related to the patient's smoking and use of oxygen. The bi-weekly interdisciplinary group (IDG) notes dated through 06/12/2024 indicated that the patient continued to smoke. The plan of care did not include interventions or education after the initial visit related to safety concerns. During the home visit with the Registered Nurse (RN) [Personnel Record 1] on 06/18/2024, a single cigarette and lighter were observed on the patient's bedside table. The house did not smell of cigarette smoke, and the patient's daughter confirmed that the patient did not smoke in the home. The patient, who was alert and oriented, stated that they smoke outside and not around the oxygen. The patient stated that they do not stay outside too long because they cannot use the oxygen. The patient had a sign on the front door that "oxygen was in use." The patient stated that the agency provided education and safety information at the initiation of care. The patient safety information was observed in the home with the home folder. Clinical Record 9: The patient elected hospice care on 06/12/2023. A review of the clinical record revealed that the Registered Nurse (RN) plan of care review and updated comprehensive assessment dated 05/28/2024 documented, "Has started marijuana gummies." The plan of care was not updated to include goals or interventions related to the patient's use of marijuana gummies. During an interview on 06/17/2024, the Patient Care Administrator confirmed that the plan of care did not include interventions related to the patient's continued smoking.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that the individualized written plan of care included the patient's drugs and treatments. Clinical Record 4/Home Visit 4: The patient elected hospice care on 03/29/2024. On 03/29/2024, the physician ordered, "monitor use and effectiveness of Aleve, Flexeril, Biofreeze, and heating pad. Biofreeze was not documented on the patient's plan of care. During the home visit on 06/19/2024, the patient reported that they prefer herbal remedies, and the hospice staff is aware. The patient reported that they smoke "Mullein" (an herbal remedy used for asthma, bronchitis, pneumonia, colds, cough) as needed for respiratory relief. The patient reported taking Turmeric (a dietary supplement used for disorders of the skin, upper respiratory tract, joints, and digestive system) for inflammation. Mullein and Turmeric were not documented on the patient's plan of care. The SW confirmed that the staff was aware that the patient prefers herbal remedies. During an interview on 06/19/2024, the National Patient Care Administrator and Patient Care Administrator confirmed that the care plans did not include the use of herbal remedies and dietary supplements.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 2 of 12 (17%) clinical records reviewed, the agency did not ensure that the Hospice Aide (HA) received written patient care instructions specific to the patient's needs. Clinical Record 5: The patient elected hospice care on 07/13/2023. On 07/20/2023 Hospice aide services were added to the plan of care and the HA care plan was documented. A Hoyer lift was added to the patient's plan of care on 09/28/2023. The HA care plan was not updated to include the use of the Hoyer lift during personal care. The HA documented that the caregivers used the Hoyer lift for transfers. The HA visit notes documented that the HA did not transfer the patient from the bed during personal care. On 06/12/2024, oxygen was ordered. The HA care plan was not updated to include the patient's use of oxygen during personal care. Clinical Record 19: The patient elected hospice on 01/15/2024 with a history of epilepsy and seizures. The HA care plan documented by RN on 01/17/2024 did not document seizure precautions. During an interview on 06/19/2024, the Patient Care Administrator confirmed that the HA care plans did not include the requirements and stated, "I understand completely."

It is required that a hospice aide provides services: included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care (POC). Clinical Record 3: The patient elected hospice care on 12/20/2023 and resided in a skilled nursing facility (SNF). The patient's diagnosis was documented as chronic pulmonary disease (COPD). The HA care plan dated 05/08/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/09/2024, 05/21/2024, 05/24/2024, 05/28/2024, 05/30/2024, 06/04/2024, 06/06/2024 and 06/13/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. Clinical Record 4: The patient elected hospice care on 03/29/2024. The patient's diagnosis was documented as neoplasm of pancreas. The HA care plan documented on 04/23/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/01/2024, 05/03/2024, 05/06/2024, 05/08/2024, 05/13/2024, 05/15/2024, 05/20/2024, 05/24/2024, 05/27/2024, 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. Clinical Record 9: The patient elected hospice care on 06/12/2023. The patient's diagnosis was documented as neoplasm of the bladder. The HA care plan documented on 06/17/2024 assigned the HA the relevant task "Infection Control -Universal Precautions." The HA visit note dated 06/17/2024 documented "Infection Control - Universal Precautions... Not performed/Not required." Clinical Record 12: The patient elected hospice care on 05/08/2024. The patient's diagnosis was documented as end stage renal disease. The HA care plan documented on 05/10/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/14/2024, 05/21/2024, 05/28/2024, 06/03/2024, 06/10/2024, 06/14/2024, and 06/18/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. During an interview and a joint record review on 06/18/2024, the Regional Patient Care Director agreed with the findings related to HA documentation.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 12 (25%) clinical records reviewed of patients that accepted Hospice Aide (HA) services, the agency did not ensure that the HA provided services included in the plan of care (POC). Clinical Record 3: The patient elected hospice care on 12/20/2023 and resided in a skilled nursing facility (SNF). The patient's diagnosis was documented as chronic pulmonary disease. The HA care plan dated 05/08/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/09/2024, 05/21/2024, 05/24/2024, 05/28/2024, 05/30/2024, 06/04/2024, 06/06/2024 and 06/13/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight.The clinical record contained no documentation that the Registered Nurse (RN) was notified that the task was not completed. Clinical Record 4: The patient elected hospice care on 03/29/2024. The patient's diagnosis was documented as neoplasm of pancreas. The HA care plan documented on 04/23/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/01/2024, 05/03/2024, 05/06/2024, 05/08/2024, 05/13/2024, 05/15/2024, 05/20/2024, 05/24/2024, 05/27/2024, 06/03/2024, 06/05/2024, 06/07/2024, 06/10/2024, 06/12/2024, 06/14/2024, and 06/17/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. The clinical record contained no documentation that the RN was notified that the task was not completed. Clinical Record 12: The patient elected hospice care on 05/08/2024. The patient's diagnosis was documented as end stage renal disease. The HA care plan documented on 05/10/2024 assigned the HA the relevant task: weigh the patient every month. The HA visit notes dated 05/14/2024, 05/21/2024, 05/28/2024, 06/03/2024, 06/10/2024, 06/14/2024, and 06/18/2024 documented “not performed/not required this visit" for the assigned task to weigh the patient monthly. There was no evidence that the HA weighed the patient monthly as assigned. A review of the clinical record revealed a weight was obtained at the time of recertification. The HA did not obtain that weight. The clinical record contained no documentation that the RN was notified that the task was not completed as assigned. During an interview and a joint record review on 06/18/2024, the Regional Patient Care Director agreed with the findings related to HA documentation.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure that the patient's clinical record contained physician orders for all care and treatment. Clinical Record 5: The patient elected hospice care on 07/13/2023. The updated comprehensive assessment completed by the Skilled Nurse (SN) on 08/16/2023 documented, "Genitourinary system...patient has a pic wick [sic] system in place." A review of the clinical record revealed no physician orders for a "PureWick" or "pic wick" system. Clinical Record 10: The patient elected hospice care on 05/24/2024 with a history of chronic obstructive pulmonary disease (COPD) and a diagnosis of lung cancer. The Skilled Nursing (SN) visit note dated 05/25/2024 documented, "Oxygen (O2) and breathing treatment available for patient and effective." The initial plan of care documented an oxygen concentrator with medical equipment and supplies. The plan of care did not include orders for the administration of oxygen. During an interview and a joint record review on 06/17/2024, the Patient Care Administrator confirmed that there was no order for Clinical Record #1 for a pure wick system and no physician order for oxygen administration on Clinical Record #10.

Based on policy review, record review, and interview, the provider failed to ensure that: - Hospice provided professional management responsibility, oversight and coordination of care/services to a patient that was receiving respite care in a long-term care facility (L0762). The cumulative effect of this deficient practice has the potential to affect all patients served by the provider.

Based on policy review, record review, and interview, the hospice provider failed to ensure professional management responsibility, oversight and coordination of care/services for a patient that received respite care in a long-term care facility (LTCF), in one of three applicable records (Record/Patient #1). This deficient practice has the potential to affect all patients on service with the hospice provider. --- Findings Included: Review of the provider's policy titled, ";Long-Term Care Facility," updated 03/28/2013, showed the following: - Purpose: Condition of Participation: Interdisciplinary group (IDG), care planning and coordination of services; - The hospice must develop and maintain a system of communication and integration, in accordance with the hospices own policies and procedures: * Ensure that the IDG maintains responsibility for directing, coordinating, and supervising the care and services provided; * Ensure the care and services are provided in accordance with the plan of care; * Ensure that the care and services provided are based on all assessments of the patient and family needs; and * Provide for and ensure that ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. - The hospice must assume responsibility for professional management of the residents hospice services provided, in accordance with the hospice plan of care and the hospice conditions of participation; - The hospice plan of care must` identify the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care; and - Long Term Care visit overview: * Obtain information regarding each patients status, has there been a change in condition, and concerns, problems, issues, and questions; * Review the patient chart to check to see if there are any new orders and review the long term facilitys plan of care for changes and consistent with the hospice providers plan of care; * Update the plan of care with new symptoms and changes in interventions; and * The hospice provider is responsible for the professional management of all hospice services provided to the long-term care facility patients as documented in the plan of care. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the hospice provider on 06/27/2023 with a terminal diagnosis of malignant neoplasm of unspecified ovary and secondary diagnosis of malignant neoplasm of unspecified lung. The patient was admitted to the LTCF, from home, on 07/10/2023 for respite care, and discharged back to home on 07/14/2023. Review of the hospice active medication list/signed physician orders, dated active as of 07/10/2023, located in the hospice providers book left at the LTCF, showed, in part, the following: - Roxanol (morphine sulfate) 20 milligrams (mg)/milliliter (ml) take 0.5 ml (10 mg) by mouth every four hours for pain, started on 07/01/2023; and - Duoneb (ipratropium/albuterol sulfate, used to relax the muscles in the airways and increase air flow to the lungs) 0.5-3 mg ampule-neb, empty one ampule and inhale by mouth every four hours as need for shortness of breath. Review of the hospice nursing-updated comprehensive assessment dated 07/10/2023 at 1:15 PM, showed: - The patient denies pain, receives morphine 0.5 ml every four hours and effective for pain; - Gastrointestinal assessment showed, constipation, bowel sounds hypoactive, decrease bowel movements since patients appetite decreased, Senna (used to treat constipation) and Dulcolax suppository (can treat constipation) to be administered for increased constipation (there was no documentation to show last bowel movement); - Respiratory assessment showed, dyspnea (shortness of breath) with talking, reports cough, and no Roxanol or duonebs at the LTCF, the patients family member to bring Roxanol and duonebs; - The hospice nurse did not find any medications in the patients bag; the LTCF nurse stated that he/she did not receive any medications for the patient. The hospice social worker said the patients family member would be bringing the medications to the facility; - A physician visited the patient and the patient stated that he/she is constipated and it seemed to be getting worse and the physician added Miralax (used to treat occasional constipation). The hospice registered nurse (RN), and the LTCF RN reviewed the medications with the physician. The documentation failed to show if the physician was aware of the patients breathing treatment medication and pain medication not being available; - The hospice nurse and LTCF nurse were expecting medications from the patients family member, especially morphine, due to patients lower back pain and right flank pain that is controlled with morphine; - The patient denied pain and requested to be able to ask for the morphine instead of receiving it every four hours as ordered. The hospice nurse instructed the patient to keep ahead of the pain, and the physician's order was for morphine every four hours, and the patient agreed (the LTCF showed morphine every four hours as needed); and - The hospice nurse left the LTCF at 3:45 PM with the understanding that the patients family member would bring the medications. The hospice failed to document the last time the patient had morphine prior to admission to LTCF (the LTCF MAR showed no doses of morphine given on 07/10/2023). The documentation failed to show physician notification of the patient's shortness of breath and cough, and the Roxanol and Duoneb not being available. Review of the LTCF MAR, dated 07/10/2023 through 07/14/2023, showed: morphine sulfate solution 20 mg/ml, 0.5 ml sublingually every four hours as needed for pain. The morphine sulfate was administered a total of three times. Two doses on 07/11/2023 at 11:06 AM and 1:40 PM, and one dose on 07/14/2023 at 12:30 PM. Review of the LTCF treatment administration record (TAR), dated 07/10/2023 through 07/14/2023, showed: - Betadine to left heel every day shift for wound care; - Prevalon boots (used to float heels off of the bed) for offloading every shift for skin integrity; and - Zinc to sacrum twice daily every shift for wound care. Review of the hospice clinical record failed to show documentation regarding skin issues and treatment. Review of the hospice psychosocial/spiritual updated comprehensive assessment, dated 07/11/2023 at 9:00 AM, showed the patient had back paint and pain in the back of the left shoulder. The patient rated the pain four to five (zero representing no pain and ten representing the worst pain possible), the frequency and duration of the pain was frequently, and medication relieves pain. The facility and hospice nurse aware. (The LTCF MAR showed the patient had not receive morphine since he/she was admitted to the LTCF for respite care on 07/10/2023.) Review of the hospice supplemental interdisciplinary note dated 07/11/2023 at 9:15 AM, showed that the registered nurse called the facility and spoke with the LTCF nurse about medications, and keeping ahead of the pain. The LTCF nurse reports the patient has refused Roxanol (morphine) and other medications, stating, ";I will let you know when I want my medications". There was no documentation to show the LTCF had received morphine to administer to the patient. Review of the hospice telephone records, dated 07/11/2023, showed the following: - On 07/11/2023 at 9:17 AM, the hospice social worker stated that the patient still does not have his/her morphine, can we get that, he/she is in pain; and - On 07/11/2023 at 10:06 AM, the hospice RN stated that the facility nurse was checking to see where the patients medications are that the family brought last night. He/she was waiting for the LTCF nurse to call back and let him/her know if he/she found the medications. The hospice RN was on standby to order medications via eScript (a digital version of a paper prescription and sent by text or e-mail by your doctor); and - On 07/11/2023 at 11:16 AM, eScripts ";done" to replace morphine in emergency kit (e-kit). Medications have all been re-ordered and medications have all been delivered except lorazepam in which patient does not like to take. Review of the hospice focus visit note, dated 07/11/2023 at 10:10 AM, showed: - The hospice RN administered Roxanol (the LTCF MAR showed the patient received morphine at 11:06 AM); - The patient reported pain four to five out of ten and the patient did display grimacing and moaning; - The patient talks softly about pain and discomfort; - All eScripts for morphine and lorazepam (antianxiety) signed by the hospice physician and the LTCF nurse aware; - Last bowel movement was 07/07/2023 the patient reported right flank pain and rated the pain five out of ten; - The hospice RN explained to the LTCF nurse that morphine is now available to administer (the note failed to contain clarification of the morphine schedule discrepancy); - The hospice RNs visit time was 10:10 AM to 12:15 PM. The RN documented the patient refused (the morphine) before he/she left (the nurse left at 12:15 PM and the patient had received a dose of morphine at 11:06 AM). The next dose of morphine was given on 07/11/2023 at 11:40 PM (12 hours after the last dose). The hospice failed to show coordination of care regarding the patients hospice orders to receive morphine every four hours, no bowel movement since 07/07/2023, and skin issues. Review of the hospice aide note, dated 07/11/2023 at 1:25 PM, showed the patient was in a lot of pain and reported to staffing (LTCF staff) that he/she was in need of pain medication. Review of the LTCF MAR showed morphine was given on 07/11/2023 at 11:40 PM (10 hours and fifteen minutes after the hospice aide reported the pain). The documentation failed to show if the hospice case manager was notified of the patients pain. Review of the hospice focus visit note, dated 07/11/2023 at 3:40 PM, showed the RN documented that he/she received a call that patient had not received Roxanol for pain, the LTCF nurse attempted to administer Roxanol and the patient refused because he/she was eating. The hospice RN talked to the patient about pain, and Roxanol, and keeping ahead of the pain. The patient rated pain five out of ten. The hospice RN administered the Roxanol (review of the LTCF MAR failed to show that the Roxanol was given). The hospice RN spoke to the LTCF assistant director of nursing (ADON) about the situation of pain for the patient and the patient needed food in his/her stomach before giving Roxanol. The assessment showed the patient was not satisfied with the current pain and symptom management, and the areas that needed focused on was the Roxanol administration. (The hospice failed to address the discrepancy of the morphine.) Review of the hospice aide note, dated 07/13/2023 at 12:35 PM, showed that the patients pain level was five. The documentation failed to show notification of the pain to the LTCF nurse and hospice manager. The last dose of morphine the patient received was on 07/11/2023 at 11:40 PM (approximately 36 hours and 45 minutes). Review of the LTCF MAR showed the patient did not receive morphine on 07/12/2023 or 07/13/2023. Review of the hospice clinical record failed to show coordination with the LTCF and the hospice IDG regarding the patients pain, constipation (no bowel movement since 07/07/2023), and wound treatment. Review of the hospice psychosocial/spiritual updated comprehensive assessment, dated 07/14/2023 at 8:15 AM, showed that the patient reported pain on side of stomach and LTCF nurse and hospice nurse made aware. The patient spoke about not wanting to be at the LTCF. The patients caregiver told the social worker he/she was unhappy with the patients stay and wanted the patient discharged. Review of a hospice note, typed on an unnamed piece of paper, dated 07/14/2023, showed the social worker visited the patient and the patient wanted to go home and was stressed and anxious (hospice failed to document if lorazepam was received for the patient). He/she was shaky and reported no bowel movement in five to six days. The social worker will find LTCF certified nurse assistant to help the patient get up to see if that would help. The patient stated that he/she had pain on his/her right side near liver. The patients blood pressure is low, and he/she is short of breath (review of the LTCF MAR showed no Duoneb treatment given for shortness of breath). The LTCF was agitated with the patient because he/she was not reporting symptoms to them, and refusing to take medications and was taking medications out of his/her purse randomly. The note failed to show if hospice addressed the patients shortness of breath, anxiety, constipation, and pain. Review of the LTCF progress note, dated 07/14/2023 at 5:45 PM, showed late entry: The staff talked to the hospice nurse regarding the patient wanting his/her morphine scheduled every four hours and not as needed (according to the hospice orders the morphine was scheduled every four hours). The hospice nurse stated that he/she would speak with the hospice physician after the patient was discharged. Review of the plan of care review (IDG meeting), dated 07/19/2023 (five days after the patient was discharged from respite care), showed: - Patient went to respite 07/10/2023 to 07/14/2023 due to patients caregiver having surgery, and the medication became missing, later found and administered; - The patient has chronic constipation, Senna and Miralax when taken is effective, education continued; and - Roxanol "10.5" ml every four hours effective for pain control, pain is in right flank area, and pain is under control with Roxanol; and - Integumentary section left blank (There was no coordination of care regarding the patients skin issues). Review of the LTCF progress note, dated 07/20/2023 at 5:07 PM, showed: - A call was received from the hospice nurse requesting the writer to speak with the hospice DON in regards to the resident threatening to call the state; - The writer spoke to the hospice DON and the patients caregiver; - The caregiver stated that the patient returned home with skin breakdown, the patient was never out of bed (during his/her stay at the LTCF), and the patients medication was supposed to be given every four hours (routinely); - The writer informed the caregiver that the LTCF wound nurse assessed the patients skin on admission, and the patient was admitted with two stage one (pressure) areas to the sacrum and left heel; and - The LTCF offered to get the patient up and he/she refused, and the writer tried to educate the caregiver on as needed medication administration. During an interview, on 08/24/2023 at 1:23 PM, the hospice social worker stated that the patient was admitted to the LTCF for respite care and the case manager did not get the patient's meds or make sure the meds were available. The patient went almost two days without meds. The facility did not have the pain meds. He/she called and e-mailed all upper management the day the incident took place 7/11/2023, the patient was admitted 7/10/2023 through 7/12/2023. The patient went without meds from 07/10/2023 evening to 7/11/2023 at 11:00 AM. He/she thinks the nurse did not get the meds or make sure the meds were available. The case manager did not manage the patient's pain. He/she called the nurse several times to let him/her know the patient was in pain and he/she said they would go back and check on the patient. During an interview on 09/26/2023 at 8:41 AM, the patients caregiver stated that he/she was having a knee replaced and needed the patient to have respite care. The patients morphine was scheduled every four hours and that manages his/her pain. The hospice case manager told the patient that he/she needed to take the morphine every four hours because it was hard telling when the LTCF nurse would give it to him/ her. The caregiver was not told to take the patients medication to the LTCF. He/she was getting ready for surgery and the case manager called him/her and said they needed the medication. The caregiver called another family member to pick up and deliver the medication. The LTCF nurse was not there to receive the medications so the family member gave it to another staff member and watched him/her lock it up in the cabinet. He/she called to check on the patient after surgery, and the patient stated that he/she had not received their pain meds all day, and he/she was in pain. The caregiver called the hospice social worker and the social worker told him/her to call hospice. The social worker went to the LTCF and the LTCF staff started looking for the medications. The next day they found the medications. On Thursday night (07/13/2023), the caregiver was thinking the patient was okay and received a call from the hospice social worker to let him/her know the patient stated that he/she was in pain and had not received their medication. The caregiver was panicking because he/she just came out of surgery and the social worker asked him/her if he/she wanted the patient to stay another five days for respite care. The caregiver said no and instructed them to bring the patient home. When the patient got home from the LTCF he/she had skin break down on his/her "bottom" (buttock) and the caregiver was trying to care for that. He/she was very upset the patient did not get his/her medication in the nursing home, and the case manager stated that he/she went to the LTCF three times and that tells the caregiver that the case manager must have left twice with the patient having no medication. The patients morphine was PRN in the LTCF and should have been routine. It has always been routine. The patient did not have medication in his/her purse. The hospice aide told him/her that he/she went to the nurses station to let the LTCF staff know he/she needed his/her pain med. The patient went to the LTCF constipated. Hospice knew the Senna was not effective then they received an order for Dulcolax (review of the LTCF MAR showed Dulcolax was not given), when the patient got home the caregiver gave him/her a Dulcolax suppository because the patient was very uncomfortable and the patient finally had a bowel movement. When the patient got home, he/she was in pain, and the caregiver got the pain controlled. During an interview on 09/26/2023 at 12:43 PM, the administrator (general manager) stated that he/she feels the LTCF charted on the wrong patient regarding the skin issues and the hospice could not get a clear picture. The social worker facilitates respite care and contacts the facility regarding the medications. The social worker quit and did not turn in all of his/her documentation. The case manager coordinates care with the nursing home and no one knew the morphine had changed to prn (as needed). During an interview on 09/26/2023 at 12:53 PM, licensed practical nurse (LPN) A stated that he/she saw the patient the night (07/14/2023) the patient returned home from the LTCF and the patient was upset about the stay. There was a small red spot on his/her buttocks. He/she complained of not receiving medications at the facility during his/her respite stay and they said they would give him/her the medication. The patients caregiver had barrier cream. The LPN provided education on turning and repositioning and importance of nutrition. He/she called the on-call physician about concerns of the small red spot on his/her inner buttock. He/she did not recall reporting the constipation. During an interview on 9/26/2023 at 10:29 AM, the hospice aide stated that he/she saw the patient twice while in the LTCF. Both times the patient stated that he/she was in a lot of pain. He/she stated his/her pain level was greater than 10. That hospice aide went to the nursing station twice on the first visit to report pain and the nurse was on break so he/she let the person at the desk know the patient was in pain prior to leaving the LTCF. The patient stated that his/her buttocks, and back was hurting, and he/she was hurting all over, he/she was not sure if the patient ever got the pain medication. On the first visit, the hospice aide delivered supplies and stayed with the patient to provide comfort. On the second visit, the patient was in bed and the hospice aide gave him/her a bath. He/she helped the patient sit up for a while. The patient finally got his/her pain pill and rated his/her pain a four out of 10, the patient was ready to go home and tired of being in bed. He/she had no skin issues. The hospice aide was almost sure he/she called the case manager to let him/her know about the pain on the first visit and the case manager stated that he/she would follow up. He/she went back the following Tuesday after the patient was home and he/she had skin issues on his/her buttocks. The case manager told him/her to use calmoseptine (moisture barrier that protects and helps heal skin irritations). The caregiver was very unhappy with respite care and reported to the supervisor. The patient was a lot better when he/she got home. The caregiver was mad that the patient was uncomfortable the whole time during his/her stay at the LTCF. During an interview on 09/26/2023 at 1:45 PM the DON (hospice patient care administrator) stated that on 07/06/2023 at 11:46 AM the social worker gave instruction to the caregiver about taking the patient's medications to the LTCF when the patient is admitted for respite. On 07/10/2023 the caregiver called the hospice social workers phone because the patient's pain was seven out of 10. The social worker called the caregiver back late that night and sent an e-mail and told the caregiver to call the hospice 800 number. The DON was not aware the patient's medications were not at the LTCF until 07/11/2023. The hospice DON told the hospice staff to reach out to the administrator on call when something needs attention. The patient left respite early and went home. During an interview on 9/26/2023 at 2:28 PM, the administrator stated that there was no information on the constipation. The nurses have until the end of the week to turn in their notes so they may not be available for IDG until the following IDG meeting. The patient was not discussed in IDG the week he/she was in the LTCF for respite care, he/she was not discussed until the next IDG meeting. The team manager audits the charts monthly. Respite stays are coordinated at the beginning. The hospice wanted to ensure at least one staff member makes daily contact with the patient while on respite but that has not always been possible. This is not policy and he/she is unable to change a policy, it is a corporation decision to change policy. The social worker and case manager coordinate equipment and medications. The RN provided a lot of communication about patient #1. During an interview on 09/26/2023 at 5:28 PM, the patients caregiver stated that, the patient stated that he/she only got his/her medications once if at all (while at the LTCF). The patient knows what is going on and is alert and oriented. The caregiver called the DON to request wound cleanser, lantiseptic skin protectant and gauze to cover it, and Duoderm dressing. The bath aide took a picture and LPN A assessed the area. During an interview on 09/26/2023 at 6:44 PM, nurse B stated that the pain medication was not administered in a timely fashion while the patient was on respite. The RN case manager should have made sure the orders were in place and the medications were there (LTCF) prior to leaving the facility. The RN case manager is to communicate to the hospice doctor any problems, and the nurse did not follow up to make sure the medications were given as directed. The LTCF orders should parallel hospice orders. The patient had not refused morphine, he/she had several types of cancer and was receiving morphine every four hours to keep the pain controlled. The caregiver state that the patient did not have a bowel movement while on respite care (07/10/2023 through 07/14/2023). The case manager told the patient he/she did not need Senna every day. Patients on narcotics should have their bowels monitored because narcotics can cause constipation, which can add additional pain and problems. The patient had a bowel movement after he/she returned home and received a Dulcolax suppository, the patient did not receive a suppository while he/she was on respite care. Hospice is supposed to be the collaborators and coordinate the patients care. During an interview on 09/27/2023 at 9:21 AM, the administrator stated that on 07/01/2023, there was an order for routine morphine every four hours, on 08/06/2023 the morphine was increased to 20 mg every four hours. There was no order for PRN (as needed) morphine.

Based on employee file review and interview, the agency failed to provide Emergency Preparedness training to two employees (E2 and E3) of eight employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the employee files (E2 and E3) showed the agency failed to include Emergency Preparedness training during initial orientation. During an interview on 11/03/2022 beginning at 9:00 AM the patient care administrator stated that he/she had supplied all the training information that was available for both employees.

Based on review of the agency's patient admission packet and home visit observation, the agency failed to include required information in the written notice of patient rights for patients admitted to hospice services in, but not limited to, one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the patient bill of rights section of the agency's admission packet showed that upon admission, the patient must be informed of the rights and responsibilities in receiving care. The information failed to include that the patient has the right to receive verbal and written notice of rights in advance of providing care in a language and manner the patient understands. RECORD/PATIENT #1: Observation on 11/01/2022, beginning at 10:00 AM, during the patient's home visit, the review of the home admission packet showed no evidence of a written copy of the patient rights. Per interview conducted during observation, the caregiver stated, ";I know that the nurse talked about Power of Attorney and Do Not Resuscitate, but not the patient rights or responsibilities." During an interview on 11/03/2022 at 2:51 PM, the patient care administrator stated that: It was their expectation that the patient rights be discussed and left in writing with the patient at the time of admission; During the current admission process, an admission nurse performs the first admission visit, and then the case manager is responsible to provide the necessary signed paperwork and copies of rights at the second visit; and It is clear this is not happening right now.

Based on policy review, record review, and interview the agency failed to: - Identify physical, psychosocial, emotional, and spiritual needs (Refer to L524); - Consider the nature and condition causing the admission (Refer to L525); - Maintain an accurate/updated medication profile (Refer to L530); - Conduct an initial bereavement assessment on the comprehensive assessment (Refer to L531); and - Update the comprehensive assessment (Refer to L533). The cumulative effect of these deficient practices have the potential to affect all patients served by the agency. --- .

Based on policy review and record review the agency failed to ensure that the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process in, but not limited to, three (Records/Patients #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy, "Job Descriptions Vitas Nurse, Registered Nurse (RN)" dated 08/09/2019, showed in part: - The Vitas RN is designated to provide coordination of care, ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care; and - Completes initial and ongoing comprehensive assessments including physical, psychosocial, spiritual, and bereavement in order to provide palliation of end of life symptoms. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 08/11/2022; - The initial comprehensive assessment dated 08/11/2022 showed that the patient had complaints of back pain, but failed to document the history of the pain, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain; and - The updated comprehensive assessments dated 08/17/2022, 08/24/2022, 09/21/2022, 09/28/2022, 10/12/2022, and 10/19/2022 failed to address the number of breakthrough doses of pain medication that were used by the patient, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to hospice services on 10/14/2022; - The initial comprehensive assessment dated 10/14/2022 showed that the patient had complaints of pain in his/her tongue, neck, and head, but failed to document the history of the pain, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain; - A focused visit dated 10/18/2022 for pain in the right ear and right side of the head failed to document the pattern of the pain, the effect of the pain on the patient's function or quality of life, factors that make the pain better or worse, or any additional symptoms associated with the pain; and - An updated comprehensive assessment dated 10/21/2022 failed to address the number of breakthrough doses of pain medication that were used by the patient, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to hospice services on 03/18/2022; - The initial comprehensive assessment dated 03/18/2022 showed that the patient had complaints of back pain radiating down his/her legs, but failed to document the history of the pain, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain; and - The updated comprehensive assessments dated 03/22/2022, 03/29/2022, 04/05/2022, 04/12/2022, 04/25/2022, 05/04/2022, 05/31/2022, 06/07/2022, 06/14/2022, 06/21/2022, 06/28/2022, and 07/05/2022 failed to address the number of breakthrough doses of pain medication that were used by the patient, the effects of the pain on the patient's function or quality of life, and any additional symptoms associated with the pain. During an interview on 11/02/2022 at 2:00 PM, the patient care administrator stated that he/she would expect that the comprehensive assessment would assess all needs of the patient.

Based on policy review, record review, and interview the agency failed to include the nature and condition causing admission in the initial assessment in, but not limited to, three (Records/Patients #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy, " Registered Nurse (RN) Job Description," dated 08/09/2019, showed the RN is: - Designated to provide coordination of care, ensure continuous assessment of each patient's and family's needs and implementation of the interdisciplinary plan of care; - Completes the initial and ongoing comprehensive assessments including physical, psychosocial, spiritual, and bereavement in order to provide palliation of end of life symptoms; and - Provides education to patients, families, caregivers and referral sources. RECORD/PATIENT #2: Review of the clinical record showed: - Admitted to hospice services on 08/11/2022 with a diagnosis of Dementia (a progressive disease that affects brain function); - The RN initial comprehensive assessment dated 08/11/2022 did not mention the diagnosis Dementia; -The patient was only oriented to self and was occasionally able to answer yes and no questions, and needs to be fed; -Care plan interventions for the patient included assess neurological system every visit, educate on ways to palliate neurological deficits, What I Need to Know (WINK) education provided; and -The patient has increased confusion, increased agitation, and requires Seroquel (a medication to manage behaviors) and Lorazepam (a medication to manage anxiety). RECORD/PATIENT #3: - Admitted to hospice services on 10/12/2022 with a diagnosis of Colon Cancer (a cancer that forms in the tissues of the colon) and co-morbidities of cancer metastasized to the brain (cancer growth in the brain) and the lymph nodes (cancer growth in the lymph nodes), and a history of colostomy (a surgical operation to bypass part of the colon); - The RN initial comprehensive assessment dated 10/14/2022 did not mention the diagnosis of Colon Cancer or the co-morbidities of cancer metastasized to the brain and the lymph nodes; - Care plan interventions for the patient included assess pain every visit, assess anxiety every visit, maintain infection control, provide WINK education; and - Under section for gastrointestinal symptoms there is no history documented. RECORD/PATIENT #4: - Admitted to hospice services on 03/16/2022 with a diagnosis of End Stage Chronic Lung Disease (a condition involving constriction of the airways of the lungs); - The RN initial comprehensive assessment dated 03/18/2022 did not mention the diagnosis of End Stage Chronic Lung Disease; - Care plan interventions for the patient included assess pain every visit, assess neurological status every visit, educate on good hand hygiene and maintaining infection control, and provide WINK education; - RN failed to assess lung sounds. During an interview on 11/02/2022 beginning at 2:00 PM, the patient care administrator stated that he/she would expect the comprehensive assessment to include the nature and condition causing admission on all patients.

Based on record review and interview, the agency failed to ensure that the medication profile was updated and accurate in one (Record/Patient #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency . --- Findings included: RECORD/PATIENT #2: Review of the record showed: - The patient resided in a long term care facility (LTFC); - The patient was admitted to hospice services on 08/11/2022; - Review of the agency's medication profile dated 11/02/2022 showed Seroquel (a medication to manage behavior) 50 milligrams (mg) one tablet twice per day and Ativan (a medication for anxiety) 0.5 mg every four hours. Both medications failed to appear on the LTCF medication list; and - Review of the agency medication profile dated 11/02/2022 showed Roxanol (a medication for pain) 20mg/milliliter (ml) take 0.25 ml every four hours and oxygen at _ [left blank] LPM [liters per minute] via nasal cannula on portable oxygen cylinder as needed. The LTCF medication list showed Roxanol 20mg/ml take 0.5 ml every four hours as needed and oxygen at 2 liters per minute as needed for shortness of breath. During an interview on 11/02/2022 beginning at 1:45 PM, the nurse consultant stated they would expect the medications to match.

Based on record review and interview, the agency failed to ensure that an initial bereavement risk assessment was completed in, but not limited to, two (Record/Patient #1 and #5) of five full records reviewed. This deficient practice has the potential to affect all bereaved individuals served by the agency. --- Findings included: RECORD/PATIENT #1: -The initial assessment dated 07/27/2022 was completed by the registered nurse (RN); -The bereavement risk assessment stated: "Assessed, no bereavement symptoms identified-N/A"; and -The agency failed to present an initial bereavement risk assessment completed in it's entirety by the staff. RECORD/PATIENT #5 -The initial assessment dated 06/17/2022 was completed by the RN; -The bereavement risk assessment stated: "Assessed, no bereavement symptoms identified-N/A"; -The Medical Social Worker initial assessment dated 06/20/2022 failed to document anything on the bereavement section of the chart; -The Chaplain made no in person visits to this patient and there was no documentation of telephone calls from admission until current; and -The agency failed to present an initial bereavement risk assessment completed in its entirety by the agency staff. During an interview on 11/02/2022, (conducted during survey) the patient care administrator stated that: The bereavement risk assessment on records/patients #1 and #5 were not documented; and The RN performed the initial assessment for immediate needs, then the social worker or chaplain should address and document detailed specifics of the bereaved.

Based on policy review, record review, and interview, the agency failed to document an ongoing comprehensive assessment that included all changes in the patient's condition and response to care and treatment provided in, but not limited to, one (Record/Patient #5) 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, ";VMS IDC POC Meeting" copyright dated 2021, showed in part: -IV. Review of patients care plan 1. Discussion of individual patient symptoms, goals, outcomes, effectiveness of interventions and discussion of possible interventions which may be valuable 2. This information can be utilized when caring for other patients with similar symptoms RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to hospice on 06/17/2022 with a terminal diagnosis of Coronary Artery Disease ( the heart's blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries). Review of the skilled nurse (SN) visit note dated 09/15/2022, showed the patient had ";Manage Dyspnea (difficulty in breathing)" as a care plan outcome reported as a level two with a goal of zero. The care plan stated to assess at each visit. Review of the SN visit notes showed: -The SN visit note dated 09/22/2022 showed a Dyspnea reported level of two with the intervention of educating on Oxygen use, -The SN visit note dated 09/29/2022 failed to show dyspnea assessment, -The SN visit note dated 09/29/2022 failed to document any interventions provided for Dyspnea or a Dyspnea reported level, -The SN visit note dated 10/06/2022 showed a Dyspnea assessment reported level two with ";No dysnea noted. Rest-Patient denies shortness of breath (SOB) this visit" documented under response to care, -The SN visit note dated 10/13/2022 showed a dyspnea assessment reported level of four, with"; No C/O (complaint of) SOB this visit."; and -The SN visit note 10/20/2022 showed a dyspnea assessment reported level of five, with ";No SPB this visit. Not used O2 (Oxygen) this week" documented under response to care. Review of the Interdiscipline Group (IDG) meeting notes showed: -On 09/06/2022 showed ";Dyspnea - @ xs-uses inhaler- effective" and Dyspnea with minimal exertion, increased inhaler use, -On 10/04/2022 and 10/18/2022 failed to show documentation of dyspnea discussion; The agency failed to provide documentation of discussion in IDG meetings of increased dyspnea reported scores or changes to care plan in response to the changes. During an interview on 11/02/2022, beginning at 2:51 PM, the Patient Care Administrator stated that he/she would expect the progress of the dyspnea to be discussed at the IDG meetings.

Based on policy review, record review, and interview the agency failed to: - Ensure that the plan of care specifies care/services to meet the needs of the patient an family identified in the comprehensive assessment (Refer to L538); - Ensure that all care/services follow an individualized plan of care (Refer to L543); - Provide education/training to the patient and care giver (Refer to L544); and - Ensure that care/services were in accordance with the plan of care Refer to L555). The cumulative effect of these deficient practices have the potential to affect all patients served by the agency. --- .

Based on record review and interview, the agency failed to ensure that the plan of care specified the care and services necessary to meet the patient's needs, 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 #3: Review of the clinical record showed: - The patient was admitted to hospice services on 10/14/2022; - The patient had a colostomy (a surgical operation to bypass part of the colon) due to a history of Colon Cancer (a cancer that forms in the tissues of the colon); - The interdisciplinary plan of care (POC) revision/physician orders dated 10/17/2022, showed that the ostomy site (the artificial opening in the colon created during colostomy surgery) was to be assessed every visit by the social worker and chaplain; and - The POC dated 10/17/2022 showed that the patient was to be instructed on how to care for the ostomy site by the social worker and chaplain. During an interview on 11/01/2022 at 11:15 AM, the patient care administrator stated that he/she would only expect the nurse to assess the ostomy site and instruct on care.

Based on policy review, record review, and interview the agency failed to ensure that each patient had an individualized plan of care in, but not limited to, three (Records/Patients #2, #3, and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy, "Job Descriptions Vitas Nurse, Registered Nurse (RN)," dated 08/09/2019, showed in part the RN develops, coordinates, and follows the patient's individualized plan of care. The following clinical record reviews showed similar plans of care (therefore, they were not individualized) for records/patients #2, #3 and #4. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 08/11/2022; - The patient resided in a long term care facility; - The patient received portable oxygen tanks from the agency; and - The interdisciplinary care plan dated 08/11/2022 showed a care plan/symptom of Initial General Plan of Care; - Interventions marked included: Instruct and reinforce to notify VITAS of any change in condition; Instruct and reinforce medication <drug interactions/treatment indications, use and side effects>; Monitor safety measures <ability to safely administer medications or biologicals as ordered>; Instruct and reinforce medications <Hospice training about medications>; Provide home medical equipment (HME) on admission- did not specify the equipment that patient was assigned; Instruct, demonstrate, and reinforce HME <safe and proper use>- did not specify the safety/proper use measures for the equipment the patient or care giver needed; Monitor safety measures <return demonstration of appropriate HME use>- did not specify if any safety measures were put into place; Provide services to adequately address symptoms/concerns; and Instruct and reinforce emergency preparedness <Hospice training about health tips> Call Vitas in the event of an emergency. Vitas staff will contact you as soon as possible; If unable to contact Vitas, call your physician; Tune in to your local radio station; Make arrangements for family/friends to check on you in case of a disaster; Notify VITAS if any change in location before or after a disaster; and Pre-register with electric company, fire department, etc. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to hospice services on 10/12/2022; - The interdisciplinary care plan dated 10/12/2022 showed a care plan/symptom of Initial General Plan of Care; - Interventions marked included: Instruct and reinforce to notify VITAS of any change in condition; Instruct and reinforce medication <drug interactions/treatment indications, use and side effects>; Monitor safety measures <ability to safely administer medications or biologicals as ordered>; Instruct and reinforce medications <Hospice training about medications>; Provide home medical equipment (HME) on admission; Instruct, demonstrate, and reinforce HME <safe and proper use>; Monitor safety measures <return demonstration of appropriate HME use>; Provide services to adequately address symptoms/concerns; and Instruct and reinforce emergency preparedness <Hospice training about health tips> Call Vitas in the event of an emergency. Vitas staff will contact you as soon as possible; If unable to contact Vitas, call your physician; Tune in to your local radio station; Make arrangements for family/friends to check on you in case of a disaster; Notify VITAS if any change in location before or after a disaster; and Pre-register with electric company, fire department, etc. RECORD/PATIENT #4: Review of the clinical record showed: - The patient was admitted to hospice services on 03/16/2022; - The patient received oxygen services from the agency; - The interdisciplinary care plan dated 03/16/2022 showed a care plan/symptom of Initial General Plan of Care; - Interventions marked included: Instruct and reinforce to notify VITAS of any change in condition; Instruct and reinforce medication <drug interactions/treatment indications, use and side effects>; Monitor safety measures <ability to safely administer medications or biologicals as ordered>; Instruct and reinforce medications <Hospice training about medications>; Provide home medical equipment (HME) on admission; Instruct, demonstrate, and reinforce HME <safe and proper use>- did not specify the safety/proper use measures for the equipment the patient or care giver needed; Monitor safety measures <return demonstration of appropriate HME use>- did not specify if any safety measures were put into place; Provide services to adequately address symptoms/concerns; and Instruct and reinforce emergency preparedness <Hospice training about health tips> Call Vitas in the event of an emergency. Vitas staff will contact you as soon as possible; If unable to contact Vitas, call your physician; Tune in to your local radio station; Make arrangements for family/friends to check on you in case of a disaster; Notify VITAS if any change in location before or after a disaster; and Pre-register with electric company, fire department, etc. During an interview on 11/02/2022 beginning at 1:45 PM, the patient care administrator stated that he/she would expect the plan of care to be individualized for each patient.

Based on policy review, record review, home visit observation, and interview, the agency failed to provide education and training for the patient as appropriate to their responsibilities in, but not limited to, one (Record/Patient #1) 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, "Nursing Updated Comprehensive Assessment," dated as of 11/01/2021, showed in part: -Documentation of care plan activities, -Provide the Care Plan interventions, -Document the interventions provided under ";Interventions Performed", -Evaluate the patients Response to Care (interventions provided) -Document the response to care includes one of the following: Verbalized understanding, Unable to verbalize understanding Successful return demonstration, Refused intervention, Reported intervention successful; and Symptom Managed RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/27/2022 with a terminal diagnosis of Cerebrovascular Disease (CVD, a condition in which blood flow is decreased to the brain). Review of the initial/comprehensive assessment, dated 07/27/2022, showed the following: -Pain Findings: no pain noted; -Respiratory Findings: normal; -Neurosensory Findings: Oriented to one, unable to answer direct questions; and -Cardiovascular Findings: Edema (swelling); The nurse failed to document the Edema symptom severity or interventions. Review of Supplemental Interdisciplinary Note dated 08/22/2022 showed the registered nurse (RN) spoke to the patients caregiver on the phone regarding ";more congestion and reports concerns of possible aspiration. Patient care giver and nurse discussed starting to thicken liquids again. Educated to monitor for symptoms of pneumonia. Discussed those symptoms." Review of skilled nurse (SN) visit notes date 08/24/2022, 08/31/2022, 09/08/2022, 09/15/2022, 09/22/2022, 09/29/2022, 10/06/2022 and 10/14/2022, showed: Respiratory assessment no symptoms identified or interventions provided. Review of SN visit note dated 10/21/2022 showed: -Respiratory assessment findings ";cough, nasal drainage, sneeze"; -Interventions performed: assess respiratory symptoms, instruct on ways to palliate cough; and -Response to care: ";Denies SOB [shortness of breath] and sore throat, nasal drainage and cough, non-productive. Patient caregiver giving Mucinex" [over the counter expectorant] ";and effective. Encouraged to continue meds and call if worsens." Review of SN visit note dated 10/28/2022 showed: -Respiratory assessment findings: Cough; -Interventions preformed: assess respiratory symptoms and instruct on ways to palliate cough; and -Response to care documented: ";Cough non-productive. Educated to use nebulizer treatment." Observation on 11/01/2022 beginning at 10:00 AM, during the patient's home visit, showed RN A failed to discuss the nebulizer medication and use with patient or caregiver. Per interview conducted during observation, the caregiver stated ";I dont know when to use the nebulizer". When asked how often the patient utilized the ordered medication, the caregiver stated that they havent ever used the nebulizer and medication.

Based on record review and interview, the agency failed to ensure that care and services were provided in accordance with the plan of care in three (Records/Patients #1, #2 and #3) in five full 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: - The updated comprehensive assessment dated 10/04/2022 showed under the plan of care "manage cardiovascular" an intervention to check lung sounds on every visit; and - Visits dated 10/12/2022 through 10/26/2022 failed to show that lung sounds were assessed by the skilled nurse. During an interview on 11/02/2022 beginning at 1:45 PM the Patient Care Administrator stated that the plan of care should be followed and he/she would expect that lung sounds would be assessed. RECORD/PATIENT #3: Review of the clinical record showed: - The patient was admitted to hospice services on 10/14/2022; - Review of the physician's orders showed visit frequency for the skilled nurse (SN) to be once per week; - According to the frequency grid that patient was not scheduled for a visit the week of 10/19/2022 to 10/25/2022; and -A SN visit dated 10/21/2022 was documented as completed. During an interview on 11/01/2022 beginning at 1:20 PM the patient care administrator stated that he/she would expect visits to be conducted according to physician orders. Findings included: RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/27/2022 with a terminal diagnosis of Cerebrovascular Disease (CVD, a condition in which blood flow is decreased to the brain). Review of the initial plan of care dated 7/27/2022 to 10/24/2022 showed skilled nurse visits were to be completed: -Two times a week for the week of 07/27/2022 through 08/02/2022 -Once weekly 08/03/2022 through 08/16/2022, 08/24/2022 through 10/04/2022, and 10/12/2022 through 10/26/2022 -No ordered visits for the week of 08/17/2022 through 08/23/2022 or 10/05/2022 through 10/11/2022 Review of the clinical record showed the agency provided documented a skilled nurse (SN) visit on 10/06/2022 The agency failed to provide an order or update to the plan of care for the skilled nurse visit on the week of 10/05/2022 through 10/11/2022 During an interview on 11/01/2022 at 10:58 AM with the Patient Care Administrator, he/she stated they would look for the order. At 1:22 PM the Patient Care Administrator stated ";We dont have one, the visit frequency orders show no visit was ordered for that week."

Based on record review and interview, the agency failed to ensure that the nursing needs were met in, but not limited to, two (Records/Patients #2 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 08/11/2022 with orders for oxygen as needed; - The updated comprehensive assessment dated 09/07/2022 showed that the patient was using oxygen at two to four liters per minute continuously; - The updated comprehensive assessment dated 09/14/2022 showed that the patient's care plan was updated to include: assess for edema every visit and encourage patient to keep feet elevated when sitting; - The updated comprehensive assessment dated 10/04/2022 showed that the patient's care plan was updated to include assess lung sounds every visit; and - The agency failed to notify the physician of any change in the patient's condition (in regards to the updates to the plan of care). RECORD/PATIENT #4: - The patient was admitted on hospice services on 03/16/2022; - The updated comprehensive assessment dated 09/06/2022 showed that the patient reported a fall to her knees after tripping over his/her dog on 09/03/2022; - The updated comprehensive assessment dated 10/11/2022 showed that the patient reported a fall on 10/08/2022 resulting in two reddened areas to his/her knee and a bruise to his/her left elbow; and - The agency failed to notify the physician of these events and any change in the patient's condition. During an interview on 11/02/2022 beginning at 1:45 PM, the nurse consultant stated that he/she would expect the physician to be notified of changes in the patient's condition.

Based on record review and interview, the agency failed to ensure that a bereavement plan of care was developed for a year in, but not limited to, two (Records/Patients #8 and #9) of eleven records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #8: -Patient was admitted to hospice services on 04/25/2022 with a terminal diagnosis of severe protein-calorie malnutrition; -Patient died on 04/28/2022; and -Agency held no record of the bereavement plan of care for this patient. RECORD/PATIENT #9: -Patient was admitted to hospice services on 03/18/2022 with a terminal diagnosis of bladder cancer; -Patient died on 05/01/2022; and -Agency held no record of the bereavement plan of care for this patient. During an interview on 11/02/2022, the patient care administrator stated that there was no documentation for the missing plans of care for these patients.

Based on contract review and interview, the agency failed to ensure that the contract with the respite facility was signed in, but not limited to, one (Record/Patient #7) of eleven records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #7: -Patient admitted to respite on 10/07/2022; and -Patient discharged from the respite facility on 10/12/2022; Review of the contract with the respite facility showed that the agency and the facility failed to sign the contract before the patient was admitted to the respite facility. During an interview on 11/2/2022 at 10:22 AM, the patient care administrator stated that the contract should be signed prior to the patient admitting to respite care.

Based on employee file review and interview the agency failed to provide orientation about the hospice philosophy to two employees (E2 and E3) of eight employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the employee files (E2 and E3) showed the agency failed to provide an initial orientation which included the hospice philosophy. During an interview on 11/03/2022 beginning at 9:00 AM the patient care administrator stated that he/she had supplied all the training information that was available for both employees.

Based on employee file review and interview the agency failed to provide an initial orientation that addresses the employee's specific job duties. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the employee files (E2 and E3) showed the agency failed to include specific employee job duties during initial orientation. During an interview on 11/03/2022 beginning at 9:00 AM the patient care administrator stated that he/she had supplied all the training information that was available for both employees.

Based on employee file review and interview the agency failed to provide documentation that the skills and/or competence had been assessed in two employees (E2 and E3) of eight employee records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the employee files (E2 and E3) showed the agency failed to provide documentation that skills checks and/or competencies had been completed for each employee. During an interview on 11/03/2022 beginning at 9:00 AM the patient care administrator stated that he/she had supplied all the information that was available for both employees.

Based on clinical record review and interview, the agency failed to maintain a complete and accurate clinical record, when the agency failed to include documentation in the clinical record related to: --- -Ensure the clinical record included all written physician orders (L678); -Ensure the clinical records would have legible, complete documentation (L679); -Document the discharge summary was sent to attending physician for a patient that transferred to another hospice agency (L682); and - Ensure the discharge summary included all required elements as stated per regulation (L684). The cumulative effect of these systemic practices has the potential to affect all patients served by this hospice agency.

Based on policy review, record review, and interview, the agency failed to ensure that all treatments had physicians orders in, but not limited to, one (Record/Patient #1) or 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 "VS Obtaining Orders," dated 06/13/2022, showed, in part, the following: -All physician orders will be obtained by a licensed nurse, pharmacist, or another physician; -Nurses should communicate with the physician to discuss the patients assessment findings and relational for requesting a new or changed order; -A physician order will be obtained for all drugs, treatments, procedures; -Order content requirements: Drug, Dosage, Frequency, Route, and Symptom RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to hospice on 07/27/2022 with a terminal diagnosis of Cerebrovascular Disease (CVD, a condition in which blood flow is decreased to the brain). A physician order dated 08/01/2022 for barrier cream failed to contain: -Dosage; -Frequency; -Route; -Symptom; -Who obtained the order; and -Documentation of the discussion with the physician as to why the need for a new order. During an interview on 11/02/2022 at 02:51 PM, the Patient Care Administrator stated that he/she would expect the physician orders to be complete and accurate, including where barrier cream should be applied, how often, who will apply it in nurse absence, who obtained the order and why the order is needed.

Based on record review and interview, the agency failed to ensure all entries were legible and clearly written in, but not limited to, three (Records/Patients #1, #2, and #3) of five full records reviewed. This deficient practice has the potential to affect all patients receiving hospice services. --- Findings included: RECORD/PATIENT #1 Review of the clinical record showed the patient was admitted to hospice on 07/27/2022 with a terminal diagnosis of Cerebrovascular Disease (CVD, a condition in which blood flow is decreased to the brain). Clinical record reviewed showed Medical Social Worker (MSW) notes: - 07/28/2022 comprehensive assessment illegible; and -09/28/2022 supplemental interdisciplinary note illegible. Clinical record review showed Chaplain comprehensive assessment dated 07/29/2022 is illegible. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 08/11/2022 with a terminal diagnosis of Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Comprehensive Assessment completed by the Chaplain dated 08/15/2022 was illegible. Psychosocial/Spiritual Updated Comprehensive Assessment notes completed by the Chaplain showed: - 08/18/2022 illegible; -09/13/2022 illegible; -10/04/2022 illegible; and -10/18/2022 illegible. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to hospice services on 10/14/2022 with a terminal diagnosis of Colon Cancer. The Comprehensive assessment dated 10/13/2022 completed by the MSW and the comprehensive assessment dated 10/17/2022 by the chaplain were illegible. During an interview on 11/02/2022 at 11:02 AM, the patient care administrator stated that the MSW and Chaplain notes were difficult to read, and therefore, was not able to read the note in its entirety. The surveyor discussed concerns regarding ongoing noncompliance from previous illegible clinical documentation issues. The patient care administrator confirmed they had received previous citations regarding this issue. Requested a policy for documentation on 11/03/2022 at approximately 2:00 PM and did not receive prior to exit.

Based on record review and interview, the agency failed to send a full discharge summary that contained the required elements in, but not limited to, one (Record/Patient #11) of eleven records reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: RECORD/PATIENT #11: -Patient was admitted to hospice services on 07/03/2022 with a terminal diagnosis of Ehlers-Danlos Syndrome (a group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls). -Patient transferred to [named facility] on 09/04/2022 for symptom control; and -The agency held no record of the discharge summary contents being sent to the receiving provider. During an interview on 11/02/2022 at 12:51 PM, the patient care administrator stated that there was no documentation of the missing items being sent to the receiving provider.

Based on record review, and interview, the agency failed to document a discharge summary in one (Record/Patient #11) of one transferred patient record reviewed. This deficient practice has the potential to affect the post-hospice medical care of all the agency's live transferred patients. --- Findings included: RECORD/PATIENT #11: -Patient was admitted to hospice services on 07/03/2022 with a terminal diagnosis of Ehlers-Danlos Syndrome (a group of inherited disorders that affect your connective tissues — primarily your skin, joints and blood vessel walls). -Patient transferred to [named facility] on 09/04/2022 for symptom control; and -The agency held no record of the patient's current plan of care or latest physician's orders being sent to the receiving provider. During an interview on 11/02/2022 at 12:51 PM, the patient care administrator stated that there was no documentation of the missing items being sent to the receiving provider.

Based on policy review, record review, and interview the agency failed to ensure that the plan of care and the long term care facility (LTCF) care plan were established and maintained as accurate in one (Record/Patient #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, " Interdisciplinary Team Policies: Long Term Care Facility," dated 06/27/2005 showed: - The plan of care will be developed with input from the patient/family, attending physician, LTCF and hospice interdisciplinary team; and - Identifies the care and services which each shall provide, and is updated to reflect changes in patient/family condition, needs, and care. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 08/11/2022; - The patient resided in a LTCF; - The patient completed an Outside the Hospital Do-Not-Resuscitate order on 08/11/2022; and - The LTCF care plan obtained during a home visit on 11/01/2022 beginning at 10:15 AM showed that the patient was a full code. - The initial comprehensive care plan dated 08/11/2022 showed: - The patient was a high fall risk; - The patient should have the bed in the lowest position, call light within reach, and fall mats in place; and - The LTCF care plan showed therapy to screen, encourage patient to participate in activities that promote exercise, physical activity for strengthening and improved mobility, and encourage/remind patient to use mobility aides- wheelchair. During an interview on 11/02/2022 beginning at 1:45 PM, the patient care administrator stated that the plans of care should be updated and match.

Based on policy review, record review, and interview the agency failed to correctly communicate skilled nurse (SN) and aide visits to the long term care facility (LTCF) to ensure that care and needed services were provided to the patient in one (Record/Patient #2) of three home observations completed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy, "Job Descriptions Vitas Nurse, Registered Nurse (RN)" dated 08/09/2019, showed in part: - Develops, coordinates, and follows the patient's individualized plan of care; - Professionally manages/coordinates the hospice plan of care; and - Delivers care in accordance with the patient's plan of care. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 08/11/2022 and resided in a LTCF. Observation on 11/01/2022 beginning at 10:15 AM, during the patient's home visit at the LTCF, showed the coordinated task plan dated 08/11/2022 listed the frequency of skilled nurse (SN) visits to be completed once a week on Fridays, and the frequency of aide visits to be completed twice a week on Tuesdays and Thursdays. Review of the clinical record showed: - SN visits dated 08/17/2022 (Wednesday), 08/24/2022 (Wednesday), 08/31/2022 (Wednesday), 09/07/2022 (Wednesday), 09/14/2022 (Wednesday), 09/21/2022 (Wednesday), 09/28/2022 (Wednesday), 10/04/2022 (Tuesday), 10/12/2022 (Wednesday), 10/19/2022 (Wednesday), and 10/26/2022 (Wednesday); - Aide visits dated 08/12/2022 (Friday), 08/19/2022 (Friday), 09/02/2022 (Friday), 09/09/2022 (Friday), 09/16/2022 (Friday), 09/26/2022 (Monday), 09/30/2022 (Friday), 10/7/2022 (Friday), and 10/22/2022 (Saturday). During an interview on 11/02/2022 beginning at 1:45 PM, the patient care administrator stated that he/she would expect visits to be done according to the plan of care and communicated correctly to the LTCF.

Based on policy review, record review, observation, and interview the agency failed to ensure that the long term care facility (LTCF) received a current hospice plan of care in one (Record/Patient #2) of three home observations completed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of the agency's policy, "Interdisciplinary Team Policies: Long Term Care Facility," dated 06/27/2005, showed, in part: - The plan of care will be developed with input from the patient/family, attending physician, LTCF staff, and hospice interdisciplinary team; and - Identifies the care and services which each shall provide, and is updated to reflect changes in patient/family condition, needs, and care. RECORD/PATIENT #2: Review of the clinical record showed: - The patient was admitted to hospice services on 08/11/2022; -The patient resided in the LTCF when admitted; and - The most recent plan of care updates were completed on 10/12/2022. Observation on 11/01/2022 beginning at 10:15 AM, during the patient's home visit in the LTCF, showed the most recent plan of care available at the LTCF was completed on 08/11/2022 and 08/12/2022. During an interview on 11/02/2022 beginning at 1:45 PM, the patient care administrator stated that he/she would expect an updated plan of care to be available at the LTCF.

Based on Missouri state statute, policy review, employee file review, and interview, the agency failed to obtain a criminal background screening for three employees (E1, E2, and E3) of eight employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. --- Findings included: Review of Section 192.2495.3, RSMo stated: "Prior to allowing any person who has been hired as a full-time, part-time or temporary position to have contact with any patient or resident the provider shall, or in the case of temporary employees hired through or contracted for an employment agency, the employment agency shall prior to sending a temporary employee to a provider: (1) Request a criminal background check as provided in section 43.540. Completion of an inquiry to the highway patrol for criminal records that are available for disclosure to a provider for the purpose conducting an employee criminal records background check shall be deemed to fulfill the providers duty to conduct employee criminal background checks pursuant to this section..." Review of Section 192.2495.6, RSMo: A provider is guilty of a class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other state or has been found guilty of a crime, which if committed in Missouri would be a class A or B felony violation of chapter 565, RSMo (Offenses Against Persons), chapter 566, RSMo (Sexual Offenses), or chapter 569 (Robbery, Arson, Burglary and Related Offenses), or any violation of subsection 3 of section 198.070, RSMo (required reporter that knowingly fails to report abuse or neglect of a resident of a residential care, intermediate care or skilled nursing facility), or section 568.020, RSMo (Incest). Review of the agency's policy, "Pre-Employment: Drug Testing and Background Checks," dated 08/09/2019 showed: - No candidate will be hired until it is determined that he or she has successfully completed the background check process; - The scope of background checking will be guided by the nature of the job for which the individual is being considered; - Background checks will include verification of Social Security Number, criminal convictions, and past employment; - Depending upon the position, driver's license verification, driving record check, educational verifications, credentialing verifications, and credit report checks may also be conducted; and - In addition, applicable state and local statutes and regulations may require other pre-employment checks to be conducted. Review of the employee file for employee (E1) showed that the employee was hired on 02/01/2022 and had first contact with patients on 04/16/2022. The agency failed to conduct a background screening check as required. During an interview on 11/03/2022 at approximately 9:00 AM, the administrator and patient care administrator stated that a criminal background screening check had not been completed on employee (E1) as required. Review of the employee files for employees (E2 and E3) showed no dates of hire and no dates of first contact with patients. The agency failed to conduct a background screening check as required. During an interview on 11/03/2022 beginning at 9:00 AM, the patient care administrator stated that he/she had supplied all the information that was available for both employees.

Based on Missouri state statutes, employee file review, and interview, the agency failed to check the Employee Disqualification List (EDL) for three employees (E1, E2, and E3) of eight employees; and failed to provide Alzheimer's/Dementia training to two employees (E2 and E3) 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: "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." Review of the agency's policies showed that the agency failed to have an EDL policy. Review of the employee file for employee (E1) showed that the employee was hired on 02/01/2022 and had first contact with patients on 04/16/2022. The agency failed to conduct an EDL check as required. During an interview on 11/03/2022 at approximately 9:00 AM, the administrator and patient care administrator stated that an EDL check had not been completed on employee (E1) as required. Review of the employee files for employees (E2 and E3) showed no dates of hire and no dates of first contact with patients. The agency failed to conduct an EDL check as required. During an interview on 11/03/2022 beginning at 9:00 AM, the patient care administrator stated that he/she had supplied all the information that was available for both employees. 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. " Review of the employee files (E2 and E3) showed the agency failed to include Alzheimer's/Dementia training during initial orientation. During an interview on 11/03/2022 beginning at 9:00 AM the patient care administrator stated that he/she had supplied all the training information that was available for both employees.