Hospice By John Knox Village

“Based on policy review, orientation and training document review, employee file review, and interview, the provider failed to ensure all staff were provided emergency preparedness (EP) training in one of five employee files reviewed (E-1). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s policy titled, “Orientation Program,” revised 05/2022, showed in part, contract personnel receive orientation to hospice by the provider’s policies regarding confidentiality, the hospice philosophy of care, including levels of care and Alzheimer’s / Dementia training, and the contract personnel’s specific job duties, as appropriate and delineated in the written agreement.The provider’s policy failed to include emergency preparedness training for contract personnel.Review of the provider’s undated document titled, “Hospice Contracted Partner/Volunteer Orientation and Training,” showed in part, training on the procedures to follow: - When an emergency is declared; and- After the emergency. EMPLOYEE #1:Review of E-1’s file showed he/she was a contracted employee with a hire date of 04/01/2024. The employee file failed to show emergency preparedness training was completed during orientation.Review of the document titled, “Hospice Contracted Partner/Volunteer Orientation and Training,” signed 06/23/2025, showed the document failed to be completed during E-1’s orientation period.During an interview on 06/24/2025 at 3:50 PM, the administrator stated that E-1 was not trained on emergency preparedness during new employee orientation and it should have been completed before 06/23/2025.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to develop an individualized plan of care (POC) that reflected the patient’s interventions based on problems identified in the initial, comprehensive, and updated comprehensive assessments, in two of five full records reviewed (Records/Patients #1 and #5). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 04/18/2025 with a terminal diagnosis of malignant neoplasm of endometrium (type of cancer that begins in the lining of the uterus). The patient resided at home alone. Review of the initial comprehensive assessment, dated 04/18/2025, showed:- The patient’s medication box was filled by the daughter in-law; and- All routine medication bottles were kept at the patient’s son and daughter in-laws home due to the patient’s memory issues. Review of the initial POC, dated 04/18/2025, showed:- Skilled nurse to educate patient/caregiver on all medications including side effects, importance of taking medications as ordered, and effects to report immediately to health care provider; - The patient’s medication box was filled by the daughter in-law; and- All routine medication bottles were kept at the patient’s son and daughter in-laws home due to the patient’s memory issues. Review of the skilled nurse (SN) visit note, dated 06/13/2025, showed:- The registered nurse case manager (RN CM) filled the patient’s pillbox for the upcoming week;- The patient was previously assisted with medications by his/her son, but the patient expressed a strong desire to manage his/her own medications independently; - The RN assured the patient’s son that at each SN visit medication compliance and pillbox review/refill would be completed; - Patient able to take medication as prescribed;- No new or changed orders to IDG plan of care required; and- Narrative note sent to IDG summary. Review of the clinical record failed to show an updated POC that included interventions for the skilled nurse to review and/or fill the patient’s pillbox at each visit. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 05/19/2025 with a terminal diagnosis of squamous cell carcinoma of skin of scalp and neck (a type of skin cancer that arises from squamous cells, which are found in the outer layer of the skin). The patient lived at home with adult family members. Review of the initial comprehensive assessment, dated 05/19/2025, showed:- Long term (current) use of anticoagulants (a medication that helps prevent blood clots from forming or growing larger);- Wound care was done to 3rd toe on left foot as per patient/caregiver instructions, but wound care would change when orders from “named podiatrist” were received; and- The caregiver requested the pillbox/med planner to be filled. Review of the initial POC dated 05/19/2025, showed:- A diagnosis of long-term current use of anticoagulants;- The patient was taking Warfarin Sodium (an anticoagulant medication that requires monitoring of the patient’s International Normalized Ratio (INR- a blood test that measures how long it takes for your blood to clot); - The patient was at risk for bleeding due to anticoagulant therapy;- The POC failed to: * Include orders for skilled nursing (SN) to obtain INRs or the method to obtain the INRs (venipuncture- the process of collecting blood from a vein or fingerstick- a minimally invasive method of collecting blood samples from the fingertip); * Include orders for SN to fill the pillbox/med planner and the frequency; and * Include orders to identify the physician managing the foot wound. Review of a faxed wound care order dated 05/20/2025 showed the physician as “named podiatrist”. Review of the SN visit note, dated 05/20/2025, showed:- The patient’s INR was 1.8; and - The “med planner” was filled. Review of the SN visit note, dated 05/27/2025, showed:- The patient’s INR was 2.4; and - The “med planner” was filled. Review of the SN visit note, dated 06/03/2025, showed “med planner filled”. Review of the SN visit note, dated 06/11/2025, showed the patient’s INR was 1.8. Review of the SN visit note, dated 06/17/2025, showed the patient’s INR was 1.9. Review of the SN visit note, dated 06/24/2025, showed:- The patient’s INR was 1.7; and- It failed to be documented that the pillbox/med planner was filled during the visit. Observation on 06/24/2025 at 10:50 AM, showed RN-A:- Performed a fingerstick to obtain an INR on the patient; and- Filled the pillbox/med planner. Review of the clinical record failed to show an updated POC that included interventions for:- The skilled nurse to fill the patient’s pillbox/med planner or the frequency;- The physician managing the patient’s wound; and- The method or frequency to obtain the patient’s INRs. During an interview on 06/25/2025 at 10:24 AM, the Registered Nurse Coordinator stated that:- The provider did not routinely add to fill the med planner to the plan of care because they routinely had the same nurse visiting;- The attending position was probably now managing the wound; and- The provider’s baseline standard was that all INRs were fingerstick so the method of obtaining the INRs was not put on the POC.”

“Based on policy review, record review, and interview, the hospice provider failed to maintain a system of communication to ensure the provision of care and services, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Interdisciplinary Team (IDT),” reviewed 02/2019, showed in part the following:- The IDT assess, plan, provide, and evaluate the care and services provided to hospice patients and caregivers; - The IDT is responsible for establishing, implementing, reviewing, and revising the patient’s plan of care; and - The registered nurse (RN) is responsible for coordinating the care and services provided by the IDT, ensuring continuous assessment of patient/caregiver needs, and implementing the interdisciplinary plan of care. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of senile degeneration of the brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior). The patient resided at a long-term care facility (LTCF).Review of the initial plan of care, dated 06/02/2025, showed the following:- At risk for skin breakdown related to bedbound;- Incontinence of bowel related to terminal diagnosis; and- Aide visit frequency of two times per week.Review of the aide visit notes, dated 06/06/2025, 06/17/2025, 06/19/2025, 06/24/2025, showed the bedbath was refused.Review of the aide visit notes dated 06/06/2025 and 06/24/2025, showed the aide notified the registered nurse of the refusal of care.Review of the aide visit notes, dated 06/17/202 and 06/19/2025, showed the aide failed to notify the registered nurse of the refusal of care.Review of the interdisciplinary group (IDG) summary and comprehensive assessment update, dated 06/10/2025, showed in part, on 06/09/2025, nystatin cream (used to treat fungal infections) was ordered to be applied to peri-area (region of the body between the anus and the vulva) and buttocks.Review of the interdisciplinary group (IDG) summary and comprehensive assessment update, dated 06/24/2025, showed in part the following:- On 06/13/2025, hydrocortisone cream (used to relieve inflammation, redness, itching, and swelling associated with various skin conditions) was ordered to be applied to peri-area, abdomen, and buttocks;- On 06/16/2025, patient continued to receive nystatin cream and hydrocortisone cream to peri-area and buttocks and patient no longer used brief and was on chux (disposable, absorbent underpads used to protect incontinence on the bed); and- On 06/23/2025, a mixture of nystatin cream, hydrocortisone cream, and Eucerin cream (used to treat dry and sensitive skin) was ordered to be applied to abdomen, peri-area, buttocks, and upper legs.Review of the IDG discussion, dated 06/24/2025, showed the following:- Anxious turning in bed;- Skin rash treated with nystatin and hydrocortisone cream;- Stopped brief and used chux;- Started oral steroids; and- Failed to show the patient/caregiver refused bedbaths.During an interview on 06/25/2025 at 9:50 AM, the registered nurse coordinator (RNC) stated that he/she would expect the IDG to talk about what had changed with the patient at the IDG meeting. The RNC stated that he/she would expect the refusal of care to be reported to the registered nurse case manager (RNCM) and for the RNCM then to report to the IDG. He/She stated that he/she would want to know that the condition of the patient was worsening. The RNC stated that there was discussion about the treatment of the rash and other interventions. The RNC stated that there was failure to discuss the refusal of bedbaths and would expect notes to be in the IDG summary.”

“Based on record review, home visit observation, and interview, the hospice provider failed to ensure that all procedures had physician orders in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 05/19/2025 with a terminal diagnosis of squamous cell carcinoma of skin of scalp and neck (a type of skin cancer that arises from squamous cells, which are found in the outer layer of the skin). The patient lived at home with adult family members.Review of the initial plan of care (POC) dated 05/19/2025 to 08/16/2025 showed:- A diagnosis of long-term current use of anticoagulants (a medication that helps prevent blood clots from forming or growing larger);- The patient was taking warfarin sodium (an anticoagulant medication that requires monitoring of the patient’s International Normalized Ratio (INR- a blood test that measures how long it takes for your blood to clot); - The patient was at risk for bleeding due to anticoagulant therapy; and- The POC failed to include orders for INRs. Review of the skilled nurse (SN) visit noted dated 05/20/2025 showed: “INR 1.8 - coordinated with “named physician” with no change in Coumadin (warfarin) dose at this time, and to check INR next week on Tuesday 05/27/25 and then 2 weeks from then on Wednesday, 06/11/2025.” Review of the SN visit noted dated 06/24/2025 showed: “INR 1.7- new order received to increase coumadin to 3 mg MON/WED/FRI and 6 mg SUN/TUES/THUR/SAT” (3 mg (milligram) Monday, Wednesday and Friday and 6 mg on Sunday, Tuesday, Thursday and Saturday). Observation on 06/24/2025 at 10:50 AM, showed RN-A performed a fingerstick to obtain an INR on the patient. Further review of the clinical record failed to show physician orders for the INRs obtained on 05/20/2025 and 06/24/2025. During an interview on 06/25/2025 at 10:24 AM, the registered nurse coordinator stated that:- The nurse had documented in the nurses notes and they were sent in teams (an instant messaging system that is currently not part of the hospice’s chart or signed by the physician);- The 06/17/2025 SN visit note did show a new order was received, but did not show when to repeat the INR; and- He/she was unable to find written orders for the INRs obtained on 05/20/2025 and 06/24/2025.”

“Based on policy review, respite facility contract review, record review, and interview, the hospice provider failed to ensure a copy of the discharge summary was provided to the hospice at the time of respite discharge in one of one respite record review (Record/Patient #6). This deficient practice has the potential to affect the coordination of respite care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Levels of Care- Inpatient Respite Care,” revised December 2022, failed to show that the hospice provider would ensure a copy of the discharge summary would be provided to the hospice at the time of respite discharge. Review of the provider’s respite facility contract, dated September 9th 2021, showed that a copy of the inpatient clinical record shall be available to hospice at the time of discharge. RECORD/PATIENT #6:Review of the clinical record showed, in part:- The patient was admitted to hospice services on 02/25/2025 with a terminal diagnosis of malignant neoplasm of the rectum (cancer that develops in the rectum, the last section of the large intestine); - The patient resided at home with his/her spouse; - The patient began inpatient respite services on 03/10/2025 for caregiver relief (The spouse had a scheduled procedure and passed away from a heart attack during the patient’s respite stay);- The patient completed five consecutive days of respite care;- The patient was discharged from inpatient respite on 03/15/2025; and- The clinical record failed to contain a discharge summary from the respite facility. During an interview on 06/25/2025 at 10:11 AM, the administrator stated that:- They (hospice provider) did not obtain a copy of the discharge summary from the inpatient respite provider; and- He/she was aware that a copy of the discharge summary should have been obtained.”

“Based on policy review, record review, home visit observation, and interview the hospice provider failed to ensure the long-term care facility (LTCF) patient record contained a copy of all required hospice documents in one of two home visit observations of patients that resided in a LTCF (Record/Patient #3). This deficient practice has the potential to affect all the provider’s patients who reside in a LTCF. Findings included: Review of the hospice provider’s policy titled, “Hospice Care for Nursing Facility Residents-Coordination of Services,” reviewed “August 2022”, showed in part, the following information is provided to the facility:- The Hospice election form;- The instructions how to access the hospice’s 24 hour on-call system; and- Any advance directives specific to each patient. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 03/04/2025 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient resided in a LTCF. Observation on 06/24/2025 at 3:00 PM, when reviewing the facility binder with the facility’s charge nurse showed the binder failed to contain:- The hospice election form;- The instructions how to access the hospice’s 24-hour on-call system; and- The advance directives specific to the patient. During an interview on 06/25/2025, at 10:15 AM, the administrator stated that he/she:- Would expect the hospice election form, the instructions how to access the hospice’s 24-hour on-call system, and the advance directives specific to the patient to be included in the binder; and- The binders had just been cleaned out, “and apparently too well”.”

“Based on review of Missouri state statutes, policy review, employee file review, and interview, the hospice provider failed to ensure that a criminal background check (CBC) was performed prior to first patient contact, in one of five employee files reviewed (E-1). This deficient practice has the potential to affect all the patients served by the provider. 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 provider’s duty to conduct employee criminal background checks pursuant to this section; except that, completing the inquiries pursuant to this subsection shall not be construed to exempt a provider from further inquiry pursuant to common law requirements governing due diligence. If an applicant has not resided in this state for five consecutive years prior to the date of his or her application for employment, the provider shall request a nationwide check for the purpose of determining if the applicant has a prior criminal history in other states.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 provider’s policy titled, “Criminal Background Checks,” dated 07/2019, showed in part the following:- Criminal background checks are required for all associates (including volunteers) and contracted staff who provide direct patient care or who have access to patient records; - Written agreements with contracted entities include a provision that a criminal background check must be provided for any contracted staff providing services for the hospice or having access to patient records; - Offers of employment contain a written statement that employment is conditional upon acceptable results from the criminal background check; and - The criminal background check is obtained prior to the date of employment for all States that the individual has lived or worked in for the past years required by state and federal regulations. EMPLOYEE #1:Review of the employee file showed the following:- Date of hire: 04/01/2024; and- The employee file failed to include a CBC as of 06/24/2025. During an interview on 06/24/2025 at 3:50 PM, the administrator stated that the provider failed to complete a CBC prior to E-1’s date of hire. The administrator corrected the CBC onsite on 06/24/2025.”