Preferred Hospice of Missouri

“Based on policy review, bereavement protocol review, record review, and interview, the hospice provider failed to have an organized program for the provision of bereavement services under a qualified bereavement care supervisor, ensure bereavement services reflected the needs of the bereaved, and develop a bereavement plan of care that included the kind of bereavement services to be offered and the frequency of service delivery (L0596). The cumulative effect of this deficient practice has the potential to affect the ability of the hospice to provide effective core services to meet the individualized needs of the bereaved.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the plan of care (POC) contained individualized goals with measurable outcomes in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the updated plans of care document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 06/17/2025, 07/01/2025, and 07/15/2025 showed that: - The patient had the goals of: * Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal;” and * Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate.”RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the updated plans of care document titled, “IDG Comprehensive Assessment Details,” dated 06/19/2025, 07/03/2025, and 07/17/2025 showed that: - The patient had the goals of: * Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal;” and * Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate.”During an interview on 07/23/2025 at 2:26 PM, the administrator stated they would expect the patient’s goals to be measurable within the confines of the patient’s disease process. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (inability to move the right side of the body, due to stroke). The patient had secondary diagnoses of hypertension (high blood pressure), and arthrosclerosis (hardening of the arteries). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/23/2025, showed that the patient had the problems and goals of:-The patient and caregiver will report an improvement in confusion and sleep. The goal failed to define “improvement”.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility.Review of the updated plans of care / IDG dated 07/17/2025, showed that the patient had the problems and goals of:-The patient would tolerate all treatments with minimum discomfort or alteration to daily routines. The goal failed to define “minimum discomfort”. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/20/2025, showed that the patient had the problems and goals of:-Dyspnea (shortness of breath), edema, hypertension (high blood pressure), and chest pain to be managed at an “acceptable level”. The goal failed to define “acceptable level”. Findings included:Review of the provider’s undated policy titled, “Physician Plan of Care Summary,” showed in part:- The physician plan of care summary will be completed by the admitting nurse using information gathered and assessed from the patient; and- The goals, scope, and frequency of service and recommended interventions must be documented on the physician plan of care summary form. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the updated plans of care document titled, “Interdisciplinary Group (IDG) Comprehensive Assessment Details,” dated 06/17/2025, 07/01/2025, and 07/15/2025 showed the patient had the following goals: - Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal”; and- Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate”.RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the updated plans of care documents titled, “IDG Comprehensive Assessment Details,” dated 06/19/2025, 07/03/2025, and 07/17/2025 showed the patient had the following goals: - Patient will achieve and maintain optimal skin integrity as disease progresses and optimal physical comfort. The goal failed to define, “optimal”; and- Patient will maintain adequate nutritional requirements and hydration as allowed by disease progression and adequate blood flow and blood pressure as disease allows. The goal failed to define, “adequate”.During an interview on 07/23/2025 at 2:26 PM, the administrator stated that they would expect the patient’s goals to be measurable within the confines of the patient’s disease process. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (muscular weakness on one side of the body). The patient had secondary diagnoses of hypertension (high blood pressure) and arthrosclerosis (an abnormal collection of calcium and cholesterol on the artery walls, also known as plaque buildup). The patient resided in their own home.Review of the updated plans of care/IDG dated 07/23/2025, showed that the patient had the problems and goals of:-The patient and caregiver will report an improvement in confusion and sleep; and-The goal failed to define “improvement”. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility. Review of the updated plans of care/IDG dated 07/17/2025, showed that the patient had the problems and goals of:-The patient would tolerate all treatments with minimum discomfort or alteration to daily routines. The goal failed to define “minimum discomfort”. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the updated plans of care / IDG dated 07/20/2025, showed that the patient had the problems and goals of:-Dyspnea (shortness of breath), edema, hypertension (high blood pressure), and chest pain to be managed at an “acceptable level”. The goal failed to define “acceptable level”.During an interview on 07/23/2025 at 2:26 PM, the administrator stated they would expect the patient’s goals to be measurable within the confines of the patient’s disease process.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the plan of care was revised and updated based on the patient’s updated comprehensive assessment and failed to note the patient’s progress toward outcomes and goals in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5).This deficient practice has the potential to affect all the patients served by the provider.Findings included: Review of the provider’s policy titled, “Plan of Care,” dated 03/24/2021 showed in part:- The plan of care will identify the care and services to which the hospice will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care; - The plan of care will be reviewed and/or revised a minimum of every fourteen days by the interdisciplinary group (IDG); and - The plan of care includes directives for managing pain and other symptoms and physician standing orders. TAG: 553 RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Review of the document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 06/17/2025 showed that the patient had a decline in skin integrity, redness noted on his/her left heel, and bilateral heels were soft and mushy (an indication of pressure injury on a boney prominence).Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/15/2025, showed that the patient’s skin integrity had continued to decline, both heels remained soft and mushy, and the redness on the patient’s left heel was treated with skin preparation pads (moistened pads used to protect skin).Observation on 07/22/2025 at 10:45 AM, showed that: - The patient was sitting in a high-backed wheelchair and leaning toward the right side; - Was frequently coughing while facility staff members fed him/her; - Had a bump in the roof of his/her mouth measuring approximately one inch in diameter that: * Had appeared about two weeks prior; * Was vascular in nature; and * Was most likely interfering with the patient’s ability to swallow; and- Had redness to bilateral heels. Review of the document titled, “Plan of Care,” dated 07/21/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - The patient’s coughing on food and fluids while staff members fed him/her; - The bump on the roof of the patient’s mouth; and- The redness to the patient’s bilateral heels. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had a pressure injury on his/her right heel. The patient resided in an assisted living facility. Review of the physician’s order dated 06/16/2025 showed that:- The nurses were to cleanse the wound on the patient’s right heel with wound cleanser then; - Apply alginate (a fabric like material used in wound care) cut to the size of the wound; - Cover with foam dressing; and- secure with tape. Review of the physician’s order dated 07/08/2025 showed that the patient had started on Bactrim DS (a sulfa based antibiotic) following a positive urine dipstick indicating a urinary tract infection. Review of the document titled, “Plan of Care,” dated 07/23/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to the change in wound care and the urinary tract infection. During an interview on 07/23/2025 at 2:26 PM, the administrator stated that they would expect the plan of care to be updated to include changes to the plan of care and progress toward goals. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 01/14/2025 with a terminal diagnosis of right sided hemiparesis (inability to move the right side of the body, due to stroke). The patient had secondary diagnoses of hypertension (high blood pressure), and arthrosclerosis (hardening of the arteries). The patient resided in their own home.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/20/2025, showed that the patient was assessed with problems which included knowledge deficit (memory issues), and comfort alteration due to pain (generalized physical pain). The goal listed as these problems to be managed at an “understandable” and “optimal” levels.Review of the document titled, “Plan of Care,” dated 07/23/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for knowledge deficit; and- Quantitative measurable goals for pain level. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of heart failure. The patient resided in an assisted living facility.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/17/2025, showed that the patient was assessed with problems which included confusion (memory impairment), and irregular heart rate. The goal list did not address these problems to be managed.Review of the document titled, “Plan of Care,” dated 07/21/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for confusion and forgetfulness; and- Quantitative measurable goals for irregular heart rate. RECORD/PATIENT #5:Review of the clinical record showed the patient was admitted to hospice services on 05/01/2025 with a terminal diagnosis of abnormal weight loss. The patient had secondary diagnoses of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and makes it difficult to breathe), traumatic brain injury (TBI), and pulmonary embolism (PE; the formation of a blood clot in the arteries of the lungs). The patient resided in their own home.Review of the document titled, “IDG Comprehensive Assessment Details,” dated 07/20/2025, showed that the patient was assessed with problems which included dyspnea (shortness of breath) during moderate exertion, hypertension (high blood pressure). The goal listed as these problems to be managed at an “acceptable level”.Review of the document titled, “Plan of Care,” dated 07/20/2025 showed the plan of care failed to contain updates to the plan of care that included the patient’s progress toward his/her goals related to: - Quantitative measurable goals for hypertension; and- Quantitative measurable goals for dyspnea.”

“Based on policy review, home visit observation, and interview, the hospice provider failed to ensure clinicians followed accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases in two of four home visit observations conducted (Records/Patients #1 and 2). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s clinical protocol titled, “Bag Technique Checklist,” dated 07/18/2022, showed in part that the clinician must:- Sanitize his/her hands; and - Wipe down reusable equipment with Sani-wipes or alcohol wipes. Wear gloves, place on clean barrier, let dry before placing back in bag. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 09/23/2022 with a terminal diagnosis of severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). The patient resided in an assisted living facility with total care. Observation on 07/22/2025 at 10:30 AM, showed the registered nurse: - Performed hand hygiene; - Retrieved a blood pressure cuff, pulse oximeter, stethoscope, and thermometer from his/her nursing bag; - Performed hand hygiene; - Assessed the patient’s blood pressure, pulse oximetry, and temperature;- Cleansed the equipment;- Placed the equipment into the bag;- Then performed hand hygiene; and- The clinician failed to perform hand hygiene before cleansing his/her soiled equipment. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Observation on 07/21/2025 at 1130 AM, showed the registered nurse: - Performed hand hygiene; - Retrieved a blood pressure cuff, pulse oximeter, stethoscope, and thermometer from his/her nursing bag; - Performed hand hygiene; - Put on his/her gloves; - Assessed the patient’s blood pressure, pulse oximetry, and temperature;- Cleansed the equipment while still wearing the gloves:- Placed the equipment into the bag;- He/she then removed his/her soiled gloves;- Then performed hand hygiene; and- The clinician failed to remove his/her gloves and perform hand hygiene before cleansing his/her soiled equipment. During an interview on 07/23/2025 at 10:00 AM, the administrator stated that they would expect clinicians to perform hand hygiene prior to cleansing his/her soiled equipment.”

“Based on record review and interview, the hospice provider failed to ensure clinicians completed accurate, complete and timely documentation in five of fifteen records reviewed (Records/Patients #2, #6, #7, #8, and #10). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 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 at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following: - The patient transferred to a long term care facility (LTCF) for respite care; and - The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025.The RNC failed to sign and record the order in a timely manner.Review of the registered nurse (RN) visit dated 05/03/2025, showed the following: - The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- Hospice team was notified.Review of the client’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025. The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record.RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 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 at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the client died on 03/22/2025 at 1:50 PM. The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the client’s physician orders dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025. The RN failed to sign and record the orders in a timely manner.RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the client’s general visit note dated 05/13/2025, showed the patient did the following:- Discharged on 05/04/2025;- Discharged to LTCF-2; and - RNC signed and recorded the event on 05/13/2025.The RNC failed to sign and record the event in a timely manner.Review of the interdisciplinary group (IDG) meeting dated 05/15/2025, showed the patient was discharged to LTCF-2.The IDG failed to document accurate information.During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient.During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information. Findings included:RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the hospice aide visit documentation showed that the aide signed his/her visit documentation for:- 07/01/2025 on 07/09/2025;- 07/02/2025 on 07/14/2025; - 07/03/2025 on 07/14/2025;- 07/16/2025 on 07/21/2025; and - The aide signed his/her documentation visits after an extended period of time. Review of the nursing visit dated 06/26/2025 showed in part that the visit narrative contained the documentation of assessment and interventions performed on a patient with a heart condition and not the patient of record Findings included:Findings included:Review of the provider’s nursing services approved 03/24/2021, showed the following: RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the hospice aide visit documentation showed that the aide signed his/her visit documentation for:- 07/01/2025 on 07/09/2025;- 07/02/2025 on 07/14/2025; - 07/03/2025 on 07/14/2025;- 07/16/2025 on 07/21/2025; and - The aide signed his/her documentation visits after an extended period of time. Review of the nursing visit dated 06/26/2025 showed in part that the visit narrative contained the documentation of assessment and interventions performed on a patient with a heart condition and not the patient of record. RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 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 at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following: - The patient transferred to a long term care facility (LTCF) for respite care; and - The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025.The RNC failed to sign and record the order in a timely manner.Review of the registered nurse (RN) visit dated 05/03/2025, showed the following: - The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- Hospice team was notified.Review of the client’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025. The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 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 at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the client died on 03/22/2025 at 1:50 PM. The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the client’s physician orders dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025. The RN failed to sign and record the orders in a timely manner. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the client’s general visit note dated 05/13/2025, showed the patient did the following:- Discharged on 05/04/2025;- Discharged to LTCF-2; and - RNC signed and recorded the event on 05/13/2025.The RNC failed to sign and record the event in a timely manner.Review of the interdisciplinary group (IDG) meeting dated 05/15/2025, showed the patient was discharged to LTCF-2.The IDG failed to document accurate information.During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient.During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information.”

“Based on policy review, bereavement protocol review, record review, and interview the hospice provider failed to have an organized program for bereavement services under a qualified bereavement care supervisor (BCS) and failed to ensure bereavement services reflect the needs of the bereaved in one of five bereavement records reviewed (Record/Patient #11) and failed to develop a bereavement care plan (BCP) in four of four additional bereavement records reviewed (Records/Patients #12, #13, #14, and #15). This deficient practice has the potential to affect all the bereaved families/caregivers of hospice patients.Findings included:Review of the provider’s policy titled, “Scope of Services,” dated approved 03/24/2021, showed the following:- Hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment and continue through 13 months of the bereavement period. The goal is to help the patient/family cope with death related to grief and loss issues; - Following the death of the patient, families will he offered support, which follows an individualized BCP; and - Bereavement services address such issues as family grief and loss issues, survivor(s) needs, social, religious, and cultural issues, risk factors and potential for complicated grief reactions. Review of the provider’s bereavement protocol, dated approved 01/2021, showed the following:-The basic framework for bereavement interventions is based on the risk assessment;-All services provided should be tailored to the specific needs of each bereaved person;-Low, medium, and high-risk interventions include the following:*Attend the visitation or funeral if at all possible;*Staff sign a sympathy card and mail it as soon as possible;*Discuss the bereaved at the first interdisciplinary group (IDG) meeting after the patient’s death;*Complete a bereavement assessment within two weeks of the IDG meeting (preferably face-to-face);*Send a bereavement introduction letter;*Provide the bereaved with the book, “My Friend, I Care”;*Send a letter around the three-month mark;*Before the sixth-month mark, make every attempt to do a face-to-face visit per regulations, with a phone call at a minimum;*Send a hand-written card at the 12-month anniversary;*Send a bereavement discharge letter and bereavement services survey at the 13-month mark;- Medium and high-risk interventions include the following:*A bereavement assessment may need to be completed prior to the first IDG meeting after the patient’s death;*Increase calls and visits in the first three months;*Send a letter around the nine-month mark; and-High risk interventions include the following:*Provide the bereaved with a list of community resources for more support;*Provide monthly contact via phone calls and/or visits. RECORD/PATIENT #11:Review of the patient’s BCP dated 07/18/2024, showed in part the following: - On 07/18/2024 (the date of the patient’s death) the following interventions were completed:*Performed the bereavement assessment*Discussed the bereaved at the first IDG meeting after the death and IDG approved the plan of care - On 07/22/2024, the following interventions were completed:*Offered community grief support groups*Sent a sympathy card signed by the staff* Provided the bereaved with the book, “My Friend, I Care”*Performed calls and visits per risk assessment and bereavement protocol*Sent bereavement introduction letter*Completed condolence call following the patient’s death*Affirmed feelings associated with the loss - On 07/23/2024, the visitation/funeral service was attended; - On 02/05/2025, the social worker (MSW) sent an invitation to the annual hospice memorial service; and- On 07/17/2025, the MSW (who was no longer employed) sent a hand-written card at the 12-month anniversary.The BCP failed to show the bereavement risk assessment level. Review of the MSW phone call note dated 07/22/2024 at 10:00 AM, showed:-The bereaved said that the family was coping fairly well; and-The bereavement risk assessment was completed with a low-risk score. Review of the chaplain’s visit note dated 07/23/2024 at 12:00 PM, showed:- The visit occurred at the funeral home; and - The family was grieving appropriately. Review of the chaplain’s visit note dated 08/30/2024 at 10:45 AM, showed the following:- The visit occurred at the home of the bereaved;- The bereaved was at a moderate risk level; - The bereaved was dealing with anger; - The chaplain mentioned support group and offered to attend with the bereaved; - The chaplain communicated with the social worker that the bereaved struggled and requested a follow-up call to the bereaved; and - The chaplain would check back with the bereaved in a couple of weeks regarding interest in the support group. Review of the chaplain’s phone call note dated 09/12/2024 at 9:45 AM, showed the bereaved was doing better, denied bereavement services, and was discharged from bereavement services. (This entry was signed and recorded on 07/21/2025, the date the state agents arrived for the recertification survey) The BCS failed to provide an organized program for the provision of bereavement services as evidenced in the following: - Allowed an intervention (from 07/17/2025) entry on the BCP that was falsely documented by the MSW who was no longer employed; - Had discrepancy in the bereavement protocol risk levels and the bereavement assessment levels; - The MSW failed to follow-up contact with the bereaved per the chaplain’s request on 08/30/2024; and- The bereavement protocol was not followed for a medium risk assessment (as per the chaplain bereavement risk assessment 08/30/2024). RECORD/PATIENT #12:Review of the patient’s BCP created 02/14/2025, showed the date of death was 02/11/2025 and failed to show any interventions were completed.Review of the chaplain’s visit note dated 02/25/2025, showed the bereaved was a low risk according to the assessment.The provider failed to develop a BCP to reflect a low risk assessment. Review of the chaplain’s visit note dated 03/25/2025, showed the bereaved was a moderate risk according to the assessment.The provider failed to update the BCP to reflect a moderate risk assessment. RECORDS/PATIENTS #13:Review of the patient’s bereavement record showed the date of death was 04/26/2025.Review of the bereavement assessment dated 05/12/2025, showed the bereaved was a low risk and bereavement services were declined. The provider failed to develop a BCP. RECORD/PATIENT #14:Review of the patient’s bereavement record showed the date of death was 04/07/2025.Review of the bereavement assessment dated 05/01/2025, showed the bereaved was a low risk and bereavement services were declined.The provider failed to develop a BCP. RECORD/PATIENT #15:Review of the patient’s bereavement record showed the date of death was 04/05/2025.The provider failed to: - Develop a BCP; - Complete a risk assessment within the first two months after death; and - Follow their bereavement protocol. During an interview on 07/22/2025 at 2:35 PM, the registered nurse coordinator (RNC) stated that he/she would expect a BCP to be created and followed according to the bereavement protocol even when services had been declined. He/She stated that the correct contact date should be entered to reflect the bereavement intervention timeline. Once the intervention was completed the date was entered and the person that completed the intervention. He/She stated that the MSW had not worked for the provider since the beginning of 2025 and he/she could not explain why the MSW’s name was on the BCP.During an interview on 07/23/2025 at 2:25 PM, the administrator stated that he/she:- Expected the bereavement assessment be completed within the two weeks following a patient’s death;- The staff were trained to wait a few days and to complete the bereavement assessment; - The day of the funeral was not appropriate to complete the bereavement assessment; - The current BCS should have corrected the error in the entry of the former BCS’s name on the BCP; - The expectation was for full bereavement services to be provided; - The services were to be offered and documented if services were refused; - Expected the bereavement protocol to be followed based on the risk assessment; - The BCP should have been updated when the risk level changed; - A BCP should have been created, regardless, if services were refused; and- Would have expected the bereavement staff to have had an encounter with the bereaved to reassess the situation for new challenges and would have expected encounters at six months and 13 months after the patient’s death.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure clinicians completed accurate, complete, and timely documentation in five of fifteen records reviewed (Records/Patients #2, #6, #7, #8, and #10). This deficient practice has the potential to affect all the patients served by the provider. Findings included: During the Medicare recertification survey, policies regarding documentation accuracy and completion timelines were requested for nursing, hospice aides, social workers, chaplains, volunteers, and any other staff responsible for documenting in the clinical record. The provider was unable to produce the requested policies for all disciplines except licensed nursing. Review of the provider’s policy titled, “Scope of Services,” dated as approved 03/24/2021, showed in part the following:A registered nurse (RN) is responsible for the coordination of all hospice services. Scope and frequency of services are based on initial and ongoing assessments of the patient’s needs. Nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care. Hospice nursing provides: Registered Nurse • Documentation of problems and appropriate goals and intervention entered into the current EMR (electronic medical record) within 24-48 hours;• Documentation of patient/family participation in and response to the plan of care (POC); and• Coordination of all patient/family hospice services.Licensed Practical Nurse (LPN)• Documentation of problems and appropriate goals and intervention;• Documentation of patient/family participation in and response to the plan of care entered into the current EMR within 24-48 hours;• Coordination of all patient/family hospice services; and• The LPN functions under the supervision of the RNCM (RN case manager) and communicates to the RNCM following a developed POC by the IDG/IDT (interdisciplinary group/interdisciplinary team). RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/18/2024 with a terminal diagnosis of senile degeneration of the brain (decline in mental capacity). The patient had secondary diagnoses of high blood pressure and anxiety. The patient resided in an assisted living facility. Review of the nursing visit, dated 06/26/2025, showed the visit narrative contained the documentation of the assessment and interventions performed on a patient with a heart condition and not the patient of record. The nurse failed to accurately document on the patient. Review of the hospice aide visits documentation showed the aide failed to sign his/her visits documentation in a timely manner:- On 07/01/2025 was signed on 07/09/2025 (eight days after the visit);- On 07/02/2025 was signed on 07/14/2025 (12 days after the visit); - On 07/03/2025 was signed on 07/14/2025 (11 days after the visit); and- On 07/16/2025 was signed on 07/21/2025 (five days after the visit). RECORD/PATIENT #6:Review of the clinical record showed the patient was admitted to hospice services on 03/12/2025 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 at home with his/her spouse.Review of the patient’s physician orders dated 05/01/2025, showed the following:- The patient transferred to a long-term care facility (LTCF) for respite care; and- The registered nurse coordinator (RNC) signed and recorded the order on 07/21/2025 (81 days later and on the day the state agents entered for the recertification survey).The RNC failed to sign and record the order within the timeframe identified in the provider’s policy. Review of the registered nurse (RN) visit dated 05/03/2025, showed the following:- The patient’s spouse had back surgery and needed three weeks to recover;- The patient’s adult grandchild wanted to speak to “someone” about keeping the patient in the facility “longer”;- The RN spoke with the social worker (SW) and he/she was going to call the grandchild; and- The hospice team was notified.Review of the patient’s undated admission record for the LTCF, showed the following:- Admission date of 05/01/2025; and- Discharged to the home on 05/13/2025.During an interview on 07/23/2025 at 11:30 AM, the RNC stated that hospice paid for the patient’s respite care from 05/01/2025 to 05/06/2025. RNC stated that the patient continued respite care with private pay until 05/13/2025. RNC stated that the patient’s spouse was at the LTCF to recover from surgery. RNC stated that the patient’s spouse was ready to leave the LTCF and to take the patient home. RNC stated the patient did not stay three weeks in respite as requested on 05/03/2025.The provider failed to document that the SW followed-up with the family regarding extending the respite stay and failed to update the patient’s record. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 03/19/2025 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 at a LTCF.Review of the skilled nurse (SN) visit dated 03/25/2025, showed the patient died on 03/22/2025 at 1:50 PM (three days prior to the SN visit). The SN failed to document the correct date of the visit. RECORD/PATIENT #8:Review of the clinical record showed the patient was admitted to hospice services on 03/27/2025 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at home with his/her family.Review of the physician orders, dated 03/27/2025 at 2:41 PM, showed the RN signed and recorded the orders on 07/21/2025 (The day the state agents arrived for the recertification survey and 116 days after the order was received). The RN failed to sign and record the orders within the timeframe identified in the provider’s policy. RECORD/PATIENT #10:Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at LTCF-1.Review of the patient’s general visit note dated 05/13/2025, showed the following:- The patient was discharged on 05/04/2025 to LTCF-2; and- The RNC signed and recorded the event on 05/13/2025 (nine days after the patient discharged).The RNC failed to sign and record the event within the timeframe identified in the provider’s policy. Review of the IDG meeting dated 05/15/2025, showed the patient was discharged to LTCF-2 (the patient discharged to LTCF-1) .The IDG failed to document accurate information. During an interview on 07/23/2025 at 11:30 AM, RNC stated that the patient resided at LTCF-1 prior to starting service with hospice, resided at LTCF-1 on hospice, and remained at LTCF-1 when discharged from hospice.The clinical record failed to document the accurate location for the patient. During an interview on 07/23/2025 at 2:15 PM, the administrator stated that he/she expected patients’ records to be updated in a timely manner and expected the record to reflect accurate information.”

“Based on record review and interview, the hospice provider failed to forward a copy of the discharge summary to the patient’s attending physician in one of two revocation record reviews (Record/Patient #9) and in one of one live discharge record review (Record/Patient #10). This deficient practice has the potential to affect all the discharged patients served by the provider.Findings included:The provider was not able to provide a policy for the discharge of patients. RECORD/PATIENT #9:Review of the clinical record showed the patient was admitted to hospice services on 10/23/2024 with a terminal diagnosis of cerebral palsy (a group of neurological disorders that affect movement, posture, and muscle coordination) with abnormal weight loss. The patient resided at his/her home with his/her family. The patient was discharged from services on 03/12/2025 to seek aggressive treatment.Review of the patient’s undated discharge summary failed to include the following: - A summary of the patient’s treatments, symptoms, and pain management; - Current plan of care; - Latest physician’s orders; - Other documentation that would assist in post-discharge continuity of care.RECORD/PATIENT # 10: Review of the clinical record showed the patient was admitted to hospice services on 03/11/2024 with a terminal diagnosis of senile degeneration (a neurological disorder that is tied to cognitive decline). The patient resided at a long term care facility (LTCF). The patient’s condition was not consistent with a terminal prognosis of six months or less and was discharged from services on 05/04/2025.The provider failed to provide a discharge summary to the attending physician that included the following: - A summary of the patient’s stay including treatments, symptoms, and pain management; - The patient’s latest physician orders; - Other documentation that would assist in post-discharge continuity of care.During an interview on 07/22/2025 at 2:05 PM, the administrator stated that a discharge summary was provided to the receiving attending physician. During an interview on 07/23/2025 at 11:15 AM, the alternate administrator (AA) stated that the provider did not have a discharge policy. He/She stated that they implemented a new process on 05/13/2025 that included elements of the discharge summary.”