One Community Hospice

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 1 of 4 (25%) home visits performed revealed the agency did not ensure the hospice followed accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. Document 1: Agency Policy titled “Hand Hygiene Policy 7-009 November 2023” stated in relevant parts: “3. Hand decontamination using an alcohol based hand rub should be performed: E. When moving from a contaminated body site to a clean body site during patient care. F. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. G. After removing gloves.” Home Visit 4: Home Visit 4 was conducted with the Hospice Aide (Personnel Record 8) on 09/09/2026 in an Assisted Living Facility. The Clinical Director was also present during the Home Visit. The Hospice Aide escorted the patient from the common area back to her room in preparation for her tasks. She began her tasks of setting up the patient’s lunch/snack then sat on the patient’s bed and began having a conversation with her. After a few minutes of this conversation, the Aide got up and emptied the patient’s trash, then went into the bathroom and briefly washed her hands. She came out of the bathroom and asked the patient about her choice of clothes. She removed the clothes from the patient’s closet and placed them in the bathroom. She did not wash her hands or sanitize her hands after touching the clothes. She then went to the bedside/tray table and picked up a carton of milk and a sandwich, asked the patient if she were going to eat it and then placed it in the fridge “for the patient to eat later.” She then asked the patient if she would like her water tumbler filled. When the patient replied “yes”, the aide left the room with the tumbler and returned a short time later with the tumbler filled with water. She was not observed to wash her hands before leaving or upon returning to the room. An interview was conducted with the Clinical Director and Hospice Aide on 09/09/2026 during which time the Hospice Aide agreed she had not “washed her hands or sanitized them in between touching items.” The Clinical Director advised the Aide she should have placed a barrier before sitting on the patient’s bed. The Clinical Director advised the Aide would be retrained that evening.”

“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 4 of 19 (21%) clinical records reviewed in which aide services were accepted revealed the agency did not ensure the hospice aide provided services included in the plan of care. CLINICAL RECORD 5: The hospice aide care plan dated 09/03/2026 included the following tasks: “Turn and position in bed; shampoo; skin care; perineal care; oral care; dressing assistance; bathing-shower; empty trash; change linens; companionship.” All tasks were to be completed every visit with an aide frequency of three times weekly. The hospice aide visit dated 9/4/2026 noted the following: “Shower N Note: NA There was no towels and bath blankets at the facility so I not able to do her shower. Change linens N NA Shampoo N NA Skin Care N NA Nail Care N NA” CLINICAL RECORD 7: The hospice aide care plan dated 08/14/2026 included the following tasks: “Turn and position in bed; Transfer client from bed/chair; bathing-shower; dressing assistance; hair care; nail care-file and clean only; peri care; shampoo; skin care-apply lotion; transfer client from bed/chair; change linens; empty trash; offer fluids; companionship.” All tasks were to be completed every visit with an aide frequency of twice weekly. The hospice aide visit dated 08/26/2026 noted: “Shower Completed: N Note: Gave patient a BB (bed bath).” CLINICAL RECORD 10: The hospice aide care plan dated 06/13/2026 included the following relevant tasks: “Bathing shower; dressing assistance; hair care; nail care-aide to file and clean only; shampoo; skin care-notify RN of any changes.” All tasks were to be completed every visit with an aide frequency of five times weekly. The hospice aide visit dated 06/24/2026 noted “Shampoo N note NA.” The hospice aide visit dated 07/15/2026 noted “Shampoo N Note NA.” The hospice aide visit dated 08/11/2026 noted “Shampoo N NA and shower N Note NA.” CLINICAL RECORD 18: The hospice aide care plan dated 12/23/2025 included the following relevant tasks: “Bathing-shower; turn and position; shampoo; oral care; nail care; skin care; change linens.” All tasks were to be completed every visit with an aide frequency of twice weekly. The hospice aide visit dated 12/24/2025 noted “Refused shower gave bed bath.” An interview and joint clinical record review was conducted with the Clinical Educator and Clinical Director on 09/09/2026 during which time they discussed a current performance improvement project involving aide care plans and then agreed the aides “needed to be reminded they could not deviate from the plan of care without making sure it was changed.””

“Based on review of the Hospice Medicare Benefit Policy Manual, policy review, record review, and interview, the hospice provider failed to provide drugs and biologicals related to the palliation and management of the terminal illness and related conditions, in two of five full records reviewed (Records/Patients #1 and #2).This deficient practice has the potential to affect all the patients on service with the provider. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 12/26/2025, with a terminal diagnosis of senile dementia (loss of mental capacity), chronic atrial fibrillation, (A-fib; an abnormal heart rhythm characterized by a rapid and irregular heartbeat), hypertension (an abnormal elevated blood pressure), and heart failure. The patient lived at a skilled nursing facility (SNF). Review of the Hospice Medicare Benefit Policy Manual showed that the hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions.Review of the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs,” dated 12/26/2025 showed:- Diagnosis related to terminal illness and related conditions (hospice is responsible to cover all items, services and drugs): senile degeneration of the brain,(loss of mental capacity), acute respiratory failure (loss of the ability to breath effectively) covid 19 (an infectious respiratory disease), chronic atrial fibrillation (A-fib; an abnormal heart rhythm characterized by a rapid and irregular heartbeat), heart failure, essential primary hypertension (pressure in your blood vessels is too high), atrial fibrillation (A fib- abnormal heart rhythm characterized by rapid and irregular heartbeat), essential (primary) hypertension (a serious, progressive disease characterized by high blood pressure in the pulmonary arteries, forcing the right side of the heart to work harder to pump blood to the lungs),depressive disorder recurrent unspecified (a serious mental health condition characterized by persistent sadness, low energy, and loss of interest in activities lasting at least two weeks), insomnia (inability to sleep), obstructive sleep apnea (a serious sleep disorder characterized by repeated, temporary pauses in breathing during sleep), lymphedema (a condition in which extra fluid builds up in tissue and causes swelling)- Non-covered items, services, and drugs determined by hospice as not related to terminal illness and related conditions, showed in part: * Albuterol sulfate (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases) 2.5mg/3 ml (milligram/milliliter) solution for nebulization (a machine used to deliver a medication to the lungs)- not related to terminal diagnosis; * Aspirin (a blood thinner), 325 mg tablet - not related to terminal illness;*Lasix (used to treat edema 20 mg tablets- not related to terminal illness;*Metoprolol Succinate ER (used to treat high blood pressure) 50 mg tablet - non formulary;*Potassium Chloride ER (dietary supplement used to treat low potassium) 20 milliequivalents (meq)- not related to terminal illness; and*Rexulti (used to treat agitation in Alzheimer’s dementia 2 mg tablet - non formulary. - Note: The hospice makes the decision as to whether conditions, items, services, and drugs are related for each patient. Review of the POC dated 12/26/2025 to 3/25/2026 showed, in part:- Aspirin 325 mg tablet by mouth daily for anticoagulation;- Lasix 20 mg tablet by mouth daily for edema;- Metoprolol Succinate ER 50 mg tablet by mouth daily for high blood pressure; -Potassium Chloride ER 20 meq tablet by mouth daily for supplement; and- Rexulti 2 mg tablet by mouth daily for Alzheimer’s dementia. - The patient was listed for being financially responsible for the medications; and- The hospice provider failed to cover drugs and biologicals that were related to the terminal diagnoses and related conditions and the palliation and management of symptoms. Findings included: Review of the Hospice Medicare Benefit Policy Manual showed that the hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions. Review of the provider’s policy titled, “Patient Bill of Rights,” revised April 2018, showed in part:- The patient has the right to be informed in advance of service about the care to be furnished, the organizations scope of serves and services under the Medicare Hospice Benefit and any limitations on those services; and- Be informed, verbally and in writing, of billing and reimbursement methodologies prior to the start of care/service and as changes occur, including fees for services/products provided, direct pay responsibilities, and notification of insurance coverage. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Review of the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs,” showed:- Diagnosis related to terminal illness and related conditions (hospice is responsible to cover all items, services and drugs): acute on chronic systolic congestive heart failure, other supraventricular tachycardia (a rapid, often regular heart rate caused by faulty electrical signaling in the hearts upper chambers), essential primary hypertension (pressure in your blood vessels is too high), bipolar disorder current episode manic severe with psychotic features (a chronic mental health condition characterized by extreme, often debilitating shifts in mood, energy, and activity levels, alternating between high mania/hypomania and low depression episodes), paroxysmal atrial fibrillation (afib- abnormal heart rhythm characterized by rapid and irregular heartbeat), pulmonary hypertension (a serious, progressive disease characterized by high blood pressure in the pulmonary arteries, forcing the right side of the heart to work harder to pump blood to the lungs), major depressive disorder recurrent unspecified (a serious mental health condition characterized by persistent sadness, low energy, and loss of interest in activities lasting at least two weeks), insomnia (inability to sleep), sleep apnea (a serious sleep disorder characterized by repeated, temporary pauses in breathing during sleep), lymphedema (a condition in which extra fluid builds up in tissue and causes swelling), and chronic kidney disease (Long term, irreversible loss of kidney function, often caused by diabetes or high blood pressure);- Non-covered items, services, and drugs determined by hospice as not related to terminal illness and related conditions, showed in part: * Albuterol sulfate (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by lung diseases) 1.25mg/3 ml (milligram/milliliter) solution for nebulization (a machine used to deliver a medication to the lungs)- not related to terminal diagnosis * Albuterol sulfate 90 (microgram) mcg/actuation aerosol inhaler- non covered medication (med) * Atorvastatin (used to lower high cholesterol and reduce the risk of heart attacks and strokes) 80mg tablet- non covered med * Biofreeze (menthol) 4% topical gel- non covered med * Melatonin (a supplement to help with insomnia) 3mg tablet- not related to terminal diagnosis * Tizanidine (used to relieve muscle spasms) 4mg tablet- non covered med * Warfarin (a blood thinner used to prevent and treat blood clots, reducing the risk of strokes, heart attacks, and deep vein thrombosis) 1mg, 5mg and 10mg tablets- non covered med; and- Note: The hospice makes the decision as to whether conditions, items, services, and drugs are related for each patient. Review of the POC showed, in part:- Albuterol sulfate HFA 90 mcg/actuation aerosol inhalation, inhale two puffs every four hours as needed for shortness of air (SOA);- Albuterol sulfate 1.25mg/3 ml for nebulization, give one inhalation every eight hours as needed for SOA;- Atorvastatin 80mg, give one tablet at bedtime for hyperlipidemia (HLD);- Melatonin 3mg give one tablet at bedtime for insomnia;- Biofreeze apply to affected areas every eight hours as needed for pain;- Tizanidine 4mg, give one tablet by mouth every four hours as needed for muscle spasms;- Warfarin 1mg, give one tablet by mouth daily for blood clots;- Warfarin 5mg, give one tablet by mouth daily for AFIB;- Warfarin 10mg, give one tablet by mouth daily for AFIB;- The patient was listed for being financially responsible for the medications; and- The hospice provider failed to cover drugs and biologicals that were related to the terminal diagnoses and related conditions and the palliation and management of symptoms. During an interview on 03/18/2026 at 3:15 PM, the Administrator stated that melatonin is a supplement so it wouldn’t be covered for insomnia. Trazadone would be the alternative option for insomnia. Warfarin is not covered due to the benefits outweighing the risks. When alternative treatments options are available the patient is informed and it should be documented in the clinical record.”

“Based on employee file review and interview, the hospice provider failed to ensure all new and existing staff and individuals providing services under arrangement received emergency preparedness training upon hire and every two years in one out of five employee files reviewed (Employee #4). This deficient practice has the potential to affect the safety of all the patients served by the provider. Findings included: Employee #4: Review of employee #4’s personnel file showed the following:- The contracted employee was hired on 08/15/2018; and- The provider failed to ensure employee #4 received emergency preparedness training upon hire and every two years thereafter. During an interview on 03/17/2026, at 3:50 PM, the business office coordinator stated that they had not done emergency preparedness training for the contracted employee, but they were on the communication thread which informed them of when an emergency was activated.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure patients received information regarding the services that were not covered under the hospice benefit, in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients on service with the provider. RECORD/PATIENT #2 : Review of the clinical record showed the patient was admitted to hospice services on 12/26/2025, with a terminal diagnosis of senile dementia (loss of mental capacity), chronic atrial fibrillation, (A-fib; an abnormal heart rhythm characterized by a rapid and irregular heartbeat), hypertension (an abnormally elevated blood pressure), and heart failure. The patient lived at a skilled nursing facility (SNF). Review of the POC showed, in part, the patient required wound care, including cleaning, dressing changes every other day and as needed (PRN), and the hospice nurse to obtain weekly wound measurements. Review of the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs,” showed:- A list of non-covered medications; and- The document failed to include non-covered items and services associated with the patient’s care, including wound care supplies and dressing changes. Findings included: Review of the provider’s policy titled, “Patient Bill of Rights,” revised April 2018, showed in part:- The patient has the right to be informed in advance of service about the care to be furnished, the organizations scope of serves and services under the Medicare Hospice Benefit and any limitations on those services; and- Be informed, verbally and in writing, of billing and reimbursement methodologies prior to the start of care/service and as changes occur, including fees for services/products provided, direct pay responsibilities, and notification of insurance coverage. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Review of the POC showed, in part, the patient required wound care, including cleaning, dressing changes every other day and as needed (PRN), and the hospice nurse to obtain weekly wound measurements. Review of the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs,” showed:- A list of non-covered medications; and- The document failed to include non-covered items and services associated with the patient’s care, including wound care supplies and dressing changes. During an interview on 03/19/2026 at 12:15 PM, the Administrator stated that the wound care supplies were not covered under the hospice benefit because the wounds were not related to the terminal diagnosis. The staff failed to document the list of non-covered wound care supplies in the electronic medical record (EMR) correctly on admission.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in three of five full records reviewed (Records/Patients #1, #3, and #4). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled,” Medication Profile” dated November 2018 stated in part: The patients receiving medications administered by the organization will have a current, accuratemedication profile in the clinical record and;The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to hospice services on 10/24/2025, with a terminal diagnosis of End Stage Renal Disease (ESRD;- a condition where the kidneys are no longer able to filter waste, toxins, and extra fluids from the blood), Hyperlipidemia; (abnormally high levels of fats in the blood), and dementia; (a decline in mental capacity). The patient lived at home with a primary caregiver /spouse. Observation and interview on 03/17/2026 at 1:00 PM, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for Flonase (a corticosteroid used to relieve allergy symptoms like nasal congestion, sneezing, itching, and runny nose) 50 micrograms (mcg) nasal spray suspension, inhale one spray in each nostril each day. The patient’s spouse stated that the patient did not use the medication; and-The medication profile showed an order for Triamcinolone acetonide (a synthetic corticosteroid used to reduce inflammation, itching, and redness caused by skin conditions like eczema, dermatitis, and allergies) 0.1% topical cream, apply to affected areas every six hours. The patient’s spouse stated that the patient no longer used the medication. Additionally, the patient’s spouse stated that the patient had used marijuana (a psychoactive drug derived from the cannabis plant, commonly used for recreational and medicinal purposes) for pain control, however, the dosage and frequency were unknown to the caregiver spouse. The medication was not included on the medication profile. During an interview on 03/17/2026 at 3:00 PM, the administrator stated that he/she had contacted the patient’s spouse by phone and stated the marijuana use was from,” ten years ago”, and was not part of the patient’s active medication profile. During an interview on 03/18/2026 at 4:30 PM, the RN coordinator (RNC) stated that clinical staff are responsible to compare all current medications in the patient’s home to the medication list each visit to ensure medication accuracy. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Observation and interview on 03/17/2026 at 10:15 AM, showed the following medication discrepancies between the hospice provider’s medication profile and the LTCF medication record: - The LTCF medication profile showed oxycodone 20 milligram (mg) tablet, give one tablet by mouth three times a day for pain. The hospice medication profile showed oxycodone 10mg Get 1 tablet by mouth 2 times daily for pain an oxycodone 15 milligram tablets give one tablet by mouth 2 times daily for pain. The Hospice medication profile failed to show oxycodone 20 milligram tablets to be given three times daily for pain; and- The LTCF Medication profile showed Warfarin 1mg tablet, give half a tablet by mouth one time a day for treating and preventing blood clots. The Hospice medication profile showed warfarin 1 mg tablet, give one tablet by mouth daily for both blood clots. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/18/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related decline in cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a long-term care facility (LTCF).Observation and interview on 03/17/2026 at 11:15 AM, showed the following medication discrepancies between the hospice provider’s medication profile and the LTCF medication record: - The LTCF medication profile showed Hyoscyamine Sulfate 0.125 mg (brand name Levsin, used to treat excessive secretions), give one tablet sublingually (under the tongue) every four hours as needed for excessive secretions. The hospice medication profile showed Levsin 0.125 mg tablet, administer one tab/0.125 mg by mouth or sublingual every four hours as needed. The LTCF medication profile failed to show the medication could also be given by mouth, not just sublingual; and- The LTCF Medication profile showed Lipoderm External Patch (generic name Lidocaine for the treatment of pain), apply to left shoulder topically in the morning for pain. The Hospice medication profile showed Aspercreme (generic name Lidocaine) 4% topical patch, apply to left shoulder topically for pain every morning and remove in the PM after 12 hours. The LTCF medication provide failed to show when to remove the Lidocaine patch.”

“Based on policy review, record review, and interview, the hospice provider failed to identify the family and other individuals that may experience difficulty coping with the patient’s death in one of six records reviewed for bereavement (Record/Patient #7). This deficient practice has the potential to affect all the patients and bereaved individuals served by the provider. Findings included: Review of the provider’s policy titled, “Bereavement Services,” revised 04/2017, showed the program should provide bereavement services to the families/caregivers of hospice patients both before and after the patient’s death in accordance with the plan of care and bereavement services will extend to families/caregivers of skilled nursing facility residents. Review of the provider’s policy titled, “Comprehensive Assessment,” dated 10/2014, showed the comprehensive patient assessment, all baseline data, and other relevant information will be documented in the patient’s clinical record, including a bereavement assessment of the needs of the patient’s family and other individuals focusing on:- The nature of the relationship to the patient;- Circumstances surrounding the illness/prognosis;- Behaviors prior to and after the illness/prognosis;- Survivor needs (social, spiritual and cultural) that may impact coping skills; and- Potential for pathological grief reactions. RECORD/PATIENT #7:Review of the clinical record showed the patient was admitted to hospice services on 01/06/2026 with a terminal diagnosis of sepsis (life threating infection in the blood stream). The patient resided at a long-term care facility (LTCF). Review of the bereavement risk assessment reports, dated 01/06/2026, 01/09/2026, 01/15/2026, and 02/12/2026, showed the survivor to be the former daughter-in -law, who was assessed at a low risk level. Review of the interdisciplinary group (IDG) summary report, dated 01/14/2026, showed the patient had, at least, one son who was incarcerated, eight grandchildren and one great grandchild. The report also indicated that the son was contacted to obtain a do not resuscitate (DNR) order. Review of the medical social worker (MSW) visit note, dated 01/14/2026, and registered nurse (RN)-A’s visit note, dated 01/14/2026, showed one of the patient’s granddaughters was at the bedside and planned to spend the night. The bereavement assessments failed to include the patient’s son or granddaughter. During an interview on 03/19/2026, at 11:35 AM, the MSW stated that the bereavement assessment was completed only on the patient’s former daughter-in-law.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that each patient received an individualized initial or revised plan of care (POC), in three of five full records reviewed (Records/Patient #1 #2, and #3).This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Review of the POC showed, in part:- The medication profile included warfarin 1 mg tablet to be given by mouth daily for both blood clots. The POC failed to include anticoagulant/bleeding precaution interventions related to the blood thinning medication; - The plan of care failed to include PT/INR (a blood test that measures how long it takes blood to clot) lab draws to monitor anticoagulation therapy to keep clotting time in a safe, therapeutic range. The LTCF record showed PT/INR labs to be drawn weekly and PRN per physician request based on results and or dosage changes;- Wound care orders showed, “facility nurse/hospice nurse/caregiver/patient utilizing clean technique perform wound care cleanse with solution, cover and change every other day and PRN (as needed) dislodgement/soilage. Instruct caregiver/facility nurse/patient in wound care caregiver/facility nurse/patient will prove competency in wound care. Hospice nurse to obtain measurements weekly. May d/c (discontinue) order when new orders received or wound is resolved.” The POC failed to include what the multiple wound locations, specific wound care orders for each wound, and the physician that was conducting weekly wound evaluations and providing the wound care orders;- Pain Will be managed at a level acceptable to the patient of zero to 10. The plan of care failed to include what the acceptable level of the patient’s pain was; and- Functional limitations showed bowel/bladder incontinence, endurance, ambulation, dyspnea with minimal exertion. The POC failed to show that the patient required a mechanical lift for transfers with the assistance of two people. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice services on 12/26/2025, with a terminal diagnosis of senile dementia (loss of mental capacity), chronic atrial fibrillation, (A-fib; an abnormal heart rhythm characterized by a rapid and irregular heartbeat), hypertension (an abnormal elevated blood pressure), and heart failure. The patient lived at a skilled nursing facility (SNF). Review of the plan of care (POC) dated 12/26/2025 to 03/25/2026 showed:The medication profile showed an order for oxygen 2 - 4 liters per minute via nasal cannula for comfort as needed. The POC failed to show oxygen level parameters and individualized goals for the intervention; andThe medication profile showed a medication order for aspirin 325 milligram tablet 1 tablet by mouth daily for anticoagulant. The POC failed to address anticoagulation precautions / bleeding precautions and individualized goals for the intervention. During an interview on 03/18/2026 at 4:30 PM, the RN coordinator (RNC) stated that:Patients on anticoagulant therapy should have a care plan for safety;Oxygen flow rates should not be a flow range, but should list interventions toward a specific oxygen level goal; PT/ INR and blood glucose readings should be listed on the POC; andThe patient’s functional status and level of assistance should also be listed on the POC. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 02/18/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related decline in cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a long-term care facility (LTCF).Review of the initial registered nurse (RN) visit note, dated 02/18/2026, showed the following:- The patient was incontinent of both bowel and bladder;- The patient used diapers and under pads;- The patient attempted to ambulate using a walker or cane, but had frequent falls that necessitated the use of a wheelchair; and- A wheelchair was owned and used by the patient. Review of the plan of care (POC) dated 02/19/2026 and the undated POC report, printed on 03/16/2026, failed to show any care plan problem, goal or intervention related to the patient’s incontinence or mobility and use of a wheelchair. During an interview on 03/19/2026, the social worker (MSW) stated the patient used his/her own wheelchair so that is why they did not put it on the care plan.”

“Based on record review and interview, the hospice provider failed to ensure the plan of care (POC) contained the durable medical equipment (DME) and wound care supplies necessary to meet the needs of the patient in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “The Plan of Care,” dated April 2013, showed in part, the written POC will contain, but will not be limited to, DME and medical supplies necessary to meet patient needs. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Review of the POC showed, in part:- DME included a concentrator (oxygen) and a Broda chair (a specialized, highly adjustable medical positioning wheelchair used in healthcare settings for long term comfort, pressure redistribution, and fall prevention); and - The POC failed to include the hoyer (mechanical) lift for transfers and the wound care supplies necessary to meet the needs of the patient. During an interview on 03/18/2026 at 3:15 PM, the RN coordinator (RNC) stated that the hoyer lift and wound care supplies should be listed on the POC Review of the clinical record showed the patient was admitted to hospice services on 02/18/2026 with a terminal diagnosis of senile degeneration of the brain (progressive, age-related decline in cognitive function resulting in severe memory loss, confusion, and reduced ability to perform daily tasks). The patient resided in a long-term care facility (LTCF).Review of the initial registered nurse (RN) visit note, dated 02/18/2026, showed the following:- The patient was incontinent of both bowel and bladder;- The patient used diapers and under pads;- Equipment owned by the patient included a hospital bed and wheelchair;- The patient attempted to ambulate using a walker or cane, but had frequent falls that necessitated the use of a wheelchair; and- The facility nurse stated the patient did not need any durable medical equipment (DME), Review of RN visit note, dated 03/05/2026, showed the following:- The patient was incontinent of both bowel and bladder;- The patient used diapers and under pads;- The patient was up in his/her wheelchair in the hallway. Review of the plan of care (POC) dated 02/19/2026 and the undated POC report, printed on 03/16/2026, failed to show any care plan problem, goal or intervention related to the patient’s incontinence or incontinence supplies, and the patient’s decreased mobility or use of a wheelchair. During an interview on 03/19/2026, the social worker (MSW) stated the patient used his/her own wheelchair so that is why they did not put it on the care plan.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure that all entries in the clinical record were in accordance with the provider’s policy, in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients on service with the provider. RECORD/PATIENT #2 : Review of the clinical record showed the patient was admitted to hospice services on 12/26/2025, with a terminal diagnosis of senile dementia (loss of mental capacity), chronic atrial fibrillation, (A-fib; an abnormal heart rhythm characterized by a rapid and irregular heartbeat), hypertension (an abnormal elevated blood pressure), and heart failure. The patient lived at a skilled nursing facility (SNF) . Review of the provider’s policy titled, “Clinical/Service Data Collection,” revised April 2013, showed in part:- Home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record;- Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary;- Entries into the clinical/service record will be clear, concise, and specific statements of fact;- Entries into the clinical/service record will be made on the day care/service is provided to the patient; and-All documentation will be turned into the office at the end of the workday. Findings included: Review of the provider’s policy titled, “Clinical/Service Data Collection,” revised April 2013, showed in part:- Home care personnel providing patient care and supervisory functions have authority to make entries into the clinical/service record;- Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary;- Entries into the clinical/service record will be clear, concise, and specific statements of fact;- Entries into the clinical/service record will be made on the day care/service is provided to the patient; and-All documentation will be turned into the office at the end of the workday. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 01/23/2026 with a terminal diagnosis of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood). The patient resided in a long-term care facility (LTCF). Review of a client coordination note, dated 03/19/2026 at 11:09 AM, showed:- The late entry note was completed by the licensed clinical social worker (LCSW-B);- Note: Late entry for 01/26/2026, the patient’s guardian did not have any questions/concerns regarding non-covered medication lost or hospice covered alternative; - The late entry failed to include what the specific alternatives covered; and- The late entry note was completed 55 days after the election of hospice benefits. During an interview on 03/19/2026 at 11:15 AM, the LCSW-B stated that he/she verbally informed the patient’s guardian about the medications that hospice would not cover. He/she was unaware that he/she needed to document the verbal communication regarding non-covered medications so a late entry note was entered after becoming aware.”

“Based on review of Missouri statutes, policy review, employee file review, and interview, the hospice provider failed to complete a criminal background check prior to the employee having patient contact in one of five personnel records reviewed (Employee #2). This deficient practice has the potential to adversely affect services provided to 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, “Selections/Hiring of Personnel,” revised 04/2018, showed in part, a criminal background check and national sex offender check, if not part of the criminal background check, will be obtained for positions as required by law and regulations. Employee #2: Review of the provider’s personnel files showed employee #2 was hired on 09/15/2025 and had his/her first patient contact on 10/31/2025. The criminal background check was completed on 03/17/2026 during the recertification survey (137 days after patient contact). During an interview on 03/18/2026 at 3:15 PM, the administrator stated that they checked the Family Care Safety Registry (FCSR, which included both a criminal background check and the employee disqualification list), but did not have the proof of it being checked prior to patient contact.”