Bristol Hospice - St Louis

“Based on policy review, record review, and interview, the hospice provider failed to ensure an accurate/updated medication profile was maintained in three of five full records reviewed (Records/Patients #1, #3 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: A review of the provider’s policy titled, “Medication Profile,” dated 09/2024, showed in part the following:- Patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record;- The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications; and- A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 02/25/2026 with a terminal diagnosis of vascular dementia (a decline in mental capacity caused by conditions that block or reduce blood flow to the brain, depriving it of essential oxygen and nutrients). The patient resided in an Assisted Living Facility (ALF). Review of the current hospice medication list, printed 06/23/2026, and the ALF current medication list, printed 06/24/2026, showed the following discrepancies:- The hospice provider’s medication list included:* Acetaminophen 650 milligrams (mg) suppository given rectally for pain as needed (PRN) every four hours;* Bisacodyl 10 mg suppository rectally once a day PRN for severe constipation;* Hyoscyamine 0.125 mg tablet every four hours PRN for respiratory secretions;* Prochlorperazine 10 mg every six hours PRN for nausea and vomiting;- The ALF medication list failed to include acetaminophen, bisacodyl, hyoscyamine, and prochlorperazine.- The ALF current medication list showed Robitussin DM liquid 10 milliliters (ml) by mouth every four hours PRN for cough. The hospice provider’s medication list failed to include the Robitussin;- The hospice provider’s current medication list included Juven one packet orally three times a day for wound healing; the ALF medication list included Juven two time daily; and- The hospice provider’s current medication list included metronidazole 500 mg two tables crushed and sprinkle in wound three times a week for wound care. The ALF medication list included metronidazole 500 mg one time daily. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of Alzheimer’s disease with early onset (a disease marked by progressive loss of mental capacity). The patient resided at a long-term care facility (LTCF).Review of the current hospice medication list printed 06/22/2026, and the LTCF current medication list, printed 06/23/2026, showed the following discrepancy, the LTCF current medication list showed nystatin suspension liquid 100000 units per milliliter (ml), give 5 ml by mouth three times a day for thrush. The hospice provider’s medication list failed to include the nystatin suspension liquid. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/14/2026 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified (progressive decline in brain function and physical brain mass). The patient resided at an assisted living facility (ALF).Review of the current hospice medication list, printed 06/23/2026, and the ALF current medication list, printed 06/24/2026, showed the following discrepancies:- The hospice provider’s medication list included carvedilol 12.5 milligrams (mg), one tablet orally two times daily for heart rate.- The ALF medication list included carvedilol 6.25 mg, one tablet by mouth two times daily for heart failure.During an interview on 06/26/2026 at 8:00 AM, the administrator designee stated the medications on the hospice medication list and the facility lists should be the same. He/she stated that dosages would be noted during the IDT meetings every two weeks.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the initial bereavement assessment identified the social, spiritual, and cultural factors that may impact the bereaved in four of six records reviewed for bereavement (Records/Patients #3, #4, #5 and #11). This deficient practice has the potential to affect the bereaved of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Scope of Services,” approved 03/24/2021, showed in part that hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment. Review of the provider’s document titled, “Bereavement Assessment,” dated July 2021 showed the following would be included when the clinician was assessing bereavement risk: - Patient and family/caregiver loss issues;- Survivor needs;- Social, spiritual, and cultural factors;- Services to be provided such as counseling, support groups, letters and cards;- Referrals needed; and- Grief risk factors and potential for pathological grief reactions. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of Alzheimer’s disease with early onset (a disease marked by progressive loss of mental capacity). The patient resided at a long-term care facility (LTCF). Review of the hospice initial bereavement assessment (known to the provider as the bereavement risk), dated 08/21/2025, showed the survivor (the bereaved) to be the adult daughter who was not present during the initial interview. The Chaplin noted that he/she would “reach out to provided spiritual support” in both the initial assessment and the assessment dated 04/16/2026. The initial bereavement assessment failed to include the patient’s spouse and/or his/her adult children. Neither assessment showed the bereavement risk of high, moderate or low risk for the bereaved. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/14/2026 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified (decline in mental ability). The patient resided at an assisted living facility (ALF). Review of the hospice initial nursing, social work and Chaplin assessments, dated 04/16/2026, failed to include the bereavement assessment, or to identify the bereaved. The initial assessment does identify that patient #4 has family. The bereavement assessment was not completed and therefore, failed to identify whether the bereaved was at low or moderate risk. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 09/26/2025 with a terminal diagnosis of Alheimer’s disease. The patient resided at his/her home with a spouse. Review of the initial bereavement assessment, dated 09/26/2025, failed to identify community support, financial concerns and living situation concerns. The provider failed to provide a complete bereavement assessment. During an interview on 06/26/2026 at 8:15 AM, the nursing supervisor (NS) stated that families should be assessed during the initial assessment, or within 5 days of admission to hospice if they are not present. He/she stated that the family should be included. The provider failed to ensure the designated bereavement risk staff considered the social, spiritual, and cultural factors (outlined in the provider’s bereavement document/program) when they assessed the bereaved and assigned risk scores to assist in monitoring bereaved families. Findings included: Review of the provider’s policy titled, “Bereavement Assessment,” dated 07/2021, showed in part the following: - The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patient’s death as part of the comprehensive assessment; - On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum, it will include:* Patient and family/caregiver loss issues;* Survivor needs;* Social, spiritual, and cultural factors;* Services to be provided including individual counseling, support groups, and letters and cards;* Referrals to be made; and* Grief risk factors and potential for pathological grief reactions. Review of the provider’s policy titled, “Scope of Services,” approved 03/24/2021, showed in part that hospice bereavement services, provided by qualified staff and volunteers, begin with the initial assessment. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of Alzheimer’s disease with early onset (a disease marked by progressive loss of mental capacity). The patient resided at a long-term care facility (LTCF). Review of the hospice initial bereavement assessment (known to the provider as the bereavement risk), dated 08/21/2025, showed the survivor (the bereaved) to be the adult daughter who was not present during the initial interview. The Chaplin noted that he/she would “reach out to provided spiritual support” in both the initial assessment and the assessment dated 04/16/2026. The initial bereavement assessment failed to include the patient’s spouse and/or his/her adult children. Neither assessment showed the bereavement risk of high, moderate or low risk for the bereaved. RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/14/2026 with a terminal diagnosis of Senile degeneration of the brain, not elsewhere classified (decline in mental ability). The patient resided at an assisted living facility (ALF). Review of the hospice initial nursing, social work and Chaplin assessments, dated 04/16/2026, failed to include the bereavement assessment, or to identify the bereaved. The initial assessment does identify that patient #4 has family. The bereavement assessment was not completed and therefore, failed to identify whether the bereaved was at low or moderate risk. RECORD/PATIENT #5:Review of the clinical record showed that the patient was admitted for hospice services on 04/07/2026 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure. The patient resided in a LTCF. Review of the SN admission visit note, dated 07/26/2026, showed in part the following regarding the bereavement assessment:- The assessment identified the patient’s sister as the bereaved, but failed to include the patient’s spouse;- SN noted the patient lived with his/her spouse and sister prior to being admitted to the LTCF; and- The sister and spouse were not present for the assessment. Review of the chaplain’s evaluation visit summary, dated 04/09/2026, identified in the bereavement assessment, the patient’s sister as the bereaved, but failed to identify the patient’s spouse. The chaplain failed to document contact with any family members for the bereavement assessment. RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 09/26/2025 with a terminal diagnosis of Alheimer’s disease. The patient resided at his/her home with a spouse. Review of the initial bereavement assessment, dated 09/26/2025, failed to identify community support, financial concerns and living situation concerns. The provider failed to provide a complete bereavement assessment. During an interview on 06/26/2026 at 8:15 AM, the nursing supervisor (NS) stated that families should be assessed during the initial assessment, or within 5 days of admission to hospice if they are not present. He/she stated that the family should be included. The provider failed to ensure the designated bereavement risk staff considered the social, spiritual, and cultural factors (outlined in the provider’s bereavement document/program) when they assessed the bereaved and assigned risk scores to assist in monitoring bereaved families.”

“Based on policy review, record review, and interview, the hospice provider failed to ensure the nursing needs of the patients were met in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to adversely affect all patients served by the hospice provider. Findings included: Review of the provider’s policy titled, “Wound Care,” dated 09/2024, showed in part the following:- The admitting registered nurse (RN) will document each wound status including, location and etiology, measurement of length, width, and depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition;- Documentation associated with each identified wound will be completed on each visit; and- At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present. RECORD/PATIENT #5: Review of the clinical record showed that the patient was admitted for hospice services on 04/07/2026 with a terminal diagnosis of hypertensive heart and chronic kidney disease with heart failure. The patient had secondary diagnosis of type 2 diabetes (a chronic disease that affects how the body uses sugar for energy) with foot ulcer (skin injury), non-pressure chronic ulcer of other part of left foot with unspecified severity, pressure ulcer of right hip, stage 2 (a partial thickness loss of the skin), and pressure ulcer of right heal, stage 3 (a full thickness loss of the skin). The patient resided in a long-term care facility. Review of the clinical record showed in part the following:- On 04/07/2026, the RN admission visit note showed the patient had five wounds (right lateral hip, right lateral lower leg, left lateral lower leg, right heel, and left lateral foot), but failed to include documentation of wound appearance and measurements of all wounds;- RN routine visit notes, dated 04/29/2026, 05/20/2026, and 06/09/2026 included documentation of wound appearance and measurements of all wounds; and- RN routine visit notes, dated 04/08/2026, 04/10/2026, 04/15/2026, 04/17/2026, 04/24/2026, 05/06/2026, 05/11/2026, 05/27/2026, 06/03/2026, and 06/17/2026, failed to include documentation of wound appearance and measurements for all wounds. During an interview on 06/26/2026 at 8:15 AM, the administrator designee stated that all wounds should be measured during the initial nursing assessment and at least once a week. test”

“Based on job description review, policy review, record review, and interview, the hospice provider failed to provide medical social services to meet the psychosocial needs in two of five full records reviewed (Records/Patients #1 and #2). This deficient practice has the potential to affect all the patients and families served by the provider. Findings included: Review of the job description for the medical social worker (MSW, known by the provider as social worker with a master’s in social work), dated 02/18/2025, showed in part the following job functions:- Assess the psychosocial status of patients and families/caregivers related to the patient’s terminal illness and environment and communicate findings to the registered nurse and other members of the interdisciplinary group;- Provide assessment in the patient’s identified residence and assistance when this is not safe and another plan is required;- Carry out social evaluations, including family dynamics, caregiver abilities, communication patters, high risks for suicide, neglect or abuse and plan intervention based on evaluation findings;- Counsel patient and family/caregivers as needed in relationship to stress, and other identified coping difficulties; provide crisis intervention when necessary;- Provide information and referral services for organization patients and families/caregivers regarding practical and environmental needs;- Maintain and develop contacts with public and private agencies as resources for patients and personnel;- Participate in the development of the individualized plan of care, involving the patient and family, and attend regularly scheduled IDG meetings, assisting the team in recognizing the effects of the psychosocial stresses on symptoms of the terminal illness; and- Assist physician and other team members in understanding significant social and emotional factors related to health problems and death/dying issues. Review of the provider’s policy titled, “Psychosocial Services,” dated 05/2020, showed in part the following:- The hospice will provide psychosocial services by qualified social workers;- Psychosocial services will include assessing emotional factors related to terminal illness, patient and family/caregiver counseling around issues of death, dying and grief, and financial and community resource referrals;- The social worker will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient. Assessment activities of the MSW will include but not limited to:* The emotional factors related to the terminal illness;* The patient and family/caregiver psychosocial status, potential for risk of suicide and/or abuse neglect;* Family dynamics and communication patterns, obstacles to learning or ability to participate in provision of care, obstacles to compliance with the plan of care;*Patient and family/caregiver response to psychosocial interventions;*Caregiver’s ability to function adequately;* Need for counseling related to risk assessment for pathological grief, suicide and/or abuse or neglect;* Support systems available to reduce stress and facilitate coping with end-of-life care;* Evaluation for long-term care when appropriate and determining the patient’s and family/caregiver’s ability to accept the change in level of care; and*Bereavement needs;- All psychosocial services will be performed at the patient’s place of residence as appropriate;- Psychosocial assessments will be performed on each new hospice admission;- Patient and family/caregiver counseling will be offered to every patient and family/caregiver and, as appropriate, will be provided to the patient and family/caregiver by a social worker or other IDG member;- Information about referrals to additional community support services will be made available to the patient and family/caregiver. The patient and family/caregiver’s ability to access these resources will be assessed; and- Patient and family/caregiver questions and concerns will be promptly addressed and answered. RECORD/PATIENT #1:Review of the clinical record showed that the patient was admitted for hospice services on 02/25/2026 with a terminal diagnosis of vascular dementia (a decline in mental capacity caused by conditions that block or reduce blood flow to the brain, depriving it of essential oxygen and nutrients). The patient resided in an Assisted Living Facility (ALF). Review of the MSW notes, dated 02/26/2026 through 6/18/2026, showed in part the following:- On 02/26/2026, evaluation visit summary, the MSW noted the patient was not alert and oriented and was not responsive to verbal stimuli. The MSW noted he/she placed a phone call to the patient’s spouse and daughter to make them aware of services provided and offer support, left voicemails on each phone and requested to call back if needed;- On 03/24/2026, 04/23/2026, 05/18/2026, and 06/182026, the MSW noted the patient was unresponsive and not alert and oriented. Review of the IDT notes, dated 04/17/2026, 05/01/2026, 05/15/2026, 05/29/2026, and 06/12/2026, showed in part the following:- The MSW goals noted as Identify need for additional supportive services within certification period and engage in therapeutic relationship within certification period;- On 04/27/2026, the MSO noted the patient in unresponsive, MSW continues to provide socialization and supportive presence, and family stated no unmet needs;- On 05/01/2026, 05/29/2026, 06/01/2026, the MSW noted the patient was unresponsive during MSW visit, the MSW will continue to provide pleasant socialization to create comforting presence for patient; and the patient’s family voices coping appropriately;- On 05/15/2026, the MSW noted the patient is unresponsive and does not engage with the MSW, the community caregivers voice no concerns; and- On 06/12/2026, the MSW noted patient unresponsive, will continue to provide socialization and supportive presence to patient, and community nurse stated no concerns. Review of the clinical record showed the MSW failed to perform additional visits or reach out to family members to further assess the psychosocial needs of the patient/family since their initial attempt during evaluation visit on 06/26/2026. RECORD/PATIENT #2:Review of the clinical record showed that the patient was admitted for hospice services on 04/07/2026 with a terminal diagnosis of Parkinsons disease (a neurological disorder that causes unintended or uncontrollable movements or stiffness). The patient resided at home with family. Review of the clinical record showed in part the following:- One medical social work (MSW) narrative note from a phone call 04/09/2026 to schedule an initial visit. The MSW stated that the spouse was unsure if they needed support services at the time and was overwhelmed with all of the other initial visits. The MSW stated they would give them a week or two to adjust being on hospice and would call them back to set up a visit; - The interdisciplinary team (IDT) note, dated 04/17/2026, showed the MSW stated they “will continue to provide patient with services” and “family is grieving appropriately”, but failed to note contact with the patient or family;- The IDT note, dated 05/29/2025, showed the MSW stated the patient had declined MSW services at this time, will continue to follow patient for future support needs, and was working on getting placement options to the spouse. The MSW failed to document contact with the patient or family;- The IDT notes, dated 05/01/2026, 05/15/2026, 06/12/2026, showed the MSW stated the patient has declined services at this time and the MSW will continue to follow the patient for future support needs, but failed to document contact with the patient or family;Review of the skilled nurse (SN) visit notes showed the following potential psychosocial needs of the patient and family:- On 04/17/2026, the SN noted the spouse had questions about a bill from a stay at a facility that the SN could not answer, and spouse stated he/she would reach out to social services;- On 05/27/2026, the SN noted the spouse reported decline the day before and the patient’s mobility is “still not great”. The spouse is exhausted;- On 05/28/2026, the SN noted the husband is having safety concerns because the patient is getting harder to move by himself/herself. The SN reached out to the MSW regarding the situation and to follow up with spouse on possible placement options/resources. - On 5/29/2026, the SN noted MSW to follow up with resources for possible placement in near future; and- On 06/16/2026, the SN noted the patient’s spouse had audible wheezing while trying to clean patient up and acknowledged his/her need to rest. SN insisted the spouse rest while he/she take over during visit Review of the clinical record showed the MSW failed to perform additional phone calls or visits to assess the psychosocial needs of the patient/family since the initial phone call 04/09/2026. During an interview on 06/26/2026 at 8:24 AM, the nursing supervisor (NS, know at the provider as the clinical supervisor) stated that he/she would expect the MSW to call the individuals, more than one time, especially during the decline in condition of the patient.”

“Based on policy review, volunteer tracking information review, and interview, the provider failed to ensure volunteers hours equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This deficient practice has the potential to affect all patients on service with the hospice agency. Findings included: Review of the provider’s policy titled, “Volunteer Services,” dated 01/2023, showed in part, the hospice will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers. The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will meet or exceed 5% of the total patient care hours of paid and contracted hospice personnel. During the survey entrance on 06/22/2026 at 11:00 AM volunteer program information including percent of volunteer hours was requested. Review of all the provided volunteer program documents showed the volunteer hours to be 3.43 percent (%) of the total patient care hours of all paid hospice employees and contract staff. During an interview with the provider’s volunteer coordinator on 06/23/2026 at 1:21 PM, he/she stated that the agency had four current active volunteers. The agency had two volunteers ready to start training. He/she voiced awareness that the goal for volunteer hours was five percent. The volunteer coordinator serves as the volunteer coordinator for provider offices in Virginia, Indiana and Ohio.”

“Based on Missouri law review, policy review, employee file review, and interview, the hospice provider failed to ensure criminal background checks were performed in, but not limited to, one of five employee files reviewed (Employee #4). This deficient practice has the potential to adversely affect services provided to all the hospice’s patients. Review of Section 192.2495.3, RSMo: 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). EMPLOYEE #4:Review of the medical director employee file showed the following:- Date of hire was 01/16/2026; and- EDL check and criminal background check was not completed as of 06/26/2026 (5 months after hire). During an interview on 06/26/2026 at 8:20 AM, the clinical director, stated that human resources had not completed the criminal background check. Review of the provider’s policy titled, “Selection Hiring of Personnel,” dated 12/2024, showed in part the following:- A criminal background check will be obtained for positions, including volunteers, as required by law and regulations; and- In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states in which individual has lived or worked during the past three years.”