Preferred Hospice of Missouri (Southwest), LLC

“Based on policy review, the provider’s bereavement protocol review, record review, and interview, the bereavement assessment failed to assess social, spiritual, and cultural factors that may impact the bereaved in three of six records reviewed for bereavement (Records/Patients #3, #4, and #11) and the hospice provider failed to incorporate the needs of the bereaved in the bereavement plan of care in one of six records reviewed for bereavement (Record/Patient #11). This deficient practice has the potential to affect all the patients served by the provider.Findings included:Review of the provider’s undated policy titled, “Death, Discharge or Revocation of the Hospice Patient,” showed, in part, the interdisciplinary team (group) would implement the following:- Discuss and assess family member(s) who may need bereavement care;- The bereavement assessment completed by the bereavement coordinator and updated as necessary; and- Complete a bereavement plan of care in the patient’s electronic medical record.Review of the provider’s bereavement protocol, approved 01/2021, showed, in part, the following:- The basic framework for bereavement interventions (are) based on the risk assessment;- All services provided should be tailored to the specific needs of each bereaved person; and- For Moderate risk increase calls and visits in the first three months.The provider failed to provide evidence that the bereavement assessment considered factors related to bereavement other than identified feelings and the expression of those feelings. RECORD/PATIENT #3:Review of the clinical record showed the patient was admitted to hospice services on 08/05/2025 with a terminal diagnosis of acute congestive heart failure (a decrease in the ability of the heart to pump blood). The patient resided at a long term care facility (LTCF). Review of the initial bereavement assessment (known to the provider as the pre-bereavement assessment) dated 08/05/2025, showed the bereaved survivor at low risk. The initial bereavement assessment failed to identify the name of the bereaved survivor.RECORD/PATIENT #4:Review of the clinical record showed the patient was admitted to hospice services on 04/25/2025 with a terminal diagnosis of sarcopenia (loss of muscle mass and strength) and dementia (decline in mental capacity). The patient resided at a LTCF. Review of the initial bereavement assessment dated 04/28/2025, showed the bereaved survivor at low risk. The initial bereavement assessment failed to identify the name of the bereaved survivor.RECORD/PATIENT #11:Review of the clinical record showed the patient was admitted to hospice services on 01/26/2025 with a terminal diagnosis of sarcopenia and dementia. The patient resided at a LTCF and his/her spouse visited regularly.Review of the social worker’s initial assessment dated 01/27/2025 showed the patient lived at a LTCF, his/her spouse visited regularly through the week, the spouse came in the morning, and stayed through lunch.Review of the initial bereavement assessment dated 01/27/2025, showed the assessment was completed on the patient’s adult child with a low risk assessment. The provider failed to complete an initial bereavement assessment for the spouse.Review of the clinical record showed the patient’s date of death was 03/04/2025.Review of the chaplain note dated 03/04/2025, showed the following:- The patient’s spouse accepted bereavement services;- There was no funeral; and- The bereavement coordinator (BC) would follow-up according to the care plan.Review of the bereavement care plan dated 03/05/2025, showed the following:- Medium risk; and- Bereaved requested extra visits.Review of the post bereavement assessment (known to the provider as the initial bereavement assessment) dated 03/19/2025, showed the following:- Low risk;- The spouse indicated that he/she would like more visits;- The spouse’s adult son (who lived out of state) would like his/her parent to have more visits;- The spouse appeared to be grieving appropriately;- The spouse wanted to receive bereavement services; and- The BC planned to make more visits.The bereavement care plan interventions showed the BC failed to:- Provide a visit to the bereaved spouse in April; and- Include plans for bereavement services for September and October.During an interview on 09/16/2025 at 11:00 AM, the social worker with a bachelor’s degree (BSW) stated that he/she did not use a set of questions to complete the bereavement assessments. The BSW stated that the risk level was determined by conversations and interactions with the family members. The BSW rated the person as low if he/she was accepting, understood the dying process, and knew what to expect during the dying process. The BSW rated the person as medium, if during the conversation, there were tons and tons of tears and the high risk would be indicated by more intense emotions. He/She stated that the primary contact was considered the bereaved and other family members would not be assessed.During an interview on 09/17/2025 at 9:45 AM, the social worker with a master’s degree (MSW) stated that he/she oversaw the pre-bereavement assessment performed by the BSW and MSW staff. The MSW stated that this assessment was subjective and was based on interview(s) of the patient, caretaker(s), and family members of the hospice patient. The MSW stated that there was no formal objective assessment tool to assess risk levels of grief/ bereavement.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that they had a bereavement assessment tool that asked questions and then generated a risk assessment score. He/She stated that they would implement the tool again to guide the team in determining a risk level for the bereaved.During an interview on 09/17/025 at 12:30 PM, the BC stated that, since he/she contacted the bereaved spouse at the end of March, he/she did not provide services in April. Since the spouse was getting better, then the visits would be less. The spouse wanted frequent visits. The primary focus of the visits was socialization, and that socialization would fall under bereavement services. Monthly visits would be beneficial to the bereaved spouse, but they would usually wait until it was time for the next letter. If the bereaved were low risk, they would not get as many visits as this bereaved had received. For moderate risk, extra visits would be one time per month and for low risk the extra visits would be about the same at one time per month.”

“Based on policy review, record review, home visit observation, and interview, the hospice provider failed to ensure the plan of care (POC) contained individualized goals with measurable outcomes in three of five full records reviewed (Records/Patients #1, #2, and #5). This deficient practice has the potential to affect all the patients served by the provider. Review of the provider’s policy titled, “Registered Nurse (RN) Coordination of Care,” dated 08/13/2025, showed in part the following:- A RN is responsible for the coordination of all hospice services; and- Documentation of problems and appropriate goals and interventions. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of cardiovascular disease (CVD - a group of conditions which affects the heart and blood vessels). The patient resided in a skilled nursing facility with total care. Review of the updated plans of care/IDG note, dated 09/15/2025, showed the patient had the following goals:- Patient to report a decrease in shortness of breath, with the intervention to encourage optimal activity with frequent rest periods. The goal failed to define, “optimal”;- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- Patient will have adequate urine output as disease process allows. The goal failed to define, “adequate”;- 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 #5:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses which included hypertension (high blood pressure), acute renal failure (a condition in which the kidneys fail to effectively remove waste products from the body), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a skilled nursing facility with total care. Review of the plans of care/IDG Comprehensive Assessment Details, dated 08/19/2025, showed the patient had the following goals:- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- 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 09/17/2025 At 11:45 AM, the administrator and director of operations stated they were aware of the issue of the POCs not being individualized with measurable goals for the referenced patients and were in the process of correcting the problem prior to the survey. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer, and additional diagnoses of restrictive lung disease (a group of conditions that limit the lungs’ ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the form titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 09/10/2025, showed in part:- Patient does have orthopnea (difficulty breathing when lying flat); - Continues to use PRN (as needed) oxygen at 2-5 liters; and- The current medication section showed the oxygen was ordered at 2-4 liters PRN for comfort use.Review of the POC dated 09/15/2025 showed the following:- An order for oxygen 2-4 liters PRN for comfort;- An order for morphine sulfate (an opioid medication used to treat pain or shortness of breath) 0.5 ml every 30 minutes as needed for discomfort, dyspnea (difficulty breathing), and pain; and - The POC failed to contain a respiratory care plan with individualized goals and interventions related to the patient’s respiratory diagnoses and symptoms.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters. During an interview on 09/17/2025 at 11:45 AM, the hospice administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters. Findings included:Review of the provider’s policy titled, “Registered Nurse (RN) Coordination of Care,” dated 08/13/2025, showed, in part, the RN had the following responsibilities: - The coordination of all hospice services; and- Documentation of problems and appropriate goals and interventions. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs’ ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 09/10/2025, showed in part:- “Patient does have orthopnea (difficulty breathing when lying flat)”; - “Continues to use PRN (as needed) oxygen at 2-5 (two-five) liters”; and- The current medication section showed the oxygen was ordered at 2-4 (four) liters PRN for comfort use.Review of the POC dated 09/15/2025 showed the following:- An order for oxygen 2-4 liters PRN for comfort;- An order for morphine sulfate (an opioid medication used to treat pain or shortness of breath) 0.5 ml every 30 minutes as needed for discomfort, dyspnea (difficulty breathing), and pain; and - The POC failed to contain a respiratory care plan with individualized goals and interventions related to the patient’s respiratory diagnoses and symptoms.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters. During an interview on 09/17/2025 at 11:45 AM, the hospice administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters. RECORD/PATIENT #2:Review of the clinical record showed the patient was admitted to hospice services on 06/02/2025 with a terminal diagnosis of cardiovascular disease (CVD - a group of conditions which affects the heart and blood vessels). The patient resided in a skilled nursing facility with total care. Review of the updated plans of care/IDG note, dated 09/15/2025, showed the patient had the following goals:- Patient to report a decrease in shortness of breath, with the intervention to encourage optimal activity with frequent rest periods. The goal failed to define, “optimal”;- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- Patient will have adequate urine output as disease process allows. The goal failed to define, “adequate”;- 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 #5:Review of the clinical record showed the patient was admitted to hospice services on 08/19/2025 with a terminal diagnosis of dementia (decline in mental capacity). The patient had secondary diagnoses which included hypertension (high blood pressure), acute renal failure (a condition in which the kidneys fail to effectively remove waste products from the body), and diabetes (a chronic disease that affects how the body uses sugar for energy). The patient resided in a skilled nursing facility with total care. Review of the plans of care/IDG Comprehensive Assessment Details, dated 08/19/2025, showed the patient had the following goals:- Patient will have needs met and will have good hygiene. The goal failed to define, “good”;- 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 09/17/2025 At 11:45 AM, the administrator and director of operations stated that they were aware of the issue of the POCs not being individualized with measurable goals for the referenced patients and were in the process of correcting the problem prior to the survey.”

“Based on policy review, record review, home visit observation, and interview, the provider failed to ensure staff provided services as ordered in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all the patients served by the provider. Findings included:Review of the provider’s policy titled, “Nursing Services,” dated 08/13/2025, showed nursing services are provided in accordance with standard nursing practice and the interdisciplinary team plan of care. RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs’ ability to expand and take in air, resulting in difficulty breathing), and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document titled, “IDG (Interdisciplinary Group) Comprehensive Assessment Details,” dated 09/10/2025, showed in part:- (Patient) “Continues to use PRN (as needed) oxygen at 2-5 (two-five) liters”; and- The current medication section showed the oxygen was ordered at 2-4 (four) liters PRN for comfort use.Review of a skilled nurse visit note, dated 09/11/2025, showed in the narrative section; (patient) “continues PRN oxygen at 2-5 liters for comfort”.Review of the plan of care (POC), dated 09/15/2025, showed an order for oxygen 2-4 liters PRN for comfort. The POC failed to contain an order for oxygen at the rate the patient was using.Observation on 09/16/2025 showed the patient was sitting in his/her recliner wearing a nasal cannula (a tube that facilitates oxygen delivery via the nostrils) that was connected to an oxygen concentrator, and the flow rate was set at 4.5 liters.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that he/she would expect the patient to have a respiratory care plan with goals and would expect a new oxygen order if the patient is using 4.5-5 liters.”

“Based on policy review, record review, and interview, the hospice aide failed to follow the aide care plan in one of five reviewed records of patients receiving aide services (Record/Patient #1). This deficient practice has the potential to affect all the patients receiving hospice aide services. Findings included:Review of the provider’s policy titled, “Hospice Home Health Aide,” dated 08/13/2025, showed the home health (and/or hospice) aide will follow an individualized assignment for each patient provided in the plan of care.RECORD/PATIENT #1:Review of the clinical record showed the patient was admitted to hospice services on 07/25/2025 with a terminal diagnosis of breast cancer, and secondary diagnoses of restrictive lung disease (a group of conditions that limit the lungs’ ability to expand and take in air, resulting in difficulty breathing) and multiple lung nodules. The patient resided at home with a spouse caregiver.Review of the document that reflected the aide tasks, last reviewed by the registered nurse on 09/12/2025 showed the aide was assigned the following tasks:- Weigh weekly;- Document date of last BM (bowel movement);- Document output; and- Personal care (PC) items and homemaker chore items were also assigned (the patient was independent and refused personal care at this time). Review of seven aide visit notes with a date range of 08/19/2025 through 09/12/2025 showed the aide failed to document/obtain a weight weekly for five of the seven visits provided and failed to document the date of the last BM or output in all seven visits.During an interview on 09/16/2025 at 8:05 AM, the administrator stated that he/she would prefer for the aide care plan to include PC items in case the patient allows the care. If the patient was in a facility, he/she would expect the aide care plan to be updated sooner. The expectation is that the aide keeps the case manager updated.During an interview on 09/17/2025 at 11:45 AM, the administrator stated that he/she would expect the aide to obtain weights and ask about BM’s and other items each visit.”