Brighton Hospice Missouri, LLC

“It is required that the hospice Interdisciplinary Group completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group (IDG) completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 7: The patient elected the hospice benefit on 05/17/2025. The initial Social Work Assessment visit was performed on 05/23/2025, six days after the patient’s election of the hospice benefit. A clinical record review revealed no evidence of communication notes or documentation in the first or second Interdisciplinary Group Meetings, dated 05/21/2025 or 06/04/2025, indicating a reason for the visit being conducted after the required five-day timeline. Clinical Record 9: The patient elected the hospice benefit on 05/02/2025. The initial Social Work Assessment visit was performed on 05/09/2025, nine days after the patient’s election of the hospice benefit. A clinical record review revealed no evidence of communication notes or documentation in the first or second Interdisciplinary Group Meetings, dated 05/07/2025 or 05/21/2025, indicating a reason for the visit being conducted after the required five-day timeline. During a joint clinical record review and interview on 06/18/2025, the Senior Director of Clinical Quality confirmed the initial social work assessments were completed late, stating that the previous Social Worker (SW) left the agency abruptly on 05/02/2025 with very short notice, so another Social Worker had to cover all visits, including admissions, until the new Social Worker, who begins on Monday, 06/23/2025, completes orientation.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. For the year 2024, the percentage of volunteer hours was 3.67%. During an interview and joint review of the QAPI Performance Improvement Projects (PIPs), and volunteer recruitment and retention activities on 06/18/2025, the Administrator and the Senior Director of Clinical Quality confirmed the volunteer hour percentage for 2024 was 3.67%. During a review of the annual volunteer percentage hours for the year 2024, the QAPI Performance Improvement Projects (PIPs), and volunteer recruitment and retention activities - along with interviews with the Volunteer Coordinator (Personnel Record 4), Administrator (Personnel Record 2), and the Senior Director of Clinical Quality on 06/18/2024, it was revealed and confirmed the volunteer hour percentage from 2024 was 3.67%. A volunteer QAPI PIP was identified and initiated on 05/29/2024 for a less than 5% volunteer percentage. The QAPI PIP and percentages have been reviewed quarterly beginning September 2024 through April 2025, with documented initiatives to recruit new volunteers through Social Work internship programs, local senior centers/activities, and word of mouth. The Volunteer Coordinator was hired on 04/30/2024 but did not assume the Volunteer Coordinator role until 05/14/2025, as this was a small program with an active census of only 24 patients at the time of the site visit. The Volunteer Coordinator was brought in to assume the duties and provide more focused attention to the volunteer program due to the agency’s struggle with a low volunteer percentage. The retention activities recorded included face-to-face encounters and phone calls, as the new Volunteer Coordinator made a point to introduce himself and get to know the current volunteers.”

“Based on policy review, clinical record review, and interview the hospice provider failed to forward to the receiving facility, a copy of the hospice discharge summary in one of three records reviewed (Record/Patient #2). This deficient practice has to potential to affect all discharged patients served by the provider. Findings included: Review of the providers policy titled, “;Transfer of a Hospice Patient to Another Agency,” dated 10/25/2021, showed in part, the following: - Continuity of care is maintained when a hospice patient is transferred to another treatment setting or provider; and - If the care of a hospice patient is transferred to a Medicare/Medicaid-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to hospice on 07/02/2024, with a terminal diagnosis of senile degeneration of the brain. He/she lived at home in a long-term care facility (LTCF). On 08/26/2024, the patients family wanted the patient sent to the hospital to seek aggressive treatment. The hospice failed to send a discharge summary to the receiving facility (hospital). During an interview on 08/09/2024 at 2:43 PM, the administrator assistant stated that he/she had sent the discharge summary to the patients physician at the LTCF and not to the receiving facility. If the patient resided in a LTCF they send the discharge summary to the patient’s primary physician and not the receiving facility.”

“Based on policy review, record review, and interview, the hospice provider failed to document a transfer summary that included a summary of the patient’s stay including treatments, symptoms, and pain management, current plan of care, and latest physician orders in two of three records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the providers policy titled, “;Discharge for reasons other than death,” dated 12/01/2021, showed in part, the following: - This discharge summary is filed in the clinical record and includes: * A summary of the patients stay including treatment, symptoms, and pain management * The patients current plan of care * The patients latest physician orders; and * Ay other documentation that will assist in post-discharge continuity of care. RECORD/PATIENT #1:Review of a discharge summary dated 08/08/2024, showed the patient was a live discharge (when a patient leaves hospice care before they die), he/she “;moved out of the service area” to pursue treatment at a medical center for nausea, vomiting, and diarrhea for three days. Review of the discharge summary that was sent to the receiving facility failed to show a summary of the patient’s stay including treatments, symptoms, and pain management, the patients current plan of care, and the latest physician orders. RECORD/PATIENT #3:Review of a discharge summary dated 07/05/2024, showed the patient was a live discharge under the primary terminal diagnosis of psychomotor deficit following a cerebral vascular accident (stroke) due to extended prognosis/no longer terminally ill. Review of the discharge summary failed to show a summary of the patient’s stay including treatments, symptoms, and pain management, the patients current plan of care, and the latest physician orders. During an interview on 08/09/2024 at 2:43 PM, the administrator assistant stated that they he/she was responsible to send the discharge summary once the patient was discharged. The diagnosis, medication list and visit frequency were sent to the physician or receiving facility. The discharge summary did not include treatment, symptoms, and pain management, current plan of care, and the latest physician orders. During an interview on 09/10/2024 at 12:22 PM, the director of nursing stated that he/she reviewed the discharge summary coordination notes for the physician and interdisciplinary group notification.”