Every finding on record at Baraga County Memorial Hospital

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record for HosRRNHV#2, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Administrator of Homecare and Hospice.

Observed in Record Review. In 1 of 2 bereavement records reviewed it was noted the organization had not developed a bereavement plan of care as required. For example, a review of HosRRBR#2 revealed no documented evidence that a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Competency Session. In 1 of 1 applicable Human Resource files reviewed, it was noted that the organization did not ensure that the provision of orientation and training consistent with hospice industry standards was completed for Volunteer #1. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Data Session. During the Data Session, it was noted that the organization did not complete a Volunteer Cost Savings report for the years 2023 and 2024. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Data Session. During the Data Session, it was noted that the organization did not completed a Volunteer Cost Savings report for the years 2023 and 2024. Since a cost savings report was not completed as required the organization did not document the provision of volunteer services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Record Review. There is no evidence that leadership and the governing body had consistently implemented requirements related to the provision of Medical Director responsibilities as evidenced by, inconsistent completion of the initial certification of terminal illness process and recertification of terminal illness process - 418.102-Medical Director. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Competency Session. In 1 of 4 applicable Human Resource files reviewed the organization did not ensure that an initial orientation for the Chaplain that addressed the employee's specific job duties was completed. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Competency Session. In 2 of 3 applicable Human Resource (HR) files reviewed, it was noted that competence for the Chaplain was last updated in 2022, and competence for the Social Worker was last updated in 2021. This observation was reviewed with agency leadership. Observed in Competency Session. In 3 of 5 Human Resource (HR) files reviewed, it was noted that competence was not initially assessed and documented as a part of orientation for the Chaplain, Registered Nurse #1, and Volunteer #1. This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the medical record for HosRRHV#2, revealed that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition].Example #2: A review of the medical record for HosRRNHV#1, it was noted that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition].Example #3: A review of the medical record for HosRRNHV#2, revealed that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #1 was completed. The Certifying Physician Summary did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This area of the document was left blank. This observation was reviewed with the Administrator of Home Care and Hospice. Observed in Record Review. Example #4: A review of the medical record for HosRRNHV#4, revealed that the Certification of Terminal Illness statement for benefit period #1, did not document clinical information to support the medical prognosis and support for certification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This area of the document was left blank. This observation was reviewed with the Director of Home Care and Hospice.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization did not ensure its policy titled Certification of Terminal Illness was implemented. For example, a review of the medical record for HosRRHV#2, it was noted that there was no documented evidence that Certification of Terminal Illness statement(s) for benefit period #2, and benefit period #3 were completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for recertification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. Example #2: A review of the medical record for HosRRNHV#1, it was noted that there was no documented evidence that a Certification of Terminal Illness statement for benefit period #2 was completed. In addition, the Physician’s physical exam statement did not document clinical information to support the medical prognosis and support for recertification of hospice services [The primary terminal condition, related diagnosis, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of the patient’s conditions unrelated to the terminal condition]. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Individual Tracer. In 2 of 2 individual tracers, it was noted that the organization did not ensure the medication list included accurate information. For example, individual tracer activities for HOSRRHV#2, revealed that the plan of care did not include an accurate description of the medication’s the patient was currently taking. The following medications were not listed: Brimonidine Tartrate 0.2% 1 drop in each eye daily and Benadryl 25 mg/1-2 tablets by mouth every 6 hours as needed for itching. The plan of care listed: Protonix 40 mg delayed release by mouth 1 tablet twice a day. An interview with the patient's caregiver revealed the patient is currently taking Protonix 40 mg by mouth once a day. This observation was reviewed with the Director of Home Care and Hospice services. Observed in Individual Tracer. Example #2: Individual tracer activities for HosRRHV#1, revealed that plan of care did not include an accurate description of the medication’s the patient was currently taking. The following medication was not listed: Carafate 10ml by mouth up to 3 times per day as needed. During interview the patient's daughter stated this medication was started 1 month ago. This observation was reviewed with the Administrator of Home Care and Hospice.

Observed in Document Review. During review of the emergency plan and discussion with agency leaders, the surveyor determined that the organization had not identified in writing the potential emergencies that could affect its ability to provide services for Home Health or Hospice, and the likely consequences of those emergencies. A Hazard Vulnerability Assessment (HVA) had been completed for the hospital, however, the HVA was not specific to Home Care, Home Health or Hospice..

Observed in Record Review. In 3 of 12 patient records reviewed, the surveyor observed that the organization did not document: - Anticipated discharge needs, including bereavement and funeral needs - Survivor risk factors, such as the nature of the relationship with the patient, circumstances surrounding the death, behaviors before and after the death, availability of coping mechanisms, and potential for pathological grief reactions. Observed in RR#7 and RR#9, there was no documented bereavement assessment by the RN or the MSW. Observed in Record Review. Example #2: A review of the medical record for HosRR#2, revealed that an initial bereavement risk assessment was not completed.

Observed in Record Review. A review of 7 of 12, patient records reviewed revealed that the organization did not ensure that the comprehensive assessment update included all required information. During record review #6, the surveyor observed that there was no documentation of the IDG meeting or discussion with the team regarding the patient's initial assessment or death. Observed in Record Review. Example#3: A review of the medical record(s) for HosHV#1, HosHV#2, HosHV#3, and HosRR#3, HosRR#4, revealed no documented evidence that the provision of hospice care review included a description of the patient’s response to care, treatment, and services every 15 days. In addition, the comprehensive assessment update did not include information about the patient’s progress toward desired outcomes and goals of care, treatment, and services every 15 days. This observation was reviewed with Quality Management Coordinator. Observed in Record Review. Example #2: During record review #7, the surveyor observed that there was no documentation of discussion of care during IDG for the initial, ongoing assessments or at time of death.

Observed in Record Review. In 3 of 12 patient records reviewed, it was noted that the organization did not ensure that the plan of care goals included specific assessed needs and outcome measures for specific care activities. For example, during a review of the medical record for HosHV#2, it was noted that the care plan included the following goal statement, “Patient’s will maintain a pain score of ______ or less, per patient/family preference, on a scale of 0-10”. The goal statement did not include the specific patient pain goal and a method to measure the effectiveness of problem interventions. Example #2: A review of the initial comprehensive for HosHV#1, and HosRR#6, revealed that pain was identified as an active problem. The plan of care did not include a goal statement, and patient care interventions related to pain. This observation was reviewed with the Quality Management Coordinator.

Observed in Data Session. The governing body did not ensure that its QAPI program maintained documentation of its operation. For example, a review of QAPI information revealed no documented evidence that QAPI indicator data was collected for the 2nd, 3rd, and 4th quarter of 2022. This observation was reviewed with the Quality Management Coordinator. Observed in Data Session. The governing body did not ensure that its QAPI plan design included quality indicator data from all services provided by the organization. For example, the QAPI plan did not include goals and measurable indicators to track the performance of hospice services [i.e. after hours care/support, volunteer services, pharmacy, supplies, durable medical equipment], and business operations. This observation was reviewed with the Quality Management Coordinator.

Observed in Data Session. Since QAPI indicator data was not collected for the 2nd, 3rd, and 4th quarter of 2022; the governing body did not ensure that performance improvement projects related to improved palliative outcomes and palliative services was completed. This observation was reviewed with the Quality Management Coordinator.

Observed in Data Session. Since the organization did not identify risks for acquiring and spreading infections for 2022; the organization did not establish written infection prevention and control goals addressing its prioritized risks. This observation was reviewed with the Quality Management Coordinator. Observed in Data Session. Since the organization did not identify risks for acquiring and spreading infections for 2022; the organization did not establish written infection prevention and control goals limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This observation was reviewed with the Quality Management Coordinator. Observed in Data Session. Since the organization did not identify risks for acquiring and spreading infections for 2022; the organization did not establish written infection prevention and control goals limiting unprotected exposure to pathogens. This observation was reviewed with the Quality Management Coordinator. Observed in Data Session. Since the organization did not identify risks for acquiring and spreading infections for 2022; the organization did not establish written infection prevention and control goals limiting the spread of infections associated with procedures. This observation was reviewed with the Quality Management Coordinator.

Observed in Record Review. Example #2: A review of the medical record for HosRR#4, revealed no documented evidence that a registered nurse supervision visit of hospice aide services was completed every 14 days. Observed in Record Review. In 2 of 7 patient records reviewed, for patients receiving hospice aide services, the surveyor observed that there was no documented aide supervisory visit every 14 days. During RR#9, there was no documented RN Supervisory note for patient receiving Aide services twice a week.

Observed in Data Session. The governing body/leadership did not ensure that the following Condition of Participation was met as determined through observations, documentation, and staff interviews: - §418.58, 418.60, and 418.100

Observed in Record Review. In 1 of 12 patient records reviewed, the surveyor observed that all entries were not dated. Observed in RR#6, the Election of Hospice Benefit was signed by the caregiver but not dated.