Every finding on record at Bonner Community Hospice

Based on a review of the agencys Emergency Plan, and staff interview it was determined the agency failed to develop and maintain an emergency preparedness communication plan that complies with federal, state, and local laws. The plan must include names and contact information for employees, entities providing services under arrangement, patient physicians, volunteers, and other hospice agencies. Failure to have a complete communication plan could result in harm to both patients and staff during an emergency. --- The following deficiencies were identified during the review of the agencys emergency plan: Incomplete Contact Information: The emergency plans communication section did not include names and contact information for all required parties, including: Employees Entities providing services under arrangement Patient physicians Volunteers Other hospice agencies Lack of Procedures: The plan did not outline procedures regarding when and how to contact volunteers and other hospice agencies during an emergency. The Hospice Manager was interviewed on 2/26/25 beginning at 9:45 AM, and the Emergency Preparedness plan was reviewed in her presence. During the interview, the Hospice Manager confirmed the absence of the required contact information, and the missing procedures related to the agencys communication plan. The agency failed to develop and maintain a comprehensive emergency preparedness communication plan that includes all necessary components as required by federal, state, and local laws

Based on a review of the agency's Emergency Plan, and staff interview, it was determined that the agency failed to test its emergency preparedness plan annually. Failure to conduct regular testing of the emergency preparedness plan may result in insufficient knowledge of emergency procedures, potentially jeopardizing the safety of both patients and staff. --- The following details were noted during the review of the agencys emergency plan: Cybersecurity Exercise: The first documented exercise was titled a ";Cybersecurity Exercise," conducted by the local hospital. However, there was no documentation indicating that any staff members from the hospice attended or participated in the exercise. Decontamination Mobil Unit Exercise: The second documented exercise involved testing the local hospitals Decontamination Mobil Unit in the event of an emergency. Similarly, there was no documentation confirming hospice staff participation in this exercise. Data Breach Incident: The third document provided was a one-page Word document detailing an incident in which the hospice manager experienced a data breach. There was no documentation to show that the agencys emergency plan was activated or deactivated, that the communication plan was utilized, that all staff were notified, or that an after-action report was completed. The Hospice Manager was interviewed on 2/26/25, beginning at 9:45 AM, at which time the Emergency Preparedness plan and associated exercises were reviewed in her presence. She confirmed that the hospice did not participate in the first and second documented exercises. Additionally, she acknowledged the lack of required documentation following the actual disaster the agency experienced. The agency failed to conduct annual testing of its emergency preparedness plan.

Based on medical record review and staff interview, it was determined the agency failed to ensure a comprehensive review of patient medications was performed for 1 of 13 patients (Patient #4) whose records were reviewed. This failure had the potential to result in adverse patient outcomes. Findings include: Patient #4 was a 96 year old female with a primary diagnosis of nondisplaced intertrochanteric fracture of left femur. She received SN and MSW services. Her record for the certification period 6/01/21 to 6/21/21 was reviewed. Patient #4's medical record included a medication list which listed Patient #4's known allergies: Hydrocodone, Morphine, and Tramadol. Additionally, her record included a note obtained from Patient #4's history and physical from her doctor. It stated, "She is intolerant to even low doses of opiates, most recent morphine hydrocodone and tramadol have caused side effects." Patient #4's current medication list included: - Morphine concentrate - Take 10 mg by mouth every 1 hours as needed for pain or shortness of breath. - Hydrocodone - Take 1 tablet by mouth every 4 hours as needed for pain. There was no documentation in Patient #4's medical record that her allergy to Morphine or Hydrocodone was reviewed or clarified with her hospice physician. The RN Manager was interviewed 3/16/22 beginning at 9:45 AM and Patient #4's medical record was reviewed in her presence. She stated she believed Patient #4's allergies were listed inaccurately and that it was most likely a clerical error. She confirmed the case manager for Patient #4 should have clarified the allergies with the doctor when she performed her medication review. The agency failed to ensure review of the Patient #4's medications included medication allergies.

Based on review of agency policy, review of CMS memorandum guidelines, review of medical records, and staff interview, it was determined the agency failed to ensure all staff screened patients for signs and symptoms of COVID-19 prior to providing care for 5 of 6 patients (#2, #6, #9, #11, and #13) who received aide services and whose records were reviewed. This created the potential for signs of COVID-19 to go unidentified by aides. Findings include: A CMS memorandum titled "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) by Hospice Agencies," dated 3/09/20, stated, "hospice agencies should be monitoring the health status of patients, residents, visitors, volunteers, and staff under their care setting for signs or symptoms of COVID-19." This guidance was not followed. An agency policy titled "BGH [Bonner General Health] Housewide Laboratory Safety Practices during the COVID-19 Pandemic," approved 8/12/21, stated, "In settings where direct patient care is provided, BGH will ...screen and triage all clients, patients." This policy was not followed. Examples include: 1. Patient #13 was a 63 year old female admitted to the agency on 7/02/21 with a primary diagnosis of breast cancer. She received SN, chaplain, social work, and aide services. Her record from her admission on 7/02/21 to her death on 7/29/21 was reviewed. Patient #13's record included an aide visit on 7/27/21. The record did not include documentation of COVID-19 screening performed by the aide. 2. Patient #6 was a 91 year old female admitted to the agency on 2/16/22 with a primary diagnosis of severe protein calorie malnutrition. An additional diagnosis included dementia. She received SN, social work, and aide services. Her record for the certification period 2/16/22 to 5/17/22 was reviewed. Patient #6's record included, but was not limited to, aide visits on 2/25/22, 3/01/22, 3/04/22, 3/08/22, and 3/11/22. The record did not include documentation of COVID-19 screening performed by the aide. 3. Patient #9 was a 94 year old male admitted to the agency on 1/27/22 with a primary diagnosis of mesothelioma. An additional diagnosis included pleural effusion. He received SN, social work, aide, and volunteer services. His record for the certification period 1/27/22 to 4/26/22 was reviewed. Patient #9's record included, but was not limited to, aide visits on 1/31/22, 2/03/22, 2/07/22, 2/10/22, and 2/14/22. The record did not include documentation of COVID-19 screening performed by the aide. 4. Patient #11 was a 69 year old male admitted to the agency on 4/07/21 with a primary diagnosis of cirrhosis of the liver. He received SN and aide services. His record for the certification period 4/07/21 to 4/22/21 was reviewed. Patient #11's record included, but was not limited to, aide visits on 4/09/21, 4/13/21, 4/16/22, and 4/20/21. The record did not include documentation of COVID-19 screening performed by the aide. 5. Patient #2 was an 84 year old female with a primary diagnosis of protein calorie malnutrition. She received SN, MSW, and aide services. Her record for the cert period of 3/04/22 to current was reviewed. Patient #2's record included, but was not limited to, an aide visit on 3/09/22. The record did not include documentation of COVID-19 screening performed by the aide. The RN Manager was interviewed on 3/16/22 at 9:30 AM and the records of Patients #13, #6, #9, #11, and #2 were reviewed in her presence. She confirmed the aides did not document COVID-19 screening of patients. The RN Manager stated aides were supposed to do COVID-19 screening on all patients. The agency failed to ensure all disciplines performed COVID-19 screening of patients.

Based on observation, CMS SOM review, website review, and staff interview, it was determined the agency failed to notify the State Agency and MAC of a change in location for the hospice agency. This resulted in potential confusion to patients and their representatives as to the agency location which provided patient care and resources. CMS SOM, Chapter 2, Section 2086, stated, "When an existing hospice intends to move from its surveyed, certified location to a new site or location, it notifies CMS either directly or through the SA, and, if deemed, it notifies its approved national accreditation organization (AO), in writing of the proposed change of location. The provider also notifies its MAC and submits all required documentation including an amended Form CMS-855A before CMS approval can be granted. The provider obtains CMS' approval of the new address before it provides Medicare services from the new address." This was not followed. Surveyors attempted to enter the hospice agency at the listed address provided to the State Agency on 3/14/22 at 3:00 PM. The same address was listed on GOOGLE and the hospice agency's website. The address listed was shared with the local hospital. Upon entrance at the listed address, the front desk employee stated the hospice agency was not at that location. She provided a different address approximately 3 miles away. Surveyors entered the provided address on 3/14/22 at 3:15 PM and confirmed the hospice agency was operating out of that location. The RN Manager was interviewed 3/15/22 beginning at 9:20 AM. She stated they had moved to this location approximately 1 year ago during the COVID-19 pandemic and thought the hospital administration had filed an CMS-855A with the change of location to the State Agency. She confirmed the CMS-855A had not been filed with the State Agency. Additionally, she was unsure if the MAC was notified of the change of location as well. The agency failed to inform the State Agency and their MAC of a change in location of the hospice agency.

Based on review of medical records and staff interview, it was determined the agency failed to ensure entries into the clinical record were clear and complete for 1 of 13 patients (Patient #13) whose records were reviewed. This resulted in a medication discrepancy that was not resolved. Findings include: Patient #13 was a 63 year old female admitted to the agency on 7/02/21 with a primary diagnosis of breast cancer. She received SN, chaplain, social work, and aide services. Her record from her admission on 7/02/21 to her death on 7/29/21 was reviewed. Patient #13's clinical record contained a physician order dated 7/16/21. The order stated, "start on 07/16/21 New Medication: Take 5 mg of Olanzapine (5 mg tablet) by mouth 1 x Day as needed ...for 7 days. DO NOT TAKE W/ [with] REGLAN/ METOCLOPERAMIDE. [sic]" Patient #13's record contained a physician order dated 7/16/21. The order stated, "start on 07/16/21 New Medication: Take 5 mg of metoclopramide HCl [hydrochloride] (metoclopramide 5 mg tablet) by mouth every 6 hrs [hours] ...DO NOT COMBINE WITH OLANZAPINE OR COMPAZINE." There was no documentation why the orders were placed on the same day yet stated that olanzapine and metoclopramide were not to be taken together. Both orders contained the same start date of 7/16/21. There was no documentation on what medication should have been taken first, or when Patient #13 should stop one medication and start the other. The RN Manager was interviewed on 3/16/22 at 9:30 AM, and Patient #13's record was reviewed in her presence. She stated she believed the olanzapine was supposed to be taken for 7 days, and then Patient #13 was supposed to start taking the metoclopramide. However, she confirmed with the same start dates of 7/16/21, the documentation was unclear on the order in which to take the medications. She stated all significant medication interactions should have been rectified with the physician. The agency failed to ensure all documentation was clear and complete.