Every finding on record at Central Montana Medical Facilities, Inc.

Based on interview and record review, the agency failed to ensure an initial assessment was completed for 1 (#3 ) of 14 sampled patients within 48 hours after a referral was received. Findings include: --- Review of patient #3's referral form showed a referral date of 8/5/24. Review of patient #3's Hospice Consult showed an initial assessment (consultation) date of 8/26/24. This was 21 days following the referral date.During an interview on 10/23/25 at 12:36 p.m., staff member A stated the agency had staffing issues related to the completion of initial assessments within 48 hours of referral. Staff member A stated the agency could not find an initial assessment document dated within 48 hours of referral for patient #3.Review of an Agency Policy, titled Admission/Discharge And Face To Face (F2F) Criteria, showed ..."1.CMMC hospice will conduct a hospice consultation upon referral from a provider. The hospice social worker and/or a hospice clinician, will meet with the client and/or their family/caregiver/legal designee pending their availability. The purpose of the consultation will be to discuss the hospice philosophy, benefit and differences in curative vs. palliative treatment prior to admission."

Based on observation, interview and record review, the agency failed to ensure staff followed the plan of care for wound care for 1 (#3) of 8 sampled patients. Findings include: --- During an observation on 11/22/22 at 10:00 a.m., staff member E performed wound care to patient #3's left heel. Staff member E prepared all needed supplies and placed them on a clean barrier. Staff member E sanitized her hands and donned clean gloves. Staff member E then removed the dressing from the patient's left heel. Staff member E then removed her gloves and sanitized her hands and donned clean gloves. Staff member E placed ointment on a large band-aid and placed it on the patient's left heel. Staff member E then placed a heel protector over the band-aid. Staff member E did not cleanse the wound according to the plan of care. During an interview on 11/22/22 at 1:45 p.m., staff member A stated annual visits were conducted, with clinicians, to identify any concerns with infection control. Staff member A stated the staff were to complete annual training on infection control. During an interview on 11/22/22 at 3:05 p.m., staff member E stated the wound care orders for patient #3's left heel were to cleanse with normal saline, apply iodosorb, and then place a band-aid or dressing , and then place the heel protector. Staff member E stated there was annual infection control training to complete. Review of patient #3's plan of care, with a certification period of 11/8/22 through 2/5/23, showed orders for wound care to cleanse with normal saline and pat dry, apply iodosorb to the wound bed, skin prep to perimeter, place optifoam or large band-aid and foam heel cup.

Based on interview and record review, the agency failed to collect and analyze data regarding all patient services and activities to identify opportunities to improve services and patient outcomes for the Quality Assurance Performance Improvement Committee. Findings include: --- Review of the agency QAPI meeting minutes, dated 10/13/22, showed the purpose of the QAPI committee was to review data to evaluate its performance. Review of the data used to ensure the agency had a hospice service that provided quality care and outcomes included discharge and timely transfer paperwork; referral dates to start of care dates for patients enrolled in hospice; a hospice compare website; and a performance improvement project regarding advanced directives were "noted as required." During an interview on 11/22/22 at 1:15 p.m., staff member B stated she was new to the Quality Assurance position. She stated she was being trained but could not say whether the data noted above would affect patient care and outcomes. During an interview on 11/22/22 at 1:20 p.m., staff member A stated she was sure the agency had what was required for a successful QAPI, and the information was located in a binder. She could not locate any further information at that time. More information was faxed to the State Agency but did not include data that was patient centered for care and improved outcomes by the hospice agency.

Based on observation, interview and record review, the agency failed to ensure staff followed accepted standards of practice for bag technique when in the patients home, and failed to ensure staff wore gloves when cleaning equipment after patient use for 1 (#3) of 8 sampled patients. Findings include: --- Bag Technique: During an observation on 11/22/22 at 10:00 a.m., staff member E was changing the dressing on patient #3's left heel. Staff member placed her equipment/supply bag directly on the patient's chair without placing a barrier between the bag and the patient's environment. During an interview on 11/22/22 at 3:05 p.m., staff member E stated the bag should be placed on a clean drape. Review of the agency document, titled Bag Technique Demonstrated, showed the bag should be placed on a barrier with no part of the bag touching the home environment. Cleaning Equipment: During an observation on 11/22/22 at 10:00 a.m., staff member E assessed patient #3's vital signs. When staff member E was done with the equipment she placed the equipment on a barrier. Staff member E took a bag of wipes out of her supply bag. Staff member E proceeded to clean the equipment without putting gloves on. During an interview on 11/22/22 at 3:05 p.m., staff member E stated equipment should be cleaned with sanitary disinfecting cloths and she would normally wear gloves to complete the task. Review of an agency document, titled IFC Home Visit Points to remember...and Survey Readiness, showed under #1.b. "When you're ready to clean supplies, use our sani cloths. (with gloves on!!)"