Every finding on record at Compassus Bsmh St. Francis Hospice, LLC

It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 5 of 23 (22%) clinical records reviewed, the agency did not ensure that the plan of care included goals and interventions based on problems identified in the patient's comprehensive assessment. Clinical Record 3: The patient elected the hospice benefit on 01/17/2025 with the diagnoses of acute and chronic respiratory failure. In the initial Registered Nurse (RN) assessment dated 01/17/2025, the RN documented that the patient reported severe back pain. The patient’s medications included hydrocodone and tramadol. The plan of care documented the patient intervention, “SN-monitor pain level using appropriate pain scale.” On 02/12/2025, the patient reported "9/10" pain; on 03/17/2025, the patient reported "8/10" pain. In the initial and updated plans of care dated 01/17/2025, 02/19/2025, 03/05/2025, and 03/19/2025, there were no documented goals for pain. During a joint record review and interview on 0318/2025, the Administrator confirmed that no goals were documented for the patient’s pain. Clinical Record 5: The patient elected the hospice benefit on 02/17/2025 with a diagnosis of Parkinson’s Disease with a documented associated diagnosis of dysphagia. In the RN’s initial assessment dated 02/17/2025, the RN documented, “patient has swallowing difficulties and poor intake. Recommended thickened liquids and meds given in applesauce.” The plan of care did not include documentation of an intervention or goal based on the patient’s problem with dysphagia. During a joint record review and interview on 03/19/2025, the Administrator confirmed no goals or interventions were documented for the patient's identified problem of dysphasia. Clinical Record 7: The patient elected the hospice benefit on 01/31/2025 with a diagnosis of malignant neoplasm of the brain. The patient resided in an assisted living facility (ALF). On 02/13/2025, the patient was transferred from the inpatient unit (IPU) to an assisted living facility (ALF). The RN “tuck-in” visit note dated 02/13/2025 documented, “Wound to sacrum area assessed with facility wound nurse; facility nurse to apply dressing every day and prn.” The RN documented assessing the sacral wound on 02/20/2025 and 03/06/2025. The plan of care did not include documentation of a goal addressing the patient’s sacral wound. During a joint record review and interview on 03/19/2025, the Administrator confirmed no goals were documented to address the sacral wound. Clinical Record 9: The patient elected the hospice benefit on 03/01/2025 with a diagnosis of respiratory failure with hypoxia. On 03/01/2025, the RN’s initial assessment documented “esophageal stricture, drinks 1-2 cups of coffee a day with difficulty swallowing and increasing secretions. Patient admits that he is no longer taking his po medications due to difficulty swallowing.” The plan of care did not include documentation of interventions or goals based on the patient’s difficulty swallowing. During a joint record review and interview on 03/19/2025, the Administrator confirmed that no goals or interventions were documented for the patient’s difficulty swallowing. Clinical Record 11: The patient elected the hospice benefit on 02/24/2025 with a diagnosis of chronic combined systolic and diastolic heart failure. On 02/24/2025, the RN documented the patient’s back pain as "1/10;" on 02/25/2025, "5/10;" and on 03/04/2025, "back and hip 5/10." On 02/24/2025, the patient started taking “Tramadol 50mg q4hrs prn.” On 03/04/2025, the patient started taking “Dilaudid 1mg/ml oral liquid q2hrs prn.” The plan of care did not include documentation of goals for pain. During a joint record review and interview on 03/20/2025, the Administrator confirmed that no goals were documented for the patient’s pain.

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice's governing body failed to ensure the hospice's EPP was reviewed and updated bi-annually. The findings include: Review of the hospice's EPP on 3/3/2022 at 1:00 PM revealed the hospice had no documentation of a bi-annual review of the hospice's EPP by the hospice's governing body. During an interview with Registered Nurse (RN) #6 and RN #7 on 3/3/2022 at 1:37 PM, RN #7 reported "We don't have that spelled out in the governing body minutes."

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice's governing body failed to ensure its EPP Communication Plan was reviewed and/or updated bi-annually. The finding includes: Review of the hospice's EPP on 3/3/2022 at 1:00 PM revealed the hospice had no documentation of a bi-annual review and/or revision of the hospice's EPP by the hospice's governing body. During an interview with Registered Nurse (RN) #6 and RN #7 on 3/3/2022 at 1:37 PM, RN #7 reported "We don't have that spelled out in the governing body minutes."

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the governing body failed to ensure documentation that the governing body reviewed and updated the hospice's EPP Training and Testing Plan bi-annually. The finding included: Review of the hospice's EPP on 3/3/2022 at 1:00 PM revealed the hospice had no documentation of the bi-annual oversite by the hospice governing body to ensure the hospice's EPP Training and Testing Plan was reviewed and/or updated bi - annually. During an interview with Registered Nurse (RN) #6 and RN #7 on 3/3/2022 at 1:37 PM, RN #7 reported "We don't have that spelled out in the governing body minutes."

Based on observations and interview, 1 of 2 Registered Nurses (RN) and 1 of 1 Certified Nurse Aides (CNA) observed failed to use accepted standards of safety for 2 of 3 patients (Patient #11 and Patient #12) in the provision of the patient's care. (RN #5 and CNA #1) The findings are: Patient #11 Observations during a visit to Patient #11's home with RN #5 on 2/28/2022 from 12:55 PM to 2:00 PM revealed RN #5 left the patient's bed twice with the bed in a moderate height position and the bed's side rails in the down position. On 3/1/2022 at 8:45 AM, RN #5 was informed of the finding. Patient #12 Observation during a visit to Patient #12's home with CNA #1 on 2/28/2022 from 3:00 PM to 3:34 PM revealed CNA #1 left the patient's bed 3 times with the bed in the high position and the bed's side rails in the down position. CNA #1 verified the finding.

Based on observations and interview, 2 of 2 Registered Nurses (RN) and 1 of 1 Certified Nurse Assistant (CNA) observed in the provision of care did not follow accepted principles of infection control to prevent the potential cross transference of infectious agents in the home care setting. (RN #4, RN #5, and CNA #1) The findings include: Patient #10 Observations in Patient #10's home (facility) visit on 2/28/2022 between 11:50 AM and 12:24 PM with RN #4 revealed RN #4 kneeled at the patient's chairside without placing a barrier on the floor. RN #4 placed a bottle of hand sanitizer on the nurse station counter without placing a barrier beneath the hand sanitizer. RN #4 reached into his/her uniform pocket without donning gloves and retrieved a bottle of hand sanitizer. RN #4 used the hand sanitizer three times during the provision of patient care, and then replaced the bottle of hand sanitizer into his/her pocket with a bare hand. During an interview on 3/1/2022 at 8:45 AM, the information was reviewed with RN #1 who reported "Should have left the sanitizer bottle out with a barrier." Patient #11 Observations in Patient #11's home(facility) visit on 2/28/2022 between 12:55 PM and 2:00 PM with RN #5 revealed RN #5 reached into his/her uniform pocket to retrieve a bottle of hand sanitizer and a pen with his/her bare hand. During the provision of the patient's care, RN #5 used the bottle of hand sanitizer twice to clean his/her soiled hands, and then, replaced the bottle of hand sanitizer with his/her bare hands into his/her pocket. The pen was not cleaned after use. RN #5 leaned against the patient's bed side rail without using a barrier, placed the stethoscope used to assess the patient's heart and lungs back around his/her neck without cleaning the stethoscope. RN #5 touched his/her goggles, uniform, and hair without performing hand hygiene afterwards. RN #5 did not wear gloves when touching the patient's brief and bed linen. During an interview on 3/1/2022 at 8:45 AM, the information was discussed with RN #1 who reported "(He/She) ran out of gloves at the end." Patient #12 Observations during a home visit with Patient #12 on 2/28/2022 from 3:00 PM to 3:34 PM with CNA #1 revealed CNA #1 reached into his/her uniform pocket and retrieved a bottle of hand sanitizer with bare hands. CNA #1 used the hand sanitizer to clean his/her soiled hands three times and and then, replaced the bottle of hand sanitizer back into his/her pocket with bare hands. During an interview on 3/1/2022 at 8:35 AM, RN #2 was informed of the finding and said "We need to educate."

Based on review of patient charts and interview, the Registered Nurse (RN) failed to identify the patient's need for wound measurements in the patient's comprehensive assessment for 2 of 3 patients requiring wound care. (Patient #8 and #11) The findings include: Patient #8 On 3/1/2022 at 1:25 PM review of Patient #8's chart revealed the patient was admitted on 12/17/2021 with skin tears on the right and left upper extremities. Wound measurements were not documented weekly during the Skilled Nurse (SN) visit for the week of 12/26/2021. On 3/2/2022 at 10:30 AM, RN #1 verified the wound policy regarding weekly wound measurements and verified the finding. Patient #11 On 3/1/2022 at 2:36 PM, review of Patient 11's chart revealed the patient had Stage 3 pressure ulcer of sacrum and Stage 2 pressure ulcer of right upper buttock. Wound measurements were not documented weekly for the week of 2/14/2022. On 3/2/2022 at 10:50 AM, RN #1 verified the wound policy regarding weekly wound measurements and verified the finding.

Based on review of patient charts, interview, and review of hospice's policy, entitled, "Bereavement Services and Follow-up", the hospice failed to provide bereavement services for 1 of 2 applicable patients. (Patient #1) The finding included: Patient #1 On 3/2/2022 at 11:30 AM, review of Patient #1's chart revealed no documentation of an initial bereavement risk assessment at the patient's Start of Care (SOC) on 4/23/2021. The hospice had no documentation of a bereavement assessment after Patient #1 expired on 5/12/2021. The hospice had no documentation of for the patient's bereavement services or on the patient's Plan of Care(POC) after the patient expired on 5/12/2021. Review of the discharge data for Patient #1 revealed "discharge for cause". On 3/2/2022 at 11:30 AM, the Administrator reported, "This patient's discharge was coded as a discharge for cause which is the wrong code. The patient shot himself in the eye on 5/12/2021. The patient was still alert and the family called 911. The patient was sent to the hospital on life support. Family took the patient off life support in the hospital and he died. We should have marked him as a discharge or revoked, not discharge for cause." On 3/2/2022 at 1:04 PM, the bereavement coordinator reported, "The Chaplin spoke with his wife after. The family didn't even know he had a gun. I'm so embarrassed." The bereavement coordinator verified the findings. Hospice policy, entitled, "Bereavement Services and Follow-up", revealed, "Prior to death: The initial bereavement risk assessment of the patient's family is completed on admission, time of death, and during bereavement follow-up. Post patient death: The bereavement coordinator in collaboration with the interdisciplinary team reviews and revises the bereavement plan of care."

Based on patient chart review and interview, the hospice failed to communicate with patient's Primary Care Physician (PCP) for 1 of 1 patient revoking hospice care. (Patient #2) The finding included: Patient #2 On 3/1/2022 at 11:37 AM, review of Patient #2's chart revealed the patient revoked hospice services on 3/19/2021. The hospice had no documentation that a Transfer summary and a copy of the patient's record, if requested were provided to the patient's PCP. On 3/2/2022 at 11:36 AM, the Administrator verified the finding.

Based on review of patient charts, interview, and review of hospice policies, entitled, "Medication Management and Disposal of Medications in the Home" and "Death in Home", the Registered Nurses (RN) failed to follow the hospice's policy for disposal of controlled drugs in the patient's home for 2 of 2 patients. (Patient #1 and #3) The finding includes: Patient #1 On 3/2/2022 at 11:30 AM, the hospice had no documentation of the disposal of controlled substances in the patient's home after the patient expired on 5/12/2021. On 3/2/2022 at 11:30 AM, the Administrator verified the finding. Patient #3 On 3/1/2022 at 11:37 AM, the hospice had no documentation of the disposal of controlled substances in the patient's home after the patient expired on 10/19/2021. On 3/2/2022 at 11:07 AM, the Administrator verified the finding. Hospice policy, entitled, "Medication Management and Disposal of Medications in the Home", revealed, "Upon the patient's death, the nurse, with a witness, will destroy all medications". Hospice policy, entitled, "Death in Home", revealed, "The Drug Disposal form must be completed for medications that are destroyed. The form should be signed by the nurse and a witness as to the disposition of the medications".