Every finding on record at Faith Regional Health Services

Nebraska State Survey Agency for HMS Surveyor #28154:Based on interview and review of the facility's Emergency Preparedness Plan (EPP), last reviewed by the facility in November 2024, the facility failed to ensure the EPP policies addressed the use of federal and/or state healthcare volunteers to meet staffing requirements during an emergency event. This failure had the potential to affect the current 24 patients receiving care from the facility. --- Findings include: Review of the facility's EPP on 12/30/25 at 4:09 PM with the Hospice Director and Hospital Manager of Safety Services, revealed no policy regarding the integration and use of State and/or Federal healthcare professional volunteers. During an interview on 12/30/25 at 4:51 PM regarding Federal and/or State healthcare volunteers, the Hospice Director stated, "I know we don't have that in the policy."

Nebraska State Survey Agency for HMS Surveyor #28154:Based on interview and a review of the facility Emergency Preparedness Plan (EPP), last reviewed by the facility in November 2024, the facility failed to include the role of the facility if a waiver was declared in accordance with section 1135 of the Social Security Act. This failure had the potential to affect the 24 patients receiving care from the facility and hinder the facility's ability to provide care and services during an emergency. --- Findings include: Review of the facility's EPP on 12/30/25 at 4:09 PM with the Hospice Director and Hospital Manager of Safety Services, revealed no policy or procedure regarding the role of the facility if the United States Department of Health and Human Services (DHHS) Secretary should declare a section 1135 waiver in an emergency. During an interview on 12/30/25 at 5:01 PM, the Manager of Safety Services stated, "The words are really close, we can change words to run through the incident command and use alternate sites." At 5:02 PM, the Hospice Director stated he/she would continue to look as it "talks about providing alternate service areas but does not identify a waiver."

Nebraska State Survey Agency for HMS Surveyor #28154:Based on interview and review of the facility's Emergency Preparedness Plan (EPP), last reviewed by the facility in November 2024, the facility failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included other arranged entities, patient physicians, and other hospices. This failure had the potential to affect the 24 patients receiving care from the organization and could delay the facility's ability to respond to an emergency. --- Findings include: Review of the facility's EPP on 12/30/25 at 5:09 PM with the Hospice Director and Hospital Manager of Safety Services, revealed the Communication Plan did not include names and contact information for entities providing services under arrangement, patient physicians, and other hospice providers. During an interview on 12/30/25 at 5:09 PM, the Hospice Director confirmed the Emergency Operations Plan (EOP) does not have each arranged entity listed, each physician that services (patients) are not listed but the Medical Director is; and (regarding other hospices) we don’t have them specified just that we would work with other agencies in the area, neighboring agencies.

Nebraska State Survey Agency for HMS Surveyor #28154:Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the facility failed to maintain a current list of contact information that included the Federal and State, emergency preparedness staff, and/or agencies in the EPP Communication Plan. This failure had the potential to affect any of the 24 patients receiving care from the facility, could potentially delay the facility's ability to respond to an emergency, and could potentially affect other sources of assistance from providing care and services to the facility  patients or staff during an emergency event. --- Findings include: A review of the facility's Emergency Preparedness Communication Plan, last reviewed by the facility in November 2024, on 12/30/25 at 4:09 PM with the Hospice Director and Hospital Manager of Safety Services revealed no inclusion of emergency contact information for the Federal and State emergency staff/agencies.                                             In an interview on 12/30/25 at 5:14 PM, the Manager of Safety Services confirmed Federal and State emergency office contacts were not included, stating, "No, we have to contact Region 11 who then approves and they contact NEMA [Nebraska Emergency Management Agency], then they call the federal level."

Nebraska State Survey Agency for HMS Surveyor #28154:Based on record review and interview, the facility failed to ensure two of 19 patients reviewed (Patient (P) 13 and P19) had an Advanced Directive in the medical record and a copy of the Durable Power of Attorney (DPOA). This failure had the potential to allow anyone to verbally state an ability to make decisions for a patient without having legal authority. --- Findings include: 1. Review of P13's medical record "Patient Information Report (PIR)" showed a "Hospice Effective Date" of 10/21/25; towards the lower section of page one there was a contact name of a daughter with a "Contact Type" listed as "Power of Attorney." Page four of the PIR showed P13 had a "Dur Pwr of Atty (Durable Power of Attorney, DPOA)" located in the patient chart. Review of P13's medical record on 12/31/25 did not reveal a DPOA on the hospice or hospital medical record. Review of P13's hospital medical record showed an entry for "Living Will," however, review of the document showed it was a "Physician Order for Sustaining Life Treatment (POLST)" which is a cardiopulmonary resuscitation directive, but not considered an advance directive. During an interview on 12/31/25, the Hospice Supervisor confirmed there was no DPOA document in the facility patient file. 2. Review of P19's medical record "PIR" showed a "Hospice Effective Date" of 05/30/24 and resided in a long term care (LTC) facility. Page four of the "PIR" showed P19 had a "Med Pwr of Atty (Medical Power of Attorney, MPOA) and the location of the document was at the facility. Further review of P19's hospice medical record on 12/31/25 with the Hospice Supervisor revealed a referral documents, dated as faxed 05/23/24, a LTC "Admission Record" that noted a daughter that had contact types listed as "Responsible for Trust" and "POA – Financial." Review of the Hospice Social Worker 05/30/24 "Visit Note Report" that stated:"Does the Patient have an advance directive?  YesWhat type of advance directives has the patient executed? …Living WillDurable Power of AttorneyOut of hospital DNR [Do not Resuscitate]" Review of the Registered Nurse 05/30/24 "Visit Note Report" showed "Contact Info" for P19's daughter and had a "Contact Type" noted as "Power of Attorney." During an interview on 12/31/25 at 3:38 PM, the Hospice Supervisor confirmed the hospice record showed a daughter as power of attorney (POA) but there was no POA on the hospice medical record. At 3:45 PM, the Hospice Supervisor reviewed the hospital medical record and stated there was a POLST there, however, no POA was on that medical file either. Review of the facility policy titled "Advance Directives," revised 12/2022, revealed, . . . "Definitions: Advance Directive is a written instruction, such as a living will, durable power of attorney for healthcare, or a Nebraska Emergency Treatment Order (NETO) declaration relating to the provision of medical treatment when the individual is incapacitated and unable to participate in healthcare decisions due to illness or incapacity statement. Living Will is a declaration made by a person, while still capable, regarding the person's wishes concerning health care. It is made before the person becomes incapacitated and is generally effective only if person is unable to express his or her wishes at the time a healthcare decision needs to be made. The declaration includes statements that describe the type of care a person wishes to receive in the event that he or she is suffering from a terminal illness or is in a persistent vegetative state."

Nebraska State Survey Agency for HMS Surveyor #28154:Based on observation, interview, and policy review, the Hospice Agency failed to ensure supplies kept for patient use were not expired. This had the potential to negatively affect any of the 24 current patients. Expired products may not perform as intended, leading to the risk of inaccurate laboratory results and additional pain from having to have a lab test redrawn. --- Findings include: During an observational tour of the hospice agency’s stockroom on 12/29/25 at 4:30 PM with the Hospice Director, a tray containing blue top vacutainer blood draw tubes were found to have expired on 10/31/25.  During an interview on 12/29/25 at 4:30 PM, the Hospice Director confirmed the count of 58 tubes and the expiration date of the available vacutainer tubes.  Review of the facility policy titled, "Medical Supplies," approved 04/2024, revealed:"Purpose: To provide a uniform procedure for providing medical supplies, including drugs and biologicals as needed for the palliation and management of the terminal illness and related conditions." The policy did not address the expiration date of supplies. The Hospice Director provided a policy titled, "Home Care Infection Control Program," approved 11/2024. A review revealed:"…F. Prevention and Control of Infections (Bag Technique)Clinician Bag and Computer. . .11. Each clinician is responsible for maintaining supplies, removing outdated supplies,restocking and cleaning the bag."

Nebraska State Survey Agency for HMS Surveyor #28154:Based on record review, interview, and facility contract review, the facility failed to ensure three of 19 patients (Patient (P) 12, P13, and P18) reviewed had a hospice benefit election form provided to the skilled nursing facility upon admission. This failure had the potential to affect the facility's ability to accurately encode a federally mandated assessment for appropriate payment. --- Findings include: 1. Review of P12's hospice "Patient Information Report" showed a hospice effective date of 11/06/25 with a primary diagnosis of Parkinson's disease. During a facility visit for care observation with P12, the nursing facility electronic medical record (EMR) were reviewed for items provided to the facility from the Hospice agency upon admission.  In an interview on 12/30/25 at 12:01 PM, the skilled nursing facility (SNF) Unit Manager (SNF UM) reviewed the EMR for a hospice benefit election form and stated, "It doesn't look like we have it."  2. Review of P13's hospice "PIR" showed a hospice effective date of 10/21/25 with a diagnosis of cerebral infarction. Review of 13's SNF EMR on 12/31/25 at 10:30 AM with the SNF Director of Nursing (SNF DON) and the SNF MDS Coordinator (SNF MDSC, joined the record review at 10:35 AM) were unable to find a hospice election form provided by the hospice agency.  During an interview on 12/31/25 at 11:12 AM, the Hospice Supervisor stated, "We have proof it [election form] was sent to the family but not sent to the facility." 3. Review of P18’s "PIR" showed a hospice effective date of 11/30/25 with medical diagnoses that included Alzheimer's disease. Review of P18’s SNF EMR on 12/30/25 at 12:20 PM with the SNF UM confirmed the hospice agency had not provided a hospice election form to the SNF.  During an interview on 12/31/25 at 12:27 PM, the Hospice Director stated there was no policy that defined what paperwork would be provided to facilities. Review of the contract 07/01/24 between the Hospice Agency and P13's SNF facility revealed:"…5. Compliance With Law.a. The parties shall comply with all applicable statutes, rules, regulations and standards of any and all governmental authorities and regulatory and accreditation bodies relating to the provision of Hospice Services under the terms of this Agreement." Review of the contract in effect until 12/31/25 between the Hospice Agency and P12's and P18's SNF facility revealed:"…3.2.4.6 Provision of Hospice Services: Contractor shall be available to provide Hospice services, as required by applicable Federal and State laws and regulations, twenty-four (24) hours a day, seven (7) days a week. Contractor will provide Hospice services to each Hospice Patient in accordance with the Plan of Care for that patient. . . ."