Every finding on record at Glendive Medical Center Hospice Prog

Based on interview and record review, the agency failed to provide an emergency preparedness training based on their established emergency plan, risk assessment, policy and procedures, and communication plan upon hire and biennially for 5 (staff members A, B, D, E, and F ) of 5 sampled staff members. Findings include: --- During an interview on 2/12/25 at 2:59 p.m., staff member A stated the agency did not have employee education for emergency preparedness based on the risk assessment for the hospice agency. She stated the education provided to employees was more specific to an inpatient setting. Review of employee personnel records, on 2/12/25, for staff members A, B, D, E, and F showed no initial on-boarding or biennial emergency preparedness training based on the agencys established emergency plan and risk assessment.

Based on interview and record review, the agency failed to ensure 3 (staff members D, E, and F) of 5 sampled staff members, were currently certified in Basic Life Support (BLS), as per their job descriptions and requirements of the agency. Findings include: --- Review of staff member D's job description, dated 4/16/24, showed under Education and Experience, "Current BLS certification." Review of staff member D's personnel file, on 2/12/25, showed her BLS certification had expired on 8/2024. Review of staff member E's job description, dated 2/25/21, showed under Minimum License Requirement, "Current BLS certification required." Review of staff member E's personnel file, on 2/12/25, showed her BLS certification had expired on 1/2025. Review of staff member F's job description, dated 4/16/24, showed under Education and Experience, "Basic Life Support required." Review of staff member F's personnel file, on 2/12/25, showed no BLS certification upon hire or thereafter was on file. During an interview on 2/12/25 at 2:20 p.m., staff member A stated when staff member F was hired, the hospital was down two positions in Human Resources and staff member F's BLS certification was not done upon hire. Staff member A stated nurses were responsible for renewing their BLS certifications, but the agency needs to keep up on the recording of their completion also. She stated the agency was looking for BLS education/certification classes as soon as possible for staff members D, E, and F.

Based on record review and interview the hospice agency failed to develop, establish, and maintain a comprehensive emergency preparedness program (EP) that identified an all-hazards approach strategy for addressing the hospice patient/staff vulnerability during emergency events. This affected all hospice staff and patients of the hospice agency. Findings include: Record review showed no specific documentation available to review of the hospice agency policy and procedures for an EP program and there was no documentation of a facility-based, or community-based risk assessment being completed specifically for the hospice agency. During an interview on 3/16/22 at 1:10 p.m. staff member A stated the hospice agency did not have an emergency preparedness program or an assessment as a hospice agency but was integrated with the affiliated critical access hospital. No documentation was available showing the hospice agency was a separate but integrated part within the affiliated critical access hospital's emergency preparedness program. Staff member A stated hospice did not have a specific EP plan but, "We are included in the hospital's program."

Based on interview and record review, the hospice agency failed to address the services the agency would be able to provide during an emergency, specifically to the population served, and to delegate authority within the hospice agency. The deficient practice had the potential to affect all home bound patients receiving care from the hospice agency. Findings include: During an interview on 3/16/22 at 12:21 p.m., staff member B stated the last EP training she was a part of occurred as a multi trauma victims coming through the emergency room, not hospice related. Staff member B had not been trained in EP for the hospice agency. During an interview on 3/16/22 at 12:30 p.m., staff member C stated all hospice staff would meet at the hospital, as part of the hospital staff, and be given assignments on what to do during an emergency. Assignments for hospice staff might not be hospice patient related, just whatever was needed. Staff member C stated she was not sure who would meet the hospice patients needs during an emergency. During an interview on 3/16/22 at 1:10 p.m., staff member A stated the hospice agency was a part of the affiliated hospital, but the hospital's emergency preparedness plan did not include the hospice as a specific entity, population, and vulnerabilities in an event of an emergency or disaster. Review of the affiliated critical access hospital's Emergency Operation Plan showed no documentation that the hospice agency and their patients, living in the community, were included in the plan.

Based on interview and record review, the agency failed to develop policy and procedures which addressed the requirement to alert emergency preparedness officials of the evacuation of home bound patients, who received care from the hospice agency. The deficient practice had the potential to affect all home bound patients receiving care from the hospice agency. Findings include: Review of the affiliated hospital integrated policy and procedures on emergency preparedness, failed to address the requirement to alert emergency preparedness officials of the need to evacuate home bound patients and the personalized equipment and medications the patients required for their individual needs. During an interview on 3/16/22 at 12:30 p.m. staff member C stated she would have to go into the patients' files to find the phone number to contact a patient in case of an emergency. The patients' paper files were in the hospice agency building. The affiliated hospital policy, which was to include the hospice agency, read all staff were to gather in the main hospital. Staff member C stated she did not know what each patient would require if the patient needed to be evacuated. During an interview on 3/16/22 at 1:10 p.m., staff member A stated the agency did not have a policy and procedure specific to the evacuation of hospice patients. The staff member stated the hospice agency used the affiliated hospital's policy and procedure, for emergency preparedness. Staff member A stated the hospice went over emergencies during intake of the patients but did not have a list of needed equipment if evacuation was required. A medication list was in each individual file. Review of the affiliated hospital's Emergency Preparedness plan, with an effective update of 9/21, failed to show policy and procedures for addressing the needs or the evacuation of hospice patients. Review of patients' #1, 8, 9, 10, and 11 care plan did not identify required equipment necessary for an evacuation from their personal living situation to another, or who would evacuate or how the patient would be evacuated. Staff member A agreed the evacuation plan was not on the care plan.

Based on record review and interview, the hospice agency failed to develop and implement emergency preparedness policies and procedures, based on the risk assessment of patients served in the hospice and addressing staffing strategies in the case of an emergency. This deficient practice had the potential to affect all home bound patients receiving care from the hospice agency. Findings include: During an interview on 3/16/22 at 1:10 p.m., staff member A stated the agency was in the affiliated hospital's emergency plan. The staff member stated they did not have a call list for volunteers or the current patients readily available for hospice staff. Review of the affiliated critical access hospital's Emergency Management Plan, dated of 9/21, showed no evidence that the hospice agency patients were identified specifically, living in private residencies and integrated into the plan. Review of the hospice policies and procedures did not show that the hospice had completed a risk assessment for the hospice agency and so no plan was written, addressing subsistence needs for the hospice patients.

Based on interview and record review, the agency failed to develop and implement emergency preparedness (EP) communication plans, including a means of providing information about the condition, and location of patients under hospice care in case of an emergency. The deficient practice had the potential to affect all patients who received care from the agency. Findings include: Review of the agency's critical access hospital's affiliated policy and procedures failed to include a written plan and interventions for communications, including a method for sharing hospice patients' medical information during shelter in place, or during an evacuation to ensure continuum of care in the event of a disaster. During an interview on 3/16/22 at 10:30 a.m., staff member A stated the affiliated critical access hospital's emergency preparedness program did not have a policy and procedure which outlined the communication protocol, specific to the sharing of hospice patients' medical needs during sheltering in place, or during an evacuation at the time of emergent event. The staff member had no policy which showed how the hospice was to handle information which included hospice patients' medical needs, cares required, and supplies during an emergency. During an interview on 3/16/22 at 12:30 p.m., staff member C stated she was not unaware of any information showing what hospice patients' needs would be if there was an emergency, if the patient would need to be evacuated, or if the patient was to stay in place, and what supplies, deliveries or what duties would need to be performed if there was a disaster affecting the hospice patient.

Based on record review and interview, the integrated emergency preparedness program of the affiliated critical access hospital, failed to integrate the hospice agency as a separate certified agency, unique circumstances, patient population and services offered. The deficient practice had the potential to affect all patients receiving hospice care through the agency. Findings include: During an interview on 3/16/21 at 10:30 a.m., staff member A stated the affiliated critical access hospital's emergency operation plans included hospice staff participation. The affiliated critical access hospital's policy did not show that the hospice agency was integrated, and included in a coordinated communication plan, training and testing program that met the specific needs for the hospice agency staff and patients served. Review of the agency documentation showed there was no policy which specifically included the hospice agency's emergency preparedness program. The affiliated critical access hospital's plan showed no risk assessments specific to the hospice agency and the hospice patient. No documentation was available which showed the hospice agency's emergency preparedness program had identified the strategies for addressing the emergency events identified by a risk assessment, which would affect the hospice's ability to provide care to the hospice patient during an emergency. During an interview on 3/16/22 at 1:10 p.m., staff member A stated there was no hospice agency specific emergency preparedness program policy and procedures completed. The staff member stated the affiliated critical access hospital had included the hospice agency staff in their emergency preparedness trainings, and staff member A did attend the planning, but the affiliated critical access hospital had not assessed and identified the hospice agency's specific risks for staff and patients.

Based on observation, interview, and record review, the agency failed to develop a patient centered care plan reflecting the needs and goals of the patient for 1 #(2) of 2 sampled patients. Findings include: During an observation on 3/15/22 at 1:15 p.m., patient #2 was lying in a hospital bed in the living room of his home. He was in pain, and staff member F was not able to take his blood pressure, related to his pain. During an interview on 3/15/22 at 1:20 p.m., NF1 stated the hospice agency staff had given patient #2 a bath on 3/14/22. She stated the staff had to cut his clothes off because of the patient's severe pain. She stated he had hollered out in pain throughout the bed bath. NF2 became so upset, she had to go sit in the basement of their home. The fentanyl patch had been placed on patient #2 after the bed bath. NF1 stated it was horrible to have to see her father hollering in pain. During an interview on 3/15/22 at 1:30 p.m., staff member F stated patient #2 had a significant decline on 3/11/22. He was no longer eating or drinking, and unable to participate in his activities of daily living. His pain had increased, and a fentanyl patch had been added to his medication regime on 3/14/22. Review of patient #2's initial care plan, dated 3/2/22, showed the only resident specific intervention was the use of a four wheeled walker. All other interventions showed the word "Assess." During an interview on 3/15/22 at 4:10 p.m., staff member A stated she was aware the care plans were not resident specific, and it was an issue the agency was working on. She stated the agency had transitioned from paper to an electronic system, which had not allowed them to create an adequate care plan. Review of patient #2's initial care plan, dated 3/2/22, showed the care plan had not been updated to reflect the resident's current decline in status. During an interview on 3/16/22 at 1:50 p.m., staff member A stated the agency staff were aware of patient #2's decline in condition, but the care plan would not be updated until the patient's next team meeting on 3/17/22. She stated the agency nurses wrote current notes regarding the patient's decline, and she thought the notes would 'cover' patient #2's current status. Review of patient #2's updated care plan, dated 3/16/22, showed the patient had a change in status. The care plan did not include the patient not wanting to be moved, the increase in pain and pain medication, or the use of suctioning.

Based on interview and record review, the agency failed to maintain an effective, ongoing quality assessment and performance improvement program that focused on indicators related to improvement of patient palliative outcomes. Findings include: Review of the agency Quality Summary Reports for March, June, and October of 2021 showed Quality Scores were not updated on the March, June, and October reports. The three quarterly reports were nearly identical. The remainder of each quarterly reports included a "lean six" project on organizing the agency equipment. This was initiated in 2018. One 'Rapid Improvement Project', dated 11/15/21, showed the social worker's documentation was not accurate or sufficient. A new social worker was hired on 11/28/21. The Quality Summary Reports for the three quarters did not include any focus on patient care and improved palliative outcomes, or education provided for COVID-19/Infection Control policies and procedures. Review of the agency report titled Quality Assurance Performance Goals, undated, showed the data to be monitored would include Quality Measures, departmental audits, Patient/Family Satisfaction survey data, Patient concerns, survey data, adverse events/complaints, and Infection Control data. During an interview on 3/16/22 at 4:10 p.m., staff member A stated she does conduct chart audits and does supervisory visits, and had no identified concerns. She stated she lost track of implementing the Quality Assurance policy and procedure.

Based on interview and record review, the hospice agency failed to follow the policy and procedure for COVID-19 precautions to protect patients from possible infections from unvaccinated agency staff. Findings include: Review of the agency Employee Immunization Policy, dated 1/2022, showed "For those staff member that an exemption has been granted, the following additional precautions will be instituted: a. Source control will be always worn in hallways, meetings of 2 or more people, in any patient facing encounters, etc.: i. Procedure mask. ii. Eye protection (appropriate goggle or face shield) b. Employees that have been granted an exemption will physically distance (at least 6 feet) from other employees during meetings, breaks, etc." Review of an updated policy, provided on 3/16/22, dated 3/22, showed "Binax test daily or every day worked before start of shift," for unvaccinated staff. During an interview on 3/15/22 at 9:56 a.m., staff member E stated she wore gloves and a regular mask during patient care. During an interview on 3/15/22 at 10:12 a.m., staff member A stated the hospice staff should be wearing the NIOSH N95 mask for patient care. She stated she believed staff member E had been wearing the NIOSH N95 for patient care. She stated staff member E did wear glasses. Staff member A did not have the mask requirement documented, but stated she had educated all of the hospice staff. Staff member E did not wear goggles or a face shield, and was not able to physically distance during patient care.