Every finding on record at Hospice of Montana, LLC

Upon personnel record review, 8 of 14 (Personnel #1,#2,#3,#5,#7,#8,#9,#10) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel 1: There was no evidence of Emergency Preparedness training since 2019. Personnel 2: There was no evidence of Emergency Preparedness training since 2019. Personnel 3: There was no evidence of Emergency Preparedness training since 2019. Personnel 5: There was no evidence of Emergency Preparedness training since orientation. Personnel 7: There was no evidence of Emergency Preparedness training since orientation. Personnel 8: There was no evidence of Emergency Preparedness training since 2019. Personnel 9: There was no evidence of Emergency Preparedness training since orientation. Personnel 10: There was no evidence of Emergency Preparedness training since 2019.

Upon patient record review, 3 of 19 (Patients #1,#3,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile contained topical camphor-menthol cream with no area defined for administration. Corrected on site. Patient 3: The medication profile contained lantus with dose not defined. Corrected on site. Patient 4: The medication profile contained diclofenac topical gel with no area defined for administration. Corrected on site.

Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 13: The medical record documented patient was on hospice services for heart failure. There were no problems, goals, and interventions related to cardiac dysfunction. Corrected on site.

Upon patient record review, 3 of 19 (Patients #1,#3,#4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The medical record contained an order for topical camphor-menthol cream with no area defined for administration. Corrected on site. Patient 3: The medical record contained an order for lantus with the dose not defined. Corrected on site. Patient 4: The medical record contained an order for diclofenac topical gel with no area defined for administration. Corrected on site.

Upon patient record review, 1 of 19 (Patient #4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 4: The medical record contained nursing documentation upon recertification 10/17/23 identifying patient use of a hospital bed and wheelchair. There was no evidence of orders for the bed and wheelchair included in the plan of care. Corrected on site.

Upon patient client record review, 1 of 19 (Patient #14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 14: election addendum requested 3/14/23, emailed 3/20/23, not received within 5 day requirement