Every finding on record at Hospice of Sweetwater County

Based on observation, medical record review, staff interview, and policy and procedure review the agency failed to ensure the plan of care (POC) included all pertinent information for 9 of 14 sample patients (#3, #4, #6, #7, #8, #9, #10, #11, #12). The findings were: --- 1. Review of the POC for patient #3 showed diagnoses including Cachexia, Parkinson’s disease, repeated falls, muscle weakness, chronic obstructive pulmonary disease (COPD), and paroxysmal atrial fibrillation. Observation during the CNA home visit on 9/3/25 at 3:30 PM showed the patient had briefs, wipes, shower chair, toilet riser with handles, grip bars, oxygen, nasal cannula, wheelchair, and a 4-wheel walker. The POC failed to include the frequency of the CNA visits.2. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include all services necessary and frequency of visits. 3. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC under active items showed oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores.  The POC failed to include all necessary services and frequency of visits.4. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed issues were functional needs, anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include all necessary services and frequency of visits.5. Review of the medical record for patient #8 showed diagnoses of prostate cancer and metastasis to bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include all necessary services and frequency of visits.6. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic and anemia. Review of the POC showed issues of shortness of breath, oxygen use, confusion, edema, air hunger, and depression.  The POC failed to include all necessary services and frequency of visits.     7. Review of the medical record for patient #10 showed diagnoses of malignant neoplasm of retroperitoneum. Review of the POC showed issues of anxiety, nausea, pain, and shortness of breath. The POC failed to include all necessary services and frequency of visits.8. Review of the POC for patient #11 showed diagnoses of chronic systolic congestive heart failure, falls, dizziness, giddiness, mood disorder, and urinary tract infection.  The POC failed to include all necessary services and frequency of visits.9. Review of the POC for patient #12 showed diagnoses of malignant melanoma of left lower limb, including hip.  The POC failed to include all necessary services and frequency of visits.10. Interview with the administrator on 9/5/25 at 10 AM confirmed the POC's did not include the services and the frequency of visits.  11. Review of policy "Plan of Care - Content" hand delivered on 9/4/25 at 3:44 PM by the administrator showed "...2.The plan of care includes, but not limited to:...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs..."

Based on medical record review, staff interview, and policy and procedure review the agency failed to ensure drugs and treatment necessary to meet the patient needs were included in the plan of corrections (POC) for 7 of 14 patients (#2, #4, #6, #7, #8, #9, #10). The findings were: --- 1.Review of the POC for patient #2 showed diagnoses including acute respiratory failure with hypoxia, pneumonia, and muscle weakness. Further review showed the agency failed to include all the patient medications on the POC. During the home visit on 9/3/25 at 11 AM, RN# 1 stated the medications, she just delivered to the patient were metoprolol (beta blocker), ondansetron (serotonin 5-HT3 receptor antagonists), nystatin (polyene antifungal medication), morphine (opiate), and docusate (laxative). The medications were not included on the POC.2. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include the patients list of medications.3. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC showed oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores.  The POC failed to include the patients list of medications. 4. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include the patients list of medications.5. Review of the medical record for patient #8 showed diagnoses of prostate cancer, and metastasis to the bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include the patients list of medications. 6. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic, and anemia. The POC failed to include the patients list of medications.7. Review of the medical record for patient #10 showed diagnosis of malignant neoplasm of retroperitoneum. The POC failed to include the patients list of medications. 8. Interview with the administrator on 9/5/25 at 10 AM revealed the POC the facility was currently using did not include the medications.9. Review of police "Plan of Care - Content" hand delivered on 9/4/25 at 3:44 PM by the administrator showed "...2. The plan of care includes, but is not limited to:...d. drugs and treatments necessary to meet the needs of the patient..."

Based on observation, medical record review, staff interview, and policy and procedure review the agency failed to ensure the plan of care (POC) included all pertinent information for 12 of 14 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12). The findings were: --- 1.Review of the POC for patient #1 showed diagnoses including Alzheimer's disease, repeated falls, and history of urinary tract infections. Observation on 9/4/25 at 9:30 AM showed the patient had a shower chair, hospital bed, wheelchair, grab bars, briefs. The POC failed to include the durable medical equipment (DME) and the safety precautions.2. Review of the POC for patient #2 showed diagnoses including acute respiratory failure with hypoxia, pneumonia, and muscle weakness. Observation during the home visit on 9/3/25 at 11 AM showed the patient had a hospital bed, oxygen, nasal cannula, shower chair, grab bars, wheelchair, bed pain, briefs, incontinent pads, foley catheter, and a medication minder. The POC failed to includes the DME and safety precautions.3. Review of the POC for patient #3 showed diagnoses including cachexia, Parkinson’s disease, repeated falls, muscle weakness, chronic obstructive pulmonary disease (COPD), and paroxysmal atrial fibrillation. Observation during the home visit on 9/3/25 at 3:30 PM showed the patient had briefs, wipes, shower chair, toilet riser with handles, grip bars, oxygen, nasal cannula, wheelchair, and a 4-wheel walker. The POC failed to include the DME and safety precautions.4. Review of the medical record for patient #4 showed diagnoses including sepsis, COPD, pneumonia, and dementia. Review of the POC failed to include the diagnoses, DME and safety precautions.5. Review of the POC for patient #5 showed a diagnosis of disseminated malignant neoplasm. The POC failed to include the DME and safety precautions.6. Review of the medical record for patient #6 showed diagnoses of malignant neoplasm of left ovary, and malignant neoplasm of retroperitoneum and peritoneum. Review of the POC showed under active items was oxygen use, urinary incontinence, diminished strength, wound under left breast, wound under right breast, shortness of breath and risk of pressure sores.  The POC failed to include the DME and safety precautions.7. Review of the medical record for patient #7 showed diagnoses of melanoma neck and scalp, and malignant neoplasm of the lung. Review of the POC showed under issues was functional needs, anxiety, bathing, confusion, edema, and shortness of breath. The POC failed to include diagnoses, DME and safety precautions.8. Review of the medical record for patient #8 showed diagnoses of prostate cancer and metastasis to the bone. Review of the POC showed issues of air hunger, bathing, confusion, depression, diminished strength, edema, oxygen use, shortness of breath, urinary incontinence, and pain. The POC failed to include diagnoses, DME and safety precautions.9. Review of the medical record for patient #9 showed diagnoses of advanced COPD chronic and anemia. Review of the POC showed issues of shortness of breath, oxygen use, confusion, edema, air hunger, and depression.  The POC failed to include diagnoses, DME and safety precautions.    10. Review of the medical record for patient #10 showed diagnosis of malignant neoplasm of retroperitoneum. Review of the POC showed issues of anxiety, nausea, pain, and shortness of breath. The POC failed to include diagnoses, DME and safety precautions.11. Review of the POC for patient #11 showed diagnoses of chronic systolic congestive heart failure, falls, dizziness, giddiness, mood disorder, and urinary tract infection.  The POC failed to include the DME and safety precautions.12. Review of the POC for patient #12 showed a diagnosis of malignant melanoma of left lower limb, including hip.  The POC failed to include DME and safety precautions.13. Interview with CNA #1 on 9/4/25 at 9:30 AM she did not know the DME and safety precautions for patient #1 and would have to ask other staff. 14. Review of policy "Plan of Care - Content" had delivered on 9/4/25 at 3:44 PM by the administrator showed "...2.The plan of care includes, but not limited to:...e. medical supplies, equipment, and appliances necessary to meet the needs of the patient.

Based on review of the bereavement records, staff interviews, and policy review the agency failed to perform an initial bereavement assessment for 6 of 7 records reviewed (#9, #10, #11, #13, #14, #15). The findings were: 1. Review of the bereavement record for pt #9 showed an admission date of 2/16/22 and the date of death as 2/23/22. Further review showed no evidence of an initial bereavement assessment. Interview with the DON on 8/24/22 at 3:40 PM confirmed "if there is nothing in the binder then the case manager has the forms." 2. Review of the bereavement record for pt #10 showed an admission date of 8/8/22 and the date of death as 8/11/22. Further review showed a blank initial bereavement assessment with the patient's identifiers on it. 3. Review of the bereavement record for pt #11 showed an admission date of 12/30/21 and the date of death as 1/19/22. Further review showed a blank initial bereavement assessment with the patient's identifiers on it. 4. Review of the bereavement record for pt #13 showed an admission date of 5/16/22 and the date of death as 7/17/22. Further review showed a blank initial bereavement assessment with the patient's identifiers on it. 5. Review of the bereavement record for pt #14 showed an admission date of 6/10/22 and the date of death as 7/11/22. Further review showed a blank initial bereavement assessment with the patient's identifiers on it. 6. Review of the bereavement record for pt #15 showed an admission date of 1/3/22 and the date of death as 7/17/22. Further review showed a blank initial bereavement assessment with the patient's identifiers on it. 7. Interview with the DON 8/22/22 at 3:44 PM confirmed the bereavement files were contained within the binders reviewed at the time of survey. In addition, the DON could not explain why an initial bereavement assessment had not been completed as required, except the agency did not have a bereavement coordinator and "everyone is helping out" with bereavement services. 8. Review of agency policy, undated, titled "Bereavement-Files'' showed "A bereavement file is developed for each patient admitted to the hospice program. 1. A bereavement file is initiated for each patient by the Bereavement Coordinator and maintained for 12 months after the patient's death..."

Based on observation, patient and staff interview and medical record review the agency failed to include all medical supplies and equipment in the plan of care necessary to meet the needs of the patient for 11 of 11 sample patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11). The findings were: 1. Observation on 8/23/22 at 2:20 PM during a home visit for pt #3 revealed the presence of incontinence supplies, wound care supplies, PPE, oxygen supplies and an oxygen concentrator, hospital bed, bedside commode, walker and a wheelchair. Interview with RN #2 at that time confirmed the supplies and the equipment were provided to the patient by the hospice. Review of the patient's medical record showed the supplies and DME were not listed on the plan of care. 2. Observation on 8/24/22 at 10:00 AM during a home visit for pt #1 revealed the presence of a port-a-cath and wound care supplies available for patient use. Interview with RN #1 at that time, confirmed the patient required the supplies for the port-a-cath maintenance and dressings for wound care and hospice had provided them. Review of the patient's medical record showed the supplies were not listed on the plan of care. 3. Observation on 8/24/22 at 12:15 PM during a home visit for pt #5 revealed the presence of incontinence supplies, oxygen supplies and a concentrator, a nebulizer, bedside commode, walker and a hoyer lift available for patient use. Continued observation showed CNA #1 used the supplies to care for the pt. Interview with the patient and caregiver at that time confirmed that hospice had provided the supplies and equipment to the patient. Review of the patient's medical record showed the supplies were not listed on the plan of care. 4. Review of the medical record for pt #2 showed a list of "covered supplies" none of which were on the plan of care. 5. Review of the medical record for pt #4 showed the patient had a feeding tube and supplies and dressings for wound care. Further review showed the supplies were not on the plan of care. 6. Review of the medical record for pt #6 revealed the patient used a oxygen concentrator in the home. Further review showed the concentrator was not on the plan of care. 7. Review of the medical record for pt #7 revealed the patient had an IV port to be maintained by the nurse. Further review showed the supplies needed to maintain the port were not on the plan of care. 8. Review of the medical record for pt #8 revealed the patient had a feeding tube and supplies and an IV port. Further review showed the feeding tube and supplies needed to maintain it and the IV port were not on the plan of care. 9. Review of the medical record for pt #9 revealed the patient had orders for wound care. Further review showed wound care supplies were not on the plan of care. 10. Review of the medical record for pt #10 revealed the patient was incontinent, had a pressure wound, and used an oxygen concentrator and supplies. Further review showed incontinence supplies,wound care supplies and the oxygen concentrator and supplies were not on the plan of care. 11. Review of the medical record for pt #11 revealed the patient had an oxygen concentrator and supplies in the home. Further review showed the oxygen concentrator and supplies were not on the plan of care. 12. Interview with the executive director on 8/25/22 at 11:45 AM verified the plans of care did not include supplies or DME. She further confirmed the EHR had a place to document this information but it did not flow easily to the plan of care so they were not entering the information into the EHR.

Based on observation, medical record review and staff interview the agency failed to ensure medical social services were provided to 4 of 11 sample patients (#6, #7, #8, #11). The findings were: 1. Observation of the IDT meeting on 8/23/22 at 4:00 PM showed the social worker was not in attendance. 2. Review of the medical record showed pt #6 was admitted to hospice services on 8/4/22 with a diagnosis of Alzhiemer's disease and an order for a social work assessment. The patient died on 8/21/22 without the social worker assessment. 3. Review of the medical record showed pt #7 was admitted to hospice services on 8/12/22 with a diagnosis of lung cancer and an order for a social work assessment. The nurse performed an assessment on 8/12/22 and the patient requested "ongoing MSW services". The patient died on 8/22/22 without a MSW visit. 4. Review of the medical record showed pt #8 was admitted to hospice services on 8/16/22 with a diagnosis of esophageal cancer and an order for a social worker visit. At the time of survey, the social worker had not seen the patient. 5. Review of the medical record showed pt #11 was admitted to hospice services on 12/30/21 with a diagnosis of lung cancer. Further review revealed on 1/1/22 the family requested a MSW visit. The patient died on 1/24/22 and the MSW had not seen the family as requested. 6. Interview with the ED on 8/25/22 at 12:05 PM confirmed the LCSW attended about 1/2 of the IDT conferences. Further interview revealed this service is in demand, it is difficult to find social work coverage and the LCSW had a limited number of hours available to the agency.

Based on bereavement record review, staff interviews, and policy review the agency failed to have an organized program for the provision of bereavement services for 6 of 7 records reviewed (#9, #10, #11, #13, #14, #15). The findings were: 1. Review of the bereavement record for pt #9 showed an admission date of 2/16/22 and the date of death as 2/23/22. Further review revealed the absence of an initial bereavement assessment or a plan of care. Interview with the DON on 8/24/22 at 3:40 PM confirmed "if there is nothing in the binder then the case manager has the forms." 2. Review of the bereavement record for pt #10 showed an admission date of 8/8/22 and the date of death as 8/11/22. Further review revealed the bereavement record for this patient had three blank forms (the initial bereavement assessment, contacts with the bereaved, and the bereavement plan of care) in the bereavement binder under the patient's identifiers. 3. Review of the bereavement record for pt #11 showed an admission date of 12/30/21 and the date of death as 1/19/22. Further review revealed the bereavement record for this patient had two blank forms (the initial bereavement assessment and the bereavement plan of care) in the bereavement binder under the patient's identifiers and 1 attempted phone call to the bereaved on 3/15/22. 4. Review of the bereavement record for pt #13 showed an admission date of 5/16/22 and the date of death as 7/17/22. Further review revealed the bereavement record for this patient had three blank forms (the initial bereavement assessment, contacts with the bereaved, and the bereavement plan of care) in the bereavement binder under the patient's identifiers. 5. Review of the bereavement record for pt #14 showed an admission date of 6/10/22 and the date of death as 7/11/22. Further review revealed the bereavement record for this patient had three blank forms (the initial bereavement assessment, contacts with the bereaved, and the bereavement plan of care) in the bereavement binder under the patient's identifiers. 6. Review of the bereavement record for pt #15 showed an admission date of 1/3/22 and the date of death as 7/17/22. Further review revealed the bereavement record for this patient had three blank forms (the initial bereavement assessment, contacts with the bereaved, and the bereavement plan of care) in the bereavement binder under the patient's identifiers. 7. Interview with the DON 8/22/22 at 3:44 PM confirmed the bereavement files were contained within the binders reviewed at the time of survey. In addition, the DON could not explain why the forms not been completed, except the agency did not have a bereavement coordinator and "everyone is helping out" with the bereavement services. An additional interview with the DON on 8/24/22 at 3:50 PM revealed she kept a spreadsheet that tracked mailings to the bereaved and this information was not included in the binder. 8. Review of the agency policy, undated, titled "Bereavement Services" showed "1. The hospice's bereavement program is under the supervision of the Bereavement Coordinator...2. The hospice provides bereavement services to the family...of the deceased hospice patient for 13 months following the patients death...Bereavement services provided are based on the assessed needs of the deceased's survivors and are in accordance with the bereavement plan of care formulated after the patient's death..." 9. Review of the agency policy, undated, titled "Bereavement-Files'' showed "A bereavement file is developed for each patient admitted to the hospice program. 1. A bereavement file is initiated for each patient by the Bereavement Coordinator and maintained for 12 months after the patient's death...2. The bereavement file contains: a. a copy of the bereavement plan of care for the person(s) for whom the hospice will provide bereavement services; and b. bereavement notes documenting all services to and contact with the bereaved person(s). 3. The Bereavement Coordinator updates information in the file as needed." 10. Review of the agency policy, undated, titled "Bereavement Care Planning" showed "A bereavement care plan is developed for identified family members...after the patient's death...an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members...to cope with the patient's death...findings from the initial bereavement assessment are incorporated into the patient's plan of care and considered in the bereavement plan of care..." 11. Review of the agency policy, undated, titled "Bereavement-Tracking and Evaluation" showed "1. A bereavement file is initiated at the time of the patient's death that contains documentation related to all bereavement services, intervention and support provided to the patient's family...2. The Bereavement Coordinator documents the dates when each of the follow-up services, as specified in the bereaved person's plan of care, has been completed. 3. At least two attempts are made to reach the family member or significant others of the deceased patient within a designated time frame as determined by the bereavement plan of care. If no one can be reached, a "No Answer" letter is sent informing the bereaved that attempts have been made to be in contact."

Based on observation and staff interview the facility failed to ensure medical records were safeguarded against loss or unauthorized use in 1 of 1 (supply room) physical medical record storage locations. The findings were: 1. Observation on 8/23/22 at 8:50 AM of the supply room showed patients' medical records in boxes, on open shelves, labeled 2017-2021. The supply room had a locked door at the entrance, however, the medical records were not secure and private within the storage room. Interview with the DON at that time revealed nursing staff and building housekeepers had a key to the supply room.