Every finding on record at Jackson County Memorial Hospital Authority

Based on record review and interview, the IDG failed to provide a current hospice POC for two (#1 and #2) of patients residing in a facility. This failed practice had the potential to prevent or delay the individualized and timely care for all 12 patients currently on census that reside in a facility. --- Patient #1During a patient visit on 03/36/26 at 9:00 AM, review of the Hospice Patient Record provided for communication between the hospice agency and the facility failed to provide evidence of a current IDG POC. The record did not include an updated IDG POC for the previous months of February or March.  Patient #2During a patient visit on 03/36/26 at 9:30 AM, review of the Hospice Patient Record provided for communication between the hospice agency and the facility failed to provide evidence of a current IDG POC. The record did not include an updated IDG POC for the previous months of February or March.During an interview on 03/26/26 at 10:00 AM, RN1 stated the IDG failed to provide the two facilities an updated IDG POC for Pt#1 and Pt#2.

Based on record review and interview, the hospice failed to ensure the plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for eleven (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14) of 14 patients reviewed. --- Patient #1 A review of the plan of care dated 03/26/23 to 05/24/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #2 A review of the plan of care dated 03/04/23 to 05/02/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #3 A review of the plan of care dated 04/02/23 to 05/31/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #4 A review of the plan of care dated 01/18/23 to 04/17/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #5 A plan of care dated 02/28/23 to 04/28/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #6 A plan of care dated 04/26/23 to 07/24/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #7 A review of the plan of care dated 05/19/23 to 08/16/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #8 A review of the plan of care dated 05/02/23 to 07/30/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #9 A plan of care dated 02/20/23 to 05/20/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #10 A plan of care dated 03/12/23 to 05/10/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #11 A plan of care dated 01/06/23 to 04/05/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #12 A plan of care dated 02/15/23 to 05/15/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #13 A plan of care dated 01/12/23 to 04/11/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. Patient #14 A plan of care dated 11/17/22 to 02/17/23 showed no plan of care development for the services necessary for the palliation and management of the terminal illness. Documentation showed no services or treatment related to either the primary or secondary diagnoses. On 06/01/23 at 11:20 am, Staff A stated the plans of care for Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 and 14 failed to include services necessary for the palliation and management of the terminal illness.

Based on record review and interview, the hospice failed to ensure quality indicator data was used in the design of the QAPI program for all 30 current patients and any new patients admitted to the hospice. --- A review of QAPI records showed no use of quality indicator data in the QAPI program documentation for 2021 and 2022. On 06/01/23 at 12:05 pm, Staff A stated the QAPI program did not include the use of quality indicator data.

Based on record review and interview, the agency failed to ensure the Infection Control Program included documentation of comprehensive infection control surveillance activities and interventions to reduce future infections and promote learning and preventative measures throughout the agency for 30 patients and all staff. --- A review of administrative records showed no documentation of an ongoing infection control program for the agency and no infection control surveillance, specific to the hospice, for the calendar years of 2021 and 2022. On 06/01/23 at 12:00 pm, Staff A stated the agency had no documented infection control program or surveillance activity specific to the hospice for the calendar years of 2021 and 2022.