Every finding on record at Margaret Mary Community Hospital, Inc.

Observed in Record Review. In 10 of 16 patient records reviewed, the organization failed to plan the patient's care. During record review for HOSRRHV#1, HOSRRHV#4, HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#8, HOSRRNHV#9, and HOSRRNHV#10, the Hospice Nurse Surveyor observed the plan of care was not based on current needs. For example in HOSRRHV#1, the patient had a goal for wound healing. The wound interventions had been resolved and the wound orders were discontinued 8 weeks prior to survey the goal had not been addressed. Also in HOSRRHV#1, the timeframe for the SC goal of Patient will utilize new ways to express/experience spirituality, sense of the divine, and sense of community support as evidenced by calm affect had expired 4 weeks prior to survey and had not been updated. In HOSRRHV#4, the patient's appetite had been decreasing per notes for at least the last 10 days and the nurse had been educating on nutrition but it was not addressed on the plan of care. The patient also had agitation requiring some medication but the agitation was not listed on the plan of care. In HOSRRNHV#1, the patient had issues with constipation and nausea which were not on the plan of care. In HOSRRNHV#2, the patient had intermittent issues with anxiety but it was not on the plan of care.In HOSRRNHV#3, the patient had a recertification 5 days prior to survey but the goal timeframes were not updated to reflect the current status. All timeframes were outdated. In HOSRRNHV#4, the patient had a SW goal with a timeframe that had expired and was not updated. The patient also had recent issues with possible SNF placement that the SW was working on but there were no goals or interventions on the plan of care. In HOSRRNHV#5, the patient was having agitation and behaviors since start of care but it was not addressed on the plan of care. In HOSRRNHV#8, the patient had the SC visiting 1x monthly but there were no goals on the plan of care. In HOSRRNHV#9, the patient had a recent decline a week prior to survey which included not eating, possible UTI and possible transitioning. This was not addressed on the plan of care. In HOSRRNHV#10, the patient had a wound that had healed but the goal was not resolved on the plan of care. This was discussed and reviewed with the Hospice Manager.

Observed in Tracer Activities. The organization's documented volunteer activities totaled 3.8% of the of the total patient care hours of all paid hospice employees and contract staff.

Observed in Record Review. In 8 of 16 patient records reviewed, the organization failed to document that the medical director reviewed the patient clinical information prior to recertification. During record review for HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#6, HOSRRNHV#8, HOSRRHV#2, and HOSRRHV#4, the documentation did not occur prior to recertification. For example in HOSRRNHV#3, the Hospice Nurse Surveyor observed the new certification period began 5 days prior to survey. The documentation of the clinical review took place the same day survey began which was 4 days after the new certification. In HOSRRNHV#4, the new certification period began 6 days prior to survey. The documentation of the clinical review took place the same day survey began which was 5 days after the new certification. In HOSRRNHV#6, the new certification began 3 weeks prior to survey and there was not documentation of medical clinical review at time of survey. In HOSRRNHV#8, the new certification period began 2 months prior to survey and the documentation was not completed until 26 days later. In HOSRRHV#2, the most recent documentation of certification review occurred 15 days after the certification period began. In HOSRRHV#4, the documentation of the certification review occurred 10 days after the certification period began. In HOSRRNHV#1, the documentation of the certification review occurred 5 days after the certification period began. In HOSRRNHV#2, the most recent documentation of certification review occurred 10 days after the certification period began. This was discussed and reviewed with the Hospice Manager.

Observed in Emergency Management Session. In review of the written emergency operations plan and discussion with the hospice manager and safety coordinator, the surveyor found that the plan did not have a succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out their duties or a delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation.

Observed in Emergency Management Session. In review of the written emergency operations plan and discussion with the hospice manager and safety coordinator, the surveyor found that the plan did not describe how the organization would inform state and local officials of any on-duty staff they are unable to contact.

Observed in Emergency Management Session. In review of the written emergency operations plan and discussion with the hospice manager and safety coordinator, the surveyor found that the plan did not describe how the organization would inform state and local emergency preparedness officials before, during, and after emergencies on the following: - Patients the organization was unable to contact (to determine service needs) - Patients in need of evacuation due to their medical or behavioral health condition or home environment.

Observed in Record Review. In 6 of 13 patient records reviewed, the surveyor found that the organization had not identified measurable goals related to findings from the assessment. For example, in review of the plan of care for HV1, the respiratory goal was that there would be maintenance of respiratory baseline as evidenced by breathing at optimal level within disease parameters. This same patient had the same target date (approximately 90 days from admission) for each goal. This target date was found for goals that should require an earlier resolution such as demonstrate proper catheter care and satisfactory control of symptoms. In review of the plan of care for HV2 and HV3, the nutritional goal was that the patient's nutritional needs would be met as patient's condition/comfort allows. In RR2, the goal was for the patient to demonstrate stabilization of pulmonary status and that patient would maintain optimal bowel functioning consistent with food intake and stage of disease process. In RR3, the goal was that the Patient's symptoms would be consistent with stage of disease process and problem managed as well as disease process will allow. In RR4, the goal for Resource Management was not a goal but an intervention, educate patient/caregiver to access services needed. These findings were discussed with the hospice manager.

Observed in Record Review. In 5 of 13 patient records reviewed, the surveyor found that the organization had not specified interventions to address identified goals. For example, in review of the medical record for HV3, the goal was for the patient/caregiver to be able to describe measures to reduce/prevent fatigue but there were no interventions to teach related to this goal, only to assess. In review of the medical record for RR1, the goal was for the caregiver to describe behaviors and promote maximum control/independence but the intervention was to encourage verbalization of concerns, feelings, stressor. In RR2, the goal was for the patient/caregiver to verbalize understanding of falls/injury prevention and home safety measures but there were no interventions to teach related to this. In RR4, there were goals that required demonstration of knowledge and/or proper administration but there were no interventions to teach. In RR6, the goal was for patient/caregiver understanding of disease process including prognosis, signs and symptoms, complications, effect of disease on body systems and what to report but there were no interventions to teach related to this goal, only to assess. There was also a goal for the patient/caregiver to describe the therapeutic diet but there were no interventions related to teaching this. This was discussed with the hospice manager.

Observed in Record Review. In 7 of 13 patient records reviewed, the surveyor noted that the organization had not specified the unique medications and treatments necessary to meet the patient's needs. For example, in review of the medical record for RR1, the plan of care contained an order for morphine 0.25ml - 0.5ml prn for moderate pain and oxycodone 5mg 1-2 tabs prn for moderate pain. It was not specified under what circumstances each dosage should be administered or when morphine should be administered as opposed to oxycodone. In addition, Guaifenesin was ordered 5ml-10ml prn cough without further specifying when each dose should be given. In review of the medical record for RR3, the surveyor found that the plan of care contained an order for Lorazepam, 0.5mg, 1-2 tablets prn anxiety. It was not specified under what circumstances each dosage should be administered. In RR4, the plan of care had Senna S and Bisac-Evac ordered as needed for constipation without further defining when each one should be taken. In RR10, the surveyor found that the plan of care contained an order for Ativan 0.5mg - 1mg prn anxiety. It was not specified under what circumstances each dosage should be administered. In RR5, the plan of care contained an order for Lorazepam 0.25ml to 0.5ml prn anxiety and Guaifenesin was ordered 5ml-10ml prn cough without further specifying when each dose should be given. In RR6, the plan of care contained an order for Lorazepam 0.25ml to 0.5ml prn anxiety without further specifying when each dose should be given. In RR9, the plan of care contained an order for Benadryl 25mg, 1-2 capsules, prn itching without further specifying when each dose should be given. These findings were discussed with the hospice manager.

Observed in HR File Review. In 2 of 2 HR files reviewed, for the hospice aide, the surveyor did not find where the organization had evaluated the following areas by observing the hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: - Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. This was not found in review of the documents provided for HR7 or HR8.

Observed in Record Review. In 3 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the registered nurse had not provided the aide with information on safety precautions to implement or when to notify the nurse. For example, in review of the medical record for RR6, the patient was found to have progressive dysphagia, at risk for aspiration and had a wound dressing in place. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. In review of the medical record for RR7, the patient was at risk for aspiration. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this finding. In review of the medical record for RR9, the patient had a diagnosis of dysphagia and wound dressings in place on the coccyx and foot. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to these findings. These findings were discussed with the hospice manager.

Observed in Record Review. In 3 of 9 patient records reviewed, where the patient had hospice aide services ordered, the surveyor noted that the aide provided care that was not indicated on the aide plan of care. For example, in review of the medical record for RR6, the hospice aide was noted to be applying nystatin powder under the patient's breasts on multiple visits. This task was not listed on the aide plan of care. In review of the medical record for RR7, the hospice aide was noted to be assisting in feeding the patient on multiple visits in June and July. This task was not on the aide plan of care. In review of the medical record for RR9, the hospice aide was noted to be assisting in feeding the patient on several occasions. This task was not on the aide plan of care. These findings were discussed with the hospice manager.

Observed in Record Review. In 5 of 5 patient records reviewed, where the patient had oxygen in place, the surveyor found that education specific to causes of fire, fire risks to neighboring residences and buildings and ways to prevent fire related injuries had not been provided. For example, In HV3, education related to causes of fire, ways to prevent fire related injuries and risks to neighboring residences and buildings, was not found. In RR1, RR4, RR6, and RR10, education related to risks to neighboring residences and buildings, was not found. This was discussed with the hospice manager.