Every finding on record at Memorial Hospital Association

Based on interview and record review the agency failed to be in substantial compliance of the condition to establish a comprehensive emergency preparedness program with all of the required elements in writing. Findings include: --- 1. Create an emergency preparedness plan, review, and update the plan every two years (E0004); 2. Complete an emergency preparedness risk assessment specific to the agencys needs (E0006); 3. Address the patient population, persons at risk, the services the agency could provide in an emergency, and continuity of agency operations (E0007); 4. Include a process for collaborating with emergency preparedness officials to maintain an integrated response in an emergency (E0009); 5. Develop, implement, and review annually policies specific to the agencys emergency preparedness needs (E0013); 6. Develop policies and procedures to follow up with staff and patients in an emergency and notify officials of staff and patients the agency was unable to contact. (E0016); 7. Develop and implement policies and procedures to communicate with authorities for homebound patients needs in the event of an emergency (E0019); 8. Develop and implement emergency preparedness policies and procedures to secure and maintain medical documentation to preserve patient information, protects confidentiality, and maintains availability (E0023); 9. Develop and implement policies and procedures for the use of volunteers or other staffing strategies in the event of an emergency (E0024); 10. Establish an agency emergency preparedness communication plan for staff and patients (E0029); 11. Develop and maintain an emergency preparedness plan including the name and contacts of staff, patients, services under contract, patients physicians, volunteers, and other agencies (E0030); 12. Maintain contact information for local authorities and other sources of assistance in an emergency (E0031); 13. Develop an emergency preparedness communication plan with primary and alternate means of communication with staff and emergency officials (E0032); 14. Develop a communication plan including the way patient information would be shared to other providers in an emergency (E0033); 15. Develop and maintain a way of providing the agencys information on its needs and ability to provide assistance to the authorities in an emergency (E0034); 16. Implement an agency staff training and testing program for emergency preparedness (E0036); 17. Provide an emergency preparedness training based on their established emergency plan, risk assessment, policy and procedures, and communication plan every two years (E0037); 18. Conduct the required agency staff emergency preparedness testing exercises for staff every two years (E0039); and 19. Implement agency specific emergency preparedness components into an integrated health system (E0042).

Based on interview and record review, the agency failed to create and maintain an emergency preparedness plan, review, and update the plan with all required components every two years. Findings include: --- During an interview on 1/31/24 at 1:00 p.m., staff members N and O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program for the health system location. Review of the policies under the [Health System] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment.

Based on interview and record review, the agency failed to complete an emergency preparedness risk assessment specific to the agencys needs. Findings include: --- During an interview on 1/31/24 at 1:00 p.m., staff members Nand O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program with one risk assessment for the health system location. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment.

Based on interview and record review, the agency failed to address the patient population, persons at risk, the services the agency could provide in an emergency, and continuity of agency operations. Findings include: --- During an interview on 1/31/24 at 2:18 p.m., staff member P stated the agency was part of the health system emergency program on one risk assessment and plan for the patient needs and communication in an emergency. Staff member P stated the agency would be included if there were an emergency through the health system emergency preparedness program. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment for their population and agency needs.

Based on interview and record review, the agency failed to include a process for collaborating with emergency preparedness officials to maintain an integrated response in an emergency. Findings include: --- During an interview on 1/31/24 at 1:15 p.m., staff member N stated during training exercises and in an emergency, a representative for the whole health system would be sent to the command center to work with the emergency officials. Staff member N stated the agency would be part of the health system represented, but the agency was not always affected or included specifically. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness elements specific to the agency. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, "Emergency Operations Plan/Home Health Policy", showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.

Based on interview and record review, the agency failed to develop, implement, and review policies specific to the agencys emergency preparedness needs and risk assessment. Findings include: --- During an interview on 1/31/24 at 1:13 p.m., staff member N stated he was unaware of any separate policies for the agencys emergency preparedness plan but would look through the health system policies. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, "Emergency Operations Plan/Home Health Policy", showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.

Based on interview and record review, the agency failed to develop policies and procedures to follow up with staff and patients in an emergency and notify officials of staff and patients the agency was unable to contact. Findings include: --- During an interview on 1/29/24 at 3:00 p.m., staff member A stated agency staff were spread out through the county and there were dead zones for cell phone reception. Staff member A stated some staff had trouble with connecting to the internet. During an interview on 1/31/24 at 1:20 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they did not have text or email capabilities. Staff member N stated there were also backup radios in an emergency but did not know if agency staff had access to them. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan or backup communication process.

Based on interview and record review, the agency failed to develop and implement policies and procedures to communicate with authorities for homebound patients needs in the event of an emergency. Findings include: --- During an interview on 1/29/24 at 2:50 p.m., staff member A stated the patient charts would not show a triage level of need for emergencies, some such as hospice, had a form sent to local law enforcement when admitted notifying of hospice election and address. Review of patient admission packets for home health and hospice showed only hospice patients had the admission form sent to local law enforcement, however, it did not provide information on care needs in the event of an emergency or homebound/evacuation status. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any emergency preparedness policies for a communication plan with authorities for homebound patients needs.

Based on interview and record review, the agency failed to develop and implement emergency preparedness policies and procedures to secure and maintain medical documentation, to preserve patient information, protect confidentiality, and maintain availability in an emergency. Findings include: --- During an interview on 1/29/24 at 2:50 p.m., staff member A stated patient charts were electronic and paper charts. In an emergency, agency staff would still be able to access and distribute paper and electronic patient records to share information with emergency officials if needed. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness medical documentation policies specific to the agency needs. Review of agency policy provided on 1/31/24 at 1:44 p.m., titled, "Emergency Operations Plan/Home Health Policy", showed an effective date of 9/28/2017, with no further review dates in the required two years. The policy was not known to agency and emergency preparedness staff before the survey.

Based on interview and record review, the agency failed to develop and implement policies and procedures for the use of volunteers and other staffing strategies in the event of an emergency. Findings include: --- During an interview on 1/31/24 at 3:15 p.m., staff member P stated depending on when an emergency took place and who was the initial response, they would call the on-call manager of the health system. The on-call manager would work though the organizational chart for different departments involvement and staffing in an emergency through the health system emergency plan. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness staff and volunteer policies specific to the agency needs.

Based on interview and record review, the agency failed to establish an agency emergency preparedness communication plan for staff and patients. Findings include: --- During an interview on 1/31/24 at 1:20 p.m., staff member N stated there was an emergency communication plan for leadership. Each department leader was responsible for contacting their staff and patients in the event of an emergency. Staff member N stated he did not know of a specific communication plan for the agency with the required people listed. During an interview on 1/31/24 at 3:00 p.m., staff member P stated in the event of an emergency the organizational chart for the whole health system would be utilized. There was no specific plan for the agency for communication. Review of the [Health System] Emergency Operations Plan, last reviewed 1/5/23, did not show a communication plan for the required staff, patients, and volunteers listed for the agency.

Based on interview and record review, the agency failed to develop and maintain an emergency preparedness plan including the name and contacts of staff, patients, services under contract, patients physicians, volunteers, and other agencies. Findings include: --- During an interview on 1/31/24 at 1:20 p.m., staff member N stated there was an emergency communication plan for leadership. Each department leader was responsible for contacting their staff and patients in the event of an emergency. Staff member N stated he did not know of a specific communication plan for the agency with the required people listed. Review of the [Health System] Emergency Operations Plan, last reviewed 1/5/23, did not show the required names and contact information for agency staff, patients, contracted services, patient physicians, other agencies, and volunteers.

Based on interview and record review, the agency failed to maintain a communication plan with the contact information for local authorities and other sources of assistance in an emergency. Findings include: --- During an interview on 1/31/24 at 1:22 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they did not have text or email capabilities. The determination of who was contacted and when was by the health system leadership for the entire system, not specifically each department, such as the agency. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan with the required names and contacts.

Based on interview and record review, the agency failed to develop an emergency preparedness communication plan with primary and alternate means of communication with staff and emergency officials. Findings include: --- During an interview on 1/29/24 at 3:00 p.m., staff member A stated agency staff were spread out through the county and there were dead zones for cell phone reception. Some staff had trouble with internet connection as well. During an interview on 1/31/24 at 1:20 p.m., staff members N and O stated the health system had an application that would send emergency communications to staff, patients, and emergency officials by text and email, and others would be called by health system staff if they did not have text or email capabilities. Staff member N stated there were also backup radios in an emergency but did not know if agency staff had access to them. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any emergency preparedness policies for a communication plan with primary and alternate means of communication.

Based on interview and record review, the agency failed to develop a communication plan including the way patient information would be shared to other providers in an emergency when the main access to records was inaccessible. Findings include: --- During an interview on 1/29/24 at 2:50 p.m., staff member A stated patient charts were electronic and paper charts. In an emergency agency staff would still be able to access and distribute paper and electronic patient records to share information with emergency officials if needed. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the agency specific communication plan for providing patient information in the event of an emergency or if original electronic or paper charts were inaccessible.

Based on interview and record review, the agency failed to develop and maintain a way of providing the agencys information on its needs and ability to provide assistance to the authorities in an emergency. Findings include: --- During an interview on 1/31/24 at 1:00 pm., staff members Nand O stated the emergency preparedness program for the health system did not have specific plan elements or risk assessment for the agency. All emergency preparedness was under one program with one risk assessment for the health system location. Review of the policies under the [health system] Emergency Operations Plan, last revised 1/5/23, did not show any agency specific emergency preparedness policies or risk assessment to show the needs and abilities of the agency in an emergency.

Based on interview and record review, the agency failed to implement, document, review, and update an agency staff training and testing program for emergency preparedness based on the risk assessment and required program components. Findings include: --- During an interview on 1/31/24 at 1:25 p.m., staff members N and O stated, the health system had an actual flood emergency for the county in 2022. Staff members N and O stated the health system had conducted other tabletop and full-scale exercises but there were none specific to the agency or showing agency participation. Staff members N and O stated ongoing training with tests for emergency preparedness were included in the health system online training program and new hire orientation in person. Human Resources and the department managers would have access to agency staff records for completion. A request was made on 1/29/24 at 2:30 p.m., at the agency entrance conference, and another on 1/31/24 at 1:00 p.m., during the emergency preparedness meeting, for training and testing records including tabletop exercises for agency staff and none were provided by the end of the survey.

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 every two years for 2 (staff members D and G) of 7 sampled staff members. Findings include: --- During an interview on 1/31/24 at 11:40 a.m., staff member N stated he provided an initial on-boarding emergency preparedness training to new staff at the beginning of their employment. He stated he did not provide a biannual emergency preparedness training for staff based on their established emergency plan, risk assessment, policy and procedures, and communication plan, because staff completed the annual computer-based trainings for emergency preparedness. He stated he was not certain what that specific training included. During an interview on 2/1/24 at 8:10 a.m., staff member Q stated the annual computer-based emergency preparedness training provided to staff included FEMA (Federal Emergency Management Agency) and incident command. She stated the computer-based training was not specific to the agencys EP plan. Review of the agency personnel files on 2/1/24 at 8:40 showed staff members D and G were not provided a biannual EP training based on the agencys EP Plan.

Based on interview and record review, the agency failed to conduct and document the required agency staff emergency preparedness testing exercises for agency staff annually. Findings include: --- During an interview on 1/31/24 at 1:25 p.m., staff members N and O stated, the health system had an actual flood emergency for the county in 2022. Staff members N and O stated the health system had conducted other tabletop and full-scale exercises but there were none specific to the agency or showing agency participation. Staff members N and O stated ongoing training with tests for emergency preparedness were included in the health system online training program and new hire orientation in person. Human Resources and the department managers would have access to agency staff records for completion. A request was made on 1/29/24 at 2:30 pm., at the agency entrance conference, and another on 1/31/24 at 1:00 p.m., during the emergency preparedness meeting, for testing records including tabletop exercises for agency staff and none were provided by the end of the survey.

Based on interview and record review, the agency failed to implement and document required agency specific risk assessment, policies, and emergency preparedness components into an integrated health system emergency preparedness program. Findings include: --- During an interview on 1/31/24 at 1:00 p.m., staff member N stated the emergency preparedness program was all in one for the health system location. There were no specific emergency plan elements for the agency. Review of the [Health System] Emergency Operation Program, last reviewed on 1/5/23, did not show the required emergency preparedness elements specific to the agency.

Due to the manner and degree of the deficient practice, the agency failed to meet the Condition of Participation: Patients' rights. --- Based on interview and record review, the agency failed to: Develop and implement policies and procedures for the notice of patient's rights; and failed to provide the patient or the patient's representative with a written notice of patient's rights and responsibilities, prior to providing care for 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. (See L0502); and Ensure a notice of patient's rights and responsibilities was signed and documented in the EMR or paper chart of 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. (See L0504). The accumulation of these deficient practices had the potential to affect all patients admitted to hospice services and had the potential for patients to not be informed of their patient's rights.

Based on interview and record review, the agency failed to develop and implement policies and procedures for the notice of patient's rights; and failed to provide the patient or the patient's representative with a written notice of patient's rights and responsibilities, prior to providing care for 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. This deficient practice had the potential to affect all patients admitted to hospice services and had the potential for patients to not be informed of their patient's rights. Findings include: --- During an interview on 1/31/24 at 2:22 p.m., staff member A stated the signed notice of patient's rights and responsibilities was not in the EMR or the paper charts for any of the hospice patients. Staff member A stated during a patient's initial assessment, the nurses documented the notice of patient's rights and responsibilities was provided to the patients. Staff member A stated the nurses assumed the information was provided to the patients during the admission process, prior to the initial assessment. Staff member A stated a form for patient's rights and responsibilities would need to be developed for it to be provided to hospice patients. Review of 14 sampled patient's EMR's (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) showed no documentation of a written notice of patient's rights and responsibilities was provided to the patients. A request for the agency's policies and procedures for patient's rights was given to staff member A on 2/1/24 at 10:00 a.m. Staff member A stated on 2/1/24 at 12:32 p.m., the agency did not have any established policies and procedures for patient's rights.

Based on interview and record review, the agency failed to ensure a notice of patient's rights and responsibilities was signed and documented in the EMR or paper chart of 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. This deficient practice had the potential to affect all patients admitted to hospice services and had the potential for patients to be unaware of their patient rights. Findings include: --- During an interview on 1/31/24 at 2:22 p.m., staff member A stated the signed notice of patient's rights and responsibilities was not in the EMR or the paper charts for any of the hospice patients. Staff member A stated a form for patient's rights and responsibilities would need to be developed for all patients or their representatives to sign, prior to the initial assessment. Review of all 14 sampled patient's EMRs (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) showed the facility lacked documentation of a signed, written notice of patient's rights and responsibilities.

Due to the manner and degree of the deficient practices, the agency failed to meet the Condition of Participation: Initial and comprehensive assessment of patient. Findings include: --- Based on observation, interview, and record review, the agency failed to: Develop and implement policies and procedures which addressed the completion and content of the comprehensive assessment; and failed to have a comprehensive assessment completed, within 5 days of election of hospice care for 3 (#s 3, 5, and 7) of 14 sampled patients. (See L0523); Ensure staff member D performed a comprehensive assessment which included a complete review of systems for 1 (#6) of 2 observed, sampled patients. (See L0524); and Ensure staff member D reviewed medications when completing a comprehensive assessment for 1 (#6) of 2 observed, sampled patients. (See L0530). The accumulation of these deficient practices had the potential to affect all patients by the potential for the agency failing to identify physical, psychosocial, emotional, and spiritual needs of each patient, which contribute to the ongoing development and updating of the plan of care; the clinician potentially failing to identify changes in physical needs related to the patients terminal illness; and for the potential of the agency to identify drug interactions, drug side effects, and duplicate drug therapy for the patients.

Based on interview and record review, the agency failed to develop and implement policies and procedures which addressed the completion and content of the comprehensive assessment; and failed to have a comprehensive assessment completed, within 5 days of election of hospice care for 3 (#s 3, 5, and 7) of 14 sampled patients. This deficient practice had the potential to affect all patients by the potential failure to identify physical, psychosocial, emotional, and spiritual needs, which contribute to the ongoing development and update of the plan of care. Findings include: --- 1. Review of patient #3s EMR showed the patient had an admission diagnosis of malignant neoplasm of unspecified site of unspecified female breast, with the start of care dated 10/24/23. An initial comprehensive assessment was completed on 10/24/23, with a certification period of 10/24/23 – 1/21/24. No further comprehensive assessment was completed for the certification period of 1/22/24 – 4/20/24. During an interview on 1/31/24 at 2:20 p.m., staff member A stated she was unable to locate patient #3s comprehensive assessment for the certification period 1/22/24 – 4/20/24. 2. Review of patient #5s EMR showed the patient had an admission diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation, with the start of care dated 7/5/23. An initial comprehensive assessment was completed on 7/5/23, with a certification period of 7/5/23 – 10/2/23. No further comprehensive assessment was completed for the certification period of 10/3/23 – 12/31/23 or 1/1/24 – 2/29/24. During an interview on 1/31/24 at 1:45 p.m., staff member A stated she was unable to locate patient #5s comprehensive assessment for the certification period 10/3/23 – 12/21/23 or 1/1/24 – 2/29/23. 3. Review of patient #7s EMR showed the patient had an admission diagnosis of Alzheimer's disease with early onset, with the start of care dated 12/27/22. An initial comprehensive assessment was completed on 12/27/22, with a certification period of 12/27/22 – 3/26/23. No further comprehensive assessment was completed for the certification period of 3/27/23 – 6/24/23. During an interview on 2/1/24 at 12:32 p.m., staff member A stated she was unable to locate patient #7s comprehensive assessment for the certification period 3/27/23 – 6/24/23. A request for the agencys policies and procedures for the completion and content of the comprehensive assessment was made on 2/1/24 at 10:00 a.m. During an interview on 2/1/24 at 12:15 p.m., staff member A stated comprehensive assessments for a recertification should be completed within 5 days of election of services. Staff member A stated on 2/1/24 at 12:32 p.m., the facility did not have a policy or procedure related to the comprehensive assessment.

Based on observation, interview, and record review, the agency failed to develop and implement policies and procedures which addressed the completion and content of the comprehensive assessment; and staff member D failed to perform a comprehensive assessment which included a complete review of systems for 1 (#6) of 2 observed patients. This deficient practice had the potential to affect all patients receiving hospice services. Findings include: --- Review of patient #6s EMR showed the patient had an admission diagnosis of liver cell carcinoma, with a start of care dated 11/2/23. During an observation on 1/30/24 at 11:35 a.m., staff member D entered patient #6s home for a scheduled visit. Staff member D assessed patient #6s vital signs, pain level, and evaluated his existing abdominal mass for any changes. No other physical assessment was observed. Staff member D did not look at patient #6s medication. During an interview on 1/30/24 at 12:05 p.m., staff member D stated she did not check patient #6s medications during the visit. She stated patient #6 was independent with his medications and did not have an emergency medication kit at this time. Review of patient #6s EMR showed the scheduled visit on 1/30/24 was for a hospice comprehensive assessment for the new certification period beginning on 1/31/24. The comprehensive assessment failed to show areas of the physical assessment uncompleted, including the following: -... ";Cardiovascular – Not assessed this visit, -... Respiratory, Status not assessed this visit, and -...Medication Profile Review, Not Assessed. ..." During an interview on 2/1/24 at 8:59 a.m., staff member D stated when completing a patients new certification period, comprehensive assessment, she used information gathered over the last couple of months. She stated she had not always completed a review of all systems. Staff member D was asked how she would identify changes in lung sounds if she had not listened to the patient #6s lungs and she stated if she did not think there was a change, she would not assess his lungs. Staff member D stated she did not always assess everything. She stated she was not trained to review all the systems on a comprehensive assessment for a new certification period. During an interview on 2/1/24 at 9:02 a.m., staff member D stated she did not always look at all the patients medications on a comprehensive assessment for a new certification period. A request for the agencys policies and procedures for the completion and content of the comprehensive assessment was made on 2/1/24 at 10:00 a.m. During an interview on 2/1/24 at 12:15 p.m., staff member A stated an initial and updated or new certification period assessment were the same assessments. She stated all systems need to be assessed and documented. Staff member A stated a head-to-toe assessment was required and medications were to be assessed during every patient visit. Staff member A stated on 2/1/24 at 12:32 p.m., the agency did not have a policy or procedure related to the comprehensive assessment.

Based on observation, interview, and record review, the agency failed to develop and implement policies and procedures which addressed the completion and content of the comprehensive assessment; and staff member D failed to review medications when completing a comprehensive assessment for 1 (#6) of 2 observed patients. This deficient practice had the potential to affect all patients receiving hospice care. Findings include: --- Review of patient #6s EMR showed the patient had an admission diagnosis of liver cell carcinoma, with a start of care dated 11/2/23. During an observation on 1/30/24 at 11:35 a.m., staff member D entered patient #6s home for a scheduled visit. Staff member D did not look at or review patient #6s medication. During an interview on 1/30/24 at 12:05 p.m., staff member D stated she did not check patient #6s medications during the visit. She stated patient #6 was independent with his medications and did not have an emergency medication kit at this time. Review of patient #6s EMR showed the scheduled visit on 1/30/24 was for a hospice comprehensive assessment for the new certification period beginning on 1/31/24. The comprehensive assessment showed, under the medication profile review, ";Not Assessed." During an interview on 2/1/24 at 9:02 a.m., staff member D stated she did not always look at all the patients medications on a comprehensive assessment for a new certification period. A request for the agencys policies and procedures for the completion and content of the comprehensive assessment was made on 2/1/24 at 10:00 a.m. During an interview on 2/1/24 at 12:15 p.m., staff member A stated medications were to be assessed during every patient visit, including a comprehensive assessment. Staff member A stated on 2/1/24 at 12:32 p.m., the agency did not have a policy or procedure related to the comprehensive assessment.

Based on observation, interview, and record review, the agency failed to identify pain as a problem on the plan of care; develop interventions, set goals for symptom management, and re-evaluate the effectiveness of the current plan of care for 4 (#s 2, 3, 4, and 5) of 14 sampled patients. This deficient practice had the potential to affect all patients who identified pain as a symptom of their terminal disease process. Findings include: --- 1. Review of patient #2s EMR showed the patient had an admission diagnosis of malignant neoplasm of unspecified part of right bronchus or lung, with the start of care dated 7/13/23. Patient #2s plan of care for the certification period 1/9/24 – 3/8/24, showed he was prescribed the following pain medications: -..."acetaminophen-hydrocodone 325 mg-5 mg oral tablet; Take 1 tab(s) orally every 6 hours as needed for moderate pain – Active, Start Date: 12/4/23, -oxycodone 5 mg tablet; Take 1 tab(s) orally every 6 hours as needed for moderate pain – Active, Start Date: 7/17/23, and -roxanol 20 mg/ml liquid; Administer 0.25 – 1.0 milliliter(s) orally every 2 hours as needed for pain – Active, Start Date: 7/12/23. ..." Pain was not identified as a problem on the plan of care, no pharmacological or alternative therapy interventions for pain were identified, and no goals were identified for levels of pain and/or the evaluation of pain. Review of patient #2s EMR, Plan of Care Summary, dated 1/13/24 showed: ..."He [patient #2] has occasional right side rib pain at night and take 1-2 pain pills per day of this. ..." 2. Review of patient #3s EMR showed the patient had an admission diagnosis of malignant neoplasm of unspecified site of unspecified female breast, with the start of care dated 10/24/23. An initial comprehensive assessment was completed on 10/24/23, with a certification period of 10/24/23 – 1/21/24. No further comprehensive assessment was completed or documented in the medical record, for the certification period of 1/22/24 – 4/20/24. During an interview on 1/31/24 at 2:20 p.m., staff member A stated she was unable to locate patient #3s comprehensive assessment for the certification period 1/22/24 – 4/20/24. Review of patient #3s EMR, Patient Face Sheet (current), showed the patient was prescribed the following pain medications: -..."fentanyl 25 mcg/hr transdermal film, extended release; Apply 1 patch transdermally every 72 hours – Active, Start Date: 11/8/23, -fentanyl 12 mcg/hr transdermal film, extended release; Apply 1 patch transdermally every 72 hours – Active, Start date: 11/1/23, -oxycodone 10 mg oral tablet; Take 1 tab(s) orally 4 times a day as needed for moderate pain – Active, Start Date: 10/27/23, -acetaminophen-hydrocodone 325 mg-5 mg oral tablet; Take 1-2 tab(s) oral every 4 to 6 hours as needed for moderate pain – Active , Start date 10/25/23, and -roxanol 20 mg/ml liquid; Administer 0.25 – 1.0 milliliter(s) orally every 2 hours as needed for pain – Active, Start Date: 10/25/23. ..." Pain was not identified as a problem on the plan of care, no pharmacological or alternative therapy interventions for pain were identified, and no goals were identified for levels of pain and/or the evaluation of pain for the patient. 3. Review of patient #4s EMR showed the patient had an admission diagnosis of malignant neoplasm of prostate, with the start of care dated 11/9/23. Patient #4s plan of care for the certification period 11/9/23 – 2/6/24, showed he was prescribed the following pain medication: -..."roxanol 20 mg/ml liquid; Administer 0.25 – 1.0 milliliter(s) orally every 2 hours as needed for pain – Active, Start Date: 11/9/23. ..." Pain was not identified as a problem on the plan of care, no pharmacological or alternative therapy interventions for pain were identified, and no goals were identified for levels of pain and/or the evaluation of pain for the patient. 4. Review of patient #5s EMR showed the patient had an admission diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation, with the start of care dated 7/5/23. An initial comprehensive assessment was completed on 7/5/23, with a certification period of 7/5/23 – 10/2/23. No further current, comprehensive assessment was completed or documented in the medical record, for the certification period of 10/3/23 – 12/31/23 or 1/1/24 – 2/29/24. During an interview on 1/31/24 at 1:45 p.m., staff member A stated she was unable to locate patient #5s comprehensive assessment for the certification period 10/3/23 – 12/21/23 or 1/1/24 – 2/29/23. During an observation on 1/30/24 at 11:05 a.m., patient #5 conveyed to staff member D she had used ";Solanpas" pain patches for her back pain, which was effective. No discussion of past or current pain levels took place at this time. During an interview on 1/30/24 at 12:10 p.m., staff member D stated patient #5 did not have chronic pain issues. Staff member D stated ";pain" was not an identified problem on patient #5s plan of care, but she assessed for pain. Pain was not identified as a problem on the plan of care, no pharmacological or alternative therapy interventions for pain were identified, and no goals were identified for levels of pain and/or the evaluation of pain for the patient. During an interview on 1/30/24 at 12:50 p.m., staff member A stated the care plan process was a basic hospice care plan, based on symptom severity and chronic pain for each patient. She stated patients were screened for pain during visits, but pain was not necessarily on the plan of care. Staff member A stated pain was charted in notes and flowsheets for each patient.

Based on interview and record review, the agency failed to follow their established policies and procedures which showed the hospices interdisciplinary group (IDG) reviewed, revised, and documented the patients individualized plan of care at intervals no less than every 15 calendar days for 14 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. These deficient practices had the potential to affect all patients being provided hospice services. Findings include: --- Review of the agencys policy and procedure titled, Interdisciplinary Group, last reviewed/revised 12/21/21, showed: -..."The Hospice Interdisciplinary Group membership must include a Medical Director who is a doctor of medicine or osteopathy, a registered nurse, social worker and spiritual counselor. -...The Interdisciplinary Group will meet on the 1st, 3rd, 5th Monday of the month. ..." Review of the agencys policy and procedure titled, Interdisciplinary Plan of Care, last reviewed/revised 12/21/21, showed: -..."IDG Care Plan -The IDG Care Plan lists IDG team assignments, patient problems, goals and interventions. -1. The plan is reviewed and updated at each IDG meeting. -...8. Signatures of the IDG Attending the IDG meeting are found at the bottom of the IDG Update form that is completed for each patient to document review of the individual plans of care by the IDG." A request was made on 1/31/24 at 12:38 p.m. for IDG documentation for patient #5. During an interview on 1/31/24 at 2:29 p.m., staff member A stated there was no IDG documentation in the medical records for any of the hospice patients. She stated, "The system is broken, even though they are having meetings every 14 days, there is no documentation to prove the meetings are happening." Staff member A stated this problem was identified in the 4th quarter of the last year (2023). No IDG documentation was available for any of the 14 sampled patients.

Based on interview and record review, the agency failed to be in substantial compliance of the condition to establish and implement a QAPI program with the required agency specific process, members, reporting, and projects. Findings include: --- During an interview on 1/29/24 at 2:45 p.m., staff member A stated there currently were no QAPI projects for the agency. Staff member A stated QAPI was managed by other staff members of the health system, and she only gave them reports. She stated the only QAPI documentation would be in the form of the CEO report to the governing board for the agency. During a QAPI interview of multiple staff on 1/31/24 at 3:00 p.m., staff members P and S stated the agency QAPI was part of the quarterly executive committee, which reported to the governing board. Staff members P and S stated if major issues arose, the agency would start to work on and would hold an ad hoc QAPI, if necessary. Staff member A stated the agency identified in the last quarter of 2023, documentation of the IDG meetings were not done, and it would be addressed in the next quarterly executive meeting. Staff member P stated the IDG meeting minutes not being documented should have been an ad hoc QAPI meeting but had not been. Review of the [Health System] Critical Access Quality Improvement Plan, last revised 7/2021, showed the agency was listed as to participate in quality improvement activities of the health system QAPI, however the plan did not have the required information for the agencys QAPI program. Review of the CEO reports for 1/2023 through 12/2023 did not show any QAPI initiatives. The only mention of the agency was in relation to increased profits and census.

Based on observation and interview, staff member D failed to adhere to standard precautions, related to hand hygiene while dispensing patient medications into weekly pill organizers for 1 (#5) of 2 observed patients. This deficient practice had the potential to affect all patients by potentially spreading transmissible infectious agents from ungloved hands. Findings include: --- During an observation on 1/30/24 at 11:12 a.m., staff member D was observed placing medications from individual pill bottles into patient #5s weekly pill organizer. Staff member D was pouring pills into her open, ungloved hand, then putting individual pills into the organizers. Staff member D dropped an aspirin on the floor, picked the pill off the floor and set it aside. She did not sanitize her hands, and she went back to filling the pill organizer with medication. Staff member D placed vitamin E capsules into the pill organizer, then discovered the medication was not on the medication administration record (MAR) in her computer. Staff member D removed all the vitamin E from the pill organizer with her bare hands. Staff member D typed information into her computer, touched her mouth with her right hand, typed into her computer, and touched her mouth again with her right hand. She then picked up a bottle of gabapentin, and placed the gabapentin pills into the hand with which she had touched her mouth and computer. No hand sanitization took place during this observation period. During an interview on 1/30/24 at 12:11 p.m., staff member D stated she would usually fill pill organizers with gloved hands, and she should have worn gloves. She stated she had not been observed in the field for any return demonstration or competencies of infection control practices by the clinical manager. During an interview on 1/30/24 at 12:57 p.m., staff member A stated medication should not be handled without gloves. She stated there was not oversight of nurses in the field and no observations of skills or competencies for any staff providing cares. During an interview on 1/31/24 at 10:25 a.m., staff member M stated any hand hygiene practices would be referred to the hospice clinical manager for oversight. She stated there were not any specific annual, infection control competencies for care providers. During an interview on 1/31/24 at 10:53 a.m., staff member M stated handling medications with bare hands would not be considered best practice.

Based on observation, interview, and record review, the agency failed to ensure staff received annual infection control education consistent with accepted standards of practice for infection prevention and treatment to be implemented in the home setting for 7 (staff members D, E, F, G, I, J, and L) of 7 sampled staff members. This deficient practice had the potential to affect all patients receiving services. Findings include: --- A review of the agency policy and procedure titled, Orientation, Mandatory and Ongoing Staff Education and Competency Assessment Cycle, last revised 7/18/17, showed: - F. Mandatory Education: 1. All [Facility Name] employees will be required to complete ongoing education that includes, but is not limited to the following: ...b. Infection control topics including, but not limited to: i. Hand hygiene ii. TB exposure control iii. Infectious waste management iv. Standard Precautions v. Isolation practices vi. Cleaning, disinfection, and sterilization..." 1. During an interview 2/1/24 at 8:10 a.m., staff member Q stated staff were expected to complete annual computer-based training on infection control and prevention. She stated the computer-based trainings were refresher courses on infection control practices, but were not specific to such practices used in the home setting. She stated the annual hands-on infection control competency-based training was provided by staff member M. Review of the agencys personnel files on 2/1/24 at 8:10 a.m., showed the following staff members had not completed an annual computer-based training on infection control practices: - Staff member D: no computer-based IFC training on file. - Staff member G: Last IFC training was completed on 6/29/22. - Staff member F: Last IFC training was completed on 9/14/22. - Staff member J: Last IFC training was completed on 5/3/22. 2. During an interview on 1/31/24 at 10:30 a.m., staff member M stated she provided the agency staff with infection control education and competency evaluations annually. She stated she had just provided a training regarding the use of PPE. Staff member M stated this education was not based on the infection control practices utilized by staff in the home setting. A review of the agencys personnel files on 2/1/24 at 8:10 a.m., showed staff members D, E, F, G, I, J, and L, received education titled, PPE Acknowledgement, which outlined the following: - ";I have received and understand education regarding PPE and donning and doffing. - I understand that it is my responsibility to properly disinfect and store my face shield/goggles/PAPR before and after use with Sani-Cloths. - If I leave the room of a designated Isolation Precaution Room, I will not wear any of my PPE I was wearing in the precaution room to prevent cross contamination. - I understand that I must wear PPE in all rooms that have been designated for isolation. - I will only wear the N-95 that I was fit tested for during orientation or annual fit testing. - Men understand that they will be clean shaven when wearing N-95 masks, no stubble or facial hair." On 2/1/24 at 9:00 a.m., a request was submitted to provide additional infection control education training for all agency staff for accepted standards of practice for infection prevention and treatment to be implemented in the home setting for staff members D, E, F, G, I, J, and L. No additional information on was provided by the end of the survey.

Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Core Services; the agency failed to hire direct care nursing staff instead of utilizing supplemental contracted agency nursing staff when there was not an unexpected staffing shortage identified by the agency for hospice nursing services for 1 (staff member D) of 4 sampled registered nurses. This deficient practice had the potential to affect all patients receiving hospice nursing services. Findings include: --- During an interview on 2/1/24 at 8:10 a.m., staff member Q stated staff member D was a direct care nurse for the agency when she left the hospice agency and joined a contract nursing agency. She stated staff member D was re-hired as a contracted agency nurse by the hospice agency on 8/27/21. Staff member Q stated staff member D had been working for the hospice agency since that date. Review of the agencys Independent Contractor Agreement showed: ";...12. Termination: this Agreement shall terminate as follows: a) By mutual written Agreement of the parties. b) Either party may terminate this Agreement upon 30 days written notice with or without cause: In witness whereof, the parties have executed this Agreement on the dates set forth below". The agreement was signed by staff member D on 8/27/21; and, by staff member Q on 8/30/21. Review of staff member Ds Independent Contractor Agreement Exhibit B Addendum, Location and Scheduled Services showed, ";Schedule: Registered Nurse will provide intermittent fill-in coverage at the request of [Hospice Agency] and agree to monthly schedule with Manager of Home Care and Hospice. For specific dates of 12/5/21 through 6/4/22, RN will provide 32 hours per week of services for this specific 26-week schedule." The agreement was signed by an ";HR Generalist" and staff member D on 11/17/21. Review of staff member Ds Independent Contractor Agreement, Exhibit C Addendum, Compensation and Payment, showed the document was dated and signed by staff member Q on 12/16/22 and staff member D on 12/19/22. The Addendum C did not include extension of scheduled services to be provided by the contractor, and did not include dates for services to be provided. During an interview on 2/1/24 at 12:15 p.m., staff member V stated although the facility currently had a hardship for staffing and hiring nurses, they had not been actively recruiting for direct care nursing staff for the hospice agency. She stated the agency did not currently have an open requisition to hire any direct care nursing staff. Staff member V stated she spoke with staff member A and noted the reason for maintaining staff member D as a contracted nurse since 8/2021, was to maintain competent nursing for the hospice agency.

Based on interview and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Home Health Aide Services. Findings include: --- The agency failed to ensure the Home Health Aide (HHA), which provided care to hospice patients, had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs for 1 (staff member J) of 1 sampled HHA, providing aide services to hospice patients. This deficient practice had the potential to affect all patients utilizing home health aide services. (See L0609); and The agency failed to ensure Home Health Aide (HHA), which provided care to hospice patients, received annual 12 hours of in-service training for 1 (staff member J) of 1 sampled HHA, providing aide services to hospice patients. This deficient practice had the potential to affect all patients receiving home health aide services. (See L0620).

Based on interview and record review, the agency failed to ensure the Home Health Aide (HHA), which provided care to hospice patients, had maintained an active home health aide endorsement of certification from the state agency for completing a training and competency evaluation program specific to the agency and patient needs for 1 (staff member J) of 1 sampled HHA, providing aide services to hospice patients. This deficient practice had the potential to affect all patients utilizing home health aide services. Findings include: --- Review of the Montana State Home Health Aide Registry, dated 2/1/24, showed staff member J had an expired CNA Home Health Aide Endorsement Staff member J's endorsement expired on 5/31/23. During an interview on 2/1/24 at 8:50 a.m., staff member Q stated they did not have an updated CNA Home Health Aide endorsement for staff member J. Staff member Q stated it would be the expectation that all certifications for services provided would be maintained and not expired.

Based on interview and record review, the agency failed to ensure a Home Health Aide (HHA), which provided care to hospice patients, received annual 12 hours of in-service training for 1 (staff member J) of 1 sampled HHA, providing aide services to hospice patients. This deficient practice had the potential to affect all patients receiving home health aide services. Findings include: --- During an interview and record review on 2/1/24 at 8:50 a.m., staff member Q stated the agency did not have documentation to show staff member J received 12 hours of in-service training within the last 12-months.

Based on interview and record review, the agency failed to complete an annual competency evaluation of direct care staff for 7 (staff members D, E, F, G, I, J, and L); and failed to complete annual in-service trainings for 2 (staff members D and F) of 7 sampled staff members. This deficient practice had the potential to affect all patients receiving direct care services. Findings include: --- A review of the agencys policy and procedure titled, - ";Policy: [Facility Name] provides general organizational orientation, general clinical provider orientation, departmental orientation and initial and ongoing mandatory education to its employees, temporary agency staff and volunteers... The competency assessment process will occur on an ongoing basis. Competencies will be identified on an annual basis through a collaborative process and assessed on a continuum throughout the employment of an individual... - A. Competency Accountabilities Defined 1. Manager is responsible for: a. Receiving and distributing information from Human Resources b. Establishing a mechanism to identify specific departmental competencies with staff involvement c. Creating an environment that promotes timely competency assessment and ongoing growth and development d. Providing education to employees on the competency process e. Monitoring employee progress f. Participating in evaluation of the competency assessment cycle and program. - 2. Employee is responsible for: a. Completing competencies as indicated b. Participating in competency selection and development c. Participating in evaluation of the competency assessment process..." 1. During an interview and record review of personnel files on 2/1/24 at 8:10 a.m., staff member Q stated staff were expected to complete an annual performance evaluation directing and evaluating the competencies needed by employees. Staff member Q stated staff member A was responsible for completing these evaluations. Staff member Q stated the evaluations were due on 9/2023, and then were postponed until 1/8/24. She stated the evaluations had not been completed as of 2/1/24. A review of the agencys personnel files showed the following staff members had not been provided an annual competency by the agency: Staff members D, E, F, G, I, J, and L. 2. During an interview and record review of personnel files on 2/1/24 at 8:10 a.m., staff member Q stated it was the expectation that staff complete an annual in-service training. A review of agencys personnel files showed the following staff members had not completed their annual in-service training: Staff members D and F.

Based on interview and record review, the agency failed to have a comprehensive assessment completed and documented in the medical record, within 5 days of election of hospice care, for 3 (#s 3, 5, and 7) of 14 sampled patients. Findings include: --- 1. Review of patient #3s EMR showed the patient had an admission diagnosis of malignant neoplasm of unspecified site of unspecified female breast, with the start of care dated 10/24/23. An initial comprehensive assessment was completed on 10/24/23, with a certification period of 10/24/23 – 1/21/24. No further comprehensive assessment was completed or documented in the medical record, for the certification period of 1/22/24 – 4/20/24. During an interview on 1/31/24 at 2:20 p.m., staff member A stated she was unable to locate patient #3s comprehensive assessment for the certification period 1/22/24 – 4/20/24. 2. Review of patient #5s EMR showed the patient had an admission diagnosis of chronic obstructive pulmonary disease with (acute) exacerbation, with the start of care dated 7/5/23. An initial comprehensive assessment was completed on 7/5/23, with a certification period of 7/5/23 – 10/2/23. No further comprehensive assessment was completed or documented in the medical record, for the certification period of 10/3/23 – 12/31/23 or 1/1/24 – 2/29/24. During an interview on 1/31/24 at 1:45 p.m., staff member A stated she was unable to locate patient #5s comprehensive assessment for the certification period 10/3/23 – 12/21/23 or 1/1/24 – 2/29/23. 3. Review of patient #7s EMR showed the patient had an admission diagnosis of Alzheimer's disease with early onset, with the start of care dated 12/27/22. An initial comprehensive assessment was completed on 12/27/22, with a certification period of 12/27/22 – 3/26/23. No further comprehensive assessment was completed or documented in the medical record, for the certification period of 3/27/23 – 6/24/23. During an interview on 2/1/24 at 12:32 p.m., staff member A stated she was unable to locate patient #7s comprehensive assessment for the certification period 3/27/23 – 6/24/23. During an interview on 2/1/24 at 12:15 p.m., staff member A stated comprehensive assessments for a recertification should be completed within 5 days of election of services.

Based on interview and record review, the agency failed to have a signed copy of the patients rights included in their medical record for 14 (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14) of 14 sampled patients. Findings include: --- Review of all 14 sampled patient's EMR (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14), showed no documentation of a signed, written notice of the patients rights and responsibilities. During an interview on 1/31/24 at 2:22 p.m., staff member A stated the signed notice of patient's rights and responsibilities was not in the EMR or the paper charts for any of the hospice patients. She stated during the initial assessment, the nurses documented the notice of patient's rights and responsibilities was provided to the patients. Staff member A stated the nurses assumed the information was provided during the admission process, prior to the initial assessment. Staff member A stated a form for patient's rights and responsibilities would need to be developed in order for it to be provided to all the patients.