Every finding on record at Memorial Hospital of Sheridan County

Observed in Emergency Management Session. Review of EOP revealed a one page 96 hour Rule that included directions to staff and no other EOP was documented or updated every 2 years. This was validated with the Hospice Manager.

Observed in Emergency Management Session. Review of the Emergency Operation Plan revealed the organization had not ensured it conducted a hazard vulnerability analysis utilizing an all-hazards approach. For example: the Hospice was a part of a hospital wide emergency management plan but the HVA did not specifically address hospice's vulnerabilities. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Emergency Management Session. During review of the Emergency Binder it was noted the HCO did not have a method to identify volunteers. This was validated with the Hospice Manager.

Observed in Emergency Management Session. During review of the Emergency Management binder revealed no contact information for the Volunteers. This was validated with the Hospice Manager.

Observed in Emergency Management Session. During review of the HR file it was noted the Volunteers were not trained or included in the Emergency Management Binder. This was validated with Hospice Manager.

Observed in Emergency Management Session. Review of the Emergency Operation Plan revealed the organization had not ensured it planned and conducted exercises to test its emergency operations plan and response procedures. For example: review of the Emergency Operation Plan's drill revealed the last drill was completed in 2021. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Emergency Management Session. Review of the Emergency Operations Plan revealed the organization had failed to document the active participation in the development of the program or had a coordinated communication plan. This was validated with the Hospice Manager.

Observed in Document Review. During Contracts review it was noted the organization had not ensured a Durable Medical Equipment contract included a Business Associate Agreement to include or language in the contract that included access to or release of patient information and clinical records as permitted in accordance with 45 CFR parts 160 and 164. This was reviewed, discussed, and validated with the Director of Nursing/Administrator.

Observed in Record Review. In 1 of 2 discharged patient records reviewed, During HOSRRDC# 1's patient record review it was noted the organization had not planned the patient's care. For example: review of HOSRRDC# 1's patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring with no update to the plan of care. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer with no update to the plan of care. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1's patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days or the plan of care was updated. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Record Review. During the Medical Director interview and patient records review it was noted the organization had not ensured it provided interdisciplinary care, treatment, or services. For example: during the Medical Director interview it was noted the Medical Director did not have a back up physician to attend the Interdisciplinary Group (IDG) when the Medical Director was not able to attend/participate. The Medical Director shared that when unable to attend/participate in the IDG, the Medical Director would follow up with the Hospice Manager for updates. The Hospice Manager shared if the Medical Director had not signed the IDG then the Medical Director did not attend. Review of the IDG's dated approximately 58 days prior to the surveyor review of the record revealed no signature of the Medical Director. During IDG and patient record review it was noted the organization had not had a Spiritual Coordinator for approximately the last two months. This was reviewed, discussed, and validated with the Hospice Manager. Observed in Record Review. In 1 of 2 discharged patient records reviewed, During HOSRRDC# 1's patient record review it was noted the organization had not ensured the plan of care was updated to reflect the patient's deterioration. For example: review of HOSRRDC# 1's patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring with no update to the plan of care. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer with no update to the plan of care. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1's patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days or the plan of care was updated. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Record Review. In 1 of 2 live discharged patient records reviewed, During HOSRRDC# 1's patient record review it was noted the organization had not ensured it provided interdisciplinary, collaborative care, treatment, or services. For example: review of HOSRRDC# 1's patient record revealed HOSRRDC# 1 revealed a terminal diagnosis of metastatic breast cancer. Review of a Skilled Nurse visit note revealed documentation that HOSRRDC# 1 had fallen and had a bruise to the right elbow with no other injuries. Review of the Skilled Nurse visit note completed one day after the fall revealed HOSRRDC# 1 was complaining of weakness and having trouble transferring. Review of the Skilled Nurse visit note dated two days after the fall revealed documentation that HOSRRDC# 1 was no longer able to walk to the bathroom and required a bedside commode and continued to have declined in the ability to transfer. Review of an On-Call phone call dated three days after the fall revealed documentation that HOSRRDC# 1 had declined and the family was no longer able to transfer her or care for her. Further review of the On-Call phone call revealed documentation that the family was informed the patient could go to the emergency department and revoke hospice services. Review of HOSRRDC# 1's patient record revealed no documentation that the physician was notified of the fall or the subsequent decline over the following three days. Further review of HOSRRDC# 1 patient record revealed HOSRRDC# 1 was diagnosed with a closed fracture of the right humerus with pneumonia. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Data Session. During the data sessions it was noted the organization had not ensured it implemented and maintained an effective ongoing hospice-wide data-driven quality assessment and performance improvement program. For example: review of the QAPI data revealed the hospice had not included pharmacy or bereavement. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Record Review. During the IDG observation and interviews with the Director of Nursing and Hospice Manager it was noted the organization had not ensured Spiritual Coordinator was available to the patient ad family to assist the patient and family in minimizing the stress and problems that arise from the terminal illness, related conditions, and the dying process. For example: the organization's Spiritual Coordinator resigned approximately two months prior to the survey and the BSW was being utilized for this role. However, review of the Spiritual Caregiver job description revealed the BSW did not meet the educational requirements of a Bachelor's Degree from a CHEA in a content area relevant to chaplaincy. This was discussed and validated with the Hospice Manager.

Observed in Record Review. In 2 of 2 bereavement records reviewed, During HOSRRBR# 1 and HOSRRBR# 2's bereavement records review it was noted the organization had not ensured it developed a bereavement plan of care that specified the types of bereavement services to be offered and the frequency of delivery. For example review of HOSRRBR# 1 and HOSRRBR# 2's bereavement records revealed a bereavement care plan with no documentation of services to be offered or a frequency of service delivery. Further review of the bereavement care plans revealed documentation after the services were completed. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed with Hospice Aide, During HR files review it was noted the organization had not ensure the hospice aide was evaluated by observing the hospice aide perform tasks on a patient or pseudo-patient. For example: Review of HOSHR# 4's HR file revealed and initial competency assessment with documentation pass on all the tasks. However, there was not documentation of whether these tasks were observed. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in HR File Review. In 3 of 12 HR files reviewed, During review of the HR files it was noted the organization had not ensure it followed it's policy Competency Assessment that included competency assessment annually. For example review of 3 of the 4 HR files revealed no competency assessment for 2024. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Patient Home. In 1 of 1 home visits conducted with hospice aide, During HOSRRHV# 3's home observation it was noted the organization had not ensured the hospice aide provided services as ordered in the plan of care. For example: during HOSRRHV# 3's home observation the hospice aide removed the continuous oxygen while bathing. However, review of the hospice aide written patient care instructions revealed no documentation regarding removing the oxygen during cares. This was discussed and validated with the Hospice Manager.

Observed in Record Review. In 1 of 1 patient records reviewed with hospice aide services, During HOSRRHV# 3's patient record review it was noted the organization had not ensured the RN completed supervisory assessments of the hospice aide's services no less frequently than every 14 days. For example: review of HOSRRHV# 3's patient record revealed the hospice aide provided hospice aide services two visits a week since approximately two months prior to the surveyor review of the record. Further review of the patient record revealed no documented RN supervisory assessments of the hospice aide services. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in HR File Review. In 1 of 1 HR files reviewed with Hospice Aide services, During HR files review it was noted the organization had note ensured the RN completed an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. For example: review of HOSHR# 4/Hospice Aide HR file revealed HOSHR# 4 date of hire was over 12 months from the day of the surveyor review of the HR file. Further review of the HOSHR# 4's HR file revealed no documentation of a RN an annual on-site supervisory visit. This was reviewed, discussed, and validated with the Hospice Manager.

Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level (CoP) deficiencies in 418.56 IDG, Care Planning, and Coordination; 418.100 Organization and Administration; 418.76 home health aides; 418.113 Emergency Manager.

Observed in HR File Review. In 1 of 1 Volunteer HR files reviewed, During HR files review it was noted the organization had not ensured it assessed the skills and competence of all volunteers. For example: review of the Volunteer Program orientation/education revealed a session with the Physical therapist for transfer training. The Volunteer Coordinator shared that Volunteers do transfer patients in the home. Review of HOSHV# 12/volunteer's HR file revealed no documentation of a competency for transfers. This was reviewed, discussed, and validated with the Volunteer Coordinator and the Hospice Manager.

Observed in Patient Home. In 2 of 2 home visits conducted with Skilled Nurse, During HOSRRHV# 1HOSRRHV# 2's home observations it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of HOSRRHV# 2's medication profile revealed Lorazepam PRN. However, when reviewing HOSRRHV# 2's medications with HOSRRHV# 2's spouse it was noted HOSRRHV# 2 had not been taking Lorazepam for several months prior to the home observation and HOSRRHV# 2's spouse had removed the medication to a cabinet away from the active medications. Further review of the medications in the home revealed HOSRRHV# 2 was taking Trazodone at bedtime as needed for sleep and had taken one the night prior to the home observation. Review of the medication profile revealed no documentation of Trazadone. During HOSRVHV# 1's home observation the RN was observed putting Senna into HOSRRHV# 1's medication minder from pm to am. However, review of the medication profile revealed no documentation of Senna. This was reviewed, discussed, and validated with the RN and Hospice Manager.

Observed in Document Review. During contract review it was noted the organization had not ensured care, treatment, or services provided through contractual agreement are provided safely and effectively. For example: review of the Durable Medical Equipment contract revealed the contract failed to requirement criminal background checks. This was reviewed, discussed, and validated with the Director of Nursing and Hospice Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, the hospice nurse surveyor noted that the clinical staff did not follow the organization's bag technique policy. The organization's policy included that the clinical bag should be closed during the visit when not being accessed, however all three zippered areas of the bag remained opened throughout the visit for HOS 1 with the CNA. This was discussed with the Home Care & Hospice Director. Observed in Patient Home. In 1 of 3 home visits conducted, the hospice nurse surveyor noted that staff failed to perform hand hygiene consistent with the organization's policy no. 06002.100 Hand Hygiene which requires hand hygiene after doffing gloves. The CNA failed to perform hand hygiene between glove changes while providing care for HOS 1. This was confirmed with the CNA who stated she did not have her hand sanitizer with her in the bathroom when providing personal care.

Observed in HR File Review. In 1 of 6 HR files reviewed, the organization did not assess competence. The hospice nurse surveyor noted in review of the personnel file for HR 2 that the medical social worker was assigned the duties of the spiritual counselor at the time the hospice chaplain retired however the organization failed to conduct a competency assessment. This was discussed with the Home Care and Hospice Director.

Observed in Record Review. In 1 of 11 patient records reviewed, documentation in the patient record was not accurate. The hospice surveyor noted in review of the medical record for HOS 3 that the oxygen safety risk assessment completed at the start of care was not accurate when the clinician documented yes to the question; are oxygen signs posted on the doors? During the home visit the surveyor observed that the Oxygen in Use sign had not been posted on the door to the apartment for the patient on continuous oxygen therapy. This was validated by the RN.