Every finding on record at Mountain Community Hospice

It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) Clinical records reviewed in the community program, the agency did not ensure that the interdisciplinary plan of care and services were provided to the patient as ordered. CLINICAL RECORD 9: The patient’s election of benefits was dated 10/11/2025 for a primary diagnosis acute and end stage CHF. A cardiovascular intervention was written on the initial plan of care and remained on the plans of care updated every two weeks; to instruct the family to monitor weight every 2 days and report an increase of 3 lbs. to the nurse. A weight was documented on 10/11/2025, as 101.4; however, the follow up visits documented 10/16/2025 ,10/23/2025, 10/31/2025, 11/10/2025, 11/24 2025 did not include any documented evidence of weights to evaluate the effectiveness of the intervention or who was monitoring the weights, however, edema was documented on each of the visit dates. On 11/10/2025 there was documentation of an order for medication for symptom management that was effective. The documentation did not follow the ordered plan of care. During interview with the clinical team on 12/04/2025, it was stated that the intervention was not generally used as symptoms were controlled but should have been changed to reflect hospice care.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: Drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records of the community program, reviewed, it was revealed that the agency did not ensure that all medications on the plan of care, documented correct dosages. CLINICAL RECORD 2/HOME VISIT 2: The hospice benefit of election was 01/17/2025 with a primary diagnosis of unspecified sequelae of cerebral infarction. The patient resided in a skilled nursing facility (SNF). During the observed home visit on 12/02/2025 with a registered nurse (RN) (Personnel Record 2), a copy of the SNF medication profile was compared to the hospice medication profile dated 12/02/2025 and the following discrepancy was identified. The facility had changed the dosage of the Magnesium Oxide on 11/18/2025 to 140 mg two times a day. The Hospice plan of care 12/02/2025 included Magnesium Oxide as 84 mg two times a day. The facility was providing this medication for the patient, but the dosage change was not correct on the hospice plan of care as of review 12/03/2025. During interview with the clinical team on 12/05/2025, they stated that the medication was provided by the facility but that the dosage should have been updated on the plan of care at the time of the change in November.

Based on interview, and review of the Emergency Preparedness policy, the agency failed to provide Emergency Preparedness training specific to the agency for 375 out of 375 staff members. This deficient practice had the potential to affect all 459 patients receiving care from the agency. --- During an interview on 06/28/24 at 4:00 PM, the Vice President and Chief Hospice Officer confirmed that the training all staff receives is through an on-line healthcare training program and includes general emergency training only. The training is not specific to the agency's emergency plan. During a review of the agency's policy titled, "Emergency Preparedness and Response Plan" dated 03/2024 revealed, "Training – [the agency] provides initial training in emergency preparedness and response to team members and to individuals providing services under contract or arrangement, consistent with expected roles ... Training is reviewed annually and updated based on findings from recent events or exercises. Training includes team member responsibilities. 1. Emergency preparedness training is provided to new team members at orientation and to existing team members at least annually. 2. Team members are expected to demonstrate knowledge of their roles in emergency preparedness and response and to participate in drills and exercises. 3. Documentation is maintained of all emergency preparedness training.

Based on record review, interview, and policy reviews, the agency failed to complete a care plan to include problems, goals, and interventions for one (Patient (P) 21) of 14 active patient records reviewed. This deficient practice had the potential to affect all 459 patients receiving care from the agency. --- Review of P21's Electronic Medical Record (EMR) under the "Care Plan" section titled "Goals/Interventions Pain" revealed the following: a. On 06/18/24 the nurse documented, "pt [patient] requiring increased pain med [medication]." The nurse did not document the patient's acceptable pain goal or interventions developed by the Interdisciplinary Team (IDT) on P21's care plan entry. b. On 04/16/24 the nurse documented, "pt takes hydrocodone or Tylenol for occasional pain." The nurse did not document the patient's acceptable pain goal or interventions developed by the IDT on P21's care plan entry. Review of P21's EMR, under the "Care Plan" section titled "Goals/Interventions Cardiovascular" revealed the following: a. On 06/18/24 the nurse documented "HR [heartrate] is irregular." The nurse did not document an acceptable measurable goal or interventions developed by the IDT on P21's care plan entry. b. On 05/08/24 the nurse documented "apical HR irregular." The nurse did not document an acceptable measurable goal or interventions developed by the IDT on P21's care plan entry. c. On 04/02/24 the nurse documented "Admit staff states pt tires easily." The nurse did not document an acceptable measurable goal or interventions developed by the IDT on P21's care plan entry. Review of P21's EMR, under the "Care Plan" section titled "Goals/Interventions GI/GU (gastrointestinal/genitourinary)/Nutritional/Endocrine" revealed the following: a. On 06/24/24 the nurse documented "incont [incontinent] of B&B [bowel and bladder]." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. b. On 06/18/24 the nurse documented "appetite varies." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. c. On 06/03/24 the nurse documented "eats approx. [approximately] 25%." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. d. On 05/29/24 the nurse documented "incont of B&B." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. e. On 05/24/24 the nurse documented "APPETITE POOR." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. f. On 05/14/24 the nurse documented "eating approx 25%." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. g. On 05/01/24 the nurse documented "incontinent of B&B." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. h. On 04/24/24 the nurse documented "appetite varies." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. i. On 04/16/24 the nurse documented "staff states patient is not eating much and holding food in [his/her] mouth." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. j. On 04/10/24 the nurse documented "eating 50-75%." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. k. On 04/03/24 the nurse documented "pt is incont of B&B [His/Her] appetite is poor to fair." The nurse did not document an acceptable measurable goal for P21, or interventions developed by the IDT on P21's care plan entry. Review of the agency's policy titled "Physician Orders and Plans of Care" dated 01/24 revealed, "Diagnostic and therapeutic orders will be obtained from the attending physician or designee, according to Hospice policy and applicable law and regulation. Physician orders are considered part of the plan of care." Review of the agency's policy titled "Pain and Symptom Management Guidelines" effective 03/23 revealed, " ... "The [agency name] nurse case manager, in cooperation with the hospice interdisciplinary team (IDT), will establish a plan of care to relieve or decrease the level of the patient's pain and symptoms. ... Documentation of the care provided, effectiveness of the pain and symptom management interventions, and the patient's satisfaction will be document in the EMR ..." During an interview on 06/28/24 at 4:00 PM, the Vice President and Chief Hospice Officer confirmed that P21's care plan was incomplete and did not include the hospice plan for symptom management or P21's measurable goals.

Based on record review, policy review, and interview, the agency failed to follow all the tasks outlined in the hospice aide's care plan for one (Patient (P) 12) of 10 active patient records reviewed for hospice aide care plans. This deficient practice had the potential to affect all 459 patients receiving hospice aide services from the agency. --- Review of P12's Electronic Medical Record (EMR) revealed in the "Aide Visit Note" section of the "hospice aide care plans" developed by the case manager, dated 01/03/24, 03/27/24, 04/01/24, 05/01/24, and 06/03/24 revealed that the hospice aide care plans instructed the hospice aide to "Report to Supervisor/Case Manager – No BM [bowel movement] in 3 days." There was no hospice aide documentation indicating if P12 had a bowel movement to determine if it was more than three days since the last bowel movement or if the hospice aide communicated with the case manager regarding P12's bowel movements for visits made on 01/03/24, 03/27/24, 04/01/24, 05/01/24, and 06/03/24. Review of the agency's policy titled "Hospice Certified Nursing Aide Services" effective 03/2023 revealed, " ... 3. CNA [certified nurse aides] written assignments, plan of care, and interventions will be made by the registered nurse. They will be documented and included in the patient's clinical EMR. 4. The CNA will document based on the electronic medical record system in place for CNA use. ..." During an interview on 06/28/24 at 4:00 PM, the Vice President and Chief Hospice Officer confirmed that the Hospice Aide did not follow the care plan regarding documenting P12's bowel movement and if it was greater than three days was this communicated to the case manager.