Every finding on record at Msm Health Care, Inc.

Upon patient record review 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. #8-No Initial Psychosocial Assessment completed. It is documented on SOC comprehensive assessment dated 08/03/25 that, "For initial assessment, will be done within 5 day period."

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #14-Per Plan of Care, SN visits were ordered for continuous care at SOC dated 05/19/25. On 05/22/25, an order was written to change level of care to routine care with daily visits. Level of care was again changed to continuous care on 05/29/25. There were no documented SN visits for the week of 05/22/25 - 05/29/25 in the patient record.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not implement their infection prevention and control activities as planned. For HOS 1 the RN did not follow the organization's bag technique policy when the nursing bag remained open throughout the visit. The organization's policy 5.4.4 states that the bag should be closed during the visit when not being accessed. The nursing bag also remained open during the visits for HOS 2 and HOS 3. This was discussed with the DPCS/Administrator Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, that received Hospice Aide services care was not provided as assigned by the RN in the plan of care. For RR 2 the Hospice Aide failed to provide light housekeeping as instructed in the Aide Plan of Care in 3 of 3 Hospice Aide visits. This was confirmed with the DPCS/Administrator Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not provided education and training to the patient and family on how to manage medical gases, specifically the e-tank of oxygen in the home. For HOS 2 it was noted that the Oxygen in Use/No Smoking sign remained in the home folder and had not been posted and the Individual Emergency Plan that the HCO provided for the patient failed to include the oxygen therapy which the patient was using. This was discussed with the visiting RN who corrected the document during the visit and also with the DPCS/Administrator Designee.