Every finding on record at Pioneer Medical Center

Based on record review and interviews the agency failed to ensure compliance with requirements of State law (whether statutory or recognized by the courts of the State) regarding advance directives by ensuring POLST forms were completed by the patient or legal decision maker and all mandatory sections of the forms were completed for 3 (#s 6, 7, and 9) of 12 sampled patients. Findings include: --- 1. Review of patient # 6's, POLST, no date, reflected patient #6's POLST was not dated by the legal decision maker and was not signed or dated by the physician.2. Review of patient # 7's POLST, dated 1/18/25, reflected patient # 7 did not complete the mandatory date section of the form.3. Review of patient # 9's medical record reflected a POLST, dated 11/22/22, without a name or date of birth on the document. The typed medical label containing the name and date of birth were not readable. During an interview on 10/21/25 at 2:45 p.m., staff member A stated she was the Hospice Director. Staff member A stated she only worked part-time and struggled to get everything done. Staff member A stated she was aware items were missing or incomplete on the POLST forms and felt another pair of eyes would be beneficial to avoid the errors of missing dates, signatures, and POA paperwork on admission documentation.  During an interview on 10/22/25, at 12:55 p.m., staff member A stated there were no other valid POLSTs available for patient #'s 6, 7, and 9. Staff member A stated the POLSTs should have all sections completed.Review of the facility provided, "POLST form," dated September 2019, reflected the patient/legal decision maker and date, and the physician/APRN/PA signature and date were mandatory sections to be completed for the document to be valid.Review of the facility's policy, "Physician Orders for Life Sustaining Treatments (POLSTS), dated 4/8/24, reflected:- "... use the POLST form and follow the DNR/POLST protocol approved by the Board of Medical Examiners and the department. ..."Review of the Mont. Admin. r. 37.10.108 - DO-NOT-RESUSCITATE PROTOCOL, effective 9/24/22, reflected:- "... When issuing a DNR order for a patient with a terminal condition, medical professionals are encouraged to use the POLST form and follow the DNR/POLST protocol approved by the Board of Medical Examiners and the department. The department adopts and incorporates by reference the Montana Provider Orders for Life-Sustaining Treatment (POLST) protocol (last revised September 2019)."

Based on record review and interviews the agency failed to ensure all required professional roles were represented in interdisciplinary team meetings for 3 (1, 3, and 4) or 12 sampled patients. Findings include: --- 1. Review of patient #1's Hospice IDG Meeting, dated 10/10/25, reflected the Chaplin was not present.Review of patient #1's Hospice IDG Meeting, dated 9/22/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present.Review of patient #1's Hospice IDG Meeting, dated 9/8/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present.Review of patient #1's Hospice IDG Meeting, dated 8/27/25, reflected the Chaplin and the Social Worker were not present.Review of patient #1's Hospice IDG Meeting, dated 8/11/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present. The form noted, "No in-person meeting."Review of patient #1's Hospice IDG Meeting, dated 7/30/25, reflected the Chaplin and the Social Worker were not present.Review of patient #1's Hospice IDG Meeting, dated 7/14/25, reflected the Chaplin and the Social Worker were not present.2. Review of patient #3's Hospice IDG Meeting, dated 12/20/24, reflected the Chaplin and medical Director were not present.Review of patient #3's Hospice IDG Meeting, dated 12/6/24, reflected the Medical Director was not present.Review of patient #3's Hospice IDG Meeting, dated 11/8/24, reflected the Chaplin was not present.3. Review of patient #4's Hospice IDG Meeting, dated 2/26/25, reflected the Chaplin was not present.Review of patient #4's Hospice IDG Meeting, dated 1/27/25, reflected the Chaplin was not present.Review of patient #4's Hospice IDG Meeting, dated 1/15/25, reflected the Chaplin was not present.Review of patient #4's Hospice IDG Meeting, dated 1/2/25, reflected the Chaplin and Social Worker were not present.Review of patient #4's Hospice IDG Meeting, dated 12/20/24, reflected the Chaplin and Medical director were not present.Review of patient #4's Hospice IDG Meeting, dated 12/6/24, reflected the Medical director was not present.During an interview on 10/22/25 at 11:04 a.m., staff member E stated she was the Social Worker for the agency and tried to attend IDG meetings if she was available. Staff member E stated the meetings were not held on consistent days and times, making it difficult to plan. Staff member E stated the multiple changes in medical directors had made scheduling difficult.During an interview on 10/22/25 at 12:13 p.m., staff member F stated barriers to attending the IDG meetings included having multiple roles in the facility/agency and lack of consistent scheduling. During an interview on 10/22/25 at 12:22 p.m., staff member A stated she sent out invites to all IDG meetings, including a Teams option, to all members of the IDG. Staff member A stated each member was responsible for many roles between the hospital, clinics, and hospice, making it difficult to get members to attend the IDG meetings.Review of the facility's policy, "Hospice Interdisciplinary Group," dated 10/17/23, reflected:- "3. The IDG involved in the care of the patient consists of, but not limited to, the following: ... B. Medical Director, C. Registered nurse, D. Social Worker, E. Chaplin ...- 5. The IDG meeting address each of the patient's needs and problems, and are held every 15 days ..."

Based on record review and interviews the agency failed to include measurable outcomes in the plan of care for 5 (#s 1, 3, 4, 5, and 8) of 12 sampled patients. Findings include: --- 1. Review of patient #1's, "Plan of Care: Respiratory," dated 7/2/25, reflected a goal/outcome of: "Patient will have optimal respiratory status within normal limits of disease". The goal/outcome failed to include any measurable data criteria.Review of patient #1's, "Plan of Care: Skin Integrity," dated 7/2/25, reflected a goal/outcome of: "Patient's skin integrity, wound drainage, and pain will be managed." The goal/outcome failed to include any measurable data criteria.2. Review of patient #3's, "Plan of Care: Respiratory," dated 10/30/24, reflected a goal/outcome of: "Patient will have optimal respiratory status within normal limits of disease". The goal/outcome failed to include any measurable data criteria.3. Review of patient #4's, "Plan of Care: Medication Self-administration," dated 1/2/25, reflected a goal/outcome of: "Patient will safely self-administer medications." The goal/outcome failed to include any measurable data criteria.4. Review of patient #5's, "Plan of Care: Respiratory," dated 12/18/24, reflected a goal/outcome of: "Patient will have optimal respiratory status within normal limits of disease". The goal/outcome failed to include any measurable data criteria.5. Review of patient #8's, "Plan of Care: Bowel Dysfunction," dated 2/10/25, reflected a goal/outcome of: "Skin integrity will be maintained". The goal/outcome failed to include any measurable data criteria.During an interview on 10/21/25 at 11:05 a.m., staff member A and D stated each patient goal/outcome should have a way to measure if the goal was being met.Review of the facility's policy, Hospice Patient Plan of Care," dated 10/17/23, did not reflect measurable goal/outcomes were required.

Based on interview and record review, the agency failed to develop, implement and evaluate performance improvement plans. Findings include: --- Review of the agency's QAPI program reflected no performance improvement plans for the 2024-2025 year.During an interview on 10/21/25 at 10:00 a.m., staff member A and D stated there were no performance improvement plans for the hospice agency during the past 12 months. Staff member A stated that due to her limited hours, she was unable to commit time to the PIP requirements.  Review of the agency's policy, "Quality Assurance and Performance Improvement Plan," dated 7/1/25, reflected:- "... The organization will conduct Performance Improvement (PI) Projects that are designed to take a systematic approach to revise and improve care or services in areas that are identified as needing attention. Team members will conduct PI projects that will lead to changes and guide corrective actions in our systems, which cross multiple departments. The PI projects will intend to improve care and service delivery, increase efficiencies, lead to improved staff, patient, and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of our PI projects is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained. ..."

Based on interview and record review the agency failed to have a program for the surveillance, identification, prevention, control, and investigation of infections. Findings include: --- During an interview on 10/21/25 at 11:23 a.m., staff members A and C stated the agency did not have a separate program for the surveillance, prevention, control, and investigation of the agency's infections. Staff member C stated she reviewed any antibiotic use for all of the facilities and agencies combined, looking for antibiotic stewardship. Staff member A stated the agency did not track and investigate the infections independently. Staff member A and C stated they were not able to show any data separated from the other facility and agencies data. Staff member C stated investigations for the agency were not investigated due to patient's in-home status.Review of the agency's policy, "Hospice Infection Control & Surveillance Plan," dated 12/4/23, reflected:a- "... The Hospice Infection Control Program incorporates the following in a continuing cycle: Surveillance, prevention and control of infections throughout the organization, Develop alternate techniques to address the real and potential exposures, Select and implement the best techniques to minimize adverse outcomes, Evaluate and monitor the results and revise techniques as needed. ..."

Based on interview and record review, the agency failed to ensure care plans were individualized and patient-centered to reflect the care and services the patients required based on the comprehensive assessment and failed to ensure care plans were developed by the Interdisciplinary Group with collaboration of patient/family/representatives for 4 (#s 1,3, 5, and 8) of 8 sampled patients. Findings include: --- 3.Review of patient #3's IDT plan of care showed no new interventions or concerns from the onset of hospice on 2/26/22 through the discharge from hospice on 10/10/22. The care plan did not include any individualized concerns or interventions. 4. Review of patient #8's care plan showed similar areas of concern as patient #3 with no new or individualized care concerns or interventions. There was no specific information regarding the patient's pain level or interventions for the pain. During an interview on 10/25/22 at 10:10 p.m., staff member B stated the care plans were initiated from a 'library' of care plans and were all similar. "I know every patient is different. Maybe going to a computerized system will assist with better care plans." 1. Review of patient #1's Interdisciplinary Group Plan of Care, dated 9/8/21, did not show individualized interventions to reflect the patient's care regarding problems identified on the comprehensive assessment. The patient's care plan contained interventions taken from a "library" and were not specific to the patient. The care plan did not show updates to the care plan as the patient's condition changed. The patient's care plan did not show collaboration with the patient and family /representative. The comprehensive assessment showed the following problems: weight loss poor appetite insomnia pain Review of patient #1's Interdisciplinary Team Plan of Care, dated 9/3/21, failed to show patient-centered interventions and were part of a "library" of problems, goals and interventions used for more than one patient. Review of patient #1's Interdisciplinary Group Comprehensive Plan of Care showed the document was completed on 9/8/21. The document failed to show selection of specific frequency of visits by Hospice staff, failed to show selection of interventions, and failed to show evidence the patient/family/representative were involved with the development of the Plan of Care. 2. Review of patient #5's Interdisciplinary Team Plan of Care showed problems, goals and interventions for Grieving/Bereavement, Coping of Patient/Family/Caregiver, Pain, and Skin Integrity. Review showed the problems, goals, and interventions were the same as patient #1's Plan of Care. There was no evidence the patient/family/representative participated in the development of the plan of care. There was no evidence of patient-centered interventions specific to the needs of the patient.

Due to the manner and degree of the deficient practice the agency was found to not be in substantial compliance for the Conditions of Participation for Quality Assessment and Performance Improvement. --- Based on interview and record review, the agency failed to have a quality assurance program that showed measurable improvement in indicators related to improved palliative outcomes and hospice services. See Findings under L0560.

Based on interview and record review, the agency failed to have a quality assurance program that showed measurable improvement in indicators related to improved palliative outcomes and hospice services by not measuring, analyzing and tracking quality indicators used to monitor quality of care. Findings include: --- During an interview on 10/25/22 at 12:50 p.m., staff member B stated she met with her volunteers every month and provided monthly Board Minutes. Review of the meeting minutes did not include the involvement of the Hospice IDT team, or any data regarding the care and services provided by the Hospice service, or ways to improve those patient services. The minutes discussed financial updates, and business services provided by the volunteers. Staff member B stated staff member A may have more information regarding a quality assurance program for the hospice services. During an interview on 10/26/22 at 1:20 p.m., staff member A stated Hospice services were covered at the hospital Quality Assurance Quarterly meetings. Review of the Quality Improvement meeting minutes for April, June and September showed Hospice Services was on the agenda once in June. The minutes showed Hospice record review was going well and 'working through a staffing grid for consistent staffing'. Patient centered services and outcomes were not on the agenda.

Due to the manner and degree of the deficient practice, the agency failed to meet substantial compliance for the Conditions of Participation for a qualified Infection Control Program. --- Based on interview and record review, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. See L0580 for findings.

Based on interview and record review, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Findings include: --- Review of the agency Hospice Infection Control and Surveillance Plan, dated 12/22/21, showed the program would include a continuing cycle of surveillance, prevention and control of infection, interventions to minimize adverse outcomes, and evaluate and monitor the results of the outcomes and interventions. The Policy did not include interventions to mitigate the spread of Covid-19 or vaccine requirements. During an interview on 10/26/22 at 2:20 p.m. staff member B was not able to provide documentation showing the implementation of the Infection Control Plan. Review of Quality Assurance Improvement meeting notes and the Hospice annual report from 1/2021 to 12/2021 did not include data from an infection control program for the hospice agency. During an interview on 10/26/22 at 2:20 p.m. staff member B stated one Hospice nurse was not vaccinated, and she was encouraged to wear an N-95 mask. Staff member B was not aware whether the staff member did wear a N-95 mask. Review of the agency form for the required supervision of the Hospice Aide did not include monitoring infection control practices.

Based on interview and record review, the agency failed to show documented evidence that the governing body was assuming full authority and responsibility for the management of the hospice agency, and reviewed and addressed the functioning of specific hospice operations, services and Quality Assurance Improvement Program. Findings include: --- Review of a facility Policy and Procedure titled Memorandum of Understanding between Pioneer Medical Center and Hearts and Hands Hospice, dated 6/20/22, did not show the Governing Body was assuming full authority and responsibility for the management of the Hospice Agency. Review of the Pioneer Medical Center QAPI meeting minutes for 3 months did not show patient-centered hospice concerns and outcomes were included in the meetings. During an interview on 10/25/22 at 12:50 p.m., staff member B said the hospice agency would need to incorporate data into the facility Quality Assurance Improvement meetings and share with the Governing Board. Review of the provided Hearts and Hands Hospice By-Laws showed the Board of Directors shall have full authority to manage and control "the affairs of the corporations, for determining its policies, and for pursuing its purposes, goals, and objectives." Review of the provided Board of Directors Meeting minutes for August, September, and December 2021 did not include information from the Hospice Agency.