Every finding on record at Saint Mariam Hospice Services Inc

Observed in Emergency Management Session. Based on a review of the available data and discussions with the DON, the drill conducted in 2024 did not fully challenge and or describe key critical areas. This critique of a heat event did not address any challenges such as securing supplies, equipment, staffing, or any security/safety issues. This observation was discussed with the director.

Observed in Record Review. In 2 of 10 patient records reviewed, the Hospice did not provide patients verbally or in writing of their rights. The consent form titled Patient Notification of Hospice Non-Covered Items Services required the RN to fill in the blanks related to non-covered diagnosis and non-covered medications. There was no option on this form for the patient to decline receipt of notification of non-covered services. The following diagnoses entered by the RN that were not covered on the consent form of RR#5 included - HTN,HDL, neuropathy, and depression. This patient was taking the following medication- metoprolol, amitriptyline, lisinopril, aspirin, atorvastatin based on the medication sheet of RR#5 and the portion of the consent form related to uncovered medications was left blank and not entered by the RN. RR#1 had a consent form that required the patient to either decline or request notification of non-covered items. This section was left unchecked on the consent form of RR#1. This observation was confirmed with the RN.

Observed in Record Review. In 1 of 10 patient records reviewed, that were recerted, did not have documentation of measurable progress toward goals. RR#1 was admitted to the hospice approximately 8 months ago. The goals listed on the current care plan were the same as the goals listed on the initial care plan and included goals related to compliance and education. This observation was discussed with the director.

Observed in Record Review. In 2 of 10 patient records reviewed, the goals listed on the care plans were not measurable/inappropriate or did not have appropriate time frames. RR#5 was identified as high risk for falls and the goal listed reflected the following- to promote safe use of a walker by xx/xx/xxxx or by the end of the certification period. The goals listed for RR#4 was restorative and reflected the following- to manage hypertension, maintain target range of BS, and to promote physical strength. There was no further numeric qualification of the goals related to blood pressure or blood sugar. This observation was discussed with the director.

Observed in Record Review. In 2 of 10 patient records reviewed, the hospice care plan did not include all of the interventions required based on the assessed needs. RR#5 was assessed as being agitated on admission there was no interventions and or goal on the care plan to manage this symptom. Hospice patient RR#4 had no goals or interventions on the care plan that addressed terminal illness. This observation was discussed with the director.

Observed in Record Review. In 3 of 10 patient records reviewed, had incomplete medications orders. RR#5 was oxygen dependent and the orders for this therapy did not include the route or frequency. The order read as follows -oxygen 5L. The orders in RR#4 reflected azithromycin- as directed. RR#3 was on 4 prn medications to manage pain which included- Motrin, hydrocodone morphine and oxycodone. With the exception of hydrocodone- (which reflected to give for moderate to severe pain), the remaining orders had no further instruction/clarification as to which medication to give first. This observation was discussed with the director.

Observed in Leadership Session. Based on a review of the QAPI data provided to the surveyor for 2024, the QAPI discussion/data did not reflect the complexity of the organization. For example, per the DON, there has been no provision of volunteer services in the field for the last 3 years because patients have refused services. However, the QAPI data did not address volunteer services or an analysis of the potential reasons why services were not provided in the home. Similarly, the QAPI did not address CMS HIS indicators or any outcome indicators related hospice even though the 2024 plan reflected that these reports would be looked at quarterly. There was no evaluation of contract services via the QAPI program or tools used to evaluate each contract. The annual evaluation for 2024 did have a check mark for Yes Criteria Met for home medical equipment. This Hospice had contracts with multiple skilled nursing facilities and a pharmacy. There was no discussion/analysis in the 2024 QAPI minutes related to the levels of care provided or not provided for example continuous care. This observation was discussed with the director.

Observed in Infection Control System Tracer. Based on a review of the available data there was no aggregated/or analyzed hand hygiene data for 2024 and therefore no opportunities identified to improve compliance. Per the director, hand hygiene compliance was measured/observed in the office and not in the field.

Observed in Record Review. In 1 of 5 patient records reviewed, hospice aide services, did not have an aide care plan that reflected all of the interventions required based on the assessment. RR#2 was oxygen dependent, and the aide care plan did not reflect oxygen precautions. This observation was discussed with the director.

Observed in Leadership Session. 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 deficiencies at COP 418.58 related to the QAPI program. This observation was discussed with the director.

Observed in Record Review. In 1 of 5 patient records reviewed, that resided in a nursing home, did not have a hospice care plan that detailed which provider would be responsible for treatments. RR#1 resided in a nursing home and had a foley and multiple wounds requiring daily treatment. The hospice care plan did not reflect which provider would do which task. For example, the care plan did not stipulate if the facility staff would manage wound care or change the foley. This observation was discussed with the director.

Observed in Record Review. In 2 of 2 patient records reviewed, that resided in a SNF, did not have the most recent hospice plan of care in the facility. Both RR#1 and RR#3 resided in a nursing home and the most recent plan of cares located in the facility were 4 weeks old. By the conclusion of the visits, the RN placed the most current updates in the records. This observation was discussed with the director.

Observed in Record Review. In 5 of 6 patient records reviewed, The hospice did not ensure patient care plan goals were individualized, measurable, and included appropriate time frames. Examples include the following: Prevent discomfort due to increasing edema, Pt/Family/PCG will verbalize understanding of safety intervention. -No panicking -Continue to achieve outlined POC goals via telephonic visits using Skype, Face-time or other technology options as needed, Daughter will freely express grief with out feeling guilt. Psychosocial distress will be scored as mild by next Idg, patient will have optimal res 6-8 hours of regulated sleep pattern within next 14 days, administering antihypertensive medications as prescribed., Maintaining blood pressure reading not greater systolic blood pressure of 159mmhg, Pt will maintain optimum peripheral circulation. -Pcg will verbalize/express understanding of medication /treatment orders and side effects. Early detection of upper respiratory infection. -Lungs will be clear. -Pt will verbalize and/or express decreased episodes of SOB at rest. Pt will have decreased anxiety related to respiratory changes and, Pt will have optimum level of oxygen. -Pt will not develop any episodes of respiratory crisis. -Respiration will be between 16-24 breaths/minute. -Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. These stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. These findings were reviewed, discussed and confirmed with the Director of Patient Care Services/Administrator, Volunteer Coordinator/Office Manager and the CEO.