Every finding on record at Saint Maryam Hospice Care

Upon patient record review, 8 of 14 (Patient #1,6,7,8,9,10,11,13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1,6,8,9,10,11,13) had evidence of a Bereavement Risk Assessment by the SCP; however, they were incomplete. There was no name or relationship of bereaved individuals. The narrative only stated, phone call with "caregiver", who denies any needs at this time. Patient #7 did not have evidence of a completed Bereavement Risk assessment. This family declined SCP and MSW on admission. The Nursing comprehensive did not address Bereavement risk score or whom would be the Bereaved.

Upon patient record review, 2 of 14 (Patient #2,7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2 had an order for Tylenol 325mg, take two tablets by mouth every 4 hours as needed for "Temperature" which is not specific. Patient #7 had an order for Budesonide Inhaler, one puff two times per day as needed for "inflammation", which is not an appropriate reason.

Upon patient record review 2 of 14 (Patient #1,7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1 during home visit, family care giver stated an aide is providing bathing once per week. There is an active Aide assignment, however; no order for CHHA in orders or on plan of care. No documentation of aide visit since 3/31/25. Routinely provided prior to 3/31/25. Patient #7 orders and plan of care for aide 2 times per week upon admission 6/5/25. No documentation of any aide visits as of 7/01/25.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #7 admitted in certification period #1 on 06/05/25, no evidence of a CTI documented in record as of 07/01/25 and no evidence of verbal certification within 2 days.

Upon patient client record review, 1 of 14 (Patient #11) did not evidence that each patient record contains physician orders. Patient #11 was discharged for cause. There was no evidence of a physician order to discharge.

Upon client record review, 1 of 14 (Patient #11) did not have evidence that the discharge summary includes all required information. Patient #11 was discharged for "non compliance with treatment and plan of care". The discharge summary did not include : • The patient's current plan of care • The patient's latest physician orders

Upon observation, there was no evidence the Emergency Preparedness plan includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. Agency had local information but no evidence of the others required. Office manager got on line, applied to region 9 disaster planning. Will be joining the organization. Obtained all contact info required. Corrected on site.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. Corrected on site.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. Corrected on site.

Upon patient record review 1 of 5 records (Patient #1) 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. Patient 1: Patient declined SC, in agency policy Spiritual assessment 4-048.1 includes: The spiritual assessment will include but not be limited to: pts spiritual response to the terminal illness and treatment interventions, Survivor risk factors, such as availability of coping mechanisms and the potential for pathological grief reactions, available religious support, anticipatory grief assessment. The SN assessment for Spiritual includes active in faith- Christian, declines discussion of spiritual matters. There was no evidence of a Spiritual assessment.

Upon patient record review, 3 of 5 records (Patient #3, #4, #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 3: Orders dated 5/17/2022 include Voltaren 1% topical gel apply to affected areas as needed mild pain. There was no evidence of the area to apply. Corrected on site. Patient 4: Order dated 4/20/2022 included Diclofenac sodium 1% topical gel apply twice daily as needed for arthritis, there was no evidence of an area to apply. Patient 5: Order dated 4/12/2022 included Nitroglycerine tab 0.4mg SL oral 1 tab under tab as needed for Angina. There was no evidence of the limit to the doses that could be given.

Upon patient record review, 4 of 5 (Patient #1, 2, 3, 4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 1, 2, 3, 4: Order dated 5/13/2022 RN 2x per week and as needed and recert. There was no evidence of the quantity of prn visits. Corrected on site.

Upon patient record review, 3 of 5 records (Patient #3, #4, #5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 3: Orders dated 5/17/2022 and on care plan include Voltaren 1% topical gel apply to affected areas as needed mild pain. There was no evidence of the area to apply. Corrected on site. Patient 4: Order dated 4/20/2022 and on care plan included Diclofenac sodium 1% topical gel apply twice daily as needed for arthritis, there was no evidence of an area to apply. Patient 5: Order dated 4/12/2022 included Nitroglycerine tab 0.4mg SL oral 1 tab under tab as needed for Angina. There was no evidence of the limit to the doses that could be given, and the medication was not included in the cardiac plan of care.

Upon personnel record review, 1 of 9 applicable records (Personnel #6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 6: the skills competency had several pages are are incomplete, and no signatures on competency.

Upon patient client record review, 5 of 5 records (Patient #1, #2, #3, #4, #5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 1, 2, 3, 4, 5: There was no evidence during record review of a written certification. Physician was called and forwarded the written certification to office, which did not include a narrative by the physician and did not include an attestation. Corrected on site.

Upon personnel record review, 1 of 8 applicable (Personnel #11) did not have evidence that personnel credentialing activities are conducted to verify qualifications of all credentialed/licensed personnel in the positions they hold at the time of hire, at renewal or in accordance with specific state practice act requirements. Personnel 11: Licensure expired 4/30/2022. There was no evidence of personnel credentialing. Corrected on site.

Upon personnel record review, 1 of 1 applicable (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. A contract exists for SLP, no employee file was provided.

Upon personnel record review, 1 of 4 applicable (Personnel #12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 12: Supplied contract for services but there was no evidence of an employee file or background check.

Upon personnel record review, 1 of 12, (Personnel #12) did not have evidence of vaccination status.