Every finding on record at Saint Paul Hospice Care LLC

Upon observation, there was no evidence the hospice complies with all applicable federal, state, and local emergency preparedness requirements by establishing and maintaining an emergency preparedness program that meets the requirements of 42 CFR 418.113. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans This is cited as it was not provided to the surveyor to review during the survey.

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. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. This is cited as it was not provided to the surveyor to review during the survey.

Upon patient record review, 4 of 11 (Patient #4, #5, #7, #9) 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 4, 5, 7, 9: The plan of care identifies patient use of oxygen equipment. There was no evidence of oxygen listed on the medication profile. Corrected on site.

Upon client record review, 2 of 11 (Patient #1, #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contains ordered nursing frequency of twice weekly. There was evidence of 1 visit week of 9/25/22. Patient 4: The medical record contains PRN nursing visits on 7/31, 8/14, and 8/21 without a PRN frequency or order for increased PRN visits. The medical record contains ordered nursing frequency of once weekly. There was no evidence of visit week of 8/7/22.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: RN wiped down used equipment with baby wipes and returned equipment to bag. Agency infection control policy #5 states "reusable equipment will be cleaned using an alcohol based or soap and water or appropriate solution to clean equipment hands will be washed and equipment and supplies will be returned to bag." Patient #2: Aide used bedside commode as place to set nursing bag, a barrier was used, however, it did not cover commode area fully and bag was still touching commode seat. Patient #3: Chaplain did not wash hands prior to starting visit with patient. Agency infection control policy #6-013.2 states that "prior to care of patient, an alcohol based hand wash or soap and paper towel must be used to wash hands."

Upon patient record review 3 of 9 applicable (Patient #4, #6, #8) 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 4: The medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 6/2/22. Patient 6: The medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 12/12/21. Patient 8: The medical record contains ordered aide frequency of twice weekly. There was evidence of 1 visit week of 12/5/21.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 This is cited as it was not provided to the surveyor to review during the survey.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence BOD/governing body minutes reflect the involvement in the hospice's management and administration of its resources to provide hospice services to patients and families. This is cited as it was not provided to the surveyor to review during the survey.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. Upon arrival, patients records were not made available to surveyor in either electronic or paper form. On day 1 the administrator was out of town and the patient records were stored behind a locked door within the office and no one had access to the patient records until day 2 when the administrator arrived.