Every finding on record at Sid Peterson Memorial Hospital

Upon patient record review, 9 of 19 (Patient #1,2,3,4,5,6,7,8,17) 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 #1-The medication profile dated 1/26/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for severe pain, Morphine Concentrate 20 mg/ml, for shortness of breath. The following are on plan of care but missing on med profile-Morphine IR 15mg for moderate to severe pain. Morphine IR 15mg for shortness of breath. #2-The medication profile dated 10/11/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Oxygen 1-5 lpm inhalation continuous, Oxygen 2-10 lpm via nasal cannula as needed for shortness of breath or comfort. Morphine Concentrate 20 mg/ml for moderate to severe pain, Morphine Concentrate 20 mg/ml for shortness of breath, Morphine IR 15 mg for moderate to severe pain, Morphine IR 15 mg for shortness of breath. #3-The medication profile dated 12/13/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain, Morphine Concentrate 20 mg/ml for shortness of breath. The following are on plan of care but missing on med profile-Morphine IR 15mg for moderate to severe pain, Morphine IR 15mg for shortness of breath. #4-The medication profile dated 10/18/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain, Morphine Concentrate 20 mg/ml for shortness of breath. The following are on plan of care but missing on med profile-Oxygen 2-10 lpm via nasal cannula as needed for shortness of breath or comfort. Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. #5-The medication profile dated 12/23/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine IR 15mg for moderate to severe pain, Morphine IR 15 mg for shortness of breath. The following are on the plan of care but missing from the med profile-Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #6-The medication profile dated 10/2/24 contains Miralax 17gm oral powder daily without instructions for reconstitution. Order dated 1/23/25 for Medihoney 80% topical gel does not give specific instructions that are on the plan of care. The following are on the plan of care but missing from the med profile- Morphine IR 15mg for moderate to severe pain, Morphine IR 15 mg for shortness of breath. Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #7- The medication profile dated 08/19/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. The following are on the plan of care but missing from the med profile- Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #8- The medication profile dated 01/03/25 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. The following are on the plan of care but missing from the med profile- Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. #17- The medication profile dated 08/08/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. The following are on the plan of care but missing from the med profile- Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath.

Upon patient record review, 9 of 19 (Patient #1,2,3,4,5,6,7,8,17) 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. #1-The plan of care dated 1/26/24 contains multiple/duplicative medications for pain and shortness of breath: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #2-The plan of care dated 10/11/24 contains multiple/duplicative medications for pain and shortness of breath: Oxygen 1-5 lpm inhalation continuous - no parameters for administration. Oxygen 2-10 lpm for shortness of breath or comfort(on plan of care but missing on med profile). Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. Morphine IR 15 mg for moderate to severe pain. Morphine IR 15 mg 1-2 tablet by mouth as needed for shortness of breath. #3-The plan of care dated 12/13/24 contains multiple/duplicative medications for pain and shortness of breath: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. Morphine IR 15mg for moderate to severe pain, Morphine IR 15mg for shortness of breath. #4-The plan of care dated 10/18/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. #5-The plan of care dated 12/23/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine IR 15mg for moderate to severe pain, Morphine IR 15 mg for shortness of breath. Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #6-The plan of care dated 10/2/24 contains Miralax 17gm oral powder daily without instructions for reconstitution. #7- The plan of care dated 08/19/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. #8- The plan of care dated 01/03/25 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath. #17- The plan of care dated 08/08/24 contains multiple/duplicative medications for pain and shortness of breath without differentiation and/or parameters for administration as follows: Morphine Concentrate 20 mg/ml for moderate to severe pain. Morphine Concentrate 20 mg/ml for shortness of breath. Morphine IR 15mg moderate to severe pain. Morphine IR 15mg for shortness of breath.

Upon patient record review, 1 of 13 (Patient #4) did not contain evidence that the Comprehensive Assessment included 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 are. This patient was admitted on 10/23/2021. The initial Bereavement Risk Assessment was not conducted/documented until 11/08/2021.

Upon patient record review, 1 of 13 (Patient # 2) 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 POC dated 02/21/22 - 04/21/22 included both of the following statements: 1) MSW effective 02/21/22 1x per month x1; and 2) SW evaluation performed. No additional visits needed.

Upon patient record review, 3 of 13 (Patients #2, #4 and 5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including comprehensive orders for both medications and treatments: Patient #2: POC included, "Wound Cleanser". The home visit RN confirmed that the patient was no longer using wound cleanser for anything in her treatment plan. Patient #4: A verbal order was obtained on 10/26/21 for, "Alginate dressing as needed for coccyx area." The order is not clear as to the indication for such 'as needed' dressing change. A verbal order was obtained on 10/29/21 for, "Sarna Cream 5%, thin layer to affected area, Q.I.D. as needed." The order is not clear as to the area of the body to apply this cream, nor an indication for such 'as needed' dressing change. A verbal order was obtained on 11/01/21 for, "Cleanse coccyx with wound cleanser, pat dry, apply Medi-Honey, then Alginate, to the coccyx and left elbow, 1-2x per week and as needed". The order is not clear as to the indication for such 'as needed' dressing change. Patient #5: At the date of survey, this patient had a supra pubic catheter in place. The current 90-day Plan of Care included the following content: 1) May irrigate Foley if patient unable to void; and 2) May irrigate Foley with N.S. or sterile water" The most current IDG POC dated 02/17/22 does not include any reference to a supra pubic catheter, its maintenance, etc.

Upon patient record review, 2 of 13 (Patients #2, 3) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions; specifically equipment and supply needs: Patient #2: During the Surveyor-attended home visit on 02/23/22, it was noted that the patient had a hospital bed and over-bed table. These DME were not included on the Plan of Care. Patient #3: On the SN Initial Assessment, the RN documented the ordering of a commode and a shower chair. These DME were not included on the SOC Plan of Care.

Upon client record review, 1 of 13 (Patient #8) did not contain evidence that the IDG had ensured that care and services were provided in accordance with the Plan of Care. A verbal order was received on 12/13/21 for, "Cleanse right hip wound with Normal Saline, pat dry, apply Medi-Honey." On the 12/13/21 SN visit the RN documented, "No Medi-Honey available." It was not evident as to whether the Hospice RN addressed the absence of such Medi-Honey, and/or verified the obtainment of the ordered Medi-Honey for this wound care, going forward. This wound care was provided by both the Hospice RN and the patient's in-home caregiver. The next date that the Hospice RN provided the ordered wound care was on the 12/20/21 SN visit, wherein the RN documented, "Right trochanter wound care provided, without any details as to the wound care provided. It is unclear as to whether the Medi-Honey was begun as ordered.

Upon personnel record review, 1 of 1 applicable Aide (Personnel #8) did not contain evidence that an Aide Skills Competency Assessment had been performed according to CMS requirement. An RN conducted such competency assessment. However, the following skill had not be evaluated for competency: The basic elements of body functioning, and changes in body function, that must be reported to an Aide's supervisor.

Upon personnel record review, 1 of 12 applicable (Personnel #13) did not contain evidence that a Skills Competency Assessment, specific to each discipline, had been conducted for all personnel, including Volunteers, initially prior to independently providing direct patient care, or Volunteer services.

Upon patient record review, 2 of 13 (Patients #8 and 10) did not contain evidence that all entries were clear, and complete: Patient #8: A verbal order was received on 12/13/22 for, "Cleanse right hip wound with Normal Saline, pat dry, apply Medi-Honey." On the 12/20/21 SN visit the RN documented, "Right trochanter wound care provided", without any details as to the wound care provided. Patient #10: A verbal order was received on 01/21/22 for, "Flush Medi-Port once monthly." On the 01/27/22 SN home visit the RN documented, "Medi-Port accessed and flushed with Normal Saline and Heparin", without any details of this flush intervention.

Upon patient record review, 13 of 13 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13) did not contain evidence that the Interdisciplinary Group, as part of the review of the Plan of Care, had determined the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient, in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the Hospice must address this issue in the patient's Plan of Care.

Upon inpatient contract review, 1 of 1 applicable (Riverhills) did not contain verbiage requiring that a copy of the Discharge Summary shall be provided to the Hospice at the time of the patient's discharge from the inpatient facility.

Upon SNF contract review, 1 of 1 applicable (Riverhills) did not contain a provision stating that the Hospice must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property, by anyone unrelated to the Hospice, to the SNF Administrator, within 24 hours of the Hospice becoming aware of such alleged violation.