Every finding on record at Ssm Health at Home Home Health - Illinois

Observed in Record Review. In 2 of 14 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. In review of the medical record for HOSRRHV #1 it was noted that the psychosocial assessment was completed on the 6th day following the election of the hospice benefit. Additionally in review of the medical record from the branch office for HOSRRHV #4 it was noted that the psychosocial assessment was completed on the 6th day following the election of the hospice benefit. This was validated with the Hospice Manager.

Observed in Record Review. In 12 of 12 patient records reviewed, the initial bereavement assessment was not completed as required by the organization's policy; Assessment of Patient and Client and the policy Bereavement Services states that a bereaved risk assessment shall be completed at the time the psychosocial assessment is completed. In review of the medical record for HOSRRHV #1 HOSRRHV #2, HOSRRHV #3, HOSRRHV #4 and 9 additional hospice patient records there was no evidence that the bereavement risk assessment had been completed at the election of the hospice benefit. Additionally, in review of 13 of 13 medical records for hospice patients there was no evidence that the organization had assessed and documented the need for volunteer services. This was validated by the Hospice Supervisor.

Observed in Patient Home. In 3 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. For HOSRRHV #2 the hospice aide did not follow the organization's hand hygiene/standard precautions policy when it was observed that the hospice aide changed gloves 5 times throughout providing care however failed to perform hand hygiene between glove changes. Also, for HOSRRHV #3 the RN failed to perform hand hygiene during wound care when she removed a glove and entered the clinical bag without performing hand hygiene. Finally, for the home visit from the branch office for HOSRRHV #4 the surveyor observed the RN enter the clinical bag without performing hand hygiene first and wearing dirty gloves. This was validated by the RN/Scribe. Observed in Patient Home. In 2 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. the organization did not implement their infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For HOSRRHV #1 the medical social worker did not follow contact time (wet time) of two minutes when cleaning the tablet with a Sani-wipe as specified by the manufacturer’s instructions for use.. Also for the patient visit from the branch office patient HOSRRHV #4 the surveyor observed the RN clean the blood pressure cuff and wipe the case and then put the equipment into the clinical bag (no dwell time) This was validated by the RN/Scribe.

Observed in Patient Home. In 1 of 1 home visits conducted, with hospice aides, the written patient care instructions for the hospice aide were not followed. For example, during the home visit for HOSRRHV #2 the hospice aide was observed shaving the patient however the aide care plan did not include the task. Additionally, the hospice aide provided a shower for the patient however the aide care plan included the task of bed bath. This was validated by the Hospice Manager.

Observed in Tracer Activities. Upon review of the data, the new volunteer coordinator confirmed that volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff since January of 2024, as there was only one active volunteer during that time.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization had not provided education and training to the patient on procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency. In review of the home folder for HOSRRHV #1 there was no evidence that the patient and family had been provided with an individualized emergency plan. This was validate with the RN/Scribe and Medical Social Worker.

Based on record review and staff interview, it was determined for 2 of 2 patients receiving massage therapy (MT) (Pt 's # 3, #11), the Hospice failed to ensure the MT clinical notes included the treatments completed and the patients' response to treatment. This failure has the potential to affect all patients receiving massage therapy from the facility, currently 10 patients. --- Findings: 1. The medical record of Pt #3 was reviewed on 1/24/23. Pt #3 was admitted for Hospice services on 11/16/22 with diagnoses of bullosa emphysema and chronic obstructive pulmonary disease. Orders dated 11/16/22 were for "Massage Therapist" to begin 11/29/22 through 2/13/23 at a frequency of 1 time weekly as family requests. A review of the MT's clinical notes indicated a visit was made per family request on 11/29/22. The clinical note is as follows: "Sitting in chair." A visit per family request was made on 1/10/23. The clinical note is as follows: "Laying in bed." There is no documentation to indicate what services the MT provided or the patient responses to the treatment provided. 2. The medical record of Pt #11 was reviewed on 1/24/23. Pt #11 was admitted for Hospice services on 1/13/22 with diagnoses of tuberous sclerosis and epilepsy. Orders dated 9/19/22 were for "Massage Therapist" to begin 9/20/22 to 11/8/22 at a frequency of 1 time weekly as the family requests. A review of the MT's clinical notes indicated a visit was made per family request on 9/20/22. The clinical note is as follow: "Peaceful response." A visit was made on 9/27/22 per the family request. The clinical note is as follows: "Laying in bed." There is no documentation to indicated what services the MT provided or the patient response to treatment. 3. An interview with the Clinical Supervisor (E#1) was conducted on 1/25/22 at 3:00 PM. E#1 reported the MT (E#3) had done a paper note in the past covering the required areas, but since going to electronic she had not documented the necessary information. E#1 reviewed the patient records and agreed the MT notes were incomplete.

Based on document review and staff interview, it was determined for 1 of 1 patient death records reviewed (Pt #11), the Hospice failed to dispose of medications at the time of patient death per their policy. This failure has the potential to affect all patients receiving care, a current census of 49 patients. --- Findings: 1. A review of the undated Hospice policy titled "Medication Disposal" was completed on 1/25/23. The policy on page 2 indicates under "Process: 5. The patient, family and/or caregiver have the right to refuse disposal of the controlled drugs and/or other medications." The policy under "7. No medications, controlled or non-controlled, will be returned to a pharmacy. If the hospice patient resides in a nursing home the unused hospice medication may be returned by the facility to their pharmacy according to nursing home policy." 2. A review of the medical record of Pt #11 was completed on 1/24/25. Pt #11 was admitted for Hospice services on 1/13/22 with diagnoses of tuberous sclerosis and epilepsy. The plan of care dated 9/10/22 through 11/08/22 were for a skilled nurse (SN) twice weekly for 8 weeks, then once weekly for 1 week. The POC also indicates orders for social work visit once a week for 1 week and 6 visits as needed. Documentation dated 10/08/22 on the SN post-mortem visit indicates Pt #11 expired at home on 10/08/22 at 10:15 am. The "medication disposal note" is a follows: Coroner to dispose of medication. Coroner came and agreed to dispose of medication for us and family." 3. An interview with the clinical supervisor (E#1) was conducted on 1/25/23 at 3:00 PM. E#1 reported the coroner in this specific county has always insisted it is "State Law" for he and a police officer to take all medications to the police station and dispose. E#1 reports this practice has gone on for many years. When asked about the Hospice policy and documentation, E#1 agreed the practice and documentation do not follow the policy.