Every finding on record at Ssm Health Businesses

Observed in HR File Review. In 3 of 3 volunteer HR files reviewed,, the pharmacist surveyor noted that there was no initial EM training for volunteer staff documented and on interview with the volunteer coordinator, the surveyor validated that emergency management training was not part of the onboarding training for volunteers at the time of the survey. The volunteer staff currently part of the hospice, had not yet had their second anniversary to review ongoing training compliance in emergency management required to be completed every two years.

Observed in Document Review. During review of documents included in the patient handbook and admission paperwork it was noted that the organization did not provide written information regarding its policies on advance directives. This was discussed with hospice leadership on site.

Observed in Record Review. In 4 of 16 patient records reviewed, it was noted that for hospice services the plan of care did not contain goals that were measurable or timed. In record reviews for hospice home visits #1, 2, 3 all of the goals were stated to be met by the end of the certification period. For example, in record for hospice home visit the following goal was stated for pain issues, Patient pain/physical discomfort will be reduced to the patient stated goal and will verbalize understanding of the pain management plan. There was no date or measurable time to reach the goal and no patient stated goal to measure the effectiveness of pain management. In hospice home visit #1 record review all goals were stated to be reached by the end of the 90 day certification period. For example, for the problem of history of falls, the following was stated, Patient and caregiver will implement strategies to reduce fall risk by end of 90 day certification period. Decrease fall frequency and reduction in injury risk. In review of record for hospice home visit #3 a stated goal was Cg will verbalize understanding of medication regimen by the end date of the certification period which was three months from now. The patient was imminent. This was discussed with the hospice supervisor and manager.

Observed in Record Review. In 1 of 16 patient records reviewed, during review of record for hospice home visit #4 it was noted that there was no order or update to the plan of care for volunteer services which had been provided the previous weekend. Additionally there is no formal process in place to document volunteer assignment or communication between the volunteer and the volunteer coordinator until the next IDG meeting. This was validated by the hospice supervisor.

Observed in Record Review. In 8 of 16 patient records reviewed, it was noted that the medication sheet for hospice home visit #2 contained multiple medications that were ordered for pain but were not clear for the indications. For example, Tylenol was ordered for pain, Naproxen was ordered for mild/general pain and Percocet was ordered for acute pain. There was no use of pain scale to differentiate when to give which medication. In review of record for hospice visit #3 and record review #2 it was noted that there was no indication for Morphine and was stated as PRN for pain. In record review #3 the Morphine was documented on the medication profile as follows 30 tabs po every 12 hours. In hospice record reviews #5, #9 and #10 the morphine was ordered for pain. In record review #6 the pain medications were stated as morphine for pain, Tylenol pain, Norco acute with no indication for severity or pain scale. This was discussed and reviewed with the hospice supervisor and manager.

Observed in Patient Home. In 1 of 4 home visits conducted, it was noted that the organization's bag technique was not followed. For example, in hospice home visit #4 the nurse placed a barrier on the floor and then placed her bag on the barrier. She needed to step over the bag many times during the visit and the handle of the bag was laying on the floor off of the barrier. Review of agency policy for bag technique stated that the bag be placed on either a solid surface, doorknob or soft surface with a barrier. Additionally, the nurse was wearing a crossbody bag and this made contact with the patient bed and linen several times during the visit. This was discussed and confirmed with the hospice supervisor who was present on the visit.

Observed in Record Review. In 2 of 14 patient records reviewed, for those patients with hospice aide services, it was noted in review of record for hospice home visit #2 that the aide assignment sheet did not include that the patient had a pluerex drain in place and requested it be covered with saran wrap during the shower. Additionally, the aide assignment included both bed bath and shower. In review of hospice record #3 the aide care plan did not include any instructions regarding the use of oxygen during the shower for this patient who was using oxygen at 3L/nc continuously. This was observed by and discussed with the hospice supervisor present on the visit.

Observed in Record Review. In 2 of 14 patient records reviewed, with hospice aide services it was noted in hospice record review #1 that in January 2024 the aide supervisory visits were not done at least every 14 days. For example there was a 21 day period between supervisory visits in January. In hospice record review #9 there was a 15 day period between supervisory visits. This was reviewed with the hospice supervisor assisting with record review.

Observed in Document Review. During a review of the pharmacy contract, the pharmacy surveyor noted that according to the pharmacy contract the following would be completed: by the contract: background checks on all of the pharmacy employees with record access or direct patient contact and validate that the pharmacists were operating within scope of their licenses or registration. In addition, the contract specified that pharmacists would offer clinical support 24 hours per day 7 days per week and provide patient medication profile reviews initially and on request by the hospice organization. However, the contract did not specify how clinical skills of the pharmacy staff would be maintained to provide these clinical services in a manner that the hospice would be able to validate that the contract pharmacy individuals would be able to be deemed qualified to provide these clinical services to the hospice patients effectively. This omission was validated with the hospice director at the time of the survey. The pharmacy provided the Hospice an addendum to the current pharmacy benefit management agreement validating on 2/22/24 that licensed pharmacists and staff would complete ongoing education and be trained to develop and maintain clinical service for patients in pain and with palliative care hospice needs,

Observed in Record Review. In 2 of 4 home visits conducted, it was noted that in review of record for hospice home visit #1 that the hospice medication profile did not match the Skilled Nursing Facility medication profile. For example, the facility medication profile contained Vitamin D3, Multivitamin and Ferrous Sulfate none of which were in the hospice record. Additionally, the frequency for Isosorbide was listed as BID on the facility profile and TID on the hospice profile and lastly Duo Neb was listed as a PRN medication on the facility profile and as regularly scheduled every 6 hours on the hospice profile. In another example in review of record for hospice home visit #4 it was noted that the medication profile and what was present in the home did not match. For example, Klor Chon was being given daily but was not on the medication profile and Wellbutrin was stated on the medication profile as 75 mg, take 2 tabs BID. The bottle in the home stated Wellbutrin 300mg daily and what was in the nurse's computer was stated as Wellbutrin 150 mg, one tab BID. This was discussed with and confirmed by the hospice supervisor who was present on the visits.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge record review #2 it was noted that the discharge summary did not include documentation regarding the patient's continued use of an implanted pain pump. This was verified by the hospice supervisor assisting with record review.

Upon patient record review, 5 of 11 (Patient #1, #4, #6, #7, and #8) 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 #1: Medication profile did not include indication for usage for bisacodyl suppository, miralax, phenergan gel and scopalamine drops. No dilutent instructions listed for miralax. Corrected on site. Patient #4: Medication profile did not include indication for usage for ativan, duonebs, norco, oxygen, and zofran. No frequency listed for Ropinirole. Corrected on site. Patient #6: Medication profile did not include indication for usage for lorazepam, promethazine gel and miralax. No dilutent instructions listed for miralax. Corrected on site. Patient #7: Medication profile did not include indication for usage for zofran, phenergan gel, norco and miralax. No dilutent instructions listed for miralax. Corrected on site. Patient #8: Medication profile did not include indication for usage for oxygen and miralax. No dilutent instructions listed for miralax.

Upon patient record review, 5 of 11 (Patient #1, #4, #6, #7, #8) 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 #1: Plan of care did not include indication for usage for bisacodyl suppository, miralax, phenergan gel and scopalamine drops. No instructions listed for preparation of miralax. Corrected on site. Patient #4: Plan of care did not include indication for usage for ativan, duonebs, norco, oxygen, and zofran. No frequency listed for Ropinirole. Corrected on site. Patient #6: Plan of care did not include indication for usage for lorazepam, promethazine gel and miralax. No instructions listed for preparation of miralax. Corrected on site. Patient #7: Plan of care did not include indication for usage for zofran, phenergan gel, norco and miralax. No instructions listed for preparation of miralax. Corrected on site. Patient #8: Plan of care did not include indication for usage for oxygen and miralax. No instructions listed for preparation of miralax.