Every finding on record at St. Anthony's Memorial Hospital

Observed in Record Review. The organization did not provide Chaplain services in accordance to the plan of care. The surveyor noted during record review for HV#1 that the Chaplain frequency of 1-2 times per month was not met in month two of the certification period. Reviewed with the Hospice leader.

Observed in Record Review. In 1 of 14 patient records reviewed, The organization did not conduct a spiritual care comprehensive assessment identifying spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness as noted in the record review for HOSHV#4. The assessment did not include the required elements defined in the organizations spiritual care assessment. Reviewed with the Hospice leader. Observed in Record Review. In 4 of 14 patient records reviewed, The organization did not complete initial spiritual care comprehensive assessments as required. The surveyor noted this during record the record reviews (HOSHV#2,3 and 6 and HOSNHV#1). The assessments did not address the spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness as defined in their spiritual care assessment. Reviewed with the Hospice leader.

Observed in Document Review. During a review of a SNF/nursing facility contract, the Hospice Manager confirmed that A delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff was not included in the contract.

Observed in Record Review. In 5 of 12 patient records reviewed, where Chaplain services had been requested, the hospice interdisciplinary group failed to ensure that the comprehensive assessment be completed no later than 5 calendar days after the election of hospice care. For example: in review of Hos HV#4, Hos RR#5, Hos RR#7, Hos RR#11, and Hos RR#12 the patient requested Chaplain, yet the spiritual assessment was not completed within 5 calendar days from the election of hospice care. This observation was reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to ensure that the patient record was accurately documented, readily accessible, and systematically organized to facilitate retrieval. For example: upon review of the informed consent for Hos HV#4 the signed informed consent was dated incorrectly by the patient and witness as 11/17/23. This observation was reviewed with the RN Manager of Home Care and Hospice Services.

Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for care and services identified in the plan of care. For example: on review of Hos RR#15 it was documented that Morphine was ordered and delivered to the patient home by the RN, however there was no documentation in the record that there was any education and training provided to the caregiver on the medication, its properties and safe usage as ordered. This observation was reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 6 of 16 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflect patient and family goals based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: on review of Hos HV#2 the patient was treated for UTI yet there were no goals to direct the care. In Hos RR#5 the patient had a respite stay and transitioned from a home to a SNF but no goals for the changes were noted on the plan of care. In Hos HV#4 the goal for psychosocial was not specific, and measurable as it states pt/family is receiving emotional support through (dates). In Hos RR#7 there was a disconnect from the interventions for wound care and the established goal, and the patient had wounds with dressing changes but the goal did not reflect this. In Hos RR#12 the documentation noted the patient had increased pain yet the changes were not reflected in the goals. In Hos RR#14 the patient had dysphagia and documented the need for honey thickened liquids, yet the issue was not reflected in the goals. These observation were reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 2 of 16 patient records reviewed, the organization failed to ensure that plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include a statement of the scope and frequency of services necessary to meet the patient and families needs. For example: in review of Hos HV#1 the patient was receiving Chaplain visits yet no frequency had been established. In Hos RR#7 the patient received an initial Chaplain assessment that noted follow up would be made, however no follow up was made and no frequency established. These observations were reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 5 of 16 patient records reviewed, the organization failed to ensure that the individualized written plan of care reflect individualized interventions that includes all services needed for the palliation and management of the terminal illness. For example: on review of Hos HV#2 the patient was treated for UTI yet there were no interventions to direct the care. In Hos RR#5 the patient had a respite stay and transitioned from a home to a SNF but no interventions for the changes were noted on the plan of care. In Hos RR#7 the only goal for wound care stated caregiver will demonstrate the ability to identify signs and symptoms of infection, yet there was no intervention to teach the signs and symptoms of infection. In Hos RR#12 the documentation noted the patient had increased pain yet the changes in issues were not reflected in the interventions. In Hos RR#14 the patient had dysphagia and documented the need for honey thickened liquids, yet there were no interventions for thickened liquids. These observation were reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 3 of 16 patient records reviewed, the organization failed to ensure that the plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include drugs and treatment necessary to meet the needs of the patient. For example: upon review of Hos HV#1 and Hos HV#4 the patient medication profile included 3 PRN laxatives however there were no patient instructions to indicate when to use which laxative. In Hos RR#7 the patient had an order for diazepam 10mg suppository. Insert one suppository rectally for seizure. There was no indication of a frequency or if was a one time order. Another order was Lorazepam 2 mg suppositories. Place 2 mg rectally as needed. Insert 1 suppository rectally every 10 min for seizures (Max 2 doses). There was no instructions as to which suppository to use first in the event of a seizure. These observations were reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 12 of 16 patient records reviewed, the organization failed to ensure that the revised plan of care include information from the patient's comprehensive assessment and noted the patient progress toward outcomes and goals specified in the plan of care. Throughout all records reviewed there was a lack of progress toward and goals and outcomes as the care plans goals and interventions remained the same IDG to IDG meeting with the exception for changing dates. At times there was documentation in the record of goals being met yet the goals continued without revision. These observations were reviewed with the Manager of Home Care Services - Hospice.

Observed in Record Review. In 4 of 12 patient records reviewed, where spiritual services were accepted by the patient, the organization failed to ensure that the Chaplain conduct and document a patient specific comprehensive assessment of the patient and family's spiritual needs. For example: upon review of Hos HV#1 the Chaplain had made 3 visits to the patient, yet no comprehensive spiritual assessment had been documented. In Hos HV#4 the Chaplain documented phone calls only but no comprehensive assessment. In Hos RR#11 and Hos RR#12 the family accepted spiritual services, yet no spiritual assessment had been documented on the record. These observations were reviewed with the Manager of Home Care Services - Hospice.

Observed in Patient Home. In 1 of 16 patient records reviewed, the organization failed to ensure that patient record contain all information to reflect the patient care, treatment, and services. For example: upon observation of the medication reconciliation for Hos HV#1 with the RN and facility staff the hospice medication profile had simvastatin 20mg tab 1 daily at night, yet the facility had a bottle for 40 mg tabs. The facility nurse noted that she cuts the 40mg tabs in half. This observation was reviewed with the Manager of Home Care Services - Hospice.