Every finding on record at St. Bernardine Hospice Care, Inc

Upon patient record review, 13 of 14 (Patient #1,2,3,4,5,6,7,8,10,11,12,13,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient #1,2,3,4,5,6,7,8,10,11,12,13,14: The RN comprehensive assessment did not contain evidence that imminence of death was being assessed.

Upon patient record review, 1 of 14 (Patient #1) 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: Upon home visit 6/24/25 noted Acetaminophen Oral Solution 160 mg/5ml on updated POC 5/21/25 order is dose 10ml (320mg) every 6 hours PRN and patient medication bottle has directions to give Acetaminophen 160mg/5ml give 20 ml (640mg) po every 12 hours PRN. Corrected on site with updated medication sent from hospice pharmacy with a corrected label with the most current order on POC.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 7: Initial POC on 4/19/25 contains an order for Xarelto 2.5mg BID with no risk for bleeding noted in POC goals and interventions and Foley cath is noted in SN documentation and POC does address need to assess foley but no specifics regarding size, flush order or balloon on initial. Corrected on site POC updated to include risk for bleeding and foley was discontinued on 4/21/25 with an order.

Upon patient record review, 3 of 14 (Patient # 1,4,9) 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: The updated POC 5/21/25 contains an order for Acetaminophen Oral Solution 160 mg/5ml Dose 10ml (320mg) every 6 hours PRN and patient medication bottle has directions to give Acetaminophen 160mg/5ml ml Dose 20 ml every 12 hours PRN. Corrected on site with updated medication order sent from hospice pharmacy to patient home and caregiver education provided. Patient 4: Initial POC 3/31/25 and updated POC at recertification on 5/22/25 contains an order for Foley cath change monthly with no orders for size of cath or balloon size. There is an order noted 4/1/25 for flush with 60 ml and SN documents on 3/31/25 in initial comprehensive assessment "foley changed with 16 FR 10 cc balloon." There is no evidence for a complete order indicating size of Foley to use and balloon size. Corrected on site with order obtained complete for foley care and POC updated. Patient 9: Initial POC 6/9/25 contains an order for a foley to assess and change every month and prn if clogged with no details on size, balloon and flushing details.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: SN documents on 3/31/25 in initial comprehensive assessment "foley changed with 16 FR 10 cc balloon." There is no evidence for a complete order indicating size of Foley to use and balloon size. SN care provided without complete order on POC. Corrected on site with obtained complete order for foley care and POC addendum updated.

Upon personnel record review, 1 of 13 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed Personnel # 6: Initial and annual competency assessment does not include direct observation of Sponge and tub bath and Shampoo, sink, tub and bed. RN did not date and sign off on Shower/tub bath and competency assessment does not give breakdown of all options of bathing and shampoo options including sink, tub and bed shampoo.

Observed in Record Review. In 5 of 5 patient records reviewed, of active patients it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#4, and RR#5, the goals were not measurable or individualized for the patients. For example, Patient will have minimal discomfort caused by confusion and Patient will remain comfortable at all times with planned interventions and caregiver will properly administer treatment for constipation.” Findings were verified by the Director of Patient Care Services and the Chief Officer of Operations.

Observed in Record Review. In 5 of 5 patient records reviewed, for active patients it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#4, and RR#5, the visit frequency as established by the IDG (interdisciplinary group) included PRN visits for the chaplain and the social worker; however, the extra PRN visits were not quantified as required by regulation. The findings were verified by the Chief Officer of Operations

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned. For example, during HV#1/RR#1, the skilled nurse went into his bag for his barriers, equipment, hand sanitizer, and alcohol spray cleanser without performing hand hygiene. He also did not zip his bag after removing all the required items. While donning his gloves one time he did not perform hand hygiene. Additionally, he did not have a defined dirty and clean barrier and laid his dirty equipment on top of his pile of clean gloves. During HV#2/RR#2, the skilled nurse put a barrier on the floor and set his bag on top of it. He then completed the head-to-toe assessment going from the patient’s feet and back to his bottom to check his skin integrity without changing gloves and performing hand hygiene. During HV#3/RR#3 with the hospice aide, she performed hand hygiene after putting her bag on a doorknob. She then switched on the bathroom light with her hand and then donned her gloves without performing hand hygiene again. The finding on HV#3/RR#3 was verified by the Director of Patient Care Services who was present during the visit.

Observed in Record Review. In 5 of 5 patient records reviewed, for active patients it was noted by the nurse surveyor that for HV#1/RR#1, HV#2/RR#2, HV#3/RR#3, RR#4, and RR#5, the hospice aide careplan did not provide any instruction regarding when the hospice aide should notify the RN such as a change in the patient’s condition or skin breakdown. Additionally for, HV#2/RR#2 and RR#5 the patients had oxygen and the hospice aide careplan did not provide any instruction on what the aide’s responsibility regarding the oxygen. All findings were verified by the Director of Patient Care Services and the Chief Officer of Operations.