Every finding on record at St. Camillus Health Center, Inc.

Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to assess and reassess the patients pain as per pain assessment policy as evidenced in HOSRRHV#2: No pain assessment completed during nursing visits, notes states staff used observation scale but unable to find it in documentation, this was observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 14 of 15 patient records reviewed, The organization failed to assess the patient’s need for physical, psychosocial, emotional, and spiritual care, as evidenced in HOSRRHV#1: HOSRRHV#4: HOSRRNV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV#5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9 and HOSRRNHV# 10 the need for volunteer services not assessed. HOSRRHV#2: Prior to visit the ALF staff informed hospice RN that patient had irritation/rash to groins bilaterally and she was concerned that it may open, RN did not assess skin during nursing visit. HOSRRBR#3, no initial bereavement assessment completed this was observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to include all services needed in the plan of care for the palliation and management of the terminal illness and related conditions as evidenced in HOSRRHV#3: No volunteer interventions or frequency was in care plan. HOSRRNHV#9: Patient had massage and music therapy with no orders. HOSRRNHV#8: Patient had massage therapy with no orders, this was observed and validated by Hospice Clinical Manager

Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to provide a written plan of care based on the patient’s goals and time frames as most of the time frames were end of cert as evidenced by in HOSRRHV#1: Patient/caregiver will verbalize understanding of falls prevention, home safety measures: target date end of cert, this was observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 8 of 14 patient records reviewed, The organization failed to establish measurable outcomes anticipated from implementing and coordinating the plan of care as evidenced in HOSRRHV#1: patient/caregiver will have no s/s complications related to impaired physical mobility for stage of disease process. HOSRRHV#2: Chaplain: Patient/family achieves feelings of spiritual comfort. HOSRRHV#3: peripheral edema will be reduced within limitations of disease process. HOSRRNHV#1: Patient symptoms will be consistent with stage of disease process and problems managed as well as disease will allow, HOSRRNHV#3:Patient will maintain optimum level of functioning appropriate for stage of disease process. HOSRRNHV#4: Patient/caregiver will express satisfactory in control on symptoms. HOSRRNHV#7: Patient will be free of preventable complications. HOSRRNHV#9: Maintains skin integrity,this was observed and validated by the Hospice Clinical Manager.

Observed in Record Review. In 12 of 14 patient records reviewed, The organization failed to clarify medications and treatment necessary to meet the patient’s needs as identified in HOSRRHV#1 and HOSRRHV#3: HOSRRNHV#1, HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4, HOSRRNHV# 5, HOSRRNHV#6, HOSRRNHV#7, HOSRRNHV#8, HOSRRNHV#9: Oxygen was ordered 2-5 litres via nasal cannula as needed for dyspnea, no indication when to choose which litre dose. HOSRRHV#2 and HOSRRHV#3: No indication: scopolamine 1mg/72hrs transdermal patch, extended release: apply 1-3 patches transdermally every 72 hours as needed for secretions. HOSRRHV#2: patient is a diabetic and there was no diabetic care in the plan of care. HOSRRHV#4: No bleeding precautions or diabetic care plan since initial plan of care and no order for hibiclens wash to left axilla 3 times a week for recurrent suppuration hidradenitis since SOC and this has been discontinued HOSRRNHV#2: Patient has a stage 1 decubitus ulcer @ SOC and no care plan about thi HOSRRNHV#7: . Patient is on a fentanyl patch and no pain care plan for high risk medication s, this was observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 11 of 14 patient records reviewed, The organization failed to revise plans and goals for care, treatment, or services based on the patient’s needs as evidenced by all target dates were end of cert HOSRRHV#2: Continuation of same goals and target dates unchanged into next cert period,e.g SN goal: patient will remain comfortable and symptom will be managed and dates were for last benefit period. HOSRRHV#3: Target date remained unchanged since last cert period for Chaplain: caregiver will consult with staff as needed for support. HOSRRHV#4: MSW: patient will be able to indicate preferred coping strategies that add to quality of life since SOC. HOSNHV#1: Patient symptoms will be consistent with stage of disease process and problems managed as well as disease will allow. HOSRRNHV#2:Patient and family have spiritual needs will be met and target date unchanged since SOC. HOSRRNHV#4: Patient/caregiver will express satisfactory in control on symptoms. HOSRRNHV#5: All goals have end of cert period: Patient will demonstrate decreased s/s of constipation. HOSRRNHV#6:goal still present since SOC: SLP Patient will demonstrate ability to perform swallow strengthening strategies with 70% accuracy given cues as needed and patient is no longer being seen by SLP. HOSRRNHV#7: Patient will be free of preventable complications by end of cert. HOSRRNHV#8: Patient will be pain free or have acceptable FLACC score with current pain management regime target date unchanged since last cert period. HOSRRNHV#9:Maintains skin integrity remained to the same target, this was observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 6 of 14 patient records reviewed, The organization failed to provide the patient with care, treatment, or services according to the patient's individualized plan of care as evidenced that the HHA did not follow the ordered frequency of visits in HOSRRHV#1: the HHA   as there was a missed visit for one week and no notification to RN or physician,. HOSRRHV#2: HHA missed visits on 3 different weeks without notification to RN or physician. HOSRRHV#3:HHA missing visit for 3 weeks without any notification to RN or physician .HOSRRHV#4; There was RN + HHA missed visits for 5/14/25 and 5/28/25 and no notification or documentation to physician. HOSRRNHV#1: HHA did not see patient for 3 weeks, missing visits. HOSRRNHV#8: HHA missed 1 week of visits without notifying RN or MD, this was observed and validated by the Hospice Clinical Manager

Observed in Data Session. The organization failed to evaluate contracts annually as evidenced the organization did not eval pharmacy or DME program, this was validated by the Administrator

Observed in Data Session. The quality assessment and performance improvement program failed to demonstrate improvement in the indicators related to improved palliative outcomes and hospice services, this was validated by the Administrator

Observed in Record Review. In 3 of 3 patient records reviewed, The hospice failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery as evidenced in HOSRRBR#1, HOSRRBR#2 and HOSRRBR#3, this was observed and validated by Hospice Clinical Manager

Observed in HR File Review. In 1 of 9 HR files reviewed, The organization failed to assess and document staff competency once every three years as evidenced in HR#1: HHA competency was not done for the last 3 years, this was observed and validated by the Administrator

Observed in Record Review. In 6 of 14 patient records reviewed, The organization failed to provide an accurate written patient care instructions for the hospice aide as evidenced by in HOSRRHV#2: HHA care plan had assist with meal planning and also meal preparation, RN should HOSRRHV#4: HOSRRNHV#2, HOSRRNHV#3, HOSRRNHV#4 & HOSRRNHV#9: patient is on anticoagulant therapy and no special bleeding precautions identified in care plan. this was observed and validated by the Hospice Clinical Manager.

Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to provide services that are ordered by the physician or allowed practitioner in the plan of care as per policy Hospice Aide- Care Plan as evidenced in HOSRRHV#1:the patient declined shower since SOC during HHA visit and no communication to RN. HOSRRHV#2: HHA did not provide shower or bath and did not document reason , this was observed and validated by the Hospice Clinical Manager

Observed in HR File Review. In 1 of 9 HR files reviewed, A registered nurse failed to make an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care as evidenced in HR #1, there is no record for on-site observation and assessment, this was observed and validated by the Administrator

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation and staff interviews 418.100,: 418.56 and 418.58

Observed in HR File Review. In 1 of 9 HR files reviewed, The organization failed to complete staff competency initially as part of orientation as evidenced by in HR# 5 emergency preparedness not completed on initial orientation, this was validated by the Administrator Observed in HR File Review. In 1 of 9 HR files reviewed, The organization failed to define the competencies it requires of its staff who provide patient care, treatment, or services as evidenced by there is no competency defined for Hospice Medical Director, this was validated by the Administrator

Observed in Tracer Activities. Leaders failed to monitor contracted services by communicating the expectations in writing to the provider of the contracted services as evidenced by the DME and therapy contract did not include criminal background checks on employees who provide direct patient care or have access to patient records. There was no key performance indicators identified in pharmacy contract, this was observed and validated by the Administrator

Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to identify the care and services that are needed and identify which provider is responsible for performing the functions that have been agreed upon and include in the plan of care as evidenced in HOSRRHV#4: Patient is being seen by SNF wound care RN and there is no coordination of care in the hospice plan of care, this is observed and validated by the Hospice Clinical Manager

Observed in Record Review. In 1 of 14 patient records reviewed, The organization failed to provide the SNF in HOSRRHV#4: hospice election form as required, this was validated by the Hospice Clinical Manager

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Surveyor found that plan of care goals and interventions were not specific, measurable, nor with an appropriate time frame for achievement. Examples include: the Hospice Surveyor found that patient plan of care goals and interventions had not been specific, measurable, nor with an appropriate time frame for achievement. Examples include: Patient/caregiver verbalize understanding/demonstrate proper skin care; Patient/caregiver verbalize understanding/demonstrate proper incontinence management and management of pessarie; Patient/caregiver able to identify s/s to report to hospice; actions to take; Patient will remain comfortable. Also, all goals were to be achieved at the end of certification period. These examples were observed in each patient record reviewed. These findings were validated with the Hospice Clinical Manger Observed in Record Review. In 3 of 13 patient records reviewed, of patients who had been recertified for continued hospice care, the hospice surveyor noted the goals and interventions had expired with the previous certification period and had not been updated. for example: HOS HV #2 HOS HV#3 and HOS RR #8, the recertification goals were all dated prior to the recertification period and expired. These findings were validated with the Hospice Clinical Manger

Observed in Record Review. The Hospice Surveyor noted orders for insertion and ongoing care of an indwelling urinary catheter were absent from the patient plan of care in HOS RR #4. This was validated with the Hospice Clinical Manager.

Observed in Patient Home. In 4 of 4 home visits conducted, the Hospice Surveyor observed that the clinicians had not performed hand hygiene per the agency's Hand Hygiene policy. For example: during HOS HV#1, The clinician had not sanitized her hands before or after having direct contact with patient nor before entering her nursing bag. The same clinician was observed washing her hands with soap and water for a much shorter duration than described in their policy. HOS HV #2, the clinician had not performed hand hygiene after removing her gloves, entering her nursing bag, or after having contact with inanimate objects in the patient vicinity. These findings were validated with the Hospice Clinical Manger present for the visits. Observed in Patient Home. the organization had not ensured their infection control policy had been observed by having staff perform disinfection of medical supplies and devices. For example: in HOS HV #3, the Hospice Surveyor noted the Hospice Aide had a cloth gait belt that was utilized in the patient's care; however, the aide had been unable to verbalize the method of cleaning the belt between uses. The aide also placed the unclean gait belt around her neck after use. This was validated with the Hospice Clinical Manager onsite during the visit.

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Surveyor noted the Hospice Aide (HA) orders included 'PRN' visits. For Example: HOS HV #1- HOS Aide had 30 'prn' visits ordered; HOS HV #3- Aide; 1 wk 13 wk 36 PRN : Symptom management; HOS HV #4: Aide; 1 wk1, 2w 13 wk 5 prn: Symptom management; The other patient records had similar orders. These findings were validated with the Hospice Clinical Manger and Administrator. Of note: The HA prn orders were removed by the organization while surveyor onsite.

Observed in Record Review. The hospice surveyor noted the Medical Director had not reviewed the patient clinical information and sign the Certificate of Terminal Illness (CTI) prior to patients recertification. This was found in HOS HV #2 and HOS RR #8. There had been a verbal CTI on the first day of the new certification period and then a delay in receiving the physician signed CTI. This was validated with the Hospice Clinical Manager.

Observed in Record Review. In 13 of 13 patient records reviewed, the Hospice Surveyor noted that patients had multiple medications ordered to treat the same symptom; however, there had been no parameters for which medication to utilize first, second, etc. For example, every record reviewed contained orders for Atropine Sulfate Ophthalmic 1%, Apply 1-3 drops ophthalmic every hour prn for 3000 days as needed for increased congestion, instill 1-3 drops SL every hour PRN for increased congestion. and Scopolamine 1mg.72 hr transdermal film, extended release; apply 1-3 films applied topically every 72 hours for 3000 days as needed for increased congestions; Apply 1-3 patches behind the ear every 72 hours prn for increased congestions. Both medications ordered for increased congestion. The patients also had multiple medications ordered for constipation, again without parameters for administration. For example: HOS HV #3 had Bisac-Evac 10 mg rectal suppository; Administer 1 suppository(ies) rectally once a day as needed for constipation; polyethylene glycol 3350 oral powder for reconstitution; Administer 17 gm(s) orally once a day for constipation; Senna 8.6 mg oral tablet; Take 1 tab(s) orally 2 times a day for constipation. These findings were validated with the Hospice Clinical Manger.

Observed in Record Review. In 4 of 4 patient records reviewed, of patients on a high risk medication, the organization had not provided education to address the risk factors associated with the medication. For example: HOS HV #2 the patient had been on Warfarin, an anticoagulant, and identified as a high falls risk on hospice evaluation visit; however, the electronic medical record had not contained documented education on the high-risk medication, including what to do after a fall, and safety precautions related to bleeding. HOS RR #5, the patient was on Eliquis, and a high falls risk, and no documented education had been in the electronic medical record. This was also noted in HOS RR #8 and HOS RR # 13. This was validated with the Hospice Clinical Manager.