Every finding on record at St. Carmen Health Providers, Inc.

Observed in Emergency Management Session. The organization's hazard vulnerability analysis did not include the required components since the organization had not conducted a hazard vulnerability analysis for 2024 or 2025. This was confirmed with the Administrator during the Leadership session when we discussed Emergency Management. Observed in Emergency Management Session. The organization had not conducted a hazard vulnerability analysis for 2024 or 2025. This was confirmed with the Administrator during the Leadership session when we discussed Emergency Management.

Observed in Record Review. In 1 out of 7 patient records, the plan of care was not updated to include changes to the patient condition, interventions and measurable outcomes. Example: In RRNHV#1, the patient experienced a change in their GI status on days 6 and 7 after admission to hospice services with med changes noted. There was no update to the plan of care to address interventions and goals related to the change in GI status The nursing visit documentation for the visits on days 6 and 7 to address these changes had not been entered into the electronic medical record. This was confirmed with the Director of Patient Care Services.

Observed in Record Review. In 1 out of 2 record reviews, the nursing assistant did not follow the ordered frequency of visits. Example: RRHV#3, the aide visit frequency made for benefit period #2 in weeks # 1, 2 and 3 was 1 visit per week. The frequency was ordered for 2 times per week. The frequency did change to 1W1 during week 4 of the benefit period. This was confirmed with the Director of Patient Care Services who relates the missed visits to a communication breakdown between what the patient wanted and who was scheduled. There was no documentation in the system related to why the visits were missed.

Observed in Tracer Activities. During review of QAPI data from 2024 and 2025, the Director of Patient Care Services confirmed that chart audits for PIPs related to missing POC updates and Patients without Mortuaries had not been collected since Q3 of 2024. Their timeframes for collection was monthly until they had achieved their target goals. The targets had not been achieved.

Observed in Patient Home. Staff fingernails were not in compliance with standard precautions and organizational policy as evidenced by: In HV#1, staff had artificial fingernails, which were prohibited by HCO policy.

Observed in Tracer Activities. 3 out of 3 Volunteer staff did not participate in ongoing education and training provided to agency staff. Examples: Volunteers were not included in staff training for Hand Hygiene training competency validation and the agency's annual emergency management drill. This was confirmed by the Volunteer Coordinator and Administrator.

Observed in Record Review. In 1 out of 7 hospice records, the organization did not have complete patient records. Example in RRNHV#1, the 2nd and 3rd Nursing visit notes had not been completed in the EMR. The visits were created but without visit content to include assessment and interventions. New medications had been ordered on each day of the unplanned and planned visits. However, agency is unable to determine the effectiveness of the changes due to the absence of the nursing documentation. This was confirmed with the Director of Patient Care Services.

Observed in Record Review. During RR#1 it was noted lack of documentation of an initial bereavement assessment the end of July 2022. This was discussed with the organization leadership team.

Observed in Record Review. In 3 of 5 patient records reviewed, During RR#1 it was noted on the H&P from the discharging facility the comorbidity/history listed included Ca of the endometrium with palliative radiation secondary to bleeding, and triple negative breast Ca. They were not identified as history or related conditions and included on the POC. During RR#2 it was noted on the RN initial comprehensive assessment diabetes mellitus and hypertension were listed as comorbidities/history but were not included on the POC. During RR#3 it was noted on the RN initial comprehensive assessment chronic kidney disease stage III, Anemia, Moderate aortic stenosis, Hyperlipidemia, and Peripheral neuropathy that were not listed as related conditions/comorbidities or history on the POC. This was discussed with the organization leadership team.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#2 it was noted on the RN comprehensive assessment that the patient has a history of diabetes prescribed Glipizide 5 mg 1 tab oral once a day. The POC lacked SN assessment of the patient diabetic status.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it was noted the POC lacked the dietary needs of the patient that were documented by the RN during the comprehensive assessment as a mechanical soft diet. This was discussed with the organization leadership team. This was discussed with the organization leadership team.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR#1 it was noted a problem identified on the POC of chronic right hip pain. This was not listed or added as a comorbidity or related diagnosis on the POC. This was discussed with the organization leadership team.

Observed in Record Review. In 1 of 4 patient records reviewed, the comprehensive assessment was not updated based on changes in the patient’s condition. Upon review of RR#1, it was noted a new wound was identified; however, on review of Interdisciplinary Group (IDG) update documentation, this change was not addressed. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 4 patient records reviewed, collaboration among the hospice Interdisciplinary Group (IDG) was not present in the record. Upon review of RR#1, RR#2, and RR#4 and IDG update documentation, there were several psychosocial and/or spiritual sections left blank by the social worker and/or spiritual counselor, and there was no documentation to validate the disciplines attended the IDG meetings and coordination among the team occurred regarding the patient’s status and/or condition. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 4 of 4 patient records reviewed, not all goals were measurable or established based on the patient’s needs. Upon review of RR#1, it was noted all goals established had a target date at the end of the certification period and were not individualized based on the patient’s needs. For example, the patient had a diagnosis of Colon cancer with pain management issues identified. The patient was on multiple pain medications to control the patient’s pain level and the goal was documented as follows: Patient will have increased comfort/satisfaction from pain by the end of the certification period. Upon review of RR#2 and RR#3, it was noted several goals established had a target date at the end of the certification period and were not measurable. For example, “the patient will maintain optimum circulation and adequate cardiac output by the end of the certification period”. Upon review of RR#4, it was noted several goals established had a target date at the end of the certification period. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 4 patient records reviewed, the plan of care did not include all interventions to meet the patient's needs. Upon review of RR#1, it was noted the patient had a diagnosis of Colon cancer and was on multiple bowel medications. On review of the plan of care, there were no interventions established related to bowel management. Upon review of RR#2, it was noted the patient had a diagnosis of end-stage renal disease and was no longer receiving dialysis. On review of the plan of care, there were no interventions established related to monitoring the patient's genitourinary status. Upon review of RR#3, it was noted the patient had a diagnosis of heart disease with angina, was taking nitroglycerin for chest pain, and prior to their hospice admission, had a recent hospital visit due to angina. On review of the plan of care, there were no interventions established related to the patient’s angina. The patient was taking Tylenol for generalized pain and gabapentin for nerve pain; however, on review of the plan of care, there were no interventions established related to pain management. The patient had a co-morbid diagnosis of diabetes and was on oral anti-diabetic medications and insulin; however, on review of the plan of care, there were no interventions established related to diabetic management. The patient was on oxygen as needed for shortness of breath and required the use of two pillows to sleep at night; however, on review of the plan of care, there were no interventions established related to respiratory management. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 4 patient records reviewed, the plan of care did not include the patient’s dietary needs. Upon review of RR#2, it was noted the comprehensive assessment indicated the patient’s nutritional requirements included a No Added Salt and Renal diet; however, on review of the plan of care, the patient’s dietary needs were not addressed. Upon review of RR#3 and RR#4, it was noted the comprehensive assessment indicated the patient’s nutritional requirements included a mechanical soft diet; however, on review of the plan of care, the patient’s dietary needs were not addressed. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 4 patient records reviewed, the plan of care did not include the equipment needs of the patient. Upon review of the comprehensive assessment for RR#1, it was noted the following equipment was needed; however, on review of the plan of care, these equipment needs were not addressed: bed, trapeze, oxygen concentrator and tanks, and a nebulizer machine. Upon review of the comprehensive assessment for RR#2, it was noted the following equipment was needed; however, on review of the plan of care, these equipment needs were not addressed: walker, shower chair, oxygen concentrator and tanks, and a nebulizer machine. Upon review of the comprehensive assessment for RR#3, it was noted the following equipment was needed; however, on review of the plan of care, these equipment needs were not addressed: wheelchair, oxygen concentrator and tanks, and a nebulizer machine. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, the plan of care was not revised based on the patient's condition. Upon review of RR#1 and the revised comprehensive assessment, changes were made to the patient’s pain medication regimen to include morphine and discontinue oxycodone and a foley catheter was ordered; however, on review of the plan of care, these changes were not addressed. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 4 patient records reviewed, orders were not followed as indicated on the plan of care. Upon review of RR#1, it was noted the patient had a pressure ulcer to their coccyx with the following wound care orders: cleanse with normal saline, pat dry, apply triple antibiotic ointment, cover with dry dressing and secure with border gauze dressing to be done twice a week. On review of nursing documentation, wound care was documented as, “cleansed with NSS, pat dry applied calmoseptine on stage II pressure injury”. During the second week after the wound was identified, there was no documentation on the nursing visit notes to validate wound care had been performed twice as week as ordered. This was reviewed and validated with the Director of Patient Care Services.

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

Observed in Record Review. In 1 of 4 patient records reviewed, the record contained inaccurate information. Upon review of RR#4, it was noted the comprehensive assessment documentation indicated, “Plan for patient is to be on Continuous care at this time due to patient unstable condition, to provide comfort and pain management. SN findings reported to Dr, with orders to give Roxanol 0.25ml every 2 hours as needed for severe pain”; however, there was no documentation to validate the patient required a higher level of care for symptom management and documentation indicated the patient was on routine level of care. This was reviewed and validated with the Director of Patient Care Services.

Observed in Tracer Activities. the organization did not train staff for their assigned roles during an emergency response. While conducting an interview with the Volunteer Coordinator, the Hospice Nurse Surveyor observed the volunteers are not trained on the Organizations' Emergency Operations plan but on a general emergency plan. Also, during HV#3, the HHA was not able to describe the actions she would take if there was an emergency. This was discussed with the DPCS.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to complete an initial bereavement assessment. During record review, the Hospice Nurse Surveyor observed there was not initial bereavement assessment completed on BR#2, RR#2, and HV#2. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review, the Hospice Nurse Surveyor observed the Plan of Care did not include all relevant active problems. For example: in HV#1, the patient had a UTI but it was not addressed on the plan of care. In HV#3, the patient had active wound orders but the Plan of Care did not contain interventions and goals. All Plan's of Care lacked Social Work and Spiritual Care goals and interventions. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment or services. During record review, the Hospice Nurse Surveyor observed that not all CORE disciplines attended all interdisciplinary meetings. In HV#3 for 3/01 meeting, there was no signature or input from the MD, SW or Chaplain. Upon discussion with the Hospice team, the call logs used for IDG did not support full IDG attendance of all members. This was discussed with the DPCS.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the Hospice Nurse Surveyor observed the goals on all care plans, from all disciplines, were expected to be achieved on the last day of the certification period. This was discussed with the DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization did not develop a bereavement plan of care that was specific to the type of services to be offered and the frequency of delivery. During record review of BR#1 and BR#2, the Hospice Nurse Surveyor observed the Bereavement Coordinator did not develop a Plan of Care, but instead wrote a note on the bottom of each assessment ( unavailable to the IDG team) stating how the family was doing and the number of notes needed. This was discussed with the DPCS.

Observed in Record Review. 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 and §418.56. This was discussed with the DPCS.