Every finding on record at St. Joseph Hospice of Southern Mississippi, LLC

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. Per NFPA 110-2010, 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises when the prime mover is located outside the building. The enclosed metal generator did not have manual emergency stop located outside the enclosure. There was a "run, auto, off" switch located in metal enclosure .

Upon patient record review, 4 of 21 (Patients #3,5,8,14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 3 of 21 (Patients #1,2,12) 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: During medication reconciliation at home visit the following did not match medication profile-Alendronate 70mg daily listed on profile/per husband and patient is no longer taking. Tums gummy 250 mg daily listed on profile/per husband and patient is no longer taking. Tylenol (acetaminophen) 325 mg 1 tab daily listed on profile/on hand in home is 650 mg tablets only. Patient #2: During medication reconciliation at home visit the following did not match medication profile-Toprol XL 25 mg 1 tab daily/on hand the prescription bottle read 1/2 tab daily and Trazodone 50 mg 1/2 tab at bedtime/On hand the prescription bottle read "as needed". Patient #12: This patient is prescribed Acetaminophen 650mg every 8 hours as needed. Acetaminophen 650mg suppositories 1 suppository every 4 hours as needed and Hydrocodone/Acetaminophen 10/325 one tablet every six hours as needed. The medication profile did not specify a maximum dose of acetaminophen within 24 hours.

Upon patient record review, 1 of 21 (Patient #1) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1: MSW visit frequency indicated "PRN visits only upon family request" This frequency did not include a baseline visit frequency for the MSW (IDG 3/11/26).

Upon patient record review, 1 of 21 (Patient #12) 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 #12: This patient is prescribed Acetaminophen 650mg every 8 hours as needed. Acetaminophen 650mg suppositories 1 suppository every 4 hours as needed and Hydrocodone/Acetaminophen 10/325 one tablet every six hours as needed. The plan of care did not specify a maximum dose of acetaminophen within 24 hours.

Upon patient record review, 6 of 21 (Patients #3,7,8,9,11,15) 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 equipment and supply needs. Patient #3: This patient had a alternating pressure mattress and side rails x2. These were not included on the Plan of Care. Patient #7: The record reflected that this patient had a cane and walker. These were not included on the Plan of Care. Patient #8: The record reflected that this patient had a Hoyer Lift and walker. These were not included on the Plan of Care. Patient #9: The record reflected that this patient had a Hoyer Lift, over-bed-table and wheelchair. These were not included on the Plan of Care. Patient #11: The record reflected that this patient had a bedside commode This item was not included on the Plan of Care. Patient #15: The record reflected that this patient had an over-bed-table and walker. These were not included on the Plan of Care.

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #11: Did not have evidence of Initial Skills Competency for Bereavement Coordinator. Had Chaplain Initial Skills Competency only.

Condition of Participation: Hospices that Provide Inpatient Care Directly.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. During review of generator testing logs for the previous 12 months revealed monthly generator exercises were conducted for approximately 10–15 minutes per occurrence. NFPA 110 (2010 edition), Section 8.4.2, requires generators to be exercised under load for a minimum of 30 continuous minutes. NFPA 99 (2012 edition), Section 6.4.4.1.1.4, requires compliance with NFPA 110 testing requirements for essential electrical systems.

Upon observation, there is no evidence the interior finish of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. Hospices are exempt from chapter 19.3.6.3.5 "exception number 1 and 2" and 19.3.6.3.6 number 2. If recommended by state survey agency, CMS may waive for periods deemed appropriate, specific provisions of the LSC which, if rigidly applied, would result in unreasonable hardship to the hospice, but only if the waiver would not adversely affect the health and safety of patients. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction During building tour, it was observed that ceiling tiles were observed to be water-stained x1 and misaligned, creating gaps in the ceiling membrane. This condition indicates a failure to maintain building components in a safe and reliable condition and may allow the passage of smoke. This is not in accordance with NFPA 101 (2012), Sections 19.3.3.2 and 4.6.12, which require interior finish materials to be maintained and building components to be in good repair. These areas included: • Nursing station/conference room • West wing near rooms #10, #14 • Near north door (stained) • North wing (missing tile) • South hallway

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #12: The contracted OT provided a patient visit in approximately 2020, but none since. There is no evidence of initial or annual training in emergency preparedness.

Upon patient record review, 1 of 13 (Patient #2) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #2: Admitted 2/3/23 with Colon CA, peritoneal metastasis. Patient experienced pain that was not effectively controlled according to documentation. SOC Comprehensive Assessment visit 2/3/23: Pain 8/10, lower back, vomiting , vomits only with pain, per husband. MS Contin 30 mg BID. Fentanyl 25 mcg patch on patient’s chest with no date. Husband reported it was put on earlier this week. RN contacted MD and obtained order to increase Fentanyl to 50 mcg. Also obtained order for Zofran 4 mg q4 hrs prn. Called to pharmacy. No documented follow up pain assessment within 48 hr. 2/6/23 SN Visit. Morphine not effective per patient. She took Percocet from old bottle. (Percocet 10/325 and Oxycontin 20 mg 1 BID). Reported confusion r/t Xanax. MD contacted. 2/7/23 MSW Note. Patient lying in bed, crying profusely and states that she is in pain – continues today throughout visit. Refuses to discuss any recent events or provide any information for LMSV. No evidence MSW updated RN. 2/9/23 SN Visit Pain 5/10. Per RN documentation, has Percocet 10/325 mg for break-thru. She has had 2 in last 24 hrs as pain occasionally increases. (obtained order for Oxycodone 2/9.) 2/13/23 SN Note: referenced Percocet again, but making her nauseated. She cried. Doesn’t take MS Contin r/t “doesn’t touch the pain. Depressed and cries a lot. 2/16/23 Pain 4/10, taking MS Contin bid again. Oxycodone and Fentanyl patch script dropped off. 2/20/23 Pain 7/10. 2/23/23 12:08 pm visit: I’m not doing well today. Pain 10/10. Fentanyl replaced Tuesday. RN gave her Morphine pills at visit and after a few minutes, she vomited. She took Zofran and was able to keep it down. Stated it helped and feeling better. Contacted Dr. Rogers and okay to bring comfort kit. Husband says he will not be able to pick up tonight and he will try MS Contin again later this evening. Says it is okay for RN to bring them tomorrow. 2/24/23 PRN Visit by on call nurse r/t increased pain. 10/10. MS Contin, Oxycodone and Fentanyl 50. Contacted MD. He ordered increase MS Contin from 30 to 60 mg bid, but vomited after dose was given at visit. He okayed bringing comfort kit. (in fact this had been approved/order yesterday visit, but not yet obtained/provided). 2/26/23 Visit Patient crying.. pain has increased 7/10. Has not slept. 0.5 ml of Morphine q 2-4 hrs – Didn’t get Ativan over the weekend. RN documented she encouraged family to give both Morphine and Ativan every 2 hrs. Patient vomited during visit. RN gave Zofran. Next Visit 3/1/23 Patient dry heaving, vomiting intermittently during visit. She wants to go to the hospital for pain control. Documented mother saying she is unable to provide care she (daughter/pt) needs due to her own health problems. There was not clear plan documented in visit note, but DON reports RN called this am to follow up on options. There was no increase in visit frequency noted in response to uncontrolled symptoms. Notes shared reviewed with team in afternoon exit 3/1/23. Education provided including but not limited to timely provision of meds when ordered and including possible but not limited to LOC change and/or acute hospitalization if that is patient desires.

Upon patient record review, 1 of 13 (Patient #1) 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 Initial orders for Colace 100 mg cap 1 tab daily and Miralax 17 gm/dose oral powder daily prn. No diluent or volume specified. RN documented educating PCG regarding Senna and/or Senakot on several occasions (1/30, 2/3, 2/1, 2/13, 2/15, 2/16, 2/24/23). Also 2/20/23, 2/24/23 PCG reportedly using Lactulose she had from past. No orders for Lactulose, Senna or Senokot. Corrected on site.

Upon client record review, 1 of 13 (Patient #6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: 1-21-23 order for CH 3m1 frequency. SC visits provided 1x monthly.

Upon personnel record review, 1 of 13 (Personnel #5) 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.) ·(C) Shampoo, sink, tub, and bed Personnel #5 - The competency form utilized by the agency does not specify types of shampoo and therefore, all 3 types are not validated.

Upon patient record review, 1 of 13 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #8: Aide Care Plan assigns shave, shampoo, linen change per patient request.

Upon patient record review 1 of 13 (Patient #2) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities Patient #2: Aide 2/7/23 visit note included "Patient was … crying. Patient didn’t want a bath r/t stomach pain. Patient took something for anxiety and after a few minutes got calmed down. Patient stated that she’s thirsty a lot, but no appetite for food. Patient finally resting on bed upon exit." No documented evidence RN was updated.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: The Administrator identifies KS as alternate administrator. Her job description does not clearly differentiate Admin/Executive Director vs. Alt Admin/ED.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #12: The contracted OT provided a patient visit in approximately 2020, but none since. There is no evidence of initial orientation, including, the hospice philosophy.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #12: The contracted OT provided a patient visit in approximately 2020. There is no evidence of initial orientation to job description/requirements.

Upon personnel record review, 1 of 13 (Personnel #12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #12: Contracted OT provided visit(s) approximately 2020. No evidence of initial competency assessment in personnel file.

Upon contract review, 1 of 7 (Alternate MD) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. Physician Contracts are not clear to differentiate Medical Director vs. Medical Director alternate. Both refer to Medical Director. The agency administrators identifies Dr. B as Medical Director and Dr. C as alternate.

Upon client record review, 1 of 13 (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #11 was transferred to another hospice facility. The transfer form was completed, but there is no evidence of coordination or information shared with receiving hospice.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. There is no clearly documented evidence that this information is provided to patients.

Upon observation, there was no evidence the hospice discussed the policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs. There is no clearly documented evidence that this information was discussed with patients.

Upon client record review, 13 of 13 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation, there was no evidence fire drills of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. The facility did not have evidence that fire drills are being conducted during their 2nd shift. Facility runs an am shift and a pm shift. Drills were conducted on 2/21/22-no time noted, 4/4/22 first shift, 7/20/22 first shift, 8/1/22 first shift, 9/26/22 first shift and 1/9/23 first shift.

Upon personnel record review, 4 of 13 (Personnel #10, 11, 12, 13 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 10, 11, 12, 13: Mississippi requires state and national criminal background check. Agency vendor performs Mississippi state only except also includes national sex offender registry.

Upon personnel record review, 9 of 13 (Personnel #1, 2, 3, 4, 5, 6, 7, 8, 9) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 1, 2, 3, 4, 5, 6, 7, 8, 9: Mississippi requires state and national criminal background check. Agency vendor performs Mississippi state only except also includes national sex offender registry.