Every finding on record at St. Mariam Hospice Care Inc.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment to identify the patient's need for hospice care and services include an initial bereavement risk assessment. On review of RRNHV#5 there was no documentation of an initial bereavement risk assessment documented as part of the comprehensive assessment. There was also no documentation of a initial bereavement risk assessment noted in RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9 or RRNHV#10. In RRNHV#6 the assessment note was opened and documentation noted that a post death risk assessment would be conducted yet no bereaved named nor the initial assessment completed. These observations were reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group (IDG) considering changes that have taken place since the initial assessment no less frequently that every 15 days. In review of RRNHV#9 there was no documentation that the update to the comprehensive assessment was accomplished in the last two IDG meetings as there was no documentation of a comprehensive assessment update. In the most recent meeting, there was documentation of a psychosocial assessment, but the patient had not been visited by the MSW since admission in December 2023 and the assessment documented was identical to the initial assessment. This observation was reviewed with the DPCS, and Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient record was complete, promptly and accurately documented. For example: on review of RRNHV#4 the physicians narrative in the CTI noted the patient was a DNR/DNI yet the patient record noted the patient was a full code and the POLST noted Attempt CPR. In RRNHV#6 the RN's documentation noted the patient as a 68 year old but the physicians narrative in the CTI noted to be 64 year old. These observations were reviewed with the Administrator, DPCS, Office Manager, and Director.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the written plan of care was individualized and included goals that were specific, measurable, and time-bound. For example: in RRHV#1 an example of a goal was Patient will achieve comfort as skin integrity changes throughout disease and dying process. In RRHV#2 a example was Patient will be maintain in a safe environment throughout care and Patients behavior will be maintained within manageable limits daily. In RRNHV#5 goals read PCG will verbalize satisfaction with spiritual services/support received from Agency throughout care and Patient will have optimum level of oxygen as evidence by decrease episodes of shortness of breath throughout care. In RRNHV#4 an example was Patient will remain comfortable as cardiac status changes throughout care. In RRNHV#7 examples were Patient will have a reduction in the level of Anxiety as evidenced by less episodes throughout care and the psychosocial goals were not time bound and included interventions noted as goals such as Complete final arrangements. MSW to reach out to B&C administration to see if mortuary is in place. MSW will provide referrals to assist if needed. Further examples of goals that were not individualized and relevantly time-bound could be noted in RRNHV#6, RRNHV#8, RRNHV#9 and RRNV#10 as most goals were noted to be assigned throughout care and were noted to be identical goals for each patient. These observations were reviewed with the Administrator, DPCS, Office Manager, and Director.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care includes all services for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#1 the patient was being seen by the spiritual counselor but had no current spiritual care plan. There were orders for sitz bath, preparation H, and MiraLAX noted on the records, but the issues were not reflected in the care plans. In RRHV#2 there were visits by the Chaplain but no spiritual care plan. In RRNHV#4 there was documentation of treatment to inflamed toes but there was no care plan to guide the care. In RRNHV#5 the patient was on dialysis 3 days a week, yet the care plan did not reflect care related to the dialysis treatment or the patient's AV fistula. The patient was also noted to be taking insulin but no care plan to guide the care of the patient's diabetes. In RRNHV#7 there was documentation of multiple wounds from the patient scratching but no care plan to guide the care of the wounds. In RRNHV#8 there was documentation of inadequate fluid intake, increasing weakness and impaired balance yet the issues were not reflected in the care plans. In RRNHV#10 there was documentation of an ear infection in February with antibiotics ordered yet no care plan established to guide the care. These observations were reviewed with the DPCS, Administrator, Office Manager and Director.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure the plan of care was revised based of information from updates to the patient's comprehensive assessment and address the patient's progress toward goals and outcomes. Throughout the record reviews from RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, RRNHV#10 the care plans were established on admission and remained the same throughout care to time of survey without updates to reflect changes in the comprehensive assessment or progress toward goals. The times on service of the records spanned from nearly 4 months in RRNHV#4, to nearly 10 months in RRNHV#9 and #10. These observations were reviewed with the Administrator, DPCS, Office Manager, and Director.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the care and services were provided in accordance with the plan of care. In review of RRHV#1 the skilled nurse was order a frequency of 1 time a week yet in the 4th week of July there were no visits documented and no documentation of an explanation for the missed visit. In RRNHV#7 and RRNHV#9 the spiritual counselor was ordered a frequency of 1 time a month yet there was no documentation of a visit in the month of June, nor any explanation documented of why the visit was missed. In RRNHV#7 the MSW was noted to be declined yet there was a visit documented for August with no documentation of why the extra visit was conducted. These observations were reviewed with the DPCS, Office Manager, and Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure the comprehensive assessment include the patient's need for physical, psychosocial, emotional, and spiritual care. On review of RRNHV#9 the spiritual counselor was declined on admission but was ordered to begin providing spiritual care three months later, however there was no initial spiritual assessment completed by the spiritual counselor prior to beginning routine visits. This observation was reviewed with the Administrator, DPCS, Office Manager, and Director.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the Hospice Aide, the organization failed to ensure the RN supervisor evaluate the required areas of: Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning by observing the aide's performance of the task with a patient or pseudo-patient as part of a simulation. On review of HR#4 for the hospice aide the initial competency does not indicate how skills were reviewed. To question on the form of observed in home with patient RN checked No. There was no further explanation on how the competencies were assessed. This observation was reviewed with the Office Manager.

Observed in Patient Home. In 3 of 9 patient records reviewed, where hospice aide services were provided, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. In home observation of the hospice aide in RRHV#1 in discussion with the hospice aide a shower had been provided to since aide services began and had documented so, as the patient was ambulatory and preferred a shower, yet the RN's written plan of care was not updated to reflect the patient's preference and needs. Further, the patient had a G-tube but the aide plan of care did not have instructions for how the aide was to handle the g-tube while providing care. In review of RRNHV#5 the patient was noted to be on dialysis and had a A-V fistula yet there were no specific instruction to the aide on how to handle the fistula while providing care. In RRNHV#9 the aide was assigned to obtain patient vital signs each visit yet there were no parameters noted to guide the aide to know when to report findings. These observations were reviewed with the DPCS, Administrator, Office Manager and Director.

Observed in Patient Home. In 2 of 9 patient records reviewed, where hospice aide services were provided, the organization failed to ensure the hospice aide provide services that were ordered per the plan of care. On home observation of the hospice aide in RRHV#1 the aide was observed to provide the patient with a shower yet the plan of care assigned a bed bath. The aide was also observed to place a split gauze to the patient's G-Tube site yet the task was not assigned on the aide plan of care. In RRNHV#9 the aide was assigned to obtain vital signs each visit per the plan of care but there was no documentation of vital signs noted in the record. These observations were reviewed with the Aide, the DPCS, Office Manager and Director.

Observed in Tracer Activities. Upon review of all tracer activities, it was noted that there was a pattern of staff failing to follow established organization policy and the governing body/leadership did not ensure that the Conditions of Participation for 418.100, 418.102, 418.54, and 418.56, were met per policy as determined through observations, documentation, and staff interviews.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course. For example: on review of RRHV#3 the physician's narrative for the CTI lacked all the required elements as it contained only a diagnosis, KPS/PPS, NYHA scale, and 5/6 ADL. In RRNHV#5 the CTI physician's narrative noted the patient with a cardiac terminal diagnosis, but the patient record and admission orders state the primary terminal diagnosis was Chronic Kidney Disease. RRNHV#6 physician's CTI narrative also lacked all of the required elements to attest the patient's life expectancy was six months or less if the illness runs its normal course. In RRNHV#8 the physicians narrative for the CTI's Benefit period (BP) 5 read like a nursing narrative stating SN will continue to follow CDC guidelines for infection precaution and assess patient every visit for signs and symptoms of coronavirus. Health teachings provided to caregiver on coronavirus prevention measures provided by CDC. Caregiver verbalized understanding. All medications reviewed and reconciled. SN refilled some medications. All DME`s checked and in good working condition. Will continue to monitor and manage patient`s condition with each visit. Similar narrative was noted in BP 6. These observations were reviewed with the Administrator, DPCS, Office Manager, and Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure before the recertification period, the medical director review the patient's clinical information. On review of RRNHV#9 the Certificate of Terminal Illness for benefit period #6 that began in September had not been completed to date of survey. This observation was reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, with discharge for extended prognosis, the organization failed to ensure that the record contain all information to reflect the patient's care, treatment and services. On review of RRDC#2 the patient was discharged for extended prognosis yet there was no documentation noted in the record prior to the discharge of what led the Interdisciplinary Group to the decision to discharge the patient for extended prognosis. This observation was reviewed with the DPCS, and Office Manager. Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to ensure the clinical record contained all information to reflect the patient's care, treatment and services. For example: on review of RRHV#1 there were physicians orders for preparation H, sitz bath and MiraLAX on the patient record yet no documentation to detail the patient status to prompt the orders noted in the record. This observation was reviewed with the DPCS.

Observed in Emergency Management Session. During review of the organization hazard vulnerability analysis (HVA) it was noted it lacked the addition of seasonal extreme heat situations and power failures to be risk prioritized for the communities served by the organization.

Observed in Emergency Management Session. During review of the organization emergency plan it was noted the plan lacked documentation of a description of the patient population served.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1-3 record review it was noted the POC included interventions related to imminent death; but, the patients were not actively dying either by assessment findings of clinical notes reviewed or observed during home visits with SN. During RR#1-2 it was noted the documentation lacked clinical findings or observations that the patients were imminently terminal.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1-3 record review and RR#1 and 2, it was noted the measure of goal achievement documented for many outcomes included optimal improvement would be achieved within 90 days. For example: pt/cg will achieve optimal grief reaction prior to pt death, maintain optimal mobility, pt/cg will receive optimal teaching and support as cardiac and pulmonary functions change during care, skin will be maintained at optimal level and optimal level of pain and/or symptom management will be achieved.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1-3 record review and RR#1 and 2, it was noted during SN visits there was documentation of instruction on COVID-19 precautions, but the organization did not follow Policy #9-001.1A Pandemic Infection Disease Policy that stated the staff will check/confirm/complete the COVID-19 questionnaire included in the policy. Clinical notes reviewed written by SN, CHHA, MSW and Chaplain lacked documentation that the COVID-19 questions outlined in the policy were asked before or during the home visit. During SN visits COVID-19 instruction was provided.

Observed in Record Review. In 1 of 5 patient records reviewed, who were receiving hospice aide services. During RR#1, it was noted the RN performed a hospice aide supervisory visit the beginning of the certification period. The second supervisory visit was documented 19 days later.

Observed in Document Review. In 2 of 5 patient records reviewed, when narcotic medication was on the POC. During HV#1 it was noted the hospice did not provide a copy of its written policies and procedures on the management and disposal of controlled medications. The policy was not in the home information material and the medical record lacked documentation from staff that the policy was provided to the patient or the patient’s representative and family. The HV#1 patient was prescribed Tramadol 50 mg one tab orally every 8 hours as needed for pain. During RR#2 it was noted the patient was prescribed Tramadol 50 mg one tab orally twice a day. The record lacked documentation that the policy was provided to the patient or patient representative and family.