Every finding on record at St. Mary's Hospice, Inc.

Observed in Record Review. In 3 of 4 patient records reviewed, The stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. During RR#1 it was noted many goals lacked measurable outcome to assess progress toward goals, for example: Blood sugar management for pt. comfort, Patient will be able to rest comfortably without excessive sadness in 14 days and onwards, Maintain adequate oxygenation and ventilation, as evidenced by normal respiratory rate, oxygen saturation levels within target range, and absence of respiratory distress. During RR#2 it was noted lack of goals that were had measurable time frames to assess progress, for example: Edema will not increase and patient will not experience any discomfort from edema, PCG and family will verbalize understanding that due to patient's poor prognosis there is no need for blood sugar checks at this time, PCG and family will verbalize understanding of patient's difficulty to swallow and will provide a puree diet with thin liquids as tolerated, PCG will verbalize understanding of fall risk safety, Patient's needs will be met daily and will minimize episodes of confusion. During RR#3 it was noted lack of measurable goals on the POC as follows: Goals: PCG will verbalize understanding of medical equipment and patient will be free from injury, Patient will experience no constipation this benefit period, Minimize complications due to patient being bed bound, Patient will have adequate fluids and food as tolerated. This was discussed with the Administrator.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR#1 it was noted lack of an oxygen order for the liter flow and direction for use on the current POC. During RR#2 it was noted lack of instruction for F/C care on the POC. In addition the wound care order for RR#2 lacked the as needed reason for additional visits and lacked who was to perform the wound care on non-SN visit days. During RR#3 it was noted lack of interventions on the POC for seizure precautions and assessment only without interventions identified for constipation. This was discussed with the Administrator.

Observed in Record Review. In 3 of 4 patient records reviewed, During RR#1 it was noted the following frequency of visits on the POC: MSW: 1 One-time then PRN, SC: 1 One-time then PRN, SN: 2 per Week +3 PRN Visits. The PRN visits lacked the reason for the additional visits and the number of PRN visits needed. During RR#2 it was noted lack of a reason and the number of PRN visits for the MSW. During RR#3 it was noted lack of the reason and number of PRN visits for the MSW and SC. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#1 it was noted the patient was prescribed Plavix 75 mg daily. The POC lacked interventions on S/S bleeding and bleeding precautions on the current POC. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, In 1 of 4 patient records reviewed, the organization failed to ensure the updated comprehensive assessment included information about the patient's progress toward goals and desired outcomes. During RR#1 it was noted lack of an update to the POC based on the RN assessment the beginning of August 2025. The POC included interventions for a F/C however the RN assessment documented no F/C present, the RN documented patients oxygen level for 5 minutes without oxygen therapy was 83% during the visit and stated she needs to place her oxygen on, shortness of breath was severe during exertion however the POC lacked an oxygen order. This was discussed with the Administrator.

Observed in Record Review. In 1 of 4 patient records reviewed, During RR#2 it was noted the SN interventions for wound care lacked documentation of the use of desitin on the wound edges per the physician order. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. Live D/CRR#2 was discharged due to an extended prognosis. There was lack the patient signed a Notice of Non Medicare Coverage (NOMNC) at least 2 days prior to the discharge date. This was discussed with the Administrator.

Observed in Record Review. In 2 of 10 patient records reviewed, During RR#3 it was noted the chaplain (SC) assessment was documented 10 days after the initial comprehensive assessment, and the MSW initial assessment was blank. There was lack of documentation to indicate why the initial evaluations for MSW and SC were not completed within 5 calendars days after the election of hospice. During RR#7 it was noted the SC documented the initial spiritual assessment 19 days after the SOC. There was lack of documentation of the reason for the delay. This was discussed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#5 it was noted the patient was prescribed insulin and Soliqua for diabetes. The initial RN evaluation documented the patient hx of NIDDM however it lacked an assessment of the patient's self care abilities and knowledge of the disease process. This was discussed with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, During RR#3, RR#5 and HV#3 record reviews, it was noted lack of initial bereavement assessments. This was discussed with the Administrator.

Observed in Record Review. In 6 of 10 patient records reviewed, The stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. During RR#3 it was noted multiple goals lacked measurable time frames to determine if goals were achieved as follows; Cg (caregiver) will verbalize understanding of notifying hospice if wound worsens, however there were no wounds identified during the RN initial assessment, Staff will verbalize understanding of notifying hospice if patient has an increase in anxiety/agitation, Pcg will verbalize understanding of offering small frequent meals, Cg will verbalize understanding of providing supplemental nutrition such Ensure or Glucerna and patient needs will be met on a day to day basis as communicated per ADL needs and Staff will verbalize understanding of giving pain medication as Ordered for prn use. During HV#2 record review it was noted the goals did not have measurable outcome time frames to assess if accomplished as follows: since May 2024: cg will verbalize understanding of monitoring patient during ambulating and calling hospice if patient has a fall, since September 2024 Daughter will verbalize understanding of administering ABH cream, Daughter will verbalize understanding of contacting hospice if patients agitation becomes worse, and since May 2024 cg will verbalize understanding of offering small frequent meals on patients bad days. During HV#3 record review it was noted goals without outcome measure time frames as follows: Since January 2024 Family/PCG will verbalize or demonstrate understanding and compliance with teachings related to equipment safety and patient will remain safe at home and free from injury, since December 2023 -Pcg will verbalize/express understanding of medication /treatment orders and side effects, since December 2023 increase strength/energy for functional activities by providing bed exercises, since January 2024-Pt needs will be met on a day to day basis as communicated to family members. During RR#4 it was noted multiple goals without measurable time frames as follows: Pt will maintain optimum peripheral circulation during recertification period .The patient will have an acceptable respiratory rate for the next 2 weeks of hospice care, documented in 2022 and continued to present, Pt will verbalize and/or express decreased episodes of SOB at rest during SN visits, goal established in 2022 and remains the same to date, Patient/PCG and family will complete final arrangements, Pt/Family/PCG will access community resources for IHSS to improve quality of life, Pt/Family/PCG will have a mortuary plan in place documented in Feb 2024 and remains the same to date. During RR#5 it was noted the following goals that lacked measurable outcomes: Patient will achieve and maintain peripheral circulation for comfort through out hospice services, Discomfort will be prevented due to increasing edema through out hospice stay, Patient's blood sugar will be managed for patient's comfort throughout hospice services, Patient will verbalize and express feelings and thoughts related to depression with each discipline visit during hospice services. RR#7 lacked measurable goals with outcome time frames as follows: Patient/Cg will verbalize understanding of calling hospice if medications are not effective, Patient/Cg will verbalize understanding of giving medications as prescribed by physician, Patient/cg will verbalize understanding of patient declining and potential to discontinue medications, cg will verbalize understanding of calling hospice if patient exhibits combative behavior`s, Complement added resources and support as needed, Complete final arrangements, Pt/Family/PCG will exhibit functional coping skills to manage and maintain symptoms of anxiety, Cg will verbalize understanding of giving pain medication as ordered. This was discussed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted on the medication profile the pt. was prescribed Plavix 75 mg daily. The POC lacked education on s/s bleeding and bleeding precautions. This was discussed with the Administrator. Observed in Record Review. In 5 of 10 patient records reviewed, During RR#1 it was noted the patient during the RN initial assessment had a dx of c-diff with antibiotics ordered. The POC lacked interventions related to the infection added during the comprehensive assessment. During HV#2 record review it was noted on the medication profile multiple medications ordered throughout the 7 certification periods for UTIs. The POC lacked interventions related to the GU status. During RR#5 it was noted a frequency of 1x/month for the MSW however the POC lacked psychosocial emotional interventions. During RR#6 it was noted lack of interventions related to G-tube care on the POC. During RR#7 it was noted 2 episodes of UTI with antibiotics ordered. The POC was updated to include the medication administration, however the POC lacked interventions that included GU instruction on care and prevention of UTIs. This was discussed with the Administrator.

Observed in Record Review. In 8 of 10 patient records reviewed, During RR#2 it was noted lack of a reason for PRN visits for the SN. During RR#1, RR#5, RR#6, HV#2 and HV#1 record review it was noted lack of the PRN reason and number of visits for the MSW and SC. The SN visits lacked the reason for the 3 PRN visits on the POC. During RR#4 it was noted MSW PRN visits without the number and SC PRN visits without the number on the POC. During RR#7 it was noted the MSW order for PRN visits without a reason or number and SN visits without a reason for PRN visits. This was discussed with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, During RR#1, RR#6 and HV#1 record review the orders for oxygen therapy 2-5L PRN shortness of breath lacked the titration orders for the different oxygen liter flows. This was discussed with the Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, In 3 of 10 patient records reviewed, the organization failed to ensure the updated comprehensive assessment included information about the patient's progress toward goals and desired outcomes. Throughout the record reviewed there was a trend noted of a lack of documented progress toward goals and desired outcomes. The care plans remained the same IDG to IDG with no indication when or if goals had been achieved. During HV#2 record review it was noted: The patient will have an acceptable respiratory rate for the next 2 weeks of hospice care however this goal was documented in 2022 and continues to present without documentation of progress, Pt will verbalize and/or express decreased episodes of SOB at rest during SN visits that was written in 2022 and remains the without documentation of progress, Patient/PCG and family will complete final arrangements, Pt/Family/PCG will access community resources for IHSS to improve quality of life, Pt/Family/PCG will have a mortuary plan in place added to the POC in February 2024 without documentation of progress toward the goal. During HV#2 record review it was noted the goals established in 2024 remain the same in the 7th benefit period without documentation of progress toward achieving goals. During RR#4 there is lack of documentation of progress toward multiple goals since hospice admission in 2022. This was discussed with the Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#6 the spiritual counselor (SC) frequency of visits documented at each IDG was SC 1x/week. The documentation from the SC was the initial assessment without subsequent visits documented. This was discussed with the Administrator. Observed in Record Review. In 2 of 2 patient records reviewed, who received bereavement services for survivors. BRRR#1 bereavement POC was documented as follows: Bereavement Letters / Material through out the first year. There was lack that bereavement mailings were sent to the survivor as planned. BRRR#2 there was lack of documentation that bereavement mailings were sent as indicated to be done in the bereavement POC. This was discussed with the Administrator.

Observed in Data Session. The organization QAPI data collection did not reflect the complexity of the organization and did not involve all hospice services. There was lack of data collected, analyzed and reported at QAPI meetings for palliative outcome measures, HIS data, review of medical records for services provided to the patients, family satisfaction surveys, Bereavement Services, Volunteer Services, contracted services that included pharmacy, DME, therapy and SNF services. This was discussed with the Administrator.

Observed in Data Session. The hospice had collected data on multiple topics relevant to the effectiveness and safety related to services, but none of the data was used by the organization to determine if effectiveness or safety was achieved. The relevant data to determine if the program was effective was not reported at QAPI meetings. This was discussed with the Administrator

Observed in Data Session. The organization did not evaluate actions to confirm that performance improvement plans resulted in improvements. Performance improvemnt projects for 2024 and 2025 lack documentation that the plans for improvment were obtained and reported at the QAPI meetings. This was discussed with the Adminisrator.

Observed in Data Session. It was noted when reviewing the Governing Body minutes for 2024 and 2025 to date, the last documented annual review and approval of the QAPI plan was dated December 2023. This was discussed with the Administrator.

Observed in Data Session. The organization has not demonstrated that it set priorities for data collection, and patient palliative outcomes, and has not adhered to the frequency of reporting data collection. During review of the QAPI plan it was noted data collection frequency was documented to be monthly, data analysis was documented to be completed quarterly and data communication to staff and governing body was documented as quarterly and annually, however the review of QAPI meetings for 2024 was documented biannually and biannual to date for 2025. The meeting minutes lack an analysis of data collected for most indicators listed in their QAPI policy.

Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide. During review of HR#2 it was noted lack of an initial competency assessment that included: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff, 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 and normal range of motion and positioning. This was discussed with the Administrator. Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide. During HR#2 file review it was noted lack of a competency assessment with a patient or a pseudo-patient for the following: ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other staff, Observation, reporting, and documentation of patient status and the care or service furnished, Basic infection control procedures, Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor, Maintenance of a clean, safe, and healthy environment, Recognizing emergencies and initiating necessary emergency procedures, The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice aide, including the need to respect the patient and their privacy and property, Adequate nutrition and fluid intake and any other task that the hospice may choose to have the home health aide or hospice aide perform as permitted under state law. This was discussed with the Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, During RR#3 it was noted the aide assignment form lacked safety instructions on bleeding precautions. The patient was prescribed Plavix 75 mg daily. During RR#1 the hospice aide assignment form lacked safety instructions on bleeding precautions and infection control measures related to the patient's dx of c-diff. During HV#1 record review it was noted the patient's oxygen order was blank on the aide assignment form. During RR#5 it was noted Eliquis on the medication profile. The aide assignment lacked safety instruction on bleeding precautions. During RR#6 it was noted on the RN initial assessment that the patient was NPO with a G-tube. The aide assignment form lacked the NPO order and the presence of the G-tube. This was discussed with the Administrator.

Observed in Document Review. During review of the volunteer program it was noted the organization has not had any active volunteers since February 2024 and lack of documented recruitment efforts. This was discussed with the Administrator.

Observed in Regulatory Review. Since there was lack of volunteer services provided since February 2024 there was lack of the identified positions occupied by volunteers. This was discussed with the Administrator.

Observed in Document Review. During review of the volunteer program it was noted the minimum number of volunteer hours of 5% has not been met for 2024 and 2025 to date. This was discussed with the Administrator.

Observed in Leadership Session. There was lack of evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Conditional Level Deficiencies (CLD) in 418.100 Organization and Administration, 418.78 Volunteers, 418.56 Interdisciplinary Group and Coordination of Services, and 418.58 QAPI. This was discussed and reviewed with the Administrator.

Observed in HR File Review. In 6 of 9 HR files reviewed, During HR#1 file review it was noted lack of an orientation to the specific job duties and responsibilities of the Administrator. During HR#4 file review it was noted lack of an orientation to the specific job duties of the Administrator Designee. During HR#5 file review it was noted lack of orientation to specific job duties as the Bereavement Coordinator and Volunteer Coordinator. During HR#2 file review it was noted the hospice aide lacked orientation to specific job duties and responsibilities. During HR#6 file review it was noted lack of orientation to the specific job duties for Medical Social Worker. During HR#7 file review it was noted lack of orientation to the specific job duties of the DPCS designee and Field RN. This was discussed with the Administrator.

Observed in HR File Review. In 3 of 9 HR files reviewed, During HR#3, and HR#5 file it was noted lack of competencies for 2022, 2023, 2024 and 2025 to date. During HR#9 file review it was noted lack of competencies from 2021 to present. This was discussed with the Administrator.. Observed in HR File Review. In 2 of 9 HR files reviewed, During HR#6 review it was noted lack of an initial competency after hire in February 2025. During HR#9 file review it was noted lack of an initial competency assessment completed after hire in May 2024. This was discussed with the Administrator

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#6 it was noted on the RN initial assessment the patient was NPO with G-tube feedings ordered. The medication profile direction on administration was by mouth for medications listed. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. Live D/C RR#1 was transferred and admitted to the hospital, however there was lack of documentation that the organization sent the hospital a discharge summary or if the hospital requested patient medical records. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. Live D/CRR#2 who was discharged for an extended prognosis lacked a discharge summary that was documented as sent to the physician. This was discussed with the Administrator.

Observed in Document Review. In 3 of 6 contracts reviewed, for Skilled Nursing facilities. It was noted the three SNF contracts lacked a provision that stated the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was discussed with the Administrator.

Observed in Document Review. In 2 of 6 contracts reviewed, During review of the contract for therapy services and pharmacy services it was noted lack of a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was discussed with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide the patient or representative with written notice of rights and responsibilities. The Administrator stated that they had revised their materials approximately 6 months ago and removed the page of Patient Rights and Responsibilities.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not update the comprehensive assessment. Upon review of documentation in the record, an RN did not visit the patient every 15 days to conduct an assessment. For example, in HV #1, RR #1 - 8 an LVN made all of the skilled nurse visits subsequent to the initial comprehensive assessment. In HV #2 an RN did not visit the patient for 60 days. In HV #3 the RN did not visit the patient for 8 weeks. This was validated by the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. Staff did not perform hand hygiene per organizational policy Hand Hygiene Compliance No. 5.7.1. During HV#1, the clinician was observed washing his hands and turning off the faucet with his hands on two occasions. The policy instructed to use a paper towel to turn off the water. In HV #1 the nurse was observed re-entering the nursing bag after contact with the patient's environment without cleansing his hands. During HV#2 and #3, the clinician was observed using alcohol wipes to cleanse his hands instead of the required soap and water or hand gel.. This was discussed and verified with the Administrator and Director of Patient Carel Services following the visits. Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned when doing the following: Cleaning and performing disinfection of medical supplies and devices. According to organizational policy Exposure Control Plan, equipment should be cleaned after each patient use before returning it to the nursing bag. During HV#2 and HV#3, the clinician was observed cleaning their vital sign equipment and placing them back on the dirty side of their barrier. This was discussed and validated with the Administrator and Director of Patient Care Services following the visits.

Observed in Individual Tracer. In 8 of 8 patient records reviewed, with hospice aide services the organization failed to assess the quality of care provided by the hospice aide. Upon review of documentation in the record, there were no aide supervisory visits conducted in the home or telephonically. The Administrator stated that they were under a blanket waiver stating aide supervision in the home was not required, however, telephonic supervision could have been conducted. There was no evidence of telephonic supervision or patient refusal.

Observed in HR File Review. In 1 of 11 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. Upon review of documentation in the personnel file of HR #2 skilled nurse, there was no initial competency found. This was confirmed by the Administrator who stated it was not done.