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

Observed in Record Review. In 8 of 12 patient records reviewed, During Live D/C RR#1 it was noted interventions on the POC were not assessed as deficits by the RN during the initial RN assessment in May 2023. This included diabetic interventions without a diabetes diagnosis, medications or assessment of diabetes documented during the comprehensive assessment. The patient bowel status was assessed as normal, 5x /week, no c/o nausea or vomiting during the initial RN assessment, however, interventions were documented for bowel and GI issues. During Live D/C RR#2 it was noted the medication profile during the initial RN assessment listed Xarelto 20 mg once daily. The POC lacked interventions on bleeding precautions. In addition, the following deficits added to the POC were not assessed as issues during the initial RN evaluation. They were: bowel interventions although no deficits were assessed. The assessment included abdomen soft, continent of bowels, stool normal, 3x/week. GU interventions were added to the POC however the GU assessment was continent, clear urine, no s/s/ uti and no urinary incontinence. During HV#1 record review it was noted interventions on the POC related to nausea and vomiting. The initial RN evaluation documented that the patient did not have nausea or vomiting. The MSW and chaplain did not document interventions on the POC however they had frequency of visits documented. During HV#3 record reivew it was noted interventions on the POC that were not documented as deficits during the RN comprehensive assessment. They were: potential for alteration in comfort related to episodes of nausea/vomiting, risk for constipation related to lack of activity and opioid use and risk for dehydration due to episodes of diarrhea.The initial RN assessment documentation was: no nausea and vomiting, no constipation, no use of opioids and no episodes of diarrhea. In addition, the POC had MSW interventions documented on the POC by the RN, however there was lack of documentation of collaboration that the RN transcribed the MSW interventions. During RR#1 there were MSW interventions documented on the POC by the RN, however there was lack of documentation of collaboration that the RN transcribed the MSW interventions. The patient was prescribed Pradaxa 150 mg twice a day. The POC lacked interventions on bleeding precautions. During RR#2 it was noted the POC had MSW interventions documented by the RN, however, there was lack of documentation of collaboration that the RN transcribed the MSW interventions. There were interventions on the POC related to nausea and vomiting. The initial RN evaluation documented that the patient did not experience nausea or vomiting, however potential for alteration in comfort related to episodes of nausea/vomiting interventions were added to the POC. The risk for constipation related to lack of activity and opioid use was added to the POC however the RN initial assessment documented normal BM 4-6 x/week. The only narcotic ordered was Morphine Sulfate in the comfort pack that had not been administered to the patient. During RR#5 it was noted on the RN assessment a Braden assessment for skin breakdown was rated as high risk. The POC lacked interventions related to the integumentary system. The RN documented interventions for the MSW without documentation that the RN collaborated with the MSW to establish the interventions. During RR#7 it was noted the patient was prescribed Xarelto. The POC lacked interventions on bleeding precautions. This was discussed with the organization leadership.

Observed in Record Review. In 5 of 12 patient records reviewed, During Live D/C RR#2 it was noted the MSW visit frequency of MSW visits: as needed to provide psychosocial support to patient and family lacked the number of proposed PRN visits. During RR#1 it was noted the SC frequency of visits was documented, Spiritual Counselor visit monthly, as needed and every recertification to provide spiritual support to patient and family lacked the number of proposed PRN visits. During RR#2 it was noted the following frequencies for the MSW and chaplain lacked the number of PRN visits: Spiritual Counselor visit as needed and every re-certification as needed for spiritual support to patient and family, MSW visit as needed and every recertification for psychosocial support. During RR#4 it was noted lack of visit frequency on the POC or POC summary or calendar for the SN, RN, and MSW. During RR#6 it was noted the Chaplain visits - on as needed basis to provide spiritual support to patient and family lacked the number of PRN visits to be completed and the duration of PRN visits. This was discussed with Leadership.

Observed in Infection Control System Tracer. During review of the infection control plan it was noted lack of a written goal limiting unprotected exposure to pathogens. This was discussed with the organization leadership. Observed in Infection Control System Tracer. During review of the infection control plan it was noted lack of a goal limiting the spread of infections associated with procedures. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 3 home visits conducted, During HV#1 it was noted the hospice aide did not provide care according to the aide assignment care plan. The aide stated she removed the 4x4 dressing around the suprapubic catheter during the bed bath at each visit, then called the facility med tech to cleanse around the catheter and replace with a clean dressing. The aide assignment form lacked any direction on removing the dressing and notifying the facility med tech. This was discussed with the organization leadership.

Observed in HR File Review. In 1 of 12 HR files reviewed, During HR#1 employee file reivew it was noted lack of an initial competency assessment for the Administrator in the file. This was discussed with the organization leadership.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV#3 when the SN was reviewing the patient medication list with the medication bottles and blister packs in the home, it was noted the blister pack containing Lomotil tabs for PRN diarrhea had a different dosage than the medication order in the medical record. The blister pack was ordered the beginning of May 2024. The SN informed the PCG that a new blister pack would be ordered and delivered with the correct dose direction for administration. This was discussed with the organization leadership.

Observed in Emergency Management Session. During review of the patient admission information packet, it was noted although the organization had prioritized extreme heat, wildfires and earthquakes on it hazard vulnerability assessment (HVA), it did not include information for patients and families on mitigation and preparedness strategies for wild fires and extreme heat events. This was discussed with the organization leadership.

Observed in Document Review. During review of the skilled nursing facility (SNF) contractual agreement it was noted lack of 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 organization leadership.

Observed in Document Review. The review of the contractual agreement with the SNF it was noted it lacked the provision of a delineation of the responsibilities of the hospice and the SNF, NF, or ICF/IID to provide bereavement services to SNF, NF, or ICF/IID staff. This was discussed with the organization leadership.

Observed in Document Review. In 2 of 4 contracts reviewed, During review of the pharmacy contract and the therapy contract 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 organization leadership.