Every finding on record at Sta-Home Hospice of Mississippi, Inc.

It is required that the patient has the right to receive information about the services covered under the hospice benefit. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 1 (100%) clinical records reviewed of a patient discharged with an extended prognosis, the agency did not ensure the patient received information about the services covered under the hospice benefit, including the notice of termination of Medicare-covered services Agency Protocol titled "Live Patient Discharge. 2049 Protocol Effective 12/05/2007, revised 02/10/2022 stated in relevant part: "When a Medicare patient is being discharged for extended prognosis, the hospice agency will notify the patient/responsible person at least two days before the discharge date. The hospice agency will explain to the patient/responsible person that they have the right to appeal the discharge decision and will provide them with the generic form of the Notice of Medicare Provider Non-Coverage (NOMNC)." Agency Policy titled "Discharge from Hospice Program HOS 2-082 Effective 01/01/2013, Revised 02/02/2026 stated in relevant part: "11. When a Medicare patient is being discharged for extended prognosis, the hospice agency will notify the patient or chosen family/caregiver at least two calendar days before the discharge date and provide them with the NOMNC. The Notice of Medicare Non-Coverage (NOMNC) will be returned to the office and retained in its original form." The document "Notice Instructions for the Notice of Medicare Non-Coverage" (NOMNC) Center for Medicare and Medicaid Services (CMS)-10123 stated in part, "A Medicare provider/plan (Medicare Advantage plans and cost plans, collectively referred to as “plans”) must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered skilled nursing, home health, comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare-covered services end, or the second to last day of service if care is not being provided daily." CLINICAL RECORD 19: A clinical record review conducted on 02/27/2026 revealed that the patient elected the hospice benefit on 03/11/2024 and was discharged from hospice care with an extended prognosis on 01/02/2025. A Notice of Medicare Non-Coverage (NOMNC) was not found in the clinical record. There was no evidence documenting that the patient or legal representative received the NOMNC or been asked to sign. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 02/27/2026 during which time it was confirmed the clinical record did not contain documentation that the NOMNC had been issued to the patient/legal representative as required by agency policy and Medicare requirements.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 6 (50%) observed home visits, it was revealed that the agency did not ensure the drug profiles contained the patients' current prescriptions and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. HOME VISIT 2/CLINICAL RECORD 2: The patient elected the hospice benefit on 11/09/2025 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a skilled nursing facility (SNF). During the observed home visit with the Registered Nurse (RN - Personnel Record 5) on 02/24/2026 the hospice medication profile (printed on 02/23/2026) was compared to the SNF medication profile (printed on 02/24/2026). The hospice medication profile included the following medications not listed on the SNF list: "Acetaminophen 650 mg rectal suppository. 1 every 6 hours as needed (ordered 11/10/2025); Bisacodyl 10 mg suppository. 1 every 24 hours as needed (ordered 11/10/2025); Haloperidol 2mg/ml. 0.5 ml every 6 hours as needed (ordered 11/10/2025); Hyoscyamine 0.125 mg. 1 tablet every 4 hours as needed (ordered 11/10/2025); Morphine 0.25 ml every 3 hours as needed (ordered 11/10/2025); Prochlorperazine 10 mg. 1 tablet every 6 hours as needed (ordered 11/10/2025). The SNF profile contained the following medications not listed on the hospice list: "Calcium D tablet. Take 1 tablet daily (ordered 06/14/2025); Hydrocortisone cream. Apply to affected areas every 8 hours as needed (ordered 06/14/2025); Triamcinolone cream. Apply to back every 12 hours as needed (ordered 10/10/2025); Vitamin C tablet. Take 1 tablet daily (ordered 06/15/2025); Vitamin D-3 tablet. Take 1 tablet daily (ordered 06/15/2025)." Additionally, the following medication discrepancies were noted: "Hospice had Trazadone 50 mg tablet at bedtime (ordered 11/10/2025) vs SNF Trazadone 50 mg tablet every other day (ordered 02/09/2026); Hospice had Duoneb nebulizer every six hours as needed (ordered 11/10/2025) vs SNF Duoneb nebulizer every six hours scheduled (ordered 01/31/2026). The most recent comprehensive nursing visit was dated 02/18/2026. HOME VISIT 3/CLINICAL RECORD 3: The patient elected the hospice benefit on 08/21/2025 with a diagnosis of Alzheimer's disease. The patient resided in an assisted living facility (ALF). During the observed home visit with the Spiritual Counselor (SC - Personnel Record 8) on 02/24/2026 the hospice medication profile (printed on 02/23/2026) was compared to the ALF medication profile (printed on 02/24/2026). The hospice medication profile included the following medications not listed on the ALF medication list: "Ativan 0.5 mg tablet. 1 tablet every 6 hours as needed (ordered 10/17/2025); Lantus 100u/ml. Give 20u daily (ordered 01/08/2026). The ALF medication profile included "acidophilus tablet. Take 1 daily." This was shown as discontinued on the hospice list dated 10/13/2025 however was still being marked as given by the ALF on the day of the observed home visit. The most recent comprehensive nursing visit was dated 02/24/2026. HOME VISIT 4/CLINICAL RECORD 4: The patient elected the hospice benefit on 06/06/2025 with a diagnosis of hypertensive heart disease. The patient resided in a personal care home (PCH). During the observed home visit the RN (Personnel Record 6) on 02/24/2026, the hospice medication profile (printed on 02/23/2026) was compared to the PCH medication profile (printed on 02/24/2026). The following medication discrepancies were noted: The PCH profile included multivitamin 1 tablet daily which was not on the hospice profile (there was not a date on this). The hospice medication profile listed Oxycodone 5/325 mg 1 tablet every 4 hours as needed (dated 06/09/2025) vs the PCH Oxycodone 5/325 mg 1 tablet every 6 hours as needed (no date). The hospice medication profile listed acetaminophen 500 mg tablet 1 tablet every 4 hours as needed (dated 06/09/2025) vs PCH acetaminophen 500 mg 1-2 tablets every 4-6 hours as needed (no date). The PCH list included the following medications on their medication profile with only the name and several had no route, dosage or specific instructions: "Tessalon Perles-PRN; Mucinex DM-PRN; Senna laxative; MOM 30 ml-PRN." The most recent comprehensive nursing visit was dated 02/18/2026. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 02/26/2026. They noted that it is the expectation that medication reconciliations "are to be performed during every nursing visit."

It is required that each patient’s individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 1 of 23 (4%) clinical records reviewed revealed the agency did not ensure the individualized plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 23: The patient elected the hospice benefit on 09/24/2025 with a diagnosis of malignant neoplasm of the right lung. His initial plan of care was developed on that date identifying a Pain problem with a goal of "Patient/Family/Caregiver will report that pain (physical, emotional, spiritual) is at an acceptable level within 3 days of below 3 each nursing visit."; a Respiratory management problem with a goal of "Patient/Family/Caregiver will report that breathing has been brought to/maintained at a level that patient or patient's chosen representative expresses is acceptable within 7 days by being able to breathe comfortably." The plan of care also included a Fluid Management problem with a goal of "Patient/Family/Caregiver will report acceptable level of edema within 14 days of less than 2+." The nursing visit frequency was twice weekly. On 09/29/2025, the clinical record included documentation of the patient having a pleural drain placed for relief of symptoms. This documentation was included in a physician order for the drain placement, supply order and drain orders and a nursing visit narrative on 09/30/2025 that documented "Patient received Pleurex drain yesterday. New orders for draining received." There were multiple calls for symptom management visits including the following: 10/04/2025 PRN (as needed) "A lot of pain, needs to be drained"; 10/06/2025 PRN "Pain in right side. Took Oxycodone, think he needs to be drained."; 10/09/2025 Routine. "Patient was drained yesterday. Absent breath sounds right lung."; 10/10/2025 PRN "Patient reporting he felt SOB (short of breath). He took Oxycodone, on 10L O2, nebulizer and thinks he needs to be drained again." Three calls to triage and two visits; 10/12/2025 PRN "Pain to side/lung area. Has taken morphine/oxycodone. Drained 450 cc"; 10/13/2025 PRN "I need my right lung drained."; 10/18/2025 "Call to get oxygen replaced, portable."; 10/20/2025 PRN "Short of breath, pain in side"; 10/22/2025 PRN "SOB and anxiety. On call note stated no comfort kit listed on med list."; 10/29/2025 PRN "Fluid in his lungs and it is causing pain"; 10/31/2025 PRN "Nurse came today to drain. Still having severe pain in my right side. Need nurse to come back"; 11/09/2025 PRN "Concentrator beeping." Interdisciplinary notes during this time frame documented the "patient continues to be appropriate for hospice with metastatic lung cancer." Routine nursing visit frequency remained at twice weekly and was not adjusted although there were approximately 3 to 4 on call nursing visits per week for symptom management. The plan of care problems, goals and interventions were not revised or adjusted from admission to the patient's death on 11/13/2025. The drain was not added to the plan of care. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 02/25/2026 during which time it was agreed the plan of care should have been "updated to include the drain, the nursing frequency should have been updated and the patient's symptoms should have been handled during the day, limiting the calls at night/weekends."

It is required that written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. 4 of 19 (21%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the hospice aide. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 07/31/2025 and resides in a skilled nursing facility (SNF). The hospice aide care plan, updated 02/11/2026, included the following tasks: "Fall precautions; turn and position; position with head of bed elevated; bathing-bed bath; deodorant; skin care-apply skin protectant to red areas; perineal care; dressing; notify RN with any changes." All tasks were to be completed every visit with an aide visit frequency of twice weekly. During the observed home visit on 02/24/2026 with the hospice aide (Personnel Record 10, the patient was noted to have a G-tube (gastrostomy tube) with continuous feedings, donut-shaped heel protectors and a wound dressing on her left iliac crest. The aide was not provided with notification of these being in place nor given specific instructions for managing these items during her assigned tasks. The aide did ask the facility staff to stop the tube feedings so she could give her bath and explained she "knew to do that as she used to work at the facility." Clinical record review evidenced a physician's order dated 10/08/2025 which ordered the following wound care: "Cleanse stage 3 wound to left iliac crest with saline and pat dry. Apply opti-foam dressing." CLINICAL RECORD 10: The patient elected the hospice benefit on 12/23/2025 and resides in a private home. The hospice aide care plan dated 12/29/2025, and updated 01/29/2026 included the following tasks: "Bathing-bed bath; bathing-shower seated on days that he can ambulate; deodorant; dressing; perineal care; post mortem care (upon death); skin care; clean multi-use items; fall precautions; oxygen precautions." All tasks were to be completed every visit unless otherwise specified, with an aide visit frequency of twice weekly. This aide care plan did not provide specific instructions for the aide on the bath type to be provided and listed both a bed bath and a shower. CLINICAL RECORD 16: The patient elected the hospice benefit on 01/12/2026 and resides in a private home. The hospice aide care plan dated 1/12/2026; and updated 2/20/2026 included the following tasks: "Bathing-bed bath; dressing; skin care; turn and position; universal precautions; oxygen safety precautions; date of last BM (bowel movement)." An additional update on 02/23/2026 added "change linens." All tasks were to be completed every visit with a visit frequency of three times weekly. A physician's order dated 01/15/2026 included orders to "Apply dressing to the spine area daily, Stage 2 wound to sacrum, apply dressing, Stage 2 wound to right heel, apply dressing. Stage 1 to left heel, apply protectant." The aide care plan did not notify the aide(s) of the wounds nor provide specific instructions for managing the dressings or wounds during care or to notify the nurse if the dressings became soiled, dislodged or wet. CLINICAL RECORD 17: The patient elected the hospice benefit on 11/04/2025 and resides in a SNF. The hospice aide care plan dated 11/24/2025 included the following tasks: "Bathing-bed bath, dressing, oral care, peri care, skin care, turn and position in bed; turn and position; universal precautions, oxygen safety, date of last BM." All tasks were to be completed every visit with an aide visit frequency of twice weekly. A physician's order dated 01/08/2026 noted a "Stage 2 sacral (wound), cover with dry covered with bordered dressing." The aide care plan did not notify the aide(s) of the wound nor provide specific instructions for managing the dressing or wound during care or to notify the nurse if the dressing became soiled, dislodged or wet. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 02/26/2026 during which time the aide care plans were discussed and how "the nurses still needed more training on the care plans to keep them individualized and up-to-date."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. 2 of 19 (11%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the hospice aide(s) provided services included in the plans of care. HOME VISIT 5/CLINICAL RECORD 5: The patient elected the hospice benefit on 02/17/2026 and resides in an Assisted Living Facility (ALF). The hospice aide care plan dated 02/17/2026, and updated 02/23/2026 included the following tasks: "Maintain universal precautions, fall precautions, oxygen precautions; bathing-shower standing, shaving, dressing, standby assistance with ambulation, date of last BM (bowel movement)." All tasks were to be completed every visit with an aide visit frequency of twice weekly. The aide was observed to shampoo the patient's hair, the task of which was not assigned on the care plan, and was observed not to shave the patient which was assigned on the care plan. The Clinical Manager was present on the visit and also observed these items. CLINICAL RECORD 7: The hospice benefit was elected on 10/15/2025. The hospice aide care plan included the following tasks: "Fall precautions; bathing-shower-seated; shampoo/style; skin care; oral care; empty trash; change linens; date of last BM (bowel movement)." All tasks were to be completed every visit with an aide visit frequency of twice weekly. The hospice aide visit dated 02/12/2026 documented: "Bathing-shower seated-No, bedbath given. Upon arrival patient was in bed. I arrived. Patient was bedbath well." The hospice aide visit dated 02/24/2026 noted: "Bathing-shower seated-No, bedbath given. Upon arrival patient was in bed. I arrived. Patient was bedbath well." The aide documented giving a bed bath instead of the assigned shower in accordance with the aide care plan. A joint clinical record review and interview was conducted with the Administrator and Clinical Manager on 02/26/2026 and they said the aide(s) know they should not "vary from the plan of care and should call the nurses for adjustments." For Home Visit 5, it was discussed that some nurses consider "shampoo as part of the shower/bath and not a separate task although it also can be listed as a separate task as well."

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 02/26/2025, during which time it was noted that the volunteer percentage for the last twelve (12) months (February 2025 to January 2026) averaged 1.08%. The Volunteer Coordinator advised she had recently hired an additional Regional Volunteer Coordinator in October 2025 and "was excited to see improvement in the volunteer percentage" already in the few months. They have many rural areas with their alternate delivery sites/offices and a lot of the home patients in those areas don't want volunteers or are hard to staff with volunteers. A review of the volunteer program was conducted with the Volunteer Coordinator and Administrator on 02/26/2025, during which time the volunteer percentage for the last twelve (12) months (February 2024 to January 2026) averaged to 1.08%. The Volunteer Coordinator advised she had recently hired an additional regional volunteer coordinator in October 2025 and "was excited to see improvement in the volunteer percentage" already in the few months. They have many rural areas with their alternate delivery sites/offices and a lot of the home patients in those areas don't want volunteers or are hard to staff with volunteers.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. 4 of 23 (17%) clinical records reviewed revealed the agency did not ensure that the plans of care included individualized interventions to meet the patient's needs. Clinical Record 1: The election of benefit was 1/5/22 with relevant diagnoses of hypertensive heart disease with heart failure and type 2 diabetes mellitus. The physician narrative dated 2/16/23 stated "multiple changes have had to be made to insulin orders due to uncontrolled blood glucose levels." A clinical note from 3/21/23 reported the family called to report the patient's blood glucose of 402, instructions were provided on insulin administration and to call back if needed. The plan of care effective from 1/5/22 to the date of review did not evidence any problems, goals or interventions related to the endocrine system or diabetes. Clinical Record 13: The election of benefit was 11/22/22 with relevant diagnoses of hypertensive heart disease and chronic kidney disease with heart failure and type 2 diabetes. The drug profile listed the following medications present on admission: Fiasp Flextouch Units-100 insulin 10-15 units 3 times a day before meals; Ozempic 2mg weekly injection; and Tresiba 32 units daily. Multiple nursing visit notes from 11/22/22 to the date of review documented that the patient was non-compliant with medications, diet, and checking blood sugars. The plan of care effective from 11/22/22 to the date of review did not evidence any problems, goals, or interventions related to the endocrine system or diabetes. Clinical Record 14: The election of benefit was 4/7/23 with a diagnosis of hemiplegia following cerebral infarct. The RN initial comprehensive assessment documented the patient was on a mechanical soft diet as the patient had difficulty manipulating food; the physician narrative dated 4/19/23, stated, "He is a high risk for aspiration due to difficulty manipulating food on mechanical soft diet." The plan of care effective from 4/7/23 to the date of review, did not include any problems, goals, or interventions related to aspiration risk/precautions. Clinical Record 16: The election of benefit was 12/22/22 with a diagnosis of Alzheimer's disease. The physician narrative dated 3/10/23 stated, "Patient is now showing nonverbal signs of pain and has a Fentanyl Patch." On 4/9/23 a PRN (as needed) nursing visit note reported that a family member told the facility staff that the patient was "uncomfortable" and the facility nurse administered morphine. The plan of care effective from 3/20/23 to the date of review, did not evidence any problems, goals, or interventions related to pain or comfort. There was an alteration in comfort problem that had been "ended" on 3/20/23 and nothing else had been added. During an interview with the Administrator and Director of Clinical Operations (DCO, Staff 4) it was reported that the directive had been given to "not care plan anything that was stable or potential" which they felt was why these items were not care planned. Upon review of the documentation, they agreed that in these instances the clinical issues were not stable nor potential problems, and thus should have been care planned.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by document review, interview and observation. In 2 of 6 (33%) home visit observations the agency did not ensure that employees followed acceptable standards of practice and adhered to the agency's Hand Hygiene policy. Protocol #2 of the agency's policy states in relevant parts: "Decontaminate the hands using an alcohol-based hand rub, or wash hands with antimicrobial soap and water when the hands are not visibly soiled in the following circumstances: a.) Before having direct contact with patients... and h.) After having contact with inanimate objects." Home Visit 4/Clinical Record 4: The Social Worker (Staff 11) was observed not utilizing hand sanitation practices before nor during the home visit. The Social Worker did touch the patient's face and hold the patient's hand. Hand hygiene practices were not utilized before nor after touching the patient. After concluding the patient encounter the Social Worker shook the caregiver’s hand before exiting the home. Home Visit 1/Clinical Record 1: The Chaplain (Staff 7) was observed not utilizing hand sanitation practices during the observed home visit upon entry to the home nor for the duration of the visit. The Chaplain did use a guitar during the visit. Hand hygiene was only observed after exiting the patient's home. The Administrator confirmed that the clinical staff did not perform hand hygiene in accordance with the agency's policy.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, in which aide services were accepted, the agency did not ensure that the RN provided specific instructions for the hospice aides, thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record 14: The election of benefit was 4/7/23. The RN documented on admission (4/7/23) that a foley catheter was inserted. The aide care plan, effective 4/7/23, included relevant tasks of bed bath and perineal care with every visit, but did not provide instructions regarding catheter care. The Administrator agreed during an interview on 4/27/23 that the aide care plan should have included catheter care as a task.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, in which aide services were accepted, the agency did not ensure that the hospice aides were providing services at the frequency ordered by the interdisciplinary group. Clinical Record 2: The care plan effective 10/7/22 to current, assigned the task of "shampoo weekly"; with the ordered aide visit frequency of 3 times per week. The week starting 4/15/23 the aides documented the "shampoo weekly" task was completed on the 4/17, 4/19, and 4/21/23 visits. The record did not evidence documentation that the care plan was changed to include "shampoo" for these visits. Clinical Record 4: The care plan effective 3/22/22 to current, assigned the task: "change linen the first visit of the week," with aide visit frequency of 5 times per week. The week starting 4/15/23 the aide documented the "change linen weekly" task was completed on the 4/17, 4/18, 4/19, 4/20 and 4/21/23 visits. The record did not evidence documentation that the care plan was changed to include "change linen" for these visits. Clinical Record 17: The care plan effective 3/11/23 to current, assigned the task: "change linen weekly." The weeks that started on 4/1/23 and 4/8/23 the aide documented the task was completed on 4/1, 4/4, 4/8, and 4/12/23 which was every visit the aides made those weeks. The record did not evidence documentation that the care plan was changed to include "change linen" for these visits. The documentation was reviewed by the Administrator who confirmed that the aides were not following the care plan and were documenting completion of these tasks with each visit.