Every finding on record at Stch South Central Mn Opco LLC

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 4 of 14 (29%) clinical records reviewed of patients who received Hospice Aide (HA) services, the agency did not ensure that the HA received written patient care instructions to meet the patient's needs. Clinical Record 3: The patient elected the hospice benefit on 11/26/2024. The plan of care dated 02/24/2025-05/24/2025 ordered wound care with a wound dressing to wounds on the patient's bilateral heels and coccyx and "Hospice Aide 1x/week." The current HA care plan dated 02/07/2025 assigned the HA the relevant task of a "Bed bath at every visit." The HA care plan did not include instructions regarding the wound dressings on the patient's bilateral heels and coccyx should the dressings become wet or dislodged during the bed bath. Clinical Record 4: The patient elected the hospice benefit on 06/25/2024. A physician's order dated 02/26/2025 included orders for wound care with a wound dressing to a wound on the patient's sacrum. The plan of care dated 02/20/2025-04/20/2025 ordered "Hospice Aide 1x/week." The current HA care plan dated 01/17/2025 assigned the HA the relevant task of a "Bed bath at every visit." The HA care plan did not include instructions regarding the wound dressings on the patient's sacrum should the dressing become wet or dislodged during the bed bath. Clinical Record 6: The patient elected the hospice benefit on 11/06/2024. The plan of care dated 02/04/2025-05/04/2025 ordered wound care with a wound dressing to a wound on the patient's left leg and "Hospice Aide 1x/week." The HA care plan dated 01/09/2025 assigned the HA the relevant task of a "Shower at every visit." The HA care plan did not include instructions regarding the wound dressings on the patient's left leg should the dressing become wet or dislodged during the shower. Clinical Record 16: The patient elected the hospice benefit on 11/13/2024. The plan of care dated 11/13/2024-02/10/2025 ordered wound care with a wound dressing to wounds on the patient's bilateral heels and "Hospice Aide 1x/week." The HA care plan dated 01/13/2025 assigned the HA the relevant task of a "Bed bath at every visit." The HA care plan did not include instructions regarding the wound dressings on the patient's bilateral heels should the dressings become wet or dislodged during the bed bath. On 03/04/2025, the Regional Director of Clinical Operations and Manager of Accreditation reviewed the records and confirmed that the aide care plans did not include wound dressing instructions for the HA.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not provided a statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example during RR2 the Surveyor noted that an order for Respite care was written as admit to the hospital order. This order did not clarify the level of care change to Respite care nor did it identify the span of intended Respite. This was confirmed by the Performance Improvement Coordinator.

Observed in Record Review. the organization had not ensured clearly defined circumstances that become active upon the release of the orders. For example in review of RR2 the patient had both tablet and liquid orders for hydrocodone and lorazepam without instructions that should be used first and under what circumstances. This was confirmed with by the Performance Improvement Coordination. Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not ensured the scope and frequency of the services necessary to meet the patient’s and family’s needs. For example during RR3 the order for wound care was incomplete as it did not have a frequency for wound care or direction for wound cleansing. This was confirmed by the Performance Improvement Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not developed and maintained a system of communication and integration in the provision of care. The interdisciplinary group members provide the care and services offered by the hospice and, in its entirety, directs, coordinates, and supervises the hospice’s services. For example during RR4 the surveyor identified several notations in the clinical record for lab work for anticoagulant monitoring. The residence where the patient lived was tasked with obtaining the specimen and reporting the results to hospice however the results were not obtained and there was no evidence of follow up from the hospice nurse. This was noted with one of 16 results This was confirmed by the Performance Improvement Coordinator. Absence of results was corrected during survey activity.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured infection prevention and control activities were followed to reduce the risk of infection. For example during HV2 the Certified Nursing Assistant had not sanitized her hands between glove changes in one out of approximately three glove changes. This was confirmed by the Charge Nurse and Nursing Manager and was corrected while on site.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the medical record was accurate for oxygen orders. For example, during RR7 and RR8 the orders for oxygen did not match the liter flow provided to the patient. The liter flow ordered for RR7 was 2 liter per minute but the patient was requiring 4 liters per minute as noted in the initial plan of care. The liter flow for RR8 was ordered as 1 liter per minutes but the patient was using 1.5 liters per minute. This was confirmed with the Performance Improvement Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the plan of care includes all services needed including treatment necessary to meet the patient’s needs. For example during the record review of HV1 the Surveyor noted the Certified Nursing Assistant plan of care planned for assistance with nutrition but failed to identify what type of diet should be followed. This was confirmed by the Charge Nurse.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization had not ensured procedures, and treatments, and their results and any specific notes on care, treatment, or services was recorded in the medical record. For example the Surveyor identified during RR3 that the wound care did notes did not reflect all of the steps outlined in the order. Cleansing the wound and what type of waterproof dressing were omitted in the documentation. This was confirmed by the Performance Improvement Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization had not ensured the hospice plan of care identified the care and services that are needed or identified which provider is responsible for performing the functions that have been agreed upon and included in the plan of care. For example in review of record accompanying HV3 the surveyor could not identify in the medical record any coordination regarding chronic foley catheter care and maintenance. This was confirmed by the Performance Improvement Coordinator.