Every finding on record at Stillwater Hospice of Northern Wyoming

Upon patient record review, 5 of 19 (Patients #6,#7,#11,#12,#13) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 6: The medication profile contained polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site with order clarification received and medication profile update. Patient 7: The medication profile contained duplicative fentanyl patch instructions for 12mcg and 50mcg. There was no evidence of instructions to indicate administration simultaneously or validate if one listing was a previous order. Patient 11: Upon home visit medication reconciliation with the patient, the hospice did not have medication instructions on the medication profile reflecting patient medication regimen. The patient stated Ativan 2- 1mg tablets were taken regularly in the morning and at bedtime without hospice record of an order for Ativan tablets on the medication profile; Norco was being taken regularly 2 tablets in the morning, and 1 tablet in the afternoon and at bedtime with no instructions for scheduled doses on the medication profile, just a PRN for 1 tablet every 6 hours; methylphenidate dose per patient was 54mg in the morning and 10mg at bedtime rather than hospice instructions for 20mg daily on the medication profile; ropinirole was taken twice daily not once daily. The patient also denied having Ativan/Benadryl/Haldol compound; and patient does not take bupropion, diclofenac sodium, Senna-S, folic acid, furosemide, levothyroxine, Restasis and perfluorohexyl octane eye drops, scopolamine patch, and ondansetron that were listed on the medication profile. The patient also stated although there have been multiple conversations with nursing regarding need for nitroglycerin, she has not received the nitroglycerin that was on the profile. Patient 12: The medication profile contained oxygen with no delivery method. Corrected on site with order clarification received and medication profile update. Upon home visit medication reconciliation, the facility and hospice medication profiles did not match for sliding scale insulin, and facility had Humalin K 14 units am and 10 units at bedtime, not on hospice profile. The facility profile did not have loperamide, benzonatate, guaifenesin, nystatin, ondansetron, and Miralax that were on hospice profile. Patient 13: The medication profile contained cephalexin and fluconazole listed as current medications. Orders were for cephalexin 5 days 9/23/25 and fluconazole one tablet one time after antibiotics. Corrected on site with removal of medications from profile.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 12: The medical record contained orders identifying patient was on Eliquis and was insulin dependent. There was no evidence of problems, goals, and interventions related to risk of bleeding and endocrine dysfunction. Corrected on site with plan of care update.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 12: The medical record contained an order for 3 PRN spiritual care visits. There was no evidence of an order for anticipated scheduled need for spiritual care. Corrected on site with order clarification received.

Upon patient record review, 5 of 19 (Patients #5,#6,#7,#11,#12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5: The medical record contained nursing documentation upon admission identifying patient has a port on left chest and requires straight catheterization regularly per care plan. There was no evidence of orders for the port maintenance or catheter size, type, and frequency of catheterization. Patient 6: The medical record contained nursing documentation upon admission identifying patient had a stage 2 coccyx wound. There was no evidence of an order for wound care with location, treatments, and frequency. The record also contained an order for polyethylene glycol oral powder with no instructions to mix with a diluent. Corrected on site with order clarifications. Patient 7: The medical record contained two fentanyl patch order with instructions for 12mcg and 50mcg. There was no evidence of instructions to indicate administration simultaneously or validate if one listing was a previous order. Corrected on site with order clarification. Patient 11: Upon home visit medication reconciliation with the patient, the hospice did not have orders reflecting patient medication regimen. The patient stated ativan 2- 1mg tablets were taken regularly in the morning and at bedtime without hospice record of an order for ativan; Norco was being taken regularly 2 tablets in the morning, and 1 tablet in the afternoon and at bedtime with no order for scheduled doses, just a PRN for 1 tablet every 6 hours; methylphenidate dose was 54mg in the morning and 10mg at bedtime rather than hospice orders for 20mg daily; ropinirole was taken twice daily not once daily. The patient also denied having ativan/benedryl/haldol compound; and patient does not take bupropion, diclofenac sodium, Senna-S, folic acid, furosemide, levothyroxine, Restasis and perfluorohexyl octane eye drops, scopolamine patch, and ondansetron. The patient also stated although there have been multiple conversations with nursing regarding need for nitroglycerin, she has not received the medication that was ordered 9/5/25. There was no evidence of orders to discontinue any of the medications that were not being taken. Patient 12: The medical record contained an order for oxygen with no delivery method. Corrected on site with order clarification. Upon home visit medication reconciliation, the facility and hospice medication orders did not match for sliding scale insulin, and facility had Humalin K 14 units am and 10 units at bedtime, not in hospice orders. The facility orders also did not have loperamide, benzonatate, guaifenesin, nystatin, ondansetron, and Miralax orders that were in hospice record.

Upon patient record review, 3 of 19 (Patients #7,#12,#13) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 7: The medical record contained nursing documentation upon recertification assessment 10/14/25 identifying patient use of an air mattress. There was no evidence of an order for the DME included in the plan of care. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and bedside table. There was no evidence of orders for the DME included in the plan of care. Patient 13: The medical record contained nursing documentation upon recertification assessment 9/23/25 identifying patient use of an air mattress. There was no evidence of an order for the DME included in the plan of care.

Upon patient record review, 4 of 19 (Patients #8,#10,#11,#12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained nursing documentation 10/28/25 identifying the nurse applied a fentanyl patch for the patient. There was no evidence of an order for fentanyl. Patient 10: The medical record contained an order for spiritual care visits monthly. There was no evidence of a July visit. In addition, the medical record contained an LPN visit 10/23/25 with no assessment documented in the visit form. Corrected on site with completion of documentation. Patient 11: The medical record contained an order for social work visits monthly. There were three visits completed in August and October, and two visits in September. Patient 12: The medical record did not contain an order for routine spiritual care visits. The chaplain completed a scheduled visit 10/3/25.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice ensures the implementation of a hospice wide Quality Assessment/Performance Improvement (QAPI) program by the designation of a person responsible for coordinating QAPI activities.

Upon patient record review, 1 of 19 (Patient #16) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 16: There was no evidence bereavement services were provided. Agency did have a Performance Improvement Plan on bereavement initiated 10/20/25.

Upon patient record review 2 of 19 (Patient #7, 13) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 7: Aide visits were being completed twice weekly after frequency order 10/15/25 contained no aide frequency. Patient 13: The medical record contained an order 10/3/25 for aide visits 1W1,2W8. After leadership investigation, visits were made but not documented. Corrected on site with late visit data entry.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency volunteer annual rate was 3.93%.

Upon observation, there was no evidence that the following services are made routinely available on a 24-hour basis 7 days a week. • Drugs and biologicals After leadership interview, the agency does not have access to any 24/7 pharmacies for drugs and biologicals. Agency states that there are no options in the area due to rural status.

Upon patient record review, 9 of 11 applicable (Patients #1, #3, #4, #7, #8, #10, #11, #12 and #13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: The Aide Care Plan revealed tasks that included: empty the catheter and record output, clean/file nails, and skin care. There was no indication of the frequency of the tasks. Patient #3: The Aide Care Plan revealed tasks that included: shower and shampoo, clean, trim and file nails, assist with dressing, light cleaning and meal prep. There was no indication of the frequency of the tasks. Although the documentation revealed the patient had falls, dysphagia and difficulty with aspiration, there were no fall and aspiration precautions listed on the Aide Care Plan. Patient #4: The Aide Care Plan revealed tasks that included: bed bath, empty catheter/record output, skin care, clean/file nails and brush/style hair. There was no indication of the frequency of the tasks. Although documentation revealed the patient had "several seizures", there was no seizure precaution listed on the Aide Care Plan. Patient #7: The Aide Care Plan revealed tasks that included: assist with beard maintenance and oral hygiene. There was no indication of the frequency of the tasks. The Aide Care Plan revealed tasks that included: assist with application of lotion/deodorant, light housekeeping and assist with dressing. All tasks were listed as "per patient request". Patient #8: The Aide Care Plan revealed tasks that included: empty catheter/record output, file/trim nails, assist with shaving, assist with transfer, assist with dressing, assist with shaving and oral hygiene. There was no indication of the frequency of the tasks. Although documentation revealed the patient had issues with aspiration, aspiration precautions was not listed on the Aide Care Plan. Patient #10: The Aide Care Plan revealed tasks that included: assist with dressing, assist with meal prep, assist with transfer, brush/style hair, clean/file nails, shampoo hair and skin care. There was no indication of the frequency of the tasks. Patient #11: The Aide Care Plan revealed tasks that included: assist with dressing, assist with feeding, brush/style hair, change linens, clean/file nails, perform light cleaning and skin care. There was no indication of the frequency of the tasks. Patient #12: The Aide Care Plan revealed tasks that included: assist with dressing, bed bath, brush/style hair, clean/file nails, perform light cleaning, shampoo hair and skin care. There was no indication of the frequency of the tasks. Patient #13: The Aide Care Plan revealed tasks that included: assist with dressing, perform light cleaning, shampoo hair, skin care and shower. There was no indication of the frequency of the tasks.

Upon patient record review, 2 of 13 (Patients #5 and #12) did not have evidence that the medical director or physician designee provided written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #5: Review of the Physician Certification revealed the Physician documented "Physician certifies patient is terminally ill with COPD/CHF. Prognosis is 6 months or less if the terminal illness runs its normal course". There was no documentation to indicate the related diagnosis, current subjective and objective medical findings, current medications and treatment and information about the medical management of any of the patient's conditions unrelated to the terminal illness. Patient #12: Review of the Physician Certification revealed the Physician documented "Physician certifies patient is terminally ill, end stage CHF/COPD with life expectancy of 6 months or less if terminal illness runs it's normal course." There was no documentation to indicate the related diagnosis, current subjective and objective medical findings, current medications and treatment and information about the medical management of any of the patient's conditions unrelated to the terminal illness.

Upon personnel record review, 1 of 12 (Personnel 8) there was no documentation to indicate COVID Vaccination or an approved exemption based on the Agency's policies and procedures.