Every finding on record at Yellowstone City-County Health Department

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure the comprehensive assessment included an initial bereavement assessment. Clinical Record 9: The patient elected the hospice benefit on 04/04/2024. Neither the initial nursing assessment dated 04/04/2024, the initial spiritual assessment dated 04/08/2024, nor the initial social worker assessment dated 04/09/2024 documented an initial bereavement assessment. There was no evidence an initial bereavement assessment was completed. During an interview on 11/21/2024, the Clinical Compliance/QAPI Coordinator confirmed the initial bereavement assessment was not completed.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, it was revealed that the organization did not ensure the patient's individualized written plan of care included a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. Clinical Record 1: The patient elected the hospice benefit on 07/16/2024. On admission, the initial nursing assessment identified that the patient had a suprapubic catheter, a J-tube, and multiple wounds (three stage 4 wounds and one stage 3 wound). The clinical record did not contain orders for treatment of the wounds, J-tube, or suprapubic catheter. There was no detailed statement of the scope and frequency of services to be provided. Clinical Record 3: The patient elected the hospice benefit on 09/06/2024. The registered nurse completed a visit on 11/01/2024 and documented that an ear wash treatment was provided to the patient. There was no evidence of a written order, verbal order or communication with the physician. The plan of care did not include a detailed statement of the scope and frequency of services. Clinical Record 15: The patient elected the hospice benefit on 10/26/2023. The patient was transferred from routine hospice care in the home to general inpatient care on 04/06/2024. There was no evidence of a written order, verbal order or communication with the physician. The plan of care did not include a detailed statement of the scope and frequency of services. During an interview on 11/21/2024, the Clinical Compliance/QAPI Coordinator confirmed the missing orders and stated the clinicians were implementing standing orders and not entering them into the patient record.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, it was revealed that the agency did not ensure the patient's individualized written plan of care included the drugs and treatment necessary to meet the needs of the patient. Clinical Record 6: The patient elected the hospice benefit on 04/30/2024. On 05/01/2024 an order for oxygen was added to the medication list with the following instructions: administer 2 liters per nasal cannula continuously as needed; titrate to comfort except for COPD diagnosis; oxygen saturation criteria not required prior to oxygen administration. However, the comprehensive assessment dated 04/30/2024 documented that the patient was on 6 liters of oxygen and the nurse titrated to 5 liters per nasal cannula. During an interview on 11/21/2024, the Clinical Compliance/QAPI Coordinator confirmed the comprehensive assessment conflicted with the plan of care. The Coordinator stated that the clinicians were implementing standing orders and not entering the orders in the clinical record.

It is required that the hospice provides nursing care under the supervision of a registered nurse. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure nursing care was provided under the supervision of a registered nurse. Clinical Record 9: Clinical record review for the benefit period dated 10/01/2024 to 11/29/2024 revealed that the patient was seen by a Licensed Vocational Nurse (LVN) on 10/03/2024, 10/18/2024 and 10/24/2024. However, there was no evidence an LVN supervisory visit was completed by a registered nurse (RN) in October of 2024. Clinical Record 11: Clinical record review for the benefit period dated 03/06/2024 to 06/03/2024 revealed that the patient was seen by an LVN on 03/08/2024, 03/22/2024, 03/28/2024, 04/02/2024, 04/12/2024, 04/19/2024, 04/26/2024, 05/03/2024, 05/14/2024, and 06/05/2024. There was no evidence an LVN supervisory visit was completed by an RN. During an interview on 11/21/2024, the Clinical Compliance/QAPI Coordinator confirmed the supervisory visits were not completed.

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 2 of 15 (13%) clinical records reviewed with an aide care plan, it was revealed that the agency did not ensure the aide care plan provided clear patient care instructions for the aide. Clinical Record 1: The patient elected the hospice benefit on 07/06/2024. The initial assessment dated 07/06/2024 completed by the registered nurse (RN), documented the following: multiple wounds (three stage 4 wounds and a stage 3 wound); a Foley catheter; and a J-tube. The aide care plan did not provide the aide with specific instruction regarding how to manage the wound care dressings while providing the ordered bath. Clinical Record 5: The patient elected the hospice benefit on 11/08/2024. The initial assessment dated 11/08/2024 completed by the RN, documented multiple wounds (one to the left big toe and to the coccyx) and a Foley catheter. The aide care plan did not provide the aide with specific instruction regarding how to manage the wound care dressings while providing the ordered bath. During an interview on 11/20/2021, the Clinical Manager confirmed the aide care plans did not provide the aide specific patient care instructions.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to: Assess the quality of care and services provided by the hospice aide; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 2 of 16 (12%) clinical records reviewed for patients that elected hospice aide services, it was revealed that the agency did not ensure hospice aide services were supervised by a registered nurse no less frequently than every 14 days. Clinical Record 12: A clinical record review for the benefit period dated 07/02/2024 to 08/30/2024 revealed the hospice aide was ordered 1 time per week. The patient received aide services as ordered beginning on 07/08/2024. The aide supervisory visits were completed on 07/12/2024, 08/23/2024, and 08/30/2024. There were approximately 42 days between 07/12/2024 and 08/23/2024, or 28 days late. Clinical Record 14: A clinical record review for the benefit period dated 04/23/2024 to 06/21/2024 revealed the hospice aide was ordered 2 times per week. The patient received aide services as ordered beginning on 04/23/2024. The aide supervisory visits were completed on 05/08/2024, 05/15/2024, 06/12/2024 and 06/26/2024. There were approximately 28 days between 05/15/2024 and 06/12/2024, or 14 days late. During an interview on 11/21/2024, the Clinical Compliance/QAPI Coordinator confirmed the supervisory visits were late.

It is required that all hospice aide services must be provided by an individual who has successfully completed one (1) of the four (4) training and competency evaluations programs described below. The individual furnishes hospice aide services on behalf of a hospice only after successfully completing a competency evaluation program also described below. The hospice maintains documentation that each hospice aide has met the requirements. Documentation of training includes: A description of the training and competency evaluation program. The qualifications of the instructor. A statement that distinguishes skills taught in a laboratory using a real person (not a mannequin). Indicators of which skills the aide was judged to be competent in. How additional skills, if any, are taught and tested if the hospice’s admission policies and case-mix of hospice patients requires aides to perform more complex procedures. The competency evaluation addresses each of the following subject areas from item 2, above; they are evaluated by observation of an aide’s performance with a patient or pseudo-patient, including: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. Reading and recording temperature, pulse, and respiration. Appropriate and safe techniques in performing personal hygiene and grooming tasks, including items on the following basic checklist: Bed bath; Sponge, tub, and shower bath; Hair shampoo (sink, tub, and bed); Nail and skin care; Oral hygiene; Toileting and elimination; Safe transfer techniques and ambulation; Normal range of motion and positioning. This standard was not met as evidenced by review of personnel record, document review, and interview that in 1 of 1 (100%) of hospice aide records failed to document observation of required skills on hire according to agency policy. Agency Policy "Hospice Aide" (revision 1/2020) was reviewed and stated, "Competency is assessed within 30 days of hire and is updated for all CHHA at least yearly. The competency evaluation must be evaluated by observing an aides performance of the following tasks with a patient: communication and reporting skills reading and recording temperature, pulse and respirations, personal hygiene: bed bath, sponge, tub and shower bath, hair shampoo (skink, tub, and bed), nail and skin care, oral care, toileting, transfer, and range of motion." Record #91114: Hospice Aide hired 06/21/2019 with a signed competency on 08/05/2019, the method of accomplishment of each competency was not documented. The skills form provided opportunity to document D - direct observation, T- test, O - oral question and answer. All skills documented on the form, failed to indicate the method of confirmation of skill. Interview with the Director of Hospice on 01/06/2022 stated that the competency form was not completed correctly

It is required that the hospice inpatient facility provides meals to each patient that are: Obtained, stored, prepared, distributed, and served under sanitary conditions. This standard was not met as evidenced by observation and interview the hospice did not ensure a process to identify and remove expired food from potential patient use during 1 of 1 kitchen observation. Observation of the kitchen during the tour only 1/6/22, found that food in the freezer for patient use contained two boxes of expired food. The meat freezer observed during the tour contained 2 boxes (28 ounces) of frozen shrimp, one expired 09/282021 and the second box expired 12/28/2021. Interview with the Director of Hospice stated that if they expired then we will throw them out.