St. Mary’s Hospice, Inc.

“Observed in Record Review. In 3 of 4 patient records reviewed, The stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. During RR#1 it was noted many goals lacked measurable outcome to assess progress toward goals, for example: Blood sugar management for pt. comfort, Patient will be able to rest comfortably without excessive sadness in 14 days and onwards, Maintain adequate oxygenation and ventilation, as evidenced by normal respiratory rate, oxygen saturation levels within target range, and absence of respiratory distress. During RR#2 it was noted lack of goals that were had measurable time frames to assess progress, for example: Edema will not increase and patient will not experience any discomfort from edema, PCG and family will verbalize understanding that due to patient’s poor prognosis there is no need for blood sugar checks at this time, PCG and family will verbalize understanding of patient’s difficulty to swallow and will provide a puree diet with thin liquids as tolerated, PCG will verbalize understanding of fall risk safety, Patient’s needs will be met daily and will minimize episodes of confusion. During RR#3 it was noted lack of measurable goals on the POC as follows: Goals: PCG will verbalize understanding of medical equipment and patient will be free from injury, Patient will experience no constipation this benefit period, Minimize complications due to patient being bed bound, Patient will have adequate fluids and food as tolerated. This was discussed with the Administrator.”

“Observed in Record Review. In 3 of 4 patient records reviewed, During RR#1 it was noted lack of an oxygen order for the liter flow and direction for use on the current POC. During RR#2 it was noted lack of instruction for F/C care on the POC. In addition the wound care order for RR#2 lacked the as needed reason for additional visits and lacked who was to perform the wound care on non-SN visit days. During RR#3 it was noted lack of interventions on the POC for seizure precautions and assessment only without interventions identified for constipation. This was discussed with the Administrator.”

“Observed in Record Review. In 3 of 4 patient records reviewed, During RR#1 it was noted the following frequency of visits on the POC: MSW: 1 One-time then PRN, SC: 1 One-time then PRN, SN: 2 per Week +3 PRN Visits. The PRN visits lacked the reason for the additional visits and the number of PRN visits needed. During RR#2 it was noted lack of a reason and the number of PRN visits for the MSW. During RR#3 it was noted lack of the reason and number of PRN visits for the MSW and SC. This was discussed with the Administrator.”

“Observed in Record Review. In 1 of 4 patient records reviewed, In 1 of 4 patient records reviewed, the organization failed to ensure the updated comprehensive assessment included information about the patient’s progress toward goals and desired outcomes. During RR#1 it was noted lack of an update to the POC based on the RN assessment the beginning of August 2025. The POC included interventions for a F/C however the RN assessment documented no F/C present, the RN documented patients oxygen level for 5 minutes without oxygen therapy was 83% during the visit and stated she needs to place her oxygen on, shortness of breath was severe during exertion however the POC lacked an oxygen order. This was discussed with the Administrator.”

“Observed in Record Review. In 2 of 10 patient records reviewed, During RR#3 it was noted the chaplain (SC) assessment was documented 10 days after the initial comprehensive assessment, and the MSW initial assessment was blank. There was lack of documentation to indicate why the initial evaluations for MSW and SC were not completed within 5 calendars days after the election of hospice. During RR#7 it was noted the SC documented the initial spiritual assessment 19 days after the SOC. There was lack of documentation of the reason for the delay. This was discussed with the Administrator.”

“Observed in Record Review. In 6 of 10 patient records reviewed, The stated goals do not contain specific information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals. During RR#3 it was noted multiple goals lacked measurable time frames to determine if goals were achieved as follows; Cg (caregiver) will verbalize understanding of notifying hospice if wound worsens, however there were no wounds identified during the RN initial assessment, Staff will verbalize understanding of notifying hospice if patient has an increase in anxiety/agitation, Pcg will verbalize understanding of offering small frequent meals, Cg will verbalize understanding of providing supplemental nutrition such Ensure or Glucerna and patient needs will be met on a day to day basis as communicated per ADL needs and Staff will verbalize understanding of giving pain medication as Ordered for prn use. During HV#2 record review it was noted the goals did not have measurable outcome time frames to assess if accomplished as follows: since May 2024: cg will verbalize understanding of monitoring patient during ambulating and calling hospice if patient has a fall, since September 2024 Daughter will verbalize understanding of administering ABH cream, Daughter will verbalize understanding of contacting hospice if patients agitation becomes worse, and since May 2024 cg will verbalize understanding of offering small frequent meals on patients bad days. During HV#3 record review it was noted goals without outcome measure time frames as follows: Since January 2024 Family/PCG will verbalize or demonstrate understanding and compliance with teachings related to equipment safety and patient will remain safe at home and free from injury, since December 2023 -Pcg will verbalize/express understanding of medication /treatment orders and side effects, since December 2023 increase strength/energy for functional activities by providing bed exercises, since January 2024-Pt needs will be met on a day to day basis as communicated to family members. During RR#4 it was noted multiple goals without measurable time frames as follows: Pt will maintain optimum peripheral circulation during recertification period .The patient will have an acceptable respiratory rate for the next 2 weeks of hospice care, documented in 2022 and continued to present, Pt will verbalize and/or express decreased episodes of SOB at rest during SN visits, goal established in 2022 and remains the same to date, Patient/PCG and family will complete final arrangements, Pt/Family/PCG will access community resources for IHSS to improve quality of life, Pt/Family/PCG will have a mortuary plan in place documented in Feb 2024 and remains the same to date. During RR#5 it was noted the following goals that lacked measurable outcomes: Patient will achieve and maintain peripheral circulation for comfort through out hospice services, Discomfort will be prevented due to increasing edema through out hospice stay, Patient’s blood sugar will be managed for patient’s comfort throughout hospice services, Patient will verbalize and express feelings and thoughts related to depression with each discipline visit during hospice services. RR#7 lacked measurable goals with outcome time frames as follows: Patient/Cg will verbalize understanding of calling hospice if medications are not effective, Patient/Cg will verbalize understanding of giving medications as prescribed by physician, Patient/cg will verbalize understanding of patient declining and potential to discontinue medications, cg will verbalize understanding of calling hospice if patient exhibits combative behavior`s, Complement added resources and support as needed, Complete final arrangements, Pt/Family/PCG will exhibit functional coping skills to manage and maintain symptoms of anxiety, Cg will verbalize understanding of giving pain medication as ordered. This was discussed with the Administrator.”

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR#1 it was noted on the medication profile the pt. was prescribed Plavix 75 mg daily. The POC lacked education on s/s bleeding and bleeding precautions. This was discussed with the Administrator. Observed in Record Review. In 5 of 10 patient records reviewed, During RR#1 it was noted the patient during the RN initial assessment had a dx of c-diff with antibiotics ordered. The POC lacked interventions related to the infection added during the comprehensive assessment. During HV#2 record review it was noted on the medication profile multiple medications ordered throughout the 7 certification periods for UTIs. The POC lacked interventions related to the GU status. During RR#5 it was noted a frequency of 1x/month for the MSW however the POC lacked psychosocial emotional interventions. During RR#6 it was noted lack of interventions related to G-tube care on the POC. During RR#7 it was noted 2 episodes of UTI with antibiotics ordered. The POC was updated to include the medication administration, however the POC lacked interventions that included GU instruction on care and prevention of UTIs. This was discussed with the Administrator.”

“Observed in Record Review. In 8 of 10 patient records reviewed, During RR#2 it was noted lack of a reason for PRN visits for the SN. During RR#1, RR#5, RR#6, HV#2 and HV#1 record review it was noted lack of the PRN reason and number of visits for the MSW and SC. The SN visits lacked the reason for the 3 PRN visits on the POC. During RR#4 it was noted MSW PRN visits without the number and SC PRN visits without the number on the POC. During RR#7 it was noted the MSW order for PRN visits without a reason or number and SN visits without a reason for PRN visits. This was discussed with the Administrator.”

“Observed in Record Review. In 3 of 10 patient records reviewed, In 3 of 10 patient records reviewed, the organization failed to ensure the updated comprehensive assessment included information about the patient’s progress toward goals and desired outcomes. Throughout the record reviewed there was a trend noted of a lack of documented progress toward goals and desired outcomes. The care plans remained the same IDG to IDG with no indication when or if goals had been achieved. During HV#2 record review it was noted: The patient will have an acceptable respiratory rate for the next 2 weeks of hospice care however this goal was documented in 2022 and continues to present without documentation of progress, Pt will verbalize and/or express decreased episodes of SOB at rest during SN visits that was written in 2022 and remains the without documentation of progress, Patient/PCG and family will complete final arrangements, Pt/Family/PCG will access community resources for IHSS to improve quality of life, Pt/Family/PCG will have a mortuary plan in place added to the POC in February 2024 without documentation of progress toward the goal. During HV#2 record review it was noted the goals established in 2024 remain the same in the 7th benefit period without documentation of progress toward achieving goals. During RR#4 there is lack of documentation of progress toward multiple goals since hospice admission in 2022. This was discussed with the Administrator.”

“Observed in Record Review. In 1 of 10 patient records reviewed, During RR#6 the spiritual counselor (SC) frequency of visits documented at each IDG was SC 1x/week. The documentation from the SC was the initial assessment without subsequent visits documented. This was discussed with the Administrator. Observed in Record Review. In 2 of 2 patient records reviewed, who received bereavement services for survivors. BRRR#1 bereavement POC was documented as follows: Bereavement Letters / Material through out the first year. There was lack that bereavement mailings were sent to the survivor as planned. BRRR#2 there was lack of documentation that bereavement mailings were sent as indicated to be done in the bereavement POC. This was discussed with the Administrator.”

“Observed in Data Session. The organization has not demonstrated that it set priorities for data collection, and patient palliative outcomes, and has not adhered to the frequency of reporting data collection. During review of the QAPI plan it was noted data collection frequency was documented to be monthly, data analysis was documented to be completed quarterly and data communication to staff and governing body was documented as quarterly and annually, however the review of QAPI meetings for 2024 was documented biannually and biannual to date for 2025. The meeting minutes lack an analysis of data collected for most indicators listed in their QAPI policy.”

“Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide. During review of HR#2 it was noted lack of an initial competency assessment that included: Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff, Reading and recording temperature, pulse, and respirations, Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination, safe transfer techniques and ambulation and normal range of motion and positioning. This was discussed with the Administrator. Observed in HR File Review. In 1 of 1 HR files reviewed, for the hospice aide. During HR#2 file review it was noted lack of a competency assessment with a patient or a pseudo-patient for the following: ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other staff, Observation, reporting, and documentation of patient status and the care or service furnished, Basic infection control procedures, Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor, Maintenance of a clean, safe, and healthy environment, Recognizing emergencies and initiating necessary emergency procedures, The physical, emotional, and developmental needs of and ways to work with the populations served by the hospice aide, including the need to respect the patient and their privacy and property, Adequate nutrition and fluid intake and any other task that the hospice may choose to have the home health aide or hospice aide perform as permitted under state law. This was discussed with the Administrator.”

“Observed in Record Review. In 4 of 10 patient records reviewed, During RR#3 it was noted the aide assignment form lacked safety instructions on bleeding precautions. The patient was prescribed Plavix 75 mg daily. During RR#1 the hospice aide assignment form lacked safety instructions on bleeding precautions and infection control measures related to the patient’s dx of c-diff. During HV#1 record review it was noted the patient’s oxygen order was blank on the aide assignment form. During RR#5 it was noted Eliquis on the medication profile. The aide assignment lacked safety instruction on bleeding precautions. During RR#6 it was noted on the RN initial assessment that the patient was NPO with a G-tube. The aide assignment form lacked the NPO order and the presence of the G-tube. This was discussed with the Administrator.”

“Observed in HR File Review. In 6 of 9 HR files reviewed, During HR#1 file review it was noted lack of an orientation to the specific job duties and responsibilities of the Administrator. During HR#4 file review it was noted lack of an orientation to the specific job duties of the Administrator Designee. During HR#5 file review it was noted lack of orientation to specific job duties as the Bereavement Coordinator and Volunteer Coordinator. During HR#2 file review it was noted the hospice aide lacked orientation to specific job duties and responsibilities. During HR#6 file review it was noted lack of orientation to the specific job duties for Medical Social Worker. During HR#7 file review it was noted lack of orientation to the specific job duties of the DPCS designee and Field RN. This was discussed with the Administrator.”

“Observed in HR File Review. In 3 of 9 HR files reviewed, During HR#3, and HR#5 file it was noted lack of competencies for 2022, 2023, 2024 and 2025 to date. During HR#9 file review it was noted lack of competencies from 2021 to present. This was discussed with the Administrator.. Observed in HR File Review. In 2 of 9 HR files reviewed, During HR#6 review it was noted lack of an initial competency after hire in February 2025. During HR#9 file review it was noted lack of an initial competency assessment completed after hire in May 2024. This was discussed with the Administrator”