Saint Mariam Hospice Services Inc.

Quality assessment & performance improvement (42 CFR 418.58)

Rule L0559. Condition-level.

Governing body and administrator (42 CFR 418.100(b))

“Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies at COP 418.58 related to the QAPI program. This observation was discussed with the director.”

Rule L0651. Condition-level.

EP Testing Requirements (42 CFR 418.113(d)(2)(ii)(C))

“Observed in Emergency Management Session. Based on a review of the available data and discussions with the DON, the drill conducted in 2024 did not fully challenge and or describe key critical areas. This critique of a heat event did not address any challenges such as securing supplies, equipment, staffing, or any security/safety issues. This observation was discussed with the director.”

Rule E0039. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

Rule L0502. Standard-level.

Update of comprehensive assessment (42 CFR 418.54(d))

“Observed in Record Review. In 1 of 10 patient records reviewed, that were recerted, did not have documentation of measurable progress toward goals. RR#1 was admitted to the hospice approximately 8 months ago. The goals listed on the current care plan were the same as the goals listed on the initial care plan and included goals related to compliance and education. This observation was discussed with the director.”

Rule L0533. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(1))

“Observed in Record Review. In 2 of 10 patient records reviewed, the hospice care plan did not include all of the interventions required based on the assessed needs. RR#5 was assessed as being agitated on admission there was no interventions and or goal on the care plan to manage this symptom. Hospice patient RR#4 had no goals or interventions on the care plan that addressed terminal illness. This observation was discussed with the director.”

Rule L0546. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

Rule L0549. Standard-level.

Control (42 CFR 418.60(b)(2)(ii))

“Observed in Infection Control System Tracer. Based on a review of the available data there was no aggregated/or analyzed hand hygiene data for 2024 and therefore no opportunities identified to improve compliance. Per the director, hand hygiene compliance was measured/observed in the office and not in the field.”

Rule L0581. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

“Observed in Record Review. In 1 of 5 patient records reviewed, hospice aide services, did not have an aide care plan that reflected all of the interventions required based on the assessment. RR#2 was oxygen dependent, and the aide care plan did not reflect oxygen precautions. This observation was discussed with the director.”

Rule L0625. Standard-level.

Hospice plan of care (42 CFR 418.112(d)(1))

“Observed in Record Review. In 1 of 5 patient records reviewed, that resided in a nursing home, did not have a hospice care plan that detailed which provider would be responsible for treatments. RR#1 resided in a nursing home and had a foley and multiple wounds requiring daily treatment. The hospice care plan did not reflect which provider would do which task. For example, the care plan did not stipulate if the facility staff would manage wound care or change the foley. This observation was discussed with the director.”

Rule L0774. Standard-level.

Coordination of services (42 CFR 418.112(e)(3)(i))

“Observed in Record Review. In 2 of 2 patient records reviewed, that resided in a SNF, did not have the most recent hospice plan of care in the facility. Both RR#1 and RR#3 resided in a nursing home and the most recent plan of cares located in the facility were 4 weeks old. By the conclusion of the visits, the RN placed the most current updates in the records. This observation was discussed with the director.”

Rule L0781. Standard-level.