St. Mary’s Hospice Services

“Based on record reviews, and staff interviews, it was determined that the agency failed to cover medications related to admission diagnoses for two patients (P) (P11, P13) of 19 sampled patients. Findings included: 1. Review of the clinical records for P11 revealed that the start of care was completed by a skilled nurse on 03/31/2026. The admission diagnoses were Parkinson’s disease (a progressive, incurable neurodegenerative disorder that impacts the nervous system and motor control), and dementia disease (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain). The agency failed to cover the following medications:Carbidopa-levodopa (Sinemet), [combination therapy for Parkinson’s disease that increases dopamine levels in the brain] 25-100 milligrams (mg), take one tablet by mouth three times dailyExelon, [(used to treat mild to moderate dementia associated with Alzheimer’s disease or Parkinson’s disease] take one capsule 6mg by mouth twice daily. On 04/07/2026 at 12:53 PM, a phone interview was conducted with Registered Nurse (RN) BB, who said that she did not know why the diagnosed medications for P11 were not covered. 2. Review of the clinical records for P13 revealed that the start of care was completed by skilled nurse on 02/10/2026. The admission diagnoses were Dementia disease (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain) and essential hypertension (high blood pressure) The hospice agency failed to cover the following medications for P13:Cozaar (losartan) 50mg take one tablet by mouth daily for hypertension to lower the risk of stroke; Namenda (memantine) [used to treat moderate to severe dementia]10mg, take 5mg tablet two times daily, On 04/07/2026 at 2:15 PM, a phone interview was conducted with RN CC who said that he did not know why the diagnosed medications for P13 were not covered. On 04/07/2026 at 2:32 PM, an interview was conducted with the Executive Director (ED) at his office. He confirmed that RN BB and RN CC did not cover the diagnosed medications for P11 and P13. Policy was requested but was not available upon exit.”

“Based on review of policy titled “Emergency Disaster/Preparedness Plan,” record review, and staff interview, it was determined that the agency failed to develop an emergency plan that includes strategies for addressing emergency events identified in the risk assessment. The emergency plan failed to include strategies to address supply shortages, hostage/shooter situations, tornadoes, or infectious disease epidemics. Findings included: Review of policy titled “Emergency Disaster/Preparedness Plan,” review date 06/05/2025, revealed the following:“POLICY 1. The Regional Director/ Administrator is responsible to provide oversight in the development and implementation of the emergency management program.2. The Agency Safety/ Emergency Preparedness Committee oversees the emergency management program. The committee provides input and assists in the coordination of the preparation, development, implementation, evaluation, and maintenance of the agency’s emergency management program. The activities include, but are not limited to:a. Hazard Vulnerability Analysis (HVA)b. Emergency operations plan, policies, proceduresc. Continuity of operations plan” Review of a binder labeled “Emergency Plan” revealed a document titled “Hazard and Vulnerability Assessment Tool,” dated 03/09/2026, identifying the agency’s highest risk events with a percentage of relative threat: 1. Information Systems Failure/ Cyber Attack (67 percent relative threat)2. Hostage/Shooter Situation (52 percent relative threat)3. Supply Shortage (48 percent relative threat)4. Tornado (44 percent relative threat)5. Emerging Infectious Disease (44 percent relative threat)6. Epidemic (44 percent relative threat) Further review of the binder failed to reveal emergency plans for hostage/shooter situations, supply shortages, tornadoes, emerging infectious diseases, or epidemics. On 04/07/2026 at 11:30 AM, an office interview was conducted with the Business/Facilities Manager (BFM), who acknowledged responsibility for the agency’s disaster plan. The BFM agreed that the policy did not include strategies for addressing hostage/shooter situations, supply shortages, tornadoes, emerging infectious diseases or epidemics.”

“Based on policy titled “HOSPICE-CARE PLANNING PROCESS,” record reviews, and staff interviews, it was determined that the facility failed to complete the spiritual initial assessment within five days, for two patients (P) (P6 and P9) of 19 sampled patients. Findings included: A review of the policy titled “HOSPICE-CARE PLANNING PROCESS,” last review 12/11/2025, revealed the following:“Policy/Procedure: 6. “Within 5 (five) calendar days from admission, the social worker and chaplain will complete their discipline specific assessment and provide input to the Plan of Care.” 1. Review of the clinical records for P6 revealed that the start of care was completed by skilled nurse on 03/06/2026, and the spiritual initial assessment completed on 03/12/2026. Review of clinical records failed to reveal that the spiritual initial assessment was completed within five days of start of care. 2. Review of the clinical records for P9 revealed that the start of care was completed by a skilled nurse on 11/22/2025, and the spiritual initial assessment completed on 11/28/2025.Review of clinical records failed to reveal that the spiritual initial assessment was completed within five days of start of care. There was no documentation in the facility’s electronic medical record system indicating that a physician or the patients’ family requested a delay in services. On 04/07/2026 at 1:38 PM, an interview was conducted with Chaplain (CH) AA, by phone at the Administrator’s office who said that he did not know why he did not complete P6 and P9 spiritual initial assessments within five days. On 04/07/2026 at 1:45 PM, an interview was conducted with Executive Director (ED), at his office. He confirmed that CH AA did not complete P6 and P9 spiritual initial assessment within five days.”

“Based on policy titled “HOSPICE – VOLUNTEER SERVICES,” facility documents, and staff interview, it was determined that the agency failed to document the cost savings achieved through the use of volunteers. Specifically the agency failed to estimate and document the dollar costs that the hospice would have incurred if paid employees occupied the positions. Findings included: Review of policy titled “HOSPICE – VOLUNTEER SERVICES,” review date 08/22/2025 revealed the following:“Purpose: To provide guidelines for volunteer services.Policy:3. Estimates of the dollar costs that the hospice would have incurred if paid employees filled the positions held by volunteers.” Review of the hospice electronic volunteer files failed to reveal cost savings data. During an interview on 04/08/2026 at 10:48 AM, the Volunteer Coordinator stated she was unaware of documenting the estimated dollar amount for services provided by volunteers. The Volunteer Coordinator states she was told to document the hours and calculate volunteer hours. She stated she was unaware of the State Regulations for calculating the cost savings. The agency failed to document the cost savings achieved through the use of volunteers. Specifically, the agency failed to document and estimate the dollar costs that the hospice would have incurred if paid employees occupied the positions.”

“Based on policies and procedures, record reviews, facility documents and staff interviews, it was determined that the agency failed the following:Failed to develop an emergency plan that includes strategies for addressing emergency events identified in the risk assessment.Failed to document the cost savings achieved through the use of volunteers. The agencyFailed to estimate and document the dollar costs that the hospice would have incurred if paid employees occupied the positions.Failed to complete the spiritual initial assessment within five days, for two patients (P) (P6 and P9) of 19 sampled patients.Failed to cover medications related to admission diagnoses for two patients (P) (P11, P13) of 19 sampled patients. Findings included: Cross reference to E0006 relating to Emergency Preparedness.Cross reference to L0795 related to Criminal Background ChecksCross reference to L0523 relating to Time frame for completion of AssessmentCross reference to L0646 relating to Cost SavingCross reference to L686 relating to Drugs, Biologics, Medical Supplies and DME”

“Based on a record review and staff interview, the agency failed to ensure that contracts include a requirement for obtaining criminal background checks for contracted employees having direct patient contact or access to patient records. Findings included: Review of agency contracts for transportation, general inpatient (GIP), and respite care failed to reveal the contracting entities’ requirement to obtain criminal background checks on all contracted employees with direct patient contact or access to patient records. No policy was provided regarding background check requirements for contracts. On 04/07/2026 at 11:00 AM, an office interview was conducted with the Regional Director of Hospice Services (RDHS), who acknowledged that the transportation and GIP/ respite contracts do not include background check requirements and further revealed being unaware of the requirement for background checks in contracts.”