St Anthony’s Hospice Inc.

“Based on interviews, record review, and agency policy review, the hospice agency failed to ensure the agency interdisciplinary group (IDG) developed a plan of care (POC) for treatment areas for two of 14 current patients (Patient (P)10, and P11) and one of three death records (P6) reviewed from a total sample of 19 patients. This had the potential to affect the planning of appropriate/anticipated care needs for the 61 patients who were currently receiving hospice services and all future hospice patients/patient family units. The findings include: Review of the November 2016 agency policy titled, “Plan of Care-Care Center,” revealed, “. . . A Plan of Care (POC) will be established for each patient admitted to the Care Center . . . At the time of admission, an individualized POC will be developed based upon the assessment by the interdisciplinary team and input from the patient/family . . . The RN [Registered Nurse] is responsible for overall development and maintenance of the POC . . . Care plans will be reviewed and updated at least every 14 days and PRN [as needed] to reflect the current plans and goals for the patient/family . . . Existing care plans of patients being transferred to the Care Center from hospice home care will be continued through review and revision to reflect change in the patient’s level of care . . .” Review of the January 2017 agency policy titled, “Plan of Care,” revealed, “. . . Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by the hospice IDG in collaboration with the patient’s attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver . . . The patient’s plan of care specified the care and services necessary to meet the needs of the patient/caregiver as identified in the initial, comprehensive and updated assessments of the patient . . .” 1. Review of P6” “Face Sheet,” located in the electronic medical record (EMR) under the “Contact Information” tab, revealed P6 started care with the hospice agency on 05/02/2024 for diagnoses of osteomyelitis (a bone infection) and gangrene (dead tissue caused by an infection or lack of blood flow). Review of P6’s “Initial Comprehensive Nursing Assessment,” dated 05/02/2024, completed by Registered Nurse (RN)1, and located in P6’s EMR under the “Clinical Entries” tab, revealed P6 would require wound care to his right foot and to the pressure ulcer on his sacrum (tailbone). In addition, RN1 identified that P6 was experiencing pain due to his disease process. Review of P6’s “Care Plan Problems,” dated 05/02/2024 and located in P6’s EMR under the “Certification and Care Plan” tab, revealed no documentation that a care plan for wound care and pain was developed by RN1. Review of the “Inpatient Visit Note,” dated 05/07/2024, completed by RN2 and located in the “Clinical Entries” tab, revealed P6 was transferred from the home setting to the inpatient care center for respite care. It was recorded P6 was now unresponsive and in the dying process. There was no “Care Plan” developed for the transfer from the home setting to the inpatient unit due to P6’s declining condition. P6 passed away on 05/08/2024 while in the inpatient care center. 2. Review of P10’s “Face Sheet,” located in the EMR under the “Contact Information” tab, revealed P10 started care with the hospice agency on 01/14/2025 for a diagnosis of malignant brain cancer. Review of P10’s “General Visit Note,” dated 01/14/2025, completed by RN3, and located in P10’s EMR under the “Clinical Entries” tab, revealed P10 was assigned a Home Health Aide (HHA) during the visit to P10’s home. Review of P10’s “Care Plan Problems,” dated 01/14/2025 and located in the EMR under the “Certification and Care Plan” tab, revealed no documentation that a care plan for the HHA was developed by RN3. 3. Review of P11’s “Face Sheet,” located in the EMR under the “Contact Information” tab, revealed P11 started care with the hospice agency on 01/18/2024 for a diagnosis of end-stage renal disease (ESRD). Review of P11’s “Comprehensive Nursing Assessment,” dated 01/18/2025, completed by RN4, and located in P11’s EMR under the “Clinical Entries” tab, revealed P11 had stopped going to dialysis, had shortness of breath, required oxygen, and had swelling in both of her legs. Review of P11’s “Care Plan Problems,” dated 01/18/2025 and located in the EMR under the “Certification and Care Plan” tab, revealed no documentation that a care plan was developed for P11’s progressive disease. During an interview on 01/23/2024 at 1:10 PM, the Director of Medical Services stated, “Yes, I am aware that the care plans are not individualized, we have struggled with this.””

“Based on interview, record review, and agency policy review, the agency failed to ensure the required Interdisciplinary Group (IDG) team members had collaborated to develop and/or revise the patient’s care plan for three of 14 (Patient (P)9, P10, and P11) current sampled patients in a total sample of 19. This failure placed the patients at risk for unmet care needs. The findings include: Review of the agency’s policy and procedures, dated 01/03/17 titled, “Interdisciplinary Group” revealed, “. . . [Hospice agency] designates an IDG composed of qualified individuals who assess, plan, provide and evaluate the care and services provided to hospice patients/caregivers . . . The IDG at [hospice agency] includes, at a minimum, the following individuals . . . A doctor of medicine or osteopathy . . . a registered nurse . . . a Social Worker . . . a pastoral or other counselor...The IDG is responsible for . . . establishing, implementing, reviewing and revising the patient’s plan of care . . . providing or coordinating care and services in accordance with patient’s plan of care . . . documenting all care and services provided in a timely manner in accordance with the hospice’s documentation requirements . . .” 1. Review of P9”s “Face Sheet,” located in the electronic medical record (EMR) under the “Contact Information” tab, revealed P9 was admitted to the hospice agency with a start of care date on 05/08/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). It was recorded P9 discharged from hospice services on 05/22/2024. Review of the “IDG Comprehensive Assessment” tab in the EMR revealed that from 05/08/24 to 05/22/2024, there was no documented evidence to show that P9 was discussed during the meetings to update/revise the comprehensive plan of care. Review of a 06/10/2024 “IDG Comprehensive Assessment” tab in the EMR revealed P9’s plan of care was reviewed; however, P9 had already discharged to seek aggressive treatment. In addition, the documentation showed that only the Social Worker and the Chaplain signed the “IDG Comprehensive Assessment.” During an interview on 01/23/2025 at 4:15 PM, the Director of Nursing stated, “I believe the 06/10/2024 ‘IDG Comprehensive Assessment’ was dated incorrectly and should have been 05/10/2024.” Review of the IDG “Sign-in” sheet for May 2024, provided by the Director of Medical Services, revealed that the IDG met on 05/13/24 and 05/20/2024. There was no documentation to show that there was an IDG meeting on 05/10/2024. 2. Review of P10’s “Face Sheet,” located in the EMR under the “Contact Information” tab, revealed P10 was admitted to the hospice agency with a start of care date of 01/14/2025 with a diagnosis of brain cancer. Review of the “IDG Comprehensive Assessment” tab in the EMR revealed no evidence to show P10 was reviewed by the IDG as the assessment was blank. Review of the January 2025 IDG “Sign-in” sheet, provided by the Director of Medical Services, revealed there was an IDG meeting held on 01/21/2025 with all members of the IDG. 3. Review of P11’s “Face Sheet,” located in the EMR under the “Contact Information” tab, revealed P11 was admitted to the hospice agency with a start of care dated 01/18/2024 with a diagnosis of end stage renal disease. Review of the “IDG Comprehensive Assessment” tab in the EMR revealed no evidence to show P11 was reviewed by the IDG as the assessment was blank. Review of the January 2025 IDG “Sign-in” sheet, provided by the Director of Medical Services revealed there was an IDG meeting held on 01/21/2025 with all members of the IDG. During an interview on 01/23/2025 at 4:15 PM, the Director of Nursing confirmed there was no documentation to show P10 and P11 were discussed during the 01/21/2025 meeting. She stated the full IDG had met on 01/21/2025 and new admissions would have been discussed.”

“Based on interview, record review, and agency policy review, the agency failed to ensure education was provided to staff regarding the Hepatitis B vaccine for six of six (Social Worker (SW)1), Senior Nurse Aide (SRNA)1, SRNA2, SRNA3, Licensed Practical Nurse (LPN)1, and Registered Nurse (RN)4) personnel files reviewed. There were 72 identified staff employed at the hospice agency. This failure placed all 61 residents at risk for the spread of infectious disease. The findings include: 1. Review of the personnel file for SW1 revealed a hire date of September 1999. There was no documentation in the employee file to show that SW1 was provided education on the Hepatitis B vaccine. 2. Review of the personnel file for SRNA1 revealed a hire date of 08/28/2019. There was no documentation in the employee file to show that SRNA1 was provided education on the Hepatitis B vaccine. 3. Review of the personnel file for SRNA2 revealed a hire date of 03/29/2023. There was no documentation in the employee file to show that SRNA2 was provided education on the Hepatitis B vaccine. 4. Review of the personnel file for SRNA3 revealed a hire date of 09/15/2023. There was no documentation in the employee file to show that SRNA3 was provided education on the Hepatitis B vaccine. 5. Review of the personnel file for LPN1 revealed a hire date of 02/23/2023. There was no documentation in the employee file to show that LPN1 was provided education on the Hepatitis B vaccine. 6. Review of the personnel file for RN4 revealed a hire date of 10/30/2024. There was no documentation in the employee file to show that RN4 was provided education on the Hepatitis B vaccine. During an interview on 01/24/2025 at 11:15 AM, the Executive Director stated, “We have been unable to locate Hepatitis B information on the above staff.” During an interview on 01/24/2025 at 12:15 PM, the Director of Operations stated, “The employee handbook covers information on the Hepatitis B vaccine; however, there are no signed documents stating the employee had received the education.””

“Based on interview, record review, and review of the agency policy, the hospice agency failed to ensure documentation of collaboration with the receiving hospice nurse and the skilled facility staff to ensure continuity of care for one of two residents (Patient (P)8) reviewed for discharge/transfer in a total sample of 19. This failure placed the patient at risk of not receiving the care and services needed for quality of life. The findings include: Review of the agency’s policy and procedures titled, “Transfer of a Hospice Patient,” dated 01/03/17, revealed, “. . . Continuity of care is maintained when a hospice patient is transferred to another treatment setting or provider . . . A written transfer summary is prepared for the receiving provider that includes, at a minimum . . . a summary of the patient’s current status and the problems, interventions, and goals identified in the patient’s plan of care... The RN [Registered Nurse] Case Manager or the Social Worker provides complete documentation of the patient’s transfer in the patient’s clinical record . . .” Review P8’s “Face Sheet,” located in the electronic medical record (EMR) under the “Contact Information” tab, revealed P8 was admitted to the hospice agency with a start of care date of 09/13/2024 for a diagnosis of hypertensive heart disease. Review of P8’s “Discharge/Transfer Checklist,” dated 09/25/2024 and located in P8’s EMR under the “Care Level Change” tab, revealed, the only items on the “Checklist” as having been completed were “Call primary physician, notify ancillary services, notify chaplain, notify clinical director, verifying his/her data.” The “Checklist” showed “Discharge planning and coordination of care” was “Not applicable.” Review of the “Skilled Nurse Phone Call,” dated 9/23/2024, completed by RN6 and located in the “Clinical Entries” tab of the EMR, revealed, “. . . Collaborated with SW [social worker] regarding pt’s [patient’s] transfer to [hospice agency]. Called pt’s daughter [name withheld], she was very appreciative of all the care [hospice agency] provided. This RN offered to provide a nurse report on pt to the SNF [skilled nursing facility] that P8 transferred to and to [hospice agency]. [Name withheld] states she will notify them both and provide this nurse’s phone number for them to call . . . This RN never received phone call from SNF or [hospice agency] . . .” Further review of the “Skilled Nurse Phone Call” documentation revealed that RN6 did not attempt to contact the SNF or the receiving hospice agency for coordination of care. During an interview on 01/23/2024 at 3:23 PM, the Director of Medical Services stated, “We did send all the documents to the receiving hospice. The nurse should have given more information in her notes when she ‘collaborated’ with the receiving hospice as to what was said.” The Director of Medical Services further stated, “The nurse should have reached out and called the SNF and the receiving hospice to ensure continuity of care.””

“Based on record review and interview, the facility failed to meet the Emergency Prep Testing Requirements in accordance with the Code of Federal Regulations (CFR) State Operations Manual (SOM), Appendix Z. The deficient practice had the potential to affect two (2) of two (2) smoke compartments, staff, and all residents. The facility had the capacity for 10 beds with a census of four (4) on the day of survey. The findings include: Record review, of the facilities Emergency Preparedness Plan on 01/23/2025 at 2:15 PM, revealed the facility failed to participate in a tabletop exercise or a community-based exercise for the previous 12 months. Interview, with the Emergency Preparedness Officer on 01/23/2025 at 2:16 PM, revealed they were under the impression the hospital was including them in the drills but there was no documentation to show any drills for the Hospice. The finding was verified by the Emergency Preparedness Officer at time of record review and the Administrator at the exit interview on 01/23/2025.”