Pioneer Medical Center

“Based on record review and interviews the agency failed to ensure compliance with requirements of State law (whether statutory or recognized by the courts of the State) regarding advance directives by ensuring POLST forms were completed by the patient or legal decision maker and all mandatory sections of the forms were completed for 3 (#s 6, 7, and 9) of 12 sampled patients. Findings include: 1. Review of patient # 6’s, POLST, no date, reflected patient #6’s POLST was not dated by the legal decision maker and was not signed or dated by the physician.2. Review of patient # 7’s POLST, dated 1/18/25, reflected patient # 7 did not complete the mandatory date section of the form.3. Review of patient # 9’s medical record reflected a POLST, dated 11/22/22, without a name or date of birth on the document. The typed medical label containing the name and date of birth were not readable. During an interview on 10/21/25 at 2:45 p.m., staff member A stated she was the Hospice Director. Staff member A stated she only worked part-time and struggled to get everything done. Staff member A stated she was aware items were missing or incomplete on the POLST forms and felt another pair of eyes would be beneficial to avoid the errors of missing dates, signatures, and POA paperwork on admission documentation. During an interview on 10/22/25, at 12:55 p.m., staff member A stated there were no other valid POLSTs available for patient #’s 6, 7, and 9. Staff member A stated the POLSTs should have all sections completed.Review of the facility provided, “POLST form,” dated September 2019, reflected the patient/legal decision maker and date, and the physician/APRN/PA signature and date were mandatory sections to be completed for the document to be valid.Review of the facility’s policy, “Physician Orders for Life Sustaining Treatments (POLSTS), dated 4/8/24, reflected:- “... use the POLST form and follow the DNR/POLST protocol approved by the Board of Medical Examiners and the department. ...”Review of the Mont. Admin. r. 37.10.108 - DO-NOT-RESUSCITATE PROTOCOL, effective 9/24/22, reflected:- “... When issuing a DNR order for a patient with a terminal condition, medical professionals are encouraged to use the POLST form and follow the DNR/POLST protocol approved by the Board of Medical Examiners and the department. The department adopts and incorporates by reference the Montana Provider Orders for Life-Sustaining Treatment (POLST) protocol (last revised September 2019).””

“Based on record review and interviews the agency failed to ensure all required professional roles were represented in interdisciplinary team meetings for 3 (1, 3, and 4) or 12 sampled patients. Findings include: 1. Review of patient #1’s Hospice IDG Meeting, dated 10/10/25, reflected the Chaplin was not present.Review of patient #1’s Hospice IDG Meeting, dated 9/22/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present.Review of patient #1’s Hospice IDG Meeting, dated 9/8/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present.Review of patient #1’s Hospice IDG Meeting, dated 8/27/25, reflected the Chaplin and the Social Worker were not present.Review of patient #1’s Hospice IDG Meeting, dated 8/11/25, reflected the Chaplin and the Social Worker were not present. The Medical Director was also not present. The form noted, “No in-person meeting.”Review of patient #1’s Hospice IDG Meeting, dated 7/30/25, reflected the Chaplin and the Social Worker were not present.Review of patient #1’s Hospice IDG Meeting, dated 7/14/25, reflected the Chaplin and the Social Worker were not present.2. Review of patient #3’s Hospice IDG Meeting, dated 12/20/24, reflected the Chaplin and medical Director were not present.Review of patient #3’s Hospice IDG Meeting, dated 12/6/24, reflected the Medical Director was not present.Review of patient #3’s Hospice IDG Meeting, dated 11/8/24, reflected the Chaplin was not present.3. Review of patient #4’s Hospice IDG Meeting, dated 2/26/25, reflected the Chaplin was not present.Review of patient #4’s Hospice IDG Meeting, dated 1/27/25, reflected the Chaplin was not present.Review of patient #4’s Hospice IDG Meeting, dated 1/15/25, reflected the Chaplin was not present.Review of patient #4’s Hospice IDG Meeting, dated 1/2/25, reflected the Chaplin and Social Worker were not present.Review of patient #4’s Hospice IDG Meeting, dated 12/20/24, reflected the Chaplin and Medical director were not present.Review of patient #4’s Hospice IDG Meeting, dated 12/6/24, reflected the Medical director was not present.During an interview on 10/22/25 at 11:04 a.m., staff member E stated she was the Social Worker for the agency and tried to attend IDG meetings if she was available. Staff member E stated the meetings were not held on consistent days and times, making it difficult to plan. Staff member E stated the multiple changes in medical directors had made scheduling difficult.During an interview on 10/22/25 at 12:13 p.m., staff member F stated barriers to attending the IDG meetings included having multiple roles in the facility/agency and lack of consistent scheduling. During an interview on 10/22/25 at 12:22 p.m., staff member A stated she sent out invites to all IDG meetings, including a Teams option, to all members of the IDG. Staff member A stated each member was responsible for many roles between the hospital, clinics, and hospice, making it difficult to get members to attend the IDG meetings.Review of the facility’s policy, “Hospice Interdisciplinary Group,” dated 10/17/23, reflected:- “3. The IDG involved in the care of the patient consists of, but not limited to, the following: ... B. Medical Director, C. Registered nurse, D. Social Worker, E. Chaplin ...- 5. The IDG meeting address each of the patient’s needs and problems, and are held every 15 days ...””

“Based on record review and interviews the agency failed to include measurable outcomes in the plan of care for 5 (#s 1, 3, 4, 5, and 8) of 12 sampled patients. Findings include: 1. Review of patient #1’s, “Plan of Care: Respiratory,” dated 7/2/25, reflected a goal/outcome of: “Patient will have optimal respiratory status within normal limits of disease”. The goal/outcome failed to include any measurable data criteria.Review of patient #1’s, “Plan of Care: Skin Integrity,” dated 7/2/25, reflected a goal/outcome of: “Patient’s skin integrity, wound drainage, and pain will be managed.” The goal/outcome failed to include any measurable data criteria.2. Review of patient #3’s, “Plan of Care: Respiratory,” dated 10/30/24, reflected a goal/outcome of: “Patient will have optimal respiratory status within normal limits of disease”. The goal/outcome failed to include any measurable data criteria.3. Review of patient #4’s, “Plan of Care: Medication Self-administration,” dated 1/2/25, reflected a goal/outcome of: “Patient will safely self-administer medications.” The goal/outcome failed to include any measurable data criteria.4. Review of patient #5’s, “Plan of Care: Respiratory,” dated 12/18/24, reflected a goal/outcome of: “Patient will have optimal respiratory status within normal limits of disease”. The goal/outcome failed to include any measurable data criteria.5. Review of patient #8’s, “Plan of Care: Bowel Dysfunction,” dated 2/10/25, reflected a goal/outcome of: “Skin integrity will be maintained”. The goal/outcome failed to include any measurable data criteria.During an interview on 10/21/25 at 11:05 a.m., staff member A and D stated each patient goal/outcome should have a way to measure if the goal was being met.Review of the facility’s policy, Hospice Patient Plan of Care,” dated 10/17/23, did not reflect measurable goal/outcomes were required.”

“Based on interview and record review, the agency failed to develop, implement and evaluate performance improvement plans. Findings include: Review of the agency’s QAPI program reflected no performance improvement plans for the 2024-2025 year.During an interview on 10/21/25 at 10:00 a.m., staff member A and D stated there were no performance improvement plans for the hospice agency during the past 12 months. Staff member A stated that due to her limited hours, she was unable to commit time to the PIP requirements. Review of the agency’s policy, “Quality Assurance and Performance Improvement Plan,” dated 7/1/25, reflected:- “... The organization will conduct Performance Improvement (PI) Projects that are designed to take a systematic approach to revise and improve care or services in areas that are identified as needing attention. Team members will conduct PI projects that will lead to changes and guide corrective actions in our systems, which cross multiple departments. The PI projects will intend to improve care and service delivery, increase efficiencies, lead to improved staff, patient, and resident outcomes, and lead to greater staff, resident, and family satisfaction. An important aspect of our PI projects is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained. ...””

“Based on interview and record review the agency failed to have a program for the surveillance, identification, prevention, control, and investigation of infections. Findings include: During an interview on 10/21/25 at 11:23 a.m., staff members A and C stated the agency did not have a separate program for the surveillance, prevention, control, and investigation of the agency’s infections. Staff member C stated she reviewed any antibiotic use for all of the facilities and agencies combined, looking for antibiotic stewardship. Staff member A stated the agency did not track and investigate the infections independently. Staff member A and C stated they were not able to show any data separated from the other facility and agencies data. Staff member C stated investigations for the agency were not investigated due to patient’s in-home status.Review of the agency’s policy, “Hospice Infection Control & Surveillance Plan,” dated 12/4/23, reflected:a- “... The Hospice Infection Control Program incorporates the following in a continuing cycle: Surveillance, prevention and control of infections throughout the organization, Develop alternate techniques to address the real and potential exposures, Select and implement the best techniques to minimize adverse outcomes, Evaluate and monitor the results and revise techniques as needed. ...””