Big Sky Hospice

“Based on interview and record review, the agency failed to complete investigations into complaints made by patients for 3 (#1, 12, and 20) of 22 sampled patients. Findings include: Review of an agency Complaint Report, dated 7/15/25, showed patient #12 stated a CNA had not called to schedule an appointment and arrived unannounced. Patient #12 reported they did not receive a CNA visit the week the complaint was submitted. The complaint form was blank for the sections listed as interventions, resolution comments, prevention, and follow-up comments. Review of an agency Complaint Report, dated 5/28/25, showed patient #1 stated she felt neglected, her caregivers did not come to give baths, her briefs were not being changed, she waited five weeks for an appointment for glasses, and she felt that staff waited long enough to give her care so she would die first and they would not have to worry about it. The follow-up was with the case manager who stated patient #1 had dementia and forgets when someone made a visit to her. The interventions section and investigation into the full list of allegations was not documented.Review of an agency Complaint Report, dated 1/15/25, showed patient #20 stated she was often offered pork for meals, which she was allergic to, and foods she was unable to swallow due to dysphagia. Patient #20 reported the Administrator at the facility where she lives stated the facility was unable to accommodate her with an alternative meal. Patient #20 reported facility staff informed her that she must provide her own applesauce for medication administration. The intervention section completed by the nurse stated she attempted to address the dietary concerns with the facility administrator who became angry and raised her voice. The nurse documented she was unable to advocate for patient #20’s needs. There was no documentation noted for the sections of prevention, or follow-up by the supervisor.During an interview on 11/6/25 at 2:10 p.m., staff member A stated the complaints were submitted during the time of a previous DCS (Director of Clinical Services), who was responsible for investigating complaints. Staff member A stated she was not sure why the complaints were not fully investigated and addressed.Review of the agency’s policy, Complaint/Grievance Process, dated November 2022, reflected:-“... The supervisor will investigate the grievance within five (5) days after receipt of such grievance and will make every effort to resolve the grievance to the patient’s satisfaction. Response to the patient regarding the complaint will occur within ten (10) days of receipt. ...-“... 4. Complaints and any action taken will be documented on a complaint form.- 5. Corrective action will be specific and related to the complaint. ...””

“Based on interview and record review, the agency failed to individualize the plan of care for 2 (#s 8 and 9) of 22 sampled patients. Findings include: Review of patient #9’s Hospice Recertification Plan of Care Update, dated 9/8/25, did not reflect an individualized care plan for patient #9. The plan of care did not include any information regarding patient #9’s dysphagia or interventions, or patient #9’s needs for assistance with transfers and ambulation. Review of patient # 8’s Hospice Recertification Plan of Care Update, dated 10/14/25, did not reflect an individualized care plan for patient #8. The plan of care did not include any information regarding patient # 8’s protein calorie malnutrition, shingles pain, dyspnea with transfer and ambulation status, severe constipation or cognitive status. Review of the agency’s policy, The Plan of Care, dated November 2022, reflected:-“ A written individualized patient and family/caregiver plan of care will be established and maintained for everyone admitted to the hospice program. ...”During an interview on 11/6/25 at 2:10 p.m., staff member A stated she was aware the plan of care for patients was not individualized, but was not sure how to correct this issue in the agency’s software. Staff member A stated the individualization of the plan of care had been a long-standing concern and the system is a click setup, and individualization was not a possibility as far as she was aware. Staff member A stated there were often care concerns that were not in the drop-down windows and there was no place to type them into the plan of care.”

“Based on interview and record review, the agency failed to investigate patient infections for 3 (#’s 13, 21, and 22) of 22 sampled patients. Findings include: Review of an Infection Report, dated 9/13/25, reflected patient #21 had urinary infection with symptoms of burning urination and cloudy, foul urine. Antibiotic administered was sulfamethoxazole 800 mg tablet. No information was provided on the form to demonstrate any investigation into the infection cause or prevention of further infections. Review of an Infection Report, dated 7/15/25, reflected patient #13 had urinary infection with symptoms of confusion and cloudy, foul urine. Antibiotic administered was Bactrim DS 800 mg-160 mg tablet. No information was provided on the form to demonstrate any investigation into the infection cause or prevention of further infections. Review of an Infection Report, dated 7/8/25, reflected patient #22 had an infection listed as “other” with symptoms of pain. Antibiotic administered was Amoxicillin 875mg-Potassium Clavulanate 125 mg tablet. No information was provided on the form to demonstrate any investigation into the infection cause or prevention of further infections. Review of the agency policy, Infection Control Plan, dated November 2022, reflected: -“ 1. Establish the mechanism by which the organization will address surveillance, prevention, identification, control, and reporting of infections, utilizing current scientific methods and epidemiologic principles.”During an interview on 11/6/25 at 2:30 p.m., staff member A stated the agency did not have any form of investigation process for infections. Staff member A stated the infections and the antibiotic administered are entered into HomeCare-HomeBase for tracking and reported during QAPI, but not further investigated to determine infections were linked to staff, improper infection control processes during care provided by patient or staff, or other investigation processes.”

“Based on interview and record review, the agency failed to ensure volunteers used in direct patient care services or helping patients and families were evident in the patient’s plan of care for 2 (#’s 8 and 11) of 22 sampled patients. Findings include: Review of an agency provided document, “Patients receiving volunteer services”, no date, reflected patient #s 8 and 11 were currently receiving volunteer services. Review of patient # 8’s Hospice POC Report, printed 11/5/25, did not reflect volunteer services were being provided.Review of patient # 11’s Hospice POC Report, printed 11/5/25, did not reflect volunteer services were being provided.During an interview on 11/5/25 at 12:30 p.m., staff member F stated volunteers are not on the plan of care for patients and she was not aware of the need to put them on the plan of care. Review of the agency’s policy, Volunteer Services, dated November 2022, reflected:-“... The volunteer coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver in accordance with the plan of care. ...””