SSM Health at Home Hospice

“Observed in Tracer Visit. In 1 out of 6 hospice home visits, hospice did not follow accepted standards of practice to prevent transmission of infections. Example: In HSRRHV #4, the patient was on contact precautions for MDRO, ESBL, and GNR. However, transmission-based precautions intended to prevent exposure to these known pathogens were not followed. This was evidenced by the aide’s failure to wear gloves and a gown while changing the patient’s bed linens during the visit. During the interview, the aide acknowledged not adhering to the contact-precaution requirements posted on the facility’s room signage for tasks such as dressing, transferring, and changing bed linens. This was subsequently confirmed by the Clinical Supervisor.”

“Observed in Tracer Visit. In 18 out of 18 applicable records, the written patient care instructions for the hospice aide prepared by the registered nurse did not include identified safety precautions. Examples: In HSRRHV#1, HSRRHV#2, HSRRHV#4, HSRRHV#5, HSRRHV#6, HSRRNHV#7, HSRRNHV#8, HSRRNHV#9, HSRRNHV# 11, HSRRNHV#12, HSRRNHV#13, HSRRNHV#15, HSRRNHV17, HSRRNHV18, HSNHV19, HSNHV20, HSNHV21, HSNHV#22 fall precautions were not included in the aide care plan. In HSRRRHV#4, contact precautions that aligned with the SNF’s posted instructions were not included in the aide’s care plan. In HSRRHV#5, safety precautions related to aspiration risk were not included in the aide’s care plan. This was confirmed by the Hospice Supervisor.”

“Observed in Document Review. The organization was unable to provide documented evidence of annual inspection and testing of fire door assemblies for 2024 and 2025. This was confirmed by the Plant Operations Supervisor. Observed in Building Tour. In 1 of 6 above ceiling checks, observed in the corridor of the front of the North Family Room entrance, ductwork was resting on top of the fire sprinkler pipe. The was confirmed by the Project Manager. This finding was observed during survey activity, but corrected onsite prior to the surveyor’s departure. The corrective action taken needs to be included in the organization’s Evidence of Standards Compliance submission.”

“Based on record review and interview the agency staff failed to ensure that testing of the Emergency Preparedness Plan was completed annually (one full-scale community-based exercise every 2 years and an additional exercise every 2 years opposite the year the full-scale was conducted) in 1 of 1 Emergency Plan reviewed. Review of the agency’s Emergency Preparedness Plan revealed the last tabletop exercise was conducted on 3/2/2020. There was no other plan testing after that date. An interview was conducted with Administrator A on 3/27/2004 at 9:45 a.m. When asked if there was any other testing exercise completed after 3/2/2020, Administrator A replied, “That’s the last one.””

“Based on observation, record review and interview the agency failed to ensure that each patients drug profile was reviewed no less than every 15 days and accurate in 2 of 2 observation visits conducted out of a total of 4 observation visits (Patients #2 and #10) and 9 of 19 (Patients #2, #3, #8, #9 #10, #11, #14, #16, & #18) patient medical records reviewed. Findings include: Review of hospice agency policy tilted, “Medication Management and Reconciliation” last reviewed on 02/2024 revealed, “I. Medication reconciliation is the process of comparing a patient’s medication list to all the medications the patient is taking in order to avoid medication errors such as omissions, duplications, dosing errors or drug interactions. Process: With start of care (SOC), resumption of care (ROS), and recertification (RECT), reconcile all medications in the home...” Review of Patient #2’s medical record start of care on 03/07/2024, skilled nursing visits ordered 2 times/week revealed the last medication reconciliations were completed once a week on 03/11/2024 and 03/18/2024. Review of Patient #10’s medical record start of care on 12/02/2023, skilled nursing visits ordered 2 times/week revealed medication reconciliation was completed only once on 03/15/2024. Review of Patient #11’s medical record start of care on 08/12/2023, skilled nursing visits ordered 2 times/week revealed the last medication reconciliations were completed once a week on 02/02/2024 and 01/23/2024. Review of Patient #16’s medical record start of care on 12/15/2023, skilled nursing visits ordered 2 times/week revealed medication reconciliations were completed on 01/06/2024 and 01/07/2024. Review of Patient #18’s medical record start of care on 02/09/2024, skilled nursing visits ordered 2 times/week revealed no documentation of medication reconciliations being completed. An observation visit was conducted at Patient #2s place of residence on 3/25/2024 at 1:45 PM. Upon surveyor review of the medication list at the facility, the facility medication list did not have a medication that was on the hospice medication list: “;Bisacodyl (Dulcolax) 10 Milligram (mg) suppository. Insert 10 mg into rectum once daily as needed for constipation (start date of 03/07/2024).” An observation visit was conducted at Patient #10s place of residence on 3/26/2024 at 9:00 AM. Upon surveyor review of the medication list at the facility, the facility had 1 medication discrepancy: “;Donepezil HCL tablet 5 mg. Give 1 tablet by mouth at bedtime (start date of 11/01/2022).” Review of hospice medication list revealed, “;Donepezil (Aricept) 10 mg tablet. Take 10 mg by mouth at bedtime (start date of 12/02/2023).” During an interview with Alternate Administrator B on 03/26/2024 at 1:15 PM, Alternate Administrator B stated that the expectation of staff is to reconcile medications at each visit. During an interview with Alternate Administrator B on 03/27/2024 at 12:15 PM, Alternate Administrator B confirmed the above findings, s/he stated that the hospice RN called s/he after Patient 10s visit to report the discrepancy. Findings include: Review of Patient #3’s medical record start of care on 02/02/2024, skilled nursing visits ordered 2 times/week revealed medication reconciliation was completed only once on 02/15/2024. Review of Patient #9’s medical record start of care on 01/26/2024, skilled nursing visits ordered 2 times/week revealed no medication reconciliation since start of care. Review of Patient #8’s medical record revealed a start of care date of 1/17/2024. Skilled nursing was ordered at 1 time per week. Further review revealed a medication reconciliation was conducted on admission. There was no documentation of any other medication reconciliations completed. Review of Patient #14’s medical record revealed a start of care date of 11/7/2023. Skilled nursing was ordered at 2 times per week. Further review revealed a medication reconciliation performed on admission and then not until 2/9/2024.”

“Based on record review and interview agency staff failed to ensure a bereavement assessment was completed for each patient on admission in 6 out of 19 patient records reviewed (Patients #8, #10, #11, #12, #16 and #18). Review of hospice agency policy titled, “Bereavement Services Hospice” last reviewed 01/25/2024 revealed, “PROCESS: 2. A bereaved risk assessment shall be completed at the time the psychosocial assessment is completed... b. Bereavement care begins on admission...” Review of Patient #10’s medical record revealed #10 was admitted to hospice on 12/02/2023 and the initial bereavement assessment was conducted on 12/26/2023, not on Medical Social Worker’s (MSW’s) initial assessment. Review of Patient #11’s medical record revealed #11 was admitted to hospice on 08/12/2023 and the initial bereavement assessment was conducted on 02/28/2024, not on Medical Social Worker’s (MSW’s) initial assessment. Review of Patient #12’s medical record revealed #12 was admitted to hospice on 01/31/2024 and that no initial bereavement assessment was conducted. Review of Patient #16’s medical record revealed #16 was admitted to hospice on 12/15/2023 and that no initial bereavement assessment was conducted. Review of Patient #18’s medical record revealed #18 was admitted to hospice on 02/09/2024 and that no initial bereavement assessment was conducted. In an interview with Alternate Administrator B on 03/26/2024 at 3:00 PM, Alternate Administrator B agreed with the above findings and stated, “It’s an issue that has been identified and we (agency) are trying to complete the assessment’s.” Review of Patient #8’s medical record revealed Patient #8 was admitted to hospice on 1/17/2024. No bereavement assessment had been completed as of survey date.”

“Based on record review and interview agency staff failed to ensure there was a method of identifying infectious and communicable disease problems in patients and employees in 1 of 1 Infection Control program reviewed. Findings include: Review of policy “Infection Control, Prevention, and Surveillance Program in Home Health” last reviewed 10/2022 revealed in part, “V. Surveillance Program. B. Focused Surveillance Activities. 1. Home Health and Hospice participate in the SSM Health at Home Infection Prevention program with surveillance occurring via information in the electronic health record, specifically medication profiles and visit data/information. This provides monthly infection rates and benchmarking data across SSM Health at Home branches/offices as well as SSM Health at Home overall infection rates.” There was nothing in the policy regarding the surveillance of employee illness and infections. Review of surveillance reports revealed the agency conducted surveillance of patient urinary tract infection rates and urinary catheter infection rates only. An interview was conducted with Nursing Supervisor C on 3/26/2024 at 9:45 a.m. to review above findings. When asked if any other patient surveillance activities were conducted, Nursing Supervisor C stated that they are only monitoring urinary tract infections and urinary catheter rates. When asked if there were any surveillance activities for employee illness, Nursing Supervisor C replied “We complete annual TB (tuberculosis) testing.””

“Based on record review and interview, agency staff failed to identify which provider was responsible for which functions on the plan of care for patients residing in facilities in 8 of 8 medical records reviewed for patients in facilities out of a total of 19 medical records reviewed (Patients #2, #4, #5, #6, #9, #10, #13 and #14). Review of Patient #2s medical record revealed Patient #2 was admitted to hospice service on 03/07/2024 and resided in a facility. The hospice Plan of Care dated 03/20/2024 – 04/02/2024 did not indicate which provider was responsible for performing which functions. Review of Patient #10s medical record revealed Patient #10 was admitted to hospice service on 12/02/2023 and resided in a facility. The hospice Plan of Care dated 03/21/2024 – 04/03/2024 did not indicate which provider was responsible for performing which functions. Findings include: Review of Patient #9s medical record revealed Patient #9 was admitted to hospice service on 01/26/2024 with a diagnosis of Mild Protein Calorie Malnutrition and Alzheimers Disease and resided in a facility. The hospice Plan of Care dated 01/26/2024-04/24/2024 did not indicate which provider was responsible for performing which functions. Findings Include: Review of Patient #4s medical record revealed Patient #4 was admitted to hospice service on 01/09/2024 with a diagnosis of COPD (chronic obstructive pulmonary disease) and resided in a facility. The hospice Plan of Care dated 01/09/2024 – 04/07/2024 did not indicate which provider was responsible for performing which functions. Review of Patient #13s medical record revealed Patient #13 was admitted to hospice service on 03/07/2024 with a diagnosis of Hepatic Encephalopathy Tumor of Ileum and resided in a facility. The hospice Plan of Care dated 03/20/2024 - 04/02/2024 did not indicate which provider was responsible for performing which functions. Interview with Supervisor C on 03/26/2024 at time of record review 1:00 PM - 3:30 PM. Supervisor C was asked if the plan of care delineated services on the plan of care for each discipline other than the area of Facility Collaboration Intervention. Supervisor C stated “No.” Findings include: Review of Policy “System SSM Health at Home-Hospice-Assessment, Care Planning, and Coordination of Services” last reviewed date of 1/30/2024 revealed in part, “Standard: Plan of Care. The Hospice will ensure that each patient and the primary caregiver receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care... Review of Patient #5’s medical record revealed Patient #5 was admitted to hospice on 2/17/2024 with a primary diagnosis of dementia and resided in a facility. The hospice Plan of Care dated 3/21/2024 - 4/3/2024 did not indicate which provider was responsible for performing which functions. Review of Patient #6’s medical record revealed Patient #6 was admitted to hospice on 1/18/2024 with a primary diagnosis of hypertensive heart disease with congestive heart failure and resided in a facility. The hospice Plan of Care dated 3/21/2024 - 4/3/2024 did not indicate which provider was responsible for performing which functions. Review of Patient #14’s medical record revealed Patient #14 was admitted to hospice on 11/7/2023 with a primary diagnosis of heart failure and resided in a facility. The hospice Plan of Care dated 3/30/2024 - 4/2/2024 did not indicate which provider was responsible for performing which functions.”

“Based on observation, record review and interview the agency failed to provide facilities with the patient’s most recent plan of care (POC) in 2 of 2 (#2 & #10) patient observations out of a total of 4 observation visits. Findings include: An observation visit was conducted at Patient #2s place of residence on 3/25/2024 at 1:45 PM with hospice Aide I. Review of hospice agency communications binder located at facility revealed no evidence of Patient #2’s POC on file. An observation visit was conducted at Patient #10s place of residence on 3/26/2024 at 9:00 AM with hospice Registered Nurse K (RN). Review of hospice agency communications binder located at facility revealed no evidence of Patient #10’s POC on file. Hospice RN asked facility staff for a copy of #10’s POC, the copy provided was dated 03/07/2024. The most recent POC was dated 03/21/2024. During an interview with hospice Aide I on 03/25/2024 at 2:15 PM, when asked if the POC was available to facility staff, s/he stated that the POC is available his/her phone and was unsure about facility staff. During an interview with facility Nurse Manager E on 03/25/2024 at 2:08 PM, when asked to view #2’s POC, s/he stated, “We might not of gotten it yet.” During an interview with hospice RN K on 03/26/2024 at 10:15 AM, hospice RN K stated that the “POC’s are faxed to facilities after updates/changes by hospice office support staff.” During an interview with Patient 10’s residence facility staff RN J, s/he wasn’t sure where Patient POC’s were kept at facility and stated that communication related to Patient’s is done verbally.”