Every finding on record at Adoration Home Health Care Virginia LLC

Based on agency policy, clinical record review, observation, and staff interviews, the agency failed to include a complete medication list in the plan of care for 1 of 2 patients with a home visit conducted (patient #7).Findings included: --- A policy, The Plan of Care-North Carolina (updated 07/15/2022), received on 09/09/2025 at 2:19 PM from the Regional Compliance Director stated, “The written plan of care will contain, but will not be limited to, the following: … Drugs and treatments… Physician (or other licensed practitioner) orders.”Patient #7 was admitted on 08/26/2025 with a diagnosis of malignant neoplasm of the ascending colon (colon cancer). The plan of care for 08/26/2025-11/23/2025 included orders for skilled nurse visits 3 times a week for 1 week, 2 times a week for 12 weeks, and 5 PRN (as needed). During a home visit conducted on 09/09/2025 at 10:00 AM a medication review completed by RN #1 found that “Morphine Concentrate (narcotic pain medication) 100mg/5mL oral solution 0.25mL by mouth every hour as needed for pain or shortness of breath” and “Lorazepam (anxiety medication) 0.5mg tablet 1 tablet every 4 hours as needed for anxiety” were not included in the plan of care.During an interview on 09/09/2025 at 11:30 AM RN #1 stated that they normally add the medications to the plan of care as soon as they are ordered.During an interview conducted on 09/10/2025 at 8:19 AM the regional compliance director stated, “On intake we do a full accurate medication reconciliation… upon each visit we should be verifying all the medications in the home verifying the medication profile is accurate.”

Based on agency policy, observation, and staff interviews, the agency failed to perform hand hygiene before and after glove changes and after providing direct patient care for 1 of 2 patients with a home visit conducted. (patient #6)Findings included: --- A policy, Hand Hygiene (revised 05/2022) received from the Regional Compliance Director on 09/10/2025 at 8:29 AM stated, “Hand decontamination using an alcohol-based hand rub should be performed: … After contact with a patient’s intact skin…When moving from a contaminated body site to a clean body site during patient care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves…”Patient #6 was admitted on 04/16/2025 with a diagnosis of senile degeneration of the brain (decline in cognitive function). Patient #6 was a skilled nursing facility resident. The plan of care for 07/15/2025-10/12/2025 included orders for skilled nurse visits 1 time a week for 1 week, 2 times a week for 12 weeks, and 4 PRN (as needed). During a home visit conducted on 09/08/2025 at 1:15 PM registered nurse (RN) #3 failed to perform hand hygiene after assessing vital signs and donning gloves, failed to remove contaminated gloves after coming in contact with the patients sacrum (lower back between the hip bones) and handling the patients personal items, and failed to perform hand hygiene after completing wound care and removing contaminated gloves.During an interview conducted on 09/09/2025 at 4:02 PM RN #3 stated that normally hand sanitizers are used after removing gloves or providing patient care.An interview conducted on 09/10/2025 at 8:15 AM with the regional compliance director revealed that the expectation is that hand hygiene be performed before and after contact with a patient, patient personal items, and before and after glove changes.

Based on agency policy, clinical record review, and staff interviews, the agency documented home hospice aid (HHA) supervisory visits included patient/caregiver satisfaction with care prior to the patients receiving hospice aide (HA) visits for 4 of 11 patients receiving HA visits. (patients #2, 5, 11, & 13)Findings included: --- A policy, Clinical/Service Data Collection-North Carolina (updated 07/15/2022) received on 09/10/2025 at 9:31 AM from the regional compliance director stated, “Documentation in the clinical/service record will be maintained timely, detailed, accurate, and reflect the care or services provided.1. Patient #2 was admitted on 10/31/2024 with a diagnosis of malignant neoplasm of the brain (brain cancer). The plan of care for 10/31/2024-01/28/2025 included orders for skilled nurse visits 2 times a week for 13 weeks, 1 time a week for 1 week, with 4 PRN (as needed) and HHA visits 2 times a week for 12 weeks and 1 time a week for 1 week. Review of the clinical record revealed that on 11/05/2024 registered nurse (RN) #9 documented a HHA supervisory note stating, “Yes, patient/family satisfied with the care delivered.” Further review revealed that patient #2 had not received an HHA visit.RN #9 was not available for an interview.2. Patient #5 was admitted on 07/07/2025 with a diagnosis of chronic obstructive pulmonary disease (lung disease). The plan of care for 07/07/2025-10/04/2025 included orders for skilled nurse visits 2 times a week for 13 weeks with 5 PRN and HHA visits 1 time a week for 13 weeks. Review of the clinical record revealed that on 07/09/2025 RN #3 documented a HHA supervisory note stating, “Yes, patient/family satisfied with the care delivered.” Further review revealed that patient #5 received the first HHA visit on 07/10/2025.3. Patient # 11 was admitted on 08/13/2025 with a diagnosis of acute systolic (congestive) heart failure (heart not pumping blood as it should). The plan of care for 08/13/2025-11/10/2025 included orders for skilled nurse visits 2 times week for 12 weeks, 4 times a week for 1 week with 3 PRN and effective 08/17/2025 HHA visits 2 times a week for 12 weeks. Review of the clinical record revealed that on 08/14/2025 RN #3 documented a HHA supervisory note stating, “Yes, patient/family satisfied with the care delivered.” Further review revealed that patient #11 received the first HHA visit on 08/18/2025.4. Patient #13 was admitted on 07/25/2025 with a diagnosis of liver cell carcinoma (liver cancer). The plan of care for 07/25/2025-10/22/2025 included orders for skilled nurse visits 2 times a week for 13 weeks, 1 time a week for 1 week with 5 PRN and effective 07/27/2025 HHA visits 1 time a week for 13 weeks. Review of the clinical record revealed that on 07/26/2025 RN #10 documented a HHA supervisory note stating, “Yes, patient/family satisfied with the care delivered.” Further review revealed that patient #13 received the first HHA visits on 07/29/2025.RN #10 was not available for an interview.During an interview conducted on 09/09/2025 at 4:00 PM RN #3 stated, “There are always supervisory questions… I ask the family or patient if they are happy.”During an interview conducted on 09/10/2025 at 8:27 AM with regional compliance director stated, “My expectation is that the documentation represents the current situation, and supervisory visits are documented to what [services] has been delivered. “

Based on agency policy, clinical record review, and staff interviews, the agency failed to include wound assessments and treatments in the clinical record for 1 of 3 patients with wounds. (patient #11)Findings include: --- A policy, Wound Care (updated 01/01/2024) received on 09/10/2025 at 9:31 AM from the regional compliance director stated, “The initial wound care assessment will be completed at admission or when the wound is first identified… Wounds will be assessed at least weekly by a qualified agency staff member… The patient’s care plan will detail wound management procedures for hospice… Orders will be complete and include the location of the wound, specific supplies to be use, exact procedure to be followed…”Patient #11 was admitted on 08/13/2025 with a diagnosis of acute systolic (congestive) heart failure (inadequate blood flow to the heart). Patient #11 is a resident of a skilled nursing facility. The plan of care included orders for skilled nurse visits 2 times a week for 12 weeks, 4 times a week for 1 week with 3 PRN (as needed). Review of the clinical record revealed that on 08/25/2025 registered nurse (RN) #3 documented, “PT [patient] refused for this nurse to look at right foot 2ed [second] toe and right arm because the wound specialist just looked at both and treated both and put drsg’s [dressings] on both.” Further review revealed that there was no documentation of assessments or treatment orders for the wounds.During an interview conducted on 09/09/2025 at 4:09 PM RN #3 stated, “I believe it’s [wounds] a skin tear; I think the treatment is xeroform [dressing type] gauze. The facility nurse takes care of it.”During an interview conducted on 09/09/2025 at 4:12 PM the director of clinical operations stated the expectation is, “that we put in a wound care order, get the measurements and assessments, and document it.”

Corrected 11/01/22. -MHB

Corrected 11/01/22. -MHB

Corrected 11/01/22 -MHB

Corrected 11/01/22/ -MHB

Corrected 11/01/22. -MHB

Corrected 11/01/22. -MHB

Corrected 11/01/22. -MHB

Based on policy review, clinical record review, and staff interview, the agency failed to obtain consents for services from an authorized representative for 2 of 14 clinical records reviewed (Patients #2 and #8). Findings included: --- Policy 9-012.1, updated 01/25/21 and titled Informed Consent/Refusal of Treatment, was received from the agencys Regional Director of Clinical Operations on 09/22/22 at 3:47 PM. This policy revealed, ";...During the admission visit, the patient or authorized representative will sign the organizations written consent for care/service...The patient/representative will be provided with, and will sign, the Hospice Election Statement..." 1. Patient #2 was admitted to the agency on 08/22/22 with a principal hospice diagnosis of acute on chronic congestive heart failure (exacerbation of a chronic condition in which the heart fails to pump adequately). Plan of Care for certification period 08/22/22 to 11/19/22 revealed orders for skilled nursing 3 times per week for 1 week, 2 times per week for 10 weeks, 3 times per week for 1 week and 2 times per week for 1 week, medical social worker 1 time per month for 1 month, home health aide 2 times per week for 13 weeks, and chaplain 1 time per month for 1 month. On 08/22/22, Employee #7, registered nurse, conducted an admission visit and documented that Patient #2 was, ";...Patient was able to have some minimal meaningful communication and now mostly stares and most words are uninnteligible [sic]..." The agencys Consent for Treatment dated 08/22/22 included an advanced directives section which revealed, ";...My Surrogate Decision Maker/Power of Attorney for Healthcare is [Name of Patient #2s son]..." however, the signature of patient/authorized representative is signed by a person whose relationship to Patient #2 is identified as ";caregiver" with a reason that the patient did not sign the consent form documented as ";patient disoriented". There was no evidence in the clinical record that the person identified as ";caregiver" was an authorized representative for Patient #2 and there was no documentation in the clinical record that Patient #2s son had given permission for the ";caregiver" to sign consents on behalf of Patient #2. 2. Patient #8 was admitted to the agency on 08/06/22 with a principal hospice diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease that causes restricted airflow). Plan of care for certification period 08/06/22 to 11/3/22 revealed orders for skilled nursing 2 times per week for 1 week, 3 times per week for 1 week, and 2 times per week for 12 weeks, medical social worker 1 time per month for 1 month, and home health aide 2 times per week for 12 weeks and 1 time per week for 1 week, effective 08/07/22. On 08/06/22, Employee #6, registered nurse, conducted an admission visit and documented Patient #8 as ";A&OX3 (alert and oriented to person, place, and time)." The signature of Patient/Authorized Representative was signed by Patient #8s spouse and did not include a reason why the patient was unable to sign and there was no other documentation in the clinical record explaining why Patient #8 was unable to sign for himself. In an interview on 09/21/22 at approximately 4:45 PM, Employee #3, the Regional Director of Clinical Operations, confirmed that the election statement and consent for care should be signed by the patient, or his/her responsible party. Employee #3 also stated if the patient or responsible party is unable to sign for himself/herself, staff are to document the reason where indicated on the form and include details in their admission narrative.

Based on policy review, clinical record review, and staff interview, the agency failed to conduct bereavement assessments containing all relevant information for 5 of 14 (Patients #2, #3, #8, #13, #14) records reviewed. Findings include: --- 3. Patient #3 was admitted 08/10/22 with a diagnosis of malignant neoplasm (cancer) of the rectum. The Plan of Care from 08/10/22 to 11/07/222 included orders for skilled nurse (SN) 2 times a week for 13 weeks with 5 PRN (as needed) visits for change in condition, Medical social work (MSW) 1 time a month, Chaplain 1 time a month, and home health aide 2 times a week. The SN admission assessment of 08/10/22 included no documentation of a comprehensive bereavement assessment. The initial MSW assessment of 08/11/22 included no documentation of a bereavement assessment. The initial Chaplain assessment on 08/22/22 did not include documentation of a bereavement assessment. 4. Patient #13 was admitted 08/12/22 with a diagnosis of malignant neoplasm (cancer) of the right bronchus or lung, liver cell carcinoma (cancer), and malignant neoplasm of the right kidney. The Plan of Care for 08/12/22-11/09/22 included orders for skilled nurse (SN) 2 times a week or 1 week, 1 time a week for 13 weeks, and 5 PRN (as needed) visits for change in condition, medical social work (MSW) 1 time a month for 1 month and Chaplain 1 time a month for 1 month. The SN admission assessment of 08/12/22 did not include documentation of a comprehensive bereavement. The initial MSW assessment of 08/16/22 did not include documentation of a bereavement assessment. 5. Patient #14 was admitted 08/11/22 with a diagnosis of unspecified protein-calorie malnutrition, COPD, and unstageable pressure ulcer of the sacrum. The Plan of Care for 08/11/22-11/08/22 included orders for skilled nurse (SN) 2 times a week for 13 weeks, 1 time a week for 1 week, and 5 PRN (as needed) for change in condition, medical social work (MSW) 1 time a month for 1 month, home health aide 2 times a week for 12 weeks, and 1 time a week for 1 week, (effective 08/14/22) and Chaplain 1 time a month for 1 month. The SN admission assessment of 08/11/22 did not include documentation of a comprehensive bereavement. The initial MSW assessment of 08/12/22 did not include documentation of a bereavement assessment. The initial Chaplain assessment on 08/18/22 included no documentation of a bereavement assessment. Policy 1-021.1, revised 05/11/20 and titled Bereavement Assessment, was received from the agencys Regional Clinical Director on 09/22/22 at 3:47 PM. This policy revealed, ";...On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. At a minimum, it will include: A. Patient and family/caregiver loss issues B. Survivor needs C. Social spiritual, and cultural factors D. Services to be provided including individual counseling, support groups, and letters and cards E. Referrals to be made F. Grief risk factors and potential for pathological grief reactions...The bereavement counselor will review the bereavement risk assessment to determine potential needs of the survivors..." Policy 1-014.3, revised 05/11/20 and titled Comprehensive Assessment, was received from the agencys Regional Clinical Director on 09/22/22 at 3:47 PM. This policy revealed, ";The hospice will conduct and document in writing a patient-specific comprehensive assessment that identifies the patients need for hospice care and services, and the patients need for physical, psychosocial, emotional, and spiritual care. This assessment will include all areas of hospice care related to the palliation and management of the terminal illness and related conditions...During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information as relevant...Z. A bereavement assessment of the patients family and other individuals focusing on: 1. The nature of the relationship to the patient 2. Circumstances surrounding the illness/prognosis 3. Behaviors prior to and after the illness/prognosis 4. Survivor needs (social, spiritual and cultural) that may impact coping skills 5. Potential for pathologic grief reactions..." 1. Patient #2 was admitted to the agency on 08/22/22 with a principal hospice diagnosis of acute on chronic congestive heart failure (exacerbation of a chronic condition in which the heart fails to pump adequately). Plan of Care for certification period 08/22/22 to 11/19/22 revealed orders for skilled nursing 3 times per week for 1 week, 2 times per week for 10 weeks, 3 times per week for 1 week and 2 times per week for 1 week, medical social work 1 time per month for 1 month, home health aide 2 times per week for 13 weeks, and chaplain 1 time per month for 1 month. On 08/22/22, Employee #7, registered nurse, conducted a nursing start of care visit for Patient #2 and on 08/23/22, Employee #15, medical social worker, conducted a medical social work initial visit for Patient #2. The bereavement portion of these visit notes revealed ";yes" documented in response to ";Was the bereavement risk assessed", however, there was no evidence in the clinical record that a bereavement assessment containing all relevant information was conducted. 2. Patient #8 was admitted to the agency on 08/06/22 with a principal hospice diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease that causes restricted airflow). Plan of care for certification period 08/06/22 to 11/3/22 revealed orders for skilled nursing 2 times per week for 1 week, 3 times per week for 1 week, and 2 times per week for 12 weeks, medical social work 1 time per month for 1 month, and home health aide 2 times per week for 12 weeks and 1 time per week for 1 week, effective 08/07/22. On 08/06/22, Employee #6, registered nurse, conducted a nursing start of care visit for Patient #8 and on 08/08/22, Employee #15, medical social worker, conducted a medical social work initial visit for Patient #8. The bereavement portion of these visit notes revealed ";yes" documented in response to ";Was the bereavement risk assessed", however, there was no evidence in the clinical record that a bereavement assessment containing all relevant information was conducted. In an interview on 09/21/22 at approximately 4:45 PM, Employee #3, Regional Director of Clinical Operations, stated, ";Theyre [bereavement assessments] not in there [clinical record]..."

Based on agency policy, record review, and staff interviews the agency failed initiate proper precautions to prevent the transmission of infection for 1 of 14 patients (#9). Findings include: --- Agency Policy Infection Control Plan Policy No. 7-001.1 Revised 05/11/20 received 09/21/22 at approximately 11:10 A.M. from the Regional Compliance Director stated the agency will ";Comply with all applicable local, state, and federal regulations, including, but not limited to: ...CDC recommendations and guidelines." Patient #9 was admitted on 07/14/22 with a diagnosis of hypertensive chronic kidney disease, chronic kidney disease stage 5. The Plan of Care for 07/14/22-10/11/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 10 weeks, 1 time a week for 1 week and 5 PRN (as needed) visits for change of condition, Medical social worker 1 time a month for 1 month, 2 times a month for 2 months. 1 time a month for 1 month and 2 PRN (as needed) for psychosocial support, home health aide effective 07/31/22 2 times a week for 10 weeks and 1 time a week for 1 week, Chaplain 1 time a month for 1 month, 3 times a month for 1 month, 2 times a month for 1 month and 2 PRN visits for Spiritual Support. The skilled nursing assessment of 08/15/22, at 9:45 A.M., nurse #7 documented, ";Patient has conversational dyspnea (shortness of breath) and reports she has had no taste since yesterday. No other signs or symptoms of COVID present." An interview was conducted with the Regional Compliance Officer at approximately 10:50 A.M. on 09/20/22. The Regional Compliance Officer was unable to find any documentation that would signal to other employees to don full PPE (personal protective equipment). The symptoms were not noted in the infection log. The Regional Compliance Officer stated, ";It was documented as an observation without follow-up." The Regional Compliance Office stated, ";questions about COVID should be asked (by all visiting staff) prior to and at the start of each visit, if any answers are yes as a potential for COVID, the employee should initiate a Point Visit Alert, signifying the need for all employees to don full PPE." On 08/15/22, at 10:35 A.M., hospice aide #9, visited with no documentation of COVID symptoms or donning full PPE. An interview was conducted on 09/21/22 at approximately 2:15 P.M. with employee #9. Employee #9 states she was not informed of COVID symptoms and donned only a surgical face mask and gloves. An interview was conducted with the Regional Director of Clinical Operations on 09/22/22 at approximately 11:00 A.M. The Regional Director of Clinical Operations stated employees ";routinely wear a surgical face mask unless something is going on, in the presence of COVID symptoms (loss of taste) PPE includes N-95 (respiratory protective device effective in filtering airborne particles), face shield or goggles, gown and booties (shoe protectors)." An interview was conducted at 10:25 A.M. on 09/22/22 with nurse #7. Nurse #7 stated that she did recall if she reported the symptoms to anyone. Nurse #7 stated, ";I donned an N-95 and gloves for every visit." Nurse #7 stated she ";did not identify signs or symptoms as a risk for COVID because the patient doesnt leave the house."

Based on agency policy, clinical record review and staff interviews the hospice aides failed to report changes to the Plan of care for 5 of 9 patients receiving hospice aide services. (#3, 5, 7, 9 and 14) Findings include: --- Policy Hospice Aide Services, North Carolina, reviewed 05/11/20 stated, ";Hospice aid [sic] services shall be performed in accordance with a written assignment..." ";Hospice aides must report changes...to a registered nurse as the changes relate to the Plan of Care." An interview was conducted with hospice aide #10 on 09/22/22 at approximately 8:15 A.M. Hospice aide #10 stated that she ";communicates most of the times she notifies the nurse but is not documenting communication notes." An interview was conducted on 09/22/22 at approximately 8:35 A.M. with nurse #4. Nurse #4 stated that the hospice aide ";should let the RN know about task refusal." An interview was conducted with the Regional Director of Clinical Operations on 09/20/22 at approximately 12:30 P.M. The Regional Director of Clinical Operations was unable to locate documentation of registered nurse notification of task not completed during hospice aide visits and states the expectation is for the hospice aide to communicate task not completed to the nurse case manager. An interview was conducted with hospice aide #9 on 09/21/22 at approximately 2:15 P.M. Hospice aide #9 stated that she notifies the nurse case manager if a patient, ";repeatedly refuses" and ";Im not good about documenting, Im still learning." 1. 1. Patient #3 was admitted 08/10/22 with a diagnosis of malignant neoplasm (cancer) of the rectum. The Plan of Care from 08/10/22 to 11/07/222 included orders for skilled nurse (SN) 2 times a week for 13 weeks with 5 PRN (as needed) visits for change in condition, and home health aide 2 times a week. The hospice aides documented task related to activities of daily living as incomplete during visits on 08/15/22, 08/18/22, 09/02/22, 09/06/22 and 09/09/22. There was no evidence the hospice aide communicated to the RN the patient refused care. 2. 2. Patient #5 was admitted 06/11/22 with a diagnosis of hypertensive heart disease with heart failure and stage 5 chronic kidney/ESRD (end stage renal disease). The Plan of Care for 06/11/22 -09/09/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 12 weeks, and home health aide 2 times a week. The hospice aides documented task related to activities of daily living as incomplete during visits on 08/02/22, 08/04/22, 08/12/22, 08/22/22, 09/13/22, and 09/15/22. There was no evidence the hospice aide communicated to the RN the patient refused care. 3. 3. Patient #7 was admitted 08/19/22 with a diagnosis of malignant neoplasm (cancer) of the bladder wall. The Plan of Care from 08/19/22-11/16/22 included orders for skilled nurse 2 times a week for 1 week, 1 time a week for 13 weeks and 5 PRN (as needed) for change in condition, home health aide 1 time a week for 13 weeks (effective 08/21/22). The hospice aides documented task related to activities of daily living as incomplete during visits on 08/25/22, 09/02/22 and 09/15/22. There was no evidence the hospice aide communicated to the RN the patient refused care. 4. 4. Patient #9 was admitted on 07/14/22 with a diagnosis of hypertensive chronic kidney disease, chronic kidney disease stage 5. The Plan of Care for 07/14/22-10/11/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 10 weeks, 1 time a week for 1 week and 5 PRN (as needed) visits for change of condition, home health aide effective 07/31/22 2 times a week for 10 weeks and 1 time a week for 1 week. The hospice aides documented task related to activities of daily living as incomplete during visits on 07/18/22, 07/22/22, 08/01/22, 08/05/22, 08/12/22, 08/15/22, 08/26/22, 09/08/22, and 09/13/22. There was no evidence the hospice aide communicated to the RN the patient refused care. 5. 5. Patient #14 admitted 08/11/22 with a diagnosis of protein-calorie malnutrition. The Plan of Care from 08/11/22-11/02/22 included orders for skilled nurse 2 time a week for 13 weeks, 1 time a week for 1 week and 5 PRN (as needed) visit for change in condition, and home health aide (HHA) 2 times a week for 12 weeks and 1 time a week for 1 week. The hospice aides documented task related to activities of daily living as incomplete during visits on 08/15/22, 08/18/22, 08/22/22, 08/29/22, 08/31/22, 09/06/22, 09/07/22, 09/09/22, 09/12/22, and 09/16/22. There was no evidence the hospice aide communicated to the RN the patient refused care.

Based on policy review, admission packet review, physician interview, and staff interview, the agency produced, stored in an unsecure location, and executed blank physicians DNR (Do Not Resuscitate) orders that had been pre-signed by the agencys Medical Director. Findings include: --- Cross refer to 418.102(d), Tag 669 Medical Director responsibility.

Based on policy review, agency admission packet review, and staff interview, the agency produced, stored and utilized blank physicians DNR (Do Not Resuscitate) orders that had been pre-signed by a physician. Immediate jeopardy was identified beginning 09/19/22 and was abated on 09/22/22 with an acceptable allegation of compliance. Findings include: --- Policy 9-008.1 titled DO NOT RESUSCITATE/DO NOT INTUBATE ORDERS was received from Employee #1, the Regional Director of Compliance, on 09/20/22 at 11:25 AM. This policy revealed, ";...A written Do Not Resuscitate (DNR) order, signed by the patients physician (or other authorized independent practitioner), must be on file in the patients clinical record and admission folder in the patients home...1. A DNR/DNI (Do Not Intubate) decision will be made by the attending physician in consultation with the patient or other legally responsible person when, in judgment of the physician, the patient suffers from an incurable medical condition, death is reasonably imminent in all medical probability, and a life threatening condition exists in which resuscitation would not be expected to render substantial improvement in the ultimate outcome. 2. The order will be written only by the attending physician (or other authorized independent practitioner)..." On 09/19/22, an onsite, recertification survey was initiated. The agency was asked to provide a copy of their admission packet to verify the presence of the state complaint information and patient rights. Upon opening the admission packet, there was an NC Department of Health and Human Services Do Not Resuscitate Order inside of the packet. The signature line of the attending physician /physician assistant/nurse practitioner was completed with what appears to be the initials of the agencys Medical Director. The last name is illegible. The printed name of the attending physician was printed ";[Medical Directors Name]" and the address and office telephone number lines were also completed. The effective date, expiration date and patients full name lines were blank. In an interview on 09/22/22 at approximately 8:35 AM, Employee #4, a registered nurse stated, ";We have some blank DNRs (Do Not Resuscitate orders) that are signed by the doctor. If we know that the patient does not already have one [a DNR order] established in their possession. We complete it and it's considered signed by the doctor already...typically, after we do all of our charting, we send the doctor a note of some sort including all of the critical information...Once we let them [the physician] know they [the patient] have been admitted, we send a communication [to the physician]." In an interview on 09/22/22 at approximately 8:40 AM, Employee #3, Regional Director of Clinical Operations, stated, ";...the expectation would be that they [the agency] would not use any pre-signed orders..." In an interview on 09/22/22 at approximately 8:40 AM, Employee #2, the Office Manager, stated that the agency places the blank DNR orders with a completed physicians signature in each of the agencys admission packets. The admission packets with the blank DNR orders with a completed physicians signature were being kept in an unlocked, common area of the agency outside of the administrative employees offices. Employee #2 also stated that she had a ";stack" of additional blank DNR orders with a completed physicians signature in a locked drawer in her office. In a telephone interview on 09/22/22 at approximately 12:10 PM, the agencys Medical Director stated, ";When people are admitted, the nurse goes over the advance care planning on the admission and they [the nurse] will call me, put their [the patient] names on a DNR order that I have already signed, like a verbal order...because a lot of times something can happen right after the admission and there is no time for me to go to the office to sign a verbal order...I do [sign] maybe a couple every few weeks..." Allegation of Compliance 1. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: On 09/19/22, an onsite, recertification survey was initiated. The agency was asked to provide a copy of their admission packet to verify the presence of the state complaint information and patient rights. Upon opening the admission packet, there was an NC Department of Health and Human Services Do Not Resuscitate Order inside of the packet. The signature line of the attending physician /physician assistant/nurse practitioner was completed with what appears to be the initials of the agencys Medical Director. The last name is illegible. The printed name of the attending physician was printed ";[Medical Directors Name]" and the address and office telephone number lines were also completed. The effective date, expiration date and patients full name lines were blank. In an interview on 09/22/22 at approximately 8:35 AM, Employee #4, a registered nurse stated, ";We have some blank DNRs (Do Not Resuscitate orders) that are signed by the doctor. If we know that the patient does not already have one (a DNR order) established in their possession. We complete it and it's considered signed by the doctor already...typically, after we do all of our charting, we send the doctor a note of some sort including all of the critical information...Once we let them [the physician] know they [the patient] have been admitted, we send a communication [to the physician]." In a telephone interview on 09/22/22 at approximately 12:10 PM, the agencys Medical Director stated, ";When people are admitted, the nurse goes over the advance care planning on the admission and they [the nurse] will call me, put their [the patient] names on a DNR order that I have already signed, like a verbal order." On 9/22/22 at approximately 8:40 AM, Employee #2, the Office Manager, confirmed that the agency places the blank DNR orders with a completed physicians signature in each of the agencys admission packets. The admission packets with the blank DNR orders with a completed physicians signature were being kept in an unlocked, common area of the agency outside of the administrative employees offices. Employee #2 also stated that she had a ";stack" of additional blank DNR orders with a completed physicians signature in a locked drawer in her office. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: a. Immediately, all copies of signed DNR orders without a patients name that were in the agencys office were destroyed. b. Immediately, all staff contacted to ensure there are no signed DNRs [without a patients name] in their vehicles or other locations. If they have signed DNRs, they are to bring to the office by end of day to be destroyed. Immediately, education provided to nurses, social work and Medical Director regarding pre-signed DNRs and that they are to no longer be used for any reason. Education included: DNR procedure-once a patient or POA makes the decision to become a DNR, staff is to call the Medical Director, enter a verbal order into the chart, then obtain a hard copy to be signed by the doctor and returned to the patients home. This will be done for every patient requesting DNR status without exception. c. On 09/22/22 at 3:40 PM, the agencys Medical Director confirmed that she would immediately stop signing blank DNR orders for the agency and would not produce any blank DNR orders in the future. On 09/22/22 at 4:00 PM, the agencys registered nurses, medical social worker, and chaplain confirmed that they had destroyed any blank, signed DNR forms in their possession and would not use any signed, blank DNR forms in the future. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements: a. A weekly audit will now be conducted within the office and with staff to ensure no pre-signed DNRs are used or are available to be used. b. Weekly check-ins with the Medical Director to ensure no DNRs are being signed without a prior verbal order. c. Once there is 100% compliance for 1 month, then monthly audits will start to ensure there are no deficiencies. Audit results will be reported to QAPI team. 4. The title of the person responsible for implementing the acceptable plan of correction: Director of Clinical Operations/Regional Director of Clinical Operations

Based on agency policy, record review, and staff interviews the agency failed to accurately document patient clinical information for 3 of 14 patients receiving skilled nursing. (Patients #3, #5 and #9). Findings include: --- Procedure, Wolters Klewer_Lippincott Nursing Procedures, Indwelling Catheter Insertion received from the Regional Compliance Director at 9:21 A.M. on 09/21/22 stated ";Record...size and type of catheter used, and the amount of sterile water used to inflate the balloon." 1. Patient #3 was admitted 08/10/22 with a diagnosis of malignant neoplasm (cancer) of the rectum. The Plan of Care from 08/10/22 to 11/07/222 included orders for skilled nursing (SN) 2 times a week for 13 weeks with 5 PRN (as needed) visits for change in condition The SN visit dated 09/14/22 Nurse #4 documented that a 14F catheter was inserted and included an interim order for an indwelling urinary catheter. The order documented by nurse #4 failed to include the size of the catheter or balloon. An interview was conducted with nurse #4 on 09/22/22 at approximately 8:35 A.M. Nurse #4 stated, ";I didnt think about the catheter size when I was adding the order, I put 14F in the assessment because I assume thats whats in the kit." The SN evaluation dated 09/17/22 completed by nurse #15 stated that the catheter size was 16F. Nurse #15 was not available for an interview. On 09/20/22 an interview was conducted with the Regional Compliance Director at approximately 2:00 P.M. The Regional Compliance Director stated that it is the agencys policy for all information in the clinical record to be accurate. An interview was conducted with Regional Director of Clinical Operations on 09/20/22 at approximately 2:20 P.M. The Regional Director of Clinical Operations stated that the order for the indwelling urinary catheter should include the catheter size and the amount of balloon inflation. 2. Patient #5 was admitted 06/11/22 with a diagnosis of hypertensive heart disease with heart failure and stage 5 chronic kidney/ESRD (end stage renal disease). The Plan of Care for 06/11/22 -09/09/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 12 weeks. The nursing evaluation on 07/18/22 included documentation of a new wound on the back of the right calf. The narrative note stated, ";No open skin with undermining." Dark necrotic (death of body tissue) area noted." The wound care worksheet stated, ";pressure spot that has undermining (significant erosion underneath an outwardly visible wound)." On 07/25/22 Nurse #6 documented the wound to be a stage 1 (reddened area of intact skin that did not blanche when touched.) On 07/27/22 nurse #4 documented that the wound was ";scabbed over." The wound documentation was inconsistent with wound guidance provided by the National Pressure Injury Advisory Panel. Nurse #6 was unavailable for an interview. An interview was conducted with Regional Director of Clinical Operations on 09/21/22 at approximately 12:15 P.M. Regional Director of Clinical Operations agreed the documentation of this wound was inconsistent. 3. Patient #9 admitted on 07/14/22 with a diagnosis of hypertensive chronic kidney disease with chronic kidney disease stage 5. The Plan of Care from 07/14/22 to 10/11/22 included orders for skilled nursing 1 time a week for 1 week, 2 times a week for 10 weeks, 1 time a week for 1 week and 5 PRN (as needed) visits for change of condition. The medication profile included an order for Acetaminophen Rectal Suppository rectally daily for constipation. An interview was conducted on 09/20/22 with the Regional Compliance Director and Regional Director of Clinical Operations at approximately 2:45 P.M. The Regional Compliance Director and Regional Director of Clinical Operations stated that acetaminophen is not used to treat constipation and the expectation is for all medication reasons to be documented accurately.