Every finding on record at Agape Care North Carolina LLC

Based on agency policy, clinical record review, and staff interviews, the agency failed to inform the primary caregiver of changes in the Plan of Care prior to making changes for 1 of 3 patients [#1]. The findings included: --- The policy, Bill of Rights [no date], was provided by RN # 3 on 8/11/25 at 4:38 pm. The policy stated, “...The Bill of Rights statement defines the right of the patient to...Be advised in advance of the right to participate in planning the care or services and in planning changes in the care and services...Be involved in developing his or her Hospice plan of care...”The policy, Patient Notification of Changes in Care [no date], was provided by RN # 3 on 8/11/25 at 2:20 pm. The policy stated, “...Whenever the plan of care is changed including services, frequencies, treatments, etc., the patient will be notified at the time of the visit...”Patient # 1 had an admission date of 5/12/25 to __________ [name of inpatient unit] for a 5-day respite stay [provides temporary relief for caregivers of individuals with disabilities or illnesses, allowing them to take a break from their caregiving duties]. The terminal diagnosis listed was neurocognitive disorder with lewy bodies [a progressive brain disorder that affects thinking, movement, behavior, and sleep]. The patient was admitted to _____ [inpatient unit] after an inpatient hospice house contract was signed. The patient originally received home hospice services from ______ [name of agency] in South Carolina. Review of the clinical record revealed the patient was originally admitted to ______ [name of in-home hospice agency in South Carolina] on 3/13/25. Review of the clinical record from ____ [name of home hospice agency in SC] dated 3/16/25 revealed the following documentation, “...wife called triage...pt [patient] is restless attempting to get out of the house, moving furniture around...order received for seriquel [sic] daily...” Review of the Plan of Care revealed Seroquel 25 mg every pm was ordered on 3/16/25. On 3/17/25 the Seroquel was discontinued and the MSW [medical social worker] from ______ [name of home hospice agency in SC] documented the following information, “_______ [name of caregiver] states patient was given Seroquel at one point but he “didn’t do go on it...” Review of the clinical record [in-patient unit] revealed the patient arrived to ______ [name of inpatient unit] by transportation [no family accompanied the patient] on 5/12/25. Review of the Visit Note Report dated 5/12/25 completed by RN # 5 revealed the patient was “awake and alert”. Further review of the clinical record revealed the patient was started on Seroquel [antipsychotic] three times per day by NP # 12. There was no evidence the caregiver was notified prior to beginning the Seroquel at the time of admission.  On 5/13/25 at 5:05 pm, RN # 5 documented the patient was “alert, disoriented and confused...appears to be experiencing symptoms of agitation/restlessness -hallucinations...pt under respite LOC [level of care...is very confused, and mostly pleasant...”  RN # 5 documented the patient received Seroquel [antipsychotic] 25 mg and Haldol [antipsychotic] 5 mg during her shift. On 5/14/25 at 4:50 pm, RN # 6 documented, “Pt has been sleeping most of the day except when pt care is being performed, then he yells and get agitated.” On 5/14/25 at 6:40 am, RN # 7 documented, “Orders received this shift: Zyprexa [antipsychotic] 10 mg IM [intramuscular] now dose giver due to extreme restlessness, agitation and hallucinations. Haldol 5 mg x 1 ineffective...has been very disoriented x 3 tis shift. Unsteady. Very restless...patient hostile and resistive to inc [sic] care, kicking at staff and attempting to hit...” There is no evidence that the wife was notified prior to the patient receiving Zyprexa or Haldol. During an interview with RN # 3 [she had spoken with RN # 9 via phone] on 8/11/25 at approximately 3:45 pm RN # 3 stated that RN # 9 had advised her that she had discussed medication changes with the wife and the wife given consent for the medication administration. RN # 3 confirmed there was no evidence in the medical record to confirm the wife was notified. During an interview with RN # 3 on 8/11/25 at 4 pm RN # 3 advised she had spoken with NP # 12 via phone. NP # 12 advised the patient brough the Seroquel from home and at the time of admission she had ordered the Seroquel 25 mg. The NP also advised the NP advised she had called the wife on 5/15/25 [admission date was 5/12/25 and patient received first dose of Seroquel on 5/13/25] and the wife was in agreement with the medications. RN # 3 confirmed there was no evidence in the medical record the NP had spoken with the wife. On 5/15/25 at 6:27 am RN # 9 documented, “Olanzapine [antipsychotic] 10 mg IM x 1 dose give for severe agitation...pt agitated at start of shift. Attempting to spit and hit this nurse. New orders received from NP [nurse practitioner]. Pt will have Seroquel increased to 50 mg at QHS [bedtime]...Pt will be assessed by NP during rounds on 5/15/25...” There was no evidence that the wife was consulted regarding the change in medications. During an interview with RN # 3 on 8/11/25 at 3:30 pm, RN # 3 stated the “patient came in with the Seroquel, so we assumed he was taking it. Since the wife was not with him, we asked that she send all the medications he was taking at home.” RN # 3 confirmed the wife was not contacted before starting the Seroquel. “We attempted to call her when he arrived, but there was no answer.” RN # 3 confirmed the agency had the ability to look back at the patient’s medical record from the in-home hospice agency in SC.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure all medications including flush medications were documented on the medication profile. Clinical Record 20: The patient elected hospice care and was admitted to the hospice IPU (the in-patient unit) on 01/15/2024. The initial comprehensive assessment documented that a peripheral IV was placed in the patient's left wrist and flushed. A review of the clinical record revealed the medication profile did not include documentation of the solution or medication used for the flush. There was no evidence that the flush was reviewed with the patient's current medication regimen. During an interview with the Director of the in-patient unit and the Director of Accreditation on 01/17/2024, they stated the peripheral was going to be removed but that the medication profile did not include the flush.

It is required that each patient’s individualized written plan of care: identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 6 of 23 (26%) clinical records reviewed, the agency did not ensure the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The initial comprehensive assessment was completed on 12/13/2022 for a patient with COPD (core pulmonary disease) and secondary CHF (congestive heart failure). During the nursing assessment visit on 12/23/2022, the patient was observed to have burns on his face and lips, and orders were received for Silvadene cream. The patient assessment was documented on 12/29/2022 for treatment of potential infection with the burns that included Bactrim (antibiotic) and Zofran for nausea. The updated plan of care did not document any intervention or goals for nausea or infection. During a comprehensive nursing assessment on 01/15/2023, the patient complained of a great deal of difficulty urinating, and Flomax was started. Still, no individualized interventions and goals were documented on updated plans for urinary difficulty. On the nursing comprehensive assessment documented on 03/17/2023, the patient had increased difficulty with constipation, and orders were received to increase Senna and add Dulcolax for constipation. Still, the plans were not updated with interventions and goals for constipation. Clinical Record 8: The comprehensive assessment was on 8/28/2023, the problem of a URI (upper respiratory infection) was identified, a Z pack was ordered, and the patient was instructed on medication. The plan of care was not updated with intervention or goals for this respiratory infection as of review 01/17/2024. Clinical Record 12: During a comprehensive assessment completed on 08/21/2023, the problem of a fall was identified with the patient having a taped ring finger potentially broken from the fall. On comprehensive assessment documented on 01/03/2024, the patient was treated for a UTI (urinary tract infection) and had had a fall the night before. The plan of care was not updated with any interventions or goals related to falls and prevention of falls as of review 01/17/2023. Clinical Record 13: A comprehensive assessment on 12/16/2023 identified a UTI (urinary tract infection), and antibiotics were started. No interventions or goals were updated on the care plan for this as of review 1/17/2024. Clinical Record 15: The initial comprehensive assessment was completed on 05/23/2023 and identified acceptance of the chaplain. The chaplain was visiting with a monthly frequency and working with the patient and family. As of the review of all updated care plans, no documented interventions or goals were documented as of review 01/17/2024. The initial chaplain visit was documented on 06/29/2023, as the family asked. Clinical Record 20: The initial comprehensive nursing assessment documented on 01/15/2024 identified that a peripheral IV line was placed in the left wrist. The initial plan of care documented on 01/15/2024 did not document any individualized interventions or goals for the peripheral line that should have included insertion site monitoring, tubing changes if infusion, flushing directions, and dressing changes. During an interview with the Director of Accreditation, they reviewed the records with the clinical director and agreed that the plans of care required updates for care.

It is required that each patient’s individualized written plan of care: includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the plan of care did not document all medications that the patient was prescribed. Clinical Record 20: The patient elected hospice care and was admitted to the hospice IPU (the in-patient unit) on 1/15/2024. The initial comprehensive assessment documented that a peripheral IV was placed in the patient's left wrist and flushed. The plan of care dated 1/15/2024 did not document the flush. As of review 1/17/2024, the flush was not documented on the plan of care. During an interview, the Director of the in-patient unit and the Director of Accreditation stated that the flush was not documented on the plan of care but should have been.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: A revised plan of care includes information from the patient’s updated comprehensive assessment and a record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 21 (5%) clinical records in which the IDG had met for updated information were reviewed, the agency did not ensure that the IDG (interdisciplinary group meeting) updated all plans with progress toward goals. Clinical Record 8: The nursing assessment documented on 08/28/2023 documented symptoms of a URI (upper respiratory infection) and orders received for a Z pack. The IDG (interdisciplinary group meeting) on 08/29/2023 did not provide an update on the respiratory diagnosis, and the next IDG, dated 09/12/2023, did not document any update related to the respiratory symptoms. During the interview with the Director of Accreditation and Hospice Director, who stated that the IDG will be added for correction and quality review.

It is required that hospice aides are assigned to a specific patient by a Registered Nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 3 of 18 (17%) clinical records reviewed of patients who accepted Hospice Aide services, the agency did not ensure the Hospice Aide care plan provided clear and specific instructions for tasks within the scope of practice for the aide. Clinical Record 4: The patient elected hospice care on 6/1/2023. The Hospice Aide care plan dated 6/1/2023 assigned the Hospice Aide (HA) the task of showering every visit. On admission to hospice, the patient had a documented wound on the right great toe, second toe, and right lower shin, each covered with a dressing and secured with Kerlix. The Skilled Nurse visit note dated 6/28/2023 documented a wound on the patient's left buttocks, which was covered with a foam dressing. The Hospice Aide care plan provided no written instruction for managing the dressings during the shower. Clinical Record 6: The patient elected hospice care on 9/1/2023. The Hospice Aide care plan dated 11/2/2023 assigned the HA the tasks of tub bath, transfer assist, walker every visit, and fall precautions. The assigned task transfer assist did not provide the HA specific instructions for the patient's transfers. The patient could transfer with the walker when admitted to hospice services on 9/1/2023. The IDT (interdisciplinary team) plan documented on 12/19/2023 changed the patient to a one-person transfer only, no longer using a walker. The Hospice Aide care plan was not updated to reflect the one-person transfer only, no longer using a walker as of the review on 01/16/2024. Clinical Record 9: The patient elected hospice care on 6/22/2023. HA services were ordered seven (7) days a week. The Hospice Aide care plan was updated on 12/08/2023. On 12/26/2023, the patient had a Foley catheter and a large drainage bag placed. A review of the clinical record revealed no evidence that the Hospice Aide care plan was updated to include instructions for the care of the Foley catheter as of the review on 01/16/2024. During an interview with the Director of Accreditation and the Hospice Director on 01/19/2024, the aide plans were all updated for more specific care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician certification and recertification of terminal illness as required. This standard was not met as evidenced by clinical record review and interview. In 1 of 23 (4%) clinical records reviewed, the agency did not ensure the correct CTI (certificate of terminal illness) was documented. Clinical Record 15: The Hospice benefit of the election was signed on 05/18/2023, and the CTI (certificate of terminal illness) dated 05/18/2023 - 08/15/2023 was for the wrong patient. The narrative contained the name of a different patient, and the narrative signs and symptoms were not accurate for the correct patient. The right narrative was documented under a coordination of care, but this was different from the narrative on the CTI in the patient record. During an interview with the Director of Accreditation and the Medical Director on 01/18/2024, they stated that the error had been corrected.

It is required that Hospice inpatient facilities dispose of controlled medications in compliance with hospice policy and in accordance with state and federal law and regulation. The hospice maintains current and accurate records of the receipt and disposition of all controlled medications. Document 2: # 10-014 Disposal of Medication in Inpatient Unit stated in part, "All controlled drugs destroyed requires two nurses and will be completed within 24 hours." In order to account for all controlled medications destroyed, the Certificate of Inventory and Destruction will be completed by the two nurses who destroyed the medications. The remaining amount listed on the Controlled Drug Records should be reconciled with the amount destroyed in the Certificate for Inventory and Destruction." This standard was not met as evidenced by document review, interview and observation. During a tour of the in-patient hospice unit on 01/18/2024, the medication room was observed, and the binder with signatures to verify the narcotic count was reviewed. There were times when the two signatures required at the beginning and end of the shift were missing. On the following dates, 12/17/2023 and 12/24/2023, the am nurse's signature was blank; on 12/25/2023 and 12/26/2023, the pm shift nurse's signature was blank. Observation of the narcotic binder on the medication cart: one was missing two nurse signatures for narcotic counts on the following dates: 12/17/2023 6:30 am, 12/27/2023 6:30 am, and 01/30/2024 6:30 pm signature. During an interview with the Director of the inpatient unit, they stated that every shift, both RNs are to sign that the narcotic counts are accurate. During a tour of the in-patient unit on 01/18/2024 the medication room was observed and the binder with signatures to verify narcotic count was reviewed. There were times when the two signatures required at the beginning and end of the shift were missing. On the following date 12/17/2023 and 12/24/2023, the am nurse's signature was blank, on 12/25/2023 and 12/26/2023 the pm shift nurse's signature was blank. Observation of the narcotic binder on the medication cart 1 was missing two nurse signatures for narcotic counts on the following dates: 12/17/2024 6:30 am, 12/27/2023 6:30 am, and 01/30/2024 6:30 pm signature.

It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met as evidenced by document review, interview and observation. Document 2: #10-004 Housekeeping in the Inpatient unit, stated in part, "Interior housekeeping of the Hospice Inpatient Unit shall, at a minimum, include: cleaning each specific area of the inpatient unit which includes high touch surfaces daily routine room cleaning and terminal cleaning to verify uncluttered, clean, and free of vermin and offensive odors. During a tour of the inpatient hospice facility on 01/18/2024, the Gardenia room toured was described by the Building Manager and Director of Nursing as a cleaned room ready for patients but held as a negative pressure room for patients with respiratory infections if needed. Observed in the room three wheelchairs folded and standing in the kitchen area. An alternating pressure mattress was located next to the clean patient bed. The pump used with the alternating pressure mattress was bunched in the chair next to the clean bed. None of the equipment was tagged or identified as clean or dirty. The Director stated that the equipment was clean but did not belong in the patient's bedroom and was cleaned and ready for patients to be admitted. She agreed that the equipment was not tagged in any fashion to verify the equipment was clean and that would be corrected. During the in-patient building tour on 01/18/2024, the Gardenia room toured was described by the building manager and director of nursing as a cleaned room ready for patients but was held as a negative pressure room for patients who might have respiratory infections if needed. The room had 3 wheelchairs folded and standing in the kitchen area and next to the clean patient bed was an APP (alternating pressure) mattress and pump that was bunched up in the chair next to the clean bed. It was unclear if the equipment was dirty or clean. The Director stated that the equipment was clean but did not belong in the patient's bedroom that was cleaned and ready for patients to be admitted. She agreed that the equipment was not tagged in any fashion to verify the equipment was clean and that would be corrected.

Based on policy and procedure review, clinical record review, and staff interview the agency failed to complete the chaplin (spiritual) assessment within 5 days for 2 of 13 records reviewed (#2, and #6), and the psychosocial assessment within 5 days for 1 of 13 records reviewed (#5). Findings included: Review of policy "Comprehensive Assessment", revised 12/2015 was received from Employee #3 on 09/21/22 at 10:56 a.m. The policy stated, " ...hospice staff gather critical information necessary to meet the patient/caregiver needs, preferences, and concerns ...spiritual component ...nature and scope of spiritual concern ...need and preference for chaplin services". 1.Patient #2 had a soc of 08/03/22 with non-displaced fracture of greater trochanter of left femur, weakness, underweight, and adult failure to thrive. The Plan of Care for 08/03/22 -10/31/22 included orders for skilled nursing to visit 2 times a week for 13 weeks, social work 2 times a month for 2 months, spiritual counselling 1 time a month for 2 months, and home health aide orders were for 1 time a week for 4 weeks. Review of the clinical record revealed the spiritual assessment completed by the chaplin was completed on 08/11/22 8 days after the soc visit on 08/03/22. Interview with Employee #3 on 09/20/22 at 4:22 p.m. confirmed the spiritual assessment was not completed in the 5-day timeframe. 2. Patient# 5 had a Start of Care date of 8/10/22 and a terminal diagnosis of Senile Degeneration of the Brain [senile dementia-loss of intellectual ability that is associated with or the characteristics of old age]. The Plan of Care for the certification period 8/10/22 to 11/4/22 included orders for social worker 1 time a day for 1 day, 1 time a month for 3 months, 4 PRN [as needed] for additional support. A review of the clinical record revealed no psychosocial assessment was conducted. During an interview with the quality assurance [QA] nurse on 9/20/22 at 2:15 pm, the QA nurse confirmed the patient did not receive a psychosocial assessment. 3. Patient # 6 had a Start of Care date of 7/22/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. A review of the Plan of Care [POC] for the certification period 7/22/22 to 9/17/22 included order for Chaplain services 1 time a week for 1 week, 1 time a month for 1 month. The clinical record revealed the initial chaplain [spiritual] assessment was not completed until 8/4/22. During an interview with the quality assurance [QA] nurse on 9/20/22 at 4 pm, the QA nurse confirmed the initial spiritual assessment was not completed within the 5 days.

Based on clinical record review and staff interviews the Plan of Care failed to include orders for wound care for 2 of 2 patients with a wound [#3, 6]; failed to include all medications/indications for medications on the Plan of Care for 2 of 13 patients [#6, 13]; failed to include an order for a speech therapy evaluation for 1 of 1 patient [# 10]. The findings included: 1.Patient # 3 had a Start of Care date of 7/26/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. A review of the Plan of Care [POC] for the certification period of 7/26/22 to 10/22/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 times a week for 9 weeks and 6 PRN [as needed]. Review of the RN # 5's visit note dated 8/4/22 revealed the following documentation, " ...Nurse removed dressing to right posterior forearm. It has scabbed over and now can be left open to air ..." Review of the POC revealed no order for dressing changes to the right forearm. On 9/20/22 at 2:30 pm, an interview was conducted with the quality assurance [QA] nurse. The QA nurse confirmed the POC did not include orders for dressings/wound care to the right forearm. 2A. Patient # 6 had a Start of Care date of 7/22/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 7/22/22 to 9/17/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 12 weeks, 4 times a day for 6 days, 2 times a week for 6 weeks, 6 PRN [as needed] symptom management. Review of the clinical record revealed LPN # 8 made a routine visit on 9/9/22 and documented the following information, " ...He has a couple of small blisters on his BLE [bilateral lower extremities] that are weeping [draining] a small amount ...Legs wrapped with ABD pad and tape to absorb fluid until over the weekend ..."RN # 9 made a routine visit on 9/12/22 and documented the following information, " ...He has dressings to BLE. Dressings removed ...No further weeping. Dressings left off ..." On 9/13/22 RN # 9 documented the following information, " ..." Received a call from the granddaughter. She stated he had fallen last night. She [sic] has a skin tear to his to his right arm. She requested I come by today and check patient ...Dressing removed from right arm. Skin tear noted. Area cleaned with NS [normal saline]. Dressing applied and secured with Coban ..." On 9/15/22, RN # 9 made a visit and documented the following information, " ...Dressing removed from skin tear on right arm ...Area cleaned. Polymem [type of wound dressing] applied wrapped with coban..." A review of the POC revealed no evidence the POC was updated with orders for dressing changes to bilateral lower extremities or the right arm. During an interview with the quality assurance [QA] on 9/20/22 at 4 pm, the QA nurse confirmed the POC was not updated with wound care orders. 2B. Patient # 6 had a Start of Care date of 7/22/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care for the certification period 7/22/22 to 9/17/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 12 weeks, 4 times a day for 6 days, 2 times a week for 6 weeks, 6 PRN [as needed] symptom management. A review of the clinical record revealed Patient # 6 was oxygen dependent. The clinical record revealed the patient required supplemental oxygen therapy 3-6 liters per minute by nasal cannula. A review of the POC did not include oxygen on the medication list. An interview was conducted with the quality assurance [QA] nurse on 9/20/22 at 3:15 pm. During the interview, the QA nurse confirmed oxygen should have been included on the POC. 3. Patient # 13 had a Start of Care date of 5/4/22. A review of the Plan of Care [POC] for the certification period 8/2/22 to 10/30/22 included a terminal diagnosis of Nonrheumatic Mitral Valve Insufficiency [heart valve disease where the aortic valve no longer functions adequately to control the flow of blood from the left ventricle into the aorta] and SN [skilled nursing] orders for 2 times a week for 14 weeks. Review of the clinical record revealed a verbal order dated 9/14/22. The order stated, "Voltaren [nonsteroidal anti-inflammatory topical medication] Gel twice a day to lower extremities PRN [as needed]. The order did not include the indications for use of the Voltaren Gel. An interview was conducted with the quality assurance [QA] nurse on 9/20/22 at 2:30 pm. The QA nurse confirmed the order on the POC should have included indications for use. 4. Patient # 10 had a Start of Care date of 8/20/22 and a terminal diagnosis of Cerebral Atherosclerosis [build-up of plaque in the blood vessels of the brain]. The Plan of Care [POC] for the certification period 8/20/22 to 11/5/22 included orders for SN [skilled nursing] 1 time a day for 1 day, 2 times a week for 13 weeks; 6 PRN [as needed]. Review of the clinical record revealed the following information: On 9/1/22 RN # 5 documented, " ...facility asked for one time speech therapy evaluation to see if pt [patient] can tolerate a diet other than pureed ..." Review of the SN IDT [interdisciplinary team] minutes dated 9/7/22 revealed the following documentation, " ...A one-time speech eval was to be completed as as [sic] requested by _______ [name of facility] to determine if they could upgrade her diet ..." The 9/19/22 IDT SN minutes stated, " ...Speech eval was completed and diet was upgraded as she has been doing well ..." The POC had not been updated with an order for a speech therapy evaluation. During an interview with the QA nurse on 9/20/22 at 2:45 pm, it was confirmed the POC was not updated.

4. Patient# 5 had a Start of Care date of 8/10/22 and a terminal diagnosis of Senile Degeneration of the Brain [senile dementia-loss of intellectual ability that is associated with or the characteristics of old age]. The Plan of Care for the certification period 8/10/22 to 11/4/22 included orders for social worker 1 time a day for 1 day, 1 time a month for 3 months, 4 PRN [as needed] for additional support. The initial social worker visit was conducted on 8/11/22. A review of the IDT [interdisciplinary team] minutes revealed IDT meetings were conducted on 8/16/22, 8/30/22 and 9/13/22. There was no social work projected visit frequencies for 2 of the 3 meetings. During an interview with the quality assurance [QA] nurse on 9/20/22 at 2:15 pm, the QA nurse confirmed there were no visit frequency projections for 2 of the 3 meetings. 5. Patient # 6 had a Start of Care date of 7/22/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. Review of the Plan of Care [POC] for the certification period 7/22/22 to 9/17/22 included order for Chaplain services 1 time a week for 1 week, 1 time a month for 1 month. The initial chaplain visit was conducted on 8/4/22. A review of the IDT [interdisciplinary team] minutes dated 8/9/22 revealed no visit projections for the next 15 days from the chaplain. During an interview with the quality assurance [QA] nurse on 9/20/22 at 4 pm, the QA nurse confirmed the POC was not updated with chaplain visit projections for the next 15 days. Based on policy and procedure, clinical record review and staff interview the agency failed to have visit frequency projections for the chaplin IDG (interdisciplinary group) for 4 of 13 records reviewed (#1, #2, #4, and #6) and frequency projections for the social work IDG for 1 of 13 records reviewed (#5). Findings included: Review of a policy "IDG Composition and Meeting Protocol", revised 05/18 was received from Employee #3 on 09/20/22 at 4:30 p.m. The policy stated," ...the interdisciplinary group conference provides a setting in which IDG members ...review the poc (plan of care) as needed and at a minimum of every 14 days ... document IDG assessments and decision, poc revisions, IDG interventions and outcomes". 1.Patient #1 was admitted on 08/13/22 with progressive supranuclear ophthalmoplegia (inability to aim eyes properly), dysphagia (difficulty swallowing), anorexia, and abnormal weight loss. The Plan of Care for 08/13/22 -11/10/22 included orders for skilled nursing to visit 2times a week for 13 weeks, social work 1 time a week for 1 week and 1 time a month for 2 months, home care aide 2 times a week for 13 weeks, and spiritual counseling 1 time a week for 1 week, and 1 time a month for 2 months. Between 08/13/22 and 09/20/22, interdisciplinary group meetings (IDG) were conducted on 08/24/22, and 09/07/22. There was no evidence of an individualized plan for visit frequencies for the next 2 weeks for the chaplin for 2 of 2 IDG meetings. 2. Patient #2 was admitted on 08/03/22 with non-displaced fracture of greater trochanter of left femur, weakness, underweight, and adult failure to thrive. The Plan of Care for 08/03/22 -10/31/22 included orders for skilled nursing to visit 2 times a week for 13 weeks, social work 2 times a month for 2 months, and spiritual counselling 1 time a month for 2 months . Between 08/03/22 and 09/20/22, interdisciplinary group meetings (IDG) were conducted on 08/10/22, 08/24/22, and 09/07/22. There was no evidence of an individualized plan for visit frequencies for the next 2 weeks for the chaplin for 3 of 3 IDG meetings. 3. Patient #4 was admitted on 08/02/22 with hypertensive heart disease, chronic kidney disease, heart failure, and type 2 diabetes. The Plan of Care for 08/02/22 to 10/30/22 included orders for skilled nursing to 2 times a week for 13 weeks, home care aide 3 times a week for 13 weeks, social work 1 time a month for 1 month, and spiritual counselling 1 time a week for 1 week, and 1 time a month for 1 month. Between 08/02/22 to 09/20/22 interdisciplinary group meetings (IDG) were conducted on 08/16/22, 08/30/22 and 09/13/22. There was no evidence of an individualized plan for visit frequencies for the next 2 weeks for the chaplin for 3 of 3 IDG meetings. An interview with Employee #3 on 09/20/22 at 4:22 p.m. revealed, "No, I can't produce chaplin IDG notes, the nurses IDG notes states yes for Chaplin, but does not have projection for 15 days".

Based on clinical record review and staff interviews the RN [registered nurse] failed to inform the physician when the patient was given an incorrect dose of medication for 1 of 1 patient [#3]. The findings included: Patient # 3 had a Start of Care date of 7/26/22 and a terminal diagnosis of Chronic Obstructive Pulmonary Disease [COPD-lung disease]. A review of the Plan of Care for the certification period of 7/26/22 to 10/22/22 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 3 weeks, 2 times a week for 9 weeks and 6 PRN [as needed].Review of the RN # 5's visit note dated 8/15/22 included the following documentation, " ...________ [name of patient's son] gave an Ativan [used to treat anxiety] while nurse was with pt [patient], he stated they have been having [sic] to give him the whole 1 mg instead of 0.5 mg as it is not enough ...nurse changed script to 1 mg every 4 hours as needed per standing order ..." There is no evidence the nurse notified the physician of the amount of Ativan the son was administering or of the change in the order. An interview was conducted with the quality assurance [QA] nurse on 9/20/22 at 2:30 pm. The QA nurse confirmed the physician was not notified of the RN's findings or when the Ativan was increased per the standing order.

Based on direct observation and staff interviews, the agency failed to store supplies [hand sanitizer and sodium chloride] in a manner which would prevent out of date supplies from being used. The findings included: A tour of _______ [name of the inpatient unit] was conducted on 9/19/22 at 4 pm with the interim administrator and director of accreditation and regulatory compliance being present. This tour included the clean supply room where hand sanitizer and bottles of sodium chloride were kept. During the tour, nine [9] bottles of Gel Hand Sanitizer were noted. Seven [7] of the bottles had an expiration date of 4/22 and 5/22. During the inspection a 1000 ml [milliliter] container of Sodium Chloride was found to have an expiration date of 5/22. During an interview with the interim administrator directly after the tour, the administrator confirmed the supplies were expired and should have been removed from the supply room.

Based on agency policy, direct observation and staff interviews, the agency failed to store food in manner which would prevent consumption of expired food. The findings included: The policy, Dietary Department Food Preparation and Storage [8/12], was provided by the director of accreditation and regulatory compliance on 9/19/22 at 4:50 pm. The policy stated, " ...If food is removed from the container in which it came, whether raw or prepared, it is transferred into a clean, covered container, labeled with date, and refrigerated. Such foods are discarded if not used within 3 days ..." A tour of ______ [name of inpatient unit] dietary department was conducted on 9/19/22 at approximately 4 pm with the interim administrator and the director of accreditation and regulatory compliance being present. Upon inspection of the refrigerator, a pitcher of orange juice was noted. There was no date noted as when the orange juice was poured into the pitcher. Upon inspection of the freezer section, an open bag of frozen Swedish meatballs was noted. There was no date to indicate when the food packaging had been opened. During inspection of the shelves in the kitchen, an opened bag of Great Value Egg Noodles [taped shut] was noted with a date open of 2/10 on the bag. During an interview with the interim administrator directly after the tour, the administrator confirmed the items listed above should have been disposed of.

Based on policy and procedure, clinical record review, and staff interview the agency failed to maintain accurate documentation of neurological checks for 1 of 1 patients with a fall (#1). Findings include: A policy titled " Inpatient/Residential In-Patient Falls", revised 11/15 was received from the compliance officer on 01/04/22 at 1:43 p.m. The policy stated "patients who choose to remain in the hospice facility and forgo outside treatment after a suspected or possible head injury will be monitored in the following manner: neurological checks will occur every 15 minutes x 4times, every 30 minutes x 2 times, every one hour x 4, then every 4 hours x 6 or until orders for discontinuing the neurological checks are given by the hospice provider". Patient #1 was admitted on 10/05/21 with diagnoses of cerebral atherosclerosis (thickening or hardening of the arteries of the brain), anorexia, abnormal weight loss, unspecified dementia, expressive language disorder, repeated falls, bipolar disorder, and schizophrenia. Review of the plan of care for 12/04/21 had orders for skilled nursing 4 times a day for 14 days. Review of skilled nursing note for 11/16/21 revealed the patient had a fall and hit her head at 5:45 p.m. Review of the neurological flow sheet for 11/16/21 revealed the following information: neurological checks were performed at 7:30 p.m., 7:45 p.m., 8:30 p.m., 9:15 p.m., 9:45 p.m., 10:30 p.m., 11:30 p.m., 12:30 a.m., 4:30 a.m., 5:30 a.m., 12:30 p.m., 4:30 p.m., 8:30 p.m., 12:30 a.m., and 4:30 a.m. Review of skilled nursing note for 12/12/21 revealed the patient had a fall and hit her head at 5:55 a.m. Review of the neurological flow sheet for 12/13/21 revealed the following information: neurological checks were performed at 0630, 0645, 0700, 0715, 0745, 0815, 0915, 1015, 1115, 1215, and 2:15. Interview with the compliance office on 01/14/21 at approximately 3:10 p.m. confirmed the neurological checks were not performed per agency policy and procedure.