Every finding on record at Augusta Health Care, Inc.

Upon patient record review, 3 of 21 (Patient #1, #2, #3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #1-On 03/15/24 the nurse documents the patient is taking Tylenol for pain. Tylenol is not listed on the medication profile. (corrected on site). Patient #2-On 02/18/24 the nurse documents the patient is taking Tylenol for fever. Tylenol is not listed on the medication profile. Erythromycin 5mg/g (0.5%) 1/2 inch tid eye ointment is listed on the profile. The profile does not specify which eye(s) for administration. (corrected on site). Patient #3- Miralax 17gm powder 1 packet daily prn for constipation is listed on the profile without a diluent. (corrected on site)

Upon patient record review, 4 of 21 (Patient #2, #3, #7, #12) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2- Erythromycin 5mg/g (0.5%) 1/2 inch tid eye ointment is listed on the plan of care. The plan of care does not specify which eye(s) for administration. (corrected on site). Patient #3- Miralax 17gm powder 1 packet daily prn for constipation is listed on the plan of care without a diluent. (corrected on site) Patient #7-The 03/11/24 plan of care includes orders for the nurse to teach the patient management of the Foley and Foley to be flushed three times weekly per protocol. The orders do not address catheter size, balloon size, frequency to be changed and specific flush and amount to be utilized. (corrected on site) Patient #12-The orders on 03/19/24 to update the plan of care read: Insert Foley catheter. The orders are not specific for size, balloon size and indications for changes. (corrected on site)

Upon client record review, 1 of 21 (Patient #4) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #4-The record indicates the IDG met on 01/17/24 to review the plan of care. The next documented IDG on record is documented on 02/14/24 (late entry documentation correction on site)

Upon patient record review, 1 of 21 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-Orders were received on 03/03/24 for the nurse to visit weekly to perform wound care to the L buttocks with wound cleanser, apply skin prep around wound and Exuderm dressing. The plan of care also includes orders to assess the wound for healing weekly. Between 03/01/24 and 03/15/24 the nursing documentation indicates the wound care was provided weekly on 3/05/24 and 03/12/24; however the documentation does not include a wound description or measurements. (late entry correction on site )

Upon patient record review, 1 of 21 (Patient #13) did not have evidence that each patient record contains: • An accurate signed election statement in accordance with 418.24 Patient #13-The patient was admitted on 01/25/24. The election statement on record is dated 01/25/27 as the effective date of election. (corrected on site)

Upon observation, there is not evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The surveyor observed three medical gas pipes in the attic of the Shenandoah House with gaps around penetrations through the fire barrier wall thus potentially reducing the fire résistance of the barrier. (the gaps were sealed with a material capable of maintaining the fire resistance and deficiency was corrected on site)

Observed in Record Review. In 3 of 10 patient records reviewed, for active patients t was noted by the nurse surveyor that for the Interdisciplinary group meeting notes did not document decline, revisions to plans of care and goals. For example, for HOSHV#1/RR#1GAP, the IDG notes did not reflect the patient’s response to wound care or change in treatment orders. HOSRR#9NNP did not reflect the decline of a wound on the patient’s buttocks or changes in treatment orders or tube feedings. HOSRR#10NNP there was no documentation to reflect the patient’s response to wound care or the addition of oxygen therapy. All findings were verified by the Branch Director.

Observed in Record Review. In 10 of 10 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient’s pain will be at a level acceptable to patient,” and “Patient/caregiver will feel relief from spiritual concerns.” Additionally, goals were the same from patient to patient with minimal individualization. Time frames for completion were not consistently updated from admission to recertification. Findings were verified by the Administrator and the Branch Director.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene – IC15 Policy and Procedure”. For example, during HOSHV#1/RR#1GAPthe Medical Social Worker did not perform hand hygiene after entering the patient’s room and touching various objects in the room and then touching the patient. During HOSHV#2/RR#2GAP the skilled nurse performed hand hygiene and donned gloves and then proceeded to perform a head-to-toe assessment on the patient, stopping at intervals to document on her phone without changing gloves and performing hand hygiene from one task to the other. During HOSHV#3/RR#3NNP the hospice aide washed her hands with soap and water and donned gloves. She then filled up two pans of water for the patient’s bath and placed them at the bedside and set up the patient’s clean clothes and towels. She then assisted the patient to ambulate into the bedroom without changing gloves and hand sanitizing before touching him. The Administrator was present during the visit and observed the infection control breaches.

Observed in HR File Review. In 2 of 16 HR files reviewed, the surveyor noted, that for HOSHR#9GAP and for HOSHR#14NNP, both chaplains/bereavement coordinators, neither had documented of verified experience or education in grief or loss counseling. Findings were verified with the Regional Human Resources Representative.

Observed in Record Review. In 1 of 8 patient records reviewed, for active patients with the hospice aide, it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days per regulation. HOSRR#4GAP, there was no documented Hospice Aide Supervisory visit for a period of 16 days at one interval and a period of 21 days for the first certificaiton period. Findings were verified with the Branch Director.

Observed in Patient Home. In 1 of 1 home visits conducted, where a medication reconciliation was completed, it was noted by the nurse surveyor that the medication profile did not accurately reflect what the patient was taking. For HOSHV#2/RR#2GAP, it was noted that the patient’s Lidocaine 4% topical patch for back pain had been discontinued by the patient’s facility provider over ten days prior. Findings were validated by the Administrator who was present during the home visits.