Every finding on record at Carolina Community Care, Inc.

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; and 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; 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 22 (5%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. HOME VISIT 3: The patient elected the hospice benefit on 03/03/2026 for a diagnosis of Volvulus. The patient resided in a skilled nursing facility (SNF). During the home visit observation with the registered nurse (RN) (Personnel Record 4) on 05/12/2026, the hospice medication profile (printed on 05/11/2026) was compared to the SNF medication profile (printed on 05/12/2026). The hospice medication profile contained the following medications not listed on the SNF list: "Robitussin DM 10 ml every 4 hours as needed. (Ordered 04/28/2026)" The last comprehensive nursing visit was 05/07/2026. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/12/2026 during which time it was confirmed that medications should be reconciled with every nursing visit.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene and use of gloves. This standard was not met as evidenced by document review, interview, and observation. In 1 of 4 (25%) home visits observed, the agency did not ensure clinical staff followed hand hygiene procedures as required by policy. Agency policy titled "Hand Hygiene Policy 5.7.1 dated 2009, revised Feb 2025" stated in relevant parts: "Procedure 1. Indications for hand hygiene are: Before and after direct patient care. After blowing or wiping the nose. Moving from contaminated patient body site to clean body site during patient care. Handwashing recommended. Before handling medication or food. Non-anti-microbial or antimicrobial soap and water." HOME VISIT 2: During the home visit with the hospice aide (Personnel Record 7) on 05/12/2026, the hospice aide began the visit by washing hands and donned (applied) gloves. The aide then proceeded to give the patient a bed bath and started by washing the patient's upper body. The aide used a large towel, dipped it in the wash basin to apply soap to the patient, used another large towel, dipped it in the wash basin to rinse the patient and then use a third large towel to dry the patient. The aide then applied lotion to the patient. The aide repeated this process for the perineal area and then washed the patient's legs and feet, repeating the same process. The aide rolled the patient over and repeated the process on the patient's back, working from top to bottom. At the end of the bath, after replacing the patient's top, the aide removed a brush from the patient's dresser drawer and brushed the patient's hair. During the entire process, the aide did not change gloves nor wash hands. An interview was conducted with the Administrator, Chief Clinical Officer, and Quality Nurse on 05/12/2026 during which time the home visit was reviewed, and the discussion was surrounding the aide. The leadership team stated the aide "would be retrained immediately on the proper hand hygiene per policy."

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 a RN (Registered Nurse) who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 21 (19%) clinical records reviewed in which hospice aide services were accepted, the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 2: The hospice aide care plan updated 05/05/2026 included the following relevant tasks: "Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care" All tasks were to be completed every visit with an aide frequency of twice weekly. A physician's order dated 02/16/2026 and the medication list noted patient is on "oxygen 2-5 liters continuously for shortness of breath." The hospice aide care plan did not notify the aide of the oxygen nor provide specific instructions for the aide during tasks. CLINICAL RECORD 4: The hospice aide care plan updated 05/12/2026 included the following relevant tasks: "Check pressure areas with each visit; complete bed bath two times a week; peri care two times a week; document BM (bowel movement) with each visit; document output with each visit; incontinence care with each visit; dress patient after bathing two times per week; hair/scalp care two times per week; change linen weekly and as needed; offer easy to grab foods with each visit; denture/mouth care with each visit; skin care two times per week with each visit." The hospice aide visit frequency was twice weekly. A physician's order dated 04/09/2026 noted a "Dressing to great right toe and leave shoe off." The aide care plan did not notify the aide of the wound nor to notify the nurse if the dressing became soiled, dislodged or wet. CLINICAL RECORD 6: The hospice aide care plan dated 12/19/2025 included the following relevant tasks: "Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care." All tasks were to be completed every visit with an aide frequency of twice weekly. A physician's order dated 04/23/2026 noted a "right ankle brace." The hospice aide care plan did not notify the aide of the brace nor provide the aide with specific instructions for the brace during tasks. CLINICAL RECORD 11: The hospice aide care plan dated 03/25/2026 included the following relevant tasks: "Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; change linen; denture/mouth care; skin care." All tasks were to be completed every visit with an aide frequency of twice weekly. A nursing visit dated 03/25/2026 noted patient had "boot on foot due to surgery." The hospice aide care plan did not notify the aide of the boot nor provide the aide with specific instructions for the boot during tasks. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/14/2026 during which time it was agreed the aide care plans "should be modified to be clearer."

It is required that a hospice aide provides services included in the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 1 of 1 (100%) home visits of patients who received hospice aide services, the agency did not ensure that the hospice aide provided services included in the plan of care. HOME VISIT 2: The hospice aide care plan dated 05/05/2026 included the following relevant tasks: "Check pressure areas; complete bed bath; peri care; incontinence care; dress patient; hair care; hair care; change linen; denture/mouth care; skin care" All tasks were to be completed every visit with an aide frequency of twice weekly. During home visit with the hospice aide (Personnel Record 7) on 05/12/2026, the aide was observed to remove the oxygen from the patient and place it on the bed beside the patient during the visit. There were not instructions for the aide in the plan of care for this task. The aide was not observed to complete the task of denture/mouth care during the visit. A joint clinical record review and interview was conducted with the Administrator and the Quality Nurse on 05/12/2026 at which time they agreed that the "aide should complete tasks as ordered per the plan of care."

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. An inspection of the kitchen during life safety code tour revealed the agency did not ensure the hospice followed the accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hygiene and use of gloves. Agency policy titled "Hand Hygiene Policy 5.7.1 dated 2009, revised Feb 2025" stated in relevant parts: "Procedure 1. Indications for hand hygiene are: Before and after direct patient care. After blowing or wiping the nose. Handwashing recommended. Before handling medication or food. Non-antimicrobial or antimicrobial soap and water." A tour of the hospice owned inpatient unit was conducted on 05/13/2026 with the Administrator (Personnel Record 2), Director of Nursing (Personnel Record 12) and the facilities supervisor. Upon touring the kitchen, Personnel Record 13 (Hospice Aide) was asked to demonstrate how to check the temperature of the food before being served to a patient as this was part of her normal duties. She came over to the counter, showed the thermometer she used, then said "Sorry, my nose is running and I need to blow it." She went to get a paper towel and blew her nose. After throwing away the paper towel, she returned and picked up the thermometer. She did not wash or sanitize her hands or don (apply) gloves. She then opened the food warmer, removed a carton of food, inserted the thermometer, and showed the temperature reading. She replaced the lid on the food and put it back in the warmer, cleaned the thermometer, and described the process for recording the temperature. The food was immediately removed and destroyed by leadership, and it was advised that the aide would receive immediate training.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 2: The medical record indicated that the patient was receiving wound care to the blisters on the foot and lower leg. No evidence that education and training with the current wound care orders was given to the primary caregiver. RN documentation indicated that the caregiver is a nurse and is aware of how to change bandages. The primary daughter who lives in town and is available during the week is not a nurse.

Upon patient record review, 5 of 21 (Patient #4, 7, 9, 14, 17) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 04: The medication profile contains Erythromycin 5mg/gram (0.5%) eye ointment, apply to affected eye four times a day for 7 days. The application site is not indicated. The medication profile includes Miralax 1 TBSP PO daily for constipation, it does not include instructions for a diluent. Patient 07: On 6/13/23 orders were received for Ativan 0.5-2mf PO/IV/SQ every 4 hrs prn anxiety, this is not included in the patients medication profile. On 6/16/23 new orders for Senna/Docusate 8.6/50mg 2 tabs/capsules PO BID was received, this was not included in the medication profile. On 6/20/23 new orders for Miralax 1 capful (17grams) in 8oz liquid PO daily prn constipation was received and was not included in the medication profile. On 8/3/23 orders were received for Cephalexin 500mg PO BID x 10 days, this has not been discontinued from the medication profile. On 8/27/23, an order for Lactulose 30ml PO x 1 dose was ordered, this was not included in the patients medication profile. Patient 09: The medication profile contains Metronidiazole 500mg crush 1 tablet and apply to affected area with each dressing change. The pt record indicates that the patient has 4 wound, the application does not indicate which wound/wounds to apply the medication to. The record includes medication orders on 7/31/23 for Flagyl 500mg crush and apply to sacral wound, this is not included in the medication profile. Orders on 8/3/23 for Dilaudid 1mg/ml give 1-2mg (1-2ml) po q 4 hrs for pain or shortness of breath, this is not included in the medication profile. Patient 14: The medication profile includes orders for Losartan, Sertraline, Pepcid, Motrin, Compazine, Zofran, Oxycodone, Morphine, Ativan, Phenergan, and Levsin all indicated as PO, the patient has a g-tube and receives these medications through his tube. (Corrected and updated on site.) Patient 17: The patient had new orders for the following medications that were not included in the medication profile: 2/14/23, Scopolamine 1mg, Duoneb 3ml vial, 2/7/23 Torsemide 10mg, 2/6/23 Levaquin 500mg, 1/30/23 Bactrim DS 800-160mg and 1/23/23 Azythromycin 250mg

Upon patient record review, 2 of 21 (Patient #10, 11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 10: The patient record indicates that he is a full code, the plan of care does not include interventions or goals to include ongoing assessment, teaching and encouragement for establishing end of life plans. (Updated to current plan of care.) Patient 11: The patient was admitted on 5/26/23 and resides at a SNF, the plan of care does not include evidence of the coordination of care with the SNF provider.

Upon patient record review, 3 of 21 (Patient #4, 9, 14) 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 04: The medication order on 3/31/23 for Erythromycin 5mg/gram (0.5%) eye ointment, apply to affected eye four times a day for 7 days" does not indicate which eye to instill the medication. The medication order on 2/27/23 for Miralax 1 TBSP PO daily for constipation, does not include a diluent. Patient 09: Medication orders on 7/27/23 for Metronidiazole 500mg crush 1 tablet and apply to affected area with each dressing change, does not include the wound location (there are 4 wounds indicated in the patient record.) (Corrected and updated on site.) Patient 14: The medication orders for Losartan, Sertraline, Pepcid, Motrin, Compazine, Zofran, Oxycodone, Morphine, Ativan, Phenergan, and Levsin are all indicated as PO, the patient has a g-tube and receives all medications through his tube. The patient receives hydration and bolus nutritional supplements, PRN through his g-tube. There are no orders in the patient record for administration of water or feedings. (Corrected on site.)

Upon patient record review, 1 of 21 (Patient #1) 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 equipment and supply needs. Patient 01: The patients wound care supplies are not included in the plan of care. (Corrected on site.)

Upon patient record review, 5 of 21 (Patient #1, 2, 4, 5, 8) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 01: The patient record indicates that the patient has 4 wounds, the plan of care does not include interventions and goals for the treatment and management of the wounds. (Corrected and update on site.) Patient 02: The patient was started on nebulizer treatments with Duonebs on 6/20/23, there is no evidence in the plan of care that includes interventions and goals for the use of the nebulizer treatments or the instruction for use. Nursing documentation on 9/8/23 indicates that the patient c/o urinary retention, a foley catheter was attempted and failed. The patient was sent to the ER and was diagnosed with a urinary tract infection and was discharged with an order for antibiotics. The plan of care has not been updated to include a problem statement with interventions and goals for the UTI. (Corrected and updated on site.) Patient 04:The patient record indicates that the patient had a fall with injury on or about 9/4/23, the plan of care is not updated to include a problem statement with goals and interventions for safety. (Updated on site.) Patient 05: The patient record indicates orders in the record for perform care of the portacath starting on 6/8/23, the plan of care is not updated to include interventions and goals for the maintenance of the portacath. The patient record reflects multiple reports of nausea requiring interventions as documented on 3/30/23, 7/13,23. 8/17/23, 8/29/23, & 9/7/23, the plan of care does not contain interventions and goals for the management of nausea. (Corrected and updated on site.) Patient 08: The patient was admitted on 7/14/23 and has a history of diabetes and uses Novolog before meals and PRN and Lantus 12 units QHS which was reinstated into the patients medication use on 7/20/23. The plan of care was not updated to include interventions and goals for the management of the diabetes. (Updated and corrected on site.)

Upon client record review, 2 of 21 (Patient #1 and 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 01: The nursing documentation on 9/5/23 indicates that a dressing change was completed on "sacrum, right leg and a new sore on right ankle." There are no orders for wound care. Documentation on 8/31/23 indicates "R. Lat shin wound dressing changed, 3 areas, cleansed with NS covered with xeroform & curlex." There are no orders for wound care. On 8/28/23, the RN documented, "Sacral dressing changed after pericare, sacral wound 5cmx2cm, bloody in color, cleansed with spray & packed with NS wet to dry/ABD pad and taped occlusive dressing placed. R lower leg dressing changed, 3 small wounds noted, 1 cm, 1cm, and 2cm in length and healing well." There are no orders for wound care. There is additional documentation on 8/21/23, 8/18/23, 8/16/23 and 8/9/23 regarding wound care being provided during SN visits. The patient record does not contain wound care orders. (Corrected on site.) Patient 9 The documentation in the patient record indicates that a "wet to dry" dressing change was performed by the SN on 7/21/23, 8/22/23, 8/28/23 and 8/30/23, there are no orders in the patient record for wet to dry dressing changes.

Upon patient record review, 2 of 21 (Patient #3, 12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable. Patient 03: The hospice aide task assignment initiated on 8/9/22 is indicated for shower or complete bed bath 2x week allowing the patient to decide. Due to her decline, the patient has been receiving a complete bed bath consistently since 7/6/23, the RN has not updated the plan of care. (Corrected on site.) Patient 12: The hospice aide task assignment initiated on 9/7/23 is indicated for a shower, complete bed bath or partial bed bath indicating that the patient is "cognitively and physically able to determine if they would like a shower or bath." The patient is admitted to hospice services with a diagnosis of Alzheimer's and is not able to decide for herself. The patient has not allowed the aide to provide bathing services. (Corrected and updated on site.)

Upon patient record review 1 of 21 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 01:The hospice aide care plan indicates that the patient should receive a shampoo for hair care 1 x per week, the patient did not get a shampoo the week of 7/16/23, 7/30/23, or 8/27/23. The hospice aide care plan indicates that the patient should receive a complete bed bath 2 x per week. The aide documentation on 9/5/23, 8/17/23, 8/10/23, 7/27/23, and 7/10/23 is incomplete and does not indicate if the patient received a complete bath or partial bath.

Upon patient record review, 2 of 21 (Patient #11 and 13) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 11: During the home visit at the SNF, it was noted that the patients recertification of terminal illness for services dates 7/25/23 - 9/22/23 is not included in the patient records at the facility. The patients medication profile/medication information has not been provided to the facility. There was no documentation in the patient record that these were provided either. (Corrected and updated on site.) Patient 13: The hospice has not provided the facility with a written hospice plan of care since 5/26/23, that includes the coordination of hospice services. (Updated and corrected on site.)