Every finding on record at Community Hospice of the Carolinas, LLC

Upon patient record review, 3 of 11 records (Patient #1,#8,#11) 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 #1: Nurse documentation dated 2/29/23 indicated that zinc cream was applied to the patient's open area on her coccyx. There was not evidence that this was on the medication profile. Corrected on site. Patient #8: The record indicated for Lasix 20mg every other day scheduled and Lasix 20 mg every day prn for edema. Corrected on site. (The correction read 20 mg prn every other day on the days that patient is not receiving the routine Lasix). Patient #11: The record indicated for Haldol 2mg/ml, 1ml q4h prn dated 1/24/23. A second order dated 1/25/23 for Haldol, 2mg/ml, 1.5ml, q4h prn, and a third order dated 1/26/23 for Haldol 2mg/ml, 2 ml q1h prn. There was not evidence of discontinuing 1 order prior to initiating the new order and all 3 orders for Haldol were on the medication profile.

Upon patient record review, 3 of 11 records (Patient #1,#8,#11) 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 #1: Nurse documentation dated 2/29/23 indicated that zinc cream was applied to the patient's open area on her coccyx. There was not evidence of an order. Corrected on site. Patient #8: The record indicated for Lasix 20mg every other day scheduled and Lasix 20 mg every day prn for edema. Corrected on site. (The correction read 20 mg prn every other day on the days that patient is not receiving the routine Lasix). Patient #11: The record indicated for Haldol 2mg/ml, 1ml q4h prn dated 1/24/23. A second order dated 1/25/23 for Haldol, 2mg/ml, 1.5ml, q4h prn, and a third order dated 1/26/23 for Haldol 2mg/ml, 2 ml q1h prn. There was not evidence of discontinuing 1 order prior to initiating the new order.

Upon patient record review, 6 of 11 (Patient #1, #2, #5, #7, #8, #10) 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 #1: The medication profile contained two orders for acetaminophen and two orders for hydrocodone without evidence of maximum allowable dose. corrected on site Patient #2: The medication profile contained acetaminophen without evidence of maximum allowable dose. corrected on site Patient #5: The medication profile contained hydrocodone without evidence of maximum allowable dose. corrected on site Patient #7: The medication profile contained acetaminophen and hydrocodone without evidence of maximum allowable dose. corrected on site Patient #8: The medication profile contained acetaminophen without evidence of maximum allowable dose. corrected on site Patient #10: The medication profile contained oxygen 2-4lpm PRN without evidence of route.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 11 (Patient #1) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: The nurse identified on 11/18 (late entry for 11/15) that patient had L lateral ankle swelling and tenderness and that she spoke to physician and an x-ray was ordered however, there was no evidence of an order for x-ray and the x-ray was not obtained. corrected on site

Upon patient record review, 3 of 11 (Patient #2, #3, #4) 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 #2: This patient admitted for hypertensive heart with chronic kidney failure however, there was no evidence of problems/interventions/goals for cardiac. corrected on site Patient #3: The patient had 2 wounds noted in nursing assessments however, there was no evidence of wound care on plan of care to include problems/interventions/goals. corrected on site Patient #4: This patient admitted with Alzheimer's however, there was no evidence of problems/interventions/goals for neuro. corrected on site

Upon patient record review, 6 of 11 (Patient #1, #2, #5, #7, #8, #10) 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 #1: There were two orders for acetaminophen 325 mg-take 2 tablets every 6 hours PRN, 650mg rectal suppository every 6 hours PRN and two orders for hydrocodone 5-325-take 1 tablet every 4 hours PRN and 5-325-take 1 tablet twice a day without evidence of maximum allowable dose. corrected on site Patient #2: There was an order for acetaminophen 325mg-take 2 tablets every 4 hours PRN without evidence of maximum allowable dose. corrected on site Patient #5: There was an order for hydrocodone 5-325 take 2 tablets every 4 hours PRN without evidence of maximum allowable dose. corrected on site Patient #7: There were orders for acetaminophen 325mg take 2 tablets every 6 hours PRN and hydrocodone 5-325 take one tablet 4 times a day PRN without evidence of maximum allowable dose. corrected on site Patient #8: There was an order for acetaminophen 500mg take 2 tablets every 6 hours PRN without evidence of maximum allowable dose. corrected on site Patient #10: There was an order for oxygen 2-4lpm PRN without evidence of route.

Upon patient record review, 7 of 11 (Patient #1, #2, #3, #5, #7, #10, #11) 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 #1: There was no evidence of walker identified in ongoing nurse visits listed on plan of care. corrected on site Patient #2: There was no evidence of hoyer lift identified in nurse visit listed on plan of care. corrected on site Patient #3: There was no evidence of bedside commode, low air loss mattress and overbed table identified in nurse visits listed on plan of care. corrected on site Patient #5: There was no evidence of bedside commode identified in initial nurse visit listed on plan of care. corrected on site Patient #7: There was no evidence of walker and overbed table identified in initial nurse visit listed on plan of care. corrected on site Patient #10: There was no evidence of shower chair, toilet riser, grab bar, wheelchair and wheelchair cushion listed on plan of care. Patient #11: There was no evidence of walker and wheelchair identified in initial nurse visit listed on plan of care.

Upon patient record review 1 of 11 (Patient #9) 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 #9: The aide plan of care instructed to perform shampoo, nail care, and linens on first visit of each week however, the week of 08/21 and 08/28 the aide performed on both visits.

Upon client record review, 1 of 11 (Patient #9) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #9: The patient was ordered on medication for thrush on 09/04 however, there was no evidence the plan of care was updated to include problems, goals and interventions when this occurred. In addition, the social worker visited 09/08 however, there was no evidence of order for this visit. The patient transferred from home to LTCF 09/09 however, there was no evidence the plan of care was updated to include problems, goals and interventions for assisting patient with placement. The initial social worker visit identified patient needed assistance with funeral arrangements and mobile notary however, the plan of care did not include problems, interventions and goals for this.

Upon patient record review, 2 of 11 (Patient #2, #7) did not have evidence that the hospice provided the following information: • Hospice election form • Physician certification and recertification of the terminal illness specific to each patient Patients #2 and #7: The facility did not have copies of election forms and physician certification of terminal illness specific to each patient. corrected on site

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record, review 4 of 11 (Patients #1, #3, #4, #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1-The patient was admitted 08/06/22 and a spiritual assessment was not performed until 08/19/22. Patient #3- The patient was admitted 07/30/22 and a spiritual assessment was not performed until 08/26/22. Patient #4- The patient was admitted 07/26/22 and a spiritual assessment was not performed until 08/25/22. Patient #5- The patient was admitted 08/11/22 and a spiritual assessment was not performed until 08/26/22.

Upon patient record review, 3 of 11 (Patient #2, #6, #11) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2 -The patient was admitted on 06/30/22 and refused Chaplain and Social Work services. A spiritual assessment was not performed by the RN. A spiritual assessment is not on record. Patient #6 -The patient was admitted on 08/03/22 and refused Chaplain services. A spiritual assessment was not performed by the RN or Social Worker. A spiritual assessment is not on record. Patient #11-The patient was admitted on 08/16/22 and refused Chaplain services. A spiritual assessment was not performed by the RN. A spiritual assessment is not on record.

Upon patient record review, 3 of 11 (Patient #1, #4, #9) 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 08/31/22 orders were received to crush all medications and administer thorough the patients PEG tube. The medication profile contains 10 medications which were not updated to be administered through the PEG tube. The 10 medications are listed as oral administration route. (corrected on site) Patient #4- The medication profile includes Metolazone 2.5 mg 1 tab daily prn CHF. Indications for prn are not specific for symptoms requiring drug administration. (corrected on site) Patient #9- On 05/18/22 the nurse received a verbal order to Discontinue Morphine 0.25 ml q4h prn pain. The medication was left active on the medication profile.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 11 (Patient #1) 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 #1-The spiritual care provider began care 08/19/22 with orders to visit twice monthly. A plan of care was not developed with interventions and goals for the spiritual needs identified in the assessment.

Upon patient record review, 2 of 11 (Patient #5, #10) did not have evidence the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all treatments. Patient #5-The 08/11/22 plan of care includes orders for skilled nurse for instructions/reinforcement of care of indwelling catheter. The orders are not specific for the catheter type and specific management to be performed. (corrected on site) Patient #10- The 06/23/22 plan of care includes orders for the nurse to provide instructions/reinforcement of ostomy care including irrigation. The orders are not specific for the actual irrigations to be performed. (corrected on site)

Upon patient record review, 5 of 11 (Patients #1, #3, #4, #5, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- On 08/10/22 the Social worker was ordered to visit monthly for 2 months. The social worker visited the patient twice in August on 08/10/22 and 08/19/22. Patient #3- The Spiritual Care Provider visited the patient on 08/26/22. There are no orders on record for spiritual care. (corrected on site) Patient #4- The Spiritual Care Provider visited the patient on 08/25/22. There are no orders on record for spiritual care. (corrected on site) Patient #5- On 08/11/22 the Social Worker is ordered to visit the patient monthly for three months. The patient was visited twice monthly by the Social Worker in August on 08/15/22 and 08/29/22. On 08/19/22 the nurse documents the patient's catheter was flushed with 10 cc NS. There are no orders on record for catheter flushes. (corrected on site) Patient #10- On 06/23/22 the Chaplain is ordered to visit twice monthly. One visit was made in July on 07/07/22. There is no documentation regarding the missed visit.

Upon observation, one of three home visits (Patient #4 with RN) did not evidence the hospice follows all acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #4- On the home visit 09/08/22 the nurse was observed placing a pulse oximeter, thermometer and BP cuff directly on patients carpet without a barrier after taking the patients vital signs. The ipad was placed on the carpet as well.

Upon patient record review, 1 of 11 (Patient #5) did not have evidence that all entries are clear, complete, and accurate. Patient #5- The record contains discrepancies regarding the type of urinary catheter the patient has inserted. On 08/19/22 at 9:32 am the nurse documents the patient has a Foley catheter. On 08/19/22 at 6:42 pm the nurse documents making a prn visit to flush the patient's suprapubic catheter. Upon interview with leadership the suprapubic catheter documentation is an error as the patient has a Foley catheter.

Upon patient record review, 1 of 1 applicable (Patient #8) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #8- The patient revoked the hospice election 06/24/22. There is no documentation on record to evidence the discharge summary was sent to the patient's attending physician.

Upon patient record review, 2 of 2 applicable (Patients #8, #11) did not have evidence that the discharge summary includes all required information. Patient #8- The patient revoked the hospice election 06/24/22. The discharge summary only indicates the patient revoked the election to pursue aggressive treatment. The summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. Patient #11- The patient was discharged 09/07/22. The summary only includes the discharge reason and does not include a summary of the patient's stay, including treatments, symptoms and pain management.

Upon patient record review, 2 of 5 applicable (Patients #1, #7) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #1- The patient resides in a skilled nursing facility. On 08/31/22 several orders are on record regarding the management of the patients PEG tube including feedings, cleansing site, and medication administration via PEG. The orders do not specify whether the Facility nurse and/or Hospice nurse is responsible for the management of the PEG tube. (corrected on site) Patient #7-The patient resides in a skilled nursing facility. On 08/29/22 orders were received to cleanse and dress the patients right heel wound daily. The orders do not specify whether the Facility nurse and/or Hospice nurse is responsible for the wound care. (corrected on site)