Every finding on record at Gaston Hospice

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 orders.. This standard was not met as evidenced by clinical record review and interview. In 1 of 3 (33%) of clinical records reviewed of patients in the IPU revealed that the agency did not ensure that patient's record included physician's orders for patient care. CLINICAL RECORD 22: The patient was admitted to the IPU on 02/13/2025 with a diagnosis Chronic Obstructive Pulmonary Disease. The patient was admitted with a tracheostomy that had been in place for a very long time. The RN documented "Trach care performed per policy and procedure" on 02/15, 02/18, 02/21, 02/23. The RN also documented "suctioned performed" on 02/13, 02/14, 02/15, 02/17. During joint review and interview with the compliance staff on 03/04/2025 there was no documented evidence presented that the physician provided orders for tracheostomy care or suctioning.

It is required that medical supplies and appliances related to the palliation and management of the patient’s terminal illness and related conditions are checked for expiration dates. This standard was not met as evidenced by document review, interview and observation. A tour of the agency's office space revealed that the agency did not ensure that all the supplies available for use in patient care were not expired. OFFICE TOUR: During a tour of the office on 03/03/2025, which included the Vice President of Hospice Services and Serious Illness Care as well as the Clinical Team Leader, CNAs, the following items were found in the medical supply room and were available for patient use: AirLife Modudose 0.9% Sodium Chloride Solution, USP, 5 ml, non-pyrogenic pH ~ 5 vials, 3 boxes of 100 vials each, 2 of which were full and the third contained 72 vials, with an expiration date of 03/01/2025; Terumo Syringe without needle, 60 cc/ml, box of 25 with 16 syringes left, with an expiration date of 09/20/2024; and BD 3 ml syringes, Luer-Lock Tip with BD Precision Glide Needle, 25G x 5/8 (0.5 mm x 16 mm), 73 syringes, with an expiration date of 01/31/2025. During an interview with the Clinical Team Leader, CNAs on 03/03/2025, who was present when the items were found in the medical supply room, she confirmed that the items identified were expired. During an interview with the Vice President of Hospice Services and Serious Illness Care on 03/03/2025, who inspected the identified items, she confirmed that the items identified were expired. POLICY AND PROCEDURES: The agency's Purchasing/Receipt of Medical Supplies policy (Policy A03.050, last revised 12/11/2023) states, in part, that "Supply clerk will verify that all supplies and enterals have a valid expiration date on a quarterly basis and will discard any expired items." A tour of the agency's office space revealed that the agency did not ensure that all the supplies available for use in patient care were not expired.

Upon patient record review, 1 of 16 (Patient #6) 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 #6 The medication profile includes O2 at 2-4liters as directed with no route.

Upon patient record review, 2 of 16 (Patient #1, #14) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1 - The SOC was 5/24/22, however, the bereavement assessment was completed on 5/31/22. Patient #14 The patient SOC was 4/27/22, however, the bereavement assessment was not completed until 5/3/22.

Upon patient record review, 2 of 16 (Patient #1, 6) 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. Patient #1 The 5/24/22 plan of care did not include Aide interventions and goals. Patient #6 The 3/15/22 plan of care did not include Aide interventions and goals.

Upon patient record review, 4 of 16 (Patient #1, 5, 6, 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 The 6/6/22 MD order reads may irrigate Foley with NS prn with no NS quantity and no prn qualifier. Order also reads to change Foley q 6weeks and prn with no qualifier. 5/24/22 POC includes a standing order for wound care frequency of q 3days and prn with no qualifier and no identification of wound location. Patient #5 The 5/16/22 MD standing order reads wound care change q 3days and prn with no qualifier and no identification of wound location. Patient #6 O2 ordered at 2-4liters as directed with no route. Patient #10 The 5/24/22 standing wound care order reads change q3days and prn with no qualifier and no location

Upon observation of the home visit, 1 of 4 applicable (Patient #4) did not have evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #4: The nurse cleansed equipment with a wipe then placed the dirty wipe in with the clean and dirty pieces of equipment and their containers vs discarding used wipes and separating clean from dirty items used.

Upon personnel record review, 1 of 1applicable (Personnel #4 ) did not have evidence in the personnel file that the aide competency included all tasks. Personnel #4 There was no evidence of shampoo competency to date.

Upon client record review, 2 of 16 (Patient #5, 10) 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 #5 The 5/16/22 wound care order does not specify who is to provide the ordered wound care. Patient #10 The 5/24/22 wound care order does not specify who is to provide the ordered wound care.