Every finding on record at Hadora Hospice of the Carolinas LLC

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency. There was no evidence of contracts with SNF/hospice providers in the event of an emergency. This was corrected onsite.

Upon patient record review 1 of 14 (Patient #2) 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 #2 - The start of hospice care was documented as 07/11/25. The spiritual care comprehensive assessment was not completed until 07/17/25.

Upon patient record review, 4 of 14 (Patient #1,2,5,7) 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 medical record contained an order for Miralax 17 gm to be given daily for constipation. There was no evidence of a diluent added to the order. Patient #2 - The medical record contained an order for Tylenol 650 mg prn. This order did not contain a frequency of medication. This was corrected onsite. Patient #5 - The medical record contained an order for Miralax 17 gm to be given daily for constipation. There was no evidence of a diluent added to the order. Patient #7 - The medical record contained an order contained an order for Miralax 17 gm to be given daily for constipation. There was no evidence of a diluent added to the order. Pain medications Ibuprofen, Tylenol, Tramadol and Norco were all ordered as needed for pain management. The directions did not include which pain medication to take and when to take each medication.

Upon patient record review, 1 of 14 (Patient #2) 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 #2 - The agency on call log report showed a call that was placed by the caregiver of patient on 7/31/25 at 9:11PM regarding a patient fall. The clinical coordination note documented by the on call nurse, noted the caregiver was "shaken" by this incident. Patient was sent to the emergency room for an EKG and CT Scan. There is no documented evidence of any follow up post this fall and emergency room visit from any member of the IDG until an RN visit on 8/13/25.

Upon patient record review, 5 of 14 (Patient #1,2,3,7,9) 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 patient's advanced directives indicated patient wishes to remain a full code. There were no problems, goals or interventions related to the full code status. The patient's medication profile indicated patient was taking aspirin as a blood thinner. There was no evidence of problems, goals or interventions related to bleeding risk. Patient #2 - The patient's advanced directives indicated patient wishes to remain a full code. There were no problems goals or interventions related to the full code status. Patient #3 - Upon home visit, the patient's POA indicated that the patient is receiving dialysis three times per week. There was no problems, goals or interventions related to dialysis in the patient's plan of care. Patient #7 - The medical record showed a physician order dated 06/26/25 for Ciprofloxacin daily for seven days for urinary tract infection. There was no problems, goals, or interventions related to infection. Patient #9 - The patient's advanced directives indicated the patient wishes to remain a full code. There were no problems, goals or interventions related to the full code status.

Upon patient record review, 5 of 14 (Patient #1,2,3,5,7) 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 medication profile indicated patient was utilizing Miralax 17 gm daily for constipation. There no evidence of a diluent added to instructions. Patient #2 - The medication profile indicated patient was on Tylenol 650 mg as needed for pain. There was no evidence of a frequency for this medication or a daily maximum acetaminophen dose. This was corrected onsite. Patient #3 - The medical record showed an RN visit note dated 6/27/25, documented patient was on 4LPM of oxygen via nasal cannula. The medication profile showed patient on 2LPM of oxygen. There was no evidence of an order for this increase. Patient #5 - The medication profile indicated patient was on Miralax 17 gm daily for constipation. There was no indication of a diluent to be added to the medication. Patient #7 - The medication profile indicated patient was on Miralax 17 gm daily for constipation. There was no indication of a diluent to be added to the medication. That same profile also contained the following medications - all as needed for pain management: Tylenol, Tramadol, Ibuprofen and Norco. There was no indication as to which medication to take related to intensity of pain or in which order.

Upon patient record review, 3 of 14 (Patient #1,3,6) 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 #1 - Upon completion of the spiritual care comprehensive assessment on 11/11/24, the plan of care indicated the following goals: to arrange patient/caregiver to received supportive visits/sacraments/rituals from the identified spiritual leader; assess spiritual needs through visits; collaborate with patient/caregiver to identify spiritual leader; and to read/pray with patient. This plan of care also indicated an order for spiritual care visits to be one time per month times three months. Following benefit periods there is no evidence of any spiritual care visits completed after the first benefit period. The spiritual problems, goals and interventions remained on the patients plan of care throughout all benefit periods. Patient #3 - Upon completion of the spiritual care comprehensive assessment dated 04/25/25, plan of care indicated the following goals: patient and caregiver will identify spiritual needs for end-of-life; patient and caregiver will utilize spiritual strengths to acknowledge and address fears and anxiety related to terminal illness. There was no evidence that the IDG assessed, reviewed or updated these goals with the patient's progress towards them. Patient #6 - Upon completion of the spiritual care comprehensive assessment date 03/19/25, the plan of care indicated the following goals: assess spiritual needs and visitation; build a trusting relationship; establish contact with patient by a visit/phone call; read and pray with patient; and provide assistance with funeral planning. There was no evidence that the IDG assessed, reviewed or updated these goals with the patient's progress towards them.

Upon patient record review, 3 of 14 (Patient #3, 6, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3 - The medical record contained an order dated 04/25/25 for spiritual care visits to occur monthly for three months. There was no evidence of those visits since the comprehensive visit done on 04/25/25 and no order present to discontinue spiritual care visits. Patient #6 - The medical record contained an order dated 03/21/25 for spiritual care visits to occur monthly for three months. There was evidence of visits completed on 04/06/25 and then on 06/11/25 missing a visit during the month of May. There was no documentation related to a missed visit. Patient #9 - The medical record contained an order dated 06/18/25 for spiritual care visits to occur monthly for three months. There was no evidence of a visit since the comprehensive assessment on 06/21/25 and no order present to discontinue spiritual care visits.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection The Governing Body meeting minutes dated January 2025, discussed 2024 performance improvement projects of fall prevention, tuck in calls, and bereavement program - very generalized discussion that did not outline the detail and/or outcomes of the data collected.

Upon patient record review 7 of 14 (Patient #1,2,3,6,7,8,9) 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 Patients #1,#2,#3,#6,#7, and #8 - All listed patients had aide frequencies at two times per week. The plan of care indicated shampooing hair and nail care to be performed one time per week. There was no documentation that these tasks were completed or refused by patient. Patient #9 - The medical record showed a physician order for aide visits to be completed two times per week. Between 7/3/25 and 8/14/25, there was only one visit per week completed on patient and no documented evidence of missed visits.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78 No evidence of the agency cost savings report.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. There was no evidence of an annual report for volunteers for 2024.

Upon patient record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1-14 All of the medical records contained a Patient Notification of Hospice Non-Covered Items, Services and Drugs Addendum form, each of which had signatures from the patient or POA. These were all dated for the specific patient's initiation of hospice care however the rest of the form was left blank. There was no documentation of diagnosis - related or unrelated - and there was no list of covered or non covered items.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. The supply closet located in the hospice agency contained boxes of patient records with a stack of boxes holding the supply room door open. In addition, the door itself did not contain an adequate locking system.

Upon patient record review, 2 of 11 (Patients #1, 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. 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 Pt #1 - RN note of 8/15/2022 states that patient has Simethicone for gas pain. No evidence this was on the medication profile. Pt #9 - Orders stated O2 concentrator 6 liters. No evidence of route or frequency on medication profile.

Upon patient record review, 2 of 11 (Patient #1 and 9) 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. Pt #1 - RN note of 8/15/2022 states that patient has Simethicone for gas pain. No evidence of order. Pt #9 - Orders stated O2 concentrator 6 liters. No route or frequency included in the order.

Upon client record review, 1 of 11 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #1 - RN orders read - 1 X every 14 days and 2 prn. Visits of 4/19/22 - 5/4/22 were 15 days apart.

Upon patient record review 1 of 11 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Pt #4 - Note of 8/2/22 by SW states: SW will be in contact with new PCG about DNR decision. No further communication noted as follow up.

Upon personnel record review, 1 of 2 applicable (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 7 no evidence of initial competency.

Upon patient record review, 1 of 8 applicable (Patient #1) 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 Pt #1 - Aide Plan of Care states shower and complete bed bath.

Upon patient record review 6 of 8 applicable (Patients #1, 2, 4, 7, 8, 10) 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 Pt #1 - Aide Plan of Care states change linens. Change linens was left blank and not addressed. Documentation on 7/18 and 7/20 includes shampoo hair as being completed and not on Aide plan of care. Pt #2 - Aide Plan of Care states shower, mouthcare, assist with dressing, clean foot care, apply lotion, walker assist, make bed, straighten room 2 times a week. Aide visit notes of 8/23/22 show evidence that aide assisted with walker only - no refusals, completions noted. 8/25 - aide documentation states partial bed bath, walker, change linen, make bed was completed. No order for bed bath. 8/30/22 note states that aide gave a partial bed bath, assist with dressing, and make bed only. Pt #4 - aide assignment stated prepare meals, set up laundry. None were addressed on 8/9, 8/11, 8/16, or 8/18. Pt #7 - aide assignment - partial bed bath, shampoo hair, comb hair, mouth care, assist with dressing, clean nails, perineal care, meal prep and set up. On aide visit of 8/10 there was no evidence any tasks were completed no documentation why not completed. Pt #8- Aide documentation includes BP, P, R while not on aide plan of care. Pt #10 - Aide documentation of 4/13/22 documented aide gave patient shower, complete bed bath, and assist with bath chair. On visit of 4/18/22 - no tasks documented.

Upon personnel record review, 5 of 10 applicable (Personnel #4, 5, 9, 11, 12) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. No evidence in staff personnel file of an annual competency or one completed on hire.

Upon patient client record review, 1 of 11 (Patient #10) did not evidence that each patient record contains physician orders. Pt # 10 revoked the benefit. No evidence of a discharge order on the chart.

Upon client record review, 1 of 1 applicable (Patient #10) 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 Pt #10 -- no evidence of a discharge summary completion.