Every finding on record at Home Health and Hospice Care, Inc-Fayetteville

Upon patient record review, 3 of 14 (Patient #1,3,8) 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, 3 - No evidence in medication profile of the way the oxygen is to be distributed - Order read - Oxygen via device. Administer 2 l/m inhaled continuous. Missing via nasal cannula or mask. (Corrected on site) Pt # 8 - Medication profile states Dilaudid 4 mg oral tab. Take 1 tab orally every 4 hours. Facility chart states 3/13/24 - Take 1.5 (6mg) every 4 hours. Pt was on Amoxicillin 500mg 3 x day for 7 days starting 5/10/24. Biofreeze 4% gel Apply 2 times a day for L shoulder pain prn. Not on agency chart (Corrected on site)

Upon patient record review, 3 of 14 (Patient #1,3,8) 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, 3 - Order read - Oxygen via device. Administer 2 l/m inhaled continuous. Missing via nasal cannula or mask. (Corrected on site) Pt # 8 - Medication profile states Dilaudid 4 mg oral tab. Take 1 tab orally every 4 hours. Facility chart states 3/13/24 - Take 1.5 (6mg) every 4 hours. Pt was on Amoxicillin 500mg 3 x day for 7 days starting 5/10/24. Biofreeze 4% gel Apply 2 times a day for L shoulder pain prn. Not on agency chart (Corrected on site)

Upon patient record review, 1 of 14 (Patient #7) 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. Pt #7 - on visits of 4/25 and 5/14 - patient rated his current pain as a 8/10. No evidence of follow up nor pain care plan. Pt stated pain was an active problem.

Upon client record review, 1 of 14 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Pt #14 - Volunteer note from 5/2/24 not in patient record. Policy states the volunteer documents visit within 24 hours and then incorporated into the EMR within a week.

Upon patient record review, 1 of 14 (Patient #13) 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 #13 - Pt is on Warfarin. No evidence that bleeding precautions are in place

Upon patient record review 1 of 14 (Patient #14) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Pt #14 - No evidence of sup visit from 4/4-4/24 and then 4/24-5/9. **Early April 2024 this was identified as a staffing issue by this agency and a POC was developed, put in place and corrected.

Upon personnel record review, 4 of 15 (Personnel #10,12,13,14 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Agency competency policy "Assessing the Competency of the professional Visiting Staff"states only that Nurses, therapists, and social workers shall be competent to perform their duties and responsibilities #10 - no evidence of skills competency completed for MSW hired 5/15/23 #12 - no evidence of skills competency completed for BC hired 5/31/22 #13- no evidence of skills competency completed for VC hired 5/31/22 #14 - new volunteer 2/1/24 No evidence of competency assessment for volunteer (COS)

Upon patient client record review, 1 of 14 (Patient #6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Pt #6- Aide services discontinued on 4/11/24. Order written to d/c aide Care plans and IDG note of 5/8 reflect the aide plan of care as being active and not resolved or discontinued. (Corrected On Site)