Every finding on record at Hospice and Home Care of Alexander County, Inc.

Upon patient record review, 3 of 14 (Patient #1, 3, 4) 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 There was no route given for these patients. These were corrected on site Pt #1- Oxygen 2 l/min prn dyspnea Pt #3- Azithromycin 250mg take 2 tabs today and then 1 tab qd X 4 days then stop. Oxycodone 5 mg take 1/2 -1 tab q 4 hours prn pain or dyspnea. Pt #4 - O2 2 l/min prn dyspnea (Corrected on site)

Upon patient record review, 3 of 14 (Patient #1, 3, 4) 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 - Pt oxygen order reads 2 l prn dyspnea. No route identified. (Corrected on site) Pt #3 - Azithromycin ordered 11/28/23 250 mg take 2 tablets today, then 1 tablet qd X 4 days then stop. Oxycodone 5 mg. take 1/2-1 tab q 4 hours prn pain or dyspnea. No route identified. (Corrected on site) Pt #4 - Oxygen ordered 11/27/23 O2 at 2l/min prn dyspnea. No route identified (Corrected on site)

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Pt #2 - No evidence in IDG notes of patient going to respite and from respite (10/25-10/29) staying in facility for care.

Upon patient record review, 1 of 14 (Patient #2) 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 #2 - No evidence the plan of care was updated to reflect patient going to respite and from respite (10/25-10/29) staying in facility for care.

Upon personnel record review, 1 of 12 (Personnel #6 ) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #6 is the SW and the BC. Competencies for the SW completed. No evidence of BC competencies.

Upon patient client record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Citing the inaccuracy of a component of the record is cited under other standards) • Initial plan of care • Updated plan of care • Initial assessments • Comprehensive assessments • Updated comprehensive assessments • Signed and dated clinical and progress notes Pt #1 - No chaplain clinical notes for patient in clinical record for November, 2023. Visits were ordered for 1x/2wks for spiritual support. Clinical Notes agency policy states: Staff shall document the services rendered on date of service. Such notes shall be incorporated into the clinical record within 72 hours of date services were rendered. Survey date was 11/29/23.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the hospice forwarded a transfer summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Pt #2 - There was no evidence in patient record that a transfer summary was provided to facility for respite stay.

Upon patient record review, 2 of 14 (Patient #2,12) 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 Pt #2 and 12 - No evidence in patient record that the election form was sent to SNF.

Based on policy review, clinical record review, and staff interview the agency failed to obtain orders for PT/INR (anticoagulation study for patients on blood thinners) for 1 of 1 patients (Patient #7) that received PT/INR; and to flush a port-a-cath according to the Plan of Care for 1 of 2 patients admitted with a port-a-cath (#8). Findings include: A policy, "Physician's Plan of Care" (approved/revised date 10/28/14), was provided by the agency director on 12/16/21 at 5:30 p.m. The policy stated, "Physical care and services provided to hospice patients shall be in accordance with the attending Physician's Plan of Care as written and verified by an RN at the time of admission and every 2 months." A policy, "Hospice Plan of Care" (approved/revised date 12/2/08), was provided by the agency director on 12/16/21 at 5:30 p.m. The policy stated, "Hospice care and services provided to patient's and their families are in accordance with an individualized, written plan of care established by the hospice IDG [interdisciplinary group] in collaboration with the patient's attending physician (if any), and, if appropriate, the patient or representative and the primary caregiver." A policy, "Physician's Supplemental Orders" (approved/revised 10/28/14), was provided by the agency director on 12/16/21 at 5:30 p.m. The policy stated, "New additions or changed in the Physician's Plan of Care and authorization of these additions or changes will be documented by a verbal/telephone order ...The clinical staff of ________[name of hospice] will complete a verbal/telephone order for any new or changed medication, treatment, service, frequency of services, or level of care as ordered by the physician." 1. Patient #7 was admitted on 10/27/21 with a diagnosis of chronic obstructive pulmonary disease (COPD-lung disease). The Plan of Care for 10/27/21-1/24/22 included orders for skilled nursing visits weekly "for skilled observation of patient, dyspnea and to teach care of terminally ill patient with 10 prn visits for crisis management of dyspnea and/or disease process/progression." The Initial Visit stated, "[Patient] wishes to continue to monitor her PT/INR (test to monitor blood thinner medication) at home as she has done for several years. Offered lab draw if needed, will monitor." On 11/1/21, RN #4 conducted a home visit. The visit note stated, "Checked pt's [patient's] PT/INR with her home Coag Machine. Reading was 6.3 [elevated]. Instructed DGT [daughter] to call MD [physician] office and notify him of results NOW. Instructed DGT to HOLD Coumadin [blood thinner] until she hears back from the MD office (which regulates Coumadin) and if she does not hear back from MD this evening to call first thing in the am [morning]." On 11/2/21, RN #4 documented, "Call to dgt to follow up on blood work results for PT.INR and recommendations from cardiovascular MD. DGT states she has not spoken to MD office yet but they have been calling back and forth. DGT states she has held coumadin." On 11/4/21, RN #3 visited patient. Visit note stated, " ...INR 5.1. Instructed pt and pcg [patient caregiver] to continue to hold warfarin [Coumadin]. We will wait to hear back from Dr. ______ office to see when he wants to recheck the INR again ...Pt stated she will contact Hospice once Dr. _____ lets her know when the recheck [sic] her INR." RN #3 documented on 11/15/21, "PT 45/INR 3.7." No further documentation this visit. A Care Coordination Note on 11/16/21 stated, "Inquired if Dr. _______ office contacted them about the warfarin dosage and rechecking the pt's INR. [Caregiver] stated they had her reduced [sic] it to 1 mg and to recheck it next week." On 11/22/21, RN #3 visit note stated, "PT 96/INR >8 [greater than 8]. Gave INR results to Dr. _____ office ....Obtained PT/INR results. INR reading 8.0. Instructed pt and pcg that with her being over her therapeutic ranged [sic] it would be best for the pt to try to eat something with vitamin K in it. We don't want the pt to have some spontaneous bleeding ...Instructed pcg to contact Hospice with next INR check that Dr. _____ office wants it to be checked [sic]. Pcg stated she would call once they contact and tell her." On 11/23/21, a Care Coordination Note from RN #3 stated, "Called and spoke to pt's daughter, [name of daughter] to see what Dr. _____ office said about rechecking the pt's INR. Pcg state they said to hold the warfarin and to recheck it again on Monday ..." On 11/29/21, RN #3 visit note stated, ""PT 57.7/INR 4.8. Unable to reporte [sic] INR results to Dr. _______ office ..." On 12/2/21, RN #3 visit note stated, "PT 40.3/INR 3.4." On 12/6/21, RN #3 visit note stated, "Checked pt's INR ...PT 26.2/INR 2.2 ...Results called to Dr. _______office." On 12/13/21, RN #3 visit note stated, "PT 75.6/INR 6.3 ...Called results to Dr. ______ office." On 12/14/21, RN #3 visit note stated, "Pcg reported Dr. _____ office is holding the pt [sic] warfarin and wants her INR to be rechecked on Thursday." In an interview with RN #3 on 12/16/21 at 11:35 a.m., it was confirmed there were no physician orders for PT/INR. The caregiver notified hospice when the cardiologist wanted the PT/INR repeated. 2. Patient #8 was admitted on 10/13/21 with a diagnosis of malignant neoplasm of cecum. The Plan of Care for 10/13/21-10/10/22 included orders for skilled nursing visits weekly "skilled observation of patient, pain and to teach care terminally ill patient [sic] 10 prn [as needed] visit for crisis management of pain and/or disease process/progression. Flush Left chest port-a-cath with 10ml NS [normal saline] follow by 2.5ml Heparin (100u/ml) Q6-8 weeks and prn [every 6-8 weeks and as needed] if port used." As of 12/16/21 at 12:00 p.m., there was no evidence of a port-a-cath flush. In an interview with RN #2 on 12/16/21 at 12:00 p.m., the RN confirmed the port-a-cath had not been flushed. The RN stated, "The weeks slipped by."

Based on clinical record review and staff interview, the agency failed to notify the physician that medications were not taken as prescribed for 2 of 12 patients (#2 and 3); and medical social work plan of care was altered for 4 of 12 patients (#2, 5, 6, and 8). Findings include: 1A. Patient #2 was admitted on 3/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 10/21/21-12/19/22 included orders for skilled nursing visits weekly for "skilled assessment and to teach care of terminally ill patient and disease process with 10 prn [as needed] visits for crisis management of disease progression." Medication included Lorazepam 1 mg tablet by mouth or place under the tongue every 4 hours as needed for anxiety or agitation. The visit note from 11/22/21 stated, "Pcg [patient caregiver] stated she doesn't think the pt [patient] is sleeping much at night. Pcg reported that the pt is refusing to take any medications of what few he was taking [sic]. Instructed pcg to administer one tab of lorazepam at bedtime to help relax the pt, so he can sleep ...Pcg stated she is afraid a whole tab maybe [sic] too strong for him. Instructed pcg she can give the pt a half tab." There was no evidence of an order for a half lab of Lorazepam. An interview with RN #3 on 12/16/21 at 11:15 a.m. revealed the daughter had been "splitting" the Lorazepam. The RN said she had discussed this with the physician but confirmed there was no order or documentation related to changing the medication dosage. 1B. The Plan of Care for 10/21/21-12/19/22 included orders for medical social work visits once every two weeks "for evaluation, counseling, and information referral and coordination with 5 prn [as needed] visits for crisis management and emotional support." A social work note on 11/8/21 stated, "TC [telephone call] to [daughter] today to ask about a visit and she declined saying she didn't sleep well last night and was still laying down ..." A social work note on 11/22/21 stated, "TC call to [daughter] to ask about a visit and she declined." A social work visit note on 12/6/21 stated, "TC call to [daughter] to ask about a visit and she declined." There was no evidence that the physician was notified the patient/caregiver declined social work visits. 2. Patient #3 was admitted on 7/22/21 with cerebral infarction (damage to brain tissue due to restricted blood flow). The Plan of Care for 10/22/21-1/17/22 included orders for skilled nursing weekly for "observation of patient, pain and to teach care of terminally ill patient with 10 prn [as needed] visits for crisis management of pain and/or disease progression." Medication included Lorazepam 1 mg tablet by mouth or place under the tongue every 4 hours as needed for anxiety or agitation. During the visit on 12/13/21 by RN #4, the RN documented, "Pt [patient] is having some mild anxiety/restlessness as was evident during my visit today. She was trying to get out of the bed and had her legs over the bed rail. ¼ of an Ativan [lorazepam] given to help with the anxiety." There was no evidence the physician was aware the patient was getting a partial dose. In an interview with RN #2 on 12/16/21 at 1:55 p.m., it was confirmed there was no evidence the physician was aware of the current Lorazepam dose. 3. Patient #5 was admitted on 12/4/19 with a diagnosis of cerebral infarction. The Plan of Care for 11/23/21-1/22/22 included orders for social work visits once every two weeks "for evaluation, counseling, and information referral and coordination with 5 prn [as needed] visits for crisis management for increased anxiety and increased depression." A social work note on 11/29/21 stated, "TC [telephone call] to [caregiver] today to ask about visit and she declined say they are doing okay." A social work note on 12/13/21 stated, "TC to [caregiver] today to ask about a visit to which she declined." There was no evidence that the physician was notified the patient/caregiver declined social work visits. 4. Patient #6 was admitted on 8/20/21 with a diagnosis of malignant neoplasm unspecified site. The Plan of Care for 11/18/21-2/15/21 included orders for social work visits once every two weeks "for evaluation, counseling, and information referral and coordination with 5 prn [as needed] visits for crisis management for increased anxiety and increased depression." A social work visit note on 11/22/21 stated, "TC [telephone call] to pt [patient] to ask about a visit and she declined." A visit note on 12/7/21 stated, "TC to pt today to ask about a visit and she declined saying she wasn't having a good day." There was no evidence that the physician was notified the patient/caregiver declined social work visits. 5. Patient #8 was admitted on 10/13/21 with a diagnosis of malignant neoplasm of cecum. The Plan of Care for 10/13/21-1/10/22 included orders for social work visits once every two weeks "for evaluation, counseling, and information referral and coordination with 5 prn [as needed] visits for crisis management for emotional support." A social work visit note for 11/9/21 stated, "TC [telephone call] to pt [patient] re: a visit and she declined saying she was doing okay and would be getting out soon." A social work visit note on 11/22/21 stated, "TC to pt today to ask about a visit and she refused." There was no evidence that the physician was notified the patient/caregiver declined social work visits. An interview with the agency director on 12/16/21 at 3:00 p.m. confirmed the physician was not notified that telephone visits were conducted instead of home visits. The interview also confirmed there was no policy on conducting telephone visits

Based on clinical record review and staff interview, the nurse failed to assess alterations in skin condition in 2 of 12 (#3 and 11). Findings include: 1. Patient #3 was admitted on 7/22/21 with cerebral infarction (damage to brain tissue due to restricted blood flow). The Plan of Care for 10/22/21-1/17/22 included orders for skilled nursing weekly for "observation of patient, pain and to teach care of terminally ill patient with 10 prn [as needed] visits for crisis management of pain and/or disease progression;" and hospice aide twice weekly for assistance with activities of daily living. A clinical note on 11/30/21 at 9:47 a.m. from RN #4 stated, "[Hospice aide] reported and itching rash on shoulders and upper arm. Plan to follow up with family." A clinical note on 11/30/21 at 9:51 a.m. from RN #4 stated, "Call to family to inform them of "itchy" rash reported by [hospice aide]. Family has OTC [over the counter] Hydrocortisone cream. Family voices understanding." On 12/1/21, RN #4 documented, "Call to the home to follow up on "itchy" rash. Family/paid caregiver has been putting OTC Benadryl (antihistamine) gel and that seems to be drying rash up ..." A home visit was conducted on 12/6/21 by RN #4. The visit note stated, "[patient] has had a rash on her shoulders and upper arms which has improved however 1 area on the right side of mid back region the size of a fifty cent piece [sic]." RN #4 was unavailable for interview. An interview with the clinical manager on 12/16/21 at 1:54 p.m. stated the expectation that the rash would be visualized by the nurse would "be sooner" than six days. Patient #11 was admitted on 10/08/21 with Chronic obstructive pulmonary disease (COPD). The Plan of care for 109/08/21 to 12/07/21 the nurse was "1 time week for skilled observation of patient, pain, dyspnea suprapubic catheter and to teach care of terminally ill patient with 10 PRN (as needed) visits for crisis management of pain, dyspnea and/or disease progression." Plan of care for hospice aide is 2 times week to assist with ADL (activities of daily living) care. Per the aide plan of care, the aide is to "report any changes in skin condition to the case manager." On 10/26/21 hospice aide visited patient at 9:35 am to 10:50 am to help with ADL's, per the document AM aide weekly Note. As evidenced by the hospice aide documentation a report was given to the RN (registered nurse) of a "red rash to groin and bottom." RN #4 made a scheduled visit to patient on 10/26/21 from 2:20 pm to 2:50 pm per skilled nursing visit note. As part of the skilled nursing note under the "Skin" assessment the following was documented by the nurse: "Color: WNL (within normal limits); Temperature: Warm; Odor: Not Noticeable; Turgor: fair; Oral Mucosa: Dry; Moisture: Dry." According to documentation there was no evidence the nurse assessed "redness and rash to groin and bottom." Care coordination note on 10/28/21 by RN #4 from hospice aide stated CNAII reported an "itchy rash on patients' inner thighs ..." Reported by hospice aide "itchy rash" on pts (patients) inner thighs and that pts foley bag has a tear in it. Plan to do PRN visit to replace bag." Note entered by nurse. Additional care coordination notes as reported by nurse a phone call was placed to patient's daughter on 10/28/21 at 3:43 pm to "discuss medication changes per hospice pharmacy/MD (medical director)/IDT (Interdisciplinary team) recommendations." The following information was given to patient's daughter: "Nystatin powder called to pharmacy for itching/rash per (medical director) MD." During an interview on 12/16/21 at 4:45 pm the Executive Director stated an expectation for the nurse to assess the patient's skin would have been sooner than two days.

Based on policy review, bereavement record review and staff interview, the agency failed to complete an individualized bereavement plan of care that included interventions and frequency of services for 2 of 2 bereavement records (1 and 2). Findings include: A policy "Bereavement Care Planning" (effective date 5/17/21), was provided by the social work/bereavement coordinator on 12/16/21 at 3:30 p.m. The policy stated, "The bereavement plan of care reflects the assessed needs of the bereaved and next of kin regarding bereavement services to be offered and the frequency of delivery." 1. Bereavement record #1 had a bereavement assessment and bereavement plan of care completed on 1/7/21. The Bereavement Plan of Care included the following "PLANNED FREQUENCY": -Phone Frequency: as needed -Visit Frequency: 2nd month visit -Mail: as scheduled -Bereavement Support Groups: none being held at this time The bereavement plan of care did not include the frequency of services. 2. Bereavement record #2 had a bereavement assessment and bereavement plan of care completed on 4/22/21. The Bereavement Plan of Care included the following "PLANNED FREQUENCY": -Phone Frequency: as needed -Visit Frequency: 2nd month visit -Mail: as scheduled -Bereavement Support Groups: none being held at this time The bereavement plan of care did not include the frequency of services. An interview was conducted with the social worker on 12/16/21 at approximately 1:30 p.m. The interview revealed the social worker was not aware that the specific frequencies for bereavement interventions were to be on the bereavement plan of care.

Based on personnel file review and staff interview, the agency failed to provide 12 hours of inservice education to the chaplain (which was a volunteer). Findings include: The chaplain had a hire date (as a volunteer) of 5/13/21. There was no evidence of 12 hours of inservice training found in the personnel file. An interview with the agency director on 12/16/21 at 3:00 p.m. confirmed the chaplain had not had the 12 hours of training required for volunteers.

Based on personnel file review and staff interview, the agency failed ensure competencies for the 1 of 3 employees reviewed (#1). Finding include: The chaplain had a hire date of 5/13/21. There was no evidence of job specific competencies found in the personnel file. An interview with the agency director on 12/16/21 at 3:00 p.m. confirmed there were no documented competencies for the chaplain.