Every finding on record at Hospice and Palliative Care of the Blue Ridge

Upon patient record review 1 of 19 (Patient #7) 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 7: Patient admitted 1/31/24. Initial spiritual assessment documented 2/8/24.

Upon patient record review, 4 of 19 (Patient #2,3,4,9) 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. 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 All COS: Patient 2,3: Medication list with order for Miralax: Miralax 17 grams by mouth every morning as directed. There is no evidence of dilutants on the medication list. Patient 4: Medication list with order for Miralax: Miralax 17 grams by miscellaneous every morning as directed. There is no evidence of appropriate route or dilutants on the medication list. Patient 9: Medication list with the following orders: Miralax 17 grams by mouth every morning as directed. There is no evidence of dilutants on the medication list. Triamcinolone acetonide 0.1 percent ointment topical. 1 dose to affected area 4 times daily as needed. There is no evidence of application site on the medication list. Fluticasone propionate spray – inhale 100mcg of fluticasone propionate (50mcg/actuation spray, suspension) into nostril daily. There is no evidence of instructions re: which nostril on the medication list. Lidocaine adhesive patch. Apply 2 adhesive patch, medicated of lidocaine (4 percent patch) topically daily. There is no evidence of application site or on/off instructions on the medication list.

Upon patient record review, 1 of 19 (Patient #18) 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 18: There is no evidence of bereavement assessments in patient's medical record.

Upon patient record review, 6 of 19 (Patient #2,3,9,10,11,13) 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. All COS: Patient 2: Identified needs: dyspnea with oxygen as an intervention, high risk for falls, bleeding precautions, pain. No evidence of problems, goals, interventions on the plan of care: oxygen as an intervention, high risk for falls, bleeding precautions. Patient 3: Identified needs: dyspnea with oxygen as an intervention, high risk for falls, bleeding precautions, pain, aspiration precautions, dysphagia, constipation, mobility, weakness. No evidence of problems, goals, interventions on the plan of care: oxygen as an intervention, high risk for falls, bleeding precautions, constipation. Patient 9: Identified needs: dyspnea with oxygen as an intervention, high risk for falls, bleeding precautions, nausea, edema, weakness, pain. No evidence of problems, goals, interventions on the plan of care: high risk for falls. Patient 10: Identified needs: high risk for falls, edema, urinary catheter, integumentary including active wound, weakness, pain. No evidence of problems, goals, interventions on the plan of care: edema, weakness, high risk for falls. Patient 11: Identified needs: high risk for falls, bleeding precautions, dyspnea with oxygen, mobility, weakness, pain. No evidence of problems, goals, interventions on the plan of care: bleeding precautions, weakness, mobility, high risk for falls. Patient 13: Identified needs: high risk for falls, bleeding precautions, edema, neuro for hallucinations and confusion, aspiration, dyspnea, weakness, pain. No evidence of problems, goals, interventions on the plan of care: bleeding precautions, dyspnea, edema, aspiration.

Upon patient record review, 4 of 19 (Patient #2,3,4,9) 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. All COS: Patient 2,3: Plan of care with order for Miralax: Miralax 17 grams by mouth every morning as directed. There is no evidence of dilutants on the plan of care. Patient 4: Plan of care with order for Miralax: Miralax 17 grams by miscellaneous every morning as directed. There is no evidence of appropriate route or dilutants on the plan of care. Patient 9: Plan of care with the following orders: Miralax 17 grams by mouth every morning as directed. There is no evidence of dilutants plan of care. Triamcinolone acetonide 0.1 percent ointment topical. 1 dose to affected area 4 times daily as needed. There is no evidence of application site plan of care. Fluticasone propionate spray – inhale 100mcg of fluticasone propionate (50mcg/actuation spray, suspension) into nostril daily. There is no evidence of instructions re: which nostril plan of care. Lidocaine adhesive patch. Apply 2 adhesive patch, medicated of lidocaine (4 percent patch) topically daily. There is no evidence of application site or on/off instructions plan of care.

Upon patient record review, 1 of 19 (Patient #1) 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: Identified DME needs not on the plan of care: hospital bed with alternating pressure pad, overbed table, high back wheelchair.

Upon client record review, 1 of 19 (Patient #14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 14: Physician's respiratory visit frequency order is monthly. There is evidence of RT visit made only 11/04/2024.

Upon patient record review, 1 of 19 (Patient #18) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 18: There is no evidence of contact for bereavement before or after patient expired.

Upon patient record review, 3 of 19 (Patient #1,2,3) 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 Patient 1,2,3: There is no evidence of stated frequencies for aide tasks on the aide care plans. COS Patient 1: There is no evidence of aspiration precautions on the aide care plan COS Patient 2,3: There is no evidence of oxygen order on the aide care plan. COS

Upon patient record review 1 of 19 (Patient #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 Patient 10: Physician's aide visit frequency order is twice weekly, written 12/13/24. There is no evidence of aide visit made until the week of 12/16/24.

Upon patient record review 2 of 19 (Patient #3,5) 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. Patient 3: Aide supervisory visits documented 12/10/24 and 12/26/24, 16 days apart. There is no evidence of aide supervisory visit between these dates. Patient 5: Aide supervisory visits documented 11/22/2024 and 12/20/2024, 28 days apart. There is no evidence of aide supervisory visit between these dates.

Upon patient client record review, 6 of 19 (Patient #1,5,6,9,11,12) 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 All COS: Patient 1: Hospice Election Statement: attending physician election has physician’s name only. No NPI or address filled in. Election addendum signed by responsible party 09/30/2022. No reason given re: patient cannot sign, despite section provided on document. Patient 5: Hospice Election Statement: attending physician election has physician’s name and NPI only. No address filled in. Patient 6: Hospice Election Statement: no evidence of effective date of hospice election, despite section provided on document. Patient 9: Hospice Election Statement: attending physician election has physician’s name and NPI only. No address filled in. Section at top of document: Medicare election/Medicaid election. Neither is chosen despite patient being a Medicare beneficiary. Patient 11: Hospice Election Statement: attending physician election has physician’s name and NPI only. No address filled in. Responsible party’s signature is not dated. Informed consent was signed by responsible party. No reason is given re: patient cannot sign, despite section provided on document. Patient 12: Hospice Election Statement: attending physician election has physician’s name and NPI only. No address filled in.

Upon inpatient contract review, 1 of 2 (contract-Greens at Spruce Pine) did not have evidence that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Does not contain verbiage that discharge summary will be provided to hospice at time of discharge from one level of care to another when patient is a resident of facility. COS

Upon patient record review, 1 of 13 (Patient # 5) did not have evidence that the patient's choice a health care provider, including an attending physician was honored. Pt # 5 - On the election statement, the patient chose an attending. The attending physician signed the verbal order for hospice, but the patient initial orders went to the hospice physician. There was no other evidence the attending was involved in the patient's care.

Upon patient record review 1 of 13 (Patient #8) 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 Pt #8 - no evidence of psychosocial assessment having been completed.

Upon patient record review, 1 of 13 (Patient # 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: Pt #10 - Medication profile for patients oxygen read - inhale 2-4 liters of oxygen as directed, As Directed, Initial dose 4 liters. No evidence of route or frequencies (nasal cannula vs mask and no continuous or prn noted.) (COS)

Upon patient record review, 1 of 13 (Patient #12) 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 # 12 - Medical treatment orders dated 2/1/22 state New medication: take 30 mg in the am and 20 mg in the pm times 2 days. Then take 20 mg bid x 2 days. then take 20 mg in the am and 10 mg in the pm x 2 days. then resume 10 mg bid daily dosage. Dosage form: tablet. Medication indication: Dyspnea (DC on 2/6/22) No name of medication found on order.

Upon patient record review, 1 of 13 (Patient # 1) 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. Pt #1 - No evidence of DME or supplies listed on patients plan of care. Pt was in hospital bed, using incontinence supplies (COS)

Upon patient record review, 1 of 13 (Patient # 8) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Pt # 8 - On initial assessment visit 12/29/21, documentation says that pt and caregiver have said yes to SW to assist with 5 Wishes and possible respite care. First SW visit noted was 1/28/22 although calls were attempted and made.

Upon patient record review, 2 of 7 (Patient #4, 10) 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 #4 - Pt on Coumadin. Bleeding precautions not listed on aide plan of care Pt #10 - Pt is on Coumadin for A fib and has a history of falls. No bleeding precautions listed on aide plan of care

Upon patient client record review, 1 of 13 (Patient #1) 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 #1 - Comfort protocol orders for this patient dated 10/13/21 - the signature lines says Physician name/nurse signature for verbal order. This says Dr. B/LC, RN. Under the physician signature line - it is signed by JP, DNP NP-BC dated 1/13/22. No evidence that this was signed by the provider who wrote the order.