Every finding on record at Hospice and Palliative Care of the Piedmont, Inc.

Based on record reviews and interview, the hospice staff failed to include measurable data elements to show the status of identified outcomes and the patient's progress made toward goals for 7 of 9 applicable patient charts. (Patient #2, #3, #6, #8, #17, #18 and #19) --- Patient #2 Chart review on 3/06/2023 at 2:15 PM reveals Patient #2 admitted on 11/28/2022 with diagnosis of Lung and Bladder Cancer. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". Patient #6 Chart review on 3/06/2023 at 2:30 PM reveals Patient #6 admitted on 09/09/2022 with diagnosis of Chronic Kidney Disease state III and Pulmonary Emboli. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". Patient #8 Chart review on 3/06/2023 at 2:30 PM reveals Patient #8 admitted on 05/07/2022 with diagnosis of Alcohol Abuse and Liver Cirrhosis. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". Patient #17 Chart review on 3/06/2023 at 2:30 PM reveals Patient #17 admitted on 05/17/2022 with diagnosis of Malignant Prostate Cancer with Bone Metastasis. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". Patient #18 Chart review on 3/06/2023 at 2:30 PM reveals Patient #18 admitted on 10/14/2022 with diagnosis of Chronic Obstructive Pulmonary Disease. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". The Findings include: Patient #3 Chart review on 3/06/2023 at 2:05 PM reveals Patient #3 admitted on 12/06/2022 with diagnosis of Malignant Neoplasm of Prostate. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data". Patient #19 Chart review on 3/07/2023 at 1:50 PM reveals Patient #19 admitted on 12/19/2022 with diagnosis of Parkinsons. There is no documentation in the patient chart of data to show outcomes towards goals. Interview on 3/08/2023 at 9:30 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings...dont assign actual data".

Based on observations and interview, the hospice failed to ensure 1 of 1 Registered Nurse (RN #1) and 1 of 1 Hospice Aide (HA #2) observed in the provision of patient care failed to follow accepted standards for infection control for 2 of 4 applicable patients observed. (Patient #3 and Patient #4) --- The findings include: On 3/06/2023 from 12:30 PM and 1:00 PM, observations during a visit in Patient #3s home revealed Registered Nurse (RN) #1 failed to sanitize his/her notebook and pen prior to replacing the items into the equipment bag. On 3/06/2023 at 1:00 PM, RN #1 verified the finding. On 3/07/2023 from 9:01 AM to 9:28 AM, observations during a visit in Patient #4s home revealed Certified Nurse Assistant (CNA) # 2 performing the patient's bed bath. CNA #2 changed the water to clean the patients perineal area, and then used the same water to wash the patients back and buttocks. In an interview with CNA #2 on 3/07/2023 at 9:28 AM, CNA #2 verified the finding.

Based on record reviews and interview, the hospice failed to ensure its staff completed an active Bereavement Plan of Care (POC) for 3 of 10 applicable patients reviewed for care and bereavement services. (Patient #7, #9 and #15) --- The findings are: Record review on 3/6/2023 at 1:00 PM the Chaplain or Social Worker did not complete a pre-bereavement assessment on Patient #9. Record review on 3/6/2023 at 1:00 PM the Chaplain or Social Worker did not complete the after-death bereavement on Patients #9, #15 and #20. This information is confirmed on 3/8/2023 at 10:00 AM in an interview with the Chaplain #9. The Findings include: Patient #7 Chart review on 3/07/2023 at 11:06 AM reveals Patient #7 expired on 10/09/2023. There is no documentation in the chart of a post death bereavement being completed. Staff documents will ";inactivate from bereavement if no response" on 12/30/2022, ";will inactivate from bereavement on 1/04/2023 and Chaplain attempt on 1/14/2023 reports ";spoke on the phone. Mrs. Strickland said she was ";on the road" and could this chaplain call later. Chaplain asked if she could describe a time that would be better to contact her. She said around 5:30 or 6 PM in the evenings. This chaplain works late one day per month and will attempt to contact Mrs. Strickland a third time in the evening next month". Interview on 3/08/2023 at 10:10 AM Home RN Manager reports. ";bereavement has been unable to speak with the spouse...wants them to call back later in the evening but doesnt answer...our policy to make a condolence call within 72 hours of death and again to contact 4-8 weeks after Condolence Call".

Based on record reviews and interview, the hospice staff failed to ensure the Hospice Aide Plan of Care (HAPC) was specific and individualized for each patient. Review of the hospice aide's plan of care revealed a generic HAPC that had no individualization in the plan of care for 8 of 8 HAPCs reviewed. (Patient #1, #2, #6, #8, #9, #12, #16 and #20) --- Patient #20 Chart review on 3/07/2023 at 1:21 PM reveals Patient #20 admitted on 12/20/2022 with diagnosis Malignant Neoplasm of Unspecified Ovary. Certified Nursing Assistant (CNA) # Plan of Care reports visit schedule 1-3 x a week and Pro Re Nata (PRN) visits. CNA POC must be specific for visit dates with individualized care by the Registered Nurse (RN). Interview on 3/08/2023 with Home RN Manager reports ";we use standing orders for schedules...change at IDT meetings". The findings are: Record view on 3/7/2023 4:00 PM reveals a generic Health Aide Plan of Care ( HAPC) which offers no detail for an individualized plan, for 9/17 HAPC inspected. Patients #1, #2, #4, #6, #8, #9, #12, #16 and #20 did not individualized HAPC in their records. This is confirmed with Homecare Manager #5 and the Director of Clinical Services #7 on 3/8/2023 at 10:00 AM. Facility policy number PC.H25 (10/1/2022) reads: 2. Hospice aide services are assigned based on the comprehensive assessment and reassessment of the patient's personal care needs and ability to perform activities of daily living. 3. The hospice RN develops a written hospice aide plan of care that provides instructions to the hospice aide of the patient-specific care to be provided.

Based on record reviews and interview, the hospice staff failed to provide updated assessments for the Plan of Care (POC) for 3 of 9 applicable patients. (Patient #2, #3 and #19) --- The Finding includes: Patient #3 Chart review on 3/06/2023 at 2:05 PM reveals Patient #3 admitted on 12/06/2022 and no documentation of updates to the POC. The interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss changes at Interdisciplinary Team (IDT) meetings". Patient #19 Chart review on 3/07/2023 at 1:50 PM reveals Patient #19 admitted on 12/19/2022 and no documentation of updates to the POC. Interview on 3/08/2023 at 9:30 AM Home RN Manager reports ";we discuss progress at Interdisciplinary Team (IDT) meetings". Patient #2 Chart review on 3/06/2023 at 2:00 PM reveals Patient #2 admitted on 11/08/2022 and no documentation of updates to the POC. The interview on 3/08/2023 at 10:20 AM Home RN Manager reports ";we discuss changes at Interdisciplinary Team (IDT) meetings".