Every finding on record at Hospice of Davidson County North Carolina, Inc.

Upon patient record review, 4 of 21 (Patient #1,10,11,16) 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 #1-5/16/25 Orders for Diclofenac 1% gel, apply 1 dose topically 4x/day, no evidence of location to apply gel on medication profile. Corrected on Site. Patient #10-4/21/25 Orders for Nystatin Powder Q12 PRN, no evidence of location to apply powder on medication profile. Corrected on Site. Patient #11-1/30/25 Acetaminophen 325mg tab, admin 2 tabs Q6 PRN and 2/12/25 Acetaminophen/Hydrocodone 325/5mg, admin 1 tab Q4 PRN exceed the maximum dosage of 4g, no evidence of maximum allowable parameters medication profile. Corrected on Site. Patient #16-3/17/25 Orders for Diclofenac 1% gel, apply 1 dose topically BID, no evidence of location to apply gel on medication profile. Corrected on Site.

Upon patient record review, 1 of 21 (Patient #13) 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 #13-5/17/25 Call received after hours by on call RN stating patient with increased anxiety, medication was given per orders but were ineffective, no evidence of SN visit was made to assess the change in patient status.

Upon patient record review, 5 of 21 (Patient #1,4,10,11,16) 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 #1-5/16/25 Orders for Diclofenac 1% gel, apply 1 dose topically 4x/day, no evidence of location to apply gel on the plan of care. Corrected on Site. Patient #4-4/29/25 NP states patient has a wound, no evidence of wound care orders on the plan of care. Corrected on Site. Patient #10-4/21/25 Orders for Nystatin Powder Q12 PRN, no evidence of location to apply powder on plan of care. Corrected on Site. Patient #11-1/30/25 Acetaminophen 325mg tab, admin 2 tabs Q6 PRN and 2/12/25 Acetaminophen/Hydrocodone 325/5mg, admin 1 tab Q4 PRN exceed the maximum dosage of 4g, no evidence of maximum allowable parameters on the plan of care. Corrected on Site. Patient #16--3/17/25 Orders for Diclofenac 1% gel, apply 1 dose topically BID, no evidence of location to apply gel on the plan of care. Corrected on Site.

Upon patient record review, 1 of 21 (Patient #5) 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 #5 4/24/25 SN states a wheelchair, hospital bed and bed side table were ordered, no evidence of DME orders on the plan of care. Corrected on Site.

Upon patient record review, 1 of 21 (Patient #4) 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 #4 4/29/25 NP states patient has a wound, no evidence of revised plan of care to reflect wound.

Upon patient record review 1 of 21 (Patient #6) 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. Patient #6 5/12/25 SN narrative states patient/family are requesting to speak with a clinical leader, no evidence that call was made. 4/17/25 Chaplain narrative states "patient biggest concern today is constipation", no evidence that information was shared with the SN. Corrected on Site.

Upon patient client record review, 1 of 21 (Patient #8) 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. Patient #8 4/22/25 MSW visit is verbatim copy & pasted from visit on 3/25/25, no evidence of authenticate visit documentation.

Upon observation, there was no evidence fire drills of a facility are provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. Existing Construction No evidence of 2nd shift fire drill in Quarter 2 of 2024 and Quarter 1 of 2025.

Upon patient record review, 4 of 13 (Patient #1, #2, #4, #9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient #1- The patient was admitted on Oxygen and Oxygen is not on the medication profile. (corrected on site) Patient #2- The medication profile includes Morphine 20mg/ml oral concentrate. Administer 5mg orally every 2 hours as needed for pain, Heart rate <(less than 100) or respiratory rate >24. The correct indication is to administer for Heart rate >(greater than 100) (corrected on site) Patient #4- The medication profile includes Miralax powder for reconstitution 17gm orally every day as needed for constipation. A diluent and amount for reconstitution is not listed. The profile also includes NTG .4mg 1 tab q5min prn chest pain. The maximal allowable number of doses is not listed on the profile. Patient #9- The medication profile includes Miralax powder for reconstitution 17gm orally every day as needed for constipation. A diluent and amount for reconstitution is not listed. (corrected on site)

Upon patient record review, 4 of 13 (Patient #2, #4, #9, #10) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific/accurate orders for all medications and treatments. Patient #2- The 05/21/22 plan of care includes Morphine 20mg/ml oral concentrate. Administer 5mg orally every 2 hours as needed for pain, Heart rate <(less than 100) or respiratory rate >24. The correct indication/order is to administer for Heart rate >(greater than 100) (corrected on site) Patient #4-The 02/04/22 plan of care includes Miralax powder for reconstitution 17gm orally every day as needed for constipation. A diluent and amount for reconstitution is not listed. The plan of care also includes NTG .4mg 1 tab q5min prn chest pain. The maximal allowable number of doses is not listed on the profile. Patient #9- The patient was admitted on 05/04/22 with a suprapubic catheter. The plan of care does not address management of the catheter. On 05/11/22 the RN documents the patient has skin breakdown on the buttocks and barrier cream is being applied. The plan of care was not updated with orders to manage the breakdown. The plan of care includes Miralax powder for reconstitution 17gm orally every day as needed for constipation. A diluent and amount for reconstitution is not listed. (corrected on site) Patient #10-On admission 05/11/22 the nurse documents the patient has a wound to the left buttocks which is to be cleansed with soap and water and a non adherent dressing is to be applied daily. The plan of care does not include the orders for wound care. (corrected on site)

Upon client record review, 6 of 13 (Patient #1, #3, #6, #8, #12, #13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- The Chaplain visited 05/02/22 and orders are not on record for Chaplain. Patient #3- On 05/20/22 the plan of care includes orders for the patient to wear Oxygen at 4 lpm continuously. On 05/23/22 and 06/02/22 the nurse documents the patient is wearing Oxygen at 2 lpm continuously. Patient #6- Effective 04/25/22 the Chaplain is ordered to visit the patient monthly. A visit was not made in May by the Chaplain. There is no documentation regarding the missed visit on record. On 06/06/22 the nurse documents performing wound care to the patients sacral wound. Standing orders for wound care were not written to update the plan of care. (corrected on site) Patient #8- On 01/20/22 the nurse documents implementing standing orders and inserting a Foley catheter. Standing orders for Foley catherization and management were not written to update the plan of care. Patient #12- On 05/14/22 The nurse documents applying Aquacell AG to the patients L heel breakdown. Standing orders for wound care were not written to update the plan of care. (corrected on site) Patient #13- On 04/28/22 the Chaplain was ordered to visit the patient monthly. A visit was not made in May by the Chaplain and there is no documentation of a missed visit.

Upon patient record review, 5 of 9 applicable (Patient #3, #6, #9, #12, #13 ) did not have evidence in the patient record that hospice aide assignments and duties are: Complete and accurate written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of a hospice aide. Patient #3-The patient is on Plavix, Aspirin and Oxygen. The Aide care plan does not include bleeding precautions or Oxygen precautions. (corrected on site) Patient #6- The patient had a Foley catheter that was discontinued 05/06/22. The Aide care plan was not updated and has an assignment to empty Foley catheter and perform cath care. (corrected on site) Patient #9- On 05/11/22 The nurse documents the aide is applying barrier cream to the patients skin breakdown on the buttocks. The Aide care plan is not updated for the barrier cream application. (corrected on site) Patient #12- The patient was admitted 05/12/22 nothing by mouth/tube feedings due to aspiration. The Aide care plan does not include aspiration precautions. (corrected on site) Patient #13-The Aide care plan includes an assignment to change the patients external catheter on each visit. The patient does not have an external catheter. (corrected on site)

Upon patient record review 1 of 9 applicable (Patient # 6) did not evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and included in the plan of care Patient #6-The Aide documented putting ABD pads on the patients sacral wound. Wound care was not an assigned task.

Upon patient record review, 1 of 1 applicable (Patient #4) 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 Patient #4- The patient revoked the election and was discharged on 03/04/22. There is no evidence on record the discharge summary was sent to the attending physician.

Upon observation, there is not evidence the smoke compartmentation and control of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association, NFPA 99, and NFPA 80 Standard for Fire Doors and Other Opening Protectives. The Hospice Inpatient Unit has a rolling cafeteria counter fire door which was last inspected in 2018. There was not evidence all sprinkler system components of a facility are consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. It was observed the hospice inpatient unit had a loosely hanging escutcheon plate around the sprinkler head in the spa and the storage closet in the laundry and vending room. The escutcheon plate was missing in patient room 1 restroom. Upon observation, there was not evidence the storage of medical gases in a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The Oxygen storage room on the Dogwood Hall had Oxygen tanks which were not labeled as empty or full. Upon observation, there was no evidence the electrical of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The Life safety inspection records were incomplete regarding the generator inspections. The weekly generator testing logs had dates only of weekly testing. The logs did not contain the specifics of items tested weekly. The monthly generator logs also had dates only for the monthly testing. Monthly testing logs did not indicate start and stop times, load, and/or transfer times.