Every finding on record at Hospice of Iredell County, Inc.

Upon patient record review, 3 of 29 (Patients #3,6,28) 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 #3: Patient Miralax 17 g (order 2/24/24) was listed without diluent on medication profile. Corrected on Site. Patient #6: Patient has allergy to Tylenol listed on medication profile and indicated at start of care on 2/21/24. This Patient on Norco 2/21/24. Med reconciliation not completed at SOC. Med reconciliation completed late on 3/4/24. Corrected on Site. Patient #28: Patient Miralax 17 g was listed without diluent on medication profile. Corrected on Site.

Upon patient record review, 5 of 29 (Patients #1,4,9,28,29) 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: The record reflected that this patient had a WC and in the home patient had a HB, SC and BST. These items were not included on the Plan of Care. Corrected on Site. Patient #4: This patient had a bed HB and BSC. These were not included on the Plan of Care. Corrected on Site. Patient #9: The record reflected that this patient had an order for Albuterol 0.83% (2/23/24) There was no nebulizer machine include on Plan of Care. Corrected on Site. Patient #28: The record reflected that this patient had a Oxygen Concentrator. This item wasnot included on the Plan of Care. Corrected on Site. Patient #29: The record reflected that this patient had an order for Albuterol 0.83% (3/1/24) There was no nebulizer machine include on Plan of Care. Corrected on Site.

Upon client record review, 1 of 29 (Patient #26) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #26: Did not have evidence that the transfer summary included transfer orders.

Upon observation, there was no evidence the hospice inpatient facility tests their power systems in accordance with NFPA 99 and NFPA 110 including the maintenance and testing of alternate power sources and transfer inspection and testing and maintenance and testing of circuitry. NFPA 110 Part 8.3.7: A fuel quality test shall be performed at least annually using appropriate ASTM standards. The agency is unable to provide evidence of annual fuel quality testing reports for the generator located at the Gordon House or at the Mitchell Mack Hospice Home.

Upon observation, there was no evidence the smoking regulations 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 The Gordon House in patient facility has designated smoking areas located away from the facility designated for family use. There is evidence at the location of smoking that takes place in non-designated areas of the campus, including outside of the Rm 1-8 Hall(cigarette butt noted in the pine straw against the building), under the patio awning (cigarette butt noted in the pine straw over the patio railing) and in the courtyard (cigarette butt noted in the pine straw around the fountain.) The agency does not have posted "No Smoking" signs in non-smoking areas.