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

Upon patient record review, 1 of 21 (Patient #20) 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. Patient #20-Admitted 7/21/25 with bilateral nephrostomy tubes for urine output, no evidence of urinary interventions/goals on the initial plan of care.

Upon patient record review 3 of 21 (Patient #2,3,7) 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 #2 Aide visits started 6/25/25 and a supervisory visit was completed on 7/14/25, no evidence of a supervisory visit within the 14 days. Patient #3 Aide visits started 6/25/25 and a supervisory visit was completed on 7/15/25, no evidence of a supervisory visit within the 14 days. Patient #7 Aide visits started 7/7/25 and a supervisory visit was completed on 7/23/25, no evidence of a supervisory visit within the 14 days.

Upon patient record review, 2 of 21 (Patient #1,7) 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 Patient #1, #7-Upon SOC notification of non-covered items addendum was requested, no evidence that was provided.

Upon patient record review, 4 of 13 (Patients #3, 4, 6, 12) 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 The med profile reads O2 @ 2l prn and Mirtazapine 5mg 1 po qhs prn with no qualifier. Patient #4 There is a One time dose of Ferrous Sulfate on 5/6/22 that is still active on the medication profile. Patient #6 The nursing visit on 7/18/22 indicates patient using oxygen at 10LPM via NC however oxygen not on medication profile. Patient #12 The med profile reads O2@2-4L prn with no qualifier.

Upon patient record review, 1 of 13 (Patient #2) 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. Patient #2 Active diagnosis of DM and on insulin, interventions do not include interventions specific to frequency of accuchecks.

Upon patient record review, 7 of 13 (Patients #1, 3, 5, 6, 8, 11, 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. Patient #1 The 7/23/22 order reads foley to BSD if needed with no specification to size of foley or if needed descriptive. The 7/25/22 order reads bedside suctioning prn with no qualifier. Patient #3 Order for O2 @ 2l prn and Mirtazapine 5mg 1 po qhs prn with no qualifier. Patient #5 The 6/18/22 poc reads change foley monthly and prn with no qualifier. Patient #6 The 7/25/22 wound care order contains no wound location. Patient #8 The 7/16/22 and 7/18/22 wound care orders contain no frequency for the wound care. Patient #11 The 7/2/22 wound care order contains a frequency of weekly and prn with no qualifier. Patient #12 Order for O2@2-4L prn with no qualifier.

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #7 There is no evidence of competency on file to date.

Upon patient record review 3 of 10 applicable (Patients #2, 6, 8) 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 #2 The aide documented hair care not scheduled on visits 7/21/22, 7/22/22 and 7/26/22 however hair care was a q visit task according to the aide care plan. Patient #6 The aide documented declinations or no need for wound care on visits 7/18/22-7/27/22, aide was to cleanse with soap and water every visit. Patient #8 The aide documented hair care/nail care not scheduled on visits 7/11/22- 7/15/22 however hair care was a q visit task according to the aide care plan. The 7/2/22 poc reads A5xweek however no aide visits made week of 7/2/22 with no rationale documented to date.

Upon personnel record review, 2 of 16 (Personnel #4, 7) 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 #4, 7 contain no competency on file to date.

Upon patient client record review, 2 of 13 (Patients #1,3) 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 #1 The nursing visits on 7/23/22 and 7/24/22 contain RN signatures with no credentials. Patient #3 The nursing visit on 7/7/22 contains RN signature with no credentials.

Upon client record review, 13 of 13 (Patients #1-13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. The policy and procedure is not included nor is it a current practice upon interview with the Administrator.