Every finding on record at Hospice of Surry County

It is required that each patient’s individualized written plan of care: reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) active clinical records reviewed, the agency did not ensure the written plan of care reflected patient and family goals, and planned interventions based on problems identified in the comprehensive assessment. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/21/2025 with a diagnosis of Parkinson's disease. The Registered Nurse (RN) documented on the initial assessment dated 03/21/2023, "patient needs medications to help manage symptoms of constipation, agitation, and nausea. Will order at today's visit." The RN also documented that the patient had dysphagia [difficulty swallowing], chokes easily, and was on aspiration precautions and that Ativan [prescribed for treatment of anxiety and agitation] and Zofran [prescribed for treatment of nausea] were ordered for the patient. The RN documented on the comprehensive assessment dated 03/25/2025 that the patient had agitation and dysphagia. The plan of care dated 03/21/2025 did not include planned interventions and goals related to the patient’s anxiety and dysphagia identified in the initial and comprehensive assessments. During joint review of the clinical record and interview on 05/29/2025, the Clinical Director agreed the plan of care should have included goals and interventions for the patient’s anxiety and dysphagia identified in the assessments.

It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) active clinical records reviewed, the agency did not ensure the nursing needs of the patient were met as identified in the patient’s updated assessments. CLINICAL RECORD 9: The patient elected the hospice benefit on 04/28/2025 with a diagnosis of neurocognitive disorder with Lewy Bodies. The patient resided at a skilled nursing facility (SNF). Review of the clinical record revealed the Registered Nurse (RN) documented on the nursing visit note dated 05/20/2024 the patient was "uncommunicative, confused, lethargic. Patient sleeping with mouth open, snoring very loudly. The nurse tried to wake [the patient], but [patient] didn't respond. O2 sat [oxygen saturation] 80% on room air, RR [respiratory rate] 26 labored, NP [nurse practitioner] contacted and gave orders for Oxygen, Morphine, Ativan, and Atropine drops." The medications were added to the hospice medication profile on 05/20/2025. There was no documentation in the clinical record that the RN followed up with the SNF to ensure that the medications had arrived and if there were any changes or improvements in the patient’s condition. On 05/25/2025, the hospice weekend triage company took a call from the SNF and documented "[Facility] RN called to notify that she gave a first dose of morphine today at 0539. O2 was 84%. Patient nodded 'yes' that he/she was experiencing pain, and he/she was fidgeting. [Facility RN] also gave atropine for secretions. Morphine did help with pain, and O2 up to 93%. The family has been notified." There was no documentation to show that the contracted triage agency had relayed the message to the hospice on-call RN and there was no documentation that the hospice followed-up with the SNF or made a visit to the patient. The RN next visited the patient on 05/27/2025, 7 days after initial comfort medications were ordered for the patient due to the patient’s symptoms of distress. The RN documented on the nursing visit note dated 05/27/2025, the patient was "minimally responsive, morphine given to patient at 0530 this morning. Spoke with the patient's spouse and made aware." During an interview with the Chief Clinical Officer and the Clinical Manager on 05/29/2025, the agency’s best practices and nursing expectations were discussed. They confirmed that the RN did not follow up on the patient’s symptoms and status appropriately according to the agency’s expectations and best practices.

Upon patient record review, 1 of 16 (Patient #8) 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 #8 - RN note of 5/4/22 states pt received an enema for abd discomfort. RN documents that the family wants medicine for gas. The MD office was called by RN and asked for a call back. 5/5/22 - RN asked by pt to make another visit where a fleets enema was given after a rectal exam. No follow up with patient about request for medication from MD. No follow up with pt noted in EMR for the abd discomfort. Next visit 5/18/22 .

Upon patient record review, 1 of 16 (Patient #16) 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 #16- In patient alert - Morphine elixir has been stolen from patients home in the past. Please count meds at each visit. Lock box present in home. No evidence of this in the patient care plan.

Upon patient record review, 1 of 2 applicable (Patient #6) 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 #6 - No evidence that the bereavement care plans were updated to reflect quarterly calls.

Upon patient record review, 1 of 12 applicable (Patient #6) 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 #6 - Documentation states patient is on Eliquis. No bleeding precautions listed on aide plan of care.

Upon patient record review 5 of 12 applicable (Patient #1, 5, 6, 8, 14) 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 1, 6 - Pt's plan of care by the RN states Bed Bath or Shower. Pt/caregiver is functionally and cognitively able to make the choice. There is no evidence that the aide asked or provided a bath or a shower on patients. Not specific as to care being provided. Patient 5 - Aide care plan included fingernail trim 2x/month, no evidence aide completed the fingernail trim 2xmonth for May. Patient 8 - Aide care plan included nail care, for Nail care, aide documented not completed Nail care not needed at this time. Patient 14 - Aide visit orders 5X/week. Week of 5/29- 6/4 - 4 visits documented this week. No evidence of refusal of visits.

Upon patient client record review, 1 of 16 (Patient #14) 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. Patient #14- SW IDG note states - "SW has not seen the patient since the last IDG due to VFO." Agency policy states approved abbreviations are listed in the Medical Abbreviations approved book or addendum. VFO is not on the agency approved addendum list. (Corrected on site)