Every finding on record at Hospice of Surry County, Inc

Based on clinical record review, agency investigative documents, and staff interview, the agency failed to provide appropriate pain control/symptom management for 1 of 3 charts reviewed [#1]. The findings included: --- Patient # 1 was admitted to the inpatient unit on 1/16/26 with a terminal diagnosis of chronic respiratory failure. Review of the agency schedule revealed RN # 1 and hospice aide # 2 were assigned to care for the patient 7p-7a on 1/16/26-1/17/26. Review of the hospice aide plan of care revealed hospice aide # 2 documented she provided care for patient # 1 on 1/16/26 at 7:00 pm, 8:23 pm, 9:20 pm, 11:00 pm, and on 1/17/26 at 1:35 am, 5:10 am, and 5:27 am. Review of a witness statement-internal investigation form dated 1/21/26 and completed by RN # 1 stated, “Nightshift at ______ [IPU name] 1/16/26-working with ______ [hospice aide # 2] around 4 am ...Family in ___  [room number] called to desk and asked if nurse was bringing pt [patient] medicine. When I entered the room, two daughters at bedside and said their mom was having a lot of trouble breathing and CNA [hospice aide # 2] had told them 45 minutes ago that nurse was on the way. I had not been notified of any patient change or need...” Review of the minutes of a phone conversation with hospice aide # 2 and the Vice President of Clinical Services dated 1/19/26 revealed the following information, “...I asked ______ [hospice aide # 2] what her recollection of Friday nights [1/16/26] events was [sic]. Below is the conversation...She said around 10 pm she noticed she felt like a heavy fog came over her mind and she couldn’t make clear words...She could not recall any of the specific patient care events for the night...” Review of hospice aide # 2’s time card/punch history revealed she did not punch out for until 6:16 am on 1/17/26.

Based on clinical record review, agency investigative documents, and staff interviews, the agency failed to ensure the hospice patient’s/family members right to refuse treatment by a specific inpatient staff member was honored for 1 of 3 charts reviewed [1]. The findings included: --- Patient # 1 was admitted to the inpatient unit on 1/16/26 with a terminal diagnosis of chronic respiratory failure. Review of the agency schedule revealed RN # 1 and hospice aide # 2 were assigned to care for the patient 7p-7a on 1/16/26-1/17/26. Review of the hospice aide plan of care revealed hospice aide # 2 documented she provided care for patient # 1 on 1/16/26 at 7:00 pm, 8:23 pm, 9:20 pm, 11:00 pm, and on 1/17/26 at 1:35 am, 5:10 am, and 5:27 am. Review of a witness statement-internal investigation form dated 1/21/26 and completed by RN # 1 stated, “Nightshift at ______ [IPU name] 1/16/26-working with ______ [hospice aide # 2] around 4 am ...Family in ___  [room number] called to desk and asked if nurse was bringing pt [patient] medicine...family stated CNA [hospice aide # 2] was distressing patient with unusual behavior and statements. When _____ [name of hospice aide # 2] came back into the room she stated, “Can I join the party?” ...CNA [hospice aide # 2] left room after multiple requests to do so from RN, family stated they did not want her back in patient’s room. When I left patient room CNA [hospice aide # 2] was in hallway...I told ______ [hospice aide # 2] not to go back in room ____ [patient’s room number] ... ____ [hospice aide # 2] went back into room ______ [patient’s room number] after clear directions not to...” RN # 1 nor hospice aide # 2 were available for interview. During an interview with the Vice President of Clinical Services on 2/17/26 at approximately 3 pm it was confirmed the patient’s/family members request for hospice aide # 2 was not honored.

It is required that each patient’s individualized written plan of care reflects patient and family goals, 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 2 of 20 (10%) of active records reviewed revealed that the agency did not ensure that planned interventions were identified based on problems identified in the comprehensive assessment. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease. The patient had a secondary diagnosis of Barrett's esophagus. RN documented on the comprehensive assessment dated 03/19/2025 that the patient had dysphagia, "dysphagia with medications and foods at times, takes medications with applesauce." RN documented again on 03/28/2025 "dysphagia, aspiration precautions." There was no documented evidence found on the initial plan of care dated 03/17/2025 or the updated POC dated 03/19/2025 that the RN had ensured that there were planned interventions based on the problem of dysphagia identified in the RN assessments. In an interview with the clinical director on 06/04/2025, she confirmed there were no interventions on the patient's written plan of care. CLINICAL RECORD 12: The patient elected the hospice benefit on 04/12/2025 with a diagnosis of Malignant neoplasm of the Colon. On the initial certification of terminal illness dated 04/12/20205 and signed by the MD on 04/14/2025, it was documented that the patient has an ileostomy and is status post port a cath placement. On the RN comprehensive assessment dated 04/15/2025 the RN documented "ileostomy present, filled with loose stool." The plan of care dated 04/12/2025 contained orders "SN to flush port a cath once monthly per protocol using normal saline and heplock." During review of the problems, goals and intervention there was no documented evidence of planned interventions or patient and family goals for the ileostomy or port a cath access. In an interview with the clinical director on 06/04/2025, she confirmed there were no interventions on the patient's written plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 20 (5%) of clinical records reviewed revealed that the agency did not ensure that measurable outcomes were included on the patients written plan of care. CLINICAL RECORD 11: The patient elected the hospice benefit on 03/17/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease and a secondary diagnosis of Chronic respiratory failure with hypoxia and interstitial pulmonary disease. The patient was taking opioids and breathing treatments daily for shortness of breath. On 04/03/2025 the RN documented "patient does feel her breathing is getting worse, O2 sat 84% on 8L after walking from bathroom to her chair initially, approximately 20ft." On 4/03/2025 a problem of "Gas exchange/breathing patterns impaired due to disease process" was added to the plan of care. There was no documented evidence of measurable goals found on the plan of care, or any updated plans of care dated 04/21/2025, 04/24/20205, or 05/01/20205. In an interview with the clinical director on 06/04/2025, she confirmed no measurable outcomes were included on the patient's written plan of care.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review and observation. In 1 of 6 (17%) home visits observed, the agency did not ensure that clinical staff followed hand hygiene procedures in accordance with the agency's policy. POLICY AND PROCEDURES: The agency's Hand Hygiene policy stated, in part, that "Hospice team members must perform hand hygiene at a minimum before and after touching a patient." HOME VISIT 3: During this home visit on 06/03/2025 by a social worker (PRR#3) with a patient (CRR#3) in the patient's home, the social worker was observed holding the patient's hand and touching the patient's immediate area, including her blanket. The social worker then touched her laptop without following hand hygiene procedures as outlined in agency policy.

It is required that the hospice inpatient facility provides meals to each patient that are palatable, attractive, and served at the proper temperature. This standard was not met as evidenced by document review, interview and observation. A tour of the kitchens in the IPUs revealed that the agency did not ensure that the food being served to patients was at the proper temperatures as per agency policy. POLICY AND PROCEDURES: The agency's Dietary Department: Food Preparation and Storage policy (policy number PC.IPU05, last revised 03/19/2025) stated, in part, that "Foods are served at proper temperatures within the following guidelines: the minimum hot temperature is 135 degrees or higher; the maximum cold temperature is 41 degrees or lower; re-heated food must reach 165 degrees for 15 seconds." IPU VISIT 1: During a tour of IPU 2 on 06/04/2025, no food temperature check logs were found nor could be produced. The kitchen included convenience and frozen foods that could be heated as needed and served to patients without needing additional preparation. During an interview on 06/04/2025 with a Certified Nursing Assistant (CNA) who identified herself as a member of the IPU staff who prepared food for patients, she stated that she used a stick thermometer to make sure hot food reached the proper temperature, but that these temperatures were not recorded. During an interview on 06/04/2025 with the Executive Director of Inpatient Units (PRR#15), she stated that there was currently no process in place to record food temperatures to verify compliance with the Food Preparation and Storage policy. IPU VISIT 2: During a tour of IPU 1 on 06/04/2025, no food temperature check logs were nor could be produced. The kitchen included ingredients and necessary tools to prepare food from scratch, along with convenience and frozen foods. During an interview on 06/04/2025 with a cook who was actively involved with food preparation, he stated that he checked all patient food at the time of preparation for temperature with a stick thermometer and that this temperature was logged in a temperature check logbook. The surveyor requested to review this logbook. An interview on 06/05/2025 with the Executive Director of Inpatient Units (PRR#15), confirmed that a food temperature check logbook was not being maintained in order to verify compliance with the agency's Food Preparation and Storage policy. A tour on 06/04/2025 of the kitchen in the agency's IPU 2 revealed that the agency did not ensure that the food being served to patients was at the proper temperatures as per agency policy.

Upon patient record review, 2 of 20 (Patient #1, 6) 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 The medication profile reveals duplicative Haldol orders dated 6/10/22 and 6/19/22. Patient #6 There was documentation on the 6/20/22 RN focused assessment note and on the 6/14/22 IDG DME update that the patient was on O2 at 5L however oxygen not included on the medication profile.

Upon patient record review, 20 of 20 (Patients #1-20) 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 1-20 The current standing orders for home/IPU contain PRN orders with no qualifiers.

Upon patient record review, 2 of 20 (Patient #1, 4) 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 5/24/22 plan of care DME not inclusive of all equipment- reads DME as needed. Patient was on oxygen. Patient #4 The 5/3/22 plan of care did not include hospital bed in DME but nursing notes indicate hospital bed in the home.

Upon client record review, 20 of 20 (Patient #1-20) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1-20 There is no current evidence in IDG's notes to date.

Upon client record review, 1 of 20 (Patient #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #12 The 5/5/22 plan of care reads N 1xweek with no visits in EMR from 5/9/22-6/2/22 and with no missed visit explanation to date.

Upon patient record review, 9 of 13 applicable (Patient #2,4,6,7,8,11,14,15,19) 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 #2,4,6,7,8,11,14,15,19 The RN Aide assignments are missing associated task frequencies for tasks assigned.

Upon patient client record review, 1 of 20 (Patient #11) 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 #11 The scanned in 5/18/22 aide visit note contains a signature and date with no associated credentials.

Upon observation, there was no 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 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 inside Oxygen storage at the Yadkinville IPU did have a designate space and label for full/empty however space did not allow adequate room for differentiation causing storage to be combined.