Every finding on record at Hospice of Yancey County

Based on policy review, clinical record review and staff interview, the agency failed to include all drugs/treatments on the Plan of Care for 7 of 13 patients (#1, 2, 3, 5, 8, 9, and 10). Findings included: --- A policy, IDG (interdisciplinary group) Care Planning Process (revised 2/22), stated, ";The care of plan [sic] specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions...The plan of care is written to include all services necessary for the palliation and management of the terminal illness and related conditions, including...drugs and treatments necessary to meet the needs of the patient." 1. #1 was admitted 8/11/22 with a diagnosis of cerebral infarction (stroke). The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits two times per week. The initial assessment was conducted on 8/11/22. The note revealed the patient had edema (swelling) to bilateral lower extremities. On 8/12/22, the nurse visit note stated, ";Has compression on BLE [bilateral lower extremities)..." The nurse visit note on 8/16/22 stated, ";Has wraps to BLE and hard to assess edema type." The POC did not include compression wraps for bilateral lower extremity edema. An interview with the clinical director on 9/13/22 at 10:45 a.m. confirmed the compression wraps were not included on the POC. 2. Patient #2 was admitted on 8/16/22 with a diagnosis of Alzheimers disease. The Plan of Care (POC) for 8/16/22-11/13/22 included orders for skilled nursing visits weekly. The initial nursing assessment conducted on 8/16/22 revealed the patient had an indwelling urinary catheter for urinary retention (inability to empty the bladder completely). The POC did not include an order for an indwelling catheter. An interview with the clinical director on 9/13/22 at 9:35 a.m. confirmed the indwelling catheter was not on the POC. 3. Patient #3 was admitted on 8/11/22 with a diagnosis of malignant neoplasm of cervix (opening of the uterus). The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits weekly. On 9/7/22, the nurse visit note stated, ";pt [patient] has as couple of small sores in mouth, she has magic mouthwash and has been using it to help with this." Magic mouthwash was not included on the POC. An interview with the clinical director on 9/13/22 at 11:25 a.m. confirmed magic mouthwash was not on the POC. 4. Patient #5 was admitted on 7/28/22 with a diagnosis of Parkinsons disease. The Plan of Care (POC) for 7/28/22-10/25/22 included orders for weekly nurse visit; and nurse to change indwelling catheter every 30 days and as needed; and to irrigate with normal saline as needed. The catheter size was ordered as 16 Fr. There was no balloon size included in the order; nor was there an amount of normal saline for flush. An update POC was completed for 8/22/22-10/20/22. The update POC included an order for the catheter size 16 Fr with 30 milliliters balloon. There was no amount of normal saline to be used for the flush. An interview with the clinical director on 9/13/22 at 9:45 a.m. confirmed there was no balloon size on the first POC and no flush amount on either POC. 5. Patient #8 was admitted on 2/3/22 with a diagnosis of amyotrophic lateral sclerosis (ALS). The Plan of Care (POC) for 8/2/22-9/30/22 included orders for skilled nursing visits weekly and aide services twice weekly. On 8/15/22, the nurse note stated, ";Hospice CNAs [nurse aides] called Nurse to report PT [patient] fell on 8/13/22...PT hit head and left arm on floor." On 8/24/22, an x-ray was obtained which confirmed a humerus [bone of the upper arm] fracture. On 8/29/22, the nurse visit note stated, ";Nurse picked up arm sling at _____________[pharmacy] and placed it on arm and showed PCG [patient caregiver] how to place it." In an interview on 9/15/22 at 9:05 a.m., the clinical director confirmed the nurse obtained an order but failed to add it to the POC. 6. Patient #9 was admitted on 4/25/22 with a diagnosis of ischemic cardiomyopathy (a condition when heart muscles are weakened as a result of a heart attack or coronary artery disease). The Plan of Care (POC) for 7/24/22-10/21/22 included orders for skilled nursing visits weekly. The nurse visit note on 9/7/22 stated, ";Patient is having surgery on left eye on 9/7/22. Eliquis [blood thinner] held due to MD [physician] order." An interview with the clinical director on 9/15/22 at 9:45 a.m. confirmed the order to hold medication was not updated in the POC. 7. Patient #10 was admitted on 8/20/21 with a diagnosis of chronic kidney disease. The Plan of Care (POC) for 8/15/22-10/13/22 included orders for skilled nurse visits weekly. On 9/6/22, the nurse visit note stated, ";Ted hose [sic] [stockings to help with swelling and blood clot prevention] placed in the am [morning] before [patient] gets [out of bed]. Taken off when she goes to bed at night." Stockings were not included on the POC. An interview with the clinical manager on 9/15/22 at 9:15 a.m. revealed the stockings were on the initial POC but was not included on the most recent POC.

Based on clinical record review and staff interview, the agency failed to assess wounds for 1 of 2 patients with wounds (#1); and to measure abdominal girth for one of one patient with documented ascites (abnormal build-up of fluid in the abdomen) (#3). Findings included: --- 1. Patient #1 was admitted 8/11/22 with a diagnosis of cerebral infarction (stroke). The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits two times per week. The initial assessment was conducted on 8/11/22. The note revealed the patient had a stage 2 pressure ulcer on the buttocks, but there was no further description of the wound or location. On 8/12/22, the nurse visit note stated, ";Has 2 open areas on either side of bottom." There was no evidence of a wound assessment. The nurse visited twice weekly between 8/11/22 and 9/9/22. Between 8/11/22 and 9/13/22, there was no evidence of a comprehensive wound assessment for 11 of 11 visits. An interview with the clinical director on 9/13/22 at 10:45 a.m. confirmed there was no evidence of a comprehensive wound assessment. 2. Patient #3 was admitted on 8/11/22 with a diagnosis of malignant neoplasm of cervix (opening of the uterus), cirrhosis of the liver, and fatty liver. The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits weekly. The interdisciplinary group (IDG) note on 8/24/22 stated, ";ascites will be monitored for increased [sic] in abdominal girth..." There was no evidence that abdominal girth was measured during the nursing visits on 8/24/22, 8/31/22, or 9/7/22. An interview with the clinical director on 9/13/22 at 11:25 a.m. confirmed there was no evidence of abdominal girth measurements.

Based on clinical record review and staff interview the hospice aide conducted a visit prior to the care plan completion for 1 of 6 patients with hospice aide services (#2). Findings included: --- Patient #2 was admitted on 8/16/22 with a diagnosis of Alzheimers disease. The Plan of Care (POC) for 8/16/22-11/13/22 included orders for skilled nursing visits weekly and hospice aide services twice weekly. The aide conducted a visit on 8/18/22 and provided personal care. The aide care plan was not completed by the RN until 8/19/22. An interview with the clinical director on 9/13/22 at 9:35 a.m. revealed the nurse had given the aide a verbal report, but the aide visited prior to the completion of the written care plan.

Based on clinical record review and staff interview, the agency failed to update the hospice aide care plan after a change in condition for 1 of 6 patients that received aide services (#2). Findings included: --- Patient #8 was admitted on 2/3/22 with a diagnosis of amyotrophic lateral sclerosis (ALS). The Plan of Care (POC) for 8/2/22-9/30/22 included orders for skilled nursing visits weekly and aide services twice weekly. On 8/15/22, the nurse note stated, ";Hospice CNAs [nurse aides] called Nurse to report PT [patient] fell on 8/13/22...PT hit head and left arm on floor." On 8/24/22, an x-ray was obtained which confirmed a humerus [bone of the upper arm] fracture. On 8/29/22, the nurse visit note stated, ";Nurse picked up arm sling at _____________[pharmacy] and placed it on arm and showed PCG [patient caregiver] how to place it...PT stated that Hoyer [total mechanical lift] was working well." In an interview on 9/15/22 at 9:05 a.m., the clinical director confirmed the aide care plan was not updated after fracture.

Based on policy review, clinical record review and staff interview, the agency failed to maintain an accurate medication list for 7 of 13 patients (#1, 3, 6, 7, 8, 10, and 11); and accurate hospice aide documentation for 1 of 6 patients with aide services (#8). Findings included: --- A policy, Medication Orders, was provided by the clinical director on 9/13/22 at 11:07 a.m. The policy stated, ";Hospice will minimize errors and misinterpretation of written or verbal medication orders." 1. Patient #1 was admitted 8/11/22 with a diagnosis of cerebral infarction (stroke). The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits two times per week. The initial assessment was conducted on 8/11/22. The note revealed the ";Patient receiving oxygen via Nasal Cannula, Concentrator [sic] at 3 liter per min [minute] PRN [as needed]." An interview with the clinical director on 9/13/22 at 10:45 a.m. confirmed oxygen was not included on the POC. 2. Patient #3 was admitted on 8/11/22 with a diagnosis of malignant neoplasm of cervix (opening of the uterus). The Plan of Care (POC) for 8/11/22-11/8/22 included orders for skilled nursing visits weekly. The nurse visit note from 8/31/22 stated, ";The magnesium oxide ordered for foot cramps gave her diarrhea and she has made the decision to stop taking it." The IDG report for 9/7/22 included the magnesium oxide as a current medication. An interview with the clinical director on 9/13/22 at 11:25 a.m. confirmed magnesium oxide was not discontinued from the POC. 3. Patient #6 was admitted on 7/30/21 with a diagnosis of chronic obstructive pulmonary disease (COPD-a lung disease). The Plan of Care for 8/24/22-10/22/22 included orders for skilled nursing visits weekly. A review of the Active Medications document revealed the following medications were listed twice: · PreserVision (supplement) 2 capsules daily · Xarelto 20 mg tablet daily used to prevent blood clots · Spiriva inhaler 18 mcg inhaled once daily for breathing An interview with the clinical director on 9/13/22 at 9:35 confirmed the medications were listed twice. 4. Patient #7 was admitted on 7/7/22 with a diagnosis of malignant neoplasm to the colon. The Plan of Care (POC) for 7/7/22-10/4/22 included orders for skilled nursing visits weekly. The POC included orders for hydrocodone-acetaminophen 5-325 tablet 1-2 tablets every 4 hours as needed for pain AND hydrocodone-acetaminophen 5-325 tablet 1 tablet every 4 hours as needed for pain. An interview with the clinical director on 9/13/22 at 9:30 confirmed the medication was listed twice. 5A. Patient #8 was admitted on 2/3/22 with a diagnosis of amyotrophic lateral sclerosis (ALS). The Plan of Care (POC) for 8/2/22-9/30/22 included orders for skilled nursing visits weekly. The POC included order for lorazepam 0.5 mg every 6 hours as needed for anxiety AND lorazepam 0.5 mg every 4 hours as needed for anxiety. The POC also included orders for oxygen 2-5 liters per min (lpm) AND oxygen 1-10 lpm as needed to maintain an oxygen sat of greater than 90%. An interview with the clinical director on 9/13/22 at 9:20 confirmed the oxygen had two different orders. 5B. Patient #8 was admitted on 2/3/22 with a diagnosis of amyotrophic lateral sclerosis (ALS). The Plan of Care (POC) for 8/2/22-9/30/22 included orders for skilled nursing visits weekly and aide services twice weekly. On 8/15/22, the nurse note stated, ";Hospice CNAs [nurse aides] called Nurse to report PT [patient] fell on 8/13/22...PT hit head and left arm on floor. PT state she was hurting too bad to allow CNAs to give shower because any movement of LUE [left upper extremity] caused pain..." The aide documentation from 8/15/22 stated, ";Nothing unusual to report." On 8/18/22, the nurse visit note stated, ";PT had a fall last weekend...Today, hospice CNAs went to home to give shower and PTs lt [left] arm with bruising now, some swelling, and continued c/o [complaints of] pain when arm is moved/touched. Nurse went to home to assess arm..." The aide documentation from 8/15/22 stated, ";Nothing unusual to report." An interview with the clinical director on 9/13/22 at 9:20 confirmed the documentation did not accurately reflect the aides reporting of the patients condition. 6. Patient #10 was admitted on 8/20/21 with a diagnosis of chronic kidney disease. The Plan of Care (POC) for 8/15/22-10/13/22 included orders for skilled nurse visits weekly. The POC revealed the following medications were listed twice: · Acetaminophen 650 mg suppository rectally every 6 hours as needed for pain/fever · Allopurinol 300 mg tablet daily for gout · Amlodipine 10 mg tablet at bedtime for blood pressure · Bumetanide 1 mg tablet three times weekly for swelling · Dulcolax 10 mg suppository rectally once daily as needed for constipation · Lasix 20 mg tablet take ½ pill daily as needed for swelling · Letrozole 2.5 mg tablet every other day for cancer treatment · Mirtazapine 30 mg tablet at bedtime for insomnia · Morphine 5-10 mg (0.25 ml-0.5 ml) orally or under tongue every hour as needed for pain/shortness of breath. An interview with the clinical director on 9/15/22 at 9:15 a.m. confirmed the POC included duplicate medications. 7. Patient #11 was admitted on 6/1/22 with a diagnosis of polycythemia vera (a type of blood cancer). The Plan of Care (POC) for 8/30/22-11/27/22 included orders for skilled nurse visits weekly. The POC included orders for oxygen 2-10 liters per minute (lpm) via nasal cannula continuously AND oxygen 1-10 lpm via nasal cannula as needed to maintain oxygen levels greater than 90%. An interview with the clinical director on 9/15/22 at 9:20 a.m. confirmed there were 2 oxygen orders on the POC.

Based on policy review and staff interview, the Mandatory COVID-19 Vaccination Policy failed to include all required components. Findings included: --- The Mandatory COVID-19 Vaccination Policy was provided by the agency director on 9/14/22 at 1:10 p.m. The policy applied to all employees but failed to include licensed practitioners, students, trainees, volunteers, and individuals who provide care, treatment, or other services for the hospice and/or its patients, under contract or by other arrangement. The policy did not include a process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by CDC. The policy lacked a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment. An interview with the agency director on 9/14/22 at 2:00 p.m. confirmed the policy did not include all required components.