Every finding on record at Hospice & Palliative Care Charlotte Region

Upon patient record review, 3 of 35 (Patient #4, 13, 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 #4: Hospice medication profile has patient Oxygen order for 2 LPM via NC continuously. Upon interview, during visit to facility resident, noted patient not using Oxygen. He stated he does not need it at this time. Verified with facility nurse he is not using continuously. Updated on site. Patient #13: Hospice medication profile has Dexamethasone 4 mg (1) tab PO twice daily. The patient's prescription bottle has 2 mg twice daily. Prescription bottle is dated 6/20/25. Upon interview, confirmed with patient/spouse taking (1) 2 mg tablet twice daily. Patient #28: 6/4/25 Bisacodyl RS 10mg Q72 hours PRN and 8/10/25 Bisacodyl RS 10mg QD PRN, no evidence of duplicate order being discontinued on medication profile. Corrected on Site.

Upon patient record review, 1 of 35 (Patient #14) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #14: 7/18/25 order volunteer effective 07/27/25 (7) prn. Staff corrected on site to specific frequency.

Upon patient record review, 5 of 35 (Patient #4, 10, 13, 20, 35) 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 #4, 10, 13: Admitted with indwelling catheter related to urinary retention. Orders to change catheter every 6 weeks OR as needed for occlusion/leakage/removal. Corrected on site. Patient #20: 8/25/25 update to POC order says insert/maintain indwelling catheter (14, 16, 18 or Coude/5-10 cc balloon). Corrected on site. Patient #35: 8/22/25 order for oxygen as follows "O2 admin 2-6LPM BID/PRN", order should be either BID or PRN. Corrected on Site.

Upon patient record review, 2 of 35 (Patient #5, 7) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: Treated for UTI 8/20/25 Cipro. No update to problems, goals and interventions specific to UTI. Patient #7: Developed rash with itching / discomfort. prn 7/26/ RN visit. Nurse suspicious of shingles. Rash lasted for days. No update to problems, goals and interventions specific to rash.

Upon client record review, 1 of 35 (Patient #32) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #32: 8/27/25 POC contains orders for wound care to Right upper Skin tear, Right lower skin tear and left upper skin tear, no evidence of wound care being performed.

Upon patient record review 1 of 35 (Patient #30) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #30: 8/22/25 MSW states a follow up visit will be made on Monday 8/25/25 to the patient and daughter, no evidence of any follow up completed.

Upon patient record review, 3 of 35 (Patient #1, 4, 13) 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 #1: Patient medications include Keppra for seizures and Eliquis anticoagulant. Aide Care Plan does not address seizure and bleeding precautions. Patient #4: Patient has order for Oxygen 2LPM NC continuously. O2 precautions not addressed in Aide Care Plan. Patient #13: Patient medications include seizure medications, but seizure precautions are not addressed on Aide Care Plan.

Upon patient client record review, 1 of 35 (Patient #11) 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 #11: In admission documents, hospice election effective date is typed as 6/13/25, but a line is manually drawn through with change to 12th. The change is initialed, but the initials were not consistent with patient/RP or agency representative. Interview with staff reveals office staff changed the date after visit completed. There is no date for change/initials as required in policy. RN was in home and performed admission 6/12/25. Patient/RP signatures dated 6/12/25.

Upon patient client record review, 1 of 35 (Patient #20) 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 #20: 18 Fr Coude catheter inserted by SN 7/16/25 visit, but balloon size not specified in documentation.

Based on policy review, Client Occurrence Report, clinical record review, and staff interview, the inpatient hospice failed to maintain a safe environment for 1 of 3 patients reviewed (#1). --- Cross refer to 418.110(c)(1) Tag L825

Based on policy review, Client Occurrence Report, clinical record review, and staff interview, the agency failed to address safety risks for 1 of 1 patient that exited the building without staff knowledge and had a fall with injuries (#1). Immediate Jeopardy was identified beginning 4/6/23 and abated 5/3/23. Findings included: --- A policy, ";Safety & Risk Management Policy" (no date), was provided by the clinical director on 5/2/23 at 12:07 p.m. The policy stated, ";[Hospice agency] develops and implements a plan that addresses the safety of patients and caregivers that includes...Implementation and documentation of interventions directed towards eliminating or minimizing safety concerns identified in the patients environment." A policy/procedure, ";IPU [inpatient unit] Elopement [act or instance of leaving a safe area or safe premises] and Wandering" (reviewed/approved 5/22), was provided by the clinical director on 5/3/23 at 9:00 a.m. The policy stated, ";On admission , a patient is assessed and may be considered at risk for elopement and wandering if he/she remains ambulatory or self-mobile in a wheelchair and...has a history of elopement or wandering at home or in a community...Exhibits in inappropriate behavior or episodes of confusion/agitation...Expresses concern about being in the Inpatient unit (IPU) of a desire to leave...Interventions to prevent elopement or wandering are initiated if the patient is assessed to be at risk...Initiate high risk falls interventions. Hourly rounds will be completed and documented...Place patient in room near the team station as soon as possible...IPU staff responds immediately to outside door alarm activation...Volunteers are utilized as available to sit with the patient...Explore options for family to sit with the patient..." A policy/procedure, ";IPU [inpatient unit] Fall Prevention" (reviewed/approved 5/22), was provided by the clinical director on 5/3/23 at 9:00 a.m. The policy stated, ";Each patient is assessed for fall risk upon admission, as their condition changes, and upon any fall. The patient is then assigned a fall risk level: Universal, Medium, or High...The fall risk level will be documented in the Electronic Medical Record and will be reported during shift report. If the fall risk level changes during the patients stay, the physician may write a new order, or a nurse may write a verbal order to change the patient to the appropriate fall risk protocol...The nurse and/or nursing assistant will document the rounds in _______[name of electronic medical record system] as indicated on the protocol for each patient." A policy, ";Plan of Care Hospice" (reviewed/approved 3/16), was provided by the clinical director on 5/2/23 at 12:07 p.m. The policy stated, ";The individualized...written Plan of Care will be developed for each patient and reflect goals of the patient and family and interventions based on active problems identified in the admission and ongoing assessments." Patient #1 was admitted on 1/16/23 with diagnoses of hypertensive heart and chronic kidney disease for home hospice services. The patient had a respite stay [short-term inpatient care to relieve caregiver] at the inpatient unit 2/15/23-2/20/23. The inpatient assessment conducted on 2/15/23 indicated the patient was at risk for falls due to mobility, mentation (mental activity), elimination, history of falls, and medications. The Aide Care Plan Report, with an effective date of 2/15/23, also identified the patient was at risk for falls. A nurse note on 2/17/23 at 6:00 p.m. stated, ";He is pleasantly confused and does wander outside of his room looking for family members." A note on 2/18/23 at 12:00 a.m. stated, ";Patient redirected back to bed after attempting to walk out of his room...Bed alarm placed and bedside video monitoring is in place." On 2/18/23 at 6:30 p.m., the Shift Summary revealed the patient was ";redirected back to his room." The patient returned home on 2/20/23 with home hospice services. On 4/4/23, the medical social worker conducted a home visit and reviewed upcoming respite stay. The social worker stated, ";Caregiver does report that at times patient will walk upstairs during the evening hours to talk with caregiver or attempt to exit the home." The patient was admitted to the inpatient unit for respite on 4/6/23. The note stated, ";... [Home hospice nurse] states that patient gets confused at night and was having some episodes of wandering at home." The Plan of Care (POC) was updated 4/6/23 for the respite stay that took place in the hospices inpatient unit. The POC did not include interventions for wandering and falls. The Aide Care Report indicated the patient was high risk for falls; alert, confused, and ambulatory. The Shift Summary by RN #4 on 4/6/23 at 6:00 p.m. revealed a bed alarm was in place. The patient was identified at risk for falls. The Shift Summary on 4/7/23 at 6:05 a.m. stated that the patient was able to ambulate independently. The note revealed that the patient wandered and had a fall on 4/5/23, the day prior to the respite admission. On 4/8/23, LPN #3 documented, ";Bed alarm turned on so staff can assist in future trips to the bathroom and around room...patient very confused, decided to leave IPU. Thinks car is parked right outside. Attempts to reorient to short term stay somewhat successful for short while. Given prn [as needed] Haldol [for agitation]1 mg po at 1440 [by mouth at 2:40 p.m.]. Offer to sit with staff refused. Lying in bed with bed alarm on. Patient rested approx. [approximately] 1 hour then headed for door. Given prn Dilaudid [for pain] 1 mg po at 1556 [by mouth at 3:56]; trying to go out back door at 1620 [4:20 p.m.]. On 4/8/23 at 11:45 p.m. the patient was not in the patient room. RN #2 documented that the patient had been in the room at 11:00 p.m. The note stated, ";...a search was done [sic] and the patient was found outside the building leaning over the metal bench asking for help to get up. He had gotten out of the building and fell outside. There was blood coming from his forehead that covered his face and glassess [sic]. He was taking [sic] back into the facility by wheelchair where an assessment was performed. The patient had acquired small laceration to the top of his head and there was a large hematoma on the top right side of his head. He has also acquired a moderate size skin tear to his right and left elbows and abrasions to both of his knees." The nurse provided wound care. The physician was notified and stated that if the caregiver wanted the patient evaluated at the hospital, the hospice may send for evaluation. The caregiver was notified of the fall and declined a hospital evaluation. On 4/9/12 at 4:00 a.m., documentation revealed large hematoma to right side of head. On 4/9/23 at 4:40 a.m. the nurses note revealed, ";...patient sitting up in bed stating that he needed to go to a wedding...He was medicated with Haloperidol [Haldol] for agitation and Hydromorphone [Dilaudid] for complaint of headache." He rated his pain at a 5 on a scale from 1-10. On 4/9/23 at 6:00 a.m., the record stated, ";Large hematoma to the right side of the head now purplish in color..." On 4/9/23 at 10:00 a.m., LPN #3 asked the patient if he remembered falling. The patient stated, ";That scared me to death." The patient was discharged home on 4/11/23. A home hospice nurse conducted a visit on 4/11/23. The visit note stated, ";Patient sustained a fall while he was at the hospice house and has multiple injuries related to the fall. Theres a large hematoma to his right forehead and his face has a lot of road rash [sic] on the right side. He also has a small laceration to the back of his head. Both arms are bruised and there are multiple lacerations in skin tears [sic] on each arm. Patient has a bruise to his right neck. Both knees have small abrasions as well." On 4/14/23, a home care nurse conducted a visit. The visit note stated, ";Pt [patient] has bruising and discoloration to face, both elbows, and [right] thigh." A Client Occurrence Report was provided by the agency clinical director on 5/2/23 at approximately 1:00 p.m. The report was completed by RN #2 on 4/9/23 at 1:44 a.m. The report stated that the patient had exited the building from a side door and ";fell to the ground." The report outlined the injuries sustained and noted that the physician and caregiver were notified. An interview was conducted with LPN #3 on 5/2/23 at 3:14 p.m. The nurse stated, ";He got up a hundred times that day [dayshift 4/8/23]." The nurse confirmed that a verbal report was given to the oncoming nightshift nurse that the patient was trying to exit the building. An interview with RN #4 on 5/3/23 at 11:20 a.m. confirmed she was the 2nd nurse working dayshift on 4/8/23. She confirmed the patient had wandered on 4/8/23. She stated, ";We were all in there [patients room]." An interview was conducted with RN #2 on 5/2/23 at 1:50 p.m. The nurse confirmed he received a report from dayshift that the patient had wandered during the day. RN #2 confirmed at 11:00 p.m. the patient was in bed. At 11:45 p.m., the second nurse returned from lunch at 11:45 p.m. and stated thar the patient was not in his room. The nurse stated the patient ";was found outside on all fours." The nurse revealed that the patient did not have bed alarm on. The bed alarm was on earlier in the night. It was taken off, because when the patient moved, he set the alarm off. The nurse thought the alarm was agitating the patient. The patients room was directly across from the team station. The nurse stated that he was sitting at the team station with his back toward his room between 11:00 p.m. and 11:45 p.m. The nurse did not hear the patient exit the room or the facility. On 5/2/23 at 1:50 p.m., an interview with the clinical director revealed she investigated the occurrence. The interview confirmed that RN #2 had turned off the patients bed alarm because it was agitating the patient. The interview also revealed the door the patient exited did not have an alarm on it to alert staff that someone had exited. An interview with the clinical director on 5/3/23 at 11:00 a.m. confirmed the POC did not include interventions for fall or wandering. An interview with the Chief Operating Officer at approximately 10:00 a.m. revealed the alarm referred to in the policy was at another site. It was confirmed that there was no alarm on the door where the patient exited. Allegation of Compliance 1. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited: Immediate Jeopardy was identified due to a patient fall outdoors, in a fenced garden connected to the hospice Inpatient Unit (IPU), resulting in injury. At approximately 11:45 pm on 4/8/2023 the RN rounded to Patient #1's room after previous visit from the other RN in room at 11:00 pm. RN found the bed empty and patient #1 was not in the room. Hospice IPU staff searched the facility and found the patient outside the building, in a fenced-in area, on his knees leaning over a metal bench asking for help. Blood from forehead covered face and glasses. Patient was brought back into the facility. A small laceration was noted to the top of the head. A large hematoma was noted to the top right side of the head. Moderate size skin tears were noted to right and left elbows and abrasions noted to both knees. The Physician on call was notified. She advised that if the daughter was agreeable that the patient be sent to the emergency department. The daughter was called and notified of the event and the status of the patient. The daughter stated that the patient gets outside and falls at home, and that she did not want the patient sent to the emergency department. The administrator on call was notified of the event. Assessments on the patient were provided throughout the night and the daughter was provided an update in the morning on 4/9/2023. Daughter was also advised on the night of 4/8/2023 to call anytime throughout the night if she wanted an update. When patient #1 first arrived at the hospice IPU, he was assessed to be a safety risk due to wandering. Patient was placed in a room directly in front of the nurses station and fall precautions, bed alarm, and flight risk precautions were initiated. 2. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: · After the nurse assessed Patient #1 on 4/6/2023 on arrival to the IPU, the patient was placed in a room across from the nurses station. · Staff were informed of the patient event on 4/9/2023. · The wandering patient safety process was initiated immediately after the event. · The physician updated the patient's medication due to extreme agitation on 4/9/2023. · Following this event, the patient was observed at least hourly, and was placed in his bed with the alarm on or put in a wheelchair at the nurse station with 1-1 observation. Effective 5/2/2023, the following will be implemented: · All patients in the building are now assessed upon admission and daily for flight/safety risks. · Installation of a door alarm to sound any time the patio door is opened with education that a staff member will immediately investigate who and why the door was opened. · Signage to STOP and instruct any patient to request staff assistance, prior to opening the patio door, was installed on the patio door. · Use of video monitoring equipment to be utilized on any patient assessed to be a wander/flight risk to allow improved visibility of staff to ensure patient safety. · Bed alarms to be used with any patient deemed to be a wander/flight risk. This alarm is to be in the ON position whenever staff is not at the bedside. · Following a wandering episode, the nurse will complete visual checks every 15-minutes for the first 4 hrs. followed by every 1-hour visual checks. · A check list has been created for the nurses to ensure that when someone is on flight precautions that all of the process is followed. This check list is kept in their report tool and will be reviewed with oncoming staff. · The Safety problem will be detailed in the plan of care for any patient assessed to be a wander/flight risk. · Education will be provided to all IPU staff regarding this plan of correction and the new checklist for flight risk patients. The education will be provided on 5/3/2023 via Teams Meeting. Any staff not in attendance will view the recorded meeting at the start of their next scheduled shift. 3. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited Inpatient Unit Clinical Directors will review all patients assessed as wander/flight risks during morning stand-up to ensure all staff are aware and compliant with new protocols and provide ongoing education. · Inpatient Unit Clinical Directors will complete chart reviews of patients assessed as wander/flight risk to ensure patient record and plan of care addresses safety documentation. 4. The title of the person responsible for implementing the acceptable plan of correction. · Hospice IPU Clinical Director

Based on policy review, clinical record review, complaint log review, and staff interview, the agency failed to document on a patient/caregiver complaint(s) for 1 of 3 records reviewed (#1). Findings included: --- Policy "Consumer Concerns" approved 10/2020 was provided by the clinical director on 03/06/23 at 9:38 a.m. The policy stated" ... definition of a concern... any expression of dissatisfaction by a patient, family member...when a consumer concern is received by a staff member, the person receiving the concern will notify the supervisor... all supervisors will compete the following sections of the consumer concern form once received: source of complete, information about the concern, nature of concern..." Patient #1 was admitted on 02/04/23 with diagnoses of myelofibrosis (rare type of blood cancer), and essential hypertension. The Plan of Care (POC) for 02/04/23 included orders for skilled nursing 2 times a week for 1 week, 5 times a week for 1 week. Clinical record review of the social workers bereavement note on 02/20/23 had documentation of spouse expressed unhappiness a number of times. Review of the agency's complaint log on 03/06/23 revealed no evidence of the spouses other concerns that were reported to the staff members. Interview with the social worker on 03/06/23 at 1:54 p.m. revealed, ";the wife told me about concerns, and I notified the clinical director and if it was medical, I notified the nurse practioner". Interview with the clinical director on 03/06/23 at 2:04 p.m. revealed, ";wife had a concern pretty much daily; we addressed the concerns when they were brought up, they are not documented as complaints".

Based on policy review, clinical record review, and staff interview, the agency provided treatments without orders for 2 of 3 records reviewed (#1 and #2). Findings included: --- 2. Patient # 2 had a Start of Care [SOC] date of 2/15/23 and a terminal diagnosis of Encephalopathy [disease in which the functioning of the brain is affected by some agent or condition]. Review of the clinical record revealed the patient was admitted to ______ [hospice in-patient unit] on 2/15/23. Review of the SOC documentation by the RN revealed the following information, ";Type of infusion access- peripheral [in vein] . Indicate peripheral catheter insertion date-prior to admission. Indicate peripheral catheter insertion site-R [right] upper arm...She has a rectal tube [inserted into the rectum to relieve flatulence] in place. Review of the admission medication record dated 2/15/23 revealed the patient was receiving pain medication IV [intravenous]. The RN daily assessment record dated 2/15/23 revealed the patient had a PIV [peripheral IV] # 20 [catheter size] and the patient had ";Flexi-Seal [brand of rectal tube]" in place. During an interview with the director of nursing on 3/6/23 at approximately 4 pm, it was confirmed the plan of care did not include an order for peripheral IV access or for the rectal tube. A policy, "Physician Orders" revised 8/22, was provided by the clinical director on 03/06/23 at 4:02 p.m. The policy stated, "...all clinical services, treatments, and medications are implemented in accordance with a plan of care established by a physician order..."1. Patient #1 was admitted on 02/04/23 with diagnoses of myelofibrosis (rare type of blood cancer), and essential hypertension. The Plan of Care (POC) for 02/04/23 included orders for skilled nursing 2 times a week for 1 week, 5 times a week for 1 week. Review of the skilled nursing visit note on 02/14/23 had documentation of a subcutaneous line in the left arm. Review of the skilled nursing note for 02/15/23 had documentation of prn (as needed) morphine 2 mg (milligrams) given via (by way of) subcutaneous line to LUE (left upper extremity) at 732 a.m. Review of the skilled nursing note for 02/17/23 had documentation of subcut [SIC] to left upper arm intact, flushes without difficulty, no erythema (redness) noted. No orders are in the record for the subcutaneous line. An interview on 03/06/23 at 4:02 p.m. with clinical director confirmed there was not an order for the subcutaneous line.

Upon patient record review, 6 of 20 (Patients #1, #3, #4, #7, #8, #10) 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. Patient #1 The medication profile includes the following medications for pain without differentiation for administration: 06/30/22 Ibuprofen 200 mg 2 tabs three times daily prn pain; 06/30/22 Tylenol extra strength 500 mg 2 tabs q6h prn pain, headache or fever; 06/30/22 Morphine Concentrate 100 mg/5ml (20mg/ml) .25 ml q3h prn pain or dyspnea; and 07/07/22 Morphine 15 mg tab 1 tab q2h prn pain. (corrected on site) Patient #3 On 07/01/22 orders were received for Valium 10mg X1 for seizure and Intensol/Ativan 2mg/ml 1ml q15 min prn seizure. The medication profile was not updated with the ordered medications. (corrected on site) Patient #4 The medication profile lists Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution. (corrected on site) Patient #7 The medication profile includes Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution.(corrected on site) Patient #8 The medication profile includes Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution.(corrected on site) Patient #10 On 02/12/22 the nurse documented oxygen had been ordered. Oxygen was not listed on the medication profile.

Upon patient record review, 2 of 20 (Patients #1, #4) 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 #1- 07/03/22 orders were received to begin Aide services weekly for thirteen weeks. The orders to update the plan of care do not include goals and interventions for Aide services. (corrected on site) Patient #4- On 06/26/22 orders were received to begin Aide services weekly for eight weeks. The orders to update the plan of care do not include goals and interventions for Aide services. (corrected on site)

Upon patient record review, 10 of 20 (Patients #1, #2, #3, #4, #7, #8, #9, #10, #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 specific orders for all medications and treatments. Patient #1-The 06/30/22 plan of care includes the following medications for pain without differentiation for administration. Ibuprofen 200 mg 2 tabs three times daily prn pain; Tylenol extra strength 500 mg 2 tabs q6h prn pain, headache or fever; Morphine Concentrate 100 mg/5ml (20mg/ml) .25 ml q3h prn pain or dyspnea; and Morphine 15 mg tab 1 tab q4h prn pain. (corrected on site) Patient #2- On 07/27/22 an order was written to update the plan of care which reads: Patient to be drained daily 1000 to 1500 ml. The orders are not specific for the drain type (ie Pleurx cath Rt lower abdomen). The orders are not specific for who is to perform the drainage and orders do not address the dressing type and frequency of changes at the Pleurx site. (corrected on site) Patient #3- On 07/01/22 the plan of care was updated with orders for Intensol/Ativan 2mg/ml 1ml q15 min prn seizure. The maximal allowable doses is not specified in the orders. (corrected on site) Patient #4- The 06/23/22 plan of care includes Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution. (corrected on site) Patient #7- The 07/06/22 plan of care includes Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution. (corrected on site) Patient #8- The 06/16/22 plan of care includes Miralax 17gm dose oral powder 17 gm daily for constipation. A diluent is not listed for reconstitution. (corrected on site) Patient #9- On 02/20/22 the order reads Foley catheter. Orders are not specific for the size and management of the catheter. (corrected on site) Patient #10- On 02/12/22 the nurse documented Oxygen had been ordered. The plan of care was not updated with Oxygen orders. (corrected on site) Patient #11-The patient was admitted 07/17/22 with a PEG tube. The plan of care orders nursing to teach administration of peg tube feedings. The specific tube feedings, type , amount and delivery method are not included in the orders. The orders do not address care of the G tube site and dressing. (corrected on site) Patient #12-The plan of care was updated 08/17/22 with orders to apply Flagyl with each dressing change. Orders are not specific for the site and actual dressing change and frequency to be performed. (corrected on site)

Upon patient record review, 4 of 20 (Patients #1, #2, #10, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- The patient was admitted 06/30/22 with orders to flush the patients port a Cath monthly beginning around 7/17/22. The patients port a cath flush did not occur until 08/10/22. There is no documentation on record regarding the delay. 07/07/22 the Social worker was ordered 1q2wk2. A visit was not documented the week of 07/17/22-07/23/22 when the visit was due. The Social Worker did not visit until 07/29/22. There is no documentation on record regarding the missed visit. Patient #2- On 07/03/22 nursing was ordered to visit twice weekly for one week. The week of 07/03/22-07/09/22 1 visit was made on 07/06/22. On 07/31/22 nursing was ordered to visit 5 times weekly for one week. The week of 07/31/22 4 visits were made on 08/01, 08/02, 08/03 and 08/05. On 08/07/22 nursing is ordered seven times weekly for one week. The week of 08/07/22 three visits were made on 08/07, 08/08 and 08/10/22. There is no documentation on record regarding the missed visits. Patient #10- On 02/13/22 the nurse documents a Foley catheter was inserted in the patient. Orders are not on record for the catheter insertion. Patient #12- On 08/16/22 the nurse documenting inserting a sub-q needle in the patients left thigh in the inpatient unit. Orders are not on record for the needle placement. (corrected on site)

Upon patient record review, 3 of 15 applicable (Patients #1, #4, #7 ) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide 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 #1- The Aide assignment includes shower, tub, and bed bath each visit. The specific bath type is not assigned. The assignment sheet does not document that the patient or caregiver is cognitively and functionally able to make the choice. The Aide is assigned to perform a shave every visit and the patient is on Aspirin. Bleeding precautions is not on the aide care plan. (corrected on site) Patient #4- The Aide assignment includes shower, tub, and bed bath each visit. The specific bath type is not assigned. The patient was admitted on Oxygen and Oxygen precautions are not included in the assignment. (corrected on site). Patient #7- The Aide assignment includes shower, tub, and bed bath each visit. The specific bath type is not assigned. The assignment sheet does not document that the patient or caregiver is cognitively and functionally able to make the choice. (corrected on site)

Upon patient record review 3 of 15 applicable (Patients #1, #9, #19) did not have documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group and Included in the plan of care Patient #1- On 07/25/22 and 08/05/22 the aide documented a shave was not required. Shaving was assigned to be performed every visit. On 08/15/22 the aide documented skin care was not required. Skin care was assigned to be performed every visit. Patient #9- On 02/16/22 the Aide documented shaving was not needed and shampoo was not required. The tasks were documented to be performed each visit. Patient #19- On 07/13/22 the aide documented linen change was not required and date of last BM as task already completed. On 08/10/22 the date of last BM is documented as not required. The tasks were assigned every visit.

Upon patient record review, 1 of 20 (Patient #8) did not have evidence that each patient record contains all clinical notes. Patient #8-The patient is receiving volunteer services. The 07/13/22 volunteer visit note is not on record. Upon interview with leadership and the Volunteer Coordinator, volunteer notes are kept in a cloud based system and are not filed in the patients records.

Upon patient record review, 12 of 12 applicable (Patients #1, #2, #3, #7, #8, #9, #10, #11, #15, #16, #17, #20 ) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. Patients #1, #2, #3, #7, #8, #9, #10, #11, #15, #16, #17, #20- The patients resided in the home setting and the records did not contain documentation that the IDG evaluated the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home.

Upon patient record review, 20 of 20 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) did not have evidence in the patients record that the written policies and procedures for managing controlled drugs was provided and discussed.

Upon observation at one of three inpatient units visited (Southminster), there was no evidence that all components related to the automatic sprinkler system were maintained consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. During the onsite visit on 08.18.2022, the surveyor observed a sprinkler head in the janitor's closet smoke partition wall that did not contain an escutcheon plate and/or fire caulk. Additionally, a ceiling tile in the front lobby above the receptionist's desk contained a gap of greater than 1/8 inch. The ceiling needs to resist the passage of smoke for smoke detectors and sprinklers to function properly; therefore, gaps are not permitted. (corrected onsite)