Every finding on record at Lower Cape Fear Hospice, Inc.

Upon client record review, 3 of 36 (Patient #8,17, 32) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: Volunteer services declined at the time of admit. SW documented that patient declined Volunteer Services in her IDT notes. Volunteer services provided on 07/03, 07/10, 07/17, 07/24, and 07/31/23 for the month of July. Patient seen 5 times for the month of August; 08/7, 08/14, 08/21, and 08/28/23. No evidence of an order for Volunteer services. Order entered during survey. Patient 17: Patient admitted with one wound. Orders from 07/29/2023 indicates that wound was to be measured weekly. No evidence that the hospice nurse measured the wound on the weeks 08/07/2023 and 08/22/2023 as ordered. No evidence that patient refused measurements. Hospice nurse wrote in the comment section of the wound chapter during both visits that the wound was covered in zinc oxide barrier cream, which was not part of the wound care order. Patient 32: RN inserted foley on admission, there is not an order for the foley insertion.

Upon client record review, 1 of 36 (Patient #1) did not have evidence that the patient/family receive instruction in the safe use of durable medical equipment and supplies. The hospice may use persons under contract to ensure patient/family are educated. The patient and family can demonstrate the appropriate use of durable medical equipment to the satisfaction of the hospice staff. Patient 1: While conducting a home visit with the patient and her nurse. Patient made reference to not using her oxygen when she needed it several days ago, due to being unsure about the water in her humidification cylinder. Upon assessing the cylinder, cloudy murky water with brown sediments was noted at the bottom of the cylinder. Nurse did clean the cylinder but was unable to refill the humidification cylinder due to not having any distilled water at the facility. DME service record obtained during survey by the agency. No evidence shown for who was educated about the upkeep of the oxygen machine, no evidence listed as to what education was provided by DME, or if a return demonstration was provide by the educated party.

Upon observation of the New Construction, there is no evidence the smoke compartmentation and control of 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. During Life Safety Code inspection of the IPU at location #2 (Bolivia), it was observed that a ceiling tile in the riser room had been compromised by a previous water intrusion, which would potentially allow the passage of smoke or fire. Additionally, at location #3 (Whiteville), it was observed that wiring from the mini split air conditioning unit in the data room passed into the ceiling without appropriate sealant/insulation via fire caulk to prevent the potential passage of smoke or fire. (corrected onsite) Upon observation of the Existing Construction, there was no evidence the automatic sprinkler system of 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. During Life Safety Code inspection of the IPU at location #1 (Wilmington), it was observed that supplies in the O2 room, aide's room, and back nurse's station med room were stored on top of upper fixed cabinets in excess of 18" from the ceiling, and in some cases completely flush with the ceiling; this could impede and prevent the proper functioning of the automatic sprinkler system. Additionally, the sprinkler head in the bathroom of patient room #4 was was observed to be physically damaged as it was no longer sitting flush with the ceiling and could function improperly. (corrected onsite) Upon observation of the Existing Construction, there was no evidence the furnishing and decorations of 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. During Life Safety Code inspection of the IPU at location #1 (Wilmington), it was observed that soiled linen was stored in a receptacle measuring approximately 45" x 30" x 60", or approximately 350 gallons, which was located in the aide's closet, rather than in an appropriate fire rated hazardous storage area. (corrected onsite)

Upon observation, there was no evidence the inpatient facility provides: • Home-like atmosphere • Ensures that patient area are designed to preserve the dignity, comfort and privacy of patients • Physical space for private patient and family visiting • Accommodations for family members to remain with the patient throughout the night • Physical space for the family privacy after a patient's death • The opportunity for patients to receive visitors at any hour, including infants and small children During Life Safety Code inspection at the IPUs of locations #1 (Wilmington), #2 (Bolivia), and #3 (Whiteville) it was observed that the children’s visiting areas/playrooms were not appropriately safe and secure for small children as there were no tamper resistant covers on the electrical receptacles. (corrected onsite)