Every finding on record at Mcleod Regional Medical Center of the Pee Dee, Inc.

Upon patient record review, 9 of 30 (Patients #1,#3,#6,#7,#8,#10,#12,#14,#18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: Upon observation during home visit, the facility medication profile did not contain magnesium hydroxide that was identified as a current medication on the hospice medication profile. Patient 3: The medication profile contained duplicative listings of amiodarone. Corrected on site. Patient 6: The medication profile contained polyethylene oral powder with no instructions for a diluent. Corrected on site. Patient 7: The medication profile contained oxygen with no delivery method. Corrected on site. Patient 8: The medication profile contained Spiriva and Wixela inhalers without instructions to rinse mouth after use. Corrected on site. Patient 10: The medication profile contained Silvadene topical ointment with no area defined for administration. Corrected on site. Patient 12: The medication profile contained polyethylene oral powder with no instructions for a diluent. Corrected on site. Patient 14: The medication profile contained Nystatin topical ointment with no area defined for administration. Corrected on site. Patient 18: The medication profile contained polyethylene oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 1 of 30 (Patient #5) 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 5: The medical record contains nursing documentation upon admission identifying patient issue with dysphagia requiring pureed foods. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care. Corrected on site.

Upon patient record review, 7 of 30 (Patients #6,#7,#8,#10,#12,#14,#18) 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 6: The medical record contained an order for polyethylene oral powder with no instructions for a diluent. Corrected on site. Patient 7: The medical record contained an order for oxygen with no delivery method. Corrected on site. Patient 8: The medical record contained orders for Spiriva and Wixela inhalers without instructions to rinse mouth after use. Corrected on site. Patient 10: The medical record contained an order for Silvadene topical ointment with no area defined for administration. Corrected on site. Patient 12: The medical record contained an order for polyethylene oral powder with no instructions for a diluent. Corrected on site. Patient 14: The medical record contained an order for Nystatin topical ointment with no area defined for administration. Corrected on site. Patient 18: The medical record contained an order for polyethylene oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 1 of 30 (Patient #3) 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 3: The medical record contained nursing documentation upon admission identifying patient use of a walker. There was no evidence of an order for the equipment included in the plan of care. Corrected on site.

Upon patient record review, 1 of 30 (Patient #10) 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 10: The plan of care contained active problems, goals, and interventions related to oxygen administration safety. Oxygen was discontinued per order 4/18/24. Corrected on site.

Upon client record review, 1 of 30 (Patient #16) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 16: The medical record did not contain an order for scheduled nursing visits between 4/30/24 and 5/5/24. There was evidence a scheduled nursing visit was completed 5/3/24. Visit was intended as PRN but was documented as scheduled.

Upon patient record review, 3 of 30 (Patients #4,#7,#10) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs and clear for aide to complete appropriate care. Patient 4: The aide care plan contained two bathing tasks for both a bed bath and a shower each visit. Corrected on site. Patient 7: The aide care plan contained two bathing tasks for both a sponge bath and a shower each visit. Corrected on site. Patient 10: The aide care plan contained active instructions related to oxygen administration. Oxygen was discontinued per order 4/18/24. Corrected on site.

Upon patient client record review, 2 of 30 (Patients #14,#19) 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 14: The medical record contained an election form stating the date of election for hospice services were to begin 3/20/24 that was crossed out as error and new date was entered for 3/22/24 with hospice clinician's initials. There was no evidence of when the change of election date was entered on the election form and agreed to by the patient's responsible party. Patient 19: The medical record contained an election form stating the date of election for hospice services were to begin 4/19/23 that was crossed out as error and new date was entered for 4/20/23 with hospice clinician's initials. There was no evidence of when the change of election date was entered on the election form and agreed to by the patient.

Upon patient client record review, 2 of 30 (Patients #1,#2) 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 1: The Medicaid election form contained a data entry error of the wrong physician labeled as attending physician. Patient 2: The CTI for benefit period mistakenly states the face to face was completed 1/11/24 when actual visit was made 1/8/24.

Upon patient record review, 1 of 30 (Patient #1) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient Patient 1: Upon observation during home visit, there was no evidence of an updated plan of care since patient's admission 4/1/24.

Upon observation, 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. It was observed the escutcheon plate surrounding a sprinkler head in the Hospice Inpatient Clinical Manager's office was loose/improperly seated. The gap can lead to reduced fire protection. (corrected on site) Upon observation, there was not evidence the electrical equipment of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 70. A large spill kit barrel was observed obstructing Electrical Panel A in the electrical room. The required 36 inches of clearance was not met. (corrected on site)

Observed in Record Review. In 20 of 20 patient records reviewed, the organization did not inform the patient of his or her rights both orally and in writing. In all records reviewed, the hospice surveyor noted the organization did not inform the patient in writing of their financial responsibility and did not provide an approximate dollar amount. This was confirmed with the hospice director of operations.

Observed in Record Review. In 4 of 20 patient records reviewed, the patient-specific assessment did not include the patient's physical needs.In LHHV #3, the surveyor noted the patient had a secondary diagnosis of diabetes mellitus type 2; however, the nurse documented no problem under the endocrine status and did not assess the patient's diabetes. This was confirmed with the hospice director of operations.In LHRR #15, the hospice surveyor noted the nurse failed to assess the left toe wound as part of the comprehensive assessment at the time of admission. The documentation only indicated that the MD stated it appeared infected. This was confirmed with the hospice director of operations.In LHRR #11, the hospice surveyor noted the nurse failed to assess the stage 2 left heel as part of the comprehensive assessment on admission. In addition, the wound was not measured on the fifth or seventh week of service. Also, the coccyx wound was not measured the ninth week of service. This was confirmed with the hospice director of operations. In LHRR #10, the hospice surveyor noted the wound to the right malleolus was not assessed the second or third week of service as required by organization policy Skin Care Assessment. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 20 of 20 patient records reviewed, the written plan of care was based on the patient's goals and the time frames, settings and services required to meet those goals. In all records reviewed, the hospice surveyor noted the plan of care goals did not include time frames. This was confirmed with the hospice director of operations. In LHHV #4, the hospice surveyor noted the plan of care included the following non-measurable goal: pain will be managed at a level acceptable to the patient. This was confirmed with the hospice director of operations. In LHHV #5 and LHRR #14, the hospice surveyor noted the plan of care included the following non-measurable goal: patient exhibits reduction/relief of any cardiopulmonary symptoms. This was confirmed with the hospice director of operations. Observed in Record Review. The plans of care developed by the agency did not have measurable outcomes or times within which time frame the established goals would be met. This was discussed with the DON. (phHV#1; phHV#2; phRR#1; phRR#2; phRR#3, phRR#4; phRR#5, phRR#6, phRR#7, phRR#8)

Observed in Record Review. In 10 of 20 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In LHHV #3, the hospice surveyor noted the patient was identified as having pain; however, the plan of care did not include interventions to address this identified need. In addition, the patient developed 2+ edema in the 4th certification period; however, the plan of care was not updated to address this identified need. This was confirmed with the hospice director of operations. In LHHV #4, the hospice surveyor noted the patient was identified as having dizziness/lightheadedness and shortness of breath; however, the plan of care did not include interventions to address these identified needs. In addition, the patient was identified at risk for falls; however, the plan of care did not include interventions to address this identified risk. This was confirmed with the hospice director of operations. In LHHV #5, the hospice surveyor noted the patient was identified as having nausea; however, the plan of care did not include interventions except assessment and initiate measures to control symptoms. In addition, the patient was identified at risk for falls; however, the plan of care did not include interventions to address this identified risk. This was confirmed with the hospice director of operations. In LHRR #15, the hospice surveyor noted the patient was identified as having constipation; however, the plan of care did not include interventions. This was confirmed with the hospice director of operations. In LHRR #14, the hospice surveyor noted the patient was identified as having edema, shortness of breath, right eye drainage and a risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director of operations. In LHRR #13, the hospice surveyor noted the patient was identified as having pain and at fall risk; however, the plan of care did not include interventions except evaluate pain on the plan of care. This was confirmed with the hospice director of operations. In LHRR #12, the hospice surveyor noted the patient was identified at being at risk for falls; however, the plan of care did not include interventions to address this identified risk. This was confirmed with the hospice director of operations. In LHRR #11, the hospice surveyor noted the patient was identified as having pain, edema, and at risk for falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the hospice director of operations. In LH RR #10, the hospice surveyor noted the patient was identified as having edema; however, there were no interventions on the plan of care only assessment. This was confirmed with the hospice clinical manager. In LHRR #9, the hospice surveyor noted the patient was identified as having nausea; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 5 of 20 patient records reviewed, the plan of care did not include all treatments necessary to meet the needs of the patient.In LHHV #3, the hospice surveyor noted the patient had a secondary diagnosis of diabetes mellitus type 2 and the patient reported she checked her blood sugar once daily; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice director of operations.In LHHV #5, the hospice surveyor noted at the home visit the patient had a Bi-Pap machine which he used at night and a pulmonary vest which he used for 30 minutes twice daily; however, these interventions were not on the plan of care. This was confirmed with the hospice director of operations.In LHRR #15, the hospice surveyor noted the patient had a wound on admission; however, the plan of care did not include interventions to address this identified need. This was confirmed with the hospice director of operations.In LHRR #14, the hospice surveyor noted the O2 order did not indicate per nasal cannula. This was confirmed with the hospice director of operations. In LHRR #12, the hospice surveyor noted the patient had a foley catheter; however, the plan of care did not include the size of catheter, balloon size or the frequency of change. This was confirmed with the hospice director of operations.In LHRR #10, the hospice surveyor noted the plan of care visit frequency was one time per week; however, the wound care orders indicated it was to be performed by the hospice nurse every 3 days. In addition, the wound care also indicated prn; however, there was no indication provided as to when to perform as needed. Also, the plan of care did not specify the diet type and only indicated nectar thickened liquids. This was confirmed with the hospice clinical manager.

Observed in Record Review. In 1 of 20 patient records reviewed, the organization did not provide the patient with care, treatment or services according to his or her individualized plan of care. In LHHV #5, the hospice surveyor noted the plan of care visit frequency for skilled nursing was 3 week 1, then one time weekly; however, the patient was seen twice the second week of service. This was confirmed with the hospice director of operations.

Observed in Patient Home. In 1 of 5 home visits conducted, this hospice surveyor observed the registered nurse at home visit #1 who failed to follow agency policy by not keeping her clinical bag closed during the visit, between entries into the bag and by not cleansing her hands prior to entry into the bag. She also kept her stethoscope hanging from her neck and allowed it to swing into and across the patient's bedding several times during the performance of wound care to the patient's sacrum. This was also observed by the hospice Administrator. Observed in Patient Home. During home visit #1, this hospice surveyor observed that the registered nurse failed to cleanse her hands on several occasions prior to entering her clinical bag as required by agency policy. This was also observed by the clinical manager.

Observed in Record Review. In 7 of 9 patient records reviewed where the patient received hospice aide services, the registered nurse did not prepare written patient care instructions for the hospice aide.In LHHV #3, LHRR #9, LHRR #11 and LHRR #15, the surveyor noted the aide plan of care did not include fall precautions. This was confirmed with the hospice director of operations.In LHRR #14, LHHV #4 and LHHV #5, the hospice surveyor noted the aide plan of care did not include fall precautions or oxygen safety precautions/instructions. This was confirmed with the hospice director of operations.

Observed in Tracer Activities. “The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.56, 418.104.

Observed in Record Review. In 1 of 20 patient records reviewed, the patient record was not accurately documented. In LHRR #13, the hospice surveyor noted the nurse documented that oxygen was present and indicated oxygen precautions on the plan of care; however, there was no order for oxygen and no DME request in the clinical record. In discussion with the hospice director of operations, this was inaccurate documentation. This was confirmed with the hospice director of operations.

Observed in Patient Home. In 1 of 5 home visits conducted, the patient record did not contain and accurate medication list.During medication review with the registered nurse on home visit #1, this hospice surveyor observed that many medications were not being administered by family as ordered by the physician. For example, the caregiver was only giving the Lasix PRN, not giving the Norco. One medication was not found in the home - Spironolactone but still on the list. The caregiver stated that some of the medications had been discontinued but were still listed as active on the agency's MAR (medication administration record) such as nitroglycerin. This was also observed by the hospice Administrator.

Observed in Record Review. In 2 of 15 patient records reviewed, the organization did not develop an individualized emergency management plan. In LHHV #4 and LHHV #5, the hospice surveyor noted the organization did not develop and individualized emergency management plan for the patient in the clinical record to include patient's oxygen and assistive device use. This was confirmed with the hospice director of operations.

Observed in Building Tour. During the building tour, above ceiling smoke/fire wall penetrations were found. In the West hall by room #5, one penetration was observed and in the electrical closet 5 penetrations were found. All penetrations were corrected on site. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. The fire doors at the main entrance to the patient unit did not close completely or latch. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. The rating plate on the frame of the main fire door into the patient unit was painted over and not legible. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.