Every finding on record at Msa Home Health and Hospice of Nc Inc.

Based on agency policy review, clinical record review, and staff interviews the Interdisciplinary Group [IDG] failed to project visit frequencies for the next 15 days for 15 of 19 charts reviewed [ #11, 12, 1, 4, 14, 2, 3, 5, 6, 7, 8, 9, 13, 17 and 18]. The findings included: The policy, Interdisciplinary Group HC.6.1 [07/2024], was provided by the agency administrator on 3/10/25 at 12:01 pm. The policy stated, ";The _______ [agency name] Hospice Interdisciplinary Group [IDG] meets at least every fifteen [15] days to discuss patient and family changes...The Interdisciplinary group responsibilities may include, but not limited to:...Reviewing and revising the plan of care..." --- 5. Patient # 14 had a Start of Care date of 10/26/24 with a terminal diagnosis of end stage renal [kidney] disease. Review of the Plan of Care for the certification period 1/24/25-4/23/25 included orders for SN [skilled nursing] 2 times a week for 12 weeks, 1 time a week for 1 week, HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 weeks; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 6. Patient # 2 had a Start of Care date of 1/11/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 1/11/25-4/10/25 revealed orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week for 12 weeks, 2 times a week for 1 week; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 1/15/25,1/29/25, 2/12/25, and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 7. Patient # 3 had a Start of Care date of 1/25/25 with a terminal diagnosis of Alzheimers Disease. Review of the Plan of Care for the certification period 1/25/25-3/25/25 included orders for SN [skilled nursing] 1 time a week for 1 week 3 times a week for 1 week, 2 times a week for 7 weeks, 1 time a week for 1 week; HHA [hospice aide] 3 times a week for 8 weeks, 1 time a week for 1 week; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 1/29/25, 2/5/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the Chaplin. 8. Patient # 5 had a Start of Care date of 2/8/25 with a terminal diagnosis of Parkinsons Disease [a disorder of the central nervous system that affects movement]. Review of the Plan of Care for the certification period 2/8/25-5/8/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 3 times a week, 2 times a week for 12 weeks; HHA [hospice aide] 2 times a week for 13 weeks; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 2/12/25 and 2/26/25 revealed no visit frequency projections for the next 15 days for the Chaplin. 9. Patient # 6 had a Start of Care date of 2/8/25 with a terminal diagnosis of COPD [chronic obstructive pulmonary disease-affects breathing]. Review of the Plan of Care for the certification period 2/8/25-4/8/25 included orders for SN [skilled nurse] 1 time a week for 1 week, 3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social work] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes for 2/12/25, 2/18/25, and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 10. Patient # 7 had a Start of Care date of 2/2/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 2/2/25-4/2/25 included orders for SN [skilled nursing] 3 times a week for 8 weeks, 1 time a week for 1 week; HHA [hospice aide] 2 times a week for 7 weeks, 1 time a week for 1 week; MSW [medical social work] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/18/25 and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 11. Patient # 8 had a Start of Care date of 2/4/25 with a terminal diagnosis of heart disease. Review of the Plan of Care for the certification period 2/4/25-4/4/25 included orders for SN [skilled nursing] 3 times a week for 9 weeks; HHA [hospice aide] 1 time a week for 1 week, 3 times a week for 8 weeks; MSW [medical social work] 1 time a month for 2 months; Chaplin 1 time a month for 2 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/12/25, 2/18/25 and 3/5/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 12. Patient # 9 had a Start of Care date of 2/14/24 with a terminal diagnosis of severe protein-calorie malnutrition [a condition resulting from an inadequate intake of protein and or calories]. Review of the Plan of Care for the certification period 2/14/25-5/14/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 14 weeks; HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 weeks; MSW [medical social work] 1 time a month for 4 months, Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/18/25 and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 13. Patient # 13 had a Start of Care date of 1/30/25 with a terminal diagnosis of cerebral vascular disease. Review of the Plan of Care for the certification period 1/30/25-4/29/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks, 1 time a week for 1 week; HHA [hospice aide] 2 times a week for 12 weeks, 1 time a week for 1 week; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 4 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 2/5/25, 2/12/25, and 2/26/25 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 14. Patient # 17 had a Start of Care date of 3/27/24 with a terminal diagnosis of acute myeloblastic leukemia [cancer affecting blood]. Review of the Plan of Care for the certification period 3/27/24-6/24/24 included orders for SN [skilled nursing] 2 times a week for 13 weeks; MSW [medical social work] 1 time a month for 4 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 4/3/24, 4/10/24, and 4/24/24 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. 15. Patient # 18 had a Start of Care date of 9/16/24 with a terminal diagnosis of malignant neoplasm [cancer] of the prostate. Review of the Plan of Care for the certification period 9/16/24-12/14/24 included orders for SN [skilled nursing] 3 times a week for 1 week, 2 times a week for 12 weeks; HHA [hospice aide] 2 times a week for 13 weeks; MSW [medical social worker] 1 time a month for 3 months; Chaplin 1 time a month for 3 months. Review of the IDG [interdisciplinary group-a group of professionals who work together to provide comprehensive and coordinated care for hospice patients/families] minutes dated 9/25/24, 10/7/24, and 10/21/24 revealed no visit frequency projections for the next 15 days for the MSW or Chaplin. During an interview with the agency administrator on 3/12/25 at approximately 11:30 am, the administator confirmed the visit projections for the next 15 days were not included in the clinical record. 1. Patient #11 had a Start of Care (SOC) date of 4/6/2024 and a terminal diagnosis of Hemiplegia (paralysis or unable to move) and hemiparesis (weakness) following cerebral infarction (stroke) affecting right dominant side. The Plan of Care (POC) for the certification period of 1/25/2025-3/25/2025 included orders for Skilled nursing (SN) 2 times a week for 8 weeks, 1 time a week for 1 week; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week; Medical Social worker (MSW) 1 time a month for 2 months; Chaplain 1 time a month for 2 months; volunteer services 1 time a week for 8 weeks. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the MSW or the Chaplain during any of the 3 IDG meetings (1/29/25, 2/5/25, 2/18/25, 3/5/25). During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for the MSW and the Chaplain were not updated with visit projections for the next 15 days during the 2/5/25, 2/18/25, and 3/5/25 IDG meetings. 2. Patient #12 had a Start of Care (SOC) date of 2/19/2024 and a terminal diagnosis of Alzheimers disease. The Plan of Care (POC) for the certification period of 2/13/2025-4/13/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 6 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 1 month; Chaplain 1 time a month for 2 months; and volunteer services 1 time a week for 8 weeks. Review of the clinical record revealed an Interdisciplinary Group (IDG) meeting was conducted on 2/26/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the Chaplain or the MSW during the IDG meeting on 2/26/2025. During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for MSW and Chaplain were not updated with visit projections for the next 15 days during the 2/26/2025 IDG meeting. 3. Patient 1 had a Start of Care (SOC) date of 1/24/2025 and a terminal diagnosis of malignant neoplasm of right ovary (ovarian cancer). The Plan of Care (POC) for the certification period of 1/24/2025-3/24/2025 included orders for Skilled nursing (SN) 2 times a week for 1 week, 1 time a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 3 months; Chaplain 1 time a month for 3 months. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 1/29/2025, 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the Chaplain or the MSW during any of the 4 IDG meetings (1/29/25, 2/5/25, 2/18/25, 3/5/25). During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for MSW and Chaplain were not updated with visit projections for the next 15 days during the 1/29/25, 2/5/25, 2/18/25, and 3/5/25 IDG meetings. 4. Patient 4 had a Start of Care (SOC) date of 1/24/2025 and a terminal diagnosis of hypertensive heart disease. The Plan of Care (POC) for the certification period of 1/24/2025-4/23/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a month for 3 months and Medical Social worker (MSW) 1 time a month for 4 months. Review of the clinical record revealed the Interdisciplinary Group (IDG) meetings were conducted on 1/29/2025, 2/5/2025, 2/18/2025, and 3/5/2025. Further review of the clinical record revealed no visit projections for the next 15 days by the SN or the MSW during any of the 4 IDG meetings 1/29/25, 2/5/25, 2/18/25, 3/5/25. During an interview with the agency director on 3/12/2025 at approximately 12:15 pm, the director confirmed the POCs for the SN and the MSW were not updated with visit projections for the next 15 days during the 1/29/25, 2/5/25, 2/18/25, and 3/5/25 IDG meetings.

Based on policy review, clinical record review and staff interview, the agency failed to ensure patients received a comprehensive medication review for 1 of 3 patients that received a virtual home visit (#9). Findings include: A policy, "Comprehensive Assessment" revised 6/2021, was provided by the Regional Administrator on 3/30/22 at 3:00 p.m. The policy stated, "The comprehensive assessment addresses the following ...prescribed medications, over the counter drugs, herbal remedies and alternative treatments that could affect drug therapy ...The comprehensive assessment is updated at a minimum of every fifteen (15) days or more frequently as needed by the patient." Patient #1 was admitted on 4/27/21 with a diagnosis of malignant neoplasm of the ovary. The Plan of Care (POC) for 2/21/22-4/21/22 included orders for skilled nursing visits twice weekly for four weeks, then three times weekly for four weeks, then twice weekly for one week. A virtual home visit was conducted on 3/30/22 at approximately 2:00 p.m. with RN #1. The review of the current medications revealed the following discrepancies: • The POC included Lasix 40 mg every day for fluid, edema. During the virtual visit the patient stated she was only taking ½ of the medication and only as needed. • The POC included Hydrocodone-Acetaminophen 5-325 mg every four hours as needed for pain, discomfort. During the virtual visit the patient confirmed she was not taking this medication; she had oxycodone and morphine ordered for pain. • The POC listed Lorazepam 1 mg every 4 hours for anxiety. Lorazepam was listed on the POC twice with begin dates of 4/27/21 and 4/28/21. • The POC included Zyrtec 10 mg daily for allergies. During the home visit the patient stated she had not taken this in "about two months." • The POC included Sodium Chloride 1 gm daily for low sodium. During the home visit the patient stated she was not taking this medication. An interview with the Regional Administrator on 3/30/22 immediately following the virtual visit, it was confirmed there were discrepancies in the medications. In an interview with RN #1 on 3/31/22 at approximately 1:00 p.m., the RN stated she had spoken with the physician and updated the medications.