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

Based on clinical record review and staff interviews, the agency failed to conduct an initial Chaplain assessment or document patient refusal of spiritual care within 5 days of the start of care for 1 of 3 patients (patient #2).Findings include: --- Patient #2 was admitted on 12/31/2025 with a diagnosis of hypertensive (high blood pressure) heart and chronic kidney disease. The plan of care for 12/31/2025-02/28/2026 failed to include orders for a Chaplain initial assessment. Further review revealed that a Chaplain evaluation was not conducted and there was no documentation of the patient refusing the Chaplain visit.An interview conducted on 02/24/2026 at 3:09PM with the Chaplain revealed that patient #2 had a prior admission to the agency that ended 12/15/2025. The Chaplain was not aware that a new initial assessment was required for a readmission.During an interview conducted on 02/24/2026 at 3:15 PM the administrator stated, “For every new admission [and readmission] you [all interdisciplinary team members] make the initial contact and document it.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to include orders for PRN (as needed) visits for 1 of 3 patients requiring additional visits for changes of condition (patient #3).Findings included: --- A policy, Plan of Care (revised 03/2026), received on 02/24/2026 at 4:23 PM from the human resource coordinator, stated, “Content of the Plan of Care… A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.”Patient #3 was admitted on 10/02/2025 with a diagnosis of severe protein-calorie malnutrition. The plan of care for 01/12/2026-04/11/2026 included orders for skilled nurse visits 1 time a week for 8 weeks and 2 times a week effective 01/28/2026. Review of the clinical record revealed that on 01/31/2026 licensed practical nurse (LPN) #9 conducted a PRN (as needed) visit for a change of condition and on 02/03/2026 LPN #6 conducted a PRN visit for a change of condition. Further review revealed that there was no physician’s order for PRN visits in the plan of care.During an interview conducted on 02/24/2026 at 2:56 PM LPN # 9 stated, “Everybody has orders for PRN visits.” LPN #9 reviewed the clinical records and acknowledged that there were no PRN visits ordered.”LPN #6 was not available for an interview.During an interview conducted on 02/24/2026 at 3:03 PM the administrator stated, “We normally use 5 PRN visits [for all patients] and increase the order as needed.”

Based on agency policy, clinical record review, and staff interviews, the agency failed to include treatment orders for 1 of 2 patients with wounds (patient #1); and failed to include orders for an indwelling urinary catheter for 1 of 2 patients requiring a urinary catheter change (patient #3).Findings included: --- A policy, Plan of Care (revised 03/2025) received on 02/24/2026 at 4:23 PM from the human resource coordinator stated, “Content of the Plan of Care… The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following: … Orders for hospice services, treatments, and procedures…”A policy, Indwelling Urinary Catheter Care and Removal (not dated) received on 02/25/2026 at 9:06 AM from the human resource coordinator stated, “Indwelling Urinary Catheter Insertion, Implementation… Verify the practitioner’s order…”1. Patient #1 was admitted on 11/30/2025 with a diagnosis of hypertensive heart disease. The plan of care for 11/30/2025-01/28/2025 included orders for skilled nurse visits 7 times a week for 8 weeks with 5 PRN (as needed) and “assess for changes in skin integrity.” Review of the clinical record revealed that on 12/04/2025 and 12/09/2025 registered nurse (RN) #7 documented, “Patient [sic] left heel has been doing much better with betadine [antiseptic].” Further review revealed that there was no physician’s order for betadine.2. Patient #3 was admitted on 10/02/2025 with a diagnosis of severe protein-calorie malnutrition and encounter for fitting and adjustment of urinary device. The plan of care for 01/12/2026-04/11/2026 included orders for skilled nurse visits 1 time a week for 8 weeks and 2 times a week effective 01/28/2026. Review of the clinical record revealed that on 01/29/2026 registered nurse (RN) #8 documented, “Foley [urinary catheter brand name] changed 01/29/2026, 18 Fr [catheter size] 20cc [balloon inflation]. Patients [sic] tolerated insertion well, 30cc of fluid in the balloon.” Further review revealed that there was no physician’s order for urinary catheter changes.An interview on 02/24/2025 at 3:45 PM with the administrator revealed that the physician should have been contacted for an order for betadine.  An interview conducted on 02/24/2026 at 3:15 PM with RN #8 revealed that the catheter was changed based on the size that the patient had inserted and there was no physician’s order.During an interview conducted on 02/24/2026 at 3:30 PM the administrator stated, “That would require a specific plan of care for a foley catheter with changes every 30days, size [of the catheter] and ballon size, and how tolerated.”

Based on agency policy, emergency preparedness review, and staff interviews, the agency failed to review and update the emergency preparedness plan every 2 years. Findings included: --- A policy, Emergency and Disaster Management (revised 06/2023) received on 12/09/2024 at 11:28 AM from the human resource coordinator stated, ";[Agency name] maintains an Emergency and Disaster Operations Plan, reviewed and updated every 2 years..." A review of the agencys emergency preparedness program was conducted on 12/12/2024 at approximately 12:00 PM. There was no evidence of the plan being reviewed and updated every 2 years. During an interview conducted on 12/12/2024 at approximately 12:20 PM the human resource coordinator stated, ";I was just assigned this... The plan was last reviewed 12/02/2021."

Based on agency policy, clinical record review, and staff interviews, the agency failed to update the plan of care based on changes in condition for 2 of 4 patients requiring wound care (patients #5 & 14) and 2 of 2 patients requiring suctioning (patients #5 & 16), and 1 of 1 patient requiring contact precautions (patient #15). Findings included: --- A policy, Plan of Care, received on 12/09/2024 at 11:26 AM from the human resource coordinator stated, ";The plan of care specifies interventions, care and services necessary to meet the needs of the patient, family and/or caregiver identified in in the comprehensive assessment and ongoing assessments... infection control interventions and goals... medical supplies and equipment necessary to meet the individualized needs of the patient... Revisions to the plan of care are based on information from the patient's updated comprehensive assessment note ..." Patient #5 was admitted on 11/08/2024 with a diagnosis of malignant neoplasm of unspecified part of left bronchus (lung cancer). The plan of care (POC) for 11/08/2024-02/05/2024 included orders for skilled nurse (SN) visits 3 times a week for 12 weeks with 5 PRN (as needed) visits. Review of the clinical record revealed that on 11/08/2024 registered nurse (RN) #1 stated, ";The patient has extensive wounds, stage 3 PI [pressure injury] to the sacrum, healing DTI [deep tissue injury] to right great toe, Unstageable PI to the left lateral pretibial [lower leg], pressure injurie [sic] to the left Buttock stage 3," Further review revealed a SN visit of 11/27/2024, RN # 10 stated, ";Pt [patient] sounds very congested... SN [skilled nurse] ordered suction set up." Further review of the clinical record revealed that the wounds and suction were not included in the POC. Patient #14 was admitted on 09/20/2024 with a diagnosis of pulmonary fibrosis (scarring of the lungs). The plan of care (POC) for 09/20/2024-12/18/2024 included orders for skilled nurse (SN) visits 1 time a week for 13 weeks with 5 PRN (as needed). Review of the clinical record revealed that for the SN visit on 10/02/2024 RN# 10 stated, ";Redness and irritation to the R [right] ear r/t [related to] oxygen tubing" and on 11/27/2024 stated, ";Patient noted to have stage 1 pressure injury to the R [right] heel... R [right] ear has open sore from oxygen tubing..." Further review of the clinical record revealed that there was no evidence of the wounds in the POC. Patient #15 was admitted on 09/23/2024 with a diagnosis of colon cancer. The plan of care (POC) for 09/23/2024-12/21/2024 included orders for skilled nurse visits 1 time a week for 13 weeks and 5 PRN (as needed) visits. Review of the clinical record revealed a PRN registered nurse (RN) visit on 12/08/2024. RN #15 stated, ";Flagyl 500mg [antibiotic] called in for 10 days for c. diff [Clostridiodes difficile, a highly contagious intestinal disease]." Further record review revealed that there was no evidence of the patient having a contagious disease in the POC. Patient # 16 was admitted on 12/01/2024 with a diagnosis of malignant neoplasm of unspecified part of the right bronchus or lung (lung cancer). The plan of care (POC) for 12/01/2024-02/28/2024 included orders for skilled nurse (SN) visits 7 times a week for 13 weeks and 5 PRN (as needed). Review of the clinical record revealed that on 12/02/2024 RN #7 ordered a suction set up. Further review of the clinical record revealed that there was no evidence of suctioning in the POC. An interview conducted on 12/11/2024 at approximately 12:46 PM with registered nurse (RN) #7 revealed that RN #7 was not aware of the need to update the POC. An interview conducted on 12/11/2024 at approximately 1:05 PM with registered nurse (RN) #10 revealed that RN #10 was not aware of the need to update the POC. During an interview on 12/11/2024 at 1:25 PM with RN #15 stated, ";I dont think that I did a care plan or aide [home health aide] care plan." An interview on 12/11/2024 at approximately 2:00 PM with the administrator revealed that the plan of care should be updated with patient changes of conditions and appropriate interventions added.

Based on The Center for Disease Control (CDC) guidelines (published 03/2024) C. diff: Facts for Clinicians | C. diff | CDC, agency policy, clinical record review, and staff interviews the agency failed to take precautions to prevent the spread of infection (patient # 15 ) Finding included: --- The CDC states, ";Patients with C-Diff (Clostridiodes difficile, a highly contagious intestinal disease) Isolate patient with possible C. diff immediately... Continue isolation and contact precautions." A policy, Infection Control (revised 04/2024) received on 12/11/2024 at 8:58 AM from the human resource coordinator stated, ";Patients identified as having an infectious disease will be marked as airborne, contract or droplet. "***PPE [personal protective equipment]" appears in the note section of the Delivery Ticket to alert delivery personnel. Expanded Precautions will be used when the patient has been identified as having an infectious disease and/or any time there is potential contact with infectious materials. Expanded Precautions include: Contact Precautions - Gown and gloves for contact with patient or environment of care (e.g. medical equipment, environmental surfaces). In some instances, these are required for entering a patient's environment." Patient #15 was admitted on 09/23/2024 with a diagnosis of colon cancer. The plan of care for 09/23/2024-12/21/2024 included orders for skilled nurse visits 1 time a week for 13 weeks and 5 PRN (as needed) visits. A PRN visit was conducted by RN #15 visit on 12/08/2024. Review of the visit information revealed the following information, ";Flagyl 500mg [antibiotic] called in for 10 days for c. diff." Further record review revealed that isolation and contact precautions were not implemented. During an interview on 12/11/2024 at 1:25 PM RN #15 stated, ";I dont think that I did a care plan or the home health aide care plan." During an interview on 12/11/2024 at 9:00 AM the administrator stated, ";We discuss them [all patients] every morning, we ask for falls and infections, the staff are supposed to report all infections, the nurse will initiate tracking in the chart, and [if contagious], wed be aware and initiate full use of PPE, update the POC to make everyone aware."

Based on agency policy, clinical record review, and staff interviews, the agency failed to complete weekly measurements and assessments of wounds for 2 of 4 patients with wounds. (patient # 5, and 14) Findings included: --- A policy, Wound Care Standards (revised 08/2024) received on 12/11/2024 at 8:42 AM from the human resource coordinator stated, ";Any patient with an open area will have the sites measured and documented weekly..." Patient #5 was admitted on 11/08/2024 with a diagnosis of malignant neoplasm of unspecified part of left bronchus (lung cancer). The plan of care for 11/08/2024-02/05/2024 included orders for skilled nurse (SN) visits 3 times a week for 12 weeks with 5 PRN (as needed) visits, assess characteristics of wound, including, color, size (length, width, depth), drainage, and odor, and measure weekly. During the admission on 11/08/2024 registered nurse (RN) #1 stated, ";The patient has extensive wounds, stage 3 PI [pressure injury] to the sacrum, healing DTI [deep tissue injury] to right great toe, Unstageable PI to the left lateral pretibial [lower leg], pressure injurie [sic] to the left Buttock stage 3," Review of the clinical record revealed that from 11/08/2024-12/07/2024 there was no evidence of wound measurements or assessments for 14 of 14 skilled nurse visits. 2. Patient #14 was admitted on 09/20/2024 with a diagnosis of pulmonary fibrosis (scarring of the lungs). The plan of care for 09/20/2024-12/18/2024 included orders for skilled nurse visits 1 time a week for 13 weeks with 5 PRN (as needed). Review of the clinical record revealed that for the skilled nurse (SN) visit on 10/02/2024 RN# 10 stated, ";Redness and irritation to the R [right] ear r/t [related to] oxygen tubing" and on 11/27/2024 stated, ";Patient noted to have stage 1 pressure injury to the R [right] heel... R [right] ear has open sore from oxygen tubing..." Further review of the clinical record revealed that there was no evidence of wound measurements or assessments for 9 of 9 RN visits. During an interview conducted on 12/12/2024 at 10:40 AM RN #16 stated, ";Wounds are to be measured on the first visit of every week." During an interview conducted on 12/12/2024 at 12:52 PM RN #10 stated, ";Probably from pressure [ear wound] ...I probably didnt [document measurements or assessments.]" An interview conducted on 12/12/2024 at 1:00 PM with the administrator revealed that wounds are to be measured and assessed weekly and documentation should include size, color, drainage, and staging if necessary.

Based on clinical record review and staff interviews, the agency failed to develop a bereavement plan of care for 3 of 3 bereavement records reviewed. (patients #6, 7 & 8) Findings included: --- Patient #6 died on 06/27/2024 from cirrhosis of the liver. The initial bereavement assessment was conducted on 09/11/2023. There was no evidence of a bereavement plan of care in the clinical record. Patient # 7 died on 07/31/2024 from bone cancer. The initial bereavement assessment was conducted on 06/27/2024. There was no evidence of a bereavement plan of care in the clinical record. Patient # 8 died on 07/28/2024. The initial bereavement assessment was conducted on 07/15/2024. There was no evidence of a bereavement plan of care in the clinical record. During an interview conducted on 12/09/2024 at 10:30 AM the bereavement counselor stated, ";I usually dont do a post death bereavement assessment." An interview conducted on 12/11/2024 at approximately 1:00 PM with the bereavement counselor revealed that individualized bereavement plans of care are not documented in the clinical record. During an interview on 12/11/2024 at 4:30 PM the administrator stated, ";Chaplains should preform bereavement assessment post death, with risk assessment and do a plan of care"

Based on agency policy, volunteer personnel record review, and staff interviews the agency failed to include evidence of orientation in volunteer personnel records for 1 of 1 volunteer personnel records reviewed. (#14) Findings included: --- A policy, Volunteer Services (revised 09/2024) received on 12/09/2024 at 4:33 PM from the human resource coordinator stated, ";Volunteers complete an orientation and training program prior to receiving assignments for hospice patients/their caregivers or bereaved... Stress management (North Carolina); Communication skills (North Carolina) ...Individual volunteer guidance." A review conducted of volunteer personnel records on 12/09/2024 at approximately 10:00 AM revealed no evidence of a completed orientation for volunteer #14. Volunteer #14 was not available for an interview. During an interview conducted on 12/09/2024 at approximately 10:30 AM the volunteer coordinator stated, ";Have you looked at [agency names] policies, I dont sign competencies... the volunteers keep their orientation checklist."

Based on agency policy, clinical record review, and staff interviews the agency failed to provide effective pain management for 1 of 2 patients with unmanaged pain. (patient #5) Finding included: --- A policy, Patient Rights and Responsibilities HC.69 (revised 09/2023) received on 09/17/24 at 11:08 AM from the agency director stated, ";The Patient Bill of Rights include the right to: ...receive effective pain management and symptom control..." A policy, Assessment and Management of Pain (revised 10/2023) received on 09/14/24 at 11:08 AM from the agency director stated, ";If the patient does not experience pain relief from the current pain medication or dosage, the nurse will contact the hospice prescribing physician and/or attending physician..." Patient #5 was admitted on 07/29/24 with diagnoses of Type 2 diabetes difficulty controlling blood sugar) and with diabetic chronic kidney disease and non-pressure chronic foot ulcer (wound). Patient # 5 was a resident of a facility. The plan of care for 07/29/24-10/26/24 included orders for skilled nurse (SN) visits 1 time a week for 13 weeks and 5 PRN (as needed), SN will provide education, contact MD (medical doctor) for orders, provide symptom management, and cleanse wound with normal saline/wound cleanser or mild skin cleaner... Apply foam dressing. Change 1-2 times a week." During the SN visit of 08/04/24 licensed practical nurse (LPN) #3 stated, ";PRN Hospice SN visit for patient c/o [complaint] severe right foot pain and asking to go to the hospital... Facial grimacing, yelling and guarding noted during wound assessment..." An interview conducted on 09/17/24 at 10:52 AM with LPN #3 revealed that the facility staff had administered acetaminophen (drug for mild pain) 325mg, 2 tablets by mouth as ordered prior to the wound care, the patients pain was during wound care, and the physician was not notified for a new order. During an interview on 09/17/24 at 10:49 AM the agency director stated, ";My expectation is that if patient that is in pain, we should contact the doctor and request an order for pain medication."

Based on agency policy, clinical record review, and staff interviews the agency failed to provide hospice aide services as ordered in the plan of care for 1 of 2 patients with orders for a hospice aide and failed to provide skilled nurse visits as ordered for 1 of 3 patients with orders for skilled nurse visits. (patient #3) Findings included: --- A policy, Patient Visits-Scheduling (revised 09/20/23) was received on 07/30/2024 at approximately 11:09 AM from the regional director. The policy stated, ";Care and/or services provided by [agency name] staff are consistent with assessment data and physician orders." Patient #3 was admitted on 06/11/2024 with a diagnosis of Hypertensive heart disease with heart failure. The plan of care for 06/11/2024-09/08/2024 included orders skilled nurse (SN) visits 5 times a week for 13 weeks, on 07/02/2024 3 times a week, and hospice aide visits 5 times a week for 13 weeks. For the hospice aide visit of 07/04/2024 hospice aide #6 stated, ";Cancellation of Care." Patient #3 received 4 of 5 ordered hospice aide visits for the week of 06/30/2024. For the SN visit of 07/05/2024 registered nurse (RN) #8 stated, ";Cancellation of Care." Patient #3 received 2 of 3 ordered SN visit for the week of 06/30/2024. There was no evidence in the clinical record of the missed visits being offered or on another day. An interview was conducted on 07/30/2024 at approximately 10:38 AM with hospice aide #6. Hospice aide #6 stated, ";We didnt have to work that day so thats why I put it like that, we just miss it [the visit]." An interview was conducted on 07/30/2024 at approximately 10:40 AM with RN #8. RN #8 stated, ";That was a documentation error." An interview was conducted on 07/30/2024 at approximately 10:57 AM with the agencys administrator. The agency administrator stated, ";The procedure is to let the patients/families know that there is a holiday coming and the office will be closed and to call on-call as needed." An interview conducted on 07/30/2024 at approximately 11:00 AM with the regional director, the regional director stated, ";The expectation is if the family refuses, we offer them another day in the week. [If the HHA has that day off] we should get the visit covered or offer it on another day during the Medi-care week."

Based on agency policy, clinical record review, and staff interviews the agency failed to notify the doctor of a medication error. (patient #2) Findings included: --- A policy, Medication Errors HC.38 (revised 06/2024) received on 07/30/2024 at 10:30 AM from the regional director stated, ";Medication error, as defined by the Institute for Safe Medication practices, stated, ";any preventable event that may cause or lead to inappropriate medication use" ... Medication errors may include... wrong time... The patient is assessed for negative response... and reported immediately to the physician. Corrective actions are taken to prevent future medication errors. Patient #2 was admitted on 07/10/2024 with a diagnosis of Parkinsonism (disorder of the central nervous system). The plan of care for 07/10/2024-10/07/2024 included orders for skilled nurse (SN) visits 7 times a week for 8 weeks and beginning 07/19/2024 and morphine sulfate 20mg/mL 0.25 mL PO/SL (by mouth or under the tongue) every 2 hours prn (as needed). There was no evidence in the clinical record of the doctor being notified of an additional dose being administered. For the SN visit of 07/20/2024 LPN #2 stated, ";Pt [patient] premedicated with morphine before wound care...An additional 0.25 ml morphine administered." An interview was conducted on 07/29/2024 at 3:46 PM with LPN #2. LPN #2 stated, ";the caregiver administered both doses, she had given it before I got there, 15 minutes plus 5 minutes [after the first dose], she went and got it [approximately 20-25 minutes apart] 0.25mg-0.5mL Q2 [every 2 hours] as needed. It is 0.25mL Q2hours as needed." An interview conducted on 07/29/2024 at 4:00 PM with the agency director, the agency director stated, ";My expectation would be that she [nurse] would have called me, we would document a medication error and complete an incident report."

Based on agency policy, the hospice medical advisor agreement, admission packet review, and staff interviews the agency stored, and utilized blank physicians Do Not Resuscitate (DNR) orders pre-signed by the Hospice Medical Advisor. --- Cross refer to 418.102(d), Tag 669 Medical Director responsibility.

Based on agency policy, the hospice medical advisor agreement, admission packet review, and staff interviews the agency stored, and utilized blank physicians Do Not Resuscitate (DNR) orders pre-signed by the Hospice Medical Advisor. Immediate Jeopardy was identified beginning 07/29/2024 and was abated 07/30/2024 with an acceptable allegation of compliance. --- A policy, Do Not Resuscitate (DNR) Do Not Intubate (DNI) HH1011 (revised 08/2023) received on 07/30/2024 at 8:28 AM from the agency administrator stated, ";The physician is responsible for discussing DNR with the patient or legal representative... Do Not Resuscitate/Do Not Intubate orders must be written and signed by the physician..." The agencys admission packet was provided on 07/29/2024 at 10:55 AM from the agency administrator. Upon opening the admission packet, there was a NC Department of Health and Human Services Do Not Resuscitate Order inside of the packet. The signature line of the attending physician /physician assistant/nurse practitioner was completed with the signature of the doctor that was identified by the agency administrator as the Medical Director. The printed name of the attending physician was printed ";[Medical Directors Name]". The effective date, expiration date, and patients full name lines were blank. The Medical Advisor Agreement (Hospice Agency) (effective 08/16/2023) received on 07/30/2024 at approximately 11:30 AM from the agency administrator stated, ";PHYSCIAN agrees to use best efforts to comply with all federal, state, county and municipal laws, rules ordinances and regulations applicable to the practice of medicine." An interview conducted on 07/29/2024 at 11:55 AM with registered nurse (RN) #9, RN #9 stated, ";If they want a DNR [Do not Resuscitate], we have a form in our packet, and another form in our packet. We fill out the form for the DNR process [medical orders for scope of treatment form], we have the patient or representative to sign it. Then I get DNR form, fill it out, take a picture and send it to the office manager, then I give it to the patients family member... The order for a DNR is a standing order, the medical director is notified on admission.... It goes into the POC [plan of care], and its sent to the doctor." An interview conducted on 07/29/2024 at 12:00 PM with the agency administrator, the agency administrator stated, ";The only one that would have that [access to pre-signed DNR forms] is the office manager and she puts them in the packets. Yes [admission packets are carried by registered nurses]. They [medical social workers] would have access [to pre-signed DNR forms] because sometimes they do the admission paperwork. The medical director should be notified the same day." An interview conducted on 07/29/2024 at 1:15 PM with the Vice President of Operations, the Vice President of Operations stated, ";Starting with communication with the patient... once they communicate that they want a DNR, its communicated with medical director, we get the physical form signed and put back in the home. We would not use pre-signed blank DNRs. Any pre-signed documentation would not be allowed." An interview conducted on 07/30/2024 at 8:15 AM with the agencys Medical Director, the Medical Director stated, ";When a patient becomes a DNR... we have 2 forms a yellow one [NC Department of Health and Human Services Do Not Resuscitate Order] and a pink one [medical orders for scope of treatment form] ... We should keep a copy in the home. When code status is discussed in IDG [interdisciplinary group meeting] I am made aware, the pink form is filled out and I sign it. No, [blank pre-signed documents other than the NC Department of Health and Human Services Do Not Resuscitate Order have been provided to the agency]." Credible Allegation of Compliance The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited. On 7/29/2024, an onsite, state survey was initiated due to a complaint. The agency was asked to provide a copy of their admission packet to verify the presence of the state complaint information and patient rights. Upon opening the admission packet, there was an NC Department of Health and Human Services Do Not Resuscitate Order inside of the packet. The signature line of the attending physician /physician assistant/nurse practitioner was completed with what appears to be the agencys Medical Directors signature. The printed name of the attending physician was printed as [Medical Director]. The Office Manager, confirmed that the agency places the blank DNR orders with a completed physicians signature in each of the agencys admission packets. The admission packets with the blank DNR orders with a completed physicians signature were being kept in an unlocked, common area of the agency outside of the administrative employees offices. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Immediately, all staff contacted to ensure there are no signed DNRs in their vehicles or other locations. If they have signed DNRs, they are to bring to the office by end of day to be destroyed. Immediately, education provided to nurses, social work and Medical Director regarding pre-signed DNRs and that they are to no longer be used for any reason. Education included: DNR procedure- once a patient or POA makes the decision to become a DNR, staff is to call the Medical Director, enter a verbal order into the chart, then obtain a hard copy to be signed by the doctor and returned to the patients home. This will be done for every patient requesting DNR status without exception. The monitoring procedure to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; A weekly audit will now be conducted within the office and with staff to ensure no pre-signed DNRs are used or are available to be used. Weekly check-ins with the Medical Director to ensure no DNRs are being signed without a prior verbal order. Once there is 100% compliance for 1 month, then monthly audits will start to ensure there are no deficiencies. Audit results will be reported to QAPI team. The title of the person responsible for implementing the acceptable plan of correction. Administrator

Based on review of the Emergency Preparedness Program there was no testing of the emergency plan in calendar year 2021. An interview with the Regional Operations Support Specialist on 1/25/22 approximately 12:00 p.m., the agency was unable to locate any testing of the emergency plan prior to January 2022.

Based on clinical record review and staff interview the agency provide visits in accordance with the plan of care for 5 of 8 patients (#1, 5, 6, 7, 10). Findings include: 1. Patient #1 was admitted on 12/25/21 with a diagnosis of intrahepatic bile duct carcinoma. The Plan of Care for 12/25/21-3/24/22 included orders for aide services three times per week for 12 weeks. The aide Missed Visit Form for 12/31/21 stated, "Off due to holiday." There was no evidence the visit was rescheduled or attempted to be rescheduled due to visit date falling on a holiday. 2. Patient #5 was admitted on 12/23/21 with a diagnosis of displaced intertrochanteric fracture of the right femur. The Plan of Care for 12/23/21-3/22/22 included orders for aide services three times per week for 12 weeks. The aide Missed Visit Form for 12/31/21 stated, "Off due to holiday." There was no evidence the visit was rescheduled or attempted to be rescheduled due to visit date falling on a holiday. 3. Patient #6 was admitted on 10/21/21 with diagnoses of hypertensive heart and chronic kidney disease with heart failure and chronic obstructive pulmonary disease (COPD-respiratory disease). The Plan of Care for 12/20/21-2/17/22 included orders for skilled nursing three times per week for eight weeks. The skilled nurse Missed Visit Form on 12/31/22 stated, "Family aware care due to holiday [sic]." LPN Missed Visit Note for 11/25/21 stated, "Reason: Family caregiver able to assist patient. Comments: Holliday [sic] ..." There was no evidence the visits were rescheduled or attempted to be rescheduled due to visit date falling on a holiday. 4. Patient #10 was admitted on 6/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 12/1/21-1/29/22 included orders for skilled nursing two times per week for one week, then three times per week for eight; and aide visits one time per week for one week, then three times per week for eight. The aide Missed Visit Notes for 12/24/21 and 12/31/21 stated, "Off due to holiday." Missed Visit note for 12/31/21 stated, "Office closed for holiday." There was no evidence the visits were rescheduled or attempted to be rescheduled due to visit date falling on a holiday. In interview with the agency director on 1/25/22 at 3:05 p.m., the agency director revealed the patient was called and offered a visit but declined. She confirmed there was no evidence the patient was offered a visit and declined.

Based on clinical record review and staff interview, the agency failed to include all medications and treatments on the Plan of Care for 5 of 8 patients (#1, 6, 5, 8, and #1). Findings include: 1. Patient #1 was admitted on 12/25/21 with a diagnosis of intrahepatic bile duct carcinoma. The initial assessment was conducted by RN #1 on 12/25/21. The visit note revealed the patient was on 2 liters of oxygen via nasal cannula. The Plan of Care for 12/25/21-3/24/22 did not include oxygen. An interview with the agency director on 1/25/22 at 3:05 p.m. confirmed oxygen was not on the plan of care. 2. Patient #6 was admitted on 10/21/21 with diagnoses of hypertensive heart and chronic kidney disease with heart failure and chronic obstructive pulmonary disease (COPD-respiratory disease). The Interdisciplinary Team note for 12/22/21 stated, "She has oxygen prn [as needed] ...Due to requirement of supplemental oxygen at rest ...appears hospice eligible [written on 12/8/21]" The Plan of Care for 12/20/21-2/17/22 did not include oxygen. An interview with the agency director on 1/25/22 at 4:40 p.m. confirmed oxygen was not on the plan of care. 3. Patient #5 was admitted on 12/23/21 with a diagnosis of displaced intertrochanteric fracture of the right femur. The Plan of Care for 12/23/21-3/22/22 included skilled nursing (SN) orders two times per week for 12 weeks. On 12/30/21, the RN visit note stated, "[Patient's brother] states [Patient] has not slept in several days ...We discussed starting [patient] on something to help her rest, he [brother] said he would consider it we discussed Remeron [sic] ..." On the 1/7/22 RN visit, RN #1 documented, "[Patient] was resting in bed on arrival the caregiver states that she has not been sleeping ask him if he had picked up the medication from the pharmacy that would help her sleep and he said no and he would do so today [sic]." There was no order for sleep medication on the Plan of Care and no interim order. On 1/13/22, LPN #4 conducted a home visit and stated, "Brother reports Remeron 15 mg is not helping patient sleep. SN called MD [doctor] and got order to increase Remeron to 30 mg. There was no evidence that the Remeron 30 mg was added to the plan of care. An interview with the agency director on 1/25/22 at 5:00 p.m. confirmed the Remeron was not added to the plan of care. 4. Patient #8 was admitted on 11/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 11/4/21-2/2/22 included orders for skilled nurse visits two times per week for 13 weeks. The LPN visit note for 11/24/21 stated, "[daughter] states redness to buttocks and requested to check buttock. Buttocks assessed with redness to both buttocks and excoriation to left buttock. Both covered with hydrocolloid dressing for protection." An interview with the agency director on 1/25/22 at 4:00 p.m. revealed hydrocolloid dressing was on the standing orders. On 11/29/21 the RN stated, "[patient's daughter] was concerned about her mother's buttocks was sore and had an opening to it [sic]. Stated she didn't have anything to put on it for several days and it has worsened. The nurse brought Allevyn dressings to place on her mother's buttocks." An interview with the agency director on 1/25/22 at 4:00 p.m. revealed there was no order for Allevyn. 5A. Patient #1 was admitted on 11/22/21 with diagnosis of Pneumonitis due to inhalation of food and vomit, unspecified, urinary incontinence, urinary tract infection, site not specified. The Plan of Care (POC) for 11/22/21 through 02/19/22 included orders for skilled nursing 3 times per week for 1 week with 2 as needed then changed on 11/28/22 to 2 times per week for 12 weeks with 10 as needed visits. On 12/11/21 the RN visit note stated, the patient was on Levaquin for a urinary tract infection (UTI). There was no physician order for the Levaquin on the POC. Interview with agency director on 01/25/22 at 5:00 pm, verified there was a missing order for the Levaquin. 5B. The skilled nurse visit on 12/11/21 stated, " ...insert a Foley to see if it provides comfort for the patient." An interview with the agency director on 01/25/22 at 5:00 pm revealed the agency used the Agency Standing Orders to cover the catheter. The Standing Orders for the catheter: "Urinary incontinence or anuria: may initiate Foley cath {sic} ..." The agency director confirmed the standing orders did not include order for catheter size.

Based on record review and staff interview, the agency failed to assess wounds in 1 of 1 patients with wounds (#8). Findings included: Patient #8 was admitted on 11/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 11/4/21-2/2/22 included orders for skilled nurse visits two times per week for 13 weeks. The initial assessment completed by the agency director on 11/4/21 stated, "Daughter states patient has a red area but does not show it to nurse stating it is covered in fanny [sic] cream that is like paste." There was no further documentation regarding the red area until 11/24/21. The LPN visit note for 11/24/21 stated, "[daughter] states redness to buttocks and requested to check buttock. Buttocks assessed with redness to both buttocks and excoriation to left buttock. Both covered with hydrocolloid dressing for protection." There was no measurement for the wounds. On 11/26/21 the LPN visit note revealed the sacral dressing was changed but no wound assessment documented. On 11/29/21 the RN stated, "[patient's daughter] was concerned about her mother's buttocks was sore and had an opening to it [sic]. Stated she didn't have anything to put on it for several days and it has worsened. The nurse brought Allevyn dressings to place on her mother's buttocks." There was no documentation of a wound assessment. On 12/6/21 the caregiver refused to allow the nurse to change the dressing. On 12/8/21 the caregiver requested transfer to another hospice. Between 11/4/21 and 12/8/21, there was not a complete wound assessment conducted for 23 of 23 nursing visits. In an interview with the agency director on 1/25/22 a 4:00 p.m. it was stated, "the daughter would not let us look at her bottom." The interview also confirmed there was only two instances of the daughter refusing wound assessment, 11/4/21 and 12/6/21. LPN #3 was interviewed on 1/25/22 at 5:00 p.m. The LPN stated the "daughter would not let us look" at her buttocks.

Based on clinical record review and staff interview, the agency failed to ensure the physician was notified of an abnormal x-ray for 1 of 1 patients (#10). Findings include: Patient #10 was admitted on 6/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 12/1/21-1/29/22 included orders for skilled nursing two times per week for one week, then three times per week for eight; and aide visits one time per week for one week, then three times per week for eight. The SN visit note for 12/1/21 stated, "She [daughter] stated the last night when she was getting her cleaned up she hollered that she was hurting her hips. She stated that her mother never does that. During the visit, the nurse helped [daughter] dry her mother up [sic]. The nurse noted that [patient] was hesitant to turn over and was pushing against us as we were turning her. Then she yelled out that we were hurting her. Usually she helps us turn and may grimace a little if we move her knees. When asking [patient] what was hurting she was unable to tell the nurse exactly what hurt ...[Daughter] thinks she may have gotten hurt when she was placed in the car on Monday and asked if we could get an X-ray ordered ..." On 12/3/21 the LPN visit note stated, "Daughter made aware of X-ray report and Fx [fracture] to left thigh." There was no evidence the physician was notified of the fracture. In an interview on 1/25/22 at 3:40 p.m. with the agency director stated she had faxed the x-ray report to the physician, but there was no evidence the physician was notified.

Based on policy review, clinical record review and staff interview, the agency failed to complete clinical record documentation within the agency parameters for 2 of 8 patients (#1, 4, 6, 10, and 2). Findings include: A policy, "Patient Clinical Records" revised 12/2021, was provided by the Regional Administrator on 1/25/22 at 5:55 p.m. The policy stated, "Documentation should occur during the patient visit or as soon as possible thereafter. Documentation should be submitted to the agency within 24 hours with later time frames applying in rare and extenuating circumstances." 1. Patient #1 was admitted on 12/25/21 with a diagnosis of intrahepatic bile duct carcinoma. The Plan of Care for 12/25/21-3/24/22 included orders for skilled nursing seven times for one week, then three times per week for 12 weeks. As of 1/24/22, the RN documentation for 1/20/22 was not complete. In an interview with RN #1 on 1/25/22 at 3:05 p.m., the RN confirmed the documentation was completed on 1/25/22. 2. Patient #4 was admitted on 1/6/21 with a diagnosis of Alzheimer's disease. The Plan of Care for 1/1/22-3/1/22 included orders for skilled nursing visits two times per week for eight weeks. As of 1/25/22 at 1:00 p.m., the RN documentation for 1/18/22 was not complete. 3. Patient #6 was admitted on 10/21/21 with diagnoses of hypertensive heart and chronic kidney disease with heart failure and chronic obstructive pulmonary disease (COPD-respiratory disease). The Plan of Care for 12/20/21-2/17/22 included orders for skilled nursing three times per week for eight weeks. As of 1/25/22 at 1:00 p.m., the visits for 1/11/22 and 1/19/22 were not complete. 4. Patient #10 was admitted on 6/4/21 with a diagnosis of senile degeneration of the brain. The Plan of Care for 12/1/21-1/29/22 included orders for skilled nursing two times per week for one week, then three times per week for eight; and aide visits one time per week for one week, then three times per week for eight. As of 1/25/22 at 1:00 p.m. the LPN visit note for 1/17/22 was not complete. In an interview with the agency director on 1/25/22 at 4:00 p.m., it was confirmed the agency had several incomplete notes. 5. Patient #2 was admitted on 12/29/21 with a diagnosis of Malignant Neoplasm of Transverse colon. The Plan of Care for 12/29/21 through 03/28/22 included orders for skilled nursing on 12/29/21 for 1 time per week for 1 week with 1 as needed, then effective 01/02/22 2 times per week for 12 weeks with 3 as needed visits. The nursing assessment for 01/11/22 was not complete as of 01/25/22. In an interview with agency director on 01/25/2021 at 5:00 pm, she reported this nurse had been assigned to assist this agency with home visits and she did not have computer access.

Based on personnel record review and staff interview, the agency failed to complete competency/skills assessment and reference checks on 2 of 3 employees (#3 and 5); and blood borne/airborne pathogen training for 1 of 3 employees (#5). Findings include: 1. Employee #3 was hired on 5/14/18. A review of the personnel file included a competency/skills assessment that was self-rated. There was no evidence the items that were scored as "Have never done" or "Have done, but need practice" were reviewed. There was no evidence of reference checks. 2. Employee #5 was hire on 8/17/21. There was no record of competency assessment in the personnel record. There were no reference checks. There was no education on bloodborne/airborne pathogens. An interview with the administrative assistant on 1/25/22 confirmed the items were missing.