Every finding on record at Pluma Care Private Duty Services, LLC

Upon patient record review, 4 of 11 (Patient #8, 9, 10, 11) 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 #8- The medical record contained information that the patient was using oxygen at 3 lpm. The oxygen was not included on the medication list. Patient #9- The medical record contained information that the patient was using oxygen at 2 lpm. The oxygen was not included on the medication list. Patient #10- The medication list included Bactroban external Cream 2% apply thin layer to affected area. The location of application was not specified. Patient #11- The medication list included triamcinolone 0.025% apply thin layer to affected area. The location of application was not specified. (Medication lists of active patients were corrected onsite)

Upon patient record review, 6 of 11 (Patient #6, 7, 8, 9, 10, 11) 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 included information that the patient has a foley catheter. The plan of care did not include orders for the foley catheter changes and management. Patient #7- Plan of care dated 3/29/22 includes orders for catheter irrigation and change foley "as ordered". The order did not include the size of the foley, frequency of changes, irrigant, amount or frequency. Patient #8- The plan of care did not include any of the medications utilized by the patient including: alka-seltzer, claritin, morphine, ativan and oxygen. Patient #9- The medical record contained information that the patient was using oxygen 2 lpm. The oxygen was not included on the plan of care. Patient #10- The plan of care included Bactroban external Cream 2% apply thin layer to affected area. The order did not include the location of application. Patient #11- The plan of care included triamcinolone 0.025% apply thin layer to affected area. The order did not include the location of application. Orders/ Plan of care for active patients were corrected onsite)

Upon patient record review, 3 of 11 (Patient #6, 8, 9) 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 #6- The patient has a foley catheter. The foley supplies were not included on the plan of care. Patient #8- There were no DME or supplies included on the plan of care. The medical record indicated the patient has a hospital bed, over the bed table, and oxygen concentrator. Patient #9- The medical record indicated that the patient has an oxygen concentrator. The DME was not included on the plan of care. (Plan of care for active patients were corrected onsite.)

Upon patient record review, 5 of 11 (Patient #5, 6, 8, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5- Plan of care dated 12/8/21 included an order for volunteer 1 x month. Volunteer visits documented 12/10/21, 12/21/21, 12/22/21, 1/7/22, 1/25/22, 1/28/22, 3/2/22 and 3/11/22. There was no evidence any of these were PRN visits. Patient #6- Plan of care dated 3/4/22 included orders for volunteer 1 x month and chaplain 1 x month. The record contained evidence of 2 chaplain visits the month of March 2022 and 2 volunteer visits the month of March 2022. There was no evidence any of these were PRN visits. Patient #8- Plan of care dated 12/28/21 included an order for volunteer 1 x month. The week of 12/28/21 there were 2 volunteer visits documented, no evidence either of them were PRN visits. Patient #9- Plan of care dated 2/7/22 included an order for chaplain 1 x week. The week of 2/7/22 there were 2 chaplain visits documented, no evidence either of them were PRN visits. Patient #10- Plan of care dated 12/7/21 included orders for volunteer 1 x month and chaplain 2 x month. Volunteer visits documented on 3/2/22, 3/17/22 and 3/31/22. Chaplain visits documented on 3/3/22, 3/11/22, 3/25/22 and 3/29/22.

Upon patient record review, 1 of 11 (Patient #6) 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 #6- The election statement was signed with a date of 3/4/2022. The date of election was indicated as 3/3/2022, which was prior to the date the election form was signed.

Upon SNF/NF contract review, 1 of 1 applicable (CCNC) did not have a delineation of the hospice's responsibilities, which include, but are not limited to the following: providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary and bereavement); social work; provision of medical supplies, durable medical equipment and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.