Mcleod Hcs - Hospice of the Pee Dee

“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, 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 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)”