Hospice of the Piedmont Inc.

“Upon patient record review 6 of 30 (Patient #1, 3, 4, 14, 15, 16) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 01: The patient was admitted on 10/9/24, the initial psychosocial assessment was completed on 10/16/24. A note was entered on 10/10/24, but the complete assessment was not performed at that time, no indication of a declined visit. Patient 03: The patient was admitted on 8/22/24, the initial spiritual comprehensive assessment was completed on 8/30/24. Patient 04: The patient was admitted on 3/6/24, the initial psychosocial assessment was completed on 3/12/24. Patient 14: The patient was admitted on 5/9/24, the initial psychosocial assessment was completed on 5/15/24. The initial spiritual care assessment was completed on 5/24/24. Patient 15: The patient was admitted on 4/19/24, the initial psychosocial assessment was completed on 4/25/24. Patient 16: The patient was admitted on 8/18/24, the initial spiritual assessment was completed on 10/23/24.”

“Upon patient record review 7 of 30 (Patient #10, 16, 17, 19, 23, 28, 29) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 10: The patient was admitted on 8/28/24, an initial comprehensive Spiritual Care assessment had not been completed to date. Patient 16: The patient was admitted on 8/18/24, an initial comprehensive psychosocial assessment has not been completed to date. Patient 17: The patient was admitted on 8/2/24, an initial comprehensive Spiritual Care assessment has not been completed to date. Patient 19: The patient was admitted on 9/26/24, an initial comprehensive Spiritual Care assessment was not completed to date. Patient 23: The patient was admitted on 7/25/24, an initial comprehensive Spiritual Care assessment was not completed to date. Patient 28: The patient was admitted on 9/25/23, an initial comprehensive Spiritual Care assessment was not completed to date. Patient 29: The patient was admitted on 6/18/24, an initial comprehensive Spiritual Care assessment or Psychosocial assessment was not completed.”

“Upon patient record review, 6 of 30 (Patient #1, 4, 14, 15, 16, 29) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 01: The patient was admitted on 10/9/24, the initial bereavement risk assessment was completed on 10/16/24. Patient 04: The patient was admitted on 3/6/24, the initial bereavement risk assessment was completed on 3/12/24. Patient 14: The patient was admitted on 5/9/24, the initial bereavement risk assessment was completed on 5/15/24. Patient 15: The patient was admitted on 4/19/24, the initial bereavement risk assessment was completed on 4/25/24. Patient 16: The patient was admitted on 8/18/24, the initial bereavement risk assessment has not been completed. Patient 29: The patient was admitted on 6/18/24, the initial bereavement risk assessment was not completed.”

“Upon patient record review, 2 of 30 (Patient #6, 16) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 06: The patient record does not include a comprehensive RN assessment completed from 7/2/24 - 10/10/24. Patient 16: The patient was transferred from RHC to GIP care on 10/21/24, a complete RN comprehensive assessment was not been performed per agency policy upon admit to GIP care.”

“Upon patient record review, 1 of 30 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family Patient 02: The patient resides in the residential hospice house managed by the hospice agency, during the home visit on 10/23/24, it was identified that the patient was out of Eliquis 5mg (BID dosing) and had not received medication since 10/20/24, due to the medication not being filled.”

“Upon patient record review, 4 of 30 (Patient #3, 10, 13, 23) 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 03: The patient was admitted on 8/22/24 and is receiving spiritual care services, the plan of care does not include a problem statement with interventions and goals for spiritual care. Patient 10: The patient was admitted on 8/28/24 with a primary diagnosis of gastrointestinal hemorrhage, unspecified. The plan of care does not include a problem statement with interventions and goals for assessing and monitoring the condition. The patient is prescribed fluticasone, an oral inhaled steroid, the plan of care does not include education, teaching, assessing and monitoring for oral thrush. Patient 13: The patient was admitted on 9/15/24 and has accepted care services from psychosocial and requested volunteer services. The plan of care does not include psychosocial or volunteer interventions and goals. Patient 23: The patient was admitted on 7/25/24 with a primary diagnosis of cervical cancer and history of DVT, she is currently taking Eliquis 5mg BID an anticoagulant, for the management and prevention of DVT, her safety measure do not include bleeding precautions.”

“Upon patient record review, 1 of 30 (Patient #6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 06: The patient record does not include RN visit frequencies for 7/21/24 - 9/7/24.”

“Upon patient record review, 3 of 30 (Patient #10, 18, 20) 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 10: The patient record indicates that the patient is prescribed Duoneb for shortness of breath and nebulized albuterol, the plan of care does not include a Nebulizer. Patient 18: The patient record includes orders for wound care, the plan of care does not include wound care supplies. The patient utilizes a cane for ambulation, this is not included in the plan of care. Patient 20: Upon admit on 6/10/24, the record indicates that the patient is incontinent and the admitting RN requested that briefs be delivered for patient care, these are not included in the supply list in the plan of care. The patient was moved from a SNF to his home on 7/10/21, the nurse visit on 7/11/24 indicated that “DME was delivered during visit.” The plan of care does not include the DME.”

“Upon patient record review, 7 of 30 (Patient #2, 6, 9, 12, 15, 16, 17) 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 02: The plan of care includes orders for access and flushing of the patients portacath, the plan of care does not include interventions and goals for the portacath care. Patient 06: New orders for Nystatin powder to be applied topically were initiated on 10/3/24, the plan of care does not include interventions and goals for the skin integrity related to the use of the topical powder. The patient was started on Macrobid 100mg BID on 10/12/24 for a urinary tract infection, the plan of care was not updated to include interventions and goals for the management of the UTI. Orders were entered on 7/2/24 for placement of a foley catheter, the plan of care does not include interventions and goals for the use of the catheter. The patient receives Volunteer services 1-2 times per week. The plan of care does not include interventions and goals for volunteer services. Patient 09: The patient record on 10/8/24 indicates that she has nutritional deficiencies, with decreasing weight since 12/2023 from 157 lbs to 135. She received supplemented nutrition with Ensure beverages, the plan of care does not include a problem statement with interventions and goals for the nutritional needs. Patient 12: Patient admitted on 9/24/24 with a primary diagnosis of Lewy Body disorder, the patient has had multiple episodes of documented aggression and agitation requiring on call visits, medication changes and interventions for management, the plan of care does not include interventions and goals for the management of the aggression and agitation. The patient has multiple wound to bilateral arms requiring wound treatment and dressing changes, the plan of care does not include interventions and goals for the wound management. Patient 15: The patient receives MSW visits 1-2 per month, and documents “patient exhibited denial of his terminal diagnosis”, the plan of care does not include interventions and goals for MSW services. Patient 16: The patient was transferred to GIP services on 10/20/24, and SW visits were initiated with patient and family. The plan of care is not updated to include psychosocial interventions and goals. Patient 17: Orders were entered 9/5/24 for skin treatment related to pressure wounds, the plan of care is not updated to include the treatment plan and goals for the wound.”

“Upon client record review, 4 of 30 (Patient #3, 6, 10, 13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 03: An order was entered on 8/2/24 for the spiritual care assessment to be completed by 8/7/24, this was not completed. Patient 06: The patient record includes RN frequency visit orders effective 7/2/24 - 7/6/24 for 2-3 visits for 1 week, there are no visits made. Orders effective 7/14/24 - 7/20/24 are entered for 1-2wk for 1 week, there are no visits made. There are no RN frequency orders for 7/21/24 - 9/7/24. RN frequency orders for 9/8/24 - 9/21/24 are for 1-2 visits within 14 day, there are no visits made. Orders for RN frequency visits for 9/22/24 - 9/28/24 are indicated for 1-2 week for 1 week, no visit was made. Patient 10: Orders for spiritual care assessment to be completed between 8/29/24 - 9/2/24 have not been performed, evidence in the patient record indicated acceptance of SC services with no additional notes. Orders for Volunteer visits are entered as 2-3 per month for 3 months effective 9/15/24, there are no visits made in the month of September. Patient 13: Frequency orders for spiritual care visits are entered as 1-2 visits per month for 3 months, effective 9/21/24. There are no visits made for September.”

“Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. HV #4; Upon surveillance of the home visit, the RN did not utilize a surface barrier to place nursing tools while assessing the patient. The RN proceeded to use the nursing tools and placed them back on the same surface with no barrier. Upon leaving the room, the nurse was observed placing the nursing tools back into her nursing bag without properly cleaning and drying the tools.”

“Upon patient record review, 7 of 30 (Patient #1, 2, 6, 7, 9, 11, 17) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 01: The hospice aide visit frequency for 10/14/24 - 10/19/24 is entered as 1-2 for 1 week. The patient was moved from home to the IPU on 10/16/24, the task assignments for the patient only include bathing and oral care, no other tasks have been assigned. Patient 02: The hospice aide visit frequency effective 9/3/24 is entered for 1 visit within 90 days, the aide visits are performed daily. Patient 06: The hospice aide frequency effective 9/30/24 is ordered for 1 visit within 60 days, the patient resides in a residential hospice house and receives daily ADL care. Upon HV#6 it was observed that the patient care was provided by 2 persons and was verbalized “we always provide her care with 2 people.” The aide task assignment does not include 2 person assist for ADL’s. The aide task assignment includes providing foley catheter care, the patient no longer has a foley catheter in place. (Removed on 10/13/24.) Patient 07: Hospice aide visit frequency for Patient 09: Hospice aide frequency orders are written for 2-3 visits per weeks effective 9/1/24 - 10/26/24. The hospice task frequency for incontinent care is ordered for “when needed.” Patient 11: Hospice aide frequency orders are written for 1-2 visits for week 1 effective 10/15/24 - 10/19/24 and 2-3 visits per week effective 10/20/24 - 1/12/25. Patient 17: The hospice aide frequency visit effective 10/5/24 - 10/30/24 is entered as 2-3 times per week for 12 weeks.”

“Upon patient record review 6 of 30 (Patient #1, 2, 6, 7, 9, 11) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 01: The hospice aide task assignment includes nail care and oral care to be provided at each visit, the hospice aide documented N/A for today on the visit performed on 10/15/24. A visit was made on 10/16/24, the task assignment includes a total bath, the hospice aide documented N/A for today. The patient resides in a residential hospice house, aide visits are made daily with the patient, there are no declined visit entries in the record. Patient 02: The patient resides in a residential hospice house, the hospice aide task assignment includes daily services and assistance with ADL’s to be provided to the patient, the records does not include aide documentation or a record of completed tasks for 9/10/24, 9/11/24, 9/13/24, 9/14/24, 9/15/24, 9/19/24, 9/20/24, 9/25/24, 9/26/24, 103/24, 10/4/24, 10/11/24, 10/14/24, 10/15/24 and 10/16/24. Patient 06: The patient resides in a residential hospice house and receives daily assistance with ADL’s, the record does not include documented aide visits with tasks performed for 10/1/24, 10/3/24, 10/10/24, 10/11/24, 10/14/24, 10/15/24, 10/17/24, or 10/21/24. The aide task assignment includes providing a partial bath 4 times a week and a full bed bath on the other 3 days of the week. An aide visit was made on 10/20/24, the aide documented N/A for today for providing a partial bath and for a full bed bath. A previous aide on the same day and earlier shift also documented N/A for today to completing either bath assignment. Patient 07: The task frequency includes oral hygiene at each visit, nail care 1 time per week, grooming (brushing/combing hair) at each visit, shampoo 1 x per week, the aide documented “N/A for today” and did not complete the tasks on the visit for 10/16/24 or 10/18/24. Patient 09: Hospice aide visit made for 10/16/24, the visit indicates shampooing and linen changes are to be performed at every visit, the aide documented “N/A for today” for these assigned tasks. Patient 11: The hospice aide frequency effective 10/15/24 - 10/19/24, was entered for 1-2 times per week, no visits were made.”

“Upon observation, there was no evidence construction, maintenance, and safety equipment at the facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. (Reference inpatient kitchen) Existing Construction It is identified at the Hospice House in accordance with 2012 editions of the LSC of the National Fire Protection Association and NFPA 99 Code 19.3.2.5.3, that the residential kitchen is: 1) not protected by a fire suppression system that meets all requirements of UL 300A, Extinguishing System Units for Residential Range Top Cooking Surfaces. 2) Does not include portable fire extinguishers in accordance with NFPA 96 are located in all kitchen areas (there is no evidence of a K-tank in the kitchen area.) 3) That a switch meeting all of the following is NOT provided: a. A locked switch, or a switch located in a restricted location, is provided within the cooking facility that deactivates the cooktop or range. b. The switch is used to deactivate the cooktop or range whenever the kitchen is not under staff supervision. c. The switch is on a timer, not exceeding a 120- minute capacity, that automatically deactivates the cooktop or range, independent of staff action.”

“Based on staff interview and document review, it was determined the hospice failed to ensure each patient had the right to fully participate in his or her plan of care. Specifically, the hospice failed to inform the patient’s representative of a change in level of care and transfer to inpatient facility. The hospice also failed to ensure it followed its established policies and procedures for changing a patient’s level of care in one (1) of six (6) clinical records reviewed in the survey sample. Clinical record #2. Six clinical records were reviewed in the agency from 12/18/23 - 12/19/23. The clinical record for patient #2 contained documentation that the patient was admitted to hospice services on 06/14/23. The record contained documentation that the patient’s daughter called the hospice on-call nurse on 06/20/23 at 6:08 AM. The daughter reported that she (the daughter) was having chest pain and had called 911 for herself and there was no one to care for the patient. The on-call Registered Nurse (RN) made a visit and arranged for the patient to be transferred to the hospice’s inpatient center for emergent respite care. Documentation indicated that the patient’s daughter was in the home upon the nurse’s arrival. The clinical record contained no documentation of the nurse communicating the change in level of care or planned transfer with the patient’s daughter. Documentation in the medical record did not indicate that the patient’s daughter was made aware of the change in level of care from routine home care to respite care. The medical record contained documentation that the nurse spoke with the physician at the time of patient transfer, but the record failed to contain an order to transfer to the patient to the inpatient facility or to change the level of care to respite. Additionally, the medical record contained no admission orders to the inpatient facility. An interview was conducted on 12/29/23 with staff member #2. Staff member #2 confirmed that patient #2’s family had been informed and involved in the transfer to the inpatient facility, but that the documentation in the medical record did not reflect the conversations between hospice staff and the family member. Additionally, staff member #2 confirmed the medical record should contain an order to transfer the patient to respite, but clinical record #2 failed to contain documentation of such an order. An interview was conducted with staff member #8 while conducting observations at the facility’s acute care unit on 12/19/23. Staff member #8 stated that all patients should have paper admission orders when arriving to the facility. These orders are then scanned into the patient’s chart. Staff member #8 provided the surveyor with a blank copy of a document, Admission Medication Orders that contained an area to document the level of care. Staff member #8 confirmed the form was not completed for patient #2. The hospice’s policy, Levels of Care was reviewed and reads in part: Documentation in the clinical record will support the level of care the patient is currently receiving and clearly reflect the need for any changes in the patient’s level of care, including the date and reason for the change, summation of the patient’s status and appropriate information to maintain continuity of care. An order shall be obtained from the physician prior to a change in the level of care. The hospice’s policy, Patient’s Rights and Responsibilities was reviewed and reads in part: The notice of the Patient’s Rights and Responsibilities includes, but is not limited to, the right to: ...f. Be involved in the development and periodic revision of his or her hospice plan of care...n. Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well any modifications to the plan of care.”