DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
341549 A. BUILDING __________
B. WING ______________ 		11/20/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
HARRIS PALLIATIVE CARE AND HOSPICE 81 MEDICAL PARK LOOP, SUITE 203, SYLVA, NC, 28779
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0513      
37615 Based on clinical record review, staff interview and caregiver interview, the agency failed to maintain caregiver involvement in developing the Plan of Care for 1 of 3 patients (#1). Findings include: Patient #1 was admitted on 8/9/19 with prostate and bone care. The Plan of Care (POC) for 8/9/19-11/6/19 included orders for skilled nursing (SN) weekly for 13 weeks. The start of care narrative note by RN #2 stated, "The daughter, ____ [daughter's name], asked us to only come every other week or as little as possible because she stated she was overwhelmed and they would prefer not to have a lot of people out very often." An interview with RN #2 on 11/20/19 revealed she had explained to the daughter that nursing could not come every other week. She stated the clinical manager had told her that the nurse "would have to go at least once a week." She revealed the daughter said if hospice had to visit weekly, they could visit the patient at the adult day care. An interview with the patient's daughter on 11/20/19 at 8:15 a.m. revealed the patient/family wanted hospice services so hospice "could get to know the patient" before death was imminent. The daughter stated she "felt she was forced to have the nurse come weekly."
L0549      
37615 Based on policy review, clinical record review, and staff interviews, the plan of care failed to include oxygen for 1 of 2 patients with oxygen (#3). Findings include: A policy, "Plan of Care" (revised 7/1/19), was provided by the hospice director on 11/20/19 at 1:40 p.m. The policy stated, "The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following ...Drugs, biologicals and treatments necessary to meet the needs of the patient." Patient #3 was admitted on 10/17/19 with prostate and bone cancer. The Plan of Care (POC) for 10/17/19-1/14/20 included orders for skilled nursing visits 2 times per week for 13 weeks, then 1 time for 1 week. The POC lists "Oxygen Precautions" as a Safety Measure. The start of care visit for 10/18/19 was conducted by RN #1. The note revealed oxygen teaching was provided. The plan of care failed to include oxygen orders. An interview was conducted with RN #1 on 11/21/19 at 10:30 a.m. The interview confirmed the patient was on continuous oxygen.
L0552      
37615 Based on policy review, record review and observation, the Interdisciplinary Group (IDG) failed to revise and document the individualized plan of care at least every 15 days in 3 of 3 patients (#1, 2, and 3). Findings include: 1. Patient #1 was admitted on 8/9/19 with prostate and bone care. The Plan of Care (POC) for 8/9/19-11/6/19 included orders for medical social worker (MSW) monthly for 2 months. The Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report revealed the MSW did not include the planned visit frequency for the next 2-week period for 3 of 6 IDG meetings-8/21/19, 9/4/19, and 9/18/19. 2. Patient #2 was admitted on 10/25/19 with leukemia, chronic kidney disease, and chronic obstructive pulmonary disease (COPD). The Plan of Care (POC) for 10/25/19-1/22/20 included orders for medical social worker (MSW) 1 time for 1 month, 2 times per month for 2 months, and 1 time for 1 month. The Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report revealed the MSW did not include the planned visit frequency for the next 2-week period for 2 of 2 IDG meetings-10/30/19 and 11/13/19. 3. Patient #3 was admitted on 10/17/19 with prostate and bone cancer. The Plan of Care (POC) for 10/17/19-1/14/20 included orders for medical social worker 2 times per month for 2 months, then 1 time per month for 1 months. The Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report revealed the MSW did not include the planned visit frequency for the next 2-week period for 2 of 3 IDG meetings-10/23/19 and 11/6/19. An interview was conducted with the medical social worker on 11/20/19 at 10:25 a.m. The medical social worker confirmed the planned frequencies were not included in the IDG notes.
L0678      
37615 Based on policy review, clinical record review and staff interview, the clinical record failed to include all physician orders for 1 of 3 patients (#1). Findings include: A policy, "Hospice Medical Record" (revised 6/1/19), was provided by the hospice director on 11/20/19 at 1:40 p.m. The policy stated, "The hospice medical record shall contain ...Physician orders." Patient #1 was admitted on 8/9/19 with prostate and bone care. The Plan of Care (POC) for 8/9/19-11/6/19 included orders for skilled nursing (SN) weekly for 13 weeks. The POC also stated, "SN to instruct on medication regimen, new and changed medications ..." In an interview with RN #2 on 11/20/19 at 11:20, the RN stated the patient was on "long acting" Morphine. This was not in the Plan of Care. A copy of a handwritten prescription dated 9/23/19 for MS Contin 15 mg by mouth 2 times per day was provided by the agency clinical manager (RN #3) on 11/20/19 at approximately 1:00 p.m. The clinical manager stated, "a lot of his orders are missing" from the clinical record.