Every finding on record at Ardent Hospice & Palliative Care of Sc, Inc.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group completed an initial comprehensive assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/25/2025. The initial orders included an order for Chaplain evaluation. Clinical record review revealed that the Chaplain made a phone call to the patient's primary caregiver on 12/01/2025, the 6th day after election of benefit and scheduled the initial evaluation for 12/02/2025, 7 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the Chaplain attempted to schedule the evaluation before day 6 but did not document the attempts. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/17/2025. The initial orders included an order for Medical Social Worker (MSW) evaluation. The MSW assessment was dated 01/30/2025, a total of 13 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the assessment before day 13 but did not document the attempts. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/15/2025. The initial orders included an order for Medical Social Worker evaluation. The MSW assessment was completed on 10/21/2025, a total of 6 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the evaluation before day 6 but did not document the attempts. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/21/2025. The initial orders included an order for Chaplain evaluation. The Chaplain completed the assessment on 04/03/2025, a total of 13 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the evaluation before day 13 but did not document the attempts

It is required that the documented comprehensive assessment include a drug profile that contains the patient's current, prescription and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by document review, clinical record review, observation, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. Agency policy No. 1-014 Comprehensive Assessment, 2019, required in part, " During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including a review of current and related past medications, including prescription, over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information, including but not limited to identification of the 1) Effectiveness of drug therapy, 2) Unwanted side and toxic effects, 3) Drug interactions (actual or potential), 4) Duplicate drug therapy, 5) Drug therapy currently associated with laboratory monitoring and 6) Whether the medication is unrelated to the terminal illness or related conditions (ensure there is clinical documentation to support unrelatedness)." CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 08/07/2025 and resided at an assisted living facility (ALF). During the home visit observation on 12/15/2025 with the Chaplain (Personnel Record 1). A medication review was completed by comparing the hospice medication profile dated 11/05/2025 with the ALF medication orders. The ALF medication orders included Geri-Tussin 100mg/5ml (10ml) by mouth every 6 hours as needed for cough (ordered 06/13/2025). The hospice medication profile did not include Geri-Tussin, and the medication was not included in the medication review process. The Administrator stated in an interview on 12/15/2025 that the medication was overlooked at the time of admission. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 11/25/2025 and resided at home. During the home visit observation on 12/16/2025 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the hospice medication profile to the patient’s current home medication. The patient was observed to be on Oxygen. A review of the patient's medication profile revealed Oxygen was not included on the drug profile. The hospice medication profile included Escitalopram 10 mg po daily. During an interview with the spouse/primary care giver it was determined that Escitalopram 20 mg daily was the correct dose as indicated in the referral orders and on the medication bottle. The patient's spouse confirmed that the medication was started in the skilled nursing facility before the hospice admission, and the dosage had not been changed. During an interview with the Administrator on 12/16/2025, after reviewing the clinical record, the Administrator stated that the dosage on the drug profile was entered in error and that the nurse was new and still learning. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/25/2025. Review of the comprehensive assessment drug profile dated 10/25/2025 revealed the following medications were duplicated: Donepezil HCI 10mg daily, Amlodipine 10 po daily, and Memantine HCL 10mg po twice daily. The Administrator, in an interview on 12/17/2025, stated that the nurse who entered the medications was new and had entered them twice in error, and that this error should have been discovered during the quality assurance review process.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions such as, hand hygiene and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene and handled soiled items in the patient’s care environment as required by agency policy. Agency policy No. 7-009 Hand Hygiene, 2019, required in part, "Hand decontamination with an alcohol-based hand rub should be performed, A) Before having direct contact with patients, B) Before donning sterile gloves when performing sterile procedures; before inserting indwelling catheters, peripheral vascular catheters, or other invasive devices, C) After contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient), D) After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated, E) When moving from a contaminated body site to a clean body site during patient care." Home Visit 2: During the home visit observation on 12/15/2025 with the Registered Nurse (Personnel Record 2), the RN was observed to provide wound care. The RN completed hand hygiene and donned (applied) clean gloves. The nurse then removed the soiled dressing, opened a pack of gauze and used wound cleanser to clean the wound. The RN then opened the new dressing and applied it to the wound. The RN did not change gloves and perform hand hygiene after contact with the soiled dressing and when the wound was cleansed prior to application of the new dressing, as required by agency policy.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care. CLINICAL RECORD 7: The aide plan of care for the certification period 11/16/2025 to 01/14/2026 assigned the aide tasks that included cleaning/filing nails and shampooing hair. No frequencies were associated with these tasks. The aide documented on the aide visit note dated 11/20/2025 that the tasks of cleaning/filing nails and shampooing hair were not applicable to the visit. During an interview on 12/16/2025, the Administrator stated that when no frequency is listed for a task, it is to be completed at every visit, and therefore, these tasks should have been completed. CLINICAL RECORD 8: The aide plan of care for the certification period of 11/14/2025 to 01/12/2026 assigned the aide tasks that included assisting with feeding, bed bath, and turning and repositioning every 2 hours. The aide documented on the aide visit note dated 10/24/2025 that the tasks of assisting with feeding, bed bath, and turning and repositioning were not applicable to the visit and noted a shower was given rather than the assigned bed bath. During an interview on 12/16/2025, the Administrator stated that when no frequency is listed for a task, it is to be completed at every visit, and that not applicable should not have been entered for these tasks. The Administrator further stated that the aide should have followed the assigned tasks outlined in the care plan, but that the aide was new and needed additional training.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. THIS IS A CMS CONDITION-LEVEL DEFICIENCY This Condition was not met, as evidenced by a review of clinical records and interviews, which revealed issues with the completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of a spiritual and bereavement assessment as part of the initial comprehensive assessment within five (5) calendar days after the election of hospice care [HCPC.9.I/L523]; failure of the medication profile to include all current medications [HCPC.15.I/L530]; failure of the hospice Interdisciplinary Group to demonstrate completion of an initial bereavement assessment [HCPC.13.I/L531]; and failure of the hospice to ensure the written plan of care included patient and family goals and interventions for chaplain services [HCPC.21.I/L545]. The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with 418.24. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 11 (45%) records reviewed revealed the agency did not ensure the initial comprehensive assessment included an assessment of the patient's spiritual needs completed no later than 5 calendar days after the election of hospice care. Clinical Record 4: The patient elected hospice care on 12/08/2022. The initial comprehensive assessment completed by the RN did not include an assessment of the patient's spiritual needs. The initial comprehensive assessment documented the answer to "was the patient part of a spiritual or faith-based community." The chaplain completed the spiritual assessment on 12/16/2022, 8 days after the patient's election of hospice care. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 5: The patient elected hospice care on 09/21/2022. The initial comprehensive assessment completed by the RN did not include an assessment of the patient's spiritual needs. The initial comprehensive assessment documented the answer to "was the patient part of a spiritual or faith-based community." The chaplain completed the spiritual assessment on 01/26/2023, 127 days after the patient's election of hospice care. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 6: The patient elected hospice care on 09/21/2022. The initial comprehensive assessment completed by the RN did not include an assessment of the patient's spiritual needs. The initial comprehensive assessment documented the answer to "was the patient part of a spiritual or faith-based community." The chaplain completed the spiritual assessment on 01/19/2023, 120 days after the patient's election of hospice care. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 7: The patient elected hospice care on 09/15/2022. The initial comprehensive assessment completed by the RN did not include an assessment of the patient's spiritual needs. The initial comprehensive assessment documented the answer to "was the patient part of a spiritual or faith-based community." The chaplain completed the spiritual assessment on 01/12/2023, 119 days after the patient election of hospice care. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. Clinical Record 11: The patient elected hospice care on 09/15/2022. The initial comprehensive assessment completed by the RN did not include an assessment of the patient's spiritual needs. The initial comprehensive assessment documented the answer to "was the patient part of a spiritual or faith-based community." The chaplain completed the spiritual assessment on 12/20/2022, 96 days after the patient's election of hospice care. There was no documented evidence an initial spiritual assessment was completed no later than five days after the election of hospice care. During an interview on 02/08/2023, the Administrator stated the nursing start-of-care assessments did not include a spiritual assessment.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) records reviewed revealed the agency did not ensure the medication profile included all current prescription drugs. Clinical Record 5: The patient elected the hospice benefit on 9/21/2022. The comprehensive assessment completed by the registered nurse on 02/01/2023 documented the patient's use of "oxygen at 3 liters per minute continuously." The patient's medication profile did not include oxygen as of 02/09/2023. During an interview on 02/08/2023, the Administrator confirmed oxygen was inadvertently omitted and had since been corrected.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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 considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 11 (36%) records reviewed revealed the agency did not ensure an initial bereavement assessment was completed. Clinical Record 5: The patient elected the hospice benefit on 09/21/2022. A clinical record review revealed no evidence that an initial bereavement risk assessment was completed as of 2/09/2023. Clinical Record 6: The patient elected the hospice benefit on 09/21/2022. A clinical record review revealed no evidence that an initial bereavement risk assessment was completed as of 2/09/2023. Clinical Record 7: The patient elected the hospice benefit on 09/15/2022. A clinical record review revealed no evidence that an initial bereavement risk assessment was completed as of 2/09/2023. Clinical Record 11: The patient elected the hospice benefit on 09/15/2022. A clinical record review revealed no evidence that an initial bereavement risk assessment was completed as of 2/09/2023. During an interview and a joint review of the records on 02/08/2023, the Administrator confirmed the findings and stated the agency could not locate the missing initial bereavement assessments.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. 9 of 11 (82%) records reviewed revealed the agency did not ensure the written plan of care included patient and family goals and interventions based on problems identified in the comprehensive assessments. Clinical Record 1: The patient elected hospice care on 12/24/2023. The plan of care dated 12/24/2022 ordered chaplain services "1 month 1." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 2: The patient elected hospice care on 05/27/2022. The plan of care dated 01/22/2023 ordered chaplain services "2 months 2." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 3: The patient elected hospice care on 11/16/2022. The plan of care dated 11/16/2022 ordered chaplain services "1 week1." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 4: The patient elected hospice care on 12/08/2022. The plan of care dated 12/08/2022 ordered chaplain services "1 week1." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 5: The patient elected hospice care on 09/21/2022. The plan of care dated 11/20/2022 ordered chaplain services "2mo1." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 6: The patient elected hospice care on 09/21/2022. The plan of care dated 01/19/2023 ordered chaplain services "2mo2." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 7: The patient elected hospice care on 09/15/2022. The plan of care dated 12/14/2022 ordered a social worker "1mo1" and chaplain services "1week1, 2mo1." The plan of care did not include goals and interventions for the social worker and the chaplain as of 02/09/2023. Clinical Record 10: The patient elected hospice care on 11/10/2022. The plan of care dated 11/10/2022 ordered chaplain services "1week1, 1 month 2." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. Clinical Record 11: The patient elected hospice care on 09/15/2022. The plan of care dated 09/15/2022 hospice plan of care chaplain ordered chaplain services "1 week 1." The plan of care did not include goals and interventions for the chaplain as of 02/09/2023. During an interview and a joint review of the records on 02/08/2023, the Administrator confirmed the findings and stated that interventions and goals were inadvertently omitted and has since been corrected.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered; the frequency of service delivery. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) records reviewed in which bereavement services were provided revealed the agency did not ensure a bereavement plan of care was developed to include interventions to address needs based on risk levels identified by the bereavement assessments. Clinical Record 10: The patient elected hospice care on 11/10/2022 and expired on 01/09/2023. A bereavement risk assessment was completed by the chaplain on 01/09/2023. There was no evidence of a bereavement plan of care as of 2/09/2023. Clinical Record 11: The patient elected hospice care on 9/15/2022 and expired on 12/14/2022. A bereavement risk assessment was completed by the chaplain on 12/20/2022. There was no evidence of a bereavement plan of care as of 2/09/2023. During an interview on 02/08/2023, the Administrator confirmed the chaplain did not include the bereavement plan of care in the electronic medical record.

It is required that a hospice aide provides services: ordered by the Interdisciplinary Group; included in the plan of care; permitted to be performed under state law and regulation; consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 9 (44%) records reviewed of patients receiving aide services revealed the agency did not ensure the hospice aide provided services as ordered by the Interdisciplinary Group (IDG) and the plan of care. Clinical Record 1: The patient elected hospice care on 8/24/2022. The plan of care dated 12/24/2022 ordered the hospice aide "0 week 1, 2 week 7." A clinical record review revealed a hospice aide visit completed on 1/3/2023. There was no evidence two (2) hospice aide visits were completed the week of 01/03/2023 and no evidence of a documented missed visit as of 2/9/2023. Clinical Record 3: The patient elected hospice care on 11/16/2022. The plan of care dated 11/16/2022 ordered the hospice aide "1week1, 3 week12." A clinical record review revealed hospice aide visits completed on 01/03/2023 and 01/05/2023. There was no evidence three (3) hospice aide visits were completed the week of 01/03/2023 and no evidence of a documented missed visit as of 2/9/2023. Clinical Record 4: The patient elected hospice care on 12/08/2022. The plan of care dated 12/08/2022 ordered the hospice aide "0 week1, 2week8." A clinical record review revealed hospice aide visits completed on 12/28/2022, 01/06/2023, and 01/09/2023. There was no evidence two hospice aide visits were completed the weeks of 12/19/2022, 12/28/2022, 01/06/2023, and 01/09/2023 and no evidence of documented missed visits as of 2/9/2023. Clinical Record 7: The patient elected hospice care on 9/15/2022. The plan of care dated 12/14/2022 ordered the hospice aide "1week1, 2week8." A clinical record review revealed hospice aide visits completed on 12/28/2022 and 01/06/2023. There was no evidence two hospice aide visits were completed the weeks of 12/28/2022 and 01/06/2023, and no evidence of documented missed visits as of 2/9/2023. During an interview and a joint record review on 02/07/2023, the Administrator stated there was no evidence of missed visits or documentation of aide visit completion as ordered on the hospice plans of care.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). This standard was not met as evidenced by a review of clinical records and interviews. 3 of 3 (100%) home visits revealed the agency did not ensure that a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications was provided to the patient or family. Home Visit 1: (Clinical Record 1) During the home visit on 02/08/2023, the patient's admission folder did not include a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications. There was no evidence of the provision of the policy in the patient record to date. Home Visit 2: (Clinical Record 6) During the home visit on 02/08/2023, the patient's admission folder did not include a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications. There was no evidence of the provision of the policy in the patient record to date. Home Visit 3: (Clinical Record 3) During the home visit on 02/08/2023, the patient's admission folder did not include a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications. There was no evidence of the provision of the policy in the patient record to date. During an interview on 02/08/2023, the Administrator reviewed the admission booklet and stated the provision of the policy had been inadvertently omitted form the booklet and has since been corrected.