Every finding on record at At Home Senior Care Hospice

Upon patient record review, 1 of 10 (Patient #1) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient#1: The medication profile indicated duplicated orders of Tylenol 500mg 1 tablet PO Q6 hours PRN and Tylenol 325mg 2 tablets PO Q6-8 hours PRN. Corrected onsite. Also, admission orders indicated oxygen 2-4L NC PRN. Nursing documentation from SOC 6/13/23 to current indicated that patient was not wearing oxygen. There was not evidence that this was reflected in the medication profile. Corrected on site. Also, admission orders indicated to "Place Hospice Emergency Medication Kit in Patient's Residence and Use PRN as Directed." This is not reflected in the medication profile. Corrected onsite.

Upon patient record review, 1 of 10 (Patient #2) did not have evidence that the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions which including interventions to manage pain and symptoms. Patient#2: The medication profile indicated patient on Acetaminophen 325mg/Caffeine 30mg/Dihydrocodeine Bitartrate 16mg 1 tablet PO Q4 PRN for pain. There was no evidence of a pain plan of care. Corrected onsite

Upon patient record review, 2 of 10 (Patient #1,#2) 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#1,#2:The SN, SW, and Chaplain visit orders included PRN visits without a frequency for those visits. Corrected onsite.

Upon patient record review, 2 of 10 (Patient #1,#2) 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#1: The record indicated patient on Colace 100mg, 1 tablet PO for constipation. For frequency it stated, "2 Tabs" instead of an accurate frequency. Corrected onsite. Also, admission orders indicated oxygen 2-4L NC PRN. Nursing documentation from SOC 6/13/23 to current indicated that patient was not wearing oxygen. There was not evidence of an order. Corrected on site. Also, admission orders indicated to "Place Hospice Emergency Medication Kit in Patient's Residence and Use PRN as Directed." This is no evidence of an order. Corrected onsite. Patient#2: Nursing documentation stated oxygen 2L NC continuous since SOC 11/18/23. There was no evidence of an order for oxygen. Corrected onsite.

Upon client record review, 1 of 10 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#1:Chaplain visit frequency 1 visit every month. The record indicated a spiritual assessment completed on 6/16/23 and 6/23/23. Corrected onsite.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence of the appropriate documentation for release of confidential information. Patient #1, #2-There is no consent on record to release confidential information for purposes of treatment or payment.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 1 of 7 (Patient #1) 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 #1-The patient was admitted 02/23/23. A spiritual assessment was not completed until 03/29/23.

Upon patient record review, 2 of 7 (Patient #1, #2) 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 #1- On admission the nurse documented the patient was on Tylenol. Tylenol is not on the med profile. On 05/22/23 in IDG the nurse documents the patient is not taking Colace or Miralax as she should. Colace and Miralax are not on the medication profile. The medication profile includes duplicative/unclear doses of Haldol. 04/03/23 Haloperidol 1 mg po qhs for agitation is listed and 04/04/23 Haldol 1 mg po daily for agitation is listed. Patient #2-The IDG note 06/19/23 on record indicates the patient takes Lisinopril, Lipitor and Tylenol. These medications are not included on the medication profile.

Upon patient record review, 2 of 7 (Patient #1, #2) 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 #1, #2-A Bereavement Risk assessment is not on record.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence in the patient record that the comprehensive assessment is updated by: • Performing a 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 #1- Between 05/25/23 and 06/12/23 and 07/08/23 and 07/27/23 a nursing visit is not on record to evidence a comprehensive assessment was performed at least every 15 days to reassess the patient's response to care. Patient #2-Between 07/08/23 and 07/27/23 a nursing visit is not on record. The time period is greater than 15 days to perform a comprehensive assessment.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 7 (Patient #1, #2) 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 #1-On 05/24/23 the nurse documented the patient had a wound to the left side of the buttock. The plan of care was not updated with goals/interventions for altered skin integrity. On 07/03/23 the nurse documented in IDG the patient complained of itching and was being treated. There are no goals interventions for itching and on 07/31/23 the nurse documented the patient had a cough with yellowish sputum. There were no goals/interventions to address altered respiratory status. The care plan also does not include goals for SW and Chaplain services. Patient #2-The care plan includes a pain goal that the patient will report pain is reduced to the level personally desired (blank) on a scale of 1-10. The personally desired level of pain control was left blank. The care plan also does not include goals for SW and Chaplain services,

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- The initial plan of care 02/23/23 does not include medications or diagnosis. On admission the nurse documented the patient was on Tylenol. Tylenol is not included on the plan of care. The 05/22/23 IDG documentation by the nurse includes the patient is not taking Colace or Miralax as she should. Colace and Miralax are not included in the plan of care. The IDG/plan of care update 05/22/23 includes duplicative/unclear doses of Haldol. 04/03/23 Haloperidol 1 mg po qhs for agitation and 04/04/23 Haldol 1 mg po daily for agitation is listed on the plan of care. Patient #2- The initial plan of care 06/13/23 does not include medications or diagnosis. The IDG/plan of care note 06/19/23 documents the patient takes Lisinopril, Lipitor and Tylenol. These medications are not included in the plan of care.

Upon patient record review, 2 of 7 (Patient # 1, #2) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #1: The initial plan of care 02/23/23 does not include equipment- On 02/23/23 there is documentation a hospital bed and over the bed table was delivered. On 03/30/23 there is documentation in the record that a hoyer lift was delivered. The plan of care was not updated for the hoyer lift. Patient #2-On 06/22/23 The nurse documents the BSC and over the bed table were delivered. The plan of care/IDG update on 07/03/23 does not include the equipment.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1- On 05/09/23 the nurse documented contacting the MD and receiving orders for dental cream secondary to patient's mouth pain. Orders were not written to update the plan of care for dental cream. The nurse is ordered to visit the patient 1-2 times weekly. Between 05/25/23 and 06/12/23 a nursing visit is not on record and there is no documentation regarding missed visits. Between 07/08/23 and 07/27/23 a nursing visit is not on record and there is no documentation regarding the missed visit. Social worker is ordered to visit 1-2 times monthly and a visit has not been performed since 03/22/23. On 05/24/23 the nurse documents cleansing the patients L sided buttock wound with soap and water and applying a gel dressing. Orders for wound care are not on record. On 07/23/23 the nurse documented the patient was itching and advised to take Benadryl. Benadryl was not an ordered medication. On 07/31/23 the nurse documented in IDG the patient had been advised to take Mucinex for yellow sputum and cough. Mucinex was not an ordered medication. On 07/07/23 and 08/14/23 the nurse documented performing telehealth visits. Telehealth visits are not ordered in the plan of care. Patient #2- As of 06/13/23 the nurse is ordered to visit 1-2 times weekly. Between 07/08/23 and 07/27/23 a nursing visit is not on record and there is no documentation regarding the missed visit. As of 06/19/23 the Social worker is ordered to visit 1-2 times monthly. There is no Social Worker on record for July and no documentation of a missed visit. On 07/07/23 and 08/14/23 the nurse documented performing telehealth visits. Telehealth visits are not ordered in the plan of care.

Upon patient record review, 3 of 7 (Patient #3, #4, #7) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #3-The patient died 03/12/23 and a bereavement plan of care on is not record. Patient #4-The patient died 05/16/23. There is not evidence of contact with bereaved after death 5/16/23 or development of a bereavement plan of care. Patient #7-The Bereavement plan of care 05/06/23 indicates the bereaved will receive weekly visits. The plan of care does not include goals and no visits/contacts are on record following 05/06/23.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions that 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 #1- The Aide care plan does not include fall precautions which is an identified safety precaution. Patient #2- The Aide care plan does not include fall precautions which is an identified safety precaution. Each of the tasks to be performed by the aide are assigned with a frequency of "as needed each visit".

Upon patient record review 2 of 7 (Patient #1, #2) did not evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #1-Between 05/25/23 and 06/12/23 aide supervisory visits are not on record. Between 07/01/23 and 08/02/23 an aide supervisory visit is not on record. Patient #2- Between 06/22/23 and 08/02/23 Aide supervisory visits are not on record.

Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence that a skills competency assessment for the RN was completed by the appropriate individual. RN must complete a competency evaluation on RNs, LPN/LVNs, and aides. Personnel #2-The Skills competency assessment for the DCS/RN was completed by the Administrator who is not an RN.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence that the medical director or physician designee provides complete written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patient #1- The CTI on record for certification period 02/23/23 does not include an attestation statement, signature, date, or certification period. Patient #2-The initial CTI on record is not dated or signed by the MD and does not include a certification period.

Upon patient record review, 1 of 7 (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1- There is no recertification CTI on record for the certification period beginning 05/24/23.

Upon patient record review, 2 of 7 (Patient #1, #2) did not have evidence that each patient record contains Advance Directives. Patient #1-The SW visit note on 02/24/23 indicates the patient has a DNR and POA. The documents are not on record. Patient #2-The SW visit note on 06/15/23 indicates the patient has a DNR and POA. The documents are not on record.

Upon patient record review, 2 of 7 (Patient # 1, #2) did not have evidence that all entries are complete. Patient #1-The nursing visit note on 05/24/23 documents addressed patient's concern of constipation and reported to MD. There is no further documentation regarding specifics of concern or how the concern was addressed in the note. There is also an incomplete unsigned nursing visit note on record for 07/28/23. Patient #2- There is an incomplete unsigned nursing visit note on record for 07/28/23.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence of criminal background checks being obtained prior to hire as required in the state of South Carolina Regulation 61-78, Standards for Licensing Hospices, Section 601.B. Personnel #6- The employee was oriented as a Hospice Volunteer on 01/01/23. The background check on record occurred 03/03/21. (corrected on site 08/16/23)