Every finding on record at Compassionate Care Hospice of South Carolina, LLC

Upon patient record review, 3 of 23 (Patient #1,2,3) 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: During the home visit, it was observed the facility medication record contained albuterol inhaler q 6hrs PRN, the medication was not on the hospice medication record. Additionally, the hospice medication record listed Simvastatin 20 mg at HS which was not on the facility medication record. Corrected on site by getting an order to add Albuterol inhaler and discontinue Simvastatin. Patient #2: During the home visit, it was observed the facility medication record contained Zyprexa 25 mg daily and Valsartan 160 mg daily. The medications were not on the hospice medication record. Corrected on site by getting an order to add Zyprexa and Valsartan. Patient #3: During the home visit, it was observed the facility medication record contained MiraLAX 17gm daily, as needed; the medication was not on the hospice medication record. Corrected on site by getting an order to add MiraLAX. Additionally, on 8/25/25 there was an order for O2 2L/min continuous. On 9/18/25 the nurse documented O2 @ 1L/min and on 10/15/25 the patient was on room air. Corrected on site by correcting the oxygen order.

Upon patient record review, 2 of 23 (Patient #1, #13) 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. Amedisys Policy Wound-002. Patient #1: Upon observation of the medical record the patient had a wound that was not assessed the week of 8/31/25-9/6/25. Patient #13: Upon observation of the medical record the patient had a wound that was not assessed the weeks of 10/8/25-10/30/25.

Upon patient record review, 4 of 23 (Patient #1,2,3,15) 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: During home visit, it was observed the facility medication record contained albuterol inhaler q 6hrs PRN, the medication was not on the hospice medication record. Additionally, the hospice medication record listed Simvastatin 20 mg at HS which was not on the facility medication record. Corrected on site by getting an order to add Albuterol inhaler and discontinue Simvastatin. Patient #2: Upon medical record review the patient had a Percutaneous cholecystectomy drain. There was no order for the drain. Additionally during the home visit, it was observed the facility medication record contained Zyprexa 25 mg daily and Valsartan 160 mg daily. The medications were not on the hospice medication record. Corrected on site by getting an order to add Zyprexa and Valsartan. Patient #3: During the home visit, it was observed the facility medication record contained MiraLAX 17gm daily, but not on the hospice medication record. Corrected on site by getting an order to add MiraLAX. Additionally, on 8/25/25 there was an order for O2 2L/min continuous. On 9/18/25 the nurse documented O2 @ 1L/min and on 10/15/25 the patient was on room air. Corrected on site by correcting the oxygen order. Additionally, the patient had an order for TED stockings which was not on the hospice medical record. Corrected on site by getting an order for TED stockings. Patient #15: Upon record review the wound order on 9/16/25 did not identify who would change the dressing. The order was updated and corrected on 10/31/25 to include who would change the dressing.

Upon patient record review, 2 of 23 (Patient #6,9) 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 #6: Upon record review the patient had a care plan for Imminent death open since admission 6/14/25. The patient was no longer imminent. Corrected on site by updating the care plan. Patient #9: Upon record review the patient had a Pleurex drain placed on 7/16/25. The plan of care was not updated with interventions and goals to include the drain. Corrected on site by updating the plan of care.

Upon client record review, 1 of 23 (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: Upon medical record review there was an order for NP 2 PRN visits for symptom management. The NP visited the patient on 7/18, 7/22, 8/19, 9/16, and 10/7/25.

Upon patient record review, 1 of 23 (Patient #3) 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 #3: During the home visit, it was noted the patient had an order at the facility for TED stockings on in AM and off in PM. TED Stockings was not on the aide plan of care. Corrected on site by getting an order for TED stockings and adding to Aide plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. There is documentation in the 2024 Volunteer cost savings report the percentage was 1.59%

Upon patient client record review, 1 of 23 (Patient #9) 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 #9: Upon record review the patient refused aide visits from 6/10/25-7/15/25. The RN continued to document aide supervision on 7/2, 7/3, and 7/9/25.

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, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and documents. In 2 of 13 (15%) clinical records reviewed the interdisciplinary group did not complete the comprehensive assessments within the required timeframe. Agency policy AA-005 states in part, "The comprehensive assessment will be completed by the interdisciplinary team within 5 days of the election of benefits." Clinical Record 6: Medical Social Work evaluation was ordered on the initial plan of care on 4/16/2021. The Medical Social Worker (MSW) completed the assessment on 4/23/21. There was no documented evidence of MSW attempts to contact the patient or family during this time. Clinical Record 13: On the initial plan of care signed by a physician on 7/19/2022, the chaplain evaluation was included in the visit frequency orders. The Chaplain made an initial visit on 7/25/2022 which is one day outside of the 5-day allowance. There was no documented evidence of attempts made to contact the patient or family during this time. Agency policy AA-005 states in part, "The comprehensive assessment will be completed by the interdisciplinary team within 5 days of the election of benefits."