Every finding on record at Heart of Hospice Lowcountry

Based on review of the hospice's Emergency Preparedness (EP)/Operational Plan, staff interview, and EP policy and procedure review, the hospice's Emergency Preparedness Plan's contact information and functional responsibilities of staff had not been updated after the hospice had many recent staffing changes. --- On 7/21/2023 at 8:51 AM, review of the hospice's Emergency Preparedness/Operational Plan revealed the staff contact information listed in the EP contact section contained many employees who were no longer employed at the hospice. New employees and leadership roles were not updated in the contact list. The findings were verified with the Executive Director of a sister hospice on 7/21/2023 at 11:15 AM. Hospice policy, titled, "Emergency Preparedness/Operational Plan," reads, "The hospice agency shall develop and document an organization and staff chart and staff roster which will include at a minimum, employees, entities providing services under arrangement, patient's physicians, volunteers, if applicable. The chart will show the names with job titles, the functional responsibilities of staff, and the chain of command and communication, which is to be followed in an emergency."

Based on review of the hospice's Emergency Preparedness (EP)/Operational Plan and staff interview, the hospice had no documentation or policies regarding communication to authorities regarding the hospice's ability to provide assistance during an emergency and specific facility needs during an emergency. --- The findings are: On 7/21/2023 at 8:51 AM, review of the hospice's Emergency Preparedness/Operational Plan revealed the hospice had no policies or letters of communication to local Emergency Preparedness authorities that showed the hospice's ability to provide assistance in an emergency. There was no documented communication to authorities regarding the hospice's needs during an emergency. On 7/21/2023 at 11:15 AM, the Executive Director of a sister hospice verified the findings.

Based on record reviews, interview, and the hospice's policies, Hospice A's Interdisciplinary Team failed to include the patient's responsible party in development of the patient's plan of care when the hospice aide services were decreased by the Interdisciplinary Team (IDT) for the patient for one of three patients. (Patient 11) --- The findings are: On 7/18/23 at 1:20 PM, during a home visit to Patient 1's home with Registered Nurse (RN) 1revealed the patient was admitted on 5/11/23 with a primary diagnosis of Alzheimer. During the home visit, the patient's responsible party asked RN #1 about the decrease in the Certified Nurse Aide (CNA) visit frequency stating, "They use to come every day. Now, just Monday, Wednesday, Friday. Why?" RN 1# stated, "It may be due to the fact that two CNA's are out right now." After RN #1 left the home, the patient's responsible party reported she/he thought the reason the CNA visits decreased was because some staff resigned or were out on leave. The patient's responsible party further reported that she/he was not included in the change to the patient's plan of care. On 7/20/23 at 2:34 PM, review of Patient #11's record revealed the patient's Plan of Care for the certification period 3/10/23 - 5/10/23 showed the CNA visit frequency was six days a week. Review of the patient's Plan of Care for the certification period dated 5/11/23 - 7/9/23 showed the CNA visit frequency decreased to five days a week. There was a physician order dated 5/15/23 to decrease the CNA visit frequency to three times a week. There was no documentation indicating the reason for the decreased CNA visit frequency, and there was no documentation indicating the patient's responsible party was involved in the change in visit frequency to the patient's plan of care. On 7/21/23 at 9:40 AM, an interview and concurrent review of Patient #11's record were conducted with the Clinical Director from Hospice B. The Clinical Director stated there was no documentation in the patient's record as to why the CNA visit frequency was decreased, but it may have been due to the decrease in staffing. The Clinical Director confirmed there was no documentation as to why Patient #11's responsible party was not involved in the change to the patient's hospice plan of care. On 7/21/23, the hospice policy, titled, "Initial & Comprehensive Admission Assessment & Plan of Care," revealed, "...The plan will include...interventions agreed upon by the patient/representative...".

Based on record reviews and interview, the hospice failed to ensure the Interdisciplinary Team (IDT) completed the patient's initial comprehensive assessment within 5 days of the patient's notice of election (NOE) for the hospice benefit for 8 of 10 patient charts reviewed. (Patient 3, 5, 8, 10, 12, 13, 14 and 26) --- Record review on 07/19/23 at 9:50 AM of Patient #5's chart revealed the patient was admitted on 12/15/22 for Senile Degeneration of Brain. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was dated 7 days after the patient's NOE. During an interview on 07/21/23 at 10:34 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/19/23 at 7:25 PM of Patient #8's chart revealed the patient was admitted on 03/17/22 for Malignant Neoplasm of Prostrate. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of the patient's notice of election. The first IDT meeting for the patient was on 03/24/22 which was 7 days after the NOE. During an interview on 07/21/23 at 11:13 AM, the Director employed by another certified hospice verified the findings. Record review on 07/17/23 at 1:05 PM of Patient 10's chart revealed the patient was admitted on 08/12/22 for Senile Degeneration of Brain. Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of the patient's notice of election. The first IDT meeting for the patient was dated 08/25/22 which was 7 days after the patient's NOE. During an interview on 07/21/23 at 10:34 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/17/23 at 3:30 PM of Patient #12's chart revealed the patient was admitted on 03/03/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the patient's chart revealed no IDT comprehensive assessment within 5 days of the patient's notice of election. The first IDT meeting for the patient was on 03/16/23,which was 13 days after the patient's NOE. During an interview on 07/21/23 at 12:24 PM, the Director of Clinical Operations employed y another certified hospice verified the findings. Record review on 07/19/23 at 8:15 PM of P 13 revealed P 13 was admitted to the hospice on 07/15/21 for Senile Degeneration of Brain. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 07/28/21, 13 days after the NOE. During an interview on 07/21/23 at 12:42 PM, the Director of Clinical Operations for Heart of Hospice verified the findings. Record review on 07/19/23 at 9:30 AM of P 14 revealed P 14 was admitted to the hospice on 03/02/22 for Atherosclerotic Heart Disease. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 03/10/22, 8 days after the NOE. During an interview on 07/21/23 at 12:49 PM, the Director of Clinical Operations for Heart of Hospice verified the findings. Record review on 07/20/23 at 10:15 AM of P 26 revealed P 26 was admitted to the hospice on 06/13/23 for Hodgkins Lymphoma. Review of the chart revealed no IDT comprehensive assessment within 5 days of the notice of election. The first IDT meeting for the patient was on 06/22/23, 9 days after the NOE. During an interview on 07/21/23 at 1:11 PM, the Director of Clinical Operations for Heart of Hospice verified the findings. The findings are: On 7/20/23 at 1:44 PM, review of Patient 3's Medicare Election Form revealed hospice care started on 6/14/22. The admission nursing Visit Note dated 6/14/22 reads, "...OPEN TO ALL DISCIPLINES...". The spiritual assessment was completed by the Chaplain on 9/22/22 which was three months after admission. There was no documented evidence that a comprehensive assessment was completed by the IDT within five days of admission. During an interview with the Clinical Director employed by another certified hospice on 7/21/23 at 9:07 AM, she/he confirmed the findings.

Based on record reviews and interviews, the hospice failed to ensure the actual medications and dosages that the patient takes is reconciled with the hospice's medication profile for 2 of 3 home visit patients. (Patient 10 and 12) --- The findings include: Home observation on 07/18/23 from 1:40 PM to 2:00 PM of Patient 10 revealed the patient's takes Hydrocodone 5 mg (milligram)-Acetaminophen 325 mg; take 1 tab every 4 hours prn (as needed) for pain, but the hospice medication profile showed Hydrocodone 5 mg-Acetaminophen 325 mg; take 1 tab every 6 hours prn pain. Patient takes Tramadol 50 mg; take 3 tabs by mouth every 12 hours as needed for pain, but the hospice medication profile showed Tramadol 50 mg; take 1 tab by mouth every 12 hours as needed for pain. The following medication the patient verifies he/she takes but is not listed on the hospice medication profile: Morphine sulfate 100 mg/5ml (20 mg/ml); take 0.25 ml (5 mg) by mouth every 3 hours as needed for pain. During an interview on 07/21/23 at 11:58 AM, the Director of Clinical Operations from Hospice B verified the findings. Home observation on 07/19/23 at 12:45 PM to 1:30 PM of Patient 12 revealed the patient takes Mucinex 600 mg; take 1 tablet daily as needed for congestion when compared to the hospice medication profile revealed Mucinex 600 mg; take 1 tab 2 times daily, take only as needed. Further review and observation revealed hospice medication profile showed Ventolin HFA 90 mcg (microgram); take 2 puffs every 6 hours as needed for shortness of breath or wheezing. Further observation revealed the following medication was not listed on the hospice medication profile which the patient takes: Breztri inhaler as needed for shortness of breath. During an interview on 07/21/23 at 12:24 PM, the Director of Clinical Operationsfrom Hospice B verified the findings.

Based on record reviews and interviews, the hospice failed to ensure initial bereavement risk assessments were completed for patients within 5 days of the patient's admission for 6 of 27 patient charts reviewed. (Patient 5, 6, 8, 10, 14, and 26) --- Record review on 07/19/23 at 12:07 PM of P 4 revealed P 4 was admitted to the hospice on 03/01/22 for Cerebral Vascular Accident (CVA) with left sided weakness. Review of the chart revealed no initial bereavement assessment within 5 days of P 4s admission. During an interview on 07/21/23 at 1:14 PM, the Director of Clinical Operations for Heart of Hospice verified the findings. Record review on 07/17/23 at 2:00 PM of P 6 revealed P 6 was admitted to the hospice on 03/31/22 for Cardiomyopathy, Neurofibromatosis and other diseases of the Spinal Cord. Review of the chart revealed no initial bereavement assessment within 5 days of P 8s admission. During an interview on 07/21/23 at 1:17 PM, the Director of Clinical Operations for Heart of Hospice verified the findings. The findings include: Record review on 07/19/23 at 9:50 AM of P 5 revealed P 5 was admitted to the hospice on 12/15/22 for Senile Degeneration of Brain. Review of the chart revealed no initial bereavement assessment within 5 days of P 5s admission. During an interview on 07/21/23 at 10:34 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/19/23 at 7:25 PM of P 8 revealed P 8 was admitted to the hospice on 03/17/22 for Malignant Neoplasm of Prostrate. Review of the chart revealed no initial bereavement assessment within 5 days of P 8s admission. During an interview on 07/21/23 at 11:13 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/17/23 at 1:05 PM of P 10 revealed P 10 was admitted to the hospice on 08/12/22 for Senile Degeneration of Brain. Review of the chart revealed no initial bereavement assessment within 5 days of P 10s admission. During an interview on 07/21/23 at 11:58 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/19/23 at 9:30 AM of P 14 revealed P 14 was admitted to the hospice on 03/02/22 for Atherosclerotic Heart Disease. Review of the chart revealed no initial bereavement assessment within 5 days of P 14s admission. During an interview on 07/21/23 at 12:49 PM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/20/23 at 10:15 AM of P 26 revealed P 26 was admitted to the hospice on 06/13/23 for Hodgkins Lymphoma. Review of the chart revealed no initial bereavement assessment within 5 days of P 10s admission. During an interview on 07/21/23 at 1:11 PM, the Director of Clinical Operations employed by another certified hospice verified the findings.

Based on record reviews and staff interviews, the hospice failed to ensure all members of the Interdisciplinary Team (IDT) were present at the IDT meeting for two of twenty-seven charts reviewed. (Patient 6 and 7) --- Record review for Patient 6 was conducted on 07/20/2023 at 2:00 PM revealed IDT meetings for 05/05/2022 and for 01/19/2023. On 05/05/2022, the electronic signature for the RN was dated 05/10/2023 and the Physician electronic signature was dated 05/12/2022. On 01/19/2023, the IDT meeting notes showed the electronic signature for the Registered Nurse (RN) was dated 01/31/2023 and the Physician' electronic signature was dated 02/02/2023. The findings were verified with the Clinical Director from Hospice B on 07 21/23 at 1:55 PM. Record review was conducted on 07/20/23 at 2:45 PM for Patient 7's IDT "New Admission" meetings for 05/05/2022. The RN's electronic signature was dated 05/10/2022. The Physician electronic signature was dated 05/12/2022. The findings were verified with the Clinical Director from Hospice B on 07/21/23 at 1:58 PM.

Based on record review and interview, the hospice failed to ensure the Registered Nurse (RN) followed the individualized written plan of care to furnish hospice care and services to the patient and their families for 3 of 14 patient charts (Patient 8, 12 and 20) and 2 of 14 focused charts reviewed (Patient 25 and 27). --- The findings include: Record review on 07/19/23 at 7:25 PM of P 8 revealed P 8 was admitted to the hospice on 03/17/22 for Malignant Neoplasm of Prostrate. Review of certification period 05/11/23 to 07/09/23, POC revealed a SN visit frequency for 1 time a week for 9 weeks. Review of RN visits revealed a RN visit was completed on 06/15/23 with the next RN visit completed on 07/06/23, 20 days between an assessment of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 10:06 AM, the Director of Clinical Operations employed by another certified hospice stated, ";I think policy probably states the nurses are to visit at least every 14 days, but I would expect at least once a week. The policy on visits is driven by the patient". Record review on 07/17/23 at 3:30 PM of P 12 revealed P 12 was admitted to the hospice on 03/03/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of certification period 06/01/23 to 08/29/23, POC revealed a SN visit frequency for 1 time a week for 1 week and 3 times a week for 12 weeks. Review of RN visits revealed a RN visit on 06/27/23 with the next RN visit completed on 07/13/23, 16 days between an assessment of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 12:24 PM, the Director of Clinical Operations employed by another certified hospice verified the findings. Focused record review on 07/20/23 at 11:07 AM of P 25 revealed P 25 was admitted to the hospice on 05/04/23 for Atherosclerotic Heart Disease. Review of certification period 05/04/23 to 07/26/23, POC revealed a SN visit frequency for 2 times a week for 13 weeks. Review of RN visits revealed a RN visit on 06/01/23 with the next RN visit completed on 06/23/23, 21 days between an assessment of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 11:13 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Focused record review on 07/20/23 at 9:45 AM of P 27 revealed P 27 was admitted to the hospice on 06/01/22 for Alzheimer Disease. Review of certification period 05/27/23 to 07/25/23, POC revealed a SN visit frequency for 1 time a week for 10 weeks. Review of RN visits revealed a RN visit on 05/27/23 with the next RN visit completed on 06/20/23, 16 days between an assessment of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 1:01 PM, the Director of Clinical Operations employed by another certified hospice verified the findings. On 07/20/23 at 9:49 AM, review of Patient 20's chart revealed the patient was admitted on 05/31/23 for Hypertensive Heart Disease with Heart Failure. Review of certification period dated 05/31/23 to present orders for Skilled Nursing 3 times a week for 12 weeks.. On 06/14/2023 skilled nurse visit decreased to 1 time a week. The chart revealed the RN completed an RN supervisory visit on 06/22/23 with the next RN visit completed on 07/18/23, which was 19 days between continuous assessment of the patient and the patients family needs based on the patient's POC. During an interview on 07/21/23 at 1:44 PM, the Director of Clinical Operations employed by a sister hospice verified the findings.

Based on record reviews and interview, Hospice A failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), Chaplain, and Volunteer completed home visits per the ordered frequency on the patient's plan of care for 5 of 29 patient charts reviewed. (Patient 10, 11, 19, 20, and 25). --- Record review on 07/20/23 at 10:33 AM of Patient #19 revealed the patient was admitted on 03/04/21 for Alzheimer. Review of the certification period dated 06/22/23 to 08/20/23, SN visit frequency was 1 time a week for 9 weeks. Review of the SN visits revealed 1 missed nursing visit the week of 06/25/23 to 07/01/23. MSW visit frequency was 1 time a month for 2 months. Review of the MSW visits revealed no MSW visits from 6/22/23 until current date. During an interview on 07/21/23 at 1:35 PM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/20/23 at 12:04 PM of Patient # 20 revealed the patient was admitted on 05/31/23 for Hypertensive Heart Disease with Heart Failure. Review of certification period dated 05/31/23 to 07/19/23 revealed SN visit frequency was 3 times a week for 12 weeks. Review of the SN visits revealed 1 missed nursing visit the week of 06/04/23 to 06/10/23. On 06/14/23, the SN visits changed to 1 time a week. No SN visit was noted the week of 07/2/23 to 07/08/23. The findings were verified with the Director of Clinical Operations another certified hospice at 1:40 PM on 7/21/23. The findings include: Record review on 07/17/23 at 1:05 PM of P 10 revealed P 10 was admitted to the hospice on 08/12/22 for Senile Degeneration of Brain. Review of certification period 04/09/23 to 06/07/23, SN visit frequency was 3 times a week for 1 week. Review of patient 10s visits revealed 1 missed nursing visit the week of 04/16/03/ to 04/22/23, 05/07/23 to 05/13/23, 05/14/23 to 05/20/23, 05/21/23 to 05/27/23 and 05/28/23 to 06/03/23. Hospice aide visit frequency was 5 times a week for 8 weeks. Review of P 10s visits revealed 2 missed hospice aide visits the week of 04/09/23 to 04/15/23 and 04/23/23 to 04/29/23. Chaplain visit frequency was 1 time a month for 2 months. Review of P 10s visits revealed 1 missed chaplain visit for the month of April. Volunteer visit frequency was 3 times a month for 1 month. Review of P 10s visits revealed 3 missed visits volunteer visits for the month of May. During an interview on 07/21/23 at 11:58 AM, the Director of Clinical Operations employed by another certified hospice verified the findings. Record review on 07/20/23 at 10:15 AM of P 25 revealed P 25 was admitted to the hospice on 05/04/23 for Atherosclerotic Heart Disease. Review of certification period 05/04/23 to 07/26/23, SN visit frequency was 2 times a week for 13 weeks and Chaplain visit frequency of 1 time a month for 3 months. Review of patient 25s visits revealed 1 missed nursing visit the week of 05/04/23 to 05/06/23, 05/07/23 to 05/13/23, and 05/14/23 to 05/20/23, with 1 extra SN visits the week of 05/21/23 to 05/27/23, 05/28/23 to 06/03/23 and 06/04/23 to 06/10/23. Review of P 25s Chaplain visits revealed 1 missed visit for the month of June. During an interview on 07/21/23 at 1:02 PM, the Director of Clinical Operations employed by another certified hospice verified the findings. On 7/17/23, at 2:20 PM, Patient 11's record was reviewed. Patient 11 was admitted to the hospice on 10/29/19 with a diagnosis of Alzheimers. The Plan of Care for the benefit periods of 3/12/23 - 5/10/23 and 5/11/23 - 7/9/23 indicated the MSW visit frequency was monthly. There was no documented evidence of a MSW visit from 4/25/23 to 7/9/23. During an interview with the Clinical Director of another certified hospice on 7/21/23, at 9:40 AM, she/he confirmed the findings.

Based on record review and interview, Hospice A failed to analyze adverse events, their causes, and implement preventive actions and mechanisms that included feedback and learning throughout the hospice. --- On 7/21/23 at 11:55 AM, a tracking log of adverse events was reviewed. The tracking log was generated from the electronic medical records (EMR) and included separately certified hospice companies under the corporate title LHC. Hospice A's QAPI Program records were reviewed. There was no documented evidence of any analysis or inclusion of the adverse events. On 7/21/23 at 12:10 PM, during an interview with the ED/Administrator 2 from Hospice B, she/he confirmed the findings. On 7/21/23, Hospice A's policy, titled, "HOSPICE QUALITY ASSURANCE PERFORMANCE IMPROVEMENT PLAN," revealed, "...Performance improvement activities track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospice agency...".

Based on review of Hospice A's governance data, review of Quality data, and interview, Hospice A failed to ensure the governing body designated an individual responsible for operating the quality assessment and performance improvement program. --- The findings are: On 7/21/23, review of Hospice A's policy titled, "HOSPICE QUALITY ASSURANCE PERFORMANCE IMPROVEMENT (QAPI)PLAN," revealed, "...The governing body delegates coordination and management of the program to the hospice Executive Administrator/Executive Director..." Cross Reference: L651 Halcyon Hospice did not have an ED/Administrator or an Alternate ED/Administrator. On 7/21/23 at 11:55 AM, a review of Hospice A's QAPI data was reviewed with ED/Administrator 2 from Hospice B.. In a concurrent interview with ED/Administrator 2 from Hospice B, she/he stated Hospice A did not have anyone designated as responsible for operating Hospice A's QAPI Program.

Based on observations, interview, and review of Hospice A's policy and procedure, 1 of 2 Hospice Aides (HA 1) failed to use acceptable principles for infection control to prevent potential cross contamination of infectious agents in the home setting for 1 of 3 home patients observed. (Patient 10) --- The findings include: Observations on 07/18/23 from 11:47 AM to 1:04 PM of Patient 10 revealed HA 1 donned a clean pair of gloves obtained from his/her pants pocket. HA 1 obtained warm water in two basins for the bed bath and two clean washcloths. HA 1 washed, rinsed off, and dried Patient 10s upper body. HA 1 opened Patient 10s brief and washed, rinsed off, and dried Patient 10s perineum area without changing gloves, performing hand hygiene, and/or changing the basin waters. HA 1 proceeded to wash, rinse off, and dry Patient 10s bilateral legs. Patient 10 was rolled to the right side of the hospital bed and the dirty brief was removed. Patient 10s back and buttock area was washed, rinsed off, and dried by HA 1 wearing the same soiled gloves initially donned. During an interview on 07/18/23 at 1:36 PM, HA 1 verified the findings. Hospice policy, entitled, ";Infection Control", revealed, ";1. Hand Hygiene Compliance: The agency will prevent transmission of infection through proper adherence of hand hygiene procedure by staff per Center for Disease Control and Prevention (CDC) guidelines. This compliance will be monitored by the Executive Administrator/Executive Director and/or their designee through demonstration during educational staff meeting and home visits which are made for supervision, competency assessment, peer reviews and survey readiness...".

Based on observation, interview and review of the hospices records, the hospice failed to show evidence that the hospice routinely provides substantially all core services directly by hospice employees when the hospice failed to ensure the hospice had the personnel resources to provide all core services to the hospice's patients. routinely provide a Registered Nurse (RN) and Medical Social Worker (MSW) who were employees of the agency. --- The findings are: Cross Reference to L591:Hospice A failed to provide nursing care and services by or under the supervision of a Registered Nurse (RN) when there was no evidence a RN assessed the patient at death for one of 32 patient records reviewed. There was no full-time RN employed by Hospice A from 6/30/23 to present 7/21/23. Hospice A had no RN Supervisor employed from 6/23/23 to 7/21/23. Cross Reference to L594: Hospice A failed to provide routine Medical Social Services when there was no Medical Social Worker (MSW) employed from 6/16/23 to present (7/21/23). Cross Reference to L596: Hospice A failed to have evidence of counselor or contracted counselor to provide bereavement counseling services to the family or other individuals in the patient's bereavement plan of care for up to a year. Cross Reference to L651: Based on observations, interviews, and review of the hospice's records, the hospice failed to demonstrate there was a governing body to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, the organizational delineation of authority and continuous quality assessment and performance improvement. The hospice also failed to ensure a qualified administrator was an employee of the hospice and appointed by and reporting to the governing body to be responsible for the day-to-day operation of the hospice.

Based on review of the Hospice A's records, interviews, and review of Hospice A's policy, Hospice A failed to provide nursing care and services by or under the supervision of a Registered Nurse (RN) when there was no evidence a RN assessed the patient at death for one of 32 patient records reviewed. There was no full-time RN employed by Hospice A from 6/30/23 to present 7/21/23. Hospice A had no RN Supervisor employed from 6/23/23 to 7/21/23. --- The findings are: On 7/17/23 at 10:06 AM, during the entrance conference for Hospice B with Clinical Director 1 from Hospice she/she stated the Clinical Director (e.g. RN Patient Care Manager) position had been vacant since June 2023. On 7/18/23 at 11:00 AM, Hospice A's policy, titled, "Branch Office Supervision," revealed, "...A full-time registered nurse (RN) shall be assigned to the branch office...The RN shall be an employee of the agency...". On 7/20/23 at 9:23 AM, review of Hospice B's payroll reports for June 2023 and July 2023 revealed the last dates worked by full-time RN employees of Hospice B were as follows: RN Patient Care Manager RN (PCMs) last day worked was 6/23/23; RN 3s last day worked was 6/25/23; and RN 4s last day worked was 6/30/23. PRN RN 2s last day worked was 6/2/23; PRN RN 3s last day worked was 6/2/23; and PRN RN 1's last day worked was 7/6/23. Contract RN was hired 7/5/23 and began patient care on 7/6/23. On 7/21/23 at 9:40 AM, during an interview with Clinical Director1 from Hospice B who is an RN, Clinical Director 1 from Hospice B stated she/he is not an employee of Hospice B and does not provide patient care. On 7/21/23 at 2:10 PM, during an interview, ED/Administrator 1 from Hospice B stated the last RN Hospice A had was PRN RN 1 who was budgeted as a 0.2 FTE (equivalent to 8 hours/week). ED/Administrator 1 from Hospice B confirmed Hospice A did not have a full-time RN routinely providing patient care beginning 6/30/23. There was no full-time RN available for patient care at Hospice A from 6/30/23 to 7/6/23. There was no full-time RN Patient Care Manager responsible for the supervision and oversight of patient care at Hospice A from 6/23/23 to present (7/21/23). On 7/21/23, at 10:44 AM, during an interview, ED/Administrator 1 from Hospice B confirmed the findings. The only documented evidence of recruitment efforts was a copy of a posting on the parent companys website for ";RN Hospice" posted 25 days ago. On 7/19/23, at 11:43 AM, during review of Hospice A's patient death discharges revealed Patient 32's record indicated Patient 32 was admitted on 3/2/22 with a primary diagnosis of Atherosclerotic Heart Disease. Review of the Visit Note Report dated 7/13/23 revealed Patient 32 died at home. The visit note was completed by a Licensed Practical Nurse (LPN) and not a Registered Nurse (RN). There was no documented evidence that a RN attended Patient 32's death, performed an assessment, and notified the physician. On 7/21/23 at 3:32 PM, Clinical Director 1 from Hospice B confirmed the findings. Hospice A's policy, titled, "HOME DEATH PRONOUNCEMENT", revealed, "...Purpose...To establish the process for hospice clinician to follow when a patient dies at home...State...South Carolina...Who Can Pronounce...Physician or Nurse Practitioner...Guidelines...RN can perform an assessment of death and report findings to the physician...". Record review on 07/19/23 at 7:25 PM for Patient 8 revealed the patient was admitted on 03/17/22 for Malignant Neoplasm of Prostrate. Review of the certification period dated 05/11/23 to 07/09/23, revealed the Plan Of Care (POC) revealed a Skilled Nurses (SN) visit frequency for 1 time a week for 9 weeks. Review of Registered Nurse (RN) visits revealed a RN visit was completed on 06/15/23 but the next RN visit completed was 07/06/23 which was 20 days between assessments of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 10:06 AM, Director of Clinical Operations from Hospice B stated, ";I think policy probably states the nurses are to visit at least every 14 days, but I would expect at least once a week. The policy on visits is driven by the patient." Record review on 07/17/23 at 3:30 PM for Patient 12 revealed the patient was admitted on 03/03/23 for Chronic Obstructive Pulmonary Disease (COPD). Review of the certification period dated 06/01/23 to 08/29/23. The POC revealed a SN visit frequency for 1 time a week for 1 week and 3 times a week for 12 weeks. Review of RN visits revealed a RN visit on 06/27/23, but the next RN visit was not completed until 07/13/23 which was 16 days between assessments of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 12:24 PM, the Director of Clinical Operations from Hospice B verified the findings. Focused record review on 07/20/23 at 11:07 AM for Patient 25 revealed the patient was admitted on 05/04/23 for Atherosclerotic Heart Disease. Review of the certification period dated 05/04/23 to 07/26/23 revealed the POC showed a SN visit frequency for 2 times a week for 13 weeks. Review of RN visits revealed a RN visit on 06/01/23,but the next RN visit was not completed until 06/23/23 which was 21 days between assessments of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 11:13 AM, the Director of Clinical Operations from Hospice B verified the findings. Focused record review on 07/20/23 at 9:45 AM for Patient 27 revealed the patient was admitted on 06/01/22 for Alzheimer Disease. Review of the certification period dated 05/27/23 to 07/25/23 revealed the POC showed a SN visit frequency for 1 time a week for 10 weeks. Review of RN visits revealed a RN visit on 05/27/23, but the next RN visit was not completed until 06/20/23, which was 16 days between assessments of the patient and the patients family needs based on the POC. During an interview on 07/21/23 at 1:01 PM, the Director of Clinical Operations from Hospice B verified the findings. On 07/20/23 at 9:49 AM, review of Patient 20's chart revealed the patient was admitted on 05/31/23 for Hypertensive Heart Disease with Heart Failure. Review of certification period dated 05/31/23 to present orders for Skilled Nursing 3 times a week for 12 weeks.. On 06/14/2023, the skilled nurse visit was decreased to 1 time a week. The patient's chart revealed the RN completed a RN supervisory visit on 06/22/23, but the next RN visit was not completed until 07/18/23, which was 19 days between continuous assessment of the patient and the patients family needs based on the patient's POC. During an interview on 07/21/23 at 1:44 PM, the Director of Clinical Operations from Hospice B verified the findings.

Based on record review and interview, Hospice A failed to provide routine Medical Social Services when there was no Medical Social Worker (MSW) employed from 6/16/23 to present (7/21/23). --- The findings are: On 7/17/23 at 2:20 PM, Patient 11's record was reviewed. Patient 11 was admitted to Hospice A on 10/29/19 with a diagnosis of Alzheimer. Review of the patient's Plan of Care for the benefit periods of 3/12/23 - 5/10/23 and 5/11/23 - 7/9/23 showed the MSW visit frequency was monthly. There was no documented evidence of a MSW visit from 4/25/23 to 7/9/23. During an interview with the Clinical Director from Hospice B on 7/21/23 at 9:40 AM, she/he confirmed the findings. On 7/20/23 at 11:01 AM, an Interdisciplinary Group (IDG) meeting at Hospice A was observed. A MSW was in attendance. After the IDG Meeting, at 12:00 PM, during an interview with the MSW, he/she stated he/she was not an employee of Hospice A. The MSW stated he/she was the Volunteer Coordinator for Hospice B, and stated he/she was also the MSW and "...just came to help..." Hospice A because they did not have a Social Worker for IDG. The MSW stated he/she covers a caseload of 45-50 patients in addition to his Volunteer Coordinator position for Hospice B. The MSW stated he/she did not make routine visits to see patients for Hospice A. The MSW stated the Hospice A's MSW left "about a month ago." On 7/20/23 at 3:00 PM, the Payroll Reports for June 2023 and July 2023 revealed the last day a MSW worked worked at Hospice A was 6/16/23. On 7/20/23 at 3:15 PM, during an interview with the ED/Administrator 2 from Hospice B, she/he stated the MSW was from Hospice B and not an employee of Hospice A. On 7/21/23 at 10:44 AM, during an interview with ED/Administrator 2 from Hospice B, he/she confirmed Hospice A did not have a MSW from 6/17/23 to 7/21/23, and confirmed there was no documented evidence of any recruitment efforts by Hospice A for a MSW. Hospice A has not provided a MSW employee beginning 6/16/23 to 07/21/2023 .

Based on interview and personnel record review, Hospice A failed to have evidence of counselor or contracted counselor to provide bereavement counseling services to the family or other individuals in the patient's bereavement plan of care for up to a year. --- The findings include: Review of Hospice A's personnel files on 07/21/23 at 3:50 PM revealed no personnel file for the Bereavement Coordinator. During an interview on 07/21/23 at 8:27 AM, the Business Office Manager (BOM) stated, ";The bereavement coordinator is from Hospice C but is borrowed here to help out. He/she has been full-time in Hospice C since May 2023 around the time the Administrator left. So he/she just helps out here".

Based on observations, interviews, and review of the hospice's records, the hospice failed to demonstrate there was a governing body to assume full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, the organizational delineation of authority and continuous quality assessment and performance improvement. The hospice also failed to ensure a qualified administrator was an employee of the hospice and appointed by and reporting to the governing body to be responsible for the day-to-day operation of the hospice. --- On 7/17/23, at 10:06 AM, during the entrance conference for Halcyon Hospice, the Clinical Director of another certified hospice stated the Executive Director (ED)Administrator (ED 1) for Halcyon Hospice also covered the Spartanburg office and was on leave of absence. On 7/18/23, at 9:15 AM, an interview was conducted with the ED/Administrator of another certified hospice. She/he stated she/he was "just helping" Halcyon Hospice. She/he stated she/he was not formally designated as the Alternate Administrator at Halcyon Hospice. On 7/18/23, at 11:05 AM, the ED/Administrator of another certified hospice stated the ED 1 also covered the Spartanburg office and started a leave of absence on 7/8/23. On 7/19/23, at 9:30 AM, during an interview with an anonymous former employee, she/he stated ED 1 had not been the ED/Administrator at Halcyon Hospice since February 2023 (five months ago). On 7/19/23, at 10:58 AM, during an interview with the ED/Administrator of another certified hospice, a document titled, "Administrative Appointments" was reviewed. The document indicated the person appointed as ED/Administrator was ED 1 and in the absence of ED 1 the person appointed was the previous Patient Care Manager (PCM) who left Halcyon Hospice 6/23/23. The ED/Administrator of another certified hospice confirmed there was no person designated by the Governing Body as the Administrator/ED for Halcyon Hospice who was actively employed by the agency and working. On 7/19/23, at 11:52 AM, during an interview with the ED/Administrator of another certified hospice, she/he stated the last day ED 1 was physically at Halcyon Hospice was 5/28/23. On 7/19/23, at 12:10 PM, ED 1's personnel file was reviewed. ED 1 signed a job description for a position as a Licensed Practical Nurse (LPN) on 10/10/19. There was no signed job description for ED 1 as ED/Administrator. On 7/19/23, at 12:49 PM, during an interview with the ED/Administrator of another certified hospice, she/he stated the personnel file she/he provided for ED 1 was the "entire file." On 7/19/23, at 3:50 PM, during an interview with the Business Office Manager (BOM), she/he stated she/he was the one responsible for the personnel files and the last day ED 1 worked at Halcyon Hospice was 5/17/23. On 7/21/23, at 9:40 AM during an interview with the Clinical Director for another certified hospice, she/he stated she/he was not an employee of Halcyon Hospice. On 7/21/23, at 12:10 PM, the hospice's governing body (GB) meeting minutes were reviewed. The last GB meeting was 2/16/23 (five months ago) and ED 1 was indicated as calling the meeting to order. There was no documented evidence of GB meeting minutes after 2/16/23. On 7/21/23, at 1:40 PM during an interview with the BOM, she/he stated she/he thinks ED 1 started as "Interim Administrator" in January 2021 but he/she "did not sign a job description for Interim Administrator." Review of the document provided titled, "Employee Term Dates," on 7/21/23, revealed the last day of employment for the Halcyon Hospice's RN PCM was 6/23/23. Halcyon Hospice did not have an ED/Administrator or an Alternate ED/Administrator. The Hospice's policy titled, "Hospice Governing Body Responsibilities" was reviewed on 7/21/23. The policy indicated, "...The Hospice governing body meets to advise on professional issues, validates and reviews agency services, and ensures the safety and quality of care, treatment and/or services provided to patients. The governing body...shall include the following...Executive Director/Executive Administrator...Agency Medical Director...Clinical leader (if applicable)...One individual from each of the IDG member disciplines...RN Case manager, Social Worker, and Chaplain/Spiritual Counselor...The governing body meets, and keeps written records of those meetings, at least once quarterly..." On 7/21/23, at 10:44 AM, during an interview with the ED/Administrator of another certified hospice, she/he confirmed Halcyon Hospice did not have an ED/Administrator, Clinical leader (PCM), RN Case Manager, or Social Worker and therefore did not have a governing body. Review of facility organizational chart on 07/17/23 at 10:30 AM revealed the organizational chart contained staff information that was not accurate related to line of authority for the nursing staff, hospice aides, volunteers, chaplain, social worker, scheduler and marketers based on documentation. During an interview on 07/21/23 at 8:54 AM with the Business Office Manager (BOM) stated, ";I didnt realize all of those people were under my name. In the system the only person I manage is the care coordinator. I guess indirectly I manage them, like the aides were under my name but then they went to the Registered Nurse (RN). We didnt use to have a Volunteer Coordinator and they (the volunteers) were under me but then we got one (Volunteer Coordinator)".