Every finding on record at Heartsong Hospice of Sc, LLC

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did not ensure that the hospice aide reported changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes related to the plan of care and any quality assessment and improvement activities. CLINICAL RECORD 1: This patient elected the hospice benefit on 11/06/2025 with a terminal diagnosis of pancreatic cancer. The hospice plan of care for the dates of 11/06/2025-12/02/2025 gave orders for hospice aide visits 3xw. The hospice aid care plan effective dates of 11/07/2025-12/2/2025 directed the hospice aide to shampoo hair at each visit. The hospice aide visit note on 11/21/2025 stated that the patient had refused the shampoo but did not include documentation that the Registered Nurse (RN) was notified. The clinical record was reviewed including the coordination notes and revealed the notification of the RN was not present in the clinical record. The Director of Nursing (DON) stated during the interview and joint review on 12/02/2025 that the documentation did not show that the hospice aide notified the Registered Nurse. The DON stated that she thought because she reviewed each hospice aide visit note for audits that this would suffice as notification of the RN. In further discussion it was stated that the audits were not documented.

It is required that the Interdisciplinary Group ensures instruction of the patient, as appropriate, and the family and/or other caregivers on the proper handling, storage, and safe utilization of durable medical equipment and/or supplies. Persons under contract with the hospice may instruct the patient and/or family. Instruction is documented in the patient record. The patient, family and/or other caregiver must be able to demonstrate the appropriate use of the DME to the satisfaction of the IDG. The IDG documents that the patient, family, and/or caregivers can demonstrate appropriate use. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) clinical records reviewed, the agency did ensure that the instructions for the proper handling, storage, and safe utilization of durable medical equipment and/or supplies was provided to the family and/or other caregivers. CLINICAL RECORD 2: This patient elected the hospice benefit 0n 07/08/2025 with a terminal illness of ALS. The clinical record documented the patient received the oxygen concentrator, overbed table, bed extension kit, hi-lo bed w mattress and rails, and shower seat with back on 07/08/2025. The patient owned an electric wheelchair, commode chair and manual hoyer lift with sling. The hospice plan of care for the dates of 07/08/2025-12/03/2025, the registered nurse initial comprehensive assessment, nursing notes, and the IDG notes for 07/08/2025-12/03/2025 were reviewed. There was no documentation of education of the DME to the patient/caregiver. During an interview and joint clinical record review on 12/02/2025, the Director of Nursing stated that there was no documentation in the clinical record that the patient/family was educated on the DME. She stated that this is usually documented in the care plan, but it was not present in this record.