Every finding on record at Hospice of Scotland County, Inc

Based on record reviews and interview, the hospice failed to ensure the hospice's Emergency Preparedness Plan had documentation for an emergency transport agreement. The hospice had the name of another hospice listed on the EPP. The findings are: On 3/30/2022 at 8:46 AM, review of the hospice's contracts revealed the hospice had no contract with a transport service for use in an emergency situation. On 3/30/2022 at 3:26 PM, the Executive Director (ED) stated, "We do not have a transport agreement." On 4/1/2022 at 11:36 AM, review of the hospice's EPP revealed the name of another hospice was listed on the EPP. The finding was verified by the Executive Director (ED) on 4/1/2022 at 11:36 AM.

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice had no policy and procedure related to the confidentiality and protection of patient medical records. The findings are: On 4/1/2022 at 11:36 AM, review of the hospice's EPP revealed there was policy and procedure for management of the confidentiality and protection of the hospice's patient medical records during an emergency situation. The finding was verified by the Executive Director (ED) on 4/1/2022 at 11:36 AM.

Based on review of the hospice's admission packet and interview, the hospice failed to ensure admission packet given to patients/caregivers was accurate with updated information that included but was not limited to: Hospice name, incorrect website address with the wrong telephone number and address, hours of operation, and listing of multiple location addresses. This has the potential to negatively impact the hospice patient/caregiver when seeking assistance from the hospice. The findings are: On 3/28/2022 and 3:26 PM, review of the hospice's Admission Packet revealed the name of the hospice was listed with name of hospice located in an adjoining state. The admission packet had a card stating the hospice's office hours are 8:00 AM to 5:00 PM. Monday through Friday but the office hours listed on the door of the hospice office revealed 9:00 AM - 2:00 PM Monday through Friday. The hospice's admission packet listed the wrong telephone number for patients/caregivers to contact the hospice. Review of the forms and the mission statement in the hospice's admission packet did have the hospice's name listed accurately. On 4/1/2022 from 12:01 PM to 1:25 PM, the Executive Director (ED) verified the findings. The ED stated the hospice revised its mission statement on January 28, 2020, and the hospice is using up all of the old mission statements. In an interview with the ED on 4/1/2022 from 12:01 PM to 1:25 PM, the ED verified the findings, and stated "patients and caregivers would think their hospice was another hospice due to the wrong name listed." The mission statement was changed so all "would be under the same mission statement as the hospital (located in another state)." On 4/1/2022 from 12:01 PM to 1:25 PM, the ED verified the address and telephone number on the hospice's website was not correct. When the telephone number was called during the interview with the ED, the telephone message revealed the telephone number called is not a working number. The findings were verified by the ED from 12:01 PM to 1:25 PM on 4/1/2021.

Based on observations, record reviews, hospice wound care protocol, and interview, the hospice failed to update the patient's comprehensive assessment to ensure the hospice medication profile matched the patient's home medications for two of two home patients (Patient #1 and Patient #4) and failed to document wound assessments and update the patient's comprehensive assessment for one of one patient with a wound. (Patient #11) The findings are: On 3/29/2022 at 9:20 AM, observations during a home visit with Patient #1 revealed the patient's home medications did not match the hospice medication profile. Aricept 23 milligrams (mgs) tablet was listed don the hospice's medication profile but was not a current medication for the patient. The patient takes Melatonin 10 milligrams one at bedtime which was not listed on the hospice medication profile. The finding is verified by Registered Nurse (RN)#2 at 9:35 AM on 3/29/2022. On 3/29/2022 at 9:46 AM, observations during a home visit with Patient #4 revealed the patient's home medications did not match the hospice medication profile. Vitamin D was listed as 5000 IU(International Units) tablet on the hospice medication profile but the patient takes a 1000 IU tablet once a day. The hospice medication profile showed Calcium 1250 one tablet by mouth once a day. The patient stated he/she takes Calcium 1250 twice a day. Allopurinol 100 milligrams tablet one tablet at bedtime was on the hospice medication profile, but the patient takes three tablets daily. The patient takes Lasix 20 milligrams one time a day and Esomeprazole 20 milligrams daily, but neither medication is on the hospice medication profile for the patient. The findings were verified by RN #2 at 10:25 AM on 3/29/2022. On 3/30/2022 at 9:16 AM, review of Patient #11's chart revealed no documentation of the patient's sacral wound measurements for Skilled Nurse (SN) visits dated 4/10/2021, 4/13/2021, 4/16/2021, 4/20/2021, 4/27/2021, 5/15/2021, 5/16/2021, 5/19/2021, 5/20/2021, 5/24/2021, 5/27/2021, 5/29/2021, 5/31/2021, 6/8/2021, 6/14/2021, 6/19/2021, 6/20/2021, 6/23/2021, 6/24/2021, 6/25/2021, 6/26/2021, 6/27/2021, 6/28/2021, 6/29/2021, 6/30/2021, and 7/1/2021. The finding was verified by RN #2 at 3/31/2022 at 10:38 AM. On 4/1/2022 at 11:55 AM, review of the hospice's Wound Care Protocol revealed "Every nurse visit assess the wound (size: length x(times) width, depth and stage). The finding was verified by the Executive Director (ED) in an interview on 4/1/2022 from 12:01 PM to 1:25 PM.

Based on record reviews and interview, the hospice had no evidence that the hospice employed a Licensed Masters Social Worker (LMSW) to provide supervision of the Licensed Baccalaureate Social Worker (LBSW). The findings are: On 4/1/2022 at 8:51 AM, review of the hospice's personnel files revealed the hospice had no evidence of employing a LMSW to provide supervision of the hospice's LBSW. The findings were verified by the Executive Director (ED) in an interview on 3/30/2022 from 12:01 PM to 1:25 PM.

Based on record reviews, interview, and review of the hospice's policy and procedure, the hospice Interdisciplinary Group (IDG) had no individualized measurable goals on the patients' Plan Of Care (POC) for 11 of 11 patient charts reviewed for goals.(Patient #1, Patient #3, Patient #4, Patient #5, Patient #7, Patient #8, Patient #9, Patient #10, Patient #11, Patient #12, and Patient #13) The findings are: Patient #1 On 3/29/2022 at 10:31 AM, review of Patient #1's chart revealed the goals on the patient's POC were not individualized or measurable: accept spiritual support from the hospice chaplain, acceptable level of appetite, be free of urinary tract infections, acceptable level of "feeling of well being", and acceptable level of pain. The finding was verified by Registered Nurse (RN)#2 at 12:02 PM on 3/31/2022. Patient #3 On 3/29/2022 at 11:23 AM, review of Patient #3's chart revealed the goals on the patient's POC were not measurable: notify hospice for changes in condition, acceptable level of pain, acceptable level of appetite, and accept IDG support to enhance coping ability. The finding was verified by RN #2 at 1:51 PM on 3/31/2022. Patient #4 On 3/29/2022 at 11:58 AM, review of Patient #4's chart revealed the goals on the patient's POC were not measurable: acceptable level of pain, promote healing of skin, self-determined life closure, accept IDG support to enhance coping ability, and verbalize/demonstrate knowledge of medication administration. The finding was verified by RN #2 at 1:31 PM on 3/31/2022. Patient # 5 On 3/29/2022 at 12:42 PM, review of Patient #5's chart revealed the goals on the patient's POC were not measurable: will receive optimal support by hospice team, will accept IDG support to enhance coping ability, the hospice team will meet the initial and ongoing needs of the patient and caregiver, will provide good hygiene, and will demonstrate ability to use problem solving skills. The finding was verified by RN #2 at 1:58 PM on 3/31/2022. Patient # 7 On 3/29/2022 at 1:50 PM, review of Patient #7's chart revealed the goal on the patient's POC was not measurable: keep patient safe in the event of a disaster. The finding was verified by RN #2 at 1:46 PM on 3/31/2022. Patient #8 On 3/29/2022 at 2:46 PM, review of Patient #8's chart revealed the goals on the patient's POC were not measurable: will be safe in home environment, will express fears, concerns and frustrations, will verbalize understanding and comfort with the patient's shortness of breath management plan, will provide good hygiene, and will receive support by the hospice team. The finding was verified by RN #2 at 1:38 PM on 3:31/2022. Patient #9 On 3/29/2022 at 3:08 PM, review of Patient #9's chart revealed the goals on the patient's POC were not measurable: will be safe in home environment, acceptable level of dyspnea, will accept spiritual support. The finding was verified by RN #2 at 2:07 PM on 3/31/2022. Patient #10 On 3/29/2022 at 3:40 PM, review of Patient #10's chart revealed the goals on the patient's POC were not measurable: the hospice team will meet the initial and ongoing needs of the patient and caregiver, will receive optimal support by hospice team, acceptable level of pain, acceptable level of appetite, acceptable level of dyspnea, and will express grief and concerns as needed in ways meaningful and acceptable to them. The findings were verified by RN #2 at 11:37 AM on 3/31/2022. Patient #11 On 3/30/2022 at 9:16 AM, review of Patient #11's chart revealed the goals on the patient's POC were not measurable: will be in a safe environment, will report pain less than 4/10 during visits, will be free of urinary tact infections, prevent further skin breakdown, will express fears, concern, and frustrations, will verbalize knowledge of medication administration. The finding was verified by RN #2 at 10:38 AM on 3/31/2022. Patient #12 On 3/30/2022 at 4:12 PM, review of Patient # 12's chart revealed the goals on the patient's POC were not measurable: will accept spiritual support from the chaplain, self- determined life closure, acceptable dyspnea level, will demonstrate knowledge of medication administration, will accept IDG support, will receive optional support by hospice team, will be sage in home environment, and will have soft, formed easily passed bowel movements. The finding was verified by RN #2 at 8:46 AM on 3/31/2022. Patient #13 On 3/30/2022 at 4:39 PM, review of Patient #13's chart revealed the goals on the patient's POC were not measurable: self-determined life closure, will demonstrate knowledge of medication administration, promote healing of skin, will receive optimal support by hospice team, acceptable level of dyspnea, will accept IDG support, will be safe in home environment, and acceptable level of pain. The finding was verified by RN #2 at 9:31 AM on 3/31/2022. On 4/1/2022 at 1:55 PM, review of the hospice's policy for Interdisciplinary Group (IDG), Care Planning, and Coordination stated "Measurable outcomes anticipated from implementing and coordinating the POC".

Based on record reviews and interview, the Skilled Nurse (SN) failed to update the patient's Plan Of Care (POC) for 1 of 11 patient records reviewed. (Patient #10) The findings are: Patient #10 On 3/29/2022 at 3:40 PM, review of Patient #10's chart revealed the patient's problem of Altered Elimination on the plan of care was began on 8/6/2021 with a goal: Patient will be free of urinary tract infections within two weeks. The documentation stated the patient's care plan is to be reviewed on 9/15/2021. The timeframe was beyond two weeks. There was no documentation if the urinary tract infection problem was ongoing or resolved. The finding was verified by Registered Nurse #2 on 3/31/2022 at 11:37 AM.

Based on hospice quality data and interview, the hospice failed to provide documentation showing the Quality Assurance Performance Improvement (QAPI) Committee is monitoring patient/caregiver complaints and grievances. The findings are: On 3/30/2022 at 4:33 PM, a review of the hospice's quality data provided for patient/caregiver complaint or grievances revealed a sheet of paper dated January 2022 through December 2022 that was blank. On 4/1/2022 at 8:42 AM, review of a revised quality form for complaints submitted by the Executive Director(ED) revealed another hospice's name typed in the left upper corner. On 4/1/2022 at 11:31 AM, review of the hospice's QAPI meeting minutes, titled with another hospice's name, dated 7/8/2021, 9/2/2021, 11/18/2021, 1/6/2022, and 3/3/2022 were blank with no data documented for monitoring patient/caregiver complaints or grievances. The finding was verified by the ED in an interview on 4/1/2022 from 12:01 PM to 1:25 PM.

Based on review of the hospice's Quality Assurance Performance Improvement (QAPI) data and interview, the hospice developed and implemented one Performance Improvement Project (PIP). The findings are: On 4/1/2022 at 11:01 AM, review of the hospice's QAPI documents revealed the hospice had documentation for only one PIP for Durable Medical Equipment (DME) for DME costs to the hospice. The finding was verified by the hospice's QAPI Director on 4/1/2022 at 11:01 AM.

Based on record reviews and interview, there was no evidence that the hospice's Governing Body appointed the Quality Assurance and Performance Improvement (QAPI) Director. The findings are: On 3/28/2022 at 12:40 PM, review of the list of the hospice's key individuals showed the hospice's QAPI Director as RN 1#. On 3/28/2022 at 2:17 PM, review of the Board of Trustees meeting minutes dated 9/30/2019, 1/28/2020, 9/10/2020, 2/23/2021, and 9/20/2021 revealed there was no appointment of RN#1 as the hospice's QAPI Director. On 4/1/2022 at 8:51 AM, review of the personnel file for RN #1 showed he/she signed the "Statement of Acknowledgement and Understanding of the Job Description for Quality Director" on 6/2/2021. On 4/1/2022 at 11:01 AM, RN #1 revealed he/she assumed the QAPI position on 6/1/2021. In an interview with the Executive Director on 3/29/2022 at 11:46 AM, he/she revealed the ED, Director #1, and Director #2 appointed RN#1 as the QAPI Director.

Based on observations and interview, Registered Nurse(RN) #2 did not use the proper nurse equipment bag technique during 1 of 2 home visits. (Patient #1) The findings are: On 3/29/2022 at 9:20 AM, observations during a home visit to Patient #1's home revealed RN #2 held a dirty wipe in his/her hand when handling the thermometer and returning the thermometer to the nursing equipment bag. The finding was verified by RN #2 at 9:35 AM on 3/29/2022.

Based on record reviews and interview, the hospice did not ensure documentation of the Interdisciplinary Group (IDG) core members were listed on the IDG meeting attendance records for 7 of 18 eighteen attendance records reviewed. The findings are: On 3/31/2022 at 2:31 PM, review of the hospice's IDG attendance logs dated 1/8/2021 to 6/25/2021 and 10/29/2021 to 3/18/2022 revealed seven of the attendance sheets did not have documentation of all of the hospices core members:Chaplain (CH) missing on 1/8/2021, 1/22/2021, 2/5/2021, 4/16/2021, 4/30/2021, and 6/25/2021, and Social Worker missing on 4/30/2021 and 6/11/2021. All IDG attendance sheets were labeled with another hospice's name. In an interview with the Executive Director (ED) on 4/1/2022 from 12:01 PM to 1:25 PM, the ED verified the findings.

Based on record reviews and interview, the hospice Volunteer Coordinator failed to provide documentation of retention and recruitment activities for volunteers. The findings are: On 3/30/2022 at 9:38 AM, the Volunteer Coordinator (VC) revealed the requested volunteer data for the hospice program's retention and recruitment information for volunteers by the surveyor was not available for review because the VC did not document any recruitment nor retention data for the hospice volunteers.

Based on observations, record reviews, and interviews, the hospice leadership failed to ensure transparency between the hospice located in South Carolina and a sister hospice with a different name located in an adjoining state by providing its patients/caregivers with an admission packet that accurately reflected the data necessary for the patient/caregiver to contact the hospice, by presenting confusing and conflicting data related to personnel for the hospice, by its failure to employ a licensed Master Social Worker to supervise the hospice's social workers (LBSW), and by its failure to ensure the responsibility for the hospice's after hours call log and by the ensuring the appropriate documentation, maintenance, and follow up for the after hours calls from patient/caregivers. documented on the hospice's call log. The findings are: On 3/28/2022 at 11:50 AM, upon arrival to the hospice, a sign on the door revealed the hospice's hours of operation were 9:00 AM to 2:00 PM Monday-Friday. The Volunteer Coordinator (VC) greeted the survey team and reported hospice staff take turns in this hospice office, and stated, "Monday is my day." The Volunteer Coordinator stated the Executive Director (ED) was at a hospice office located in an adjoining state but was on the way. The Volunteer Coordinator stated the other hospice staff office is located about twenty minutes away in another state. The information was verified in an interview with the ED after his/her arrival to the hospice from 4/1/2022 from 12:01 PM to 1:25 PM. Admission Packet On 3/28/2022 and 3:26 PM, review of the hospice's Admission Packet given to hospice patients and caregivers revealed the name of the hospice listed on the admission packet and all of the forms in the admission packet was the name of the other hospice located in an adjoining state. The admission packet had a card stating the hospice's office hours are 8:00 AM to 5:00 PM which was contradictory to the sign on the hospice's door. The hospice's admission packet listed the wrong telephone number for patients/caregivers to contact the hospice. On 4/1/2022 from 12:01 PM to 1:25 PM, the ED verified the address and telephone number on the hospice's website was not correct. When the telephone number was called during the interview with the ED, the telephone message revealed the telephone number called was not a working number. The findings were verified by the ED from 12:01 PM to 1:25 PM on 4/1/2021. This inaccurate information in the hospice's Admission packet has the potential to negatively impact the patient/caregiver when seeking assistance. Personnel On 3/28/2022 at 12:40 PM, review of the hospice's core personnel revealed Director #1 was listed as the Bereavement Coordinator. On 3/28/2022 at 3:36 PM, review of the form with a list of personnel employed by the hospice had the name of the hospice from an adjoining state. The personnel form showed eleven full time hospice employees that included two part-time physicians. Director #1 was not listed on the employee list. On 3/29/2022 at 2:17 PM, the Executive Director submitted a revised list of hospice employees that revealed 19 hospice employees that included two part-time physicians. Director #1 was on the revised personnel list but was not listed as the Bereavement Coordinator. There was no Bereavement Coordinator on the revised personnel list. On 3/30/2022 at 1:15 PM, when the Centers for Medicare and Medicaid Services (CMS) Form 417 was completed and authenticated by the ED, the CMS 417 form revealed 2.05 full-time equivalents for the hospice. On 3/31/2022 at 8:30 AM, the ED presented a second revised personnel list on a form titled with the name of a hospice from an adjoining state. The revised personnel list had 23 employees that included two part-time physicians, two part -time Registered Nurses, a Bereavement Coordinator (full-time), and other full-time employees. On 3/28/2022 at 12:54 PM, review of the hospice census data revealed the hospice has six patients. The finding was verified by the Administrator on 3/28/2022 at 12:54 PM. On 3/28/2022 at 2:19 PM, review of the organizational chart provided by the Executive Director revealed the organizational chart listed the name of the hospice location in an adjoining state, but did not drill down to the hospice location in South Carolina to show the specificity of how the two hospices operated. On 4/1/2022 at 8:51 AM, review of the hospice personnel files revealed the hospice does not employ a Licensed Masters Social Worker (LMSW) to provide the required supervision of the Licensed Baccalaureate Social Worker (LBSW) employees. The findings were verified by the Executive Director in an interview on 3/30/2022 from 12:01 PM to 1:25 PM. On 3/30/2022 at 9:02 AM, review of the hospice's call log book revealed the call log book was unorganized by dates, missing dates, and had no documentation of review and/or follow up on the calls received. There was only forms for January 18, 19, and 29, 2022, one sheet for February 6, 2022, and two sheets for March 11 and 12, 2022. There were no forms for any other dates. On 3:26 AM, the Executive Director identified Manager #1 was the responsible person for management of the hospice call log book. On 3/31/2022 at 10:10 AM, Manager #1 verified he/she is the Office Manager, but he/she does not have an office at this hospice location. Manager #1 reported he/she only comes to this hospice every other week on Wednesday to work from 9 AM - 2 PM. Manager #1 verified he/she is the responsible person for the hospice's call log book, but Manager #1's has the responsibility to bring the call sheets to the hospice when he/she comes to the hospice every other Wednesday. Manager #1 stated he/she does not do oversight to ensure the call has documented follow-though and stated there is no one performing oversight for the hospice's call log entries. The finding was verified by Manager #1 at 10:10 AM on 3/31/2022.

Based on record reviews and interview, the hospice failed to appropriately document the strength of the medications during the medication disposal procedure after a patient's death for 1 of 3 deceased patients. (Patient #10) The findings are: Patient #10 On 3/29/2022 at 3:40 PM, review of Patient #10's chart revealed the patient's discharge summary had a list of medications disposed by the nurse that did not list the strengths of the medications disposed of. The finding was verified by Registered Nurse #2 at 11:37 AM on 3/31/2022.

Based on record reviews and interview, the hospice failed to provide Licensed Social Workers (SW) performing SW activities for the hospice and failed to employ a Licensed Masters Social Worker (LMSW) for supervision of Licensed Baccalaureate Social Workers (LBSW). The findings are: On 3/29/2022 at 12:18 PM, review of the SW call schedule for January 2022 to March 2022 revealed LBSW #1, Bereavement Coordinator (BC) #2, and LBSW #3 listed on the call schedule. Bereavement Coordinator #2 was scheduled on call on 1/10/2022 to 1/16/2022, 1/31/2022 to 2/6/2022, 2/21/2022 to 2/27/2022 and from 3/14/2022 to 3/20/2022. On 4/1/2022 at 8:51 AM, review of the hospice personnel file revealed Bereavement Coordinator #2's job description form was titled with another hospice's name. Bereavement Coordinator #2's job description reads, "Back-up Social Work: Make home visits to patients/families for the purpose of assessing their psycho-social needs as needed during the admission process and over-flow crisis calls and work with the interdisciplinary team in developing the patient/family plan of care and in determining the patient/family ability to cope with activities of daily living during the stressful time of illness, dying, and bereavement." Bereavement Coordinator #2's job description stated the minimum education requirements were a Baccalaureate Degree in Social Work, Psychology, Human Service field or related experience." Bereavement Coordinator #2's personnel file did not have a license for Social Worker. In an interview 3/30/2022 at 2:21 PM, Bereavement Coordinator #2 verified he/she was not licensed in South Carolina for Social Work. When the surveyor requested the Social Worker's license for Bereavement Coordinator #2 on 4/1/2022 at 10:05 AM, the Director stated "..... did not need a Social Work license as a Bereavement Coordinator, and verified he/she did not have a license to practice as a Social Worker in South Carolina." The finding was verified by the Executive Director (ED) in an interview on 4/1/2022 from 12:01 PM to 1:25 PM. On 4/1/2022 at 8:51 AM, review of the hospice's personnel files revealed the hospice did not employ a Licensed Masters Social Worker (LMSW) required for the supervision of the Licensed Baccalaureate Social Workers (LBSW). The findings were verified by the Executive Director in an interview on 3/30/2022 from 12:01 PM to 1:25 PM.

Based on record reviews and interview, the hospice had no evidence that it employed a Licensed Masters Social Worker (LMSW) to provide supervision of the Licensed Baccalaureate Social Workers (LBSW) on staff. The findings are: On 4/1/2022 at 8:51 AM, review of the hospice's personnel files revealed the hospice had no personnel file for a LMSW licensed to practice in South Carolina. The findings were verified by the Executive Director (ED) in an interview on 3/30/2022 from 12:01 PM to 1:25 PM. Review of the South Carolina Board of Medical Examiners revealed South Carolina does not have any formal license reciprocity with any other state for LMSW per the SC Board of Medical Examiners. Per the Board of Social Work Practice Act, Section 40-63-30(B) "A person providing social work services to a client in this State, through telephonic, electronic, or other means, regardless of the location of the social worker, who is not licensed in this State, is practicing without a license." Review of Regulation 61 -78 Standards for Licensing Hospices, reads, under Section 100 - Definitions " at "WW. Social Worker. An individual who is licensed by the South Carolina Board of Social Worker Examiners."