Every finding on record at Intrepid of the Lowcountry, Inc

Upon patient record review, 5 of 13 (Patient #2, 3, 4, 7, 10) 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 Record #2: 3/7/22 SN Visit - Patient requested Foley be removed. Later that same day, there was SN Communication note that patient called with c/o dysuria. Nurse notified NP and received order for Amoxicillin. IDG Care Plan was not updated including interventions and goals to reflect changes. Patient Record #3 3/2/22 SN Note Patient has rash under her breasts per CG. CG using Nystatin cream to affected area twice daily. Order for Nystatin updated, but IDG POC not updated to include related problem/interventions/goals. 3/15 SN Note Fungal infection under both breasts. Order for Diflucan obtained, but IDG POC not updated to include related problem/interventions/goals. 3/15/22 SN Note also "open area RLE". Not clear if wound care was ordered. IDG POC not updated to include related problem/interventions/goals.. Patient Record #4 3/5/22 Patient had UTI and Bactrim/Pyridium ordered. Also was "raw between her legs" and "using zinc oxide..which was effective." IDG Care Plan was not updated including interventions and goals to reflect changes. Patient Record #7 3/1/22 SN Note: Patient c/o ear pain.. history tumor removal... ear drum removed 2015... screams out in pain when turns her head. SN notified NP and she instructed SN to discuss possible MRI with patient. Didn't want to go to hospital but was going to think about it. 3/8/22 IDG Note states no pain, but no clear follow up documented r/t SN/patient discussion about MRI. IDG POC not updated to reflect ear pain problem, interventions and goals. 3/15 SN Visit c/o pain after urinate -- refused catheterization for specimen, but plan to obtain specimen next day. 3/22/22 Visit documented urine pain resolved. No documentation follow up related to specimen. IDG POC not updated r/t dysuria problem and interventions and goals. Patient Record #10 3/11/22 note referenced right hip redness, ankles and healing skin/scab left ankle. IDG POC not updated r/t problem, intervention and goals.

Upon patient record review, 1 of 13 (Patient #4) 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 Record #4: 3/7/22 SN Note Patient c/o "raw between her legs" ... "using zinc oxide", which was effective. No order obtained for zinc oxide.

Upon personnel record review, 1 of 1 applicable (Personnel # 4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(C) Shampoo, sink Personnel File #4: The competency checklist utilized by agency excludes shampoo at sink.

Upon patient record review 1 of 13 (Patient #1) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient Record #1: HA Assignment for Shampoo first visit of the week. Shampoo was provided 3/15 and 3/18, both visits in same week.