Every finding on record at Musc Health Hospice Lugoff

Upon patient record review, 2 of 19 (Patient #2,12) 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 2: Medication list contains order for diclofenac 1 percent with instructions: 1 unit PRN external/topical mild pain. There is no evidence of application site for this medication. Patient’s medication list contains order for oxygen with instructions: 2-4 liters daily, inhaled for COPD. There is no evidence of instruction for use of inhalation route in the medication list instructions. Medication list contains order for hydrocodone/acetaminophen 7.5-325mg/15ml containing instructions: one tablet/capsule every 4 hours PRN by mouth for moderate to severe pain. There is evidence of order discrepancy between type of medication ordered (tablet vs. capsule). COS Patient 12: Medication list contains order for flonase 50mcg/actuation with instructions: 2 sprays daily intranasal for seasonal allergies. There is no evidence of further instruction re: 2 sprays daily and if intended for each nostril. Medication list contains order for SalonPas topical patch 3-1-6-10 percent with instructions: apply to skin up to three times daily as needed for mild pain. Remove for 8 hours between doses. There is no evidence of application site for this order.

Upon patient record review, 4 of 19 (Patient #3,4,12,13) 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 3: Patient has physician’s order for Plavix 75mg PO daily. There is no evidence of bleeding precautions on the patient’s plan of care. Patient’s care plan has no evidence of bleeding precaution interventions. Patient has aspiration precaution interventions in care plans. There is no evidence of aspiration precautions on the patient’s plan of care. Patient has documentation in the medical record re: foley catheter. There is documentation as recent as 09/19/24 regarding catheter. There is no evidence of physician’s orders for foley catheter or foley catheter care in patient’s plan of care. COS Patient 4: Patient has physician’s order for Eliquis 2.5mg PO twice daily. There is no evidence of bleeding precautions on the patient’s plan of care. Patient’s care plan has no evidence of bleeding precaution interventions. Patient has aspiration precaution interventions in care plans. There is no evidence of aspiration precautions on the patient’s plan of care. COS Patient 12: Patient has physician’s order for Aspirin 81mg chewable tablet by mouth daily for blood thinner. There is no evidence of bleeding precautions on the patient’s plan of care. Patient’s care plan has no evidence of bleeding precaution interventions. Patient 13: Patient has seizure precaution interventions in care plans. There is no evidence of seizure precautions on the patient’s plan of care. COS

Upon patient record review, 2 of 19 (Patient #2,12) 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 2: Plan of care contains order for diclofenac 1 percent with instructions: 1 unit PRN external/topical mild pain. There is no evidence of application site for this medication. Patient’s Plan of care contains order for oxygen with instructions: 2-4 liters daily, inhaled for COPD. There is no evidence of instruction for use of inhalation device in the Plan of care instructions. Plan of care contains order for hydrocodone/acetaminophen 7.5-325mg/15ml containing instructions: one tablet/capsule every 4 hours PRN by mouth for moderate to severe pain. There is evidence of order discrepancy between type of medication ordered, i.e. liquid versus tablets. COS Patient 12: Plan of care contains order for flonase 50mcg/actuation with instructions: 2 sprays daily intranasal for seasonal allergies. There is no evidence of further instruction re: 2 sprays daily. Plan of care contains order for SalonPas topical patch 3-1-6-10percent with instructions: apply to skin up to three times daily as needed for mild pain. Remove for 8 hours between doses. There is no evidence of application site for this order.

Upon patient record review, 2 of 19 (Patient #6,7) 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 equipment and supply needs. Patient 6: Assessed DME need: walker, shower chair, bed, overbed table. DME on plan of care: cane, shower chair, bed, overbed table. There is no evidence of walker on the plan of care in DME needs. COS Patient 7: Assessed DME need: bedside commode, walker, wheelchair, bed. DME on plan of care: bedside commode, walker. There is no evidence of bed and wheelchair on plan of care in DME needs. There is evidence of wheelchair and hospital bed need located in the Safety care plans. COS

Upon client record review, 1 of 19 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 11: During benefit period 5, beginning 08/11/2024, registered nurse has seen patient twice every week. Physician’s order for SN visits are weekly. There is no evidence that any of the visits made are PRN visits. RN visit dates: 08/12/2024, 08/15/2024, 08/19/2024, 08/22/2024, 08/26/2024, 08/29/2024, 09/03/2024, 09/06/2024, 09/09/2024, 09/10/2024, 09/12/2024, 09/16/2024, 09/19/2024. COS

Upon patient record review, 5 of 19 (Patient #2,3,4,6,13) 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 2: Hospice aide assigned following tasks with frequency as PRN: shampoo; oral care; nail care; foot care; assist with dressing; incontinent care; barrier cream; reposition; housekeeping; change linen. COS Patient 3,4,13: Hospice aide was assigned the following task with frequency as PRN: change linen. COS Patient 6: Patient has a quad cane and this equipment is not listed on the aide plan of care as a DME need. COS

Upon patient record review 2 of 19 (Patient #2,5) 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 2: Physician order for aide visits is twice weekly. There is a documented missed aide visit on 07/01/2024 and 09/09/2024. There is no evidence of a second aide visit made during either of those weeks. COS Patient 5: Physician order for aide visits is 5 days per week. There is evidence of missed visits on 09/02/2024 and 09/04/2024. There is evidence of documented missed visits. The missed visit documentation is dated 09/03/2024 and 09/06/2024. There is no evidence of documentation that these notes are meant for other dates. COS

Observed in Record Review. In 1 of 11 patient records reviewed, the comprehensive assessment was not completed no later than five calendar days after the election of hospice care. In HSPRR #5, the hospice surveyor noted the chaplain did not perform the spiritual assessment within the first 5 days of service. The first contact documented was 10 days after the election of benefit and the visit was not completed until 14 days after the election of benefit.

Observed in Record Review. In 3 of 11 patient records reviewed, the comprehensive assessment did not include the severity of symptoms. In HSPRR #1 and HSPRR #3, the hospice surveyor noted the comprehensive admission assessment did not include the severity of the symptom dyspnea. This was confirmed with the interim hospice clinical manager. In HSPRR #2, the hospice surveyor noted the comprehensive admission assessment did not include the severity of the symptom anxiety. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In 3 of 11 patient records reviewed, the hospice did not perform a bereavement risk assessment as part of the comprehensive assessment on admission. In HSPRR #4, HSPRR #5, and HSPRR7 the hospice surveyor noted the bereavement risk assessment was not performed as part of the initial comprehensive assessment. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In 4 of 11 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames, settings and services required to meet those goals. In HSPV #1, the hospice surveyor noted the plan of care included cardiovascular interventions; however, there was no goal identified. In addition, the plan of care included the following non-measurable goal: patient/caregiver verbalizes pain is controlled within their desired comfort level. This was confirmed with the interim hospice clinical manager. In HSPV #2, the hospice surveyor noted the plan of care included the following non-measurable goal: patient maintains level of mobility and participation in ADLS within disease limitations. This was confirmed with the interim hospice clinical manager. In HSPRR #1, the hospice surveyor noted the plan of care included the non-measurable goal: decrease the patient's fall risk. In addition, the plan of care included the interventions to instruct patient on COVID 19; however, there was no goal identified for this intervention. This was confirmed with the interim hospice clinical manager. In HSPRR #4, the hospice surveyor noted the plan of care included chaplain goals that were not measurable and did not include an appropriate time frame: patient/caregiver identifies feelings of spiritual support provide until PCG verbalizes needs are reduced or resolved. Patient/caregiver will have reduced evidence of anxiety/worry provide until patient and PCG show or express stress/worry declines. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In review of the medical record for HSP RR7, the hospice surveyor noted that the patient was identified as having pain. The plan of care did not have goals and interventions to address this identified need. Observed in Record Review. In 8 of 11 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms.In HSPV #1, the hospice surveyor noted the patient was identified as having pain; however, the plan of care did not include interventions to address this identified need. This was confirmed with the interim hospice clinical manager. In HSPV #2, the hospice surveyor noted the plan of care included the goal caregiver verbalizes understanding of patient's changing cognitive function; however, there were no interventions identified except to assess medications. In addition, the patient was identified as being on tramadol on admission; however, the plan of care did not address pain management. Also, the plan of care was not updated to remove DNR to be signed by MD which was identified on admission 5 months ago. This was confirmed with the interim hospice clinical manager.In HSPV #3, the hospice surveyor noted the plan of care included the goal patient to remain free from infection throughout certification period; however, there were no interventions identified to reach this goal. In addition, the patient was identified as having pain on admission; however, the plan of care did not include interventions, only included assessments. This was confirmed with the interim hospice clinical manager.In HSPRR #1, the hospice surveyor noted the patient was identified as having dyspnea on admission; however, the plan of care did not include interventions to address this identified need. This was confirmed with the interim hospice clinical manager.In HSPRR #3, the hospice surveyor noted the patient was on oxycodone at admission and the plan of care did not include interventions for pain management. In addition, the patient was identified at risk for falls; however, the plan of care did not include interventions to address this identified need. This was confirmed with the interim hospice clinical manager.In HSPRR #4, the hospice surveyor noted the plan of care included goals: maintain bowel function within limits of disease progress, patient maintains urinary function without complications and patient's incontinence episodes are managed; however, these goals did not have interventions identified to reach these goals. This was confirmed with the interim hospice clinical manager.In HSPRR #5, the hospice surveyor noted the patient developed pain the fourth week of service; however, the plan of care was not updated to include interventions to address this identified need. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In review of the medical record for HSP RR7, the hospice surveyor found that the plan of care did not address the patient's safety needs related to the use of Eliquis. This was discussed with organization leadership. Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient.In HSPV #1, the hospice surveyor noted the plan of care indicated insert catheter and change as prescribed; however, the plan of care did not specify the frequency, size or type of catheter. In addition, the plan of care indicated obtain and educate on oxygen safety contract; however, the patient was not on oxygen. This was confirmed with the interim hospice clinical manager.In HSPV #2 and HSPRR #5, the hospice surveyor noted the plan of care included the medication order meclizine 0.5 - 1.0 mg every 8 hours by mouth; however, there were no specific instructions on when to give 0.5 mg versus 1.0 mg. In addition In HSPV #2, the plan of care included an order for docusate 100 mg 1 capsule twice daily as needed; however, no indication was given. This was confirmed with the interim hospice clinical manager.In HSPRR #1, the hospice surveyor noted the plan of care indicated both diet as tolerated and NPO. In addition, the plan of care included the order insert foley catheter prn for urinary retention. foley care every shift if catheter present. This was confirmed with the interim hospice clinical manager.In HSPRR #3, the hospice surveyor noted the plan of care did not include safety measures for the patient. This was confirmed with the interim hospice clinical manager.In HSPRR #5, the hospice surveyor noted the plan of care supplemental order indicated place foley to bedside drainage; however, the order did not include foley size, balloon size or frequency of change. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HSPV #1, the hospice surveyor noted the nurse doffed sterile gloves after inserting suprapubic catheter and donned clean gloves without performing hand hygiene as required by organization policy. This was discussed with the interim hospice clinical manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice did not conduct an assessment of the patient's and family's spiritual needs. In HSPRR #3, the hospice surveyor noted the chaplain did not evaluate the patient's faith/spiritual concerns on admission. The chaplain documented unable to assess; however, there was no documentation as to why it was not assessed. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In 4 of 8 hospice records reviewed where the patient received aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In HSPV #3, the hospice surveyor noted the aide plan of care indicated general safety precautions; however, the plan did not specify the precautions to include fall precautions. In addition, the aide plan of care omitted the application of calazime cream to stage 1 coccyx ulcer as the aide indicated she performed on the home visit. This was confirmed with the interim hospice clinical manager. In HSPRR #2 HSPRR #3 and HSPRR #5, the hospice surveyor noted the hospice aide plan of care did not include specific oxygen instructions for the aide. This was confirmed with the interim hospice clinical manager. Observed in Record Review. In review of the medical record for HSPRR7, the hospice surveyor noted that the patient was on Eliquis and continuous oxygen. The plan of care for the hospice aide did not specify the unique safety precautions or notification requirements related to this medication or the continuous oxygen. This was discussed with organization leadership.

Observed in Record Review. In 2 of 8 hospice patient records reviewed where the patient received aide services, the registered nurse did not supervise the hospice aide every 14 days. In HSPV #3, the hospice surveyor noted the first aide supervisory visit was done six weeks after the first aide visit. This was confirmed with the interim hospice clinical manager. In HSPRR #2, the hospice surveyor noted the registered nurse did not perform a hospice aide supervisory visit. This was confirmed with the interim hospice clinical manager.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.104.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain all clinical information. In HSPV #1, the surveyor noted the hospice did not have documentation of the interdisciplinary discussion of the patient's care or documentation of review of the plan of care until the 17th certification period. This was confirmed with the director of hospice. In HSPV #2, the surveyor noted the hospice did not have documentation of the interdisciplinary discussion of the patient's care or documentation of review of the plan of care in the second month of service. This was confirmed with the director of hospice. Observed in Patient Home. In 1 of 3 home visits conducted, the clinical record did not contain an accurate medication list. In HSPV #1, the hospice surveyor noted the medication profile indicated Ativan 1mg twice daily; however, the wife reported the patient took the medication at bedtime only and as needed in the morning. Second example, the medication profile indicated enema 1 bottle as directed per standing order; however, the medication profile did not include specific instructions on use. Third example, the medication profile indicated benadryl itch stopping external gel and hydrocortisone external cream 1% 1 layer twice a day external/topical for itching; however, the wife reported she applied as needed and the instructions did not specify the location of application. Fourth example, the medication profile indicated milk of magnesia 30 ml by mouth daily and stool softener by mouth 1 capsule 100 mg; however, the wife reported she administered these medications as needed for the past three months for the milk of magnesia and two weeks for the stool softener. Fifth example, the medication profile indicated morphine 0.25 ml to 0.5 ml; however, did not specify when to given which dose. This was discussed with the interim hospice clinical manager.

Observed in Record Review. In review of the medical record for HSPRR6, the surveyor noted that the organization obtained an order to discontinue hospice aide services but failed to create an order for signature. This was confirmed with the administrator and interim hospice clinical manager.

Observed in Record Review. In 1 of 11 patient records reviewed, all entries in the clinical record were not appropriately authenticated. In HSPV #2, the hospice surveyor noted the initial assessments of the skilled nurse, medical social worker and the chaplain were not appropriately authenticated with an electronic signature. This was confirmed with the interim hospice clinical manager.

Observed in Record Review. In 1 of 1 discharged records reviewed, the organization did not provide a written discharge summary that included the patient's medical and health status at the time of discharge. In HSPRR #2, the hospice surveyor noted the discharge summary did not include the patient's medical and health status at the time of discharge. This was confirmed with the interim hospice clinical manager.