Every finding on record at Prisma Health Blount Memorial Hospital Inc.

Observed in Tracer Visit. In 1 of 4 home visits conducted, It was noted during hospice home visit #1 the registered nurse did not conduct a pain assessment. The patient had recently had an increase in dosage of pain medication and stated she was taking that medication, hydrocodone/apap, every 4 hours while awake. This was observed by the hospice staff member on site during visit and the hospice director.

Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted during hospice home visit #1 that the hospice organization did not involve the patient in developing the plan of care when there was a change in service delivery. For example, the patient was normally visited on Monday and Thursday to set up medication boxes, however patient and family member stated that for the last 3 weeks there was no visit made on Monday, they were not notified of the change and therefore the medication box was not filled in a timely manner. This was observed by the hospice staff present on the visit and discussed with the hospice director.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted in record review for hospice home visit #2 that the chaplain did not complete the assessment until 6 days after the election of benefit. There was no other documentation in the record to explain the delay in service. This was confirmed by the intake coordinator assisting with record review.

Observed in Record Review. In 3 of 6 patient records reviewed, with volunteer services it was noted that the orders for visit frequency in record reviews #1, #2, and #3 were open ended PRN visits stated as 4 PRN, 11 PRN, etc. although the patient had agreed to have this service provided. This was confirmed by the intake coordinator assisting with record review. Observed in Record Review. In 2 of 6 patient records reviewed, with volunteer services it was noted that there were no orders for visit frequency for this discipline. This was noted in record review for hospice home visit #2 and #3. This was confirmed by the intake coordinator assisting with record review.

Observed in Record Review. In 16 of 16 patient records reviewed, it was noted in record review that goals were not measurable or timed. For example, in record review for hospice home visit #2 all of the goals were stated to be met at the end of the certification period or 90 days. In record review for home visit #3 all of the goals were stated to be met at the end of the certification period or 60 days. For example, pt and caregiver will verbalize understanding of measure to manage cardiac symptoms with a stated date of three months later. Additionally, goals were not measurable, for example, a goal for respiratory issues was stated as changes in respiratory status will be identified and managed, Pt. care needs will be safely met, Pt desired nutrition/hydration needs will be met, Pt will remain safe in environment and Changes in cardiac status will be identified and managed. This was noted in all records review and was confirmed with the intake coordinator for hospice assisting with record review.

Observed in Record Review. In 1 of 6 patient records reviewed, with volunteer services ordered it was noted that volunteer services were started however the volunteer coordinator did not document a volunteer assignment sheet until three days after the visit. This was confirmed by the hospice intake coordinator assisting with record review.

Observed in HR File Review. In 2 of 2 HR/Competency files of hospice aides reviewed, only 10 of the required 12 hours of in-service training were documented for calendar year 2024. Discussion with hospice leadership indicated that planned 1 hour training for the months of February and August of 2024 had not been provided to the two aides.

Observed in Record Review. In 1 of 16 patient records reviewed, it was noted in record review for hospice home visit #3 that the aide assignment sheet did not contain any information regarding the wounds to the patient's buttocks, coccyx and legs. This was confirmed by the hospice intake coordinator who assisted with record review.

Observed in Tracer Visit. In 1 of 4 home visits conducted, It was noted during home visit #1 during medication reconciliation that the medication profile did not accurately reflect what the patient was taking. For example, pepcid and tylenol were listed on hospice medication profile, however the patient stated that she had not taken the pepcid for 3 months and was no longer taking the tylenol due to regular usage of hydrocodone/apap. This was observed by the staff present on the visit and discussed with hospice director. Observed in Tracer Visit. In 1 of 4 home visits conducted, it was noted in hospice home visit #2 that the current medication sheet listed Lorazepam as a not yet activated medication however the patient was currently using this medication. This was observed by the hospice staff present on the visit and discussed with hospice director.

Observed in Record Review. In 2 of 2 patient records reviewed, it was noted in hospice discharged record review #1 who was transferred to another hospice and in hospice discharged record review #2, a revocation that the discharge summary did not include a summary of the patient's hospice care to include treatments, symptoms, etc. Record review #1 was on hospice services for 8 days and record review #2 was on hospice services for 7 months however both discharge summaries simply stated hospice care provided by multi-disciplines to care for patient, instruct caregivers and facilitate symptom management and comfort care during the patient's time on hospice. This was confirmed by the intake coordinator assisting with record reviews.

Observed in Document Review. In 1 of 5 contracts reviewed, the surveyor noted that while written expectations for the provider had been developed and communicated, the organization was unable to provide documentation of monitoring and evaluation of the provider's compliance with the expectations. This pertained to the durable medical equipment (DME) contracted provider. The issue was discussed with hospice leadership.

Observed in Individual Tracer. In 1 of 13 patient records reviewed, it was found that the social worker had complete the social worker initial evaluation on day six. There was no further information found in the record that clarified why the evaluation was not completed in the five day requirement RR # 5. This was validated by the Hospice manager.

Observed in Individual Tracer. In 13 of 13 patient records reviewed, it was identified that the goals for the plans of care were generic/computer generated and had not contained specific measurable goals/time frames. Foe example, for HOS HV # 1 the goal for GI/GU was pt will remain free from UTI achieve 5/8/2022 effective date 4/4/2022. For Musculoskeletal problem the goal was pt will remain comfortable as disease progression and muscle stiffness continues to progress achieve date 5/8 effective date 3/9/2022. For integumentary the goal was pt skin will remain intact by achieve date 5/8 effective date 2/27/2022. For HOS HV # 2 the goals was Pt.cg will demonstrate understanding of skin breakdown preventive measures achieve date 4 /20/2022 effective date 1/21/2022 , Spiritual goal pt/cg will have spiritual needs achieved by 4/20 effective date 2/27/2022, pt skin will remain intact achieve date 4/20/22 effective date 2/27/2022 . Pain goal pain will be controlled at level 3 or less by achieve date 4/20 effective date 2/27/2022 ( stated/specific) rarely has pain and is well controlled). For HOS HV # 3 the goal for respiratory was pt/cg will verbalize understanding of measures to manage SOB achieve date 6/1/2022 effective date 2/28/2022, for anxiety the goal was pt will verbalize decrease anxiety achieve date 6/1/2022 effective date 2/28/2022, MSW goal was pt/cg will verbalize/identify/demonstrate effective coping skills achieve date 4/2/2022 effective date 2/28/2022. These were validated by the Hospice Manager HOS RR # 1-10.

Observed in HR File Review. In 1 of 1 HR files reviewed, of a hospice home health aide it was found that there was no evidence that the organization evaluated the following subject areas through written examination, oral examination, or after observation of the hospice aide with a patient; communication skills , the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other staff, observation, reporting, and documentation of patient status and the care or service furnished , basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor ,maintenance of a clean, safe, and healthy environment ,recognizing emergencies and initiating necessary emergency procedures, the physical, emotional, and developmental needs of and ways to work with the populations served by the hospice aide, including the need to respect the patient and their privacy and property, adequate nutrition and fluid intake .developmental needs of and ways to work with the populations served by the home health aide or hospice aide, including the need to respect the patient and their privacy and property, and adequate nutrition and fluid intake . Three areas that were documented were reading and recording temperature , pulse, and respirations and basic infection control procedures. HOS HR # 1. This was validated by the Hospice manager.

Observed in Document Review. In 1 of 3 contracts reviewed, it was identified that the written agreement had not addressed, in writing, the manner in which contracted services would be evaluated by the hospice. This was validated by the Hospice Manager. Observed in Document Review. In 1 of 3 contracts reviewed, it was identified that the written agreement had not addressed, in writing, a stipulation that the outside agency will complete a criminal background checks on contracted employees who provide direct patient care or have access to patient records. Also, the written agreement had not identified the qualifications of the individuals providing the services.- This was validated validated by the Hospice Manager.