Every finding on record at Spartanburg Regional Med Center Hospice

Upon patient record review 3 of 31 (Patient #9, 21, 25) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 09: The patient was admitted on 11/16/23, the initial spiritual care assessment was completed on 11/29/23. Patient 21: The patient was admitted on 1/23/23, the initial spiritual care assessment was completed on 1/30/23. Patient 25: The patient was admitted on 12/18/22, the initial spiritual care assessment was completed on 12/28/22.

Upon patient record review 5 of 31 (Patient #10, 12, 14, 15, 26) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 10: The patient was admitted on 1/17/23, the primary caregiver declined spiritual care services but an initial spiritual care assessment has not been completed to date by any other disciplines. Patient 12: The patient was admitted on 4/10/23, an initial spiritual care assessment has not been completed to date. Patient 14: The patient was admitted on 1/12/24, an initial spiritual care assessment has not been completed to date. Patient 15: The patient was admitted on 7/31/23, an initial spiritual care assessment has not been completed to date. Patient 26: The patient was admitted on 4/13/23, an initial spiritual care assessment was not completed.

Upon patient record review, 4 of 31 (Patient #1, 3, 4, 7) 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 01: The medication profile includes nystatin cream, apply 1 application topically in the morning and 1 application in the evening for skin infection due to fungus, it does not include an application site. (Corrected on site) Patient 03: During the home visit, it was identified that the patient has the following medications that are not included in the medication profile; QVAR Redihaler 40mcg, Levothyroxine 88mcg (hospice profile is indicated as 75mcg) (Corrected on site.) Patient 04: During the home visit, it was identified that the patient has the following medications that are not included in the medication profile; Ketoconazole 2% shampoo, Ferrous Sulfate EC 324mg, Amlodipine 10mg, Losartan 100mg (total dose of 150mg), Aspirin 81mg Benzonatate 100mg, Duoneb 0.5 - 3mg/3ml. (Corrected on site.) Patient 07: The medication profile includes polyethylene glycol 17 gram powder, take 17g by mouth in the morning for constipation. The profile does not include a diluent. (Corrected on site.)

Upon patient record review, 5 of 31 (Patient #3, 13, 14, 21, 22) 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 03: The patient was admitted on 1/22/22, with evidence in the patient record that the patient is prescribed Eliquis 5mg PO BID for history of DVT and insulin to be given daily. The plan of care does not include a cardiovascular problem to include interventions and goals to include bleeding precautions or a problem statement with interventions and goals for diabetes. (Corrected on site.) Patient 13: The patient was admitted on 5/3/23 for protein calorie malnutrition with secondary conditions of atrial fibrillation, dysphagia and a history of TIA's. The patient takes Eliquis 5mg by mouth twice daily, the plan of care does not include cardiovascular interventions and goals to include bleeding precautions, the plan of care does not include gastrointestinal interventions and goals for the management of the nutrition and dysphagia. Patient 14: The patient was admitted on 1/12/24 with a diagnosis of alcoholic cirrhosis of the liver with ascites, the plan of care does not include a gastrointestinal problem with interventions and goals for the management of the ascites. (Corrected on site.) Patient 21: The patient was admitted on 1/23/23 with a secondary diagnosis of seizures related to Epilepsy, the patient takes Keppra 1000mg in the morning and 1500 mg at bedtime, the plan of care does not include a neurological problem statement with interventions and goals for the management of the seizures. (Corrected on site.) Patient 22: The patient was admitted on 6/10/23 with a primary diagnosis of protein calorie malnutrition, secondary diagnosis of BMI less than 19, the patients weight is entered as 89 lbs. The plan of care does not include a problem statement with interventions and goals for the nutritional management of the patient. (Corrected on site.)

Upon patient record review, 4 of 31 (Patient #1, 3, 4, 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 medications and treatments. Patient 01: The medication order on 4/4/23 for nystatin cream, apply 1 application topically in the morning and 1 application in the evening for skin infection due to fungus, does not include an application site. (Corrected on site.) Patient 03: During the home visit, it was identified that the patient has the following medications that are not included in the plan of care; QVAR Redihaler 40mcg, Levothyroxine 88mcg (hospice profile is indicated as 75mcg) (Corrected on site.) Patient 04: The patient resides in a long term care facility, a medication review performed during survey visit indicates the patient has the following medications, not included in the hospice plan of care: Ketoconazole 2% shampoo, Ferrous Sulfate EC 324mg, Amlodipine 10mg, Losartan 100mg (total dose of 150mg), Aspirin 81mg, Benzonatate 100mg, Duoneb 0.5 - 3mg/3ml. (Corrected on site.) Patient 07: The medication order on11/22/23 for polyethylene glycol 17gram powder, by mouth in the morning does not include a diluent. (Corrected on site.)

Upon patient record review, 1 of 31 (Patient #18) 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 18: The nursing visit not for 1/18/24 indicates that a bed was orders and to be delivered that day to the assisted living facility where the patient resides, the bed is not included in the DME list of the plan of care.

Upon patient record review, 3 of 31 (Patient #18, 19, 20) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 18: The nursing documentation on 1/16/24 indicates that the patient had non-verbal indicators of pain, a new order for pain medications was received for scheduled dosing Norco 5/325mg three times a day, the plan of care was not updated to include a problem statement for pain with interventions and goals. (Corrected on site.) Patient 19: The patient was admitted on 10/12/22 and was indicated as a full code which is included in the plan of care, the patients code status was changed effective 1/31/23, this has not been updated in the plan of care. The patient began using oxygen on or about 4/14/23, orders entered for oxygen use on 4/17/23, the plan of care is not updated to include oxygen/respiratory needs with interventions and goals, it does not include oxygen precautions. (Corrected on site.) Patient 20: The hospice aide services were discontinued on 8/27/23, the plan of care has not been updated to remove intervention and goals related to the hospice aide services. (Corrected on site.)

Upon client record review, 4 of 31 (Patient #8, 9, 17, 22) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 08: The current frequency order for skilled nursing is 1 time a week, the patient did not receive a visit the week of 1/14/24 - 1/20/24 Patient 09: The current frequency order for skilled nursing is 1 time a week, the patient did not receive a visit the week of 12/17/23 - 12/23/23 Patient 17: The frequency order for the MSW is 1 visit every month for 8/15/23 - 10/31/23, there was no visit made for the month of October. Patient 22: The frequency order for Spiritual Care is 1 visit every 4 weeks, effective 12/7/23 - 2/4/24, there was no visit made for 12/7/23 - 1/4/24. Frequency orders for spiritual care effective 9/8/23 - 12/6/23 is 1 visit every 4 weeks, there is no visit made between 11/6/23 - 12/6/23.

Upon observation, there was no evidence the Home Health Aide competency evaluation is performed by a Registered Nurse in consultation with other skilled professionals, as appropriate. Personnel record #6: The hospice aide record review indicated a hire date on 2/14/22, the competency evaluation was performed by a peer hospice aide, identified as the preceptor for the new hire, the competency was not completed by a Registered Nurse as required.

Upon patient record review, 4 of 31 (Patient #3, 4, 11, 19) 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 03: The patient takes Eliquis, a blood thinner, the hospice aide task assignment does not include bleeding precautions. (Corrected on site.) Patient 04: The patient record indicates the patient has a foley catheter, the aide task assignment for patient care does not include foley catheter care, linen changes, dressing, or shaving. (Corrected on site.) Patient 11: The patient is prescribed Clopidogrel, a blood thinner, the hospice aide assignment does not include bleeding precautions. (Corrected on site.) Patient 19: The patient was admitted with a diagnosis of astrocytoma and uses oxygen for shortness of breath, the hospice aide plan of care does not include oxygen precautions. (Corrected on site.)

Upon patient record review 9 of 31 (Patient #2, 3, 9, 12, 13, 18, 20, 22, 24) 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 02: The scheduled frequency for aide visits is 2 times per week. The patient received only 1 visit the week of 12/24/23 - 12/30/23 and one visit for the week of 12/31/23 - 1/6/24 Patient 03: The scheduled frequency for aide visits is 2 times per week. The patient received only 1 visit the week of 11/19/23 - 11/25/23, one visit during the week of 12/24/23 - 12/30/23 and 1 visit the week of 12/31/23 - 1/6/24. Patient 09: The patient was admitted on 11/16/23 and aide visits scheduled 2 times per week, the patient has only received 1 aide visit to date. Patient 12: The schedule frequency for aide visits is 2 times per week, the patient received only 1 visit the week of 1/7/24 -1/12/24 Patient 13: The schedule frequency for aide visits is 2 times per week, the patient received only 1 visit the week of 12/31/23 - 1/6/24 Patient 18: The hospice aide documentation for visits performed on 12/26/23, 12/28/23 and 1/2/24 indicated that the patient refused her bath, there is no documentation that additional interventions were performed or declined. (Hair care, linen change) In addition, the hospice aide documentation on 1/4/24, 1/11/24, 1/16/24, 1/18/24 and 1/23/24 are indicated patient discharged from discipline services, the patient remains on scheduled aide visits. Patient 20: The hospice aide visits were discontinued effective 8/27/23, the hospice aide continued to see the patient on 8/31/23, 9/13/23, and 9/21/23. Patient 22: The scheduled frequency for aide visits is 2 times per week, the patient received 1 visit the week of 12/24/23 - 12/30/23, and 1 visit the week of 12/31/23 - 1/6/24. Patient 24: The scheduled frequency for the hospice aide indicates a bed bath is to be performed daily, the bath has been provided every other day since 1/18/24 - 1/23/24, there is no evidence in the record that the patient refused the bath on the days not provided.

Upon patient client record review, 1 of 31 (Patient #12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 12: The patient record includes a visit note on 12/13/23 for a bereavement visit "post death" the patient has not passed away, documentation has been entered into the wrong patient chart.

Upon client record review, 3 of 31 (Patient #2, 4, 19) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 02: The frequency orders for skilled nursing visits effective 12/31/23 is indicated for 2 x per week x 9 weeks. The patient received 1 visit for the week of 1/7/24 - 1/13/24. Patient 04: The frequency order for skilled nursing visits for 12/31/23 - 3/16/24 are 2 times per week. The patient received 1 visit the week of 1/7/24 - 1/13/24. Patient 19: The frequency order for spiritual care is 1-4 visits every 3 weeks, effective 10/7/23 - 12/5/23, the visit frequency was not met, the patient was not visited between 10/7/23 and 11/11/23.