Every finding on record at Thi of South Carolina Hospice, LLC

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. (L670) Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of patients with wounds, the hospice did not ensure the clinical record contained a physician's order to discontinue wound care. Clinical Record 1: The patient elected the hospice benefit on 8/8/2023 with a diagnosis of Unspecified Protein Calorie Malnutrition. On admission, the patient had a documented wound on bilateral buttocks. On 8/30/2023, the physician ordered: "cleanse wound with cleanser. Apply Xeroform and cover with island dressing two times a week with skilled nurse visit. May change as needed for dislodgement and/or soilage." The Licensed Practical Nurse (LPN) visit note dated 8/30/2023 did not include documentation that wound care was provided. The Registered Nurse (RN) visit note dated 9/1/2023 did not include documentation of wound care. The RN visit note dated 9/1/2023 documented that the wound was healing. The RN visit notes dated 9/5/2023 and 9/7/2023 did not include documentation that wound care was provided. The LPN visit note dated 9/12/2023 did not include documentation that wound care was provided. A clinical record review revealed no documentation that the wound was healed. There was no evidence of a physician's order documenting the discontinuation of the wound care. During an interview, the Director of Clinical Services stated that the wound was healed, which was why wound care was not provided.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) clinical records reviewed revealed that the agency did not ensure that the interdisciplinary group completed the initial comprehensive assessments within 5 calendar days after the election of hospice care. Clinical Record 7: The patient's start of care was 2/20/2023. No chaplain visit is documented as of the date of review, 3/15/2023. The chaplain attempted a phone call to the patient on 2/21/2023 however, no further follow -up is documented. Clinical Record 8: The patient was admitted to services on 12/30/2022. Social Work (SW) did not provide an initial assessment within five calendar days from the start of care. A clinical note present in the record, dated 12/30/22, reads in part, "Social Work not available. Patient wishes to see Social worker in person upon her return." As of the date of record review, 3/15/2023, SW has not been been successful in providing a home visit assessment. There is missed visit documentation related to the patient's refusal of SW dated 1/2/2023, 1/8/2023, and 2/18/2023. Unsuccessful SW attempts to reach patient via phone were documented by the SW on 1/6/2023, 1/12/2023, and 1/17/2023. The chaplain documented an assessment visit type on 12/28/2023, however when the note is opened, the documentation read that the chaplain called the patient but did not complete an in-person assessment. Clinical Record 10: The patient's start of care was 1/18/2023. The initial spiritual assessment was completed by a registered nurse on 2/20/2023 (33 calendar days after the start of care). The patient did not have an assessment completed by a counselor or chaplain. According to the Area Clinical Director, the nurse is doing spiritual assessments followed by phone visits from a chaplain from an alternate office until the agency can get a chaplain hired which is scheduled March 23, 2023. In 3 of 11 (27%) clinical records reviewed revealed that the agency did not ensure that the interdisciplinary group completed the initial comprehensive assessment within 5 days.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) of clinical records reviewed revealed that the agency did not ensure that the plan of care specified the care and services necessary to meet the needs of the patient and family. Clinical Record 3: The patient's start of care was 7/22/2022. The registered nurse's re-assessment, completed on 2/15/2023, identified two pressure wounds on the buttocks and bilateral heels. The plan of care dated 3/5/2023-5/3/2023 did not document wounds or include any orders related to wound care. The skilled nursing visit note dated 3/5/2023 documented that the heel wounds were healed but the coccyx wound remained and a new wound to the patient's shoulder had developed. There are no orders for wound care on the recertification plan of care effective 3/5/2023. The Area Clinical Director stated, in interview on 3/14/2023, "We have discovered if the nurse enters the order in the wrong manner it does not flow to the 485 in the software system." 1 of 11 (9%) of clinical records reviewed revealed that the agency did not ensure that the plan of care specified the care and services necessary to meet the needs of the patient and family.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician and the patient or patient representative. This standard was not met as evidenced by clinical record review and interview. 3 of 11 (27%) records reviewed revealed that the agency did not ensure that the individualized interdisciplinary care plan was followed as established by the IDG and physician with respect to clinician visit frequencies. Clinical Record 1: The initial plan of care dated 11/2/2022- read "CH (chaplain) 1M1" with an additional order written on 11/6/2022 that read, "CH effective 11/2/2022 1M3." The patient was seen by the chaplain on 11/6/2022 and 12/8/2022. On 1/2/2023 the chaplain performed a phone visit but no in-person visit. There were no orders evidenced for the chaplain to complete a phone visit versus a face-to-face visit. Clinical Record 2: The patient was admitted to services on 9/12/2022. The recertification plan of care dated 12/11/2022 - 3/10/2023 reads, CH effective 2m1, 1m1. The patient was only seen one time by the chaplain during the first month of the episode, on 12/20/2022. Clinical Record 6: The initial plan of care dated 4/14/2021 - 5/25/2021 reads, Chaplain 1M1. No further orders for visit frequency were evidenced. The chaplain saw the patient on 4/15/2021 and 5/24/2021. There is no order for a visit on 5/24/2021. The plan of care for the certification period dated 5/26/21-7/24/2021 reads in part, "MSW 1M1." No social work visit was performed in the first month of the episode. A social work visit was completed on 6/5/2021 and 7/22/21 without evidence of additional visit frequency orders. The plan of care for a subsequent certification period reads in part, "CH effective 11/22/2021 1M1." There are no orders for MSW. The chaplain did not provide care during this subsequent certification period. The MSW did conduct home visits on 12/15/22 and 1/20/2023 without orders for additional visits. The Area Clinical Director stated during interview, "I know what they did, they plotted the visit frequency on the calendar instead of going through the order screen (in the EMR)." 3 of 11 (27%) of records reviewed revealed that the agency did ensure that the individualized interdisciplinary care plan was followed as established by the IDG and physician.

It is required that each patient’s individualized written plan of care: a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. 1 of 11 (9%) of clinical records reviewed revealed that the agency did not ensure that the plan of care visit frequency for chaplain services was included. Clinical Record 5: The patient's start of care was 7/21/2022. Chaplain services were active in the plan of care for the certification periods dated 7/21/2022-10/18/2022 and 10/19/2022-1/16/2023. The interdisciplinary group note dated 1/11/2023 documented that the plan of care and visit frequency should remain the same with no changes. The plan of care for the subsequent certification period dated 1/17/2023 -3/17/2023 did not include visit frequency orders for the chaplain. There is no documentation indicating that Chaplain services should be discontinued. The Area Clinical Director stated, in interview on 3/15/2023, "I see that. It's like when we lost the chaplain for this office the frequency just didn't get plotted at all." 1 of 11 (9%) of clinical records reviewed revealed that the agency did not ensure that chaplain services were consistent with patient and family agreement and acceptance of service.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. 1 of 5 (20%) clinical records reviewed with hospice aide services revealed that the agency did not ensure that the registered nurse prepared specific care instructions for the aide as the patient's status changed. Clinical Record 3: The patient was admitted to services on 7/22/2022 with Parkinson's Disease. The hospice aide care plan was developed by the registered nurse on 7/22/2022 and was reviewed and updated on 9/16/2022. The skilled nursing notes in February and March 2023 documented that the patient had pressure ulcers on heels, buttocks and shoulder with wound care and dressings. The hospice aide care plan was never updated to inform the aide how to handle the wounds and dressings. The Area Clinical Director stated, in interview on 3/14/2023, "I would doubt that it is on there. We have just started to do education related to aide care plans and we really haven't started with this office yet." 1 of 5 (20%) of clinical records reviewed with a HHA revealed that the agency did not ensure that the registered nurse prepared specific care instructions for the aide as patient status changed.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of: the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by review of clinical records and interview. 2 of 2 (100%) discharged clinical records revealed that the agency did not ensure that the discharge summaries were forwarded to the receiving facilities. Clinical Record 10: The patient was admitted on 1/18/2023 and discharged on 2/15/2023 after being admitted to a hospital. There was no evidence that that the discharge summary was sent to the receiving facility. Clinical Record 4: The patient was admitted on 8/17/2022 and transferred to a hospital on 2/24/2023. A Discharge/Transfer summary was created on 2/26/23 but there is no documentation to evidence that the summary was sent to the receiving facility. The Area Clinical Director reviewed the clinical records and stated, "I cannot find where it was sent to the hospital, and I looked at the three possible places it could be."

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. 2 of 2 (100%) discharged clinical records revealed that the agency did not ensure that the discharge summaries were forwarded to the patient's attending physicians. Clinical Record 10: The patient was admitted on 1/18/2023 and discharged on 2/15/2023 after being admitted to a hospital. There was no evidence that that the discharge summary was sent to the physician. Clinical Record 4: The patient was admitted on 8/17/2022 and transferred to a hospital on 2/24/2023. A Discharge/Transfer summary was created on 2/26/23 but there is no documentation to evidence that the summary was sent to the physician. The Area Clinical Director reviewed the clinical records and stated, "I cannot find where it was sent to the doctor, and I looked at the three possible places it could be." 2 of 2 (100%) discharged clinical records revealed that the agency did not ensure that the discharge summary was forwarded to the patient's attending physician.

It is required that Hospice contracts require that all contracted employees who have direct patient contact or access to patient records obtain criminal background checks. This standard was not met as evidenced by document review and interview. 1 of 2 (50%) relevant contracts reviewed revealed that the agency did not ensure that the contract included the requirement for all contracted employees who have direct patient contact or access to patient records to have a background check. Contract 1: The Medical Director Services Agreement (Contract form 14 Revised 10/2013) signed and dated November 1, 2019, does not include language requiring the Medical Director to have a criminal background check. NOTE: the personnel record for the Medical Director does contain a background check. During the end-of-day conference on 3/15/2023, the Corporate Vice President of Clinical Quality and Standards stated, "That has been brought to our attention and our legal department is working on updating the contracts." 1 in 2 (50%) relevant contracts reviewed revealed that the agency did not ensure that the contract included the requirement for all contracted employees who have direct patient contact or access to patient records to have a background check.