Every finding on record at Traditions Hospice of Greenville, LLC

Observed in Tracer Activities. During the review of the Volunteer Training Program, it was noted that education on their role during an Emergency was not included in the biannual training for volunteers. Per policy, all volunteers receive biannual training. Finding was verified by the Vice President for Operations South Region.

Observed in Tracer Activities. It was noted by the nurse surveyor that the organization not document their after action report after the activation of their emergency plan due to a tornado warning in their coverage area. Finding was verified by the Branch Director and the Vice President for Operations South East.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient exhibits reduction/relief of any cardiopulmonary problems,” and “Pain will be managed at a level acceptable to patient”. Additionally, goals were mostly the same from patient to patient with minimal individualization. Findings were discussed with the Branch Director and Clinical Team Lead.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that medication orders were not clear or complete. Medication orders were consistently missing instructions for administration. For example, RRHV#1, Colace 100mg capsule, 1 capsule every 12 hours PRN. RRHV#3, Acetaminophen 500mg 2 tablets three times daily prn. Findings were verified by Branch Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene IC15” During RRHV#2, the chaplain hand sanitized prior to entering the patient’s home but not at any other time during the visit. He sat on the patient’s couch, documented on his tablet, held the patient’s hands in prayer, and documented on his tablet again, all without hand sanitizing. Findings were verified by the Branch Director who was present on the home visit.

Observed in Record Review. In 2 of 10 patient records reviewed, for active patients, It was noted by the nurse surveyor that the hospice aide care plan did not include all of the information for the hospice aide to effectively provide care. RRHV#2, the patient was on oxygen prn there were no instructions to indicate if the patient’s oxygen could be removed for his shower if he had it on at the time. For RRHV#3, the hospice aide care plan had not been updated to reflect that they were no longer to shave his head as part of hair care. Additionally, the aide care plan did not note that the patient only spoke Spanish. Findings were verified by the Branch Manager.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#2 the hospice aide did not provide care according to the hospice aide plan of care. The hospice aide plan of care instructed the hospice aide to shave the patient's head and face at each visit, however the hospice aide just shaved his face per family request. The hospice aide had not shaved the patient's head in over a month. Finding was validated by the Branch Manager who was present on the home visit.

Observed in Tracer Activities. It was noted by the nurse surveyor upon review of the Volunteer Services Program that the organization had three pet therapy volunteers, however, the organization had not defined the role of pet therapy volunteers. Finding was verified by the Volunteer Coordinator and the Vice President for Operations South Region.

Based on observations, record reviews, and interview, the hospice failed to ensure the hospice staff updated the patient's medication profile for 3 of 3 patients during home care visits. (Patient #1, Patient #3, and Patient # 10) --- The findings include: Observations in the home for Patient #1 on 10/30/2023 between 2:00 PM and 2:35 PM revealed the patient reported taking Carvedilol 3.125 mg (milligram) tablet once a day by mouth, but the hospice medication profile showed Carvedilol 3.125 mg tablet twice a day by mouth. On 10/30/2023 at 2:25 PM, Skilled Nurse (SN) #1 verified the finding. On 10/31/2023 at 11:43 AM, review of Patient #3's facility Medication Administration Record (MAR) during the home visit revealed: Guaifenesin Oral Syrup 30 ml by mouth every 4 hours as needed for cough, Melatonin tablet 3 mg 2 tablets by mouth as needed for insomnia, Omeprazole Delayed Release 20 mg tablet 1 tablet by mouth daily as needed for GERD (Reflux), Tylenol 325 mg tablet 2 tablets every 6 hours as needed for pain, and Narcan Liquid 4 mg/0.1 ml (milliliters) administer 4 mg/0.1 ml into one nostril as needed for suspected opioid overdose and call 911. The medications were not on the hospice medication profile for the patient. On 11/01/2023 at 2:27 PM, the Administrator confirmed the finding. Oon 11/01/2023 at 12:01 PM, during home visit, and then review of for Patient #10 nurse visit note dated 09/16/2023, revealed, ";Visit made. patient had burned his nostrils while smoking and using oxygen...Instructed in using Silvadene Cream and applying Lidocaine gel that I had purchased for him...". RN failed to add the medications to the hospice medication profile for the patient. On 11/01/2023 at 4:20 PM, the Administrator verified the findings and stated, ";Should have been added".

Based on record reviews and interview, the hospice failed to ensure the patient a systematic assessment for coordination of patient care with goals with established dates for 14 of 14 patient charts reviewed. (Patient #1- #14) --- The findings include: Review of 14 of 14 patient charts on 10/31/2023 and 11/01/2023 revealed the patient's goals lacked dates and individualization for the hospice staff to review the effectiveness of the hospice services provided for care management and coordination. The goals for each patient read ";established by 1 week, met by 1 week, met by next IDG (Interdisciplinary Group), by EOE (end of episode), and met each visit". On 11/01/2023 at 3:25 PM, the Administrator reported ";Problems at other offices too. Home Care Home Base (computer system) is not letting us use different information".

Based on record reviews and interview, the hospice staff failed to follow the Interdisciplinary Team (IDT) Plan of Care (POC) regarding discipline visit schedule for 11 of 14 patient charts reviewed. (Patient #1, #2, #4, #5, #6, #7, #8, #9, #10, #11 and #14) --- The findings include: Record review on 10/31/2023 at 9:10 AM of Patient #1's chart revealed visit schedule orders starting 08/10/2023: Skilled Nurse (SN) 2 visits every week and 3 Pro Re Nata (PRN) visits for symptom management and Hospice Home Aide (HHA) 3 visits every week. One visit was documented by the SN on 08/10/2023 for the first week and no visits were documented by the HHA in the first week. Interview on 11/01/2023 at 3:25 PM, the Administrator reported ";Problems with scheduling" and verified the finding. Record review on 10/31/2023 at 10:24 AM for Patient #2 revealed visit schedule orders starting 09/30/2023: SN 2 visits every week and 3 PRN visits for symptom management and HHA 2 visits every week. There were no visits documented for the week of 09/30/2023 by the SN or HHA. On 11/01/2023 at 3:40 PM, the Administrator reported ";Problems with scheduling" and verified the finding. Record review on 10/31/2023 at 11:43 AM for Patient #4 revealed visit schedule orders starting 09/27/2023: SN 2 visits every week and 3 PRN visits for symptom management and HHA 2 visits every week. There was one visit documented by SN on 09/27/2023 for the first week and no visits documented by the HHA in the first week. On 11/01/2023 at 4:30 PM, the Administrator verified the findings. Record review on 10/31/2023 at 12:45 PM for Patient #5 revealed visit schedule orders starting 08/23/2023: HHA 5visits every week. HHA visit is documented on 8/25/2023, and no others for the first week of the episode. On 11/01/2023 at 4:40 PM, the Administrator verified the findings. Record review on 10/31/2023 at 12:25 PM for Patient #6 revealed visit schedule orders starting 08/26/2023: SN 2 visits every week and 3 PRN visits for symptom management and HHA 2 visits every week. There were no visits documented for the week of 08/26/2023 by the SN or HHA. On 11/01/2023 at 4:45 PM, the Administrator verified the findings. Record review on 10/31/2023 at 1:30 PM for Patient #7 revealed visit schedule orders starting 09/15/2023: SN ";7 visits a week from 09/18-09/30/2023, then 2 visits a week, and 3 PRN visits for symptom management" and HHA 2 visits every week. There were no visits for the week of 09/15/2023 by the HHA and SN visits were documented on 09/15/2023 and 09/16/2023 only. On 11/01/2023 at 4:50 PM, the Administrator verified the findings. Record review on 10/31/2023 at 11:00 AM for Patient #8 revealed visit schedule orders starting 09/19/2023: HHA 2 visits every week. Documentation of 1 missed visit by HHA first week, no second visit documented. On 11/01/2023 at 4:47 PM, the Administrator reported ";Never called the office that we know of" and verified the finding. Record review on 11/01/2023 at 11:19 AM for Patient #9 revealed visit schedule orders starting 09/13/2023: HHA 2 visits every week. Documentation for HHA visit on 9/15/2023, but no second visit documented for this week. On 11/01/2023 at 4:15 PM, the Administrator verified the finding. Record review on 11/01/2023 at 12:01 PM for Patient #10 revealed visit schedule orders starting 09/15/2023: HHA 2 visits every week. There was no documentation of HHA visits the first week. On 11/01/2023 at 4:20 PM, the Administrator verified the finding. Record review on 11/01/2023 at 10:05 AM for Patient #11 revealed visit schedule orders starting 02/23/2023: SN 2 visits every week and 3 PRN visits for symptom management and HHA 2 visits every week. There were no visits documented for the week of 02/23/2023 for HHA and 1 visit documented by the RN on 02/23/2023. On 11/01/2023 at 3:55 PM, the Administrator verified the finding. Record review on 10/31/2023 at 1:51 PM for Patient #14 revealed visit schedule orders starting 05/10/2023: SN 2 visits every week and 3 PRN visits for symptom management and HHA 2 visits every week. There were no visits documented for the week of 05/10/2023 for HHA and 1 visit documented by the RN on 05/10/2023. On 11/01/2023 at 3:32 PM, the Administrator verified the finding.

Based on record reviews and interview, the hospice failed to ensure an individualized Plan Of Care (POC) for 10 of 14 patient charts reviewed for care and services (Patient #2, #3, #4, #6, #7, #9, #10, #11, #12, and #14) --- The findings include: Record review on 10/31/2023 and 11/01/2023 revealed Patient #2, #3, #4, #6, #7, # 9, #10, #11, #12 and #14 had the same discipline visit schedule that read: Skilled Nurse (SN), 2 visits a week and 3 prn (as needed) visits for symptom management, Hospice Health Aide (HHA), 2 visits a week, Master of Social Work (MSW) 1-2 visits a month and 3 prn visits for psychosocial needs, Chaplin 1-2 visits a month and 3 prn visits for spiritual needs. Uniform scheduling has the potential that specific patient needs may not be met. On 11/01/2023 at 3:25 PM, the Administrator reported ";I see where it is a problem, especially with scheduling".

Based on record reviews and interview, the hospice Registered Nurse (RN) failed to update the patient's Plan Of Care (POC) for 1 of 1 patient with significant events requiring wound care and Oxygen safety. (Patient #10) --- The Finding includes: Record review on 11/01/2023 at 12:01 PM for Patient #10 revealed a Registered Nurse note dated 09/16/2023 that reads, ";Visit made patient had burned his nostrils while smoking and using oxygen...Instructed in using Silvadene Cream and applying Lidocaine gel that I had purchased for him...". There was no documentation of an update in the patient's POC for increased oxygen safety and wound care. On 11/01/2023 at 4:20 PM, the Administrator verified the finding.

Based on record reviews and interview, the hospice Registered Nurse (RN) failed to provide specific instructions for patient care by the Hospice Home Aide (HHA) to ensure safe personal care for 10 of 13 applicable patients. (Patient #2, #3, #4, #5, #6, #8, #9, #10, #12 and 14) --- The finding includes: Record review on 10/31/2023 at 10:24 AM for Patient #2 revealed the Aide Care Plan effective date 04/08/2022, reads, "Bathing-Bed Bath, weekly; Bathing-Shower, weekly; Shampoo, weekly; Hair Care, weekly". These instructions are not specific and have not been updated since the patient's Start of Care (SOC) on 04/08/2022. On 11/01/2023 at 3:35 PM, the Administrator verified the findings. Record review on 10/31/2023 at 11:43 AM for Patient #3 revealed the Aide Care Plan effective date12/31/2022, reads, "Assist to dress, every visit if needed; Assist with feeding, every visit if needed; Shampoo, every visit if needed; Oral Care, every visit if needed; Bathing-Shower, every visit if needed; Nail care, weekly; Ear care, weekly." These instructions are not specific and have not been updated since 12/31/2022. On 11/01/2023 at 2:27 PM, the Administrator verified the findings. Record review on 10/31/2023 at 12:25 PM for Patient #4 revealed the Aide Care Plan effective date 03/31/2023, reads, "Bathing-Bed Bath, weekly; Shampoo, weekly; Ear Care, weekly; Bathing-Shower, weekly". These instructions are not specific and have not been updated since the patient's SOC on 03/31/2023. On 11/01/2023 at 4:30 PM, the Administrator verified the findings. Record review on 10/31/2023 at 12:45 PM for Patient #5 revealed the Aide Care Plan instructions reads, "Ear Care, weekly, Nail Care, weekly." These instructions are not specific. On 11/01/2023 at 4:40 PM, the Administrator verified the findings. Record review on 10/31/2023 at 12:25 PM for Patient #6 revealed the Aide Care Plan instructions reads, "Shampoo, weekly; Bathing-Shower, weekly". These instructions are not specific. On 11/01/2023 at 4:45 PM, the Administrator verified the findings. Record review on /2023 at 11:00 AM for Patient #8 revealed the Aide Care Plan instructions, reads, "Shampoo, weekly." This instruction is not specific for date. On 11/01/2023 at 4:47 PM, the Administrator verified the finding. Record review on 11/01/2023 at 11:19 AM for Patient #9 revealed the Aide Care Plan instructions, reads, "Nail care, weekly." The instruction is not specific for care. On 11/01/2023 at 4:15 PM, the Administrator verified the finding. Record review on 11/01/2023 at 12:01 PM for Patient #10 revealed the Aide Care Plan instructions, reads, "Nail Care, weekly". These instructions are not specific. On 11/01/2023 at 4:20 PM, the Administrator verified the findings. Record review on 10/31/2023 at 2:33 PM for Patient #12 revealed the Aide Care Plan instructions, reads, "Shaving, weekly". These instructions are not specific. On 11/01/2023 at 3:44 PM, the Administrator verified the findings. Record review on 10/31/2023 at 1:51 PM for Patient #14 revealed the Aide Care Plan instructions reads, "Nail care, weekly". These instructions are not specific. On 11/01/2023 at 3:32 PM, the Administrator verified the finding.

Based on record reviews and interview, the hospice aide failed to provide care as directed in the patient's Plan of Care (POC) for 1 of 14 patient charts reviewed. (Patient #1) --- The finding includes: Record review on 10/31/2023 at 9:10 AM of Patient #1 revealed the Hospice Aide failed to assist the patient with a shower at the visit dated 08/18/2023. The Hospice Aide documented ";Bathing-Shower, Completed: N. Note: BB was done". Hospice Aide POC showed ";Bathing-Shower, every visit". There was no documentation the Hospice Aide contacted the Registered Nurse (RN) for report and change in instruction. On 11/01/2023 at 3:25 PM, the Administrator reported ";BB means a bed bath was done...not in the POC".

Based on record reviews and interview, the hospice aide failed to report changes in condition or missed visits to the hospice Registered Nurse (RN) for 2 of 13 applicable patients. (Patient #1 and Patient #3) --- The finding includes: Record review on 10/31/2023 at 9:10 AM of Patient #1 revealed aide missed visit on 08/18/2023, 08/15/2023, 09/05/2023, and 09/15/2023. There was no documentation in the patient's chart that the aide notified the hospice RN. On 11/01/2023 at 3:25 PM, the Administrator verified the finding. Record review on 10/31/2023 at 11:00 AM for Patient #8 revealed visit schedule orders starting 09/19/2023: "HHA 2 visits every week". Documentation of 1 missed visit by HHA first week. There was no documentation in the chart that the aide notified the hospice RN. On 11/01/2023 at 4:47 PM, the Administrator verified the finding.

Based on record reviews and interview, the hospice Registered Nurse (RN) failed to document aide supervisory visits every 14 days for 3 of 13 applicable patients. (Patient #7, #9 and #12) --- The finding includes: Record review on 10/31/2023 at 1:30 PM of Patient #7 revealed RN documenting supervisory visits on 10/10/2023 and 10/12/2023. RN visits on 10/17/2023, 10/19/2023, 1024/2023 and 10/27/2023 provided no documentation of supervisory visit performed. This was greater than 14 days between supervisory visits. On 11/01/2023 at 4:47 PM, the Administrator reported ";Should have been done" and verified the finding. Record review on 11/01/2023 at 11:19 AM for Patient #9 revealed documentation for aide supervisory visit on 09/19/2023 and next on 10/05/2023. This was 16 days between supervisory visits. On 11/01/2023 at 4:15 PM, the Administrator reported ";Should be doing them every visit". Record review on 10/31/2023 at 2:33 PM for Patient #12 revealed documentation for aide supervisory visit on 04/26/2023 and next on 05/31/2023. This was 35 days between supervisory visits. Interview on 11/01/2023 at 3:44 PM, the Administrator verified the findings.

Based on record reviews and interview, the hospice Registered Nurse (RN) failed to obtain accurate orders for wound site and care for 2 of 3 applicable patients. (Patient #9 and #10) --- The findings include: Record review on 11/01/2023 at 11:19 AM for Patient #9 revealed a RN Pro Re Nata (PRN) note dated 10/14/2023 that reads, ";...bruising of left thigh...purplish area to left hip...applied skin prep to hip and applied foam dressing". Physican orders for wound care dated 10/23/2023 showed ";Clean area to right hip with skin prep and apply foam dressing...". RN note and physician orders are for opposing hips for wound care. On 11/01/2023 at 4:15 PM, the Administrator reported ";Got it backwards. Dont know why he waited to get the order". Record review on 11/01/2023 at 12:01 PM for Patient #10 revealed RN note dated 09/16/2023 that reads, ";Visit made patient had burned his nostrils while smoking and using oxygen...Instructed in using Silvadene Cream and applying Lidocaine gel that I had purchased for him...". There is no documentation the RN notified the physician to obtain orders for wound care. On 11/01/2023 at 4:20 PM, the Administrator reported ";must have forgot".