Every finding on record at Via Health Partners - Laurens County

Upon patient record review, 2 of 25 (Patient #11, 13) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 11: The patient consent forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina. Patient 13: The patient consent forms for admission to hospice services was signed by a person identified as the patients daughter-in-laww. The patients son was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina.

Upon patient record review, 2 of 25 (Patient #11, 13) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient 11: The Patient Rights and Responsibilities forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina. Patient 13: The Patient Rights and Responsibilities forms for admission to hospice services was signed by a person identified as the patients daughter-in-law. The patients son was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina.

Upon patient record review, 2 of 25 (Patient #11, 13) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 11: The Patient Rights and Responsibilities forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies or the regulations of the State of South Carolina. Patient 13: The Patient Rights and Responsibilities forms for admission to hospice services was signed by a person identified as the patients daughter-in-law. The patients son was present for the admission, the signature does not follow the company policies or the regulations of the State of South Carolina.

Upon patient record review, 2 of 25 (Patient #11, 13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 11: The patient consent forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina. Patient 13: The patient consent forms for admission to hospice services was signed by a person identified as the patients daughter-in-law. The patients son was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina.

Upon patient record review, 2 of 25 (Patient #11, 13) did not have evidence of the appropriate documentation for release of confidential information. Patient 11: The patient consent forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina. Patient 13: The patient consent forms for admission to hospice services was signed by a person identified as the patients daughter-in-law. The patients son was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina.

Upon patient record review, 1 of 25 (Patient #13) 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 13: The medication profile includes Polyethylene Glycol 3350 17G powder, one dose daily for constipation. It does not include a diluent or mixing instructions.

Upon patient record review, 1 of 25 (Patient #23) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 23: The patient was admitted on 6/14/24, the record does not include an initial bereavement risk assessment.

Upon patient record review, 2 of 25 (Patient #13, 15) 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 13: The medication orders on 1/6/25 for Polyethylene Glycol 3350 17G powder, one dose daily for constipation, does not include a diluent or mixing instructions. Patient 15: The patient record includes documentation on 3/28/25 that wound care was provided to the sacrum and right heel due to stage II and stage III wounds, the record does not include wound care orders.

Upon patient record review, 1 of 25 (Patient #9) 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 09: The initial spiritual care assessment was completed on 3/18/24, with subsequent visits to be made monthly for spiritual support. The plan of care does not include interventions and goals for spiritual needs.

Upon client record review, 3 of 25 (Patient #4, 14, 24) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 04: The plan of care includes orders for Spiritual Care services 1 x per month, there are no visits made in the month of March. Patient 14: The plan of care includes orders for Spiritual Care services 1 x per month, there are no visits made in the month of March. Patient 24: Documentation on 2/14/25 states "RN placed foley catheter in pt." The plan of care does not include MD orders for foley placement.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 02: Upon home visit, it was observed that the RN obtained an electronic blood pressure cuff from the facility nurse that was positioned on a medication cart and placed it up on the patients left and right wrist without having performed a cleaning on the device. The RN was observed performing a physical assessment, reaching into her nursing bag, cleaning a wound to a toe on the right foot (including extracting serosanguinous fluid and puss) and then applying iodine to the wound, while wearing the same pair of gloves. The nurse also cleaned her nursing tools ie; stethoscope and pulse oximeter, and placed them immediately into her nursing bag without allowing for drying time.

Upon patient record review 5 of 25 (Patient #2, 5, 6, 10, 24) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 02: An aide supervisory visit was performed on 2/27/25, the record does not include a supervisory aide visit since that time. Patient 05: An aide supervisory visit was performed on 3/13/25, the subsequent supervisory visit was performed on 4/3/25, day 21. Patient 06: An aide supervisory visit was performed on 2/28/25, the subsequent supervisory visit was performed on 4/1/25, day 32. Patient 10: An aide supervisory visit was performed on 3/10/25, the record does not include a supervisory aide visit since that time. Patient 24: An aide supervisory visit was performed on 1/27/25, the record does not include a subsequent supervisory visit performed leading up to the time of death on 2/15/25, 19 days.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Volunteer service hours for 2024 equals, 3.61 percent of the total patient care hours, it does not meet the minimum 5 percent.

Upon patient client record review, 2 of 25 (Patient #11, 13) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 11: The patient consent forms for admission to hospice services was signed by a person identified as the patients step-mother. The patients father was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina. Patient 13: The patient consent forms for admission to hospice services was signed by a person identified as the patients daughter-in-law. The patients son was present for the admission, the signature does not follow the company policies as indicated by regulations of the State of South Carolina.

Upon client record review, 1 of 25 (Patient #13) 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 13: The patient record includes documentation and orders on 1/15/25 that the patient was started on Cipro 500 mg, 1 tab daily for infection. The medication order was changed on 1/17/25 to Cephalexin 500 mg every 6 hours due to drug interaction, the plan of care was not updated to include interventions and goals for the infection management. The patient record includes documentation on 1/8/2025 and 1/20/25 indicating the patient has a deep tissue injury to the left heel, the skilled nursing facility is treating this with sure prep. The plan of care is not updated to include interventions and goals for the wound/injury.

Upon observation, there was no evidence the electrical of a facility is provided consistent with the 2012 editions of the LSC of the National Fire Protection Association and NFPA 99. The provisions of the adopted edition of the Life Safety Code do not apply in a State if CMS finds that a fire and safety code imposed by State law adequately protects patients in hospices. New and existing Construction Upon review of NFPA 99, 2012 with regard to Type 2 and 3 systems, Section 6.6 on Type 3 EES (essential electrical systems, i.e. - generator systems) code 6.4.2.2.3.2: The life safety branch shall supply power for lighting, receptacles, and equipment as follows: (1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code (2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code (3)*Hospital communications systems, where used for issuing instruction during emergency conditions (4) Generator set location as follows: (a) Task illumination (b) Battery charger for emergency battery-powered lighting unit(s) (c) Select receptacles at the generator set location and essential electrical system transfer switch locations (5) Elevator cab lighting, control, communications, and signal systems (6) Electrically powered doors used for building egress (7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code The emergency power system at Hospice of Laurens County, Inpatient was non-functional for a period exceeding one month, from 9/27/24 to 1/10/25. On 9/27/24, during a severe weather event the facility lost power and did also encountered a failure of the alternate source of power, the facility appropriately evacuated patients when the generator failed. However, patients were returned to the facility on 9/28/24 once the main power systems were restored, but before the emergency power system was fully restored. Due to the events of the catastrophic weather that occurred with Hurricane Heleen and Hurricane Irene, the agency was unable to obtain an inspection of the unit, or a replacement in a timely manner. Upon inspection on 10/31/24, it was found that the alternate back up power (generator) was non-functional and beyond repair. A back up source of power was not established until 1/10/2025 with the use of a rental generator. The facility did not have a documented risk assessment or contingency plan in place to ensure patient safety during the outage.

Corrcted

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to ensure the hospice's EPP included the use of volunteers during an emergency/disaster to address surge needs. --- The findings are: Review of the hospice's EPP revealed there was no policy addressing the role of volunteers, no listing of agency volunteers, and no data for outside volunteers in the event of a disaster/emergency. The finding was confirmed on 3/2/2023 at 3:35 PM in an interview with Administrator #1.

Based on review of the hospice's Emergency Preparedness Program and interview, the hospice failed to meet the criteria for Emergency Officials contact information to include staff, physicians, other local facilities, or volunteers. --- The findings are: Review of the hospice's EPP revealed there was no name and contact information for the immediate staff, physicians, other agencies, or volunteers, with telephone numbers that should be immediately available in an emergency/disaster situation. The finding was confirmed with Administrator #1 on 3/2/2023 at 3:50 PM. During the interview, Administrator #1 reported all emergency operations are initiated out of the main office located in Charlotte, North Carolina and only at the direction of the Chief Executive Officer (CEO) or Chief Operating Officer (COO).

Based on review of the hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to demonstrate evidence of participation in annual Emergency Prep (EP)Testing Requirements at least annually. Documentation was missing for annual drills for the past 12 months. --- The findings are: Record review determined that there has been no community-based Emergency Prep Testing/Drills done for at least the past 12 months. This information is confirmed on 3/2/2023 at 4:00 PM with Administrator #1 and Administrator #3. Record review of "Disaster Preparedness/Drill Evaluation" on 03/02/23 at 3:30 PM revealed the facility had broken water pipes on 12/26/22 which was not a community based emergency preparedness drill. During an interview on 03/02/23 at 3:30 PM with Area Vice President of Quality stated, "The broken water pipes was our annual emergency preparedness drill". Facility policy, entitled "Emergency Operations Manual" revealed, "8. Produce an Emergency Management Testing plan that includes: a. Sufficient tests to comply with the requirements of the CMS Final Rule. Currently: i. At least two annual exercises of which one must be a full-scale community-based exercise; the second can be a tabletop exercise...".

Based on record reviews and interview, the hospice failed to ensure the Skilled Nurses (SN), Master of Social Worker (MSW), Chaplain, Hospice Aide (HA), and Volunteer completed home visits per the ordered frequency on the patient's plan of care for 8 of 17 patient charts reviewed. (Patient 4, 7, 9, 10, 11, 12, 13 and 21) --- The findings include: On 02/28/23 at 1:20 PM, review of Patient 7s chart revealed a visit frequency for the MSW for 1 time a week for 2 weeks starting 12/28/22 and the HA visit frequency for 5 times a week for 8 weeks starting 12/18/22. Review of the benefit period dated 12/17/22 to 02/14/22 revealed 1 missed MSW visit the week of 12/25/22 and 1 missed HA visit the week of 12/25/22, 1 missed visit the week of 01/01/23 and 1 missed visit the week of 01/22/23. During an interview on 03/01/23 at 3:03 PM, the Clinical Manager (CM) verified the findings. The findings are: On 3/2/2023 at 2:00 PM, review of Patient #4 records revealed Hospice Aide (HA) orders for once a week for 13 weeks. Review of the HA visit notes revealed HA missed the visit in week 4 with no missed visit note. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #9 with a SOC of 12/29/2022 has orders for the social worker for once a week for one week, then once every other week for 10 weeks with 5 as needed visits. The social worker missed the visit on week 3 with no missed visit note. Additionally, the aide has orders for twice a week for 1 week yet missed the visit in week 1 with no missed visit note. The chaplain has orders for once every other week for 12 weeks and missed the visit in week 3 with no missed visit note. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #10 with a SOC of 9/13/2022 has orders for the social worker for once in the first week of service, then once every 4 weeks for 4 months, then 1 every 5 weeks for 5 months with 5 as needed visits. The social worker missed the visit in week 9 with no missed visit note. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #11 with a SOC of 4/12/2022 has orders for the nurse for twice a week for 9 weeks with 10 as needed visits, and the aide for twice a week for 9 weeks. The nurse missed one visit in week 6 with no missed visit note. The aide missed a visit in week 1 with no missed visit note. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #12 with a SOC of 5/20/2022 has orders for the social worker for once per week for 1 week, once every 2 weeks for 10 weeks and 5 as needed visits. The social worker missed the visits on weeks 6 and 8 with no missed visit notes. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #13 with a SOC of 12/28/2022 has orders for the nurse to visit 3 times in week 1, 2 times a week for 12 weeks (effective 1/4/2023) and 11 additional ";as needed" visits. The nurse, in addition to the as needed visits, made additional visit in weeks 6,7,8 and 9 without additional orders being sought. The chaplain has orders for one visit in week 1, then one visit every 2 weeks for 12 weeks with 2 as needed visits. The visit in week 3 was missed with no missed visit note. The social worker has orders for one visit in week 1, with 1 visit every 2 weeks for 10 weeks with 5 as needed visits. The social worker missed the visit in week 3 with no missed visit note. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM. On 3/2/2023 record review of Patient #21 with a SOC of 12/22/2022 has orders for the social worker effective 12/25/2022 of 3 visits per week for 12 weeks, changed 12/29/2022 to once for 1 week, changed 12/30/2022 to once every 2 weeks for 12 weeks with 5 as needed visits. The social worker failed to make the visits or make a missed visit note for weeks 4 and 6. This was confirmed by Administrator #3 in in interview on 3/2/2023 at 3:00 PM.

Based on record reviews and interview, the hospice failed to provide ongoing sharing of information between all disciplines providing care and services for patients in all settings whether provided directly or under arrangement for 2 of 17 patient chart reviews. (Patient 1 and 2) --- The findings include: Observations in Patient 1s (facility) home on 02/28/23 at 9:06 AM revealed the facility book provided by hospice contained the patients ";Hospice IDG Comprehensive Assessment and Plan of Care Update Report" for 01/12/23 and not the most updated IDG notes dated 02/23/23. The book did not contain any physician certification and recertification documentation, no medication profiles, or any hospice physician and/or attending physician orders. Patient 1 was admitted to hospice on 11/23/22 for Senile Degeneration of Brain. During an interview on 02/28/23 at 09:15 AM, the facility staff Licensed Practical Nurse (LPN 1), stated, ";Whatever is in the books is all the information that we have for the patients." During an interview on 03/01/23 at 2:38 PM, the hospice Clinical Manager (CM), stated, ";That information I thought was in the books at the facility." Observations in Patient 2s (facility) home on 02/28/23 at 10:30 AM revealed the facility book provided by hospice did not have the patient's medication profile from admission to current or the hospice physician and/or attending physician orders from admission to present. Patient 2 was admitted to hospice on 01/02/23 for Sepsis, Unspecified. During an interview on 02/28/23 at 10:30 AM, the (facility) Registered Nurse 2 stated, ";Hospice provides us with the book and the information." During an interview on 03/01/23 at 2:38 PM, the hospice Clinical Manager (CM) stated, ";That information I thought was in the books at the facility".

Based on observations and interview, the hospice staff failed to follow accepted standards of practice for infection control by 1 of 2 Registered Nurses (RN) and 1 of 2 Hospice Aides. (RN 1 and HA 1). --- The findings include: Observations in Patient 1s (facility) home on 02/28/23 from 08:00 AM to 09:03 AM revealed HA 1 performing the patients bed bath. HA 1 washed the patient's perineum, dried the area with a towel, and rolled the patient on his/her left side. HA 1 washed the patients back and buttocks area without obtaining clean bath water to complete the bath. During an interview on 03/01/23 at 2:38 PM, the CM stated, ";The water should have been changed". Observations in Patient 2s (facility) home on 02/28/23 from 09:42 AM to 10:18 AM revealed RN 1 post equipment usage on the patient with soiled gloves donned, cleaned his/her Oxygen sensor, wrist blood pressure cuff, thermometer, and stethoscope with an alcohol wipe and placed the items directly into his/her nursing bag. RN 1 discarded his/her soiled gloves and performed hand hygiene. During an interview on 03/01/23 at 2:50 PM, CM verified the gloves should have been clean.

Based on record reviews, interview and review of facility policy and procedure, the hospice failed to ensure bereavement services were available to the family up to one year post death based on the bereavement plan of care for 3 of 3 deceased patients. (Patient 15, 16, 17 and 20). --- The findings include: On 02/28/23 at 3:21 PM, review of Patient 15s chart revealed the patient expired on 02/28/22. Review of the patients bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the plan of care. During an interview on 03/01/23 at 3:07 PM, the Area Vice President (AVP) 2 verified the findings. On 02/28/23 at 3:55 PM, review of Patient 16s chart revealed the patient expired on 03/29/22. Review of the patients bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the plan of care. During an interview on 03/01/23 at 3:32 PM, the AVP 2 verified the findings. On 03/01/23 at 8:58 AM, review of Patient 17s chart revealed the patient expired on 05/25/22. Review of the patients bereavement plan of care revealed there was no documentation that the patient's plan of care was completed based on services and frequencies outlined in the plan of care. During an interview on 03/01/23 at 3:34 PM, the AVP 2 verified the findings. Facility policy, entitled "Bereavement Services Procedure" revealed, "Bereavement care services are available for thirteen months after the death of the patient and longer upon care plan recommendations...".

Based on record reviews and interview, the facility failed to ensure that supervisory visits by the registered nurse for the Hospice Aide (HA) was completed every 14 days for 1 of 17 patient records reviewed. (Patient #6) --- The findings are: On 3/2/23 at 10:30 AM, review of Patient #6 chart showed the Start of Care (SOC) dated 5/16/2022 had Hospice Aide (HA) orders for 5 days a week for 13 weeks. There were no supervisory visits documented by the registered nurse during the entire episode. The finding was confirmed by Administrator #3 in an interview on 3/2/23 at 10:45 AM.

Based on record review and interview, the hospice operated another location providing patient services that had not been approved by Medicare. --- The findings include: During the entrance interview on 02/27/23 at 11:25 AM, Area Vice President 1 and the Inpatient Clinical Director reported the hospice operated a multiple location office that consisted of its own staff and provided patient service for the hospice's upstate patients and approved by state. Review of the hospice's admissions list, unduplicated census, and revocation and discharge list revealed data and documentation of patient services from the upstate location. The hospice submitted a CMS 855 A Medicare Enrollment Application requesting enrollment of the upstate location from 03/10/22 that was authenticated on 02/27/23.

Based on record reviews, interviews, and review of the hospice's policy and procedure, the inpatient hospice unit failed to ensure proper food serving temperatures for patient meals for 3 of 3 hospice house inpatients. (Patient 13, 14, and 21) --- The findings include: Observations on 03/01/23 from 12:30 PM to 12:34 PM of the hospice's kitchen area revealed the patients' meals were catered from a outside vendor. Staff transported the patient meals from the vendor to the hospice house. Observations showed Certified Nursing Assistant (CNA) 1 obtained a calibrated thermometer and obtained the temperature of the meals for Patient 13, 14, and 21. The following food items on the meal trays tested as: rice with beef and broccoli 60 degrees. CNA 1 did not obtain the temperature for the green beans, broccoli, or egg rolls on the meal trays. During an interview on 03/01/23 at 12:35PM, CNA 1 stated, ";I use the thermometer for the main dish on the trays, but I dont check the other food items. I figured if the main dish is hot enough, then the rest of it is hot too. I havent been trained on what the proper temperatures for food should be". During an interview on 03/01/23 at 12:48 PM, the Inpatient Unit Manager (IPUM) stated, ";I was told when the food was brought in that we just check it to make sure it's at the right temperature, but Im unsure what that temperature should be. I havent been trained on the proper temps (temperature) myself. I was told that staff had already been trained on it, but I dont know where that documentation is. I dont know where the sheets for the month are where we document the temps". Observations on 03/02/23 at 12:00 PM in the kitchen area revealed CNA 2 had a new thermometer. During an interview on 03/02/23 at 12:01 PM, CNA 2 stated, ";I checked the temps for the breakfast and lunch meals. We have a new thermometer, but I wasnt trained how to calibrate it". During an interview on 03/02/23 at 12:07 PM, the IPUM stated, ";I went out and bought a new thermometer because no one told me the other one (thermometer) wouldnt go below 60 degrees. But I read the instructions on it, and it didnt state how to calibrate it. I havent done any training because none of the other IPUMs stated that they temp food". Hospice policy, entitled, "Dietary Nutritional Needs of Patients", revealed, "D. The meals will be palatable, attractive, and served at proper temperature. The meals will be obtained, stored, prepared, distributed, and served under sanitary conditions".

Based on record review and staff interview the facility failed to provide an comprehensive emergency preparedness plan Record review revealed that the facility could not provide an updated emergency preparedness plan. This was verified by the Clinical Director at the time of discovery and during the exit interview approximately 11:00.