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

Upon patient record review 3 of 14 records (Patient #2,#7,#10) 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 #2: The patient was admitted on 11/7/23. The record indicated that the spiritual assessment was completed on 3/7/24. Patient #7: The patient was admitted on 4/8/24. The record indicated that the spiritual assessment was completed on 4/16/24. Patient #10: The patient was admitted on 1/23/24. The record indicated that the spiritual assessment was completed on 3/19/24.

Upon patient record review 1 of 14 records (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #4: There was not evidence of a spiritual assessment.

Upon patient record review, 3 of 14 records (Patient #1, #4,#6) 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 #1: Upon home visit, the record at the ALF did not contain Acetaminophen, Levsin, or Ondansetron. These medications were part of the medication profile on the hospice record. Patient #4: The medication profile contained Azithromycin for a URI, dated 5/31/23. Give 2 tabs on the first day and 1 tab for 4 days after. This remained on the medication profile. Corrected on site. Patient #6: The medication profile contained Acetaminophen 500mg tabs, 2 tabs daily prn pain or fever. There was not evidence of a parameter for the fever. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #1) 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 #1: The record indicated that the patient had a spouse that lived at the facility (ALF, in the same room). The record indicated that a bereavement risk assessment was conducted on the patient's daughter but not the spouse.

Upon patient record review, 1 of 14 records (Patient #10) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10: The record indicated a call to triage dated 2/24/24 at 2:20pm. The caller stated that he thinks the patient has a UTI as she is hallucinating. A visit was advised. An order for Levaquin was noted on this date but there was not evidence of a contact to the caller or a visit until 2/29/24 at 3:13pm.

Upon patient record review, 2 of 14 records (Patient #5,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #5: The patient was admitted with a diagnosis of malignant neoplasm of the colon. There was not evidence that pain was included to reflect patient/family goals and interventions. Corrected on site. Patient #9: The patient was on Eliquis 5mg BID. There was not evidence that bleeding precautions were a part of the plan of care. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #6) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #6: The record contained an order for Acetaminophen 500mg tabs, 2 tabs daily prn pain or fever. There was not evidence of a parameter for the fever. Corrected on site.

Upon patient record review, 1 of 14 records (Patient #10) 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 #10: The patient was started on Levaquin on 2/24/24 for a UTI, and on Cephalexin, dated 2/6/24 for cellulitis. There was not evidence that problems/goals/interventions related to infections were added to the plan of care.

Upon client record review, 3 of 14 records (Patient #4,#7,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The skilled nurse visit frequency for the benefit period beginning 3/16/24 was 1 every 2w2, 1w8. The visits occurred on 3/19/24, 3/26/24, 4/2/24... (1x/week) Patient #7: The skilled nurse visit frequency was 3w1, 2w11. The patient was admitted on 4/8/24 and the record indicated that visits were conducted only on 4/8/24 and 4/10/24 for the first week. In addition the patient had a biliary drain on his right side. The patient was caring for the drain but there was not evidence in the plan of care of problems/goals/interventions regarding the care or dressings required to care for this drain. Corrected on site. Patient #9: The record indicated a visit dated 2/12/24 by the occupational therapist. There was not evidence that this was in the plan of care. Corrected on site. In addition, the patient had a Foley catheter inserted on 2/8/24. The Foley catheter was changed on 4/1/24. There was not evidence of an order to change the Catheter or if a flush was to be attempted, and for what reason. Corrected on site. In addition, the skilled nurse visit frequency at the start of care (2/5/24) was 3w1, 2w11. Visits were conducted on 2/5/24 and 2/7/24.

Upon patient record review 2 of 14 records (Patient #3,#8) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #3: The aide plan of care indicated to provide a shave at every visit. For the dates of 3/21/24 and 3/26/24, the aide documented, 'No, per frequency not needed.' Patient #8: The aide plan of care indicated to provide a shave at every visit. For the dates of 3/12/24, 3/26/24, 4/2/24, and 4/19/24, the aide documented, 'No, per frequency not needed.'

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. The volunteer usage for the year 2023 was reported as 2.04%.

Upon patient client record review, 2 of 14 records (Patient #2,#7) did not have evidence that each patient record contains Advance Directives. Patient #2,#7: The admission legal paperwork signed by the patient/caregiver indicated that the patient had an Advance Directive. There was not evidence that this was a part of the hospice record. Corrected on site.

Upon patient client record review, 1 of 14 records (Patient #12) did not evidence that each patient record contains physician orders. Patient #12: The patient was discharged for cause as the patient and family were no longer following the plan of care. The patient and family could not be reached through phone calls (which included all contacts) or attempted visits (showing up at the home and knocking on the door) for greater than 15 days. There was not evidence of a physician order to discharge the patient.

Upon patient client record review, 1 of 14 records (Patient #10) 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. Patient #10: Aide visits were discontinued on 1/30/24. The last aide visit was dated 1/25/24. There were aide supervisory visits on 2/5/24 and 2/12/24 where the aide supervisory questions were answered as if an aide was still providing care.

Upon client record review, 1 of 14 records (Patient #12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #12: There was not evidence that a discharge summary was sent to the attending physician.