Medical Services of America Hospice-Columbia

“Based on interview, document review, and agency policy review, the agency failed to ensure volunteers provided any administrative services ot direct patient care in 2024 and from 01/2035 to 07/11/2025. This deficient practice had the potential to affect all patients who received services from the agency. An agency policy titled “Volunteer Services HC.13,” revised 09/2024, revealed,” Medical Services of America Hospice-Columbia ensure qualified volunteers are available to assist with the provision of hospice services to patients and their caregivers. Hospice volunteers provide day-to-day administrative or direct patient care services.”During an interview on 7/10/2025 at 2:45 PM, the Volunteer Coordinator (VC) stated the agency did not have any volunteers to provide volunteer services, and she could not provide any documentation of volunteers who provided administrative or patient care services in 2024 or from 01/2025 through 07/2025.The agency “Volunteer Hour Report,” revealed no evidence to indicate there were volunteers for 2024 and 2025.During an interview on 7/11/2025 at 1:05 PM, the Administrator stated the agency currently did not have any volunteers available to provide either administrative or direct patient care services. The Administrator stated the agency did not have volunteers available to provide volunteer services during the entire year of 2024 or in 2025. According to the Administrator, the expectation was that volunteers would be included in the emergency preparedness plan, but since the agency did not have volunteers, she acknowledged the agency did not meet the requirement.”

“Based on interview, record review and agency policy review, the agency failed to ensure timely symptom management for 1 (Patient #5) of 16 sampled patients. An agency policy titled “Plan of Care HC.31” revised 03/2025, revealed, “Updates to the plan of care are made promptly in response to changes in patients’ condition.”Patient #5 “Plan of Care Order” dated 01/21/2025, revealed the agency admitted Patient #5 on 01/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (an inability of the respiratory system to maintain adequate blood oxygen level to preserve normal organ function).During an interview conducted on 07/09/2025 at 11:10 AM, Patient #5 stated the agency admitted them in 01/2025 as the nurses did not return their telephone calls. Patient #5 deferred the interview to their Paid Caregiver. The Paid Caregiver stated it took a lot of telephone calls from them to get things straightened out.Patient #5’s “LPN/LVN [licensed practical nurse/licensed vocational nurse]-Skilled Nursing Visit” note dated 01/27/2025 revealed one of Patient’s #5 family members reported to LPN #2 that the patient was awake “most of the night” and was keeping them awake at night. The LPN/LVN-Skilled Nursing Visit note indicated LPN #2 planned to contact Patient #5’s physician to discuss prescribing a medication that could help the patient sleep at night.Patient #5 “Physician Order” dated 01/30/2025, revealed the patient’s physician ordered Trazodone (an antidepressant medication) for the patient to take at bedtime.During an interview on 07/11/2025 at 8:50 AM, LPN #2 stated the agency expected nurses to follow up with a patient’s physician within 24 hours regarding any medication needs. LPN #2 stated the first time she discussed Patient #5 concern with sleep issues with a physician was during the interdisciplinary group (a team of healthcare professional who worked together to meet the physical, medical, psychosocial, emotional, and spiritual needs of hospice patients and their families) meeting on 01/30/2025.During an interview on 7/10/2025 at 3:45 PM, the Administrator stated the agency expectation was for the nurse to contact the physician the same day a patient concern was identified, and she would look for any additional documentation.The agency did not provide documentation to indicate the agency followed up with Patient #5’s physicians prior ti 01/30/2025 regarding the patient’s sleep issues.”

“Based on interview, record review, and agency policy review, the facility failed to ensure all members of the agency interdisciplinary group (IDG, a team of healthcare professionals who work together to meet the physical, medical, psychosocial, emotional and spiritual needs of hospice patients and their families) completed a comprehensive assessment for 2 (Patient #5 and Patient #10) of 16 sampled patients within five days of the patients election of hospice care. An agency policy titled, “Comprehensive Assessment HC.28,” revised 05/2025, revealed, “The initial and comprehensive assessments are foundational to hospice care and must be completed within federally mandated timelines.” The policy specified, “Comprehensive Assessment-Completed by the interdisciplinary group (IDG), in consultation with the attending physician (if applicable) no later than five (5) calendar days of hospice election.Patients #5’s “Plan of Care Order” dated 01/21/2025, revealed the agency admitted Patient #5 on 01/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (an inability of the respiratory system to maintain an adequate blood oxygen level to preserve a normal organ function). The Plan of Care Order revealed an order for the chaplain to provide spiritual support. Patient #5 medical record revealed no evidence to indicate the IDG completed a comprehensive assessment within five days of Patient #5’s election of hospice services or a chaplain assessment. 2. Patient #10’s “Plan of Care Order” dated 07/08/2025, revealed the agency admitted Patient #10 with a terminal diagnosis of primary biliary cirrhosis (an autoimmune disease that caused progressive destruction of the bile ducts). The Plan of Care Order revealed an order dated 06/18/2025 for social services to facilitate/encourage on advance planning counseling/support to the patient’s caregiver during the disease process.Patient #10 medical record revealed no evidence to indicate IDG completed a comprehensive assessment within five days of Patient 10’s election of hospice services or a social service assessment.During an interview on 07/11/2025 at 1:05 PM, the Administrator stated the agency expectation was that comprehensive assessments should be completed within five calendar days of a patient’s admission to the agency. Per the Administrator, if all disciplines had not assessed the patient within five days of a patients’ admission, the agency did not follow their policy. The Administrator stated the agency could not provide any additional documentation related to the delayed completion of comprehensive assessments for Patient #5 or Patient #10.”

“Based on interview, record review, and agency policy review, the agency’s interdisciplinary group (IDG, a team of healthcare professionals who work together to meet the physical, medical, and psychosocial, emotional and spiritual needs of hospice patients and their families) failed to update the plan of care for 1 (Patient #4) of 16 sampled patients. An agency policy titled “Plan of Care HC.31, revised 03/2025, revealed, “The interdisciplinary team (IDG) is responsible for regularly reviewing, updating and documenting the patient’s plan of care to reflect the patient’s current health status, care needs, and goals. These updates occur at least every 15 calendar days or whenever there is contact between team members and the patient or their family.”Patient #4 demographic record review revealed the agency admitted Patient #4 on 10/12/2024 with a terminal diagnosis of chronic obstructive pulmonary disease.Patient #4’s medical record revealed no evidence to indicate the patient’s plan of care was reviewed/revised after the patient was ordered an antibiotic medication on 03/13/2025.During an interview on 07/11/2025 at 1:05 PM, the Administrator stated the agency expected staff to update each patient’s plan of care as soon as staff identified a care change. The Administrator acknowledged the agency did not follow their policy and could not provide any additional documentation related to updates to Patient #4’s plan of care.”

“Based on interview, record review, and agency policy review, the agency failed to provide services as ordered in the plan of care (a comprehensive plan developed by nurses, social workers, chaplains, and medical directors that included the frequency of staff visits and interventions that guide the staff in providing patient care) for 2 (Patient #5 and Patient #15) of 16 sampled patients. An agency policy titled “Plan of Care HC.31,” revised 03/2025, revealed “Hospice services are delivered in accordance with the plan of care, which is developed collaboratively by the IDG [interdisciplinary group], the attending physician (if applicable), the patient or their representative, and the primary caregiver.”Patient #5’s “Plan of Care Order” dated 01/21/2025, revealed the agency admitted Patient #5 on 01/20/2025 with a terminal diagnosis of acute respiratory failure with hypoxia (an inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function). The Plan of Care Order revealed an order for a chaplain one time a month for the timeframe 01/20/2025 to 04/19/2025. According to the Plan of Care Order, the patient was seen on 01/23/2025 for anticipatory grief. There was no further evidence to indicate the patient was visited by the chaplain.Patient #15’s “Plan of Care Order” dated 04/20/2025, revealed the agency admitted Patient #15 on 04/16/2025 with a terminal diagnosis of malignant neoplasm of head pancreas. The plan of care ordered revealed an order for skilled nursing two times a week for 13 weeks. According to the Plan of Care Order, the patient was not provided two skilled nursing visits during the week of 04/27/2025. During an interview on 07/11/2025 at 1:05 PM, the Administrator stated the agency expected all staff visits would be delivered to patients as ordered by their patients as ordered by their physician. Per the Administrator, if the visits were not provided as ordered the agency did not follow their policy. The Administrator acknowledged the agency could not provide any additional documentation regarding skilled nursing visits for patient #15 during the week of 04/17/2025.”

“Based on observations, interview, and record review, the agency failed to follow accepted standards of practice to prevent the transmission of the infections and communicable disease for 1 (Patient #5) of sampled patients observed for a home visit. Patient #5’s “Plan of Care Order” dated 01/21/2025, revealed the agency admitted Patient #5 on 01/20/2025 with terminal diagnosis of acute respiratory failure with hypoxia (an inability of the respiratory system to maintain an adequate blood oxygen level to preserve normal organ function) During a home visit observation on 07/09/2025 at 10:36 AM, Registered Nurse (RN) #1 did not set up a barrier after she entered Patient # 5’s home. RN #1 was noted to place her tablet (small computer) directly on the arm of the patient’s couch with no barrier under the tablet. During an interview on 07/09/2025 at 11:08 AM, RN #1 stated she did not set up any barriers in the home and confirmed she placed her tablet directly on the arm of the patient’s couch. RN #1 stated that the agency expectation was any equipment brought into the patient’s home should be placed on a barrier. During an interview on 07/09/2025 at 11:05 AM, Patient #5’s Paid Caregiver stated RN #1 never set up a barrier when she provided care to the patient. During an interview on 07/09/2025 at 12:30 PM, the Administrator stated that when in a patient’s home, the agency expectation was staff should only place equipment down on a barrier. The administrator stated that when placed a tablet directly on the surface of furniture in patient #5’ s home they were not following the agency process.”

“Based on the interview, document reviews, and policy review, the agency failed to ensure that volunteers provided administrative or direct patient care services during 2024 and from January 2025 through July 11, 2025. This deficient practice had the potential to affect all patients receiving hospice services. The agency policy “Volunteer Services HC.13” (revised September 2024) stated that qualified volunteers should assist with the provision of hospice services.During an interview on July 10, 2025, at 2:45 PM, the Volunteer Coordinator (VC) confirmed the agency had no active volunteers or volunteer documentation for 2024 or 2025.A review of the “Volunteer Hour Report” confirmed that there were no recorded volunteer hours for 2024 or 2025.During an interview on July 11, 2025, at 1:05 p.m., the Administrator acknowledged that the agency was not meeting expectations regarding the provision of volunteer services.”

“Based on the interview, document review, and policy review, the agency failed to document volunteer hours and cost savings related to administrative or direct patient care services in 2024 and from January 2025 through July 11, 2025. This deficient practice had the potential to affect all patients served by the agency. An agency policy titled “Volunteer Services HC.13,” revised 09/2024, revealed, Medical Services of America Hospice ensure qualified volunteers are available to assist with the provision of hospice services to patients and their caregivers. Hospice volunteers provide day-to-day administrative or direct patient care services.During an interview on 07/10/2025 at 2:45 PM, the Volunteer Coordinator (VC) stated the agency’s expectation was volunteer services should be available to be provided to patients. The VC stated the agency she did not have volunteers to provide volunteers services, and she could not provide documentation of volunteers who provided administrative or patient care services in 2024 or from 01/2025 to 07/2025.The agency “Volunteer Hour Report,” revealed no evidence to indicate there were volunteers for 2024 and 2025.During an interview on 07/11/2025 at 1:05 PM, the Administrator stated the agency did not track any cost savings in 2024 and 2025 to date because there were no volunteers to provide the service and acknowledged the agency was not meeting expectations regarding the provision of volunteer services.”

“Based on the interview, document review, and policy review, the agency failed to ensure that volunteers provided administrative and/or direct patient care services equal to at least five percent of the total patient care hours for calendar year 2024 and from January 2025 through July 11, 2025. This deficient practice had the potential to affect all patients receiving services from the agency. Review of the agency policy “Volunteer Services HC.13” (revised September 2024) indicated that the agency ensures qualified volunteers are available to assist in providing hospice services.During an interview on July 10, 2025, at 2:45 PM, the VC stated that there were no volunteers available during 2024 or to date in 2025, and no documentation was available to show volunteer participation.A review of the “Volunteer Hour Report” confirmed that no volunteer hours were recorded for 2024 or 2025.During an interview on July 11, 2025, at 1:05 PM, the Administrator confirmed that the agency did not meet the five percent volunteer requirement due to the absence of volunteers in 2024 or 2025 to date, and acknowledged the agency was not meeting expectations regarding the provision of volunteer services.”

“Based on the interview, document review, and policy review, the agency failed to ensure that volunteers provided either administrative or direct patient care services during the calendar year 2024 and from January 2025 through July 11, 2025. This deficient practice had the potential to affect all patients receiving services from the agency. Review of the agency policy titled “Volunteer Services HC.13” (revised September 2024) stated that the agency “ensures qualified volunteers are available to assist with the provision of hospice services to patients and their caregivers. Hospice volunteers provide day-to-day administrative or direct patient care services.”During an interview on July 10, 2025, at 2:45 PM, the Volunteer Coordinator (VC) stated that volunteer services were expected to be available for patients; however, the agency did not have any volunteers providing services in 2024 or from January through July 2025. The VC was unable to provide documentation demonstrating volunteer participation in administrative or direct patient care activities.Review of the agency’s “Volunteer Hour Report” revealed no evidence of volunteer hours or activity for 2024 or 2025.During an interview on July 11, 2025, at 1:05 PM, the Administrator confirmed that the agency had no active volunteers as of 2025 to date and acknowledged that the agency was not meeting the regulatory expectations for volunteer service provision.”