Agape Care South Carolina II

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, observation, and interview. Agency policy #2-004 “Medication Profile,” stated in part, “A drug regimen review will be performed at the time of initial and comprehensive assessment when updates to the comprehensive assessments are performed when care is resumed, after a patient has been placed on hold, and with the addition of a new medication. The review will identify drug/food interactions, potential adverse effects, and drug reactions. The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy.” In 2 of 27 (7%) clinical records reviewed of community patients, the agency did not ensure that the medication profile was updated to document all medications and treatments for review for potential interactions and effectiveness of therapy. Clinical Record 2: The patient elected hospice care on 11/27/2023. The nursing assessment visit completed by the LPN (Licensed Practical Nurse) dated 03/08/2024 documented that peppermint oil and Aspercreme were working well for the patient’s joint pain and pain tolerance. The medication profile was not updated to include documentation of peppermint oil and Aspercreme. There was no evidence that peppermint oil and Aspercreme had been reviewed with the patient’s medication regimen. Clinical Record 3: The patient elected hospice care on 09/01/2023. The patient changed to a GIP (general inpatient care) level of care on 02/18/2024 for pain and nausea control. A peripheral IV (intravenous) was started in the right forearm. Morphine and Haldol were administered every 6 hours, and morphine was available hourly. Nurses documented flushing the IV but did not include documentation of the flush used. The medication profile was not updated to include the saline flush as of 12/03/2024. During an interview and a joint record review on 12/03/2024, the Director of Accreditation stated that the medication profiles were incomplete.”

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; [and} ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 8 (12%) clinical records reviewed of community patients with a wound, the agency did not ensure the continuous assessment of the patient’s needs and the implementation of the interdisciplinary plan of care. Clinical Record 15: The patient elected hospice care on 07/11/2024. On 07/22/2024, the physician ordered the Unna boot to be changed weekly, and on 8/28/2024, an additional weekly change of the Unna boot was ordered. The skilled nurse (SN) visit notes documented that the Unna boot was changed on 07/22/2024 and 08/06/2024, with 15 days outstanding; on 09/06/2024, with 5 weeks outstanding; on 09/24/2024, with 14 days outstanding; on 10/09/2024, with 14 days outstanding; on 10/22/2024, with 12 days outstanding; and on 11/12/2024, with 21 days outstanding. The patient’s legs were described as having no deterioration during this time period. A sacral wound was identified on 10/18/2024 with a physician’s orders for an Optifoam dressing change every three (3) days. The next documented dressing change was eleven (11) days later, on 10/29/2024, with no wound description, and on 11/19/2024, 21 days later, documenting the pressure area on the sacrum and no wound assessment. The plan of care ordered instruction for wound care, but the instruction or who was instructed was not documented in the record. During an interview, the nurse stated that the family was changing the dressing, but that had not been documented. Documentation of the wounds did not include wound measurements, a description of the wound, or the implementation of care for the every 3-day dressing change. The wound did not deteriorate during this time period, as reported during an interview with the case manager, During the interviews on 12/04/2024 and 12/05/2024, the Director of Accreditation and the Nursing Supervisor of the office who interviewed the nurse confirmed that the documentation regarding frequency and wound description was not clear.”

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. Includes all services necessary for the palliation and management of the terminal illness, including the following: drugs and treatment necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #9-017, “The Interdisciplinary Plan of Care,” stated in part, “The written plan of care will contain, but will not be limited to, the following: individualized interventions to assist with end-of-life care.” In 4 of 27 (15%) clinical records reviewed of community patients, the agency did not ensure that the plan of care documented drugs and treatment necessary to meet the needs of the patient. Clinical Record 2: The patient elected hospice care on 11/27/2023. The nursing assessment visit completed by the LPN (Licensed Practical Nurse) on 03/08/2024 documented that peppermint oil and Aspercreme were working well for the patient’s joint pain and pain tolerance. As of 12/02/2024, the plan of care did not include documentation of peppermint oil and Aspercreme. Clinical Record 3: The patient elected hospice care on 09/01/2023. The patient changed to a GIP (general inpatient care) level of care on 02/18/2024 for pain and nausea control. A peripheral IV (intravenous) was started in the right forearm. Morphine and Haldol were administered every 6 hours, and morphine was available hourly. Nurses documented flushing the IV but did not include documentation of the flush used. The plan of care was not updated to include the saline flush. During an interview on 12/02/2024, the in-patient staff stated that the flush would have been saline. Clinical Record 11: The patient elected hospice care on 10/26/2024. The initial comprehensive assessment dated 10/26/2024 and follow-up assessment dated 10/27/2024 documented the patient’s 14 (fr) French Foley catheter to be changed every four (4) weeks. The initial plan of care dated 10/26/2024 did not include documentation of an intervention for the Foley catheter. A coordination note completed by the Registered Nurse (RN) on the evening of 11/04/2023 documented the patient’s daughter was instructed on how to apply a condom catheter, and further orders were documented for the condom catheter. The updated plans of care did not document interventions for a condom catheter. The nursing assessment dated 12/02/2024 documented that the Foley catheter had been changed on 12/02/2024 with a 14-french catheter, but the updated plan of care did not document interventions for the catheter. Clinical Record 15: The patient elected hospice care on 07/11/2024. The initial comprehensive assessment dated 0711/2024 documented that the patient’s Unna boots were intact on the lower extremities and were to be changed weekly. The initial plan of care dated 07/11/2024 did not document specific interventions for wound care. On 08/20/2024, the updated nursing assessment documented a sacral pressure area with an Optifoam dressing started. The documented interventions for wounds were to provide wound care per order and to instruct in performing wound care. The plan of care did not document interventions that included the details of the wound care. During an interview and a joint record review on 12/05/2024, the Director of Accreditation stated that the medications and interventions were updated.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy #7-011, “Hand Hygiene,” stated in part, “Hand decontamination using an alcohol-based hand rub should be performed before having direct contact with patients.” In 1 of 6 (17%) home visits observed of care in the community setting, the agency did not ensure that hand hygiene was performed when indicated per the agency’s policy. Home Visit 1: During the home visit with the Social Worker (SW) [Personnel Record 13] on 12/02/2024, the SW did not decontaminate their hands before direct contact with the patient, specifically rubbing the patient on the back. During an interview on 12/06/2024, the agency’s Director of Accreditation stated that the SW was retrained on hand hygiene procedures on 12/03/2024.”

“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 an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review, observation, and interview. In 7 of 29 (24%) clinical records reviewed in which a Hospice Aide (HHA) was accepted, the agency did not ensure that the Registered Nurse prepared a HHA plan of care that contained clear and specific instructions to meet the patient’s needs. Clinical Record 2/Home Visit 2: The patient elected hospice care on 11/27/2023 and resided in a skilled nursing facility (SNF). The HHA care plan dated 11/27/2023 and the updated HHA care plans assigned the HHA the relevant task: transfer with assistance. During the home visit with the Certified Nursing Assistant (CNA) [Personnel Record 11] on 12/02/2024, the patient had a Hoyer lift in the bathroom. During an interview, the CNA stated the family did not want to use it, yet the patient was transferred with one person’s assistance. On admission, the patient took a shower. On 07/17/2024, a bed bath was assigned as the patient could not tolerate the activity and transfer. The skilled nursing (SN) visit notes documented that maximum and medium assistance was needed. The HHA care plan did not provide the HHA with clear instructions for the transfer with assistance. During the interview and observation, the HHA demonstrated they were competent to transfer the patient. Clinical Record 3: The patient elected hospice care on 09/01/2023 and resided in a SNF. The HHA care plan dated 09/01/2023 and updated 09/07/2023 and 11/27/2023 with no further updates as of 12/03/2024 assigned the HHA the relevant task: bath/shower every visit. The patient’s ordered activity for every visit was bedbound. The HHA care plans provided no instructions or direction for assistance to transfer the patient to the shower. The hospice Face-to-Face dated 02/10/2024, 06/11/2024, 08/06/2024, and 10/10/2024 documented that the patient was no longer able to get up and to transfer using a Hoyer lift. The HHA care plan was not updated to include using a Hoyer lift for transfers as of 12/03/2024. Clinical Record 11: The patient elected hospice care on 10/26/2024. The HHA care plan dated 10/26/2024 and updated 10/29/2024 assigned the HHA the relevant task: perineal care every visit. The updated nursing comprehensive assessment dated 11/01/2024 documented that the patient had a Foley catheter. The HHA care plan did not provide the HHA with instructions for caring for the Foley catheter during personal care. The HHA care plan was updated on 12/06/2024 to include catheter care. Clinical Record 15: The patient elected hospice care on 07/11/2024. The HHA care plan dated 07/12/2024 with no documented updates as of 12/02/2024 assigned the HHA the relevant task: sponge bath each visit. The plan of care ordered HHA services five (5) times a week. The initial comprehensive assessment documented Unna boots on the patient’s lower extremities. On 08/20/2024, the updated nursing assessment documented a sacral decubitus ulcer with wound care ordered to include an Optifoam dressing. The HHA care plan was not updated to include the wounds and instructions should the dressings become dislodged or saturated during the bath. As of 12/03/2024, all wounds were still in place. Clinical Record 16: The patient elected hospice care on 11/06/2024. The HHA care plan dated 11/07/2024, with no documented updates, assigned the HHA the relevant task: bed bath every visit. The initial nursing comprehensive assessment dated 11/06/2024 documented the patient’s gastrostomy tube (G-tube) with a dressing and G-tube feedings six (6) times a day, which the family provided. The HHA care plan did not document instructions for the care of the G-tube or what to do if the dressing became saturated or dislodged during the care. Clinical Record 18: The patient elected hospice care on 08/19/2024. The HHA care plan dated 08/19/2024 with no documented updates as of 12/04/2024 assigned the HHA the relevant task: shower every visit and empty the drainage bag every visit. The plan of care ordered HHA services three (3) times a week. The patient was admitted with a colostomy and a pressure area on the buttocks that required a daily dressing. The HHA care plan did not include documentation of instructions for the dressing and colostomy during the shower if the ostomy bag or the dressing became dislodged, wet, or soiled. The wound dressing was discontinued on 09/23/2024 as the wounds had healed. Clinical Record 30: The patient elected hospice care on 10/10/2024. The HHA care plan dated 10/10/2024 and updated on 11/20/2024 for care assigned the HHA the relevant task: bathing every visit and showering every visit, with the patient as the decision maker. The patient was oriented and capable of making decisions. The initial nursing comprehensive assessment documented an Aspira drain in the right breast with a dressing. The patient was a resident of the agency’s inpatient unit (IPU) for routine and general inpatient (GIP) care. The bath provided during visits was a bed bath during visits. The HHA care plan provided no instructions for caring for the Aspira drain and dressing during bathing or showering should the dressing become wet or dislodged. During the interview on 12/05/2024, the Director of Accreditation confirmed the findings, and the aide care plans were updated with the specific care for the patients identified.”

“It is required that the clinical patient record, its content, and the information it contains is safeguarded against loss or unauthorized use and must be in compliance with the Department’s rules regarding personal health information as set out at 45 CFR parts 160 and 164. The hospice addresses: leaving and protecting patient record information in the home; prevention of physical or electronic altering of the patient record. The hospice complies with state and federal law and regulation addressing privacy, including the Health Insurance and Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). This standard was not met as evidenced by document review and interview. Agency policy #6-006, “Protected Health Information/ Individually Identifiable Health Information,” stated in part, “Information designated as Protected Health Information/Individually Identifiable Health Information (PHI/IIHI), whether written, electronic or oral, will be protected from unauthorized access and disclosure, both intentional and unintentional, by all reasonable means and accepted business practices.” Agency policy #6-036, “Encryption of Confidential Data Over the Internet,” stated in part, “Information classified as confidential must be encrypted, following Hospice standards, when transmitted over the internet or another open, public network.” The agency did not ensure that the patient’s clinical record information and content were safeguarded against loss or unauthorized use. During an interview on 12/02/2024, the Volunteer Coordinator (VC) [Personnel Record 9] stated that volunteers had sent volunteer progress notes containing patient information, including patient names, to the VC using their personal email or a non-secure text. The VC stated the volunteers were educated at orientation and after an occurrence that this was inappropriate and that the agency was instituting an electronic note-filing system. The VC stated that not all volunteers currently use this system. An email dated 09/06/2024 from an agency volunteer who used their Gmail account and sent it to the VC was reviewed. The email included the full names (first and last) of three separate agency patients, those patients’ specific buildings within their residential facility, and their room numbers within those buildings. During an interview on 12/03/2024, the agency’s Director of Compliance stated that the agency was supplying all agency volunteers with agency-internal emails and phone numbers, but that was not entirely in place. In an interview on 12/06/2024, the Director of Accreditation stated that the agency’s secure transmission of protected patient information by volunteers is a current performance improvement project.”