Pruitthealth Hospice- Columbia

“Based on observations, interviews, and record reviews, the agency failed to follow accepted infection control prevention for 2 of 4 home patients reviewed (Pt. #3 and #2). The findings included:Review on 8/7/25 at 2:00 PM of Pt. #3s “ Plan Of care (POC),” dated 7/15/2025, revealed the agency admitted Patient #3 with diagnoses that included Alzheimer disease late onset (most common cause of late onset dementia and is most often characterized by problems with short-term and long-term memory) , depression, bradycardia (a condition where the heart beats fewer that 60 times per minute), hepatic encephalopathy (a conditions that occurs when the liver is unable to filter toxins from the blood). Additional review revealed Patient #3 was incontinent of bowel and bladder (problems with controlling the release of urine and stool) and was non-verbal (not involving or using words).During a concurrent observation and interview conducted in Patient #3’s bedroom on 8/7/2025 at 9:50 AM, Registered Nurse (RN) #1 placed his/her tablet directly on top of a dresser in the room without a barrier (a material that was intended to block or stop movement or access). RN #1 then moved the tablet and placed it on a second dresser without a barrier. RN #1 stated the agency expected staff to place a barrier between patient furniture surfaces and tablets, confirmed she/he had not placed a barrier between tablet and furniture surfaces in the room, andacknowledged she/he did not follow agency practice. Review on 8/7/25 at 3:00 PM of Pt. #2’s “POC,” dated 7/23/2025, revealed the agency admitted Pt. #2 with diagnoses that included Alzheimer’s Disease, unspecified (a classification of Alzheimer’s disease when there is no clear identification or the type of Alzheimer’s), moderate protein-calorie malnutrition (a condition resulting from an inadequate intake of calories with insufficient protein), schizoaffective disorder, mixed hyperlipidemia (elevated levels of fat in the blood) and dysphagia (difficulty swallowing).During a concurrent observation and interview conducted in the facility memory unit’s common area on 8/7/2025 at 10:55 AM, Social Worker (SW) #1 placed his/her personal bag on the table without a barrier. SW #1 stated that she/he was not aware of any guidelines for social workers and the use of barriers.On 8/8/2025 at 11:38 AM, the Director of Health Services (DHS) stated the agency expected staff to use barriers for tablets and any equipment while in patients home. A policy regarding use of barriers was requested, but not provided.On 08/08/25 at 1:00 PM, the Administrator confirmed barriers are required when equipment, including tablets are placed on furniture in patients home. Equipment should be sanitized before leaving a patient’s home.”

“Based on record reviews, staff interview, and review of agency personnel files, the agency failed to ensure nursing staff conducted and documented supervision of hospice aides (HA) for 2 of the 19 patient clinical records reviewed. The findings included: On 08/07/2025 at 10:00 AM, a review of patient #10’s medical record revealed no hospice aide supervisory visits were made between 06/22/2025-07/31/2025. A review of patient #12 medical record revealed no HA supervisory visits were made between 07/15/2025 – 08/06/2025. On 08/08/2025 at 11:28 AM, the Director of Health Services (DHS) #1 of the primary location stated that his/her role included supervision of nurses and HA. DHS #1 states that the Registered Nurses (RN)s conduct supervisory visits over the HA every 14 days, but he/she prefers that they are completed weekly. DHS #1 also stated that RNs are educated upon hire and annually, and scheduled reminders are in the patient’s medical record on HA supervisory visits. On 08/08/2025 at 11:45 AM, Administrator (ADM) #2 was interviewed. ADM #2 was introduced as the former DHS and current ADM of location #2. ADM #2 states that the minimum time frame for HA supervisory visits are done every fourteen days, but he/she prefers they are done weekly. ADM #2 serves as navigator and verified findings in patient medical record #10 and #12.”

“Based on agency document reviews and interviews, the agency’s primary location, location #2, and location #3, functioned independently of each other; each office employed an administrator who supervised their own staff and their own administrative functions. Findings included: On 08/07/2025 at 9:40 AM, a review of “PruittHealth Hospice Organizational (Org) C Chart” (Org #1), dated 4/3/2025 and “PruittHealth Hospice and Palliative Care”, provided 08/07/2025, (Org #2), revealed the primary location, location #2, and location #3 each employed their own Administrator (ADM). On 08/07/2025 at 9:47 AM, the Area Vice President (AVP) stated that all three offices each have their own ADM and verified that all three ADMs report directly to the AVP, as shown in the organizational chart. On 08/07/2025 at 10:25 AM, Director of Health Services (DHS) #1, DHS #2, and DHS #3 revealed they each have the same role and carry out the same functions, each in their location. On 08/07/2025 at 11:28 AM, ADM #2 stated that he/she reports directly to the AVP. During that same interview, ADM # 3 revealed he/she also reports directly to the AVP. On 08/07/2025 at 11:34 AM, during an interview with Bereavement Coordinator (BC) #1, BC #2, and BC #3; each stated that they each supervise/coordinate the bereavement process for their own location. On 08/07/2025 at 12:11 PM, Volunteer Coordinator (VC) #1, VC#2, and VC #3; each stated they each supervise, coordinate, recruit, and collect data for volunteer services at their separate locations. On 08/08/2025 at 10:30 AM, a review of agency personnel files revealed ADM #1, ADM #2, and ADM #3 have nearly identical job duties and functions. On 08/08/2025 at 1:30 PM, ADM #1 stated she/he is aware that all three ADMs have the same job description.”

“Based on agency document review and interview, the hospice failed to clearly define the authority and roles of the Primary location, in relation to locations #2 and locations #3; branches of the Primary location. Findings included: On 08/07/2025 at 09:40 AM, a review of Organizational (Org) Charts #1 and #2 revealed that the primary location, location #1, and location #2 functioned as separate agencies with separate Administrators (ADM)s, of each location, who reported directly to Area Vice President (AVP). On 08/07/2025 at 9:47AM, the AVP verified that all three ADMs of the Primary and branch locations, report directly to him/her, as shown in the org chart.”

“Based on agency document review and interviews, the hospice failed to ensure there was only one Physician Medical Director responsible for the medical component of the hospice program. Findings included:On 08/07/2025 at 12:30 PM, a review of “Hospice Medical Director Agreements” revealed there was one Physician Medical Directors (PMD) for the Primary location and a different PMD for the two branch locations. On 08/08/2025 at 10:00 AM, Administrator (ADM) #1 verified findings of two PMDs. On 08/08/2025 at 10:57 AM, PMD #1 stated that his/her official title was Medical Director, at the hospice’s Primary office in Columbia, and he/she never provided physician services at the agencies branch offices. On 08/08/2025 at 12:26 PM, PMD #2 stated that his/her official title is Medical Director at the hospice’s two branch locations, and he/she has never provided physician services at the hospice’s Primary location.”