Embrace Hospice of South Carolina, LLC

“Based on interview and document review, the facility failed to ensure a hospice facility interdisciplinary group met the psychosocial, emotional, and spiritual needs for 18 of 18 patients; develop a plan of care that included outcomes for 18 of 18 patients; provide social work services that met the psychosocial and emotional needs for 18 of 18 patients; develop an interdisciplinary group plan of care and implement a program to provide bereavement services; assess the patients’ spiritual needs and provide counseling services to meet the spiritual needs for 18 of 18 patients; and provide social services, spiritual counseling, and bereavement services to meet the psychosocial, emotional, and spiritual needs for 18 of 18 patients. Findings included: Refer to deficiencies cited at L539, L548, L594, L596, L598, and L652.”

“Based on interview and document review, the facility failed to complete an initial comprehensive assessment (an assessment completed within five days of a patient’s admission to the hospice that identified the patient’s physical, social, spiritual, and cultural needs that might impact the patient’s wellbeing while dying) for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. The ED stated the facility did not complete a comprehensive assessment on any of their patients because the CRHs completed that assessment on their patients. According to the ED, the facility had not submitted any Medicare billing since 2018.During a follow-up interview on 06/27/2025 at 3:15 PM, the ED stated the facility staff did not complete comprehensive assessments on any facility patients, based on the facility’s business model.On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of a comprehensive assessment for the patients in the facility and the facility provided no evidence to indicate they completed a comprehensive assessment of any of the patients in the facility.”

“Based on interview and document review, the facility failed to complete an initial bereavement assessment (an assessment completed within five days of the patient’s admission to the hospice of the needs of the patient’s family and other individuals focused on the social, spiritual, and cultural factors that might impact their ability to cope) for the family members of 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. The ED stated the facility did not complete a bereavement assessment on any of their patients because the CRHs completed that assessment on their patients. According to the ED, the facility had not submitted any Medicare billing since 2018.During a follow-up interview on 06/27/2025 at 3:15 PM, the ED stated the facility staff did not provide any bereavement services to patients, to include the completion of an initial bereavement assessment, based on the facility’s business model. On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of an initial bereavement assessment for the patients in the facility. The facility provided no evidence to indicate they completed an initial bereavement assessment of any of the patients in the facility.”

“Based on interview and document review, the facility failed to complete an initial comprehensive assessment (an assessment completed within five days of a patient’s admission to the hospice that identified the patient’s physical, social, spiritual, and cultural needs that might impact the patient’s wellbeing while dying) that included data designed to measure how the care provided helped the patient for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. The ED stated the facility did not complete a comprehensive assessment on any of their patients because the CRHs completed that assessment on their patients. According to the ED, the facility had not submitted any Medicare billing since 2018.During a follow-up interview on 06/27/2025 at 3:15 PM, the ED stated the facility staff did not complete comprehensive assessments on any facility patients, based on the facility’s business model.On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of a comprehensive assessment for the patients in the facility and the facility provided no evidence to indicate they completed a comprehensive assessment of any of the patients in the facility.”

“Based on interview and document review, the facility failed to ensure their interdisciplinary group (a team that included different professionals and disciplines that worked together to provide the best possible care for patients and their families) met the psychosocial, emotional, and spiritual needs for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. The ED stated the facility staff and medical director met every 14 days to conduct what were “essentially case management meetings.” According to the ED, the facility had not submitted any Medicare billing since 2018.During an interview on 06/26/2025 at 12:40 PM, the Chaplain stated he had never participated in a facility interdisciplinary group meeting. During an interview conducted on 06/26/2025 at 2:30 PM, Registered Nurse (RN) #1 stated that when the facility admitted a patient, the CRH developed and managed the patient’s plan of care for the patient while they were in the facility. RN #1 stated the facility staff met to develop and update a nursing plan of care, but this plan of care did not include any psychosocial or spiritual goals and interventions, as those needs were managed and provided by the CRH staff.During an interview on 06/27/2025 at 9:15 AM, the Social Worker stated she had never attended an interdisciplinary group meeting at the facility.During an interview conducted on 06/27/2025 at 3:28 PM, the ED stated the facility’s interdisciplinary group discussed any identified spiritual or psychosocial needs a patient might have and shared that information with the CRH staff to follow up. The ED stated the facility did assist the referring hospice when requested with chaplain or social work services but did not manage the patient’s plan of care per the facility’s business model.On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of their interdisciplinary group meeting for patients in the facility and the facility provided no evidence to indicate their interdisciplinary group met to discuss the psychosocial and spiritual needs of any of the patients in the facility.”

“Based on interview and document review, the facility failed to provide patients and family members education and training related to the patients’ plans of care (a comprehensive plan developed to provide care to meet the physical, psychosocial, emotional, and spiritual needs of the patient that included goals and interventions) for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. According to the ED, the facility had not submitted any Medicare billing since 2018. The ED stated the patients’ CRHs developed, updated, and maintained their patients’ plans of care. During an interview on 06/26/2025 at 2:30 PM, Registered Nurse #1 stated that when a patient was admitted to the facility, the CRH managed the patient’s plan of care for the patient while they were in the facility. During a follow-up interview on 06/27/2025 at 3:28 PM, the ED stated the facility did not provide training to the patient or family related to the patient’s plan of care developed by the CRH per their business model. On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of plan of care training to the patients and/or the patients’ family members in the facility and the facility provided no evidence to indicate they provided training to the patients and/or the patients’ family member regarding the patients’ plan of care.”

“Based on interview and document review, the facility failed to develop a plan of care (a comprehensive plan developed to provide care to meet the physical, psychosocial, emotional, and spiritual needs of the patient that included goals and interventions) that included outcomes for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. According to the ED, the facility had not submitted any Medicare billing since 2018. The ED stated the patients’ CRHs developed, updated, and maintained their patients’ plans of care. During an interview on 06/26/2025 at 2:30 PM, Registered Nurse #1 stated that when a patient was admitted to the facility, the CRH managed the patient’s plan of care for the patient while they were in the facility. During a follow-up interview on 06/27/2025 at 3:28 PM, the ED stated the facility did not document or track measurable outcomes in a patient’s hospice plan of care, based on their business model.On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation to show how they documented or tracked outcome data in the patients’ plans of care and the facility provided no evidence to indicate they provided these services to any of the patients in the facility.”

“Based on interview and document review, the facility failed to provide social work services that met the psychosocial and emotional needs for 18 of 18 patients. Findings included:The facility inpatient unit care agreement with CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024, revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. According to the ED, the facility had not submitted any Medicare billing since 2018. The ED stated the CRHs provided all social work services for their own patients residing at the facility (for “residential,” inpatient or respite stays). The ED stated the facility employed one social worker on site, but that individual’s primary responsibilities were to coordinate admission of referred patients to the facility and the coordination of services between the facility and the CRH. Per the ED, if a patient required social work services, the facility staff notified the patient’s social worker at the CRH, who would then address the patient’s needs.During an interview on 06/27/2025 at 9:15 AM, the Social Worker stated she occasionally assisted the facility’s patients fill out paperwork and communicated with the CRH’s social workers, but the CRH’s social workers developed and implemented the patients’ plans of care. On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of how they provided social work services to meet the psychosocial needs of patients in the facility and the facility provided no evidence to indicate they provided these services to any of the patients in the facility.”

“Based on interview and document review, the facility failed to develop and implement a program to provide bereavement services. Findings included:The facility inpatient unit care agreement with CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024, revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. The ED stated the facility did not provide bereavement services to any of their patients; the CRHs provided all bereavement services to their patients admitted to the facility. According to the ED, the facility had not submitted any Medicare billing since 2018.During an interview on 06/27/2025 at 3:19 PM, the Administrator stated the facility did not provide any bereavement services to patients, to include the completion of an initial bereavement assessment, based on the facility’s business model.During a follow-up interview on 06/27/2025 at 3:36 PM, the ED stated the facility did not provide bereavement services. On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of their bereavement program and how they provided bereavement services to the families of the patients who received care in the facility and the facility provided no evidence to indicate they provided bereavement services to any families of patients who received care in the facility.”

“Based on interview and document review, the facility failed to assess patients’ spiritual needs and provide counseling to meet the spiritual needs for 18 of 18 patients. Findings included:The facility inpatient unit care agreement with CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024, revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. According to the ED, the facility had not submitted any Medicare billing since 2018.The ED stated the facility did not provide chaplain (spiritual counseling) services because the patients’ CRHs provided chaplain services to their patients. During an interview on 06/26/2025 at 12:40 PM, the Chaplain stated he did not provide chaplain services to the facility’s patients unless the patient had been referred to the facility by the CRH that employed him.During a follow-up interview on 06/27/2025 at 3:28 PM, the ED stated the facility did not provide chaplain services to the facility’s patients, based on their business model.On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of how they assessed and provided for the spiritual needs of patients in the facility and the facility provided no evidence to indicate they provided these services to any of the patients in the facility.”

“Based on interview and document review, the facility failed to provide social services, spiritual counseling, and bereavement services to meet the psychosocial, emotional, and spiritual needs for 18 of 18 patients. Findings included:Review of the facility inpatient unit care agreements with contracted referring hospices (CRH’s) on 06/24/25 revealed the CRH staff were expected to provide care to patients and families as they would for any other patient who received such services. The contracts were as follows: CRH #1 dated 02/01/2022, CRH #2 dated 07/20/2024, CRH #3 dated 08/01/2024, CRH #4 dated 07/01/2022, CRH #5 dated 11/11/2024, CRH #6 dated 02/11/2022, CRH #7 dated 04/15/2022, CRH #8 dated 05/13/2025, CRH #9 dated 05/23/2024, CRH #10 dated 02/14/2020, CRH #11 dated 10/19/2023, CRH #12 dated 04/29/2025, and CRH dated 08/08/2024.During an interview on 06/24/2025 at 12:50 PM, the Executive Director (ED) stated the facility functioned as a community hospice, other hospices sent their patients to the facility for inpatient care, the facility did not directly admit hospice patients, and the facility beds were “contracted to community hospices.” The ED stated the contracted referring hospices (CRHs) signed a contract with the facility, and the facility invoiced the CRHs for care provided to their patients while in the facility. According to the ED, the facility had not submitted any Medicare billing since 2018.The ED stated the facility did not provide chaplain (spiritual counseling) services because the patients’ CRHs provided chaplain services to their patients. The ED stated the CRHs provided all social work services for their own patients after the facility admitted the patient. The ED stated the facility employed one social worker on site, but that individual’s primary responsibilities were to coordinate admission of referred patients to the facility and the coordination of services between the facility and the CRH. Per the ED, if a patient required social work services, the facility staff notified the patient’s social worker at the CRH, who would then address the patient’s needs.During an interview on 06/26/2025 at 12:40 PM, the Chaplain stated he did not provide chaplain services to the facility’s patients unless the patient had been referred to the facility by the CRH that employed him.During an interview on 06/27/2025 at 9:15 AM, the Social Worker stated she occasionally assisted the facility’s patients fill out paperwork and communicated with the CRH’s social workers, but the CRH’s social workers developed and implemented the patients’ plans of care. During a follow-up interview on 06/27/2025 at 3:28 PM, the ED stated the facility did not provide chaplain services to the facility’s patients, based on their business model. On 06/27/2025 at 4:00 PM, the facility was asked to provide documentation of how they provided social work and chaplain services to the patients, documentation of a bereavement program, and the provision of bereavement services to families of the patients who received care in the facility and the facility provided no evidence to indicate they provided these services to any of the patients in the facility.”