Agape Hospice of the Lowcountry

“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. THIS IS A CONTINUING REQUIRED ACTION This standard was not met as evidenced by clinical record review and interview. In 1 of 11 (9%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 8: The patient elected the hospice benefit on 05/15/2025 with a primary diagnosis of senile degeneration of the brain. The plan of care dated 05/15/2025 documented the intervention “Instruction regarding insulin administration” and the goal “Demonstrate appropriate knowledge of insulin administration.” This was documented on all of the plans of care (that had been updated every two weeks) as of this review on 06/24/2025. The patient had the medication Lantus insulin on 05/01/2025, which was discontinued on 05/01/2025 as historical. The patient was not on any insulin or injections during the record review time period. The interventions that were documented for endocrine monitoring were incorrect for insulin and insulin administration. During an interview on 06/25/2025, the Director of Quality stated that the patient was not on insulin and that the interventions had not been changed for the patient.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. THIS IS A CONTINUED REQUIRED ACTION. This standard was not reviewed as this agency currently had two months of patient care hours for review. Previous Evidence: It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services that equaled or exceeded 5% of patient care hours. The agency’s “Volunteer Program Activity Report” documented that the average percentage for volunteer cost savings (eligible volunteer hours as a percentage of total patient care hours) in 2024 was 1.88%. This included the following percentages by quarter in 2024: Quarter 1 (Q1) - 1.10%; Q2 - 1.69%; Q3 - 2.12%; and Q4 - 2.13%. The same report included the following monthly updates for Q1 of 2025: January 2025 - 3.74%; February 2025 - 3.45%; and March 2025 - 4.16%. The same report included documentation of a performance improvement project (PIP) focused on increasing volunteer cost savings that was instituted in January 2025. During an interview on 05/12/2025, the Volunteer Coordinator (VC) stated that the agency has not been able to accrue volunteer hours in direct patient care or day-to-day administrative services, so they total at least 5% of total patient care hours. The VC stated that they have been unable to do so since COVID waivers were lifted. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services that equaled or exceeded 5% of patient care hours. THIS IS A CONTINUED REQUIRED ACTION. The agency’s “Volunteer Program Activity Report” documented that the average percentage for volunteer cost savings (eligible volunteer hours as a percentage of total patient care hours) in 2025 so far in May and June was 3.50% The report included all recruitment and orientation opportunities and efforts made in the various locations during the month. The PIP (process improvement plan) continues to be in action.”

“It is required that a clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION was not met as evidenced by a review of clinical records and interviews with the Clinical Director, which revealed the hospice: Failed to ensure that the patient’s clinical record included physician orders for care and services in 3 of 27 (11%) hospice homecare clinical records reviewed [HSIM.3.I/L678/ 418.104(a)(7). The cumulative effect of these systemic problems resulted in the hospice agency’s inability to ensure the provision of quality health care in a safe environment for the condition of participation CFR 418.104: Clinical Records. The deficient practice illustrated systemic process failures that had the potential to affect all patients cared for by the agency.”

“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. This standard was not met as evidenced by clinical record review and interview. In 4 of 31 (13%) clinical records reviewed, the agency did not ensure that the written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected the hospice benefit on 04/21/2025 with a diagnosis of chronic systolic congestive heart failure. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 04/21/2025, documented “pain 7/10, aching in the abdomen.” On 04/22/2025, the RN documented “pain 7/10.” On 04/23/2025, the RN documented “pain 8/10.” The plan of care dated 04/21/2025 had no goals for the patient’s pain. During the joint record review of the record and interview on 05/13/2025, the Clinical Director confirmed that pain interventions did not include goals. Clinical Record 4: The patient elected the hospice benefit on 06/05/2024 with chronic diastolic congestive heart failure. The visit notes dated 04/03/20205, 04/05/20205, 04/07/20205, and 04/10/2025, completed by multiple staff members, including the RN, triage RN’s and Chaplain (SC) documented that the patient had feelings of anxiousness, feelings of restlessness, fear, scared, and frustration. The patient’s plan of care dated 04/09/2025 did not include documentation of planned interventions for the patient’s anxiety. Clinical Record 5: The patient elected the hospice benefit on 07/06/2024 with a diagnosis of pulmonary fibrosis. The certification of terminal illness (CTI) dated 02/04/2025 documented the patient’s “increased dyspnea and anxiety.” The patient is on 6L of oxygen and requires frequent rest periods with exertion. The RN visit note dated 03/03/2025 documented, “dyspnea score of 4, anxiety score of 3”...” patient becomes short of breath when transferring to bedside commode.” The RN visit note dated 03/11/2025 documented, “dyspnea score 4, anxiety score 4”... “patient is becoming short of breath when making her way to sitting on the edge of the bed. Patient will use the rest of her energy to make it to the commode and has no reserve left after completing her toileting regimen to return to bed.” The RN visit note dated 03/14/2025 documented, “dyspnea score of 3, anxiety score of 3.” The RN visit noted dated 03/17/2025 documented, “declining energy endurance as evidence by finding the patient sitting on the edge of the bed trying to get to her commode, she must lay back down and returns to baseline within 5 minutes of resting.” The patient’s plans of care for the certification period dated 03/03/2025 through 05/01/2025 did not include documentation of planned interventions for the patient’s identified problems with dyspnea and anxiety. During the joint record review and interview on 05/13/2025, the Clinical Director confirmed that no interventions for dyspnea and anxiety were included in the patient’s plans of care. Clinical Record 29: The patient was admitted to the hospice inpatient unit on 05/06/2025. The plan of care dated 05/06/2025 ordered the skilled nurse (SN)/caregiver (CG) to perform wound care to the unstageable wound on the patient’s sacrum, “utilizing clean technique cleanse with wound cleaner, pat dry, apply Dakins solution-soaked gauze, cover with abd, secure with tape, change every 2-4/days and prn if soiled or dislodged. Instruct caregiver in wound care.” The plan of care did not include documentation of goal(s) for wound care. During a joint record review and interview, the Clinical Director agreed that there were no goals for wound care on the plan of care dated 05/06/2025”

“It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, interview, and observation. In 3 of 31 (13%) clinical records reviewed and home visits observed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 05/03/2025 with a diagnosis of malignant neoplasm of the colon. During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 05/13/2025, the RN completed an assessment of the patient, documenting that the patient’s pain was 8/10. The patient had a fungating abdominal tumor and had frequent pain issues. The patient described the pain as sharp and constant. The son stated that the patient had her as-needed Norco at 8 am. The RN administered the patient’s morphine 0.25ml for pain during the visit. The plan of care dated 05/03/2025 documented, “Intervention: Evaluated effectiveness of pain control measures. Goal: Pt/cg will verbalize satisfaction with the level of pain management.” The patient’s plan of care did not include documentation of a goal for pain with a measurable outcome. During a joint review of the clinical record and interview with the clinical director on 05/12/2025, she agreed that the documented goal was not an appropriate measurable goal for the problem identified. Clinical Record 7: The patient elected the hospice benefit on 02/08/2025 with a diagnosis of chronic obstructive pulmonary disease. The plan of care dated 02/08/2025 documented the problem: “Need for assessment of effectiveness of cardiopulmonary measures” with the goal: “Patient exhibits reduction/relief of any cardiopulmonary symptoms.” The goal did not include a measurable outcome. During a joint review of the clinical record and interview on 05/13/2025, the Clinical Director agreed that the documented goal for the problem identified was not measurable. Clinical Record 8: The patient elected the hospice benefit on 02/15/2025 with a diagnosis of multiple myeloma. The patient had bilateral Aspira drains and used oxygen continuously at 4 liters per minute (LPM). The RN assessments dated 02/15/2025, 02/25/2025, and 05/06/2025 documented that the patient had dyspnea at rest and on exertion. The plans of care for the certification period dated 02/15/2025 through 05/15/2025 documented the patient’s goal: “Symptoms of respiratory infection will be controlled or reduced as evidenced by freedom from respiratory distress.” The goal did not include a measurable outcome. During a joint review of the clinical record and interview on 05/12/2025, the Clinical Director agreed that the documented goal for the identified problem was not an appropriate one.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by clinical record review, interview, and document review. Agency policy #1-022 stated in part, “Hospice will provide bereavement services for up to one (1) year after the patient’s death to the surviving family/caregiver member...After the death occurs, the Hospice Social Worker, Bereavement Coordinator, or designee will complete the bereavement follow-up assessment...The Bereavement Coordinator, or designee, will develop a plan for intervention based on the findings of the bereavement follow-up assessment...The Bereavement Coordinator, designee or volunteer will document the family bereavement interventions... Upon completion of all bereavement services, documentation will be maintained...” In 1 of 4 (25%) clinical records reviewed of patients who accepted bereavement services, the agency did not ensure that bereavement services were provided or available to the patient’s family. Clinical Record 26: The patient elected the hospice benefit on 09/10/2024 with a diagnosis of senile degeneration of the brain and expired at home on 02/25/2025. A clinical record review revealed the patient accepted bereavement services, and a bereavement plan of care was completed on 01/05/2025. However, there was no evidence of bereavement activity or follow-up for this patient’s surviving family/caregiver members following the death of the patient as of 05/15/2025. During the joint review of the clinical record on 05/15/2025, the Clinical Director confirmed that there was no evidence of bereavement activity or follow-up for this patient’s surviving family/caregiver members. Policy No. 1-022 states in part, “Hospice will provide bereavement services for up to one (1) year after the patient’s death to the surviving family/caregiver member.””

“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 a 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 2 of 27 (7%) home hospice care clinical records reviewed, the agency did not ensure that the Hospice Aide received written patient instructions to meet the patient’s needs. Clinical Record 6: The patient elected the hospice benefit on 05/01/2025 with a diagnosis of inflammatory demyelinating polyneuritis. The initial comprehensive assessment completed by the Registered Nurse (RN) dated 05/01/2025 documented that the patient had a suprapubic catheter with a dressing changed by the RN. Hospice Aide (HA) services were ordered on the plan of care dated 05/01/2025, 3 times a week. The HA care plan dated 05/01/2025 assigned the HA the relevant task of routine catheter care at every visit. There were no specific instructions for the HA regarding the suprapubic catheter or the dressing. The HA documented that routine Foley care was provided at each visit. During an interview and a joint review of the clinical record on 05/14/2025, the Clinical Director confirmed that the RN did not specify instructions for a suprapubic catheter and dressing. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 05/03/2025 with a diagnosis of malignant neoplasm of the colon. The patient resided in an assisted living facility (ALF). During the home visit with the Registered Nurse (RN) [Personnel Record 2] on 05/13/2025, the patient was observed to have a large fungating tumor on their abdomen that required dressings due to drainage and open areas. The plan of care dated 05/03/2025 ordered HA services two (2) times a week. The HA care plan dated 05/03/2025 assigned the HA the relevant task of a shower every visit. The HA care plan did not provide the HA with instructions regarding how to care for the dressing, what to do if the dressing was dislodged, or to whom to report dressing needs. During an interview and a joint review of the clinical record on 05/13/2025, the Clinical Director agreed that the HA care plan should provide specific instructions for the aide to follow regarding the tumor dressing during the shower.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The agency did not ensure that volunteers provided day-to-day administrative or direct patient care services that equaled or exceeded 5% of patient care hours. The agency’s “Volunteer Program Activity Report” documented that the average percentage for volunteer cost savings (eligible volunteer hours as a percentage of total patient care hours) in 2024 was 1.88%. This included the following percentages by quarter in 2024: Quarter 1 (Q1) - 1.10%; Q2 - 1.69%; Q3 - 2.12%; and Q4 - 2.13%. The same report included the following monthly updates for Q1 of 2025: January 2025 - 3.74%; February 2025 - 3.45%; and March 2025 - 4.16%. The same report included documentation of a performance improvement project (PIP) focused on increasing volunteer cost savings that was instituted in January 2025. During an interview on 05/12/2025, the Volunteer Coordinator (VC) stated that the agency has not been able to accrue volunteer hours in direct patient care or day-to-day administrative services, so they total at least 5% of total patient care hours. The VC stated that they have been unable to do so since COVID waivers were lifted. A review of the agency’s Volunteer Program Activity Report revealed that the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services that equaled or exceeded 5% of the total patient care hours.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review and interview. In 3 of 27 (11%) hospice homecare clinical records reviewed, the agency did not ensure that the patient’s clinical record included physician orders for care and services. Clinical Record 6: The patient elected the hospice benefit on 05/01/2025 with a diagnosis of inflammatory demyelinating polyneuritis. The patient was admitted to hospice services with a suprapubic catheter in place. On 05/01/2025, the RN documented, “suprapubic cath in place, dressing changed.” On 05/08/2025, 05/09/2025, and 05/12/2025, the RN documented, “Foley irrigated.” The plan of care dated 05/01/2025 documented the problem: “Need for skilled nurse to insert/maintain indwelling catheter.” During the joint record review and interview on 05/14/2025, the Clinical Director confirmed there were no written orders for continuing the suprapubic catheter, dressing changes, or irrigation. Clinical Record 8: The patient elected the hospice benefit on 02/15/2025 with a diagnosis of multiple myeloma. On the initial comprehensive assessment dated 02/15/2025, the RN documented, “pleuravac insert sites are tender with movement.” On 02/25/2025, the RN documented “wife states she will drain the chest tubes.” On 05/06/2025, the RN documented “wife cleaning bilateral Aspira chest tubes, drains approximately 700ml every other day on each side.” A clinical record review revealed no physician orders for the care and maintenance of the patient’s bilateral Aspira drains. During a joint review of the record and interview on 05/12/2025, the Clinical Director confirmed that there were no orders for the chest tubes, draining, or dressing changes. Clinical Record 16: The patient elected the hospice benefit on 04/23/2025 with a diagnosis of atherosclerotic heart disease. The RN visit note dated 04/23/2025 documented, “laceration right lower extremity cleaned with wound cleanser, dried, Santyl applied to wound bed, covered with Allevyn dressing...Infected laceration 3 cm x 3 cm x 0.25 purulent drainage.” During a joint review of the clinical record and interview on 05/15/2025, the Clinical Director confirmed there was no evidence of a physician’s order for the wound care.”