Ardent Hospice & Palliative Care of SC, Inc.

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 4 of 14 (29%) clinical records reviewed, the agency did not ensure that the hospice Interdisciplinary Group completed an initial comprehensive assessment no later than five calendar days after the election of hospice care. CLINICAL RECORD 2: The patient elected the hospice benefit on 11/25/2025. The initial orders included an order for Chaplain evaluation. Clinical record review revealed that the Chaplain made a phone call to the patient’s primary caregiver on 12/01/2025, the 6th day after election of benefit and scheduled the initial evaluation for 12/02/2025, 7 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the Chaplain attempted to schedule the evaluation before day 6 but did not document the attempts. CLINICAL RECORD 3: The patient elected the hospice benefit on 01/17/2025. The initial orders included an order for Medical Social Worker (MSW) evaluation. The MSW assessment was dated 01/30/2025, a total of 13 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the assessment before day 13 but did not document the attempts. CLINICAL RECORD 4: The patient elected the hospice benefit on 10/15/2025. The initial orders included an order for Medical Social Worker evaluation. The MSW assessment was completed on 10/21/2025, a total of 6 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the evaluation before day 6 but did not document the attempts. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/21/2025. The initial orders included an order for Chaplain evaluation. The Chaplain completed the assessment on 04/03/2025, a total of 13 days after the election of benefit. The Administrator, in an interview on 12/17/2025, stated that the MSW attempted to schedule the evaluation before day 13 but did not document the attempts”

“It is required that the documented comprehensive assessment include 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; 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 measurements 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 document review, clinical record review, observation, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. Agency policy No. 1-014 Comprehensive Assessment, 2019, required in part, “ During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including a review of current and related past medications, including prescription, over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information, including but not limited to identification of the 1) Effectiveness of drug therapy, 2) Unwanted side and toxic effects, 3) Drug interactions (actual or potential), 4) Duplicate drug therapy, 5) Drug therapy currently associated with laboratory monitoring and 6) Whether the medication is unrelated to the terminal illness or related conditions (ensure there is clinical documentation to support unrelatedness).” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 08/07/2025 and resided at an assisted living facility (ALF). During the home visit observation on 12/15/2025 with the Chaplain (Personnel Record 1). A medication review was completed by comparing the hospice medication profile dated 11/05/2025 with the ALF medication orders. The ALF medication orders included Geri-Tussin 100mg/5ml (10ml) by mouth every 6 hours as needed for cough (ordered 06/13/2025). The hospice medication profile did not include Geri-Tussin, and the medication was not included in the medication review process. The Administrator stated in an interview on 12/15/2025 that the medication was overlooked at the time of admission. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 11/25/2025 and resided at home. During the home visit observation on 12/16/2025 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the hospice medication profile to the patient’s current home medication. The patient was observed to be on Oxygen. A review of the patient’s medication profile revealed Oxygen was not included on the drug profile. The hospice medication profile included Escitalopram 10 mg po daily. During an interview with the spouse/primary care giver it was determined that Escitalopram 20 mg daily was the correct dose as indicated in the referral orders and on the medication bottle. The patient’s spouse confirmed that the medication was started in the skilled nursing facility before the hospice admission, and the dosage had not been changed. During an interview with the Administrator on 12/16/2025, after reviewing the clinical record, the Administrator stated that the dosage on the drug profile was entered in error and that the nurse was new and still learning. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/25/2025. Review of the comprehensive assessment drug profile dated 10/25/2025 revealed the following medications were duplicated: Donepezil HCI 10mg daily, Amlodipine 10 po daily, and Memantine HCL 10mg po twice daily. The Administrator, in an interview on 12/17/2025, stated that the nurse who entered the medications was new and had entered them twice in error, and that this error should have been discovered during the quality assurance review process.”

“It is required that the documented comprehensive assessment include 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; 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 measurements 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 document review, clinical record review, observation, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. Agency policy No. 1-014 Comprehensive Assessment, 2019, required in part, “ During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including a review of current and related past medications, including prescription, over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information, including but not limited to identification of the 1) Effectiveness of drug therapy, 2) Unwanted side and toxic effects, 3) Drug interactions (actual or potential), 4) Duplicate drug therapy, 5) Drug therapy currently associated with laboratory monitoring and 6) Whether the medication is unrelated to the terminal illness or related conditions (ensure there is clinical documentation to support unrelatedness).” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 08/07/2025 and resided at an assisted living facility (ALF). During the home visit observation on 12/15/2025 with the Chaplain (Personnel Record 1). A medication review was completed by comparing the hospice medication profile dated 11/05/2025 with the ALF medication orders. The ALF medication orders included Geri-Tussin 100mg/5ml (10ml) by mouth every 6 hours as needed for cough (ordered 06/13/2025). The hospice medication profile did not include Geri-Tussin, and the medication was not included in the medication review process. The Administrator stated in an interview on 12/15/2025 that the medication was overlooked at the time of admission. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 11/25/2025 and resided at home. During the home visit observation on 12/16/2025 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the hospice medication profile to the patient’s current home medication. The patient was observed to be on Oxygen. A review of the patient’s medication profile revealed Oxygen was not included on the drug profile. The hospice medication profile included Escitalopram 10 mg po daily. During an interview with the spouse/primary care giver it was determined that Escitalopram 20 mg daily was the correct dose as indicated in the referral orders and on the medication bottle. The patient’s spouse confirmed that the medication was started in the skilled nursing facility before the hospice admission, and the dosage had not been changed. During an interview with the Administrator on 12/16/2025, after reviewing the clinical record, the Administrator stated that the dosage on the drug profile was entered in error and that the nurse was new and still learning. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/25/2025. Review of the comprehensive assessment drug profile dated 10/25/2025 revealed the following medications were duplicated: Donepezil HCI 10mg daily, Amlodipine 10 po daily, and Memantine HCL 10mg po twice daily. The Administrator, in an interview on 12/17/2025, stated that the nurse who entered the medications was new and had entered them twice in error, and that this error should have been discovered during the quality assurance review process.”

“It is required that the documented comprehensive assessment include 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; 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 measurements 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 document review, clinical record review, observation, and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure an accurate review of the medications the patient was currently using to identify any potential adverse effects and drug reactions. Agency policy No. 1-014 Comprehensive Assessment, 2019, required in part, “ During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient’s clinical record, including a review of current and related past medications, including prescription, over-the-counter medications, supplements, herbal remedies, alternative treatments, allergy history and other medication information, including but not limited to identification of the 1) Effectiveness of drug therapy, 2) Unwanted side and toxic effects, 3) Drug interactions (actual or potential), 4) Duplicate drug therapy, 5) Drug therapy currently associated with laboratory monitoring and 6) Whether the medication is unrelated to the terminal illness or related conditions (ensure there is clinical documentation to support unrelatedness).” CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 08/07/2025 and resided at an assisted living facility (ALF). During the home visit observation on 12/15/2025 with the Chaplain (Personnel Record 1). A medication review was completed by comparing the hospice medication profile dated 11/05/2025 with the ALF medication orders. The ALF medication orders included Geri-Tussin 100mg/5ml (10ml) by mouth every 6 hours as needed for cough (ordered 06/13/2025). The hospice medication profile did not include Geri-Tussin, and the medication was not included in the medication review process. The Administrator stated in an interview on 12/15/2025 that the medication was overlooked at the time of admission. CLINICAL RECORD 2/HOME VISIT 2: The patient elected the hospice benefit on 11/25/2025 and resided at home. During the home visit observation on 12/16/2025 with the Registered Nurse (RN) (Personnel Record 2), a medication review was completed by comparing the hospice medication profile to the patient’s current home medication. The patient was observed to be on Oxygen. A review of the patient’s medication profile revealed Oxygen was not included on the drug profile. The hospice medication profile included Escitalopram 10 mg po daily. During an interview with the spouse/primary care giver it was determined that Escitalopram 20 mg daily was the correct dose as indicated in the referral orders and on the medication bottle. The patient’s spouse confirmed that the medication was started in the skilled nursing facility before the hospice admission, and the dosage had not been changed. During an interview with the Administrator on 12/16/2025, after reviewing the clinical record, the Administrator stated that the dosage on the drug profile was entered in error and that the nurse was new and still learning. CLINICAL RECORD 6: The patient elected the hospice benefit on 10/25/2025. Review of the comprehensive assessment drug profile dated 10/25/2025 revealed the following medications were duplicated: Donepezil HCI 10mg daily, Amlodipine 10 po daily, and Memantine HCL 10mg po twice daily. The Administrator, in an interview on 12/17/2025, stated that the nurse who entered the medications was new and had entered them twice in error, and that this error should have been discovered during the quality assurance review process.”

“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 and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure staff performed hand hygiene and handled soiled items in the patient’s care environment as required by agency policy. Agency policy No. 7-009 Hand Hygiene, 2019, required in part, “Hand decontamination with an alcohol-based hand rub should be performed, A) Before having direct contact with patients, B) Before donning sterile gloves when performing sterile procedures; before inserting indwelling catheters, peripheral vascular catheters, or other invasive devices, C) After contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient), D) After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated, E) When moving from a contaminated body site to a clean body site during patient care.” Home Visit 2: During the home visit observation on 12/15/2025 with the Registered Nurse (Personnel Record 2), the RN was observed to provide wound care. The RN completed hand hygiene and donned (applied) clean gloves. The nurse then removed the soiled dressing, opened a pack of gauze and used wound cleanser to clean the wound. The RN then opened the new dressing and applied it to the wound. The RN did not change gloves and perform hand hygiene after contact with the soiled dressing and when the wound was cleansed prior to application of the new dressing, as required by agency policy.”

“It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 10 (20%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide provided services included in the plan of care. CLINICAL RECORD 7: The aide plan of care for the certification period 11/16/2025 to 01/14/2026 assigned the aide tasks that included cleaning/filing nails and shampooing hair. No frequencies were associated with these tasks. The aide documented on the aide visit note dated 11/20/2025 that the tasks of cleaning/filing nails and shampooing hair were not applicable to the visit. During an interview on 12/16/2025, the Administrator stated that when no frequency is listed for a task, it is to be completed at every visit, and therefore, these tasks should have been completed. CLINICAL RECORD 8: The aide plan of care for the certification period of 11/14/2025 to 01/12/2026 assigned the aide tasks that included assisting with feeding, bed bath, and turning and repositioning every 2 hours. The aide documented on the aide visit note dated 10/24/2025 that the tasks of assisting with feeding, bed bath, and turning and repositioning were not applicable to the visit and noted a shower was given rather than the assigned bed bath. During an interview on 12/16/2025, the Administrator stated that when no frequency is listed for a task, it is to be completed at every visit, and that not applicable should not have been entered for these tasks. The Administrator further stated that the aide should have followed the assigned tasks outlined in the care plan, but that the aide was new and needed additional training.”