Southerncare Greenville

“Upon patient record review, 2 of 5 (Patients #1,#5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the wheelchair included in the plan of care. Patient 5: The medical record contained nursing documentation 7/22/26 identifying a suction machine was ordered for delivery by the DME supplier. There was no evidence of an order for the suction machine included in the plan of care.”

“Upon patient record review, 4 of 27 (Patient #2,3,4,6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: During home visit medication reconciliation, it was noted that Meloxicam 15mg, Memantine 10mg, and HCTZ 25mg were not in the home. These medications remain active on the current medication profile. The medication bottle in the home stated HCTZ 12.5mg tabs 1 tab daily. No evidence that an order for HCTZ 12.5mg tabs was added to the medication profile. Patient 3: During home visit medication reconciliation, it was noted that Claritin 10mg 1 daily and clonidine HCL 0.1mg 1 daily PRN were not in the home. Both medications remain active on the current medication profile. The nurse indicated that patient is no longer taking these medications. Patient 4: RN documentation indicated that patient uses oxygen at 2LNC PRN for shortness of breath. No evidence that an order for oxygen at 2LNC was ordered by the MD. The hospice medication profile does not have an order for oxygen at 2LNC. The hospice medication profile has an order for 3LNC. Patient 6: The medication profile includes an active order for Bumetanide 1mg 1 by mouth every night. However, during home visit this medication was not present and the caregiver states patient no longer taking that dose. The medication profile listed Bumetanide 2mg 1 every am by mouth. However the bottle in the home states Bumetanide 2mg take 2 in the am and 1 in the pm. The bottle indicated that it was filled on 6/3/26. The caregiver also stated the patient is actively taking the following over the counter medications: Milk thistle 175mg daily, Berberine 1000mg 2 daily for blood sugar, D3 125mcg 1 daily, Sportscaps dietary supplement 1 daily, Vit C 1000mg 3 daily, Calcium citrate magnesium and zinc with vit D3 2 daily, and turmeric 500 plus ginger50 2 daily. These over the counter supplements are not listed on the medication profile. The caregiver indicates patient does occasionally skip some of these a day or so but is taking consistently.”

“Upon patient record review, 1 of 27 (Patient #20) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 20: No evidence that a comprehensive assessment was completed every 15 days. The medical record indicated that it was 22 days between each comprehensive assessment on 05/28/2026 and then on 06/19/2026.”

“Upon patient record review, 2 of 27 (Patient #1,7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family’s needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 1: The medical record indicated that the patient developed a new skin tear to the left elbow on 06/04/26. No evidence that the wound has been measured at the time that the wound was identified. Gentiva policy is for wounds to be measured weekly. Patient 7: The medical record indicated that the patient was admitted with a stage 2 to the right buttock. No evidence that wound measurements were obtained for the weeks of 05/18/26 and 06/01/26. Gentiva policy is for wounds to be measured weekly.”

“Upon patient record review, 1 of 27 (Patient #11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 11: The medical record indicated that the patient was admitted with contractures to the left upper extremities and stiffness to bilateral lower extremities. No evidence that problems, goals, and interventions related to altered mobility was added to plan of care.”

“Upon patient record review, 1 of 27 (Patient #2) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 2: The current plan of care has MSW frequency ordered as 2 PRN visits. On the most recent MSW note, it is documented that the MSW will continue to follow the patient 2 times a month. No evidence that a routine frequency was included with the order.”

“Upon patient record review, 4 of 27 (Patient #2,3,4,6) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 2: During home visit medication reconciliation, it was noted that Meloxicam 15mg, Memantine 10mg, and HCTZ 25mg were not in the home. The medication bottle in the home stated HCTZ 12.5mg 1 tab daily. No evidence that was an order was received from the physician for HCTZ 12.5mg tabs or that an order was obtained to discontinue Meloxicam 15mg or Memantine 10mg. Patient 3: During home visit medication reconciliation, it was noted that Claritin 10mg 1 daily and clonidine HCL 0.1mg 1 daily PRN were not in the home. Both medications remain active orders. The nurse indicated that patient is no longer taking these medications. No evidence that an order was obtained to discontinue those medications from the MD. Patient 4: RN documentation indicated that patient uses oxygen at 2LNC PRN for shortness of breath. The plan of care does not have an order for oxygen at 2LNC. The plan of care has an order for 3LNC. No evidence that an order was received from the physician for oxygen at 2LNC. Patient 6: There is an active order for Bumetanide 1mg 1 by mouth every night. However, during home visit this medication was not present and the caregiver states patient no longer taking that dose. There is an active order for Bumetanide 2mg 1 every am by mouth. However, the bottle in the home states Bumetanide 2mg take 2 in the am and 1 in the pm. The bottle in the home indicated that it was filled on 6/3/26. The caregiver also states the patient is actively taking the following over the counter mediations: Milk thistle 175mg daily, Berberine 1000mg 2 daily for blood sugar, D3 125mcg 1 daily, Sportscaps dietary supplement 1 daily, Vit C 1000mg 3 daily, Calcium citrate magnesium and zinc with vit D3 2 daily, and turmeric 500 plus ginger50 2 daily. These over the counter supplements were not listed on the medication profile. No evidence that an order for these medications were obtained from the MD. The caregiver indicates patient does occasionally skip some of these a day or so but is taking consistently.”

“Upon patient record review, 3 of 27 (Patient #2,5,16) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 2: During the home visit, it was observed that the patient has grab bars within the home. No evidence that grab bars were included on the active DME supply list on the plan of care. Patient 5: Patient was admitted with a wound. The medical record indicated that wound was healed and wound care was discontinued on 10/21/2025. Wound care supplies remain on the active supply list for in the current benefit period. Patient 16: The medical record indicated that the patient had 2 skin tears that were discontinued on 05/06/26 and 05/11/26. Wound care supplies remain on the active supply list on the plan of care.”

“Upon client record review, 2 of 27 (Patient #3,20) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient#3: The medical record indicated that the MSW had not completed IDG updates since the recert IDG that occurred on 05/12/2026. IDG’s that occurred on 05/27/26 and 06/10/26 were signed by the MSW but did not have updates. MSW IDG notes contained an auto populated template and all of the questions were left blank. The medical record indicated that the MSW completed 3 routine visits and 2 PRN visits during that time. The PRN visits were to address the patient’s final arrangements and the patient’s spouse needing help with banking/financial paperwork. Patient#20: No evidence of an IDG note for 06/04/26 for MSW. The medical record indicated that the MSW did not complete an IDG update for the IDG meeting that occurred on 06/04/2026. MSW IDG notes contained an auto populated template and all of the questions were left blank. The medical record indicated that the patient did not have an initial IDG until 22 days after admission. The patient was admitted on 04/30/2026, first documented IDG occurred on 05/21/2026. The agency did provide IDG binder sign in sheet and an agenda that has the patient listed as an admit for the IDG that occurred on 05/12/2026. The agency scribe did document in her IDG note for 05/21/2026 that the initial IDG occurred on 05/12/2026. No evidence that the patient’s progress towards goals was reviewed during that IDG.”

“Upon patient record review, 3 of 27 (Patient #6,9,12) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 6: The medical record indicated that the patient has new complaints of nausea and vomiting, requiring a prescription for Zofran. No evidence that the plan of care was updated to include problems, goals, and interventions related to nausea and vomiting. Patient 9: The plan of care has interventions for the MSW to evaluate the patient for psychosocial needs. The MSW completed the evaluation with the 5 day window. No evidence that the plan of care was updated to removed that intervention. Patient 12: The medical record indicated that the patient’s caregiver scored HIGH on the initial bereavement risk assessment. The MSW documented on her initial visit and in the initial IDG meeting that she spoke to the caregiver about high bereavement risk assessment and that a plan was put in place to address the caregivers needs. No evidence that the plan of care was updated to include pre-bereavement or grief problems, goal, and interventions.”

“Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 10: The medical record indicated that the patient fell on 06/14/26. No evidence that an incident report was completed at the time that the chart was surveyed. This is out of compliance with Gentiva policy 5.005. Patient#13: LPN documentation on 06/18/2026 indicated that the patient was smoking with his oxygen on and his face caught on fire. No evidence that an incident report was completed within 24 hours. This is out of compliance with Gentiva policy 5.005.”

“Upon patient record review, 1 of 27 (Patient #17) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 17: The medical record indicated that the patient uses a walker and rollator due to unsteady gait. Patient also uses a shower chair while showering. No evidence that the assistive devices were added to the aide POC.”

“Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Patient#13: On 6/18/26 LPN made a visit to patient and documents that patient was smoking with his oxygen and caught his face on fire. LPN documents no facial hair remains on patient. Also documents he has first degree burns and the top layer of skin peeled off bilateral cheeks and upper lip. She educated to keep area clean and dry and suggested the patient use Vaseline and his tri cream that he already has in home to help with the burns. LPN documents that no wound care is needed. It should be noted that the use of Vaseline and the tri cream are petroleum based and contraindicated in the use with oxygen. Use of these items with oxygen could cause harm to the patient. There is no evidence of documentation in the chart that the LPN consulted with an RN or an MD for assessment and treatment of the patient. This is not consistent with accepted standards of nursing practice.”

“Upon patient client record review, 1 of 27 (Patient #2) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2: The plan of care contained a confusing order for weekly weights to be completed daily. The agency verified that weekly weights were being obtained on the patient. The medical record reflected that weekly weights were being obtained.”