Southeast Hospice Network

“Based on medical record (MR) review, agency policy and procedure, and interviews, it was determined the Registered Nurse (RN) failed to provide patient specific written instructions for the hospice aide (HA) providing care. This affected Home Visit (HV) # 1, one of four MRs reviewed with a HV, and had the potential to negatively affect all patients receiving aide services.Findings include: Agency Policy: Hospice Aide Assignments and DutiesPolicy Number: PC.H20Revised Date: NonePolicy:HAs are assigned to specific patients by a hospice RN and follow written patient care instructions in providing care to assigned patients.Procedure:1. The hospice RN responsible for supervising the hospice aide prepares written patient care instructions that are patient-specific and not generic. 1. HV # 1 was admitted to the agency on 12/11/23 with a diagnosis of Alzheimer’s Disease, and recertified for care 8/2/25 to 9/30/25.Review of the Hospice Plan of Care (POC), effective 8/1/25, revealed HV # 1 was bedbound and had orders for the Hospice Aide to visit three times a week.Review of the HA visit task list written by the RN for 8/1/25 to 9/30/25 revealed instructions for the HA to provide a shower.Review of 13 HA visits from 8/4/25 to 9/8/25 revealed the HA documented a shower was provided each visit for the bedbound patient.An interview was conducted on 9/17/25 at 2:24 PM with Employee Identifier (EI) # 2, Branch Director, who confirmed the HA task list was not specific to the needs of HV # 1.”

“Based on review of medical records (MR), agency policy, and staff interviews, it was determined the agency failed to ensure the staff completed documentation within seven days of the patient visit.This deficient practice affected five of 19 MRs reviewed including MR # 5, MR # 9, MR # 10, MR # 15, MR #13, , and had the potential to negatively affect all patients admitted to the agency.This is a continuing deficiency from the survey of 12/15/22.Findings include:Agency Policy: Clinical RecordsPolicy Number: PC.C15Revision Date: NonePolicy:A clinical record is established and maintained for every patient receiving care and services from Southeast Hospice Network. The record is complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval.All hard copy documentation should be filed in the hospice MR or electronically locked in the electronic medical record (EMR) within seven days of service... 4. MR # 15 was admitted to the agency on 7/9/25 with diagnoses of Multiple Sclerosis and Adult Failure to Thrive. A SN visit was conducted on 7/15/25 and completed by the SN on 7/28/25, thirteen days after the visit occurred. A SN visit was conducted on 7/18/25 and completed by the SN on 7/28/25, ten days after the visit occurred. A HA visit was conducted on 7/15/25 and completed by the HA on 8/5/25, twenty one days after the visit occurred. A HA visit was conducted on 7/17/25 and completed by the HA on 8/5/25, nineteen days after the visit occurred. A HA visit was conducted on 7/22/25 and completed by the HA on 8/5/25, fourteen days after the visit occurred. An interview was conducted on 9/17/25 at 1:02 PM with EI # 6, Administrator, who confirmed the staff failed to follow the agency policy for completion of documentation in the EMR.5. MR # 13 was admitted to the agency on 8/14/25 with a diagnosis of Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. A SN visit was conducted on 8/15/25 and completed by the SN on 8/24/25, nine days after the visit occurred. A SN visit was conducted on 8/25/25 and completed by the SN on 9/8/25, fourteen days after the visit occurred.A SN visit was conducted on 8/27/25 and completed by the SN on 9/8/25, twelve days after the visit occurred. An interview was conducted on 9/17/25 at 1:26 PM with EI # 6, who confirmed the staff failed to follow the agency policy for completion of documentation in the EMR. 1. MR # 5 was admitted to the agency on 8/21/25 with a diagnosis of Parkinsonism, Unspecified. A Hospice Aide (HA) visit was conducted on 8/26/25 and was completed by the HA on 9/7/25, twelve days after the visit occurred. An interview conducted on 9/16/25 at 5:15 PM with Employee Identifier (EI) # 1, Executive Director, confirmed staff failed to follow the agency policy for completion of documentation in the EMR.2. MR # 9 was admitted to the agency on 8/18/25 with a diagnosis of Alzheimer’s Disease, Unspecified. Skilled Nurse (SN) visits were conducted on 8/26/25 and 8/29/25. The visit notes were completed by the SN on 9/8/25, thirteen and ten days after the visits occurred. An interview conducted on 9/17/25 at 1:40 PM with EI # 1 confirmed the staff failed to follow the agency policy for completion of documentation in the EMR. 3. MR # 10 was admitted to the agency on 8/14/25 with a diagnosis of Cerebrovascular Disease, Unspecified. A SN visit occurred on 8/15/25 and the visit note was completed on 8/24/25, eight days after the visit. SN visits were also completed on 8/25/25 and 8/27/25. The visit notes were completed by the SN on 9/8/25, fourteen and twelve days after the visits occurred. An interview conducted on 9/17/25 at 1:35 PM with EI # 1 confirmed the staff failed to follow the policy for documentation completion in the EMR.”

“Based on Home Visit (HV) observations, agency procedure, and interview, it was determined the hospice agency failed to ensure the Skilled Nursing Facility (SNF) was provided the following:1. The most recent hospice plan of care (POC).2. Hospice election form and any advance directives. 3. Physician certification and recertification of the terminal illness.4. Names and contact information for hospice personnel involved in hospice care.5. Instructions on how to access the hospice’s 24-hour on-call system.6. Hospice medication information specific to the patient.7. Hospice physician orders.This affected HV # 4, one of one HVs conducted in a SNF, and had the potential to affect all patients with the hospice agency residing in a SNF.Findings include:Agency Policy: Hospice Care For Nursing Facility Residents-Coordination of ServicesPolicy Number: PC.H40Revised Date: NoneProcedures:1. The hospice designates a member of each interdisciplinary group (IDG) that is responsible for a patient who is a resident of a facility. The designated IDG member is responsible for:a. Providing overall coordination of the hospice care of the resident with facility representatives;b. Communicating with facility representatives...for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family.....3. The following information is provided to the facility:a. the most recent hospice POC...b. hospice election form and any advance directives...c. physician certification and recertification of the terminal illness...d. names and contact information for hospice personnel involved in the hospice care...e. instructions on how to access the hospice’s 24 hour-on-call system;f. hospice medication information specific to each patient; andg. hospice physician...orders specific to each patient 1. HV # 4 was admitted to the agency on 9/30/24 with a diagnosis of Alzheimer’s Disease With Late Onset.A HV was conducted to the SNF where HV # 4 resided on 9/16/25 at 10:05 AM to observe care provided by Employee Identifier (EI) # 3, Chaplain. After the visit was completed, the surveyor went to the SNF nurse station to review the documentation provided by the hospice for HV # 4’s coordination of care. There was no documentation available. The surveyor asked the SNF Registered Nurse (RN) on duty for any information available from the hospice for HV # 4. The RN searched the unit, but was unable to find any documentation on-site from the hospice for HV # 4.The hospice failed to provide documentation required to the SNF for coordination of HV # 4’s care.An interview was conducted on 9/17/25 at 2:04 PM with EI # 2, Branch Director, who confirmed there was no documentation provided to the SNF to coordinate the care provided.”