Regency Southerncare

“Based on review of agency policy titled “On-call/Weekend Services,” on call record review, patient family interview, and staff interviews, it was determined the hospice agency failed to organize, manage, and administer resources by failing to make a timely home visit after patient family called with concerns and notify of patient death for two patients (P) (P#1 and P#2) of two sampled patients. Findings include: Cross Reference to L650 regarding meeting patient and family needs and goals.Cross Reference to L653 regarding providing 24-hour availability of services to meet patient and family needs.”

“Based on review of a policy titled “Complaint/Grievance Process,” record reviews, agency documents, and staff interview, it was determined the hospice failed to investigate and document complaints according to agency policy for two patients (P) (P#1, P#2) of four sampled patients. Findings include: Review of the policy titled “Complaint/Grievance Process,” Policy No. 2-006, revised 7/31/2025, revealed the following:PURPOSETo set forth guidelines for the resolution of patient concerns, dissatisfaction, or complaints and to protect patient and family rights.PROCEDURE3. Complaints and any action taken will be documented in the QI Report section of the electronic medical record or on a complaint form.a. A record of complaints received will be kept with documentation to include: the name of the complainant, the relationship to the patient, the nature of the complaint, and the action taken to resolve the complaint.4. Corrective action will be specific and related to the complaint.5. Resolution information will be communicated to the patient or his/her representative filing the complaint.9. Reports may include:c. Action and resolution of complaints 1. Review of agency documents titled “Complaint Report,” revealed a complaint made on 11/16/2025 about care of the patient; specifically, complaints regarding the nurse of P#1. The complaint reported it took multiple phone calls and an extended amount of time for the nurse to arrive after the patient died.The report failed to reveal specific interventions or corrective actions taken to resolve the complaint, communicate resolution information to the complainant, or document investigation findings. 2. Review of agency documents titled “Complaint Report” revealed a complaint on 9/28/2025 regarding pain medications that were sent to the wrong pharmacy for P#2. The report failed to reveal specific interventions or corrective actions taken to resolve the complaint, communicate resolution information to the complainant, or document investigation findings. On 11/25/2025 at 9:25 a.m., an interview was conducted with the Executive Director, who confirmed that all complaint documentation had been provided.”

“Based on policy titled “Patient Bill of Rights,” record reviews and staff and family interviews, it was determined the agency failed to provide effective pain management and symptom control for one patient (P) (P#2) of four patients sampled. Findings include: Review of the policy titled “Patient Bill of Rights,” Policy No. 2-002, revised 11/17/2025, revealed the following:PURPOSETo encourage awareness of patient rights, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning.PROCEDURE1. The Patient Bill of Rights and Responsibilities defines the right of the patient to:d. Patients have the right to receive effective pain management…Addendum A: State Specific RequirementsGeorgia1. The hospice must ensure that patients and their families receive hospice care and palliative care for persons with advanced and progressive diseases, when offered, in a manner that respects and protects their dignity and ensures all patients’ rights to:c. Receive care in a setting and manner that preserves the patient’s dignity, privacy, and safety to the maximum extent possible. Clinical record review revealed the family of P#2 first reported concerns of pain on 9/24/2025. Review of Licensed Practical Nurse (LPN) AA’s “Visit Note Report,” dated 9/24/2025, revealed the family member felt the patient was experiencing pain and an order for pain medicine was received and called to the pharmacy. Further review of the clinical chart failed to reveal P#2 received the medication. On 11/24/2025 at 2:33 p.m., a telephone interview with P#2’s family confirmed trying to get pain medications for the patient beginning 9/24/2025. The family member revealed giving LPN AA the name of the pharmacy she wanted to get medications from. Family attempted to pick up the prescription on 9/24/2025, 9/25/2025, and 9/26/2025. Family member explained that on 9/24/2025, the pharmacy told the family that they did not have a prescription for the patient. The family member then called LPN AA, who reported the medication had not been called in yet. On 9/25/2025, another family member went to the pharmacy and was again told there was no prescription for the patient. The family member called LPN AA, who reported the pharmacy had not yet processed the medication order. When the family went to (the same) pharmacy on 9/26/2025, the pharmacy staff determined that medication had been called in to a different pharmacy. Because it was a controlled substance, the pharmacy was unable to transfer the prescription and fill it. The family further revealed calling the agency the night of 9/26/2025 to report P#2 was in severe pain and was moaning and crying out “Oh God, oh God,” just hours before death. The patient never received the Tramadol (medication used for management of moderate to moderately severe pain) that was ordered on 9/24/2025. Review of on call record: Client Coordination Note dated 9/26/2025 at 11:52 pm- family member called and reported they still didn’t have pain medications. Client Coordination Note dated 9/27/2025 by RN regarding needing pain medication and a 24-hour pharmacy. On 11/24/2025 at 2:20 p.m., a telephone interview with LPN AA confirmed the family of P#2 had expressed concerns regarding pain on 9/24/2025 and explained that the medication was called in to the pharmacy as instructed by the family. LPN AA acknowledged she did not follow up to assess the new medication’s effectiveness or confirm receipt of the medication.”

“Based on review of policy titled “The Plan of Care,” record reviews, agency documents, and staff interview, it was determined the hospice failed to ensure the plan of care included interventions to manage pain and symptoms for one patient (P) (P#2) of four patients sampled. Findings include: Review of the undated policy titled “The Plan of Care,” reveals the following:POLICYThe plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by the members of the interdisciplinary group and will be reviewed on a regular basis. This plan will focus on identified problems, goals, and interventions.PROCEDURE4. The hospice interdisciplinary group will use the data obtained during the initial, comprehensive, and ongoing hospice assessments to develop a plan of care that identifies the patient’s problems and needs and interventions and services to meet those needs, including the management of pain and discomfort and symptom relief.10. Any change in the patient’s condition must result in a change in the plan of care, prior to the implementation of the new service. Review of the clinical record revealed that P#2 experienced delays in receiving pain medication. Review of document titled “Client Coordination Note Report” dated 9/26/25 revealed that the family member of P#2 called the agency’s triage line on 9/26/2025 at 11:52 p.m. and reported that P#2 did not have any pain medication and was lying in bed screaming in pain. Review of document titled “Hospice Certification and Plan of Care,” Goals identified in the “Hospice Certification and Plan of Care” include the following:1. To achieve an acceptable level of pain relief (pain goal: 2/10) and display no verbal or nonverbal cues of discomfort.2. To control or resolve P#2’s symptoms On 11/24/2025 at 2:33 p.m., during a telephone interview, the family member revealed P#2 was moaning and crying out in pain just hours prior to death. On 11/24/2025 at 2:20 p.m., a telephone interview with Licensed Practical Nurse (LPN) AA explained that the medication for P#2 was called in to the pharmacy as instructed by the family. LPN AA acknowledged she did not follow up to assess the new medication’s effectiveness or confirm receipt of the medication.”

“Based on review of policies titled “Hospice Care Services Nursing services,” and “On-Call/Weekend Services,” record reviews, agency documents, and staff and family interviews, it was determined the agency failed to ensure that nursing needs of the patients were met as identified in the updated assessments for one patient (P) (P#2) of four patients reviewed. Findings include: Review of policy titled “Hospice Care Services Nursing services,” revised 10/20/2025 reveals the following:PROCEDURE3. The hospice nurse will:a. Manage discomfort and provide symptom relief according to physician orders.5. A hospice nurse will be available on a 24-hour basis to meet the physical, psychosocial, spiritual, and practical needs of patients and families/caregivers admitted to the hospice program. Review of policy titled On-Call/Weekend Services,” revised 11/5/2025 reveals the following:GUIDELINES:The following list is meant to guide the on-call nurse. It is not an exhaustive list but includes many problems that may require a visit from the hospice nurse. 2. Unusual, severe, or uncontrolled pain 14. Duplicate calls regarding the same problem 15. Patient/family/caregiver/facility perceives a problem and requests a visit Review of the clinical records for P#2 revealed that patient was admitted to hospice on 9/23/25. Further review of the clinical record for P#2 revealed P#2’s family member first reported concerns of pain on 9/24/2025. Review of “Visit Note Report dated 9/24/25 Licensed Practical Nurse (LPN) AA revealed a nurse visit and family member was concerned that patient will moan and cry at night due to pain. Note further revealed that Tramadol (opioid medication used for pain) prescribed and called into pharmacy. Review of agency document titled “Client Coordination Note Report,” dated 9/26/25 revealed that the family member of P#2 called the agency’s triage line on 9/26/2025 at 11:52 p.m. and reported that P#2 was lying in bed screaming in pain. The family member requested a return call from the agency’s management. Client Coordination Note dated 9/27/2025 by on call RN reveals the call was transferred at approximately 0030 hours and lasted 50 plus minutes. New order received for Dilaudid (opioid pain reliever) and Ativan (medication used to treat anxiety disorders). On 11/24/2025 at 2:20 p.m., during a telephone interview, LPN AA confirmed the family member of P#2 had expressed concerns regarding pain on 9/24/2025. On 11/24/2025 at 2:33 p.m., during a telephone interview, the family member of P#2 revealed that she called the agency’s triage line regarding pain medications for P#2. The family member further revealed that she reported that P#2 was in severe pain and was moaning and crying out “Oh God, oh God.” On 11/25/2025 at 10:47 a.m., during an in-office interview, the Executive Director (ED) and Regional Director of Operations (RDO) confirmed the process for triaging calls and identifying the need for patient home visits for all on-call nurses. The ED and RDO acknowledged that the agency has recently identified a problem with on-call nurses following up with in-home visits after the on- call triage nurse identifies a need for in-home visit.”

“Based on review of agency policy titled “On-call/Weekend Services,” review of records, on call record review, patient family interview, and patient staff interviews it was determined the hospice agency failed to provide services consistent with patient and family needs and goals which optimized comfort and dignity for two patients (P) (P#1 and P#2) of two sampled patients. Findings include: Review of agency policy titled “On-call/Weekend Services,” revised 11/5/2025 revealed the following:Procedure5. The on-call will provide follow-up appropriate to the calla. Call the patient/family/caregiverb. visits the patient if necessaryc. Obtain physician (or other authorized independent practitioner) orders, as neededd. Arrange for the hospice services, as needed7. If the visit is required, the on-call nurse will attempt to arrive at the patient’s home/facility as quickly as possible, but no later than (2) hours unless a shorter response time is required by state regulation. Response time must meet state specific regulation, when applicable. Addendum A: State Specific RequirementsGeorgia – Nursing ServicesOn-sight nursing services must be made available within one hour of the notification where the terminally ill patient and the patient with an advanced and progressive disease who has contracted for nursing services experiences a symptoms-management crisis situation. 1. Review of document titled “Client Episode Coordination Notes” dated 11/10/2025 revealed family of P#1 called on-call triage nurse at 1:58 a.m. to report patient expired. Review of document titled” Pronouncement of Death” dated 11/10/2025 revealed agency registered nurse (RN) pronounced death of P#1 on 11/10/2025 at 5:25 a.m. Review of agency’s on-call log revealed a phone call from family member of P#1 on 11/9/2025 at 2:36 p.m., 11/9/2025 at 11:07 p.m., 11/10/2025 at 2:16 a.m., and 11/10/2025 at 4:36 a.m., with concerns requesting a nurse visit. P#1 expired and was pronounced by agency RN on 11/10/2025 at 5:25 a.m. 2. Review of document titled “Client Coordination Note Report” dated 9/27/2025 at 6:17 a.m. revealed the on-call triage nurse identified a PRN (as needed) visit is needed, per agency best practice, after caller reported P#2 had died. No visit was made by agency nurse until 8:50 a.m., on 9/27/2025. Review of document titled” Pronouncement of Death” dated 11/10/2025 revealed agency registered nurse (RN) pronounced death of P#2 on 9/27//2025 at 8:50 a.m. Review of agency’s on-call log revealed a phone call from family member of P#2 on 9/26/2025 at 11:58 p.m. reporting P#2 was lying in bed screaming in pain. The record further revealed family member of P#2 was requesting a call back from the management team. The on-call nurse advised the family of P#2 that triage was unable to support need and further advised caller to contact the branch with any additional concerns or changes. On 11/24/2025 at 2:33 p.m., during a telephone interview with family member of P#2, it was confirmed family had made a call to the agency’s on-call on 9/26/2025 to report P#2 had no pain medication and P#2 was in severe pain, patient was moaning and crying out “oh God, oh God”. Family member of P#2 confirmed agency nurse did not make a home visit until after patient had died. No visit was made to assess the patient before patient died on 9/27/2025 at 8:50 a.m. On 11/25/2025 at 10:47 a.m. the Executive Director (ED) and Regional Director of Operations (RDO) confirmed the process for on call included a cooperate triage nurse who determines if the patient requires a home visit based on needs. The triage nurse then contacts the on-call registered nurse (RN) to relay the need for a home visit. The ED and RDO admitted the agency have recently identified a problem with on-call nurses following up with in-home visits after triage identifies the need for a visit. The ED and RDO admitted the agency planned to start education for all on-call nurses, starting this week, regarding the on-call process.”

“Based on review of agency policy titled “Patient Bill of Rights,” review of records, on call record review, patient family interview, and staff interviews it was determined the agency failed to provide medication on a 24-hour basis to meet the patients’ needs for one patient (P) (P#2) of one sampled patient. Findings include: Review of agency policy titled “Patient Bill of Rights,” dated 11/17/2025 revealed the following:Procedure1. The Patient Bill of Rights and Responsibilities define the right of the patient to:e. Patients have the right to receive effective pain management Review of records revealed P#2 has a physician order dated 9/24/2025 for Tramadol (opioid medication used for pain) 50 mg (Milligrams) tablets to be given by mouth every six hours and a physician order dated 9/27/2025 for Dilaudid (opioid medication used for severe pain) 2 mg tablets to be given by mouth every six hours. P#2 failed to receive the medications before he expired on 9/27/2025 at 8:50 a.m. Client Coordination Note dated 9/26/2025 at 11:52 pm- daughter called and reported they still didn’t have pain medications. Client Coordination Note dated 9/27/2025 by RN regarding needing pain medication and a 24 hour pharmacy. Confirmed in family interview. Review of the agency’s on call logs revealed a phone call at 11:58 p.m. on 9/26/2025 reporting P#2 was lying in bed screaming in pain. The records further revealed P#2 was experiencing symptoms and that the caller was advised to contact the branch with any additional concerns. No visits were made to assess P#2 until the patient died on 9/27/2025 at 8:50 a.m. On 11/24/2025 at 2:33 p.m., a telephone interview with the family of P#2 confirmed trying to get pain medications for the patient beginning 9/24/2025. The family states that the medication was called in to the wrong pharmacy. The family further revealed calling the agency the night of 9/26/2025 to report the patient in severe pain. Patient moaning and crying out “Oh God, oh God,” just hours before death. On 11/24/2025 at 2:20 p.m., a telephone interview with Licensed Practical Nurse (LPN) AA confirmed the family of P#2 had expressed concerns regarding pain on 9/24/2025. LPN AA confirmed she had called the pain medication into the wrong pharmacy and P#2 never received the pain medication.”

“Upon patient record review 1 of 27 (Patient #9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 9: Initial plan of care has orders for the chaplain to perform evaluation visit. No evidence that the evaluation visit was completed. No evidence that agency policy was followed with completing a mini spiritual assessment if the initial assessment is refused by the family. Completed during survey.”

“Upon patient record review, 4 of 27 (Patient #5,11,20,25) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 5: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 07/28/2023, assessment completed on 08/03/2023. Patient 11: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 011/29/2023, assessment completed on 12/08/2023. Patient 20: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 11/15/2023, assessment completed on 11/21/2023. Patient 25: No evidence that initial bereavement risk assessment was completed within 5 days of admit. Admitted on 05/11/2021, assessment completed on 05/25/2021.”

“Upon patient record review, 2 of 25 (Patient #2,15) 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 2: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added active on current plan of care. Patient currently on oxygen. No evidence that oxygen safety was added on current plan of care. Patient 15: Patient identified as a risk for falls upon admit and ongoing via RN assessments. No evidence that risk for falls was added active on current plan of care.”

“Upon patient record review, 3 of 27 (Patient #3,5,13) 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 3: Patient currently has a foley catheter and a wound. No evidence that wound care supplies or foley catheter supplies were added to the active plan of care. Patient 5: Wound care supplies on current plan of care. No evidence of an active wound at the time of survey. Wound and wound care orders discontinued on 01/17/2023. Patient 13: Aide plan of care has orders instructions for a Hoyer lift to be used while transferring patient from bed to chair and from chair to bed. No evidence that a Hoyer lift was added to the active plan of care.”

“Upon patient record review 4 of 19 (Patient #10,11,16,17) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 10: Aide plan of care has frequency set as twice weekly. No evidence that 2 visits occurred for the week of 01/07/2024 and 01/21/2024. No missed visit notes and orders to change frequency noted at the time of survey. Aide task on current plan of care ordered to be performed at every visit. No evidence that all task were completed on 11/24, 11/28, 11/30, 12/02, 12/05, 12/12,12/19, 12,21,12/26, 12/28, 01/02, and 01/30. Patient 11: Aide plan of care has linen changes to be completed weekly. Aide documentation shows that the hospice aide provided linen changes at every visit instead of weekly as ordered. Patient 16: Aide plan of care has linen changes to be completed weekly. Aide documentation shows that the hospice aide provided linen changes at every visit instead of weekly as ordered. Patient 17: Aide plan of care has hair care, shampoo, and linen changes to be completed weekly. Aide documentation shows that the hospice aide provided those treatments at every visit instead of weekly as ordered.”

“Upon patient client record review, 3 of 27 (Patient #13,15,16) 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 13: Missed visit note entered on 12/12/2023 and 02/18/2024. No evidence that the date of the missed visit or what physician/RN was notified that the visit was missed was included in the note. Patient 15: Missed visit note entered on 01/09/2023, 01/26/2023, and 02/02/2024. No evidence that the actual date of the visit or what physician/RN was notified that the visit was missed was included in the note. Patient 16: Missed visit note entered on 12/25/2023 and 01/01/2024. No evidence that the date of the visit or what physician/RN was notified that the visit was missed was included in the note.”

“Upon client record review, 2 of 27 (Patient #9, 18) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 9: Order for PT/OT referral made on 11/27/2023 and 12/28/2023. No evidence that an OT assessment was completed at the start of survey. PT assessment was completed on late on 02/01/2024. Patient 18: Plan of care has chaplain frequency as 2 routine visits a month. No evidence that patient received 2 visits for the month January. No missed visit notes or physician orders entered to skip visits for the month.”