Every finding on record at South Mississippi Home Health, Inc-Region L

*GULFPORT BRANCH OFFICE * COMPLAINT INVESTIGATION #MS002697259 The investigation conducted on 02/09/2026 - 02/10/2026 for the facility-reported Incident (FRI) concerning reports and services provided without proper orders revealed the allegation, Falsification of records/reports and Services Provided without proper orders, was substantiated for one (1) of three (3) reported medical records. Standard Level Deficiencies were cited. ______________________________________

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on staff interview, medical record review, communication note review, and policy and procedure review, the facility failed to ensure the facility obtained a valid physician order for discharge from homecare services for one (1) of four (4) medical records reviewed; Patient #1. Findings Include: An interview on 02/10/2026 at 2:17 p.m., via phone call with Registered Nurse (RN) #1, confirmed she spoke with Patient #1’s son and daughter-in-law about hospice services without a physician order. An interview on 02/10/2026 at 2:21 p.m. with Patient #1’s daughter-in-law confirmed RN #1 spoke with her about Hospice services for Patient #1 and suggested hospice services. Review of the “Discharge Visit Note,” dated 06/20/2025 at 11:59 a.m. and completed on 06/24/2025 at 11:58 a.m. confirmed RN #1 discharged Patient #1 to a non-institutional Hospice and a current reconciled medication list was provided to the subsequent provider. Further review of a “Physician Order,” dated 06/20/2025 at 1:37 p.m. by Licensed Practical Nurse (LPN) #1 states, “… Patient to be discharged from Home Health Services effective week of 06/15/2025 due to admission to Hospice, VO: Nurse Practitioner (NP) # 1 / LPN #1 Goal: Patient to be able to transition to Hospice with no delay, Patient aware…”. The order is not signed by the physician and written in the signature is “DO NOT SEND”. Review of facility’s policy, Patient Rights and Responsibilities, dated 05/04/99 with revised date 01/01/2020, reveals “…The patient or legal representative…is informed of patient rights and responsibilities prior to the beginning of care, treatment and services, or during the initial evaluation visit, and throughout their length of stay…”. Review of facility policy, Patient Discharge/Transfer Process dated 04/15/1999 revised date 10/01/2023, reveals “…criteria for patient discharge or transfer…Agency and physician agree that the agency can no longer meet the patient’s needs, based on patient’s acuity…When patients are transferred…or discharged…the agency will assist the patient/caregiver in selecting a post-acute provider by providing…information on local post-acute providers’ quality measures and resource use measures…Revisions to plan for patient’s discharge will be communicated to…All physicians issuing orders…Patient’s primary care practitioner…In Mississippi, a discharge order is required for any services that are terminated prior to the established frequency or end of episode…or patient requires services beyond the capability of the agency…A Transfer Summary is sent to the primary care physician…This form includes agency name, transfer date, reason for the transfer, patient’s condition…a list of community resources…Point of Care Agencies…the field clinician will access the appropriate Medicare.gov websites…to provide information to the patient/caregiver…The discussion will be documented within the medical record…”. Exit conference was held on 02/10/2026 at 4:45 p.m. with Executive Director, RN and the following were present via Zoom; Regional Director, RN, Performance Improvement (Regional), RN, Division President of Operations, RN, Survey and Performance Improvement Coordinator. Exited facility and report to the Deputy Director.