Every finding on record at Regency Southerncare Hospice, LLC

Upon patient record review, 1 of 14 (Patient #2) 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 as active on the current plan of care.

Upon patient record review, 1 of 14 (Patient #10) 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 10: Patient developed a wound on 10/04/2023. Wound was inactivated on 11/09/2023. No evidence that wound care orders were removed from the current recertification plan of care that started on 11/04/2023.

Upon client record review, 5 of 14 (Patient #2,3,4,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: Elected volunteer services on initial RN assessment. Volunteer referral, assessment, and care plan entered. No evidence that an order was placed to start volunteer services. Currently receiving volunteer services at once a week tuck-in calls. Patient 3: Declined volunteer services on initial RN assessment. Volunteer referral, assessment, and care plan entered. No evidence that an order was placed to start volunteer services. Volunteer services were declined according to current plan of care. Currently receiving volunteer services at once a week tuck-in calls. Patient 4: Declined volunteer services on initial RN assessment. Volunteer assessment and care plan entered. No evidence that an order was placed to start volunteer services. Volunteer services were declined according to current plan of care. Currently receiving volunteer services at once a week tuck-in calls. Patient 7: Accepted volunteer services on initial RN assessment. Volunteer referral, assessment, and care plan entered. No evidence that an order was placed to start volunteer services. Volunteer services were declined on to current plan of care. Currently receiving volunteer services at once a week tuck-in calls. Patient 8: Accepted volunteer services on initial RN assessment. No volunteer referral, assessment, and care plan entered. No evidence that an order was placed to start volunteer services. Volunteer services were declined on to current plan of care. Currently receiving volunteer services at once a week tuck-in calls.