Every finding on record at Seasons Hospice & Palliative Care of Southern Florida Inc

Based on records review and staff interview, it was determined that the facility failed to establish and maintain an Emergency Preparedness Plan in accordance with the Code of Federal Regulations (CFR) 42, Part 418.113. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, facility failed to provide evidence of their emergency preparedness plan. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. 42 CFR 418.113 (a)

Based on records review and staff interview, the facility failed to develop and maintain an Emergency Preparedness Plan in accordance with the Code of Federal Regulations (CFR) 42, Part 418.113. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, the facility failed to review and update their emergency preparedness plan at least every two years. The plan shall include a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. 42 CFR 418.113(a)(1)-(2)

Based on records review and staff interview, it was determined that the facility failed to establish and maintain an Emergency Preparedness Plan in accordance with the Code of Federal Regulations (CFR) 42, Part 418.113. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, the facility failed to develop Emergency Preparedness Policy and Procedures that align with the identified hazards within the facilities risk assessment and the overall emergency preparedness program. Policy and procedures are required to be reviewed every two years. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. 42 CFR 418.113(b)

Based on records review and staff interview, the facility failed to perform emergency lights testing and maintenance in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no documentation for the performance of emergency lights testing for the last 12 months. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.2.9.1, 7.9, 7.9.3, 7.9.3.1.1

Based on records review and staff interview, the facility failed to maintain the fire alarm system testing and maintenance in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed as follows: 1. There was no program for the maintenance and testing of fire alarm system. 2. There was no documentation for the performance of fire alarm system tests. 3. There was no documentation for the performance of smoke detectors and duct detectors sensitivity tests. 4. There was no documentation for the performance of fire alarm duct detector airstream sampling using a method acceptable to the manufacturer or published instructions. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged these findings. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 72 (2010 Edition) Chapter 14, Table 14.4.5

Based on records review, observations, and staff interview, the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed as follows: 1. There was no program for the maintenance and testing of automatic fire sprinkler system. 2. There was no documentation for the performance of automatic fire sprinkler system tests. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged these findings. During the Life Safety Survey tour of the facility at 4:34 pm on 02/10/2025 with the Business Operations Manager, it was observed that there was no updated list posted in spare sprinkler cabinet. During the staff interview at 4:34 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.3.5, 18.3.5.1, 9.7, 9.7.5 NFPA 25 (2011 Edition) Table 5.1.1.2, 5.4.1, 5.4.1.1 through 5.4.1.4.2

Based on observations and staff interview, the facility failed to maintain the fire extinguishers in accordance with NFPA 101. --- Findings included: During the Life Safety Survey tour of the facility at 4:12 pm on 02/10/2025 with the Business Operations Manager, it was observed that there was no fire extinguisher location sign indicator. During the Staff Interview at 4:12 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.3.5.12, 9.7.4.1 NFPA 10 (2010 Edition) 6.1.3.3, 6.1.3.3.1 through 6.1.3.3.2

Based on records review and staff interview, the facility failed to maintain written copies of an approved fire safety plan for the protection of all persons in the event of fire or other emergencies in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no written copies of an approved fire safety plan for the protection of all persons in the event of fire or other emergencies. No additional documentation was provided during survey. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. She was unable to provide any additional documentation during survey. NFPA 101 (2012 Edition) 18.7.1.1 through 18.7.3

Based on records review and staff interview, the facility failed to perform fire drills in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no documentation for fire drills performed within the last 12 months. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.1.4 through 18.7.1.7

Based on records review and staff interview, the facility failed to maintain fire doors in accordance with NFPA 101. --- The findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no documentation for the performance of fire doors testing by knowledgeable individuals within the last 12 months. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1, 8.3.3.1 NFPA 80 (2010 Edition) 5.2.1, 5.2.3.1, 5.2.4.1

Based on records review and staff interview, the facility failed to maintain fire dampers in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no documentation for the performance of fire dampers test. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 80 (2010 Edition) 19.4, 19.4.1, 19.4.1.1, 19.4.10

Based on records review and staff interviews, the facility failed to maintain receptacles in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed that there was no documentation for the performance of receptacles testing. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 99 (2012 Edition) 6.3.3.2 NFPA 70 (2011 Edition) Article 517

Based on records review, observations, and staff interview, the facility failed to maintain electrical equipment in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed as follows: 1. There was no program for the maintenance and testing of the 240KW generator. 2. There was no documentation for performance of generator weekly, monthly, annual, and 4-hour load tests. 3. There was no documentation for the performance of fuel quality test. 4. There was no documentation for the performance of Main & Feeder Breaker exercise. Manufacturer's recommendations were not available at the time of the survey. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged these findings. During the Life Safety Survey tour of the facility at 4:26 pm on 02/10/2025 with the Business Operations Manager, it was observed that there were no generator high mortality spare parts on site. During the Staff Interview at 4:24 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 99 (2012 Edition) 6.4.4.1.2.1 NFPA 110 (2010 Edition) 8.4.1, 8.4.2.3, 8.4.9, 8.4.9.1 through 8.4.9.7, 8.4.7, 8.2 through 8.2.4.1

Based on record review, observations, and staff interview, the facility failed to maintain electrical equipment in accordance with NFPA 101. --- Findings included: During the records review process of the facility between 10:30 am and 3:00 pm on 02/10/2025 with the Business Operations Manager, it was revealed as follows: 1. There was no program for the maintenance and testing of the electrical equipment. 2. There was no documentation for the performance of electrical equipment testing. During the Staff Interview between 10:30 am and 3:00 pm on 02/10/2025, the Business Operations Manager acknowledged these findings. During the Life Safety Survey tour of the facility between 3:30 pm and 5:30 pm on 02/10/2025 with the Business Operations Manager, it was observed that patient beds were not inspected and labeled upon arrival at facility. During the Staff Interview between 3:30 pm and 5:30 pm on 02/10/2025, the Business Operations Manager acknowledged this finding. NFPA 101 (2012 Edition) 18.7.6, 4.6.12, 4.6.12.1 NFPA 99 (2012 Edition) 10.3, 10.5.2.1, 10.5.2.1.2

Based on review of Florida Statutes, the hospices Job Descriptions, observation, record review and interview, the facility failed to provide 3 of 23 sampled patients (Patient #3, 8, and 21) social services only by qualified social workers in accordance with Florida Statutes. --- 491.002 F.S. documents, part, ";The Legislature finds that as society becomes increasingly complex, emotional survival is equal in importance to physical survival. Therefore, in order to preserve the health, safety, and welfare of the public, the Legislature must provide privileged communication for members of the public or those acting on their behalf to encourage needed or desired counseling, clinical and psychotherapy services, or certain other services of a psychological nature to be sought out. The Legislature further finds that, since such services assist the public primarily with emotional survival, which in turn affects physical and psychophysical survival, the practice of clinical social work, marriage and family therapy, and mental health counseling by persons not qualified to practice such professions presents a danger to public health, safety, and welfare." 491.003 F.S. documents, in relevant parts, ";The ";practice of clinical social work" is defined as the use of scientific and applied knowledge, theories, and methods for the purpose of describing, preventing, evaluating, and treating individual, couple, marital, family, or group behavior, based on the person-in-situation perspective of psychosocial development, normal and abnormal behavior, psychopathology, unconscious motivation, interpersonal relationships, environmental stress, differential assessment, differential planning, and data gathering. The purpose of such services is the prevention and treatment of undesired behavior and enhancement of mental health. The practice of clinical social work includes methods of a psychological nature used to evaluate, assess, diagnose, treat, and prevent emotional and mental disorders and dysfunctions (whether cognitive, affective, or behavioral), sexual dysfunction, behavioral disorders, alcoholism, and substance abuse. The practice of clinical social work includes, but is not limited to, psychotherapy, hypnotherapy, and sex therapy. The practice of clinical social work also includes counseling, behavior modification, consultation, client-centered advocacy, crisis intervention, and the provision of needed information and education to clients, when using methods of a psychological nature to evaluate, assess, diagnose, treat, and prevent emotional and mental disorders and dysfunctions (whether cognitive, affective, or behavioral), sexual dysfunction, behavioral disorders, alcoholism, or substance abuse" and ";The definition of ";clinical social work" contained in this subsection includes all services offered directly to the general public or through organizations, whether public or private, and applies whether payment is requested or received for services rendered." 491.012 F.S. documents, in part ";It is unlawful and a violation of this chapter for any person to: (i) Practice clinical social work in this state for compensation, unless the person holds a valid, active license to practice clinical social work issued pursuant to this chapter or is an intern registered pursuant to s. 491.0045." The Hospices Job Description for ";Social Worker I" documents in Qualifications for state specific requirements in Florida, ";must receive a Master Social Work (MSW) from a CSWE-accredited program or be verified as a Registered Clinical Social Worker Intern (RCSWI); latter preferred" and within Essential Duties and Responsibilities, ";Assess the social, spiritual, and emotional needs/factors in order to estimate the patients and involved caregivers capacity and potential to cope with the problems of daily living and with the terminal diagnosis and illness" and ";... Provide services planned to assist in achieving the optimum social, spiritual, and health adjustment within their capacity and level of health literacy" and ";ongoing evaluation of patients social determinants of health." 1) Review of Patient #3's record reveals she started care with the hospice in September 2024. Patient #3's Hospice IDG [Interdisciplinary Group] Comprehensive Assessment and Plan of Care Update Report for the IDG Meeting date of 01/21/25 documents the following "MSW plan for next 2 weeks," electronically signed by Social Worker, Staff A, "will continue to assess pt's [patient's] psychosocial needs. PCG [primary caregiver] bereavement risk and provide education and psychosocial support. Will follow up with one visit monthly unless there is a change in LOC [level of care]." During observation in the presence of the Director of Patient Experience on 01/29/25 beginning at 11:55 AM, Staff A was observed to talk to nursing home staff, and make the Social Work visit to Patient #3. During interview between discussion with nursing home staff and entering the Patient #3's room, Staff A stated he usually visits with Patient #3. During interview on 01/29/25 at 12:25 PM with the Director of Patient Experience, she stated all of the hospice's Social Workers are Registered Clinical Social Work Interns (RCSWIs) or licensed Social Workers and that she is Qualified Supervisor of Social Work who supervises some of their RCSWIs as they work towards obtaining their licensure in Social Work. 2) Review of Patient #21's record reveals they were admitted to hospice in February 2024. Patient #21's Social Work visit note by Staff A for 10/22/24 documents he assessed Patient #21 and their caregiver for psychosocial needs, assessed Patient #21 for current degree of depression and there were no evident signs of depression, assessed the caregiver as low risk for bereavement, and attempted to contact the guardianship program regarding consent to a medical procedure. 3) Review of Patient #8's record reveals he was admitted to hospice on 01/22/25. Patient #8's Social Work Evaluation Visit dated 01/23/25 documents "low bereavement risk," "patient sees self/situation as a burden" and was completed by Staff A . Review of Staff A's employee file revealed no evidence of licensure or registered internship for Social Work. A search on the Department of Health's licensure verification website for Staff A's first and last name also revealed no evidence of Social Work licensure or registered internship.

Based on review of the hospices Bereavement Services 2026 Protocol, record review and staff interview the Hospice failed to ensure services provided reflected the needs of the bereaved for 3 of 4 sampled bereaved records (the bereaved of Patients# 24, 25, and 26). --- 1) The hospices Bereavement Services 2026 Protocol, provided upon request for the Policy and Procedures for the Bereavement program documents under Program Structure, ";Bereavement Committee - will be organized by the Bereavement Center in coordination with the local Director-Clinical Operations (DCO) or the Director-Patient Experience (DPE)" and ";The Bereavement Committee will meet once a month with the support of the Bereavement Center" and ";Patient Experience Staff will be responsible for the identification of moderate- and high-risk bereaved clients for active patients..." and under IDG Bereavement Review, ";a. a member of the bereavement center staff will join the IDG discussion for new patient admissions and deaths to provide expertise. b. All patient deaths that occurred since the previous IDG meeting will be discussed by the IDG. c. Discussion will include circumstances of the death and identification of the primary bereaved persons, including the most recent bereavement risk assessment. d. Based on discussion and assessment findings, the bereavement risk assessment identifies whether the bereaved client is considered at a high, moderate, or low risk. e. An IDG Bereavement Summary is completed to document the items above by the designated scribe" The hospices Bereavement Services 2026 Protocol further documents at one month a Bereavement Center Grief Counselor offering a bereavement visit from the sites designated psychosocial counselor would make at least 2 attempts to call or contact low risk bereaved clients but does not specify more than one call to reach moderate risk bereaved; and that for high risk clients does not specify any time to make a bereavement assessment call/contact after the initial outreach assessment in 7 days for all patients, until 6- and 12- month calls/contacts and a 13 month discharge letter as for all levels of risk. The fewest contacts to offer services are specified for high risk patients. 2) Review of the record reveals Patient #24 died on 09/14/24 and her bereaved family member was assessed as low risk on 09/18/24, then high risk on 11/01/24 with risk factors that included traumatic death circumstances but no evidence of a Bereavement Summary. 3) Review of the record reveals Patient #25 died on 11/05/24 and her bereaved family member was assessed as moderate risk on 11/01/24, then high risk on 11/04/24 but no evidence of a Bereavement Summary. 4) Review of the record reveals Patient #26 died on 07/16/24 and his bereaved family member was assessed as moderate risk on 8/14/24 and 01/13/25 but no evidence of a Bereavement Summary. Bereavement Summaries for Patients# 24, 25, and 26 were requested from the Director of Patent Experience on 02/03/25 at 4:10 PM. Upon further inquiry 02/03/25 at 4:56 PM for the requested Bereavement Summaries for Patients# 24, 25, and 26, the Director of Patient Experience stated simply, ";I dont have them." No Bereavement Summaries were provided by 02/13/25 at 5:00 PM.

Based on record review and staff interview the Hospice failed to meet the requirement for volunteer hours. --- Review of the hospices Volunteer Department Monthly Summary Reports reveals the ";total volunteer hours" were equal to 2.3% of the ";total Hospice hours" for December 2024 and 3.19% of the hospices hours for the 12 months from January 2024 to December 2024. During interview on 01/31/25 at 2:16 PM, the Volunteer Manager confirmed the Hospice did not meet the minimum volunteer hours of 5% of the hospices direct patient care hours; verified that direct care and administrative volunteer hours were included in the volunteer hour calculations (as appropriate); that clinical hours reported in ";total hospice hours" were calculated from visit notes for contract and direct staff and after deducting any volunteer hours (also appropriate); and explained the Hospice relies heavily on students for volunteer hours which results in significant drops when school is not in session.

Based on record review and interview, the provider failed to demonstrate it obtain the patient's or representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 (SP# 3) out of 4 sampled patients. --- Findings include: Clinical record review of SP#3 revealed that patient was admitted to hospice service on 09/29/2022 and the consent was signed by [name] and listed as the patients legal representative and further documented as ";friend/NOK" (next of kin). The Patient information Report list [name of signature on consent] as ";legal representative" and the patients sister [name] as ";primary caregiver". Interview conducted with Associate Executive Director on 06/12/2023 at 1:06 PM, he stated that they will talk to the next of kin to confirm that the next of kin is the right person to make health care decisions. For a person who is a proxy or a power of attorney they will require documentation but a next of kin they would not. The Associate Executive Director acknowledges that the hospice staff on service notes reflect [name of signature on consent] as the legal representative and/or proxy. The Associate Executive Director confirmed the provider does not have a copy of legal representation by name of signature on consent for admission to service. Telephone interview conducted on 06/12/23 at 1:16 pm with [name] signed consent for SP#3. The caregiver stated that he met SP#3 when he came out of the hospital [September 2022]. They became friends and he helped SP#3 find the ALF (assisted living facility). Once in the ALF, the hospice care was offered, and he spoke to the patient about how it would be beneficial for him to get help since he was so weak. Review of the policy and procedures titled ";Admission Criteria and Process" reads ";C. At admission, the patient, if applicable, shall identify a family member/caregiver or legal representative who agrees to be a primary support care if and when needed. Persons without such an identified individual who are independent in their activities of daily living (ADLs) shall require a specific plan to be developed at the time of admission with the social worker. F. The patient or legal representative shall agree to the plan of care, complete the election of hospice benefit and signa any other required consent form to initiate hospice care." The Florida Statues - Chapter 765 (Health Care Advance Directives) – states: 765.101 Definitions.—As used in this chapter: (1) ";Advance directive" means a witnessed written document or oral statement in which instructions are given by a principal or in which the principals desires are expressed concerning any aspect of the principals health care or health information, and includes, but is not limited to, the designation of a health care surrogate, a living will, or an anatomical gift made pursuant to part V of this chapter. (3) ";Close personal friend" means any person 18 years of age or older who has exhibited special care and concern for the patient, and who presents an affidavit to the health care facility or to the primary physician stating that he or she is a friend of the patient; is willing and able to become involved in the patients health care; and has maintained such regular contact with the patient so as to be familiar with the patients activities, health, and religious or moral beliefs. (19) ";Proxy" means a competent adult who has not been expressly designated to make health care decisions for a particular incapacitated individual, but who, nevertheless, is authorized pursuant to s. 765.401 to make health care decisions for such individual. (21) ";Surrogate" means any competent adult expressly designated by a principal to make health care decisions and to receive health information. The principal may stipulate whether the authority of the surrogate to make health care decisions or to receive health information is exercisable immediately without the necessity for a determination of incapacity or only upon the principals incapacity as provided in s. 765.204. 765.401 The proxy.— (1) If an incapacitated or developmentally disabled patient has not executed an advance directive, or designated a surrogate to execute an advance directive, or the designated or alternate surrogate is no longer available to make health care decisions, health care decisions may be made for the patient by any of the following individuals, in the following order of priority, if no individual in a prior class is reasonably available, willing, or competent to act: (g) A close friend of the patient.