Every finding on record at South Mississippi Home Health, Inc

Based on staff interview, review of cost savings report, and policy and procedure review, the facility failed to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five (5) percent (%) of the total patient care hours of all paid hospice employees and contract staff on two (2) of four (4) survey days. --- Findings Include: Interview with the Volunteer Coordinator on 04/10/2024 at 2:48 p.m. confirmed cost savings total for volunteer services from April 2023 to April 2024 is one percent (1.00%). Second quarter (2nd) 2023 – one percent (1%), Third quarter (3rd) 2023 – one percent (1%), Fourth quarter (4th) 2023 – one percent (1%) and further confirms no logs for review and no other documents to submit. Review of the facility Quality Assurance Performance Improvement documents revealed no documented information of Performance Improvement Projects for volunteer cost savings for 2023 -2024. Review of the document titled, ";Hospice Volunteer Requirement Report", revealed ";...For Year 2023, April Percentage 3.08%, May Percentage 1.92%, June Percentage 3.80%, July Percentage 1.69%, August Percentage 2.04%, September Percentage 2.86%, October Percentage 0.17%, November L Percentage 0.73%, December Percentage 0.79%, ... For the Year 2024 January Percentage 0.98%, February Percentage 1.22%, March 1191 Percentage 1,12%...". During exit conference on 04/11/2024 at 12:16 p.m., with RN #1, RN #2, Business Office Manager (BOM), Regional Vice President of Operations (RVPO), and Executive Director (ED)the survey findings were discussed, and no further documentation was submitted for review.

Based on staff interview the facility failed to ensure documented evidence that the Governing Body assumes full authority and responsibility for the management of the hospice program for three (3) of three (3) days of survey. --- Findings Include: Interview with Executive Director (ED), on 01/11/2024 at 11: 00 a.m. confirmed there was no evidence of documentation for Governing Body Meetings or Governing Body meeting minutes. The ED further confirmed she contacted corporate office requesting the Governing Body Minutes, Governing Body Bylaws and policy and procedure with no response at this time. No Governing Body By-Laws, policy and procedure or Governing Body Meeting Minutes submitted for review. During the exit conference on 04/11/2024 at 1:00p.m., with Executive Director, Registered Nurse (RN) #1, Regional Vice President of Operations, Business Office Manager, RN #2, Patient Care Manager (PCM), survey findings were discussed. No further documentation was submitted.