Every finding on record at Southern Grace Hospice South, LLC

Based on interview and record review, the agency failed to ensure a criminal background check was completed for 1 (S3Medical Director) of 8 sampled personnel records reviewed for criminal background checks.Findings: --- Review of S3Medical Director’s personnel file revealed, in part, a hire date of September 1, 2025.  Further review of S3Medical Director’s personnel file revealed no evidence a criminal background check had been completed. Surveyor requested a copy of S3Medical Director’s criminal background check on 02/11/2026 at 1:50PM from S2Director of Nursing.In an interview on 2/11/2026 at 5:09PM, S1Area Vice President indicated the agency does not have documentation that a criminal background check was conducted for S3Medical Director as required.

Based on record review and interview the agency failed to ensure the hospice aide provided services per the plan of care for 1 (Patient #9) of 9 patients reviewed for care and services per the plan of care. Findings: --- Review of Patient #9s Plan of Care for the certification period of 02/14/2023-05/14/2023 revealed Patient #9 was to receive hospice aide services five times a week. Review of Patient #9s record revealed the only hospice aide visits made the week of 02/19/2023 to 02/25/2023 were completed on 02/20/2023, 02/22/2023, 02/23/2023, and 02/24/2023. Further review revealed no documented evidence and the agency presented no documented evidence of the reason as to why the fifth hospice aide visit was not conducted as required. In an interview on 03/01/2023 at 4:00 p.m., S1Administrator stated the agency had no documented evidence of Patient #9 having received five hospice aide visits for the week of 02/19/2023 to 02/25/2023, or documented evidence of the reason as to why the visit was not conducted as required.

Based on record review and interview the agency failed to ensure a registered nurse developed a hospice aide care plan prior to hospice aide services being rendered for 1 (Patient #8) of 9 patients reviewed for hospice aide services. Findings: --- Review of Patient #8s record revealed Patient #8 was admitted to the agency on 10/03/2022. Review of Patient #8s record for certification period of 01/01/2023 to 03/31/2023 revealed Patient #8 was receiving hospice aide services three times a week. Further review of Patient #8s record revealed no documented evidence and the agency did not present any documented evidence of a hospice aide care plan having been developed by a registered nurse prior to 02/28/2023. In an interview on 03/01/2023 at 11:23 a.m., S1Administrator stated Patient #8 did not have a hospice aide care plan prior to yesterday. S1Administrator further stated the hospice aide care plan should have been developed prior to the hospice aide providing services.

Based on record review and interview the agency failed to ensure criminal background checks were completed upon hire as required for 2 of 9 employees (S2Medical Director and S3Hospice Aide) reviewed for personnel files. Findings: --- Review of S2Medical Directors Personnel File revealed S2Medical Director was hired in the year 2020. Further review revealed no documented evidence and the agency presented no documented evidence of a criminal background check having been completed prior to 02/27/2023. Review of S3Hospice Aides Personnel File revealed S3Hospice Aide was hired on 02/10/2021. Review of S3Hospice Aides Personnel File revealed the only documented criminal background check was completed on 06/18/2020. Further review revealed no documented evidence and the agency presented no documented evidence of the agency having completed a criminal background check once S3Hospice Aide was rehired on 02/10/2021. In an interview on 03/01/2023 at 12:51 p.m., S4Human Resources stated the agency did not have a criminal background check on S2Medical Director prior to the survey, and had no documented evidence of a criminal background check having been completed once S3Hospice Aide was re-hired by the agency.