Every finding on record at Wiregrass Hospice, LLC

Upon patient record review, 1 of 5 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 4: Orders received for PT services to evaluate and treat for 3 visits. The medical record also contains orders written on 02/18/2026 and 02/26/2026 for 3 additional visits to be completed. No evidence that time frame was given for PT to complete the 3 visits.

Upon patient record review, 1 of 5 (Patient #3) 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 3: MSW documentation indicated that the patient and daughter needed help with coping skills, code status, and funeral arrangements. No evidence that problems, goals, and interventions related to coping skills, code status, or final arrangements on the current plan of care. The only interventions on the plan of care for the MSW are related to developing and maintaining the Hospice plan of care in collaboration with the facility staff.

Upon patient record review, 6 of 23 (Patients #9,#13,#15,#16,#17,#18) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 9: The medication profile contained MiraLAX oral powder with no instructions to mix with a diluent and oxygen with no delivery method. Corrected on site with order clarification and profile update. Corrected on site with order clarification and profile update. Patient 13: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility acetaminophen frequency was for every four hours PRN and hospice was for every six hours PRN. Corrected on site with order clarification and profile update. Patient 15: Upon home visit medication reconciliation the facility and hospice medication profiles did not match. The facility profile contained medications not on the hospice profile including Pepto Bismol, loratadine, hydrocortisone suppository, vitamin D3, and an acetaminophen PRN. The hospice profile contained medications not on the facility profile including an albuterol nebulized treatment, scheduled Ativan, calmoseptine, and lactulose PRN. The facility also had twice daily frequencies for methenamine Hippurate, metoprolol, solifenacin, and Xifaxin, whereas hospice frequency was daily for the medications, and the facility had oxygen for 2-4 liters if oxygen saturations were below 93%, whereas hospice had oxygen for 4 liters continuous. The hospice profile also contained duplicative orders for Benedryl listed as Banophen and diphenhydramine. Corrected on site with order clarifications and profile update. Patient 16: The medication profile contained duplicative listing for nicotine patches with start dates of 9/17/25 and 10/22/25. Corrected on site with order clarification and profile update. Patient 17: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen on the medication profile. Corrected on site with order clarification and profile update. Patient 18: During home visit medication reconciliation, the caregiver denied patient use of alendronate for approximately six weeks and furosemide since admission, and did not have lorazepam or Milk of Magnesia in the home. Corrected on site with order clarification and profile update.

Upon patient record review, 2 of 23 (Patients #16,#17) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 16: There was no evidence of a comprehensive physical assessment by an RN from 12/18/25 to 1/8/26. Patient 17: There was no evidence of a comprehensive physical assessment by an RN from 12/18/25 to 1/6/26.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 23 (Patients #7,#8) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 7: The medical record contained nursing documentation identifying patient had a deep tissue injury to the left heel. There was no evidence of weekly wound measurements from 12/23/25 to 1/6/26 as required per agency policy. Patient 8: The medical record contained nursing documentation identifying patient had a wound to the right heel 11/25/25 to 12/19/25. There was no evidence of weekly wound measurements and assessments as required per agency policy. The only measurement and assessment was upon initiation of the wound 11/25/25.

Upon patient record review, 6 of 23 (Patients #3,#5,#10,#12,#14,#16) 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 3: The medical record contained nursing documentation upon admission identifying patient history of a CVA and dementia. There was no evidence of problems, goals, and interventions related to neurological dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 5: The medical record contained nursing documentation upon admission identifying patient issues with orthopnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 10: The medical record contained nursing documentation upon admission identifying patient history of recurrent falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. The plan of care also contained inappropriate problems, goals, and interventions for discharge planning with no documentation to support plan to discharge patient. Corrected on site with plan of care update. Patient 12: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of problems, goals, and interventions related to oxygen use included in the plan of care. Corrected on site with plan of care update. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of oxygen, history of hypertension and pitting edema, and an H&P identifying history of a DVT. There was no evidence of problems, goals, and interventions related to oxygen use and cardiovascular dysfunction. Cardiovascular correct on site with plan of care update. Patient 16: The medical record contained nursing documentation upon admission identifying patient history of recurrent falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 1 of 23 (Patient #6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences. Patient 6: The medical record contained chaplain documentation identifying the patient elected to discontinue spiritual care visits. There was no evidence of an order to discontinue spiritual care visits per request. Corrected on site with order received.

Upon patient record review, 7 of 23 (Patients #6,#9,#13,#15,#16,#17,#18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a Bi-PAP. There was no evidence of an order for Bi-PAP parameters. Corrected on site with order clarification. Patient 9: The medical record contained an order for MiraLAX oral powder with no instructions to mix with a diluent and oxygen with no delivery method. Corrected on site with order clarification. Patient 13: Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility acetaminophen order was for frequency of every four hours PRN and hospice order was for every six hours PRN. Corrected on site with order clarification. Patient 15: Upon home visit medication reconciliation the facility and hospice medication orders did not match. The facility record contained medications orders not in the hospice record including Pepto Bismol, loratadine, hydrocortisone suppository, vitamin D3, and an acetaminophen PRN. The hospice record contained medication orders not in the facility record including an albuterol nebulized treatment, scheduled Ativan, calmoseptine, and lactulose PRN. The facility also had orders with twice daily frequencies for methenamine Hippurate, metoprolol, solifenacin, and Xifaxin, whereas hospice order frequencies were daily for the medications, and the facility had an oxygen order for 2-4 liters if oxygen saturations were below 93%, whereas hospice order was for oxygen 4 liters continuous. The hospice medical record also contained duplicative orders for Benedryl identified as Banophen and diphenhydramine. Corrected on site with order clarification. Patient 16: The medical record contained duplicative orders for nicotine patches 9/17/25 and 10/22/25. Corrected on site with order clarification. Patient 17: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site with order clarification. Patient 18: During home visit medication reconciliation, the caregiver denied patient use of alendronate for approximately six weeks and furosemide since admission, and did not have lorazepam or Milk of Magnesia in the home. There was no evidence of orders to discontinue the medications. Corrected on site with order clarification.

Upon patient record review, 3 of 23 (Patients #5,#10,#18) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received. Patient 10: The plan of care contained order for oxygen equipment, CPAP, trapeze, cane, and walker with no supporting documentation the patient has the DME in the home for use. Corrected on site with orders discontinued. Patient 18: The medical record contained nursing documentation upon recertification assessment 12/24/25 identifying patient use of a nebulizer and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site with order received.

Upon client record review, 1 of 23 (Patient #1) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 1: The IDG notes did not show updates with social worker involvement 11/12/25, 11/26/25, 12/10/25, 12/24/25, and 1/7/25.

Upon patient record review, 5 of 23 (Patients #1,#3,#5,#6,#18) 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 1: The medical record contained nursing documentation 11/21/25 and 11/24/25 identifying family was looking at nursing home placement. There was no evidence the plan of care was updated to include problems, goals, and interventions related to the need for placement and progress toward the goal. Corrected on site with plan of care update. Patient 3: The medical record contained nursing documentation upon recertification assessment 11/18/25 identifying the patient as a high risk for skin impairment. There was no evidence the plan of care was updated to include problems, goals, and interventions related to the risk for skin impairment. Corrected on site with plan of care update. Patient 5: The medical record contained a DNR form signed 11/4/25. The record also contained nursing documentation 12/18/25 identifying report that the patient was aggressive the day prior. There was no evidence the plan of care was updated to change the code status from full code to DNR, and to include problems, goals, and interventions related to agitation. Corrected on site with plan of care update. Patient 6: The medical record contained chaplain documentation identifying the patient elected to discontinue spiritual care visits. The plan of care contained active spiritual problems, goals, and interventions to be completed by the chaplain. Corrected on site with plan of care update. Patient 18: The medical record contained nursing documentation upon recertification assessment 12/24/25 identifying increased nausea and vomiting, high risk of skin impairment, and oxygen use. There was no evidence the plan of care was updated to include problems, goals, and interventions related to nausea, risk for skin impairment, and oxygen use. Corrected on site with plan of care update.

Upon client record review, 2 of 23 (Patients #2,#20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record contained an order for social work visits once monthly. There was no evidence of November and December visits. Corrected on site with late data entry of reason for missed visits. Patient 20: The medical record contained nursing documentation 2/8/25 stating the scheduled visit was missed due to RN having an emergency with another patient. There was no evidence of attempts to reschedule with another nurse or complete another day.

Upon home visit observation 1 of 6 visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. During the home visit, after the RN cleansed the stethoscope, it was placed in area where dirty equipment had been.

Upon patient record review, 1 of 23 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 8: The aide care plan contained a task to shave patient per patient request and did not note patient was cognitively able to make own decisions. Corrected on site with aide care plan update.

Upon patient record review 2 of 23 (Patients #10,#15) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group. Patient 10: The medical record contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 12/21/25 and 12/28/25. Patient 15: The medical record contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 11/23/25 and 12/28/25. Corrected on site with late data entry of reason for missed visit.

Upon patient record review 2 of 23 (Patients #15,#17) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 15: The medical record contained one aide supervisory visit on 12/29/25 for benefit period 11/12/25-1/10/26. Patient 17: There was no evidence of an aide supervisory visit between 12/18/25 and 1/6/26.

Upon patient client record review, 1 of 23 (Patient #10) did not have evidence that each patient record contains Advance Directives. Patient 10: The plan of care identified the patient as DNR. There was no evidence of a DNR form or living will to support the code status. Corrected on site with order form completed.

Upon patient client record review, 4 of 23 (Patients #1,#4,#7,#23) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The initial CTI was signed 7/23/25 but contained documentation in error that the verbal certification was received 6/21/25 instead of 7/21/25. Corrected on site with documentation of error in record. Patient 4,7: The DNR form was incomplete with the physician name not printed in the section provided for physician identification. Corrected on site with new form completed. Patient 23: The Notification of Medicare Non-Coverage was misdated for discharge 11/13/25. Patient was not discharged until 11/14/25.

Upon client record review, 1 of 23 (Patient #8) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 8: The medical record contained a wound care order 11/25/25 with no specification of facility and hospice responsibility.

Upon personnel record review, 1 of 15 (Personnel #13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 13: There was no evidence the agency received a copy of the criminal background check, OIG and sex offender registry prior to patient care. Corrected on site with reception from contracted agency.

Upon patient record review 2 of 16 (Patient #11, #15) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #11- The patient was admitted 11/21/22 and a spiritual assessment was not performed until 11/27/22. Patient #15- The patient was admitted 02/08/22 and a spiritual assessment was not performed until 02/14/22

Upon patient record review, 1 of 16 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1-The patient was admitted 12/11/22 and declined Social Worker and Chaplain services. A spiritual assessment was not performed by the RN. A spiritual assessment is not on record. (corrected on site)

Upon patient record review, 9 of 16 (Patient #1, #2, #4, #7, #9, #10, #11, #12, #16) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications that could affect drug therapy. Patient #1-On 12/20/22 the nurse documents Oxygen was ordered. The medication profile does not include Oxygen. (corrected on site) Patient #2-The medication profile includes Morphine 100mg/5ml .25-1ml to be administered hourly and every three hours prn for pain/dyspnea (discrepancy in frequency of administration). The profile is not specific for differentiating the dosage to be administered. The profile also includes Hydrocodone 5mg-325mg 1 q6h prn pain. (Duplicative medications for pain without differentiation for prn administration). (corrected on site) Patient #4-The medication profile includes Miralax 17 gm powder daily prn constipation. The profile does not include a diluent. On 11/18/22 Spironolactone 1 tab was ordered daily prn for fluid retention. Spironolactone is not on the medication profile. On 11/21/22 the nurse documents the patient has Oxygen available. Oxygen is not on the medication profile. The medication profile has duplicative/unclear dosages of Tylenol for administration. 11/15/22 Tylenol 325 mg 1 tab prn pain (no hourly interval of frequency is specified). Tylenol 650 mg extended release 1 tab as needed for pain is also on the profile (no hourly interval of frequency is specified), there is also no differentiation for administration or maximal allowable daily dosage specified. (corrected on site) Patient #7- On 12/12/22 Valium was ordered 2mg tid X 3 days. The medication was added to the medication profile with a start date of 12/12/22 and an end date of 12/12/22. Morphine is listed on the profile as 20mg/ml .25-1ml q4h prn pain. There are no parameters or differentiation for prn dosage administration. (corrected on site) Patient #9- The medication profile includes Miralax 17 gm powder daily prn constipation. The profile does not include a diluent. (corrected on site) Patient #10-The medication profile includes Morphine 100mg/5ml .25-1ml to be administered hourly prn pain. The profile is not specific for differentiating the dosage to be administered. The profile also includes Tramadol 1 tab po q4h prn pain. (Duplicative medications for pain without differentiation for prn administration). The medication profile also includes Imodium per package instructions prn diarrhea (not specific). (corrected on site) Patient #11- The medication profile includes Morphine 100mg/5ml .25-1ml to be administered hourly prn pain/SOB in nebulizer. The profile is not specific for differentiating the dosage to be administered. The profile also includes Tramadol 1 tab three times daily prn pain. No hourly allowable intervals of frequency is specified. (Duplicative medications for pain without differentiation for prn administration). Miralax 17 gm powder daily for constipation is listed on the profile. The profile does not include a diluent. (corrected on site) Patient #12-On 05/31/22 Imodium 1-2 tablets was ordered daily as needed for diarrhea. It was added to the medication profile as a scheduled medication 4 times daily. On 06/23/22 Senna 8.6 mg 1-2 tabs bid prn constipation was ordered. The medication profile does not include the number of tablets to be administered. Patient #16-Lasix was ordered 11/27/22 40 mg po bid x 3 days. The medication was not updated on the profile

Upon patient record review, 2 of 16 (Patient #1, #11 ) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Patient #1-The patient was admitted on 12/11/22 and refused Social Worker and Chaplain services. A bereavement risk assessment was not performed by the RN. A bereavement risk assessment is not on record. (corrected on site) Patient #11- The patient was admitted 11/21/22 and a Bereavement Risk assessment was not performed until 12/01/22.

Upon patient record review, 9 of 16 (Patient #1, #2, #4, #7, #9, #10, #11, #14, #15) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1- On 12/20/22 the nurse documented Oxygen had been ordered. The plan of care was not updated with orders for Oxygen. (corrected on site) Patient #2-The 12/20/22 plan of care includes Morphine 100mg /5ml .25-1ml to be administered hourly and every three hours prn for pain/dyspnea (discrepancy in frequency of administration). The orders also are not specific for differentiating the dosage to be administered. The record also has Hydrocodone 5mg-325mg 1 q6h prn pain. (Duplicative medications for pain without differentiation for administration). (corrected on site) Patient #4- The 11/15/22 plan of care includes Miralax 17 gm powder daily prn constipation. The orders do not include a diluent. On 11/21/22 the nurse documents the patient has Oxygen available. Oxygen is not on the plan of care. The plan of care has duplicative/unclear dosages of Tylenol for administration. 11/15/22 Tylenol 325 mg 1 tab prn pain ( no hourly interval of frequency is specified). Tylenol 650 mg extended release 1 tab as needed for pain is also on the plan of care ( no hourly interval of frequency is specified). There is also no differentiation for Tylenol administration or maximal allowable daily dosage specified. The plan of care includes orders for SN to teach diabetic care including administration of insulin. The patient is not on insulin. The plan of care includes orders to teach management of rt abdominal drain and assessment of output of drainage system if indicated. The orders are not specific for indications and frequency for abdominal drainage and any limits on amount of fluid that may be drained. (corrected on site) Patient #7-Morphine orders were updated on the plan of care 12/31/22 and written as 20mg/ml .25-1ml q4h prn pain. There are no parameters or differentiation for prn dosage administration. (corrected on site) Patient #9- The 12/12/22 plan of care includes Miralax 17 gm powder daily prn constipation. The orders do not include a diluent. (corrected on site) Patient #10-The 11/23/22 plan of care includes Morphine 100mg /5ml .25-1ml to be administered hourly prn pain. The orders are not specific for differentiating the dosage to be administered. The plan of care was also updated 12/12/22 with orders for Tramadol 1 tab po q4h prn pain. (Duplicative medications for pain without differentiation for prn administration). Imodium was ordered 12/04/22 per package instructions prn diarrhea (not specific). (corrected on site) Patient #11- The 11/21/22 plan of care includes Morphine 100mg /5ml .25-1ml to be administered hourly prn pain/SOB in nebulizer. The profile is not specific for differentiating the dosage to be administered. The plan of care was updated 11/25/22 with orders for Tramadol 1 tab three times daily prn pain. No hourly allowable time intervals for frequency is specified. (Duplicative medications for pain without differentiation for prn administration). Miralax 17 gm powder daily for constipation is listed on the 11/21/22 plan of care. The orders do not not include a diluent. (corrected on site) Patient #14- The record contains orders 12/12/22 to update the plan of care which read: Cleanse decubitus on spine with wound cleanser, pat dry and apply antibiotic ointment. Cover with border dressing . The frequency of wound care is not in the orders. Patient #15- The orders 05/04/22 to update the plan of care read : Insert Foley Cath. The orders are not specific for size, including balloon size.

Upon patient record review, 3 of 16 (Patient #3, #12, #14) 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 #3- The patient was admitted 11/15/22 and receives Chaplain services monthly. Each of the IDG/revised plans of care 11/16/22-12/28/22 only document the Chaplain will visit monthly. There is no documentation regarding the comprehensive assessment findings in regards to patients spiritual preferences and progress towards spiritual outcome/goals from the plan of care. Patient #12- The patient was admitted 05/24/22 and received a Spiritual Care evaluation on 05/26/22. Each of the IDG/revised plans of care 06/01/22 and 06/15/22 only document the Chaplain will visit monthly. There is no documentation regarding the comprehensive assessment findings in regards to patients spiritual preferences and progress towards spiritual outcome/goals from the plan of care. Patient #14-The patient was admitted 12/03/22 and received a Spiritual Care evaluation on 12/06/22. The IDG/revised plan of care 12/14/22 does not contain documentation regarding the comprehensive assessment findings in regards to patients spiritual preferences and spiritual needs to be addressed.

Upon patient record review, 5 of 16 (Patient #1, #5, #6, #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 #1- The nurse is ordered twice weekly. The week of 12/18/22-12/24/22 one visit was made on 12/20/22 and the week of 12/25/22-12/31/22 one visit was made on 12/28/22. There is no documentation regarding the missed visits. Patient #5- The Social Worker is ordered to visit the patient monthly. A visit was not performed in November or December 2022. The social worker documented 11/30/22 the November visit was unable to be made due to caseload. On 12/30/22 the social worker documented unable to complete the visit and will follow up on next visit. Patient #6 -The Social Worker is ordered to visit the patient twice monthly. One visit was performed in November on 11/15/22. On 11/28/22 the social worker documented the visit was unable to be performed due to caseload. One visit was performed in December on 12/13/22. On 12/30/22 the social worker documented unable to complete the visit and will follow up on next visit. Patient #7- The Social Worker is ordered to visit twice monthly. One visit was performed in December 2022 on 12/13/22. On 12/30/22 the social worker documented unable to complete the visit and will follow up on next visit. Patient #8- The Social Worker is ordered to visit twice monthly. One visit was performed in November on 11/09/22. On 11/30/22 the social worker documented the visit was unable to be performed due to caseload.

Upon patient record review, 2 of 16 (Patient #2, #4) did not have evidence that all visit note entries are clear, complete, and accurate. Patient #2- On 01/06/23 The nurse documented Oxygen was placed on the patient for dyspnea and Zofran was administered for nausea. The documentation is not specific for the Oxygen liter flow placed on the patient and the dosage of Zofran that was administered. (late entry correction on site) Patient #4-On 11/16/22 the nurse documented the patient has a Pleurx catheter. This is an error in documentation as the patient has an Aspira abdominal drain in place for ascites.

Upon patient record review, 1 of 16 (Patient #13) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient #13- On 10/04/22 the patient transferred to another Hospice. There is no documentation on record that a transfer summary was sent to the new Hospice.

Upon personnel record review, 1 of 13 (Personnel # 5) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel 5- The personnel record documents the employee received one dose of Pfizer 01-25-22 which is a 2 part vaccine. A second dose and/or medical or religious exemption is not on record.