Every finding on record at Wiregrass Hospice, LLC

Upon patient record review, 1 of 23 (Patient #21) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient 21: Order on 1/16/25 to discontinue Norco and start oxycodone as needed due to poor pain control, however there was no evidence of follow up by nurse to assess medication effectiveness until 1/20/25. Nursing documentation from visit on Monday, 1/20/25 states patient had no pain relief since last Friday, 1/17/25. During the visit on 1/20/25, oxycodone was discontinued and new order to start Morphine ER and Morphine IR for breakthrough pain. No evidence of nursing follow up to assess effectiveness until visit on 1/23/25.

Upon patient record review 1 of 23 (Patient #4) 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 4: The initial spiritual assessment was completed on 4/24/25 with start of care on 4/11/25.

Upon patient record review 1 of 23 (Patient #3) 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 3: There was no evidence of an initial comprehensive spiritual assessment.

Upon patient record review, 6 of 23 (Patient #2,#5,#6,#10,#13,#17) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 2: Medication profile contained an order for Gavi lax, however there was no diluent instructions. Also, Ibuprofen was ordered as PRN, however order contained no frequency instructions. Both were corrected on site with orders received. Patient 5: During medication reconciliation, the facility and hospice medications did not match. The hospice medication profile contained the medications Loperamide and Trazadone, but the facility medication profile did not. Medical record also contains order for oxygen with no rate or delivery method. Oxygen corrected on site with orders received. Patient 6: Medication profile contained an order for MiraLAX, however there was no diluent instructions. Medication profile also contained oxygen with no delivery method. Both were corrected on site with orders received. Patient 10,13: Medication profile contained oxygen with no delivery method. Corrected on site with orders received. Patient 17: Documented use of DuoNeb treatments on 12/2/25 and 12/4/25, however no evidence on medication profile. Medication profile also contained oxygen with no delivery method. Both were corrected on site with orders received.

Upon patient record review, 1 of 23 (Patient #18) 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 18: Admission on 2/13/25. There was no evidence of an initial bereavement assessment being completed. Corrected on site.

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

Upon patient record review, 2 of 23 (Patient #14,#21) 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 14: No evidence of weekly wound measurements and wound assessments per agency policy 11/20/25 through 12/2/25. Patient 21: Order on 1/16/25 to discontinue Norco and start oxycodone as needed due to poor pain control, however there was no evidence of follow up by nurse until 1/20/25. Nursing documentation from visit on Monday, 1/20/25 states patient had no pain relief since last Friday, 1/17/25. During the visit on 1/20/25, oxycodone was discontinued and new order to start Morphine ER and Morphine IR for breakthrough pain. No evidence of nursing follow up until visit on 1/23/25.

Upon patient record review, 14 of 23 (Patient #2,#3,#4,#5,#6,#7,#8,#9,#12,#14,#15,#16,#17,#18)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: On admission, documented high risk for falls, however there is no plan of care for safety/fall prevention. Also, documented risk for aspiration, however the plan of care was not updated to include problems, goals and interventions related to aspiration precautions. Admitting diagnosis is a neurocognitive disorder and documented dementia, however there is no plan of care for neuro dysfunction. Corrected on site with plan of care updates. Patient 3: Documented dementia on admission, however there is no plan of care for neuro dysfunction. Patient 4: Documented high risk for falls, however there is no plan of care for safety/fall prevention. Corrected on site with plan of care update. Patient 5: Documented high risk for falls on admission, however there is no plan of care for safety/fall prevention. Patient 6: High risk for falls documented from admission, however there is no plan of care for safety/fall prevention. Corrected on site by updating plan of care. Patient 7: Documented high risk for falls, respiratory and cardiac dysfunction from admission, however there is no evidence of problems, goals and interventions. Corrected on site. Patient 8: Documented high risk for falls on admission, however there is no plan of care for safety/fall prevention. Corrected on site by updating plan of care. Patient 9: High risk for falls and respiratory dysfunction documented on admission, however there is no evidence of plan of care for either. Patient 12: Admission documentation identifies high risk for falls and neuro dysfunction, however there is no plan of care for safety/fall prevention or neuro dysfunction. Corrected on site. Patient 14: Documented high risk for falls from admission, however there is no plan of care for safety/fall prevention. Patient 15: Bleeding precautions documented on admission, however there is no plan of care for risk for bleeding. Corrected on site by updating plan of care. Patient 16: Documented high risk for aspiration, endocrine and neuro dysfunction from admission, however there is no evidence of problems, goals and interventions. Corrected on site by updating plan of care. Patient 17: Documented nausea/vomiting, oxygen use, risk for falls, risk for bleeding and anxiety from admission, however there is no evidence of problems, goals and interventions. Corrected on site by updating plan of care. Also, plan of care open for DuoNeb treatments, however no evidence of DuoNeb order. Corrected on site with plan of care updates. Patient 18: Risk for skin breakdown and risk for aspiration were documented on admission, however there was no evidence of plan of care for either issue. Corrected on site by updating plan of care.

Upon patient record review, 6 of 23 (Patient #2,#5,#6,#10,#13,#17) 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 2: An order for Gavi lax with no diluent instructions. Also, Ibuprofen was ordered as PRN, however order contained no frequency instructions. Both were corrected on site with orders received. Patient 5: Medical record also contains order for oxygen with no rate or delivery method. Oxygen corrected on site with orders received. Patient 6: An order for MiraLAX with no diluent instructions. Order for oxygen with no delivery method. Both were corrected on site with orders received. Patient 10,13: Order for oxygen with no delivery method. Corrected on site with orders received. Patient 17: Documented use of DuoNeb treatments on 12/2/25 and 12/4/25, however no evidence of medication order. Order for oxygen with no delivery method. Both were corrected on site with orders received.

Upon patient record review, 13 of 23(Patients #1,#2,#5,#6,#7,#8,#10,#11,#12,#13,#14,#15,#17) 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 1,2: Documented on admission patient use of a wheelchair, but there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 5: Admission identified patient use bed and oxygen, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 6: Nursing documentation upon admission identified patient use of a commode and shower chair, however no evidence of an order for the DME included in the plan of care. Patient 7: Nurse identified on admission patient use of oxygen, however no evidence of an order for the DME included in the plan of care. Patient 8: Admission nurse documents patient use of a bed rails and Geri chair, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 10: Nursing documentation upon admission identified patient use of a bedside commode, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 11: Documented on admission patient use of a bed. Also, on 12/9/25, there was documented use of rollator, however no evidence of DME orders for bed or rollator included in the plan of care. Corrected on site with order received. Patient 12: Documented on admission patient use of bed and shower chair, however there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 13: Nursing documentation identified patient use of wheelchair, nebulizer, walker and bed. There was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 14: Nursing documentation upon admission identified patient use of a commode, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 15: Documented on admission patient use of a walker, but there was no evidence of an order for the DME included in the plan of care. Corrected on site with orders received. Patient 17: Nursing documentation identified patient use of oxygen and nebulizer, however no evidence of an order for the DME included in the plan of care. Corrected on site with orders received.

Upon patient record review, 5 of 23 (Patients #1,#3,#9,#10,#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 1: Plan of care contained active problems, goals, and interventions to be completed by the chaplain; however, chaplain services were discontinued on 11/13/25. Corrected on site by updating plan of care. Patient 3: Plan of care contained active SN task to obtain copy of advance directives, however, the document was received upon admission with paperwork but plan of care was not updated. Patient 9: Plan of care contained active respite problems, goals and interventions from October but had not been updated with level of care change. Patient 10: Plan of care open to obtain copy of advance directives, however copy of advance directives was provided upon admission. Plan of care was not updated. Corrected on site with plan of care update. Patient 14: Dysphasia documented since recert assessment on 10/21/25, however there is no plan of care related to dysphagia. Corrected on site by updating plan of care.

Upon client record review, 2 of 23 (Patient #2,#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: Orders received for PT services, however no evidence visits were completed in the medical record. Patient 8: Order for nurse visit frequency of twice weekly. There was no evidence of second visit made week of 11/2/25.

Upon patient record review, 2 of 23 (Patient #22,#23) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 22,23: Documentation in bereavement activity report states bereaved was receiving mailings. Personnel documented coordination notes that mailings were not being sent due to lack of address. No evidence of attempts to obtain address.

Upon patient record review, 6 of 23 (Patient #3,#5,#7,#8,#9,#12) 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 3: Aide care plan task for hair care with frequency of per patient request. Patient unable to make needs known due to dementia. Also, RN documented axilla wound care with dressing in place. There was no evidence of dressing instructions on the aide care plan. Patient 5: Nursing documentation and plan of care identify patient is a fall risk, however there is no evidence of instructions for fall risk on the aide care plan. Corrected on site. Patient 7: Aide care plan task for transfers with frequency of per request and no evidence patient is cognitively able to make decisions and there was no evidence of instructions for max assist with transfers. Corrected on site. Patient 8: Medication profile contains order for an anticoagulant, however there is no evidence of instructions for bleeding risk on the aide care plan. Corrected on site. Patient 9: Documentation since 11/26/25 states patient is bedbound and no longer able to transfer, however aide care plan task for ambulation and shower provide instructions of standby assist. No evidence of care plan update. Patient 12: Nursing documentation since admission identified patient as a fall risk, however there is no evidence of instructions for fall risk on the aide care plan. Corrected on site.

Upon patient record review 3 of 23 (Patient #3,#4,#5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 3: Order for aide visit once weekly. There was no evidence of visit made week of 11/23/25. Patient 4: Order for aide visits three times weekly. There was only evidence of one visit made week of 11/23/25. Patient 5: Order for aide visit twice weekly. There was no evidence of second visit made week of 11/30/25.

Upon patient record review 1 of 23 (Patient #12) 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 12: There was no evidence of aide supervision until 12/6/25 and first aide visit was 11/17/25.

Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 7: No evidence of orientation of hospice philosophy. Corrected on site by orientation provided.

Upon patient client record review, 1 of 23 (Patient #15) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 15: The election form identified the patient elected to receive the Notification of Hospice Non-Covered items upon admission 4/7/25. There was no evidence the patient received the requested addendum.

Upon patient client record review, 1 of 23 (Patient #8) did not have evidence that each patient record contains Advance Directives. Patient 8: The advanced directive consent noted a living will, however, no evidence of document uploaded as part of medical record.

Upon patient client record review, 2 of 23 (Patient #12,#22) 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 12,22: Incomplete DNR form as physician signed, but physician's name was not printed to identify physician.

Upon patient record review 3 of 16 (Patient #5, #6 and #10) 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. #5-The patient was admitted on 9-22-22. The patient declined Chaplain services. There is no documentation of a completed spiritual assessment performed by the MSW or RN. #6-The patient was admitted on 10-13-22. The patient declined Chaplain services. There is no documentation of a completed spiritual assessment performed by the MSW or RN. #10-The patient was admitted on 11-4-22. The patient declined Chaplain services. There is no documentation of a completed spiritual assessment performed by the MSW or RN.

Upon patient record review, 5 of 16 (Patient #5, #7, #8, #14 and #15) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. #5-MSW visit note on 10-25-22 documents patient took Tylenol for low grade fever to bring fever down. No order for Tylenol on Medication Profile. #7-Medication profile includes haloperidol, without identifying the number of tablets to be taken by patient. Medication profile documents Medrol without a dose. #8-Morphine sulfate .25-1 mL ordered on Medication Profile. No parameters for dosage. Oxygen at 2L PRN via NC ordered on 12-12-22. Oxygen not documented on Medication Profile. #14-Morphine sulfate .25-1 mL ordered on Medication Profile. No parameters for dosage. #15- On 12-05-22 the nurse documented an order was received for Bumex and on 12-14-22 the nurse documented an order was received for Prazosin. Bumex and Prazosin were not added to the medication profile.

Upon patient record review, 4 of 16 (Patient #2, #6, #9 and #14) 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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. #2-The patient was admitted on 5-18-22. The Bereavement Risk Assessment was not completed until 6-7-22. #6-The patient was admitted on 10-13-22. The Bereavement Risk Assessment was not completed until 10-26-22. #9-The patient was admitted on 11-21-22. There was no Bereavement Risk Assessment completed. #14-The patient was admitted on 4-19-22. The Bereavement Risk Assessment was not completed until 5-5-22.

Upon patient record review, 3 of 16 (Patient #7, #8 and #12) 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. #7-Hydrocodone documented on patient Plan of Care, but no pain management goals for Alteration in Comfort. #8-The patient had nausea and vomiting. The Plan of Care was not updated with interventions or goals for Alteration in Comfort. #12-The Chaplain is ordered to visit the patient monthly for three months. Patient/family goals and interventions were not included in the Chaplain orders.

Upon patient record review, 6 of 16 (Patient #5, #6, #7, #8, #12 and #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. #5-MSW visit note on 10-25-22 documents patient took Tylenol for low grade fever to bring fever down. No order for Tylenol on Plan of Care. #6-Plan of Care dated 10-13-22 includes nutritional requirement G-tube Jevity 1.5. Orders are not specific for the G-tube feeding and do not address the management of the G-tube site. #7-Medical Director documented on patient CTI, "She has to have Trilogy (vent dependent practically). Trilogy vent is not included in the plan of care. Foley catheter orders on Plan of Care dated 11-17-22 incomplete. No documentation of catheter size, balloon size, or irrigation solution. Order dated 11-25-22 documents haloperidol. No specificity of number of tablets to be taken by patient. Same order documents Medrol as directed. No specificity to dosing. #8-Morphine sulfate .25-1 mL is ordered on the SOC Plan of Care. There are no parameters for the dosage. Oxygen at 2L PRN via NC ordered on 12-12-22. Oxygen not documented on Plan of Care. #12- The 11-3-22 plan of care includes orders for the Hospice nurse to place an indwelling urinary catheter 20 Fr with 30 cc balloon. May irrigate with 10cc NS. The catheter type (suprapubic) and indications for irrigation are not included in the orders. #15- On 12-05-22 the nurse documented an order was received for Bumex and on 12-14-22 the nurse documented an order was received for Prazosin. The plan of care was not updated with the medication orders.

Upon patient record review, 1 of 16 (Patient #6) 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. #6-Updated comprehensive Plan of Care/IDG documentation on 11-3-22 and 11-17-22 - nursing section was blank and did not address the progress toward outcomes and goals.

Upon client record review, 2 of 16 (Patient #5, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. #5-There is an order dated 10-2-22 for MSW visits for 2M3. There was one MSW visit documented on 10-25-22, but no documentation for a second, missed visit for the month of October. #10-There is no documentation of a missed SN Visit for the week of 11-6-22 -- 11-12-22. One visit was performed during this week. SN visit frequency orders are 2W3 (not following visit frequency).

Upon patient record review 1 of 16 (Patient #12) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. #12-On 11-06-22 a referral was made to the volunteer coordinator to make contact with the family as they would like a volunteer for errands. The record does not include documentation that the family was contacted regarding the need.

Upon patient record review, 4 of 16 (Patient #6, #7, #9 and #12) did not have evidence that all entries are clear, complete, and accurate. #6-The Missed SN Visit note dated 10-17-22 documented, "Offer to reschedule visit was declined." It is unclear why missed visit couldn't be made. #7-The RN Note dated 11-30 documents excoriated buttocks with scant bleeding. There is no specific wound descriptor. #9-The RN documented Aide Supervision on visits dated 11-28-22 and 11-30-22. There is Missed Visit documentation from the Aide for both of those dates. The Aide had not made visits to the patient prior to those documented supervision visits (documentation discrepancy). #12-The Chaplain visit note on 11-15-22 contains a discrepancy in documentation. The narrative portion of the note documents the patient refused an in person visit and the Chaplain prayed with the patient over the phone. The visit is also marked as a billable in person visit with time in and time out and drive time.

Upon patient record review, 1 of 16 (Patient #11) 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. #11-On 09-14-22 the patient transferred to another Hospice. There was no evidence in the patient record that a transfer summary was forwarded to the facility.

Upon patient record review, 1 of 16 (Patient #10) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested #10-There is no evidence in the patient record that a copy of the hospice discharge summary was forwarded to the attending physician.

Upon patient record review, 1 of 16 (Patient #10) did not have evidence that the discharge summary includes all required information. #10-The computer-generated Discharge Summary on record did not include a complete summary of the patient's stay. The summary did not include treatment, symptom, or pain management details, or a brief description of services provided. No specific reason for revocation was included in the summary.