Every finding on record at Southern Comfort Hospice, LLC

Based on record reviews and staff interview it was determined the agency failed to include a qualified Doctor of Medicine, with evidence of a signature, in the Interdisciplinary Group (IDG) meetings for two Patients (P) (P2, P8) of 10 current patients records reviewed (P1, P2, P4, P8, P9, P10, P11, P12, P13, P14). --- Findings include: 1. Review of the document titled IDG Comprehensive Assessment Details dated August 30, 2023, failed to indicate the signature of the Medical Doctor (MD) ensuring participation of a qualified Doctor of Medicine in the creation and review of the plan of care (POC) for P2. 2. Review of the document titled IDG Comprehensive Assessment Details dated April 5, 2023 failed to indicate the signature of the MD ensuring participation of a qualified Doctor of Medicine in the creation and review of the POC for P8. Review of the document titled Job Description Medical Director, dated November 7, 2019, signed by MD BB reveals the following: Essential Functions: The duties and responsibilities of the Medical Director include, but are not limited to: Participates in the establishment and implementation of the plan of care, which is coordinated with the attending physician and IDG prior to providing care. Participates in conjunction with the attending physician and IDG to review, update and sign the plan of care when changes are made and at least every 15 days. During an interview on September 13, 2023 at 10:45 am, the Administrator revealed she was aware of the absence of the MD signatures on the IDG meetings for P2 and P8. The Administrator verbalized ";We do the IDG meetings remotely over the computer". The Administrator further revealed the MD has problems signing electronically. She stated she signs as the Registered Nurse and the system is then locked and will not allow any other signatures and is aware this is a glitch with the Electronic Medical System (EMR) that needs to be addressed.

Based on observation, and staff interviews, it was determined that the hospice agency failed to follow accepted standards of practice to prevent the transmission of infection by not changing the water during bathing for one patient (P) (P4) of three home visits (P1, P2, P4). --- Findings include: During a home visit with P4 at 9:30 am on 9/12/2023, surveyor observed Certified Nursing Assistant (CNA) GG perform a bed bath. CNA GG brought one basin of clean water to the bedside and proceeded to wash upper torso of P4. She rinsed the washcloth in the basin and washed her legs and feet. She then placed a second wash cloth into the same basin of water and proceeded to wash the vaginal area and her buttocks. CNA GG failed to change the water after she washed P4s feet and before she washed the vaginal area. During an interview with Administrator on 9/13/2023 at approximately 10:45 am, the Administrator revealed that the initial home visit with each new CNA is accompanied by a Registered Nurse (RN) to observe and assess the CNA competencies while he or she is performing personal patient care and that the observation was documented but was not able to find at the time of the survey. Administrator further stated that the initial home visit to assess CNA GG competencies did not include a bed bath but assistance with a shower was observed instead. Administrator stated that observation of CNA GG performing a bed bath has not been assessed. During an interview with CNA GG and the Administrator on 9/13/2023, at approximately 11:10 am revealed that they were unaware of the need to change water after washing a patients feet and before washing the perineal area and buttock areas. The Administrator confirmed there was no policy specifically related to procedures involved in performing bed baths or other personal patient hygiene.

Based on record reviews, staff interview and review of the agency policy titled ";Bereavement Care Planning", it was determined the agency failed to provide an initial and ongoing bereavement plan of care (POC) for three patients (P5, P6, P15) of three bereavement records reviewed (P5, P6, P15). --- Findings include: Review of the undated policy titled ";Bereavement Care Planning" (1, 2, 5, 6) revealed the following: Procedures: 1. During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social, and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patients death. 2. Findings from the initial bereavement assessment are incorporated into the patients plan of care and considered in the bereavement plan of care. 5. The bereavement plan of care reflects the assessed needs of the bereaved and notes the kind of bereavement services to be offered and the frequency of delivery. 6. The Bereavement services listed in the patients bereavement plan of care may include, but not limited to bereavement visits and counseling, mailing and/or telephone contact. 1. Record review for P5 failed to indicate initial and ongoing bereavement assessments and a bereavement care plan with goals and interventions for each patient referenced. The agency failed to make available bereavement services outlining the kind of bereavement services offered and frequency of service delivery in each patients initial and ongoing POC. 2. Record review for P6 failed to indicate initial and ongoing bereavement assessments and a bereavement care plan with goals and interventions for each patient referenced. The agency failed to make available bereavement services outlining the kind of bereavement services offered and frequency of service delivery in each patients initial and ongoing POC. 3. Record review for P15 failed to indicate initial and ongoing bereavement assessments and a bereavement care plan with goals and interventions for each patient referenced. The agency failed to make available bereavement services outlining the kind of bereavement services offered and frequency of service delivery in each patients initial and ongoing POC. During an interview on September 13, 2023 at 10:30 am, the Administrator revealed she was aware that bereavement assessments were not completed. She stated her agency has struggled to maintain a full time Chaplain for bereavement services and the Chaplains that she had hired did not/would not complete documentation for bereavement.