Every finding on record at Southern Ohio Medical Center

Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record for HosInpt#2, it was noted that the patient was admitted to the Inpatient Unit for altered mental status, however the initial assessment documented the “patient was alert, and oriented x3, and behavior appropriate for situation.” The clinician did not document the areas of patient orientation in the section titled orientation [i.e. person, place, time, name, age]. This observation was reviewed with the leadership team.

Observed in Record Review. In 3 of 3 patient records reviewed, the Hospice pharmacy surveyor noted that the organization had not completed a post death bereavement assessment on these patients, including development of a meaningful care plan. The assessment is a requirement based on organization policy. This omission was validated with Hospice at the time of the survey.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization did not ensure the comprehensive assessment update included all required information. For example, a review of the interdisciplinary group meeting notes for HosRRNHV#2, revealed that the following information was not documented by any member of the interdisciplinary team: changes since the last updated assessment, response to care, treatment, and services, and progress toward goals. This observation was reviewed with the leadership team.

Observed in Record Review. In 1 of 2 patient records reviewed, the written plan of care is based on the patient goals and the timeframes required to meet those goals. In HOSRRLiveDC#1, the surveyor noted the plan of care did not have timeframes for achieving those goals. For example, patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below this level. Patient self-identified pain goal is 3/10; Patient will exhibit a decrease in pain-related behaviors; patient/caregiver will verbalize understanding of oxygen safety and use of equipment. This was discussed with the clinical manager. Observed in Record Review. In 3 of 17 patient records, it was noted that the organization did not ensure goals were individualized to the patient’s needs and condition. For example, during the review of the medical record for HosInpt#1, it was noted that the patient was admitted to the inpatient unit for pain and symptom management. The plan of care included the following goal statement: Patient will report pain using a standardized pain scale, establish a self-identified pain goal, and report/demonstrate that pain is managed at or below this level. Patient self-identified pain goal is 2. The goal statement did not include a time frame for goal achievement. Example #2: During a review of the medical record for HosRRHV#2, it was noted that the patient's terminal illness diagnosis was Chronic Obstructive Pulmonary Disease. The plan of care included the following goal statement: Patient will remain free of signs of respiratory distress and/or report dyspnea is managed at acceptable level of zero. The goal statement did not include a time frame for goal achievement. Example #3: During a review of the medical record for HosRRHV#3, it was noted that the patient's terminal illness diagnosis was Chronic combined systolic and diastolic heart failure. The plan of care included the following goal statement: Patient will remain free of signs of respiratory distress and/or report dyspnea is managed at acceptable level of 4/10. The goal statement did not include a time frame for goal achievement. This observation was reviewed with the agency leadership team.

Observed in Data Session. The organization did not take action when it did not achieve planned improvements. For example, the performance improvement goal for the organization's fall prevention program was to achieve zero falls. The patient falls total for the 1st quarter of 2025 was equal to eight. There was no documented evidence that a performance improvement plan related to the fall prevention program was implemented. This observation was reviewed with the organization's leadership team.

Observed in Record Review. In 3 of 3 patient records reviewed, the hospice pharmacy surveyor noted that the bereavement care plans did not include specific, individualized goals and interventions, based on a post-death assessment as required Therefore, the timing and frequency were the same or very similar for all levels of bereavement risk The lack of individualized care plans was validated with hospice clinical managers and social work at the time of the survey.

Observed in Medication Management Tracer. During the medication management session with a focus on the hospice written policy and procedure for management and disposal of controlled drugs to be followed by the patient/caregiver, the Hospice pharmacist surveyor noted that what was provided in the patient care booklet to each patient/caregiver on admission was only a summary of the medication accountability policy rather than the policy itself as required to be provided by the CoP outlined in this standard. This omission was validated with Hospice management at then time of the survey.

Observed in Building Tour. A conduit with data cabling was unsealed with an approved fire stop material in the ceiling space of the fire rated storeroom / hallway. Observed by the Administrative Director of Plant Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. Electric cabling was resting on sprinkler piping in the hallway ceiling space by the kitchen. Observed by the Administrative Director of Plant Operations. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Document Review. The 2025 kitchen suppression testing documents did not include the required NFPA code edition used to conduct the testing. Observed by the Administrative Director of Plant Operations.