Every finding on record at Southerncare, Inc.

Upon patient record review 1 of 27 records (Patient #11) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #11: There was not evidence of a spiritual assessment.

Upon patient record review, 5 of 27 records (Patient #1,#4,#6,#10,#20) 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 #1: The medication profile indicated for Lasix 40mg 1 prn for swelling and Lasix 40mg, 1 q am. Corrected on site. Patient #4. The medication profile contained Oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #6: The record included Acetaminophen 650mg rectal supp, 1 q4h prn for fever. There was not evidence of a parameter for the fever. Corrected on site. In addition oxygen was on the medication profile at 4L/min continuously. The record indicated that the patient was not using her oxygen since 6/30/23. Corrected on site. Patient #10. The medication profile contained Oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #20: The medication profile includes Oxygen 2-4 liters prn dyspnea. A route is not listed. The profile contains orders for Lorazepam 0.5 mg .5-1tablet q6h prn dyspnea effective 06/26/23. The medication was discontinued on 07/07/23 and remains current on the profile. The profile includes Ipratropium/.5mg/Albuterol 3mg (2.5mg base/3ml nebulization) dosage is listed as "per instructions" q4 h prn Sob/wheezing(dosage not specific). (corrected on site)

Upon patient record review, 2 of 27 records (Patient #5,#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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan. Patient #5: The patient was admitted on 4/25/23. The record revealed that the bereavement assessment was not completed until 5/10/23. Patient #11: The patient was admitted on 12/19/22. The record revealed that the bereavement assessment was not completed until 12/27/22.

Upon patient record review, 4 of 27 records (Patient #2,#3,#4,#12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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: The record indicated that the patient was a Full code and has not yet prepared end of life decisions including funeral plans. There was not evidence that the plan of care reflected goals and interventions related to end of life preparations. Corrected on site. Patient #3: Documentation by the social worker dated 6/22/23 indicated that final arrangements were complete and that the patient had completed an Advance Directive. There was not evidence that the plan of care was revised to reflect the changed code status. Patient #4: The patient was admitted with a diagnosis of Alzheimer's Disease, late onset. There was not evidence that the plan of care reflected goals and interventions related to the patient's neurological disease. Corrected on site. Patient #12: The record indicated that the patient was a Full code and has not yet prepared end of life decisions including funeral plans. There was not evidence that the plan of care reflected goals and interventions related to end of life preparations. Corrected on site.

Upon patient record review, 1 of 27 records (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 rather than be solely a response to a crisis. Patient #6: The visit frequency for the social worker and the spiritual care counselor was 1 prn to evaluate. Corrected on site.

Upon patient record review, 4 of 27 records (Patient #4,#6,#10,#20) 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 #4. The record contained an order for Oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #6: The record included Acetaminophen 650mg rectal supp, 1 q4h prn for fever. There was not evidence of a parameter for the fever. Corrected on site. In addition, there was an order for oxygen at 4L/min continuously. The record indicated that the patient was not using her oxygen since 6/30/23. Corrected on site. Patient #10. The record contained an order for Oxygen 2L/min prn SOB. There was not evidence of a route. Corrected on site. Patient #20: On admission 05/31/23 the nurse documents the patient has a port. The plan of care does not address management of the port. On 07/03/23 the nurse wrote orders to update the plan of care which read: Skilled nurse to place Foley catheter for comfort. The orders do not address the size/balloon size and management of the Foley. The plan of care includes Oxygen 2-4 liters prn dyspnea. A route is not listed. The plan of care contains orders for Lorazepam 0.5 mg .5-1tablet q6h prn dyspnea effective 06/26/23. The Lorazepam tablets were discontinued when sublingual Lorazepam was ordered on 07/07/23. Orders were not written to update the plan of care to discontinue the Lorazepam tablets. The plan of care includes Ipratropium/.5mg/Albuterol 3mg (2.5mg base/3ml nebulization) dosage is listed as "per instructions" q4 h prn Sob/wheezing(dosage not specific) The plan of care contains orders that the Facility nurse may perform pulse oximetry. The orders were not applicable to the plan of care as the patient did not reside in a Facility. (corrected on site)

Upon patient record review, 1 of 27 records (Patient #6) 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 #6: The record indicated that equipment was present including oxygen supplies, a hospital bed and wheelchair. There was not evidence that any equipment was included in the plan of care. Corrected on site.

Upon client record review, 4 of 27 records (Patient #11,#20,#22,#24) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #11: The spiritual care counselor entered missed visit documentation, dated 5/24/23, that indicated the reason for missing the visit was that the patient was in respite. Patient #20:On 06/01/23 the Chaplain was ordered to visit once monthly. Routine visits were performed twice in July on 07/06/23 and 07/10/23. On 06/01/23 the Social Worker was ordered to visit once monthly. Routine visits were performed twice in July on 07/06/23 and 07/17/23. (orders clarified corrected on site). Patient #22: Chaplain was ordered to visit once monthly in June effective 06/01/23. Routine visits were performed twice in June on 06/05/23 and 06/16/23. Effective 06/01/23 Social worker was ordered to visit once monthly. Routine visits were performed on 06/05/23 and 06/30/23. (orders clarified corrected on site). Patient #24: Social Worker was ordered to visit once monthly effective 06/14/23. The Social Worker visited twice in June on 06/16/23 and 06/26/23.(orders clarified corrected on site).

Upon patient record review, 2 of 27 records (Patient #5,#6) did not have evidence in the patient record that hospice aide assignments and duties are: • Written patient care instructions, including alerts and precautions for a hospice aide that 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 specifically 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 #5: The record indicated that the patient was on Eliquis 5mg BID. There was not evidence that the aide plan of care included bleeding precautions. Corrected on site. Patient #6: The aide plan of care contained numerous tasks assigned for the aide to perform. There was not evidence of a frequency for any of the tasks. Corrected on site.

Upon patient record review 5 of 27 records (Patient #2,#3,#5,#9,#10) did not have evidence of documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #2: The aide plan of care indicated to provide nail care and shampoo weekly. The record indicated that nail care was provided at each visit and a shampoo was performed 2 out of 3 days per week for the weeks of 7/2/23-7/8/23 and 7/9/23-7/15/23. Patient #3:The aide plan of care indicated to transfer patient from bed to chair every visit and to transfer from chair to bed every visit. Also to shampoo 3x/week. (The aide visit frequency was 5x/week). The documentation in many visits indicated that the transfer was "per frequency, not needed." Also shampoo was performed at all visits from 5/30/23 to current. Patient #5: The aide plan of care indicated to provide the tasks of shave, shampoo and nail care weekly. Aide documentation revealed that these tasks were conducted at all visits. Patient #9: Hair care, shampoo, and bathing were all tasks on the aide plan of care to be conducted at every visit. On 6/5/23 and 7/10/23, hair care and shampoo were listed as "per frequency, not needed." For the date of 6/2/23, bathing was listed as "per frequency, not needed." In addition, there were numerous notations for tasks where the aide documentation indicated that the task was not completed per patient preference. There was not documentation that the patient was functionally and cognitively able to make the decision. Patient #10: The task of walker was indicated to be performed at every visit. From 7/7/23 to 7/19/23 (Day of death), the aide documented, "per frequency, not needed."

Upon patient record review 1 of 27 records (Patient #20) did not have evidence of 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 #20-The patient receives Aide services and there are no Aide supervisory visits on record between 06/29/23 and 07/17/23.

Upon patient record review, 1 of 27 records (Patient #2) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #2: The record indicated that the certification of terminal illness was signed by a nurse practitioner.

Upon patient client record review, 1 of 27 records (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1: Documentation by the social worker dated 7/5/23 indicated that final arrangements were complete and that the patient was no longer a full code. There was not evidence that Advance Directive documentation was added to the record.

Upon patient client record review, 1 of 27 records (Patient #15) did not evidence that each patient record contains physician orders. Patient #15: The patient was discharged for no longer meeting hospice criteria. The record indicated that the discharge order was by the attending physician, not the medical director.

Upon patient client record review, 1 of 27 records (Patient #20) 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 #20-On 07/03/23 the nurse documents a Foley catheter was placed today. The documentation is not specific for the catheter size/balloon size. (late entry clarification corrected on site)

Upon client record review, 1 of 27 records (Patient #13) 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 Patient #13: The record indicated that the patient revoked hospice services on 6/5/23. A document dated 6/5/23 that contained an area to be completed if the discharge summary was sent to the physician, was blank. A coordination note dated 6/6/23 indicated that the discharge summary was faxed. There was not evidence of to whom or where this document was faxed.

Upon client record review, 1 of 27 records (Patient #4) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient #4: The frequency for the skilled nurse was 2w1, 1w6, 2w1, 1w5. There was not evidence that 2 visits were made for week 8. In addition, the visit frequency for the social worker was for an evaluation, then 1m1. The patient was admitted 5/1/23. The evaluation was conducted, however there was not evidence of a visit after the initial evaluation. Also, the record indicated visits by the volunteer on 5/5/23 and 6/26/23. There was not evidence of an order. Corrected on site.