Every finding on record at Southerncare, Inc.

Upon patient record review 1 of 11 (Patient #7) 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 #7 The patient was admitted on 6/10/21, the spiritual care assessment was completed on 7/8/21.

Upon patient record review, 2 of 11 (Patient #5, 7) 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 #5 The medication profile includes an order for Azelastine 137mcg nasal spray aerosol, spray once daily. The order does not include instructions for one or more nostrils. The medication profile includes orders for cyclosporine 0.05% eye drops, instill 1 dropperette 2 times daily, it does not indicate which eye/s to instill drops into. The medication profile includes orders for nitroglycerine 0.3mg sublingual, give now then every 5 min x 2 if chest pain is not resolved, the order is not clearly indicated as a PRN order. The medication profile includes duplicated orders for Restasis 0.05% 1 dropperette every 12 hours, this is the same as cyclosporine. (All orders corrected on site) Patient #7 The medication profile includes orders for hydrocortisone plus 1% topical cream, apply 1 inch 2 times daily for itching, it does not indicate the location for application. (All orders corrected on site.)

Upon patient record review, 1 of 11 (Patient #9) 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 #9 The patient was admitted on 6/2/22, the bereavement risk assessment was completed on 6/28/22

Upon patient record review, 3 of 11 (Patient #2, 5, 7) 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 The wound care orders for 2/13/23 for "stage III pressure ulcer, clean with wound cleanser, pat dry, apply hydrogel" the site of the wound is not specified. The patient has orders 0n 12/28/22 for Physical Therapy, Evaluate and Treat to help with transfers and bed mobility, the order does not contain an indicated number of treatments. Patient #5 The order for Azelastine 137mcg nasal spray aerosol, spray once daily, does not include instructions for one or more nostrils. The medication order for cyclosporine 0.05% eye drops, instill 1 dropperette 2 times daily, does not indicate which eye/s to instill drops into. The medication order for Restasis 0.05% 1 dropperette every 12 hours, does not indicate which eye/s to instill. The medication order for nitroglycerine 0.3mg sublingual, give now then every 5 min x 2 if chest pain is not resolved, the order is not clearly indicated as a PRN order. (corrected on site) Patient #7 Orders on 6/9/22 for hydrocortisone plus 1% cream apply 1 inch 2 times daily, the order does not include an application site. (corrected on site)

Upon client record review, 1 of 11 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 The plan of care has orders for Spiritual Care evaluation for 1wk1 effective 6/13/21, there is no evidence that a visit was made.

Upon patient record review, 2 of 11 (Patient #1, 4) 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 #1 The aide plan of care includes orders for "linen changes as needed if visibly soiled." (corrected on site) Patient #4 The aid plan of care includes order for "Shampoo hair per patient request." (corrected on site)