Every finding on record at Southerncare, Inc.

Upon patient record review, 3 of 12 (Patient #8, #9 and #12) 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. Patient #8 RN visit on 9/15/21 documented Tylenol used for pain. No evidence of Tylenol on medication profile. Patient #9 RN visit on 10/7/21 documented oxygen 10L in use. No evidence of oxygen on medication profile. Patient #12 RN visit on 9/10/21 documented oxygen 10L in use. No evidence of oxygen on medication profile.

Upon patient record review, 2 of 13 (Patient #2 and #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient #2 admitted on 7/8/21, no evidence a bereavement risk assessment was completed. Patient #6 admitted on 7/13/21, bereavement risk assessment completed on 8/10/21.

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

Upon patient record review, 1 of 13 (Patient #3) 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 #5 RN visits from 9/13/21, 9/17/21, 9/20/21 and 9/24/21 did not provide wound measurements. Agency practice is to document weekly measurements of the wound.

Upon patient record review, 3 of 13 (Patient #2, #3, and #4) 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 mechanical soft diet and difficulty swallowing. No evidence of goals and interventions for identified aspiration risk. Patient #3 RN visits documented condom catheter in place. Patient on Warfarin then Aspirin. Patient on soft mechanical diet with aspiration precautions on aide care plan. No evidence of goals and interventions for identified genitourinary problems, aspiration risk, or bleeding risk. Patient #4 on enteral feeding and NPO. No evidence of goals and interventions for identified aspiration risk.

Upon patient record review, 8 of 13 (Patient #1, #2, #3, #4, #5, #6, #10 and #13) 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. Patients #1, #2, #3, #4, #5, #6, #10 and #13 plan of care included NP frequency of 1prn as requested by the IDG for symptom management.

Upon patient record review, 6 of 13 (Patient #3, #5, #7, #8, #9 and #12) 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 #3 RN visits on 9/27/21, 10/4/21 and 10/11/21 documented condom catheter in place. No evidence of an order for condom catheter. Patient #5 wound care order on 8/27/21 and order to discontinue wound care on 9/27/21 did not include the location of the wound. Patient with multiple wounds. Patient #7 order on 8/15/21 for Ativan 0.5mg tab 4 times per day prn and Oxycodone/Acetaminophen 7.5mg/325mg Q6h prn. Both medications did not include a reason for prn. Patient #8 RN visit on 9/15/21 documented Tylenol for pain. No evidence of an order for Tylenol. Patient #9 RN visit on 10/7/21 documented foley catheter and oxygen in use. No evidence of orders for foley placement or oxygen. Patient #12 RN visit on 9/10/21 documented foley catheter and oxygen in use. No evidence of orders for foley placement or oxygen.

Upon patient record review, 4 of 13 (Patient #2, #3, #11 and #13) 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 #2 order on 7/15/21 for Oxygen 2-5LPM NC prn sob. No evidence oxygen DME included in plan of care. Patient #3 order on 9/13/21 for Oxygen 2-5LPM NC prn sob and RN visits on 9/15/21, 9/19/21, and 9/27/21 documented Hoyer lift in use for transfers. No evidence of Oxygen or Hoyer DME included in the plan of care. Patient #11 order 8/4/21 for Oxygen 2LPM NC prn dyspnea. No evidence of Oxygen DME included in the plan of care. Patient #13 order on 5/18/21 for Oxygen 2-5LPM NC prn dyspnea. No evidence of Oxygen DME included in the plan of care.

Upon patient record review, 5 of 10 applicable (Patient #2, #3, #4, #8 and #10) 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 #2 on mechanical soft diet, RN documented on 7/9/21 no longer takes daily scheduled meds due to difficulty swallowing. No evidence of aspiration precautions on aide care plan. Patient #3 on Warfarin, then Aspirin. No evidence of bleeding precautions on aide care plan. Patient #4 on enteral feeds with dysphasia. No evidence of aspiration precautions on aide care plan. Patient #8 identified as high risk for falls and on oxygen. No evidence of fall risk or oxygen precautions on aide care plan. Aide care plan included partial bed bath 2x/week and shower weekly. Aide visit frequency ordered as 2x/week. Patient #10 with dysphagia. No evidence of aspiration precautions on aide care plan.

Upon patient record review 4 of 10 applicable (Patient #1, #4, #6 and #8) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the interdisciplinary group and included in the plan of care Patient #1 aide care plan dated 7/15/21 included shampoo Monday and Friday. Aide visits on 9/22/21 and 10/6/21 documented shampoo completed. Patient #4 order on 7/30/21 for aide frequency of 2w12, 1w1. Aide visit made on 10/5/21, no evidence of a second visit or refusal of a second visit this week. Patient #6 aide care plan dated 8/3/21 included clean/file nails weekly on Thursday, Bathing bed bath weekly on Tuesday, and bathing shower weekly on Thursday. Aide visit on 10/11/21 documented clean/file nails and bed bath completed. Aide visit on 10/12/21 documented clean/file nails performed. Aide visit on 10/13/21 documented clean/file nails and bed bath performed. Aide visit on 10/14/21 documented shower and bed bath performed. Aide visit on 10/15/21 documented clean/file nails and bed bath performed. Patient #8 aide visit frequency ordered on 7/17/21 as 2x/week. Aide visits made on 8/25/21, 9/15/21, and 10/5/21, no evidence of a second visit these weeks or refusal of visit these weeks.

Upon patient record review, 1 of 11 applicable (Patient #8) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #8 recertification of illness on 10/6/21 documented primary diagnosis of COPD and heart disease. Plan of care documented terminal diagnosis of COPD and Heart Failure as a secondary diagnosis.

Upon patient record review, 1 of 2 applicable (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 order on 8/3/21 for spiritual care frequency effective 8/1/21 of 1 visit twice a month and 3prn. Spiritual care visits made on 9/3/21, 9/17/21, and 9/28/21.