Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 14 (Patient #6) 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 #6: Oxygen is on the medication profile but there is no care plan goals and interventions for oxygen safety. Corrected on site.

Upon home visit observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: Upon observation during the home visit, The nurse cleaned his equipment, did not allow the required 2 minute drying time required on the Santi-Wipe package, and returned it to his nursing bag. In addition, the nurse did not wash his hands after removing his gloves and then entering his nursing bag. Corrected on site.

Upon patient record review 3 of 14 (Patient #8,#9,#10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #8:The aide care plan states nail care is to be completed weekly. Nail care is completed multiple times per week in December 2024 to January 8th of 2025. In addition, a shampoo was to be completed weekly. Shampooing was completed multiple times per week during 2 weeks in December 2024. Corrected on site. Patient #9:The aide care plan states hair care and shaving weekly. Both are marked completed multiple times per week and on every aide visit in December 2024 to January 8th 2025. Corrected on site. Patient #10:The aide care plan states nail care weekly. The aide completed nail care on every visit multiple times per week in December 2024 to January 8th 2025. In addition, during the home visit interview, the aide stated she shampoos the patients hair weekly on Fridays. Weekly shampoo is not on the aide care plan. Corrected on site.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Volunteer activity for 2024 was 4%.

Based on clinical record review and staff interviews, it was determined that the agency failed to update Patient (P#1) plan of care (POC) for gastrostomy feeding tube (G-Tube) care, for one of three (3) sampled patients. --- The Findings include: Review of the Skilled Nurse (SN) assessment and Plan of Care (POC) dated 10/13/22, revealed that P#1 had gastrostomy tube (G-tube). In a review of the clinical record, it was discovered that the physician order written to change G-tube, did not specify the size of the catheter needed. On 11/30/22 at 2:00 p.m., an interview was conducted with the Case Manager (CM), who stated that there was no G-tube size written in the physicians order to change the catheter care. During an interview on 11/30/22, at 2:50 p.m., the Administrator confirmed that the agency did not have G-tube size on physicians order.

Based on clinical record review and staff interviews, it was determined that the agency failed to transcribe clearly the physicians verbal order for gastrostomy catheter care size, for one of three (3) sampled patients (P#1). --- The Findings include: Review of the Skilled Nurse (SN) assessment, notes, and physicians order dated 10/13/22, revealed that P#1 had gastrostomy tube (G-tube). In a review of the clinical record, it was discovered that the physicians verbal order written by Registered Nurse (RN) AA, was not clear and did not specify the size of catheter needed to change the G-tube. On 11/30/22, at 1:30 p.m., an interview was conducted with (RN) AA, stated that she forgot to include the size of the G-tube on physicians order, plan of care, and nurses notes. On 11/30/22, at 2:00 p.m., an interview was conducted with the Case Manager (CM), who stated that there was no G-tube size written on physicians order to change catheter care. During an interview on 11/30/22, at 2:50 p.m., the Administrator confirmed that the agency did not have G-tube catheter size on physicians order.

Based on clinical record review, family, and staff interviews, it was revealed that the agency failed to supply the gastrostomy tube (G-tube) when patient needed it, for one (1) of three (3) sampled patients (P#1). --- The Findings include: On 11/30/22 at 1:30 p.m., an interview was conducted with Registered Nurse (RN) AA, revealed that the family of P#1 called on 10/13/22, and wanted (RN) AA, to come out to change G-tube because it was leaking. The (RN) AA, made the home visit and changed the GT. On 10/18/22, P#1s family called and reported the GT was leaking again and (RN) AA, made home visit. She stated physician ordered a bigger size catheter. She informed P#1s family she would revisit on 10/18/22, with supplies. (RN) AA, stated she failed to return with supplies, nor did she call the family to inform them the G-tube size was not available in the agency supplies and would need to be order. On 10/19/22, (RN) AA, made a visit and changed the G-tube. On 11/30/22 at 2:00 p.m., an interview was conducted with the Administrator, who confirmed the agency did not have the G-tube size in their supplies and the agency had to order the correct size for P#1. On 11/30/22, at 2:35 p.m., an interview was conducted with P#1s wife, who stated that she called the agency on 10/13/22, and reported the patients G-tube was leaking with difficulty flushing. (RN) AA, did home visit. On 10/18/22, P#1s wife reported to the agency that P#1 G-tube was leaking again. (RN) AA, went with order from physician to insert larger G-tube. (RN) AA, informed P#1s wife that she would obtain needed supplies and revisit however, (RN) AA, did not return nor call family. Review of nurse's note dated on 10/19/22, (RN) AA, visited P#1 and removed old G-tube and inserted new G-tube. On 11/30/22 at 2:00 p.m., the wife confirmed sometimes the agency have had problems with their supplies.

Upon patient record review, 1 of 13 (Patient #13) 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 #13 The nursing visits 11/29/21-12/2/21 indicate the patient is using oxygen however it is not on the medication profile

Upon patient record review, 3 of 13 (Patient #9, 10, 12) 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. Patient #9 The 1/20/22 plan of care includes diagnosis of Type II DM and medication profile indicates the patient is on sliding scale insulin however no intervention/goals related to DM noted on the plan of care to date. The 12/2/21 nursing note indicates patient has a 16Fr indwelling catheter managed by the facility however no interventions or goals related to the alteration in urinary status included in the plan of care. Patient #10 The 1/13/22 SOC assessment indicated patient has a s/p Foley. The plan of care did not contain interventions or goals related to the alteration in urinary status. Patient #12 The 12/3/21 nursing note indicates patient has a 16Fr indwelling catheter managed by the CG however the plan of care did not contain interventions or goals related to the alteration in urinary status.

Upon patient record review, 10 of 13 (Patient #2, 3, 4, 5, 6, 8, 9, 10, 12, 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 medications and treatments. Patient #2 Physician orders on 12/27/21, 1/24/22, and 3/1/22 for wound care allows for the caregiver to provide PRN dressing changes without a reason for the PRN. Patient #3 The 2/21/22 physician order for wound care includes SN to instruct CG to change every 7 days and PRN without a reason for the PRN. Patient #4 The 2/7/22 physician order for wound care is incomplete - reads SN to change dressing to PU Stage 1 located, irrigate with, cleanse with, apply cover with using clean technique, change q days. SN to perform and instruct CG. The 2/15/21 physician order allows for the caregiver to provide PRN dressing changes without a reason for the PRN. Patient #5 The 1/14/22 physician order for wound care allows for the caregiver to provide PRN dressing changes without a reason for the PRN. Patient #6 The 1/18/22 plan of care order for R post flank wound care allows for the caregiver to provide PRN dressing changes without a reason for the PRN. Patient #8 The 2/2/22 plan of care reads SN to provide instructions related to wound care which is incomplete/lacks details. There is missing evidence of wound care orders for wound on sternum. Patient #9 The 12/2/21 nursing note indicates patient has a 16Fr indwelling catheter managed by the facility however no Foley care indicated on the plan of care to date. Patient #10 The 1/13/22 SOC assessment indicated patient has a s/p Foley placed on 1/13/22 and to be changed q60d by facility staff however there are no orders related to catheter change on the plan of care to date. Patient #12 The 12/2/21 nursing note indicates patient has a 16Fr indwelling catheter managed by the CG however no Foley care indicated on the plan of care to date. Patient #13 Patient #13 The nursing visits 11/29/21-12/2/21 indicate the patient is using oxygen however there is no associated order included on plan of care to date.

Upon client record review, 1 of 13 (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 1/27/22 order for PT eval has not been completed to date with no evidence of rationale for delay/communication regarding delay.

Upon patient record review, 2 of 9 applicable (Patient #3,7) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #3 On the 2/22/22 aide visit the aide did not perform the assigned task of linen change Patient #7 On the 2/21/22 aide visit the aide did not perform the assigned task of make bed.

Upon patient client record review, 3 of 13 (Patient #2, 3, 9) 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. Patient #2 The 3/1/22 MD order written by the nurse contains no credentials with the associated signature and date. Patient #3 The 2/21/22 aide visit note contains no credentials with the associated signature and date. Patient #9 The 2/28/22 aide visit note contains no credentials with the associated signature and date.