Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 14 (Patient #10) 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 10: Plan of care has only 3 PRN visits per month ordered for the SW. No evidence that routine visits were ordered. Corrected during survey.

Upon client record review, 4 of 14 (Patient #5,7,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: Plan of care has chaplain frequency as 2 routine visits in 30 days. Patient received 3 routine visits for the mon the of April. No evidence that an order was received to increase visits for the month. Patient 7: Order written on 03/18 to remove SW visits from the plan of care due the patient requesting to stop visits. Patient received a SW visit on 04/19/2024. No evidence that an order was received to restart visits. Patient 8: Plan of care has volunteer visit frequency as 4 visits every 30 days. Patient received 5 visits for the month of April. No evidence that an order was received to increase visit for the month. Patient 9: Plan of care has SC and SW frequency as 2 routine visits in 30 days. Patient received 3 routine visits for the month the of April from the SC and the SW. No evidence that an order was received to increase visits for the month.

Upon patient record review 2 of 14 (Patient #3, #7) 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 3: Aide plan of care has orders for the aide to change linens weekly and wash hair with every visit. Aide documentation shows that the hospice aide did not provided those treatments weekly as ordered. Patient 7: Aide plan of care has orders for the aide to clean/file nails to be completed weekly. Aide documentation shows that the hospice aide provided those treatments at every visit instead of weekly as ordered.

Upon client record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient 11 and 12: No evidence that a discharge summary was completed.

Upon client record review, 1 of 14 (Patient #1) 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 1: POC has SC frequency ordered as 2 times every 30 days. Patient received 3 visits for the month of April, 04/04, 04/17, 04/30. No evidence that an order was received to increase visit frequency. Order for volunteer referral made on 04/05/2024. No evidence that VC assessment was completed or that a volunteer plan of care was done.