Every finding on record at Southerncare, Inc.

Upon patient record review, 4 of 19 (Patient #1,2,3,4) 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 contains multiple laxative medications, Docusate Sodium, Lactulose, and Polyethylene Glycol with no parameters. Upon home visit, Mylanta and Milk of Magnesia are in the patient's home but not on the medication profile. Patient #2: Upon home visit, the caregiver states the patient has been taking New Chapter Multi-Vitamin, Premier protein Powder, and D-Mannose Powder as supplements for a long time, however these are not on the medication profile. Patient #3: Morphine Concentrate is on the medication profile, but not in the home during home visit. In addition, Joint and muscle support supplement and cool and heat pain relieving cream are in the home and not on the medication profile. Patient #4: Upon home visit, Allopurinol is on the medication profile ordered to take 1 tablet daily, the patient is taking 1/2 tablet daily. Additionally, Ativan, Gabapentin, Levsin, Meloxicam, Morphine, Pantoprazole, Tramadol, and Senna, are on the medication profile, but not in the home. The caregiver states she does not have or take them. Miralax is in the home, but not on the medication profile.

Upon patient record review, 1 of 19 (Patient #3) 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 #3: There was not evidence of a bereavement assessment completed within 5 days. SOC 7/11/24, bereavement assessment 7/26/24.

Upon patient record review, 1 of 19 (Patient #7) 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 #7: The patient has a history of falls on the diagnosis list. Fall precautions are not part of the care plan.

Upon patient record review, 4 of 19 (Patient #1,#2,#3,#4) 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 #1: There was not evidence of orders for Mylanta and Milk of Magnesia, they are in the patient's home for use as needed. Patient #2: There was not evidence of orders for New Chapter Multi-Vitamin, Premier protein Powder, and D-Mannose Powder. The caregiver states the patient has been taking them as supplements for a long time. Patient #3: Joint and muscle support supplement and cool and heat pain relieving cream are in the home used PRN and there was not evidence of an order. Patient #4: Allopurinol is ordered to take 1 tablet daily, the patient is taking 1/2 tablet daily, however there is not evidence of an order. Miralax is in the home, but no evidence of an order.

Upon observation, there was not evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: During the home visit, the nurse kept her equipment and supplies in her pocket. After using the equipment, she cleaned it with Santi-wipes, and then placed the equipment back into her pocket without letting it dry. The package requires 2 minute dry time to be effective. The agency policy states, "When the bag is not brought into the patient's care area, the items needed for the patient encounter should be either hand-carried or placed in a disposable bag, with the disposable bag left in the patient's care area, and the equipment carried out after cleaned and disinfected."

Upon patient record review, 1 of 19 (Patient #7) 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 #7: There was not evidence of fall precautions on the aide care plan. The patient has a history of falls on the diagnosis list.

Upon patient record review 2 of 19 (Patient #10,#11) 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 #10: The aide care plan indicates shaving 1 time a week. The aide documented shaving every visit during thee week with visits on, 11/11/24, 11,13/24, 11/15/24. Patient #11: The aide care plan indicates shaving 1 time a week. The aide documented shaving every visit during thee week with visits on, 11/12/24, 11/14/24 in the same week.

Upon patient record review, 2 of 13 (Patient #1, 9) 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 #1 - Fleets enema per instructions for constipation - did not include frequency. Patient #9 - Heparin flush not on medication profile.

Upon patient record review, 1 of 11 (Patient #5) 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 - SN visit frequency - No documentation of wound measurements 10/30/2021 thru 12/15/2021.

Upon patient record review, 1 of 13 (Patient #2) 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 a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #2 - POC 10/23/2021 contained orders for NP PRN, with no define scope and frequency.

Upon patient record review, 3 of 13 (Patient #6, 7, 9) 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 #6 - POC dated 10/10/2021 included teach Trach wound care and suctioning - did not include specifics wound care orders, frequency of site care, or suctioning frequency. Patient #7 - POC 11/07/2021 contained MSW goals and interventions but MSW no longer visiting patient. Patient #9 - POC dated 10/09/2021 did not differentiate if INR was finger stick or VP. Port-a-cath flush did not contain site preparation or Huber needle gauge or length.

Upon patient record review, 3 of 13 (Patient #6, 8, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6 - POC dated 10/10/2021 MSW visit frequency 1 within every 30 days - MSW made visits weekly 10/17/2021 thru 12/10/2021 no order for weekly visits. Patient #8 - POC dated 11/05/2021 SC visit frequency 1 within 30 days effective 11/08/2021 2 scheduled visits and 1 PRN made in month of November. Patient #10 - POC dated 11/02/2021 SC and MSW visit frequency effective 11/04/2021 1 visit within 30 days - 2 visits made in month of November.

Upon patient record review, 1 of 2 applicable (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care Patient #13 - Patient expired 10/30/2021, bereavement plan included follow up staff contact 7-14 days following death - documentation on 11/22/2021 indicated that contact was missed.

Upon patient record review 3 of 8 applicable (Patient #2, 6, 9) 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 #2 - Aide to provide shampoo and shave every Friday - Aide performed shampoo and shave 3 times a week from 10/26/2021 thru 11/26/202. Patient #6 - Aide to provide Shampoo weekly - Aide performed 3 x week 10/12/2021- 10/22/2021, then 2 x week 10/24/2021 thru 11/05/2021. Patient #9 - Aide to provide linen change weekly but performed 3 x week 10/11/2021 thru 10/23/2021.

Upon patient record review, 2 of 13 (Patient #4,9) 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. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #4 - SN frequency 1 x week - SN visit notes 11/24/2021 - 12/13/2021 only contained the RN's name but not credentials. SN obtained verbal orders for wound care on 12/13/2021 and HHA frequency on 12/07/2021 but did not include credentials of the person receiving the order. Corrected on site Patient #9 - SN visit note 12/04/2021 did not contain how port-a-cath site prepared prior to flushing or gauge size or length of Huber needle used. INR ordered 1 x week effective 10/17/2021 - 12/08/2021 - SN did not document how accessed, tolerance, site or after care.