Every finding on record at Southerncare, Inc.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patients 1,4,7,9: There was no evidence the patient received information regarding advance directives.

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patients 1,4,7,9: There was no evidence the patients received a copy of the Patient Rights and Responsibilities.

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patients 1,4,7,9: There was no evidence of consents signed by a person with legal authority.

Upon patient record review, 1 of 14 (Patient #7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 7: There was no evidence the patient chose an attending physician.

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence of the appropriate documentation for release of confidential information. Patients 1,4,7,9: There was no evidence of a consent to release confidential information.

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that the patient received information about the services covered under the hospice benefit. Patients 1,4,7,9: There was no evidence information was received about hospice services.

Upon patient record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patients 1,4,7,9: There was no evidence information was received about the scope of services and limitations.

Upon patient record review, 1 of 14 (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 medical record contained an initial bereavement assessment completed 3/17/24 with start of care 3/11/24.

Upon patient record review, 4 of 14 (Patients #4,#6,#9,#10) 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 4: The medical record contained nursing documentation upon admission identifying patient is a high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Patient 6: The medical record contained nursing documentation upon recertification 3/19/24 identifying patient issues with edema and the patient profile indicated diagnosis of hypertensive heart disease. There was no evidence of problems, goals, and interventions related to cardiovascular dysfunction included in the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to risk for skin impairment included in the plan of care. Patient 10: The medical record contained nursing documentation 4/5/24 identifying patient issue with dysphagia requiring modified diet. There was no evidence of problems, goals, and interventions related to dysphagia included in the plan of care.

Upon patient record review, 4 of 14 (Patients #1,#2,#4,#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 equipment and supply needs. Patient 1: The medical record contained orders for equipment included in the plan of care that the patient did not require including but not limited to standard wheelchair, high-backed wheelchair, powered wheelchair, geri-chair, scooter, oxygen, trilogy vent, and BIPAP. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Patient 4: The medical record contained orders for equipment included in the plan of care that the patient did not require including but not limited to oxygen, CPAP, spirometer, humidifier, suction machine, Hoyer lift, stand aide, powered wheelchair, crutches, cane, walker, IV supplies, and catheter supplies. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of a walker and wheelchair. There was no evidence of orders for the equipment included in the plan of care. Corrected on site.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon personnel record review, 1 of 13 (Personnel #8) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel 8: The agency job description requires a bachelor's degree in counseling, theology or a related field. The personnel has a bachelor's degree in business marketing.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 13 (Personnel #5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 5: There was no evidence of a competency assessment.

Upon patient record review, 3 of 14 (Patients #1,#6,#8) 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 care plan did not contain instructions for transfer assistance needed. Patient 6: The aide care plan did not contain instructions for transfer assistance needed. Patient 8: The aide care plan did not contain instructions for transfer assistance needed. Corrected on site.

Upon patient record review 4 of 14 (Patients #1,#3,#5,#6) 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 Patient 1: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of a second visit completed the week of 4/14/24. Patient 3: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of second visits completed the weeks of 3/31/24, 4/7/24, and 4/14/24. Patient 5: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of visits completed since 4/5/24. Patient 6: The medical record contained an ordered aide frequency of twice weekly. There was no evidence of second visits completed the week of 3/31/24.

Upon personnel record review, 1 of 14 (Personnel #10) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 10: There was no evidence of orientation.

Upon patient client record review, 5 of 14 (Patients #1,#4,#6,#7,#9) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1: The election form identified the patient representative elected to receive the Notification of Non-Covered Items. There was no evidence the notification was received. There was no evidence the patient received a copy of the patient rights. Patient 4: The election form identified the patient representative elected to receive the Notification of Non-Covered Items. There was no evidence the notification was received. There was no evidence the patient received a copy of the patient rights. Patient 6: The election form identified the start date for the election was determined 1/8/24. The patient was not admitted to hospice services until 1/9/24. Patient 7: There was no evidence of a signed election form. There was no evidence the patient received a copy of the patient rights. Patient 9: There was no evidence the patient received a copy of the patient rights.

Upon client record review, 1 of 14 (Patient #13) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 13: There was no evidence of a discharge summary sent to the patient's physician for continuity of care.

Upon client record review, 4 of 14 (Patients #1,#4,#7,#9) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients 1,4,7,9: There was no evidence the patient received information on the management of controlled drugs.

Upon personnel record review, 1 of 13 (Personnel #7) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 7: There was no evidence of a criminal background check.