Every finding on record at Southerncare, Inc.

Upon patient record review 1 of 19 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: No evidence that initial spiritual assessment was completed within 5 days of admit. Patient admitted on 03/01/2024. Visit completed on 03/07/2024.

Upon patient record review, 3 of 19 (Patient #2,12,14) 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 2: Miralax 17grams - give 17grams by mouth daily. No evidence that instructions were given to dilute the medication. Patient 12: Duplicate drug therapy - Bisacodyl 10mg rectal supp daily for constipation listed on the current MAR twice with 2 different order dates. Patient 14: Duplicate drug therapy - Miralax 17grams daily PRN for constipation, Colace 10MG rectal supp daily PRN. No evidence that instructions were given on which medication for constipation to take first.

Upon patient record review, 2 of 19 (Patient #1,10) 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 1: No evidence that the bereavement risk assessment was completed within 5 days of admission. Patient admitted on 03/01/2024. Completed on 03/18/2024. Patient 10: No evidence that the bereavement risk assessment was completed within 5 days of admission. Patient admitted on 10/21/2023. Not completed at the time of survey.

Upon patient record review, 4 of 19 (Patient #2,4,7,14) 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: History of seizures. Currently prescribed Keppra 250MG every 12 hours for seizures. No evidence that risk for seizures was added to the current plan of care. Patient identified as a risk for falls via ongoing RN assessments. No evidence that risk for falls was added to the current plan of care. Corrected on site. Patient 4: Patient identified as a risk for falls via ongoing RN assessments. No evidence that risk for falls was added to the plan of care. Corrected on site. Patient 7: New onset of seizures started 01/12 before patient was admitted. Currently prescribed Depakote 250mg 1 tab daily for seizures. No evidence of risk for seizures was added to the plan of care. Corrected on site. Patient 14: Patient identified as a risk for falls via ongoing RN assessments. No evidence that risk for falls was added to the plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patient #12,14) 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 12: Duplicate drug therapy - Bisacodyl 10mg rectal supp daily for constipation listed on the current MAR twice with 2 different order dates. Patient 14: Duplicate drug therapy - Miralax 17grams daily PRN for constipation, Colace 10MG rectal supp daily PRN. No evidence that instructions were given on which medication for constipation to take first.

Upon patient record review, 3 of 19 (Patient #4,6,12) 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 equipment and supply needs. Patient 4: Wound care supplies on current plan of care. No evidence that the patient had wounds during time on hospice services. Patient 6: Wound care supplies on current plan of care. No evidence that the patient had wounds during time on hospice services. Patient 12: Wound care supplies on current plan of care. No evidence that the patient had wounds during time on hospice services.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 1: No evidence that an initial IDG was completed within 15 days. Patient was admitted on 03/01/2024, first IDG update occurred on 03/21/2024.

Upon client record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: POC has RN frequency as three times week one and aide frequency as twice weekly. No evidence that the patient was seen 3 times during week 1 by the RN. Patient not seen until 03/03/2024, which started week 2 of the benefit period. No evidence that HHA visits were completed on week 1. Plan of care has HHA frequency as twice a week.

Upon patient record review 6 of 19 (Patient #2,3,4,7,9,13) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2: No evidence that the hospice aide received an on-site visit every 14 days. Patient received an on-site visit on 03/04/2024 and the next on-site visit was on 03/22/2024. 18 days occurred between on-site visits. Patient 3: No evidence that the hospice aide received an on-site visit every 14 days. No evidence that the patient received an on-site visit between 02/06/2024 and 02/27/2024. Patient received an on-site visit on 03/04/2024 and the next on-site visit was on 03/22/2024. 18 days occurred between on-site visits. Patient 4: No evidence that the hospice aide received an on-site visit every 14 days. No evidence that the patient received an on-site visit during the month of March. Patient 7: No evidence that the hospice aide received an on-site visit every 14 days. No evidence that the patient received an on-site visit during the patients time on hospice services. Patient 9: No evidence that the hospice aide received an on-site visit every 14 days. Patient received an on-site visit on 03/04/2024 and the next on-site visit was on 03/22/2024. Patient 13: No evidence that the hospice aide received an on-site visit every 14 days. Patient received an on-site visit on 03/08/2024, no other on-site visit performed between then and the start of the survey. 18 days occurred between on-site visits.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 1: No evidence that a written certificate of terminal illness was completed by the physician for the first benefit period.

Upon patient client record review, 1 of 19 (Patient #12) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 12: Attending Certificate of terminal illness for the first benefit period was signed by a Physician Assistant for the first benefit period.

Upon client record review, 1 of 19 (Patient #7) 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 7: Patient admitted with one wound to coccyx. No evidence that the hospice nurse measured the wound weekly between 03/06/2024 & 03/28/2024 as ordered and per Gentiva policy. No evidence that patient refused measurements.