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.

Upon patient record review 1 of 23 (Patient #4) 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 4: The medical record contained a comprehensive spiritual assessment completed 3/8/24 with start of care 2/28/24.

Upon patient record review, 5 of 23 (Patients #5,#8,#9,#10,#17) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medication profile contained lidocaine topical patches with no area defined for administration. The medication profile also did not contain accurate medications to match the facility medication list. An order was entered 5/20/24 at 5:25 pm after selection of patient for a home visit and request for medication profiles. The order stated medication reconciliation included adding artificial tears and refresh tears, aspirin 81 mg, fluoxetine change from 30mg to 20 mg daily, add metoprolol succinate ER 25mg daily, and oxygen changed from 1-5L to 2-4L Corrected on site. Patient 8: The medication profile contained active di-dak wound cleanser and Santyl for wound care. The wound was documented as healed 5/8/24. Corrected on site. Patient 9: The medication profile contained duplicative listings of senna plus. Corrected on site. Patient 10: The medication profile contained active Medi-honey for wound care. The wound was documented as healed 4/18/24. Corrected on site. Patient 17: The medication profile contained active Medrol listed however instruction were for only 6 days with start date 3/20/24.

Upon patient record review, 4 of 23 (Patients #1,#8,#12,#13) 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: There was no evidence of a bereavement assessment. Patient 8: There was no evidence of a bereavement assessment. Patient 12: There was no evidence of a bereavement assessment. Corrected on site. Patient 13: The medical record contained a bereavement assessment completed 3/29/24 with a start of care 3/9/24.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 23 (Patients #8,#10,#13) 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 8: There was no evidence of wound measurements and assessments from admission to inactivation of wound 5/8/24. Patient 10: There was no evidence of wound measurements and assessments from admission to inactivation of wound 4/18/24. Patient 13: There was no evidence of wound measurements and assessments from admission to inactivation of wound 3/25/24.

Upon patient record review, 7 of 23 (Patients #1,#3,#10,#13,#14,#16,#17) 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 1: The medical record contained nursing documentation upon admission identifying patient has issues with dysphagia and a feeding tube. There was no evidence of problems, goals, and interventions related to dysphagia and the feeding tube included in the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon admission identifying patient has issues with dyspnea. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient has an indwelling catheter and is high risk for falls. There was no evidence of problems, goals, and interventions related to catheter use and fall safety included in the plan of care. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient is high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 14: The medication profile identifies patient is insulin dependent requiring sliding scale doses three times daily. There was no evidence of problems, goals, and interventions related to endocrine dysfunction included in the plan of care. Patient 16: The medical record contained nursing documentation upon admission identifying patient is high risk for falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site. Patient 17: The medical record contained nursing documentation upon admission identifying patient has issues with risk for recurrent skin impairment and dysphagia. There was no evidence of problems, goals, and interventions related to risk for skin impairment and dysphagia included in the plan of care. Skin corrected on site.

Upon patient record review, 2 of 23 (Patients #5,#10) 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 5: The medical record contained an order for lidocaine topical patches with no area defined for administration. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of an indwelling catheter. There was no evidence of an order for catheter type, size, change frequency, and maintenance. Corrected on site.

Upon patient record review, 11 of 23 (Patients #1,#2,#8,#9,#10,#11,#13,#14,#15,#16,17) 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 nursing documentation upon admission identifying patient use of a Hoyer lift and bedrails. There was no evidence of orders for the DME included in the plan of care. There were also orders for excessive items with no evidence of patient use including gait belt, wound supplies, heel and elbow protectors, and diabetic lancets with no evidence of appropriateness for the patient. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, walker, wheelchair, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, bedside table, specialty mattress, fall mat, wheelchair, and oxygen. There was no evidence of orders for the DME included in the plan of care. The hospital bed was corrected on site. Patient 9: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of catheter supplies and walker. There was no evidence of an order for the DME and supplies included in the plan of care. The plan of care also incorrectly contains an order for a Hoyer lift with no evidence of use in documentation which states patient is a transfer assist of one. Patient 11: There were also orders for excessive equipment and supplies with no evidence of patient use catheter supplies, gait belt, bedpan/urinal, and heel protectors. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, bedside table, specialty mattress, walker, wheelchair, commode, and oxygen. The medication profile contained an order for duoneb prescription administered via a nebulizer. There was no evidence of an order for the DME included in the plan of care. Patient 14: The medical record contained nursing documentation upon recertification 3/15/24 identifying patient use of a walker. There was no evidence of an order for the DME included in the plan of care. Patient 15: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedside table, wheelchair, floor mat, and gait belt. There was no evidence of an order for the DME and supplies included in the plan of care. Corrected on site. Patient 16: The medical record contained nursing documentation upon admission identifying patient use of a cane and 5/8/24 identifying use of a walker. There was no evidence of an order for the DME included in the plan of care. Patient 17: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care.

Upon client record review, 7 of 23 (Patients #3,#6,#9,#11,#14,#16,#17) 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. Patients 3,6,9,11,14,16,17: The medical records contained signed election forms identifying patient selection of community physicians to act as their attending physicians. There was no evidence the IDG acts in collaboration with the attending physician to update the plan of care no less than every 15 days.

Upon patient record review, 3 of 23 (Patient #7,10,11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 7: The medical record contained nursing documentation upon recertification 3/14/24 identifying patient is high risk for aspiration. There was no evidence of problems, goals, and interventions related to risk for aspiration included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation identifying patient wound was healed 4/18/24. The plan of care was not updated to resolve the wound care interventions. Corrected on site. Patient 11: The medical record contained nursing documentation upon recertification 3/15/24 identifying patient has issues with vomiting. There was no evidence of problems, goals, and interventions related to nausea and endocrine dysfunction included in the plan of care.

Upon client record review, 1 of 23 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained an ordered spiritual care frequency of once monthly. There was no evidence of a visit made in April.

Upon patient record review, 3 of 23 (Patients #19,#20,#21) 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 • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 19: There was no evidence the bereavement care plan tasks of a 6 month phone call and quarterly newsletters were completed. Patient 20: There was no evidence the bereavement care plan task of quarterly newsletters were completed. Patient 21:There was no evidence the bereavement care plan tasks of quarterly newsletters support group invitations were completed.

Upon patient record review, 8 of 23 (Patients #1,#2,#5,#9,#12,#14,#15,#18) did not have evidence in the patient record that hospice aide assignments and duties are specific to the needs of the patient. Patient 1: During interview with the CNA at the home visit, the aide stated the patient will be transferred to the Broda chair via hoyer after a bed bath is complete. There was no instructions on the aide care plan for use of a Hoyer for transfers. Patient 2: The aide care plan did not contain instructions for transfer assistance needs and use of a walker. Patient 5: The aide care plan did not contain instructions for transfer assistance needs. Corrected on site. Patient 9: The aide care plan did not contain instructions for transfer assistance needs and use of a wheelchair. Corrected on site. Patient 12: The aide care plan did not contain instructions for use of a walker. Corrected on site. Patient 14: The aide care plan did not contain instructions for use of a walker. Patient 15: The aide care plan contained unclear instructions for task of shower stating keep hair dry but also task of shampoo every visit. Corrected on site. Patient 18: The aide care plan did not contain instructions for transfer assistance needs. Corrected on site.

Upon personnel record review, 1 of 15 (Personnel #12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 12: There was no evidence of orientation in the personnel file.

Upon personnel record review, 1 of 15 (Personnel #12) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 12: There was no evidence of orientation in the personnel file.

Upon personnel record review, 2 of 15 (Personnel #1,#7) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 1: There was no evidence of a skills competency assessment was completed. Personnel 7: There was no evidence of a skills competency assessment was completed.

Upon patient record review, 1 of 23 (Patient #12) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 12: The CTI for benefit period starting 9/20/23 did not contain an eligibility narrative from the medical director or hospice physician.

Upon patient client record review, 2 of 23 (Patients #15,#18) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 15: The medical record contained an uploaded form identifying the patient representative requested to receive the notification of hospice non-covered items. 4/9/24. There was no evidence the form was provided. Patient 18: The medical record contained an election form identifying the patient representative requested to receive the notification of hospice non-covered items. upon admission. There was no evidence the form was provided.

Upon patient client record review, 2 of 23 (Patient #3, 14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 3,14: There was no evidence of an initial CTI signed by the elected attending physicians.

Upon patient client record review, 1 of 23 (Patient #23) did not evidence that each patient record contains physician orders. Patient 23: There was no evidence of an order to discharge per agency policy.

Upon client record review, 1 of 23 (Patient #23) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. Patient 23: There was no evidence the agency forwarded a transfer summary or additional documentation to the receiving hospice agency for coordination of care.