Every finding on record at Southerncare, Inc.

Upon patient record review, 4 of 14 (Patient #1,#2,#3,#5) 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 indicate the patient has an active order for Aspirin to be taken daily. However, there is evidence in the record of an order to discontinue the aspirin dated 5/8/26. Patient#2: The order indicates ammonium lactate 12% lotion to be applied daily to entire body except face. However, the medication profile does not include the "except face" on the instructions. This medication is active but was not found in the home during home visit. It was also noted in the home that the patient has a bottle of atorvastatin 80 mg and a bottle of atorvastatin 40mg. Patient states she is taking both. However, only atorvastatin 80mg is listed on the medication profile. Patient#3: During the home visit it was noted that oxygen and Eliquis are both active medications on the hospice medication profile. However, there is no evidence of these on the facility MAR or their order sheet. Patient#5: The medication profile indicates patient to take lactulose 30ml daily if senna and milk of magnesia do not provide BM. Senna and milk of magnesia are ordered as PRN. However, the lactulose is scheduled to take daily.

Upon patient record review, 1 of 14 (Patient #3) 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#3: There is no evidence of a wound assessment or measurements the week of 4/19/26 for wound #2 to left buttock and wound #3 to right buttock.

Upon patient record review, 1 of 14 (Patient #5) 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 order indicates patient to take lactulose 30ml daily if senna and milk of magnesia do not provide BM. Senna and milk of magnesia are ordered as PRN. However, the lactulose is ordered as scheduled daily.

Upon patient record review, 3 of 14 (Patient #3,#7,#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 equipment and supply needs. Patient#3: The record indicates the plan of care order for supplies/equipment includes a nebulizer. However, there is no evidence the patient is ordered any medication requiring a nebulizer. Patient#7: The record indicates the plan of care order for supplies/equipment includes ostomy supplies. However, there is no evidence the patient has an ostomy. Patient#10: The record indicates the patient is ordered humidified oxygen. However, there is no evidence of that or humidifier for the oxygen on the plan of care order for supplies/equipment.

Upon client record review, 1 of 14 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient#3: The wound order for these wounds state the hospice nurse is to complete wound care 1x a week and facility nurse to complete daily and PRN. There is no evidence the hospice nurse completed wound care any day the week of 4/19.

Upon patient record review 1 of 14 (Patient #6) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient#6: On visit 4/6/26 and in IDG 4/15/26 the nurse documented that patient wants to start taking cranberry pill for UTI since she cannot take the antibiotic. Nurse documents she will follow up with the physician. There is no evidence of any follow up decision from physician or reporting back and discussing with physician recommendation with patient.

Upon patient record review, 2 of 14 (Patient #8,#10) 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#8: The aide plan of care indicates patient is on oxygen precautions. However, this patient is not ordered oxygen. Patient#10: The record indicates this patient is on oxygen. There is no evidence of oxygen precautions on the aide plan of care.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2025. The total usage of volunteers for 2025 was 4.02%

Upon patient client record review, 3 of 14 (Patient #1,#6,#7) 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#1: On 4/16/26 and 4/28/26 the aide documents "Patient SOB FSN and RNCM notified". She also documents "patient unable to sign FSN Shamir". FSN is not an acceptable abbreviation per company policy. Patient#6: On 3/14/26 the nurse uses "FSN" during her documentation. This is not an acceptable abbreviation per company policy. Patient#7: On 3/26/26 the chaplain documents "conveyed by SCC to BU" and "SCC to schedule subsequent visits". These are not acceptable abbreviations per company policy.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the hospice assumes responsibility for professional management of the resident's hospice services in accordance with the hospice plan of care. The hospice is responsible for providing all hospice services including: • Ongoing assessment, care planning, monitoring, coordination and provision of care by the Hospice IDG • Assessment, coordination and provision of any needed general inpatient or continuous care • Consultation about the patient's care with facility staff • Coordination by the hospice RN for the implementation of the plan of care for the patient • Provision of hospice aide services, if these services are determined necessary by the IDG to supplement the nurse aide services provided by the facility • Provision, in a timely manner, of all supplies, medications, and DME needed for the palliation and management of the terminal illness and related conditions • Financial management responsibility for all medical supplies, appliances, medications and biologicals related to the terminal illness and related conditions • Determination of the appropriate level of care to be given to the patient (routine homecare, inpatient, or continuous care) • Arranging any necessary transfers from the facility, in consultation with the facility personnel Patient#1: The record indicates that on 4/30/26 the facility contacted the hospice triage to report that the patient had a low blood pressure and was requesting transfer to the hospital. Triage recommended a nursing visit. The on-call hospice RN subsequently contacted the facility and discussed the patient's condition with the facility nurse. During that conversation, the hospice RN informed the facility nurse that the patient's blood pressure typically ran low. Documentation indicated that the patient continued to express a desire to go to the hospital; however, the hospice RN relied upon the facility nurse's assessment and determined that there was no reason for hospitalization rather than directly assessing the condition.

Upon client record review, 1 of 14 (Patient #8) 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#8: The plan of care states skilled nurse, aide, and facility staff to perform active and passive ROM exercises. There is no evidence of this being provided.

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient#6: The plan of care indicates an order for patient's blood sugar to be monitored. However, there is no evidence if the facility or the hospice nurse is responsible for monitoring the blood sugar.

Upon patient record review, 2 of 19 (Patient #2#7) 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: The patients medication administration record with acetic acid flush for wound profiled on 12/29/22. Patients current wound care order does not include acetic acid flush as part of the regimen. Corrected on Site Patient 7: The patients medication administration record with Medrol dose pack profiled on 6/10/23. The medication record does not include dose or frequency present and instructions for use states "see package instructions". Corrected on site

Upon patient record review, 1 of 19 (Patient #14) 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 14: The patient medical record contains documentation that the patient was admitted to hospice services on 5/27/23. The initial Bereavement Risk Assessment was completed on 6/13/23.

Upon patient record review, 8 of 19 (Patient #1,#2,#4,#9,#10#11,#12,#13) 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 patients medical record contained documentation upon admission of history of aspiration pneumonia, dysphagia and altered diet of pureed consistency with nectar thickened liquids. The plan of care does not include problems, interventions and goals related to dysphagia. Corrected on site. Patient 2:The patients medical record contains documentation upon admission of the primary diagnosis of cardiac disease and the plan of care does not include problem, goals and interventions for cardiac disease. The patients medical record contains documentation upon admission that patients diet is pureed consistency with nectar thickened liquids with dysphagia and risk for aspiration and the plan of care does not include problems goals and interventions related to dysphagia. The patients medical record contains documentation that the patient resides in a skilled facility and the plan of care does not contain problems, goals and interventions to support coordination of care with the facility. Corrected on site. Patient 4: The patients medical record contains documentation upon admission of dysphagia with aspiration risk, diagnosis of cardiac disease with Imdur ordered on 5/12/23 due to active chest pain, suprapubic catheter in place, and nephrostomy tubes in place. The plan of care does not include evidence of problem, interventions or goals for identified issues of dysphagia/aspiration risk, cardiac disease, management of suprapubic catheter and nephrostomy tube. Corrected on site Patient 9:The patients medical record contains documentation upon admission of altered neuro and aspiration risk. The plan of care does not include evidence of interventions and goals for altered neuro and no evidence of problems, interventions and goals for aspiration risk . Corrected on site. Patient 10: The patients medical record contains documentation upon admission of altered cardiac, altered neuro, and dysphagia The plan of care does not include evidence of goals and interventions for altered cardiac and altered neuro as well as no evidence of problem, interventions and goals for dysphagia. Corrected on site. Patient 11: The patients medical record contains documentation upon admission of foley catheter in place and diabetes mellitus with sliding scale insulin. The plan of care does not include evidence of problems goals and interventions for management of catheter and diabetes. Corrected on site. Patent 12: The patients medical record contains documentation upon admission of active problems of depression with medication changes on 6/4/23, diabetes mellitus, blood glucose monitoring, skin integrity, genitourinary problems and altered nutrition. The plan of care does not include evidence of interventions for depression, diabetes mellitus and blood glucose monitoring and no evidence of interventions and goals for skin integrity, genitourinary issues and altered nutrition. Corrected on site. Patient 13: The patients medical record contains documentation upon admission that patient is bedbound with contractures. The plan of care does not include evidence of problems, goals and interventions related to skin integrity. Corrected on site.

Upon patient record review, 3 of 19 (Patient #2,#4,#6) 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 2: On 5/18/23 an order was written for treatment of venous stasis ulcer that did not include the location of the wound, patient has more than one wound. Order on 5/26/23 for oxygen to be delivered at 3 liters per minute via nasal cannula. Documentation by the nurse on 6/6/23 included that the patient was receiving oxygen at 4 liters per minute via nasal cannula. Corrected on site. Patient 4: The patients medical record contained documentation of nephrostomy tube and suprapubic catheter within nursing admission assessment on 5/5/22. The plan of care does not include orders to include location, size or care of suprapubic catheter and nephrostomy tube. Patient 6: Order for O2 at 3-4 liters per minute via NC. The nurse had documented on 5/12/23 that the patient was using O2 via NC during the day at 5 LPM and via mask at 3-4 LPM at night. On 6/7 the order was changed and the patient was to receive O2 via 5 LPM via nasal cannula and the RN documented that the patient was receiving O2 via NC at 4 LPM.

Upon patient record review, 4 of 19 (Patient #2,#3,#10,#11) 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 2: The patients medical record contains documentation of order for nebulization treatment on 5/25. There is no evidence that nebulization supplies were added to the plan of care. Corrected on site Patient 3: The patients medical record contains documentation upon admission that a wheelchair and overbed table were in use. There is no evidence that wheelchair or overbed table were present on the plan of care. Corrected on site. Patient 10: The patients medical record contains documentation upon admission that an overbed table and wheelchair were in use. There is no evidence that wheelchair or overbed table were present on the plan of care. Corrected on site. Patient 11: The patients medical record contains documentation upon admission that a broda chair was in use. There is no evidence that broda chair was present on the plan of care. Corrected on site.

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: The plan of care contained documentation on 4/3/23 that the medical social worker visit frequency would be 2 visits within every 30 days. The patients medical record included visits completed by the medical social worker on 5/4, 5/15 and 5/20.

Upon patient record review 2 of 19 (Patient #1,#2) 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 1: The patients medical record contains the hospice aide care plan dated 4/1/23 with the task of shampoo hair assigned weekly. Aide visits on 4/5/23, 4/7/23, 4/13/23, 4/14/23, 5/9/23 and 5/11/23 notes task of shampoo hair was completed. Patient 2: The patients medical record contains the hospice aide care plan dated 5/17/23 with the task of weighing the patient assigned on the first visit of the month. The aide visit on 6/3/23 notes that task was not completed, not required and that supplies were not available.

Upon patient client record review, 2 of 19 (Patient #13 and 14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 13 and 14: There is no evidence in the medical record that a Verbal Certification of Terminal Illness was obtained within 2 days of admission from elected attending physician.