Every finding on record at Southerncare, Inc.

Upon patient record review, 2 of 5 (Patient #1,#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 During record review it was noted each patient and family. Patient#1: During the record review it was noted that wound #1 had no evidence of measurements or assessment the week of 1/18/26. On nurse visit 1/19 the RN documents patient refused wound care and it would be completed on the next visit. The second SN visit that week was completed by LVN who documented on 1/21 that dressing was in place and intact. Agency policy is for RN to complete wound measurement and assessment weekly. Patient#5: During the record review it was noted that there was no evidence of wound measurement the week of 1/12/26 by RN as both SN visits were completed by LVN and contained no measurements. There is also no evidence of wound measurements the week of 1/18/26. On nurse visit 1/19 the RN documents patient refused. The LVN completed the second visit for that week on 1/21 and documented caregiver completed care. Agency policy is for RN to complete wound measurement and assessment weekly.

Upon patient record review, 2 of 5 (Patients #2,#4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained conflicting routes of oral and instructions to crush and administer via G-tube for amlodipine, cilostazol, senna plus, and tramadol. Corrected on site with order clarification and medication profile update. Patient 4: The medication profile contained nursing documentation 12/3/25 identifying new order received for simethicone to be crushed and placed in applesauce or pudding. The profile did not include the instructions for crushing simethicone. Corrected on site with order clarification and medication profile update.

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

Upon patient record review, 1 of 5 (Patient #1) 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 1: The medical record contained nursing documentation upon admission identifying patient has fluid filled blister to left heel, and documentation 12/24/25 stating left heel healing well. There was no evidence of any wound assessments and measurements. Agency policy requires weekly assessments and measurements.

Upon patient record review, 1 of 5 (Patient #4) 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 history of multiple falls. There was no evidence of problems, goals, and interventions related to fall safety included in the plan of care. Corrected on site with plan of care update.

Upon patient record review, 1 of 5 (Patient #3) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 3: The medical record contained an order for social work frequency of 1 PRN. There was no evidence of an anticipated need for social work visits. Corrected on site with order clarification.

Upon patient record review, 3 of 5 (Patients #1,#2,#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: The POC contained nursing documentation upon admission identifying patient has fluid filled blister to left heel, and documentation 12/24/25 stating left heel healing well. There was no evidence of a wound care order. Patient 2: The POC contained conflicting routes of oral and instructions to crush and administer via G-tube for amlodipine, cilostazol, senna plus, and tramadol. Corrected on site with order clarifications. Patient 4: The POC contained nursing documentation 12/3/25 identifying new order received for simethicone to be crushed and placed in applesauce or pudding. The order did not include the instructions for crushing. Corrected on site with order clarifications.

Upon patient record review, 1 of 5 (Patient #1) 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 12/5/25 stating patient received low air loss mattress. There was no evidence of an order for the specialty mattress included in the plan of care. Corrected on site with order clarification.

Upon client record review, 1 of 5 (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 medical record contained an order for nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 12/21/25. Corrected on site with late data entry of reason for missed visit.

Upon client record review, 1 of 5 (Patient #1) 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 1: The medical record contained an order for daily nursing visits 11/30/25. The patient received 4 visits the week of 11/30/25, 3 visits the week of 12/7/25, and 2 visits the weeks of 12/14/25 and 12/21/25.

Upon patient record review, 1 of 19 (Patient #14) 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. Corrected on site with agency obtaining a copy from the patient's home.

Upon patient record review, 1 of 19 (Patient #14) 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. Corrected on site with agency obtaining a copy from the patient's home.

Upon patient record review, 1 of 19 (Patient #14) did not have evidence of the appropriate documentation for release of confidential information. Corrected on site with agency obtaining a copy from the patient's home.

Upon patient record review 1 of 19 (Patient #13) 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 13: The medical record contained an initial spiritual assessment 1/23/25 with admission 9/16/24.

Upon patient record review 2 of 19 (Patients #3,#9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 3: There was no evidence of a comprehensive spiritual assessment. Corrected on site with assessment completed 11/6/25. Patient 9: There was no evidence of a comprehensive spiritual assessment. Corrected on site with assessment completed 11/7/25.

Upon patient record review, 5 of 19 (Patients #2,#3,#4,#10,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained instructions for two differing doses of fentanyl patches. There was no evidence of instructions to administer together or differentiate if one dose was outdated. Corrected on site with order clarification and removal of former dose from profile. Patient 3: Upon home visit medication reconciliation, the patient stated she does not take the scheduled prednisone and Senna. Patient also stated she takes daily vitamin B12 and aspirin 81mg that were not on the medication profile. Corrected on site with order clarification and medication profile update. Patient 4: The medication profile contained oxygen with no delivery method. Corrected on site with order clarification and medication profile update. Patient 10: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain guaifenesin on hospice profile, contained morphine extended release tablets for a PRN instead of hospice immediate release, and Ondansetron every 6 hours PRN instead of hospice instructions for daily PRN. Corrected on site with order clarification and medication profile update. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility profile did not contain PRNS for acetaminophen, guaifenesin, Levsin, Robitussin, and Tramadol that were on hospice profile. Facility also contained hydroxyzine every 6 hours PRN instead of hospice four times daily, and morphine every 3 hours PRN instead of hospice every 4 hours PRN. Corrected on site with order clarification and medication profile update.

Upon patient record review, 2 of 19 (Patients #9,#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 9: The medical record contained an initial bereavement assessment 7/23/24 with admission 4/16/24. Patient 13: The medical record contained an initial bereavement assessment 9/27/24 with admission 9/16/24.

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

Upon patient record review, 3 of 19 (Patients #3,#6,#7) 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 was no evidence of weekly wound measurements and assessments between 9/1/25 and 10/2/25 as required per agency policy. Nurse documentation stated patient refused however refusal documentation required per policy was not completed. Patient 6: There was no evidence of weekly wound measurements since admission 9/17/25 and no weekly assessments as required per agency policy between 9/22/25 and 10/13/25, and 10/13/25 to date of review 11/4/25. Patient 7: There was no evidence of weekly wound measurements and assessments between 9/29/25 and 10/21/25 as required per agency policy.

Upon patient record review, 4 of 19 (Patients #2,#6,#7,#12) 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: The medical record contained nursing documentation upon admission identifying patient history of seizures and high risk for falls. There was no evidence of problems, goals, and interventions related to seizure precautions and fall safety included in the plan of care. Corrected on site with plan of care update. Patient 6: The medical record contained documentation identifying patient prescriptions of Eliquis and insulin since admission. There was no evidence of problems, goals, and interventions related to risk for bleeding and endocrine dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 7: The medical record contained nursing documentation upon admission identifying patient has issues with dyspnea upon minimal exertion since admission. There was no evidence of problems, goals, and interventions related to respiratory dysfunction included in the plan of care. Corrected on site with plan of care update. Patient 12: 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 with plan of care update.

Upon patient record review, 1 of 19 (Patient #13) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 13: The medical record contained an order to discontinue spiritual care scheduled visits and allow 2 PRN visits 9/23/25. There was no anticipated need for spiritual care and order stated care was to be discontinued per patient request. Corrected on site with order clarification.

Upon patient record review, 5 of 19 (Patients #2,#3,#4,#10,#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 2: The medical record contained orders for two differing doses of fentanyl patches. There was no evidence of instructions to administer together or differentiate if one dose was outdated. Corrected on site with order clarification and discontinuation of former dose. Patient 3: Upon home visit medication reconciliation, the patient stated she does not take the ordered prednisone and Senna. Patient also stated she takes daily vitamin B12 and aspirin 81mg that hospice did not have orders for. Corrected on site with order clarification. Patient 4: The medical record contained an order for oxygen with no delivery method. Corrected on site with order clarification. Patient 10: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility orders did not contain guaifenesin on hospice record, contained morphine extended release tablets for a PRN instead of hospice immediate release, and ondansetron every 6 hours PRN instead of hospice instructions for daily PRN. Corrected on site with order clarification. Patient 14: Upon home visit medication reconciliation, the facility and hospice medication orders did not match. The facility orders did not contain PRNS for acetaminophen, guaifenesin, Levsin, Robitussion, and Tramadol that were on hospice profile. Facility also contained orders for hydroxyzine every 6 hours PRN instead of hospice four times daily, and morphine every 3 hours PRN instead of hospice every 4 hours PRN. Corrected on site with order clarification.

Upon patient record review, 5 of 19 (Patients #3,#5,#6,#8,#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 equipment and supply needs. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a commode. There was no evidence of an order for the commode included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a shower bench. There was no evidence of an order for the bench included in the plan of care. Corrected on site with order received. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of bedrails. There was no evidence of an order for the rails included in the plan of care. Corrected on site with order received. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site with order received. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed, bedrails, overbed table, Hoyer lift, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received.

Upon patient record review, 2 of 19 (Patients #7,#13) 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 assessment 9/29/25 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 with plan of care update. Patient 13: The medical record contained nursing documentation upon recertification assessment 10/21/25 identifying patient history of seizures. There was no evidence of problems, goals, and interventions related to seizure precautions included in the plan of care. Corrected on site with plan of care update.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 14: The medical record contained nursing documentation identifying patient fall 10/9/25. There was no evidence of a hospice investigation of the incident. Corrected on site with late data entry.

Upon 1 of 4 home visit observations, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: The RN was witnessed going into the home with stethoscope and blood pressure cuff hanging on neck and oximeter and thermometer in pocket. After using the equipment on the patient, the RN returned it to same place for transport to vehicle prior to cleansing.

Upon patient record review, 3 of 19 (Patients #16,#17,#18) 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 Patients 16,17:There was no evidence the bereavement care plan tasks of sending out memorial service invitations was completed. After leadership investigation, the memorial invitations were sent but not documented. Corrected on site with late entry documentation. Patient 18: There was no evidence the bereavement care plan tasks of sending out a sympathy card, one month letter, and memorial service invitation were completed. After leadership investigation, the memorial invitations were sent but not documented. Corrected on site with late entry documentation.

Upon patient record review, 1 of 19 (Patient #6) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient's needs. Patient 6: The aide care plan contained two bath types of bed bath and shower to each be completed every visit. Corrected on site with aide care plan update.

Upon patient record review 1 of 19 (Patient #14) 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 14: There was no evidence of aide supervision by an RN since 8/25/25.

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. Agency annual volunteer utilization rate was 3.42%.

Upon personnel record review, 1 of 17 (Personnel #12) 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 12: There was no evidence of an initial skills competency. Corrected on site with completed of assessment.

Upon patient record review, 1 of 19 (Patient #12) did not have evidence that there is a physician's brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification forms, or as an addendum to the certification forms. Patient 12: There was no evidence of a physician narrative reflecting patient's circumstances requiring hospice. Corrected on site with physician completion of an Addendum to Physician CTI Narrative documented per agency procedures.

Upon patient client record review, 1 of 19 (Patients #8) 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 8: The election upon admission identified the patient's responsible party requested the Notification of Hospice Non-Covered Items. There was no evidence the addendum was provided within the allowable five day limit. Addendum was documented as furnished 6/6/25.

Upon client record review, 1 of 19 (Patient #14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 14: There was no evidence the patient or responsible party received policies for managing controlled drugs. Patient was prescribed Lorazepam upon admission. Corrected on site with agency obtaining a copy from the patient's home.

Upon patient record review, 2 of 19 (Patients #6,#14) did not have evidence that the hospice provided the following information: • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Hospice medication information specific to each patient Patient 6: Upon observation during home visit, the facility did not have a signed CTI with physician narrative of eligibility, election form, advance directives, or names of hospice personnel involved with hospice care. Corrected on site with delivery of missing documentation. Patient 14: Upon observation during home visit, the facility did not have any CTIs prior to the most recent benefit period ending 10/30/25, election form, advance directives, or names of hospice personnel involved with hospice care. Corrected on site with delivery of missing documentation.

Upon personnel record review, 1 of 17 (Personnel #8) 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 8: There was no evidence of a criminal background check, OIG, or National Sex Offender registry check.

Upon patient record review 2 of 13 (Patient #2, 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 #2 Patient admitted on 08/24/2022 MSW assessment completed on 08/30/2022 and SC assessment completed on 08/30/2022. Patient #4 Patient admitted on 09/23/2022 MSW assessment completed on 09/30/2022 and SC assessment completed on 09/30/2022.

Upon patient record review, 1 of 13 (Patient #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 #10 - SOC 10/08/2022 - unable to locate initial bereavement assessment.

Upon patient record review, 1 of 13 (Patient #6) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #6 POC dated 10/20/2022 MU therapy frequency 10/27/2022 5 PRN.

Upon client record review, 5 of 13 (Patient #4, 5, 6, 7, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 POC dated 09/23/2022 SN frequency 1wk1, 3wk1, 1wk11, 2 scheduled visits and 1 PRN made week 4. Patient #5 POC dated 10/07/2022 order for MU therapy to evaluate on 10/21/2022, no evidence MU therapy assessment completed. Patient #6 VP for TSH completed on 11/10/2022 but no order for bloodwork. Patient #7 POC dated 10/05/2022 - Foley catheter #16- 10cc balloon to be changed every month and prn to maintain patency. SN changed 10/14/2022 used a #14- 10cc foley catheter. Patient #9 POC dated 10/20/2022 SN visit frequency 1wk1, 2wk1, 6wk1, 2wk 10 - only 4 SN visits and 1 missed visit week 3.

Upon patient record review, 1 of 13 (Patient #4) 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 #4 - Aide care plan has O2 precautions "patient may have O2 @ 4L/M for SOB" - patient's order is for O2 2L/M continuous.

Upon patient record review 1 of 13 (Patient #4) 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 #4 - POC dated 09/23/2022 Aide visit frequency 1wk1, 5wk1, 3wk11. Aide only made 2 visits week 5.

Upon client record review, 1 of 13 (Patient #12) 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 #12 - POC dated 09/07/2022 did not include who was going to provide wound care or a frequency for the wound care.