Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 14 (Patient #3) 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 3: Patient has multiple pain medications present on medication record; Acetaminophen 325mg every 8 hours as needed for elevated temperature/pain and Hydrocodone 5mg-Acetaminophen 325mg every 4 hours as needed for pain. There is no further instruction for clarification of medication administration based upon pain rating, severity, or intensity. Further, there is no evidence of maximum dose instructions related to use of Acetaminophen containing medications.

Upon patient record review,1 of 14 (Patient #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 7: LPN documentation 5/8/24 reveals RN notification of "wrong labs" obtained on patient. No evidence found of RN follow up with facility and/or physician on incident, need for new or revised MD orders, or changes to the plan of care.

Upon patient record review, 2 of 14 (Patient #3 & 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 3: Patient plan of care lists Acetaminophen 325mg every 8 hours as needed for elevated temperature/pain. Pt. also has Hydrocodone 5mg-Acetaminophen 325mg every 4 hours as needed for pain. There is no further instruction for clarification of medication administration based upon pain rating, severity, or intensity. Further, there is no evidence of maximum dose instructions related to use of Acetaminophen containing medications. Patient 5: Foley catheter initiated 4/12/24. Plan of care does not specify catheter size, whether this is to be completed by facility or hospice skilled nurse, additional instruction on replacing or reinserting as needed for occlusion or displacement, etc., or instructions/indications for flushing of catheter.

Upon patient record review 1 of 14 (Patient #1) 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 1: RN visits were conducted on 4/11/24, 4/19/24, & 4/26/24. No evidence found of supervisory oversight or assessment of the quality of aide services provided to the patient between 4/3/24 - 4/29/24 (26 days).

Upon patient client record review, 2 of 14 (Patient #2 & 5) 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 2: RN visit note on 5/7/24 indicates no pain per "staff observation" but the narrative note of same visit states patient complained of pain upon nurse entering room. Documentation is unclear as to congruency of pain assessment, interventions and re-assessment. Patient 5: Foley catheter initiated on 4/12/24. All SN and CNA documentation after that date reflects catheter remains in place. LVN documentation on 4/26/24 specifies there is no catheter in place with urinary incontinence. All SN and CNA documentation after this date reflects presence of urinary catheter. No evidence found of removal and reinsertion of catheter in SN notes, coordination notes, or patient orders. Catheter status at the LPN visit is unclear.