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. There was not evidence of participation in a full-scale exercise that is community-based every two years.

Upon patient record review 1 of 19 records (Patient #13) did not have evidence in the patient record that the comprehensive assessment identifies the 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. There was not evidence of a spiritual assessment.

Upon patient record review, 6 of 19 records (Patient #2,#6,#7,#8,#9,#13) 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 medication profile contained Pepto Bismol 262mg/15ml, 30 cc Q30 min (not to exceed 240 ml/24h), and Pepto Bismol 262mg/15ml, administer 5cc. Corrected on site. Patient #6: The medication profile contained Nystatin 100,000u topical cream, thin layer to affected area BID prn. There was not evidence of a specific location. Corrected on site. Patient #7: The record contained 2 orders for Fentanyl: One dated 4/22/23 for Fentanyl 100mg patch with a frequency of q8h and another dated 3/12/24 for Fentanyl 50mg patch every 72 hours. Corrected on site. Patient #8: The hospice medication profile contained Colace. There was not evidence that this medication was on the MAR at the facility. Patient #9: Hyoscyamine was on the hospice medication profile. There was not evidence that this was on the MAR at the facility. And TUMS was on the facility MAR but there was not evidence that this was on the medication profile at the hospice. Patient #13: The medication profile contained Diclofenac 1% topical gel 4x daily prn to affected area without evidence of a specific location. Corrected on site Also Lidocaine Plus 4% topical cream q4h prn to affected area without evidence of a specific location. Corrected on site. And, Silvadene 1% topical TID to affected area without evidence of a specific location. Corrected on site. In addition, Fentanyl 100mg q72h dated 11/3/23, Fentanyl 25mg q72 h (dated 11/26/24). Add to 100mg to total 125mg, and Fentanyl 50mg q72h (dated 3/22/24) Add to 100mg and 25 mg to total 175mg. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #3,#8) did not have evidence in the patient record that the hospice has developed an individualized written plan of care that reflects 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 #3: The patient was admitted with a diagnosis of Parkinson's. She was an extensive assist with all activities, had behavioral issues, hallucinations, and mostly not able to understand. She also had Alzheimer's Disease. There was not evidence of a neuro care plan with goals and interventions. Corrected on site. Patient #8: The patient was admitted with a diagnosis of hemiplegia following cerebral infarct. There was not evidence of a neuro care plan with goals and interventions. Corrected on site.

Upon patient record review, 3 of 19 records (Patient #3,#6,#13) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #3: The record contained an order for Acetaminophen 325mg tabs, 2 tads q4h prn. There was not evidence of a maximum allowable dose per 24 hours. Corrected on site. Patient #6: The record contained an order for Nystatin 100,000u topical cream, thin layer to affected area BID prn. There was not evidence of a specific location. Corrected on site. Patient #13: The record contained orders for Diclofenac 1% topical gel 4x daily prn to affected area without evidence of a specific location. Corrected on site. Also Lidocaine Plus 4% topical cream q4h prn to affected area without evidence of a specific location. Corrected on site. And, Silvadene 1% topical TID to affected area without evidence of a specific location. Corrected on site. In addition, Fentanyl 100mg q72h dated 11/3/23, Fentanyl 25mg q72 h (dated 11/26/24). Add to 100mg to total 125mg, and Fentanyl 50mg q72h (dated 3/22/24) Add to 100mg and 25 mg to total 175mg. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #1,#11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress towards outcome/goals from the plan of care. Patient #1: The record indicated that the patient had a fall, dated 3/23/24 and sustained a wound on his left buttock, left elbow and left knee. There was not evidence that a revised plan of care included information from the patient's updated comprehensive assessment regarding wounds. Patient #11:The record indicated that the patient had developed wounds on her right outer foot (2/21/24) and on her left heel (4/8/24). There was not evidence of a care plan related to her wounds. Corrected on site.

Upon client record review, 5 of 19 records (Patient #2,#3,#6,#10,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The visit frequency for the social worker was for an evaluation then 1 every 2m2, 1m1. The evaluation was conducted on 2/16/24 with subsequent routine visits on 3/18/24 and 4/1/24. In addition, the skilled nurse visit frequency was 6w1, 3w1, 2w11. The patient was admitted on 2/12/24, and visits were conducted on 2/12/24, 2/14/24, 2/15/24, and 2/17/24. Patient #3: The initial care plan indicated for an assessment by the volunteer coordinator. There was not evidence of this evaluation. In addition, the visit frequency for the spiritual care counselor was for an evaluation, then 2 every 2m2, 2m1. The evaluation was conducted on 1/29/24 with subsequent routine visits on 2/8/24, 2/22/24, 3/13/24 and 3/28/24. Also, the visit frequency for the social worker was for an evaluation, then 2 every 2m2, 2m2. The evaluation was conducted on 1/29/24 with subsequent routine visits on 2/6/24, 2/20/24, 3/5/24 and 3/19/24. Patient #6: The initial plan of care indicated for an assessment by the volunteer coordinator. There was not evidence of this assessment Patient #10: The initial plan of care indicated for an assessment by the volunteer coordinator. There was not evidence of this assessment Patient #14: The visit frequency for the spiritual care counselor was for an evaluation, then 1 every 2m2, 1m1. The evaluation was conducted on 12/28/23 with subsequent routine visits on 1/31/24, and 2/28/24. Also, the visit frequency for the social worker was for an evaluation, then 1 every 2m2, 1m2. The evaluation was conducted on 12/29/23 with subsequent routine visits on 1/19/24 and 2/7/24.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #9: The staff member was observed retrieving the blood pressure cuff from her bag. After using the cuff on the patient, she reached into her bag to retrieve more equipment without first sanitizing her hands.

Upon patient record review, 1 of 19 records (Patient #13) did not have evidence in the patient record that hospice aide assignments and duties are: • Specific written patient care instructions for a hospice aide that 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 Patient #13: The aide plan of care indicated to perform light housekeeping without specifying what tasks include light housekeeping. Corrected on site.

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. Documentation revealed the percentage of volunteer usage for the year 2023 was 3.16%

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #15: There was not evidence that the discharge summary was sent to the attending physician

Upon client record review, 1 of 19 records (Patient #15) did not have evidence that the discharge summary includes all required information. Patient #15: There was not evidence of a summary of the patient's stay, including treatments, symptoms and pain management. Corrected on site.

Upon client record review, 3 of 19 records (Patient #5,#9,#11) 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 #5: The visit frequency for the spiritual care counselor was for an evaluation, then 2 every 2m2, 2m2. The evaluation was conducted on 12/28/23 with subsequent routine visits on 1/8/24, 1/22/24,2/1/24, 2/23/24, 3/6/24 and 3/18/24. Also, the visit frequency for the social worker was for an evaluation, then 2 every 2m2, 2m2. The evaluation was conducted on 12/29/23 with subsequent routine visits on 1/4/24, 2/1/24, 3/7/24. Patient #9: The visit frequency for the spiritual care counselor was for an evaluation, then 2 every 2m2, 2m. The evaluation was conducted on 1/22/24 with subsequent routine visits on 2/6/24, 2/20/24, 3/6/24 and 3/19/24. Also, the visit frequency for the social worker was for an evaluation, then 1 every 2m2, 1m2. The evaluation was conducted on 1/23/24 with subsequent routine visits on 2/2/24, 3/1/24, 4/1/24. Patient #11: The visit frequency for the social worker for the benefit period beginning 2/20/24 was 1 every 2m2, 1m1. Routine visits were conducted on 3/4/24 and 4/1/24.

Upon client record review, 1 of 19 records (Patient #11) 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 #11: The record indicated an wound order dated 4/8/24 for the left heel stage III wound to cleanse with wound cleanser, pat dry, apply betadine dampened gauze to wound base. Cover with super absorbent pad or ABD. Secure with kerlix and tape. Wound care to be performed by hospice nurse, facility nurse daily or prn soiling or damp. There was not evidence of which provider specifically was to provide the wound care. Corrected on site.