Every finding on record at Southerncare, Inc.

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) Upon review of the emergency preparedness plan, it is the agency protocol to print the Emergency Plan communication information on each patient weekly in the event their is an emergency and the ability to print the information is lost however, there was no evidence of this information.

Upon patient record review 3 of 19 (Patient #1, #9, #11) 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 #1: The record indicated the patient was admitted on 4/16/24. The spiritual assessment was completed on 4/30/24 which is greater than 5 days. Patient #9: The record indicated the patient was admitted on 11/9//23. The spiritual assessment was completed on 4/11/24 which is greater than 5 days. Patient #11: The record indicated the patient was admitted on 3/16/23. The spiritual assessment was completed on 4/12/24 which is greater than 5 days.

Upon patient record review, 2 of 19 (Patient #4, #6) 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 #4: The medication profile indicates Pharmacy Compound, q4h. Apply 4 clicks topically to skin q. 4 hours as needed agitation. There was not evidence of the names of the compounded drug or the amount of each drug. (Corrected on site.) Patient #6: The medical record indicates on 4/29/24 an order for Oxygen 2L via NC. On 5/7/24 the Oxygen was set at 5L and on 5/28/24 the Oxygen was set at 8L. No orders were found in the record to increase Oxygen. (Corrected on site.)

Upon patient record review, 1 of 19 (Patient #2) 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 #2: The record indicates the patient was admitted on 3/18/24. The bereavement assessment was completed on 4/4/24.

Upon patient record review, 1 of 19 (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 record indicated a call was placed to triage on 5/11/24 at 8:36 pm due to complaints of chest pain/indigestion. After a follow up call, the triage noted at 9:13 pm, triage identified a PRN visit is needed per company policy. There is no evidence of nurse visit until 5/15/24 at 11:56 am.

Upon patient record review, 3 of 19 (Patient #2, #6, #14) 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 patient declined Chaplain services. A care plan with problems, interventions and goals was been created and not resolved when services were declined. In addition, the patient was a combat veteran, service connected for PTSD. He was experiencing anger, frustration and financial distress at the time of admission. There was not evidence of problems/goals/interventions for identified patient needs. (Corrected on site.) Patient #6: The patient declined Chaplain services. A care plan with problems, interventions and goals was created and not resolved when services were declined. (Corrected on site.) Patient #14: The patient declined Chaplain and social work services. A care plan with problems, interventions and goals had been created and was not resolved when services were declined. (Corrected on site.)

Upon patient record review, 7 of 19 (Patient #4, #6, #8, #9, #11, #12, #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 #4: The medical record indicates an order to start ABH gel, apply 4 clicks topically to skin q. 4 hours as needed agitation. The order does not indicate the amount of of each medication in the compound. (Corrected on site.) Patient #6: The medical record indicates on 4/29/24 an order for Oxygen 2L via NC. On5/7/24 the Oxygen was set at 5L and on 5/28/24 the Oxygen was set at 8L. No orders were found in the record to increase Oxygen. (Corrected on site.) Patient #8: The record indicates an order on 4/29/24 for wound care. The order did not include the location of the wound. Patient #9: The patient was admitted on 11/9/23 with a foley catheter in place. There is not an order for foley catheter with catheter and balloon size flushing and changing directions. Patient #11: The patient was admitted on 3/16/24 with a foley catheter in place. There is not an order for foley catheter with catheter and balloon size flushing and changing directions. (Corrected on site.) Patient #12: The benefit period starting 4/14/24, order for oxygen 2L/min prn SOB. During visits several visits the patient was noted to be using oxygen 3L /min. There was not evidence the plan of care was followed. (Oxygen order corrected on site.) Patient #14: The patient was admitted on 4/10/24 with a foley catheter in place. There is not an order for foley catheter with catheter and balloon size flushing and changing directions. (Corrected on site.)

Upon patient record review, 2 of 19 (Patient #6, #8) 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 #6: The record indicated an order for antibiotic on 5/16/24. The plan of care was not updated to include infection. Patient #8: The patient had a wound with wound care orders that were initiated on 4/29/24. There was not evidence that wound care was on the plan of care that reflected patient/family goals and interventions based on the problems related to the wound.

Upon client record review, 4 of 19 (Patient #1, #4, #5, #12) 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 record indicates a volunteer assessment was requested on the initial plan of care. There is no evidence in the chart that a volunteer assessment was completed. Patient #4: The record indicates a volunteer assessment was requested on the initial plan of care. There is no evidence in the chart that a volunteer assessment was completed. Patient #5: The record indicates SN visits 2 times week. The week 4/28 to 5/4/24 had one SN visit. Patient #12: The record indicates volunteer visits 2 times a month. There were no visits found in the record for May. In addition the skilled nurse frequency was 3 visits per week. Patient #14: SN visits Week 1indicated 4 visits per week. Week 1 documented 3 visits. SN visits Week 2 indicated 3 visits per week. Week 2 documented 2 visits.

Upon patient record review, 1 of 19 (Patient #6) 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 #6: The record indicates an order for Oxygen. The HHA plan of care does not include Oxygen precautions.

Upon patient record review 5 of 19 (Patient #3, #6, #7, #9, #14) 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 #3: The Home Health Aide Plan of Care indicated nail care every visit. On 5/7/24, the aide indicated for nail care, completed: no. Notes: per frequency-not needed this visit. Patient #6: The record indicates HHA visits 2week13. No HHA visits were scheduled. Patient #7: The record indicates HHA visits 6 times a week. The week of 5/26 to 6/1/26, 4 HHA visits were recorded. Patient #9: The Home Health Aide Plan of Care indicated nail care every visit. On 6/5 and 6/7/24, the aide indicated for nail care, completed: no. Notes: per frequency-not needed this visit. Patient #14: The record indicates HHA visits 2 times a week. The week of 5/26 to 6/1/26, 1 HHA visits was recorded as a missed visit with no additional visits. In addition, The Home Health Aide Plan of Care indicated hair care every visit. On 5/6 and 5/21/24, the aide indicated hair care, completed: no. Notes: per frequency-not needed this visit. Also, the task of shave was indicated to be performed at every visit. On 6/5/24, the aide indicated shave, completed: no. Notes: per frequency-not needed this visit.

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 reveals the 2023 annual total volunteer hours were 3.4 %.

Upon patient record review, 1 of 19 (Patient #11) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #11: The certification of terminal illness narrative indicated: "Patient is an 89 yo WM w primary diagnosis of neoplasm of unspecified infarction affecting the right dominant side". The terminal diagnosis listed was not complete and the terminal diagnosis could not be determined.

Upon patient client record review, 1 of 19 (Patient #4) 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 #4: The signed election statement indicated that the patient/caregiver wished to receive the notification of non-covered items, services and drugs. There was not evidence that this document was provided.

Upon patient client record review, 2 of 19 (Patient #2, #6) 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: The patient was transferred into the hospice on 3/18/24 into the first benefit period. The election of benefit date was noted as 3/18/24, however the date of election for the first benefit period was 3/5/24. In addition, The record indicates the HHA did not visit the patient after 4/17/24. On 5/8/24, the RN completed a supervisory question, "did the patient receive visits in the last 14 days?" The RN answered yes. Patient #6: The record indicated no HHA visits were completed. On 5/9/24, the RN completed a HHA supervisory visit, all questions were answered as if the aide were providing services.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Upon office tour, a storage closet containing boxed patient records was noted to be open and not locked.