Every finding on record at Southerncare, Inc.

Upon patient record review 3 of 19 (Patient #2,6,10) 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: No evidence that initial spiritual assessment was completed within 5 days of election. Assessment completed on 01/24/2023 and patient admitted 01/05/2023. Patient 6: No evidence that initial spiritual assessment was completed within 5 days of election. An initial and mini assessment were completed on 07/03/2023 and patient admitted 06/26/2023. Patient 10: No evidence that initial social assessment was completed within 5 days of election. Assessment completed on 08/08/2023, admit date 08/02/2023.

Upon patient record review, 1 of 19 (Patient #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 13: Miralax 17grams powder orally PRN daily for constipation. No evidence of instruction for how diluent powder on MAR. Corrected on site.

Upon patient record review, 3 of 19 (Patient #2,5,6) 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: No evidence that the initial bereavement risk assessment was completed within 5 days of election. Bereavement risk assessment completed 01/24/2023. Patient admitted 01/05/2023. Patient 5: No evidence that the initial bereavement risk assessment was completed within 5 days of election. Bereavement risk assessment completed 07/07/2023. Patient admitted 06/30/2023. Patient 6: No evidence that the initial bereavement risk assessment was completed within 5 days of election. Bereavement risk assessment completed 07/03/2023. Patient admitted 06/26/2023.

Upon patient record review, 4 of 19 (Patient #5,6,9, 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 5: CTI on 7/01/2023 list patient as a full code. Patient has advanced directive uploaded to the chart which list patient as a DNR dated on admission 6/30/23. Patient 6: CTI 09/13 list patient as a full code. Patient has advanced directive uploaded to the chart on 07/14/2023 which list patient as a DNR. RN documented on admit assessment that patient was listed as DNR . Social worker list patient as full code during 10/31/2023, 09/12/2023, and 08/08/2023 assessment. Patient 9: MD states that patient is a full code on admit CTI. RN documented patient as a DNR on admission assessment. Active DNR on file for 03/23/2023 which is the day of admit. Patient 13: Volunteer services not addressed on current plan of care. Volunteer services were ordered to started on 01/06/2023 at once a month. Volunteer has visits documented as occurring or being refused by the family monthly since January.

Upon patient record review, 1 of 19 (Patient #13) 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 13: Miralax 17grams powder orally PRN daily for constipation. No evidence of instruction for how diluent powder on order. Corrected on site.

Upon patient record review, 1 of 19 (Patient #7) 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 7: Wound care supplies listed on current plan of care. No evidence that patient had a wound at anytime during both benefit periods.

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: Volunteer services provided on 10/27/2023. No evidence that an order was placed to start care. Volunteer referral coordination note entered stated the family asked to start volunteer services once a month. Clarification order entered during survey.

Upon patient record review, 1 of 19 (Patient #1) 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 1: Aide POC has alert/precautions for wound dressings to left hand and left wrist that should be left in place. Patient wounds were discontinued on 10/31/2023. No evidence that alerts were removed from aide POC at that time. Corrected on site.

Upon patient record review 2 of 19 (Patient #7,13) 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 7: Plan of care has aide frequency as 2 visits a week. No evidence that 2 visits occurred for the week of 09/04/2023, only one visit is documented for the week, 09/07/2023. Patient 13: Plan of care has aide frequency ordered at twice weekly. 09/28/2023 visit missed due to "Aide having a flat tire leaving Battle Creek and was unable to complete the last visit of the day." No evidence that the aide offered to reschedule the visit or that the caregiver refused a visit on the remaining 2 days of the week.

Upon patient record review, 3 fo 19 (Patient #5, #6, #9) 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 5: CTI on 7/01/2023 list patient as a full code. Patient has advanced directive uploaded to the chart which list patient as a DNR dated on admission 6/30/23. Patient 6: CTI 09/13 list patient as a full code. Patient has advanced directive uploaded to the chart on 07/14/2023 which list patient as a DNR. RN documented on admit assessment that patient was listed as DNR . Social worker list patient as full code during 10/31/2023, 09/12/2023, and 08/08/2023 assessment. Patient 9: MD states that patient is a full code on admit CTI. RN documented patient as a DNR on admission assessment. Active DNR on file for 03/23/2023 which is the day of admit.

Upon patient client record review, 2 of 19 (Patient #5, #6) did not have evidence that each patient record contains Advance Directives. Patient 5: Agency provided advance directives not filled out completely. Name of physician that issued the DNR left blank. Patient 6: Agency provided advance directives not filled out completely. Name of patient that the DNR was issued for was left blank.

Upon client record review, 2 of 19 (Patient #3,12) 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 3: Plan of care has SN frequency ordered as twice weekly. No evidence that 2 visits were completed on the week of 09/03/2023. No evidence that SN offered to reschedule the visit or that the caregiver refused a visit on the remaining 2 days of the week, Missed visit note entered during survey. Patient 12: Plan of care has SN frequency ordered at 3 times a week for week 1 of benefit period. No evidence that 3 visits occurred during week 1. Documentation for 2 visits only for that week on 09/19/2023 and 09/20/2023.