Every finding on record at Southerncare, Inc.

Upon patient record review 2 of 19 (Patients #7,#14) 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 7: The medical record contained an initial spiritual assessment on day 6, 12/1/22, with start of care 11/25/22. Patient 14: The medical record contained an initial spiritual assessment on day 7, 5/30/23, with start of care 5/23/23.

Upon patient record review 1 of 19 (Patient #3) 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.

Upon patient record review, 1 of 19 (Patient #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site.

Upon patient record review, 2 of 19 (Patients #7,#9) 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 7: The medical record contained an initial bereavement assessment day 7, 12/2/22, with start of care 11/25/22. Patient 9: The medical record contained an initial bereavement assessment 1/20/23 with start of care 4/26/22.

Upon patient record review, 3 of 19 (Patients #8,#10,#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 8: The medical record contained nursing documentation upon admission identifying patient was a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to integumentary. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient had dysphagia requiring pureed diet and nectar thick liquids. There was no evidence of problems, goals, and interventions related to dysphagia. Corrected on site. Patient 12: The medical record contained nursing documentation upon admission identifying patient was a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to integumentary. Corrected on site.

Upon patient record review, 1 of 19 (Patient #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 5: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site.

Upon patient record review, 4 of 19 (Patients #3,#4,#5,#9) 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 wheelchair. There was no evidence of the wheelchair included as DME in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon recertification 7/26/23 identifying patient use of a wheelchair and walker. There was no evidence of the wheelchair and walker included as DME in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation upon admission identifying patient use of a shower chair. There was no evidence of the shower chair included as DME in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation upon recertification 8/7/23 identifying patient use of a hospital bed, over the bed table, and nebulizer. There was no evidence of the bed, table, and nebulizer included as DME in the plan of care. Corrected on site.

Upon client record review, 1 of 19 (Patient #11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 11: The medical record contained an initial POC order for a volunteer evaluation. There was no evidence of the volunteer assessment completed.

Upon patient record review, 1 of 19 (Patient #17) 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 Patient 17: The medical record contained documentation 4/20/23 identifying the bereaved party was accepting of monthly calls for bereavement care plan. There was no evidence of calls made in July, August, and September. The last call documented was 6/1/23.

Upon patient record review, 2 of 19 (Patients #9,#10) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient 9: The medical record contained nursing documentation upon recertification 8/7/23 identifying patient use of oxygen and documentation 8/30/23, 8/31/23, 9/6/23, 9/7/23 identifying patient was a 2 person assist for transfers. There was no evidence of instructions regarding oxygen use and transfer assistance included on the aide care plan. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient was a 1-2 person assist for transfers. There was no evidence of instructions regarding transfer assistance included on the aide care plan. Corrected on site.

Upon personnel record review, 1 of 13 (Personnel #9) 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 9: There was no evidence of an initial skills competency assessment.

Upon client record review, 1 of 19 (Patient #10) 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 10: The medical record contained an order 8/30/23 for wound care stating hospice nurse/facility nurse to perform. The order did not designate responsibility agreed upon by the facility and the hospice agency.