Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 19 (Patient #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 6: Duplicate drug therapy: The active medication list has PRN Dulcolax and PRN Lactulose listed for constipation. No evidence that instructions were given on which PRN medication to use when in the event of constipation. Corrected on site.

Upon patient record review, 1 of 19 (Patient #2) 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 2: The record indicated that the patient developed a wound on 1/23/24. Wound care orders were entered on 01/24/2024 which indicated that the hospice nurse was to perform wound care twice a week. No evidence that wound care was performed twice a week. No evidence that the wound had been measured since the wound was initially found by the nurse. Gentiva policy is for wounds to be measured weekly.

Upon patient record review, 4 of 19 (Patient #1,2,6,9) 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 1: Patient has depression listed as a related diagnosis and currently takes Lexapro for depression daily. Nursing documentation identified the patient as a risk for aspiration. There was no evidence of problems, goals, and interventions related to depression or aspiration included in the plan of care. Corrected on site- plan of care updated during survey. Patient 2: Patient has depression listed as a related diagnosis and currently takes Sertraline 50mg for depression daily and Valproic acid for behavior control. There was no evidence of problems, goals, and interventions related to depression or other neurological problems included in the plan of care. Corrected on site - plan of care updated during survey. Patient 6: The nursing documentation indicated that the patient has an active problem with altered mobility due to weakness and fatigue. No evidence of problems, goals, and interventions related to altered mobility on the current plan of care. Patient 9: Nursing documentation identified the patient as having altered mobility and at a risk for falls upon admit and ongoing assessments. The patient also had recent hematuria No evidence that problems, goals, and interventions for risk for falls or risk for bleeding was added to the active on current plan of care. Corrected

Upon patient record review, 3 of 19 (Patient #3,5,8) 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 current plan of care has wound care supplies listed on the current POC. The record indicates that patient developed a wound 10/22/2024. That would was deactivated in the wound chapter on 11/2/2024. No evidence that an order was received to d/c those wound care orders or to take the wound care supplies off the current POC supply list. Corrected on site. Patient 5: The medical record contained nursing documentation since admission identifying patient having oxygen equipment available in the home for treatment. There was no evidence that oxygen was included in the plan of care for the DME supply list. Patient 8: The medical record indicated that the patient uses walker/rollator to help with mobility. No evidence that the walker/rollator was included on the current plan of care.

Upon patient record review, 1 of 19 (Patient #2) 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 2: The record indicated that the patient developed a wound on 1/23/24. Wound care orders were entered on 01/24/2024 which indicated that the hospice nurse was to perform wound care twice a week. No evidence that wound care was performed. The plan of care was not updated of the wound care to be performed.

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 frequency of service delivery Patient 17: There was no evidence that the 3 month letter due on June 20th, 2024 was sent timely to the bereaved person. The bereavement activity reflected that the 3 month letter was sent 8/16/24.

Upon patient record review, 3 of 19 (Patient #1,3,8) 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 1: The record indicated that the aide entered a missed visit note on 10/02/2024 that was not completed, had no evidence of the visit date or which RN was notified that the visit was missed. Patient 3: Lacosamide 100mg listed on the active medication list for seizures. The record does not indicate that the patient has had seizures but that this medication was started to help provide relief for muscle contractures. Corrected on site. New physicians order received to reflect the reason why the medication is being given. Patient 8: The during chart review, it was noted that the RN narrative documentation entered on 1/14/2025 and 01/17/2025 were the same notes, copied by the same nurse. With the exception on the opening statement, no other information was changed or updated.

Upon patient record review, 2 of 13 records (Patient #9, #10) 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. Patient 9: An order dated 3/4/2022 includes Add oxygen concentrator. Oxygen not included on med profile. Corrected on site. Med profile included Medrol tapered dose as instructed on package by mouth for 6 days without specific instructions on how to dose. Patient 10: Med profile includes O2 oxygen 2-4 L PRN oxygen provider SOB titrate as needed without a route. Corrected on site.

Upon patient record review, 1 of 13 records (Patient #9,) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient 9: SOC 12/17/2021. SW notes dated 12/20/2021 include there is a bereavement contact. The EMR denotes assessment to be entered into the Bereavement activity console. There was no evidence of a bereavement assessment entered.

Upon patient record review, 2 of 13 records (Patient #3,5) 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. Patient 3: SOC date 7/22/2021. Terminal diagnosis Parkinson's, with history of non traumatic sub arachnoid hemorrhage. Order dated 1/3/2022 includes DC Cardiac, Pharmacy and Neurologic interventions, all goals met. There was no evidence in the care plan for Neurological problems/interventions. Corrected on site. Patient 5: SOC terminal diagnosis hemiplegia after sub arachnoid hemorrhage with COPD exacerbation. History of Encephalopathy and epilepsy. There was no evidence of a Neuro Problem/interventions. Corrected on site.

Upon patient record review, 2 of 13 records (Patient #9, #10) 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 9: An order dated 3/4/2022 includes Add oxygen concentrator. Nurses note dated 3/3/2022 included Equipment ordered by Hospice agency O2 concentrator and cylinder. There was no evidence of a complete order for Oxygen. Corrected on site. Order dated 1/20/2022 included Medrol tapered dose as instructed on package by mouth for 6 days. There was no evidence of how to dose. Patient 10: Order dated 2/27/2022 includes O2 oxygen 2-4 L PRN oxygen provider SOB titrate as needed. There was no evidence of a route. Corrected on site.

Upon client record review, 3 of 13 records (Patient #8, #10, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: Orders dated 12/19/2021 and 2/4/2022 include SN visits 2x week. For week of 1/30/2022 there was no evidence of visits or missed visits. For week of 2/6/2022, there was one visit dated 2/10/2022 and no evidence of a second visit or missed visit documentation. Patient 10: Order dated 1/20/2022 included RN visits 2xweek effective 1/23/2022. For week of 1/23/2022 one visit dated 1/27/2022. There was no evidence of missed visit documentation. Patient 12: SOC 10/1/2021 Order included RN visits 2x week. For week of 10/24/2021 one visit dated 10/25/2021. There was no evidence of missed visit documentation.

Upon patient record review, 1 of 1 applicable (Patient #5) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient 5: SOC dated 9/9/2022 Medicaid waiver homemakers 6 hours a day 7 days a week. There was no evidence of collaboration.

Upon patient record review 1 of 11 applicable records (Patient #10) 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 Patient 10: Order dated 1/20/2022 included HHA 2x week x 12 effective 1/23/2022. Week of 1/23/2022 one visit dated 1/27/2022. There was no evidence of a missed visit.

Upon patient client record review, 1 of 13 records (Patient #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. Patient 5: A narrative note per RN dated 1/31/2021 includes, Patient lying in bed with eyes closed when there is a robber visit. Patient son present sitting in recliner OH.

Upon client record review, 1 of 1 applicable records (Patient #11) did not have evidence that the hospice forwarded a summary and a copy of the patient record, if requested, to a facility when transferring the patient to that facility. • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 11: Patient revoked on 12/20/2021. There is a narrative dc summary faxed. There is no evidence where summary was faxed.

Upon client record review, 1 of 3 applicable records (Patient # 2) did not have evidence that the hospice plan of care reflects the participation of the hospice, the SNF/NF or ICF/IID and the patient/caregiver. Patient 2: There was no evidence that the SNF participated in the development of the plan of care for this patient that resides in a SNF.

Upon patient record review, 3 of 3 applicable records (Patient #2, #3, #4) did not have evidence that the hospice provided the SNF with all required information. Patient 2: No evidence exists of a Hospice file at the facility. Patient 3: SOC 7/22/2021. The lasted dated plan of care 1/12/2022.No evidence exists of an updated Plan of Care. Patient 4: There was no evidence of an Election of benefit or names and contact information for hospice personnel involved.