Every finding on record at Southerncare, Inc.

Upon patient record review, 6 of 19 (Patients #5, #6, #9, #12, #13, #14) 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 Patient 5 Patient has Dulcolax order route of oral, the facility has medication route ordered PEG tube. In addition, Per the hospice medication profile, the Humulin sliding scale order has for CBG of 301-400=10 units, the facility Humulin order is 301-350= 8 units, 351-400= 10 units. The facility has Mucinex on order, the hospice did not have it ordered-Corrected on site. Patient 6 The oxygen order does not have a delivery method.-Corrected on site. Patient 9: The admission note recorded that oxygen was in use. There was evidence on medication profile for oxygen therapy.-Corrected on site. Patient 12 The gabapentin route is oral while all other medications route is through the PEG tube.-Corrected on site Patient 13 There are two different Klonopin doses listed on medication profile without clarification on timeframe the doses can be administered. In addition, the facility has Citalopram dose at 20 mg, the hospice dose is ordered at 10 mg.-Corrected on site. Patient 14 The patient is not taking Budesonide, MiraLAX, Vitamin B-1, Vitamin D3, and Yupelri. In addition, patient states that she is taking Melatonin 10mg 3 tabs every night for sleep, the hospice does not have these on medication profile.-corrected on site

Upon patient record review, 1 of 19 (Patient #6) 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 6: Patient would have coumadin placed on hold for 24 hours on 3/3/25 due to elevated INR results. There was no evidence of follow up in the hospice chart. Upon investigation, the agency found lab results from 3/4/25 and 4/21/25 that had not been placed in hospice chart. Agency added order for follow up recheck.-Corrected on site.

Upon client record review, 1 of 19 (Patient #7) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 7: Patient signed a change of attending form on 06/17/24, there was no evidence that the outside attending has been collaborated with in the hospice chart.-Corrected on site.

Upon patient record review, 1 of 19 (Patient #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 9: Patient has a documented foley catheter, but has a urinary incontinence plan of care.-corrected on site.

Upon patient record review, 6 of 19 (Patients #5, #6, #9, #12, #13, #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 5 Patient has Dulcolax order route of oral, the facility has medication route ordered PEG tube. In addition, Per the hospice order, the Humulin sliding scale order has for CBG of 301-400=10 units, the facility Humulin order is 301-350= 8 units, 351-400= 10 units. The facility has Mucinex on order, the hospice did not have it ordered-Corrected on site. Patient 6 The oxygen order does not have a delivery method.-Corrected on site. Patient 9: The admission note recorded that oxygen was in use. There was evidence of an order written for oxygen therapy.-Corrected on site. Patient 12 The gabapentin ordered route is oral while all other medications route is through the PEG tube.-Corrected on site Patient 13 There are two different Klonopin doses ordered without clarification on timeframe the doses can be administered. In addition, the facility has Citalopram dose at 20 mg, the hospice dose is ordered at 10 mg.-Corrected on site. Patient 14 The patient is not taking Budesonide, MiraLAX, Vitamin B-1, Vitamin D3, and Yupelri. In addition, patient states that she is taking Melatonin 10mg 3 tabs every night for sleep, the hospice does not have an order for.-Corrected on site.

Upon patient record review, 2 of 19 (Patient #1, #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 equipment and supply needs. Patient 1 The patient was noted to have a rollator on admission. There was no order written for a rollator. -corrected on site Patient 5 There were no orders for app pad, feeding tube supplies, over the bed table, or nebulizer. -corrected on site.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 4: Patient has a recorded fall charted, there is no evidence of an incident report of the event.-Corrected on site.

Upon patient record review, 2 of 19 (Patients #16, #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 16 There was no evidence that the memorial service invitation was sent out per the bereavement plan of care.-corrected on site Patient 17 The medical record, there was no evidence that the memorial service invitation was sent out per the bereavement plan of care.-corrected on site

Upon patient record review, 1 of 19 (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 Patient 8: The aide care plan contains instruction for dressing management during showers, as of 02/25/25, there are no active wounds on the patient. The aide care plan was not updated to reflect this change.-Corrected on site.

Upon patient client record review, 4 of 19 (Patients #6, #9, #10, #12) 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 6: The patient had documented hospital bed in the home upon admission and documented nebulizer in recertification visit. Upon investigation, the agency revealed that both pieces of equipment were documented in error.-corrected on site. Patient 9: On nursing visits from 3/11/25, 3/20/25, and 4/3/25 the nurse documents that the patient does not have a foley catheter, even though there was documented evidence of foley since admission. Upon investigation, the agency revealed that patient continues to have foley catheter and the nurse had documented in error.-corrected on site. Patient 10: The nurse documented a supervised aide visit was on visit 4/14/25, though no scheduled aide visits or aide plan of care. Upon investigation, the agency determined that the patient has never had aide services and the nurse had documented in error.-corrected on site Patient 12: The admit nurse note charts that there is a nebulizer in home and on the recertification visit, the nurse charts that there is a Geri Chair in home. No orders were written for those pieces of medical equipment. Upon investigation, the agency determined that the patient has never had a nebulizer or Geri chair in home, that this was documented in error.-corrected on site

Upon patient record review, 1 of 19 (Patient #5) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient Patient 5 There was no evidence of the Election of Benefit or the most recent plan of care update sent to SNF/NF, the most recent dated plan of care update was dated 03/28/25.

Upon patient record review, 1 of 13 records (Patient #11) 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 #11: At the time of admission, the medication profile reflects the order for Miralax 17 Grams oral powder. There was no diluent included. Corrected onsite

Upon patient record review, 1 of 13 records (Patient #11) 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 #11: At the time of admission, the medication profile reflects the order for Miralax 17 Gram oral powder; however, there was no diluent included. Corrected on-site

Upon client record review, 2 of 13 applicable records (Patient #3, #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: On 3/4 an order was written for chaplain frequency 1 time every 2 months x 2. Chaplain made a visit on 3/4 and then again on 4/6 which is not in compliance. Patient #5: On 3/7 an order for Chaplain was written 1 time every 2 months x 2. The Chaplain then made a visit on 3/8 and again on 4/7 which is not in compliance.

Upon patient record review, 1 of 12 applicable (Patient #8) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient #8: The medication Eliquis was documented on the medication profile since admission; there was no evidence that bleeding precautions was on the aide plan of care. Corrected on-site.

Upon patient record review 3 of 12 applicable records (Patient #2, #11, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #2: The aide care plan reflects that the patient is to have a shampoo 1 time a week. During the weeks of 3/6, 3/13, 4/3 and 4/17, the aide performed a shampoo 2 x week instead of weekly. Patient #11: An order dated 3/9/22 indicated for the aide to discontinue services, effective 3/6/22. The record reflects that an aide provided care on 3/7/22. Patient #13: The aide plan of care stated that shampoo and nail care was to be done 1 time a week; however the week of 12/19/2021 the aide provided the shampoo and nail care at both visits.