Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #1-The patient is a 61 year old with Malignant Neoplasm of Connective Tissue and was admitted 01/19/24 under BC/BS of Mississippi. The patient attachments include insurance authorization stating: Please be advised hospice benefits are limited to 6 months per the lifetime of the member. The consents and/or other documentation on record do not evidence the patient was advised on the specific limitations of coverage. (corrections on site)

Upon patient record review, 4 of 14 (Patient #2, #5, #6, #10) 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 #2-The patient was admitted 02/22/24 and declined the Chaplain. A Spiritual Assessment was not performed by the RN or MSW. A Spiritual Assessment is not on record. (corrected on site) Patient #5-The patient was admitted 03/06/24 and declined the Chaplain. A Spiritual Assessment was not performed by the RN or MSW. A Spiritual Assessment is not on record. (corrected on site) Patient #6-The patient was admitted 01/03/24 and declined the Chaplain. A Spiritual Assessment was not performed by the RN. A Spiritual Assessment is not on record. (corrected on site) Patient #10-The patient was admitted 02/27/24 and declined the Chaplain. A Spiritual Assessment was not performed by the RN. A Spiritual Assessment is not on record. (corrected on site)

Upon patient record review, 6 of 14 (Patient #2, #3, #4, #7, #8, #9 ) 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 #2-Mucinex and Amicar are listed on the medication profile to be administered orally. The correct route of administration is via G Tube.(corrected on site). Patient #3- Upon home visit 03/14/24 the caregiver reviewed the patents current med list and stated Memantine had been discontinued about 8 months ago and Ondansetron had also been discontinued for a while. Memantine 10 mg 1 tablet bid and Ondansetron 4 mg disintegrating tablet is listed on the medication profile.(corrected on site). Patient #4-The medication profile includes 2 medications prescribed for pain without differentiation for administration. The profile includes Tramadol 100 mg 1 tab q6h prn pain and Oxycodone-Acetaminophen 1 tab q6h prn pain. 12/20/24 orders were received to DC Zofran. Ondansetron (generic for Zofran) is still listed on med profile. (corrected on site) Patient #7-The medication profile contains Medrol(pak) 4mg tab in a dose pack daily per instructions on package. The profile does not include the specific dosage(s) to be administered. (corrected on site) Patient #8-The following medications are listed on the medication profile to be administered via PEG tube: Buspirone, donepezil, and megestrol, The patient does not have a PEG tube and the correct route of administration is oral. Acetaminophen is listed as Acetaminophen 325 mg tablet 1-2 every 4 hours scheduled for temp. MiraLax 17 gm dose powder daily does not contain a diluent on medication profile (corrected on site) Patient #9-Orders were received 02/28/24 to discontinue Benazepril. Benazepril remains active on medication profile.(corrected on site).

Upon patient record review, 4 of 14 (Patient #2, #3, #4, #8) did not have evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #2-Mucinex and Amicar are listed on the plan of care to be administered orally. The correct route of administration is via G Tube. The 02/22/24 plan of care includes orders for the nurse to instruct the patient on the management of tracheostomy and proper site care. The orders do not specify trach type/size, how often to change, and actual site care to be performed. The patients nutritional status on the plan of care is listed as G Tube. The plan of care is not specific for the G tube feedings to be administered. (corrected on site) Patient #3-Memantine 10 mg 1 tablet bid and Ondansetron 4 mg disintegrating tablet is listed on the plan of care. Upon home visit 03/14/24 the caregiver stated Memantine had been discontinued about 8 months ago and Ondansetron had also been discontinued. 12/20/24 orders are also on record to DC Zofran. Ondansetron (generic for Zofran) is still listed on the current plan of care. (corrected on site) Patient #4-The 03/08/24 plan of care includes 2 medications prescribed for pain without differentiation for administration. The profile includes Tramadol 100 mg 1 tab q6h prn pain and Oxycodone-Acetaminophen 1 tab q6h prn pain. (corrected on site) Patient #8-The following medications are listed on the plan of care to be administered via PEG tube: Buspirone, donepezil, megestrol. The patient does not have a PEG tube and correct route of administration is oral. Acetaminophen is listed as Acetaminophen 325 mg tablet 1-2 every 4 hours scheduled for temp. MiraLax 17 gm dose powder daily does not contain a diluent on the plan of care. Nutrition is listed as Jevity 1 can 5 times daily via PEG. The patient does not have a PEG tube (corrected on site)

Upon patient record review, 1 of 14 (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-Effective 02/01/24 the Chaplain is ordered to visit monthly. A Chaplain visit is not on record for February 2024 and there is no documentation of a missed visit. (late entry missed visit documentation corrections on site)

Upon patient record review, 1 of 14 (Patient #11) did not have evidence the hospice offers bereavement counseling that includes: Ensuring that bereavement services reflect the needs of the bereaved Patient #11-The patient died on 07/07/23. A phone call was placed per the plan of care by the Bereavement Coordinator on 07/19/23. The Bereavement coordinator documented providing active listening and spiritual guidance and would follow up on the next scheduled call. The documentation is not specific for when the next call would be and there are no further documented phone calls on record. The record is unclear that the bereaved needs were met.

Upon patient record review, 2 of 14 (Patient #5, #6) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions for a hospice aide prepared by a Registered Nurse. Patient #5-The Aide Care plan does not include Oxygen precautions which are applicable to the plan of care. (corrected on site) Patient #6-The Aide Care Plan does not include fall precautions, aspiration precautions or Oxygen precautions. (corrected on site)

Upon patient record review, 1 of 14 (Patient # 7) did not evidence documentation in the patient record that a hospice aide provides services that are: included in the plan of care. Patient #7-The Aide is ordered to visit the patient three times weekly. The week of 02/26/24-03/02/24 the patient was visited once on 03/01/24. A missed visit is documented on 02/26/24; however the third visit that was ordered is not on record. The week of 03/03/24-03/09/24 the patient was visited once on 03/07/24. A missed visit is documented on 03/08/24;however documentation regarding the third visit that was ordered is not on record (corrected on site)

Upon patient record review, 1 of 14 (Patient #13) did not have evidence that the discharge summary includes all required information. Patient #13-The discharge summary on record only documents the patient revoked to receive more aggressive treatment. The summary does not include a summary of the patient's stay, including treatments, symptoms and pain management