Every finding on record at Southerncare, Inc.

Upon patient record review, 4 of 14 (Patients #4,#6,#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. 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 4: The medication profile contained oxygen with no delivery method. Patient 6: Upon observation during the home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility list did not contain an albuterol inhaler, duoneb, lorazepam, and miralax identified on the hospice profile. Corrected on site. Patient 9: Upon observation during the home visit medication reconciliation, the patient did not have albuterol nebulizing solution in the home. There was no evidence the nurse recognized the missing medication during request of refills two days prior. Corrected on site. Patient 10: Upon observation during the home visit medication reconciliation, the facility and hospice medication profiles did not match. The facility list did not contain an albuterol nebulizing solution and lorazepam identified on the hospice profile. Corrected on site.

Upon patient record review, 1 of 14 (Patient #2) 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: There was no evidence of a bereavement assessment. Corrected on site with completion 3/19/25.

Upon patient record review, 2 of 14 (Patients #3,#7) 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 3: There was no evidence of weekly wound measurements since 2/19/25, as required per agency policy. Patient 7: There was no evidence of weekly wound measurements from 3/7/25 to 3/17/25, as required per agency policy.

Upon patient record review, 1 of 14 (Patient #4) 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 4: The medical record contained an order for oxygen with no delivery method.

Upon patient record review, 6 of 14 (Patients #1,#2,#5,#6,#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 equipment and supply needs. Patient 1: The medical record contained nursing documentation upon admission identifying patient use of a hospital bed and over bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of hospital bed, bedrails, shower chair, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a cane. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 6: Upon observation during the home visit, the patient had a wheelchair and shower chair. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 9: The medical record contained nursing documentation since admission identifying patient use of a hospital bed, wheelchair, and raised toilet seat that were confirmed during home visit. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 10: Upon observation during the home visit, the patient had a broda chair, hospital bed with rails, and over the bed table. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 8: The election form identified the patient's wife elected a community physician as an attending. Evidence of collaboration with the attending physician occurred 12/27/24, 1/23/25, and 2/19/25, not meeting the frequency of no less than every 15 days.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: The medical record contained nursing documentation 3/10/25 identifying patient was receiving oxygen at 3 liters per minute. The order was for 2 liters and there was no evidence of the nurse correcting the flow for accurate administration.

Upon patient record review, 1 of 14 (Patients #11) 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 11: There was no evidence bereavement care plan tasks including providing information on support groups and invitation to memorials were completed for both bereaved family members. There was also no evidence of monthly contact completed unless declined by the high risk bereaved family member.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: There was no evidence of the competency assessment for the required tasks observed with the aide performing on a patient or pseudo patient. Obtaining required vital signs was corrected on site.

Upon patient record review, 2 of 14 (Patients #3,#6) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 3: The aide care plan did not contain instructions regarding the patient having a sacral wound dressing. Corrected on site. Patient 6: The medical record contained nursing documentation since admission identifying the patient is a max assist for transfers. There was no evidence of instructions for transfer assistance included on the aide care plan. Corrected on site.

Upon patient record review 1 of 14 (Patient #10) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 10: There was no evidence of an aide supervisory visit between 2/25/25 and 3/14/25.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. The agency had a volunteer utilization rate of 3.73% for 2024.

Upon personnel record review, 1 of 14 (Personnel #10) 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 10: There was no evidence of a skills competency assessment included in the personnel file.

Upon patient record review, 1 of 14 (Patient #3) 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 3: The medical record contained sacral wound care orders in the initial plan of care order and on 3/4/25 that did not specify facility and hospice responsibility. Corrected on site.

Upon patient record review, 1 of 5 records (Patient #5) 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 5: The medical record contained nursing documentation 5/9/22 identifying patient had received ativan 1ml prior to nurse arrival. There was no evidence of ativan listed on the medication profile.

Upon patient record review, 1 of 5 records (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 5/9/22 identifying patient had received ativan 1ml prior to nurse arrival. There was no evidence of an order for ativan in the medical record.

Upon patient record review, 3 of 13 records (Patient #6,#7,#12) 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: The record indicated Diclofenac 1% topical gel. Apply to affected areas BID prn pain. There was not evidence of a specific location. Patient #7: The IDG narrative by the nurse for the IDG dated 3/10/22 indicated that the patient was started on Eliquis. There was not evidence that Eliquis was on the medication profile. Corrected on on site. Patient #12: The record indicated Mupirocin 2% topical ointment, 1 cm prn. The medication profile was incomplete without evidence of a specific frequency or a location.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 13 records (Patient #7) did not have evidence that a Registered Nurse ensured continuous assessment of the patient and family's needs and coordinated activities with other members of the interdisciplinary group (IDG). Patient #7: The nurse documentation dated 3/11/22 indicated the presence of a right medial buttock stage II new wound. There was not evidence of an assessment including measurements. There was not evidence of any further assessments, documentation or resolution of this wound from 3/11/22 until current.

Upon patient record review, 3 of 13 records (Patient #1, #4, #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: The record indicated that the patient had an 'in and out' catheter inserted on 1/24/22. Then on 2/3/22, an indwelling Foley catheter was placed. There was not evidence that the revised plan of care included progress towards outcomes and goals related to the urinary Foley catheter. Corrected on site. Patient #4: The plan of care listed a problem with goals and interventions related to training and skilled teaching in the prevention of drug diversion and misuse. There were 19 goals and 18 interventions which included but were not limited to lockbox usage, opioid counts every visit, ensure there is a trusted individual to manage medications. There was no evidence in the record of any misuse of medications or drug diversion. The leadership confirmed that this care plan with goals and interventions did not relate to this patient. The plan of care was not individualized to meet the needs of this patient. Corrected on site. Patient #9: The patient was admitted with a diagnosis of Hemiplegia following a cerebral infarct affecting the left side. The patient also had a history of previous strokes. Documentation included that the patient had left sided weakness, decreased strength, and used assistive devices for ambulation. There was not evidence of neurological problems with goals and interventions. Corrected on site.

Upon patient record review, 3 of 13 records (Patient #6,#7,#12) 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 medications and treatments. Patient #6: The record indicated an order for Diclofenac 1% topical gel. Apply to affected areas BID prn pain. The order did not contain evidence of a specific location. Patient #7: The IDG narrative by the nurse on3/10/22 indicated that the patient was started on Eliquis. There was not evidence of an order for Eliquis. Corrected on site. Patient #12: The record indicated an order for Mupirocin 2% topical ointment, 1 cm prn. The order was incomplete without evidence of a specific frequency or a location.

Upon patient record review, 1 of 13 (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: The IDG narrative note written by the nurse for the IDG dated 2/24/22 indicated that a Hoyer lift was ordered. There was not evidence of an order. Corrected on site.

Upon client record review, 2 of 10 applicable records (Patient #3,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The visit frequency for the spiritual care counselor was 2m1, 4m1, 6m1, 3m1 and 2 prn, effective 3/16/22. The record indicated that the spiritual care counselor conducted visits on 3/18/22, 3/24/22, and 3/31/22. Corrected on site. Patient #6: The visit frequency for the skilled nurse was 2x/week, changed to daily on 2/12/22 and back to 2x/week on 2/15/22. For the weeks of 2/20/22-2/26/22 and 2/27/22-3/5/22, the visit frequency was increased to 3x/week. From 2/15/22-2/19/22 (after the frequency was decreased to 2x/week), 3 visits were made. The visit frequency for the spiritual care counselor was 4m1,5m1,3m1,2m1 effective 2/8/22. The record indicated 6 visits in February.

Upon client record review, 1 of 3 applicable records (Patient #2) 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 #2: The record indicated an order from admission (1/17/22) for the skilled hospice nurse or the facility nurse to provide wound care to a stage III pressure ulcer in the coccyx area and for the skilled hospice nurse or the facility nurse to provide wound care to an unstageable wound on the patient's left great toe. These orders were updated on 2/23/22, 3/16/22, and 3/28/22. None of these orders contained clear directives as to who was to provide the wound care. Corrected on site.