Every finding on record at Southerncare, Inc.

Upon patient record review 1 of 19 (Patient #4) 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 4: The initial spiritual assessment was completed 10/10/24 with start of care 9/30/24.

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, 6 of 19 (Patients #1,#6,#7,#10,#11,#14) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 1: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile contained tamsulosin and tramadol that was not on the hospice profile. Patient 6: The medical record contained nursing documentation 3/17/25 identifying oxygen was delivered. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The medication profile also contained latanoprost eye drops with no instruction of which eye or eyes identified for administration. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile did not contain lorazepam, melatonin, and morphine that was on the hospice profile. Corrected on site. Patient 11: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile contained atorvastatin and valproate acid solution at bedtime that was not on the hospice profile. Patient 14: 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, 1 of 19 (Patient #3) 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 3: The initial bereavement assessment was completed 3/19/25 with start of care 3/13/25.

Upon patient record review, 2 of 19 (Patients #2,#3) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 2: There was no evidence of an RN assessment from 3/20/25 to 4/10/25. Patient 3: There was no evidence of an RN assessment from 3/18/25 to 4/14/25.

Upon patient record review, 1 of 19 (Patient #9) 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 9: There was no evidence of weekly wound assessments and measurements from 4/3/25-4/22/25 as required per agency policy.

Upon patient record review, 3 of 19 (Patients #3,#10,#11) 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 3: The medical record contained nursing documentation upon admission identifying patient unresolved issues with nausea. There was no evidence of problems, goals, and interventions related to nausea included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient unresolved issues with high risk for skin impairment and dysphagia. There was no evidence of problems, goals, and interventions related to skin and dysphagia included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation upon admission identifying patient is a high risk for skin impairment. There was no evidence of problems, goals, and interventions related to skin included in the plan of care. Corrected on site.

Upon patient record review, 6 of 19 (Patients #1,#6,#7,#10,#11,#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 1: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. Hospice did not have orders for tamsulosin and tramadol that were listed on the facility medication profile. Patient 6: The medical record contained nursing documentation 3/17/25 identifying oxygen was delivered. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. The record also contained an order for latanoprost eye drops with no specification on which eye or eyes are appropriate for administration. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. The facility profile did not contain lorazepam, melatonin, and morphine that was on the hospice profile. Hospice did not have orders to discontinue the medications. Corrected on site. Patient 11: Upon medication reconciliation during home visit, the facility and hospice medication profiles did not match. Hospice did not have orders for atorvastatin and valproate acid solution at bedtime that were listed on the facility medication profile. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency, and delivery method. Corrected on site.

Upon patient record review, 7 of 19 (Patients #2,#4,#7,#8,#10,#11,#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 equipment and supply needs. Patient 2: The medical record contained nursing documentation 4/1/25 identifying patient use of a wheelchair and commode. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of a nebulizer and walker. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 7: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 8: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair. There was no evidence of an order for the DME included in the plan of care. Corrected on site. Patient 10: The medical record contained nursing documentation 4/15/25 and 4/22/25 identifying patient use of a Hoyer lift and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 11: The medical record contained nursing documentation identifying patient use of a hospital bed and over bed table since admission, and a Hoyer lift since 3/6/25. There was no evidence of orders for the DME included in the plan of care. Corrected on site. Patient 14: The medical record contained nursing documentation upon admission identifying patient use of a wheelchair, and hospital bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #12) 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 12: The medical record contained nursing documentation upon recertification assessment 2/27/25 identifying patient's anticoagulant use. There was no evidence the plan of care was updated to include problems, goals, and interventions related to bleeding risks. Corrected on site.

Upon patient record review, 1 of 19 (Patient #3) 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 plan of care contained an order 3/17/25 for volunteers to visit 4 times monthly. There was no evidence of volunteer visits made.

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: The medical record contained nursing documentation 3/24/25 identifying a patient fall on 3/21/25. There was no evidence of incident investigation. Corrected on site. Patient 9: The medical record contained nursing documentation 4/9/25 identifying a patient fall. There was no evidence of incident investigation. Corrected on site.

Upon patient record review, 2 of 19 (Patients #9,#13) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • 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 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 9: The aide care plan did not contain instructions regarding wound management during bathing. Corrected on site. Patient 13: The aide care plan contained bathing tasks for a shower twice weekly and bed bath weekly. The patient was receiving two aide visits a week per orders. Corrected on site.

Upon patient record review 1 of 19 (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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 10: The medical record contained an order for aide visits three times weekly. There was no evidence of a third visit completed the week of 4/27/25.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 10: The initial POC order 4/7/25 indicated the patient accepted to receive volunteer services. There was no evidence of follow up on the request.

Upon patient record review, 2 of 19 (Patients #1,#5) 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 1: The medical record contained an order 4/23/25 to obtain a UA that did not specify which provider is responsible for performing the duty. Patient 5: The initial plan of care order for foley size, change frequency, and maintenance did not specify which provider is responsible for performing the duties. Corrected on site.

Upon patient record review 1 of 13 records (Patient #8) did not have evidence in the patient record that the comprehensive assessment identifies the 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 #8: There was not evidence of a spiritual assessment. Corrected on site.

Upon patient record review, 2 of 13 records (Patient #1,#3) 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 #1. The medication profile indicated Mupirocin 2% topical, 2 times daily per instructions. The instructions indicated to apply to affected area twice daily. There was not evidence of a specific location. Corrected on site. Patient #3: The medication profile indicated an order for Mupirocin 2% topical ointment 1 cm daily prn. Apply to affected area. There was not evidence of a specific location. Corrected On Site.

Upon patient record review, 2 of 13 records (Patient #3,#10) 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. Patient #3: The patient was admitted on 11/22/21. The record indicated that the bereavement assessment was completed on 11/30/21. Patient #10: The patient was admitted on 12/28/21. The record indicated that the bereavement assessment was completed on 3/24/22.

Upon patient record review, 4 of 13 records (Patient #2,#5,#12,#13) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that reflects 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 #2: The patient was admitted with a primary diagnosis of Hypertensive chronic kidney disease, stage 1-4. Documentation referenced the patient's neurological status indicating that the patient had a stroke which resulted in left hemiparesis, his speech was slurred and he was difficult to understand. this would often leave him very frustrated. He had an unsteady gait and was a high fall risk. he carried a towel due to frequent drooling out of the left side of his mouth. He was hypertensive, on several antihypertensive medications and his BP ranged from 140/88 to 216/126. There was not evidence that the plan of care reflected patient/family goals and interventions based on his neurological status. Corrected on site. Patient #5: The patient was admitted with a diagnosis of Alzheimer's Disease with late onset. The record indicated that the patient was forgetful, confused, gets frustrated, has a difficult time communicating wants and needs, and is incontinent. There is also documentation of severe sadness and depression, recent weight loss and requiring assistance with all ADL's. There was not evidence that the plan of care reflected patient/family goals and interventions based on the patient's Alzheimer's disease or neurological status. Corrected on site. Patient #12: The patient was admitted with a diagnosis of Alzheimer's Disease with late onset. There was not evidence that the plan of care reflected patient/family goals and interventions based on the patient's Alzheimer's disease or neurological status. Patient #13: The patient was admitted with a diagnosis of Chronic diastolic heart disease. She also had co-morbid problems of kidney disease and dementia. There was not evidence of problem statements with goals and interventions related to any of these disease processes.

Upon patient record review, 3 of 13 records (Patient #1,#3,#4) 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 #1. The record indicated an order for Mupirocin 2% topical, 2 times daily per instructions. The instructions indicated to apply to affected area twice daily. There was not evidence of a specific location. Corrected on site. Patient #3: The record indicated an order for Mupirocin 2% topical ointment 1 cm daily prn. Apply to affected area. There was not evidence of a specific location. Corrected on site. Patient #4: The record indicated an order for Iodosorb 0.9% topical 1cm as needed bilateral wounds for odor and drainage. There was not evidence of a quantifier for the number of uses per day/week. Corrected on site.

Upon client record review, 2 of 12 applicable records (Patient #2,#7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The visit frequency for the skilled nurse was 2w13 and 4 prn. For the week of 3/27/22-4/2/22, the record indicated only 1 visit on 3/29/22. For the week of 4/3/22-4/9/22, the record indicated only 1 visit on 4/8/22. There was not evidence of missed visit documentation or a change in the ordered frequency. Corrected on site. Patient #7: The patient had a Pleurix Drain with orders dated 3/31/22 and 5/11/22 to drain the Pleurix drain 3x/week. Drain no more than 1000cc. Cleanse site with alcohol. Change catheter tip after draining. Allow to air dry. Apply split gauze. Cover with 4x4 and adhesive dressing. There were multiple dates where it could not be determined that the plan of care was followed including 4/16/22. Documentation by the nurse from 4/16/22 indicated, "Visit performed for Pleurix drain care. 900cc drained. Bandaged drain area to cover." (Wound care correctly documented since 5/2/22 as the agency self recognized the missing components)

Upon patient record review, 1 of 13 (Patient #2) did not have evidence that Social work services are based on the patient's psychosocial assessment and the patient/family's needs and acceptance of these services. Patient #2: A social work note dated 4/12/22 indicated that the patient (who was a full code) did not want to be a full code and if he stopped breathing, wanted to go. The note also indicated that the social worker would return on Thursday or Friday with the paper work. There was no evidence of follow-up. As of the IDT plan of care update on 5/3/22, the record indicated that the patient remained a full code. Corrected on site.

Upon patient record review 6 of 12 applicable records (Patient #4,#5,#7,#8,#12,#13) 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 #4: The aide plan of care dated 3/25/22 and 5/9/22 indicated to provide nail care and shave weekly. From 4/18/22 to current the aide documentation indicated that these tasks were performed at each visit. The aide visit frequency was 3x/week. In addition, a shampoo was indicated to be conducted at every visit. On 5/9/22, the aide documentation indicated that a shampoo per frequency was not needed this visit. Patient #5: The aide plan of care dated 3/21/22 indicated to perform the tasks of nail care and shampoo weekly. The aide documentation revealed that both of these tasks were completed at every visit from 4/12/22 to current. The aide visit frequency was 2x/week. Patient #7: The aide visit frequency was 2x/week starting 4/1/22 until 5/4/22 when the aide services were discontinued. For the week of 4/10/22-4/16/22, there was not evidence of a visit by the aide. Patient #8: The aide plan of care indicated for stand by assistance with every visit. The documentation by the aide for the dates of 4/18/22, 4/25/22, 4/29/22, 5/2/22, 5/6/22, and 5/9/22 indicated, 'per frequency not needed.' Patient #12: The aide plan of care indicated for the task of shampoo to be completed weekly. The record indicated that this task was performed at each visit. The aide visit frequency was 3 times per week. Patient #13: The aide visit frequency was 2x/week. For the week of 11/21/21-11/27/21, the record indicated only 1 visit on 11/23/21. For the week of 12/5/21-12/11/21, the record indicated only 1 visit on 12/19/21.

Upon personnel record review, 1 of 7 applicable records (Personnel #6) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially. Personnel #6: The staff member was in the role of spiritual care counselor and bereavement coordinator. There was not evidence of a competency assessment for the roll of bereavement coordinator. Corrected on site.

Upon patient record review, 2 of 13 records (Patient #4,#7) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4: This patient was an 81 year old male with malignant neoplasm of the prostate. The ICD 10 indicated the primary diagnosis was malignant neoplasm of the prostate. The certification of terminal illness indicated, "80 year old black male with CVA. Also has dementia, CAD, MI, PVD, venous stasis ulcers. Septic shock..." Patient #7: The record contained a certification of terminal illness which indicated, "an 80 year old female admitted with a primary terminal diagnosis of cerebral or rashes..." There was also an addendum which was signed by the medical director and dated 4/7 which discussed a Pleurix drain that had been place. The patient was admitted on 3/29/22 with a diagnosis of Unspecified cirrhosis of the liver, and the patient did have a Pleurix Drain. Corrected on site.

Upon patient client record review, 1 of 13 records (Patient #9) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #9: The patient was admitted on 2/27/22. The record indicated a request for the “Patient Notification of Hospice Non-Covered Items, Services, and Drugs." on 4/18/22. The document was signed by the agency staff and the patient/representative on 4/26/22.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Patient #7: The certification of terminal illness and the initial plan of care of another patient was attached to this record. Corrected on site.

Upon patient record review, 1 of 1 applicable record (Patient #5) did not have evidence that the hospice provided the following information to the SNF: • The most recent hospice plan of care specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Corrected on site.