Every finding on record at Southerncare, Inc.

Upon patient record review 1 of 27 (Patient #5) 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 5: There was no evidence of a comprehensive spiritual assessment. Corrected on site.

Upon patient record review, 2 of 27 (Patients #1,#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 1: The medical record contained nursing documentation upon recertification visit 7/12/23 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site. Patient 6: The medication profile contained Seroquel listed twice for 100 mg twice daily and 25 mg twice daily. There was no evidence of instructions if the doses were to be taken together or at separate times of day. Corrected on site.

Upon patient record review, 1 of 27 (Patient #6) 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 6: The medical record contained an initial bereavement assessment completed 1/17/23 with a start of care 12/18/22.

Upon patient record review, 1 of 27 (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: The medical record contains documentation of wound onset 8/23/23. There is no evidence of nurse wound assessments after initial onset.

Upon patient record review, 1 of 27 (Patient #19) 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 19: The plan of care contained problems, goals, and interventions regarding oxygen use despite an order to discontinue oxygen 7/24/23. Corrected on site.

Upon patient record review, 2 of 27 (Patients #1,#6) 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: The medical record contained nursing documentation upon recertification visit 7/12/23 identifying patient use of oxygen. There was no evidence of an order for oxygen. Corrected on site. Patient 6: The medical record contained two orders for Seroquel doses 100 mg twice daily and 25 mg twice daily. There was no evidence of instructions if the doses were to be taken together or at separate times of day. Corrected on site.

Upon patient record review, 6 of 27 (Patients #5,#6,#7,#13,#17,#19) 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 5: The medical record contained nursing documentation upon recertification visit 7/3/23 identifying patient use of a hospital bed, bed rails, and commode. There was no evidence of the bed, rails, and commode included as DME in the plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 8/6/23 identifying patient use of a Hoyer lift for transfers. There was no evidence of the lift included as DME in the plan of care. Corrected on site. Patient 7: The medical record contains nursing documentation upon admission identifying patient use of a hospital bed, lift chair, and raised toilet seat. There was no evidence of the lift included as DME in the plan of care. Corrected on site. Patient 13: The medical record contains nursing documentation upon recertification visit 6/26/23 identifying patient use of hospital bed, commode, and walker. Corrected on site. Patient 17: The medical record contained nursing documentation 7/20/23 identifying patient use of a BIPAP. There was no evidence of the BIPAP included as DME in the plan of care. Corrected on site. Patient 19: The plan of care contained an oxygen concentrator and supplies despite an order to discontinue oxygen 7/24/23. Corrected on site.

Upon client record review, 7 of 27 (Patients #1,#7,#9,#13,#14,#19,#20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The medical record contained an order for spiritual care visits 4 times in August. There was evidence of 3 scheduled visits made in August. Corrected on site with missed visit documentation. Patient 7: The medical record contains an oxygen order for dose of 2 liters per minute. Nursing documentation upon admission and follow up visits identifies 3 liters administered instead of the 2 liters ordered. Patient 9: The medical record contained an ordered nursing frequency of 3 times weekly. There was evidence of 1 visit completed the week of 9/3/23. Corrected on site with missed visit documentation. Patient 13: The medical record contained an ordered nursing frequency of twice weekly. There was evidence of 3 scheduled visits completed the week of 8/13/23. Patient 14: The medical record contained an ordered nursing frequency of twice weekly. There was evidence of 3 scheduled visits completed the week of 8/20/23 and daily nursing visits during respite stay 9/5/23-9/9/23. Patient 19: The medical record contained ordered frequencies for social work 1 every 2 month 2, 1 month 2, and spiritual care 1 every 2 month 2, 1 month 1. Visits were completed monthly for both the MSW and SC. Corrected on site. Patient 20: The medical record contained ordered frequencies for social work 1 every 2 month 2, 1 month 1, and spiritual care 2 every 2 month 2, 1 month 2. Visits were completed monthly for both the MSW and SC. Corrected on site.

Upon patient record review, 2 of 27 (Patients #7,#19) 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 Patient 7: The medical record contained an aide care plan with task to shower. Patient is alert and oriented and has refused showers since admission. There was no evidence of an update to the aide care plan to reflect the patient preferences. Corrected on site. Patient 19: The aide care plan contained instructions for oxygen precautions. The patient did not have oxygen ordered for use and agency confirmed there was no oxygen present. The aide care plan also contained bath tasks for both bed bath and shower each visit. Corrected on site.

Upon patient record review 2 of 27 (Patients #14,#19) 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 14: The medical record contained an ordered aide visit frequency of twice weekly. There were 3 aide visits completed the weeks of 7/30/23 and 8/27/23. There were 4 aide visits completed the week of 8/3/23. Patient 19: The medical record contained an ordered aide visit frequency of twice weekly. There was no evidence of a second aide visit completed the week of 8/20/23. The aide care plan also contained bathing tasks of bed bath and shower. There was no evidence either bath task was completed on visits 7/28/23, 7/31/23, 8/4/23, 8/7/23.

Upon patient client record review, 1 of 27 (Patient #6) did not have evidence that each patient record contains a signed election statement in accordance with 418.24, Patient 6: The election of benefit form identified patient representative elected to receive the Notification of Hospice Non-Covered Items. There was no evidence the hospice agency provided the requested form.

Upon patient client record review, 2 of 27 (Patient #25 and 26) did not evidence that each patient record contains physician orders. Patient 25: There was no evidence of an order to discharge patient due to transfer per agency Discharge policy. Patient 26: There was no evidence of an order to discharge patient due to extended prognosis per agency Discharge policy.

Upon client record review, 1 of 27 (Patient #4) 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 4: The medical record contained an order 8/29/23 that stated hospice nurse/facility nurse to perform wound care. There was no identification of which provider is responsible for the respective care. Corrected on site.

Upon client record review, 5 of 8 (Patient #2, #4, #6, #7, #8) 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 nurse documented "this RN completed all wound care as ordered" on 08/02/2023 however, there was no evidence of details. Patient #4: The nurse visit frequency ordered 05/09 was 3W1, 2W12, 4 PRN however, the week of 07/23 and 07/30 there was only evidence of one visit each week on 07/25 and 08/03. COS Patient #6: The social work visit frequency ordered 07/03/2023 was 2M and 1 PRN however, there was no evidence of any visits in July. COS Patient #7: The social work visit frequency ordered 05/20/2023 was 1M1, 2M2, 1M1, 3 PRN however, the month of July there was only evidence of a visit on 07/13. COS Patient #8: The social work visit frequency ordered 05/26 was 2 PRN and on 07/11 was 5x monthly. 1 month July however, there was evidence of 3 PRN visits on 07/10, 07/11, and 07/14 and one routine visit 08/11. In addition, the nurse visit frequency 06/04/2023 was 1W4, 2W7 however, the week of 07/16 there was no evidence of any visits and one missed visit documented on 07/19. COS

Upon patient record review 1 of 8 (Patient #7) 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 #7: The aide visit frequency ordered 05/21/2023 was 2W12, 1W1 however, the week of 08/06 there was only one visit on 08/07. COS

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

Upon patient record review, 3 of 5 (Patient 2,4,5) 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. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: The medical record contains evidence the patient has a Foley catheter. There is no evidence of a urinary/ catheter care plan. Patient 4: The medical record contains evidence the patient has a Foley catheter and frequent falls with increased periods of confusion. There is no evidence of care plans for falls or urinary/Foley. Patient 5: There is evidence in the patient record that the patient requires straight catheterization, there is no evidence of a urinary/catheter care plan.

Upon patient record review, 1 of 5 (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 start of care POC contained an order for a Foley catheter. The recertification POC did not contain an order for the Foley catheter.

Upon client record review, 4 of 5 (Patient 2,3,4,5) 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 medical record did not have evidence of orders for the Foley, peg tube care or feedings, trach care or suction orders. The RN documented on 3/10/23 and 3/12/23 " Pt receiving Diabeta Source 237ml Q6 hours with 30ml flush before and after, trach care completed, peg tube patent". Nurse documented 3/17/23 "Pt suctioned for small amount of thick yellow sputum". On 6/14/23 the nurse documented "Trach care provided, inner cannula changed". 6/16/23 the RN documented "Peg tube patent, site care provided, T drain applied, scant serous drainage noted". On 6/14/23 the nurse documented "Trach care provided, inner cannula changed". 6/16/23 the RN documents "Peg tube patent, site care provided, T drain applied, scant serous drainage noted". Patient 3: The POC contains an order to replace catheter for s/sx of infection including cloudy urine and to notify physician of any signs or symptoms of infection. The RN documents on 4/2/23 "Urine yellow with sediment and mucus" there is no evidence the catheter was changed or that the physician was notified. The RN documents on 4/4/23 "PICC line removed from right arm". There was no evidence of orders for a PICC line. 4/7/23 the RN documented "flushed Foley with 40ml of NSS, the POC order is for 10ml NSS flush. Patient 4: The POC on 1-10-22 has a Foley order "Indwelling catheter 16fr, 10cc balloon, assess and flush each visit and prn and change prn. No PRN reason to flush, no substance or amount to flush with, no reason for PRN change of catheter. The nurse documented on 6/5/23 "Irrigated Foley with 30ml NS for blockage". There is no evidence of an order to irrigate the Foley. Patient 5: The nurse documented on 3/29/23 "The patient needs catheterized multiple times daily". On 6/2/23 and 6/14/23 the nurse documented straight cath BID for urinary retention. There is no evidence of an order to catheterize patient.

Upon patient client record review, 3 of 5 (Patient 2,3,4) 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 2: On 4/11/23 nurse documents "New order obtained for UA reflex". The LPN documents on 5/12/23 in the urinary section, there is a box that indicates whether or not pt has a catheter and LVN marks no catheter and there is no evidence of the Foley being assessed. Patient 3: On 4/7/23 the RN documented "flushed Foley with 40ml of NSS", the POC order is for 10ml NSS flush. There is no evidence that NSS is an approved abbreviation. Patient 4: The nurse documents on 6/5/23 "pt having multiple falls" The RN also chooses box in documentation of "No falls in the past 3 months".