Every finding on record at Southerncare, Inc.

Upon patient record review, 2 of 14 (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: Pt has Famotidine on medication profile. Pt has not been taking Famotidine since prior to last SN visit. Corrected on site, new MD orders obtained. Patient 3: The hospice medication profile contains Benadryl 25mg 1 tab every 12 hours prn. The facility MAR has 2 tabs every 12 hours. The facility MAR has pt taking Vitamin D3, Senexon S and Ondansetron these medications have been on the facility MAR since prior to the last SN visit. These medications were not included on the hospice medication profile. Corrected on site. New orders obtained.

Upon patient record review, 1 of 14 (Patient #5) 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 5: During all visits this week 7/7/25, the wound documentation for all wounds the SN documented under "wound assessed, no, wound assessed by facility staff. There is no evidence the SN assessed the wound this week. Per agency policy Wound Assessment, Documentation and Clinical Oversight (CLIN.14) wounds are to be assessed and measured weekly. There was no assessment by Hospice staff, only facility staff assessed wound, and no wound measurements obtained the week of 7/6/25. SN went out 7/15/25 during survey to measure the wounds.

Upon patient record review, 2 of 14 (Patient #1,3) 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: Pt has Famotidine on POC. Pt has not taking Famotidine since prior to the last SN visit. Corrected on site, MD order to Discontinue Famotidine. Patient 3: The hospice POC contains Benadryl 25mg 1 tab every 12 hours prn. The facility MAR has 2 tabs every 12 hours. The facility MAR has pt taking Vitamin D3, Senexon S and Ondansetron these medications have been on the MAR since prior to the last SN visit. These were not included on the hospice POC. Corrected on site, new orders obtained.

Upon patient record review 1 of 14 (Patient #10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 10: SN documented 6/26/25, Caregiver is overwhelmed with caring for patient, pt being combative and roaming unsafely at night. Caregiver requesting a family meeting with MSW and to discuss possible respite care. MSW notified and will follow up with caregiver. SN made another visit 7/2/25 and documented pt having an increase in agitation and lethargy. The MSW did not contact the family until 7/3/25 to discuss respite options.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient 5: Pt placed on "watch list" to increase visits due to change of condition on 7/8/25 vital signs temp 100.3, pulse 112, bp 79/48. SN documented on 7/10/25 a temp of 101.3, pulse 108 Bp 84/36 and there was no evidence the SN updated the attending physician or Medical Director, On 7/11/25 The SN documented the patient's temp was 100.9, pulse 111 bp 117/58 and "pt combative unable to measure wounds due to this". There was no evidence the attending physician or Medical director was notified. SN documented on 7/13/25 temp 97.8, pulse 82 bp 99/62 “Wound care performed by facility, wound very foul smelling today”. Pt sleeping in bed and wakes to name. There is no evidence the attending physician or medical director was notified regarding the foul odor of the wounds, change in condition/vital signs.

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: The SN performed an Aide supervisory visit on 5/30/25, the next one was completed on 6/20/25 this is greater than 14 days.

Upon patient client record review, 5 of 14 (Patient #5,6,7,8,10) 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 5: SN documented 7/3/25 wound care by restating the order, the order was not edited to past tense to indicate the details of the wound care completed and then documented “WOC completed, pt tolerated well" on each of the patient’s wounds. There are no details of the wound care provided. The SN documented on 6/27/25 wound care by restating the order and then “Done” and “provided” under the wound care provided section. There are no details of the wound care provided. Patient 6: SN documented on 6/5/25 by restating the order and then “wound care provided” there no details of the wound care provided. On 6/12/25 The SN documented by restating order in wound care provided section and then documented “wound care provided by RN case manager” in narrative. There are no details of the wound care provided. Patient 7: SN documented 6/5/25 and all subsequent weekly visits, the wound care by restating the order and not editing to past tense to indicate wound care was completed. The SN then documented after the order “WOC completed; pt tolerated well”. There is no details of the wound care provided. Patient 8: The SN 7/11/25 documented “Fentanyl patch changed” there is no evidence of what dose or where the patch was applied. The SN documented on 6/27/25, in the wound care provided section, by restating the order and did not edit to past tense and then documented “wound care performed”. There are no details of the wound care provided. Patient 10: The SN documented 6/16/25 “Pt had a bell movement during this visit”.

Upon patient record review 3 of 13 (Patient #3, 7, 9) 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 #3 - SOC 05/16/2022, MSW did not complete their section of the comprehensive assessment within 5 days per agency policy. Patient #7 - SOC 05/18/2022, MSW first visit on 05/26/2022. MSW did not complete their section of the comprehensive assessment within 5 days per agency policy. Patient #9 - SOC 05/26/2022, MSW first visit on 06/11/2022. MSW did not complete their section of the comprehensive assessment within 5 days per agency policy.

Upon patient record review, 1 of 13 (Patient #1) 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 #1 admitted 07/21/2021 first bereavement assessment completed 02/23/2022.

Upon client record review, 1 of 5 applicable patients (Patient #2) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 - POC dated 05/16/2022 SC visit frequency effective 05/22/2022 4 visit within 30 days - only 3 visits made between 05/22/2022 to 06/21/2022.

Upon patient record review 3 of 13 (Patients #3, 4, 12) 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 #3 - Effective 05/16/2022 All aide task frequencies ordered every visit - CNA did not complete the following tasks: assist with dressing, nail care, comb hair, linen change, offer fluids or partial bed bath 06/15/22, 06/29/22. Did not complete assist with dressing, partial bath, offer fluids or clean room on 06/02/22, 07/01/22, 06/24/22 or 06/10/22. Provided skin care and repositioning on 06/10/22, 06/15/22 and 06/29/22 but not on aide care plan. Patient #4 - Effective 05/25/2022 All aide task frequencies ordered every visit - CNA did not complete the following tasks: assist with dressing, complete bed bath, file nails, mouth care, perineal care, repositioning, or emotional support on 06/17, 06/18, 06/20, 06/27, 06/29. Provided skin care and made bed 06/17/22, 06/20/2022, 06/27/22 and 06/29/22 but not on aide care plan. Patient #12 - Effective 06/01/2022 All aide task frequencies ordered every visit - CNA did not complete the following tasks: assist with dressing, mouth care, linen change, offer fluids and snack, 06/15/22, 06/17/22, 06/20/22 or 06/22/22. Provided skin care 06/15/22, 06/17/22, 06/20/22 and 06/22/22 but not on aide care plan.

Upon client record review, 2 of 8 applicable (Patient #4 and 11) 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 #4 POC dated 05/25/2022 SN visit frequency effective 1wk1, 1q2wk2, 1wk10. No visit made week 1. Patient #11 POC dated 03/08/2022 SN visit frequency effective 3wk1, 1wk12. Only 1 visit made week 1.