Every finding on record at Southerncare, Inc.

Upon patient record review, 1 of 7 (Patient #2) 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#2: Upon review of the record, it was noted that the medication profile had duplicate oxygen orders. Order on 5/19 indicated oxygen 2LPM daily PRN via nasal cannula. Order on 5/29 indicated oxygen 2LPM continuous via nasal cannula. Corrected on site.

Upon patient record review, 2 of 7 (Patient #2,#4) 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: RN admit visit documents patient has history of dysphagia. The record also indicates patient has history of squamous cell carcinoma of head and neck involving larynx and lymph nodes. Patient has a neck resection and continues to have neck and throat pain. There is no evidence of problems with goals and interventions related to aspiration precautions. Corrected on site. Patient#4: Documentation on IDG 5/22/25 list patient has a diagnosis of dysphagia. There is no evidence of problems with goals and interventions for aspiration precautions on plan of care. Corrected on site.

Upon patient client record review, 1 of 7 (Patient #2) 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: The plan of care order for admit states aide service frequency is 1w1, 3w12, then 2w1. The RN documentation for IDG on 5/5/25 states aide services are being provided and POC was reviewed. However, admit note stated aide services were declined. No aide visits were made.

Upon patient record review 1 of 19 records (Patient #4) 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 #4: There was not evidence of a spiritual assessment.

Upon patient record review, 9 of 19 records (Patient #1,#2,#3,#4,#5,#6,#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. 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 record indicated for Acetaminophen 500mg 2 tabs, BID (straight order) with a parameter not to exceed 3 Gm/24 hours. The record also contained Hydrocodone 5mg-Acetaminophen 325mg at bedtime and Hydrocodone 5mg-Acetaminophen 325 mg Q6h prn. There was not evidence of a maximum allowable for these medications or a maximum allowable from all Acetaminophen sources. Corrected on site. Patient #2: The record indicated for Acetaminophen 325mg, 2 tabs q4h prn under the tongue for pain or fever. Tylenol tabs are not administered under the tongue, and there was no evidence of a maximum allowable dose per 24 hours or a parameter for the fever. Corrected on site. Patient #3: Miralax 17 GM prn for constipation and Fleets enema 19 GM-7 GM prn for constipation. There was not evidence of what order and under what circumstances to administer each of these medications. Corrected on site. Patient #4: The record indicated Dexamethasone 2 mg tabs, as directed on steroid taper down to 2mg daily. Corrected on site. Patient #5: The medication profile included Insulin u-100 as needed 3x/day per sliding scale. Corrected on site. Also, lorazepam 0.5mg, route is O2 nightly. Corrected on site. In addition, Triamcinolone 0.025, dated 2/6/24 to wash right ear, pat dry, apply cream every night. Corrected on site. And,Tylenol 325mg 2 tabs q6h as needed for pain or fever without evidence of fever parameters. Corrected on site. The hospice medication profile contained Claritin, Lorazepam prn, and Risperidone which were not on the Facility MAR. Also, Seroquel 25mg, 2 tabs in the am and 3 tabs at night was on the hospice record and was inconsistent with the dosage on the facility MAR. The facility MAR contained Latanoprost, Colace, Artificial tears, fleets enema and MOM but not on the hospice medication profile. And, Seroquel was 100mg 2x daily. Patient #6: The medication profile included Acetaminophen 325mg, 2 tabsq6h prn fever with no evidence of fever parameters. Corrected on site. Also, Novolin R u-100 3x daily using sliding scale. Corrected on site. Patient #7: The medication profile included Diclofenac 1%, apply to affected area q4h prn without evidence of a specific location. Corrected on site. Also Lidocaine top cream to affected area 2x/day prn without evidence of a specific location. Corrected on site. In addition, Mupirocin 2% topical ointment 1 inch to redness 3x/day without evidence of a specific location. Also Bisacodyl 10mg rectal supp and MOM 30cc as needed. There was not evidence of what order and under what circumstances to administer each of these medications, and there was not a specific frequency. Corrected on site. Patient #8: The medication profile included MOM 30cc daily for constipation and Miralax 17 GM 2x/week prn constipation. There was not evidence of specific instructions on of the circumstances to administer these medications. Corrected on site. Also, the record indicated in nurse documentation (3/26/25 and 3/28/25) that the patient was on Oxygen. There was not evidence that this was in the medication profile. Corrected on site. Melatonin was on the hospice medication profile but not in the facility MAR. Trazadone was on the facility MAR but not on the hospice medication profile. Patient #9: The record indicated that the patient was on Oxygen 2L/min via nasal cannula prn. There was not evidence that oxygen was on the medication profile. Glargine insulin 35u at bedtime and Insulin Lispro 13u 3x daily was not the hospice medication profile but not on the facility MAR. Lantus 21u BID, Humalog 13u with meals, Dulcolax, Fleets enema, MOM and Preparation H were on the facility MAR but not on the hospice medication profile.

Upon patient record review, 1 of 19 records (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: The patient was admitted on 1/14/25. The record indicated that the bereavement assessment was completed on 1/21/25 which is greater than the 5 day requirement.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 4 of 19 records (Patient #3,#6,#7,#13) 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). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: The record indicated that the patient had wounds on her bilateral feet. There was not evidence of an assessment between 2/19/25-4/3/25. Documentation by the hospice nurse indicated 'assessed by facility staff' or 'not ordered this visit.' Agency policy indicates that wounds are to be assessed weekly. Patient #6: The patient record had documentation of 5 wounds on the patient's lower extremities. There was not evidence of wound assessments from 3/21/25-4/1/25 and the note indicated that it was not assessed due to the dressing being dry. Patient #7: The record indicated a phone call into triage from the facility on 4/4/25 at 12:08pm stating that they needed a nurse "to drain him." There was not evidence of a phone call back or a visit until 4/7/25 at 10:53 am when 900cc was drained (PleurX catheter). Patient #13: The record indicated that the patient had a sacral wound. There was not evidence of an assessment since 3/4/25.

Upon patient record review, 7 of 19 records (Patient #4,#5,#6,#9,#10,#11,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient that 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 #4: The patient was admitted with a terminal diagnosis of malignant neoplasm of the frontal lobe. He was forgetful, confused, drowsy, and had delayed responses. There was not evidence that plan of care reflects patient/family goals and interventions based on the neuro problems identified. Corrected on site. Patient #5: Documentation indicated that when the patient was admitted, she had difficulty swallowing, would pocket food and was at risk for aspiration. There was not evidence of aspiration precautions in the plan of care. Corrected on site. Patient #6: The record indicated that the patient had a S-P catheter. There was not evidence of goals and interventions in the plan of care relating to the catheter. Corrected on site. Also, the patient was admitted with Multiple Sclerosis. She had sensory impairment, could not use feeding utensils, and was declining. There was not evidence that plan of care reflects patient/family goals and interventions based on the neuro problems identified. Corrected on site. In addition, she complained of pain, especially with wound care, touching or movement. There was not evidence that pain issues were addressed in the plan of care. Corrected on site. Patient #9: The record indicated that the patient had multiple falls and had progressive dysphasia (On a puree diet with thickened liquids). There was not evidence that fall safety/precautions or aspiration risk was a part of the plan of care. Corrected on site. Patient #10: The record indicated that the patient was on Eliquis and ASA. There was not evidence of bleeding precautions on the plan of care. Also, the patient was admitted with a diagnosis of heart failure. She wore continuous oxygen at 5L/min, was short of breath with any activity and consistently had +3 to +4 edema of her lower extremities. She received increased doses of Lasix (80mg), was changed to Bumex and, albuterol and guaifenesin were added to her treatments. She also had legs that were weeping and required dressing changes. There was not evidence the the care plan goals and interventions addressed the edema related to her cardiac condition or her difficulty with respiratory issues. Corrected on site. Patient #11: The patient was admitted with a diagnosis of Parkinson's. The record indicated that the patient has had multiple falls, has associated dysphasia, extra pyramidal movements, history of seizure disorder. She also has a Foley catheter, and is chair-bound. There was not evidence that the care plan addressed these issues. In addition, she is a Full Code, had minimal family, and does not have funeral and end of life plans. The care plan does not address goals and interventions for end of life issues. Corrected on site. Patient #14: The record indicated wounds on the patient's left breast, upper left quadrant, and left thoracic area. There was not evidence that wounds were a part of the care plan.

Upon patient record review, 3 of 19 records (Patient #6,#13,#14) 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 the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #6,#13,#14: The initial frequency order for the social worker was 1 prn. (This was changed after the initial visit).

Upon patient record review, 9 of 19 records (Patient #1,#2,#3,#4,#5,#6,#7,#8,#9) 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 record indicated for Acetaminophen 500mg 2 tabs, BID (straight order) with a parameter not to exceed 3Gm/24 hours. The record also contained Hydrocodone 5mg-Acetaminophen 325mg at bedtime and Hydrocodone 5mg-Acetaminophen 325 mg Q6h prn. There was not evidence of an order for the maximum allowable for these medications or a maximum allowable from all Acetaminophen sources. Corrected on site. Patient #2: The record indicated for Acetaminophen 325mg, 2 tabs q4h prn under the tongue for pain or fever. Tylenol tabs are not administered under the tongue, and there was no evidence of an order for a maximum allowable dose per 24 hours or a parameter for the fever. Corrected on site. Patient #3: Wound care orders dated 2/12/25 indicated to cleanse with VASHE moistened gauze to wound bed. Cover with ABD pad, wrap with Kerlix and secure with tape. There was not evidence of a location or frequency. Corrected on site. In addition, Miralax 17 GMs prn for constipation and Fleets enema 19 Gm-7 Gm prn for constipation. There was not evidence of an order for what order and under what circumstances to administer each of these medications. Corrected on site Patient #4: The record indicated an order for Dexamethasone 2 mg tabs, as directed on steroid taper down to 2mg daily. Corrected on site. Patient #5: The record included an order for Insulin u-100 as needed 3x/day per sliding scale. Corrected on site And, Tylenol 325mg 2 tabs q6h as needed for pain or fever without evidence of fever parameters. Corrected on site. The facility MAR contained Latanoprost, Colace, Artificial tears, fleets enema and MOM but there was not evidence of an order. And, Seroquel was 100mg 2x daily on the facility record but no order on the hospice record. Patient #6: The record indicated an order for Acetaminophen 325mg, 2 tabsq6h prn fever with no evidence of fever parameters. Corrected on site. Also, Novolin R u-100 3x daily using sliding scale. Corrected on site. Patient #7: The record indicated an order for Diclofenac 1%, apply to affected area q4h prn without evidence of a specific location. Corrected on site. Also Lidocaine top cream to affected area 2x/day prn without evidence of a specific location. Corrected on site. In addition, Mupirocin 2% topical ointment 1 inch to redness 3x/day without evidence of a specific location. Also Bisacodyl 10mg rectal supp and MOM 30cc as needed. There was not evidence of what order and under what circumstances to administer each of these medications, and there was not a specific frequency. Corrected on site. Patient #8: The record indicated an order for MOM 30cc daily for constipation and Miralax 17 GM 2x/week prn constipation. There was not evidence of specific instructions or of the circumstances to administer these medications. Corrected on site. Also, the record indicated in nurse documentation (3/26/25 and 3/28/25) that the patient was on Oxygen at 2L/min via nasal cannula. There was not evidence of an order. Corrected on site. Trazadone was on the facility MAR but there was there was not evidence of an order on the hospice record. Patient #9: The record indicated that the patient was on Oxygen 2L/min via nasal cannula prn. There was not evidence of an order for Oxygen. Lantus 21u BID, Humalog 13u with meals, Dulcolax, Fleets enema, MOM and Preparation H were on the facility MAR but there was not evidence of an order in the hospice record.

Upon patient record review, 3 of 19 records (Patient #8,#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 #8: The record indicated that the patient had an ostomy, nebulizer, Oxygen, hospital bed and a Rock-N-Go chair. There was not evidence that these were included in the plan of care. Corrected on site. Patient #9: Documentation included that the patient was in a hospital bed and had prn Oxygen. There was not evidence that this was in the plan of care. Corrected on site. Patient #10: The record indicated that the patient had a wheelchair and a nebulizer. There was not evidence that this equipment was a part of the care plan. Corrected on site.

Upon patient record review, 4 of 19 records (Patient #3,#10,#14,#18) 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 #3: The patient was admitted on 8/15/25 and had wounds on her bilateral feet with wound care orders for care 2 times/day. On 4/3/25, the record indicated new wound care orders without evidence of an update to the plan of care. Corrected on site. Patient #10: The record indicated a respite stay starting on 3/29/25. There was not evidence that the care plan was revised to include changes regarding respite. Patient #14: The record indicated a respite stay starting on 3/26/25. There was not evidence that the care plan was revised to include changes regarding respite. Patient #18: The documentation dated 6/6/24 by the nurse indicated that the patient was confused, talking nonsense, getting weaker with more deconditioning, no longer OOB, no urine output, 10% intake with trouble swallowing. Voice was weak and raspy and had difficulty speaking. On 6/10/24, documentation revealed the patient was very confused, he had fallen over the week-end and was showing increased signs of end of life. On 6/13/24 a prn visit was requested due to behaviors. Documentation indicated the imminence of death. There was not evidence that the visits were increased, that other disciplines were notified, or that the plan of care was revised to accommodate these changes at any time during the documented decline.

Upon client record review, 2 of 19 records (Patient #6,#14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6: A note by the RN dated 3/5/25 indicated that the S-P catheter was changed yesterday. There was evidence that the plan of care included changing the catheter including the frequency, reason, and size. Patient #14: The visit frequency for the social worker and the spiritual care counselor was for an evaluation then 2 every 2m2, 2m2. The record indicated that the social worker conducted the evaluation visit on 2/24/25 followed by routine visits on 3/11/25, 3/25/25, and 4/8/25. The spiritual care counselor conducted the evaluation visit on 2/24/25 followed by routine visits on 3/10/25, 3/24/25, 4/7/25.

Condition of participation: Hospice aide and homemaker services. All hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section.

Upon patient record review, 6 of 19 records (Patient #2,#3,#5,#8,#9,#11) 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 #2: The aide plan of care indicated for wheelchair and bedpan as needed. Corrected on site. Patient #3: The CTI for the 3rd benefit period beginning 2/11/25 indicated that the patient used a Hoyer lift. The equipment list indicated a Hoyer lift. The aide plan of care indicated the tasks of transfer from bed to chair and a tub bath. There was not evidence that Hoyer lift (for moving the patient) was included in the aide plan of care. Corrected on site. Patient #5: Documentation indicated that when the patient was admitted, she had difficulty swallowing, would pocket food and was at risk for aspiration. There was not evidence of aspiration precautions in the aide plan of care. Corrected on site. Patient #8: The aide plan of care indicated to provide a bed bath on M-W-F, and a shower weekly. The aide visit frequency was 3x/week. Patient #9: The aide plan of care indicated to shampoo as needed 2x/week and transfer to chair per caregiver request. Corrected on site. Patient #11: The aide plan of care indicated the tasks of bed bath every visit and shower as needed. Corrected on site.

Upon patient record review 3 of 19 records (Patient #1,#2,#11) 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 #1: The aide plan of care indicated to provide a shower and shampoo at every visit. For the date of 2/25/25, the aide documentation indicated a shower was not performed due to the staff showering the patient yesterday and a shampoo was not performed, per frequency, not needed. In addition, the aide visit frequency was 2 times/week. For the week of 3/16/25-3/22/25, the record indicated only 1 aide visit on 3/22/25. Patient #2: The aide plan of care indicated for the task of shampoo to be completed at every visit. For the dates of 3/11/25, 3/14/25 and 3/18/25, the aide documentation revealed, per frequency not needed. Patient #11: The aide plan of care indicated the tasks of bed bath every visit and shower as needed. Documentation by the aide indicated that both a bed bath and a shower was provided at every visit (for the benefit period beginning 2/27/25).

Upon patient record review 1 of 19 records (Patient #7) did not have evidence in the patient record that the hospice aides report: • Changes in the patient's medical, nursing, rehabilitative, and social needs to a registered nurse, as the changes relate to the plan of care and quality assessment and improvement activities • Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures. Patient #7: For the date of 3/14/25, the aide documentation revealed that the patient refused bathing because he had pain in his stomach. There was not evidence that the nurse was notified of the pain.

Upon patient record review 2 of 19 (Patient #3,#7) 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 #3: The CTI and equipment list both included the use of a Hoyer lift. For the benefit period 2/11/25 - 4/11/25, aide supervisory visits were conducted every 7-14 days. Questions/answers for the aide supervision included "Was the aide plan of care reviewed?" Yes. "Was the plan of care updated?" No. There was not evidence that the supervisory visit reviewed or updated the plan of care to include a Hoyer lift, which the patient had been using since admission Patient #7:The aide plan of care indicated for the tasks of transfer patient from bed to chair and from chair to bed. Documentation by the aide from 3/1/25 to current indicated that this was not done because the patient is mobile. Aide supervisory visits were conducted every 7-14 days. Questions/answers for the aide supervision included "Was the aide plan of care reviewed?" Yes. "Was the plan of care updated?" No. There was not evidence that the supervisory visit reviewed or updated the plan of care in regards to the patient's mobility.

Upon personnel record review, 1 of 14 records (Personnel #12) did not have evidence in the hospice aide personnel file that a registered nurse made an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include all required content. Personnel #12: The annual skills competency performed on 10/28/24 did not show evidence that required tasks were return demonstrated. These included but were not limited to TPR, BP, bathing , hygiene, grooming, and ambulation. An arrow was drawn from the top of the column to the bottom, indicating that all tasks were verbalized.

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 percentage of usage for volunteers for the year 2024 was reported as 3.23%.

Upon personnel record review, 1 of 14 records (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • There is a signed job description for this role • The employee has been orientated to this role Corrected on site.

Upon patient client record review, 6 of 19 records (Patient #2,#3,#4,#6,#7,#10) did not have evidence that each patient record contains Advance Directives. Patient: #2,#3,#4,#6,#7,#10: The record indicated that the patient had an OOH-DNR. There was not evidence that this was a part of the record.

Upon patient client record review, 1 of 19 records (Patient #16) did not evidence that each patient record contains physician orders. Patient #16: The patient was discharged due to an admission to a non-contracted facility (hospital). There was not evidence of a discharge order.

Upon patient client record review, 3 of 19 records (Patient #3,#7,#12) 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 #3: The EOB contained a section titled Care Coordination which stated, "to assist in the appropriate coordination of health care, representatives of hospice or home health may visit me in any facility, or post-acute rehabilitation facility- to which I might be admitted while receiving my health care needs from. Evaluate me for possible transition to a different level of care should it become appropriate based on my clinical condition. This consent includes permission to review my medical record for the purpose of coordinating transition to a different level of care, including home health, palliative and community care." There was a checkbox to indicate yes or no. The checkbox indicating "no" was checked. (The patient was in a SNF). Patient #7: Multiple documentation notes by the nurse including but not limited to 4/3/25 indicated that fluid was drained from the patients abdomen for approximately 900cc. Tolerated well and new sterile dressing applied. There was not evidence of what procedure followed, the condition of the insertion site or the dressing procedure. Patient #12: A note by the RN on 4/4/25 indicated that a call came from the LPN that the patient was bedbound. Documentation by the aide indicated that a tub bath, walker and stand-by assistance was provided. (Aide service was provided by the LPN). On 4/7/25, the documentation indicated that the patient was unresponsive. Again the aide documented that tub bath, walker and stand-by assistance was provided.

Upon client record review, 2 of 19 records (Patient #7,#8) 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 #7: The care plan indicated to instruct to measure abdominal girth before and after drainage. The record revealed only 1 time that this was performed (1/22/25). There was not evidence that this plan was followed. Patient #8: The visit frequency for the social worker and the spiritual care counselor was for an evaluation then 2 every 2m2, 2m2. The record indicated that the social worker conducted the evaluation visit on 1/24/25 followed by routine visits on 2/5/25, 2/18/25, 3/7/25, and 3/21/25. The spiritual care counselor conducted the evaluation visit on 1/24/25 followed by routine visits on 2/3/25, 2/17/25, 3/5/25 and 3/17/25.

Upon patient record review, 2 of 19 records (Patient #5,#8) did not have evidence that the hospice provided the following information: Patient #5,#8: Names and contact information for hospice personnel involved in hospice care of each patient

Upon personnel record review, 1 of 14 (Personnel #11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.

Upon patient record review, 2 of 16 (Patient #6, 11) 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 #6 - Wound care order dated 04/01/2022 did not have modifier for as needed. Patient #11 - Wound care order dated 04/25/2022 did not have what to clean wound with or wound care frequency.

Upon client record review, 1 of 5 applicable (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 - POC dated 03/07/2022 SN visit frequency 2 x week - only 1 visit made 04/17/2022.

Upon patient record review 3 of 14 applicable patients (Patient #3, 7, 9) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #3 - Aide care plan order: Shampoo every visit, did not provide on 03/16/2022, 03/23/2022 03/24/2022, 03/25/2022 or 03/29/2022. Patient #7 - Aide care plan order: Shampoo 2 x week but completed 3 times a week 03/20/2022; change bed linen weekly but change 2 times a week weeks of 03/14/2022, 03/20/2022, 03/27/2022 and 04/10/2022 Patient #9 - Aide care plan order: Shampoo 1 x week, completed 2 x week 04/14/2022 and 04/28/2022.

Upon patient client record review, 1 of 16 (Patient #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. Patient #10 - Initial assessment SN documented foley catheter #22 - 10cc. On visit dates 03/23/2022, 04/20/2022 and 04/27/2022 that patient had a #16 - 10cc catheter. SN interviewed and stated she documented wrong catheter size.

Upon client record review, 2 of 11 applicable (Patient #9) did not have evidence that the IDG ensures all care and service are provided in accordance with the plan of care for patients in a SNF. Patient #9 - MSW visit frequency dated 04/01/2022 1 visit within every 7 days - MSW visit made 04/11/2022 and then 04/19/2022 - greater than 7 days. Vol Coordinator visit ordered 04/03/2022 but no visit ever made or documentation why visit wasn't made. Patient #10 - No order for for lab work completed on 03/25/2022.