Every finding on record at Southerncare, Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient#4: The record indicates per IDG notes on 4/2/25 that patient primary language is Spanish. There is no evidence that the Patient's rights and responsibilities were provided in writing in the preferred language. Patient#10: Upon record review it was noted per nurse documentation that patient primary language is Spanish. Patient is AAOx3 and able to make needs known. There is no evidence that the Patient's rights and responsibilities were provided in writing in the preferred language.

Upon patient record review, 1 of 19 (Patient #13) 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#13: During home visit it was noted that there was no Losartan in home as listed on hospice medication profile. The caregiver confirmed the patient is not taking medication. Additionally, bumetanide 2 mg and Olmesartan medoxomil 20mg was found in home but is not on the med profile. The caregiver confirmed the patient is currently receiving these medications. Corrected on site.

Upon patient record review, 1 of 19 (Patient #10) 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#10: Upon review of the record, RN documentation on 4/8/25 nurse visit states patient has lymphedema to left arm that was not previously documented in record. There is no evidence of follow-up.

Upon patient record review, 6 of 19 (Patient #3,#4,#5,#7,#10,#12) 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 record indicates patient is taking 4 medications to assist with constipation and is at risk for aspiration. There is no evidence of problems with goals or interventions related to constipation or aspiration precautions. Corrected on site. Patient#4: The RN admit note indicates patient has dysphagia. There is no evidence of problems with goals and interventions related to aspiration precautions. Corrected on site. Patient#5: The plan of care indicate SN to assess shunt status and requires bleeding precautions. There is no evidence that the patient has a shunt nor does it indicate that patient takes a blood thinner. Corrected on site. Patient#7: The record indicates skin precautions are needed. There is no evidence of problems or interventions related to skin precautions listed on the plan of care. Corrected on site. Patient#10: The plan of care indicates the SN to assess shunt status. There is no evidence in record that patient has a shunt. Corrected on site. Patient#12: The record indicates patient requires Basaglar Kwikpen insulin SQ three times a day. There is no evidence of problems, goals, or interventions related to endocrine needs on plan of care. Corrected on site.

Upon patient record review, 2 of 19 (Patient #4,#13) 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 record indicates per RN on 3/24/25 patient requires thickened liquids. There is no evidence of orders for nectar thick liquids. Corrected on site. Patient#13: There is no evidence of orders for ensure as nutritional supplement as noted on RN documentation. Corrected on site.

Upon patient record review, 2 of 19 (Patient #3,#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 equipment and supply needs. Patient#3: The record indicates the patient requires use of hoyer lift. There is no evidence of hoyer lift listed on DME order for plan of care. Corrected on site. Patient#11: The record indicates that patient requires wheelchair and bedside commode. There is no evidence of wheelchair or bedside commode on DME order for plan of care. Corrected on site.

Upon patient record review, 1 of 19 (Patient #8) 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#8: Upon review of the record, IDG on 4/2/25 has no indication of an RN narrative stating patient changes of condition. RN only checked no wounds and checked patient and caregiver can administer medication. IDG on 3/19/25 has no note only states "no changes or concerns". RN note for IDG on 3/5/25 states "no changes". There was no other IDG updates of the patient changes indicated in the record.

Upon patient record review, 2 of 19 (Patient #4,#10) 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 plan of care indicates patient to be provided with written materials in Spanish. There is no evidence this has been provided to patient. Patient#10: The plan of care indicates MSW to assess patient/caregiver preferred means of communication. There is no evidence this has been addressed by MSW.

Upon patient record review, 3 of 19 (Patient #17,18,19) 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#17,#18,#19: There is no evidence of Holiday card being sent after Christmas as noted on bereavement plan of care.

Upon patient record review, 2 of 19 (Patient #5,#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#5: The hospice aide plan of care does not contain aspiration precautions as indicated on physician order. Additionally, the aide plan of care list droplet precautions which according to documentation in record no longer applies to this patient needs. Corrected on site. Patient#13: The hospice aide plan of care does not contain bleeding precautions or foley care. Corrected on site.

Upon patient record review, 2 of 19 (Patient #8,#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#8: The record indicates the terminal diagnosis listed in profile and in RN visit on 3/14/25 as malignant neoplasm of rectum. However, the RN recertification visit on 3/20/25 list terminal diagnosis as ischemic cardiomyopathy on 3/20. Patient#12: The record indicates the RN note on IDG 3/24/25 states patient has wounds. However, under the narrative RN checked "No wounds".

Upon patient record review 1 of 13 (Patient #5) 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 #5 - Patient admitted on 01/13/2022 MSW made initial visit on 01/19/2022 and SC made initial visit 01/20/2022.

Upon patient record review, 3 of 13 (Patient #3, 7, 13) 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 - SOC 02/23/2022 - initial bereavement completed 04/20/2022. Patient #7 - SOC 05/03/2022 - initial bereavement not completed as of 06/03/2022. Patient #13 - SOC 09/20/2021 - initial bereavement completed 10/11/2021.

Upon patient record review, 1 of 13 (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 - Aide documented on 05/02/2022 she notified the RN that the patients wound looked worse. No documentation by RN that she assessed the wound on 05/02/2022 or her next visit on 05/05/2022.

Upon patient record review, 1 of 13 (Patient #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 #6 - Wound care order on 05/28/2022 did not include modifier for "as needed". Order on 05/25/2022 for blood work and UA and C&S did not include how blood or urine was to be accessed.

Upon client record review, 1 of 13 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #5 - Visit note 05/13/2022 SN documented manual removal of fecal impaction - no order for procedure.

Upon patient record review 3 of 11 applicable patients (Patient #3, 6, 8) 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 #3 - Aide to shave and shampoo hair weekly. Week 3 shaved patient x 2, week 4 shampoo x 2, week 8 shave and shampoo x 2 and week 11 shaved x2. Patient #6 - Aide to shampoo hair and file nails every visit. Week 4 aide did not shampoo hair or file nails 3 of the 5 visits - documented nails and hair clean and neat and did not provided. Aide visit frequency 1wk1, 2wk2, 5wk10. No visit week 1 - no documentation of reason for missed visit. Patient# 8 - Aide to provide shower every visit on 05/19/2022 aide documented bed bath. Aide visit frequency 2wk13 - only 1 visit made week 1 - no documentation of reason for missed visit.

Upon patient client record review, 1 of 13 (Patient #9) 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 #9 - Patient has #18 foley catheter inserted on 04/26/2022 - SN documented on 05/02/2022, 05/11/2022 and 05/31/2022 patient had #16 foley catheter - all other visits documented #18 foley catheter. Foley catheter had not been changed since 04/26/2022.

Upon client record review, 2 of 7 applicable (Patient #8, 9) 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 #8 - POC dated 05/22/2022 hospice nurse to assess wound weekly - SN did not assess wound week of 05/22/2022 or 05/29/2022. Patient #9 - POC dated 04/19/2022 hospice nurse to assess wound weekly - SN did not assess wound week 1 - 7.