Every finding on record at Southerncare, Inc.

Upon patient record review, 5 of 19 (Patients #3,#5,#6,#7,#9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 3: The medication profile contained duplicative listing of cholestyramine scheduled doses. Corrected on site with removal of one listing. Patient 5: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. Corrected on site with order received and medication profile updated. Patient 6: The medication profile contained diclofenac topical gel with no area defined for administration. Corrected on site with order clarification and medication profile updated. Patient 7: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The profile also contained instructions for oxycodone tablets with a route in the vein. Corrected on site with orders received and medication profile updated. Patient 9: The medical record contained care planning regarding use of oxygen and orders for oxygen equipment. There was no evidence of oxygen listed on the medication profile. Corrected on site with order received and medication profile updated.

Upon patient record review, 2 of 19 (Patients #7,#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. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: The medical record contained an initial bereavement assessment 6/18/25. Start of care occurred 6/9/25. Patient 10: The medical record contained an initial bereavement assessment 7/30/25. Start of care occurred 7/23/25.

Upon patient record review, 4 of 19 (Patients #2,#7,#11,#13) 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 contained nursing documentation since admission identifying patient issues with dyspnea, pitting edema, and a peritoneal dialysis catheter in place. The CTI for benefit period starting 7/13/25 also indicated the patient has diagnosis of heart failure. There was no evidence of problems, goals, and interventions related to the dialysis catheter or respiratory and cardiovascular dysfunction. Plan of care updated for addition of respiratory and cardiovascular. Corrected on site with plan of care update. Patient 7,11: The medical record contained an order for Eliquis. There was no evidence of problems, goals, and interventions related to the risk for bleeding. Corrected Patient 13: The medical record contained nursing documentation since admission identifying patient issues with alcohol dependence and depression. There was no evidence of problems, goals, and interventions related to chemical dependency and depression. Corrected on site with plan of care update.

Upon patient record review, 4 of 19 (Patients #5,#6,#7,#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 5: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of an order for oxygen rate, frequency and delivery method. Corrected on site with order received. Patient 6: The medication profile contained diclofenac topical gel with no area defined for administration. Corrected on site with order clarification. Patient 7: The medical record contained nursing documentation since admission identifying patient use of oxygen. There was no evidence of oxygen listed on the medication profile. The profile also contained instructions for oxycodone tablets with a route in the vein. Corrected on site with orders received and medication profile updated. Patient 14: The medical record contained nursing documentation since admission identifying patient use of a CPAP. There was no evidence of an order for CPAP parameters.

Upon patient record review, 4 of 19 (Patients #1,#2,#5,#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 equipment and supply needs. Patient 1,13: The medical record contained an order for a nebulized medication. There was no evidence of an order for a nebulizer included in the plan of care. Corrected on site with order received. Patient 2: The medical record contained nursing documentation 7/2/25 identifying patient use of a walker. There was no evidence of an order for the walker included in the plan of care. Corrected on site with order received. Patient 5: The medical record contained nursing documentation since admission identifying patient use of a walker and nebulizer. There was no evidence of orders for the walker and nebulizer included in the plan of care. Corrected on site with orders received.

Upon patient record review, 2 of 19 (Patients #3,#19) 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 medical record contained a CTI for benefit period starting 6/30/25 identifying patient diagnosis of chronic proctitis with diarrhea. There was no evidence the plan of care was updated to include problems, goals, and interventions related to gastrointestinal dysfunction. Corrected on site with plan of care update. Patient 19: There was no evidence the plan of care was updated to include plan to discharge.

Upon personnel record review, 1 of 16 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 8: The skills competency did not observe temp, pulse, respiration, tub bath, and shower. Required vitals corrected on site with skills competency completed.

Upon patient record review, 3 of 19 (Patients #4,#9,#14) did not have evidence in the patient record that hospice aide assignments and duties are specific to patient needs. Patient 4: The aide care plan included instructions for the aide to leave a wound dressing in place. There was no evidence the patient had a wound. Corrected on site with aide care plan update. Patient 9: The medical record contained nursing documentation 5/29/25 identifying patient is a 2 person max assist with transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site with aide care plan update. Patient 14: The medical record contained nursing documentation upon admission identifying patient need for moderate assist with transfers. There was no evidence of transfer instructions included on the aide care plan. Corrected on site with aide care plan update.

Upon patient record review 1 of 19 (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 medical record contained an order for aide visits twice weekly. There was no evidence of second visits completed the weeks of 6/29/25 and 7/20/25.

Upon patient record review 2 of 19 (Patients #11,#14) 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 11: There was no evidence of an aide supervisory visit documented from 5/15/25 to 7/28/25. Patient 14: There was no evidence of an aide supervisory visit documented from 6/19/25 to 7/10/25.

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 provider had a volunteer utilization rate of 0.62% in 2024. Current year to date rate is 1.73% despite performance improvement project since February 2025.

Upon patient client record review, 3 of 19 (Patients #7,#15,#17) did not have evidence that each patient record contains Advance Directives. Patient 7,15,17: The plan of care identified the patient as DNR. There was no supporting evidence of code status such as a POLST or living will in the medical record.

Upon patient client record review, 1 of 19 (Patient #19) did not evidence that each patient record contains physician orders. Patient 19: There was no evidence of an order to discharge for extended prognosis.

Upon patient client record review, 1 of 19 (Patient #11) 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 11: The medical record contained nursing documentation identifying patient use of a walker upon admission and a hospital bed 5/12/25. After agency investigation, the patient does not have this equipment and the documentation was inaccurate. Corrected on site with documentation clarification.

Based on review of medical records and interviews with staff the agency failed to ensure staff followed the visit schedule as ordered for by the physician on the plan of care for two (2) of three (3) records reviewed. MR #1-2. --- findings include: A review of medical records completed May 14, 2024, between approximately 11:30AM and 2:30PM revealed the following: MR#1, SOC: 6/30/2023, Certification period: 4/25/2024-6/23/2024, Physician Orders dated 4/29/24: "Frequency changes HHA reduce from 5x weekly to 3x weekly M/W/F not enough aide support to justify 5x weekly event though patient has minimal other supports and is showing declines and needs assistance. MSW visit needed to manage patient needs." Documentation showed home health aide visits made: M 4/29, W 5/1, Th 5/2, W 5/8, Th 5/9 and M 5/13. No documentation to show the physician was notified of the missed visits or the change to ordered schedule. MR #2, SOC:10/26/2023; certification period: 4/23/24-6/21/24: Physician Orders dated 4/9/24: "Calendar frequency HHA 2wk1, 3wk8". Documentation showed the home health aide made visits 4/29, and 5/1. No other visits were documented for the Month of May. No documentation to show the physician was notified of the missed visits. Interview with EMP#2 at approximately 12:30PM confirmed the above findings.

Based on review of policies and procedures, medical records and interviews with staff the agency failed to ensure wound care was performed as ordered for one (1) of three (3) records reviewed. MR #2. --- findings include: A review of policies/procedures completed 5/14/2024 between approximately 5:00PM and 7:00PM revealed the following: Wound assessment, Documentation and Clinical Oversight: CLIN.14; Role of the LPN/LVN in wound care; 1. "The RN retains the overall responsibility for patient care." 3. The LPN/LVN will execute interventions in accordance with the Plan of Care, collect data on wound status, document the patient record, and contribute to the evaluation of individualized interventions related to the Plan of Care". A review of medical records completed May 14, 2024, between approximately 11:30AM and 2:30PM revealed the following: MR #2, SOC:10/26/2023; certification period: 4/23/24-6/21/24: Physician Orders: Right side of stump Stage II diabetic ulcer cleanse with Normal sterile saline, pat dry with gauze, use skin prep on surrounding skin place square of aquacel with silver on open area of wound cover with optifoam dressing. Change daily by caregivers and nurse during visits". Visit note: 5/8/24 did not contain any documentation showing the nurse followed the above order. Interview with EMP#2 at approximately 12:30PM confirmed the above findings.

Based on review of policy/procedures, review of volunteer services documentation and interview with the agency administrator, the agency failed to ensure documentation showed volunteers services equaled, at a minimum, five (5)% of the total patient care hours of all paid hospice employees and contract staff for one (1) of one (1) year reviewed. 2023. --- Review of policy 4-007 on 6/20/24 between approximately 11:00 AM through 1:30 PM revealed: Policy: Volunteer Services; "Gentiva, Hospice division (the hospice) will provide volunteer services under the direction of a Volunteer Coordinator and with the assistance of trained hospice volunteers. Section: Procedure 1. "The Volunteer Coordinator will develop, implement and evaluate the volunteer services program on an ongoing basis but at least annually". 7. "The Volunteer Coordinator will ensure that volunteers provide a minimum of 5% of the total number of patient care hours of paid and contracted hospice personnel... The volunteer coordinator will maintain records of cost savings achieved through the use of volunteers". Review of agency documentation completed on 6/20/24 between approximately 10:00 AM and 12:00 PM revealed the following: Volunteer cost savings report for 2023 broke down as follows: January total patient care hours was = 2% February was = 2% March was = 2% April was = 2% May was =4% June was = 2% July was = 2% August was = 2% September was = 4% October was = 3% November was = 4% December was = 4% An interview with the agency administrator completed on 6/20/24 between approximately 2:00PM and 3:00PM confirmed the above findings.

Upon patient record review, 4 of 13 (Patients #1,#3,#4,#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. Patient 1: The medication profile contained duplicative acetaminophen prn listings, one for 1000 mg every 6 hours as needed for mild pain, and one for 650 mg every 4 hours as needed for pain. Corrected on site. Patient 3: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 4: The medication profile contained dulcolax suppository and fleet enema with frequency of as needed. There was no evidence of a time parameter for spacing between doses included for the medications. Corrected on site. Patient 9: The medication profile contained oxygen with no defined delivery method. Corrected on site.

Upon patient record review, 2 of 13 records (Patients #4,#6) 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 4: The medical record contained nursing documentation 8-10-22 identifying a new area of concern identified on patient heel. There was no evidence of active problems, goals, and interventions related to skin impairment. The medical record also contained an order 6-10-22 to discontinue volunteer services. There were active problems, goals, and interventions related to volunteer services included on the current plan of care. Corrected on site. Patient 6: The medical record contained nursing documentation 8-15-22 identifying chronic nausea, vomiting, and anxiety. There was no evidence of problems, goals, and interventions related to anxiety and nausea or nutritional status. Corrected on site.

Upon patient record review, 4 of 13 (Patients #3,#4,#9,#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 3: The medical record contained an order for miralax with no instructions for a diluent. Corrected on site. Patient 4: The medical record contained orders for a dulcolax suppository and fleet enema with frequencies listed as needed. There was no evidence of a time parameter for spacing between doses included for the medications. Corrected on site. Patient 9: The medical record contained an order for oxygen with no defined delivery method. Corrected on site. Patient 11: The medical record contained an order for wound care 2-11-22 with no defined location of the wound and no frequency for foam dressing changes.

Upon patient record review, 4 of 13 (Patients #2,#5,#12,#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 equipment and supply needs. Patient 2: The medical record contains nursing documentation upon admission identifying patient use of a mechanical lift for transfers. There was no evidence of the lift included as DME on the plan of care. Corrected on site. Patient 5: The medical record contains documentation by the NP 7-13-22 identifying patient use of a cane for ambulation. There was no evidence of the cane included as DME on the plan of care. Corrected on site. Patient 12: The medical record contains nursing documentation 5/17/22 identifying patient use of a walker. There was no evidence of the walker included as DME on the plan of care. Patient 13: The medical record contains social worker documentation upon admission identifying patient use of a wheelchair and oxygen equipment. There was no evidence of the wheelchair and oxygen included as DME on the plan of care.

Upon client record review, 2 of 13 (Patients #4 and #11) 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 medical record contained ordered frequency upon recertification for social work visits 3 PRN for psychosocial concerns and spiritual care visits 2 PRN for spiritual concerns. There was evidence of social work visits completed monthly for June, July, and August and spiritual care visits completed monthly for June and July. Corrected on site. Patient 11: The medical record contained ordered frequencies for social work and spiritual care visits daily 2/21/22 then a order change for once weekly 2/25/22. There was no evidence of social work or spiritual care visits completed the week of 2/20/22.

Upon patient record review, 1 of 12 applicable (Patient #7) 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 7: The aide care plan contained two bathing tasks for shower every visit and complete bed bath if patient refused shower. Corrected on site.

Upon patient record review 1 of 12 applicable (Patient #2) 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 2: The medical record contained aide documentation 8/17/22 stating complete bed bath was given and linens were changed. There was no evidence of tasks for bed bath and linen change included on the aide care plan.

Upon client record review, 1 of 6 applicable (Patient #2) 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 2: The medical record contained an order for wound care on the initial plan of care that does not indicate hospice and facility responsibility for completion. Corrected on site.