Every finding on record at Southerncare, Inc.

Upon patient record review, 10 of 19 records (Patient #1,#4,#5,#6,#7,#9,#10,#11,#12,#14) 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 duplicate orders for Tylenol/Acetaminophen; Tylenol 325 mg, 2 tabs q4h prn pain dated 5/1/23 and Acetaminophen 500 mg, 1 tab q4h prn pain, dated 7/13/23. Corrected on site. Patient #4: The record indicated for Dulcolax, 10 mg rectal daily prn for constipation, Fleets enema 19 GM-7 Gm/118 ml daily prn constipation and MOM 400 mg/5 ml, 30 cc daily prn constipation. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second and third. Corrected on site. Patient #5: The record indicated for Glutose-15, 40% oral gel. Administer 1 tube as needed for low blood sugar. There was not evidence of a parameter for the 'low blood sugar.' Corrected on site. In addition, Calmoseptine 0.44%-20.6% topical, 1 inch as needed and zinc oxide 20%top ointment 1" as needed. There was not evidence of specific frequencies or locations. Corrected on site. Patient #6: The record indicated Nystatin 100,000 units/Gm topical powder under both breasts daily, dated 5/16/23. In addition Nystatin 100,000 units/Gm topical powder under both breasts TID, dated 5/18/23. Corrected on site. Patient #7:The record indicated for Hydrocodone 5-Acetaminophen 325 0.5 tablet, q8h prn pain. There was not evidence of a maximum allowable dose/24h from all sources. (The record also indicated another Tylenol order). Lidocaine pain relief 4% topical patch. 1 adhesive patch as needed. There was not evidence of a specific frequency or a location. Corrected on site. Also, Novalog flex pen u-100 insulin aspart 100u/ml SQ sliding scale, per instructions. There was not evidence of instructions for the sliding scale dosages. Corrected on site. Patient #9: The record indicated for Tylenol 325 mg caps, 2 q6h prn for pain or fever. There was not evidence of a parameter for fever. Corrected on site. In addition, the record indicated for Dulcolax, 10 mg rectal as needed for constipation, Fleets enema 19 GM-7 Gm/118 ml as needed for constipation and MOM 400 mg/5 ml, 30 cc as needed for constipation. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second and third. And there was not evidence of a frequency. Corrected on site. Patient #10: The record indicated Antifungal spray 1% topical powder. Apply to affected area daily. There was not evidence of a location. Corrected on site. Patient #11: The record indicated Calmoseptine 0.44%-20.6% topical, 1 inch as needed. In addition, Humidified oxygen 2L/min prn without evidence of a route. And Tylenol 325 mg caps, 2 caps QID prn for pain or fever and no evidence of a parameter for the fever. Corrected on site. Patient #12: The record indicated Nystatin 100,000 units/Gm topical cream, 1" as needed. There was not evidence of a specific frequency or a location. In addition, MOM 30 cc as needed for constipation and Bisacodyl 10 mg rectal supp, 1 as needed. There was not evidence of a specific frequency or which drug to use first or under what conditions to use the first one followed by the second. Corrected on site. Patient #14:The record indicated for Dulcolax 10 mg supp 1 daily prn and MOM 30 cc daily prn. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second. Corrected on site.

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 3/7/23. The record indicated that the bereavement assessment was completed on 3/13/23.

Upon patient record review, 1 of 19 records (Patient #2) 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 #2: The nursing admission assessment, dated 5/17/23 indicated that the patient had a stage II ulcer on her right arm. On 6/6/23, the nurse documentation indicated that the right arm scab came off and the area continues to seep. There was not evidence of an assessment of the wound since the initial assessment on admission.

Upon patient record review, 1 of 19 records (Patient #11) 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 #11: The record indicated that the patient had a colostomy. There was not evidence that the plan of care reflected patient/family goals and interventions based on the problems identified. Corrected on site.

Upon patient record review, 9 of 19 records (Patient #2,#4,#5,#7,#9,#10,#11,#12,#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 #2: The nursing admission assessment, dated 5/17/23 indicated that the patient had a stage II ulcer on her right arm, and wound care was not provided because the caregiver had completed care. There was not evidence of a wound care order. Patient #4: The record indicated for Dulcolax, 10 mg rectal daily prn for constipation, Fleets enema 19 GM-7 Gm/118 ml daily prn constipation and MOM 400 mg/5 ml, 30 cc daily prn constipation. The orders did not contain evidence of which drug to use first or under what conditions to use the first one followed by the second and third. Corrected on site. Patient #5: The order indicated for Glutose-15, 40% oral gel. Administer 1 tube as needed for low blood sugar. There was not evidence of a parameter for the 'low blood sugar.' Corrected on site. In addition, Calmoseptine 0.44%-20.6% topical, 1 inch as needed and zinc oxide 20%top ointment 1" as needed. There was not evidence of specific frequencies or locations. Corrected on site. Patient #7: The record indicated for Hydrocodone 5-Acetaminophen 325 0.5 tablet, q8h prn pain. There was not evidence of a maximum allowable dose/24h from all sources. (The record also indicated another Tylenol order). Corrected on site. In addition, Lidocaine pain relief 4% topical patch. 1 adhesive patch as needed. There was not evidence of a specific frequency or a location. Corrected on site. Also, Novalog flex pen u-100 insulin aspart 100u/ml SQ sliding scale, per instructions. There was not evidence of instructions for the sliding scale dosages. Corrected on site. Patient #9: The record indicated for Tylenol 325 mg caps, 2 q6h prn for pain or fever. There was not evidence of a parameter for fever. Corrected on site. In addition, the record indicated for Dulcolax, 10 mg rectal as needed for constipation, Fleets enema 19 GM-7 Gm/118 ml as needed for constipation and MOM 400 mg/5 ml, 30 cc as needed for constipation. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second and third. And there was not evidence of a frequency. Patient #10: The order indicated Antifungal spray 1% topical powder. Apply to affected area daily. There was not evidence of a location. Corrected on site. Patient #11: The record indicated Calmoseptine 0.44%-20.6% topical, 1 inch as needed. In addition, Humidified oxygen 2L/min prn without evidence of a route. And Tylenol 325 mg caps, 2 caps QID prn for pain or fever and no evidence of a parameter for the fever. Corrected on site. Patient #12: The record indicated Nystatin 100,000 units/Gm topical cream, 1" as needed. There was not evidence of a specific frequency or a location. In addition, MOM 30 cc as needed for constipation and Bisacodyl 10 mg rectal supp, 1 as needed. There was not evidence of a specific frequency or which drug to use first or under what conditions to use the first one followed by the second. Corrected on site. Patient #14:The record indicated for Dulcolax 10 mg supp 1 daily prn and MOM 30 cc daily prn. There was not evidence of which drug to use first or under what conditions to use the first one followed by the second. Corrected on site.

Upon patient record review, 2 of 19 records (Patient #6,#8) did not have evidence in the patient record that hospice aide assignments and duties are: • Evidenced in the patient record that the plan of care specifically 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 #6: The aide plan of care indicated for stand-by assist as needed and for walker daily (The aide visit frequency was 2x/week). Corrected on site. Patient #8: The aide plan of care indicated the task/alert of visually impaired every visit prn and bedside commode prn. Corrected on site.

Upon patient record review 5 of 19 records (Patient #3,#5,#7,#12,#13) 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: The aide plan of care indicated to provide a bed bath weekly. The aide visit frequency was 2x/week and increased to 3x/week on 7/21/23. The record indicated that the aide provided a bed bath at every visit from 7/3/23 until current. Patient #5: The aide plan of care indicated to shampoo and shave the patient weekly. The aide visit frequency was 2x/week. For the weeks of 7/2/23-7/8/23, 7/9/23-7/15/23, and 7/23/23-7/29/23, the aide documentation indicated that a shave was performed at all visits. For the weeks of 7/16/23-7/22/23 and 7/23/23-7/29/23, documentation indicated that a shampoo was performed at all visits. Patient #7: The aide plan of care indicated to provide nail care, hair care, shampoo and shave weekly. The aide visit frequency was 2x/week. The record indicated that these tasks were performed at all visits for the weeks of 6/18/23-6/24/23, 7/2/23-7/8/23, 7/9/23-7/15/23, and 7/23/23-7/29/23. Patient #12: The aide plan of care indicated to provide nail care weekly. The aide documentation revealed that this task was performed at all visits. Patient #13: The record indicated for a bed bath weekly. The aide visit frequency was 2x/week. The record indicated that a bed bath was provided at all visits during the month of July.