Every finding on record at Southerncare, Inc.

Upon patient record review, 3 of 11 (Patients #1,#5,#8) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 1: The medical record contained an election of benefit form and consents signed by sister stating sister has POA authority. There was no evidence of legal documentation giving the sister authority in the chart or that this is the closest next of kin. Patient 5: The medical record contained an election of benefit form and consents signed by niece. There was no evidence of legal documentation giving the niece authority in the chart or that this is the closest next of kin. Patient 8: The medical record contained an election of benefit form and consents signed by stated POA with no name identified or additional relationship to the patient. There was no evidence of legal documentation identifying a POA with legal authority in the chart or that this is the closest next of kin.

Upon patient record review, 5 of 11 (Patients #2,#5,#8,#9,#10) 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 2: The medication profile contains duplicative lorazepam listed with same dose and frequency dated 12/22/21 and 12/23/21. Corrected on site. Patient 5: The medication profile contains potassium chloride oral packet with no instructions for a diluent. Corrected on site. Patient 8: The medication profile contains duplicative potassium chloride listed with same dose and frequency dated 6/11/21 and 8/23/21. Corrected on site. Patient 9: The medical record contains nursing documentation 4/7/22 identifying oxygen in the patient's home. There was no evidence of oxygen listed on the medication profile. Patient 10: The medication profile contained Metamucil oral powder with no instructions to mix with a diluent.

Upon patient record review, 3 of 11 (Patients #5,#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 medications and treatments. Patient 5: The medical record contains an order for potassium chloride oral packet with no instructions for a diluent. Corrected on site. Patient 9: The medical record contains nursing documentation 4/7/22 identifying oxygen in the patient's home. There was no evidence of an order for oxygen treatment. Patient 10: The medical record contains an order for Metamucil oral powder with no instructions to mix with a diluent.

Upon patient record review, 3 of 11 records (Patients #4,#6,#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 4: The medical record contains nursing documentation 8/25/22 identifying patient use of oxygen. There was no evidence of oxygen included as required equipment on the plan of care. Corrected on site. Patient 6: The medical record contains nursing documentation 9/2/22 identifying patient use of a wheelchair. There was no evidence of the wheelchair included as required equipment on the plan of care. Corrected on site. Patient 10: The medical record contains nursing documentation upon admission identifying patient use of a mechanical lift. There was no evidence of the lift included as required equipment on the plan of care.

Upon client record review, 1 of 11 records (Patient #4) 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 contains an ordered nursing frequency of twice weekly. There was no evidence of a second visit completed the week of 8/14/22.

Upon personnel record review, 1 of 1 applicable (Personnel #7) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. No evidence in personnel file to verify credentials or educational background meets job qualifications.

Upon patient record review, 1 of 9 applicable (Patient #2) 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 medical record contains nursing documentation starting 8/19/22 identifying patient is a max assist of two for transfers. The aide care plan states ambulation/mobility with standby assist. Corrected on site.

Upon patient record review 2 of 9 applicable (Patients #6,#10) 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 6: The medical record contains aide documentation 8/10/22 identifying completion of housekeeping duties including folding laundry and meal set up. There was no evidence of tasks for housekeeping and food offering or assistance with meals included in the aide care plan. Patient 10: The medical record contains an ordered aide visit frequency of three times weekly. There was no evidence of third visits completed the weeks 1/16/22 and 1/23/22.

Upon patient client record review, 2 of 11 (Patients #1,#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 1: The medical record contains nursing documentation 7/27/22 discussing condition of a male patient, then proceeding with accurate documentation of condition of this female patient matching previous assessments. Corrected on site. Patient 10: The medical record contains missed visit documentation 1/14/22 and 1/31/22 with no data entered into the template to identify date of missed visit and reason.