Every finding on record at Southerncare, Inc.

Upon patient record review, 2 of 14 (Patient #2, #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. 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: The medication profile indicated Nystop topical powder without evidence of specific area for application. COS Patient #10: The medication profile indicated D-mannose powder without evidence of mixing directions. COS

Upon patient record review, 2 of 14 (Patient #2, #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 #2: The order for Nystop topical powder without evidence of specific area for application. COS Patient #10: The order for D-mannose powder without evidence of mixing directions. COS

Upon patient record review, 1 of 14 (Patient #2) 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 admission note indicated patient was using a shower chair however, there was no evidence of this on the plan of care. COS

Upon client record review, 3 of 14 (Patient #4, #7, #8) 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 spiritual visit frequency ordered on 05/30/23 1M, increase to 2M 07/01 and 2 PRN however, the month of June there were two visits noted on 06/06 and 06/23/23. Patient #7: The nurse visit frequency ordered 06/04 was 3W1, 7W and on 06/11 3W however, the week of 06/04 there were visits on 06/04, 06/05, 06/06, 06/06, 06/08, and 06/09. COS Patient #8: The spiritual and social work visit frequency ordered 04/04/23 was 2M, 2 PRN and on 06/17 1M then 2M, 2 PRN however, the month of June there were noted visits for social work on 06/15 and 06/27 and for spiritual care on 06/16 and 06/28/23.

Upon patient record review 1 of 14 (Patient #6) 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 #6: The aide visit frequency ordered 07/11 was 1W1, then 2W effective 07/23 however, the week of 07/16 there were visits on 07/17 and 07/19. COS

Upon personnel record review, 1 of 13 (Personnel #2 ) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: There was no evidence of a signed job description. COS