Every finding on record at Southerncare, Inc.

Upon patient record review, 2 of 14 (Patient #1,9) 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. This review includes, but is not limited to: Patient 1: Upon home visit per spouse, patient is taking Tylenol 500mg 3 tabs every am, the medication profile says Tylenol 325mg 2 tabs Q6 hours prn. Pt has not taken tamsulosin in a long time per spouse and it is still on the medication profile. Pt has taken One a day multivitamin for years and it is not on the medication profile. Corrected on site, SN obtained new orders and updated medication profile. Patient 9: The SN documented on 5/30/25, patient is taking Pepto Bismol for PRN stomach upset. There is no order for this medication on the medication profile. Corrected on site. SN obtained new order.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 6: The SN documented on 7/1/25 “daughter states patient has reddened sacrum again” Assessment reveals red sacrum. There was no teaching about applying barrier cream.

Upon patient record review, 3 of 14 (Patient #1,6,9) 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 1: Per spouse, patient is taking Tylenol 500mg 3 tabs every am, POC says Tylenol 325mg 2 tabs Q6 hours prn, Pt has not taken tamsulosin in a long time per spouse and it is still on POC. Pt has taken One a day multivitamin for years and it is not on POC. Corrected on site. SN obtained new order and updated POC. Patient 6: Barrier cream is in the list of supplies on the POC but there is no directive on how often to apply it or where to apply. Corrected on site, SN obtained new order. Patient 9: The SN documented on 5/30/25, patient is taking Pepto Bismol for PRN stomach upset. There is no order for this medication on the POC. Corrected on site. SN obtained new order.

Upon patient record review, 3 of 14 (Patient #4,8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 4: Visit 6/19/25 SN documented patient is using a heating pad for stiff neck. There is no order for a heating pad modality. Patient 8: SN documented on 6/25/25 patient has a red area on the tip of his penis from tugging on his catheter. The SN applied barrier cream to the tip of the penis with no order to apply barrier cream to the penis. Corrected on site, SN obtained orders. In addition, SN documented 6/4/25 “Bilat buttocks excoriated, Barrier cream applied as ordered.” Order is to wash with soap and water, pat dry and apply barrier cream. There is no evidence the SN followed the POC. Patient 10: SN documented 6/5/25 patient wearing compression stockings. There is no order for compression stockings. The SN documented 6/30/25, patient using heating pad to right knee for pain control, there is no order for a heating pad. Corrected on site, SN obtained orders.

Upon patient record review 1 of 14 (Patient #7) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 7: The SN documented 6/3/25 the granddaughter was tearful and complained of being burned out due to no help with patient. Pt complained to MSW on 6/12/25 of having a high level of stress and wanting 1 day off per week to help her be "OK" as she continues to have no support. Caregiver strain documented by MSW in IDG with “SW to provide opportunity for PCG to address concerns, frustrations, etc”. There was no evidence of offering respite or volunteers for support.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again. Patient 7: Pt had a fall documented by SN on 6/29/25 with no incident report filed.

Upon patient record review, 1 of 14 (Patient #13) did not have evidence the hospice offers bereavement counseling that includes: Patient 13: The medical record does not contain 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 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.

Upon patient record review 2 of 14 (Patient #1,8) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 1: Aide is ordered 5 days per week. There were 4 visits made from 5/25/25-5/31/25, with no missed visit documentation, no evidence of refusal. The week of 6/29/25-7/5/25 there were only 3 visits made no missed visit documentation or evidence of refusal. Patient 8: The medical record contains an order on 5/15/25 for aide 3 times per week. The week of 5/25-5/31/25 the aide saw the patient twice and there is no missed visit documentation or evidence of refusal.

Upon patient record review 1 of 14 (Patient #1) 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 1: Last aide supervisory visit was 6/19/25, the next aide supervisory visit due 7/3/25, it was not completed.

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 agency had 4.9% in 2024.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that each patient record contains: Patient 6: The patient's caregiver elected to receive patient notification of hospice non-covered items, services and drugs. There is no evidence the patient received the addendum.

Upon patient record review, 5 of 14 (Patient #5,6,9,11,12) 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 5: The SN documented on 5/28/25 wound care by restating the order and documenting “wound care as per care plan”. The SN then also documented in the narrative “Caregiver applying triple antibiotic ointment to right toe lesion which is almost completely healed”. The order is to cleanse the right great toe with soap and water, cover with triple antibiotic ointment, cover with band aid or leave open to air twice daily. It is unclear if the order was followed. Patient 6: The SN documented on 6/27/25 “Patient was slightly brand a car d---”. Patient 9: The SN documented “POX” on 5/13/25. This is not an approved abbreviation. Patient 11: Wound care documented on 11/18/24 by restating order and then SN documented "wound care provided, tolerated well". There is no details of wound care that was provided. Patient 12: SN documented wound care on 2/28/25 by restating the order then at the end documented "wound care provided per order". There is no details of wound care that was provided.

Upon patient record review, 1 of 11 (Patient #4) 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 #4 The 7/7/22 nursing visit note reads O2@ 5/LPM via NC continuous, however, Oxygen is not on medication profile to date.

Upon patient record review, 1 of 11 (Patient #4) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient#4 The 7/11/22 physician orders for MSW and SC frequency reads 3 prn.

Upon patient record review, 2 of 11 (Patient #4, 5) 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 7/7/22 nursing visit reads O2 @5LPM via NC continuous however no order for O2 and O2 is not included on the plan of care to date. Patient #5 The 7/3/22 physician order reads cleanse skin tear with normal saline, apply triple antibiotic and redress qd until healed with no location identified and no directive on who is to perform.

Upon client record review, 1 of 11 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 The 6/25/22 plan of care SC frequency reads 1wk2 however no visit completed week 6/22/22.

Upon patient record review 4 of 9applicable (Patient #4, 6, 7, 10) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the POC. Patient #4 The aide performed tasks not ordered on the 7/6/22 aide assignment: comb hair, oral hygiene, nail care, bed transfer and housekeeping Patient #6 The aide frequency on the 5/25/22 plan of care reads 3wk1, 5wk12, however, only 2 visits made week of 5/25/22 and 4 visits made the week of 5/31/22 and 6/7/22. Patient #7 The 6/30/22 aide care reads weekly frequency for bath, nail care, shampoo and linen/bed change however the aide documented completion on each visit 7/8/22-7/14/22 Patient #10 The aide frequency on the 5/6/22 plan of care reads 2wk13 however no visits made first week of care and only one visit made on week of 5/8/22

Upon patient client record review, 2 of 11 (Patient #3, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated. Patient #3 The aide signature 6/3/22-6/27/22 only contains initials of first and last name, date, and no credentials. The aide signature 6/28/22-6/30/22 contain first initial and last name with date and no credentials. Patient #5 The aide signature on 6/23/22 and 6/24/22 and the RN signature on the 6/17/22 aide care plan contain no credentials with the associated name and date.