Every finding on record at Southerncare, Inc.

Upon patient record review, 3 of 19 (Patient #6, #7, #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 #6-The medication profile includes duplicative/unclear dosages of Oxycontin. 10/27/23 Oxycontin 30 mg tab crush resistant extended release 1 tab q12h for pain is listed on the profile. The profile also includes 11/21/23 Oxycontin 20 mg tab crush resistant extended release 1 tab q12h for pain. (corrected on site) Patient #7-On 11/08/23 the nurse documents receiving a verbal order for Ondansetron 4 mg q6h prn nausea. Ondansetron is not listed on the medication profile. On 01/03/24 the nurse documents spoke with patient regarding pain management. Patient agrees to take Hydrocodone as ordered. Hydrocodone is not included on the medication profile. (corrected on site) Patient #9-On 01/03/24 Lorazepam 2mg/ml .25 ml was ordered q4h prn restlessness/agitation. The medication profile has Lorazepam listed as every four hours scheduled for agitation/restlessness (inaccurate). (corrected on site)

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). Patient #7- On 11/23/23 triage documents the patient called stating his son was in for the holidays and tested positive for CoVid. The patient states he is very tired and thinks he will be testing positive too. The patient stated his son is taking Benzonatate and his sister who tested positive last month was given Paxlovid. The patient asked if either or both meds could be taken by him to reduce his chances of becoming ill. Triage documented dispatching the call to the RN on call. There is no documentation on record from the RN on call to address the patients concerns. (late entry documentation/correction on site)

Upon patient record review, 6 of 19 (Patient #1, #2, #4, #6, #7, #11) did not evidence the plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including specific orders for all medications and treatments. Patient #1-The 11/09/23 plan of care contains wound care orders as follows: Hospice nurse/caregiver to perform wound care to L arm. Cleanse with NS, apply Xeroform and cover with bordered gauze. The frequency of the wound care is not included in the order. (corrected on site) Patient #2-The plan of care 11/06/23 documents Advanced Directives as Medical Power of Attorney. The patient also has a DNR on record which is not included in the plan of care. (corrected on site) Patient #4-On 12/12/23 the nurse documents the patient is on Oxygen 4lpm/continuously and the 11/08/23 plan of care includes orders for the nurse to assess/teach usage of Oxygen however, Oxygen is ordered at 2lpm continuously. (late entry correction on site) Patient #6-The plan of care includes duplicative/unclear dosages of Oxycontin. 10/27/23 Oxycontin 30 mg tab crush resistant extended release 1 tab q12h for pain. The plan of care also includes 11/21/23 Oxycontin 20 mg tab crush resistant extended release 1 tab q12h for pain. (corrected on site) Patient #7-On 01/03/24 the nurse documents spoke with patient regarding pain management. Patient agrees to take Hydrocodone as ordered. Hydrocodone is not included in the plan of care. (corrected on site) Patient #11-On visit notes 12/08/23, 12/19/23, 12/21/23 and 12/29/23 the nurse documents oxygen is ordered at 3lpm as needed and the 11/20/23 plan of care includes orders for the nurse to instruct the patient on medications and treatment however, Oxygen is ordered at 2lpm as needed for shortness of breath. (late entry orders correction on site)

Upon patient record review, 3 of 19 (Patient #6, #9, #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #6-On 11/21/23 the Chaplain is ordered to visit 1q2m2 (once every 2 months). The Chaplain visited monthly on 11/27/23 and 12/06/23. (late entry orders correction on site) Patient #9-Effective 11/13/23 the Chaplain was ordered to visit monthly for one month (1m1). The Chaplain visited twice in November on 11/16/23 and 11/27/23. (late entry orders correction on site) Patient #10-Effective 11/15/23 the Chaplain is ordered to visit monthly. The Chaplain made visits on 11/16/and 11/27/23 (Twice monthly in November). Effective 11/15/23 the Social Worker was ordered to visit once monthly. The Social Worker visited on 11/16/23 and 11/29/23 (Twice monthly in November)(late entry orders correction on site)

Upon observation, there was not evidence in 1 of 4 home visits (Patient #4) that the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #4-On the home visit 01/04/24, the RN was observed donning gloves and performing incontinence care. The nurse changed gloves to begin the patient's sacral wound care. Hand Sanitizer or handwashing was not performed between glove changes.

Upon patient record review, 1 of 19 (Patient # 16) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved Patient#16-On 07/05/23 the bereavement coordinator documented contacting the deceased patients daughter. The bereavement coordinator documented the bereaved would like another phone call in a month and phone calls would be made monthly. There are no other phone calls/attempts on record.

Upon patient record review, 2 of 19 (Patient #2, #9) did not have evidence in the patient record that hospice aide assignments and duties are: • Complete written patient care instructions prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 Patient #2-The Aide Care plan documents Advanced Directives as Medical Power of Attorney. The patient is also a DNR which is not on the Aide Care Plan. (corrected on site) Patient #9-The patient has aspirations precautions identified on the team care plan. Aspiration precautions are not included in the Aide Care Plan. (corrected on site)

Upon patient record review 3 of 19 (Patient #1, #10, #13) did not have evidence documentation in the patient record that a hospice aide provides services that are: Ordered by the interdisciplinary group and included in the plan of care. Patient #1-The Aide is ordered to visit twice weekly effective 11/12/23. The week of 12/03/23-12/09/23 one Aide visit was made on 12/07/23. There is no documentation on record regarding the missed visit. (late entry documentation/correction on site) Patient #10-The Aide is ordered to visit three times weekly. The week of 11/19-11/24/23 the Aide visited twice on 11/20 and 11/22/23. There is no documentation on record regarding the missed visit. (late entry documentation/correction on site) Patient #13- The Aide is assigned to transfer the patient from bed to chair and from chair to bed each visit. On 11/30/23 and 01/03/24 the aide documented the task was not done and not needed.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient #1- On 11/13/23 the Social Worker documents that the patient has a DNR located on their refrigerator. The record does not contain a copy of the DNR and there is no documentation on record that a copy was requested. (corrected on site)

Upon patient record review, 1 of 19 (Patient #19) did not have evidence that the discharge summary includes all required information. Patient #19-The patient was discharged 11/01/23 due to condition plateaued. The Discharge summary does not include a summary of the patient's stay, including treatments, symptoms and pain management. The summary only documents the patients condition has plateaued per IDG. Pt needs minimal assistance with transfer, ambulation and ADLs.

Upon patient record review, 1 of 19 (Patient #7) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient #7-On 11/08/23 the nurse documents receiving a verbal order for Ondansetron 4 mg q6h prn nausea. The orders were not written and sent to the physician for signature.