Every finding on record at Southerncare, Inc.

Upon patient record review 2 of 19 records (Patient #6, #11) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #6: The record indicated that the Start of Care was 01/25/24 there was no evidence of the Spiritual Comprehensive Assessment was completed until 2/5/24. Patient #11: The record indicated that the Start of Care was on 12/5/23 there was no evidence of the Spiritual Comprehensive Assessment was completed until 2/27/24.

Upon patient record review, 6 of 19 records (Patient #1, #2, #4, #5, #6, #8) 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 medication profile indicated Lidocaine Topical patch daily for pain apply 12 hours, off 12 hours. There was not evidence of a specific location. Corrected on site. Patient #2: The medication profile indicated Oxygen @ 1.5 to 2.5 liters prn, there was no evidence of a route of administration. Corrected on site. Patient #4: The medication profile indicated there were no OTC supplements, there was evidence the patient was being given Vitamin D3 400IU BID. Corrected on site. Patient #5: The medication profile indicated Humalog Kwikpen(U-100) Insulin 100U/ml SQ per instructions, Sliding Scale notify MD if BS > 400 or <70. There was no evidence of a sliding scale. Corrected on site. Patient #6: The medication profile indicated Ciprofloxacin 0.3% dexamethasone 0.1% ear drop suspension, there was not evidence of which ear the drops needed to go in. Corrected on site. In addition, Acetaminophen 500mg two tabs po Q4hours prn. There was no evidence of a max allowable dose for 24 hours. Also, Acetaminophen Hydrocodone 5/325 one tab po Q6hours prn and there was no evidence of a max allowable dose for 24 hours. Corrected on site. Patient #8: The medication profile indicated Nitroglycerin 0.4mg SL by mouth/under the tongue every 5 minutes as needed. There was no evidence of the number of doses to take before taking another action. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #2) 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 #2: The record indicated the patient was on Eliquis 2.5mg po BID. There was no evidence in the plan of care regarding bleeding precautions. Corrected on site.

Upon patient record review, 6 of 19 records (Patient #1, #2, #4, #5, #6, #8) 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: The record indicated an order for Lidocaine Topical patch daily for pain apply 12 hours, off 12 hours. There was not evidence of a specific location. corrected on site. In addition: The record indicated an order dated 12/21/23 for Vaseline Gauze with Stretch wrap or gauze wrap to left leg. There was not evidence of a specific location. Corrected on site. Patient #2: The record indicated an order for Oxygen @ 1.5 to 2.5 liters prn, there was no evidence of a route of administration. Corrected on site. Patient #4: The there were no orders for OTC supplements, there was evidence upon home visit the patient was being given Vitamin D3 400IU BID. Corrected on site. Patient #5: The record indicated an order for Humalog Kwikpen (U-100) Insulin 100U/ml SQ per instructions, Sliding Scale notify MD if BS > 400 or <70. There was no evidence of a sliding scale. Corrected on site. In addition, there was no evidence of a complete order for the foley catheter on 3/27/24 as it was written Catheter 18 French, 10 ml balloon, patient and family agreed to placement. There was no evidence in the order to include irrigation and or when to change out the catheter. Corrected on site. Patient #6: The record indicated an order for Ciprofloxacin 0.3% dexamethasone 0.1% ear drop suspension, there was not evidence of which ear the medication needed to go in. Corrected on site. In addition, Acetaminophen 500mg two tabs po Q4hours prn. There was no evidence of a max allowable dose for 24 hours. Also, Acetaminophen Hydrocodone 5/325 one tab po Q6hours prn and there was no evidence of a max allowable dose for 24 hours. Corrected on site. Patient #8: The record indicated an order for Nitroglycerin 0.4mg SL by mouth/under the tongue every 5 minutes as needed. There was no evidence of the number of doses to take before taking another action. Corrected on site. In addition: The record indicated foley catheter supplies were given on 4/1/24 with a plan to insert a foley catheter with a 10cc balloon inflation. There was no evidence in the record for an order for the foley catheter. Corrected on site.

Upon patient record review, 1 of 19 records (Patient #5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: The record indicated a foley catheter was placed on 03/27/24. There was no evidence that the plan of care was revised to include goals and interventions related to the foley catheter.

Upon client record review, 5 of 19 records (Patient #2, #3, #6, #10, #12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The record indicated the visit frequency for the Chaplain was for an evaluation then 2M2, 1M1. The Chaplain completed the evaluation on 12/20/23 with routine visits on 1/24/24 and 2/3/24. There was no evidence of the second visit in January or February 2024. There was no evidence of a visit in March 2024. In addition, the visit frequency for the Social Worker was for an evaluation then 2M2, 1M1. The Social Worker completed the evaluation on 12/20/23 with routine visits on 1/29/24 and 2/26/24. There was no evidence of the second visit in January or February 2024. There was no evidence of a visit in March 2024. Patient #3: The record indicated the visit frequency for the Social Worker was four every 2M2. The record indicate the Social Worker made four visits in February 2024 and four visits in March 2024. Patient #6: The record indicated there was skilled nursing visit frequency orders on 1/25/24 for 3W1. There was no evidence of 3 visits being made between 1/25/24 to 1/27/24. Patient #10: The record indicated a social worker frequency of 1M3 on 1/11/24. The record had no evidence of the scheduled visit in January 2024 and no visit made in February 2024. Patient #12: The record indicated nurse frequency of 2W13 effective starting on 3/5/24. There was no evidence of nursing visits from 3/5/24 to 3/9/24.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1: Upon observation and home visit (Patient #4, Aide) the hospice aide wiped the shower chair with sanitizing wipes in the shower room, leaving wet towels on the floor and went to the patients room touching her face with both dirty gloves hands. She took the patient into the dirty shower room then cleaned up the dirty towels on the floor.

Upon patient client record review, 1 of 19 records (Patient #4) did not have evidence that each patient record contains Advance Directives. Patient #4: The record indicated the patient did have an Advanced Directive. There was no evidence of a copy of the patients Advanced Directives on the chart.

Upon patient client record review, 1 of 19 records (Patient #3) 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 #3: This patient was on hospice for COPD, the record indicated in the Social Workers initial assessment that this patient was on service for Parkinson and Dementia. Corrected on site.

Based on a review of clinical records, the complaint log, abuse/neglect policy, and interviews with staff and patient's family, the agency failed to exercise the rights of the patient by the person appointed pursuant to state law to act on the patient's behalf. Specifically, an agency staff member removed a patient from their home without permission from the agent who was legally designated to make decisions on the patient's behalf and/or follow procedure of possible abuse/neglect for one (1) of five (5) patients in the survey sample (Clinical record #1). --- The findings:The agency complaint log and five clinical records were reviewed in the agency on June 06, 2023 and June 07, 2023, with read only access for the electronic medical records with the following findings: On 06/06/2023 at 3 PM the agency's complaint log was reviewed with the following: The agency's complaint log contained a complaint regarding patient #1 dated 05/12/2023. The complainant called the agency to notify that patient #1's spouse informed the complaint that their spouse was removed from their residence on 05/08/2023 to another paid private residence without a court order. The complainant caller notified the agency that the spouse is the power of attorney (Power of Attorney) unless the spouse was unwilling to act as the POA, then it would pass to the patient's adult child (name redacted). On 06/06/2023 the MFI (Medical Facilities Inspector) asked the Administrator if the hospice had investigated this complaint. The Administrator stated, "Yes." On 06/07/2023 the MFI requested the investigative complaint, and the Administrator provided the investigation report and resolution. The investigation described an account that occurred on 05/08/2023 where the patient's paid caregiver stopped the hospice Aide at the end of the road and reported the patient was not safe with the spouse. The hospice Aide reported this to the Alternate Administrator who sent a Social Worker and a Social Worker orientee to investigate. The Social Worker reported having conversations with the patient's adult child who agreed to move the patient out of the home due to the patient's spouse "drinking". The Social Worker arrived at patient's home and notified the spouse that patient needed to be removed from the home for safety reasons. The report noted the Social Worker denied witnessing any inappropriate behavior. On 05/15/2023 the patient was transferred back home. On 05/18/2023, the complainant called the hospice agency to inform them the private caregiver residence (where patient #1 was transferred to) reported that the agency's Social Worker represented themselves as working with social services and had removed the patient from the home and placed there due to spouse's abuse. The clinical record for patient #1 was reviewed for the recertification period of 03/10/2023 to 5/16/2023. The patient's plan of care contained a primary diagnosis of Heart Failure and other related diagnosis of Vascular Dementia and Anxiety Disorder. The clinical record contained documentation of the patient's bedbound status, unable to feed self and unable to verbalize pain due to cognitive impairment. A Durable Power of Attorney was also noted in the clinical record that read as follows: Option #1 I appoint (patient #1's spouse) as my agent to make decisions on my behalf as set out below. Option #2 if (patient #1's spouse) is not reasonable available or is unable or unwilling to act as my agent, then I appoint (patient's daughter) to serve as my successor agent to make decisions on my behalf as set out below: This document was dated May13, 2013. In addition, the clinical record was reviewed for any documentation that would render safety concerns toward the patient. No documentation was revealed that would render any safety concerns toward the patient. Family Interviews: On 06/06/2023 and 06/07/2023, the MFI interviewed patient #1's child and spouse as follows: - 06/06/2023 at 7:30 PM, the MFI called patient #1's daughter. The daughter explained how thankful she was of APS and that her father was the primary POA and she is second in command if her father became incompetent in which he is not. "The hospice's Social Worker (name redacted-terminated) and the Alternate Administrator called to tell me that my mother was unsafe at home because of complaints of food shortage and inability to take care of mother reported by paid caregivers and agency staff. They advised me that mother was going to a residential home where she would be safe and that law enforcement would enforce this. I went along with hospice because I didn't know any better until I spoke with APS that this was wrong. My mother stayed a week with strangers and came back unresponsive. I was robbed of spending time with her and had no closure. I asked the residential home if I could visit my mother on Mothers Day and I was told no because they did not want drama. My dad is not perfect and is an alcoholic but he had paid caregivers at home and she was not unsafe at home". - 06/07/2023 at 9:47 AM, the MFI called patient #1's spouse. The spouse explained the Social Worker (name redacted-terminated) came to my house and I thought she had an order to remove my wife because of mistreatment. "The paid caregivers told them I didn't have enough food and I don't know what else. My wife did not want to go but at the time I didn't know what to do. I should have stopped it but was such a surprise I didn't know what was going on". Staff interviews: On 06/07/2023, the MFI (Medical Facilities Inspector) interviewed all available staff involved with patient #1's visitation as follows: -9:09 AM, the MFI called the hospice Aide (staff member #3) if there were concerns with patient #1. The Aide stated, " I was met outside in the road by the paid caregiver who said it was unsafe in the home because the husband was drinking alcohol and mouthy. I did not go inside and called the Alternate Administrator who was going to report this to the hospice Social Worker". The Aide confirmed during the interview there were no safety issues before. -9:17 AM, the MFI called the hospice LPN (Licensed Practical Nurse-staff member #8) if there were concerns with patient #1. The LPN stated, "No but she was tearful on a visit and busted out crying. I did document that but there were no other concerns". -9:20 AM, the MFI called the hospice RNCM (Registered Nurse Case Manager-staff member #6) if there were concerns with patient #1. The RNCM stated, "Never had any concerns or issues while I was there. I was on a three-way call with the Alternate Administrator and hospice Aide, when the Aide said the paid caregivers said it was unsafe because the husband was drinking. The Alternate Administrator said she was sending the Social Worker out there to see what was going on". -9:29 AM, the MFI called the hospice Social Worker (staff member #4) if there were concerns with patient #1. The Social Worker explained there was some missing medication but the other Social Worker (name redacted-terminated from agency at present) educated the spouse that they were the only person who could open the lock box to administer medications. The spouse signed the hospice lock agreement form and no other issues after that. The Social Worker stated, "I was shadowing the Social Worker (name redacted-terminated) the day this Social Worker thought it was unsafe for the patient due to the paid caregivers refused to come back to the house because the spouse's behavior of intoxication. The Social Worker (name redacted-terminated) tried to get the spouse's permission for the patient's removal from the home but the spouse did not agree or disagree and just cried. The Social Worker (name redacted-terminated) did explain to the spouse the reasons of patient removal due to medication discrepancy, intoxication and paid caregivers leaving because of sexual passes. The Social Worker (name redacted-terminated) called the patient's social worker at social services and left a voice mail. The patient was then transported to a private caregiver residence (name redacted) on 05/08/2023. -12:24 PM, the MFI spoke with the hospice Alternate Administrator (staff member #2) in the agency and asked if there were concerns with patient #1. The Alternate Administrator explained a three-way call had been carried out with hospice Aide and RNCM because the hospice Aide reported the paid caregivers statement of an awful weekend and need to get help for the patient. The MFI asked the Alternate Administrator what the specifics was of an awful week and the need for help. The Alternate Administrator stated, "The paid caregiver didn't give specifics and then I called the patient's daughter and reported the paid caregiver's concerns." The Alternate Administrator recalled the patient's daughter saying that her mom would be better cared for if placed someone else. The Alternate Administrator stated, "At 4 PM we had a stand down meeting (team app to discuss major issues) and the Social Worker (name redacted-terminated) said they are planning to move patient to the private caregiver residence (name redacted). At the time we didn't think anything of it because the daughter thought it was a good idea to move her. I didn't know the whole story of what was going on and what options were taken just knew the patient had been moved. I don' recall anyone asking if APS had been notified. -1:10 PM, the MFI spoke with the hospice Administrator (staff member #1) in the agency and asked why APS was not notified. The Administrator stated, We didn't see a problem because we were told the spouse didn't have anymore paid caregivers to take care of the patient and he couldn't physically alone. The MFI asked why respite was not an option. The Alternate Administrator did not provide an answer. APS (Adult Protective Services) Interview: -06/07/2023 at 10:46 AM, the MFI received a telephone call back from APS (complainant) who explained how the Social Worker (name redacted-terminated) did not follow the guidelines of reporting abuse/neglect. The APS stated, "If a case is reported and valid a face-to-face contact is made within 7 days. An investigation is done with collection of information from collaterals. We don't have the right to remove a person, we have to go in front of circuit court and get a court order to remove a person from the abuse/neglect. I happened to be reviewing a case at the same private caregivers residence (name redacted) and spoke to the owner who said I reported this case in which I did not. APS and Police Department (county police department -name redacted) had previously investigated an earlier case with patient #1 (name redacted) spouse in April 2023 but it was unfounded by us and the Police Department." Select Policy and Procedure: On 06/07/2023 the Regional Director of Clinical Operations provided the MFI with the abuse/neglect policy as requested. The policy was titled, Assessment of Possible Abuse/Neglect Policy No. 2-035 a select portion read as follows: "The Hospice division (the hospice) will report all suspected cases of abuse, neglect, or exploitation in compliance with appropriate state statutes to appropriate protection organizations. Virginia 12VAC5-391-190 The clinician will submit a verbal report of the suspected abuse/neglect to the proper authorities, to include the adult protective services (APS) unit of the local social services department with the following information: A. Name of alleged perpetrator B. Relationship to patient, if any C. Information regarding suspected abuse/neglect: 1. Date of occurrence 2. Witness to occurrence, if any 3. Nature of occurrence 4. Description of the abuse/neglect."

Based on a review of clinical records and staff interview it was determined the agency failed to ensure their interdisciplinary group (IDG) documented the patient's progress toward outcomes and goals specified in the plans of care for five (5) of five (5) patients in the survey sample (Clinical record #'s 1 - 5). --- The findings:Five clinical records were reviewed in the agency on June 06-07, 2023 with read only access. The IDG failed to contain evidence of IDG documentation of the patient's progress toward outcomes and goals specified in the plans of care below. Many were left blank and/or the nurse wrote in how many Skilled Nurse visits to manage care, patient will report symptom management with current regimen, patient will remain free from falls, anxiety and pain. 1. The clinical record for patient #1 was reviewed for the time period of 03/10/2023 through 05/16/2023. 2. The clinical record for patient #2 was reviewed for the time period of 03/31/2023 through 06/28/2023. 3. The clinical record for patient #3 was reviewed for the time period of 05/22/2023 through 08/19/2023. 4. The clinical record for patient #4 was reviewed for the time period of 03/22/2023 through 6/19/2023. 5. The clinical record for patient #5 was reviewed for the time period of 04/20/2023 through 07/18/2023. Interview:During the electronic medical record review conducted on 06/07/2023 at 12 PM the Administrator and the Regional Director of Clinical Operations acknowledged the failure of IDG to document the patients progress towards outcomes and goals. The lack of documentation by the agency's IDG regarding the patient's progress toward outcomes and goals specified in the plans of care for the above noted patients was acknowledged and reviewed with the Administrator and the Regional Director of Clinical Operations during the exit conference of 06/07/2023.