Every finding on record at Southerncare, Inc.

Upon patient record review, 2 of 14 (Patients #2,#10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 2: The medication profile contained oxygen with no delivery method. Patient 10: During home visit medication reconciliation, the caregiver confirmed carvedilol dose was 12.5 mg twice daily, rather than once daily per hospice profile.

Upon patient record review, 2 of 14 (Patients #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 medical record contained an order for oxygen with no delivery method. Patient 10: During home visit medication reconciliation, the caregiver confirmed carvedilol dose was 12.5 mg twice daily, rather than once daily per hospice profile.

Upon patient record review, 3 of 14 (Patients #2,#4,#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 equipment and supply needs. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a low air loss mattress. There was no evidence of an order for the DME included in the plan of care. Patient 4: The medical record contained nursing documentation 12/15/25 identifying patient use of a hospital bed, shower chair, and wheelchair. There was no evidence of orders for the DME included in the plan of care. Patient 9: The medical record contained nursing documentation 2/11/26 identifying patient use of a hospital bed and half rails. There was no evidence of orders for the DME included in the plan of care.

Upon patient record review, 2 of 14 (Patients #7,#9) 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 7: The plan of care indicated code states as DNR awaiting signature. There was no evidence the plan of care was updated to reflect signature received by the physician after admission and DNR status was active. Patient 9: The plan of care containing contradicting code statuses with advance directive listed as full code and diagnosis code entered as DNR. There was no evidence the plan of care was updated to remove the former full code status when the DNR form was received.

Upon observation and home visit, 1 of 3 (Patient #6) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #6 During the home visit with the hospice aide, the aide was observed placing her bag on the floor and keys on a table, without cleansing surfaces or using a barrier.

Upon patient record review, 1 of 14 (Patient #12) did not have 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 when appropriate 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 Patient 12: The medical record contained bereavement phone calls at two and five months that were not tasks in the bereavement care plan.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence in the patient record that hospice aide assignments and duties are specific to the patient's needs. Patient 10: The aide care plan contained expired instructions for the aide to keep wound dressing in place.

Upon patient record review 2 of 14 (Patients #6,#7) 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 contained an order for aide visits twice weekly. There was no evidence of a second visit completed the week of 2/15/26. Patient 7: The medical record contained an order for aide visits twice weekly. There was no evidence of a second visit accounted for the week of 1/23/26.

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. Agency volunteer utilization rate was 4.94% for 2025.

Upon patient client record review, 1 of 14 (Patient #2) did not have evidence that each patient record contains Advance Directives. Patient 2: The medical record contained a DNR form stating the son was making the decision for code status based on a written advance directive put in place when the patient was able to make decisions. There was no evidence of any additional advance directives. Upon agency investigation during survey, the information on the DNR form was inaccurate and the son confirmed no additional advance directives were in place.

Upon patient client record review, 1 of 14 (Patient #14) did not evidence that each patient record contains physician orders. Patient 14: There was no evidence of an order to discharge the patient for extended prognosis.

Upon patient record review 1 of 11 (Patient #4) 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 #4 The patient was admitted on 10/3/21, the psychosocial evaluation was completed on 10/14/21.

Upon patient record review 1 of 11 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1 The patient was admitted on 11/21/22, there is no psychosocial evaluation completed to date.

Upon patient record review, 2 of 11 (Patient #2, 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. 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 patient medication list includes 3 duplicated orders for Torsemide 20mg (11/21/22 take one pill daily, 11/22/22 take 2 pill daily, 11/23/22 take 1 pill 2 times daily.) Corrected on site. Patient #4 Medication orders for Neomycin-Polymyxin-Hydrocort ear drops ordered on 8/11/22, do not indicate which ear to instill the drops into. Corrected on site.

Upon patient record review, 3 of 11 (Patient #4, 8, 11) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #4 The patient was admitted on 10/3/21, the bereavement assessment was completed on 4/15/22. Patient #8 The patient was admitted on 4/23/22, there is no bereavement assessment completed. Patient #11 The patient was admitted on 11/20/22, the bereavement assessment was completed on 12/1/22.

Upon patient record review, 6 of 11 (Patient #1, 2, 3, 6, 7, 11) 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 #1 The initial comprehensive assessment indicates the patient has Type II DM and nutritional changes related to her disease process. The plan of care does not include a problem statement with interventions and goals related to the diabetes and/or nutrition. The plan of care does not include a problem statement with interventions or goals for the Spiritual Care being provided to the patient. Corrected on site for all problems. Patient #2 The initial comprehensive assessment indicates the patient has Type II DM and nutritional changes, he receives Lantus 25 units SQ at bedtime, the plan of care does not include a problem statement with interventions and goals for the diabetes. Corrected on site. The patient record indicates the patient was started on docusate sodium 50mg daily as needed for constipation, the plan of care is not updated to include a problem statement with interventions and goals for the patient needs. The patient received new orders for Tradjenta 5mg and Metformin 500 mg on 1/13/23, the plan of care was not updated to include a problem statement with interventions or goals for monitoring the patients diabetes or educating on the new medications. (Corrected on site for all problems) Patient #3 The patient record shows significant issues with anxiety and behavior issues starting on 11/15/22 and requiring medication management and multiple medication changes including lorazepam, Seroquel and haloperidol. There is no problem statement with interventions and goals to address the patient needs. The patient has evidence of incontinence as noted in the skilled nursing visit on 1/16/23, the plan of care is not updated to include interventions and goals for the management of incontinence. The plan of care was not updated to include a problem statement of constipation with interventions and goals related to evidence in the record on 2/10/23 reporting "no BM since 1/20/23" in which the nurse performed a check for impaction. The patient has evidence of aspiration and choking on food documented on 12/24/22, the plan of care is not updated to include a problem statement with interventions and goals for nutritional education. The plan of care includes a problem statement for Altered Neurological/Sensory but does not include interventions or goals. There is evidence in the patient record of "elopement" and the patient does not have interventions or goals in place for safety related to wandering. (Corrected on site for all problems) Patient #6 The patient record indicates evidence of bowel and bladder incontinence, the plan of care does not include a problem statement to include interventions or goals for the incontinence. The patient record indicates that the patient was unable to care for himself and did not have adequate care in the home, requiring placement to a long term care facility. The plan of care was not updated to include a problems statement with interventions and goals for the placement of the patient for long term care. (Corrected on site) Patient #7 The plan of care was not updated to resolve the problem statements with interventions and goals in place for Social Worker, the family requested that services be discontinued effective 10/18/22. (Corrected on site.) Patient #11 The patient plan of care upon admit includes a problem statement for altered genitourinary related to incontinence but does not include interventions or goals.

Upon patient record review, 2 of 11 (Patient #2, 4) 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 patient record includes orders for Torsemide 20mg (11/21/22 take one pill daily, 11/22/22 take 2 pill daily, 11/23/22 take 1 pill 2 times daily) there are no discontinued orders on file. Corrected on site Patient #4 Medication orders for Neomycin-Polymyxin-Hydrocort ear drops ordered on 8/11/22, do not indicate which ear to instill the drops into. Corrected on site.

Upon patient record review, 1 of 11 (Patient #7) 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 #7 The patient record indicates that the patient utilizes a rollator walker and a wheelchair for ambulatory needs, these are not included in the plan of care. (corrected on site)

Upon client record review, 1 of 11 (Patient #7) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #7 The plan of care for 8/5/22 includes orders for MSW visits: 2x month for 1 month, 3 x month for 1 month, 2x month for 1 month and 1x month for 1 month. The patient was seen on on 8/25/22, and 9/20/22 but no additional visits were made. The family requested no additional SW visits to be made effective 10/18/22, a dc order was entered into the plan of care on 2/28/23.