Southerncare New Beacon N Birmingham

“Upon patient record review, 5 of 23 (Patient #1,6,7,10,13) 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: RN documentation indicated that the patient was using oxygen at 2.5LNC and 4LNC as needed. The active medication list has an entry for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes an entry for 2.5 or 4LNC. No evidence that the active medication list includes a titration instructions to increase the patient’s oxygen to 2.5LNC or 4LNC. During home visit medication reconciliation, Nexium 40mg 1 cap daily was noted in the home. No evidence that medication was included on the current medication list. Patient 6: The active medication profile has 2 active entries for oxygen. One for oxygen at 2-4LNC every 4 hours PRN and another for oxygen 2LNC PRN as needed for shortness of breath. No evidence that instructions were given on when to use which liter flow for shortness of breath. Patient 7: RN documentation indicated that the patient was using oxygen at 4LNC. The active medication list has an entry for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes an entry for 4LNC. No evidence that the active medication list includes a titration instructions to increase the patent’s oxygen to 4LNC. Patient 10: The active medication profile has MiraLAX entries that does not have instructions on how to dilute the powder. Patient 13: RN documentation indicated that the patient’s oxygen was being titrated to both 4.5LNC and 5LNC. The active medication list has an entry for oxygen at 2-4LNC PRN for shortness of breath. No evidence that the active medication list includes an entry for 4.5LNC or 5LNC. No evidence that the active medication list includes instructions to titrate the oxygen the patient’s oxygen to 4.5L or 5LNC.”

“Upon patient record review, 2 of 23 (Patient #3,11) 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). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 3: The medical record indicated that the patient had a wound to the left knee. No evidence that the patient’s wound was measured for the week of 07/27/2026. Patient 11: RN documentation indicated that patient was having breakthrough pain to the right abdomen on 07/07/26. The nurse indicated that she was reaching out to the doctor. No evidence in the chart that the nurse reached out to the doctor at that time.”

“Upon patient record review, 4 of 23 (Patient #1,4,7,13) 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: RN documentation indicated that the patient’s oxygen was being titrated to both 2.5LNC and 4LNC. No evidence that an order was received for the oxygen at 2.5L or 4LNC. The current order is for oxygen at 2LNC. During home visit medication reconciliation, Nexium 40mg 1 cap daily was noted in the home. No evidence that an order was received for that medication. Patient 4: The medical record indicated that the patient had a chest X-Ray on 08/03/2026. No evidence that an order was received for the chest x-ray. Patient 7: RN documentation indicated that the patient’s oxygen was being used at 4LNC. No evidence that an order was received for the oxygen at 4LNC. The current order is for oxygen at 2LNC. Patient 13: RN documentation indicated that the patient’s oxygen was being titrated to both 4.5LNC and 5LNC. No evidence that an order was received for the oxygen at 4.5L or 5LNC. The current order is for oxygen at 2-4LNC PRN.”

“Upon patient record review, 3 of 23 (Patient #5,9,16) 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 5: The current DME supply list has a nebulizer listed. No evidence that the patient has nebulizer treatments ordered. Patient 9: The medical record indicated that patient had a skin tear that healed in May 2026. New benefit period started on 07/16/26. No evidence wound care supplies was removed from the active supply list. Patient: 16: RN documentation indicated that the patient is using a walker due to altered mobility. No evidence that a walker was added to the current DME supply list.”

“Upon patient record review, 4 of 23 (Patient #5,8,13,15) 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 current plan of care has interventions for wound care to a skin tear on the right forearm. The medical record indicated that the wound was healed and inactivated on 03/30/2026. No evidence that the plan of care was updated to remove those interventions. Patient 8: The medical record indicated that the social worker was helping the patient/family with ALF/senior apartment placement. No evidence that the plan of care was updated to include interventions related to placement. Patient 13: The medical record indicated that the patient was admitted with a pacemaker. No evidence that problems, goals, interventions related to the pacemaker was included on the initial plan of care or following care plans as of date of survey. Patient 15: Plan of care has interventions for the social worker to complete an evaluation. The medical record indicated that the evaluation was completed on 07/09/26. No evidence that the plan of care was updated remove that intervention.”

“Upon patient client record review, 1 of 23 (Patient #14) 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 14: On the initial IDG, the social worker documented that the pt/family was coping well with illness, had no concerns, and that she would visit the pt monthly and PRN as needed. The medical record indicated that the pt/POA had refused social services and the social worker had not completed a visit on the patient.”