Southerncare New Beacon Scottsboro

“Upon patient record review, 2 of 19 (Patient #5,6) 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 5: RN documentation indicated that the patient’s caregiver was crushing medications at times. No evidence that the active medication profile contained alternate administration instructions for acetaminophen, donepezil, furosemide, levothyroxine, lorazepam, risperidone, Seroquel, tramadol, Zoloft, or trazodone. Patient 6: The active medication profile has 2 entries for Tramadol, both are ordered as needed every 6 hours for moderate pain.”

“Upon patient record review, 1 of 19 (Patient #13) 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 13: No evidence that an initial bereavement assessment was completed at the time that the chart was surveyed.”

“Upon patient record review, 1 of 19 (Patient #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 11: The patient’s hospice admit diagnosis is malignant neoplasm of the brain. No evidence that problems, interventions, and goals related to neurological deficits on the current plan of care.”

“Upon patient record review, 3 of 19 (Patient #2,5,15) 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 has CBC/CMP lab results from 07/03/2026 on the chart. No evidence that the patient had an order was obtained for those labs. Patient 5: RN documentation indicated that the patient’s caregiver was crushing medications at times. No evidence that the orders for acetaminophen, donepezil, furosemide, levothyroxine, lorazepam, risperidone, Seroquel, tramadol, sertraline or trazodone contained alternative administration instructions. Patient 15: No evidence that the a discharge order was placed at the time of discharge.”

“Upon patient record review, 2 of 19 (Patient #3,8) 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 equipment and supply needs. Patient 3: Wound care supplies are listed on the active supply list. No evidence that the patient has or had a wound during the time on service. Patient 8: The medical record indicated that the patient uses a rolling walker due to weakness. No evidence that the rolling walker was added to the active supply list.”

“Upon patient record review, 3 of 19 (Patient #5,11,14) 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 active interventions that include foley care to be completed by the hospice nurse or the facility nurse. No evidence that patient is a current nursing home patient. The medical record indicated that the patient lives at a private residence and that has never resided at a nursing home during the time of service. Patient 11: The current plan of care has problems, interventions, and goals related to spiritual care. The chaplain documented on his initial assessment that the patient declined further visits/spiritual support from the hospice chaplain. Patient 14: The medical record indicated that the patient had started to have problems with nausea and vomiting since being admitted. No evidence that the current plan of care has problems, interventions, and goals related to nausea and vomiting.”

“Upon patient record review, 1 of 19 (Patient #3) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient 3: No evidence that the initial CTI (benefit period 02/13/2026-05/13/2026) narrative contains current subject/objective medical findings for the patient. The narrative on the chart references clinical information for another patient, S.M..”

“Upon patient client record review, 1 of 19 (Patient #2) 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 2: LPN narrative documentation on 08/11/2026 indicated that the patient was using oxygen at 3LNC. LPN assessment from the same day indicated that the patient was using 2LNC at the time. All other nursing documentation indicated that the patient routinely uses oxygen at 2LNC.”