Southern Care Youngstown

“Upon patient record review, 8 of 27 (Patient #2,#3,#11,#13,#14,#15,#17,#18) 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 medication profile indicates Dulcolax as a scheduled medication. However, the instructions state to take as needed if no results 8 hours after taking milk of magnesium. The medication profile indicates Imodium AD 2mg as a scheduled medication. However, the directions indicates to take as needed for diarrhea. Patient#3: During home visit, it was noted that patient has a bottle of atorvastatin 40mg 1 daily filled 7/21/26. However, the agency medication profile indicates atorvastatin is 20mg daily. It was also noted that patient medication profile indicates patient on oxygen PRN. However, there is no oxygen equipment noted in the home. Patient confirms she does not have or use oxygen. Patient#11: The medication profile indicates trazadone is schedule daily. However, the instructions state take at bedtime if melatonin ineffective. Docusate 50mg is listed on profile as scheduled but instructions read as 4th line bowel regimen. Milk of magnesia is also listed as scheduled but instructions indicate take as third line bowel regimen if no bowel movement for 4 days. MiraLAX 17grams is also listed as scheduled. However, instructions state third line of bowel regimen if no BM for 4 days. Patient#13: Medication profile indicates patient currently on oxygen PRN. However, CTI on 7/14/26 and nurse visit 7/30 indicate patient is on continuous oxygen. Patient#14: The medication profile indicates patient is on oxygen 2-4LPM NC PRN. However, nurse documentation on 7/27/26 and IDG 7/28/26 states patient using oxygen continuously. The medication profile list lidocaine patch 4% as being scheduled. However, the instructions state apply one to affected area twice a day as needed. There is also no specified area of application. Patient#15: Medication profile indicates patient is on oxygen 2-4 lpm PRN. However, nurse documentation on 8/4/26, 8/5, and 8/6 indicates patient now using continuous oxygen. Patient#17: The medication profile marks the following medications as “no” for not having reviewed directions, purpose, side effects or interactions of the following medications: ASA 81mg, cilostazol 50mg, finasteride 5mg, Insulin glargine 100 units sub-q pen, metoprolol 25, Plavix, Protonix, Tylenol arthritis 650mg. Patient#18: The medication profile indicates side effects and interactions were not reviewed for Morphine 100/5ml. The medication profile also indicates the following medications were marked “no” for not having reviewed directions, purpose, side effects and interactions: amantadine HCL 100mg, amlodipine 10mg, aspirin 325mg, Ativan 0.5mg, bisacodyl 10mg, Levsin 0.125mg, methimazole 10mg, and Senna. Also, the following medications are listed as the route being oral, however patient has PEG tube for nutrition and hydration. Medications are amlodipine, methimazole, amantadine, ASA, ondansetron. Patient is listed as NPO per recert plan of care on 5/12/26. These medications were all ordered 5/13/26 or 4/13/26.”

“Upon patient record review, 1 of 27 (Patient #4) 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#4: The record indicates patient has surgical wound to abdomen from PEG tube placement 7/6/26. Nurse assessed and measured on 7/7/26. There is no indication of measurement after this date but wound remains active in chart.”

“Upon patient record review, 5 of 27 (Patient #1,#2,#3,#4,#9) 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 record indicates patient is using prescription topicals for antifungal under breast and a topical for rectal buttock area. However, there is no evidence of problems, goals or interventions related to maintaining skin integrity on POC. Patient#2: Patient is a diabetic and is ordered Baqsmi PRN for low blood sugar. There is no evidence of problems, goals or interventions related to controlling or monitoring her blood sugar. Patient#3: The nurse documentation and aide POC indicate patient struggles with dyspnea on exertion there is no evidence of interventions for this on POC. POC indicates patient is using oxygen and has interventions regarding safe and appropriate use in the home. However during home visit it was noted there was no oxygen in home as patient refused it. Patient#4: There is no evidence of problems goals or interventions on the main plan of care for speech and communication issues for patient. Documentation by nurse and chaplain indicates on multiple visits patient unable to speak or having great difficulty speaking due to pain related to disease process. Patient#9: Nurse documents Alzheimer’s patient lives alone. The granddaughter monitors him from her house with cameras. There is no evidence of problems, goals or interventions related to home safety. However, nurse and MSW document working on options, educating, and discussing these issues with family.”

“Upon patient record review, 2 of 27 (Patient #3,#14) 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#3: During home visit, it was noted that patient has a bottle of Atorvastatin 40mg 1 daily filled 7/21/26. However, the agency order indicates Atorvastatin is 20mg daily. It was also noted that patient is currently ordered oxygen PRN. However, there is no oxygen equipment noted in the home. Patient indicates she refused it awhile ago and does not use or require oxygen. Patient#14: The medication order indicates patient is on Oxygen 2-4LPM NC PRN. However, nurse documentation on 7/27/26 and IDG 7/28 states patient using oxygen continuously. There is also evidence of a medication order that list Lidocaine patch 4% with instructions to apply to affected area twice a day as needed. There is also no specified area of application.”

“Upon patient record review, 4 of 27 (Patient #1,#3,#8,#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 equipment and supply needs. Patient#1: IDG notes from 7/2/26 indicate patient is ordered nectar thick liquids. There is no evidence of thickener on the supply order for plan of care. Patient#3: DME supply order indicates patient currently requires oxygen equipment however there was none noted in home during home visit. Patient indicates she doesn’t need it and refused delivery. Patient#8: The record indicates patient has weakness and dyspnea with exertion requiring assistance. There is no evidence of bath or shower equipment on supply/DME order for plan of care. Patient#15: The plan of care indicates nurse to monitor fasting blood sugar and report to physician if less than 65 or over 400. There is no evidence of glucometer used at the facility on the supply order for the plan of care.”

“Upon patient record review, 1 of 27 (Patient #1) did not have evidence that the IDG documents the sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement. Patient#1: Plan of care intervention states hospice nurse/facility nurse to perform fasting blood sugar monitoring two times daily using patient/facility equipment and report to MD if below 60 or greater than 250. During home visit agency RN obtained blood sugar monitoring log from facility. Between 6/21/26 - 8/7/26 there were 27 occurrences of blood sugar being elevated over 250. The highest being 539. There is no evidence of this being reported to MD.”

“Upon patient record review, 3 of 27 (Patient #3,#6,#19) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#3: The main plan of care indicates patient requires skin precautions. However, there is no indication of skin precautions on the aide plan of care. Patient#6: The aide plan of care indicates patient requires bleeding precautions. However, patient is no longer on anticoagulant medication and bleeding precautions have been removed from the main plan of care. Patient#19: There is no evidence of aspiration precautions on the aide plan of care. The main plan of care indicated aspiration precautions, goals and interventions are dated 6/1/26.”

“Upon client record review, 4 of 27 (Patient #1,#5,#13,#15) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient#1:Plan of care indicates hospice nurse and facility nurse are to monitor fasting blood sugars. There is no evidence of documentation indicating coordination, collaboration, or documentation in chart of blood sugars being monitored. There is no evidence of any results documented in the patient record. Patient#5: Plan of care indicates hospice nurse and facility nurse are to monitor fasting blood sugars. Patient is prescribed 2 medications for diabetes. There is no evidence of documentation indicating coordination, collaboration, or documentation in chart of blood sugars being monitored. There is no evidence of any results documented in the patient record. Patient#13: On 7/28/26 the nurse documents facility requesting nectar thick liquids for patient. There is no evidence of follow up on this request. The record indicates patient current plan of care list oxygen as PRN. However, CTI on 7/14/26 and nurse visit 7/30 indicate patient is on continuous oxygen. Patient#15: Plan of care indicates hospice nurse and facility nurse are to monitor fasting blood sugars. There is no evidence of documentation indicating coordination, collaboration, or documentation in chart of blood sugars being monitored. Medication profile indicates patient is on Oxygen 2-4lpm PRN. However, nurse documentation on 8/4, 8/5, and 8/6 indicates patient now using continuous oxygen.”