Hospice of West Alabama

“Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment and reassessment included the patient’s need for physical, psychosocial, emotional and spiritual care. On review of RRNHV#14 there was documentation the patient was admitted with a laceration to the head with staples yet there was no documentation of an assessment of the wound on admission or subsequent visits. In review of RRNHV#13 there was documentation of a stage 2 wound and a skin tear yet there was no documentation of an assessment of the wounds when discovered and weekly as required by policy. Further, in the visit documentation there were portions of the assessment that were left blank such as physical mobility, home safety, endocrine, sleep, and coping sections. In RRNHV#12 there was documentation of a skin tear to the left buttocks while the patient was in respite yet there was no documentation of the wound after the patient returned home until 3 weeks later. These observations were reviewed with CCO, Manager of Home Care and Executive Director.”

“Observed in Record Review. In 5 of 14 patient records reviewed, the organization failed to ensure the update to the comprehensive assessment was accomplished by the hospice interdisciplinary group considering changes that have taken place no less frequently than every 15 days. On review of RRNHV#12 the Interdisciplinary Group (IDT) met every 15 days or less yet on IDT#2, IDT#3, and IDT#4 in June and July there was no documentation of an update to the comprehensive assessment as all clinician comments were blank. In RRNHV#11 there was no documentation of the update on IDT#2 in July and in RRNHV#10 similar lack of documented update to the comprehensive assessment was noted in IDT# 2, IDT#3 and IDT#4. In RRNHV#9 there was no documentation of updates for IDT#3. Similar finding could be seen on RRNHV# 7, especially in the 2nd benefit period and in RRNHV#6. These observations were reviewed with the Manager of Home Care and Executive Director.”

“Observed in Record Review. In 4 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness. On review of RRNHV#14 the documentation noted the patient with a laceration to the head with staples and later removal of the staples yet there was no integumentary care plan established to guide the care. In RRNHV#13 the documentation noted issues with pain management with adjustments in scheduled Oxycodone from 2 times a day to 4 times a day. The changes pain management were not reflected in the plan of care. In RRNHV#12 there was documentation of a UTI, and patient was on Eliquis yet there was no care plan to guide the care for the infection or bleeding precautions. The patient had been twice to respite but there were no goals and interventions to guide the respite stay. In RRNHV#8 there was also a respite stay documented but the stay was not reflected on the care plan. In RRNHV#6 the patient was treated for multiple urinary tract infections yet there was no urinary care plan to guide the care. These observations were reviewed with the CCO, and executive director.”

“Observed in Record Review. In 2 of 14 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#12 there was documentation that the patient was on oxygen and oxygen concentrator was included on the DME list yet there were no orders for oxygen nor was oxygen and oxygen safety reflected in the care plan. In RRNHV#11 there were two pain medications as needed, Ibuprofen and Hydrocodone, but there were no specific instructions to guide the patient to know when to choose which medication. Further, the hydrocodone was ordered 1/2 to 1 tab as needed but no instruction as to when to take 1/2 and when to take 1 tab. These observations were reviewed with the Manager of Home Care.”

“Observed in Record Review. In 2 of 14 patient records reviewed, the organization failed to ensure the ongoing sharing of patient information between all disciplines providing care and services. On review of RRNHV#12 there was documentation of change in patient condition that included diarrhea, hypotensive episode, blood tinged urine and recommendations to hold Eliquis yet there was no documentation that the physician was informed of the changes. In RRNHV#8 there was documentation that the volunteer witnessed a patient fall yet no indication the fall was reported to the volunteer coordinator until 3 days later. This observation was reviewed with the Manager of Clinical Practice and Executive Director. Observed in Tracer Activities. In 1 of 14 patient records reviewed, the hospice did not inform physician of patient medication being placed on hold. The surveyor noted in RRHV#1 the registered nurse documented that on 06/22/26 the patient’s hydrochlorothiazide, rosuvastatin, valsartan were placed on hold, at the spouse’s request. However, there was no evidence of the physician being notified. The clinical manager validated this.”

“Observed in Record Review. In 1 of 3 IPU Record Review, the hospice registered nurse did not provide complete instructions for hospice aide care. For example, the surveyor noted in RRIPU#2, under inpatient positioning, on the aide care plan, the frequency for turning the patient was left blank. Additionally, the time frame for the aide to notify the registered nurse when there was no bowel movement was not filled in. This was confirmed with the Director of Nursing. Observed in Record Review. In 4 of 12 patient records reviewed, with aide services provided, the organization failed to ensure the registered nurse prepare written patient care instructions. On review of RRNHV#14 the documentation noted the patient was admitted with a laceration to the head with staples yet there were no specific care instructions for the hospice aide as to how to handle the area while providing care. RRNHV#13 also had wounds with wound treatments but no specific instructions for how the aide was to handle the dressings while providing care. In RRNHV#12 the patient was on Eliquis and the aide was assigned to provide shave with razor yet there were no bleeding precautions specified. In RRNHV#9 the patient had documented wounds with wound treatment yet no instructions for how the aide was to handle the wounds while providing care. These observations were reviewed with the CCO and Executive Director.”

“Observed in Building Tour. There was no GFCI outlet or circuit breaker within 6’ of the sink in the main kitchen. There was no GFCI outlet or circuit breaker within 6’ of a sink. This finding was observed by the Executive Director. Observed in Document Review. The vendor that performed the fire suppression inspection in 2026 did not reference the correct NFPA they tested to as required in NFPA 101-2012. They inspected per NFPA 25-2023 rather than the NFPA 25-2011 version. Also, the vendor that performed the annual fire extinguisher inspection on 6/18/2026 did not state what NFPA they inspected too. This finding was observed by the Executive Director.”