Acg Hospice-Birmingham

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a review of the patient’s current medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/05/2022 and resided in an Assisted Living Facility (ALF). The hospice medication profile dated 05/28/2024 documented “Acetaminophen Pain Relief 500mg tablet, one tablet three times a day orally for pain.” During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 05/29/2024, the patient’s ALF medication profile documented “Acetaminophen Pain Relief 500mg tablet, one tablet three times a day orally for pain,” and “Acetaminophen 500mg tablet, one tablet every four hours as needed for pain,” effective 11/02/2023. The RN [Personnel Record 6] confirmed that the Acetaminophen 500mg tablet, one tablet every four hours as needed for pain, effective 11/02/2023, was not on the hospice medication profile. The ALF nurse confirmed that the patient had the medication available for use. The hospice RN [Personnel Record 6] stated they would reconcile the medications. During a joint record review and interview on 05/29/2024, the Manager of Accreditation and Regulatory Compliance confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.”

“It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above and at least one (1) year of social work experience in a health care setting or a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by personnel record review, clinical record review, document review, and interview. In 1 of 2 (50%) personnel records reviewed of social workers, the agency did not ensure that the social worker was legally authorized in accordance with state regulations. The rules of the agency’s state board of health read in part, “Social Worker” means a person who holds at least a bachelor’s degree in social work from an accredited school of social work, and is currently licensed by the State of... or supervised in accordance with Title … Chapter … of Code of …, 1975.” Personnel Record 8: The Social Worker (SW) was hired on 09/30/2022. A review of the SW personnel record revealed a documented master’s degree in social work on 05/04/2018, a competency for the social worker upon hire, and an annual skills evaluation. The personnel record did not include evidence of a license for the social worker as required by state regulation. During a joint personnel record review and interview on 05/31/2024, the Manager of Accreditation and Regulatory Compliance confirmed that the personnel record did not include a license for the SW. The Manager of Accreditation and Regulatory Compliance stated that the agency discovered in February 2024 that the Social Worker (SW) did not have a license. Since then, the Social Worker has been supervised by a Clinical Supervisor. In April 2024, the SW was scheduled for a review course. The request to test was submitted and received approval in April 2024. The test was scheduled for 06/25/2024. Clinical Record 1: The patient elected hospice care on 01/05/2022. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 01/12/2023, 02/09/2023, 03/03/2023, 04/04/2023, 05/19/2023, 06/22/2023, 07/12/2023, 08/24/2023, and 09/13/2023. Clinical Record 2: The patient elected hospice care on 05/16/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented a visit on 05/17/2024. Clinical Record 3: The patient elected hospice care on 04/10/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 04/12/2023, 04/20/2023, and 05/18/2023. Clinical Record 4: The patient elected hospice care on 10/20/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 11/27/2023, 12/11/2023, 01/09/2024, 01/30/2024, 02/08/2024, 03/11/2024, 04/05/2024, 04/22/2024, 05/06/2024. Clinical Record 6: The patient elected hospice care on 12/28/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 01/03/2024, 02/26/2024, and 04/25/2024. The SW made a phone call to the patient on 01/11/2024. Clinical Record 7: The patient elected hospice care on 10/13/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 10/18/2023, 11/14/2023, 12/22/2023, 01/08/2024, 01/30/2024, 02/12/2024, 02/21/2024, 03/12/2024, 04/08/2024, 04/15/2024, and 05/13/2024. Clinical Record 8: The patient elected hospice care on 12/23/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 12/29/2023, 01/12/2024, 01/25/2024, 02/15/2024, 02/20/2024, 03/25/2024, and 04/10/2024. The SW made phone calls to the patient on 02/02/2024 and 03/28/2024. Clinical Record 9: The patient elected hospice care on 02/07/2024.A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 02/09/2024, 03/27/2024, and 04/12/2024. The SW made phone calls to the patient on 02/22/2024 and 05/21/2024. Clinical Record 10: The patient elected hospice care on 03/06/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 03/08/2024, 04/05/2024, 04/18/2024, and 05/17/2024. The SW made a phone call to the patient on 04/15/2024. Clinical Record 13: The patient elected hospice care on 05/07/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/09/2024, 05/15/2024, 05/22/2024, and 05/28/2024. Clinical Record 14: The patient elected hospice care on 09/12/2023. A review of the clinical record revealed that the Social Worker [Personnel Record 8] documented visits on 09/14/2023, 09/26/2023, 11/14/2023, 11/27/2023, 12/20/2023, 01/30/2024, and 02/19/2024. Clinical Record 15: The patient elected hospice care on 02/12/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 02/13/2024 and 03/25/2024. Clinical Record 16: The patient elected hospice care on 05/17/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/22/2023, 06/21/2023, 08/09/2023, 09/25/2023, 10/11/2023, and 11/08/2023. Clinical Record 17: The patient elected hospice care on 05/01/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/03/2023, 05/18/2023, 06/16/2023, 06/26/2023, 07/26/2023, 08/31/2023, and 09/15/2023.”