Hospice of Alabama

“Upon patient record review, 2 of 19 (Patient #5,10) 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: The medication profile contained Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medication profile contained 2 duplicate orders for Hydrocodone-acetaminophen 5-325mg 1 tab PRN both ordered on 02/24/2025. One entry had a frequency of every 4 hours and the second entry had a frequency listed as every 6 hours. No evidence that clear instructions were given to the patients on what frequency the medication should be taken.”

“Upon patient record review, 1 of 19 (Patient #4) 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 4: The medical record indicated that the patient has diagnosis of seizures and currently takes Lamictal 150mg twice daily for seizures. There was no evidence of problems, interventions, and goals related to seizures included in the plan of care.”

“Upon patient record review, 2 of 19 (Patient #5,10) 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 5: The medical record contained an active order for Miralax oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medical record contained 2 active duplicate orders for Hydrocodone-acetaminophen 5-325mg 1 tab PRN both ordered on 02/24/2025. One entry had a frequency of every 4 hours and the second entry had a frequency listed as every 6 hours. No evidence that clear instructions were given to the patients on what frequency the medication should be taken.”

“Upon patient record review 2 of 19 (Patient #5,6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 5: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 2/10/2025 - 03/03/2025 (21 days between supervised visits) and 04/01/2025 - 04/16/2025 (15 days between supervised visits). Patient 6: No evidence that a registered nurse made supervised visits every 14 days between the following dates: 12/27/2024-01/17/25 (27 days between supervised visits).”

“Based on review of medical records (MR), agency policies and procedures, and interviews, it was determined the hospice agency failed to ensure: 1. The skilled nurse (SN) documented the specific wound care provided to each wound. 2. New wounds were reported to the physician and Interdisciplinary Group (IDG). 3. The physician was notified of increase in wound size. 4. Physician orders were obtained for wound care provided. This deficient practice affected Home Visit (HV) # 1, HV # 5, MR # 8, HV # 3, MR # 6 and HV # 4, and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Wound Assessment and Evaluation Policy Number: PC.C72 Date Updated: January 15,2025 Purpose: To record baseline information for wounds in order to identify and record changes in wounds as they occur... Policy: Assessment and evaluation of wounds should be carried out on admission to hospice, at the first sign of a wound, and at regular intervals. The assessment, evaluation and Plan of Care (POC) should be clearly documented... Procedure: Patients admitted to hospice with a wound will have their wound assessed by a Registered Nurse (RN) on admission or at the time the wound is identified, and the wound assessment will be completed at that time in the patient’s records. Findings will be reported to the patient’s Hospice physician/attending physician for wound care treatments and orders. ...3. All patients with wounds(s) will have them reassessed, including measurements in alignment with the POC. This includes but is not limited to: dressing change completed by the RN...the hospice RN will schedule a visit...so that she/he is present and can assess the wound, including wound measurements, description of wound, and wound care dressing no less frequency than weekly. ...5. All patients with a wound(s) will have their wound dressing changed and the wound evaluated according to the MD (Medical Doctor) order... ...10. Wound Care and/or management must have an MD order incorporated into the POC with collaboration of the IDG (Interdisciplinary Group). Agency Policy: Documentation Requirements Policy Number: PC.D25 Date Updated: August 09,2024 Policy: Members of the IDG document the interventions provided to the patient/caregiver, their response to care, services provided and the goals or outcomes achieved. Procedure: ...2. Documentation is completed by all Care Hospice (owners of Hospice of Alabama) staff...whenever: a. Patient/caregiver visits occur... d. Physician or healthcare provider contact is made on behalf of the patient. 3. The patient record documentation provides patient information specific to care and services/products provided, current patient status and progress towards goals and outcomes of care... ...9. All documentation contains complete, factual, essential and accurate information. Staff...clearly state what was seen (assessment), what was done (intervention) and how the patient/caregiver reacted (outcome)... 5. MR # 6 was admitted to hospice services on 2/21/24 and recertified for care 11/18/24 to 1/16/25 with a diagnosis of Liver Cell Carcinoma. Review of the 12/30/24 SN visit note skin assessment revealed MR # 4 had developed a new stage two PU to the sacrum. Review of the SN clinical note dated 12/30/24 revealed the physician was notified and a new order obtained for the SN to cleanse the wound with soap and water, pat dry with 4 X 4 gauze, and apply a liberal amount of zinc cream daily and as needed. Further review of the 12/30/24 SN visit note revealed the following documentation: Dressing Changed this Visit: Yes, per orders, see Care Plan. The SN failed to document the specific wound care provided during the visit. Review of the 1/8/25 IDG note revealed no documentation IDG was made aware of the new wound discovered on the 12/30/24 SN visit. The SN failed to notify IDG of the new wound. An interview was conducted on 1/16/25 at 5:12 PM with EI # 1, Clinical Director, who confirmed the SN failed to document the specific wound care provided, and failed to notify IDG of the new wound. 6. HV # 4 was admitted to hospice services on 12/12/24 with a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the Team Care Plan as of 1/14/25 revealed the following orders: SN visit frequency one time a week for 13 weeks. SN to provide wound care to right below knee amputation (BKA) wound by cleansing with wound cleanser, pat dry, apply adequate amount of Santyl cream to wound bed, apply gauze and wrap with stretch gauze daily and PRN. Review of SN visit notes dated 12/18/24, 12/27/24 and 1/14/25 revealed the following documentation: Dressing Changed this Visit: Yes, per orders, see Care Plan. The SN failed to document the specific wound care provided during the visit. An interview was conducted on 1/16/25 at 4:41 PM with EI # 3 who confirmed the SN failed to document the specific wound care provided, 4. HV # 3 was admitted to the hospice agency on 9/9/24 and recertified from 12/8/24 to 3/7/25 with a diagnosis of Anoxic Brain Damage, Not Elsewhere Classified. A home visit was conducted on 1/14/25 at 1:45 PM to observe care provided by EI # 5, SN. A new wound was identified on the left ankle by EI # 5 during the assessment. Wound care was completed using three sprays of wound cleanser and medihoney gel. A hydrocellular foam dressing was then applied to the site. The physician was not notified of the new wound and no orders for wound care were received prior to the wound care being provided by EI # 5. An interview was conducted on 1/15/25 at 3:45 PM with EI # 2, Clinical Director, who confirmed EI # 5 did not follow the agency’s policy for wound care. 1. HV # 1 was admitted to the hospice agency on 3/25/24 and recertified for care 11/20/24 to 1/18/25 with a diagnosis of Cerebral Infarction, Unspecified. Review of the MR Team Care Plan provided for the recertification period dated 11/20/24 to 1/18/25 revealed the following orders: SN visit frequency of two times per week. SN/CG (caregiver) to cleanse stage 3 pressure ulcer to tracheal stoma with gauze moistened with sterile water, pat dry with sterile gauze, apply alginate wound dressing to wound bed, cover with optifoam. Wound care to be provided every other day and PRN (as needed) for soilage/dislodgement. Review of the SN visit notes dated 11/20/24, 11/25/24, 11/27/24, 12/2/24, 12/5/24, 12/9/24, 12/12/24, 12/16/24, 12/18/24, 12/23/24, 12/26/24, 12/30/24, 1/2/24, 1/6/24, 1/8/24, and 1/14/24 revealed the following documentation: Dressing changed this visit: yes, per orders, see Care Plan. There was no documentation of the specific wound care provided. Review of the SN visit note dated 12/2/24 revealed a wound of the tracheal stoma which measured 2.5 cm (centimeters) x (by) 2.5 cm x 0.5 cm. Review of the SN visit note dated 12/9/24 revealed wound measurements increased to 2.8 x 2.7 x 0.5. Review of the SN visit note dated 12/16/24 revealed wound measurements increased to 3 x 2.5 x 0.5. Review of the SN visit note dated 1/13/24 revealed wound measurements increased to 3.1 x 2.4 x 0.5. There was no documentation the increase in wound measurements were reported to the physician. An interview was conducted on 1/16/24 at 4:16 PM with Employee Identifier (EI) # 3, Program Director, who confirmed there was no documentation of the specific wound care provided by the SN, and no documentation the physician was notified of the increase in the wound measurements. 2. HV # 5 was admitted to the agency on 1/9/25 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Physician’s Order/Plan of Care revealed: SN visit frequency of one visit week one, then two visits a week for eight weeks. Review of the Team Care Plan dated 1/9/25 revealed the following: Wound Care Interventions Patient/Caregiver/SN (PCG/SN) to perform: Stage two Pressure Ulcer (PU) sacrum- Gently cleanse with mild soap and water, pat dry, apply adequate amount of zinc oxide cream BID (two times a day) and PRN. Wound Care PCG/SN to perform: MASD (moisture associated skin damage) left groin- Gently cleanse site with soap and water. Apply adequate amount zinc oxide cream followed by adequate amount miconazole powder BID and PRN. Wound Care PCG/SN to perform: MASD right groin- Gently cleanse site with soap and water. Apply adequate amount zinc oxide cream followed by adequate amount miconazole powder BID and PRN. Wound Care PCG/SN to perform: Skin tear left forearm site- Cleanse with mild soap and water, pat dry. Apply foam dressing. Change daily and PRN. Review of the SN visit notes dated 1/9/25, 1/13/25 revealed wound documentation for each wound as follows: Dressing changed this visit: Yes, per orders, see Care Plan. There was no documentation of the specific wound care provided. An interview was conducted on 1/16/25 at 4:59 PM with EI # 3, who confirmed there was no documentation of the specific wound care provided by the SN. 3. MR # 8 was admitted to the agency on 1/2/25 with a diagnosis of Alzheimer’s Disease, Unspecified. Review of the MR Physician’s Order/Plan of Care dated 1/2/25 revealed: SN visit frequency of one visit week one, then two visits per week for 12 weeks. Review of Team Care Plan dated 1/2/25 revealed the following orders: Cleanse arterial wound to distal right outer ankle with 15 ml (milliliter) of Vashe (wound cleanser), pat dry with 4 x 4 gauze, paint wound bed with one Betadine swabstick, cover with bordered foam every 3 days and PRN per SN/facility nurse. Cleanse arterial wound to proximal right outer ankle with 15 ml of Vashe, pat dry with 4x4 gauze, paint wound bed with Betadine swabstick, cover with bordered foam every three days and PRN per SN/facility nurse. Use 15 ml Vashe to cleanse non-healing surgical wound to mid back, pat dry, with 4x4 gauze, cut to fit calcium alginate and apply to wound bed, cover with bordered foam daily and PRN per SN/facility nurse. Review of SN visit notes dated 1/2/25, 1/3/25, 1/9/25, 1/14/25 revealed wound documentation for each wound as follows: Dressing changed this visit: Yes, per orders, see Care Plan. There was no documentation of the specific wound care provided. An interview was conducted on 1/16/25 at 4:49 with EI # 1, Clinical Director, who confirmed there was no documentation of the specific wound care provided by the SN.”

“Based on review of Medical Records (MR), policy and procedures, and interviews, it was determined the hospice agency failed to ensure: 1. Staff performed foley catheter changes every 15 days per physician order. 2. Staff provided wound care per physician order. This deficient practice affected Home Visit (HV) # 1, MR # 4, and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Physician Orders. Policy Number: PC.P40 Date Updated: August 10, 2024 Policy: Physician orders are obtained as needed... Procedure: ...3. Some of the reasons orders are obtained from physicians include: ... d. Care, treatment and services... Agency Policy: Wound Assessment and Evaluation Policy Number: PC.C72 Last Updated: Jan 15, 2025 Procedure: ...3. All patients with a wound(s) will have them reassessed, including measurements in alignment with the plan of care. This includes...dressing change completed by the Registered Nurse (RN) or witnessed by the RN during the time of visit... 2. MR # 4 was admitted to hospice services 12/24/24 with a diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the Team Care Plan for benefit period 12/24/24 to 3/23/25 Skin/Wound Interventions revealed an order for the SN to cleanse the stage 2 wound to the sacrum with soap and water, pat dry with 4 X (by) 4 gauze, apply liberal amount of zinc (oxide) cream daily and as needed per CG (caregiver)/SN. Review of the SN Visit Note dated 1/3/25 revealed no documentation wound care was provided, or had been provided by the CG. The SN failed to follow the physician order and provide wound care daily as ordered. An interview was conducted on 1/16/25 at 5:12 PM with EI # 1, Clinical Director, who confirmed there was no documentation wound care was provided during the 1/3/25 SN visit. 1. HV # 1 was admitted to the hospice agency on 3/25/24 and recertified for care 11/20/24 to 1/18/25 with an admitting diagnosis of Cerebral Infarction, Unspecified. Review of the Physician’s Orders/Plan of Care from 11/20/24 to 1/18/25 revealed the following: Skilled nurse (SN) visit frequency two times a week for eight weeks. Treatments- Insert catheter (cath) and change as prescribed (specify cath, balloon size, type, and frequency) SN to insert 20 FR (french) / 10 ML (milliliter) Foley cath using sterile technique, every 15 days and PRN (as needed) occlusion/dislodgment. Review of the SN visit notes from 11/20/24 to 1/14/25 revealed documentation the SN changed the Foley catheter on 12/5/24 and 12/30/24 which was 25 days. There was no further documentation after 12/30/25 the Foley catheter was changed. The SN failed to change the Foley catheter every 15 days per the physician’s order. An interview was conducted on 1/16/24 at 4:16 PM with Employee Identifier (EI) # 3, Program Director, who confirmed there was no documentation the catheter was changed every 15 days per physician’s order.”

“Based on observations, agency policy, and interview, it was determined the hospice agency failed to ensure staff followed the policy for hand hygiene (HH). This deficient practice affected one of five home visits (HV), including HV # 3, and had the potential to negatively affect all patients served by the hospice agency. Findings include: Policy: Hand Hygiene Policy Number: 5.5a Revised: 11/27/24 Purpose: To reduce the risk and/or transmission of infection to patients and colleagues... Definition: Hand Hygiene includes both handwashing with either plain or antiseptic containing soap and water, and use of alcohol based products (gels, rinses, foams) that do not require the use of water... Policy: ...Hygiene will be performed at a minimum: ...After removal of personal protective equipment (PPE), including gloves... 1. HV # 3 was admitted to the hospice agency on 9/9/24 and recertified from 12/8/24 to 3/7/25 with a diagnosis of Anoxic Brain Damage, Not Elsewhere Classified. A home visit was conducted on 1/14/25 at 1:45 PM to observe care provided by Employee Identifier (EI) # 5, Registered Nurse. During the HV, EI # 5 removed his/her dirty gloves three times and without performing HH, donned clean gloves. An interview was conducted on 1/15/25 at 3:45 PM with EI # 2, Clinical Director, who confirmed EI # 5 failed to perform HH per policy.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice failed to ensure: Staff provided accurate and current documentation to the Interdisciplinary Group (IDG) for evaluation and updates to the plan of care (POC). The skilled nurse (SN) documented accurately in visit notes. This deficient practice affected MR # 6 and MR # 4, two of 14 active records reviewed, and had the potential to affect all patients served by this agency. Findings include: Agency Policy: Documentation Requirements Policy Number: PC.D25 Last Updated: Aug 09, 2024 Policy: Members of the IDG document the interventions provided to the patient/caregiver, their response to care, services provided and the goals...achieved. Procedure: ...3. The patient record documentation provides patient information specific to care and services/products provided, current patient status, and progress toward goals... 4. Documentation must be...accurate and timely. ...9. All documentation contains complete, factual, essential and accurate information. 1. MR # 6 was admitted to hospice services on 2/21/24 and recertified for care 11/18/24 to 1/16/25 with a diagnosis of Liver Cell Carcinoma. Review of the SN Charts/Clinical Notes IDG documentation dated 11/20/24, 12/4/24, 12/18/24, 12/27/24 and 1/8/25 revealed the SN documented each note that Morphine concentrate and Fentanyl patch doses were increased that week due to increased pain. Review of the medication list for MR # 6 as of 1/15/25 revealed the last change in dose strength for Morphine concentrate and Fentanyl patch was 10/10/24. The SN failed to provide accurate documentation to the IDG. Further review of the SN IDG documentation dated 12/4/24, 12/18/24 and 12/27/24 revealed each note was worded exactly the same. An interview was conducted on 1/16/25 at 4:55 PM with Employee Identifier (EI) # 3, Program Director, who confirmed that Morphine concentrate and Fentanyl patch doses were not increased each week as documented, and the SN did not document accurately for IDG care planning. 2. MR # 4 was admitted to hospice services on 12/24/24 with a diagnosis of Chronic Obstructive Pulmonary Disease Unspecified. Review of the Team Care Plan revealed orders for a SN visit frequency of three times a week for 12 weeks beginning 12/29/24. Review of the SN visit note dated 12/30/24 revealed MR # 4 had a new stage two pressure ulcer on the sacrum measuring 0.7 centimeters (cm) in length, 0.7 cm in width and 0.01 cm in depth. Review of the 1/3/25 SN visit note skin evaluation revealed documentation that skin was intact. Review of the SN visit note skin evaluations dated 1/6/25 and 1/8/25 revealed documentation MR # 4 had a non-surgical wound to the sacrum. There was no documentation the wound was measured on these visits. Review of the 1/13/25 SN visit note skin evaluation revealed documentation that skin was intact. The SN failed to document accurately in the clinical record. An interview was conducted on 1/16/25 at 5:12 PM with EI # 1, Clinical Director, who confirmed wound care orders were still active for the wound to the sacrum, there was no documentation the wound had healed, and the SN did not document accurately in the clinical record.”