Adoration Hospice

“Based on medical record (MR) review, interviews, agency policy and procedure, it was determined the agency’s staff failed to maintain an accurate medication profile in the clinical record. This deficiency affected two of four Home Visits (HV) including HV # 1 and HV # 4 and had the potential to negatively affect all patients served at this hospice. Findings include: Agency Policy: Medication Profile Policy Number: 2-004.1 Date Reviewed: None listed Purpose: To define the use of the medication profile in evaluating a patient’s medication regimen. Policy: Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. Procedure: 1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter medications, nutritional supplements, herbal remedies, vitamins and minerals, and oxygen therapy. Documentation will include medication name, date prescribed (and discontinued, as applicable), dose, strength, route, frequency, and classification. Prescribed date and time of administration will be included as applicable. For oxygen therapy, delivery method, flow rate, and frequency (continuous, at night, as needed, etc.) will be specified... ...3. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed...and with the addition of a new medication... 2. HV # 4 was admitted to the agency on 7/15/23 and recertified from 6/9/24 to 8/7/24 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. A HV was conducted on 7/16/24 at 2:00 PM to observe care provided by EI # 9, Chaplain. During the visit, a comparison was made between the medications listed on the CMR and the medications observed in the home. Oxygen was observed in the home but not listed on the CMR. Review of RN (registered nurse) visit note report dated 6/10/24 revealed the following documentation: “Indicate respiratory treatment utilized at home”, Oxygen 2L (liters) PRN (as needed). An interview was conducted on 7/18/24 at 1:43 PM with EI # 4, Vice President of Operations, who confirmed the hospice agency failed to maintain an accurate medication profile. 1. HV # 1 was admitted to the agency on 2/9/24 and recertified from 6/8/24 to 8/6/24 with a terminal diagnosis of Cerebral Infarction Due to Thrombosis Unspecified Cerebral Artery. HV # 1 resides in a Skilled Nursing Facility. A HV was conducted on 7/16/24 at 1:45 PM to observe care provided by Employee Identifier (EI) # 10, Medical Social Worker. During the visit, a comparison was made between the medications listed on the Client Medication Report (CMR) printed 7/16/24, and the medications observed on the Physician Orders List (POL) in the facility. Celexa 20 Milligrams (Mg) tablet oral, take 1 tablet daily, and Simvastatin 20 Mg tablet oral, take 1 tablet at bedtime was noted on the CMR but not listed on the POL. Oxybutynin Chloride (CL) 5 Mg tablet oral, take 1 tablet daily was noted on the CMR but listed as Oxybutynin CL ER (Extended Release) 10 Mg tablet, give one tablet by mouth twice daily on the POL. Buspirone HCL 5 Mg tablet, give one tablet by mouth twice daily and Ondansetron HCL 4 Mg tablet, administer 1 tablet orally every 6 hours as needed was noted on the POL but not listed on the CMR. An interview was conducted on 7/18/24 at 1:30 PM with EI # 2, Clinical Supervisor-Gadsden location, stated, “...The medications should have been discontinued 5/23/24,” and confirmed the hospice agency failed to maintain an accurate medication profile.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to ensure the nursing staff received the pronouncement of death via telecommunication with the physician as required by the Alabama Board of Nursing. This deficiency affected in one of three Bereavement MR’s reviewed and had the potential to negatively affect all patients admitted to the hospice. Findings include: Agency Policy: Death At Home Policy Number: 2-034.1 Revision Date: October 2019 Purpose: To establish the process to follow when a patient dies. Policy: ...Individual state and community regulations and practices will be followed. ...4. The hospice Registered Nurse (RN) or physician will pronounce death unless prohibited by state regulations. In such cases, state regulations will be followed. Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice Revised: September 8, 2016 610-X-6-.15 Telecommunication for Pronouncement of Patient Death The licensed nurse may receive pronouncement of a patients death from a physician via telecommunication. MR # 12 was admitted to the hospice agency on 6/25/24 with terminal diagnoses of Hepatic Encephalopathy and Hepatic Failure, Unspecified without Coma. Review of the MR revealed a RN Hospice Death Visit note dated 7/9/24. The RN documented the following in the Narrative Note, “...Patient pronounced at 7:00 PM.” There was no documentation the RN received the pronouncement of death from the physician. An interview was conducted on 7/18/24 at 1:30 PM with Employee Identifier # 2, Clinical Supervisor-Gadsden location, who confirmed there was no documentation the physician made the death pronouncement.”

“Based on review of personnel files, agency policy, and staff interviews, it was determined the agency failed to ensure newly hired employees were given an orientation that included the hospice philosophy. This affected one of five Registered Nurse files reviewed and had the potential to affect all patients served by the hospice agency. Findings include: Agency Policy: Orientation- Alabama Policy Number: 1-027.1 Published: 2/11/20 Policy: All personnel will be required to attend an orientation program upon employment and as needed at the time of reassignment. The goal of orientation will be to inform and instruct new personnel regarding the hospices mission... Procedure: 1. The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: A. General company orientation including the organizations mission, policy and procedures, environmental safety program... ...9. A Personnel Orientation Checklist will be completed for all new personnel. New personnel will sign and date when the orientation is complete. 10. The supervisor will sign and date the checklist when new personnel have completed all the required activities. Addendum 1027.A Personnel Orientation Checklist-Alabama Published: 5/11/20 ...6. The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: A. General orientation to organization, including philosophy, mission... Review of the personnel file for Employee Identifier (EI) # 6, Registered Nurse, revealed a hire date of 9/13/21. Review of online training courses for EI # 6 revealed the “;Introduction to Hospice” training course, which includes the hospice philosophy, was not complete. Further review of the personnel file revealed there was no Personnel Orientation Checklist. An interview conducted on 7/18/24 at 10:00 AM with EI # 1, Director of Clinical Operations, and EI # 8, Human Resources, confirmed the “;Introduction to Hospice” training course was not complete and the Personnel Orientation Checklist was not in the personnel file for EI # 6.”

“Based on review of personnel files, agency policies, and staff interviews, it was determined the agency failed to ensure an initial orientation was provided for each employee that addressed the employees specific job duties. This affected one of five Registered Nurse files reviewed and had the potential to affect all all patients served by the hospice agency. Findings include: Agency Policy: Orientation- Alabama Policy Number: 1-027.1 Published: 2/11/20 Policy: All personnel will be required to attend an orientation program upon employment and as needed at the time of reassignment. The goal of orientation will be to inform and instruct new personnel regarding the hospices mission, policies and procedures...as well as individual responsibilities. Procedure: 1. The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: ...E. Position responsibilities and limitations. ...9. A Personnel Orientation Process Checklist will be completed for all new personnel. New personnel will sign and date when the orientation is complete. 10. The supervisor will sign and date the checklist when new personnel have completed all the required activities. Addendum 1-027.A Personnel Orientation Checklist-Alabama ...6. The orientation content for all personnel will include the following as applicable and appropriate to the care and service provided: ...E. Job related responsibilities and limitations. Review of the personnel record for Employee Identifier (EI) # 6, Registered Nurse, revealed a hire date of 9/13/21. Further review of the personnel record for EI # 6 revealed no documentation for initial orientation to include specific job duties, along with the Personnel Orientation Checklist. An interview conducted on 7/18/24 at 10:00 AM with EI # 1, Director of Clinical Operations, and EI # 8, Human Resources, confirmed there was no documentation for initial orientation, which includes specific job duties, or the Personnel Orientation Checklist for EI # 6.”

“Based on review of personnel files, review of agency policies, and staff interviews, it was determined the agency failed to ensure employees were given an annual skills competency evaluation. This affected one of five Registered Nurse files and one of two Chaplain files reviewed and had the potential to affect all the patients served by the hospice agency. Findings include: Agency Policy: Annual Core Competence Policy Number: 3-005.1 Published: 7/19/18 Purpose: To ensure that all hospice personnel are able to display competence in skills specific to the hospices needs on an annual basis. Policy: Hospice will implement an objective, measurable system to evaluate competency. The performance criteria list the required behavior hospice personnel must demonstrate to be deemed proficient on the skills required. Procedure: 1. Hospice personnel will demonstrate proficiency in the performance criteria/skills during the orientation period, and at least annually thereafter as part of the annual performance evaluation process. Agency Policy: Competency Program Policy Number: 3-001.1 Published: 3/11/20 Purpose: To ensure that the competence of clinical organizational personnel is assessed, maintained, and improved on a continuing basis. Policy: The hospice will define and implement an objective, measurable assessment system to evaluate the competency of patient contact personnel. Procedure: ...3. Specific competencies will clearly identify and define the skills, which are essential to observe for the determination of competence, for each job category. In the identification of core competence, the essential skills will be demonstrated upon hire and annually thereafter. ...6. After the completion of orientation, competency will be monitored annually thereafter as part of the annual performance evaluation process. 1. Review of the personnel record for Employee Identifier (EI) # 6, Registered Nurse, revealed a hire date of 9/13/21. Further review of the personnel record revealed EI # 6 did not have an annual skills competency assessment for 2022 or 2023. An interview conducted on 7/18/24 at 10:00 AM with EI # 1, Director of Clinical Operations, and EI # 8, Human Resources, confirmed there was no documentation of the annual skills competency assessment in the personnel record for EI # 6 for 2022 and 2023. 2. Review of the personnel record for EI # 7, Chaplain, revealed a hire date of 6/27/22. Further review of the personnel record for EI # 7 revealed there was no annual skills competency assessment for 2024. An interview conducted on 7/18/24 at 9:45 AM with EI # 8, Human Resources, confirmed there was no documentation of the 2024 annual skills competency assessment in the personnel file for EI # 7.”