Acg Hospice-Enterprise

“Based on Medical Record (MR) review, and interviews with staff members it was determined the agency failed to ensure the staff obtained and completed orders for all care performed for the patient. This affected MR # 14, one of 14 MR’s reviewed, and had the potential to negatively affect all patients cared for by this agency. 1. MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the nurse Visit Note Report dated 1/24/25 revealed the nurse documented a foley catheter was placed during the visit to promote wound healing. A review of the Hospice Certification and POC dated 1/13/25 revealed no documentation of an order for the placement of a foley catheter. Further review of the Hospice IDG Comprehensive Assessment and POC Update Reports dated 1/17/25, 1/31/25 and 2/14/25 revealed no documentation of an order for the placement of a foley catheter. A review of the nurse Visit Note Report dated 2/3/25, revealed a pressure wound stage two was identified on the coccyx. The nurse documented wound care provided as ordered. The previous nurse visit notes did not identify this wound. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed no documentation of an order for the care of a wound to the coccyx. Further review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and POC Update Reports dated 1/17/25, 1/31/25, and 2/14/25 revealed no documentation of an order for the care of a wound to the coccyx. An interview was conducted on 2/27/25 at 12:25 PM with EI # 1, Manager of Accreditation, Regulatory, and Compliance who confirmed the clinician failed to obtain an order and document the order for the foley placement or the care performed on 2/3/25 to the wound on the coccyx”

“Based on Medical Record (MR) review, interviews with staff and agency policies and procedures it was determined the agency failed to document missed visits per agency policy. This affected MR # 14 and MR # 9, 2 of 14 MR’s reviewed and had the potential to negatively affect all patients cared for by this agency. Findings include: Agency Policy: Missed Visits Policy Number: 1-028 Review date: None listed Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG Meeting. A missed visit will be rescheduled that the same week if possible. Missed visits will be documented in the medical record. Procedure: ...2. If a visit missed and not rescheduled in the same week, the clinician will: ...B. Document in the patient’s medical record the following information: Patient name Date and type of visit missed Reason for the missed visit Description of any unmet needs and how the patient’s needs were met Any follow-up needed Any other person(s) that were notified of the missed visit Signature of the staff reporting the information 1.MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed an ordered frequency for the Hospice Aide (HA) of four times a week for one week and five times weekly for twelve weeks. A review of the HA visit notes week of 1/19/25 revealed the HA visited two times, and not five as ordered. The HA completed one missed visit note dated 1/23/25. There were no missed visit notes documented for the remaining two visits scheduled. A review of the HA visit notes week of 2/2/25 revealed the HA visited four times, and not five as ordered. No missed visit note was completed for the remaining visit scheduled. An interview was conducted on 2/27/25 at 12:25 PM with Employee Identifier (EI) # 1, Manager of Accreditation, Regulatory, and Compliance, who confirmed the clinician did not complete the documentation for the missed visits per agency policy. 2. MR # 9 was admitted to the agency on 1/27/25 with a primary diagnosis of Hypertensive Heart Disease without Heart Failure. A review of the Hospice Certification and POC dated 1/27/25 revealed an ordered frequency for the Skilled Nurse (SN) of four times a week for one week and two times a week for twelve weeks with three as needed visits for symptom management, and an ordered frequency for the Volunteer Coordinator once a month for one month. A review of the SN visit notes dated 1/27/25 revealed the SN completed three of the four scheduled visits ordered. No missed visit note was completed for the fourth visit. A review of the MR revealed no visit was made by the volunteer coordinator as ordered by the physician. An interview was conducted on 2/27/25 at 12:39 PM with EI # 1, who confirmed the clinician did not complete the documentation for the missed visit per agency policy, and the volunteer coordinator visit was never assigned to the clinician.”

“Based on medical record (MR) review, agency policy and procedure, and interviews with staff it was determined the agency failed to ensure the Registered Nurse (RN) supervised the Hospice Aide (HHA) at least every 14 days. This deficient practice did affect 2 of 10 patients receiving HHA services including MR # 6, Home Visit (HV) # 2, and had the potential to affect all patients receiving HHA services. Findings include: Agency Policy: Standards of Care, Service, and Practice Policy Number: 2-001 Policy Date: Not Listed Purpose: To provide guidelines for developing and implementing standards of care, service, and practice... Certified Nursing Assistants (Hospice Aides): A supervisory visit will be conducted by the Registered Nurse for each Hospice Aide not less than every 14 days, if any areas of concern are noted during the visit, the Registered Nurse will provide a follow up on-site supervisory visit with the Aide in order to further assess and provide education... 1. MR # 6 transferred to ACG Hospice from another Hospice agency on 1/6/25 and recertified from 1/12/25 to 3/12/25 with a primary diagnosis of Parkinson’s Disease. Review of the Aide Care Plan Report dated 1/12/25 revealed orders for HHA two times a week and SN three times a week. Review of the physician’s order dated 1/19/25 revealed orders to increase HHA to three times a week. Review of the HHA Visit Notes revealed the HHA visited MR # 6 three times a week from 1/14/25 to 1/21/25. Review of the SN Visit Notes dated 1/14/24 to 2/24/25 revealed no documentation an HA supervisory visit was conducted. An interview was conducted on 2/27/24 at 8:40 AM with Employee Identifier (EI) # 5, Director of Operations, Montgomery, who confirmed the agency failed to ensure an Aide Supervisory visit was conducted every 14 days. 2. HV # 2 was admitted on 11/20/24 and recertified for hospice from 1/19/25 to 3/19/25. Review of the POC dated 11/20/24 revealed orders for HA two times a week for one week then three times a week for eight weeks. Review of the Aide Care Plan Report dated 1/19/25 revealed orders for HHA two times a week for one week then three times a week for eight weeks. Review of the HHA Visit Notes revealed the HHA completed three visits per week beginning 1/20/25 to 2/7/25. Review of the SN Visit Notes from 1/20/25 to 2/10/25 revealed a HHA Supervisory Visit was not conducted until 2/10/25, which was 21 days after the start of HHA services. An interview was conducted on 2/27/25 at 8:45 AM with EI # 5 who confirmed the agency failed to ensure an Aide Supervisory visit was conducted every 14 days.”

“Based on Medical Record (MR) review, interviews with staff and the Alabama Board of Nursing Standards of Nursing Practice and Standards for Wound Assessment and Care it was determined the agency failed to ensure the clinician documented the wound and care performed. This affected MR # 14, one of three wound care charts reviewed, and had the potential to negatively affect all wound care patients served by this agency. Findings include: Alabama Board of NursingChapter 610-x-6: Standards of Nursing Practice 610-X-6-.06 Documentation Standards: (1) The standards of documentation of nursing care provided to patients by registered nurses or licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be:(a) Legible(b) Accurate(c) Complete. Complete documentation includes reporting and documenting on appropriate records a patient’s status, including signs and symptoms, response,treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient... 1. MR # 14 was admitted to the agency on 1/13/25 with a primary diagnosis of Malignant Neoplasm of the Bladder, Unspecified. A review of the Hospice Certification and Plan of Care (POC) dated 1/13/25 revealed an order for Hospice Nurse/Caregiver to perform wound care to stage two pressure ulcer on left hip and left ear. Utilizing clean technique, cleanse with water, pat dry, apply Medihoney, and change every day and as needed if soiled or dislodged. Instruct caregiver in wound care. A review of the Hospice Start of Care Visit Note Report dated 1/13/25 revealed two wounds, wound number one: a stage two pressure ulcer to the left hip measuring 6 centimeters (cm) x 6 cm x 0 cm. Wound number two: a stage two pressure ulcer to the left ear measuring 1 cm x 1 cm x 0 cm. A review of the twenty nurse Visit Note Reports dated 1/14/25 to 2/25/25 revealed there was no documentation of the assessment or care performed to the wound on the left ear. A review of the seven nurse Visit Note Reports dated from 1/15/25 to 2/3/25 revealed no documentation of the wound care performed to the left hip. An interview was conducted on 2/27/25 at 12:25 PM with Employee Identifier (EI) # 1, Manager of Accreditation, Regulatory, and Compliance, who confirmed the nurse did not document the wound assessment and care of the left ear and left hip as ordered.”