Alabama Hospice Care of Birmingham

“Based on Medical Record (MR) review, agency’s policy and procedure, observation, and interview with staff it was determined the agency’s staff failed to follow its Medication Administration policy.This affected two of four Home Visits (HV), including HV # 1, HV # 3, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Medication AdministrationAgency Policy Number: 3.002Revision Date: 02/01/23Purpose:To provide a process to ensure safe administration of medications in the home.Policy:...The Executive Director, with the attending physician, will make the decision regarding medication administration in the home...Procedure:...The RN (Registered Nurse) will initiate a medication profile upon admission and will update with any changes throughout the course of care... 2. HV # 3 was admitted to the agency on 1/15/26 and recertified for care 3/16/26 to 5/14/26 with a diagnosis of Alzheimer’s Disease Unspecified.Review of the Recertification Plan of Care Order dated 3/1/26 revealed the SN effective on 3/16/26 visit two times a week for nine weeks, and three PRN for urgent symptom management needs/changes in condition. The MSW effective on 4/1/26 visit one time per month for two months and three PRN visits for urgent psychosocial needs/interventions. The Chaplain effective 4/1/26 visit one time per month for two months and three PRN visits for urgent spiritual care needs/interventions. The Hospice Aide effective on 4/1/26 visit two times a week for eight weeks then, one time a week for one week. Review of physician’s orders dated 4/21/26 revealed orders to discontinue the following medications: Donepezil 10 mg tablet and Memantine 10 mg tablet.A HV was conducted on 4/28/26 at 1:50 PM to observe care provided by EI # 5, MSW and medication review.The medications at the nursing home were compared to the ML provided by the agency on 4/28/26. The following discrepancies were identified:Donepezil HCL Oral Tablet 10 MG, give one tablet by mouth one time a day with an order date and start date of 1/14/26.Memantine HCL Oral Tablet 10 MG, give one tablet by mouth two times a day, with an order date and start date of 1/14/26.An interview was conducted on 4/30/26 at 3:30 PM with EI # 1, RN, Director of Clinical Operations, who confirmed the staff failed to update the medication profile per the agency’s medication administration policy. 1. HV # 1 was admitted to the agency on 10/2/24 and recertified for care 3/26/26 to 5/24/26 with a diagnosis of Senile Degeneration of Brain Not Elsewhere Classified.Review of the Recertification Plan of Care Order dated 3/11/26 revealed the Skilled Nurse (SN) effective on 3/26/26 visit one time for one week, two times a week for eight weeks and three PRN (as needed) for urgent symptom management needs/changes in condition. The Medical Social Worker (MSW) and Chaplain effective on 4/1/26 visit one time per month for two months and three PRN visits. The Hospice Aide effective on 3/26/26 one time a week for one week then, two times a week for eight weeks. A HV was conducted on 4/28/26 at 1:15 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide (HA) and medication review.The medications in the home were compared to the Medicine List (ML) provided by the agency on 4/28/26 and verified by the patient’s spouse. The following discrepancy was identified:Lexapro 10 milligrams (MG) tablet, take one tablet daily was listed on the ML. Lexapro 20 mg tablet, take one tablet daily was in the home with the filled date of 4/2/26.An interview was conducted on 4/30/26 at 2:30 PM with EI # 2, Executive Director (ED), who confirmed the staff failed to update the medication profile per the agency’s medication administration policy.”

“Based on review of Medical Records (MR), agency policy and procedures, and staff interviews it was determined the agency failed to ensure an initial bereavement risk assessment was completed for each patient/family. This affected two of 19 records reviewed including HV #2 and MR # 10. This deficient practice had the potential to affect all patients/families served by the hospice.Findings include:Agency Policy: Bereavement AssessmentPolicy Number: 2.004Revised Date: 3/1/21 ...Procedure:The social worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice... 1. HV # 2 was admitted to the agency on 2/24/2024 with the diagnosis of Senile Degeneration of the Brain.Review of the initial assessment completed by the nurse on 2/24/2024 and the Interdisciplinary Group (IDG) Summary Report dated 2/28/2024 revealed no documentation of an initial bereavement risk assessment.An interview conducted on 4/30/2026 at 3:00 PM with Employee Identifier (EI) # 1, Director of Clinical Operations, confirmed there was no documentation the initial bereavement risk assessment was completed.2. MR # 10 was admitted to the agency on 12/15/2025 with the diagnosis of Chronic Obstructive Pulmonary Disease.Review of the initial assessment completed by the nurse on 12/15/2025 and the IDG Summary Report dated 12/29/2025 revealed no documentation of an initial bereavement risk assessment.An interview conducted on 4/30/2026 at 3:00 PM with EI # 1, confirmed there was no documentation the initial bereavement risk assessment was completed.”

“Based on review of agency policy and procedure, observation, and interview with staff it was determined the agency’s staff failed to follow its own hand hygiene policy.This affected one of four Home Visits (HV), including HV # 1, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Hand Hygiene - Infection ControlAgency Policy Number: 10.002Revision Date: 4/01/26Purpose:To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines.Policy:Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact...Procedure:Staff perform hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer:a. before direct contact with patients...e. if moving from a contaminated body site to a clean body site during patient care.f. ...before and after removing personal protective equipment (PPE) such as gloves... 1. HV # 1 was admitted to the agency on 10/2/24 and recertified for care 3/26/26 to 5/24/26 with a diagnosis of Senile Degeneration of Brain Not Elsewhere Classified.A HV was conducted on 4/28/26 at 1:15 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide (HA).EI # 3 transported HV # 1 to the bed. EI # 3 removed gloves, without performing hand hygiene, reached into his/her uniform pocket retrieved and donned gloves from the pocket. EI # 3 washed HV’s # 1 face and proceeded with the bed bath. EI # 3 applied lotion to HV # 1’s legs and chest with gloved hands. EI # 3 then removed gloves, without performing hand hygiene, donned clean gloves, dressed top half and placed pull up on HV # 1. EI # 3 then transported HV # 1 to the rollator, removed gloves, without performing hand hygiene, donned clean gloves and shampooed HV’s # 1 hair.EI # 3 failed to follow the agency’s hand hygiene policy. An interview was conducted on 4/30/26 at 2:30 PM with EI # 2, Executive Director (ED), who confirmed the staff failed to follow the agency’s hand hygiene policy.”

“Based on medical record (MR) review, agency policies and procedures, and interviews, it was determined the agency failed to ensure:1. The physician pronounced the death of a patient.2. The physician was notified of changes in wound status.3. The hospice staff accurately documented wound assessments.This deficient practice affected one of three Bereavement MRs reviewed, including MR # 13 and two of four MRs reviewed with wounds including MR # 8, MR # 12 and had the potential to negatively affect all patients admitted to the agency. Findings include:Agency Policy: Home Death PronouncementPolicy Number: 3.013Revised Date: 8/1/25Purpose:To establish the process for the hospice clinician to follow when a patient dies at home.Policy:…State: AlabamaWho Can Pronounce: PhysicianGuidelines: Registered Nurse/Licensed Practical Nurse can pronounce per verbal communication with the physician.Agency Policy: Hospice Medical RecordPolicy Number: 9.001Revised Date: 10/1/24Purpose:To define the contents and requirements of the hospice medical record.…Procedure:2. The hospice medical record shall contain the following clinical information:…b. Any summaries of care, treatment, or services, including changes in patient’s condition, furnished to the patient’s physician or licensed independent practitioner.…l. Documentation and communication with the patient, caregivers, and physicians.m. Any assessment relevant to care, treatment, or services.Agency Policy: Wound Assessment, Documentation and PhotographyPolicy Number: 3.029Revised Date: 3/1/21Purpose:To ensure the accurate and consistent assessment and documentation of wounds.Policy:Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation with the medical record...Procedure:...2. Perform wound care according to physician orders specified in the patient’s plan of care. 3. Document the following in the medical record:a. Treatment and condition of the wound (each visit)b. Appearance of the wound bed (black, yellow, red)c. Wound measurements (weekly) including the length, depth, and width of the wound in centimetersd. Depth and location of the undermining in centimeterse. Surrounding tissuef. Color, odor, and estimated amount of drainageg. Stage the wound weeklyh. Patient/representative/caregiver instructions...i. Other pertinent findings...4. Redress the wound using appropriate wound care... 3. MR # 12 was admitted to the agency on 3/13/26 with primary diagnosis of Alzheimer’s Disease. Review of SN Visit Note dated 3/13/26 revealed the patient had multiple stage 3 or 4 decubitus ulcers, pale skin and bruising on upper and lower extremities, and a sacral wound. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/14/26 revealed the patient had poor skin turgor. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/17/26 revealed the patient had pale skin. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/19/26 revealed the patient had pale skin, wounds, pressure ulcers, injuries, and stated, “see wound assessment tool.” There was no evidence of a wound assessment documented. Review of SN Visit dated 3/25/26 revealed the patient had pale skin and no skin conditions. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/26/26 revealed the patient had pale skin. There was no evidence of a would assessment documented. Review of SN Visit dated 3/31/26 revealed the patient had pale skin and a Mid-Sacral Pressure Ulcer, Stage IV, onset date 3/31/26 with measurements of 4.5 cm length, 6.5 cm width, and 0.1 cm depth.Review of a physician’s order dated 3/31/26 revealed orders to “cleans sacral wound with wound cleanser, pat dry with clean gauze, apply Hydrogel (brand) and cover with border gauze daily, and as needed (PRN) if soiled. Facility Staff Nurse (FSN) can perform wound care in absence of Staff Nurse (SN).” Review of SN Visit dated 4/2/26 revealed the patient had pale skin, poor skin turgor, wounds, and stated, “see wound assessment tool.” Review of the wound assessment tool revealed the following documentation, “wound assessment and wound care not ordered this visit.” Review of SN visit dated 4/2/26 revealed the patient was being admitted to the hospital for sepsis. The Hospice revocation date was noted as the same day, 4/2/26. An interview was conducted on 4/30/26 at 3:00 PM with EI # 1 who confirmed the agency failed to ensure the hospice staff accurately documented wound assessments. 1. MR # 13 was admitted to the agency on 9/3/25 with primary diagnosis of End Stage Renal Disease.Review of the Skilled Nurse (SN) Visit Note dated 9/22/25 revealed the patient expired at 4:26 PM. There was no documentation the physician pronounced the patient’s death.An interview was conducted on 4/30/26 at 3:14 PM with Employee Identifier (EI) # 1, Director of Clinical Operations, who confirmed there was no documentation the physician pronounced the patient’s death.2. MR # 8 was admitted to the agency on 2/5/25 with primary diagnosis of Chronic Obstructive Pulmonary Disease Unspecified.Review of the SN Visit Note dated 3/16/26 revealed a wound in the Abdominal Left Upper Quadrant, Pressure Ulcer Stage II with measurements of 1.5 centimeters (CM) length, 1.5 CM width, and 0.2 CM depth. SN Visit Note dated 3/22/26 revealed a significant increase in wound measurement of 4 CM length, 4 CM width and 0.2 CM depth.There was no documentation the physician was notified of changes in the patients condition.An interview was conducted on 4/30/26 at 3:11 PM with EI # 1, who confirmed there was no documentation the physician was notified of of changes in the patients condition per agency policy.”