Alabama Hospice Care of East Alabama

“Based on review of the Emergency Preparedness documentation, agency policy and procedure, Hospice Emergency Preparedness Disaster Review form, and interview with staff it was determined the agency failed to conduct an analysis/critique of emergency events/drills. This had the potential to affect all patients served by the agency.Findings include: Policy and Procedure: Emergency Preparedness/ Operational PlanPolicy Number: 7.001Date Revised: 8/1/24...B. Preparation for Emergencies and Disasters:...8. The plan shall test each exercise...as follows:d. Documentation of the actual or drill critique (Disaster Review) will be kept on file in the agency. (Refer to Emergency Preparedness Disaster Review form)...1. Review of the Hospice Emergency Preparedness Disaster Review dated 1/12/23, identified as an actual disaster event, failed to include documentation that a critique of the actual emergency by the multidisciplinary team (MDT), administrative clerical, and support staff was conducted. Further review of agency disaster drills dated 5/9/24, 5/27/24, 7/9/24, 8/2/24, 8/17/24, 1/10/25, 6/6/25, and 6/17/25 failed to include documentation that a critique of the emergency exercise drill by the MDT, administrative clerical, and support staff was conducted.An interview was conducted on10/16/25 at 8:30 AM with Employee Identifier # 2, Executive Director, who confirmed the staff failed to conduct and document emergency event analysis/critiques.”

“Based on review of medical record (MR), review of the agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff completed the comprehensive assessment, no later than five calendar days after the election of hospice care, per the agency policy.This deficient practice affected four of 14 MR reviewed including MR # 8, MR # 9, Home Visit (HV) # 2, MR # 11, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Care, Treatment, and ServicesPolicy Number: 3.003Date Revised: 10/01/2024Procedure:1. ...Within 5 calendar days after the election of hospice care, the hospice interdisciplinary group (IDG) will complete the comprehensive assessment... 4. MR # 11 was admitted to the agency on 10/8/24 with a primary diagnosis of Unspecified Dementia, Unspecified Severity, Without BEH (Behavioral Health)/Psych(Psychiatry)/Mood/ Anx (Anxiety). Review of the Hospice Certification and Plan of Care dated 10/8/24 revealed orders for MSW one visit per month for one month.Review of the Medical Social Worker Psycho-Social Assessment dated 10/10/24 revealed the MSW initial comprehensive assessment was completed on 10/15/24, which was seven days after admission, and not within five days of admission.An interview was conducted on 10/16/25 at 2:04 PM with EI # 5, MSW, who confirmed the psycho-social comprehensive assessment was not completed within five days of admission. 3. HV # 2 was admitted 7/23/25 with a primary diagnosis of Multiple Sclerosis.Review of the Hospice Certification and Plan of Care dated 7/23/25 revealed physician’s orders for Medical Social Worker (MSW) one visit per month for one month.Review of the MSW Psycho-Social Assessment dated 7/31/25 revealed the MSW initial assessment was not completed until eight days after admission.An interview was conducted on 10/16/25 at 1:35 PM with EI # 2 who confirmed the comprehensive assessment was not completed within five days of admission. 2. MR # 9 was admitted to the facility on 3/25/25 with a primary diagnosis of Acute Hepatitis B without Delta Agent and without Hepatic Coma.Review of the Hospice Certification and Plan of Care dated 3/25/25 to 6/22/25 revealed an order for Chaplain visits, one visit monthly for one month.Review of the Chaplain Hospice Spiritual Assessment documentation dated 3/31/25 revealed the Chaplain’s comprehensive assessment was completed six days after the start of care.An interview was conducted on 10/16/25 at 1:16 PM with EI # 2, who confirmed the Chaplain failed to complete the comprehensive assessment within five days of election to hospice care per the agency policy. 1. MR # 8 was admitted to the agency on 5/5/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Hospice Certification and Plan of Care dated 5/5/2025 to 6/27/2025 revealed an order for Chaplain visits one visit monthly for one month.Review of the Chaplain Hospice Spiritual Assessment dated 5/13/2025 revealed the Chaplain’s comprehensive assessment was completed eight days after the start of care. An interview was conducted on 10/16/2025 at 2:18 PM with Employee Identifier (EI) # 2, Executive Director, who confirmed the Chaplin’s initial visit did not occur within five days after the election of hospice care.”

“Based on review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the facility failed to ensure staff provided patient/caregiver (pt/cg) education and training as appropriate to their responsibilities for the care and services identified in the plan of care. This affected MR # 2 in one of one MR reviewed with C-Diff (Clostridiodes difficile, a germ that causes diarrhea and colitis [an inflammation of the colon] and can be life-threatening [per the Centers for Disease Control] and had the potential to negatively affect all patients served by the agency with an infectious disease. Findings include: Agency Policy: Care, Treatment, & ServicesPolicy Number: 3.029Date Revised: 03/01/2021Procedure: 3. ..Document the following in the medical record: ...h. Patient/representative/caregiver instructions on wound care and compliance with wound management; including ability to change dressings. Education and instruct should include return demonstration and documentation of patient/representative/caregiver level of understanding... 1. MR # 2 was admitted to the agency on 8/22/25 with a primary diagnosis of Atherosclerosis of Coronary Artery Bypass Graft, Unspecified, with Unstable Angina Pectoris.Review of the Hospice Certification and Plan of Care dated 8/22/25 to 10/20/25 revealed nurse orders to instruct patient/caregiver on infection specific precautions for care of a patient with C-Diff. Home medications included Dificid 200 milligram twice daily for ten days for C-Diff Colitis.Review of the thirteen nurse visits dated 8/22/25 to 10/8/25 failed to include education on infection control precautions for C-Diff.An interview was conducted on 10/16/25 at 9:42 AM with EI # 1, Patient Care Manager, who confirmed there was no patient/caregiver education on infection control for care of C-Diff documented.”

“Based on home visit (HV) observations, review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure the patient plan of care (POC) was developed, individualized, and updated with interventions and goals to meet identified patient and family needs.This affected HV # 1, MR # 11, in two of fourteen records reviewed and had the potential to negatively affect all patients admitted to hospice care. Findings include:Agency Policy: Plan of CarePolicy Number: 3.003Date Revised: 10/1/24Policy:A written POC is developed for each patient/family by the attending physician, if any, the Medical Director, or hospice physician designee, and the interdisciplinary Group (IDG).Procedure:...5. The IDG, in collaboration with the patient’s attending physician, if any, will review, revise, and document the POC as frequently as the patient’s condition changes, but no less than every 15 calendar days...The updated POC must include information from the patient’s updated comprehensive assessment and note the patient’s progress toward outcomes and goals specified in the POC. 1. HV # 1 was admitted to the agency on 4/23/25 and recertified for continued care on 7/22/25 to 10/19/25 with primary diagnosis of Hypertensive Heart Disease with Heart Failure.Review of the record included a Nurse Visit Note Reports (NVNR) dated 8/27/25 which revealed three plus pitting edema (excess fluid buildup) to BLEs (bilateral lower extremities), dressings performed BID (twice daily), and the NVNR dated 9/3/25 which revealed BLE weeping (fluid leaking from skin), three plus edema.Review of the next IDG (interdisciplinary group) Summary Report dated 9/4/25 failed to include documentation regarding the BLE three plus weeping and or care requiring BID dressing changes to manage the drainage.The 9/4/25 plan of care was not individualized and failed to address the BLE assessment findings and care required to manage the edema/weeping LEs.Review of the NVNR dated 9/10/25 revealed BLE three plus pitting, dressed with iodine and gauze BID by caregivers.Review of the next IDG dated 9/18/25 revealed no documentation regarding the three plus edema, weeping BLE, iodine and gauze BID dressing changes. The 9/18/25 plan of care was not individualized, and failed to address the BLE assessment findings and care required to manage the BLE edema/weeping.Review of the Hospice Recertification Assessment Visit dated 10/1/25 NVNR revealed three plus pitting edema to BLE dressings covered with gauze dressings for weeping. Review of the IDG Summary Report dated 10/3/25 revealed no documentation regarding the three plus pitting edema and care required to manage the weeping BLE edema.The hospice staff failed to ensure HV # 1’s plan of care reflected all medical conditions, care/services managed by the agency. A HV was conducted on 10/15/25 with Employee Identifier (EI) # 4, Registered Nurse. The surveyor observed bilateral lower extremities (BLE) with three plus pitting edema and gauze wraps on both legs from ankle to knee. An interview was conducted on 10/16/25 at 9:56 AM with EI # 1, Patient Care Manager, who confirmed the POC was not updated and accurate with interventions and goals for conditions addressed in nursing assessments.2. MR # 11 was admitted to the agency on 10/8/24 with a primary diagnosis of Unspecified Dementia, Unspecified Severity, Without BEH (Behavioral Health)/Psych(Psychiatry)/Mood/ Anx (Anxiety).Review of the Hospice Certification and POC dated 10/8/24 revealed orders for Medical Social Worker (MSW) one visit per month for one month.Review of the MSW Psycho-Social Assessment documentation dated 10/10/25 revealed MR # 11 lived alone, was isolated within his/her community, would benefit from a full time caregiver, was supported by a family member, who was the power of attorney, relatives were not able to provide adequate care, family relational support needs/concerns revealed signs of stress related to patient illness, caregiver struggling physically/mentally/emotionally to take care of patient, needs nursing home referral, patient agreeable to go. Review of the IDG Summary Report New Admission documentation dated 10/11/24 revealed the following:”... Social Worker...Patient/Family Current Primary Goals for Care: Patient (Pt) will have psychosocial needs met as evidenced by having a plan of care by 10/25/24.Progress towards patient/family primary goals for care since admission: Pt has been admitted and SW visits have been scheduled.Plan/Intervention(s) for next 14 days to meet patient/family primary goal(s) for care: Social Worker will meet Pt and perform a psychosocial assessment...” The Psychosocial Plan of Care was not developed and individualized for MR # 11s needs. There were no interventions to meet the psychosocial concerns documented in the Psycho-Social Assessment which included long term care placement.An interview was conducted on 10/16/25 at 1:35 PM with EI # 5, MSW, who confirmed the Psychosocial POC had not been developed and was not individualized for MR # 11s needs.”

“Based on medical record (MR) review and interview with staff, it was determined the agency failed to ensure issues identified during the Medical Social Work (MSW) evaluation included follow thorough to to address and assist the patient and caregiver to function effectively and manage at the end of life. This affected MR # 11, one of two death records reviewed, and had the potential to affect all patients admitted to hospice. Findings include: 1. MR # 11 was admitted to the agency on 10/8/24 with a primary diagnosis of Unspecified Dementia, Unspecified Severity, Without BEH (Behavioral Health)/Psych(Psychiatry)/Mood/ Anx (Anxiety).Review of the Medical Social Worker Psycho-Social Assessment documentation dated 10/10/24 revealed the patient lived alone, would benefit from a full time caregiver (CG), was supported by a family member, the power of attorney, seeking nursing home placement, needs nursing home referral, the patient was isolated within the community, family relational support needs/ concerns revealed signs of stress related to patient illness, the caregiver struggling physically, mentally, emotionally to take care of patient.Review of the MR revealed no MSW actions/intervention documentation including contact(s) with the CG, nursing homes, or outside resources to assist the CG and patient in managing the struggles with end of life care following the 10/10/24 visit.An interview was conducted on 10/16/25 with Employee Identifier # 5, MSW, who confirmed there was no MSW documentation of any actions/interventions to address the risks, obstacles, social, emotional, functioning and coping of the patient and caregiver.”

“Based on review of the medical record (MR) documentation, and interview with staff, the agency failed to ensure the Hospice Aide (HA) reported changes in the patients condition which affected the aide plan of care, in two of fourteen record reviews including MR # 10, MR # 7, and had the potential to negatively affect all patients who received personal care services.Findings include: 2. MR # 7 was 9/8/25 with a primary diagnosis of Vascular Dementia, Unspecified Severity.Review of the Hospice Certification and Plan of Care (HC and POC) dated 9/8/25 revealed physician’s orders for HA two times per week for nine weeks. Review of the Aide Care Plan Report dated 9/8/25 revealed orders for HA to obtain the date of the last bowel movement (BM) and notify the Registered Nurse (RN) if greater than three days since last BM. Review of the HA Visit Note Report (VNR) dated 9/17/25 revealed no documentation of the last BM. There was no documentation the RN was notified. An interview was conducted on 10/16/25 at 11:35 AM with Employee Identifier (EI) # 2, Executive Director, who confirmed the Aide Care Plan was not followed. 1. MR # 10 was admitted to the agency on 8/28/24 with a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified.Review of the Aide Care Plan Report revealed activities of daily living services (ADLS) ordered included shampoo, shaving, dressing, shower bath to be performed every visit.Review of the Hospice Aide (HA) Visit Note Reports (VNR) dated 9/9/24, 9/13/24, and 9/30/24, revealed documentation the client refused ADLS services. There was no documentation the HA reported to the nurse that MR # 10 refused ADL services on the above three visits.An interview was conducted on 10/16/25 at 1:35 PM with Employee Identifier (EI) # 1, Patient Care Manager, who confirmed the Aide Care Plan as not followed, and the HA failed to report this to the nurse.”

“Based on review of medical record (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to provide a discharge summary after patient revocation. This affected one of two discharged MR’s reviewed including MR # 8 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Management of Information Policy Number: 9.001Date Revised: 10/01/204Procedure:2. ...The hospice medical record shall contain the following clinical information: ...z. Transfers/discharge summary... 1. MR # 8 was admitted to the agency on 5/5/2025 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. Review of the Client Coordination note dated 6/27/2025 revealed MR # 8 requested to revocate from hospice. Review of the SN Discharge With Visit Note dated 06/27/2025 revealed that the SN presented to the resident to obtain a signature for the hospice revocation statement. Signature obtained from the caregiver (CG) for hospice revocation statement. Further review of the MR revealed that a discharge summary was not completed after revocation. An interview was conducted on 10/16/2025 at 2:18 PM with Employee Identifier (EI) # 2, Executive Director, who confirmed that a discharge summary was not completed after revocation of hospice services.”

“Based on review of hospice contracts, agency policy, medical record (MR), and staff interviews, it was determined the agency failed to ensure general inpatient (GIP) care for all hospice patients was provided under a written agreement with an inpatient provider. This affected MR # 11, in one of one GIP record reviews, and had the potential to negatively affect all patients admitted for hospice care.Findings include:Policy: Admission for Short Term General Inpatient ServicesPolicy Number: 3.012...Policy:Short term general inpatient care will be provided as specified under Medicare, Medicaid, and specific private insurance hospice benefits...Inpatient care for pain...symptom management...must be provided in a hospital or Skilled Nursing Facility...that meets Medicare guidelines for inpatient care... 1. MR # 11 was admitted to the agency on 10/8/24 with a primary diagnosis of Unspecified Dementia, Unspecified Severity, Without Behaviors/Psychosis/Mood/Anxiety.Review of the record revealed Hospice Nurse Visit documentation dated 10/21/24 revealed MR # 11 had abnormal respiratory rhythm, periods of apnea, abnormal urine color, urine odor, nausea/vomiting, and the nurse instructed patient to go to Emergency Department for Computerized Tomography (CT) of abdomen related to (R/T) yellow/orange vomiting, and x ray of head R/T increased confusion and mental status change after a fall.Further record review revealed a hospice physician order dated 10/21/24 which revealed...”Pt (patient) at named inpatient hospital for GIP for symptom management, and an order dated 10/24/24 to change level of care to routine home care.The surveyor requested the written GIP contract for GIP provider on 10/16/25 from Employee Identifier (EI) # 1, Patient Care Manager. EI # 1 reported there was no current GIP contract, but their would have been a one time contract for GIP care with the inpatient provider.An interview was conducted on 10/16/25 at 2:15 PM with EI # 2, Executive Director. The surveyor requested to review the one time GIP contract. None was provided.The hospice failed to ensure inpatient care provided to hospice patients was performed under a written agreement.”

“Based on review of the medical record (MR), and staff interview, it was determined the agency failed to ensure hospice record documentation included a summary of inpatient care events/services provided during a General Inpatient (GIP) admission. This affected MR # 11, in one of one GIP record reviews, and had the potential to affect all patients admitted to the agency.Findings include: 1. MR # 11 was admitted to the agency on 10/8/24 with a primary diagnosis of Unspecified Dementia, Unspecified Severity, Without BEH (Behaviors)/Psych(Psychosis)/Mood/ Anx (Anxiety). Review of the MR revealed a hospice physician’s order dated 10/21/24, “...Pt (patient) at [named inpatient hospital] for GIP for symptom management, level of care General Inpatient Care”, and a physician’s order dated 10/24/24 to change level of care to Routine Home Care.Further review of the MR revealed no GIP care documentation, and no inpatient discharge summary.An interview was conducted on 10/16/25 at 2:15 PM with Employee Identifier (EI) # 2, Executive Director, and EI # 5, Medical Social Worker. The surveyor requested the GIP discharge summary for MR # 11. No discharge summary or other GIP care documentation was provided.”