Every finding on record at Agape Care Alabama, LLC

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; [and] other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy; drug side effects; actual or potential drug interactions; duplicate drug therapy; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed and home visits observed, the agency did not ensure that the comprehensive assessment included a review of the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected hospice care on 01/05/2022 and resided in an Assisted Living Facility (ALF). The hospice medication profile dated 05/28/2024 documented "Acetaminophen Pain Relief 500mg tablet, one tablet three times a day orally for pain." During the home visit with the Registered Nurse (RN) [Personnel Record 6] on 05/29/2024, the patient's ALF medication profile documented "Acetaminophen Pain Relief 500mg tablet, one tablet three times a day orally for pain," and "Acetaminophen 500mg tablet, one tablet every four hours as needed for pain," effective 11/02/2023. The RN [Personnel Record 6] confirmed that the Acetaminophen 500mg tablet, one tablet every four hours as needed for pain, effective 11/02/2023, was not on the hospice medication profile. The ALF nurse confirmed that the patient had the medication available for use. The hospice RN [Personnel Record 6] stated they would reconcile the medications. During a joint record review and interview on 05/29/2024, the Manager of Accreditation and Regulatory Compliance confirmed that there was no documented evidence that the medications were reconciled at the time of each comprehensive assessment and updated to the drug profile.

It is required that a social worker has a Master of Social Work (MSW) degree from a school of social work accredited by the Council on Social Work Education, or a baccalaureate degree in social work from an institution accredited by the Council on Social Work Education, or a baccalaureate degree in social work, psychology, sociology, or other field related to social work and is supervised by an MSW meeting the qualification as stated in No. 1 above and at least one (1) year of social work experience in a health care setting or a baccalaureate degree from a school of social work accredited by the Council on Social Work Education and was employed by the hospice before December 2, 2008, is not required to be supervised by an MSW. This standard was not met as evidenced by personnel record review, clinical record review, document review, and interview. In 1 of 2 (50%) personnel records reviewed of social workers, the agency did not ensure that the social worker was legally authorized in accordance with state regulations. The rules of the agency's state board of health read in part, "Social Worker" means a person who holds at least a bachelor's degree in social work from an accredited school of social work, and is currently licensed by the State of... or supervised in accordance with Title … Chapter … of Code of …, 1975." Personnel Record 8: The Social Worker (SW) was hired on 09/30/2022. A review of the SW personnel record revealed a documented master's degree in social work on 05/04/2018, a competency for the social worker upon hire, and an annual skills evaluation. The personnel record did not include evidence of a license for the social worker as required by state regulation. During a joint personnel record review and interview on 05/31/2024, the Manager of Accreditation and Regulatory Compliance confirmed that the personnel record did not include a license for the SW. The Manager of Accreditation and Regulatory Compliance stated that the agency discovered in February 2024 that the Social Worker (SW) did not have a license. Since then, the Social Worker has been supervised by a Clinical Supervisor. In April 2024, the SW was scheduled for a review course. The request to test was submitted and received approval in April 2024. The test was scheduled for 06/25/2024. Clinical Record 1: The patient elected hospice care on 01/05/2022. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 01/12/2023, 02/09/2023, 03/03/2023, 04/04/2023, 05/19/2023, 06/22/2023, 07/12/2023, 08/24/2023, and 09/13/2023. Clinical Record 2: The patient elected hospice care on 05/16/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented a visit on 05/17/2024. Clinical Record 3: The patient elected hospice care on 04/10/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 04/12/2023, 04/20/2023, and 05/18/2023. Clinical Record 4: The patient elected hospice care on 10/20/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 11/27/2023, 12/11/2023, 01/09/2024, 01/30/2024, 02/08/2024, 03/11/2024, 04/05/2024, 04/22/2024, 05/06/2024. Clinical Record 6: The patient elected hospice care on 12/28/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 01/03/2024, 02/26/2024, and 04/25/2024. The SW made a phone call to the patient on 01/11/2024. Clinical Record 7: The patient elected hospice care on 10/13/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 10/18/2023, 11/14/2023, 12/22/2023, 01/08/2024, 01/30/2024, 02/12/2024, 02/21/2024, 03/12/2024, 04/08/2024, 04/15/2024, and 05/13/2024. Clinical Record 8: The patient elected hospice care on 12/23/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 12/29/2023, 01/12/2024, 01/25/2024, 02/15/2024, 02/20/2024, 03/25/2024, and 04/10/2024. The SW made phone calls to the patient on 02/02/2024 and 03/28/2024. Clinical Record 9: The patient elected hospice care on 02/07/2024.A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 02/09/2024, 03/27/2024, and 04/12/2024. The SW made phone calls to the patient on 02/22/2024 and 05/21/2024. Clinical Record 10: The patient elected hospice care on 03/06/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 03/08/2024, 04/05/2024, 04/18/2024, and 05/17/2024. The SW made a phone call to the patient on 04/15/2024. Clinical Record 13: The patient elected hospice care on 05/07/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/09/2024, 05/15/2024, 05/22/2024, and 05/28/2024. Clinical Record 14: The patient elected hospice care on 09/12/2023. A review of the clinical record revealed that the Social Worker [Personnel Record 8] documented visits on 09/14/2023, 09/26/2023, 11/14/2023, 11/27/2023, 12/20/2023, 01/30/2024, and 02/19/2024. Clinical Record 15: The patient elected hospice care on 02/12/2024. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 02/13/2024 and 03/25/2024. Clinical Record 16: The patient elected hospice care on 05/17/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/22/2023, 06/21/2023, 08/09/2023, 09/25/2023, 10/11/2023, and 11/08/2023. Clinical Record 17: The patient elected hospice care on 05/01/2023. A clinical record review revealed that the Social Worker [Personnel Record 8] documented visits on 05/03/2023, 05/18/2023, 06/16/2023, 06/26/2023, 07/26/2023, 08/31/2023, and 09/15/2023.

Based on agency policy and procedure, medical record (MR) review and interview with staff it was determined the agency failed to ensure pain was assessed and symptom management was provided for 1 of 11 MRs reviewed including MR # 6. This deficient practice had the potential to affect all patients served by the agency. Findings include: Agency Policy: Pain Assessment and Reassessment Policy Number: 9.9.1 Revised: 2014 Policy: Appropriate Hospice staff will assess and reassess patients pain. Each patient will receive effective pain management and symptom control for conditions related to the terminal illness... Purpose: To define processes for pain assessment and management. Procedure: ...2. Each patient will have pain reassessed on an ongoing basis using established criteria, including: ...Current pain therapy or treatment. Effectiveness of current therapy or treatment. --- 1. MR # 6 was admitted to the agency on 7/25/22 with diagnoses of Malignant Neoplasm of Pancreas, Unspecified and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Review of the Medication List (ML) revealed the following pain medications were prescribed to MR # 6: Morphine Sulfate 20 mg (milligrams)/ml (milliliter) 0.5 ml every four hours as needed for pain. Hydrocodone-Acetaminophen (Norco) 10-325 mg every six hours as needed for pain. Methadone 10 mg two and a half tablets every eight hours for pain. Hydromorphone 4 mg two tablets every three hours as needed for pain. Review of the Skilled Nurse Visit (SNV) dated 7/26/22 revealed MR # 6 reported pain in the right arm at a seven and current pain management and effectiveness was ";semi-effective." There was no documentation of the pain medications the patient had taken or how frequently the patient took the pain medication. Review of the SNV dated 8/5/22 revealed MR # 6 reported pain in the right arm and hand at a five and current pain management and effectiveness was ";semi-effective." There was no documentation of the pain medications the patient had taken or how frequently the patient took the pain medication. Review of the SNV dated 8/10/22 and 8/15/22 revealed MR # 6 reported pain in the right arm and hand at a seven and current pain management and effectiveness was ";effective". Further review revealed documentation the patient verbalized he/she had not taken pain medication on 8/10/22 and does not take pain medication as prescribed. There was no documentation of when and what pain medications were taken last. The reason for the patient's noncompliance with pain medications was not assessed, and there was no documentation of education on pain management. An interview was conducted on 11/18/22 at 2:45 PM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed the agency staff failed to perform a complete pain assessment for pain management on the above dates.

Based on review of the agencys policy and procedure, medical record reviews, observations, and interviews, it was determined the agencys staff failed to ensure all patient medication lists were current and accurate. This affected three of three home visits (HV) conducted including HV # 1, HV # 2 and HV # 3. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: 8.20.1 Revised: 6/30/18 Policy: Hospice will reconcile patients medications at time of admission and on an ongoing basis. Purpose: To define the medication reconciliation process. Procedure: 1. At time of initial assessment, the RN (Registered Nurse) will create and document a complete list of medications that patient is taking, including dose, route, and frequency. a. Any discrepancies will be reconciled by a RN with the patients physician. b. Discrepancies include duplications, omissions, changes, contradictions and/or unclear information. 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. --- 3. HV # 3 was admitted to hospice on 8/2/22 and recertified for hospice care from 10/1/22 to 11/29/22 with diagnoses including Cerebral Atherosclerosis and Unspecified Atrial Fibrillation. Review of the POC dated 11/2/22 revealed orders for SN one time a week and six PRN visits for 60 days. A HV was conducted on 11/8/22 at 10:10 AM to observe care provided by EI # 2, Chaplain. During the visit, the patients medications were compared with the ML provided by the agency on 11/8/22 with the caregiver (CG). The following discrepancies were revealed: a) Metoprolol Tartrate Oral Tablet 25 mg, two tablets twice daily. The CG stated HV # 3 has always taken one tablet, twice a day, two tablets twice a day was listed on the ML. b) Zofran Oral Tablet Disintegrating 4 mg, one tablet, every six hours as needed was observed on the ML but was not in the home. The CG stated HV # 3 does not have any Zofran and was unaware of the medication. c) Hyoscyamine Sulfate Sublingual Tablet 0.125 mg, one tab every four hours as needed was observed on the ML but was not in the home. The CG stated HV # 3 does not have any Hyoscyamine and was unaware of the medication. d) Remeron Oral Tablet 15 mg, one tab at bedtime, was observed on the ML but was not in the home. The CG stated HV # 3 does not have any Remeron and was unaware of the medication. e) Centrum Multi-Vitamin one tablet daily was observed in the home but was not on the ML. The CG reported HV # 3 has been taking the medication for more than twenty years. f) An oxygen concentrator was observed in the home, but not in use by HV # 3 during the home visit. The CG reported HV # 3 has not used oxygen but its available if needed. Oxygen was not listed on the ML. In an interview conducted on 11/9/22 at 11:20 AM with EI # 1 confirmed the staff failed to update the ML per the agencys policy. 2. HV # 2 was admitted to hospice on 4/7/2022 and recertified for hospice care from 10/4/22 to 12/2/22 with diagnoses including Acute Kidney Failure, unspecified and Chronic Kidney Disease Stage 4 (severe). Review of Plan of Care Order (POC) dated 10/4/22 revealed orders for SN one time a week and six PRN (as needed) visits for 60 days. A HV was conducted on 11/8/2022 at 10:46 AM to observe care provided by EI # 4, Registered Nurse. During the visit, the patients medications were compared with the Medication List (ML) provided by the agency on 11/8/22 at with patient. The following discrepancy was observed and reviewed with the patient. a) Metoprolol Succinate ER (extended release) Oral Tablet 25 mg one tablet daily. Review of the ML provided to the surveyor on 11/8/22 revealed an order for Metoprolol Succinate ER one half tablet twice daily. Patient stated that he/she takes it as ordered on the bottle (one tablet daily.) Bottle was recently prescribed on 11/1/2022. In an interview conducted on 11/9/22 at 11:17 AM, EI # 1 confirmed the staff failed to reconcile the medications per agency policy. 1. HV # 1 was admitted to the agency on 6/30/2020 and recertified for hospice care from 9/18/22 through 11/16/22 with a terminal diagnosis of End Stage Heart Failure. Review of the Plan of Care (POC) Order dated 11/2/22 revealed orders for Skilled Nurse (SN) one time a week and medication orders including Norco oral tablet 5/325 mg (milligrams) one tablet two times a day for pain and Neurontin oral capsule 300 mg take one tablet two times a day for neuropathy. A HV was conducted at the residents home in a Skilled Nursing Facility (SNF) on 11/8/22 at 11:18 AM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide. A review of the medications conducted with the SN of the SNF and the SNF Order Summary Report dated 11/8/22 revealed neither Norco nor Neurontin were listed as current medications. In an interview conducted on 11/9/22 at 11:25 AM, EI # 1 confirmed the medications had not been reconciled per agency policy and the Norco and Neurontin should have been listed on the SNF medication list.

Based on review of medical records (MR), agency policy and procedure, and interview with agency staff it was determined the agency failed to ensure the physician ordered frequencies were followed for Hospice Aide (HA) and Skilled Nurse (SN). This did affect 3 of 11 MR reviewed including MR # 1, MR # 7, and MR # 6, and had the potential to negatively affect all patients served by the hospice agency. Findings include: Agency Policy: IDG (Interdisciplinary Group) Planning Process Revised: June 2018 Policy: In order to assure that care provided is appropriately planned to meet each patient's specific needs and problems... Procedure: ...8. ...The Plan of Care includes all services necessary for the palliation and management of the terminal illness and related conditions including: ...A detailed statement of the...frequency of services necessary to meet the specific patient and family needs... --- 1. MR #1 was admitted to the agency on 10/24/22 with a diagnosis of Unspecified Severe Protein-Calorie Malnutrition. Review of the IDG Meetings dated 10/26/22 and 11/2/22 revealed a HA frequency of five times per week. Review of the HA visit documentation for the week of 10/30/22 to 11/5/22 revealed three HA visits were completed and two HA visits were missed. There was no documentation the HA attempted to reschedule the missed visits to provide the five ordered HA visit for the week. An interview was conducted on 11/8/22 at 2:42 PM with Employee Identifier (EI) # 1, Director of Nursing, who confirmed there was no documentation the HA attempted to reschedule the missed visits to provide the five ordered HA visit for the week of 10/30/22 to 11/5/22. 2. MR # 7 was admitted to the agency on 10/10/22 with a diagnosis of Chronic Hepatic Failure without Coma. Review of the Physician's Order dated 10/11/22 revealed a HA frequency of twice a week for the week of 10/10/22. Review of the IDG Meeting dated 10/12/22 revealed a HA frequency of three times per week. Review of the HA visit documentation for the week of 10/10/22 to 10/15/22 revealed two HA visits were missed. There was no documentation the HA attempted another HA visit and to reschedule the missed visits to provide the three ordered HA visits for the week. An interview was conducted on 11/8/22 at 2:58 PM with EI # 1, who confirmed there was no documentation the HA attempted another HA visit and to reschedule the missed visits to provide the three ordered HA visit for the week of 10/10/22 to 10/15/22. 3. MR # 6 was admitted to the agency on 7/25/22 with diagnoses of Malignant Neoplasm of Pancreas, Unspecified and Secondary Malignant Neoplasm of Liver and Intrahepatic Bile Duct. Review of the IDG Meetings dated 7/27/22 and 8/10/22 revealed a SN frequency of three times per week. Review of the SN visit documentation for the week of 7/31/22 to 8/6/22 revealed two SN visits were missed. There was no documentation the SN attempted to reschedule the missed visits to provide the three ordered SN visit for the week. Review of the SN visit documentation for the week of 8/7/22 to 8/13/22 revealed one SN visit was missed and one completed. There was no documentation the SN attempted another SN visit and to reschedule the missed visits to provide the three ordered SN visit for the week. An interview was conducted on 11/8/22 at 2:45 PM with EI # 1, who confirmed there was no documentation the SN attempted another SN visit and/or to reschedule the missed visits to provide the three ordered SN visit for the above weeks.

Based on home visit (HV) observations, agency policy and procedure, and interviews it was determined the agency failed to ensure staff followed hand hygiene guidelines for the prevention of infection. This deficient practice affected one of three HV patients including HV # 1 and had the potential to negatively affect all patients served by this agency. Findings include: Agency policy: Hand Hygiene Policy and Compliance Program Policy Number: none listed Revised: 2016 ... 7. Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: ...After removing gloves. ...Moving from contaminated patient body site to clean site during patient care... --- 1. HV # 1 was admitted to the agency on 6/30/2020 and recertified for hospice care from 9/18/22 through 11/16/22 with a terminal diagnosis of End Stage Heart Failure. Review of the Plan of Care (POC) dated 11/2/22 revealed orders for Hospice Aide (HA) two times a week times 60 days. A home visit was conducted on 11/8/22 at 11:10 AM to observe a bed bath performed by Employee Identifier (EI) # 3, Hospice Aide. After providing the bed bath, EI # 3 changed lined and place dirty linen in a bag. EI # 3 then removed gloves and replaced the Oxygen cannula on HV # 1. EI # 3 failed to perform hand hygiene after removing gloves. In an interview conducted on 11/9/22 at 11:25 AM, EI # 1, Director of Nursing, confirmed the staff failed to follow hand hygiene guidelines and perform hand hygiene after removing gloves.

Based on observations, agency policy and procedure, Medical Record (MR) review and interviews it was determined the agency failed to ensure the Hospice Aide notified the Skilled Nurse (SN) of changes in the patient condition. This deficient practice affected one of eight patients receiving Hospice Aide services including Home Visit (HV) # 1 and had the potential to affect all patients receiving aide services. Findings include: Agency Policy: Hospice Aide Documentation Policy Number: None listed Revised: June 2018 ...Procedure: 1. The Hospice Aide will document services...as directed in the Aide care plan/assignment sheet. 2. The Hospice Aide will be responsible for reporting any changes in the patient's condition and/or pertinent observations to the supervising RN (Registered Nurse)... --- 1. HV # 1 was admitted to the agency on 6/30/2020 and recertified for hospice care from 9/18/22 through 11/16/22 with a terminal diagnosis of End Stage Heart Failure. Review of the Aide Care Plan dated 9/18/22 revealed orders for the Aide to check pressure areas each visit and to contact the case manager or supervisor for any problems, concerns, or abnormals. Review of the Plan of Care (POC) Order dated 11/2/22 revealed Skin Integrity was listed under the Problems list. Interventions included for staff to assess for changes in skin integrity. Further review of the POC Order dated 11/2/22 revealed documentation on 10/27/22 the assessment was performed, there was no documentation of any skin breakdown. Review of the Skilled Nursing Visit note dated 10/27/22 revealed no documentation of skin breakdown. A HV was conducted at the residents home in a Skilled Nursing Facility (SNF) on 11/8/22 at 11:18 AM to observe care provided by the Employee Identifier (EI) # 3, Hospice Aide. During the observation of the bath the Aide turned the patient to each side. The surveyor observed EI # 3 apply cream to skin breakdown of appoximately 3 cm (centimeters) x 5 cm on each lower buttock. Review of the Aide Care Visit note dated 11/8/22 revealed the task for checking pressure areas was marked as completed. There was no documentation of any abnormal findings and no documentation the SN was notified ot the skin breakdown. In an interview conducted on 11/9/22 at 11:25 AM, EI # 1, Director of Nurses, stated if HV # 1 had any skin breakdown it was new and confirmed there was no documentation the SN was notified of the changes.