Every finding on record at Camellia Hospice of South Alabama, LLC

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met, as evidenced by clinical record review and interview. In 3 of 16 (19%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 1: The patient's date of election was 01/23/2026. The Hospice Plan of Care dated 01/25/2026 stated bathing (bed bath), dressing, foot care, hair care, medications: observe & remind, passive/active ROM [range of motion], perineal care, routine catheter care, shampoo once per week and per caregiver request, turn and position in bed, observe for change in condition, 2 patient identifiers used this visit, bleeding precautions, fall precautions, and oxygen precautions. The Hospice Plan of Care dated 02/04/2026 stated bathing (bed bath), clean nails, dressing, hair care, medications: observe & remind, oral care, perineal care, routine catheter care, shampoo once per week, skin care (lotion), turn and position in bed, change linens once per week, empty trash, indicate date of last BM, observe for change in condition, 2 patient identifiers used this visit, bleeding precautions, fall precautions every visit keep siderails up when patient is unattended, and oxygen precautions. The Hospice Aide Visit dated 01/28/2026 documented, "medications observe & remind completed: N [no] Note: NA [not applicable], routine catheter care completed: N Note: Pt do not have cath [catheter], passive/active ROM completed: N Note: N/A." The Hospice Aide Visit dated 01/30/2026 documented, "medications observe & remind completed: N Note: Daughter gives medications, shampoo completed: N Note: patient refused, routine catheter care completed: N Note: Pt do not have cath, passive/active ROM completed: N Note: patient refused." The Hospice Aide Visit dated 02/02/2026 documented, "medications observe & remind completed: N Note: Daughter gives medications, shampoo completed: N Note: patient refused, routine catheter care completed: N Note: Pt do not have cath, passive/active ROM completed: N Note: patient refused." The Hospice Aide Visit dated 02/09/2026 documented, "medications observe & remind completed: N Note: patient refuse, and routine catheter care completed: N Note: Pt do not have cath." The Hospice Aide Visit dated 02/18/2026 documented, "medications observe & remind completed: N Note: patient refuse, and routine catheter care completed: N Note: Pt do not have cath." The documentation lacked evidence that the aide had notified the registered nurse of changes to the plan of care. CLINICAL RECORD 7: The patient's date of election was 02/04/2026. The Hospice Plan of Care dated 02/04/2026 stated bathing (bed bath), clean nails, dressing, hair care, oral care, shampoo, skin care (lotion), turn and position in bed, change linens, empty trash, indicate date of last BM [bowel movement], fall precautions, and swallowing precautions. The Hospice Aide Visit dated 03/06/2026 documented, "shampoo completed: N Note: patient refused." The Hospice Aide Visit dated 03/11/2026 documented, "bathing (bed bath) completed: N Note: Caregiver provided care; shampoo completed: N Note: Caregiver provided care; oral care completed: N Note: Caregiver provided care; dressing completed: N Note: Caregiver provided care." The documentation lacked evidence that the aide had notified the registered nurse of changes to the plan of care. CLINICAL RECORD 19: The patient's date of election was 08/30/2026. The Hospice Plan of Care dated 08/31/2025 stated bathing (bed bath), dressing, routine catheter care, skin care (lotion), turn and position in bed, change linens once per week and per caregiver request, empty trash, empty urinal drainage bag, observe for change in condition, seizure precautions, gastrostomy tube precautions, oxygen precautions, swallowing precautions, wound precautions. The Hospice Aide Visit dated 12/10/2025 stated turn and reposition in bed, patient (bed bath), skin care (lotion), routine catheter care, dressing, empty trash, and change linens were documented as caregiver-provided care. The documentation lacked evidence that the aide had notified the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 03/13/2026, the Director of Operations (Personnel Record 1) confirmed that the hospice aide's documentation lacked notification to the registered nurse of the changes in the plan of care.

It is required that a patient's clinical record, containing past and current findings, is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, signed copies of the notice of patient rights and the hospice election statement. This standard was not met, as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure the patient's signed consents included the date of election. CLINICAL RECORD 5: The patient elected the hospice benefit on 10/29/2025. The consent forms, signed and dated 10/29/2025, had a space for the date of election, but the space was left blank. During a joint clinical record review and interview on 03/13/2026, the Director of Operations (Personnel Record 1) confirmed that the patient's signed consent lacked the hospice date of election.

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 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, interview, and observation. 1 of 4 (25%) home visit observations, the hospice did not ensure the drug profile contained the patient's current medications. Home Visit 1/Clinical Record 18: The patient elected hospice care on 9/7/2022 with skilled nurse visits twice weekly. During the home visit on 4/26/2023 with the Registered Nurse (RN), a medication reconciliation was performed comparing the medication profile dated 4/25/2023 with the medicine bottles in the home. The patient's daughter reported that the patient had issues with the gums. For the last four months, the patient has had three rounds of the antibiotic Amoxicillin, dated 1/15/2023, 2/9/2023, and most recently, 4/24/2023. The daughter stated the patient was taking Children's Motrin 100mg/5mL, 10mL by mouth daily as needed for oral/gum gingivitis pain. The medication Motrin was not listed on the patient's medication profile. The daughter said it was her third bottle of Children's Motrin over the last year. There was no evidence that the medication profile was updated to include Motrin. The RN confirmed the finding and updated the medication profile to include Motrin.

It is required that a hospice aide provides services that are ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation, and consistent with the hospice aide training. This standard was not met as evidenced by clinical record review, observation, and interview. 1 of 4 (25%) home visit observations of patients that accepted hospice aide services, the hospice did not ensure that the hospice aide provided services ordered by the Interdisciplinary Group, included in the plan of care. Home Visit 1: During the home visit on 4/26/2023 with the Registered Nurse, the patient's daughter stated that the hospice aide comes once or twice weekly and trimmed and filed the patient's nails. Nail care was not assigned on the aide care plan dated 3/8/2023. In an interview with the Administrator and Branch Director after the home, the Administrator confirmed the nail care task was not assigned on the care plan and additionally stated that the hospice aides were not allowed to trim/cut nails but were allowed to file.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes any advance directives. This standard was not met as evidenced by clinical record review and interview. 1 of 19 (5%) clinical records reviewed, the hospice did not ensure the clinical record contained an advance directive. Clinical Record 15: The patient with an election of hospice benefits dated 7/21/2022. The certification of terminal illness narrative signed 7/27/2022 by the Medical Director documented, "She is a DNR." The Plan of Care dated 7/21/2022 documented, "Advance Directives...Living Will." The Interdisciplinary Team (IDT) meeting dated 4/26/2023 and previous meetings documented the patient's advance directives as "Living Will and Comfort Measures only." The clinical record did not contain an advance directive. During the joint record review, the Administrator confirmed the Living Will and documentation of the patient's resuscitation wishes were missing from the clinical record.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes physician orders. This standard was not met as evidenced by clinical record review and interview. 1 of 7 (14%) clinical records reviewed of patients receiving wound care, the hospice did not ensure the clinical record included a physician’s order for the treatments provided. Clinical Record 12: The patient with an election of hospice benefits dated 1/23/2023 had a primary diagnosis of protein-calorie malnutrition. The Registered Nurse (RN) visit note dated 2/16/2023 documented, "Proximel applied to patient's coccyx, coccyx noted to have non-blanchable erythema and at risk of skin breakdown." The physician's order dated 2/16/2023 documented "foam border gauze to coccyx for skin integrity." The physician's order did not include the frequency of wound care or how often the foam border gauze should be changed. On 3/7/2023, the physician ordered "Baza protectant cream, apply to coccyx daily for skin integrity." The physician's order did not include evidence of the discontinuation or continuation of the foam border gauze." During the joint record review, the Administrator confirmed the finding and called the registered nurse, who stated the border foam gauze was discontinued and the protectant cream was the current treatment of the coccyx.