Every finding on record at Chattahoochee Hospice Inc

Based on Medical Records (MR), observations, agency policy and procedures, it was determined the agency failed to ensure the staff maintained a current and accurate medication profile for each patient per the agency's policy. This affected two of four Home Visits (HV), including HV # 1, HV # 3, and has the potential to negatively affect all patients served by this agency.Findings include:Agency Policy: Medication ProfilePolicy Number: PC.M60Revision date: NonePolicy:A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days.Procedures:1. When a patient is admitted to hospice, a medication profile is initiated to document all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatment that could affect drug therapy... 4. The patient's medication profile review includes...a. determining accuracy and completeness of the profile...c. ensuring appropriateness of the medication...e. determining if there are medications that have been or may be discontinued... --- 2. HV # 3 was admitted to the agency on 5/31/25 and recertified from 8/29/25 to 11/26/25 with the terminal diagnosis of Heart Disease Unspecified.A HV was conducted on 10/21/25 at 12:00 PM to observe care provided by EI # 6, Licensed Medical Social Worker.During the visit, the agency medication profile was compared to HV # 3's medications observed in the home with the following discrepancy.Hydroxyzine Hydrochloride 25 mg tablet, take one tablet every eight hours as needed for itching, filled on 9/29/25 was observed in the home and not on the medication profile provided. The caregiver stated, " the patient takes the medication as needed for itching and last Friday was the last time the medication was taken."An interview was conducted on 10/23/25 at 2:45 PM with EI # 2, Nurse Practitioner, who confirmed the medication profile was not reconciled per the agency policy and procedure.   1. HV # 1 was admitted to the agency on 12/28/24 and recertified from 8/25/25 to 10/23/25 with a terminal diagnosis of Alzheimer's Disease with Late Onset.A HV was conducted on 10/21/2025 at 1:00 PM to observe care provided by Employee Identifier (EI) # 3, Clinical Coordinator.During the home visit, EI # 3 reviewed the medications with HV # 1's caregiver and compared the medications with the agency medication list. The following is a list of discrepancies:Seroquel 100 milligrams (mg) take one tablet by mouth every night; take one tablet by mouth every night at bedtime (in addition to 50 mg every morning). HV # 1's caregiver stated patient had not been taking the medication "for awhile."Eliquis 2.5 mg take one tablet every day, prescription dated 6/5/25, was in the home but not on the medication list. HV # 1's caregiver stated patient was currently taking daily.Levothyroxine 150 micrograms take one tablet every day, prescription dated 4/9/25, was in the home but not on the medication list. HV # 1's caregiver stated patient was currently taking daily.Zofran Hydrochloric 4 mg one tablet every six hours as needed for nausea, vomiting, prescription dated 7/10/25, was in the home but not on the medication list. HV # 1"s caregiver stated patient took the medication as needed.An interview was conducted on 10/23/25 at 3:18 PM with EI # 1, Administrator, who confirmed the medications were not reconciled per agency policy and procedure.

Based on medical record (MR), agency policy and procedure, and interviews it was determined the agency failed to ensure an initial Bereavement Risk Assessment was completed for each patient and family.This did affect two of 19 MRs reviewed, including MR # 12, and MR # 15, and has the potential to negatively affect all patients and families served by the agency. Findings include:Agency Policy: Bereavement Risk AssessmentPolicy Number: PC.B25Date: NonePolicy:Hospice patients and family members, caregivers and significant others are assessed for grief and bereavement needs before and after the patient's death. 1. During the comprehensive assessment of the patient, an initial bereavement assessment is conducted to determine the cultural, social and spiritual factors that may impact the ability of family members or other involved individuals to cope with the patient's death. 2. Findings from the initial bereavement assessment are incorporated into the patient's Plan of Care (POC) and considered in the bereavement POC... --- A review of the initial assessments completed by the social workers and chaplains revealed no documentation of an initial bereavement risk assessment for MR # 12, was admitted on 8/6/24, and MR # 15, was admitted on 10/4/2024, per agency policy.An interview was conducted 10/23/25 at 2:05 PM with Employee Identifier # 1, Administrator, who confirmed there was no documentation the initial bereavement risk assessment was completed and incorporated into the patient's POC or the Bereavement POC.

Based on observation, agency policy and procedure, and staff interview it was determined the agency failed to ensure the staff followed the agency's policy regarding infection control.This affected one of four home visits (HV), HV # 2 and has the potential to affect all patients served by this agency.Findings include:Agency policy: Infection Control-Hand Hygiene.Policy number: PC.125Revision date: None listed.Policy: Chattahoochee Hospice Inc. follows hand hygiene guidelines recommended by the Centers for Disease Control and the World Health  Organization. Procedure: Hospice staff must wash hands:a. before touching a patient...c. after performing tasks that may involve risk of exposure to body fluids;d. after touching a patient;e. before and after wearing gloves; and f. after any activity involving physical contact with a patient's immediate environment.. --- 1. HV # 2 was admitted to the agency on 10/31/24 with a terminal diagnosis of Heart Failure.       An observation was performed on 10/22/25 at 7:45 AM  with Employee Identifier (EI) # 5, Hospice Aide to observe care provided during a shower.EI # 5  performed hand hygiene, then obtained gloves from his/her pocket. and donned gloves to perform patient care. EI # 5 then removed the gloves after helping the patient with toileting, and failed to perform hand hygiene prior to putting on a new pair. EI # 5 used the second pair of gloves throughout the remainder of the patient care to include shower, shampoo, dressing, and applying lotion. An interview was conducted on 10/23/25 at 1:37 PM with EI # 1, Administrator, who confirmed the staff failed to follow the agency's policy and procedure for hand hygiene.

Based on review of medical records (MR), agency policy and procedure, the Alabama Board of Nursing Administrative Code and Standards of Nursing Practice, and staff interview, it was determined the agency failed to ensure the nursing staff received the pronouncement of death via telecommunication with the physician as directed by the Alabama Board of Nursing.This affected two of three MR's reviewed for death, including MR # 13 and MR # 15. This also affected two of three unsampled on-call visits and this deficient practice has the potential to affect all patients admitted to this agency.Findings include:Agency Policy: Death of a Hospice PatientPolicy Number: PC.D10Revised Date: NonePolicy:Members of the hospice's interdisciplinary group are available to attend patient deaths 24 hours a day, 7 days a week.Procedures:...4. The patient's death is pronounced, documented and communicated in accordance with State laws and regulations.Alabama Board of Nursing Administrative Code Chapter 610-X-6Standards of Nursing Practice610-X-6-.15 Telecommunication For Pronouncement of Patient Death(1) The licensed nurse may receive pronouncement of a patient's death from a physician via telecommunication without a physical examination of the patient by that physician.(2) The facility policy shall specify the permissible patient conditions for which the licensed nurse in a specific health care facility or agency may receive the pronouncement of a patient's death by telecommunication.Author: Alabama Board of NursingStatutory Authority: Code of Ala. 1975, SS22-31-2, 34-21-2 (c) --- 4. MR # 15 was admitted 10/4/2025 with a terminal diagnosis of Cerebrovascular Accident/Disease.Review of the Discharge Summary Visit dated 10/23/24 revealed the RN documented the patient was unresponsivewith the absence of vital signs upon arrival. The RN further documented the pronouncement of death at 11:20 PM.Further review of the Discharge Summary Visit note revealed the physician was notified of the patient's death at 11:26 PM,six minutes after the pronouncement of death.An interview was conducted on 10/23/25 at 2:05 PM with EI # 1, who confirmed staff failed to follow the agency policy for the pronouncement of death as required by the Alabama Board of Nursing. 1. MR # 13 was admitted on 7/24/25 with a terminal diagnosis of Sarcopenia. Review of the Discharge Summary Visit dated 9/7/25 revealed the Registered Nurse (RN) documented, "Patient pronounced at 10:18 AM ... by hospice RN." Further review revealed no receipt of a pronouncement of death by a physician was received by the RN.An interview was conducted on 10/23/25 at 3:03 PM with EI # 1, Administrator who confirmed staff failed to follow the agency policy for the pronouncement of a death as required by the Alabama Board of Nursing.2. Review of unsampled patient one from the on-call log dated 10/5/25 at 7:58 AM revealed a call was received by the agency with a message, "Patient is non-responsive. Needing nurse." Review of the Discharge Summary visit dated 10/5/25 revealed the RN documented, "Patient pronounced at 12:45 AM ... by hospice RN." Further review revealed no receipt of pronouncement of death by a physician was received by the RN.An interview was conducted on 10/23/25 at 3:20 PM with EI # 8, Billing and Medical Records, who confirmed staff failed to follow the agency policy for the pronouncement of a death as required by the Alabama Board of Nursing.3. Review of an unsampled patient # 2 from the on-call log dated 9/11/25 at 8:52 PM revealed a call was received by the agency with the message, "believes patient has passed. Need the nurse to come out."Review of the Discharge Summary visit dated 9/11/25 at 9:30 PM revealed no documentation the physician pronounced the patient's death. An interview was conducted on 10/23/25 at 3:20 PM with EI # 8, Billing and Medical Records, who confirmed staff failed to follow the agency policy for the pronouncement of a death as required by the Alabama Board of Nursing.

Based on medical record (MR) review and staff interview, it was determined the agency failed to ensure the hospice aide (HA) was supervised at least every 14 days. This did affect four of 16 MRs reviewed of patients receiving HA services including Home Visit (HV) # 4, MR # 15, HV # 2, MR # 11 and had the potential to negatively affect all patients receiving HA services.Findings include: --- 4. MR # 11 was admitted to the agency on 7/1/25 with a terminal diagnosis of Chronic Respiratory Failure with Hypoxia.A review of the POC dated 7/1/25 revealed an order for the Hospice Aide one time a week for one week, then two times a week.A review of the NVR dated from 7/1/25 to 9/28/25 revealed no documentation of a hospice aide supervisory visit.An interview was conducted on 10/23/25 at 3:03 PM with EI # 4, Nurse Practitioner, who confirmed no supervisory visit was completed 7/1/25 to 9/28/25. 3. HV # 3 was admitted on 10/31/24 with a terminal diagnosis of Heart Failure.A review of the POC dated 8/4/25 revealed an order for hospice aide two times a week.A review of the Nursing Visit Record (NVR) dated 8/27/25 to 10/23/25 revealed no documentation of a hospice aide supervisory visit.An interview was conducted on 10/23/25 at 1:37 PM with EI # 4, Nurse Practitioner, who confirmed no hospice aide supervisory visit was completed 8/27/25 to 10/23/25.   1. HV # 4 was admitted to the agency on 1/4/25 with a terminal diagnosis of Alzheimer's Disease with Late Onset.A review of the Plan of Care (POC) dated 9/1/25 revealed skilled nurse (SN) frequency of one time a week and HA frequency of two times a week.A review of the Nursing Visit Record (NVR) from 9/4/25 to 10/13/25 revealed no documentation of a HA supervisory visit every 14 days.An interview was conducted on 10/23/25 at 3:20 PM with Employee Identifier (EI) # 1, Administrator who confirmed there was no documentation of HA supervisory visits completed  9/4/25 to 10/13/25. 2. MR # 15 was admitted to hospice on 10/4/24 with a terminal diagnosis of Cerebrovascular Accident/Disease. A review of the POC dated 10/4/24 for MR # 15 revealed orders for SN two times a week and HA three times a week.A review of the NVR from 10/4/24 to 10/23/24 revealed no documentation of a HA supervisory visit every 14 days. An interview was conducted on 10/23/25 at 2:05 PM  with EI # 1 who confirmed no supervisory visit was completed 10/4/24 to 10/23/24.

Based on observations, agency policy and procedure and interview with the staff it was determined the agency failed to ensure the medication profile was complete and accurate for one of three observations conducted. This affected Home Visit (HV) # 2 and had the potential to negatively affect all patients served by the agency. Findings include: Policy: Medications - Profile Number: PC.M60 Date: Not documented Policy: A patient-specific medication profile is maintained for each patient and reviewed, at a minimum, every fifteen days. Procedures: 4. The patient's medication profile review includes, but is not limited to: a. determining accuracy and completeness of the profile... --- 1. HV # 2 was admitted to the agency on 10/24/18 with diagnoses including Amyotrophic Lateral Sclerosis and Muscle Weakness, Generalized. A HV was conducted on 2/14/23 at 2:27 PM with Employee Identifier (EI) # 3, Registered Nurse, to observe wound care. The agency Med (Medication) Sheet, printed by the agency on 2/14/23, was compared to the medications in the home and verified by the patient. The following medication discrepancies were found in the home and verified by the patient via typing on an electronic tablet. Astaxanthin 4 mg (milligrams) one capsule daily was observed in the home, which the patient typed has been the dosage since 12/14/21. Review of the agency med sheet revealed documentation of Astaxanthin 12 mg one capsule daily. Tramadol 50 mg one tablet every six hours as needed for pain was documented on the agency med sheet. The patient typed Tramadol was discontinued in August 2022. DuoNeb one inhalation twice daily and every four hours as needed for shortness of breath was documented on the agency med sheet. The patient typed DuoNeb was discontinued two months ago. Colloidal Silver 300 mcg (micrograms) two teaspoons daily was observed in the home, which the patient typed he/she has been taking for six months. There was no documentation of the Colloidal Silver on the agency med sheet. Tamiflu 75 mg one tablet twice daily for five days was documented on the agency med sheet. The patient typed Tamiflu was discontinued on 12/20/22. Bactrim DS (Double Strength) one tablet at bedtime was documented on the agency med sheet. The patient typed Bactrim DS was discontinued on 1/26/23. An interview was conducted on 2/16/23 at 12:37 PM with EI # 2, Clinical Coordinator, who confirmed the staff failed to ensure the med sheet was complete and accurate for HV # 2.

Based on medical record (MR) review, agency policy and procedure and staff interview, it was determined the agency failed to ensure all interventions needed for patient care were included in the patient's plan of care and a goal identified. This affected one of one record reviewed of a patient with a Foley catheter, including Home Visit (HV) # 2, and had the potential to negatively affect all patients served by the agency with a Foley catheter. Findings include: Agency Policy: Plan of Care - Content Number: PC.P45 Date: Not documented Policy: The plan of care reflects patient and family goals and interventions that are based on the problems identified... Procedure: ...2. The plan of care includes, but is not limited to: ...c. measurable outcomes anticipated from implementing...the plan of care; d. ...treatments necessary to meet the needs of the patient... --- 1. HV # 2 was admitted to the agency on 10/24/18 with diagnoses including Amyotrophic Lateral Sclerosis and Muscle Weakness, Generalized. Review of three Skilled Nursing (SN) notes, dated 1/31/23 to 2/14/23, revealed documentation of a Foley catheter which was last changed on 1/19/23 by the SN. Review of the Plan of Care/Comprehensive Assessment Update dated 2/8/23 revealed no documentation of a Foley catheter intervention and goal. During a HV conducted on 2/14/23 at 2:27 PM with Employee Identifier (EI) # 3, Registered Nurse, a Foley catheter was observed in use by the patient. An interview was conducted on 2/16/23 with EI # 2, Clinical Coordinator, who verbalized the patient had required the use of a catheter since 10/6/22 and there was no documentation of an intervention and goal on the patient's plan of care for the catheter.

Based on review of agency policy and procedure, medical records (MR) and interviews it was determined the agency failed to ensure the Plan of Care contained the the scope and frequency for all disciplines. This affected two of 13 records reviewed including MR # 4, MR # 9 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Plan of Care - Content Number: PC.P45 Date: Not documented ...Procedure: ...2. The plan of care includes, but is not limited to: ...b. a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs... --- 1. MR # 4 was admitted to the agency on 1/15/23 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Dyspnea, Unspecified. Review of the Volunteer Coordinator Progress Note dated 1/23/23 revealed documentation the patient was "...receptive to volunteer visiting...when in the facility." Review of the Plan of Care/Comprehensive Assessment Update dated 2/8/23 revealed no documentation of the scope and frequency of the volunteer discipline. An interview was conducted on 2/16/23 at 12:26 PM with Employee Identifier (EI) # 2, Clinical Coordinator, who confirmed there was no documentation of the scope and frequency for the volunteers on the patient's Plan of Care. 2. MR # 9 was admitted to the agency on 8/12/22 with diagnoses including Unspecified Cirrhosis of Liver and Essential (Primary) Hypertension. Review of the Plan of Care/Comprehensive Assessment - Initial dated 8/12/23 revealed no documentation of the scope and frequency of the chaplain discipline. Review of the Spiritual Care Visit Record - Initial Assessment dated 8/16/22 revealed documentation a chaplain visit was performed and plan to continued chaplain visit once a month. An interview was conducted on 2/16/23 at 12:08 PM with EI # 2, who confirmed there was no documentation of the scope and frequency for the chaplain on the patient's Plan of Care.

Based on medical record review, observation, and interview with staff, it was determined the agency failed to follow physician orders for wound care. This affected Home Visit (HV) # 2, one of three observations of care, and had the potential to negatively affect all patients with wounds served by the agency. Findings include: --- 1.HV # 2 was admitted to the agency on 10/24/18 with diagnoses including Amyotrophic Lateral Sclerosis and Muscle Weakness, Generalized. Review of the Plan of Care/Comprehensive Assessment Update dated 2/8/23 revealed documentation of a wound care intervention as "clean area to buttocks/sacrum with warm soapy water, pat dry, apply betadine daily, allow to dry then apply zinc ointment..." A HV was conducted on 2/14/23 at 2:27 PM with Employee Identifier (EI) # 3, Registered Nurse, to observe wound care. EI # 3 cleaned the wound to the buttocks with a wipe then applied a pressure sore relief cream, which did not contain zinc, to the wound. EI # 3 failed to clean the wound with warm soapy water, pat dry, apply betadine and zinc ointment. An interview was conducted on 2/16/23 at 12:37 PM with EI # 2, Clinical Coordinator, who confirmed EI # 3 failed to follow the physician's order for wound care to the buttock wound.