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

Based on observation, interview, policy and procedure it was determined the agency failed to ensure the staff performed proper hand hygiene per the agency's policy and procedure. This affected one of four home visits and had the potential to negatively affect all patients served by this agency. Findings Include: Agency Policy: Hand Hygiene Policy and Procedure Policy Number: HCP-034 Revised Date: 03/2020 Purpose: Effective hand hygiene reduces the incidence of healthcare-associated infections. Policy: All members of the healthcare team will follow the current Centers for Disease Control hand hygiene guidelines. Procedure: Indications for Handwashing: ...3. Handwashing may also be used for routine decontamination hands in the following clinical situations. Before having direct contact with patients... After contact with body fluid or excretions, mucous membrane, non-intact skin and wound dressings, even if hands are not visibly soiled. When moving from a contaminated body site to a clean body site during patient care... After removing gloves... --- HV #2 was admitted to the agency on 8/9/2022 with the diagnosis of Alzheimer's Disease Unspecified. An observation was conducted on 8/14/24 at 8:40 AM with Employee Identifier (EI) # 3, Hospice Aide (HA). During the visit EI # 3 washed the buttocks then, without performing hand hygiene and without changing gloves, applied clean bed linens to the bed and dressed HV # 2 in clean clothing. EI # 3 failed to perform hand hygiene after washing the buttocks. An interview conducted on 8/15/24 at 1:15 PM with EI # 1, Executive Director, confirmed the HA did not follow the policy and procedure for hand hygiene.

Based on review of the medical records (MR), interview, and the Alabama Board of Nursing Administrative Code; Documentation Standards, it was determined the agency failed to ensure the staff accurately documented in the patient chart. This affected one of 19 MR reviews and had the potential to negatively affect all patients served by this agency. Findings Include: ALABAMA BOARD OF NURSINGADMINISTRATIVE CODE 610-X-6-.06 Documentation Standards. (1) The standards for documentation of nursing care provided to patients by registered nurses and licensed practical nurses are based on principles of documentation regardless of the documentation format. (2) Documentation of nursing care shall be: (a) Legible.(b) Accurate.(c) Complete... --- MR # 4 was admitted to the agency on 1/12/24 with the diagnosis of Non Rheumatic Aortic Valve Stenosis. A review of six skilled nurse (SN) visit notes dated 7/23/24, 7/26/24. 7/30/24, 8/1/24, 8/5/24, and 8/12/24 revealed the RN documented the foley catheter was changed and Irrigated. On further review of the SN visit note dated 8/1/24 revealed a urinalysis was collected. An interview conducted on 8/15/24 at 12:39 PM with EI # 1, Executive Director confirmed the foley catheter changes and irrigations did not occur on any of the six dates listed in the MR, nor was a urinalysis collected on 8/1/24. EI # 1 confirmed the RN failed to document accurately in the MR

Based on review of medical records (MR), interviews, and policy and procedure, it was determined the agency failed to complete/electronically sign (esign) clinical notes per the agency's policy. This affected seven of 19 MR's reviewed including MR # 1, MR # 8, MR # 11, MR # 3, HV # 4, MR # 5, MR # 9 and had the potential to negatively affect all patients served by the agency. Findings Include: Agency Policy: Documentation / Charting Expectations Policy Number: HOP-043 Effective Date: 6/19/23 Policy: ...Clinical notes will be completed in a timely manner... ...Documentation (to include notes, orders, and updating medication profile) will be completed/esigned (electronically signed) within 72 hours after any patient contact. --- 5. HV # 4 was admitted to the agency on 6/22/23 with diagnoses including Senile Degeneration of the Brain Not Elsewhere Classified (NEC) and Dementia. Review of the MR revealed the following SN visit notes were not completed/esigned within 72 hours per policy: SN visit note dated 7/15/24 was esigned 7/26/24 which was 11 days later. SN visit note dated 7/17/24 was esigned 7/26/24 which was 9 days later. SN visit note dated 7/29/24 was esigned 8/14/24 which was 16 days later. SN visit note dated 7/31/24 was esigned 8/14/24 which was 14 days later. An interview conducted on 8/15/24 at 12:30 PM with EI # 1 confirmed the SN visit notes were not completed per policy. 6. MR # 5 was admitted to the agency on 1/23/23 with diagnoses including Senile Degeneration of Brain NEC and Syncope and Collapse. Review of the MR revealed the following SN visit notes were not completed/esigned within 72 hours per policy: SN visit note dated 7/17/24 was esigned 8/13/24 which was 27 days later SN visit note dated 7/22/24 was esigned 7/30/24 which was 8 days later. An interview conducted on 8/15/24 at 12:30 PM with EI # 1 confirmed the SN visit notes were not completed per policy. 7. MR # 9 was admitted to the agency on 7/17/24 with diagnoses including Multiple Myeloma Not Having Achieved Remission and Syncope and Collapse. Review of the MR revealed the following HA visit notes were not completed/esigned within 72 hours per policy: HA visit note dated 7/31/24 was esigned 8/11/24 which was 11 days later. HA visit note dated 8/2/24 was esigned 8/11/24 which was 9 days later. An interview conducted on 8/15/24 at 12:30 PM with EI # 1 confirmed the HA visit notes were not completed per policy. 4. MR # 3 was admitted to the agency on 7/6/24 with the diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of the MR revealed the following SN visit notes were not completed/esigned within 72 hours per policy. SN visit note dated 7/7/24 was esigned on 7/17/24 which was 10 days later. SN visit note dated 7/9/24 was esigned on 7/17/24 which was 8 days later. SN visit note dated 7/17/24 was esigned on 8/13/24 which was 27 days later. SN visit note dated 7/19/24 was esigned on 8/8/24 which was 20 days later. SN visit note dated 7/23/24 was esigned on 8/12/24 which was 20 days later. SN visit note dated 7/26/24 was esigned on 8/13/24 which was 18 days later. SN visit note dated 7/30/24 was esigned on 8/13/24 which was 14 days later. An interview conducted on 8/15/24 at 12:26 PM with EI # 1 confirmed the SN visit notes were not completed per policy. 2. MR # 8 was admitted to the agency on 7/11/24, and readmitted on 7/16/24 with a diagnosis of Malignant Neoplasm of Unspecified Part of Left Bronchus or Lung. Review of the MR revealed the following SN visit notes were not completed/esigned within 72 hours per the agency policy: SN visit note dated 7/12/24 was esigned on 8/4/24 which was 23 days later. SN visit note dated 7/13/24, 10:15 AM, was esigned on 8/4/24 which was 22 days later. SN visit note dated 7/13/24, 9:10 PM, was esigned on 8/5/24 which was 23 days. SN visit note dated 7/14/24 was esigned on 8/13/24 which was 30 days later. SN visit note dated 7/17/24 was esigned on 7/26/24 which was 9 days later. An interview conducted on 8/15/24 at 1:00 PM with EI # 1, Executive Director (ED) confirmed the SN visit notes were not completed per policy. 3. MR # 11 was admitted to the agency on 4/11/24 with a primary diagnosis of Unspecified Cirrhosis of the Liver. Review of the MR revealed the following SN visit notes were not completed/esigned within 72 hours after patient contact per the agency policy and procedure: SN visit note dated 4/12/24 was esigned on 5/10/24 which was 28 days later. SN visit note dated 4/19/24 was esigned on 4/30/24 which was 10 days later. SN visit note dated 4/23/24 was esigned on 5/16/24 which was 23 days later. SN visit note dated 4/26/24 was esigned on 5/6/24 which was 10 days later. SN visit note dated 4/29/24 was esigned on 5/6/24 which was 7 days later. SN visit note dated 5/1/24 was esigned on 5/9/24 which was 8 days later. SN visit note dated 5/3/24 was esigned on 5/21/24 which was 18 days later. SN visit note dated 5/7/24 was esigned on 6/17/24 which was 41 days later. SN visit note dated 5/8/24, 11:08 AM, was esigned on 6/19/24 which was 42 days later. SN visit note dated 5/8/24, 9:56 PM, was esigned 6/13/24 which was 36 days later. SN visit note dated 5/9/24 was esigned on 6/13/24 which was 35 days later. SN visit note dated 5/10/24 was esigned on 6/19/24 which was 40 days later. An interview conducted on 8/15/24 at 12:20 PM with EI # 1 confirmed the SN visit notes were not completed per policy. 1. MR # 1 was admitted to the agency on 4/2/24 with the diagnosis of Unspecified Severe Protein-Calorie Malnutrition. Review of the MR revealed the following skilled nurse (SN) and Hospice Aide (HA) visit notes were not completed/esigned within 72 hours per the agency policy: SN visit note dated 7/2/24 was esigned on 7/14/24 which was 12 days later. SN visit note dated 7/4/24 was esigned on 8/13/24 which was 40 days later. SN visit note dated 7/16/24 was esigned on 7/26/24 which was 10 days later. SN visit note dated 8/2/24 was esigned on 8/9/24 which was 7 days later. HA visit note dated 7/1/24 was esigned on 7/10/24 which was 9 days later. HA visit note dated 7/3/24 was esigned on 7/11/24 which was 8 days later. HA visit note dated 7/5/24 was esigned on 7/15/24 which was 10 days later. HA visit note dated 7/8/24 was esigned on 7/15/24 which was 7 days later. An interview conducted on 8/15/24 at 12:55 PM with EI (Employee Identifier) # 2, Clinical Nurse Manager (CNM) confirmed the SN and HA visit notes were not completed per policy.

Based on review of personnel files and staff interviews it was determined the agency failed to ensure background checks were conducted for all volunteers who have direct patient contact and/or access to Medical Records (MR). This had the potential to negatively affect all patients served by the agency. --- A review of the Volunteer Program was conducted on 8/14/24 at 3:30 PM with EI (Employee Identifier) # 11, Volunteer Coordinator. Review of the personnel records for 21 volunteers currently being utilized by the agency, who have direct patient contact and/or access to MR's, revealed no documentation of background checks. An interview conducted on 8/15/24 at 1:30 PM with EI # 1, Executive Director confirmed the agency failed to conduct background checks for volunteers per requirement.