Every finding on record at Cullman Regional, Inc.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the organization did not ensure all requirements related to a comprehensive assessment were implemented. For example, during a review of the medical record(s) for RRNHV#4, and RRNHV#5, it was noted that the comprehensive assessment did not include the initial bereavement risk assessment. This observation was reviewed with the Director of Homecare and Hospice.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients discharged from the organization, it was noted that the discharge summary did not include all required information. For example, a review of the discharge summary for RRDC#1, revealed that the discharge summary did not include a summary of the patient's stay, including treatments, symptoms, and pain management; the patient’s current plan of care, the patient’s latest physician’s order, and information that would assist in post-discharge continuity of care. This observation was reviewed with the Hospice Clinical Manager.

Observed in Individual Tracer. During 3 of 3 Individual Tracers, the Hospice Surveyor was not able to validate that a plan to provide education regarding procedures to follow if care, treatment, or services are disrupted by a natural disaster or an emergency was established. For example, during a review of patient education information in the home for RRHV#1, RRHV#2, and RRHV#3, an individualized disaster/emergency management plan was not identified. This observation was reviewed with the Director of Homecare and Hospice.

Based on review of medical records (MR), hospice policy and procedure, and interviews, it was determined the hospice failed to ensure all patients/families received an initial bereavement assessment. This affected two of fourteen records reviewed including Home Visit (HV) # 2 and MR # 9 and had the potential to negatively affect all patients/families served by the agency. Findings include: Agency Policy: Hospice Bereavement Services Policy Number: HC/HOS-120-1207.01 Revised Effective Date: 6/2019 Purpose: To ensure that appropriate and coordinated bereavement services are provided to families/caregivers. Policy: Hospice of Cullman county will provide an organized bereavement program for at least thirteen months following the death of a patient... The program will provide bereavement services to the families/caregivers of Hospice patients both before and after the patient's death... Procedure: I. A bereavement assessment will be completed by the Chaplain or Medical Social Worker within five days of patient's admission into the hospice program and within five weeks after the patient's death... --- 1. HV # 2 was admitted to the hospice agency on 6/24/2024 with the diagnosis of Senile Degeneration of the Brain, Not Elsewhere Classified. A review of the MR revealed no documentation an initial bereavement assessment was completed. An interview was conducted on 7/25/24 at 2:31 PM with Employee Identifier (EI) # 1, Hospice Director, who confirmed there was no documentation an initial bereavement assessment was completed. 2. MR # 9 was admitted to the hospice agency on 1/9/24 with a diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the MR revealed no documentation an initial bereavement assessment was completed. An interview was conducted on 7/25/24 at 2:15 PM with EI # 1 who confirmed there was no documentation an initial bereavement assessment was completed.

Based on a review of medical records (MR), policy and procedure, and staff interviews, it was determined the agency failed to ensure the interdisciplinary team (IDT) met to develop and update the plan of care (POC) and review the effectiveness of care a minimum of every fifteen days. This deficient practice affected nine of ten MRs reviewed including Home Visit (HV) # 2, MR # 4, MR # 5, MR # 2, MR # 6, MR # 7, MR # 9, HV # 3, and MR # 3, and had the potential to negatively affect all patients admitted to the agency. Findings include: Agency Policy: Hospice Interdisciplinary Coordination of Care Policy Number: HC/HOS-120-1203.01 Date Revised: April 2021 Purpose: To ensure the coordination of services for each patient. Policy: Cullman Regional Hospice will utilize a case management system to provide comprehensive, coordinated health care to patients/clients serviced by the agency... Procedure: ...V II: The IDT will conduct assessments, develop and update the POC, and review the effectiveness of care a minimum of every 15 days... --- 8. HV # 3 was admitted to hospice services on 6/20/24 with a diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/25/24 and the next IDT meeting was on 7/12/24, 17 days later. An interview was conducted on 7/25/24 at 2:32 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days. 9. MR # 3 was admitted to hospice services on 5/20/24 with a diagnosis of Malignant Neoplasm of the Colon, Unspecified. Review of the following IDT Meeting Notes revealed IDTs were not conducted every 15 days as required: a. An IDT meeting was conducted on 5/28/24 and the next IDT meeting was on 6/14/24, 17 days later. b. An IDT meeting was conducted on 6/25/24 and the next IDT meeting was on 7/12/24, 17 days later. An interview was conducted on 7/25/24 at 1:46 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days. 1. HV # 2 was admitted to the hospice on 6/24/24 with a diagnosis of Senile Degeneration of Brain, not Elsewhere Classified. A review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/25/24. The next IDT Meeting was conducted on 7/12/24, 17 days later. An interview was conducted on 7/25/24 at 2:31 PM with Employee Identifier (EI) # 1, Hospice Director, who confirmed the agency failed to ensure the IDT met a minimum of every fifteen days. 2. MR # 4 was admitted to the hospice on 5/30/24 with a diagnosis of Hypertensive Heart Disease with Heart Failure. A review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/18/24. The next IDT meeting was conducted on 7/5/24, 17 days later. An interview was conducted on 7/25/24 at 2:04 PM with EI # 1, who confirmed the agency failed to ensure the IDT met a minimum of every fifteen days. 3. MR # 5 was admitted to the hospice on 6/16/24 with a diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. A review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/18/24. The next IDT meeting was conducted on 7/5/24, 17 days later. An interview was conducted on 7/25/24 at 2:51 PM with EI # 1, who confirmed the agency failed to ensure the IDT met a minimum of every fifteen days. 4. MR # 2 was admitted to the hospice on 3/1/24 and recertified from 5/30/24 to 8/27/24 with a diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. Review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/25/24 and the next IDT meeting was on 7/12/24, 17 days later. An interview was conducted on 7/25/24 at 2:17 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days. 5. MR # 6 was admitted to the hospice on 3/26/24 and recertified from 6/24/24 to 9/21/24 with a diagnosis of Malignant Neoplasm of Unspecified Site of Unspecified Female Breast. Review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/25/24 and the next IDT meeting was on 7/12/24, 17 days later. An interview was conducted on 7/25/24 at 2:23 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days. 6. MR # 7 was admitted to the hospice on 4/23/23 and recertified from 6/16/24 to 8/14/24 with a diagnosis of Acute and Chronic Respiratory Failure With Hypoxia. Review of the IDT Meeting Notes revealed an IDT meeting was conducted on 6/18/24 and the next IDT meeting was on 7/5/24, 17 days later. An interview was conducted on 7/25/24 at 2:12 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days. 7. MR # 9 was admitted to the hospice on 1/9/24 with a diagnosis of Chronic Obstructive Pulmonary Disease Unspecified. Review of the IDT Meeting Notes revealed an IDT meeting was conducted on 1/23/24 and the next IDT meeting was on 2/9/24, 17 days later. An interview was conducted on 7/25/24 at 2:15 PM with EI # 1 who confirmed the agency failed to ensure the IDT met a minimum of every 15 days.

Based on review of personnel files, agency policy and procedure, and interview it was determined the hospice failed to document an ongoing assessment of skills/competency for all staff providing care. This deficient practice affected one of one registered nurse (RN) personnel files reviewed, including Employee Identifier (EI) # 2, RN, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Ongoing In-service and Education of the Home Care/Hospice Staff Policy Number: HC/HOS-120-407.01 Revised Date: 04/2022 Purpose: To provide ongoing education to all staff so that they may ensure a current knowledge base for providing quality patient care. Policy: Each employee is to participate in ongoing in-service...to maintain skills necessary to do their jobs. Procedure: I. In-service or Continuing Education Programs A. Each employee is to participate in ongoing in-services or continuing education programs as appropriate to maintain skills necessary to perform their respective jobs. B. Each employee is to participate in ongoing in-services...based on individually identified needs. ...D. Documentation of in-service/continuing education program attendance is to be documented and placed in the individual's personnel file... --- 1. A review of the personnel file for EI # 2, RN, was conducted on 7/25/24. The review revealed documentation an assessment of skills/competency was performed at time of hire, 8/1/22. There was no other documentation of assessment of skills/competency. An interview was conducted on 7/25/24 at 1:35 PM with EI # 1, Hospice Director, who confirmed skills/competency was to be assessed annually, and there was no documentation of an assessment of competency for EI # 2 in 2023.

Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice agency failed to ensure the skilled nurse (SN) accurately documented wound assessments. This deficient practice affected Home Visit (HV) # 3, one of five MRs reviewed with a wound, and had the potential to negatively affect all patients with wounds serviced by the hospice agency. Finding include: Agency Policy: Skin and Wound Care Policy Number: HC/HOS-120-1016.01 Reviewed Date: 08/2018 Procedure: ...V. Full assessment and documentation of wounds will be done at each SN visit. VI. Measurements of wounds will be performed and recorded weekly. VII. Wound documentation will include: A. Wound size - length _ cm (centimeters) x (by) width _ cm x depth _ cm B. Wound tunneling or undermining of wound will be measured using a clock face as a guide, i.e. "tunneling noted from 10 to 2 o'clock." --- 1. HV # 3 was admitted to hospice services on 6/20/24 with a diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Review of the 6/20/24 SN admission assessment documentation revealed HV # 3 had a stage 2 (open) pressure wound to the coccyx. Further review revealed the SN documented the measurements of the wound as 1.3 x 0.3 cms. There was no documentation of the depth of the wound. Review of the SN wound assessments for visits on 6/26/24, 7/8/24, 7/10/24, 7/17/24 and 7/19/24 revealed the SN documented length and width of the coccyx wound, but did not document the depth. Review of the SN wound assessment documentation for visits made 7/10/24 and 7/17/24 revealed the SN documented HV # 3 had undermining and tunneling present. The SN failed to document the location of the undermining and tunneling as directed in the agency policy. Review of the 7/19/24 SN wound assessment documentation revealed the SN failed to document the presence of undermining and tunneling. An interview was conducted on 7/25/24 at 2:32 PM with Employee Identifier # 1, Hospice Director, who confirmed the SN failed to document the wound assessments as directed in the agency policy.