Every finding on record at Eh Health Hospice of Alabama, LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and observation. In 4 of 27 (15%) clinical records reviewed, the agency did not ensure the plan of care included specific patient interventions that were developed based on the problems identified in the initial and updated comprehensive assessments. Clinical Record 2: The patient elected hospice care on 6/1/22. The hospice physician documented in the Interdisciplinary Group (IDG) note dated 7/19/23, "Pt (patient) taking Norco more often now to control pain. Ordered Nitro-Glycerin tablets for chest pain." The comprehensive assessment dated 8/22/23 documented, " During the visit or in the last 24 hours, has the patient verbalized or demonstrated any symptoms of pain...yes." The patient rated the pain at 7 out of 10 (10 being the worst). The plan of care (POC), effective 6/1/2022 through the present, documented "alteration in comfort" as a problem. The POC did not include documentation of goals or interventions for the identified problem. Clinical Record 5: The patient elected hospice care on 10/5/22. The comprehensive assessment completed by the Registered Nurse (RN) on 8/3/23 documented the patient's pain level at 9 out of 10 (10 being the worst pain), and the patient was using Gabapentin as the scheduled pain medication, and Oxycodone was used in the last 24 hours for breakthrough pain. The POC, effective 8/1/23 through present, did not include documentation of problems, goals, or interventions related to the patient's pain and comfort. Clinical Record 9: The patient elected hospice care on 6/7/23. The initial comprehensive assessment dated 6/7/23 documented, "The patient's fall score is 6. Based on the total score, the risk for falls is moderate, so consider adding safety interventions to POC (plan of care)." The updated comprehensive assessment dated 8/17/23 documented the patient fell. The POC, effective 6/7/23 through the present, did not include documentation of problems, goals, or interventions related to the patient's safety and fall prevention. Clinical Record 12: The patient elected hospice care on 6/23/23. The comprehensive assessment completed by the RN on 7/12/23 documented, "Right foot is not as painful it is still slightly red and swollen and scaly. She states she is tolerating the antibiotics well." The coordination note dated 8/15/23 documented that the patient was seen in the emergency room for "Ischemic necrosis of right foot. Foot swollen and purple with skin peeling...started on Bactrim 800mg BID (twice daily) and Cephalexin 500 mg BID 'right foot infection." The plan of care, effective from 6/23/23 to the present, did not identify problems, goals, or interventions related to the patient's circulatory issue or infection. During a joint review of the clinical records and interviews on 8/25/23, the Director of Operations and Administer confirmed the plans of care were not individualized to meet the specific needs of these patients.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 24 (4%) clinical records reviewed of patients receiving hospice aide services, the agency did not ensure the hospice aide care plan provided specific care instructions, thus leaving the aide to make decisions outside the scope of practice. Clinical Record 20: The patient elected hospice care on 6/17/23. The initial comprehensive assessment completed by the Registered Nurse (RN) on 6/17/23 documented that the patient was admitted with a PEG (percutaneous endoscopic gastrostomy) tube. The Interdisciplinary Group (IDG) meeting note dated 8/16/23 documented, "Has PEG tube in place but no longer in use." The Hospice aide care plan, effective 6/17/23 to present, assigned the Hospice aide the tasks: bed bath, and dressing every visit. The Hospice aide care plan did not include documentation alerting the aide that the patient had a PEG tube and did not include instructions on what, if any, care the hospice aide should provide for the PEG tube site/dressing during personal care. During an interview on 8/25/23, the Director of Operations (DO) and the Administrator confirmed that the aide care plan should have included information for the aide to be aware that the patient had a PEG tube in place.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed of discharged patients requiring a discharge summary be sent to the attending physician, the hospice did not ensure that the patient’s attending physician received a copy of the discharge summary. Clinical Record 21: The patient elected hospice care on 1/13/22 and was discharged from hospice services for an extended prognosis on 5/5/23. The coordination note dated 4/27/23 documented that the patient's son would make an appointment with the patient's attending physician, whom the patient used before hospice services. A clinical record review revealed documented evidence that the hospice physician received a copy of the discharge summary. There was no documented evidence that the receiving, attending physician was provided with a copy of the hospice discharge summary. During an interview on 8/24/23, the Director of Operations reported that, per the Branch Manager, "They only sent the copy to the hospice physician."

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed, the agency did not ensure that all planned interventions for problems identified on the comprehensive assessment were documented on the plan of care. Clinical Record 4: The patient was admitted on 04/21/2023 with a diagnosis of Protein Calorie Malnutrition. A bladder stimulator was not working, and the Medical Director was contacted for orders for a Foley catheter. The skilled nurse visit to place a Foley catheter was unsuccessful. The patient was approved by the hospice to visit the emergency room for placement of the urinary catheter which was successful. The nurse visited on 04/22/2023 with instructions for Foley catheter management. The catheter remained in place until death 05/17/2023 when it was removed. The plan of care was not updated with interventions for the Foley catheter prior to death. An interview with the Administrator and Alternate Administrator revealed that there were no documented interventions for the catheter that was placed. The patient did not have any infections during care.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that clear and specific written instructions were provided for the aide assignment, thus leaving the aide to make decisions outside the aide's scope of practice. Clinical Record 4: Patient admitted 04/21/2023 diagnosed with Protein Calorie Malnutrition, and the Plan of Care ordered aide visits thrice a week. A physician's order for a Foley catheter was obtained later on 04/21/2023 and placed late on 04/21/2023. The Foley was removed during the death visit on 05/17/2023. The aide plan of care was updated on 04/23/2023 and 05/11/2023 but was not updated to include care instructions for the Foley catheter care. An interview with the Administrator and Alternate Administrator revealed that the aide plan had not been updated to include the Foley catheter care.