Every finding on record at First Choice Hospice, LLC

Based on the review of medical records (MR), policy and procedure, observations, and interviews, it was determined the agency failed to ensure a current, accurate medication profile was available in the MR. This affected one of three home visits (HV), including HV # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Policy: Medication ProfilePolicy Number: 2-004Purpose: To define the use of the medication profile in evaluating a patient's medication regimen.Policy: Patients receiving medications... will have a current, accurate medication profile in the medical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.Procedure:  1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen... 2. A drug regimen review will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication... 3. During subsequent HVs, the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians, understand the medication regimen...      5. Based on review of the medication profile... changes in the plan of care may be required... 7. Deviations from taking medications as ordered will be documented in the MR, and the physician... will be notified. --- HV # 2 was admitted to the agency on 5/28/25 with the primary diagnosis of Hypertensive Heart Disease with Heart Failure. A HV was conducted on 7/23/25 at 9:20 AM with Employee Identifier (EI) # 3, Hospice Aide, to observe care provided in the home. During the HV, the surveyor and the caregiver (CG), reviewed the Client Medication Report (CMR). The following discrepancies were observed:Allopurinol 300 milligram (mg) tablet, take 1 tablet by mouth (PO) daily, was available in the home and was listed as current on the CMR. The CG stated that HV # 2 has not taken the medication for "a couple of months."Atorvastatin 80 mg tablet, take 1 tablet PO daily, was available in the home. The medication was listed as discontinued on the CMR but the CG stated HV # 2 still takes it daily. An interview was conducted on 7/24/25 at 12:11 PM with EI # 1, Manager of Regulatory Compliance and Accreditation, who confirmed the CMR was not current or accurate.

Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to provide education to the patient/caregiver (cg) for new medications ordered. This deficient practice affected Home Visit (HV) # 1, one of seven active records reviewed, and had the potential to affect all patients served by this hospice.Findings include: Policy: Medication ProfilePolicy Number: 2-004Purpose:To define the use of the medication profile in evaluating a patient's medication regimen.Policy:Patients receiving medications... will have a current, accurate medication profile in the medical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.Procedure: 1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen... 2. A drug regimen review will be performed... with the addition of a new medication... 3. During subsequent HVs, the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians, understand the medication regimen.  This includes but will not be limited to:...B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications. --- HV # 1 was admitted to the agency on 3/21/25 with a primary diagnosis of End Stage Heart Failure.Review of the Hospice Recertification and Plan of Care Update dated 5/5/25 for certification period 5/20/25 to 7/18/25 revealed the following orders:a. Effective 5/20/25, SN (Skilled Nurse) to visit one time a week for one week, two times a week for eight weeks.b. Hospice nurse to assess medication response and instruct on schedule, actions, purpose, side effects, compliance and need to report side effects to hospice staff.Review of physician orders revealed the following orders:Beginning 6/4/25, Lexapro 10 milligrams (mg), one tablet daily by mouth for depression and Buspar 15 mg, one tablet BID (twice daily) as needed for anxiety and depression.Beginning 6/23/25, Cipro 250 mg by mouth BID for seven days for UTI (urinary tract infection) symptoms.Review of SN visit notes dated 6/6/25 to 7/18/25 revealed no documentation the patient or cg were provided education on the new medications.The agency failed to provide education to the patient/cg on the new medications.An interview was conducted on 7/24/25 at 12:39 PM with Employee Identifier (EI) # 2, Director of Operational Support, who confirmed the agency failed to provide education to the patient or cg on the new medications.

Based on review of Medical Records (MR), agency policy and procedure, and staff interview it was determined the hospice staff failed to obtain physician orders for oxygen.This deficient practice affected MR # 6, one of ten MRs reviewed and had the potential to affect all patients served by this hospice.Findings Include: Hospice Policy: Verification of Physicians OrdersPolicy Number: 2-002Revised Date: NonePurpose: To ensure that accurate physician orders are obtained in accordance with applicable law and regulations. Policy: Orders will be obtained from a licensed physician for care and services to be provided to hospice patients. Procedure: …3. Orders will be documented by hospice in the electronic medical record… --- MR # 6 was admitted to hospice on 1/2/25 with primary diagnosis of End Stage Renal Disease.Review of the Skilled Nurse (SN) visit note report dated 1/15/25 revealed "…patient using oxygen at 2 Liters (L) majority of the time to relieve dyspnea …"Review of the SN visit note reports dated 1/17/25 and 1/18/25 revealed, on oxygen 2 L, documented under vital sign details.  Review of the SN visit note report dated 1/19/25 SN narrative revealed, “…Only requires oxygen PRN…"Review of the Hospice IDG (Interdisciplinary Group) Comprehensive Assessment and Plan of Care Update Report dated 1/17/25 revealed no physician order for oxygen. There was no documentation oxygen was ordered by the physician.An interview was conducted on 7/24/25 at 12:19 PM with Employee Identifier (EI) # 2, Director of Operation Support, who confirmed staff failed to obtain a physician’s order for Oxygen.

Based on medical record (MR) review, Alabama Board of Nursing Administrative Code, agency policy and procedure, and interview, it was determined the the agency failed to ensure a physician pronounced the death of patients.This deficient practice affected four of five Bereavement MRs reviewed, including MR # 7, MR # 6, MR # 8 and MR # 5, and had the potential to negatively affect all patients admitted to this hospice.Findings include:Agency Policy: Death At HomePolicy Number: 2-035Revised Date: NonePurpose:To establish the process to follow when a patient dies.Policy:...Individual state and community regulations and practices will be followed....Note: Hospice should check specific state law regarding death at home and adapt policy to meet state law/statute.Procedure:...4. The nurse will notify the attending physician of the patient's death.  It will be the attending physician's responsibility to pronounce death (depending on state regulations) ...Alabama Board of Nursing Administrative CodeChapter 610-X-6Standards of Nursing PracticeRevised: September 8, 2016610-X-6-.15   Telecommunication for Pronouncement of Patient DeathThe licensed nurse may receive pronouncement of a patient’s death from a physician via telecommunication. --- 4. MR # 5 was admitted to the agency on 6/8/25 with a primary diagnosis of Senile Degeneration of Brain, Not Elsewhere Classified. Review of the SN Visit Note dated 7/11/25 revealed the patient expired at 5:12 AM. There was no documentation the physician pronounced the patient's death.An interview was conducted on 7/24/25 at 12:24 PM with EI # 2 who confirmed there was no documentation the physician pronounced the patient's death.  2. MR # 6 was admitted to the agency on 1/2/25 with a primary diagnosis of End Stage Renal Disease. Review of the SN Visit Note dated 1/20/25 revealed the patient expired at 11:38 AM. There was no documentation the physician pronounced the patient's death.An interview was conducted on 7/24/25 at 12:19 PM with EI # 2, Director of Operation Support, who confirmed there was no documentation the physician pronounced the patient's death.3. MR # 8 was admitted to the agency on 3/29/22 with a primary diagnosis of Malignant Neoplasm of Colon Unspecified.Review of the SN Visit Note dated 10/21/24 revealed the patient expired at 11:04 PM. There was no documentation the physician pronounced the patient's death.An interview was conducted on 7/24/25 at 12:34 PM with EI # 2, who confirmed there was no documentation the physician pronounced the patient's death. 1. MR # 7 was admitted to the agency on 3/5/25 with a primary diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. Review of the Skilled Nurse (SN) Visit Note dated 4/11/25 revealed the patient expired at 10:31 PM. There was no documentation the physician pronounced the patient's death.An interview was conducted on 7/24/25 at 12:33 PM with Employee Identifier (EI) # 1, Manager of Regulatory Compliance and Accreditation, who confirmed there was no documentation the physician pronounced the patient's death.

Based on review of medical records (MR), agency procedure, observations and interview with the staff it was determined the agency failed to ensure the staff updated the Medication Form per the agency procedure. This affected two of eleven MR's reviewed and did affect Home Visit (HV) # 2, MR # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Review Purpose: To identify appropriateness, inconsistencies, and/or significant drug interactions in the patient's current medication regimen. Procedure: 1. A current medication listing will be competed at least at the time of admission, recertification, resumption of care and with any major changes in condition. The medication list is entered/scanned into the computer system and a medication list is generated. The RN's (Registered Nurse) signature on the medication list signifies a review of medications... 2. When medication changes or additions are received... 1. HV # 2 was admitted to the agency on 7/18/22 with admitting diagnoses of End Stage Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder and Primary Essential Hypertension. A HV was conducted on 7/19/22 at 1:10 PM with Employee Identifier (EI) # 3, Hospice Aide. During the HV the patients medications were reviewed with the caregiver using the medication bottles in the home and the Medication Form given to the surveyor by the agency. The following medications were found in the home and not on the Medication Form: Pantoprazole 40 mg (milligrams) enteric coated tablet take one tablet by mouth two times a day. Date on bottle 7/16/22. Caregiver stated the medication bottles were in the home at the time of admission. Furosemide 40 mg one tablet daily. Date on bottle 7/16/22. Caregiver stated the medication bottles were in the home at the time of admission. Prednisone 20 milligrams (mg) take 2 tablets daily. Date on bottle 7/16/22. Caregiver stated the medication bottles were in the home at the time of admission. Vitamin D 25 micrograms (mcg) one tablet daily. Caregiver stated patient has been taking for two years and were in the home. An interview was conducted on 7/21/22 at 2:25 PM with EI # 1, Quality Assurance Director, who confirmed the listed medication should have been put on the Medication Form on admission. 2. MR # 3 was admitted to the agency on 7/1/22 with admitting diagnoses of End Stage Lung Cancer with Metastasis, Cerebral Edema and Malignant Neoplasm of The Brain. Review of the Medication Form dated 7/1/22 revealed the following medication were on the Medication Form and not discontinued when complete: Dexamethasone 6 mg by mouth TID (three times a day times 5 days started on 7/1/22 and ended on 7/6/22 then Dexamethasone 6 mg by mouth BID (twice a day) started on 7/6/22 times 5 days ending on 7/11/22. An interview was conducted on 7/21/22 at 1:30 PM with EI # 1 who confirmed the Dexamethasone should have been discontinued on the Mediation Form once the patient had completed them.

Based on review of medical records (MR), policy and interviews, it was determined the agency failed to ensure an individualized Plan of Care (POC) was developed which included an infusaport (port used to deliver Intravenous medications). This affected one of one records reviewed with an infusaport including Home Visit (HV) # 3, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: POC Effective Date: 6/20/06 Policy: 1. A written POC is developed and maintained for each individual admitted to the hospice prior to providing care... ...4. The POC is based on the following data: ...C. Current medical findings... 5. The POC includes: ...Scope, frequency, and type of services, including team member interventions... 1. HV # 3 was admitted to the agency on 3/28/22, and recertified from 6/26/22 to 9/23/22, with a diagnosis of End Stage Metastatic Endometrial Cancer. Review of the Certification of Terminal Illness and Medication Form, which are not included as part of the POC, both dated 3/28/22, revealed documentation of a infusaport to the left chest to be flushed with Normal Saline 10 milliliters (ml) and Heparin 5 ml every 4 weeks and as needed. Review of the POC dated 3/28/22 revealed no documentation of the infusaport and the every 4 week flush intervention. Review of the Interdisciplinary Team (IDT) Meeting dated 6/24/22 revealed no documentation of the infusaport and the every 4 week flush intervention. Review of the Skilled Nurse (SN) visit note dated 7/1/22 revealed documentation the SN accessed the infusaport to the left chest with a 22 Gauge Huber needed and flushed Normal Saline and Heparin then removed the Huber needle. Review of the IDT Meeting dated 7/8/22 revealed no documentation of the infusaport, the every 4 week flush intervention and the completion of the flush on 7/1/22. An interview was conducted on 7/21/22 at 1:19 PM with Employee Identifier (EI) # 1, Quality Assurance Director, who confirmed there was no documention of the infusaport and ordered flush on the patient's POC.

Based on observation, agency policies and procedures, Lysol Disinfecting Wipes Manufacturer's Guidelines for Use, and staff interviews, it was determined the agency failed to ensure the staff followed agency policy for Hand Hygiene and Infection Control This deficient practice affected two of three home visits (HV) including HV # 1 and HV # 2 and had the potential to negatively affect all patients admitted to the agency Findings include: Agency policy: Hand Washing Revised date 03/04/2020 Policy: All home healthcare/patient care personnel will wash their hands before and after contact with each patient and anytime their hands become soiled... Purpose: Hand washing is the first line of defense in preventing the spread of infection. ...Procedure: 1. Hand washing with alcohol-based hand rubs is recommended by CDC Guidelines when: ...g). After taking off gloves... Lysol Disinfecting Wipes Manufacturer's Guidelines Date 2018 To disinfect: Allow surface to remain wet for four minutes. Allow to air dry. 1. HV # 1 was admitted to the agency on 3/29/22 and recertified for care 6/27/22 to 9/24/22 with diagnoses End Stage Colon Cancer and Hypertension. Review of the Interdisciplinary Team Meeting- Patient Summary dated 7/8/22 revealed documentation of a Skilled Nurse (SN) frequency of one time weekly and prn (as needed) and a physician's order for wound care to wound # 2 left abdomen, clean with wound cleanser or soap/water, pat dry, apply bacitracin ointment, leave open to air every day or prn. The SN is to measure/monitor every week until resolved. A HV was conducted on 7/19/22 at 1:40 PM to observe Employee Identifier # 2, Registered Nurse perform wound care. At the end of the visit, EI # 2 removed gloves used for patient care then cleaned the BP cuff, pulse oximeter, stethoscope and thermometer used for patient assessment, with Lysol wipes and immediately placed each piece of equipment into nursing bag without allowing time to dry. SN failed to perform hand hygiene following glove removal and prior to cleaning equipment. An interview was conducted on 7/21/22 at 2:30 PM with EI # 1, Quality Assurance Director, who confirmed Hand hygiene should be performed per agency policy and equipment allowed to dry four minutes per manufacturer's Guidelines. 2. HV # 2 was admitted to the agency on 7/18/22 with admitting diagnoses of End Stage Chronic Obstructive Pulmonary Disease (COPD), Anxiety Disorder and Primary Essential Hypertension. A HV was conducted on 7/19/22 at 1:10 PM with EI # 3, Hospice Aide. During the HV a bed bath was provided to the patient by EI # 3. Once the bed bath was complete and the water basins were emptied EI # 3 removed gloves, sanitized hands and began to clean equipment,which was placed on a contaminated barrier,with Clorox wipes. Once clean the equipment was placed back on the contaminated barrier. EI # 3 failed to sanitize hands and reclean the contaminated equipment before placing the equipment back in the bag An interview was conducted on 7/21/22 with EI # 1, who confirmed EI # 3 should have sanitized hands after removing gloves, donned clean gloves, sanitize all the equipment and place on clean barrier, remove gloves and sanitize hands. EI # 3 then should have placed the clean equipment back into the clean side of the bag.

1. MR # 6 was admitted to the agency on 1/6/22 with admitting diagnoses of End Stage Cerebral Vascular Accident and Hypertension and date of death 2/4/22. Review of the SN visit note dated 2/4/22 at 8:05 AM revealed the SN made an on call visit after receiving a call from the caregiver stating the patient had passed away. The SN documented " SN auscultated for pulse/ respirations time 2 minutes with none noted...Time of death 8:09 AM. Evans Funeral Home of Florala contacted at 8:15 AM. MD made aware via EI # 6, Outreach/Education staff per fax." An interview was conducted with EI # 1 who confirmed the Coroner was not notified and EI # 1 also stated the nurse failed to notify the physician for pronouncement of the patients death. Based on review of agency policy, medical records (MR), Alabama Board of Nursing Standards of Nursing Practice 610-X-6-.15 and interview with agency staff, it was determined the agency failed to follow its own policy and procedure regarding pronouncement of death. This deficient practice did affect one of two death MRs reviewed, MR # 6 and had the potential to negatively affect all patients served by the agency. Findings include: Policy: Death Preparation and Attendance Purpose: ... To assure compliance with all county, state and/or federal laws/regulations pertaining to deaths within their jurisdictions... Procedures: ...5. Nurse or nurse on call will respond immediately to family when they state they feel the patient has died... ...7. Listen for a heart beat or signs of respirations for one minute with a stethoscope.... ...8... Ask for approximate time patient stopped breathing, if not witnessed by a hospice nurse. ...10. Notify the attending physician of the date and time of death.... ...16. The local coroner/authorities will be notified as soon as possible once it is appropriate to leave the family Alabama Board of Nursing Standards of Nursing Practice 610-X-.15 Telecommunication For Pronouncement of Death (1) The licensed nurse may receive pronouncement of a patient's death from a physician via telecommunications 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.