Every finding on record at Five Points Healthcare of Alabama, LLC

Based on observations, review of medical records (MR), agency policy and procedure and interviews with staff, it was determined the hospice staff failed to ensure all patient medication profiles (MP) were current and accurate. This affected 2 of 3 home visits (HV) conducted and 5 of 8 active records reviewed including HV # 1, MR # 1, HV # 2, MR # 4, and MR # 2. This deficient practice had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Policy number: 8.20.1 Date revised: June 2019 Policy Hospice will reconcile patient's medications at time of admission and on an ongoing basis. ...Procedure 1. At time of initial assessment, the RN (Registered Nurse) will create and document a complete list of medications that patient is taking... 2. Medications ordered while the patient is receiving care will be compared to the medication list/ profile. The medication list/ profile will be updated with each new or changed medication... 1. HV # 1 was admitted to hospice on 11/6/21 with diagnosis including Age Related Physical Debility. Review of the Skilled Nursing SOAP (Subjective, Objective, Assessment and Plan)Visit note dated 11/10/21 revealed, "Supply had left the Oxygen Concentrator, ...prior to nurse arrival. Administration of 2 liters Oxygen helped the patient..." Review of the IDG (Interdisciplinary Group) Meeting dated 11/23/21 revealed no documentation of Oxygen on the MP. Review of the MP printed for the HV on 1/12/22 revealed no documentation of Oxygen. A written statement received on 1/13/22 at 7:36 PM from Employee Identifier (EI) # 1, Executive Director confirmed the MP was not updated to include Oxygen. 2. MR # 1 was admitted to hospice on 8/6/21 with diagnosis including Age Related Physical Debility and A Fracture of Unspecified Part of Neck of Left Femur, Initial Encounter for Closed Fracture. Review of the Plan of Care dated 11/9/21 revealed a problem with shortness of breath and interventions to educate patient and/or caregiver on Oxygen safety and equipment maintenance. Review of the MP dated 11/9/21 revealed no documentation of Oxygen. A written statement received on 1/13/22 at 7:36 PM from EI # 1 confirmed the Medication Profile was not updated to include Oxygen. 3. HV # 2 was admitted to hospice on 12/2/21 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Hypoxemia. Review of the Plan of Care Order dated 12/2/21, and IDG Meeting dates 12/8/21 and 12/22/21 revealed the SN (Skilled Nurse) frequency of 2 / wk (2 times per week). A HV was conducted on 1/11/22 at 1:00 PM to observe care provided by EI # 3, MSW (Medical Social Worker). Prior to the HV, the surveyor was provided a MP dated 12/2/21 to 3/1/22. The MP was compared to the medications observed in the home, and the following discrepancies were observed: a) Anoro Ellipta Inhalation Aerosol Powder, 1 puff via inhalation daily was listed on the MP, but not in the home. The patient stated she/he hasn't used this medication since admission to hospice. b) Equate Pain Relief Cream 4 % Lidocaine was in the home and not on the MP. The patient stated she/he used the cream as needed for knee pain for the past 4 months. An interview was conducted on 1/13/22 at 10:34 AM with EI # 1, who confirmed staff failed to update the MP. 4. MR # 4 was admitted to hospice on 12/13/21 with diagnoses including Heart Failure, Unspecified, and Major Depressive Disorder, Single Episode. Review of the RN Initial Assessment dated 12/13/21 revealed the SN documented, "...Educated on all equipment and oxygen safety ...Unable to ambulate 20 feet without increase SOB and needing rest period. Patient is currently using supplemental oxygen at 2L (Liters) via NC (Nasal Cannula)..." Review of the Plan of Care Order dated 12/15/21 revealed a medication list that did not include oxygen. Review of the current Patient Medication Record, dated 12/13/21 to 3/12/22, revealed the record was not updated to include oxygen. An interview was conducted on 1/13/22 at 2:47 PM with EI # 1, who confirmed staff failed to update the patient's medication list to include oxygen. 5. MR # 2 was admitted to hospice on 10/9/2020, with recertification dates 12/3/21 to 1/31/22. Admitting diagnoses included Malignant Neoplasm of Upper Lobe, Unspecified Bronchus or Lung. Review of the IDG Meeting dated 12/8/21 revealed a SN frequency of 2 / wk (two times per week). Review of the Skilled Nursing Visit dated 12/14/21 revealed the following documentation, "...PT (patient) is being treated at this time for a respiratory infection... PT is currently taking prednisone and doxycycline prescribed by the BVAMC (Birmingham Veterans Administration Medical Clinic)..." Review of the Plan of Care dated 12/22/21 with Medication list, revealed the MP had not been updated to include the doxycycline order. An interview was conducted on 1/13/22 at 1:40 PM with EI # 1, who confirmed staff failed to update the MP.

Based on review of agency policy and procedure, medical records (MR) and interviews it was determined the agency failed to ensure the visit frequencies for all disciplines were followed as ordered. This affected 4 of 8 active records reviewed including home visit (HV) #1, MR # 1, HV # 2, MR # 2, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: IDG (Interdisciplinary Group) Care Planning Process Policy number: 9.12.1 Date revised: February 2021 Policy ...The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. ...Procedure ...4. A registered nurse that is a member of the IDG is designated to provide coordination of care... The RN (Registered Nurse) ensure that the plan of care is individualized, updated and relelvant to the needs of patient/family by: ...Communicating with the IDG any changes in the delivery of services from the established plan of care. 1. HV # 1 was admitted to hospice on 11/6/21 with diagnosis including Age Related Physical Debility. Review of the Plan of Care Order dated 11/10/21 revealed Hospice Aide (HA) frequency of 3 times per week. Review of the Aide Care Visit notes revealed only 2 HA visits the week of 11/28/21 and not 3 as ordered. Further review of the Aide Care Visit notes revealed only 2 HA visits the week of 12/19/21 and not 3 visits as ordered. A written statement received on 1/13/22 at 7:36 PM from Employee Identifier (EI) # 1, Executive Director confirmed the ordered visit frequency was not met. 2. MR # 1 was admitted to hospice on 8/6/21 with diagnosis including Age Related Physical Debility and A Fracture of Unspecified Part of Neck of Left Femur, Initial Encounter for Closed Fracture. Review of the Aide Care Plan dated 11/4/21 revealed Aide Frequency of 2 visits per week. Review of the Missed Visit Form (Aide Care Visit) note dated 11/4/21 revealed, "...I asked to reschedule until tomorrow." Review of the HA visits for the week of 11/4/21 revealed no aide visit as scheduled and the next HA visit documented was for the following week on 11/9/21. Review of the Plan of Care (POC) orders dated 11/9/21 revealed Chaplain frequency of one time per month. Review of the Chaplain/Counselor Visit note dated 11/23/21 revealed, "Chaplain has reviewed POC and visits one time per month and as needed for additional support remains appropriate." Further review of the medical record revealed no Chaplain visit for December as ordered. A written statement received on 1/13/22 at 7:36 PM from EI # 1 confirmed the ordered visit frequency was not met. 3. HV # 2 was admitted to hospice on 12/2/21 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Hypoxemia. Review of the IDG Meeting dated 12/22/21 revealed an ordered frequency for the HA of 2 / wk (two times per week). Review of the MR revealed no HA Visit Records for the week of 12/26/21. The HA failed to meet the visit frequencies of 2 times per week. An interview was conducted on 1/13/22 at 10:34 AM with EI # 1, who confirmed the HA failed to meet the visit frequency of 2 times per week. 4. MR # 2 was admitted to hospice on 10/9/2020, with recertification dates 12/3/21 to 1/31/22. Admitting diagnoses included Malignant Neoplasm of Upper Lobe, Unspecified Bronchus or Lung. Review of the IDG Meeting dated 12/8/21 revealed an ordered chaplain frequency of 2 / mo (two times per month), and an ordered HA frequency of 2 / wk (two times per week). Review of the MR revealed a chaplain visit on 12/7/21. There were no other visits documented. Review of the HA visits for the week of 12/26/21 revealed one visit and not two as ordered. An interview was conducted on 1/13/22 at 1:40 PM with EI # 1, who confirmed the chaplain made one visit in December, and not two as ordered, and the HA failed to meet visit frequencies the week of 12/26/21.

Based on review of medical records (MR), policy and procedure, and interview with staff it was determined staff failed to follow the plan of care established in the IDG (Interdisciplinary Group) Meeting for 1 of 1 patients reviewed with suicidal ideations. This affected MR # 4 and had the potential to affect all patients with suicidal ideations served by the hospice. Findings include: Agency policy: IDG Care Planning Process Policy number: 9.12.1 Date revised: February 2021 Policy ...The Hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Purpose To define the IDG care planning process and documentation of care planning. Procedure 1. Hospice has designated an interdisciplinary group which ...prepares a written plan of care for each patient... 2. The plan of care specifies the care and services necessary to meet the patient and family-specific needs... ...4. A registered nurse (RN)... is designated to provide coordination of care... The RN ensures that the plan of care is individualized... by: ...Monitoring for successful implementation of the plan of care. 1. MR # 4 was admitted to hospice on 12/13/21 with diagnoses including Heart Failure, Unspecified, and Major Depressive Disorder, Single Episode. Review of the IDG Meeting dated 1/5/22 revealed the following documentation by the SN (Skilled Nurse), "...Patient c/o (complains of) wanting to die. States she has thoughts of suicide. States she had thought of strangling self with O2 (oxygen) cord, but she decided against it. Patient re-started on Lexapro... Zoloft discontinued... Plan for next two weeks: Continue to monitor patient's mental status frequently. Daily calls to assess patient's status." Review of the MR revealed no contact with the patient on 1/5/22, or 1/6/22. A nurse SOAP (Subjective, Objective, Assessment, and Plan) visit was documented on 1/7/22 and an order to increase SN visit frequency to 5 times per week, and to add Hospice Aide services 2 times per week, both effective the following week, 1/10/22. There was no documented contact/ visits for 1/8/22, or 1/9/22. An interview was conducted on 1/13/22 at 2:47 PM with Employee Identifier (EI) # 1, Executive Director. The surveyor asked if daily calls were being made to the patient per the plan of care. EI # 1 stated there was no documentation of any phone calls. EI # 1 confirmed staff failed to make contact with patient daily, as ordered.

Based on review of medical records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure the staff screened all patients for Covid-19 every visit as directed per the agency policy. This affected 5 of 8 active MR's reviewed, including MR # 3, home visit (HV) # 1, HV # 2, MR # 4, MR # 2, and had the potential to negatively affect all patients and staff. Findings include: Agency Policy: Guidelines for COVID-19 Virus Policy: 5.20.1 Revised: February 2021 Purpose: To prevent or decrease exposure of patients and staff to the COVID-19 virus. Procedure: 9. Actively monitor all patients upon admission and every visit for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat) and document. ...18. All patients and employees should be screened to identify exposure to COVID-19 pandemic. Employees will be screened daily and patients with each home visit. 1. MR # 3 was admitted to hospice on 12/14/21 with terminal diagnoses including Chronic Kidney Disease Stage 4, and Heart Failure, Unspecified. Review of the Hospice Plan of Care (POC) dated 12/14/21 to 3/14/22 revealed a Chaplain frequency of 1 x (times) a month. Review of the Chaplain/Counselor Assessment dated 12/15/21 revealed there was no documentation the patient was screened for COVID-19 per the agency policy. An interview was conducted on 1/13/22 at 1:37 PM with Employee Identifier (EI) # 1, Executive Director, who verified there was no documentation the Chaplain screened MR # 3 for COVID-19 on 12/15/21 per the agency policy. 2. HV # 1 was admitted to hospice on 11/6/21 with diagnosis including Age Related Physical Debility. Review of the POC dated 11/6/21 to 2/3/22 revealed a Skilled Nurse (SN) frequency of 2 times per week and 8 PRN (as needed) visits for symptom management. Review of the SN SOAP (Subjective, Objective, Assessment and Plan) visit dated 11/10/21 at 10:46 AM revealed there was no documentation the patient was screened for COVID-19 as directed per the agency policy. Review of the SN SOAP visit dated 11/13/21 at 4:28 PM revealed there was no documentation the patient was screened for COVID-19 as directed per the agency policy. A written statement received on 1/13/22 at 7:36 PM from EI # 1 confirmed there was no documentation the patient was screened for COVID-19 prior to the visits on 11/10/21 and 11/13/21. 3. HV # 2 was admitted to hospice on 12/2/21 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Hypoxemia. Review of the MR revealed a Chaplain/ Counselor Assessment dated 12/6/21. Further review of the assessment revealed there was no documentation the patient was screened for COVID-19 per policy. An interview was conducted on 1/13/22 at 10:34 AM with EI # 1, who verified there was no documentation the Chaplain screened HV # 2 for COVID-19 per agency policy. 4. MR # 4 was admitted to hospice on 12/13/21 with diagnoses including Heart Failure, Unspecified, and Major Depressive Disorder, Single Episode. Review of the Plan of Care Order dated 12/15/21 revealed a SN ordered frequency of 2 times per week. Review of 5 SN SOAP Visit notes, dated 12/16/21, 12/19/21, 12/21/21, 12/26/21, and 12/28/21, revealed the SN failed to document a COVID-19 screen per agency policy. An interview was conducted on 1/13/22 at 2:47 PM with EI # 1, who confirmed there was no documentation the SN screened MR # 4 for COVID-19 per agency policy. 5. MR # 2 was admitted to hospice on 10/9/2020, with recertification dates 12/3/21 to 1/31/22. Admitting diagnoses included Malignant Neoplasm of Upper Lobe, Unspecified Bronchus or Lung. Review of the MR revealed a Chaplain/ Counselor Visit note dated 12/7/21. Review of the visit note revealed the chaplain failed to document a COVID-19 screen per agency policy. An interview was conducted on 1/13/22 at 1:40 PM with EI # 1, who confirmed there was no documentation the chaplain screened MR # 2 for COVID-19 per agency policy.

Based on observation, review of agency policy and procedure and staff interviews, it was determined the agency failed to ensure staff followed their policy for hand hygiene. This deficient practice affected 1 of 3 home visits (HV) performed and did affect HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene Policy and Compliance Program Policy number: 5.7.1 Date revised: June 2019 Policy Hand hygiene will be done by all employees... to reduce the transfer of microbes to patients... ...Procedure 1. Indications for hand hygiene are: Before and after direct patient care. ...4. The proper procedure for handwashing when using soap and water is as follows: ...Using a clean paper tower, dry hands thoroughly. Turn off water faucet using towel. Discard paper towel in a disposable bag or waste can. ...7. Hospice will follow the Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene: ...After removing gloves. 1. HV # 1 was admitted to hospice on 11/6/21 with diagnosis including Age Related Physical Debility. A HV was conducted on 1/12/22 at 9:30 AM with Employee Identifier (EI) # 2, Licensed Practical Nurse to observe wound care. During the HV, EI # 2 performed hand hygiene (HH), donned gloves, cleaned scissors, removed soiled dressing from the right heel, doffed the right glove and without performing HH, donned a clean glove to the right hand and continued with cleaning the wound and measuring the wound on the right heel. EI # 2 then doffed the right glove and without performing HH, donned a clean glove to the right hand, then applied betadine to the wound bed, xeroform application, non-adherent dressing, and a wrap dressing. EI # 2 then doffed both right and left gloves and without performing HH, donned clean gloves and completed dressing application using coban and tape. EI # 2 doffed gloves, performed HH, donned gloves and removed the soiled dressing on the left heel, measured the wound, cleaned the wound and without changing gloves or performing HH, applied betadine, xeroform gauze, non-adherent dressing and roll gauze. EI # 2 then doffed gloves and performed hand washing at HV # 1's bathroom sink and without using clean disposable towels, used HV # 1's cloth towel hanging on the towel bar in the bathroom. EI # 2 donned gloves and donned a second glove over the right glove, cleaned the labia wound, removed one of the right hand gloves and without performing HH, applied zinc ointment to the wound bed. A written statement received on 1/13/22 at 7:36 PM from EI # 1, Executive Director confirmed the policy for HH was not followed.

Based on observation, review of medical records (MR), agency policy and procedure and interview with hospice staff, it was determined the Registered Nurse (RN) failed to develop written instructions for the Hospice Aide (HA), which were patient-specific and updated with changes in the patient condition. This affected Home Visit (HV) # 1 which was 1 of 7 records reviewed receiving HA Services and had the potential to affect all patients receiving HA services. Findings include: Agency Policy: IDG (Interdisciplinary Group) Care Planning Process Policy number: 9.12.1 Date revised: February 2021 Policy ...The hospice IDG develops a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. ...Procedure ...2. The plan of care specifies the care and services necessary to meet the patient and family-specific needs... ...4. A registered nurse (RN) that is a member of the IDG is designated to provide coordination of care... and implementation of the IDG plan of care....The RN ensures that the plan of care is individualized, updated and relevant to the needs of patient/family by: ...Developing and revising patient care goals/ objectives in coordination with other members of the IDG, Monitoring for successful implementation of the plan of care... 1. HV # 1 was admitted to hospice on 11/6/21 with diagnosis including Age Related Physical Debility. Review of the Aide Care Plan dated 11/6/21 revealed aide frequency 3 times per week and included the following personal Care interventions assigned: Assist in Ambulation every visit Catheter Care every visit Assist with Bedside Commode every visit Empty Ostomy Bag every visit Review of the Aide Care Visit notes dated 11/19/21, 11/22/21, 11/24/21, 11/29/21, and 12/6/21 revealed no documentation the interventions were completed as assigned, including assist with ambulation, catheter care, assist with bedside commode and empty ostomy bag. Review of the IDG Meeting Details dated 11/23/21 revealed, "Patient continues to be bed bound." A written statement received on 1/13/22 at 7:36 PM from Employee Identifier (EI) # 1, Executive Director confirmed the Aide Care Plan was not individualized to meet the needs of the bedbound patient and HV # 1 did not have a catheter or ostomy bag.

Based on a review of medical records (MR), agency policies and procedures, and staff interviews, it was determined the agency failed to ensure the staff: 1. Documented accurately in the clinical record. 2. Completed all documentation within the agency timeframes. This affected 1 of 2 discharge records reviewed, including MR # 7, 1 of 1 death records reviewed, including MR # 6, and 1 of 8 active records reviewed including MR # 4, and had the potential to negatively affect all patients served by this agency. Findings include: Agency Policy: Record Review Policy: 11.7.1 Revised: June 2019 Purpose: To assure that the documentation is complete, accurate and timely and services provided are appropriate. Procedure: 4. Record review indicators for data and information contained within the record include: ...Quality, consistency, clarity, accuracy and completeness. Agency Policy: Timely Submission of Patient Documentation Policy: 11.6.1 Revised: June 2019 Policy: Hospice will ensure the timely and proper submission of patient documentation. Procedure: 2. Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) business days. 1. MR # 7 was admitted to hospice on 9/23/2020 with a primary diagnosis of Unspecified Severe Protein-Calorie Malnutrition. Review of the MR revealed MR # 7 was discharged on 4/15/21. Review of the 4/30/21 IDG (Interdisciplinary Group) meeting note documented by the Registered Nurse (RN) revealed, "Patient was discharged on 4/15/21 for extended prognosis..." Further review of the 4/30/21 IDG meeting note documented by the physician revealed, "IDG team reviewed and updated the plan of care with the hospice physician along with the involvement of the attending. Current frequencies of all disciplines were reviewed. Patient discussed for continued hospice services. Med (medication) reconciliation completed. Discussed all missed visits." MR # 7 was discharged on 4/15/21 and there was no plan to continue hospice services. The physician failed to accurately document in the MR per agency policy. An interview was conducted on 1/13/21 at 10:08 AM with Employee Identifier (EI) # 1, Executive Director, who stated the physician uses a "canned statement" and it was not an accurate note for a discharged patient. 2. MR # 6 was admitted to hospice on 11/6/21 with diagnoses including Malignant Neoplasm of Unspecified Kidney, Except Renal Pelvis. MR # 6 expired on 12/6/21. Review of the IDG Meeting dated 12/22/21 revealed the following documentation by the hospice medical director, "...IDG team reviewed and updated plan of care with the hospice physician along with the involvement of the attending. Current frequencies of all disciplines were reviewed. Patient discussed for continued eligibility of hospice services. Med (medication) reconciliation completed. Discussed all missed visits." The patient had been deceased for 16 days. An interview was conducted on 1/13/22 at 2:45 PM with EI # 1, who confirmed the physician used 'canned statements' and the documentation was inaccurate. 3. MR # 4 was admitted to hospice on 12/13/21 with diagnoses including Heart Failure, Unspecified, and Major Depressive Disorder, Single Episode. Review of the Plan of Care Order dated 12/15/21 revealed a SN (Skilled Nurse) ordered frequency of 2 times per week. Review of the MR provided to the surveyor on 1/11/22, revealed no documented visits for the week of 1/2/22. The surveyor made a second request on 1/12/21 for any SN visit notes for the week of 1/2/22, none were received. The surveyor made a third request on 1/13/22 for visit notes the week of 1/2/22 and was told by EI # 1 "...the nurse is completing them now." On 1/13/22 at 11:00 AM, the surveyor received two SN Visit Notes, dated 1/3/22 and 1/4/22, and 1 SN SOAP (Subjective, Objective, Assessment, and Plan) Visit note dated 1/7/22. All three notes were digitally signed by the SN on 1/13/22, which was 10 days later, 9 days later, and 6 days later, respectively. The notes contained no 'Late Entry' notations. An interview was conducted on 1/13/22 at 2:47 PM with EI # 1, who confirmed the SN failed to complete the notes timely, per policy.

Based on observation, agency policy and procedure, and interview, it was determined the agency failed to ensure oxygen was secured safely in 1 of 3 home visits (HV) conducted with patients receiving Oxygen (O2) therapy. This had the potential to affect all patients receiving O2 therapy, and did affect HV # 1. Findings Include: Agency policy: Safety Management Program Policy number: 1.1.1 Date revised: January 2020 Policy Hospice Administrator and staff will implement safety procedures as appropriate. Hospice's safety management plan addresses real and potential threats to the health and safety of patients, staff, others, and property. Purpose To maintain the safety of the environment and equipment which support patient care or services. Procedure 1. Home safety assessments are done on all patients at time of admission that include: ...Oxygen safety. ...Adequate storage and handling of medical gases, drugs... ...3. Staff is responsible for giving oral or written education to patients/ caregivers at the initial assessment and on an ongoing basis as appropriate... 1. HV # 2 was admitted to hospice on 12/2/21 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Hypoxemia. Review of the Plan of Care Order dated 12/2/21, and IDG Meeting dates 12/8/21 and 12/22/21 revealed the SN (Skilled Nurse) frequency of 2 / wk (2 times per week). A HV was conducted on 1/11/22 at 1:00 PM to observe care provided by Employee Identifier (EI) # 3, MSW (Medical Social Worker). Prior to the HV, the surveyor was provided a Medication Profile (MP) dated 12/2/21 to 3/1/22. The MP included O2 at 2 - 4 LPM (Liters Per Minute) NC (Nasal Cannula) continuous, start date of 12/2/21. During the HV, the surveyor requested to view the O2 concentrator the patient was using, and any oxygen tanks for back up. HV # 2 lead the surveyor to her/his "second bedroom" where 4 oxygen tanks were leaning at an angle, one on top of the other, against a desk. The tanks were unsecured. HV # 2 stated, "...these scare me to death." EI # 3 stated she/he would bring a box to secure the O2 tanks. An interview was conducted on 1/13/22 at 10:34 AM with EI # 1, Executive Director, who confirmed staff failed to ensure the safe storage of the O2 tanks.