Every finding on record at Homestead Hospice of Cahaba, LLC

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to complete the comprehensive assessment no later that 5 calendar days after the election of hospice care. For example: in review of RRNHV#13 the MSW initial assessment to establish plan of care did not occur until day 7 after start of care. There was no documentation noted on the record to explain the delay. This observation was reviewed with the Regional Administrator, Branch Director, and Clinical Team Lead.

Observed in Record Review. In 14 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals that were specific, measurable, and time-bound. For example: in RRHV#3 the goals were not all specific, measurable, and time-bound such as patient/caregiver verbalize/demonstrate understanding of proper safety measures related to fall prevention, patient constipation is controlled, and patient/caregiver exhibit improved coping skills. In RRHV#4 examples of goals that were not measurable were patient/caregiver will verbalize/demonstrate reduction or relief of cardiopulmonary symptoms by 6/28/24, and patient safety needs met by 6/28/24. In RRHV#1 an example was pain is currently managed at a level acceptable to patient. Example in RRNHV#7 was patient/caregiver will verbalize/demonstrate adequate knowledge of gastrostomy feedings and care by the end of the certification period. Throughout all records reviewed there was a pattern of goals not being time-bound. Goals on the Plan of Care report were not time bound. Some goals were noted on the update orders with time frames such as by the end of the cert or by a particular date but in each record the time frames specified were not individualized as they were all the same for each goal and not specific to the individualized patient situation. These observations were reviewed with the Regional Administrator, Branch Director, and Clinical Team Lead.

Observed in Record Review. In 6 of 14 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRHV#3 the patient was being treated for a UTI with antibiotics yet there was no urinary care plan to guide the care. Further, the patient was diabetic with insulin use and blood glucose monitoring yet there were no goals and interventions for endocrine. In RRHV#1 the patient was treated for a UTI in March, and a URI in February yet there was no care plan opened to guide their care. In RRNHV#6 there was documentation of constipation that required addition of a laxative but no care plan for constipation. There were also issues with pain management that required orders for Tylenol and Tramadol but no pain care plan opened. In RRNHV#7 the patient was diabetic with insulin use but no care plan for endocrine. In RRNHV#8 there was frequent documentation of dysphagia with swallowing precautions, and an eye infection with antibiotics but the issues were not reflected in the care plans. RRNHV#12 the patient was being seen by the Chaplain yet there was no spiritual care plan to guide the care. The documentation also noted patient issue with diarrhea but it was not reflected on the care plan. These observations were reviewed with the Regional Administrator, Branch Director, and Clinical Team Leader.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions to include a detailed statement of the scope and frequency of services to meet the specific patient and family needs. For example: on review of RRHV#3 the documentation of the MSW noted seeing the patient 1 time a month yet there was no physicians order as part of the plan of care to specify the MSW frequency until the most recent recertification in July nearly 3 month after the initial assessment. In RRHV#4 the MSW was noted to be seeing the patient in Feb, March, and April yet there was no established frequency for MSW noted in the plan of care. In RRNHV#10 both the MSW and Chaplain had visits with the patient and documented seeing the patient 1 x month yet there were no physicians orders noted for their frequency noted on the plan of care. These observations were reviewed with the Regional Administrator, and Clinical Team Lead.

Observed in Record Review. In 7 of 14 patient records reviewed, for active records, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: In RRHV#1 there were PRN medication orders for Vitamin C and Podiapn that indicated PRN use but failed to specify a frequency for the PRN use of the medication. In RRHV#3 during the home observation the caregiver and RN discussed the patient's home blood glucose monitoring yet there were no physicians order for the monitoring noted on the plan of care. In review of RRNHV#7 the patient was diabetic with sliding scale insulin yet there were no physicians orders for blood glucose monitoring. The patient also had a g-tube for meds and feeding yet no physicians orders for the g-tube site care. Further, in the medication profile the orders for Tramadol, Midodrine, and Glucerna were listed as oral route yet the instructions noted to be given per peg tube. In RRNHV#9 the patient had two antiemetics of ondansetron and promethazine yet there were no specific instruction to guide the patient/caregiver on which medication to choose. Further, there were two PRN pain medications of Hydromorphone 4mg tabs 2-4 mg every 6 hours PRN and Methadone 5mg oral 3 times daily PRN yet there were no instructions on which medication to choose for what situation, nor were there instructions for the 2-4 mg range order for Hydromorphone. In RRNHV#8, RRNHV#9 and RRNHV#11 the oxygen order did not include a route, and the order had a range of 2-5 liters but no specific instructions to guide the user on how to choose the particular oxygen flow rate. In RRNHV#13 the documentation noted the patient to utilize home oxygen yet there were not oxygen orders noted on the record. These observations were reviewed with the Administrator, Branch Director, and Clinical Team Lead.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure written patient care instructions by the registered nurse are prepared for the hospice aide. In review of RRNHV#13 the patient was on oxygen yet the aide's plan of care did not include oxygen precautions nor instructions on how to handle the oxygen while providing patient care. This observation was reviewed with the Regional Administrator, Branch Director, and Clinical Team Lead.

Observed in Patient Home. In 3 of 4 home visits conducted, the organization failed to ensure the patient record contain information that reflects the patient's care, treatment, and services. For example: on observation of medication reconciliation for RRHV#1 it was noted the medication profile on the clinical records noted the patient was ordered oxygen 2-4 lts via NC as needed, yet in the patient home the RN and patient caregiver stated the patient was utilizing oxygen at 4 lts continuously. Further, there was Santyl noted on the med profile but the RN and the caregiver noted the medication had been discontinued some time prior. In RRHV#2 there was an order for Oxygen continuous however on home observation the oxygen was not in use and the caregiver noted it was only used as needed. In RRHV#3 there was an order for Humalog that the RN and caregiver noted was only given PRN and instructions noted BS > 180, yet the medication profile noted the insulin to be daily and not listed as PRN. These observations were reviewed with the Administrator, and Branch Director.

Observed in Record Review. In 1 of 2 patient records reviewed, for live discharge, the organization failed to ensure the hospice provide the receiving facility with a copy of the hospice discharge summary and, if requested, a copy of the patient’s clinical record. In review of RRDC#2 the patient revoked hospice services seeking aggressive treatment at the hospital. There was no documentation that the receiving hospital was sent a discharge summary of the patient's care. This observation was reviewed with the Regional Administrator, Branch Director, and Clinical Team Lead.

Based on observation, agency policy and procedure, and interview, it was determined the hospice agency failed to maintain an accurate drug profile of all of the patient's prescription and over-the-counter drugs currently in use. This affected two of four Home Visits (HV) conducted, and one of 20 medical records (MR) reviewed, including HV # 4, HV # 1, and MR # 7, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication List and Monitoring Policy Number: PC.85 Reviewed Date: 01/27/23 Purpose: 1. To outline a process for ongoing medication monitoring. Policy: IV. Medication monitoring will include...an accurate patient medication history and a current, complete medication profile... Procedure: I. The hospice will maintain a current, accurate medication profile of all prescription, over-the-counter (OTC)...medications... II. The medication will be documented on the medication profile... IV. The RN (registered nurse) will compare the medication information (list) the patient is currently taking with the medications ordered to identify and resolve discrepancies,.. --- 3. MR # 7 was admitted to the agency on 4/4/24 with diagnoses including Malignant Neoplasm of Unspecified Main Bronchus and Type Two Diabetes Mellitus with Unspecified Complications. A review of the Hospice Certification and Plan of Care dated 4/4/24 revealed Hospice nurse to instruct in safe use of oxygen and monitor its effectiveness. A further review of the Skilled Nurse (SN) VNR dated 4/8/24 Assessment revealed Oxygen 3-4 Liters Per Minute (LPM) via nasal cannula (NC). In the Narrative, the SN wrote, Oxygen in continuous use at 3 LPM via NC. A review of the medication list revealed there was no documentation the Oxygen had been added to the list. An interview was conducted on 5/15/24 at 4:33 PM with EI # 2, Branch Director who confirmed oxygen had not been added to the Medication List and the agency failed to maintain an accurate medication list. 2. HV # 1 was admitted to the agency on 3/30/24 with the diagnoses of Malignant Neoplasm of Unspecified Bronchus or Lung and Hemoptysis. A home visit was conducted on 5/13/24 at 2:03 PM to observe patient care and medication review provided by EI # 4, RN. Medication reconciliation was observed with the following discrepancies: a. Torsemide 20 mg tablet, take one tablet daily was listed on the CMR. Review of the bottle's label filled on 4/4/24 in HV # 1's home read Torsemide 100 mg tablet, take one-half tablet every other day. HV's # 1 caregiver reported HV # 1 has been taking one-half tablet daily for about one month. b. Bactrim DS 800 mg -160 mg tablet, take one tablet by mouth twice daily times seven days for was listed on the CMR. The medication was not in the home. The caregiver reported HV # 1 completed the medication about a month ago. c. Morphine was not listed on the medication list provided to the surveyor. The caregiver was unable to locate the morphine medication during the HV. EI # 4 charted the medication reconciliation was performed with a narcotic count of morphine 30 ml during the HV. Review of the hospice physician order dated 4/2/24 revealed an order for morphine concentrate 20 mg/ml (milliliter) oral, give 0.25 - 0.5 ml SL (sublingual) every 2-4 hours as needed for pain. An interview was conducted on 5/15/24 at 4:41 PM with EI # 1, who confirmed the staff failed to maintain an accurate medication profile. 1. HV # 4 was admitted to hospice services on 1/24/24 and recertified for care 4/23/24 to 6/21/24 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified, and Abdominal Aortic Aneurysm, without Rupture, Unspecified. A HV was conducted on 5/14/24 at 10:04 AM to observe care provided by Employee Identifier (EI) # 3, Master of Social Work. During the visit, a comparison was made between the medications listed on the Client Medication Report (CMR) and the medications observed in the home. The following medications were observed in the home and not listed on the CMR: a. Aspirin 81 milligrams (mg) tablets (tab), take one tab daily, with fill date 3/19/24. b. Montelukast 10 mg tabs, take one tab at bedtime, with fill date 2/27/24. c. Losartan 50 mg tabs, take one tab three times daily, with fill date 3/19/24. d. Cranberry 500 mg OTC caplets. e. Viactiv OTC calcium soft chews. HV # 4 stated during the visit he/she was currently taking all the medications daily. The following medications were observed in the home as having a different strength than what was listed on the CMR: a. Cholecalciferol (Vitamin D 3) 25 mcg (micrograms) OTC bottle was in the home. HV # 4 stated he/she took one 25 mcg tab daily. The CMR listed the strength as 125 mcg. b. Alprazolam 0.25 mg tabs, take one tablet three times a day as needed, was observed in the home with fill date 4/29/24. HV # 4 stated he/she took one tablet at bedtime nightly. The CMR listed the strength as one mg. An interview was conducted on 5/15/24 at 4:05 PM with EI # 1, Branch Director Selma and Prattville locations, who confirmed the hospice agency failed to maintain an accurate drug profile for all of HV # 4's prescription and over-the-counter drugs currently in use.

Based on medical record (MR) reviews, policy and procedure and interviews, it was determined the agency failed to ensure a bereavement risk assessment was completed on admission and a bereavement plan of care (POC) was completed on admission per policy. This affected four of 20 MR reviews including HV # 3, MR # 3, MR # 7, MR # 13 and had the potential to negatively affect all patients served by the hospice agency. Findings include: Policy: Bereavement: Standard Operating Procedure Effective Date: 5/2022 Purpose: ...Bereavement counseling. The hospice must: i.) Have an organized program for the provision of bereavement services furnished under the supervision of a qualified professional with experience or education in grief or loss counseling. ...Initial Bereavement Assessment: The initial Bereavement Assessment is initiated at start of care (SOC) as part of the Comprehensive Assessment and included in the POC developed by the interdisciplinary group (IDG). ...The Bereavement Care Plan: The bereavement care plan must be personalized to the patient's loved ones. It is completed initially at the SOC and again after the patient's death. ...The care plan is reviewed and individualized to the needs of the bereaved contact during the IDG meeting. The Team should discuss and initiate the appropriate interventions needed for the contacts listed for the patient. It is important to assign the IDG member who will be responsible for completing the Interventions as well. ...The Chaplain and branch leadership will be responsible for ensuring the interventions are completed and will periodically review the Care Plan... --- 5. An interview was conducted on 5/14/24 at 2:00 PM with EI # 6, Chaplain, Bereavement Coordinator Selma/Prattville, who stated there was no designated Bereavement Coordinator at the Butler location, services were offered but a POC was not developed and individualized for each patient. 3. MR # 7 was admitted to the agency on 4/4/24 with diagnoses including Malignant Neoplasm of Unspecified Main Bronchus and Type 2 Diabetes Mellitus with Unspecified Complications. A review of the MR revealed no documentation of a bereavement risk assessment on admission or bereavement POC. An interview was conducted on 5/15/24 at 4:33 PM with EI # 2, who confirmed there was no documentation of a bereavement risk assessment on admission or a bereavement POC. 4. MR # 13 was admitted to the agency on 8/28/23 with diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified and Essential Primary Hypertension. A review of the MR revealed no documentation of a bereavement risk assessment on admission or a bereavement POC. An interview was conducted on 5/15/24 at 4:40 PM with EI # 2, who confirmed there was no documentation of a bereavement risk assessment performed on admission or a bereavement PoC. 2. MR # 3 was admitted on 4/3/23 with the diagnoses including Malignant Neoplasm of Frontal Lobe and Personal History of Irradiation. A review of the MR revealed no documentation of a bereavement risk assessment on admission or bereavement POC. An interview was conducted on 5/15/24 at 5:20 PM with EI # 2, RN, Branch Director Butler, who confirmed there was no documentation of a bereavement risk assessment on admission or a bereavement POC. 1. HV # 3 was admitted to the agency on 5/12/23 with a diagnosis of Cerebral Infarction (Unspecified). Review of the Medical Record (MR) revealed no documentation of a bereavement risk assessment upon admission. An interview conducted on 5/14/24 at 11:03 AM with Employee Identifier (EI) # 1, Registered Nurse (RN) Branch Director Selma/Prattville, confirmed there was no bereavement risk assessment completed upon admission.

Based on review of medical records, observations, and staff interview, it was determined the facility failed to ensure services were coordinated between the hospice agency and the long term care nursing facility. This affected Home Visit (HV) # 2, one of one HVs in a facility, and had the potential to affect all the patients residing in facilities. Findings Include: Agency Policy : None provided Agency Policy Number: None Date Reviewed: None --- Findings Include: HV # 2 was admitted to the agency on 11/29/23 with diagnoses including Alzheimers Disease with late onset and Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbances and resides in a skilled nursing facility (SNF). A home visit was conducted on 5/13/24 at 2:05 PM, to observe care provided by Employee Identifier (EI) # 6, Chaplain, Bereavement Coordinator Selma/Prattville. A review of HV # 2's hospice coordination binder revealed the latest hospice information provided was dated February 2024. There was no evidence of care coordination for over 2 months. An interview was conducted on 5/15/24 at 1:40 PM with EI # 1, RN Branch Director Selma/Prattville, who confirmed the agency failed to ensure services were coordinated the hospice and SNF.

Based on observations, agency policy and procedure, and interviews, it was determined the hospice agency failed to ensure staff performed hand hygiene (HH) per policy. This had the potential to negatively affect all patients and staff of the hospice agency and did affect one of four home visits (HV), including HV # 3. Findings include: Policy: Hand Hygiene-IC15 Effective Date: 4/2022 Purpose: To ensure patient care staff practice proper hand hygiene techniques in the prevention and spread of infection per CDC guidelines. ...D. If hands are not visibly soiled, staff may use an alcohol-based hand rub for routinely decontaminating hands in the clinical situations described below: ...8. After removing gloves... --- HV # 3 was admitted to the agency on 5/12/23 with a diagnosis of Cerebral Infarction, Unspecified. A HV was conducted on 5/13/24 at 12:45 PM to observe Employee Identifier (EI) # 5, Hospice Aide (HA), perform a bed bath. During the bed bath, EI # 5 removed his/her gloves four times and without performing HH, donned clean gloves. An interview was conducted on 5/14/24 at 11:03 AM with EI # 1 Registered Nurse, Branch Director Selma/Prattville, who confirmed staff failed to perform HH per policy.

Based on review of medical records (MR), observation, interviews, and agency policy and procedures, it was determined the staff failed to ensure each patient and/or the caregiver received education and training with return demonstration as appropriate for the care and services identified in the plan of care in one of six MRs reviewed and one of one home visits (HV) observed. This affected MR # 4, HV # 1, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Continuous IDT (Interdisciplinary Team) Patient Education Agency Policy Number: PF15 Effective Date: 4/2022 Purpose: To provide consistent, standardized information to the patient and/or caregiver based on continuous assessment and prioritization... Policy: The Hospice will provide ongoing assessment... Procedure: I. All disciplines,...will plan, prioritize and coordinate the implementation of patient education... A. A formal and/or informal teaching plan...and B. Return demonstrations by patient and/or caregiver. --- 2. HV # 1 was admitted to the agency 8/7/18 and recertified 3/14/23 through 5/12/23 with diagnoses including Alzheimer's Disease, Unspecified and Type I Diabetes Mellitus without Complications. Review of Physician Orders dated 1/18/23 revealed, "Stage II Pressure Ulcer lower buttock: clean with wound cleanser, pat dry, apply vaseline gauze, cover with ABD pad and secure with paper tape. Caregiver (CG) to perform daily and as needed when soiled. SN to perform during visit." Review of the HCPOC Update dated 3/14/23 to 5/12/23 revealed a SN frequency of one time a week for one week, then twice per week for eight weeks. Review of Physician Orders dated 3/15/23 revealed, "Stage II wound to right heel: clean with wound cleanser, pat dry, apply xeroform gauze, cover with bordered dressing. CG to perform daily and SN to perform during visit." A HV was conducted on 3/21/23 to observe wound care provided by EI # 4, Registered Nurse (RN). The CG was present in the room during patient wound care. No return demonstration for wound care was observed. During the HV, an interview was conducted with the CG. He/she Stated, "I watch the nurses provide wound care so I can do it when needed." The CG also stated he/she has not performed a return demonstration for wound care. Review of the SN visits dated 3/14/23 through 3/21/23 revealed no return demonstration for wound care documented. The surveyor requested documentation of patient/CG wound care teaching with return demonstration from admission to present, and none was provided. An interview conducted on 3/23/23 at 11:50 AM with EI # 3 RN, CTL (Clinical Team Lead) confirmed staff failed to provide the patient and/or CG proper wound care teaching with return demonstration. 1. MR # 4 was admitted to the agency on 12/16/22 with diagnoses including Heart Failure, Unspecified and Acute Respiratory Failure with Hypoxia. Review of the Hospice Certification and Plan of Care (HCPOC) dated 12/16/22 to 3/15/22 revealed a Skilled Nurse (SN) frequency of twice per week for one week, then once per week for thirteen weeks. Further review of the HCPOC dated 12/16/22 to 3/15/22 revealed the following wound care orders for a stage two sacral wound: Utilizing clean technique, cleanse with wound cleanser, cover with non-adherent pad and change every day and as needed. The caregiver to perform wound care daily and the SN to perform when present n the home. Instruct the caregiver in wound care. Review of the Physician's Order dated 12/17/22 revealed, "Stage Two Pressure Ulcer to Coccyx area: Clean wound with wound cleanser, pat to dry, apply triple antibiotic ointment, dress with non-adherent pad daily. Caregiver to perform daily and SN to perform when present in home". Review of the Physician's Order dated 2/3/23 revealed, "Wound care for Stage Two Pressure Ulcer to Coccyx: Cleanse stage two pressure ulcer to coccyx with wound cleanser, pat dry, apply saline moisten(d) gauze to wound bed, cover with dry gauzes or ABD (Abdominal) pad and secure with paper tape. Caregiver to perform wound change daily and PRN (as needed) for soiled or dislodged (dressing). SN may perform when in the home. Measure wound weekly or until healed or resolved". Review of all 15 SN Visit Note Reports (VNR) dated from 12/16/22 to 3/14/22 revealed no documentation the patient/caregiver was taught wound care with a return demonstration. An interview conducted on 3/23/22 at 11:50 AM with Employee Identifier (EI) # 1, Branch Director confirmed there was no documentation the patient/caregiver received education and training with return demonstration per policy.