Every finding on record at Hospice of Clay County

Based on agency policy and procedure and medical record (MR) reviews, observation, and interviews, it was determined the agency failed to ensure a current, accurate medication profile was 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 ProfileDate reviewed: 3/25/24Policy: ...Hospice patients shall have a current, accurate medication profile in the medical record.Procedure:A. Upon admission to hospice, a medication profile shall be completed to document the current medication regime...B. During subsequent visits, the medication profile shall be used as a care planning and teaching guide to assure the patient, family, caregiver (CG), and hospice personnel understand the medication regimen... --- HV # 2 was admitted to the hospice agency on 6/30/25 and recertified for care from 9/28/25 to 12/26/25, with a terminal diagnosis of Alzheimer's Disease. A HV was conducted on 10/21/25 at 1:30 PM to observe care provided by Employee Identifier (EI) # 2, Hospice Aide.  After the observation was completed, the medication list was compared to the medications in the home. The following discrepancies were identified:  1. Ambien 10 milligrams (mg) daily at bedtime was available in the home and not on the agency medication list. The fill date on the bottle was 10/8/25. The CG stated HV # 2 had been taking the medication for "three to four months."MR review revealed a physician's order for Ambien 10 mg at bedtime dated 7/2/25.  2. Aricept 5 mg daily was on the agency medication list but was not available in the home. The CG stated HV # 2 stopped taking the medication "four or five months ago."An interview was conducted on 10/22/25 at 10:45 AM with EI # 1, Hospice Director, who confirmed the staff failed to follow agency policy and ensure a current, accurate medication profile was in the MR.

Based on observations, agency policy and procedure, employee file review, and interview, it was determined the hospice agency failed to ensure the Registered Nurse (RN) followed standard precautions to prevent the transmission of infections.This deficient practice affected one of three Home Visits (HV), including HV # 3, and had the potential to negatively affect all patients served by this hospice.Findings include:Agency Policy:  Hand HygienePolicy Number:  NoneLast Reviewed Date:  03-25-24Policy:  It is the policy of Hospice of Clay County to provide effective hand hygiene practices to reduce transmission of pathogenic microorganisms to patients and personnel..Procedures:...B. Hand Hygiene with Hand Sanitizer:1.  Use an alcohol based hand sanitizer for routine decontamination of hands:...b. Before donning gloves, especially prior to insertion of invasive devices, before performing an aseptic task......e. Before and after removing gloves. --- 1.  HV # 3 was admitted to hospice services on 10/8/25 with a terminal diagnosis of Amyotrophic Lateral Sclerosis.Review of the MR revealed a physician's order dated 10/8/25 for the RN to change HV # 3's suprapubic catheter every week.A HV was conducted on 10/22/25 at 9:09 AM to observe care provided by Employee Identifier (EI) # 4, RN.  The following observations were made during the visit:a. EI # 4 removed his/her gloves twice and did not perform hand hygiene.b. Sterile gloves were donned without first performing hand hygiene.c. A sterile insertion tray for use during the changing out of the suprapubic catheter was opened, and contents dumped out onto a non-sterile paper barrier.EI # 4 failed to follow agency policy and standard precautions for infection prevention.A review of EI # 4's employee file revealed no documentation of a competency evaluation for the insertion and removal of a suprapubic catheter.An interview was conducted on 10/23/25 at 12:01 PM with EI # 1, Hospice Director, who confirmed the staff failed to follow standard precautions for infection prevention and confirmed there was no documentation EI # 4 completed a competency evaluation for insertion and removal of a suprapubic catheter.

Based on policy and procedure, medical record (MR) reviews, and interviews, it was determined the agency failed to ensure the hospice aide provided services included in the plan of care (POC). This deficiency was identified on the prior recertification survey dated 4/13/23.This affected two of seven MRs, including MR # 9 and MR # 10, reviewed with aide services and had the potential to negatively affect all patients served by the agency.   Findings include:Agency Policy: Home Care Aide ServicesLast Review date: 3/5/25Policy: It is the policy of Clay County Healthcare Authority to specify the role of hospice home care aide. Hospice home care aide services include personal care and non-skilled services provided by trained home care aides. Procedure: A. The interdisciplinary team identifies the need for home care aide service. C. The clinical record contains the home care aide’s assignment, plan of care, and interventions. …D. Routine care includes home care aide services for personal care as needed. Home care aides provide services such as giving a bath, shampooing hair, range of motion activities, helping the patient to the bathroom, helping with use of commode or bed pan, helping with meal preparation, light housekeeping, and/or linen changes as needed… --- 2.  MR # 10 was admitted to hospice services on 6/23/25 with a terminal diagnosis of Coronary Artery Disease. Review of the Hospice IDG Review and Update to Plan of Care dated 6/23/25 revealed orders for the hospice aide to visit three times a week, beginning 6/23/25.Review of the Aide Assignment Sheet revealed the following tasks assigned to the aide each visit:Bed bath, perineal care, skin care, comb hair, assist with dressing, and record BM.Review of the aide visit note dated 9/26/25 revealed the aide did not perform all assigned tasks.An interview was conducted on 10/23/25 at 12:43 PM with EI # 1, who confirmed the aide did not perform all assigned tasks. 1.  MR # 9 was admitted to hospice services on 9/12/25 with a terminal diagnosis of Parkinson's with Dyskinesia.Review of the Hospice Interdisciplinary Group (IDG) Review and Update to Plan of Care dated 9/16/25 revealed orders for the hospice aide to visit two times a week, beginning 9/15/25.Review of the Aide Assignment Sheet revealed the following tasks assigned to the aide each visit:Shower, perineal care, skin care, shave, shampoo, comb hair, assist with dressing, assist with toileting, record bowel movement (BM), and assist with ambulation.Review of seven aide visit notes from 9/17/25 to 10/8/25 revealed the aide did not perform all the tasks as assigned.An interview was conducted on 10/23/25 at 11:52 AM with Employee Identifier (EI) # 1, Hospice Director, who confirmed the aide did not perform all assigned tasks.

Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the hospice agency failed to ensure the Medical Director reviewed patient clinical information prior to the recertification for continued care per the agency policy.This deficient practice affected MR # 7, one of ten active records reviewed receiving hospice services, and had the potential to affect all patients receiving hospice services.Findings include:Agency Policy:  Terminal Illness Re-CertificationPolicy Number:  NoneLast Reviewed Date:  03-27-2024...Procedure:...B. After 180 days of hospice service (2-90 day certification periods) the patient shall need a face-to-face re-certification, to be repeated every 60 days either until the patient passes or no longer qualifies for hospice care.C. The face-to-face portion of the recertification can be completed by the hospice Medical Director, or a hospice contracted physician up to 30 days prior to, but no later than the first day of the new certification period.  These findings shall be reported to the Medical Director who shall then review the documentation and, based on qualification, shall submit a narrative and complete the certification form no more than 2 days beyond the start of the new certification period. --- 1.  MR # 7 was admitted for hospice services on 6/29/22 with a terminal diagnosis of Chronic Obstructive Pulmonary Disease, then recertified for care 10/11/25 to 12/9/25.Review of the MR revealed a face-to-face visit was conducted by a physician on 10/11/25.  Further review revealed the hospice Medical Director signed the Recertification of Terminal Illness form on 10/9/25, which was two days prior to the face-to-face encounter.The hospice Medical Director failed to review MR # 7's face-to-face encounter prior to the recertification of terminal illness.An interview was conducted on 10/23/25 at 12:29 PM with Employee Identifier # 1, Hospice Director, who confirmed the Medical Director failed to review MR # 7's face-to-face encounter prior to the recertification of terminal illness.

Based on review of medical records (MR), agency policy and procedure and staff interviews, it was determined the hospice failed to develop an individualized written plan of care to include patient/family goals identified in the initial and comprehensive assessments and failed to include interventions based on problems identified in one of one patient record reviewed receiving physical therapy (PT). This deficient practice did affect MR # 8 and had the potential to negatively affect all patients admitted to hospice. Findings include: Agency Policy: Plan of Care Interdisciplinary Team (IDT) Reviewed Date: 6/2022 Policy: ...A Master Plan of Care is...developed after the required information has been gathered from the IDT. The IDT reviews the Master Plan of Care regularly. This plan is based on identified problems, goals and interventions... Procedure: B. The Master Plan of Care... must be signed by the IDT. C. The IDT reviews and revises the Master Plan of Care as frequently as deemed necessary. F. The Master Plan of Care shall include: 5. The IDT's assessments and plans for interventions and expected outcomes:... Agency Policy: IDT Coordination of Care Reviewed Date: 6/2022 Policy: ...Hospice uses a comprehensive, coordinated healthcare process and an IDT to provide services... Procedure; A. The IDT consists of ...therapists. --- 1. MR # 8 was admitted to hospice on 6/6/22, certified for hospice 6/6/22 through 9/3/22 and discharged on 7/19/22 with a diagnosis of Hepatic Failure. Review of the Standing Order Set (no date) revealed General Orders: Consult if needed: PT... Review of the Initial Plan of Care dated 6/6/22 revealed no plan of care developed for PT. Review of the Master Plan of Care dated 6/6/22 revealed no documentation that PT updated the plan. Review of the PT Evaluation dated 6/10/22 revealed assessment of MR # 8 with plans to visit three times per week for four weeks. There was no documentation of communication with the IDT including no update documented to the Master Plan of Care. Review of 16 Home Care visit notes by the PT dated from 6/13/22 to 7/18/22 revealed PT initiated and implemented a plan of action with a visit frequency of three visits per week. Review of all four IDT meetings with Updates to the Plan of Care dated 6/14/22, 6/28/22, 7/12/22 and 7/26/22 revealed no documentation that PT was included in the plan including no frequency for PT visits, no goals and no progress towards goals. An interview conducted on 4/13/23 at 2:15 PM with Employee Identifier (EI) #1, Director and EI # 2, Clinical Nurse Manager confirmed, there was no documentation an individualized written plan of care was developed for PT to include patient/family goals identified in the initial and comprehensive assessments and no documentation of interventions and progress toward goals on the plan of care.

Based on review of medical records (MR), Alabama Board of Nursing (ABON) Administrative Code for Standards of Nursing Practice, and interviews, it was determined the hospice failed to ensure the Skilled Nurse (SN) contacted the physician to pronounce deaths of patients. This deficient practice affected two of two Bereavement MRs reviewed and did include MR # 10 and MR # 11 and had the potential to negatively affect all patients being served by the hospice. Findings include: ABON Administrative Code Standards of Nursing Practice Chapter 610-X-6 1. The Licensed nurse may receive pronouncement of a patient's death from a physician via telecommunication 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. --- 1. MR # 10 was admitted to hospice on 9/16/22 with diagnosis including Alzheimer's Disease. Review of the Report of Death and Drug Disposal form dated 10/27/22 revealed MR # 10 expired at 9:58 PM pronounced by Employee Identifier (EI) # 2 Clinical Manager at 9:58 PM on 10/27/22. Further review of the Report of Death and Drug Disposal form dated 10/27/22 revealed the physician was notified of the death on 10/28/22 at 9:10 AM. There was no documentation the nurse contacted the physician for pronouncement of the patient's death. An interview conducted on 4/13/23 at 2:15 PM with EI # 2 and EI # 1, Director confirmed the nurse failed to contact the physician to pronounce the patient's death. 2. MR # 11 was admitted to hospice on 3/9/22 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the Report of Death and Drug Disposal form dated 4/11/22 revealed MR # 11 expired at 4:06 PM pronounced by EI # 7, RN (Registered Nurse) at 4:20 PM. Further review of the Report of Death and Drug Disposal form dated 4/11/22 revealed the physician was notified of the death on 4/12/22 at 8:30 AM. There was no documentation the nurse contacted the physician for pronouncement of the patient's death. An interview conducted on 4/13/23 at 2:15 PM with EI # 2 and EI # 1 confirmed the nurse failed to contact the physician to pronounce the patient's death.

Based on review of medical records (MR), agency policy, and interview with agency staff, it was determined the Hospice Aide (HA) failed to provide care as ordered by the Interdisciplinary Group (IDG) in the Hospice Aide Assignment in three of ten active records reviewed with aide services. This affected MR # 3, HV # 1, MR # 5 and had the potential to negatively affect all patients served by the agency receiving HA services. Findings include: Agency Policy: Job Description - Home Care Aide Policy Number: None Reviewed: 6/22 Job Summary: Performs duties essential to personal care and palliative care... Supervised by: registered hospice nurse. Duties and Responsibilities: A. Performs duties as assigned by RN, including baths, oral hygiene, nail care, foot care, skin care, pressure relief, dressing patient, feeding and transferring patient. B. Takes accurate vital signs... --- 2. HV # 1 was admitted to the agency on 3/15/23 and certified for care 3/15/23 to 6/12/23 with diagnosis including Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Cerebral Artery. Review of the Initial Plan of Care dated 3/15/23 revealed HA visits five times a week and as needed (PRN). Review of the Aide Assignment Sheet dated 3/15/23 revealed: Oral Hygiene ordered five times a week. Review of the AVN dated 3/16/23, 3/20/23 and 4/7/23 revealed no documentation of oral hygiene provided to the patient. An interview was conducted on 4/13/23 at 8:24 AM with EI # 1 and EI # 2 who confirmed there was no documentation the HA provided oral hygiene care as ordered for the dates 3/16/23, 3/20/23 and 4/7/23. 3. MR # 5 was admitted to the agency on 2/10/23 and certified for care 2/10/23 to 5/10/23 with admitting diagnosis of Alzheimer's. Review of the Initial POC dated 2/10/23 revealed HA visits three times a week and PRN. Review of the Aide Assignment Sheet dated 2/10/23 revealed: VS record each visit. VS include temperature, Blood Pressure (BP), pulse and respirations. Review of the AVN dated 3/9/23 revealed no documentation VS obtained. Review of the AVN dated 3/30/23, 4/3/23, 4/5/23, 4/6/23 revealed no documentation BP obtained. An interview was conducted on 4/13/23 at 9:01 AM with EI # 1 and EI # 2 who confirmed the HA failed to obtain VS each visit as ordered by the IDG. 1. MR # 3 was admitted to the agency on 11/14/22 and recertified on 1/24/23 to 3/24/23 and 3/25/23 to 5/23/23 with diagnoses including Senile Degeneration of Brain and Dementia. Review of the Hospice IDG and Plan of Care (POC) dated 1/24/23 revealed HA to visit two times weekly and updated on 3/7/23 HA to visit three times weekly. Review of the Aide Assignment Sheet dated 11/15/22 updated weekly through 4/4/23 revealed HA to take and record vital signs (VS), perform chair bath, shower, peri care, skin care, shampoo, comb hair, oral hygiene, nails: clean/file, assist with dressing, assist with toileting, record BM (bowel movements), OOB (out of bed) with assist, OOB in wheelchair, assist with ambulation, linen change and make bed on every visit. Review of Aide Visit Notes (AVN) dated 1/25/23 1/27/23, 2/6/23, 2/8/23, 2/10/23, 2/13/23, 2/15/23, 2/17/23, 2/20/23, 2/22/23, 2/24/23, 2/27/23, 3/1/23, 3/10/23, 3/13/23, 3/15/23, 3/17/23, 3/20/23, 3/22/23, 3/31/23, 4/3/23 revealed no documentation of oral hygiene, assist with toileting, OOB with assist, OOB in wheelchair, linen change or make bed tasks completed. Further review of AVNs dated 2/27/23 and 3/1/23 revealed no documentation VS taken. An interview conducted on 4/13/23 at 2:57 PM with Employee Identifier (EI) # 1, Director and EI # 2, Clinical Nurse Manager confirmed the HA failed to complete the assigned tasks.

Based on review of medical record (MR), agency policy, and interview with agency staff, it was determined the Hospice Aide (HA) failed to report changes related to the patient's plan of care as ordered by the Registered Nurse (RN) in the Hospice Aide Assignment in four of ten active records reviewed with aide services. This affected MR # 3, HV # 1, MR # 2, MR # 5 and had the potential to negatively affect all patients served by the agency receiving HA services. Findings include: Agency Policy: Job Description - Home Care Aide Policy Number: None Reviewed: 6/22 Job Summary: Performs duties essential to personal care and palliative care... Supervised by: registered hospice nurse. Duties and Responsibilities: A. Performs duties as assigned by RN... G. Identifies and communicates findings to the RN or Clinical Nurse Manager including changes... --- 2. HV # 1 was admitted to the agency on 3/15/23 and certified for care 3/15/23 to 6/12/23 with admitting diagnosis Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Left Cerebral Artery. Review of the Initial POC dated 3/15/23 revealed HA visits five times a week and as needed (PRN). Review of the Aide Assignment Sheet dated 3/15/23 revealed: Oral Hygiene: five times a week. Vital Signs (VS) record each visit with parameters as follows: Temperature: Report above 100 degrees. Blood Pressure (BP): Report if above 150/90 or below 100/60. Pulse: Report above 100 or below 60. Respirations: Normal range for this patient is 20. Review of the AVN dated 3/16/23 revealed oral hygiene not performed and BP 147/91. Review of the AVN dated 3/17/23 revealed oral hygiene not performed and pulse 104. Review of the AVN dated 3/20/23 revealed oral hygiene not performed and BP 147/100. Review of the AVN dated 3/21/23 revealed oral hygiene not performed and BP 142/92. Review of the AVN dated 3/22/23 revealed oral hygiene not performed, BP 129/92, and Temperature 100.1. Review of the AVN dated 3/30/23 revealed oral hygiene not performed and BP 140/96. Review of the AVN dated 4/3/23 revealed oral hygiene not performed and BP 145/99. Review of the AVN dated 4/5/23 revealed oral hygiene not performed and BP 139/94. Review of the AVN dated 4/7/23 revealed oral hygiene not performed and BP 142/100. There was no documentation the HA notified the RN of oral hygiene not performed and VS out of parameters. An interview conducted on 4/13/23 at 8:24 AM with EI # 1 and EI # 2 confirmed there was no documentation the HA notified the RN of VS out of parameters. 3. MR # 2 was admitted to the agency on 7/25/22 and recertified for care on 3/22/23 to 5/20/23 with admitting diagnosis of Congestive Heart Failure. Review of the Hospice IDG Review and the Update to POC dated 4/4/23 revealed HA frequency five times a week and PRN. Review of the Aide Assignment Sheet dated 7/26/22 revealed: VS record each visit: Pulse: Below 50. Respirations: Normal range for this patient is 14-20. Review of the AVN dated 3/27/23 revealed pulse of 47 respirations 10. Review of the AVN dated 3/29/23 revealed pulse 45. There was no documentation the HA notified the RN of VS out of parameters. An interview conducted on 4/13/23 at 8:49 AM with EI # 1 and EI # 2 confirmed there was no documentation the HA notified the RN of VS out of parameters. 4. MR # 5 was admitted to the agency 2/10/23 and certified for care 2/10/23 to 5/10/23 with admitting diagnosis of Alzheimer's. Review of the Initial POC dated 2/10/23 revealed HA visits three times a week and PRN. Review of the Aide Assignment Sheet dated 2/10/23 revealed: Shower each visit. VS record each visit: BP: Report if above 150/90 or below 100/60. Pulse: Report above 100 or below 60. Respirations: Normal range for this patient is 20. Review of the AVN dated 2/15/23 revealed pulse 56. Review of the AVN dated 2/16/23 revealed pulse 58. Review of the AVN dated 2/20/23 revealed pulse 53 BP 127/58. Review of the AVN dated 2/22/23 revealed pulse 52 BP 118/52. Review of the AVN dated 2/23/23 revealed pulse 58 BP 120/51. Review of the AVN dated 2/27/23 revealed pulse 59. Review of the AVN dated 3/6/23 revealed respirations 30. Review of the AVN dated 3/8/23 revealed pulse 54 BP 120/55. Review of the AVN dated 3/9/23 revealed no VS obtained. Review of the AVN dated 3/13/23 revealed BP 126/57. Review of the AVN dated 3/15/23 revealed BP 127/58 Respirations 10. Review of the AVN dated 3/22/23 revealed BP 121/58, pulse 57 respirations 10. Review of the AVN dated 3/23/23 revealed shower/bath refused. Review of the AVN dated 3/29/23 revealed pulse 58 respirations 10. Review of the AVN dated 4/6/23 revealed respirations 10. There was no documentation HA notified RN of VS out of parameters or shower bath refused. An interview was conducted on 4/13/23 at 9:01 AM with EI # 1 and EI # 2 who confirmed there was no documentation the HA notified the RN of care refused or VS out of parameters. 1. MR # 3 was admitted to the agency on 11/14/22 and recertified on 1/24/23 to 3/24/23 and 3/25/23 to 5/23/23 with diagnoses including Senile Degeneration of Brain and Dementia. Review of the Hospice Interdisciplinary Group (IDG) and Plan of Care (POC) dated 1/24/23 revealed HA visit two times weekly and updated on 3/7/23 HA visit three times weekly. Review of the Aide Assignment Sheet dated 11/15/22 updated weekly through 4/4/23 revealed vital sign parameters for Blood Pressure (BP) readings and report to the RN if above 140/100 or below 90/60. Review of the Aide Visit Note (AVN) notes revealed no documentation the HA reported to the RN the diastolic BP readings were below 60 as follows: AVN dated 1/25/23 BP reading 124/56. AVN dated 1/27/23 BP reading 128/54. AVN dated 2/8/23 BP reading 158/56. AVN dated 2/10/23 BP reading 120/52. AVN dated 2/13/23 BP reading 131/56. AVN dated 2/17/23 BP reading 127/57. AVN dated 2/28/23 BP reading 128/56. AVN dated 3/15/23 BP reading 120/51. AVN dated 3/17/23 BP reading 123/53. AVN dated 3/29/23 BP reading 118/57. AVN dated 3/31/23 BP reading 112/57. AVN dated 4/5/23 BP reading 101/54. AVN dated 4/7/23 BP reading 103/57. An interview conducted on 4/13/23 at 2:57 PM, with Employee Identifier (EI) # 1, Director and EI # 2, Clinical Nurse Manager confirmed the HA failed to communicate the diastolic BP readings were below the patient's ordered parameters to the RN.

Based on observation, review of medical records (MR), agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure staff charted accurately and according to professional standards. This affected one of three Home visits (HV) reviewed including HV # 1 and had the potential to affect all patients served by the agency. Findings include: Agency Job Description: Home Care Aide Agency Policy Number: None Reviewed: 6/22 Duties and Responsibilities: H. Demonstrates the ability to chart according to professional standards. Agency policy: Clinical Record Entry Agency Policy Number: None Date Reviewed: 6/22 Policy: It is the policy of Clay County Healthcare Authority to delineate who has authority to make entries into the clinical record. Hospice personnel providing direct patient care and supervisory functions shall have the authority to make entries into the clinical record. Documentation in the clinical record shall be timely, detailed and accurate and reflect the care or services provided... Procedure: A. A clinical record shall be initiated and maintained for patients receiving care/service... H. Home Care Aides (HCA) shall only make entries on the HCA assignment sheet and the Interdisciplinary Team Meeting form. --- 1. HV # 1 was admitted to the agency on 3/15/23 and certified for care 3/15/23 to 6/12/23 with an admitting diagnosis including Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Cerebral Artery. Review of the Initial Plan of Care (POC) dated 3/15/23 revealed skilled nurse (SN) visits one time a week and as needed (PRN). Hospice Aide (HA) visits five times a week and PRN. Review of the Initial POC dated 3/15/23 revealed "Problem Identified: Mobility Impairment." Review of the Nursing Clinical Note/Admission dated 3/15/23 revealed "Activity/Function:" Patient is bedfast, Unable to Ambulate. Review of the Physician Progress Note dated 3/21/23 revealed the patient is bedbound and unable to to ambulate or stand. Review of the Aide Assignment Sheet dated 3/15/23 revealed "Problem Limitations:" patient unable to walk, Complete Care. Review of the Aide Visit Note (AVN) dated 3/16/23 revealed the HA documented task performed: "out of bed (OOB) with/assist." Review of the AVNs dated 3/24/23, 3/27/23, 3/31/23, 4/3/23, and 4/7/23 revealed the HA documented task performed: "OOB with/assist and Assist with Ambulation." A HV was conducted on 4/11/23 at 10:30 AM to observe wound care provided by SN. The patient appeared semi-conscious and did not respond to verbal greetings by SN or to caregiver. An interview conducted on 4/13/23/ at 8:24 AM with Employee Identifier (EI) # 1, Director and EI # 2, Clinical Nurse Manager confirmed the patient was unable to get OOB w/assist or be assisted with ambulation and the HA did not document accurately in the MR or according to professional standards.

Based on review of medical records (MR) and staff interviews, it was determined hospice failed to have written policies and procedures for safe disposal of controlled drugs in the patient's home. This deficient practice affected one of two bereavement records reviewed and did affect MR # 11 and had the potential to negatively affect all patients admitted to the hospice. Findings include: (No Agency Policy for drug disposal) --- 1. MR # 11 was admitted to hospice on 3/9/22 and certified for hospice 3/9/22 to 6/6/22 with diagnoses including Chronic Obstructive Pulmonary Disease and Congestive Heart Failure. Review of the Report of Death & (and) Drug Disposal form dated 4/11/22 revealed the following drugs were destroyed and disposed of: Ativan 2 mg/ml (milligrams/milliliter), quantity: 22 ml Morphine 20 mg/ml, quantity: 24.5 ml Tramadol 40 mg, quantity: 62 (tablets) Ativan 0.5 mg, quantity: 48 (tablets) Further review of the Report of Death & Drug Disposal form dated 4/11/22 revealed there was no documentation of how the medications were disposed of. The surveyor requested the hospice policy for drug disposal and no policy was provided. An interview conducted on 4/13/23 at 2:15 PM with EI # 1, Director and EI # 2, Clinical Manger confirmed hospice did not have a policy for drug disposal and confirmed that on the death of a patient, the nurses transport the drugs in their cars, back to the hospice and the drugs are counted at the hospice. Once the drugs are counted, two hospice employees walk the drugs down to the hospital pharmacy (located in the same building) for disposal. The surveyor asked for the pharmacy policy for drug disposal and none was provided.

Based on observation, policy and procedure, and interview with agency staff, it was determined the hospice agency failed to provide the Skilled Nursing Facility (SNF) a Plan of Care (POC). This affected one of one Home Visits (HV) for a patient residing in a SNF including HV # 2, and had the potential to affect all patients served by the facility. Findings include: Agency Policy: Interdisciplinary Team Coordination of Care Policy Number: None Date Reviewed: 06/2022 Policy: It is the policy of Clay County Healthcare Authority to ensure the coordination of services for each patient. Hospice uses a comprehensive, coordinated healthcare process and an Interdisciplinary Team (IDT) to provide services and aid patients, families or caregivers. Procedure: ...D... It is the responsibility of the team to facilitate communication about changes in the patient's status among all assigned personnel. E. The team communicates changes via telephone, one-on-one meetings, case conferences and home visits. Hospice personnel include documentation of all communications in the clinical record on a communication note, IDT Meeting form, and/or clinical note. Documentation includes the date and time of the communication, individuals involved with the communication, information discussed and the outcome of the communication. ...G. Written evidence of care coordination is found in the POC and /or IDT Meeting Forms in the patient's clinical record. H. The Team conducts assessments and develops and updates the POC. The Team reviews the effectiveness of the POC every two weeks. I. All Team members, including those providing contracted services or volunteers have access to the POC to ensure coordination and continuity. J. Hospice personnel (via contract arrangement or direct employees) participate in the preparation of the POC. Hospice personnel submit documentation of services provided (including clinical notes, the schedule of visits and patient evaluations) at least twice a week and participate in IDT meetings... --- 1. HV # 2 was admitted to the agency on 6/29/22 and recertified for care 2/24/23 to 4/24/23 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A HV was conducted on 4/11/23 at 11:35 AM to observe care provided by Employee Identifier (EI) # 6, Spiritual Counselor for the patient residing in a SNF. Review of HV # 2's clinical record in the SNF revealed no documentation of a POC in the record. An interview was conducted 4/11/23 at 11:50 AM with Licensed Practical Nurse (LPN), an employee of the SNF, who confirmed there was no documentation of a POC located in the patient's clinical record or in any other location in the SNF. An interview was conducted on 4/13/23 at 8:43 AM with EI # 1, Director and EI # 2, Clinical Nurse Manager, who confirmed there was no documentation a POC was received by the SNF.