Every finding on record at Hospice of North Alabama LLC

It is required that each patient’s individualized written plan of care reflects patient and family goals with measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. In 6 of 27 (22%) clinical records reviewed, the agency did not ensure that the patient’s plan of care included measurable outcomes anticipated from implementing and coordinating the plan of care. Clinical Record 20: The patient elected the hospice benefit on 02/23/2024 with a diagnosis of cerebral vascular accident (CVA). The plan of care (POC) dated 02/23/2024 identified the patient’s problem: “Altered comfort.” The POC documented the patient’s goal: “(Patient/Caregiver) Pt/Cg understands the pain scale, how to manage pain, and report changes to hospice.” The goal did not include a measurable outcome for managing and reporting the patient’s pain. Clinical Record 22: The patient elected the hospice benefit on 04/12/2024 with a diagnosis of chronic obstructive pulmonary disease (COPD). The POC dated 04/12/2024 identified the patient’s problem: “Altered comfort.” The POC documented the patient’s goal: “(Patient/Caregiver) Pt/Cg understands the pain scale, how to manage pain, and report changes to hospice.” The goal did not include a measurable outcome for managing and reporting the patient’s pain. Clinical Record 24: The patient elected the hospice benefit on 09/29/2023 with a diagnosis of malignant neoplasm of the right bronchus or lung. The POC dated 09/29/2023 identified the patient’s problem: “Altered Respiratory Status.” The POC documented the patient’s goal: “Respiratory status is stabilized.” The goal did not include a measurable outcome for stabilizing the patient’s respiratory symptoms. Clinical Record 25: The patient elected the hospice benefit on 09/13/2023 with a diagnosis of malignant neoplasm of the biliary tract unspecified. The POC dated 09/13/2023 identified the patient’s problem: “Altered Respiratory Status.” The POC documented the patient’s goal: “Respiratory status is stabilized.” The goal did not include a measurable outcome for stabilizing the patient’s respiratory symptoms. Clinical Record 26: The patient elected the hospice benefit on 10/07/2023 with the diagnoses of unspecified protein-calorie malnutrition and wounds. The POC dated 10/07/2023 identified the patient’s problem: “Alteration in skin integrity. The patient’s wounds will be minimized.” The goal did not include a measurable outcome for “wounds will be minimized.” Clinical Record 27: The patient elected the hospice benefit on 01/31/2024 with the diagnoses of CVA and wounds. The POC dated 01/31/2024 identified the patient’s problem: “Altered Respiratory System.” The POC documented the patient’s goal: “Respiratory status is stabilized.” The goal did not include a measurable outcome for stabilizing the patient’s respiratory symptoms. During a joint record review and interview on 09/18/2024, the Clinical Supervisor/Administrator confirmed that the plans of care did not include measurable outcomes anticipated from coordinating and implementing the plan of care.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 3 of 23 (13%) clinical records reviewed of patients with Hospice Aide (HA) services and changes related to the plan of care, the agency did not ensure that the HA reported changes in the patient’s care needs to the Registered Nurse (RN). Clinical Record 5: The patient elected the hospice benefit on 09/11/2024. The HA care plan dated 09/11/2024 assigned the HA the tasks: shampoo and bed bath every visit. The HA visit notes dated 09/12/2024 and 09/17/2024 documented that the “patient refused bed bath and shampoo.” A clinical record review revealed no evidence that the HA had notified the Registered Nurse (RN) of the change in the patient’s needs related to the HA care plan. Clinical Record 9: The patient elected the hospice benefit on 08/22/2024. The HA care plan dated 08/22/2024 assigned the HA the task of oral care every visit. The HA visit note dated 08/30/2024 documented that the “patient refused oral care.” A clinical record review revealed no evidence that the HA had notified the RN of the change in the patient’s needs related to the HA care plan. Clinical Record 25: The patient elected the hospice benefit on 09/13/2023. The HA care plan dated 09/13/2023 assigned the HA the tasks of oral care and shaving the patient every visit. The HA visit notes dated 10/01/2023 and 10/12/2023 documented that the ”patient refused oral care and shaving.” A clinical record review revealed no evidence that the HA notified the Registered Nurse (RN) of the change in the patient’s needs related to the HA care plan. During a joint record review and interviews on 09/18/2024, the Clinical Supervisor/Administrator confirmed that the aides had not reported changes in the patient’s care needs to the RN.

It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years; documentation of each training including the date(s), participants, and content. This standard was not met as evidenced by review of personnel records and interview. 1 of 10 (10%) records reviewed revealed the hospice did not ensure the contracted employee was provided emergency preparedness training every 2 years. Record #54252-Hospice Medical Director: The record was reviewed and identified the hospice did not provide emergency preparedness training for this contracted employee for 2019, 2020, and 2021. The Regional Director of Operations was interviewed on 12/17/2021 and indicated there was no documentation of emergency preparedness training nor was there any additional information to provide.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand hygiene. This standard was not met as evidenced by observation, interview and document review. 1 of 4 (25%) observed visits revealed the hospice did not ensure adherence to hospice infection control and prevention procedures. Record #36770: During the observed home visit on 12/15/2021 at 11:15am, the RN (Record #43609) was observed assessing the patient's blood pressure with gloved hands, then removing gloves and donning new gloves without sanitizing hands. The Clinical Director was interviewed on 12/15/2021 and indicted the RN did not follow agency policy and procedures for hand hygiene.

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes: education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by review of personnel records and interview. 1 of 10 (10%) records revealed the hospice did not provide education to contracted employees in infection control. Record #54252: This record was reviewed and revealed there was no infection control training provided by the hospice for this Medical Director for 2019 and 2020. The Clinical Director and Regional Director were interviewed on 12/17/2021 and stated there was no documentation of infection control for the contracted employee and there was no additional information to provide.