Every finding on record at Lhcg Xx II LLC

Based on Medical Record (MR) review, agency's policy and procedure, observation, and interview with staff it was determined the agency's staff failed to follow its Medication Administration policy.This affected two of four Home Visits (HV), including HV # 1, HV # 3, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Medication AdministrationAgency Policy Number: 3.002Revision Date: 02/01/23Purpose:To provide a process to ensure safe administration of medications in the home.Policy:...The Executive Director, with the attending physician, will make the decision regarding medication administration in the home...Procedure:...The RN (Registered Nurse) will initiate a medication profile upon admission and will update with any changes throughout the course of care... --- 2. HV # 3 was admitted to the agency on 1/15/26 and recertified for care 3/16/26 to 5/14/26 with a diagnosis of Alzheimer’s Disease Unspecified.Review of the Recertification Plan of Care Order dated 3/1/26 revealed the SN effective on 3/16/26 visit two times a week for nine weeks, and three PRN for urgent symptom management needs/changes in condition. The MSW effective on 4/1/26 visit one time per month for two months and three PRN visits for urgent psychosocial needs/interventions. The Chaplain effective 4/1/26 visit one time per month for two months and three PRN visits for urgent spiritual care needs/interventions.  The Hospice Aide effective on 4/1/26 visit two times a week for eight weeks then, one time a week for one week. Review of physician’s orders dated 4/21/26 revealed orders to discontinue the following medications: Donepezil 10 mg tablet and Memantine 10 mg tablet.A HV was conducted on 4/28/26 at 1:50 PM to observe care provided by EI # 5, MSW and medication review.The medications at the nursing home were compared to the ML provided by the agency on 4/28/26. The following discrepancies were identified:Donepezil HCL Oral Tablet 10 MG, give one tablet by mouth one time a day with an order date and start date of 1/14/26.Memantine HCL Oral Tablet 10 MG, give one tablet by mouth two times a day, with an order date and start date of 1/14/26.An interview was conducted on 4/30/26 at 3:30 PM with EI # 1, RN, Director of Clinical Operations, who confirmed the staff failed to update the medication profile per the agency's medication administration policy.  1. HV # 1  was admitted to the agency on 10/2/24 and recertified for care 3/26/26 to 5/24/26 with a diagnosis of Senile Degeneration of Brain Not Elsewhere Classified.Review of the Recertification Plan of Care Order dated 3/11/26 revealed the Skilled Nurse (SN) effective on 3/26/26 visit one time for one week, two times a week for eight weeks and three PRN (as needed) for urgent symptom management needs/changes in condition. The Medical Social Worker (MSW) and Chaplain effective on 4/1/26 visit one time per month for two months and three PRN visits. The Hospice Aide effective on 3/26/26 one time a week for one week then, two times a week for eight weeks. A HV was conducted on 4/28/26 at 1:15 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide (HA) and medication review.The medications in the home were compared to the Medicine List (ML) provided by the agency on 4/28/26 and verified by the patient's spouse. The following discrepancy was identified:Lexapro 10 milligrams (MG) tablet, take one tablet daily was listed on the ML. Lexapro 20 mg tablet, take one tablet daily was in the home with the filled date of 4/2/26.An interview was conducted on 4/30/26 at 2:30 PM with EI # 2, Executive Director (ED), who confirmed the staff failed to update the medication profile per the agency's medication administration policy.

Based on review of Medical Records (MR), agency policy and procedures, and staff interviews it was determined the agency failed to ensure an initial bereavement risk assessment was completed for each patient/family. This affected two of 19 records reviewed including HV #2 and MR # 10. This deficient practice had the potential to affect all patients/families served by the hospice.Findings include:Agency Policy: Bereavement AssessmentPolicy Number: 2.004Revised Date: 3/1/21 ...Procedure:The social worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice... --- 1. HV # 2 was admitted to the agency on 2/24/2024 with the diagnosis of Senile Degeneration of the Brain.Review of the initial assessment completed by the nurse on 2/24/2024 and the Interdisciplinary Group (IDG) Summary Report dated 2/28/2024 revealed no documentation of an initial bereavement risk assessment.An interview conducted on 4/30/2026 at 3:00 PM with Employee Identifier (EI) # 1, Director of Clinical Operations, confirmed there was no documentation the initial bereavement risk assessment was completed.2. MR # 10 was admitted to the agency on 12/15/2025 with the diagnosis of Chronic Obstructive Pulmonary Disease.Review of the initial assessment completed by the nurse on 12/15/2025 and the IDG Summary Report dated 12/29/2025 revealed no documentation of an initial bereavement risk assessment.An interview conducted on 4/30/2026 at 3:00 PM with EI # 1, confirmed there was no documentation the initial bereavement risk assessment was completed.

Based on review of agency policy and procedure, observation, and interview with staff it was determined the agency's staff failed to follow its own hand hygiene policy.This affected one of four Home Visits (HV), including HV # 1, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Hand Hygiene - Infection ControlAgency Policy Number: 10.002Revision Date: 4/01/26Purpose:To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines.Policy:Staff are required to perform hand hygiene prior to, at specified time points during, and following patient contact...Procedure:Staff perform hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer:a. before direct contact with patients...e. if moving from a contaminated body site to a clean body site during patient care.f. ...before and after removing personal protective equipment (PPE) such as gloves... --- 1. HV # 1  was admitted to the agency on 10/2/24 and recertified for care 3/26/26 to 5/24/26 with a diagnosis of Senile Degeneration of Brain Not Elsewhere Classified.A HV was conducted on 4/28/26 at 1:15 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide (HA).EI # 3 transported HV # 1 to the bed. EI # 3 removed gloves, without performing hand hygiene, reached into his/her uniform pocket retrieved and donned gloves from the pocket. EI # 3 washed HV's # 1 face and proceeded with the bed bath. EI # 3 applied lotion to HV # 1's legs and chest with gloved hands. EI # 3 then removed gloves, without performing hand hygiene, donned clean gloves, dressed top half and placed pull up on HV # 1. EI # 3 then transported HV # 1 to the rollator, removed gloves, without performing hand hygiene, donned clean gloves and shampooed HV's # 1 hair.EI # 3 failed to follow the agency's hand hygiene policy. An interview was conducted on 4/30/26 at 2:30 PM with EI # 2, Executive Director (ED), who confirmed the staff failed to follow the agency's hand hygiene policy.

Based on medical record (MR) review, agency policies and procedures, and interviews, it was determined the agency failed to ensure:1. The physician pronounced the death of a patient.2. The physician was notified of changes in wound status.3. The hospice staff accurately documented wound assessments.This deficient practice affected one of three Bereavement MRs reviewed, including MR # 13 and two of four MRs reviewed with wounds including MR # 8, MR # 12 and had the potential to negatively affect all patients admitted to the agency. Findings include:Agency Policy: Home Death PronouncementPolicy Number: 3.013Revised Date: 8/1/25Purpose:To establish the process for the hospice clinician to follow when a patient dies at home.Policy:…State: AlabamaWho Can Pronounce: PhysicianGuidelines: Registered Nurse/Licensed Practical Nurse can pronounce per verbal communication with the physician.Agency Policy: Hospice Medical RecordPolicy Number: 9.001Revised Date: 10/1/24Purpose:To define the contents and requirements of the hospice medical record.…Procedure:2. The hospice medical record shall contain the following clinical information:…b. Any summaries of care, treatment, or services, including changes in patient’s condition, furnished to the patient’s physician or licensed independent practitioner.…l. Documentation and communication with the patient, caregivers, and physicians.m. Any assessment relevant to care, treatment, or services.Agency Policy: Wound Assessment, Documentation and PhotographyPolicy Number: 3.029Revised Date: 3/1/21Purpose:To ensure the accurate and consistent assessment and documentation of wounds.Policy:Upon initial visit and subsequently as applicable, all wounds will be assessed with appropriate documentation with the medical record...Procedure:...2. Perform wound care according to physician orders specified in the patient's plan of care. 3. Document the following in the medical record:a. Treatment and condition of the wound (each visit)b. Appearance of the wound bed (black, yellow, red)c. Wound measurements (weekly) including the length, depth, and width of the wound in centimetersd. Depth and location of the undermining in centimeterse. Surrounding tissuef. Color, odor, and estimated amount of drainageg. Stage the wound weeklyh. Patient/representative/caregiver instructions...i. Other pertinent findings...4. Redress the wound using appropriate wound care... --- 3. MR # 12 was admitted to the agency on 3/13/26 with primary diagnosis of Alzheimer's Disease. Review of SN Visit Note dated 3/13/26 revealed the patient had multiple stage 3 or 4 decubitus ulcers, pale skin and bruising on upper and lower extremities, and a sacral wound. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/14/26 revealed the patient had poor skin turgor. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/17/26 revealed the patient had pale skin. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/19/26 revealed the patient had pale skin, wounds, pressure ulcers, injuries, and stated, "see wound assessment tool." There was no evidence of a wound assessment documented. Review of SN Visit dated 3/25/26 revealed the patient had pale skin and no skin conditions. There was no evidence of a wound assessment documented. Review of SN Visit dated 3/26/26 revealed the patient had pale skin. There was no evidence of a would assessment documented. Review of SN Visit dated 3/31/26 revealed the patient had pale skin and a Mid-Sacral Pressure Ulcer, Stage IV, onset date 3/31/26 with measurements of 4.5 cm length, 6.5 cm width, and 0.1 cm depth.Review of a physician's order dated 3/31/26 revealed orders to "cleans sacral wound with wound cleanser, pat dry with clean gauze, apply Hydrogel (brand) and cover with border gauze daily, and as needed (PRN) if soiled. Facility Staff Nurse (FSN) can perform wound care in absence of Staff Nurse (SN)." Review of SN Visit dated 4/2/26 revealed the patient had pale skin, poor skin turgor, wounds, and stated, "see wound assessment tool." Review of the wound assessment tool revealed the following documentation, "wound assessment and wound care not ordered this visit." Review of SN visit dated 4/2/26 revealed the patient was being admitted to the hospital for sepsis. The Hospice revocation date was noted as the same day, 4/2/26. An interview was conducted on 4/30/26 at 3:00 PM with EI # 1 who confirmed the agency failed to ensure the hospice staff accurately documented wound assessments.     1. MR # 13 was admitted to the agency on 9/3/25 with primary diagnosis of End Stage Renal Disease.Review of the Skilled Nurse (SN) Visit Note dated 9/22/25 revealed the patient expired at 4:26 PM. There was no documentation the physician pronounced the patient’s death.An interview was conducted on 4/30/26 at 3:14 PM with Employee Identifier (EI) # 1, Director of Clinical Operations, who confirmed there was no documentation the physician pronounced the patient’s death.2. MR # 8 was admitted to the agency on 2/5/25 with primary diagnosis of Chronic Obstructive Pulmonary Disease Unspecified.Review of the SN Visit Note dated 3/16/26 revealed a wound in the Abdominal Left Upper Quadrant, Pressure Ulcer Stage II with measurements of 1.5 centimeters (CM) length, 1.5 CM width, and 0.2 CM depth. SN Visit Note dated 3/22/26 revealed a significant increase in wound measurement of 4 CM length, 4 CM width and 0.2 CM depth.There was no documentation the physician was notified of changes in the patients condition.An interview was conducted on 4/30/26 at 3:11 PM with EI # 1, who confirmed there was no documentation the physician was notified of of changes in the patients condition per agency policy.

Based on review of Medical Records (MR), agency policy and procedure, and interviews, it was determined the agency failed to ensure the Plan of Care for visit frequency was followed. This affected two of four Home Visits (HV), and three of fifteen MR reviewed including HV # 1, MR # 12, MR # 14, MR # 13, HV # 3, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Plan of Care Policy number: 3.003 Revised: 11/1/21 ...A written plan of care is developed for each patient/family by the ... hospice physician and the Interdisciplanary Group (IDG). Procedure: ...2. The plan of care must include all sevices necessary...including the following: ...b. Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs... --- 4. MR # 13 was admitted on 5/17/22 with a primary diagnosis of Alzheimer's Disease, Unspecified. Review of the Hospice Recertification Orders dated 6/26/23 revealed orders for an Aide visit frequency of two times a week for nine weeks, effective 7/11/23. Review of the Hospice Aide VNRs for week 8/6/23 through 8/12/23 revealed only one Aide visit was completed and not two as ordered. An interview was conducted on 8/31/23 at 2:50 PM with EI # 1 who confirmed the Aide frequency was not followed. 5. HV # 3 was admitted on 9/8/22 with a primary diagnosis of Alzheimer's Disease With Early Onset. Review of the Hospice Recertification Orders dated 6/20/23 revealed orders for an Aide visit frequency of two times a week for one week, then three times a week for eight weeks, effective 7/5/23. Review of the Hospice Aide VNRs revealed no documentation visits were made by the Aide the week of 7/23/23 through 7/29/23, a total of three missed visits. An interview was conducted on 8/31/23 at 3:03 PM with EI # 2, Patient Care Manager, who confirmed the Aide frequency was not followed. 1. HV # 1 was admitted on 7/7/23 with a primary diagnosis of Senile Degeneration of Brain. Review of the physician's order dated 8/15/23 revealed orders for Skilled Nurse (SN) effective 8/13/23, four times a week for one week, three times a week for three weeks, four times a week for one week, three times a week for two weeks, then two times a week for one week. Review of the SN Visit Note Reports (VNRs) for the week of 8/20/23 through 8/26/23 revealed only two SN visits were completed and not three as ordered. An interview was conducted on 8/31/23 at 3:40 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed there should have been three SN visits for the week of 8/20/23 and the SN frequency was not followed. 2. MR # 12 was admitted on 7/14/23 with a primary diagnosis of Senile Degeneration of Brain. Review of the Hospice Certification and Plan of Care dated 7/14/23 revealed physician's orders for Hospice Aide two times a week for twelve weeks then one time a week for one week beginning 7/16/23. Review of the Hospice Aide VNRs from 7/16/23 through 7/22/23 revealed only one Aide visit was completed and not two as ordered. Review of the Hospice Aide VNRs from 7/23/23 though 7/29/23 revealed only one Aide visit was completed and not two as ordered. An interview was conducted on 8/29/23 at 3:38 PM with EI # 1, who confirmed the Aide frequency was not followed. 3. MR # 14 was admitted on 7/22/23 with a primary diagnosis of Senile Degeneration of Brain. Review of the Hospice Certification and Plan of Care dated 7/22/23 revealed physician's orders for Hospice Aide three times a week for twelve weeks then two times a week for one week beginning 7/23/23. Review of the Hospice Aide VNRs from 8/13/23 through 8/19/23 revealed only two Hospice Aide visits were completed and not three as ordered. An interview was conducted on 8/31/23 at 4:05 PM with EI # 1, who confirmed the Aide frequency was not followed for the week of 8/13/23.

Based on observations, agency policy, procedure and protocols, and interview it was determined the agency failed to ensure staff followed agency protocol to allow re-usable equipment to air dry after cleaning and disinfection before returning to the home care bag. This deficient practice affected Home Visit (HV) # 2, one of two HV observations with staff utilizing a home care bag, and had the potential to negatively affect all patients served by this hospice. Findings include: Agency Protocol: Home Care Bag Protocol Job Aid Revision Date: 5/10/21 ...Use the home care bag to prevent the potential spread of infection...Adherence to this protocol is mandatory... Home Care Bag Protocol: ...14. Never return soiled equipment to the bag. Items such as stethoscopes shall be cleaned per policy/procedure and allowed to dry prior to returning them to the bag. --- 1. A HV was conducted on 8/29/23 at 12:30 PM to observe care provided by Employee Identifier (EI) # 4, Registered Nurse (RN). At the conclusion of the visit, EI # 4 obtained a disinfectant wipe and cleaned his/her blood pressure cuff, thermometer, stethoscope, pulse oximeter, and hand held computer device, and immediately dropped each item into his/her home care bag after wiping them individually. EI # 4 failed to follow agency policy/protocol and allow each item to dry before returning them to his/her bag. An interview was conducted on 8/31/23 at 3:15 PM with EI # 2, Patient Care Manager, who confirmed staff did not follow agency policy/protocol to allow re-usable equipment to air dry before returning to the home care bag after cleaning.

Based on review of medical records (MR), Alabama Board of Nursing Administrative Code, agency policy, and interview, it was determined the nursing staff failed to obtain the death pronouncement from the physician as required by the Alabama Board of Nursing. This deficient practice affected one of five death records reviewed, and did affect MR # 19, and had the potential to affect all death pronouncements by this hospice. Findings include: 610 Alabama Board of Nursing Alabama Administrative Code r. 610-x-6-.15 (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 shall specify the permissable 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. Agency Policy: Home Death Pronouncement Policy Number: 3.013 Revised Date: 03/01/22 Purpose: To establish the process for the hospice clinician to follow when a patient dies at home. Policy: ...Individual state...regulations...will be followed. Alabama: RN/LPN (Registered Nurse/Licensed Practical Nurse) can pronounce per verbal communication with the physician --- 1. MR # 19 was admitted to the hospice agency on 2/9/23 with the primary diagnosis Malignant Neoplasm of Prostate. Review of the RN Hospice Death at Home Visit Note Report dated 5/6/23 revealed the RN arrived to the home at 8:26 AM, and documented the following in the Assessment: "Indicate Time of Death Confirmed" 8:30 AM. There was no documentation the RN received the pronouncement of death from the physician. In an interview on 8/31/23 at 2:32 PM with Employee Identifier # 1, Executive Director, it was confirmed there was no documentation the RN received the death pronouncement from the physician.

Based on observations, Medical Record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to ensure the Hospice Aide (HA) followed the Plan of Care (POC). This affected three of fifteen MR's reviewed for patients who received HA services including Home Visit (HV) # 1, MR # 14, and HV # 4 and had the potential to affect all patients admitted to this agency requiring HA services. Findings include: Agency policy: Plan of Care Policy number: 3.003 Revised: 11/1/21 ...A written plan of care is developed for each patient/family by...hospice physician designee and the Interdisciplinary Group (IDG). ...2. The plan of care must include all services necessary...including the following: b. Detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs... --- 3. HV # 4 was admitted 10/20/22 with a primary diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. Review of the Aide Care Plan Report dated 7/14/23 revealed orders for HA one time a week for one week, three times a week for twelve weeks then one times a week for one week with orders to shampoo every visit. Review of the HA VNRs dated 8/16/23 and 8/23/23 revealed the HA documented the shampoo was not completed with a note stated, "once a week." An interview was conducted on 8/31/23 at 3:31 PM with EI # 1, who confirmed the Aide Care Plan was not followed as ordered. 1. HV # 1 was admitted on 7/7/23 with a primary diagnosis of Senile Degeneration of Brain. Review of the Aide Care Plan Report dated 7/7/23 revealed orders for the HA three times a week for twelve weeks then two times a week for one week and to shampoo every visit. A HV was conducted on 8/29/23 at 11:55 AM to observe care provided by Employee Identifier (EI) # 3, HA. During the observation EI # 3 failed to shampoo the hair of HV # 1. Review of the Aide Visit Note Reports (VNRs) dated 8/8/23, 8/14/23, 8/18/23, 8/23/23, and 8/29/23 revealed the Aide documented the shampoo was not completed with a note stating, once a week. An interview was conducted on 8/29/23 at 3:48 PM with EI # 1, Executive Director (ED), who confirmed the Aide Care Plan was not followed. 2. MR # 14 was admitted on 7/22/23 with a primary diagnosis of Senile Degeneration of Brain. Review of the Aide Care Plan Report dated 7/26/23 revealed orders for HA three times a week for twelve weeks then two times a week for one week and to shampoo every visit. Review of the HA VNRs dated 7/26/23, 7/31/23, and 8/13/23 revealed the HA documented the shampoo was not completed with a note stating once a week. An interview was conducted on 8/31/23 at 4:05 PM with EI # 1, who confirmed the Aide Care Plan was not followed.