Every finding on record at Lhcg Xxii, LLC

Based on review of medical records (MR), hospice policy and procedure, and interviews, it was determined the hospice failed to ensure all patients/families received an initial bereavement assessment. This affected one of five closed records reviewed including MR # 11 and had the potential to negatively affect all patients/families served by the agency.Findings include:Policy: Bereavement AssessmentPolicy Number: 2.004Revised Date: 3/1/21Purpose:To ensure appropriate and coordinated bereavement services are provided to families and caregivers of hospice patients.Policy:The agency will make available bereavement services … This information is incorporated into the plan of care.Procedure:1. The Social Worker or designee will complete a Bereavement Risk Assessment within 5 days of admission to hospice. --- MR # 11 was admitted to the hospice agency on 12/5/24 with the diagnosis of Malignant Neoplasm of Pancreas, Unspecified.A review of the MR revealed no documentation an initial bereavement assessment was completed.An interview was conducted on 5/15/25 at 3:58 PM with Employee Identifier (EI) # 1, Executive Director, who confirmed the agency failed to ensure all patients/families received an initial bereavement assessment.

Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to ensure the Hospice Aide (HA) notified the Registered Nurse (RN) with changes in the patient's condition which included a fall. This affected one of one MR reviewed with a patient fall, including MR # 4, and had the potential to negatively affect all patients with HA services.Findings include:Agency Policy: Patient Fall Reduction ProgramPolicy Number: 3.031Date Revised:  11/01/17Policy:... The hospice agency will ensure the visiting staff is educated on fall risk assessment and prevention strategies.Procedure:...2. Patient Fallsa. ...the RN will be notified for injury assessment... --- 1. MR # 4 was admitted to the agency on 4/15/25 with the primary diagnosis of Alzheimer's Disease, Unspecified. Review of the Aide Care Plan Report dated 4/15/25 revealed fall precautions every visit. Notify nurse if fall occurs.Review of the Aide Visit Note Report dated 4/18/25 revealed the HA documented the patient had a spell, passed out, and fell in the floor.There was no documentation the HA notified the RN of the patient fall.An interview was conducted on 5/15/25 at 3:21 PM with Employee Identifier # 1, Executive Director, who confirmed the agency failed to ensure the HA notified the RN with changes in the patient's condition.

Based on review of agency policy and procedure, medical records (MR), and interview, it was determined the agency failed to ensure caregivers were provided education regarding wound care and were deemed competent to perform wound care in one of two records reviewed with wounds, including MR # 2, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Patient/Family Education Policy Number: 4.001 Revision Date: 8/1/12 Policy: The agency plans, supports, and coordinates patient/representative education that is designed to promote optimal patient safety and care. Patients/family will receive oral and/or written information for this purpose on an ongoing basis while being cared for by the agency. Procedure: 1. Educational resources are made available through appropriate education methods to the patient/family based on assessed and/or potential learning needs of the patient/family, including access to: a. qualified nurses... b. oral and written educational information c. appropriate educational methods designed to enhance patient/family learning 2. Education provided is coordinated among the interdisciplinary group, according to the plan of care... ...6. The nurse...documents education provided to the patient/family, including level of comprehension and compliance. 1. MR # 2 was admitted to the agency on 6/8/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, and Cardiomyopathy, Unspecified. Review of the Hospice Certification and Plan of Care (POC) dated 6/8/22 to 9/5/22 revealed a Skilled Nurse (SN) ordered visit frequency of two times a week for eleven weeks, with orders for the hospice nurse to perform/instruct the caregiver (CG) on the procedure of wound care to the right calf as follows: "Cleanse with wound cleanser, pat dry with gauze, apply mupirocin ointment, cover with gauze, secure with six by six bordered dressing." "Instruct patient/CG signs symptoms of wound infection and proper disposal of dressings." Review of the 6/8/22 SN Start of Care Visit Note (VN) revealed the SN documented he/she provided wound care as ordered. Further review revealed no documentation the patient/CG was provided education on wound care, signs and symptoms of wound infection, or proper disposal of dressings. Review of the 6/10/22 and 6/17/22 SN VN Wound Assessment revealed the SN documented he/she did not provide wound care due to the CG had completed care. There was no documentation the CG was competent to provide the ordered wound care. Review of the SN VN's dated 6/13/22, 6/17/22, and 6/20/22 revealed no documentation the patient/CG was provided education on wound care, signs and symptoms of wound infection, or proper disposal of dressings. Review of the 6/24/22 SN VN narrative revealed documentation the wound to the right calf had yellow drainage. The physician was contacted and an order for Bactrim DS 800-160 milligrams, one tab twice daily for seven days for skin infection was received. Review of the SN VN's dated 6/27/22, 7/1/22, 7/8/22, 7/11/22, and 7/15/22 revealed no documentation the patient/CG was provided education on wound care, signs and symptoms of wound infection, or proper disposal of dressings. Review of the Hospice Physician Order dated 7/15/22 revealed orders for the right calf wound as follows: "Cleanse with wound cleanser, pat dry with gauze, apply mupirocin ointment, cover with four by four gauze, and secure with bordered dressing." "CG demonstrated active listening as evidenced by return demonstration." There was no documentation in the MR the CG was educated and deemed competent to provide wound care to the right calf wound. In an interview conducted 7/28/22 at 2:15 PM with Employee Identifier (EI) # 1, Executive Director, EI # 1 confirmed the staff failed to educate the CG and ensure the CG was competent to provide the ordered wound care.

Based on Medical Record (MR) review, agency policy and procedure, and interviews, it was determined the agency failed to ensure the care services were provided based on the identified needs of a patient including bug infestation, heating and cooling issues, and food insecurity. This deficient practice affected 1 of 10 active records reviewed including MR # 3 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Interdisciplinary Group (IDG) Membership and Responsibilities Policy Number: 3.002 Revised: 11/01/2021 ...2. The IDG responsibilities include but are not limited to: e. Ensuring that the plan of care and services provided are based on all assessments of the patient and family needs. f. Providing for and ensuring the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly of under arrangement... 1. MR # 3 was admitted for hospice care on 6/23/22 with diagnoses including Emphysema, Unspecified and Other Pneumonia. Review of the Hospice Certification and Plan of Care (POC) dated 6/23/22 revealed orders for Skilled Nurse (SN) three x a week for two weeks then two times a week for seven weeks and Medical Social Work (MSW) one time a month. Further review of the Hospice Certification and POC dated 6/23/22 revealed the following documentation under Orders of Discipline and Treatments: "The following housing concerns were observed, bug infestations, heating/cooling issues...concerns about food insecurity..." Review of the SN Visit Note Report dated 6/23/22 revealed the SN documented "...fair appetite but no food in the home at this time. (He/She) states that someone broke into (his/her) house while (he/she) was in the hospital and stole everything...the MSW will visit tomorrow to try and help (him/her) with (his/her) needs especially getting food in the home..." Review of the MSW Visit Note Report dated 6/24/22 revealed the MSW documented "...lives alone...MSW will check on getting a fridge for PT (patient) and check on homebound meals for PT..." Further review of the MSW Visit Note Report dated 6/24/22 revealed no documentation the housing concerns of bug infestation and heating/cooling concerns were addressed. Review of the Hospice IDG Comprehensive Assessment and POC Update Report dated 7/5/22 revealed no documentation from the MSW about the lack of food in the home or plans for meal delivery. There was no documentation the MSW address the problems of bug infestation and heating/cooling concerns. In an interview conducted on 7/28/22 at 1:57 PM, Employee Identifier # 1 confirmed the staff failed to document follow up on identified needs of the MR # 3 and update the IDG.

Based on review of agency policy and procedure, observation, and interview with staff it was determined the agency's staff failed to follow its on policy for hand hygiene. This affected one of three Home Visits (HV), including HV # 3 and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Hand Hygiene - Infection Control Policy number: 10.002 Effective 3/01/21 Purpose: 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. Hand hygiene will be performed using soap and water or an alcohol-based hand sanitizer. Procedures: 1. Staff performs hand hygiene ... e. if moving from a contaminated body site to a clean body site during patient care... 1. HV # 3 was admitted on 5/20/22 with Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side and Unspecified Atrial Fibrillation. A HV was conducted on 7/27/22 at 9:00 AM with Employee Identifier (EI) # 4 Hospice Aide (HA) to observe care provided to the patient. During observation of the bed bath, EI # 4 performed hand hygiene, donned gloves and bathed HV # 3 including perineal area with soap and water. Then without removing gloves and performing hand hygiene, EI # 4 applied deodorant to underarms and lotion to the body including chest, back and extremities of HV # 3. EI # 4 failed to remove gloves and perform hand hygiene after moving from a contaminated body site to a clean body site per agency policy. An interview was conducted on 7/28/2022 at 2:29 PM with EI # 1, Executive Director who confirmed the staff failed to follow the agency's hand hygiene policy.

Based on review of medical records (MR), the Alabama Board of Nursing Administrative Code and Standards of Nursing Practice, and interview with staff, it was determined the agency failed to ensure the nursing staff received the pronouncement of death via telecommunication with the physician as directed by the Alabama Board of Nursing. This affected 1 of 1 records reviewed for death, including MR # 8. This deficient practice had the potential to negatively affect all patients admitted to the hospice. Findings include: Alabama Board of Nursing Administrative Code Chapter 610-X-6 Standards of Nursing Practice: 610-X-6-.15 Telecommunication For Pronouncement Of Patient Death. (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. Author: Alabama Board of Nursing Statutory Authority: Code of Ala. 1975, §§22-31-2, 34-21-2(c)(21). 1. MR # 8 was admitted to the agency on 7/3/22 with diagnoses including Malignant Neoplasm of Colon, Unspecified, and Secondary Malignant Neoplasm Of Unspecified Site. A review of the RN Hospice Death at Home Visit Note dated 7/8/22 revealed no documentation the RN notified the hospice physician of the absence of vital signs and receipt of a pronouncement of death by a physician. In an interview conducted 7/28/22 at 1:48 PM with Employee Identifier (EI) # 1, Executive Director, EI # 1 confirmed there was no documentation the nurse contacted the physician for the pronouncement of a death as required by the Alabama Board of Nursing.

Based on medical record (MR) review, Home Visit (HV) observation, policies and procedures, and interview, it was determined the Skilled Nurse (SN) failed to document accurate assessment information for the HV observed. This affected one of three HV's, including HV # 1, and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Patient Reassessments Policy Number: 2.003 Revision Date: 7/1/12 Purpose: To provide guidelines for ongoing assessment of patients during hospice care. Policy: The hospice is responsible for continual assessment of the effectiveness of the plan of care (POC)... Procedure: ...2. The nurse...will complete an assessment of the patient on each visit according to the patient POC. This assessment may include: ...b. Breath sounds ...f. Bowel sounds... Agency Policy: Hospice Medical Record Policy Number: 9.001 Revision Date: 11/1/21 Purpose: To define the contents and requirements of the hospice medical record. Procedure: ...2. The hospice medical record shall contain the following clinical information: ...m. Any assessment relevant to care, treatment or services. ...7. Changes in entries in the Hospice record must be according to acceptable standards of practice. a. All entries recorded in the hospice record must be legible and accurate... 1. HV # 1 was admitted to the agency on 1/29/2020, and recertified for care for dates 7/17/22 to 9/14/22 with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, and Aphasia Following Cerebral Infarction. A HV was conducted on 7/26/22 at 1:02 PM to observe care provided by Employee Identifier (EI) # 3, Registered Nurse (RN). HV # 1 was unresponsive at the time of the visit, and the Caregiver (CG) requested the RN only provide wound care to the wound on the left leg, and not do vital signs. Review of the SN visit note dated 7/26/22 revealed the RN documented he/she performed cardiovascular and respiratory assessments, with clinical findings of hypertension, arrythmia, and abnormal breath sounds. There was no observation of EI # 3 assessing vital signs, performing cardiovasular or respiratory assessments during the HV. Further review of the visit note dated 7/26/22 revealed the RN documented he/she performed hospice aide supervisory functions. There was no observation of EI # 3 performing aide supervisory functions during the HV. Review of the SN narrative revealed the RN documented education to the caregiver on skin care, oxygen safety, medications that can cause respiratory depression, and that bowel and lung sounds were auscultated. There was no observation of caregiver teaching including skin care, oxygen safety, or medications performed and no observation of bowel and lung sounds being auscultated during the HV. In an interview conducted on 7/28/22 at 1:39 PM with EI # 1, Executive Director, EI # 1 confirmed the VN documentation should include only assessments and interventions completed during the visit.

Based on review of medical mecords (MR), agency policy and procedure, and interviews it was determined the agency failed to ensure the staff completed documentation within 24 hours of the patient visit. This deficient practice affected 2 of 13 MR reviewed including MR # 2, MR # 4, and had the potential to affect all patients admitted to this hospice. Findings include: Agency Policy: Hospice Medical Record Policy Number: 9.001 Revision Date: 11/01/21 Purpose: To define the contents and requirements of the hospice medical record. Policy: A medical record is maintained for all patients receiving services and care from the agency. Procedure: ...2. The hospice medical record shall contain the following clinical information: ...j. Any specific notes on care, treatment or services. ...l. Documentation and communication with the patient caregivers, and physicians. m. Any assessment relevant to care, treatment or services. n. Physician's orders. o. Current medication profile... ...4. Clinical notes for all services the patient has received shall be: a. ...for point of care users, synchronization (completing documentation and making it available for other staff to review) will occur within 24 hours from visit. 1. MR # 2 was admitted to the agency on 6/8/22 with diagnoses including Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, and Cardiomyopathy, Unspecified. Review of the SN Visit Notes (VN) revealed the following VN were not completed and synchronized within 24 hours per policy: - 6/10/22 VN, completed and synchronized 6/13/22, which was three days. - 6/13/22 VN, completed and synchronized 6/17/22, which was four days. - 6/20/22 VN, completed and synchronized 6/24/22, which was four days. - 6/24/22 VN, completed and synchronized 6/27/22, which was three days. - 7/8/22 VN, completed and synchronized 7/11/22, which was three days. - 7/15/22 VN, completed and synchronized 7/18/22, which was three days. In an interview conducted 7/28/22 at 2:15 PM, Employee Identifier (EI) # 1, Executive Director confirmed all the notes listed above were not completed and synchronized within 24 hours of the patient visit as directed in agency policy. 2. MR # 4 was admitted to the agency on 6/21/22 with diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacebration and Gastrointestional Stromal Tumor of Small Intestine. Review of the Chaplain VN's revealed the following VN's were not completed and synchronized within 24 hours per the agency's policy: -6/24/22 VN, completed and synchronized on 6/27/22, which was three days later. -7/21/22 VN, completed and synchronized on 7/25/22, which was three days later. In an interview conducted on 7/28/22 at 2:25 PM, EI # 1 confirmed the Chaplain VN's were not completed and synchronized within 24 hours as directed by agency policy.