Every finding on record at St. Joseph Hospice of South Alabama, LLC

Observed in Record Review. In 1 of 1 patient records reviewed, for discharge with extended prognosis, the organization failed to respect the patient's rights to participate in decisions about their care, treatment, and services. On review of RRDC#1 who was discharged for extended prognosis there no documentation of a Notice of Medicare Non-Coverage (NOMNC) signed prior to patient discharge. There was a signed Advance Beneficiary Notice (ABN) form but no NOMNC with the discharge date and required appeal information. This observation was reviewed with the DON and Executive Director.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to conduct a patient-specific comprehensive assessment and reassessment that identified the patient's need for hospice care and services. On review of RRNHV#6 there was documentation on the initial comprehensive assessment that there was a skin tear identified with treatment however there was no wound assessment documented to note details of the wound such as size, character, drainage as required. This observation was reviewed with the Director of Nursing, Clinical Supervisor, and Executive Director.

Observed in Record Review. In 8 of 14 patient records reviewed, the organization failed to ensure the plan of care reflect patient and family goals based on problems identified in the initial, comprehensive and updated comprehensive assessment that were Specific, Measurable, and time-bound. On review of RRHV#1 there were goals established that were not specific and measurable such as Patient/caregiver will verbalize understanding of effects of urinary (date), and Patient/caregiver will verbalize/demonstrate understanding of managing cardiopulmonary symptoms within constraints of the disease by (date). In RRHV#2 an example of a non-specific, not measurable goal was Medications will be managed appropriately as evidenced by steady symptom control. In RRHV#3 a goal was Blood glucose level is obtained and any applicable action taken and in RRHV#4 a goal was Patient exhibits reduction/relief of any cardiopulmonary symptoms. In RRNHV#6 an example of a goal was Patient/caregiver will understand measures to cope with depression. Patient’s depression will be reduced AEB symptoms controlled by (date). Further examples of non specific, not measurable goals could be seen in RRNHV#9, and RRNHV#11. In RRNHV#12 an example of a goal that had a target/achieve by date that was not individualized to the goal was Patient/caregiver will verbalize/demonstrate how to use oxygen safely and effectively by (Mid August) yet the goal was established in May. These observations were reviewed with the Executive Director, Director of Nursing, and Clinical Supervisor.

Observed in Record Review. In 7 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. On review of RRHV#1 there was documentation of issues with edema, shortness of breath, cough and diarrhea with multiple medication adjustments to address the issues however the issues were not addressed nor updated in the care plans to guide the care. In RRNHV#5, RRNHV#6, RRNHV#10, and RRNHV#12 there was documentation of the patient's difficulty with swallowing and aspiration risk yet there was no care plan related to aspiration precautions to guide the care. In RRNHV#9 the documentation noted a focus of the patient was nerve pain yet the care plan for pain was not specific to the patient's focus on nerve pain and did not address the issue. In RRNHV#13 there was documentation of weight loss and falls yet the issues were not addressed on the care plan. These observations were reviewed with the Executive Director, Director of Nursing and Clinical Supervisor.

Observed in Record Review. In 3 of 14 patient records reviewed, the organization failed to ensure the plan of care include all services necessary for the palliation and management of the terminal illness and related conditions. On review of RRNHV#5 there was an order for IV fluids that read Sodium Chloride 0.9% IV solution 1000ml weekly in the vein> The order was incomplete as there was no further instruction as to how to administer such as where and what type of line, who to administer, and over how much time. In RRNHV#6 there was documentation a skin tear but no orders for treatment noted on the record. In RRNHV#10 the documentation noted the patient was admitted with a foley catheter and the documentation showed the foley was changed in May yet there were no orders for the catheter or catheter changes on the record. These observations were reviewed with the Director of Nursing, and Executive Director. Observed in Record Review. In 13 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. On review of RRHV#4 there were medications with range orders without detailed explanations for when to give what dose for what situation . Examples were: Morphine concentrate 100mg/5ml oral solution. give 0.5 - 1 ml hourly PRN for pain/dyspnea/restlessness, and Tramadol 50 mg tablet give 1 - 2 tab PO Q6H PRN. Further, there were 3 pain medications ordered as needed, Tramadol was noted for mild pain, Hydrocodone was for Moderate pain, and Morphine was noted simply As needed for Pain/Dyspnea/Restlessness without further instruction. Throughout all the records reviewed (except RRNHV#14 in a SNF) there were further examples of medications with ranges without instruction on when to give what dose as all patients had the same Morphine order (as above) from the comfort kit (or oxycodone range for RRNHV#12). Multiple pain medications without instructions for which medication to give for which situation could be seen in RRHV#2, RRHV#3, RRNHV#5, RRNHV#7, and RRNHV#11. These observations were reviewed with the Executive Director and Clinical Supervisor.

Observed in Patient Home. In 1 of 14 patient records reviewed, The organization failed to provide care, treatment, or services according to the patient's individualized plan of care. In RRNHV#5 the patient medication profile noted orders for IV fluids weekly, however there was no documentation noted in the record of the fluid being administered per the plan of care. Upon discussion with the Director of Nursing it was noted the fluid were never initiated yet there was no documentation in the record to explain why the fluids were not started nor was the medication profile updated to reflect the change. These observations were reviewed with the Director of Nursing and Executive Director.

Observed in Record Review. In 3 of 11 patient records reviewed, with aide services provided, the organization failed to ensure written patient care instructions for the hospice aide were prepared the Hospice Aide by the Registered Nurse. On review of RRHV#3 there was no instructions on the Aide plan of care for mobility. On home observation the patient was bed bound and unable to assist with bed mobility or transfers yet there was no indication if the patient was one or two person assist. Further, there was a hoyer lift noted in the home yet the lift was not list on the aide plan of care. In RRHV#1 the patient had a foley catheter, yet there were no instructions on how the aide was to handle the foley catheter wile providing perineal care. In RRNHV#9 the patient was anticoagulants yet the aide plan of care failed to address bleeding precautions. These observations were reviewed with the Executive Director and the Clinical Supervisor.

Observed in HR File Review. In 1 of 10 HR files reviewed, The organization failed to assess and document the skills and competence of volunteers furnishing services as part of orientation. On review of HR#1 for the volunteer, there was no documentation of a competency assessment as part of the orientation. This observation was reviewed with the Volunteer Coordinator, Executive Director and Director of Nursing.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization failed to ensure the patient record contain information that reflected the patient's care, treatment, and/or services. On review of RRNHV#9 the patient was admitted in the Skilled Nursing Facility (SNF) and then was transitioned to home, yet there was no documentation in the record besides a address change to note that the patient was no longer residing in the SNF and the details surrounding the transition. These observations were reviewed with the Director of Nursing, and Executive Director.

Observed in Patient Home. In 2 of 4 home visits conducted, the organization failed to ensure the patient record contain all information to reflect the patient's care, treatment and services. On home observation for RRHV#1 during medication reconciliation there were multiple medications that were ordered per the plan of care yet the patient was no longer taking and not in the patient home. The patient was not taking Ativan, Morphine, Aleve, Ipratropium/Albuterol, and Omeprazole. Per the patient's wife the patient had not taken the medications for quite some time which she described as up to a year. The medication profile ordered Mucinex 600mg extended release yet the medication in the home was 1200 mg/Dextromethorphan 60 mg. Further, In RRHV#4 home medication reconciliation, the hydrocodone/acetaminophen on the medication profile was 5mg/325mg yet in the home the bottle was for 7.5 mg (the bottle had been filled in March). Hydroxyzine HCL 25 mg tablet was ordered 1 tab PO Q6H PRN but the bottle in the home read Q4h PRN. For Vitamin B12 the order was for 1 tablet daily yet the caregiver confirmed she gave it 3 times a week. These observations were reviewed with the RN, Executive Director, and Clinical Supervisor.

Observed in Patient Home. In 1 of 2 home visits conducted, with oxygen in place, the organization failed to ensure the patient as well as family and/or other caregivers receive instruction in the safe use of oxygen and supplies. On home observation for RRHV#1 there was an unsecured e-tank standing upright in the room. The patient's wife noted the tank along with a secured tank had been delivered for a storm in 2025 and had been stored since that time and had not ever been used. When inquired about the unsecured tank the wife stated she was not aware the upright tank was a hazard. This observation was reviewed with the Executive Director and Clinical Supervisor.

Observed in Competency Session. In 1 of 4 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for the hospice included a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. On review of the contract for Therapy services there was no documentation that the contract included a stipulation for background checks. This observation was reviewed with the Executive director and Director of Nursing.

Observed in Record Review. In 6 of 6 patient records reviewed, During 6 of 6 Records Reviewed, the surveyor observed that the written plan of care is based on the patient’s individualized goals. For example goals were phrased as: pain is currently managed at a level acceptable to the patient without a definition. Patient's constipation will be controlled without defining how many times the patient is expected to have a BM. The goals in all six were identical and not individualized for each patient. This was validated in a discussion with and observation by the Hospice Executive Director and the Sr Regional Director of Clinical Operations.

Observed in Individual Tracer. In 2 of 3 home visits conducted, During the Home visits, the surveyor observed that hand hygiene policy practices were not followed. For example in HV 1 the nurse removed gloves three times and did not gel or wash after removal. In HV 2 the aide did not change her gloves during the shower after finishing the peri area nor did she change them after cleaning feces off the rollator seat. This was validated in a discussion with and observation by the Hospice Executive Director.

Observed in Infection Control System Tracer. During the Document Review, the surveyor observed that the hand hygiene data did not demonstrate compliance with HH Policy 5.7.2 which stated that the organization would be monitored monthly. This was validated in a discussion with and observation by the Hospice Executive Director and the Sr Regional Director of Clinical Operations.

Observed in HR File Review. In 8 of 10 HR files reviewed, During the HR Review in 8 of 10, the surveyor observed that orientation to pain management and infection control practices were not provided on hire as required. This was validated in a discussion with and observation by the Hospice Executive Director and the Sr Regional Director of Clinical Operations.

Observed in Document Review. During the Document Review, the surveyor observed that the patient information packets did not contain the organization's written policy (or summation) of the destruction of controlled drug at the time of the patient's death. This was validated in a discussion with and observation by the Hospice Executive Director and the Sr Regional Director of Clinical Operations.

Observed in HR File Review. In 2 of 2 contracts reviewed, During the Contract/HR Review, the surveyor observed that the license verification was not done on hire or expiration. For example, in MD 1 the hire/contract date was 12/1/22 and not verified until 2/2 23. In MD 2, the license expired on 12/12/21 and not verified until 7/12/22, it expired again on 12/31/22 and was not verified until 5/3/23. This was validated in a discussion with and observation by the Hospice Executive Director and the Sr Regional Director of Clinical Operations.

Observed in Record Review. In 3 of 3 patient records reviewed, The patients progress toward goals had not been documented on IDG updates. The surveyor noted that the team had meet and discussed patients however there had been no documentation of progress toward goals that had been set. Discussion with regional director was done and issue had been confirmed.

Observed in Record Review. In 3 of 3 patient records reviewed, The surveyor observed that the goals on the plan of care had not been measurable and some of the goals had been used repeatedly. For example some of the goals observed on the 3 care plans stated : patient will follow effective bowel program, pain will be managed at a level acceptable to patient, patient/caregiver will verbalize understanding of managing cardiopulmonary symptoms within constraints of the disease , patient will receive assistance with personal care and hygiene and other activities of daily living as needed, a chaplain plan of care will be established The issue was discussed and confirmed with regional director.