DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
011548 A. BUILDING __________
B. WING ______________ 		03/05/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
JOURNEY HOSPICE OF ALABAMA 4128 CROSSHAVEN DRIVE, VESTAVIA, AL, 35243
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0578      
39098 Based on review of medical records (MR), policies and procedures, and interviews, it was determined the agency failed to ensure screening calls for Covid symptoms and exposure were performed and documented per policy, to help mitigate and contain the Covid virus. This affected 4 of 4 medical records (MR) reviewed and 7 of 8 Unsampled Patient (UP) notes including Patient Identifier (PI) # 1, PI # 2, PI # 4, PI # 3, UP # 3, UP # 4, UP # 5, UP # 6, UP # 8, UP # 1, UP # 2, and had the potential to affect all patients served by the agency. Findings include: Policy: Covid-19 Emergency Operations Disaster Plan Date: 3/23/2020 ...Prevention: ...Journey Hospice employees will screen all patients by making phone calls prior to any home visits made. Patients will be asked if they or anyone they have had contact with has exhibited fever or any symptoms such as shortness of breath or cough, and any history of travel abroad or being around someone who has traveled abroad or is exhibiting symptoms. ...Preparedness: ...All patients will be phone triaged for symptoms prior to home/facility visits in order for staff to be prepared to use the correct PPE (Personal Protective Equipment). Policy: Covid-19 Prevention and Transmission Date: 3/16/2020 All patients on Journey Hospice service will be screened for signs and symptoms of viral illness, including COVID-19, on each visit. During the COVID-19 Pandemic the following will be used to screen all patients and their family members or caregivers: 1. Has anyone within the household traveled internationally within the last 14 days... 2. Has the patient or caregiver shown signs or symptoms of a respiratory infection... 3. In the last 14 days, has the patient or caregiver had contact with someone with or under investigation for COVID-19... 4. Has the patient or caregiver been exposed to anyone residing in a community where community-based spread of COVID-19 is occurring?... 1. PI # 1 was admitted to the agency on 2/8/19 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Unspecified, and Acute and Chronic Respiratory Failure with Hypoxia. Review of 13 SN (Skilled Nurse) Visits, dated 12/3/21 to 2/26/21, revealed no documentation of screening calls for Covid symptoms or exposure, per policy. During an interview conducted on 3/3/21 at 11:39 AM with Employee Identifier (EI) # 1, Director of Nursing, it was confirmed the nurses did not document a screening call prior to each visit, per policy. EI # 1 further explained a Covid screening template had been developed to document the call, and confirmed it had not been used by staff. 2. PI # 2 was admitted to the agency on 1/5/21 with diagnoses including Alzheimer's Disease, and Heart Failure. PI # 2 expired on 1/22/21. Review of SN Visits dated 1/5/21 and 1/12/21 revealed no documentation of Covid screening call to the patient prior to the visit, per policy. An interview was conducted on 3/3/21 at 12:00 PM with EI # 1, who confirmed the above findings. 41623 3. PI # 4 was recertified for Hospice care on 10/29/2020 with diagnoses including Cerebral Atherosclerosis, Dementia, and Alzheimer's Disease. Review of the SN Visit notes dated 10/29/2020, 11/12/2020, 11/19/2020, 11/23/2020, and 12/1/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. PI # 4 revocated on 12/4/2020 due to being positive for Covid-19 and admitted to the hospital. 4. PI # 3 was recertified for hospice care on 11/11/2020 with diagnoses including Cerebral Atherosclerosis, Vascular Dementia, Delusional disorders, and Chronic Obstructive Pulmonary Disease. Review of the SN Visit notes dated 12/10/2020, 12/15/2020, and 12/22/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. Further review of the SN Visit note dated 12/15/2020 revealed the physician was notified of the PI # 3 having Covid-19 symptoms including; Temperature of 100.5, lethargy, and oxygen saturation of 80 percent. In an interview conducted on 3/2/2021 at 11:30 AM, EI # 1 confirmed the above findings. Upon request by the survey team for documentation of on-call visits an email was received on 3/5/2021 from EI # 1 stating " I have attached 5 of (his/her) notes on visits from December (not visit notes...)... and "(PI # 2) - this patient and on call situation on 2/14/2021. A visit was in fact made, by (EI # 3, RN), but the visit was not added or documented on. I have attached (his/her) on-call information and variance/occurrence report for review." The email contained the following documentation on UP # 1, UP # 2, UP # 3, UP # 4, UP # 5, UP # 6, and UP # 8. 5. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 3. The handwritten note read: "106 - (UP # 3) feeling light headed "not in body" Itching horrific Current med not working. O2 (Oxygen) 99 P (pulse) 54-86 T (temperature) 97.5 BP (blood pressure) 113/56. Diarrhea last night and today tx (treatment) Immodium AD effective. Afraid of Excedrin or Tylenol @ (at) times. Chest pain due to valve disorder." In the margins was written "12/31 15 mg Morphine pill - not helping pain still c/o pain per caregiver." "Benadryl??" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the itching or chest pain, and there was documentation provided of the visit being entered into the patients medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 6. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 4. The handwritten note read: "112 B (UP # 4) No pain - eating good - BM? (bowel movement) T 98 O2 Sat (oxygen saturation) 94 BP 94/72 P 49 R 18 No pain Sore?" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the low pulse rate and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 7. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 5. The handwritten note read: "(UP # 5) lying on (left) side - respond name. No response verbal - T 97, BP 224/55, P 63, R 20. BM today. Appetite good - feels good - rare pain." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 8. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 6. The handwritten not read: "(UP # 6) Occ. (occasionally) wets self - has to holler for help. Occ not hungry - BM daily - occ pain (with) urination. O2 97, P 88, BP 122/69, P 85." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 9. Review of the handwritten SN Visit note dated 12/28/2020 at 9:50 PM to UP # 8 revealed no nurse signature and no documentation of a pre-screening phone call for Covid symptoms. 10. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 1 on 2/14/2021 at 1:50 PM. The handwritten note read: "(UP # 1) Revocation CHF (Congestive Heart Failure) HBP (High Blood Pressure) - wife signed revocation." There was no signature of the nurse and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 11. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made on UP # 2 to 2/14/2021. The handwritten note read: "(UP # 2) Pt (patient) fell 2/14/2021. Pt. (UP # 2) fell again - no signs of injury - Teaching done ... standing, waiting, then walking - BSC (bedside commode) (at) bedside to use bath room... BP 138/80, T 97, P 68, R 18, O2 99 % (percent)...BM 2/13." There was no documentation of the time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. An interview was conducted on 3/3/21 at 11:15 PM with EI # 1, who confirmed there was no pre-visit Covid screening documented on PI # 4 and PI # 3. EI # 1 confirmed via email on 3/5/2021 at 11:46 AM there was no documentation of a pre-visit Covid screening on UP # 1, UP # 2, UP # 3, UP # 4, UP # 5, UP # 6, and UP # 8.
L0648      
39098 Based on review of agency policies and procedures, medical records (MR), personnel files, and interviews with agency staff, it was determined the Governing Body failed to ensure staff followed/ developed the policies, procedures, and processes concerning infection control, orientation, skills competencies, and documentation. Nor did they ensure all professional staff had a current license. Findings include: Please refer to tags L 651, L 662, L 672, L 679, and L 784.
L0651      
39098 Based on review of medical records (MR), policies and procedures, and interviews with agency staff it was determined the Governing Body and Administrator failed to ensure the hospice maintained policies and procedures to provide guidance to the hospice staff for conducting new employee orientation and medical record documentation. Staff further failed to ensure screening calls for Covid symptoms and exposure were performed and documented per policy, to help mitigate and contain the Covid virus. This affected 4 of 4 medical records (MR) reviewed and 7 of 8 Unsampled Patient (UP) notes including Patient Identifier (PI) # 1, PI # 2, PI # 4, PI # 3, UP # 3, UP # 4, UP # 5, UP # 6, UP # 8, UP # 1, UP # 2, and had the potential to affect all patients served by the agency. Findings include: Policy: Covid-19 Emergency Operations Disaster Plan Date: 3/23/2020 ...Prevention: ...Journey Hospice employees will screen all patients by making phone calls prior to any home visits made. Patients will be asked if they or anyone they have had contact with has exhibited fever or any symptoms such as shortness of breath or cough, and any history of travel abroad or being around someone who has traveled abroad or is exhibiting symptoms. ...Preparedness: ...All patients will be phone triaged for symptoms prior to home/facility visits in order for staff to be prepared to use the correct PPE (Personal Protective Equipment). Policy: Covid-19 Prevention and Transmission Date: 3/16/2020 All patients on Journey Hospice service will be screened for signs and symptoms of viral illness, including COVID-19, on each visit. During the COVID-19 Pandemic the following will be used to screen all patients and their family members or caregivers: 1. Has anyone within the household traveled internationally within the last 14 days... 2. Has the patient or caregiver shown signs or symptoms of a respiratory infection... 3. In the last 14 days, has the patient or caregiver had contact with someone with or under investigation for COVID-19... 4. Has the patient or caregiver been exposed to anyone residing in a community where community-based spread of COVID-19 is occurring?... 1. Surveyors requested policies and procedures on the subject of employee orientation and complete documentation in the medical record. None were received. During an interview on 3/3/21 at 6:60 PM with Employee Identifier (EI) # 1, Director of Nursing, EI # 2, President, and EI # 3, Office Manager, it was confirmed there were no policies for employee orientation and documentation. 2. PI # 1 was admitted to the agency on 2/8/19 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Unspecified, and Acute and Chronic Respiratory Failure with Hypoxia. Review of 13 SN (Skilled Nurse) Visits, dated 12/3/21 to 1/26/21, revealed no documentation of screening calls for Covid symptoms or exposure, per policy. During an interview conducted on 3/3/21 at 11:39 AM with Employee Identifier (EI) # 1, Director of Nursing, it was confirmed the nurses did not document a screening call prior to each visit, per policy. EI # 1 further explained a Covid screening template had been developed to document the call, and confirmed it had not been used by staff. 3. PI # 2 was admitted to the agency on 1/5/21 with diagnoses including Alzheimer's Disease, and Heart Failure. PI # 2 expired on 1/22/21. Review of SN Visits dated 1/5/21 and 1/12/21 revealed no documentation of Covid screening call to the patient prior to the visit, per policy. An interview was conducted on 3/3/21 at 12:00 PM with EI # 1, who confirmed the above findings. 4. PI # 4 was recertified for Hospice care on 10/29/2020 with diagnoses including Cerebral Atherosclerosis, Dementia, and Alzheimer's Disease. Review of the SN Visit notes dated 10/29/2020, 11/12/2020, 11/19/2020, 11/23/2020, and 12/1/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. PI # 4 revocated on 12/4/2020 due to being positive for Covid-19 and admitted to the hospital. In an interview conducted on 3/2/2021 at 11:30 AM, EI # 1 confirmed the above findings. 5. PI # 3 was recertified for hospice care on 11/11/2020 with diagnoses including Cerebral Atherosclerosis, Vascular Dementia, Delusional disorders, and Chronic Obstructive Pulmonary Disease. Review of the SN Visit notes dated 12/10/2020, 12/15/2020, and 12/22/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. Further review of the SN Visit note dated 12/15/2020 revealed the physician was notified of the PI # 3 having Covid-19 symptoms including; Temperature of 100.5, lethargy, and oxygen saturation of 80 percent. In an interview conducted on 3/2/2021 at 11:30 AM, EI # 1 confirmed the above findings. Upon request by the survey team for documentation of on-call visits an email was received on 3/5/2021 from EI # 1 stating " I have attached 5 of (his/her) notes on visits from December (not visit notes...)... and "(PI # 2) - this patient and on call situation on 2/14/2021. A visit was in fact made, by (EI # 3, RN), but the visit was not added or documented on. I have attached (his/her) on-call information and variance/occurrence report for review." The email contained the following documentation on UP # 1, UP # 2, UP # 3, UP # 4, UP # 5, UP # 6, and UP # 8. 6. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 3. There was no documentation of a pre-screening phone call for Covid symptoms. 7. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 4. There was no documentation of a pre-screening phone call for Covid symptoms. 8. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 5. There was no documentation of a pre-screening phone call for Covid symptoms. 9. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 6. There was no documentation of a pre-screening phone call for Covid symptoms. 10. Review of the handwritten SN Visit note dated 12/28/2020 at 9:50 PM to UP # 8. There was no documentation of a pre-screening phone call for Covid symptoms. 11. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 1 on 2/14/2021 at 1:50 PM. There was no documentation of a pre-screening phone call for Covid symptoms. 12. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made on UP # 2 to 2/14/2021. There was no documentation of a pre-screening phone call for Covid symptoms. An interview was conducted on 3/3/21 at 11:15 PM with EI # 1, who confirmed there was no pre-visit Covid screening documented on PI # 4 and PI # 3. EI # 1 confirmed via email on 3/5/2021 at 11:46 AM there was no documentation of a pre-visit Covid screening on UP # 1, UP # 2, UP # 3, UP # 4, UP # 5, UP # 6, and UP # 8.
L0662      
39098 Based on review of personnel files, and interviews, it was determined the agency failed to ensure employees completed orientation and competencies in 2 of 5 personnel files reviewed. This affected Employee Identifier (EI) # 3 RN (Registered Nurse) and EI # 5, RN, and had the potential to affect all persons served by the agency. Findings include: 1. Review of EI # 3's personnel file, date of hire 4/30/19, revealed there was no documentation of orientation. An interview was conducted on 3/3/21 at 12:14 PM with EI # 1, Director of Nursing, who confirmed there was no documentation of an orientation. 2. Review of EI # 5's personnel file, date of hire 1/28/20, revealed a blank General Orientation Checklist, containing EI # 5's name and title, but no other information was listed. The signature lines at the bottom of the page for "Staff Signature" and "Supervisor" were also blank. Further review of EI # 5's personnel file revealed a form titled, "Journey Healthcare- Hospice Employee Annual Manual Review Signature Sheet. (Done on hire and annually)." The form contained EI # 5's name, but no signatures or dates. Further review of EI # 5's personnel file revealed the following three forms: 1) Mandatory Education Competency Test Answer Sheet, with the following statement, "A score of 84 % (32 of 38 questions answered correctly) is required." EI # 5's score was blank. 2) QAPI (Quality Assessment Performance Improvement) Manual Competency Test, with the statement, "Required in Orientation and Annually with passing Score of 84 or above." There was no score on the test. 3) Pain Management Competency Test, with the statement, "Required in Orientation and Annually with a passing score of 85 or above." There was no score on the test. Further review of the personnel file revealed no skills competency check list. An interview was conducted on 3/3/21 at 5:06 PM with EI # 1, who confirmed orientation was incomplete, tests were not scored, and there was no skills competency check list for EI # 5. 3. Policies regarding Employee Orientation were requested and none were received. An interview was conducted on 3/3/21 at 6:20 PM with EI # 1, Director of Nursing, EI # 2, President, and EI # 7, Office Manager, who all confirmed there was no policy for orientation.
L0672      
39098 Based on review of medical records (MR), policies and procedures, call log, and interviews, it was determined the agency failed to ensure: a) Documentation was completed on visits and/or phone calls made by agency staff. b) Screening calls for Covid symptoms and exposure were documented per policy. This affected 4 of 4 medical records (MR) reviewed and 8 of 8 Unsampled Patient ((UP) notes, including Patient Identifier (PI) # 1, PI # 2, UP # 8, UP # 7, PI # 4, PI # 3, UP # 3, UP # 4, UP # 5, UP # 6, UP # 1, UP # 2, and had the potential to affect all patients served by the agency. Findings include: Policy: Covid-19 Emergency Operations Disaster Plan Date: 3/23/2020 ...Prevention: ...Journey Hospice employees will screen all patients by making phone calls prior to any home visits are made. Patients will be asked if they or anyone they have had contact with has exhibited fever or any symptoms such as shortness of breath or cough, and any history of travel abroad or being around someone who has traveled abroad or is exhibiting symptoms. ...Preparedness: ...All patients will be phone triaged for symptoms prior to home/facility visits in order for staff to be prepared to use the correct PPE (Personal Protective Equipment). Policy: Covid-19 Prevention and Transmission Date: 3/16/2020 All patients on Journey Hospice service will be screened for signs and symptoms of viral illness, including COVID-19, on each visit. During the COVID-19 Pandemic the following will be used to screen all patients and their family members or caregivers: 1. Has anyone within the household traveled internationally within the last 14 days... 2. Has the patient or caregiver shown signs or symptoms of a respiratory infection... 3. In the last 14 days, has the patient or caregiver had contact with someone with or under investigation for COVID-19... 4. Has the patient or caregiver been exposed to anyone residing in a community where community-based spread of COVID-19 is occurring?... 1. Review of the call log revealed three calls received by Employee Identifier (EI) # 3, RN, dated 1/4/21 at 1:33 PM, 1/7/21 at 10:42 PM, and 1/14/21 at 5:52 PM. During this time, EI # 3's RN license had expired. The surveyor requested the documentation related to the three calls, and none was received. An interview was conducted on 3/2/21 at 12:14 PM with EI # 1, Director of Nursing (DON) who confirmed there was no documentation related to the calls. 2. PI # 1 was admitted to the agency on 2/8/19 with diagnoses including COPD (Chronic Obstructive Pulmonary Disease), Unspecified, and Acute and Chronic Respiratory Failure with Hypoxia. Review of 13 SN (Skilled Nurse) Visits, dated 12/3/21 to 1/26/21, revealed no documentation of screening calls for Covid symptoms or exposure, per policy. During an interview conducted on 3/3/21 at 11:39 AM with EI # 1, Director of Nursing, it was confirmed the nurses did not document a screening call prior to each visit, per policy. EI # 1 further explained a Covid screening template had been developed to document the call, and confirmed it had not been used by staff. 3. PI # 2 was admitted to the agency on 1/5/21 with diagnoses including Alzheimer's Disease, and Heart Failure. PI # 2 expired on 1/22/21. Review of SN Visits dated 1/5/21 and 1/12/21 revealed no documentation of a Covid screening call to the patient prior to the visit, per policy. An interview was conducted on 3/3/21 at 12:00 PM with EI # 1, who confirmed there was no documentation of a Covid screening call prior to each visit. 41623 4. Review of the SN Visit note dated 12/28/2021 at 9:16 PM of Unsampled Patient (UP) # 8 revealed no signature of nurse and no documentation of a pre-visit Covid-19 screening phone call to patient or caregiver. 5. Review of the On-Call Log dated 1/14/2021 at 5:52 PM the on call center received a call from Unsampled Patient (UP) # 7. The message delivered to the on-call nurse EI # 3, RN, was "medication called in for patient is out of stock until next week. Please call." There was no documentation provided of EI # 3 contacting the patient or family. In an interview conducted on 3/3/2021 at 9:30 AM with EI # 1, stated information was received from family to send the prescription to another pharmacy but there was no documentation of the conversation with the family. 6. PI # 4 was recertified for Hospice care on 10/29/2020 with diagnoses including Cerebral Atherrosclerosis, Dementia, and Alzheimer's Disease. Review of the SN Visit notes dated 10/29/2020, 11/12/2020, 11/19/2020, 11/23/2020, and 12/1/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. PI # 4 revocated on 12/4/2020 due to being positive for Covid-19 and admitted to the hospital. 7. PI # 3 was recertified for hospice care on 11/11/2020 with diagnoses including Cerebral Atherosclerosis, Vascular Dementia, Delusional disorders, and Chronic Obstructive Pulmonary Disease. Review of the SN Visit note dated 12/15/2020 revealed the physician was notified of the PI # 3 having Covid-19 symptoms including; Temperature of 100.5, lethargy, and oxygen saturation of 80 percent. Further review of the SN Visit notes dated 12/10/2020, 12/15/2020, and 12/22/2020 revealed no documentation of a Covid pre-screening phone call to the patient or caregiver. Upon request by the survey team for documentation of on-call visits an email was received on 3/5/2021 from EI # 1 stating " I have attached 5 of (his/her) notes on visits from December (not visit notes...)... and "(PI # 2) - this patient and on call situation on 2/14/2021. A visit was in fact made, by (EI # 3), but the visit was not added or documented on. I have attached (his/her) on-call information and variance/occurrence report for review." The email contained documentation of visits made on UP # 1, UP # 2, UP # 3, UP # 4, and UP # 5. 8. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 3. The handwritten note read: "106 - (UP # 3) feeling light headed "not in body" Itching horific Current med not working. O2 (Oxygen) 99 P (pulse) 54-86 T (temperature) 97.5 BP (blood pressure) 113/56. Diarrhea last night and today tx (treatment) Immodium AD effective. Afraid of excedrine or Tylenol @ (at) times. Chest pain due to valve disorder." In the margins was written "12/31 15 mg Morphine pill - not helping pain still c/o pain per caregiver." "Benadryl??" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the itching or chest pain, and there was documentation provided of the visit being entered into the patients medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 9. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 4. The handwritten note read: "112B (UP # 4) No pain - eating good - BM? (bowel movement) T 98 O2 Sat (oxygen saturation) 94 BP 94/72 P 49 R 18 No pain Sore?" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the low pulse rate and no ducumentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 10. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 5. The handwritten note read: "(UP # 5) lying on (left) side - respond name. No response verbal - T 97, BP 224/55, P 63, R 20. BM today. Appetite good - feels good - rare pain." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documention of a pre-screening phone call for Covid symptoms. 11. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 6. The handwritten not read: "(UP # 6) Occ. (occasionally) wets self - has to holler for help. Occ not hungry - BM daily - occ pain (with) urination. O2 97, P 88, BP 122/69, P 85." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documention of a pre-screening phone call for Covid symptoms. 12. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 1 on 2/14/2021 at 1:50 PM. The handwritten note read: "(UP # 1) Revocation CHF (Congestive Heart Failure) HBP (High Blood Pressure) - wife signed revocation." There was no signature of the nurse and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 13. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 2 on 2/14/2021. The handwritten note read: "(UP # 2) Pt (patient) fell 2/14/2021. Pt. (UP # 2) fell again - no signs of injury - Teaching done ... standing, waiting, then walking - BSC (bedside commode) (at) bedside to use bath room... BP 138/80, T 97, P 68, R 18, O2 99 % (percent)...BM 2/13." There was no documentation of the time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. An interview was conducted on 3/3/2021 at 11:15 AM with EI # 1, who stated "we call and ask if the patient has cough, fever, or other symptoms of Covid prior to going on visit, sometimes it is documented on the comments section. EI # 1 confirmed there was no documentation of a pre-screening phone call on the above visit dates.
L0679      
41623 Based on review of Medical Records (MR), emailed documents, and interviews it was determined the agency failed to ensure complete and accurate documentation of patient visits were recorded in the medical record. This deficient practice affected 7 of 8 Unsampled (UP) patients including UP # 3, UP # 4, UP # 5, UP # 6, UP # 7, UP # 1, UP # 2, and had the potential to affect all patients served by this agency. Findings include: Upon request by the survey team for documentation of on-call visits an email was received on 3/5/2021 from Employee Identifier (EI # 1), DON (Director of Nurses), stating " I have attached 5 of (his/her) notes on visits from December (not visit notes...)... and "(PI # 2) - this patient and on call situation on 2/14/2021. A visit was in fact made, by (EI # 3), but the visit was not added or documented on. I have attached (his/her) on-call information and variance/occurrence report for review." The email contained documentation of visits made including UP # 1, UP # 2, UP # 3, UP # 4, UP # 5, UP # 6, and UP # 8. 1. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 3. The handwritten note read: "106 - (UP # 3) feeling light headed "not in body" Itching horrific Current med not working. O2 (Oxygen) 99 P (pulse) 54-86 T (temperature) 97.5 BP (blood pressure) 113/56. Diarrhea last night and today tx (treatment) Immodium AD effective. Afraid of Excedrin or Tylenol @ (at) times. Chest pain due to valve disorder." In the margins was written "12/31 15 mg Morphine pill - not helping pain still c/o pain per caregiver." "Benadryl??" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the itching or chest pain, and there was documentation provided of the visit being entered into the patients medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 2. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 4. The handwritten note read: "112 B (UP # 4) No pain - eating good - BM? (bowel movement) T 98 O2 Sat (oxygen saturation) 94 BP 94/72 P 49 R 18 No pain Sore?" There was no date and time of the visit, no signature of nurse, no documentation the physician was notified of the low pulse rate and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 3. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 5. The handwritten note read: "(UP # 5) lying on (left) side - respond name. No response verbal - T 97, BP 224/55, P 63, R 20. BM today. Appetite good - feels good - rare pain." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 4. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made by EI # 3 to UP # 6. The handwritten not read: "(UP # 6) Occ. (occasionally) wets self - has to holler for help. Occ not hungry - BM daily - occ pain (with) urination. O2 97, P 88, BP 122/69, P 85." There was no date and time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 5. Review of the handwritten Skilled Nurse Visit note dated 12/28/2020 at 9:50 PM on UP # 8 revealed no nurse signature and no documentation of a pre-screening phone call for Covid symptoms. 6. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 1 on 2/14/2021 at 1:50 PM. The handwritten note read: "(UP # 1) Revocation CHF (Congestive Heart Failure) HBP (High Blood Pressure) - wife signed revocation." There was no signature of the nurse and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. 7. A copy of a handwritten note on a plain piece of paper was provided by email on 3/5/2021 for visit made to UP # 2 on 2/14/2021. The handwritten note read: "(UP # 2) Pt (patient) fell 2/14/2021. Pt. (UP # 2) fell again - no signs of injury - Teaching done ... standing, waiting, then walking - BSC (bedside commode) (at) bedside to use bath room... BP 138/80, T 97, P 68, R 18, O2 99 % (percent)...BM 2/13." There was no documentation of the time of the visit, no signature of nurse, and no documentation was provided of the visit being entered into the patient's medical record for review. There was no documentation of a pre-screening phone call for Covid symptoms. EI # 1 confirmed via email on 3/5/2021 at 11:46 AM that there was no other documentation for the above visits and the visit notes were not entered into the patients medical record.
L0784      
39098 Based on review of personnel files, Journey Hospice Employee Licensure policy, call logs, on call nurse schedules, payroll reports, and interviews, it was determined the agency failed to ensure: a) Staff maintained a current Registered Nursing license. b) Staff did not perform nursing duties without a current license. This affected Employee Identifier (EI) # 3 RN (Registered Nurse), 1 of 4 RN personnel files reviewed, and had the potential to affect all persons served by the hospice agency. Findings include: Policy: Employee Licensure Form Number: Form HR (Human Resources)-17 Date Revised: 11/06 Purpose: To establish a process by which Journey Hospice can ensure that all employees maintain current licenses... at all times, as required by legal and/or regulatory requirements... Policy: ...The employee is responsible for on-going, timely renewal of licenses and/ or immediately notifying the DON (Director of Nursing)/ Administrator of any status changes in license... Employees who fail to present renewal information by the expiration date (per State guidelines) will be put on unpaid leave for a maximum of ten days until the license is brought current. Employees may return to work when the renewal information is submitted to and verified by the DON/ Administrator. Employees who fail to provide timely notification to the DON/ Administrator of any status changes for current license... may receive corrective action up to and including discharge. The DON/ Administrator is accountable for ensuring: 1. Employees renew licenses... within established timeframes. 2. That Documentation is included in the Employee's department file, OR the license number and expiration date is in a centralized database. The DON/ Administrator is responsible for monitoring status changes in license... as reported by the license board and for taking appropriate action as necessary. 1. Review of EI # 3's personnel file revealed a registered nursing license with an expiration date of 12/31/2020. The surveyor asked EI # 1, Director of Nursing, if EI # 3 had a current license, and received a Licensure Lookup Report, dated 3/3/21, from the Alabama Board of Nursing, listing EI # 3 with a RN license expiring 12/31/22. A hand written note on the form stated, "License reinstated 2/2/2021," and signed by EI # 7, Office Manager. An interview was conducted on 3/3/21 at 12:14 PM with EI # 1 who confirmed EI # 3's license had lapsed on 12/31/2020, but the agency was unaware until 1/14/21. The surveyor asked EI # 1 if EI # 3 had worked from 12/31/2020 until the license was reinstated on 2/2/21. EI # 1 stated, "No, not as an RN. She/he has given two baths, as an aide." The surveyor requested the documentation of the visits where baths were performed, and EI # 3 stated, "There is none, she/he must have taken it. She/he doesn't document in the computer, just on paper." Review of the On Call nurse schedule for January 2021, revealed EI # 3 was scheduled as the second on call nurse everyday from January 1st through January 13th. Review of the call log revealed EI # 3 received calls on 1/4/21 at 1:33 PM, 1/7/21 at 10:42 PM, and 1/14/21 at 5:52 PM. The surveyor requested all documentation regarding the calls, and was told by EI # 1 there was no documentation. 41623 Review of the Call Log dated 1/4/2021 revealed EI # 3, RN, was delivered a message from HPS (Health Provider Services) at 1:33 PM requesting a medication approval for UP # 10. There was no documentation of the call provided to surveyors. An interview was conducted on 3/3/2021 at 11:30 AM with EI # 1 who stated he/she also received the text from HPS and made the contact for the medication approval. Review of the Call Log dated 1/7/2021 revealed EI # 3 received message from a family member of UP # 9 at 10:42 PM stating he/she was at home. There was no documentation provided the patient/family was contacted or of the conversation with the patient/family member. An interview was conducted on 3/3/2021 at 11:30 AM with EI # 1 who stated EI # 3 did contact the patient's spouse but UP # 9 was not a current patient but an order to admit was obtained the next day. Review of the Call Log dated 1/14/2021 revealed EI # 3 received message from the call center at 5:52 PM from the pharmacy stating "Medication called in for patient is out of stock until next week. Please call." There was no documentation provided to surveyors of the call to the pharmacy or the patient. An interview was conducted on 3/3/2021 at 11:30 AM with EI # 1 who stated information was received from the family to send the prescription to another pharmacy. EI # 1 confirmed there was no documentation of the conversation with the family.