Every finding on record at Alc Palliative and Hospice Care, Inc.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, if any of them so desire, and the primary caregiver in accordance with the patient's needs, if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) Clinical records reviewed in which a patient had a wound, the agency did not ensure that the physician ordered plan of care was followed for documentation of the wound care frequency. CLINICAL RECORD 8: The physician order effective 02/18/2025 and additional orders dated 04/10/2025 and 05/15/2025 for wound care to the ear and right forearm stated, "Hospice SN (skilled nurse) to change the dressings twice a week. FSN (Facility skilled nurse) may change dressing PRN (as needed) soiling". The dressing was documented as changed by the hospice nurse on 04/21/2025, 04/24/2025, 05/01/2025, 05/08/2025, then 05/12/2025, and twice a week after that. For a two-week period, there was no documentation that the plan was followed for the twice-a-week dressing change, or who changed the dressing the second time during those two weeks. The wound did document improvement and did eventually heal. During the interview with the director of nursing who reviewed the record on 06/04/2025, it was stated that the documentation did not document the twice-a-week changes and that the facility nurse changed the dressing in between but agreed that this was not documented.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the plans of care documented all interventions for the care of the patients. Agency Policy: No.9-017 [revised April 2019], titled, The Plan of Care, stated in part, "The written plan of care will contain, but will not be limited to, the following: Individualized intervention to assist with end-of-life care." CLINICAL RECORD 6: The plan of care was dated 01/25/2024 documented the following interventions, "Observe patient as he/she stands up from a chair without using his/her arms, walks several paces, turns, returns to chair, and sits down to assess patient fall risk. This continued to be documented every two weeks to the last updated plan of care dated 05/26/2025, though the patient was documented on 01/24/2025 as standing with help for short periods only, and on 07/29/2025 documented as became a Hoyer transfer as increasingly unsteady and unable to support self." The intervention was not updated as the patient's assessment was updated. Additionally, the updated Interdisciplinary Group meeting (IDG) dated 02/27/2024 documented the patient was using an Ensure supplement due to decreased oral intake. The updated IDG on 05/21/2025 documented the patient was eating less and using 3 bottles of Ensure a day. There were no documented interventions or goals related to this identified nutritional need. CLINICAL RECORD 8: The physician order dated 02/18/2025, documented "Rinse left ear with wound cleanser, pat dry, apply medihoney, cover with border gauze dressing. Hospice SN to change dressing twice weekly. Facility SN to change/reinforce dressing PRN soiling or dislodgement." The physician order dated 04/10/2025 stated, "Cleanse left ear with wound cleanser, pat dry, apply medihoney cover with bordered gauze dressing. Hospice SN to change dressing twice weekly, FSN to change/reinforce dressing PRN soiling, dislodgement. 05/15/2025 right forearm rinse with wound cleanser, pat dry, cover with bandage, Hospice SN to change dressing twice weekly. FSN to change, reinforce/dress PRN soiling. The plans of care from 02/18/2025, updated every 2 weeks, did not document any interventions or goals for skin integrity. The IDG meeting minutes dated 4/8/2025, 04/23/2025, 05/06/2025, and 05//20/2025 updates documented that the dressings were changed and on 05/06/2025 documented non-healing wounds but no interventions or goals were documented. During the interview with the director of nursing on 06/05/2025, who reviewed the records, it was stated that the interventions were missing from the plan of care, but that the orders were present.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. A revised plan of care includes information from the patient’s updated comprehensive assessment, and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, it was revealed that the agency did not ensure that there were documented goals for all problems that were documented. CLINICAL RECORD 2: The need for volunteer services was identified 10/09/2023 and family was called by the coordinator. The volunteer visit was dated 01/20/2025. There was no reason for the long delay documented in the IDG documentation dated 10/10/2023, 10/24/2023, and 11/07/2023 of what was being pursued for the volunteer need identified. CLINICAL RECORD 3: The need for pet therapy was identified and documented on a volunteer assessment completed 01/20/2025. The IDG notes documented 01/28/2025, 02/11/2025, and 02/25/2025 did not include any updates for the pet therapy and no notes that documented it was provided or why it might not have been. CLINICAL RECORD 14: The nursing assessments documented 2 times a week visits documented the wound status and the unstageable wound with measurements and the dressing change but the updates to progress or lack of progress was not documented on the IDG meetings.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (66%) clinical records reviewed in which bereavement services would have been provided, it was revealed that the agency did not ensure there was documentation of a bereavement plan of care with the frequency of interventions to be provided. Agency Policy: Policy No. 1-021 [revision date 12/2018] titled Bereavement Assessment, stated in part, "After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow up assessment. The Bereavement Coordinator will develop a plan of intervention based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions." CLINICAL RECORD 16: The patient died on 10/15/2024. A phone call was made to triage by the bereavement coordinator on 10/16/2024 and spoke to the daughter, who was a low bereavement risk, and documented in part, "Letters to continue in the mail contact as needed. There was no documented bereavement plan, and the mailings are not defined by frequency. A sympathy card was documented as sent on 10/22/2024, and on 02/12/2025, the #2 Newsletter was documented as sent to the daughter. It was documented that continuation of the plan of care would be followed, but there was no documented plan of care. CLINICAL RECORD 17: The patient died on 12/12/2024. A phone call was made from the social worker on 12/15/2024 and documented in part, "Spoke with daughter. Bereavement to follow up and update POC accordingly. On 12/16/2024, a documented email was sent to reach out to the family. On 02/12/2025, the family was sent newsletter # 1. There was no documented bereavement plan with interventions or frequency of bereavement services to be provided. During the interview with the administrator and director of nursing, who stated that the bereavement plan was not documented. There was no documented bereavement plan with interventions or frequencies.

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient's required care. CLINICAL RECORD 5: The hospice aide's plan of care was documented on 05/09/2025 with an aide visit frequency of 2 times a week—no updates were documented for the aide plan. The hospice aide documented on 05/29/2025 the completion of the assigned task of a shower every visit. The visits on 05/12/2025 and 05/29/2025 documented that TED (antiembolism hose) hoses were worn bilaterally. (These would require removal and reapplied if a shower were provided). The hospice aide visit note dated 05/22/2025 documented that TED hoses were applied. The visit note dated on 05/20/2025 documented that the TED hose were not available. The aide documented each visit, updating the hospice RN and the facility nurse. The hospital aide's plan with assigned tasks did not assign a task to apply the TED hose, as of the review date, 06/03/2025. During interview with the Director of Nursing on 06/03/2025 it was stated that the TED hose should have been documented on the aide care plan.

It is required that volunteers be used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care, and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, of patients that accepted a volunteer, it was revealed that the agency did not ensure that the volunteer's assigned visits were documented. CLINICAL RECORD 2: The documented need for a volunteer was identified on 10/09/2023, on a social work assessment visit, and the family was called by the volunteer coordinator. The volunteer visit was dated 01/20/2025. There was no reason documented for the long delay in providing the service. CLINICAL RECORD 3: The documented need for a volunteer was identified, and the volunteer assessment was documented on 01/20/2025 with the need for PET therapy. There was no documentation as of the date of review 06/05/2025, that the PET therapy was provided or a reason why it was not, or communication with the patient and family as to why it was not provided. During interview with the administrator and the volunteer coordinator on 06/05/2025, the volunteer coordinator (in her role for less than six months), stated that as she entered the position some rebuild of the program was necessary and that the volunteer who provided PET therapy disappeared and could not be reached so documentation was not obtained. Efforts were made but the resolution was not documented in the clinical record.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Review of the documented hospice volunteer cost savings for the calendar year 2024 was 3.1%. The volunteer coordinator had achieved cost savings of 3% year to date, 2025 and had also been working on recruitment opportunities. During the interview with the Quality Director and the Volunteer Coordinator on 06/06/2025 they stated that the volunteer program had an active process improvement plan in place. Review of hospice volunteer cost savings for 2024 was 3.1%. The volunteer coordinator has achieved cost savings of 3% so far in 2025, but has also been working on recruitment and opportunities.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: Prescription and over-the-counter (OTC) drugs. The medication review process includes the identification of the following: The effectiveness of drug therapy; Drug side effects; Actual or potential drug interactions; Duplicate drug therapy; Drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 11 (9%) records reviewed, it was revealed that agency policy was not followed for medication profile update. Agency policy, "2-004 Medication Profile [revised December 2018]", stated in part, "The medication profiles will be updated for each change to reflect current medications, an new and/or discontinued medication." Clinical Record 6 - Hospice Benefit of Election was 05/13/2022. Documentation on the nursing clinical visit note dated 05/26/2022 stated that Doxycycline was started to treat a bacterial infection, and Robitussin was started for their cough and respiratory congestion. These added medications were not documented on the medication profile at the time of review on 8/23/2022. Interview with the Director of Hospice confirmed the finding, and they stated the medication profile had not been updated. Agency Policy 2-004 Medication Profile [revised December 2018] stated in part, "The medication profiles will be updated for each change to reflect current medications, an new and/or discontinued medication."

It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 4 of 11 (36%) records, the agency did not ensure that plans of care were updated to include goals and intervention to address all problems identified on the initial comprehensive assessment or subsequent assessments. Agency policy, "9-017 The Plan of Care [revised April 2019]", stated in part: "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by the members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. Clinical Record 6 - Hospice benefit of election date was 05/13/2022. On 05/26/2022, respiratory congestion was documented on the nursing clinical visit note and was treated with an antibiotic. On 06/02/2022 a nursing clinical visit note documented a COVID test for the patient was positive. A nursing clinical note on 06/07/2022 IDT [interdisciplinary team] meeting stated that COVID test was positive but there was no documented evidence of goals or interventions added to the plan of care related to respiratory problem or COVID status up to the time of review on 08/23/2022. Clinical Record 13 - Hospice benefit of election date was 2/22/2022. On 06/02/2022 a stage 2 scrotum pressure area was documented on the nursing clinical visit note and was treated with zinc oxide. The plan of care was not updated with a goal or interventions related to skin integrity. Also a UTI [urinary tract infection] was documented on the nursing clinical visit note on 06/13/2022 and was treated with an antibiotic. No update to the plan of care was documented with goals and interventions as of review on 08/23/2022. Clinical Record 10 - Hospice benefit of election date was 03/07/2022. The initial comprehensive assessment documented a primary diagnosis of COPD [chronic obstructive pulmonary disease]. On 03/11/2022 a nursing clinical visit note documented the patient was imminent and presented with death rattle and cheyne stokes breathing. Documentation on 03/12/2022 described increased death rattle and the date of death was 03/12/2022. There was no evidence of updated goals or interventions from nursing that addressed imminent death noted on the plan of care. Clinical Record 2 - Hospice benefit of election was 07/07/2022. The initial comprehensive assessment documented the presence of a non-healing wound on the right toe and it was unclear if a dressing was in place. The assessment stated the patient had a high risk Braden scale score for pressure areas. The right toe wound was documented as healed on 08/07/2022. The initial plan of care on 07/13/2022 as well as updated plans of care dated 07/19/2022 and 08/02/2022 did not identify a problem with skin integrity or document any interventions and goals to address this. During interview with the Director of Hospice confirmed the finding and stated that care plans are a focus with the quality program for completeness and updates as well as appropriate goals. Agency Policy 9-017 The Plan of Care [revised April2019] stated in part, "The plan of care will be based on the intial, comprehensive and ongoing ccomprehensive assessments performbed by the members of the interdisciplinary group and will be reviewed on a regualr basis but no less than every 15 days.

It is required that each patient’s individualized written plan of care: Includes all services necessary for the palliation and management of the terminal illness, including the following: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 5 of 7 (71%) applicable records in which music therapy was provided, the records were missing documentation of the scope and frequency of planned visits on the plan of care. Agency policy, "9-017 The Plan of Care [revised April2019]", stated in part: "The written plan of care will contain, but will not be limited to, the following detailed statement of scope and frequency of services." Clinical Record 17 - Hospice benefit of election was 01/21/2022. The music therapist visited the patient initially on 01/24/2022. The updated plan of care on 02/01/2022 did not include documented evidence of the scope or frequency of visits for music therapy. Clinical Record 0 - Hospice benefit of election was 01/06/2022. The initial music therapist visit was made on 01/12/2022 and 2 additional visits were documented as provided. The updated plan of care on 01/18/2022 did not include documented evidence of the scope or frequency of visits for music therapy. Clinical Record 9 - Hospice benefit of election was 11/03/2022. The initial music therapist visit was made on 11/16/2022. There was no scope and frequency for music therapy visits documented on the plan of care dated 11/23/2022. Clinical Record 5 - Hospice benefit of election was 12/3/2022. The initial music therapist visit was made on 12/06/2022. The updated plan of care dated 12/7/2022 did not document the scope or frequency for music therapy visits. Clinical Record 10 - Hospice benefit of election was 03/07/2022. The initial music therapy visit was made on 3/11/2022. The updated plan of care dated 03/12/2022 did not document the scope and frequency for music therapy visits. During interview with the Director of Hospice they confirmed the finding and stated that the clinical record software had to update their technology so they could include music therapy on the plan of care. Agency Policy 9-017 The Plan of Care [revised April2019] stated in part, "The written plan of care will contian, but will not be limited to, the following detailed statement of scope and frequency of services."

It is required that licensed professionals participate in hospice sponsored in-service training. This standard was not met as evidenced by review of documents, personnel records, and interview. In 1 of 11 (9%) records review revealed there was no documented evidence that annual education was completed as described in agency policy. Agency policy, "1-028 Personnel Responsibilities [revised December 2018], stated in part: " Palliative and Hospice care requires that each staff member and staff under arrangement complete a minimum of the following related programs each year: Patient Rights and Responsibilities, Standard precautions and infection control, Safety including OSHA and Medical Device, Body Mechanics, Emergency Management Plan, Corporate Compliance and Standards of Conduct and HIPPA." Staff 3 - The employee file for this social worker hired on 05/03/2018 did not contain evidence of annual OSHA education completed in 2020 or 2021. Interview with the human resource director stated that the documentation was not present. Agency Policy1-028 Personnel Responsibilities [revised December 2018] stated in part, " Palliative and Hospice care requires that each staff member and staff under arrangement complete a minimum of the following related programs each year: Patient Rights and Responsibilities, Standard precautions and infection control, Safety including OSHA and Medical Device, Body Mechanics, Emergency Management Plan, Corporate Compliance and Standards of Conduct and HIPPA."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 10 (10%) records in which hospice aide service was accepted, the aide plan of care did not clearly describe all equipment to be used for safely transferring the patient during care. Clinical Record 17 - The hospice aide was visiting the patient 2 times a week and duties included completing a bed bath and providing personal care. Documentation on the nursing clinical note dated 01/23/2022 described the transferring the patient using a Hoyer lift. Also, the Hoyer lift was documented as used to move the patient off of the bedpan. The aide plan did not include use of a Hoyer lift for safety while the aide provided care. Interview with the Director of Hospice confirmed the finding and the Director stated the Hoyer Lift should have been included, however the software does not provide the option of including this information on the aide plan of care.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by a review of clinical records, document review and interview. In 1 of 8 (12%) records that required additional physician orders, the record was missing documentation of a physician order in accordance with the agency's policy. Agency policy, "2-002 Verification of Physician Orders [Revised December 2018]", stated in part, "Orders will be obtained from a licensed physician for care and services to be provided to hospice patients." Clinical Record 9 - Hospice Benefit of Election 11/13/2021. The initial assessment documented the presence of a sacral decubitus dressing, a skin tear on the right arm with dry dressing, and a left arm abrasion with a dry dressing. On 11/19/2021, the nursing clinical note documented that the Opti-foam dressing on the sacral wound was stopped and the application of Skin Barrier was started with each diaper change. There was no documented physician order present in the record for the change in wound care. Interview with the Director of Nursing of Hospice stated that the order was not documented. Agency Policy 2-002 Verification of Physician Orders [Revised December 2018] stated in part, "Orders will be obtained from a licensed physician for care and services to be provided to hospice patients."

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of: The hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 1 (100%) record of a patient who was discharged to a Medicare certified facility, the agency did not ensure that the discharge summary was sent to the receiving facility. Agency policy, "1-025 Discharge from Hospice", stated in part: "When a patient is discharged, transferred, or referred to another organization, relevant information will include: reason for discharge, physical and psychosocial status at time of transfer or discharge, summary of care, current plan of care, a copy of the medication profile and latest physician orders." Clinical Record 0 - Hospice benefit of election was 1/06/2022 with a primary diagnosis of chronic obstructive pulmonary disease. On 01/30/2022 it was documented that the patient was transferred to the hospital for aggressive treatment and discharged from hospice. There was no documented communication with the hospital or documentation that any paperwork was sent to the hospital. Interview with the Director of Hospice confirmed the finding and they stated that the patient called an ambulance for hospital transport and not the hospice, but agreed no documentation of communication with the hospital was found. Agency Policy 1-025 Discharge from Hospice stated in part, "When a patient is discharged, transfeeerred, or referred to another organization, relevant infomration will include: reason for discharge physical and pshcbosocial status at time of transfer or discharge, summary of care, current plan of care, a compy of the medication profile and latest phhsician orders."

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group: Documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 1 of 2 (50%) records of patients who died, the record did not contain documented evidence that the policies and procedures for managing and disposing of controlled medications was provided and discussed, as described in agency policy. Agency policy stated in part, "At the time of discontinuation of a controlled substance, the caregiver will be instructed by a hospice representative that all controlled substances should be destroyed for safety reasons." Clinical Record 9 - Hospice benefit of election date was 11/13/2021 and date of death was 11/22/2021. Documentation at the time of the patient's death did not include evidence of any instruction related to drug disposal or that any medications were disposed. The medication profile included Morphine, which was used to treat severe pain, ordered at 20mg per milliliter, and Lorazepam, used for anxiety, ordered at 0.5 mg. The patient was using both drugs prior to death. During interview with the Director of Hospice, they confirmed the finding and stated that the drug disposal was supposed to be documented but was not. Agency Policy statedin part, " at the time of discontinuation of a controlled substance, the caregiver will be instructed by a hospice representative that all conrolled substances should be destryed for safety reasons."