Every finding on record at All Time Hospice Care Inc

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 3: Right to Choose an Attending Physician section of consents was blank with no choice selected.

Upon patient record review 1 of 14 (Patient #5) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 5: The initial spiritual assessment was completed on 3/8/26 with start of care 2/25/26.

Upon patient record review, 4 of 14 (Patient #1,#3,#4,#7) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: The medication profile contained Amoxicillin ordered on 2/20/26 with treatment for 10 days and was not discontinued. Profile also contained scheduled Benadryl and Atorvastatin; however, patient and caregiver advised patient does not take any longer. Patient uses oxygen PRN; however, there was no evidence on medication profile. Patient 3: RN documented continuous O2 use; however, there was no evidence of oxygen on the medication profile. Miconazole fungal cream on med profile with no instructions of location to apply the cream. Patient 4: RN documented continuous O2 use; however, there was no evidence of oxygen on the medication profile. Patient 7: The medication profile contains Polyethylene Glycol, however, there were no instructions for diluent when preparing this medication.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 6: There was no evidence of an initial bereavement assessment being completed.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Patient 6: No evidence of continuous assessment by RN since 1/21/26 including no updates to the comprehensive assessments.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient 6: No evidence of continuous assessment by RN since 1/21/26.

Upon patient record review, 5 of 14 (Patient #2,#3,#5,#6,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 2: Anticoagulant therapy since admission; however, there was no evidence of care plan for bleeding risk. Patient 3: On admission documented problems were respiratory, oxygen safety, and risk for falls. However, psychosocial was the only open care plan. Patient 5: Admission identified problems were incontinence, foley catheter, risk for falls and bleeding and unresolved end of life plans; however, there was no evidence of care plans for these problems. Patient 6: On admission documented problems were incontinence, risk for bleeding and falls, neurocognitive decline and primary diagnosis of heart failure. However, psychosocial was only open care plan. Patient 7: Anticoagulant therapy since admission; however, there was no evidence of care plan for bleeding risk.

Upon patient record review, 4 of 14 (Patient #1,#3,#4,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Order on 2/20/26 for Amoxicillin was not discontinued after 10 days of treatment. Medical record also contained orders for Benadryl and Atorvastatin; however, patient and caregiver advised patient does not take any longer. Patient uses oxygen PRN; however, there was no evidence of an order. Patient 3: RN documented continuous O2 use; however, there was no evidence of order for oxygen in the medical record. Order for Miconazole fungal cream with no instructions of location to apply the cream. Patient 4: RN documented continuous O2 use; however, there was no evidence of order for oxygen in the medical record. Patient 7: Order for Polyethylene Glycol with no instructions for diluent when preparing this medication.

Upon patient record review, 7 of 14 (Patient #1,#2,#3,#4,#5,#6,#7) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: During home visit, patient identified as having a walker, wheelchair, hospital bed, bedrails, shower chair, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 2: Patient identified as using a shower chair; however, there was no evidence of DME on the POC order. Patient 3: During home visit, patient identified as having a walker, wheelchair and shower chair. There was no evidence of DME on the POC order. Patient 4: Admission documentation includes DME as hospital bed, walker, wheelchair, nebulizer and oxygen concentrator. There was no evidence of DME on the POC order. Patient 5: Admission documentation includes DME as hospital bed, over bed table, walker and wheelchair. There was no evidence of DME on the POC order. Patient 6: Admission documentation includes DME as a nebulizer, walker and wheelchair. There was no evidence of DME on the POC order. Patient 7: Patient has a hospital bed; however, there was no evidence of DME on the POC order.

Upon client record review, 1 of 14 (Patient #6) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 6: No evidence of continuous assessment by RN since 1/21/26. There was no evidence of documentation of updates from visits as no visits were made and no progress towards goals.

Upon patient record review, 3 of 14 (Patient #2,#3,#6) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2: RN assessment on 2/25/26 identified patient decline with aspiration, decreased nutrition and potential for skin breakdown; however, there was no evidence of problems, interventions and goals. Patient 3: RN documentation has identified aspiration risk, but there is no evidence of problems, interventions and goals with update to the plan of care. Patient 6: No evidence of updated comprehensive assessment since 1/21/26 with no revision/updates to the plan of care.

Upon client record review, 2 of 14 (Patient #3,#6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: Order for SN frequency is 1x/week. Admission on 3/19/26 with no evidence of a SN as of 4/2/26. Patient 6: Order for SN frequency is 1x/week. There was no evidence of SN visit since 1/21/26.

Condition of Participation: Licensed Professional Services.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence that licensed professional actively participate in the coordination of all aspects of the patient's hospice care, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. Patient 6: No evidence of active coordination of care or ongoing comprehensive assessments as last documented RN visit was 1/21/26.

Upon personnel record review, 3 of 14 (Personnel #3,#4,#8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel 3,4,8: No evidence of withholding forms were present for these personnel.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 14: No development of a bereavement plan of care. No evidence bereavement offered or provided to patient's sister.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: No evidence of competencies assessed by RN in personnel file.

Upon personnel record review, 1 of 14 (Personnel #6) did not have evidence in the personnel file that the hospice aide had received at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. Personnel #6: No evidence in the personnel file of in-service training from aide date of hire 2/14/25 to date of survey.

Upon observation, there was no evidence in-service training for Hospice Aides are supervised by a Registered Nurse.

Upon observation, there was no evidence the hospice must maintain a written description of the in-service training provided during the previous 12 months.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#5,#6,#7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: During home visit observation, the patient was identified as using a shower chair. There was no evidence of instructions to utilize a shower chair on the aide care plan. In addition, instructions on the aide care plan for continuous oxygen use, as patient is O2 dependent. However, there is not evidence of oxygen dependency or oxygen orders. Patient 2,5,6,7: Patient is taking anticoagulants; however, there was no evidence of instructions for bleeding risk on the aide care plan. Patient 3: Aide care plan contains task for shower but no evidence of instructions for shower chair. Care plan contains task instructions for walker but not wheelchair. Patient taking anticoagulants; however, there was no evidence of instructions for bleeding risk included. In addition, the Aide care plan contains task for foley catheter with instructions for foley care, measure output and empty BSD bag; however, patient does not have a foley catheter.

Upon patient record review 3 of 14 (Patient #5,#6,#7) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 5: Order for aide visit frequency is 2x/week effective 3/1/26. There was no evidence of any aide visits. Patient 6: Order for aide visit frequency is 2x/week effective 2/5/26. Week of 2/9/26 only 1 of 2 visits documented. No aide visits documented weeks of 2/16/26, 2/23/26, 3/2/26 and 3/9/26. Patient 7: Order for aide visit frequency is 2x/week effective 2/27/26. There was only 1 of 2 visits documented each week.

Upon patient record review 3 of 14 (Patient #5,#6,#7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 5: RN documented supervisory visits on this patient. The aide documented in the record worked in the office and had not provided care to the patient. An aide was ordered but had not made a visit. Patient 6: No evidence of supervisory visit since admission on 12/22/2025. Patient 7: No documented aide supervision documented on aide providing the aide visits. The RN documented supervisory visits on the LPN instead of the aide, instead of the aide that was providing care to the patient.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The hospice administrator and governing body failed to maintain oversight of the hospice agency as evidenced by widespread noncompliance in personnel management, patient care, and the delivery of hospice services, resulting in noncompliance with applicable standards of care. Personnel files were incomplete and missing required documentation, including evidence of employment (W-2 and I-9 forms), criminal background checks, and verification of qualifications, education, and experience. The Administrator’s personnel file, as well as an Alternate Administrator's personnel file, did not contain required documentation, including orientation to hospice philosophy and defined job responsibilities in addition all required personnel forms. There was an absence of Physical Therapy, Occupational Therapy and Speech Therapy personnel files for the executed contract. Additionally, competency evaluations were either absent or not conducted by the hospice personnel. Plan of Care deficiencies were also identified. The registered nurse failed to provide ongoing assessments, and plans of care were not reviewed or updated to reflect current patient needs. Medication orders and supply needs were not consistently maintained. There was a lack of adherence to professional standards, evidenced by failure to visit patients per physician orders and hospice standards, including one patient was not seen since January 2026 and another whose location was unknown to the agency indicating serious gaps in patient oversight and quality of care. Furthermore, hospice aide services were not provided in accordance with regulatory standards. There was no documentation of required in-service training or competency evaluations. Supervisory visits were inaccurately documented, including instances where supervision was recorded for patients the aide had not visited. Aide written care instructions provided by the registered nurse were incomplete. Overall, the agency failed to implement and maintain ongoing compliance audits of personnel and patient records, resulting in adequate oversight of operations and inability to ensure personnel were providing care within acceptable professional standards of care.

Upon personnel record review, 2 of 14 (Personnel #1,2) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel 1,2: No evidence of orientation on the hospice philosophy.

Upon personnel record review, 2 of 14 (Personnel #1,#2,#3) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel 1,2,3: No evidence of orientation related to specific job requirements/duties.

Upon personnel record review, 7 of 14 (Personnel #3,#4,#6,#7,#8,#9,#10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 3,4,6,7,9: No evidence of competency assessment upon hire. Personnel 8: Competency assessment for SC completed by an LPN. No evidence of competency assessment for the Bereavement Coordinator role. Personnel 10: Competency assessment for the LPN incomplete and signed by administrator who is not an RN.

Upon contract review, 2 of 4 (Medical Director/Alt Medical Director contracts) did not have evidence of a contract to fulfill the role of medical director or alternate medical director, if applicable. No evidence of Medical Director or Alternate Medical Director contracts. The hospice only had a signed paragraph stating they would agree to fill this role. Also, no evidence of signed job description for alternate medical director.

Upon patient client record review, 4 of 14 (Patient #1,#2,#3,#10) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 1,3,10: No date in the blank for the election effective date. Patient 2: No date in the blank for effective date of election. Patient signed election statement but no evidence of signature dates.

Upon patient client record review, 2 of 14 (Patient #3,#10,#12) did not have evidence that each patient record contains Advance Directives. Patient 3,10,12: No evidence of fully executed POLST form in medical record.

Upon patient client record review, 3 of 14 (Patient #1,#2,#5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: Medical chart contained 2 sets of election statements and consents. One set was signed by patient without any signature dates, and the other set was dated and signed as "verbal" with reason unable to sign as "shaky hands". RN assessment visit on 3/20/26 states patient non-ambulatory but documented in narrative that patient ambulates with walker. RN assessment on 3/20/26 documented check boxes as no dyspnea, no cough, lungs clear, resp normal, no oxygen use; however, narrative states dyspnea present, continuous O2, breath sounds diminished bilaterally, wheezing and chronic cough present. Patient 2: On 3/20/26 RN documented patient is completely dependent for ADLs and mobility and is bedbound. Also, oral intake remains poor and requires extensive cueing. On home visit, patient sat at dining table in regular chair and ate 100% of breakfast without any assistance, drank coffee and conversed with other residents in home. Group home caregiver states patient has not required assistance and ambulates independently inside and outside home. 2/25/26 RN check box documentation as no dysphagia but narrative states impaired swallowing and risk for aspiration. Patient 5: RN documented multiple supervisory visits on the LPN who have never seen the patient.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 1: Upon home visit, the group home caregiver and patient stated the hospice RN discontinued Atorvastatin and Benadryl 2 weeks ago during the visit when she called the hospice Medical Director about patient's medications. MD gave verbal order to discontinue both the medications. There was no evidence of documentation the RN wrote the verbal order given by the MD. Patient had not been taking this medication since that RN visit and hospice LPN called MD during survey visit and confirmed meds were to be discontinued.

Upon personnel record review, 1 of 14 (Personnel #14) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 14: No evidence of SLP personnel file.

Upon personnel record review, 1 of 14 (Personnel #13) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 13: No evidence of OT personnel file.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel 12: No evidence of PT personnel file.

Upon personnel record review, 11 of 14 (Personnel #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 1,2: No evidence of a criminal background check in personnel file. Personnel 1,2,3,4,5,6,7,8,9,10,11: No evidence of OIG list or sex offender registry check.

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. The hospice had a change of name and change of office location. Arizona DHS completed an onsite survey and provided a letter of disapproval of location and name change. Address on license is incorrect, as location has changed twice since license was originally issued 5/6/2022.

Upon patient record review, 1 of 5 (Patient #4) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient 4: Patient representative signed Election of Benefits, Advanced Directives, and Revocation form. No evidence as to why the beneficiary could not sign for her self or what relationship the representative was to the beneficiary.

Upon patient client record review, 1 of 5 (Patient #4) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 4: Patient representative signed Election of Benefits, Advanced Directives, and Revocation form. No evidence as to why the beneficiary could not sign for her self or what relationship the representative was to the beneficiary.