Every finding on record at Allay Home and Hospice Inc

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; Supplements; Herbal remedies; Other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that all of the patient's current medications were included in the patient's drug profile and reviewed for the effectiveness of drug therapy. Agency Policy 2-004.1, Medication Profile (dated 05/11/2020), stated in part, "Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including over-the-counter (OTC) medications, nutritional supplements, herbal remedies, vitamins and minerals, and oxygen therapy...A drug regimen review will be performed at the time of the initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.” CLINICAL RECORD 9: The patient elected the hospice benefit on 08/27/2025. A physician's order dated 08/27/2025 read in part, "Acetic Acid 0.25% solution, flush foley catheter with 60ml (milliliters) three times per week.” The patient's medication profile dated 08/27/2025 did not include Acetic Acid solution therefore it was not included in the medication review process. During a joint record review and interview on 09/30/2025, the Director of Clinical Operations confirmed the above finding and stated, "The patient's medication profile should have had the Acetic Acid solution included.”

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, medical supplies and appliances necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed the agency did not ensure that all medical supplies and appliances necessary to meet the needs of the patient were included in the patient's individualized written plan of care. CLINICAL RECORD 8: The patient elected the hospice benefit on 05/16/2025 with a diagnosis of malignant neoplasm of the female breast. The plans of care dated 05/16/2025 through 08/13/2025 and 08/14/2025 through 11/11/2025 ordered, "Oxygen 1-5 liters via facemask as needed for shortness of breath.” The plans of care lacked documentation of the patient's oxygen concentrator and oxygen supplies. CLINICAL RECORD 19: The patient elected the hospice benefit on 05/15/2025 with a diagnosis of cerebral atherosclerosis. The plan of care dated 05/15/2025 through 08/12/2025 ordered, "Oxygen 1-5 liters via nasal cannula as needed for shortness of breath.” The plan of care lacked documentation of the patient's oxygen concentrator and oxygen supplies. During joint record reviews and interviews on 09/30/2025 and 10/02/2025, the Director of Clinical Operations confirmed the above findings that oxygen supplies were not included in the patients plans of care.

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 clinical record review and interview. In 1 of 18 (6%) clinical records reviewed, with hospice aide services provided, it was revealed that the agency did not ensure that all written patient care instructions were included in the hospice aide care plan. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/10/2024. A physician's order dated 06/12/2025 ordered wound care, with a dressing, to the wound on the patient's right arm. The plan of care dated 06/04/2025 through 08/02/2025 ordered "Hospice aide 3 times per week.” The hospice aide care plan dated 05/07/2025 included relevant instructions of "Bed bath every visit.” The hospice aide care plan was not updated to include instructions regarding what the hospice aide should do if the wound dressing becomes wet or dislodged during the bed bath. During a joint record review and interview on 10/01/2025, the Director of Clinical Operations confirmed the above finding and stated, "We have a performance improvement plan that we have been working on over the last several months to help make sure that all patient care is included in the aide care plans.”

It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed, with hospice aide services provided, it was revealed that the agency did not ensure that hospice aide supervisory visits were completed by a registered nurse no less frequently than every 14 days. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/10/2024. The plan of care dated 08/08/2024 through 10/06/2024 ordered, "Hospice Aide one (1) time per week.” The first hospice aide visit was dated 08/09/2024. The record included a hospice aide supervisory visit was dated 09/17/2024. The next documented hospice aide supervisory visit was dated 10/02/2024, 15 days later and 1 day outstanding. During a joint record review and interview on 10/01/2025, the Director of Clinical Operations confirmed the above finding that hospice aide supervisory visits were not completed within the 14 days as required.

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 clinical record review and interview. In 1 of 19 (5%) clinical records reviewed the agency did not ensure that all physician's orders were included in the patient's clinical record. CLINICAL RECORD 14: The patient elected the hospice benefit on 02/25/2025 and resided in a skilled nursing facility (SNF). A nursing visit note dated 04/17/2025 read in part, "Patient had a 16 French foley catheter placed by facility staff yesterday.” The record lacked documentation of a physician's order for the foley catheter. During a joint record review and interview on 10/01/2025, the Director of Clinical Operations confirmed the above finding that a physician's order for the foley catheter was not included in the patient's clinical record.

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 interview. 1 of 13 (8%) records of patients where a hospice aide was accepted, revealed a lack of clear and specific written instructions for the aide assignment thus leaving the aide to make decisions outside of the aide's scope of practice. Clinical Record 5: The Aide Plan of Care (POC) dated 4/26/22, assigned a partial sponge bath weekly and a bed bath with each visit. The hospice aide visit frequency was ordered at 2x per week. There was no clear guidance documented on whether the patient was alert and oriented and able to make safe decisions with respect to personal care. The patient's diagnosis is Multiple Sclerosis, and they reside in a nursing facility. The Director of Clinical Operations confirmed that the plan of care was incorrect.

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). This standard was not met as evidenced by a review of clinical records and interviews. In 13 of 13 (100%) records reviewed the hospice failed to provide the patient/caregiver with a copy of the written policies and procedures for the management and disposal of controlled medications at the time when controlled medications were ordered. Clinical Record 1: The patient elected the Hospice Benefit on 10/7/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 2: The patient elected the Hospice Benefit on 10/18/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 3: The patient elected the Hospice Benefit on 8/20/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 4: The patient elected the Hospice Benefit on 5/29/20. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 5: The patient elected the Hospice Benefit on 3/2/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 6: The patient elected the Hospice Benefit on 11/9/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 7: The patient elected the Hospice Benefit on 11/1/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 8: The patient elected the Hospice Benefit on 3/13/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 9: The patient elected the Hospice Benefit on 3/2/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 10: The patient elected the Hospice Benefit on 3/22/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 11: The patient elected the Hospice Benefit on 11/17/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 12: The patient elected the Hospice Benefit on 5/6/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. Clinical Record 13: The patient elected the Hospice Benefit on 11/29/22. The clinical record lacked evidence that a copy of the written policies and procedures for the management and disposal of controlled medications were given to the patient at the time that controlled medications were ordered. In a joint record review with the Director of Clinical Operations, she agreed that patients were not given a copy of the written policies and procedures for the management and disposal of controlled medications as that had never been their hospice's practice.

It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IDF representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 4 of 4 (100%) records reviewed of patients receiving hospice services in a skilled nursing facility (SNF) revealed the agency did not ensure that the plans of care included the identification of which provider was responsible for performing the interventions on the plan of care (POC). Clinical Record 1: On joint review of the record with the Clinical Director, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 7: On joint review of the record with the Clinical Director, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 10: On joint review of the record with the Clinical Director, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. Clinical Record 13: On joint review of the record with the Clinical Director, it was discovered that the plan of care did not state whether hospice or the facility were responsible for the interventions in the plan of care. The Director of Clinical Operations stated that the organization does not delineate responsibility for performing the functions in the plans of care.