Every finding on record at Alleo Health of Florida LLC

Upon patient record review 2 of 19 (Patient #8,11) 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 8: The record indicates that the SC assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 1/22/2025. Psychosocial assessment completed on 01/28/2024, 6 days after election. Patient 11: The record indicates that the psychosocial assessment was not completed within 5 calendar days following the election of hospice. Patient was admitted on 08/07/2024. Psychosocial assessment completed on 09/05/2024, 29 days after election.

Upon patient record review, 3 of 19 (Patient #7,10,13) 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 7: The medication profile contained miralax oral powder with no instructions for a diluent. Corrected on site. Patient 10: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen on the medication profile. Corrected on site. Patient 13: The medical record contained nursing documentation upon admission identifying patient use of oxygen. There was no evidence of oxygen on the medication profile. There were two medications listed for nausea/vomiting, Ondansetron & Prochlorperazine Maleate. No evidence instructions were given on which medication to give first to treat the nausea/vomiting. Corrected on site.

Upon patient record review, 4 of 19 (Patient #1,2,3,4) 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 1: The medical record indicated that patient developed a wound on their left forearm on January 15, 2025. No evidence that the wound was measured from the day it was discovered through the time of survey. Patient 2: The medical record indicated that patient developed a wound on the sacrum on February 1, 2025. No evidence that the wound was measured from the day it was discovered through the time of survey. Patient 3: The medical record indicated that patient developed a wound on the coccyx on April 9th, 2025. No evidence that the wound was measured from the day it was discovered through the time of survey. Patient 4: The medical record indicated that patient was admitted with a wound on the sacrum. No evidence that the wound was measured from the day it was discovered through the time of survey.

Upon patient record review, 2 of 19 (Patient #9,10) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patient 9: No evidence in patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician. Patient 10: No evidence in patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician.

Upon patient record review, 3 of 19 (Patient #3,4,14) 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 3: Patient currently takes sertraline for depression and NovoLog for diabetes. There are no problems, goals, and interventions related to endocrine/diabetes or depression listed on the POC. Patient 4: Admitted with related diagnosis of epilepsy current medications include Keppra 500MG twice a day. Secondary diagnosis of depression. There are no problems, goals, and interventions related to seizures, neurological deficit, or depression listed on the POC. Patient 14: Currently has depression listed as a diagnosis and takes Lexapro daily for depression. There are no problems, goals, and interventions related to depression listed on the POC.

Upon patient record review, 1 of 19 (Patient #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 7: The plan of care has an active order for miralax oral powder with no instructions for a diluent. Corrected on site.

Upon patient record review, 3 of 19 (Patient #3,4,9) 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 3: The medical record states the patient is oxygen dependent per initial SN comprehensive assessment. No evidence that the related supplies were listed on plan of care. Patient 4: The medical record indicated that DME and supplies were not listed on the initial plan of care. The record indicated that the patient had a G-tube, tube feedings, wound care supplies, incontinence supplies, and a wheelchair. Patient 9: The medical record indicated that all DME and supplies were not listed on the initial plan of care. The record indicated that the patient had incontinence supplies. No evidence that the supplies were listed on the current plan of care.

Upon patient record review, 2 of 19 (Patient #9,10) 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 9: No evidence in patient record that the written plan of care was reviewed and revised by the IDG, in consultation with the patient's attending physician. Patient 10: No evidence in patient record that the written plan of care was reviewed and revised by the IDG, in consultation with the patient's attending physician.

Upon patient record review, 1 of 19 (Patient #1) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: 04/09/2025 SN visit referenced cleaning a wound to the patient left forearm with saline and betadine before covering with a bandage. No evidence that an order was received for wound care. Corrected on site.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. No evidence that governing body meetings/QAPI review occurred for the 3rd and 4th quarter of 2024. QAPI binder only contains meeting minutes for a meeting that occurred on 04/29/2025 which reviewed the 1st quarter of 2025. No evidence to support that the governing body is involved in the QAPI program. Agency policy is for agency governing body and QAPI review be completed quarterly.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No evidence that governing body meetings/QAPI review occurred for the 3rd and 4th quarter of 2024. QAPI binder only contains meeting minutes for a meeting that occurred on 04/29/2025 which reviewed the 1st quarter of 2025. No evidence to support that the governing body is involved in the QAPI program. Agency policy is for agency governing body and QAPI review be completed quarterly.

Upon patient record review 1 of 19 (Patient #12) 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 12: No evidence that task were completed by the aide on the 04/25 visit. Assisting the patient with dressing, standing, and transferring left blank.

Upon patient record review 4 of 19 (Patient #5,8,9,12) 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: The record indicated that an aide supervisory visit was conducted on 02/27/2025 and not again until 03/25/2025, Patient 8: The record indicated that an aide supervisory visit was conducted on 03/19/2025 and not again until 04/09/2025. Patient 9: The record indicated that an aide supervisory visit was conducted on 03/18/2025 and not again until 04/14/2025. Patient 12: The record indicated that an aide supervisory visit was conducted on 03/18/2025 and not again until 05/02/2025.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles. No evidence that the agency has the ability to provide volunteers in administrative and/or direct patient care roles.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 0%.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 10: The medical record does not contain an appropriately completed initial certification of terminal illness. The patient’s choice of attending physician did not provide oral or written certification of terminal illness, only the hospice Medical Director completed the certification of terminal illness.

Upon patient record review, 4 of 19 (Patient #4,7,10,13) 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 4: The RN documented the patient was admitted with stage 4 CKD in the IDG note for 04/10/2025. No evidence that the patient has stage 4 CKD. Patient admitting diagnosis is sequalae of cerebral infarction. Patient 7: The MD documented that the patient admitting dx was Lung and tongue CA. The initial POC has the primary dx listed as Dementia. Patient 10: The MD documented that the patient admitting dx was Lung CA with brain mets. The initial POC has the primary dx listed as COPD. Patient 13: The SW documented the patient was admitted with cervical cancer on 03/17/2025 in the IDG note. No evidence that the patient has cervical cancer. Patient admitting diagnosis is COPD.

Upon patient record review, 2 of 19 (Patient #4,5) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 4: SNF resident admitted 04/05/25 with a wound and g-tube for feedings. There is no documented evidence of coordinated Plan of Care between the hospice and SNF regarding wound care and gastrostomy care. Patient 5: SNF resident admitted 02/26/25 with a wound. Wound care orders stated that the SNF was to provide care 3 days a week, however the order called for the wound care to be performed 5 times a week. There is no documented evidence of coordinated plan of care between the hospice and SNF as to who was to perform wound care for the 2 remaining days of the week.