Every finding on record at Alliance Care Hospice Inc.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 8 of 14 (Patient #1,2,3,4,5,6,7,8) 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 1: On the plan of care there is an order for SW to see patient for a psychosocial assessment within 5 days of admission with SOC 10/20/25. Agency completed during the survey. Patient 1,2,3,4: On the plan of care there is an order for spiritual care to see patient within 5 days of admission, there is not a spiritual care compressive assessment completed. Corrected on site, agency completed during the survey.

Upon patient record review 5 of 14 (Patient #5,6,7,8,10) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 5,6,7,8,10: On the plan of care there is an order for spiritual care to see patient within 5 days of admission, there is not a spiritual care compressive assessment completed.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 6: On the RN comprehensive assessment, the RN does not take into consideration the imminence of death.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,7,8,10) 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 1,2,3,4,5,6,7,8,10: There is an order on the plan of care, “Bereavement to assess and evaluation bereavement and grieving risk factor within 5 days of SOC and POST death". There is no evidence that an initial bereavement assessment was performed within 5 days of admission.

Upon patient record review, 1 of 14 (Patient #1) 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 1: On the plan of care there is an order for Eliquis 2.5mg daily, there is not a risk of bleeding on the plan of care with goals and interventions. Corrected on Site.

Upon patient record review, 1 of 14 (Patient #5) 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 5: The IDG note from the medical director is not signed on 10/16/25, 10/2/25, 9/18/25, 9/4/25, 8/21/25, and 8/7/25.

Upon patient record review, 1 of 14 (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: On the plan of care there is an order for SN visits one time per week. There were no SN visits documented the week of 10/26/25. The hospice policy stated to have all visits documented within 7 days.

Upon personnel record review, 1 of 12 (Personnel #5) 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.) Personnel 5: There is no evidence in the personnel file that the competency assessment, shampoo, sink, tub, and bed, was performed by aide. ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(C) Shampoo, sink, tub, and bed

Upon patient record review, 1 of 14 (Patient #1) 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: On the aide plan of care there is an order for change patient linens, this order does not contain a frequency.

Upon patient record review 1 of 14 (Patient #1) 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 1: On the aide POC dated 10/20/25 there is an order for aide visits 2 times per week. There is no documentation of visits made for the week of 10/19/25, there is not an order to discontinue visits or documentation of missed visits.

Upon patient record review 2 of 5 (Patient #1,#3) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1 and 3: The record indicated there was not a Spiritual Assessment.

Upon patient record review, 1 of 5 (Patient #3) 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 3: The medication profile indicated that Miralax17grams 2 times per day was ordered. There was not evidence of a diluent to mix with the Miralax powder.

Upon patient record review, 1 of 5 records (Patient #3) 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 3: The medication profile indicated that Miralax17grams 2 times per day was ordered. There was not evidence of a diluent to mix with the Miralax powder.