Every finding on record at Alliance Healing Hospice & Palliative Care LLC

It is required that one or more individual(s) is appointed by the governing body as responsible for operating the QAPI program. This standard was not met as evidenced by document review and interview, which revealed the agency did not ensure the governing body meeting documentation included the appointment of an individual responsible for operating the QAPI program. DOCUMENT 1: The agency policy AD.G10, titled Governing Body, stated in part, "Designates at least one individual to be responsible for the performance improvement operation." The governing body minutes from hears 2023, 2024, and 2025 to date were reviewed. There was no documentation of an appointment of an individual as responsible for the QAPI program. During an interview with the Administrator/CEO on November 19. 2025, he confirmed that there was no documentation in the governing body agendas or meeting minutes for the past three years indicating the appointment of an individual to be responsible for the QAPI program The standard was not met, as evidenced by a review of the agency's governing body minutes over the past three years. The reviewed minutes revealed that the agency has not appointed an individual to be responsible for the operation of the QAPI program during the last three years (2023, 2024 & 2025).

It is required that the hospice informs and distributes to the patient written information about its policies on advance directives, including a description of applicable state law. It is the patient’s right to formulate an advance directive should she or he wish to do so. The hospice maintains written policies and procedures concerning advance directives with respect to all adult individuals receiving care by or through the hospice. The hospice provides written information to patients about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives at the individual’s option. The hospice updates and disseminates changes to state law on advance directives no later than 90 days from the effective date. This standard was not met as evidenced by a review of document reviews and interviews. The sample admission packet provided by the agency for review revealed that the agency did not include or provide to the patients and families a copy of their written policies on advance directives. Document 4: Agency policy PC.A35, titled Advance Directives without an effective date stated in part under subtitle Procedure (1) During the admission interview, and prior to receiving care, the hospice Nurse or Social Worker provides written information and instructions on advance directives to the patient. If the patient is unable to understand this information, it is given to the patient's legal healthcare representative or proxy. The written information given to the patient and or legal representative includes (a) The hospice's policies on the implementation of the patient's advance directives including any limitations; and (b) a description of the patient's rights under State law, including the patient's right to formulate an advance directive and the right to accept or refuse medical or surgical treatment, including do no resuscitate (DNR) orders. Document 1: The sample admission packet reviewed contained a patient information handbook and consent forms. The handbook documented on page 20, under the subtitle Advance Directives, provided general information and education on advance directives. For example, it stated in part... "the right to make decisions about own health care...an advance directive is a document created to describe the medical treatment wanted or not wanted to receive...request to provide a copy of any advance directives...and "we will provide health care to you based on your physician orders, and your care will be provided in accordance with our policies and procedures." However, the handbook or admission packet did not contain the agency's policies on advance directives. During an interview with the Director of Clinical Services on 1/18/2023 confirmed the agency's policy on advance directives was not included in the sample admission packet. The sample admission packet provided by the agency for review revealed that the agency did not include or provide to the patients and families a copy of their written policies on advance directives.

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; verbal remedies; and other alternative treatments that could affect drug therapy. 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, interviews and observations. In 2 of 3 (67%) home visits where medication reconciliations were conducted revealed the agency did not have accurate medication profiles compared to the patients medications or profiles. Record 1: The patient, with the election of hospice benefit dated 12/28/2022, had a primary diagnosis of hypertensive heart disease and the patient resided in an assisted living facility. The Hospice Plan of Care (POC) dated 12/28/2022 for the certification period 12/28/2022 through 3/27/2023, documented medication administration by the facility staff. The POC listed the patient's current medications, which included Tums 600 oral tablet, chewable 1-2 tablets every six hours as needed (PRN) for indigestion, and Guaifenesin-Dextromethorphan 100mg-5mg/5mL oral liquid 10mL every 12 hours PRN for cough; and Lidocaine 4% topical film one patch apply once daily to the right knee in the morning and remove at bedtime for knee pain. Home Visit 2: During the home visit (record 1) on 1/17/2023, a medication reconciliation was requested and performed with the ALF med tech by comparing the agency's medication profile with the medications labeled for the patient in the medication drawer. As a result, it was revealed that Colace 100mg was missing from the agency's medication profile. In addition, the medication missing at the facility was Tums 500mg chewable tablets and the Guaifenesin-Dextromethorphan and Lidocaine 4% patches. Record 4: The patient, with the election of hospice benefit dated 1/12/2023, had a primary diagnosis of congestive heart failure and resided in an assisted living facility. The Hospice POC dated 1/12/2023 for certification period 1/12/2023 through 4/11/2023, documented medication administration by the facility staff and an unrelated diagnosis of Type 2 Diabetes Mellitus. In addition, the POC listed the patient's current medications, which included Melatonin 5mg oral tablet at bedtime for insomnia, but no medications for Diabetes. Home Visit 3: During the home visit (record 4) on 1/18/2023, a medication reconciliation was performed by comparing the agency's and facility's medication profiles with the facility nurse. Precisely, Lantus 100U/ML, inject 5 units subcutaneously at bedtime for diabetes type II, was listed on the facility's medication profile but missing from the agency's medication profile. Likewise, Melatonin 5mg oral at bedtime was listed on the agency's medication profile but not on the facility's medication profile. During an interview with the DON on 1/18/2023, after discussing the findings of Home Visit 2 for Record 1, were confirmed regarding med discrepancies.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by a review of document reviews and observations. 1 of 1 (100%) Home visits where a bag was utilized to carry medical equipment, revealed the agency did not adhere to proper bag technique procedures and infection control practices. Home Visit 1: During the home visit on 1/17/2023, it was observed the RN examined the patient, performed hand hygiene, and cleansed reusable equipment, including an electric wrist blood pressure monitor, pulse oximeter, stethoscope, and temporal thermometer, with a Super Sani-Cloth® Germicidal Disposable Wipe. However, the RN wiped the equipment and dropped the equipment directly into the bag without waiting for the proper drying time per the manufacturer's directions of 2 minutes. As a result, the equipment was still wet when dropped into the bag and not disinfected. During an interview with the Director of Nursing and Director of Clinical Services on 1/18/2023 confirmed that the manufacturer's directions and two-minute drying time were not followed during the visit.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; safe handling of soiled items in the patient’s care environment and other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by a review of documents, interviews and observations. In 1 of 3 (33%) Home visits where infection-controlled practices were observed revealed the agency did not ensure to follow agency policy. Document 3: The agency's policy PC.I10 titled Infection Control - Hand Hygiene and Bag Technique with no effective date stated in part under the subtitle Procedure; (1) Use of alcohol-based hand sanitizer is preferred (until dry). If antimicrobial hand soap is used, it must be for a period of at least 15 seconds. (a) Before and after caring for patients, or when coming in contact with inanimate object/equipment in the immediate vicinity of the patient. Home Visit 3: During the home visit on 1/18/2023 with the Chaplain, it was observed that the Chaplain did not perform hand hygiene before, during, or after the visit. The Chaplain played spiritual music for the patient using a small Bluetooth speaker, placed it on the bedside table without a barrier, and did not disinfect the speaker before returning it to its case. During an interview with the Director of Nursing on 1/18/2023 confirmed that infection control practices per the agency's policy were not followed.

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, interviews and observations. In 1 of 7 (14%) records reviewed where the hospice aide services were accepted revealed the agency did not document accurate instructions of the patient's functional status on the hospice aide care plan. Record 1: Patient with an Election of Hospice benefit dated 12/28/2022 accepted and received hospice aide services with a frequency of twice weekly. The Aide Care Plan dated 12/28/2022 had the Safety Measures section blank. The Hospice Plan of Care (POC) dated 12/28/2022 for certification period 12/28/2022 through 3/27/2023, documented Safety Measures (14) as "O2 precautions, slow position change, proper position during meals, use of assistive devices, safety in ADLs, equipment use, keep pathway clear, walker, lock with transfers, fall precautions, standard precautions, support during transfer, patient demonstrates knowledge, caregiver demonstrates knowledge." The Functional Limitations (17A) section documented hearing, dyspnea minimal exertion, weakness, bowel incontinence, fatigue, and decreased endurance," and Activities Permitted (17B) section documented "transfer bed/chair, wheelchair, walker." Home Visit 2: For the home visit with the hospice aide on 1/17/2023, the agency provided the printed Hospice Aide Care Plan dated 12/28/2022. The care plan had the safety measure section blank and documented the assigned task of "Transfer to chair/wheelchair with assistance" at every visit. During the visit, the patient ambulated with a rollator with standby assistance from the hospice aide. However, the functional status instructions on the hospice aide care plan were not clear or accurate. Interview 5: During interview with the Director of Nursing and the Director of Clinical Services on 1/17/2023, confirmed that the functional status documented on the hospice aide care plan was unclear.

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: Discusses the policies and procedures in a language and manner that the patient and family or patient’s legal representative understand; Ensures that the safe use and disposal of controlled drugs is understood. This standard was not met as evidenced by a review of document reviews and interviews. The sample admission packet provided by the agency for review revealed that the agency did not include or provide to the patients and families a copy of their written policies and procedures for managing and disposing of controlled medications. Document 1: The sample admission packet reviewed contained a patient information handbook and consent forms. The handbook documented on page 14 under the subtitle Management and Disposal of Medications and Controlled Substances stated in part the agency would contact the pharmacy regarding the medications prescribed by Physician, the medicines would be delivered to the patient's home or a family member could sign for and pick up at the pharmacy, education would be provided on proper storage and disposal, the hospice staff or volunteers could not remove medications from home or dispose of medicine, but a family member would need to destroy the drugs. The nurse would document its destruction. If the family refuses the disposal, a statement must be signed, and the Physician will be notified. The following section provided education on the proper flushing of specific prescriptions per the FDA website and drug take-back programs. However, it did not include the agency's written policy and procedures for using and disposing of controlled medications. Document 2: The agency policy PC.M60 titled Medication - Use and Disposal of Controlled Substances with no documented effective date, stated in part under the subtitle Procedure, (1) At the time when controlled substances are first ordered, the hospice nurse: (a) provides a copy of the hospice's written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. (b) Discusses the hospice's policies and procedures for managing the safe use and disposal of controlled drugs with the patient or representative and the family in a language and manner that they understand to ensure that these parties are educated regarding the safe use and disposal of controlled drugs; and (c) Documents in the patient's clinical record that the written policies and procedures for the managing-controlled drugs were provided and discussed. (2) Patient/caregiver education regarding the hospice's policies and procedures on controlled substances may be in the form of written educational information on the safe use and disposal of controlled substances. (3) All education/information provided to the patient/caregiver related to controlled substances is documented in the patient's clinical record, (4) The RN Case Manager or designee identifies and documents any misuse of controlled substances and notifies the attending Hospice Physician, the Pharmacist and the Director of Clinical Services for further investigation. (5) An incident report is completed for suspected or actual diversion of controlled substances, and the IDG, in consultation with the Hospice Physician, the patient's attending Physician, and the Pharmacist, determines the appropriate course of action, including reporting the diversion to appropriate authorities. During interview on 1/18/2023 with the Director of Clinical Services, confirmed the agency's written policy was not included in the admission packet. The sample admission packet provided by the agency for review revealed that the agency did not include or provide to the patients and families a copy of their written policies and procedures for managing and disposing of controlled medications.