Every finding on record at Alliance Health Services, Inc

Upon patient record review, 1 of 25 (Patient #15) did not have evidence of the appropriate documentation for release of confidential information. Patient 15: The patient record does not contain consent for release of confidential information. Updated on site.

Upon patient record review 1 of 25 (Patient #3) 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 03: Th patient was admitted on 04/09/20. The Spiritual care assessment was performed on 04/15/23

Upon patient record review, 5 of 25 (Patient #04,05,06,11,15) 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 04: The medication profile does not include Elecare enteral feedings, order date 9/28/21. This was updated on site. Patient 05: The medication profile includes orders for Hydromorphone IV every 2 hours prn severe pain, Syrex IV every hour prn flush, and Posiflush IV every 12 hours. The infusion therapy problem statement and goals was resolved on 11/17/23. There was no MD order to discontinue. Updated on site. Patient 06::The medication profile includes orders that were initiated on 08/23/23, assess the Right hand PIV, flush peripheral IV with NS. The infusion therapy problem statement and goals was resolved on 08/27/23. There is no MD order to discontinue. Updated on site. Patient 11: The medication profile includes Nystatin powder 100,000 units/gram, apply 1 application topically 4 times a day as needed to affected area, initiated on 11/9/23. The profile does not indicate the application site or the indication for PRN application. Patient 15: Upon admission, the patient record indicates that the patient receives nourishment via peg tub with Complete Pediatic 1.0 480ml over 1 hour x 4 daily, the medication profile does not include the enteral feedings for the patient. Orders were received on 9/8/23 to change to infuse 342ml over 1 hour 4 times a day, this in not included in the medication profile. Updated on site.

Upon patient record review, 4 of 25 (Patient #03,04,24,25) 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 03: Admission date of 04/09/20, the initial bereavement assessment has not been completed to date. Patient 04: Admission date of 09/09/2019, the initial bereavement assessment has not been completed to date. Patient 24: Admission date of 02/04/23, the initial bereavement assessment has not been completed to date. Patient 25: Admission date of 09/05/23, the initial bereavement assessment has not been completed to date.

Upon patient record review, 4 of 25 (Patient #2,15,16,19) 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 02: Upon admission on 1/17/23, patient was admitted with secondary conditions of dysphagia, severe protein-calorie malnutrition and a BMI of less than 19.9. The plan of care does not include a problem statement to address interventions and goals for nutrition. Patient 15: Upon admit on 7/6/23, the bereavement risk assessment is considered to be "moderate." The plan of care does not include interventions and goals to address the anticipated grief of the mother or family members. It was identified at the time of admission that the patient has dysphagia and uses a feeding tube but is allowed to have 1 soft meal per day, the plan of care does not include a nutritional plan of care with interventions and goals to address aspiration risks. Patient 16: The patient was admitted on 10/17/23, his medication profile includes Eliquis 5mg PO BID, the plan of care does not include bleeding precautions. Patient 19: Upon admit on 5/1/23, the initial comprehensive assessment indicates that the patient has dysphagia, failure to thrive and a weight loss of 50lbs. The plan of care does not include a problem statement with interventions and goals for the nutritional management or aspiration risks.

Upon patient record review, 1 of 25 (Patient #09) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 09: The plan of care for includes orders the MSW visits 4 times per month with 7 prn for support and companionship effective 10/11/23,an excessive PRN amount.

Upon patient record review, 5 of 25 (Patient #02,05,06,07,11) 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 02: The wound care order was received on 11/28/23 for the right outer hip, the initial order for wound care on 8/22/23 has not been discontinued. Patient 05:The patient's infusion therapy was discontinued on 11/17/23.The medication orders from 11/13/23 include Hydromorphone IV every 2 hours prn severe pain, Syrex IV every hour prn flush, and Posiflush IV every 12 hours has not been discontinued. Updated on site. In addition, the patient was admitted on 11/13/23, his admit orders are written to admit to GIP, RHC and respite on the same date. Patient 06: The patient's infusion therapy was discontinued on 8/27/23. The medication orders include NS IV flush 2cc before and 10cc after medication administration. Updated on site. In addition, the patient was admitted on 8/24/23, his admit orders are written to admit to GIP, RHC and respite on the same date. Patient 07: The patient records includes wound care orders on 12/1/23 for multiple wounds with instructions to perform wound care "at each shift and prn when soiled." The patient services are received at home and the patient does not receive wound care "per shifts." Patient 11 : Medication order initiated on 11/9/23 for Nystatin powder 100,000 units/gram, apply 1 application topically 4 times a day as needed to affected area, does not include an application site or and indication for prn use. Updated on site.

Upon patient record review, 3 of 25 (Patient #01,02,05) 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 01: The plan of care initiated on 11/21/23 does not include incontinent supplies. Updated on site. Patient 02: The plan of care initiated on 11/13/23 does not include wound care supplies including gauze, bordered dressing and calcium alginate with silver per wound care orders reconciled with the facility orders. Updated on site. Patient 05: The plan of care initiated on 11/13/23 does not include incontinent supplies and foam dressings per the wound care orders. Updated on site.

Upon patient record review, 3 of 25 (Patient #03,15,18) 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 03: Spiritual care counselor was declined effective 11/01/22, spiritual problem statement remains in the Plan of care. The plan of care includes a problem statement and treatment orders for a skin tear received on 5/2/23, the patient no longer has a skin tear and the treatment order has not been discontinued .The plan of care includes a problem statement and treatment orders for a skin tear right elbow received on 8/3/23, the patient no longer has a skin tear and the treatment order has not been discontinued. The plan of care includes a problem statement and treatment orders for a laceration right eyebrow received on 8/3/23, the patient no longer has a skin tear and the treatment order has not been discontinued Patient 15: The patient record indicates that on 11/8/23, the patient suffered an ankle fracture, the plan of care was not updated to include a problem statement with interventions and goals for the management of the fracture. Patient 18: Order for Nystatin oral suspension ordered for thrush on 11/27/23. There is no problem statement, interventions, or goals for the patient.

Upon client record review, 7 of 25 (Patient #02,04,05,06,07,17,20) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 02:The patient was seen by MSW on 11/22/23 and 11/29/23 utilizing PRN orders, The patient was also seen on routine visits on 11/17/23 and 11/21/23 with no evidence of psychosocial needs. The PRN orders are indicated for psychosocial support due to terminal illness. Document on 11/29/23 by the MSW indicated the visit was a routine visit. Patient 04: RN frequency order 10/22/23, 1 time a week for 8 weeks, routine visits by an RN occurred 11/21/23, 11/22/23, 11/25/23. Patient 05: The frequency order for nursing services ended 11/25/23. There was a follow up nursing visit completed 11/30/23, there is no nursing frequency in the record. Patient 06: Certification period 11/21/23-12/18/23, the record does not include frequency orders for Nursing however, visits were being made by nurse. Patient 07: There is evidence in the patient record on 12/2/23 that the visiting RN performed wound care to the right elbow with no treatment orders for wound care. Patient 17: Patient was admitted 12/02/23, there is no frequency orders for nursing however, visits were being made by nurse. Patient 20: The plan of care does not include frequency orders for skilled nursing visits however, visits were being made by nurse.

Upon patient record review, 1 of 25 (Patient #15) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient 15: There is evidence in the patient record that the patient receives private duty nursing care 7 days a week at night, there is no evidence in the record of shared information with the private duty nursing services. The updated comprehensive assessment on 8/13/23 indicates that the patient was hospitalized, the plan of care does not include interventions and goals for the coordination of care with the hospital. The patient was also admitted on 11/6/23, the plan of care was not updated to include the coordination of care with the hospital.

Upon patient record review, 3 of 25 (Patient #23,24,25) 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 23-25:There is no evidence of a post death bereavement assessment completed.

Upon patient record review, 7 of 25 (Patient #01,02,03,09,10,11,16) 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 01: The hospice aide task assignment for incontinent care, linen change and bathing do not include frequency of tasks. Updated on site. Patient 02: The hospice aide task assignment for perineal care, bathing, oral care, shampoo, and incontinent care do not include frequency of tasks. Updated on site. Patient 03: The hospice aide task assignment for bathing, and soaking patient's feet do not include the frequency of tasks. Updated on site. Patient 09: The hospice aide task assignment for bathing, changing linen and providing incontinent care does not include a frequency for the tasks. Updated on site. Patient 10: The hospice aide task assignment for bathing, changing linen, incontinent, care and dressing does not include a frequency for the tasks. Updated on site. Patient 11: The hospice aide task assignment for bathing, shampooing, skin care, linen change and incontinent care does not include a frequency to perform the tasks. Updated on site. Patient 16: Hospice aide service orders were initiated on 12/4/23, there is no hospice aide assignment of duties in the patient record.

Upon patient record review 5 of 25 (Patient #05,06,17,19,20) 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 05:Hospice aide services began on 11/15/23, patient is being seen 2 times per day for ADLs, the patient receives RHC services as a resident at the hospice facility. There are no order for aide services in the plan of care. Patient 06: Certification period 11/21/23-12/18/23, the record does not include frequency orders Hospice Aid services however, visits were being made by aide. Patient 17: Hospice Aide services began on 12/02/23 there in no order in the record for Hospice Aide services. Patient 19: Hospice aide services are ordered for 2x week for 13 weeks initiated on 5/1/23, the record indicates that the patient received 1 HHA visits for week 1 (missed visit on 5/5/23) and 1 on week 3 (missed visit on 5/19/23.) Patient 20: The patient was admitted on 7/6/23 and received Hospice Aide services starting on 7/6/23 through 7/31/23, there are no orders for Hospice Aide services.

Upon patient record review 2 of 25 (Patient #09,20) 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 09: There is no evidence in the patient record that a supervisory visit was performed between 11/7/23 and 11/27/23. Patient 20: The patient was admitted on 7/6/23 and began hospice aide services on that date. There was no evidence of a supervisory visit performed on the aide services until 7/29/23

Upon patient client record review, 1 of 25 (Patient #3) did not have evidence that each patient record contains Advance Directives. Patient 03: The record does not contain the Advanced Directive documents.

Upon patient record review, 1 of 25 (Patient #02) did not have evidence that the hospice provided the following information: • The most recent hospice plan of care specific to each patient • Hospice election form and any Advance Directives specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient • Instructions on how to access the hospice's 24-hour on-call system • Hospice medication information specific to each patient • Hospice physician and attending physician (if any) orders specific to each patient Patient 02: There was no evidence in the SNF records that the Certification of terminal illness was provided for benefit periods starting on 01/17/23, 04/17/23, 07/16/23, 09/14/23, and 11/13/23. Updated on site.