Every finding on record at Alliance Hospice and Palliative Care, Inc

Based on record review and interview, the hospice failed to document the change in the patient’s condition in the patient’s clinical record for one of three sampled patients (Patient 1). This failure had the potential to compromise the integrity of the clinical record which could negatively impact the continuity of care and informed decision-making by the interdisciplinary team. --- Review of the hospice’s P&P titled Notification of Changes in Care revised November 2020 showed documentation of the notification will include date/time of notification, specific changes in the plan of care, and patient response and/or acceptance.Review of Patient 1’s clinical record was initiated on 1/21/26.  The clinical record showed the SOC was 9/30/25.  The patient was certified for hospice services during the certification period from 9/30/25 to 11/28/25. Review of the short-form visit note dated 10/9/25, for an as-needed visit, showed the caregiver reported the patient had shortness of breath and was unable to eat or drink fluids. Review of the electronic mail dated 10/9/25, from LVN 1 to the interdisciplinary group, showed the patient was awake and surrounded by family, appeared weak and tired, had poor oral intake, facial swelling, and swelling in both hands. Documentation showed there were no signs or symptoms of pain and the current pain medication was effective.On 1/22/26 at 1600 hours, an interview and concurrent clinical record review was conducted with the Administrator. The Administrator stated the nurse had updated the change of condition to the interdisciplinary group by electronic mail; however, there was no documentation in the clinical record. The Administrator further stated the nurse should have documented the patient’s change of condition in the clinical record. The Administrator was informed and verified of the above findings.

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: signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review and interview. 8 of 11 (72%) clinical records reviewed revealed the hospice did not ensure the notification of hospice non-covered items were provided to the patient within 5 days of the request upon admission. Record #51015: SOC 12/9/2021. The hospice election statement was reviewed and identified the daughter requested the addendum on 12/9/2021. The notification of hospice non-covered items was completed and sent to the daughter on 12/15/21, which was 6 days after the hospice election date. Record #26292: SOC 10/21/2021. The hospice election statement was reviewed and identified the son requested the addendum on 10/21/2021. The notification of hospice non-covered items was completed and sent to the son on 10/29/2021, which was 8 days after the hospice election date. Record #21445: SOC 2/10/2022. The hospice election statement was reviewed and identified the patient requested the addendum on 2/9/2022. The notification of hospice non-covered items was completed and sent to the patient on 2/23/2022, which was 13 days after the hospice election. Record #98397: SOC 11/4/2021. The hospice election statement was reviewed and identified the daughter requested the addendum on 11/3/2021. The notification of hospice non-covered items was completed and sent to the daughter on 11/18/2021, which was 14 days after the hospice election. Record #65273: SOC 1/20/2022. The hospice election statement was reviewed and identified the spouse requested the addendum on 1/20/2022. The notification of hospice non-covered items was completed and sent on 1/27/2022, which was 7 days after the hospice election. Record #80503: SOC 11/3/2021. The hospice election statement was reviewed and identified the spouse requested the addendum on 11/1/2021. The notification of hospice non-covered items was completed and sent on 11/18/2021, which was 15 days after the hospice election. Record #36018: SOC 2/15/2022. The hospice election statement was reviewed and identified the son requested the addendum on 2/15/2022. The notification of hospice non-covered items was completed and sent to the son on 2/23/2022, which was 8 days after the hospice election. Record #51204: SOC 3/9/2021. The hospice election statement was reviewed and identified the daughter requested the addendum on 3/9/2021. The notification of hospice non-covered items was completed and sent to the daughter on 3/19/2021, which was 10 days after the hospice election. The Administrator Designee was interviewed on 6/30/2022 and stated, “We need to update our process to get them out within the required time.”