Every finding on record at Alliance Hospice LLC

Upon patient record review, 3 of 14 (Patient #2,5,8) 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 2: Polyethylene glycol 3350 on the active medication profile does not have instructions on how to dilute. COS - Order written to included instructions on how to dilute. Patient 5: The RN documentation indicated that the patient is using oxygen at 2LNC. No evidence on medication profile for the oxygen at 2LNC. The current medication profile is for oxygen 4LNC. COS - New order written to update during survey. Patient 8: The RN documentation indicated that the patient is titrating oxygen at 4LNC, 4.5LNC, and 6LNC. No evidence on medication profile for the oxygen by titrated. The current medication profile is for oxygen is 5LNC. COS - New order written to update during survey.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 1: No evidence that a comprehensive assessment was completed every 15 days between the following dates: 12/20/2024 and 01/07/2025, 25 days between assessments, and 02/17/2025-03/07/2025, 18 days between assessments.

Upon patient record review, 2 of 14 (Patient #7,9) 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 7: The record indicates that patient developed a wound to the right buttock on 06/24/2025. No evidence that the wound was measured for the weeks of 07/07/2025 and 07/21/2025. Agency policy is for wounds to be measured weekly. Patient 9: The record indicates that patient was admitted with a wound to the sacrum. No evidence that the wound was measured for the weeks of 06/16/2025, 07/07/2025, and 07/21/2025. Agency policy is for wounds to be measured weekly.

Upon patient record review, 1 of 14 (Patient #2) 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 2: The medical record indicated that the patient was admitted with a foley catheter and takes Enoxaparin injections as a blood thinner for history of pulmonary embolus. No evidence of problems, goals, and interventions related to risk for bleeding, Genito/urinary system, or risk for infection due foley catheter included in the plan of care. The medical record indicated that the patient was admitted with a foley catheter.

Upon patient record review, 4 of 14 (Patient #2,5,7,8) 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 2: Plan of care has an active order for Polyethene glycol that does not have instructions on how to dilute. The record indicated the patient was admitted with indwelling Foley catheter. No evidence of related orders for the care and management of the Foley catheter. COS- New order written add instruction of how to dilute polyethene glycol and for foley catheter management. Patient 5: The RN documentation indicated that the patient is using oxygen at 2LNC. No evidence that an order was received for the oxygen at 2LNC. The current order is for oxygen 4LNC. COS-New order written for oxygen titration order during survey.The medical records indicated that patient had a foley catheter at the time of admit. No evidence that an order was received to identify who was responsible for performing care/maintenance of the foley catheter, hospice staff or facility staff. COS -New physician order to identify who was responsible for performing care/maintenance of the foley catheter during survey. Patient 7: The medical record indicated that the patient had wounds to the left and right buttocks. No evidence that an order was received for wound care to be provided to those wounds and frequency for the wound care to be provided. Patient 8: The RN documentation indicated that the patient is titrating oxygen at 4LNC, 4.5LNC, and 6LNC. No evidence that an order was received for the oxygen by titrated. The current order is for oxygen 5LNC. New order written to update during survey.

Upon patient record review, 3 of 14 (Patient #1,3,4) 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 1: The clinical documentation indicated that the patient uses a rolling walker to help with altered mobility. No evidence that a rolling walker was included on the current DME list. COS - order written to add rolling walker to the current DME list. Patient 3: No evidence that supplies related to foley catheter insertion or maintenance was included in the current supply list. COS - order written to add foley catheter to the current supply list. Patient 4: The medical record indicated that the patient uses a walker for help with altered mobility. No evidence that a walker was included on the current DME list. COS - order written to add walker to the current DME list.

Upon patient record review 1 of 14 (Patient #10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 10: The initial social worker evaluation performed on 06/02/2025 indicated that the patient agreed with a plan of care that included "one visit a month and PRN visits" There was no evidence of a follow-up or any additional scheduled visits by the social work provider. No evidence that patient/CG declined further visits.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The aide POC has active DNR precautions. The medical record indicated that the patient's current code status is full code. COS - Aide plan of care undated to remove DNR precautions.

Upon patient record review 3 of 14 (Patient #4,7,9) 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 4: No evidence that the RN completed a supervisory visit every 14 days. The record indicated that an aide supervisory visit was conducted on 07/03/2025 and not completed again until the start of survey. Patient 7: No evidence that the RN completed a supervisory visit every 14 days. The record indicated that an aide supervisory visit was conducted on 06/17/2026 and not completed again until 07/08/2025. Patient 9: No evidence that the RN completed a supervisory visit every 14 days between the following dates: 05/20/2025 and 06/04/2025 (15 days), and 07/01/2025 and 07/30/2025 (29 days).

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 1.71%.

Upon patient client record review, 1 of 14 (Patient #5) 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 5: RN documentation stated that the patient admission diagnosis was cerebral infarction. The medical director stated in the CTI that the patients admit diagnosis was Chronic subdural hematoma.

Upon client record review, 1 of 14 (Patient #2) 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 2: The medical records indicated that patient had a foley catheter at the time of admit and a wound to the sacrum. No evidence that an order was received to identify who was responsible for performing wound care, the hospice staff or facility staff. No evidence that the order received from the physician for the foley catheter included the size, change frequency, and who was responsible for performing care/maintenance of the foley catheter, hospice staff or facility staff. COS -New physician order both the foley catheter and wound care received during survey.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by a review of clinical records and interviews. 5 of 8 (62%) clinical records reviewed revealed the hospice did not ensure that hospice aides reported changes related to the plan of care. THIS IS A CONTINUED REQUIRED ACTION Record 1: The clinical record was reviewed and identified that the patient elected the hospice benefit on 7/29/2022. The aide assignment initiated by the Registered Nurse (RN) on 7/29/2022 assigned the aide to complete a bed bath every visit; change bed linens weekly and when soiled; shampoo on Monday. The hospice aide documented that the patient refused a bed bath on 2/10/2023. There was no documented communication with the hospice RN that the assigned task was not completed as assigned in the Plan of Care (POC). Record 2: The clinical record was reviewed and identified that the patient elected the hospice benefit on 1/18/2023. The aide assignment initiated by the RN on 1/18/2023 assigned the aide to shampoo at each visit. The Hospice Aide documented on 1/25/2023 and 1/27/2023 that the caregiver refused the shampoo. There was no documented communication with the hospice RN that the assigned task was not completed as assigned in the POC. Record 4:The clinical record was reviewed and identified that the patient elected the hospice benefit on 11/4/2022. The aide assignment initiated by the RN on 11/4/2022 assigned the aide to provide mouth care using Mouth Swabs every visit, shampoo each visit and turn and reposition the patient at each visit. The Hospice Aide documented on 1/23/2023 the patient refused shampoo and turn and reposition; 1/25/2023 and 1/27/2023 the patient refused shampoo and 2/8/2023 the patient refused oral care and shampoo. There was no documented communication with the hospice RN that the assigned tasks were not completed as assigned in the POC. Record 5: The clinical record was reviewed and identified that the patient elected the hospice benefit on 1/21/2023. The aide assignment initiated by the RN on 1/21/2023 assigned the aide to: Apply lotion every visit after bathing and notify Hospice RN if skin tears, bruises or reddened skin is present; Assist with dressing/undressing every visit; Change bed linens weekly and when soiled; Provide perineal care every visit; shampoo three times per week; shower each visit. The Hospice Aide documented on 1/26/2023 that the caregiver completed all items of care prior to visit. There was no documented communication with the hospice RN that the assigned task was not completed as assigned in the plan of care. Record 6: The clinical record was reviewed and identified that the patient elected the hospice benefit on 8/22/2022. The aide assignment initiated by the RN on 8/22/2022 assigned the aide to: Apply lotion every visit after bathing and notify Hospice RN if skin tears, bruises or reddened skin is present; Assist with dressing/undressing every visit; Provide perineal care every visit; shave each visit; shampoo at each visit. The Hospice Aide documented on 8/29/2022 that the caregiver completed the following items prior to visit: Assist with dressing/undressing every visit; Provide perineal care every visit; shampoo at each visit. The Hospice Aide documented on 8/31/2022 that the caregiver completed all items of care plan prior to visit. There was no documented communication with the hospice RN that the assigned task was not completed as assigned in the POC. During an interview with the Executive Director on 2/14/2023, it was agreed that the hospice aides reporting changes in the plan of care remains an ongoing problem. She stated that a new Performance Improvement Plan was initiated on 2/1/2023. THIS IS A CONTINUED REQUIRED ACTION

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical records and interview. 3 of 9 (33%) clinical records reviewed revealed the hospice did not ensure the initial spiritual assesments were completed within 5 calendar days after the election of hospice benefit. Record #12186 was reviewed and identified the patient elected hospice care on 01/15/2021. No documented evidence of an initial assessment within 5 days of the patient's election of hospice and my review period 01/15/2021 to 02/13/2021. There was no documented explanation in the clinical notes the reason for the delay. Record #41486 was reviewed and identified the patient elected hospice care on 04/13/2022. No documented evidence of an initial assessment by the chaplain within 5 days and within my review period 04/13/2022 to 04/19/2022. There was no documented explanation in the clinical notes the reason for the delay. Record #37152 was reviewed and identified the patient elected hospice care on 02/25/2022. No documented evidence of an initial assessment by the chaplain until 03/08/2022 11 days after the election of hospice. There was no documented explanation in the clinical notes the reason for the delay. The Director was interviewed on 04/19/2022 and she agreed that the initial assessments initial assessment were not completed within 5 days of the patient's election of Hospice benefit. There was no documented explanation in the clinical notes the reason for the delay. She had no additional information to provide.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plans frequently as the patient's condition requires; but no less frequently than every 15 calendar days. A revised plan of care include information from the patient’s updated comprehensive assessment. Record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview, 2 of 12 (17%) clinical records reviewed revealed that there was no documentation that the POC was reviewed/updated at a minimum every 15 days. The IDG meeting document form was blank. Record # 12186 was reviewed and identified that the patient elected hospice benefit on 01/15/2021. There was no documentation in the clinical record of IDG review of the updated comprehensive assessment or any record of the patient's progress towards the outcomes and goals that were specified in the plan of care. The IDG meeting document was blank. Record # 21590 was reviewed and identified that the patient elected hospice benefit on 10/01/2019. There was no documentation in the clinical record of IDG review of the updated comprehensive assessment or any record of the patient's progress towards the outcomes and goals that were specified in the plan of care. The IDG meeting document was blank. The Director was interviewed on 04/19/2022 and she agreed that there was no documented evidence that the clinical records were reviewed at least every 15 days and no updated comprehensive assessment or any record of the patient's progress toward goals and outcomes were documented. She was able to provide the documentation from the IDG meetings however, the clinical records did not contain notes of the review that occurred during the IDG meeting. She had no additional information to provide.

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 clinical record review and interview. 3 of 6 (50%) records in which hospice a hospice aide was accepted revealed a lack of clear and updated specific instructions for the aide assignment, thus leaving the hospice aide to make decisions outside of the aide's scope of practice. Record # 12186 was reviewed and identified the patient elected hospice care on 01/15/2021 with a diagnosis of Congestive Heart Failure. The Hospice aide assignments initiated by the RN on 01/19/2021 assigned the aide to " shave patient, provide nail care and change brief every visit and prn." There was no documented evidence that described criteria that was to be used by the hospice aide to determine the type of frequency of the assigned prn tasks the patinet was to receive. Record # 21590 was reviewed and identified the patient elected hospice care on10/01/2019 with a diagnosis of heart disease. The hospice aide assignment initiated by the RN assigned the aide to "make patient's bed, change linen and tidy room as needed." No documented evidence to confirm that described the criteria to be used to determine as needed tasks. There was no documented evidence that described criteria that was to be used by the hospice aide to determine the type of frequency of the assigned prn tasks the patient was to receive. Record # 89770 was reviewed and identified the patient elected hospice care on 11/10/2021 with a diagnosis of senile degeneration of the brain. The aide POC dated 11/15/2021 assigned the aide to "shampoo and brush hair, shower and apply lotion every visit and PRN." Per ongoing skilled nursing assessments and POC updates, the patient was unable to make their needs known due to being oriented only to person (self). There was no documented evidence that described criteria that was to be used by the hospice aide to determine the type of frequency of the assigned prn tasks the patient was to receive. In addition, there was no documentation to confirm that the patient could demonstrate their capacity to safely determine the need for a shower. The Director was interviewed on 04/19/2022 and she agreed that the aide POC lacked specific instructions for care. She had no additional information to provide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and is consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. 4 of 6 (67%) applicable records revealed the aide services provided were inconsistent with the Interdisciplinary Group orders and the plan of care. The frequency of the aide visits provided did not match the care plan. Record # 12186 was reviewed and identified the patient elected hospice care on 01/15/2021 diagnosis CHF. The aide plan of care initiated on 01/19/2021 assigned the aide to visit the patient 5 times a week to provide care. There was a missed visit the week of 01/17/2021, 4 visits completed. There was no documentation in the clinical record that described why the hospice aide visit was missed. Record # 29908 was reviewed and identified the patient elected hospice care on 01/15/2021 diagnosis included CHF. The hospice aide plan of care initiated on 02/21/2021 assigned the aide to provide "shampoo 2 times a week." The orders for the aide visit frequency were written as 5 times a week. The aide documented the weeks of 02/21/2021, 02/27/2021, and 03/06/2021 that shampoo was completed 5 times a week. There was no documentation in the clinical record that described the reason an additional shampoo was provided. Record # 21590 was reviewed and identified the patient elected hospice care on 10/01/2019 diagnosis included heart disease. The hospice aide plan of care initiated by the RN assigned the aide frequency 5 times a week. There were 4 missed visits the week of 10/01/2019, 1 missed visit the week of 10/06/2019, 2 missed visits the week of 10/13/2019, 3 missed visits the week of 10/20/2019, and 2 missed visits the week 0f 10/27/2019. There was no documented evidence in the clinical record that described why the hospice aide visits were missed. Record # 89770 was reviewed and identified the patient elected hospice care on 11/10/2021 diagnosis included Senile Degeneration of the Brain. The aide plan of care initiated on 11/15/2021 assigned the aide to visit patient 2 times a week to provide care. There was 1 missed visit the week of 11/21/2021. There was no documented evidence in the clinical record that described the reason the hospice aide visit was missed. The Director was interviewed on 04/19/2022 and she agreed that the aide did not follow the POC as ordered by the interdisciplinary group. She had no additional information to provide.

It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. 4 of 6 (67%) records of patients receiving hospice aide visits revealed the hospice did not ensure hospice aides reported patient changes related to the plan of care. Record # 12186 was reviewed and identified the patient elected hospice care on 01/15/2021 diagnosis CHF. The aide assignment initiated by the RN on 01/19/2021 assigned the aide visit frequency 5 times a week. There was a missed visit the week of 01/17/2021. The record lacked evidence that the RN was notified of the hospice aide missed visit. Record # 29908 was reviewed and identified the patient elected hospice care on 01/15/2021 diagnosis included CHF. The aide assignment initiated by the RN on 02/21/2021 assigned the aide to shampoo the patient's hair 2 times a week. The visit frequency for the aide was 5 times a week. The Hospice Aide documented the week of 02/21/2021, 02/27/2021, 03/06/2021 that shampoo was completed 5 times a week. There was no documented communication with the hospice RN as to why the assigned tasks were not performed or changed from the original order. Record # 21590 was reviewed and identified the patient elected hospice care on 10/01/2019 diagnosis included heart disease. The aide assignment initiated by the RN assigned the visit frequency for the aide was 5 times a week. There were 4 missed visits the week of 10/01/2019, 1 missed visit the week of 10/06/2019, 2 missed visit the week of 10/13/2019, 3 missed visits the week of 10/20/2019, and 2 missed visits the week 0f 10/27/2019. The record lacked evidence that the Hospice Aide notified the RN of the hospice aide missed visits. Record # 89770 was reviewed and identified the patient elected hospice care on 11/10/2021 diagnosis included Senile Degeneration of the Brain. The aide plan of care initiated on 11/15/2021 assigned the aide to visit patient 2 times a week. There was a missed visit the week of 11/21/2021. The record lacked evidence that the Hospice Aide notified the RN of the hospice aide missed visits. The Director was interviewed on 04/19/2022 and she agreed that the aide did not follow the POC initiated by the RN and did not inform the RN of the missed visits and the tasks not completed. She had no additional information to provide.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid/MediCal-certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. 1 out of 1(100%) applicable record revealed th hospice did not ensure a patient transferred to another Medicare certified facility was sent a transfer/discharge summary. Record # 92876 was reviewed and identified that the patient revoked hospice services on 03/02/2022 to seek aggressive treatment. Documentation that the patient's medication list, history and physical and discharge summary had not been forwarded to the receiving facility. There was a discharge summary completed. However, the record lacked documentation that the transfer/discharge summary was sent to the receiving facility for continuity of care. The Director was interviewed on 04/19/2022 and she agreed that the record lacked the required documentation of the transfer/discharge summary being sent to the receiving facility. She had no additional information to provide.