Every finding on record at Alliant Palliative Care and Hospice Co LLC

Upon patient record review, 5 of 14 (Patient #1,2,4,5,7) 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: There is evidence in the medical record on the initial nursing comprehensive assessment, the patient has a small open ulcer on the RLE. No care plan with problem/interventions/goals was opened for wound. Patient #2: There is evidence in the medical record on the initial nursing comprehensive assessment, the patient has stage 1 pressure ulcer on coccyx. No care plan with problem/interventions/goals was opened for skin integrity. (Corrected on site by adding skin integrity to the Plan of Care.) Patient #4: There is evidence in the medical record on the initial nursing comprehensive assessment identified patient with a "couple of falls prior to admission with most recent last week with cut over left eye brow". No care plan with problem/interventions/goals was opened for fall risk. (Corrected on site by adding fall risk to the Plan of Care.) Patient #5: There is evidence in the medical record on the initial nursing comprehensive assessment stating the patient had "no desire to eat", and primary diagnosis protein calorie malnutrition. No care plan with problem/interventions/goals was opened for nutrition. (Corrected on site by adding nutrition to the Plan of Care.) Patient #7: There is evidence in the medical record on the Medical Director certification of terminal illness stating the patient had "20 lb. weight loss in the past several months, patient eats 25% of meals". No care plan with problem/interventions/goals was opened for nutrition. (Corrected on site by adding nutrition to the Plan of Care.)

Upon patient record review, 2 of 14 (Patient #1,9) 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 #1: There is evidence on the medical record initial nursing comprehensive assessment, the patient had a wound on RLE with a description of the treatment being provided prior to admission, to clean wound with cleanser, apply Medi honey and foam dressing. There was not an order for the wound treatment. Patient #9: There is evidence in the medical record on 3/13/25 an order "clean wound with wound cleanser and apply bandage". The order did not contain wound location, what bandage, frequency or who would change the bandage.

Upon patient record review, 3 of 14 (Patient #4,8,9) 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 #4: There is evidence in the medical record of a nursing recertification note stating "weight loss since admission" and physician recertification of terminal illness indicates MAC decrease 27 cm to 26 cm. There is no Problem/Interventions/Goals added for nutrition. (Corrected on site by adding nutrition to the plan of care.) Patient #8: There is evidence in the medical record of nursing assessment for recertification identifying "weight loss in past month", also diet changed to pureed with difficulty chewing. There is no problem/interventions/goals added for nutrition. (Corrected on site by adding nutrition to the plan of care.) Patient #9: There is evidence in the medical record of a new wound identified on 3/13/25 with no problem/interventions/goals added for the wound.

Upon patient record review, 2 of 14 (Patient #4,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: There is evidence in the medical of an order 2/27/25 for MSW frequency 1XM and 1 PRN for emotional support. In the month of March MSW visited 1X (3/14/25) and 2 PRN (3/21/25 and 3/27/25). Patient #10: There is evidence in the medical of an order 4/21/25 for MSW frequency 1XM and 1 PRN for emotional support. In the month of May MSW visited 1X (5/21/25) and 2 PRN (5/19/25 and 5/27/25).

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. QAPI plan was not available to the surveyor.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by understanding how they affect palliative outcomes, patient safety and quality of care.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. QAPI plan was not available to the surveyor.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence in QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the hospice's Quality Assessment and Performance Improvement program. QAPI reports were not available to surveyor.

Upon patient record review, 2 of 14 (Patient #3,7) 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 #3: There is evidence on the aide POC of the task "partial bath/shower" every visit. The aide POC must specify one task for the aide. Patient #7: There is evidence in the medical record the patients diagnosis "convulsions unspecified". Seizure precautions was not on the aide POC. (Corrected on site by adding seizure precautions to Aide POC.)

Upon patient record review 1 of 14 (Patient #8) 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 #8: There is evidence in the medical record of an order 3/17/25, aide 3Xwk. During the week of 4/13/25 the aide visited 4X week and the week of 4/21/24 the aide visited 5X week.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #2: The medical record does not contain an appropriately completed initial certification of terminal illness. The patient's choice of attending physician did not provide an oral/written certification of terminal illness, only the hospice Medical Director completed the certification of terminal illness.

Upon patient record review, 2 of 14 (Patient #1,2) 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 #1: There is evidence in the medical record the election statement did not have a legible, appropriately authenticated nurse's signature. Patient #2: There is evidence in the medical record the election statement did not have a legible, appropriately authenticated nurse's signature.

Upon patient record review 6 of 10 applicable (Patients #1, 3, 4, 5, 8, 11) 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 Shampoo order weekly. Shampoo provided July 6, 8, 9, 19, 20, 22, 23, 25, 27. Nail care was not assigned but was provided July 6, 7, 8, 11. Patient 3 Shampoo, nail care, linen change assigned weekly. Shampoo provided July 5, 8, 11, 15. Nail care provided July 5, 6, 11, 13, 15, 18, 20, 22, 25, 27. Linens changed July 13, 15, 18, 20, 22. Patient 4 Shampoo, foot care and nail care assigned weekly. Shampoo provided July 20, 22, 25, 26. Foot care provided July 20, 21, 22, 25, 26, 27. Nail Care provided July 20, 21, 22, 25, 26, 26. Patient 5 Shampoo assigned every other visit. Shampoo provided subsequent visits May 23, 26, 30. Patient 8 Shampoo assigned weekly. Shampoo provided May 10, 13, 16. Patient 11 Shampoo assigned weekly. Shampoo provided May 10, 13.

Upon patient record review, 1 of 7 applicable (Patient #4) 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 #4 - Aide plan of care comments 3/4/22 - skin care, shampoo, lotion, assist to dress, incontinence care prn. (Corrected on site)

Upon personnel record review, 1 of 8 applicable (Personnel #4) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4 - No evidence of competency completion documentation in HR file for RN during orientation. Self assessment completed only.

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

Upon patient record review 1 of 11 (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. Pt #3 - Pt admitted to services 11/6/21. Psychosocial assessment completed on 11/12/21.

Upon patient record review 2 of 11 (Patient #6, 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. Pt #6 - Pt admitted to services 10/8/21. No evidence of a spiritual assessment Pt #10 - Pt was admitted 5/27/21 No evidence of a spiritual assessment.

Upon patient record review, 3 of 11 (Patient #3, 6, 10) 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. Pt #3, 6, 10 - Record contained information that the patient was on oxygen. Oxygen was not listed on the medication profile.

Upon patient record review, 1 of 11 (Patient #2) 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. Pt 2 - The patient was admitted on 10/18/21. The bereavement risk assessment was completed 10/28/21.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 2 of 11 (Patient #2, 3) 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. Pt #2 - Documentation from 10/25/21 indicated that the patient had developed breathing concerns and was using a nebulizer. There was no evidence that patients plan of care was updated to include breathing concerns and nebulizer use. (COS) Pt #3 - The patient was evaluated to have shortness of breath and utilized oxygen. No evidence a plan of care was developed related to respiratory including interventions and goals. (COS)

Upon patient record review, 4 of 11 (Patient #1, 2, 3,11 ) 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. Pt #1 - During home visit it was identified that patient was taking Tylenol. There was no evidence of an order for Tylenol. Pt #2 - The record indicated the patient was using a nebulizer. There was no evidence of an order for the nebulizer or medication to use in the nebulizer. (COS) Pt #3 - The admission order for patient included Oxygen 1-10 liters/min via nc prn. The order did not include parameters for the use of different liter dose. (COS) Pt #11 - Record indicated patient using oxygen 2 l/min nc continuous. No evidence of an order for oxygen. Visit note dated 5/2/21 indicated oxygen increased to 4 l/m. No evidence of MD order to change the oxygen.

Upon patient record review, 2 of 11 (Patient #2, 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 equipment and supply needs. Pt #2 - Pt was using a hospital bed and nebulizer which were not listed on the plan of care. (COS) Pt #11 - Pt had a rollator and oxygen. Oxygen supplies and rollator were not listed on patient plan of care.

Upon patient record review, 1 of 4 applicable (Patient #2) 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 Pt # 2 - Aide care plan included O2 saturation rates. No evidence of parameters of when to notify RN . Pt also had a condom catheter which was not included on aide plan of care. (COS)

Upon patient record review, 2 of 11 (Patient #2, 11) 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. Pt #2 - SN visits dated 10/20/21, 10/25/21, 10/27/21 and 10/29/21 did not include the discipline credentials with the signature. Pt #11 - SN visits documented did not include the discipline credentials with the signature. Record indicated that patient died 5/2/21. IDG note on 5/6/21 included no evidence no evidence of patient death. IDG notes on the following dates 6/3/21 and 7/1/21 included "POC updated. Reviewed diagnosis, 3POC, medications, fall risk,...... Pt is experiencing disease progression in spite of optimal care; pt is dependent for more than 2 ADL's. "

Upon client record review, 2 of 2 applicable(Patient #4, 5) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26. Pt #4, 5 - There was no evidence of a discharge summary having been completed.