Every finding on record at Allstate Hospice, LLC

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by observation and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/11/2024. The skilled nurse documented on the initial nursing assessment dated 09/11/2024, that the patient had a G-tube [gastrostomy tube]. The plan of care dated 09/11/2024 to 12/09/2024 did not include planned interventions addressing assessment and care of the G-tube. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/28/2025. The skilled nurse documented on the nursing assessment dated 04/09/2025, that the patient had a urinary tract infection. The plan of care dated 03/28/2025 to 06/25/2025 did not include planned interventions related to the patient’s urinary tract infection. CLINICAL RECORD 11: The patient elected the hospice benefit on 11/07/2024. The skilled nurse documented on the nursing assessment dated 12/04/2024, that the patient had a stage 2 wound to the coccyx and the facility was providing wound care. The plan of care dated 11/07/2024 to 02/04/2025 did not include planned interventions related to the patient’s wound identified during the nursing assessment. During an interview on 06/24/2025, the Director of Nursing (Personnel Record 7) stated she would have the nurse update the plan of care and they will be doing additional education regarding updating the plan of care.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes: the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by document review, clinical record review, and interview. In 3 of 3 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure the bereavement plan of care included the types of bereavement services offered and the frequency of service delivery. Agency policy PC.130 Bereavement, last reviewed 090124, required in part, "The bereavement coordinator will complete a follow-up assessment and develop a bereavement POC [plan of care] for bereavement services based on the re-assessment and the family and/or caregiver's willingness to receive services." CLINICAL RECORD 15: The patient elected the hospice benefit on 01/05/2024 and the date of death was 06/24/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and multiple phone calls were also completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/29/2024, and the date of death was 11/01/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and multiple mailings were also completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 17: The patient elected the hospice benefit on 11/15/2024, and the date of death was 11/18/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and one phone call had been completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. During an interview the Bereavement Coordinator/Chaplain (Personnel Record 4) was able to verbalize the bereavement process and stated that she had been adding the task into the electronic medical record, but that she had not been generating a bereavement plan of care. She stated that she would review and update the process.

It is required that hospice aides are supervised by a registered nurse who makes 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 ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient's needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide was supervised by the Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/18/2025 with a diagnosis of senile degeneration of the brain. The plan of care dated 02/18/2025 to 05/18/2025 included an order for hospice aide visits one time per week. Clinical record review revealed an aide supervisory visit was completed on 03/26/2025 and the next aide supervisory visit was dated 05/01/2025, a total of 36 days after the 03/26/2025 visit and 22 days outstanding. During an interview and record review on 06/25/2025, the Director of Nurses (Personnel record #7) stated she cannot believe an aide supervisory visit was missed. She explained that the agency has been focusing on monitoring that aide supervisory visits are done timely.

It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. The hospice did not ensure hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all hospice employees and contract staff. During a review of the agency’s hospice volunteer program, a review of the volunteer hours report revealed that the agency percentage of volunteer hours for the most recent 12 months was 2.88%. During an interview and review of the volunteer program on 06/26/2025, the Volunteer Coordinator stated that they are increasing the recruitment efforts and have recently been able to connect with some of the local college programs for potential short-term volunteers. During a review of the volunteers hours it was found that the agency did not ensure that the volunteer percentage was above 5%. The volunteer hours report documented that for the average for the most recent 12 months was 2.88%.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure documentation of physician orders. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/28/2025 with a diagnosis of malignant neoplasm of the colon. The clinical record review revealed the nurse documented on the nursing assessment dated 04/09/2025 that Ertapenem (Invanz) 1g reconstituted with 3.1 ml lidocaine was ordered for the patient. The clinical record did not include a physician order for Ertapenem. CLINICAL RECORD 11: The patient elected the hospice benefit on 11/07/20024 with a diagnosis of Alzheimer's disease. The clinical record review revealed the Licensed Vocational Nurse documented on the nursing assessment dated 11/13/2024 that the patient is receiving Flagyl IV [intravenous] for urinary tract infection. The clinical record did not include a physician order for Flagyl. During an interview and record review on 06/25/2025, the Director of Nursing (Personnel record #7) stated she did not know what happened, but that education would be provided soon to the clinical staff.

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 a review of clinical records and interviews. 2 of 13 (15%) records reviewed of patients who accepted psychosocial services revealed the agency did not ensure that the psychosocial assessment was completed within 5 days of admission to the hospice as required. Record #11 was reviewed and identified the patient elected hospice care on 8/5/2022. Review of the clinical record revealed the record lacked evidence a psychosocial assessment completed within 5 days of the election of hospice care. There was no evidence that the physician was notified that the Medical Social Worker’s (MSW) initial comprehensive assessment was not completed within 5 days of the election of hospice care. During an interview and a joint review of the record on 9/7/22, the Alternate Director of Nursing (ADON) stated that the MSW did not complete a comprehensive assessment within 5 days of the election of hospice benefit or during the month of August. Record #6 was reviewed and identified the patient elected hospice care on 7/19/2022. Review of the clinical record revealed the Medical Social Worker (MSW) evaluation was completed on 7/27/2022, nine (9) days after the election of hospice care. The record revealed a MSW phone call note dated 7/23/2022, which read in part, “Due to unforeseen circumstances family and MSW cannot meet until next week.” There was no evidence that the physician was notified regarding the delay in the MSW’s initial comprehensive assessment. During an interview and a joint review of the record on 9/7/22, the ADON confirmed the MSW did not complete a comprehensive assessment within 5 days of the election of hospice benefit.

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, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measurements are implemented to manage the side effects. 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, document reviews, and interviews. 2 of 13 (23%) records reviewed revealed the hospice did not ensure the patient's medication profile was updated. Record #11 was reviewed and identified the patient elected hospice care on 8/5/2022. The initial comprehensive assessment completed by the Register Nurse (RN) on 8/5/2022, documented a skin tear measuring "5cmx3cmx0.1 cm on the patient's left arm." The wound care provided by the RN on 8/5/22, and during the subsequent SN visits completed on 8/8/22, 8/9/22, 8/10/22, 8/11/22, 8/12/22, and 8/13/22 was documented as, "cleanse wound with normal saline, pat dry, apply layer of Triple Antibiotic Ointment (TAO), cover with Adaptec dressing and gauze, wrap with Kerlix and secure with tape." The TAO was not included on the patient's medication profile. During the home visit conducted on 9/7/2022, a review of the patient’s medication profile, with the caregiver, revealed Centrum Silver 50+ Men Oral Tablet was not in the home. The caregiver stated, he did not give the Centrum Silver to the patient. The Centrum Silver was listed on the medication profile. The caregiver stated he gave the patient “Tylenol 500 mg tab, 1-2 tablets for pain." The medication Tylenol was included on the patient’s medication profile. Record #3 was reviewed and identified the patient elected hospice care on 8/3/2022. Review of the clinical record revealed the patient’s medication profile and the plan of care documented, "Gabapentin 100 mg tablets 2 tablets by mouth twice a day." During the home visit conducted on 9/7/22, a review of the patient's medication profile and an interview with the patient’s caregiver revealed the caregiver gave the patient "Cranberry Urinary Tract pills 2 by mouth every day, Vitamin E 400 IU 1 by mouth every day, and Gabapentin 100 mg twice a day by mouth only when needed." The medication profile did not reflect the patient's current medication use of Gabapentin on an as needed basis. The Cranberry Urinary Tract pills and the Vitamin E 400 IU were not included on the medication profile.

It is required that all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 13 (16%) records reviewed revealed the hospice did not ensure services followed the patient's plan of care. Record #0 was reviewed and revealed the patient elected hospice care on 4/8/22. The plan of care dated 4/8/22 through 7/6/22, ordered the skilled nurse (SN) for a follow-up visit the day after the 4/8/22 start of care. The licensed vocational nurse (LVN) documented a missed visit dated 4/9/22, which read in part, "not on my schedule, can't find him on my time sheet." The missed visit form included a section to indicate if the supervisor and physician were notified of the missed visit. Both sections of the form were blank and contained no information. During an interview and a joint record review, the Alternate Director of Nursing (ADON) stated, “neither the Nursing supervisor nor the MD were notified of the missed visit." Record #5 was reviewed and revealed the patient elected hospice care on 6/13/22. A review of the clinical record revealed the plan of care dated 8/9/2022, ordered the Medical Social Worker (MSW), "one time a month." The clinical record lacked documentation of a MSW visit for the month of August. During an interview and joint record review, the ADON stated, "there was not a MSW visit for the month of August and no missed visit completed."

It is required that a hospice aide provides services that ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 12 (33%) records reviewed of patients receiving hospice aide services revealed the agency failed to ensure the hospice aide services were provided as ordered in the plan of care.. Record #5 was reviewed and identified the patient elected hospice care on 6/13/22. A review of the clinical record revealed the plan of care dated 8/9/22 ordered the aide three times a week. The aide documented two visits as completed for the week of 8/7/22. The clinical record was missing documentation of a missed visit or communication with the physician. During an interview and a joint record review on 9/7/22, the Alternate Director of Nursing (ADON) (Staff #5), stated there was no reason as to why there was not a third visit and no missed visit report was completed. Record #0 was reviewed and identified the patient elected hospice care on 4/8/22. The plan of care ordered the hospice aide two times a week. For the week of 4/10/22, the aide documented missed visits on 4/12/22 and 4/14/22. For the week of 4/17/22, the aide documented missed visits on 4/19/22 and 4/21/22. For the week of 5/1/22 the aide documented a missed visit on 5/3/22. The missed visit form for each missed visit documented the family -caregiver was able to assist patient and the supervisor was notified. The form did not include documentation in the section labeled , "was MD notified," the information for each missed visit was missing. During an interview and a joint record review, the ADON stated the MD was not notified of the aide missed visits. Record #3 was reviewed and identified the patient elected hospice care on 2/15/2020. For the benefit period dated 8/3/22 through10/1/22, the hospice aide was ordered for daily visits. A review of the record revealed, during the weeks of 8/14/22, 8/21/22, and 8/28/22, six aide visits were completed each week. The clinical record was missing documentation of the missed visits or communication with the physician. During an interview and a joint record review, the ADON stated there were 6 visits completed each of those weeks and there were no missed visits completed by the aide. Record #12 was reviewed and identified the patient elected hospice care on 1/17/22. For the benefit period dated 4/17/2022 -7/15/2022, the aide documented visits as completed three times a week from the week of April 17, 2022 through the week of 7/10/2022. There was an aide care plan completed for this time frame and aide supervisory visits were completed every 14 days. The POCs for 4/18/22, 5/2/2022, 5/16/2022, 5/30/2022, 6/13/2022, 6/27/2022 and 7/11/2022 did not include orders for aide services. During an interview and a joint record review on 9/7/2022, the ADON confirmed there was no order for aide visits for those dates.

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. This standard was not met as evidenced by a review of clinical records and interviews. 1of 1 (100%) records reviewed of patients transferring to the hospital revealed the hospice did not ensure the receiving facility received a copy of the hospice discharge/transfer summary. Record #10 was reviewed and revealed the patient elected hospice care on 12/23/21. Review of the clinical record revealed that the patient was transferred to the hospital for a blood transfusion on 4/28/22. The clinical record lacked evidence that the agency forwarded a hospice transfer summary to the hospital. During an interview and joint record review, the Alternate Director of Nursing stated, "I did not find where we sent anything to the hospital."