Every finding on record at Ally Hospice LLC

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 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 clinical record review, and interview. In 1 of 14 (7%) clinical records reviewed it was revealed that the agency did not ensure that the drug profile included the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. Clinical Record 7: The Interdisciplinary Group (IDG) care plan dated 1/11/2024 included orders for Oxygen 2-5 lpm as needed. The clinical record lacked evidence that the medication profile reconciled on 1/24/2024 included oxygen as noted in the IDG care plan dated 1/24/2024. Personnel Record 1: The Alternate Administrator confirmed the findings in a joint record review and interview on 1/24/2024, that the hospice medication profile did not include oxygen.

It is required that a hospice aide provides services are ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure that hospice aide services were included in the plan of care. Clinical Record 11: A physician order was written on 11/24/2023 to discontinue hospice aide services. A hospice aide visit was provided on 12/28/2023 and documented that the aide provided personal care services. There was no evidence of an active aide plan of care on 12/28/2023, or any orders for aide services to be provided. Personnel Record 1: The Alternate Administrator confirmed the finding in a joint record review and interview on 1/24/2024, stating that hospice aide services were not included in the plan of care dated 12/12/2023 or IDG update dated 12/28/2023.

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 need. This standard was not met as evidenced by clinical record review and interview. In 5 of 14 (36%) clinical records reviewed of patients that received hospice aide services, it was revealed that the agency did not ensure that a supervisory visit was made no less frequently than every 14 days to assess the quality of care and services provided and ensure that the services provided met the patient's need. Clinical Record 1: The hospice aide visited three times a week beginning 12/4/2023 through the date of review on 1/24/2024. A hospice aide supervisory visit was completed on 12/18/2023. There was no evidence of any further aide supervisory visits as of the date of review on 1/24/2024 (37 days since the last documented hospice aide supervisory visit). Clinical Record 2: The hospice aide visited three times a week beginning 12/12/2023 through the date of review on 1/24/2024. A hospice aide supervisory visit was completed on 12/20/2023. There was no evidence of any further aide supervisory visits as of the date of review on 1/24/2024 (35 days since the last documented hospice aide supervisory visit). Clinical Record 7: The hospice aide visited five times a week beginning 11/11/2023 through the date of review on 1/24/2024. A hospice aide supervisory visit was completed on 12/4/2023. There was no evidence of any other aide supervisory visits as of the date of review on 1/24/2024 (50 days since the last documented hospice aide supervisory visit). Clinical Record 9: The hospice aide visited five times a week beginning 12/16/2023 through the date of review on 1/24/2024. A hospice aide supervisory visit was completed on 12/20/2023. There was no evidence of any further aide supervisory visits as of the date of review on 1/24/2024 (35 days since the last documented hospice aide supervisory visit). Clinical Record 10: The hospice aide visited three times a week beginning 12/12/2023 through the date of review on 1/24/2024. A hospice aide supervisory visit was completed on 12/19/2023. There was no evidence of any further aide supervisory visits as of the date of review on 1/24/2024 (36 days since the last documented hospice aide supervisory visit). Personnel Record 1: During joint record review and interview on 1/24/24, the Alternate Administrator confirmed the findings that the records did not contain evidence that a hospice aide supervisory visit was not performed at least every 14 days.

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: The initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes including the care and services provided. This standard was not met as evidenced by clinical record review, document review and interview. In 5 of 14 (36%) clinical records reviewed it was revealed that the agency did not ensure that the clinical record included documentation of all past and current clinical notes. Document 3: Agency policy, Timeliness of Documentation, dated 11/8/2022 stated in part, "Documentation must be completed in its entirety and must be accurate, descriptive, and contain only factual information. Documentation is required for each clinical encounter. The patient's medical record should be completed and signed electronically in the Electronic Health Record (EHR) or signed legibly in ink during EHR down-time by those clinicians involved in the patient's care within 72 hours of each encounter". Clinical Record 1: The plan of care effective 12/4/2023 included orders for skilled nursing visits 1 time per week. The clinical record did not contain documentation of the nursing visits that were scheduled and documented as provided on 1/6/2024 and 1/9/2024. Clinical Record 2: The plan of care effective 12/12/2023 included orders for skilled nursing visits 1 time per week. The clinical record did not contain documentation of the nursing visits that were scheduled and documented as provided on 1/6/2024 and 1/9/2024. Clinical Record 7: The plan of care effective 11/13/2023 included orders for skilled nursing visits 1 time per week. The clinical record did not contain documentation of the nursing visits that were scheduled and documented as provided on 1/6/2024, 1/8/2024, and 1/19/2024. Clinical Record 9: The plan of care effective 12/16/2023 included orders for skilled nursing visits 1 time per week. The clinical record did not contain documentation of the nursing visits that were scheduled and documented as provided on 1/5/2024, 1/8/2024, or 1/20/2024. Clinical Record 10: The plan of care effective 12/12/2023 included orders for skilled nursing visits 1 time per week. The clinical record did not contain documentation of the nursing visits that were scheduled and documented as provided on 1/5/2024, 1/8/2024, or 1/16/2024. Personnel Record 1: The Alternate Administrator confirmed the findings in an interview on 1/24/2024 and stated in part "The nurse quit without notice; we are trying to get her to complete the documentation for the completed visits."

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 contains at a minimum physician orders. This standard was not met as evidenced by clinical record review, interview and observation. In 4 of 14 (29%) clinical records reviewed it was revealed that the agency did not ensure that the clinical record included physician orders for visits provided and the changes in the level of care provided. Clinical Record 2: During the home visit observation with the Registered Nurse on 1/24/2024, a review of the assisted living medication record included the medication Colace 100mg two times daily. There were no orders for this medication and the medication was not listed on the hospice medication profile reconciled on 1/24/2024. Clinical Record 3: The nursing clinical note dated 1/5/2024 included documentation that the patient had Oxygen 2-5 lpm as needed. During the home visit observation with the Chaplain, an oxygen cylinder was observed in the patient's room by the site visitor. There was no evidence that a physician order was obtained for oxygen, listed on the medication profile, or included in the plan of care. Clinical Record 11: A physician order was written on 11/24/2023 to discontinue Hospice Aide services. A hospice aide visit was provided on 12/28/2023 and the clinical record contained documentation that the Aide provided personal care services. The clinical record did not contain evidence that a physician order was obtained for the aide services provided. Clinical Record 13: The clinical note dated 5/12/2023 noted that the patient was on a respite level of care from 5/11/2023-5/15/2023. There was no evidence that a physician order was obtained to change the level of care from routine to respite. Personnel Record 1: In a joint record review and interview on 1/24/24, the Alternate Administrator confirmed the findings that the clinical records did not contain evidence of physician orders.

It is required that the hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients under the respite level of care at a facility, it was revealed that the agency did not ensure that the written plan of care did not specifically identify which provider would be responsible for that care and services. Clinical Record 13: The clinical note dated 11/15/2023 noted that the patient was at a facility for respite care for 5 days beginning 11/15/2023. The plan of care did not identify the care and services that each provider would be responsible for providing. Clinical Record 5: The clinical note dated 5/12/2023 noted that the patient was at a facility for respite care from 5/11/2023-5/15/2023. The plan of care did not identify the care and services that each provider would be responsible for providing. In a joint record review and interview, the QAPI Coordinator confirmed findings that the clinical record did not contain evidence that the plan of care was established identifying which provider would be responsible for the care and services.