Every finding on record at Aloria Healthcare

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 3 of 14 (21%) clinical records reviewed, the agency did not ensure the plan of care included patient and family goals and planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The initial nursing assessment dated 11/15/2025 included documentation in the narrative portion that the patient had bladder and bowel incontinence. The plan of care dated 11/15/2025 did not include goal(s) and intervention(s) for the patient’s assessed bladder and bowel incontinence. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/19/2025 with diagnosis of senile degeneration of the brain. The initial nursing assessment dated 11/19/2025 included in the narrative portion that the patient had bladder and bowel incontinence. The plan of care dated 11/19/2025 did not include goal(s) and intervention(s) for the patient’s assessed bladder and bowel incontinence. CLINICAL RECORD 10: The patient elected the hospice benefit on 11/14/2025 with diagnosis hypertensive heart disease without heart failure. The initial psychosocial assessment dated 11/17/2025 included documentation that the Social Worker would see the patient one time per month. The initial spiritual assessment dated 11/16/2025 included documentation that the Spiritual Counselor would see the patient one time per month. The plan of care did not include goal(s) and intervention(s) for the Social Worker and the Spiritual Counselor. During an interview and joint clinical record reviews on 02/18/2026, the Licensed Vocational Nurse, the Director of Patient Care Services Designee, and the Alternate Administrator stated they agreed the plans of care for clinical records 4 and 9 lacked specific goals and interventions for bladder and bowel incontinence that were identified on the initial nursing assessments. They also agreed the plan of care for clinical record 10 was missing specific goals and interventions for the social worker and the spiritual counselor that had planned frequency of visits once a month.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary and the patient's record, if requested. This standard was not met as evidenced by clinical record review and interview. In 4 of 4 (100%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient's attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient and family revoked the hospice benefit on 02/12/2026 to pursue curative treatment. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/22/2026 with diagnosis of hypertensive heart disease with heart failure. The patient and family revoked the hospice benefit on 02/11/2026 to leave the country. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient and family revoked the hospice benefit on 02/04/2026 to pursue curative treatment. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient's attending physician. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/14/2025 with diagnosis of heart failure. The patient and family revoked the hospice benefit on 01/09/2026 to relocate. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient's attending physician. During an interview and joint clinical record reviews on 02/18/2026, the Licensed Vocational Nurse, the Director of Patient Care Services Designee, and the Alternate Administrator stated they agreed the clinical records for the patients/families that revoked the hospice benefit did not include documentation that the discharge summaries were forwarded to the patient's attending physician.

It is required that the comprehensive assessment includes an initial bereavement assessment of 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. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 5 (40%) clinical records reviewed revealed the agency did not ensure that the clinical record contained an initial bereavement assessment of the needs of the patient's family and other individuals. Agency Bereavement Assessment Policy #1-021, "Bereavement Assessment (Dated: 11/2020)," stated in part, "Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator." Clinical Record 3: The patient was admitted on 12/14/22. The clinical record lacked a completed initial bereavement assessment as part of the comprehensive assessment. Clinical Record 2: The patient was admitted on 12/14/22. The clinical record lacked a completed initial bereavement assessment as part of the comprehensive assessment. In an interview on 1/12/23, the Administrator and Director of Patient Care Services reviewed and agreed with the above findings.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 1 of 5 (20%) clinical records reviewed revealed the patient's individualized written plan of care (POC) lacked goals and interventions based on problems identified in the initial and updated comprehensive assessments. Agency Policy #9-017, "The Plan of Care (Dated: 11/2020)," stated in part, "Policy: The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments. . .The plan will focus on identified problems, goals, and interventions." Clinical Record 5: The patient was admitted on 8/24/22. The patient had a diagnosis of COPD and was on oxygen 3 LPM via nasal cannula per the initial nursing assessment dated 8/24/22. The interdisciplinary group plan of care (POC) dated 8/24/22 lacked a goal and interventions for the respiratory problem/oxygen use. In an interview on 1/12/23, the Administrator and Director of Patient Care Services reviewed and agreed with the above findings.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid 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, document reviews and interviews. 2 of 2 (100%) clinical records reviewed revealed that for patients that revoked hospice services and were transferred to a hospital, the record lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the receiving facility. Agency Transfer Information Policy, Policy #1-022, "Transfer Information (Dated: 11/2020)," stated in part, "Procedure: 4. Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hours of transfer and file the original in the clinical record." Clinical Record 5: The patient was admitted on 8/24/22. The patient was hospitalized and chose to revoke hospice services on 8/29/22 to pursue aggressive treatment. The clinical record lacked evidence that the discharge summary was forwarded to the receiving facility (hospital). Clinical Record 4: The patient was admitted on 8/16/22. The patient was hospitalized and revoked hospice services on 8/21/22 to pursue aggressive treatment. The clinical record lacked evidence that the discharge summary was forwarded to the receiving facility (hospital). In an interview on 1/12/23, the Administrator and Director of Patient Care Services reviewed and agreed with the above findings.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 2 (100%) clinical records reviewed for patients that revoked hospice services revealed the record lacked evidence that the hospice forwarded a copy of the hospice discharge summary to the patient's attending physician. Agency Revocation of Hospice Benefit Policy #1-024, "Revocation of Hospice Benefit (Dated: 11/2020)," stated in part, "Procedure: 3. The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." Clinical Record 5: The patient was admitted on 8/24/22. The patient was hospitalized and revoked hospice services on 8/29/22 to pursue aggressive treatment. The clinical record lacked evidence that the discharge summary was forwarded to the attending physician. Clinical Record 4: The patient was admitted on 8/16/22. The patient was hospitalized and revoked hospice services on 8/21/22 to pursue aggressive treatment. The clinical record lacked evidence of the discharge summary being forwarded to the attending physician. In an interview on 1/12/23, the Administrator and Director of Patient Care Services reviewed and agreed with the above findings.