Every finding on record at Alpha Healthcare Management, Inc

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Upon observation, there was no evidence the hospice develops and maintains an emergency preparedness communication plan that complies with federal, state, and local laws and must be reviewed and updated every two years. Upon review of the agencies Emergency Preparedness plan, there was no evidence of a detailed communication plan which outlined the hospice employees and their contact information, contracted entities, patient and physician contact information, or a means of providing information about the general location and condition of patients

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. Upon review of the Emergency Preparedness binder, there was no evidence provided in the plan that listed employee contact information ie.phone numbers, addresses, etc

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) Upon review of the Emergency Preparedness binder, there was no evidence that the emergency plan included communications and/or contracts with other health care providers should the patients require a transfer of their care to the other health care provider. There was no evidence of steps required to provide the necessary patient information to the other health care providers in the event of an emergency

Upon patient record review 7 of 14 (Patient #3,4,5,7,8,9,12) 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. Patient #3 -Upon chart review, noted the patient/POA elected the hospice benefit to begin on 02/28/24. The record indicates that the psychosocial assessment was not completed within 5 calendar days of admission. Psychosocial assessment was completed on 03/07/24. Patient#4 -Elected the hospice benefit to begin on 11/15/23. The medical record showed evidence of an order for a psychosocial assessment. The record indicates the the psychosocial assessment was not completed within 5 calendar days of admission. Psychosocial assessment was completed on 01/22/24. Patient #5 -Upon chart review, noted the patient/POA elected the hospice benefit to begin on 11/30/23. The record indicates that the first contact to complete the spiritual assessment was conducted on 12/12/23. Patient #7 -Upon chart review, noted the patient/POA elected the hospice benefit to begin on 10/02/25. There was no evidence of a spiritual care comprehensive assessment within 5 calendar days of admission. Spiritual assessment was completed 10/09/25. Patient #8 -Upon chart review, noted the patient/POA elected the hospice benefit 12/19/23. There was no evidence of a psychosocial assessment completed within 5 calendar days of admission. Psychosocial assessment completed on 01/02/24. Patient #9 -Upon chart review, noted the patient/POA elected the hospice benefit to initiate on 06/12/24. There is no evidence of a psychosocial assessment completion within 5 calendar days of admission. The psychosocial was completed on 06/20/24. Patient#12 -Upon record review, noted the patient/POA elected the hospice benefit to begin on 01/27/25. There was no evidence of a psychosocial assessment completion within 5 calendar days of admission. They psychosocial was completed on 02/06/25.

Upon patient record review, 3 of 14 (Patient #2,3,5) 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 -The medication profile contained Miralax oral powder - the instructions on the order indicated "mix into liquid as indicated" but did not include specific amount of diluent. In addition, the medication profile showed evidence of an order for Dulcolax suppository to be given prn for constipation with no other parameters as to when to initiate this medication. Patient #3 -The medication profile contained Miralax oral powder 17 gm daily with no evidence of a diluent listed. Patient #5 -The medication profile contained Miralax oral powder -give 8.5gm daily with no evidence of a diluent listed.

Upon patient record review, 6 of 14 (Patient #1,#2,#3,#5,#7,13) 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 -Upon record review, it was noted that patient had a order dated 01/01/25 for Albuterol 1.25mg/3ml nebulized q 6 hours prn. There was no evidence of problems, goals, and interventions related to the use of the nebulized medication. Patient #2 -Upon record review, noted on the nursing comprehensive dated 08/09/24 that the patient was taking Tradjenta for Diabetes Mellitus. There was no evidence of problems, goals, and interventions related to diabetes and signs and symptoms to monitor. Patient #3 -Patient has an order for Aspirin daily as a blood thinner without evidence of problems, goals, and interventions related to bleeding precautions noted. Patient #5 -Patient admitted with a primary diagnosis of Diabetes Type II with chronic kidney disease. There is no evidence of goals, problems or interventions related to Endocrine. Patient #7 -Upon record review, there was evidence on the medication profile, that patient had Miralax and Dulcolax ordered. There was no evidence of constipation problems, goals, or interventions initiated. Patient #13 Upon chart review, noted a physician order to change the level of care from routine to continuous care. There was no evidence of the plan of care being updated with problems, goals, and interventions for the level of care change.

Upon patient record review, 7of 14 (Patient #1,2,3,4,5,8,12) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #1,2,3,4,5,8,12 -Upon record review, noted the IDG's showed evidence that the psychosocial and spiritual frequency orders were written for "1x and prn" - there was no evidence of clear documented frequency specific to patient/family needs throughout patient record dating back to the initiation of care.

Upon patient record review, 3 of 14 (Patient #2,3,5) 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 -The plan of care orders contained Miralax oral powder - the instructions on the order indicated "mix into liquid as indicated" but did not include specific amount of diluent. In addition, the medication profile showed evidence of an order for Dulcolax suppository to be given prn for constipation with no other parameters as to when to initiate this medication. Patient #3 -The plan of care orders contained Miralax oral powder 17 gm daily with no evidence of a diluent listed. Patient #5 -The plan of care orders contained Miralax oral powder -give 8.5gm daily with no evidence of a diluent listed.

Upon patient record review, 2 of 14 (Patient #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 equipment and supply needs. Patient #7 -Upon record review, the nursing comprehensive dated 10/02/23, it was noted that the patient was incontinent of bowel and bladder. There was no evidence of incontinent supplies listed on patients plan of care. Patient #8 -Upon record review, there is a documented wound on nursing notes between dates of 01/08/23 and 01/15/24 with no wound care supplies. In addition, documentation related to patient being incontinent as documented on the initial nursing assessment with no incontinent supplies on the plan of care.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8 -Upon record review, there was evidence of a physician order dated 01/08/25 for Amoxicillin po daily for 7 days for infected wound. There was additional evidence of nurse visits during the dates of 01/08/25 and 01/15/25 documenting the stage IV wound to sacrum and left hip as well as documentation of the use of "medihoney to wound and cover with bandage." There was no evidence of a physician order for this treatment.

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 review of the QAPI manual, evidence of 1 initiative (Infection) was the only initiative worked on in 2024. There was no evidence of changes or updates to that PIP related to data collected. In addition, there was no initiation of any additional performance improvement projects for the year of 2024

Upon personnel record review, 3 of 11 (Personnel #8,9,10) did not show evidence that the contract employees - PT/OT and Speech therapists, received orientation on the hospice philosophy.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content. Patient #7 - Upon patient record review, there was evidence that the patient lived in a boarding house environment which provided twenty-four caregiving. There was no evidence that orientation to hospice was provided to those caregivers to include: hospice philosophy, hospice policies and procedures, principles of death and dying, individual responses to death etc.

Observed in Record Review. In 6 of 11 patient records reviewed, the surveyor found no documentation of how the comprehensive assessment had include progress towards desired outcomes related to MSW and spiritual issues. This issue had been discussed and confirmed with organization leaders.

Observed in Record Review. In 7 of 11 patient records reviewed, The surveyor observed that the goals in the patient record had not been measurable . The following is for example taken from multiple POCs : Issue of edema and goal Prevent discomfort due to edema Issue of wound and goal Resolve wound status for comfort through the next review date Issue of ADL's goal minimize patients complications due limited mobility. Issue of pain goal Pain will remain in comfortable level during care. and needs will be met on a day to day basis as communicated. Issue Neuro : goal minimize episodes of confusion and forgetfulness. Issue potential aspiration Goal : Pt will have adequate food and fluid as tolerated or desired. The surveyor discussed issue with organization leaders who confirmed issue. The surveyor noted patient POCs in February, March and to date in April 2022 had improved more measurable goals .

Observed in Competency Session. Initial required aide competencies had been completed, but the documentation failed to confirm competencies completed with an actual patient or a qualified pseudo patient. The organization leadership stated that the competencies for this new aide had been assessed in office and done verbally.

Observed in Record Review. In 5 of 11 patient records reviewed, The surveyor observed that the IDG POC had not been electronically signed by one or more of the IDG members. The members had attended team meeting, but had not signed IDG/updated POC electronically , nor on paper. This issue was discussed and confirmed with organization leaders.

Observed in Record Review. In 2 of 4 patient records reviewed, of discharged/revoked patients the surveyor observed that the next provider had not been provided a discharge summary . This was confirmed by organization leaders.