Every finding on record at Alternative Hospice Care Inc.

Upon patient record review 2 of 5 (Patient #2,3) 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. Patient #2: The patient did not want a spiritual care initial assessment until 01/21/26. This is outside the 5 day requirement and the nurse did not complete the spiritual portion of the comprehensive assessment. Patient #3: The patient refused initial spiritual care assessment, The RN did the initial spiritual assessment however it was not completed before the 5 days.

Upon patient record review, 1 of 5 (Patient #5) 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. Patient #5: Although Bereavement assessment was completed, it was done on day #7.

Upon patient record review, 1 of 5 (Patient #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. Patient #3: This patient is seeing spiritual care monthly however there are no interventions or goals in the plan of care surrounding spiritual care.

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

Upon patient record review 8 of 19 (Patient #1,2,3,4,7,10,13,14) 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 1: The MSW, SC and Bereavement assessments were not completed with in 5 days and were not assessed by the RN. Patient 2: The MSW and SC providers did not complete their comprehensive assessment with in 5 calendar days. The RN did not complete the psychosocial and spiritual assessments as part of their comprehensive assessment. Patient 3: The Bereavement comprehensive assessment was not completed. The RN did not complete the bereavement assessment as part of their comprehensive assessment. Patient 4: The SC performed their comprehensive assessment 10/7/25, The MSW performed their comprehensive assessment 10/17/25 both greater than 5 days of admission. The RN did not complete spiritual or psychosocial assessments as part of their comprehensive assessment. Patient 7: The MSW comprehensive assessment was performed on 11/18/25 this is greater than 5 days. The RN did not complete the psychosocial assessment as part of their comprehensive assessment. Patient 10: The MSW comprehensive assessment was performed on 10/20/25, the SC assessment was completed 10/22/25, both greater than 5 days and they were not completed by the RN at SOC. Patient 13: There was no MSW comprehensive assessment completed with in 5 days. The RN did not complete the psychosocial assessment as part of their comprehensive assessment. Patient 14: The SC made a visit on 11/24/25 though pt declined assessment/visit. No SC assessment was made with in 5 days. The RN did not complete the spiritual assessment as part of their comprehensive assessment.

Upon patient record review 5 of 19 (Patient #5,7,9,11,15) 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. Patient 5: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment. Patient 7: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment. Patient 9,11,15: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment.

Upon patient record review, 2 of 19 (Patient #1,4) 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: Patient 1: The facility MAR has magnesium citrate, this was not included on the hospice medication profile. Corrected on site, orders updated. Patient 4: The medication profile contains MiraLax with no diluent. Corrected on site, order updated.

Upon patient record review, 4 of 19 (Patient #7,8,10,13) 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. Patient 7: The bereavement assessment was completed 11/11/15. Patient 8: The Bereavement assessment was completed 11/11/25. Patient 10: The Bereavement assessment was completed 10/20/25. Patient 13: The Bereavement assessment was completed 3/8/25.

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

Upon patient record review, 1 of 19 (Patient #15) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient 15: The SN documented on 11/21/25 that the patient was educated to cleanse wound on left hip with NS, apply Dakin's and cover with a dry dressing. This was not the order that was on the POC and there was no order to apply Dakins.

Upon patient record review, 3 of 19 (Patient #5,7,9) 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 5: The SN documented on 12/1/25 that patient has a wound with skin breakdown on coccyx, there is no nursing care plan with goals and interventions for this wound. Corrected on site, nursing care plan updated. Patient 7: The patient is taking Eliquis daily and there is not risk for bleeding care plan with goals and interventions. Corrected on site, nursing care plan updated. Patient 9: The SN documented in comprehensive assessment that patient has dementia and is a high fall risk. There is no care plan for high fall risk. Corrected on site, nursing care plan updated.

Upon patient record review, 1 of 19 (Patient #5) 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: Patient 5: The current POC contains an order for MSW PRN there is no frequency. A PRN frequency cannot stand alone and is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Corrected on site, order updated.

Upon patient record review, 8 of 19 (Patient #1,2,4,7,8,11,14,15) 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: The current Hospice POC contains acetaminophen 650mg rectal, Dulcolax 10mg rectal both PRN however, these were not included on the facility MAR. The facility MAR has magnesium citrate, this was not included on the hospice POC. Corrected on site, orders updated. Patient 2: The current POC contains an order for Polyvinyl Alcohol drops, the facility MAR did not have this medication ordered. Corrected on site, orders updated. The current POC contains an order "if unable to void after 8 hours post foley removal, then replace new foley catheter 18F. There is no balloon size or technique to use or who to insert the catheter. Corrected on site, orders updated. Patient 4: The current POC contains an order for MiraLax with no diluent. The current POC contains an order "Contact hospice case manager if pt noted with blood clots in brief, use large bore catheter 16F and normal saline 0.9% to flush out blood clots as needed due to history of prostate cancer". There is no amount to flush, frequency to flush or order to insert the catheter. Corrected on site, order updated. Patient 7: The current POC does not contain an order for oxygen though it is listed in the DME supplies and the SN documents pt using O2 11/18/25. Patient 8: The POC contains wound care orders to coccyx and does not state who is to perform. Pt in a ALF. Corrected on site, order updated. Patient 11: The current POC and medication profile contain an order for Jevity feeding to G tube. There are no orders for the G tube site care, flushes or orders for assessment. Family is performing the site care per conversation with SN and they are cleansing daily and applying a drain sponge. On 12/2/25 and other routine SN visits is assessing the G tube site and documenting G tube without signs and symptoms of infection. Corrected on site, order updated. Patient 14: The current POC contains an order for wound care to sacral ulcer but does not include who is to perform the wound care. Corrected on site, order updated. Patient 15: The medical record contains an order for wound care on 11/11/25 to left hip with no frequency or who to provide the wound care.

Upon client record review, 2 of 19 (Patient #5,15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The SN documented on 12/1/25 "Coccyx wound examined-area cleansed, dried and skin barrier applied". There is no order for this wound care or for barrier cream to apply. The current POC contains an order for SN 1 every 2 weeks. The SN saw the pt on 11/24/25 and 12/1/25 with no evidence of the visit being PRN or an order for the extra visit. Patient 15: The SN documented on 11/21/25 "new wound cleaned with wound cleanser and packed with new dry bandage". The order was to pack with iodoform and cover with gauze.

Upon patient record review, 5 of 19 (Patient #1,2,3,4,5) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The current aide POC contains the following tasks with no frequencies: transfer with mechanical lift, record bowel movements, turn and reposition,change linens. Corrected on site, aide POC updated. Patient 2: The current aide POC contains the following tasks with no frequencies: turn and reposition, change pt linens. Corrected on site, aide POC updated. Patient 3: The current aide POC contains the following tasks with no frequencies: record BM, change patient linens, turn and reposition. Corrected on site, aide POC updated. Patient 4: The current aide POC contains the following tasks with no frequencies: record BM, change patient linens, turn and reposition. Corrected on site, aide POC updated. Patient 5: The current aide POC contains the following task with no frequency: record BM. Corrected on site, aide POC updated.

Upon patient record review 4 of 19 (Patient #2,3,7,13) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The aide POC has ordered to dress patient every visit. The aide did not dress the pt on 11/25/25. No evidence of refusal or communication with RN. Patient 3: The POC 12/3/25 contains an order for aides twice a week, the aide did not visit the week of admission, they started 12/9/25. There was no missed visit documentation or evidence of refusal. Patient 7: The POC contains an order for Aide twice weekly beginning 11/14/25. The aide did not start seeing patient until 11/17/25 which is in the next Medicare week. Patient 13: The POC contains an order for aide twice weekly. The aide made 1 visit the week of 11/23-11/29/25 with no evidence of refusal or missed visit documentation.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Agency Volunteer percentage for 2024 was 3.27%.

Upon personnel record review, 1 of 19 (Personnel #8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Patient 8: The ST does not have evidence of a competency performed.

Condition of Participation: Medical Director.

Upon patient record review, 11 of 19 (Patient #1,3,4,6,7,8,9,10,11,12,18) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 1,3,4,6,7,8,9,10,11,12,18: The Admission CTI only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement.

Upon patient record review, 5 of 19 (Patient #5,12,14,15,16) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient 5: The CTI's/face to face encounters completed on 11/8/25 and 9/9/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 12: The recert CTI only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 14: The recert CTI/face to face on 9/18/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 15: The Recert CTI on 9/2/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 16: The recert CTI on 3/27/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician's brief narrative explanation of the clinical findings that supports the life expectancy statement.

Upon patient client record review, 1 of 19 (Patient #2) did not have evidence that each patient record contains: Patient 2: The notification of the individual's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice area was not marked yes or no to indicate whether or not the individual wanted a copy of the addendum and the addendum was not sent.

Upon patient client record review, 1 of 19 (Patient #13) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 13: The patient chose an attending that was not the hospice medical director, there is no CTI written by the attending MD.

Upon patient client record review, 17 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17) 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: The hospice election form contains information that the patient does not wish to choose an attending physician then the facility medical director's name was written in. The hospice medical director is the attending. All of the documentation by the SN, aide, and MSW are not appropriately authenticated and dated. Patient 2: the aide, nurse, MSW, SC did not authenticate and date any of their visits. Patient 3: The MSW has not appropriately authenticated and dated their note on 12/8/25 and the SC has not appropriately authenticated their note on 12/4/25. The election form has marked "I do not wish to choose an attending " then the facility doctor's name is written in the blank. Patient 4,8,12,14,15,16: The SN, MSW, SC and Aide notes from admission to current are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 5,11: The Aide notes from admission to current are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 6,9,10: The SN, SW, Aide visits are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 7: The aide visit notes are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 13: The SN notes on 11/25/25, 11/6/25, 11/4/24 are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 14: The aide visit notes from admission to current and the SN notes on 11/6/25, 11/5/25, 11/4/25, 9/23/25 have not been appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 17: The SN notes on 1/25/25, 1/24/25, 1/20/25 are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice.

Upon client record review, 1 of 19 (Patient #15) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient 15: There was no evidence that a copy of the hospice discharge summary was sent to the patient's attending physician.

Upon client record review, 2 of 19 (Patient #15,16) did not have evidence that the discharge summary includes all required information. Patient 15,16: The discharge summary did not include: A summary of the patient's stay, including treatments, symptoms and pain management,The patient's current plan of care, The patient's latest physician orders, Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.

Upon patient record review, 2 of 19 (Patient #7,8) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 7: The SN documented in the narrative on 11/26/25 receiving order from MD to cleanse the wound area and leave open to air. There was no order transcribed for wound care. Patient 8: The SN documented on 11/4/25 in the narrative: patient with blood clots, called MD and received order that if this persists to insert a foley and bladder irrigations using NS will be initiated as needed. This order was never transcribed into the medical record.

Upon inpatient contract review, 1 of 4 (Palomar) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented. Corrected on site, agency amended contract.

Upon SNF/NF contract review, 1 of 4 (Palomar) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: Palomar: The contract did not include when a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions. Corrected on site, agency amended contract.

Upon SNF/NF contract review, 1 of 4 (Palomar) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation. Corrected on site, agency amended contract.

Upon client record review, 2 of 19 (Patient #3,4) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 3: The SN documented 12/4/25, 12/8/25 wound care to right toe as "treatment Betadine" there is no evidence the order was followed. The order was to cleanse with NS, pat dry and leave open to air. SN documented on 12/4/25, 12/8/25 for right heel wound care "treatment skin prep", there is no evidence the order was followed. Order was to cleanse with NS, pat dry apply skin prep and leave open to air. Patient 4: The SN documented on 11/10/25 "RN Flushed bladder with 60ml of NS" there is no order in place to flush irrigate the bladder until 12/10/25. SN documented on 12/1/24 "Patient's bladder was flushed with NS until blood clots resolved and irrigation showed clear". There is no order until 12/10/25 and there is no specifics of how much NS was used. Corrected on site, orders updated for continued use.

Upon client record review, 1 of 19 (Patient #3) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 3: The current POC contains wound care orders but does not state who is to perform the wound care. Corrected on site, order updated.

Upon patient record review, 3 of 19 (Patient #1,2,3) did not have evidence that the hospice provided the following information: Patients 1,2,3: The SNF clinical record did not include the hospice elections forms. Corrected on site, hospice uploaded and printed copies of the election forms on site and placed in facility chart.

Upon personnel record review, 1 of 19 (Personnel #8) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel 8: The ST did not have evidence of a criminal background check.

Upon personnel record review, 1 of 13 (Personnel #13) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel 13: The NP did not have a criminal background check upon hire. Corrected on site, they ran a criminal background check day 3 survey.