Every finding on record at Altruistic Hospice, Inc.

Observed in Record Review. In 2 of 3 active patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In RRNHV #2, he plans of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, has teaching goals from admission 8 months ago of Pt/Family/PCG will verbalize confidence in the management of patient`s pain and Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. On RRNHV #3, the plan of care had not been updated to reflect the current needs. For example, has teaching goals from admission 8 months ago of Family/PCG will verbalize understanding of increased risk of fall by next SN visit and Family/PCG will verbalize understanding of fall and safety interventions by next SN visit. This finding was reviewed with hospice leadership.

Observed in Record Review. In 1 of 3 active patient records reviewed, the organization failed to plan the patient's care with measurable and specific goals. On RRNHV #1, it was noted that the goals were not measurable and specific to the patient with the example of Pt/Family/PCG will verbalize having elimination needs met at an acceptable level. and Pt/Family/PCG will verbalize having urinary elimination needs met at an acceptable level. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 3 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRNHV # 3 the physician's orders in the plan of care documented duplicate medication therapy for constipation with no indication of how to handle the duplicate therapy. On RRNHV #3, it was noted that there was duplicate constipation medications of Docusate sodium and Lactulose with no indication on how to handle the duplicate therapy. This finding was discussed with Hospice leadership.

Observed in Tracer Activities. The organization failed to provide volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. During tracer activities for volunteer services, the Hospice Nurse Surveyor observed that the organization was a 0% hours for their volunteer hours for 1st and 2nd quarter in 2025. This finding was reviewed with Hospice Leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization had not provided education and training to the patient based on the patient's needs. In the chart for RRDC#2, there was no documentation that the patient or caregiver had been provided any discharge instructions upon the patient's revocation of the hospice benefit. This was discussed with the DON.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice plan of care did not include all services needed. In the chart for RRNHV#1, the Social Worker had identified that the patient had not formulated an advance directive nor had funeral home arrangements been made. The clinician identified that education was provided about the importance of these items and forms/information would be provided. These problems/interventions were not included on the hospice plan of care. This was discussed with the DON.

Observed in Record Review. In 1 of 2 patient records reviewed, The organization failed to respect the patients right to elect and revoke hospice care. On review of RRNHV#2 per the Administrator the patient had been discharged live yet there was no revocation or transfer form noted on the record. This observation was reviewed with the Administrator.

Observed in Record Review. the organization failed to ensure a confidential clinical record. At the time of survey surveyor noted per the Administrator clinical documentation were kept off site with the DPCS in a computer yet was unable to validate the system was HIPAA compliant. This observation was reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, that not all patient needs had been addressed on the plan of care (POC). For example: in RRBR2 the patient was bedbound with a documented high risk for skin breakdown, however this had not been included on the POC. In RRBR3 the patient had ALS with a moderate risk for skin breakdown and this was not included on the POC. In RRBR1, RRBR2, RRBR3, RRBR4, and RRBR5 the patients all had short POC prior to death, and the POC had not included death and dying education and intervention. This was validated with the DOPCS. Unable to validate compliance as there was no documentation present at the time of survey to include: in review of 2 records there were no visit noted in the record since the last survey date. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure the patient and primary care giver receive education and training provided by the hospice as appropriate to their responsibilities as identified in the plan of care. On review of RRNHV#2 the Administrator noted the patient had been discharged from hospice however there was no documentation of discharge noted in the record nor any discharge instructions provided to the patient and/or caregiver. This observation was reviewed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions. On review of RRNHV#2 the Administrator noted that the patient had been discharged for service yet there was no discharge order noted on the record. This observation was reviewed with the Administrator.

Observed in Data Session. The hospice surveyor noted the QAPI program did not include indicators that were related to improved palliative outcomes as evidenced by the HCO was not able to produce this documentation at the time of survey. Unable to validate compliance as there was no documentation present at the time of survey to include: the QAPI meeting in October did not involve all services provided by the organization, nor reflected the complexity of the organization and its services. There had been no governing body meeting documented since the last survey. This observation was reviewed with the Administrator. Observed in Data Session. The surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey. Unable to validate compliance as there was no documentation present at the time of survey to include: On survey there was evidence of a QAPI yet the minutes did not include all required elements and showed no data collection or analysis. This observation was reviewed with the Administrator. Observed in Data Tracer. The surveyor noted the HCO did not have an effective, ongoing, organizationwide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. No documentation at time of survey of program established. There is a signed QAPI/Safety Committee meeting October yet there was no evidence of data collection or analysis of data at the time of survey. This observation was reviewed with the Administrator.

Observed in Data Session. the Hospice Surveyor noted the HCO had not collected any data to identify improvement opportunities related to patient care and safety. This was validated with the Administrator. Unable to validate compliance as there was no documentation present at the time of survey to include: the QAPI meeting that was documented in October did not include any documentation of data collected to identify improvement opportunities related to patient care and safety. There was a listing for pain management that noted 100% of patients report adequate pain management, yet the section that prompts (how many active patients) was left blank. Similar lack of data was noted for the Management of other symptoms section. This observation was reviewed with the Administrator.

Observed in Data Session. The HCO had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. Unable to validate compliance as there was no documentation present at the time of survey to include: There was no documentation of Governing Body meeting since survey to show leadership had set priorities for data collection, and no data collection had been noted when reviewing the QAPI program. This observation was reviewed with the Administrator.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by CLD's at 418.100, 418.104, 418.52, 418.56 and 418.58. This was validated with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to maintain a patient record that was complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. On review of RRHV#1 the clinical record contained no visit notes since last survey in early October. Upon arrival to the org there was no CTI, and IDG meeting documents since last survey, yet the DPCS was able to email the documents for print. RRNHV#2 there was no evidence that the entire record had been updated since last survey, with no visit notes, no IDG meeting documentation since last survey. Per the Administrator the patient had been discharged live yet there no documentation of the discharge on the record. These observations were reviewed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to ensure that when the patient was discharged it gave information about the care, treatment, or services to the patient or other service providers who with provide the patient with care, treatment or services. On review of RRNHV#2 the Administrator noted that the patient had been discharged from service yet there was no documentation of discharge in the record to include the discharge summary. This observation was reviewed with the Administrator.

Observed in Emergency Management Session. The Surveyor noted that the HCO had not followed their policy related to Emergency Management as they had not documented a drill since early 2023. The HCO policy states the drills would be conducted Bi-Annually. This was validated with the DOPCS.

Observed in Record Review. the Hospice Surveyor noted an executed POLST signed by the MD and Spouse of patient; however, the rest of the document indicating cardiopulmonary resuscitation and medical interventions had been blank. This was validated with the Administrator.

Observed in Record Review. In 9 of 9 patient records reviewed, the Hospice Surveyor noted the initial assessment by the Spiritual Care provider (SC), Medical Social Worker (MSW) had not been completed and/or the initial Bereavement Assessment had not been completed. In RRHV 1, the initial Bereavement Assessment had not been completed. In RRHV 2, there had been no contact initiated by the spiritual care provider. In RRBR 1, there had been no initial bereavement assessment completed and there had been no documented SC or MSW communication with the patient or the family. In RRBR 4 there had been no documented initial bereavement assessment completed. In RRHV 1, RRHV 3, RRBR 1, RRBR 2, RRBR 3, RRBR 4, RRBR 5, and RRBR 6, there had been no documented contact by the SC or the MSW. Each record had the documentation: Family declined services. All Needs Met This was validated with the DOPCS

Observed in Record Review. In 4 of 6 patient records reviewed, where the patient expired while on HCO service, the Hospice Surveyor had been unable to validate that education related to death and dying and what to expect had been provided to the patient and family. For example, in RRBR 1, the patient passed within 7 days of starting hospice services, but no documentation related to death and dying process had been documented as addressed with the family. In RRBR 2, the patient passed within 8 days of starting hospice services, but no documentation related to death and dying process had been documented as being provided to the family. In RRBR 3, the patient passed at day 15 of hospice services, and there had been no documentation related to death and dying process had been documented as addressed with the family and in RRBR 5, the patient passed 19 days after starting hospice services, but there had been no documentation related to death and dying process and what to expect. This was validated with the Administrator.

Observed in Record Review. In 1 of 9 patient records reviewed, the Hospice Surveyor noted the patient in RRHV 1 had a certification plan of care that expired 14 days ago, yet the patient was still on service, and visits had been conducted. This was validated with the DOPCS

Observed in Record Review. In 5 of 9 patient records reviewed, the Hospice Surveyor noted that not all patient needs had been addressed on the plan of care (POC). for example, in RRBR 2, the patient was bedbound with a documented high risk for skin breakdown; however, this had not been included on the POC. In RRBR 3, the patient had ALS with a moderate risk for skin breakdown and this was not included on the POC. In RRBR 1, RRBR 2, RRBR 3, RRBR 4 and RRBR 5, the patient's all had a short POC prior to death, and the POC had not included death and dying education and interventions. This was validated with the DOPCS

Observed in Tracer Activities. The surveyor noted the HCO was not able to demonstrate the operation of its QAPI program as evidenced by the HCO was not able to produce the documentation of the program at the time of survey. Observed in Tracer Activities. The hospice surveyor noted the QAPI program did not include indicators that were related to improved palliative outcomes as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Tracer Activities. The surveyor noted the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Tracer Activities. the Hospice Surveyor noted the HCO had not collected any data to identify improvement opportunities related to patient care and safety. This was validated with the Administrator

Observed in Tracer Visit. The surveyor noted the HCO did not have an effective, ongoing, organizationwide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey.

Observed in Tracer Activities. The HCO had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. This was validated with the Administrator

Observed in Tracer Activities. Surveyor unable to evaluate the volunteer program as the coordinator was on vacation and out of the country and there had been no documentation presented to support the program. The last updated information was from the year 2023. This was validated with the Administrator

Observed in Tracer Activities. Surveyor unable to evaluate the volunteer program as the coordinator was on vacation and out of the country and there had been no documentation presented to support the program. The last updated information was from the year 2023. This was validated with the Administrator

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by CLD's at 418.114, 418.78, 418.56 and 418.58. This was validated with the Administrator.

Observed in Record Review. In 1 of 9 patient records reviewed, the Hospice Surveyor noted in RRHV 1, the Medical Director had not reviewed the clinical information and signed the CTI prior to recertification. This was validated with the DOPCS.

Observed in Patient Home. In 1 of 3 home visits conducted, the Hospice Surveyor noted the medication list in the medical record had not contained all the medications the patient was being administered. For example, in RRHV 2 the medication list in the medical record had been missing: Pregabalin 100mg as needed, Lidocaine 5% topical gel, Lidocaine 4% patches, Diclofenac 1% topical and Fluticasone nasal spray that the patient had been taking prior to admission to hospice services. Also, the medication Digoxin 0.125mg had been listed 2 times on the profile.This was validated with the DOPCS.

Observed in Record Review. In 3 of 9 patient records reviewed, the Hospice Surveyor noted clinician documentation with a signature and no credentials identifying who they were. For example, in RRBR 4 and RRBR 5, and RRBR 6 there had been documentation related to continuous care and pronouncements that had been signed with first initial, last name, but no credentials. This was validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, in RRHV 2, the Hospice Surveyor observed Oxygen cannisters propped against a wall and unsecured. Upon review of the medical record, there had been no documented patient or family education on the proper storage of home oxygen equipment. This was validated with the DOPCS.

Observed in Record Review. In 3 of 6 patient records reviewed, where the patient had expired while on HCO service, with the LVN attending the death, the staff did not provide patient care within the scope of their license. For example, In RRBR 4 the surveyor noted the LVN pronounced the patient’s death, as evidenced by the LVN documentation ‘Patient pronounced at 15:16 in presence of wife and children, Notified Hospice.’ There had been no documentation that the Physician was notified. In RRBR 5, the LVN documented ‘Patient pronounced dead at 6:33 pm, Office notified.' There had been no documentation that the Physician was notified. And in RRBR 6, the LVN documented: ‘0952- Patient expired at this time. Hospice was notified.’ Again, there had been no documentation that the Physician was notified.This was confirmed with the Administrator present during the survey.

Observed in Data Session. It was observed that the organization had not documented what performance improvement projects were conducted, the reasons for conducting these projects, and the measurable progress achieved on them. This was reviewed and discussed with Leadership and validated.

Observed in HR File Review. In 1 of 1 home health aide personnel records reviewed, During HR# 8's personnel record review, the nurse surveyor noted that the personnel file of the home health aide did not include evidence that the competency assessment had included the observation of the aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. The initial competency on file had documentation that the aide had verbalized all the tasks. This was reviewed and discussed with Leadership and validated.

Observed in Patient Home. In 1 of 1 home visits conducted with home health aide services, During HV# 1's home observation, it was noted the patient had an indwelling urinary catheter, but the Aide Care Plan did not provide directions regarding the catheter care. During the home observation the home health aide was observed performing catheter care. This was discussed with Leadership and validated.

Observed in Record Review. In 2 of 11 patient records reviewed, During HV# 2 and RR# 8's patient record review, it was noted the organization had not ensured entries into the clinical record were authenticated. For example: review of HV# 2's Certificate of Terminal Illness revealed documentation a verbal order was received by the RN and no signature by the RN. Review of RR# 8's patient record revealed a revocation that was not dated. This was reviewed and discussed with Leadership and validated.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 5's patient record review it was noted the organization had not ensured medical record error correction indicated the author and date of correction as required by organizational policy. This was discussed with Leadership and validated.