Aleca Hospice

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. (L523) This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed revealed that the agency did not ensure that an initial comprehensive assessment was completed no later than 5 calendar days after the election of hospice care. CLINICAL RECORD 4: The patient elected hospice care 07/30/2025 with a diagnosis of senile Degeneration of Brain. The initial plan of care dated 07/30/2025 included an order for social worker visit 1 time for initial evaluation. The Social Worker’s initial assessment was not completed until 08/05/2025. This was 6 days after the election of hospice care. There was no documented reason why the initial psychosocial assessment was not completed by the social worker within 5 calendar days and no explanation or a missed visit within the 5 days. During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the social worker’s initial assessment was not completed within 5 calendar days.”

“It is required that a hospice aide provides services: Ordered by the Interdisciplinary Group; Included in the plan of care; Permitted to be performed under state law and regulation; and Consistent with the hospice aide training. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) clinical records of patients receiving hospice aide services revealed that the agency did not ensure that the hospice aide was completing tasks as ordered by the Interdisciplinary Group (IDG). CLINICAL RECORD 2: The patient elected hospice care on 02/25/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral hygiene and nail care every visit. On 03/11/2026 the aide documented that these tasks were not completed. CLINICAL RECORD 3: The patient elected hospice care on 02/21/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral care, ROM and nail care every visit. On 02/23/2026 the aide documented that these tasks were not completed. CLINICAL RECORD 4: The patient elected hospice care on 07/30/2025 with a diagnosis of Atherosclerotic Heart Disease Without Angina. The aide care plan created by the RN included oral hygiene and nail care every visit. On 02/26/2026, the aide documented on 02/26/2026 that these tasks were not completed. CLINICAL RECORD 5: The patient elected hospice care on 03/31/2026 with a diagnosis of Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung. The aide care plan created by the RN included denture care, shave, trim, and nail care every visit. On 04/02/2026 and 04/06/2026, the aide documented that these tasks were not completed. CLINICAL RECORD 8: The patient elected hospice care on 02/05/2026 with a diagnosis of COPD. The aide care plan created by the RN included shampoo every visit. On 02/06/2026, aide documented that this tasks were not completed. CLINICAL RECORD 10: The patient elected hospice care on 01/22/2026 with a diagnosis of Hepatic Encephalopathy. The aide care plan created by the RN on 01/22/2026 included complete shower every visit. On 01/26/2026 the aide documented “ Bed bath was given.” During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the aide did not follow the aide plan of care. No further information was provided.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) clinical record reviewed of patient receiving hospice aide services revealed that the agency did not ensure that the hospice aide reported changes to the aide plan of care regarding tasks not completed. CLINICAL RECORD 3: The patient elected hospice care on 02/21/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral care, ROM and nail care every visit. The aide documented on 02/23/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 5: The patient elected hospice care on 03/31/2026 with a diagnosis of Malignant Neoplasm of Unspecified part of Unspecified Bronchus or Lung. The aide care plan created by the RN included denture care, shave and trim, and nail care every visit. The aide documented on 04/02/2026 and 04/06/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 4: The patient elected hospice care on 07/30/2025 with a diagnosis of Atherosclerotic Heart Disease Without Angina. The aide care plan created by the RN included oral hygiene, and nail care every visit. The aide documented on 02/26/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 2: The patient elected hospice care on 02/25/2026 with a diagnosis of Atherosclerotic Heart Disease. The aide care plan created by the RN included oral hygiene, and nail care every visit. The aide documented on 03/11/2026 that these tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 8: The patient elected hospice care on 02/05/2026 with a diagnosis of COPD. The aide care plan created by the RN 0n 02/05/2026 included shampoo every visit. The aide documented on 02/06/2026 that this tasks were not completed. There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. CLINICAL RECORD 10: The patient elected hospice care on 01/22/2026 with a diagnosis of Hepatic Encephalopathy. The aide care plan created by the RN on 01/22/2026 included complete shower every visit. The aide documented on 01/26/2026 “ Bed bath was given.” There was no documented evidence that the aide reported changes to the RN regarding tasks not completed. During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that the aide did not inform the RN of tasks not completed and changes in the plan of care. No further information was provided.”

“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; Ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s need. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical record reviewed for patients receiving aide services revealed the agency did not ensure that the RN made an onsite visit to do a supervisory visit no less than 14 days to assess the quality of care and services provided by the hospice aide. CLINICAL RECORD 7: The patient elected hospice care on 01/09/2026 with Parkinson’s Disease. The aide’s first visit was on 01/14/2026. A supervisory visit was not complete until 02/05/2026 (21 days after the first aide visit). During an interview and clinical record review on 04/07/2026, the RN/Administrator confirmed the findings that an RN supervisory visit was not completed on time. No further information was provided.”

“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 described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical record reviewed, in which the patient was admitted to a Medicare/Medicaid certified hospital, revealed that the agency did not ensure that a discharge summary was forwarded to the receiving facility. CLINICAL RECORD 15: The patient elected hospice care on 07/04/2025 with the diagnosis of Atherosclerotic Heart Disease. The registered nurse documented on 01/19/2026 that the patient revoked and was admitted to a hospital to seek aggressive treatment. A discharge summary was completed. A review of clinical records revealed no evidence that the completed discharge summary was forwarded to the receiving hospital. On 04/07/2026 a joint record review and interview was conducted with the RN/ Administrator (Personnel Record 3) who confirmed that a discharge summary was not forwarded to the receiving hospital. No further information was provided.”

“It is required that each patient’s individualized written plan of care: 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 1 of 5 (20%) clinical records reviewed, the agency did not ensure the individualized plan of care included specific interventions based on the problems identified in the comprehensive assessment. Clinical Record 2: The patient elected the hospice benefit on 12/12/2023 with terminal diagnoses of protein-calorie malnutrition and senile degeneration of the brain. The initial comprehensive assessment dated 12/12/2023 included documentation that the patient had a Foley catheter in place. On the Skilled Nurse visit notes dated 12/14/23 and 12/15/23 the Skilled Nurse documented that the Foley catheter was patent and draining yellow urine. The plan of care dated 12/12/2023 did not include problems, goals, or interventions related to the genitourinary system or Foley catheter. During the joint record review and interview on 12/18/2023, the Administrator confirmed that the plan of care did not include goals or interventions related to the Foley catheter.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. 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; Physician orders. This CONDITION was not met as evidenced by clinical record review and interview. The hospice failed as follows: To maintain clinical records containing current clinical information including updated comprehensive assessments; updated plans of care, and clinical visit notes which included the care and services provided to patients [HSIM.3.I/L672]; To maintain physician’s orders for care and services provided HSIM.3.I/L678. The cumulative effect of these systemic issues resulted in the potential for compromised quality health care and patient safety. This is a CMS CONDITION DEFICIENCY at 418.104.”

“It is required that the update of the comprehensive assessment is completed by the hospice Interdisciplinary Group, who, in collaboration with the individual’s attending physician, if any, consider the changes that have taken place since the initial assessment. The update of the comprehensive assessment includes information on the patient’s progress toward desired outcomes and the reassessment of the patient’s response to care. The assessment update is completed as frequently as the condition of the patient requires and no less frequently than every 15 days. This standard was not met as evidenced by clinical record review and interview. In 2 of 4 (50%) clinical records reviewed revealed the agency did not ensure the IDG completed updated comprehensive assessments no less frequently than every 15 days to consider patients’ changes that have taken place since the initial assessment. In an interview with the Administrator about both of these clinical records she stated that there were IDG meetings, and these patients were on the agenda. She stated it was the Director of Nursing responsibility to enter the IDG notes for these patients. No other explanations were given. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of the pancreatic duct. During review of the clinical record, it was found that the agency failed to provide updated comprehensive assessments or information on the patient’s progress toward outcomes or change in patient condition. No RN visits were documented on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023. There were no documented IDG meetings with evidence of information on patients decline or progression towards goals. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. During the clinical record review, it was found that the agency failed to provide updated comprehensive assessments or information on the patient’s progress toward outcomes or change in patient condition. This is by evidence of no documented RN visits on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3. There was no input by the RN in the IDG meeting notes that were recorded in September and no IDG meetings recorded for the month of October. In an interview with the Administrator about both of these clinical records she stated that there were IDG meetings, and these patients were on the agenda. She stated it was the Director of Nursing responsibility to enter the IDG notes for these patients. No other explanations were given.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient’s condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by clinical record review and interview. 2 of 4 (50%) clinical records reviewed revealed the agency did not ensure that IDG meetings to review, revise and document the patient’s plan of care were held at least every 15 calendar days. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. There was no documented IDG meetings in the month of October and no other evidence that the plan of care was reviewed or revised at least every 15 calendar days. The Administrator had no explanation for why there were no IDG meetings documented. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. There was no documented evidence of collaboration with the interdisciplinary team and no evidence the plan of care was reviewed or revised since the patient’s admission. The Administrator had no explanation for why there were no IDG meetings documented.”

“Is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. This standard was not met as evidenced by clinical record review and interview. 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure that spiritual counseling services were provided to meet the needs of the patient’s and family’s acceptance of the service. Clinical Record 2: The patient elected the hospice benefit on 9/1/2023 with a diagnosis of Hypertensive Heart Disease & Chronic Kidney Disease. On admission the patient and family accepted Chaplain services and they were ordered on the plan of care for 1 time every month. The Chaplain made an initial visit within 5 days of the admission. There was no other evidence or documentation of any other Chaplain visits or contact with the patient or family. In an interview with the Administrator, she stated that the patient had declined further chaplain services. There was no evidence to support this statement. There was no order to discontinue chaplain services and no changes were made to the plan of care.”

“is required that a hospice aide provides services ordered by the Interdisciplinary group. This standard was not met as evidenced by clinical record review and interview. In 1 of 4 (25%) clinical records reviewed revealed that the agency did not ensure that the aide provide services ordered by the interdisciplinary group. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. Aide services were elected by the patient and were ordered on the plan of care 1 time a week. The aide plan of care was in place and ordered that the aide assist with all activities of daily living. Visits made by the aide on 9/21/2023 and 9/29/2023 revealed that the aide did not complete any of the ordered tasks. In an interview with the administrator, she agreed that the aide did not complete all tasks on the aide care plan.”

“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 and interview. In 2 of 4 (50%) clinical records reviewed revealed that the agency did not ensure clinical records contained updated comprehensive assessments, updated plans of care, and clinical notes of the care and services provided to patients. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse (RN) visits were ordered on the plan of care 1 time a week. The RN case manager made visits on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3/2023. There were no clinical notes to represent the care/service provided on these dates. There were no updated comprehensive assessments since the patient’s admission and no updated plan of care. In an interview with the Director, she stated that she has had problems with the RN not putting in her visit notes in a timely manner. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. On the plan of care RN visits were ordered 1 time a week. The RN made patient visits on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023. There was no documented evidence of the care/services provided to the patient on these dates. There was no updated comprehensive assessment since the patient’s admission and no updated plan of care. In an interview with the Administrator, she agreed that the visits were not documented in a timely manner.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum: Physician orders. This standard was not met as evidenced by clinical record review. 2 of 4 (50%) records revealed skilled nurse visits beyond the ordered frequency in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 9/7/2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. The Registered Nurse (RN) visits were ordered on the plan of care 1 time a week. During the weeks on 10/13, 10/20, 10/23, 10/27, 10/31, and 11/3/2023 biweekly visits were made. There were no physician’s orders in the record to cover these extra visits. Clinical Record 4: The patient elected the hospice benefit on 10/9/2023 with a diagnosis of Malignant neoplasm of pancreatic duct. On the plan of care RN visits were ordered 1 time a week. During the weeks on 10/17, 10/20, 10/23, 10/26, 10/30, and 11/02/2023 biweekly visits were made. There were no physician’s orders in the record to cover these visits.”