Alpha Hospice Care

“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.”