Alpha Care Hospice Inc.

“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. A revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review, document review, and interview. In 10 of 14 (71%) clinical record reviewed, it was revealed that the agency did not ensure the patient’s plans of care were revised to reflect progress towards the outcomes and goals. Agency’s Policy 1-033, Prioritizing Patient Problems/Needs (November 2021), stated in part “the plan of care should include needs, goals, dates identified and resolution dates. As goals are achieved, additional interventions may be added to the plan of care to direct patient care.” CLINICAL RECORD 1: The patient’s plan of care, dated 02/28/2025, included the stated goal, “patient/caregiver will verbalize understanding of safety measures re: oxygen use by end of visit on 03/05/2025.” The patient remained on oxygen therapy and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 2: The patient’s plan of care, dated 02/17/2023, included the stated goal, “patient/caregiver will verbalize understanding of safe use of Durable Medical Equipment (DME) dispensed to patient on first nursing visit after equipment is present.” The equipment was delivered on 02/17/2023 and the next nursing visit was conducted on 02/21/2023. The DME remained in the home and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 3: The patient’s plan of care, dated 05/20/2025, included the stated goal, “patient/caregiver will verbalize understanding of safe use of Durable Medical Equipment (DME) dispensed to patient on first nursing visit after equipment is present.” The equipment was delivered on 05/20/2025 and the next nursing visit was conducted on 05/25/2025. The DME remained in the home and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 4: The patient’s plan of care, dated 06/30/2025, included the stated goal, “patient/caregiver will verbalize understanding of oxygen safety measures re: including all elements from oxygen safety checklist by second visit 07/03/2025.” The patient remained on oxygen therapy and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 8: The patient’s plan of care, dated 01/14/2023, included the stated goal, “patient/caregiver will verbalize understanding of oxygen safety measures re: including all elements from oxygen safety checklist by second visit 01/17/2023.” The patient remained on oxygen therapy and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 9: The patient’s plan of care, dated 11/29/2023, included the stated goal, “patient/caregiver will verbalize understanding of safe use of Durable Medical Equipment (DME) dispensed to patient on first nursing visit after equipment is present.” The equipment was delivered on 11/29/2023 and the next nursing visit was conducted on 12/05/2023. The DME remained in the home and as of the date of this review 09/10/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 11: The patient’s plan of care dated 05/24/2025, included the stated goal, “patient/caregiver will verbalize understanding of oxygen safety including all elements from 02 safety checklist by second visit dated 05/30/2025.” The patient remained on oxygen therapy and as of the date of this review 09/11/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 12: The patient’s plan of care, dated 01/30/2025, included the stated goal, “patient/caregiver will verbalize understanding of safety measures re: oxygen use by end of visit date of second 02/10/2025.” The patient remained on oxygen therapy and as of the date of this review 09/11/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 13: The patient’s plan of care, dated 09/16/2024, included the stated goal, “patient/caregiver will verbalize understanding of safe use of Durable Medical Equipment (DME) dispensed to patient on first nursing visit after equipment is present.” The equipment was delivered on 09/16/2024 and the next nursing visit was conducted on 09/18/2024. The DME remained in the home and as of the date of this review 09/11/2025, there have been no revisions or progress towards the goal documented. CLINICAL RECORD 14: The patient’s plan of care, dated 03/19/2025, included the stated goal, “patient/caregiver will verbalize understanding of oxygen safety including all elements from 02 safety checklist by second visit dated 03/27/2025.” The patient remained on oxygen therapy and as of the date of this review 09/11/2025, there have been no revisions or progress towards the goal documented. During an interview on 09/11/2025 the Administrator/Director of Patient Care Services said that the process was to leave the interventions and goals open once they were initiated and confirmed that these had not been revised or closed once the goal dates had expired.”