Allpoint Hospice

“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 14 (7%) clinical records reviewed, the agency did not ensure that the plan of care included interventions based on problems identified in the initial and updated comprehensive assessments CLINICAL RECORD 7: The patient elected hospice on 10/17/2025. The initial comprehensive assessment dated 10/17/2025 documented dysphasia as a co-morbidity. The initial plan of care dated 10/17/2025 did not include goals and intervention for dysphagia. During the interview on 10/29/2025, The Hospice Clinical Director stated that sometimes when standing orders are entered for palliation of symptoms the nurses forget to enter goals and interventions in the plan of care. She stated she would educate the nurses on entering goals and interventions associated with all identified needs or current problems.”

“It is required that nursing care and services are provided by or under the supervision of a registered nurse and per the patient plan of care. Nursing services ensure that the nursing needs of the patient are met as identified in the patient’s initial assessment, comprehensive assessment, and any updated assessments. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed, revealed the agency did not ensure that nursing services were provided as ordered on the plan of care. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/17/2025 with a diagnosis of Senile degeneration of the brain. The plan of care dated 10/17/2025 ordered nursing visits 1 time weekly (1W12), there was an initial visit documented on 10/17/2025. As of the record review on 10/28/2025 there were no additional visits documented. There was no documentation to explain a missed or canceled visit. During the interview on 10/29/2025 the Hospice Clinical Director verified that there was no evidence of a nursing visit provided within 11 days since admission and no documentation explaining why.”

“It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed of patients who accepted bereavement services, the agency did not ensure that bereavement services were provided based on the bereavement plan of care. CLINICAL RECORD 13: The patient expired on 11/22/2024. The bereavement plan of care documented that letters would be sent at 1, 3, 6, 9, 12, and 13 months. Bereavement letters for 6 months (07/06/2025) and 9 months (10/06/2025) were documented as overdue. The records lacked documented evidence that the services were declined. CLINCAL RECORD 14: The patient expired on 01/06/2025. The bereavement Plan of care documented that letters would be sent at 1, 3, 6, 9, 12, and 13 months. Bereavement letters for 6 months (07/06/2025) and 9 months (10/6/2025) were documented as overdue. The records lacked documented evidence that the services were declined During the interview on 10/29/2025, the Hospice Clinical Director reviewed the record and did not provide evidence that the letters were sent.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide must be prepared by a registered nurse who is responsible for the supervision of a hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 13 (8%) clinical records reviewed of patients accepting hospice aide services the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instruction for patients required care. CLINICAL RECORD 1: A physician order was documented on 09/08/2025 to insert a foley catheter and per nursing assessments from 09/08/2025 through 10/28/2025 a foley catheter was present. The hospice aide plan of care dated 02/01/2025 documented a task for incontinence care. As of the review on 10/28/2025 the hospice aide plan of care was not updated with specific instructions to include foley catheter care. During an interview on 10/28/2021, the Hospice Clinical Director stated that the plan of was not updated to include the foley catheter.”

“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 physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) clinical records reviewed , the agency did not ensure a physician order was obtained. CLINICAL RECORD 7: The patient elected the hospice benefit on 10/17/2025 with a diagnosis of Senile degeneration of the brain. The initial plan of care dated 10/17/2025 documented an oxygen concentrator on the durable medical equipment list. There was no evidence of physician order for use of oxygen, liter flow, route, or frequency. During an interview on 10/29/2025 the Hospice Clinical Director verified there was no physician order entered for oxygen.”

“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 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 records reviewed for patients who were discharged live, the agency did not ensure a discharge summary was sent to the receiving facility. CLINICAL RECORD 12: The patient elected hospice benefit on 07/30/2025 with a diagnosis of Acute on chronic combined systolic and diastolic heart failure. The patient chose to transfer to a hospice facility on 08/08/2025. There was no evidence documented that a discharge summary was sent to the Medicare Certified facility. During the interview on 10/29/2025 the Director of Patient Care stated that she spoke with nurse practitioner at the facility who was caring for patient on the day of discharge 04/30/2025 and provided a copy of the medication record and plan of care for the patient but did not complete the discharge summary or document that it was sent to the facility.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were discharged the agency did not ensure that the hospice discharge summary was documented in the record. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/18/2025 with a diagnosis of Hypertensive heart failure, and revoked his benefit on 04/30/2025. There was no discharge summary in the clinical record documenting his hospice stay, a summary of care provided by hospice, treatments, symptoms and pain management. During the interview on 10/29/2025 the Hospice Clinical Director verified there was no discharge summary documented in the record.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were discharged the agency did not ensure that the hospice discharge summary was documented in the record. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/18/2025 with a diagnosis of Hypertensive heart failure, and revoked his benefit on 04/30/2025. There was no discharge summary in the clinical record documenting his hospice stay, a summary of care provided by hospice, treatments, symptoms and pain management. During the interview on 10/29/2025 the Hospice Clinical Director verified there was no discharge summary documented in the record.”

“It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge includes at least the following: A summary of the patient’s hospice stay, including treatments, symptoms, and pain management, the patient’s current plan of care, the patient’s latest physician orders and any other documentation that will assist in the post-discharge continuity of care or that is requested by the receiving facility or the attending physician. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed for patients who were discharged the agency did not ensure that the hospice discharge summary was documented in the record. CLINICAL RECORD 11: The patient elected the hospice benefit on 04/18/2025 with a diagnosis of Hypertensive heart failure, and revoked his benefit on 04/30/2025. There was no discharge summary in the clinical record documenting his hospice stay, a summary of care provided by hospice, treatments, symptoms and pain management. During the interview on 10/29/2025 the Hospice Clinical Director verified there was no discharge summary documented in the record.”