Alternative Hospice Care Inc.

“Based on interview and record review, the agency failed to update the Plan of Care (POC) for two of five sampled patients (1, 2). This failure may have lead to patients not receiving needed care and services. Findings: 1. Per the agency’s Plan of Care for the certification period 6/20/26 through 8/18/26, Patient 1 was admitted to the agency on 2/20/26 with diagnoses to include Alzheimer’s disease (causes a mental and physical decline). Per the agency’s Frequency of Visit, dated 7/28/26, there was an order dated 2/23/26 for the Certified Home Health Aide (CHHA) to visit Patient 2 two times per week. There were no orders changing the frequency of CHHA visits after 2/23/26. On 7/28/26 a review was conducted of Patient 1’s home visits. From 5/3/26 through 6/12/26, the Certified home Health Aide (CHHA) provided three home visits per week to Patient 1. On 7/28/26 at 3:43 P.M., a telephone interview was conducted with the Case Manager (CM). The CM stated, he increased the frequency of Patient 2’s CHHA visits from two times per week to three times per week in May 2026. The CM further stated, he should have updated the order and POC to reflect the change in CHHA visit frequency, but he forgot to do so. On 7/29/26 at 10:08 A.M., an interview was conducted with the Director of Patient Care services (DPCS). The DPCS stated, the CM should have updated the order and POC to reflect the increase in CHHA visit frequency for Patient 2. 2. Per the agency’s Plan of Care for the certification period 7/17/26 through 9/14/26, Patient 2 was admitted to the agency on 7/22/25 with diagnoses to include heart failure. Per the agency’s Frequency of Visit, dated 7/28/26, there was an order on 7/24/25 for the Spiritual Counselor (SC) to visit Patient 2 one time per month. There were no orders after 7/24/25 to change the SC visit frequency. On 7/28/26 at 5:28 P.M., a telephone interview was conducted with the SC. The SC stated, that he spoke with the responsible party (RP) for Patient 2 on 7/6/26, and at that point they told him that they no longer wanted any further SC home visits. The SC further stated, he should have updated the order and the POC to change his visit frequency for Patient 2, but he forgot to do so. On 7/29/26 at 10:08 A.M., an interview was conducted with the Director of Patient Care services (DPCS). The DPCS stated, the SC should have documented his conversation with Patient 2’s RP, and updated his visit frequency on the orders and POC. Per the facility’s policy, titled IDG (Interdisciplinary group) care Planning Process, revised February 2025, “The RN (Registered Nurse) ensures that the plan of care is individualized, updated and relevant to the needs of patient/family””

“Based on interview and record review, the agency failed to conduct home visits per the Plan of Care (POC) for three of five sampled patients (1, 2, 4). As a result, patients may not have received needed care and services. Findings: 1. Per the agency’s Plan of Care for the certification period 6/20/26 through 8/18/26, Patient 1 was admitted to the agency on 2/20/26 with diagnoses to include Alzheimer’s disease (causes a mental and physical decline). Per the agency’s Frequency of Visit, dated 7/28/26, there was an order on 2/20/26 for the Medical Social Worker (MSW) to visit Patient 1 one time per month. On 7/28/26 a review was conducted of Patient 1’s Visit Notes. There were no MSW home visits documented for the month’s of April, May, or June in 2026, and there were no communication notes documented to explain the missed visits. On 7/28/26 at 3:37 P.M., a telephone interview was conducted with the MSW. The MSW stated, she did not document her home visits for Patient 1 in the month’s of April, May, or June. The MSW further stated, that she should have documented on the same day as each visit. On 7/29/26 at 10:08 A.M., an interview was conducted with the Director of Patient Care services (DPCS). The DPCS stated, the MSW should have documented her visits to Patient 1. The DPCS further stated, if there was no documentation of a visit, then it could not be known if the visit was completed. 2. Per the agency’s Plan of Care for the certification period 7/17/26 through 9/14/26, Patient 2 was admitted to the agency on 7/22/25 with diagnoses to include heart failure. Per the agency’s Frequency of Visit, dated 7/28/26, there was an order on 7/24/25 for the Spiritual Counselor (SC) to visit Patient 2 one time per month. There were no orders after 7/24/25 to change the SC visit frequency. On 7/28/26 a review was conducted of Patient 2’s medical record. There were no SC home visits documented in May 2026, and there were not any communication notes to explain the missed visit. On 7/28/26 at 5:28 P.M., a telephone interview was conducted with the SC. The SC stated, the scheduled visit for Patient 2 in May 2026 was not completed because of their heavy workload during that period. On 7/29/26 at 10:08 A.M., an interview was conducted with the Director of Patient Care services (DPCS). The DPCS stated, the SC should have documented a communication note to explain why he missed the visit for Patient 2 in May 2026. 3. Per the agency’s Plan of Care for the certification period 6/9/26 through 8/7/26, Patient 4 was admitted to the agency on 12/16/24 with diagnoses to include Parkinson’s disease (a nerve and movement disorder). Per the POC, the MSW was to visit the patient monthly. On 7/28/26, a review of Patient 4’s clinical record was conducted. There was no documented evidence that the MSW visited Patient 4 in June. On 7/29/26 at 10:52 A.M., an interview was conducted with the MSW. The MSW stated she visited Patient 4 but did not document it in Patient 4’s clinical record. The MSW stated it was important to document because if it was not documented, it did not happen. The MSW acknowledged this oversight and accepted full responsibility for the lack of documentation. The agency could not provide a policy and procedure regarding documentation of missed visits.”

“Upon patient record review 2 of 5 (Patient #2,3) 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 #2: The patient did not want a spiritual care initial assessment until 01/21/26. This is outside the 5 day requirement and the nurse did not complete the spiritual portion of the comprehensive assessment. Patient #3: The patient refused initial spiritual care assessment, The RN did the initial spiritual assessment however it was not completed before the 5 days.”

“Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5: Although Bereavement assessment was completed, it was done on day #7.”

“Upon patient record review, 1 of 5 (Patient #3) 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 #3: This patient is seeing spiritual care monthly however there are no interventions or goals in the plan of care surrounding spiritual care.”

“Upon patient record review 8 of 19 (Patient #1,2,3,4,7,10,13,14) 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 1: The MSW, SC and Bereavement assessments were not completed with in 5 days and were not assessed by the RN. Patient 2: The MSW and SC providers did not complete their comprehensive assessment with in 5 calendar days. The RN did not complete the psychosocial and spiritual assessments as part of their comprehensive assessment. Patient 3: The Bereavement comprehensive assessment was not completed. The RN did not complete the bereavement assessment as part of their comprehensive assessment. Patient 4: The SC performed their comprehensive assessment 10/7/25, The MSW performed their comprehensive assessment 10/17/25 both greater than 5 days of admission. The RN did not complete spiritual or psychosocial assessments as part of their comprehensive assessment. Patient 7: The MSW comprehensive assessment was performed on 11/18/25 this is greater than 5 days. The RN did not complete the psychosocial assessment as part of their comprehensive assessment. Patient 10: The MSW comprehensive assessment was performed on 10/20/25, the SC assessment was completed 10/22/25, both greater than 5 days and they were not completed by the RN at SOC. Patient 13: There was no MSW comprehensive assessment completed with in 5 days. The RN did not complete the psychosocial assessment as part of their comprehensive assessment. Patient 14: The SC made a visit on 11/24/25 though pt declined assessment/visit. No SC assessment was made with in 5 days. The RN did not complete the spiritual assessment as part of their comprehensive assessment.”

“Upon patient record review 5 of 19 (Patient #5,7,9,11,15) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient 5: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment. Patient 7: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment. Patient 9,11,15: There has been no SC comprehensive assessment completed. The RN did not complete as part of comprehensive assessment.”

“Upon patient record review, 4 of 19 (Patient #7,8,10,13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: The bereavement assessment was completed 11/11/15. Patient 8: The Bereavement assessment was completed 11/11/25. Patient 10: The Bereavement assessment was completed 10/20/25. Patient 13: The Bereavement assessment was completed 3/8/25.”

“Upon patient record review, 3 of 19 (Patient #5,7,9) 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 5: The SN documented on 12/1/25 that patient has a wound with skin breakdown on coccyx, there is no nursing care plan with goals and interventions for this wound. Corrected on site, nursing care plan updated. Patient 7: The patient is taking Eliquis daily and there is not risk for bleeding care plan with goals and interventions. Corrected on site, nursing care plan updated. Patient 9: The SN documented in comprehensive assessment that patient has dementia and is a high fall risk. There is no care plan for high fall risk. Corrected on site, nursing care plan updated.”

“Upon patient record review, 8 of 19 (Patient #1,2,4,7,8,11,14,15) 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 1: The current Hospice POC contains acetaminophen 650mg rectal, Dulcolax 10mg rectal both PRN however, these were not included on the facility MAR. The facility MAR has magnesium citrate, this was not included on the hospice POC. Corrected on site, orders updated. Patient 2: The current POC contains an order for Polyvinyl Alcohol drops, the facility MAR did not have this medication ordered. Corrected on site, orders updated. The current POC contains an order “if unable to void after 8 hours post foley removal, then replace new foley catheter 18F. There is no balloon size or technique to use or who to insert the catheter. Corrected on site, orders updated. Patient 4: The current POC contains an order for MiraLax with no diluent. The current POC contains an order “Contact hospice case manager if pt noted with blood clots in brief, use large bore catheter 16F and normal saline 0.9% to flush out blood clots as needed due to history of prostate cancer”. There is no amount to flush, frequency to flush or order to insert the catheter. Corrected on site, order updated. Patient 7: The current POC does not contain an order for oxygen though it is listed in the DME supplies and the SN documents pt using O2 11/18/25. Patient 8: The POC contains wound care orders to coccyx and does not state who is to perform. Pt in a ALF. Corrected on site, order updated. Patient 11: The current POC and medication profile contain an order for Jevity feeding to G tube. There are no orders for the G tube site care, flushes or orders for assessment. Family is performing the site care per conversation with SN and they are cleansing daily and applying a drain sponge. On 12/2/25 and other routine SN visits is assessing the G tube site and documenting G tube without signs and symptoms of infection. Corrected on site, order updated. Patient 14: The current POC contains an order for wound care to sacral ulcer but does not include who is to perform the wound care. Corrected on site, order updated. Patient 15: The medical record contains an order for wound care on 11/11/25 to left hip with no frequency or who to provide the wound care.”

“Upon client record review, 2 of 19 (Patient #5,15) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The SN documented on 12/1/25 “Coccyx wound examined-area cleansed, dried and skin barrier applied”. There is no order for this wound care or for barrier cream to apply. The current POC contains an order for SN 1 every 2 weeks. The SN saw the pt on 11/24/25 and 12/1/25 with no evidence of the visit being PRN or an order for the extra visit. Patient 15: The SN documented on 11/21/25 “new wound cleaned with wound cleanser and packed with new dry bandage”. The order was to pack with iodoform and cover with gauze.”

“Upon patient record review, 5 of 19 (Patient #1,2,3,4,5) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The current aide POC contains the following tasks with no frequencies: transfer with mechanical lift, record bowel movements, turn and reposition,change linens. Corrected on site, aide POC updated. Patient 2: The current aide POC contains the following tasks with no frequencies: turn and reposition, change pt linens. Corrected on site, aide POC updated. Patient 3: The current aide POC contains the following tasks with no frequencies: record BM, change patient linens, turn and reposition. Corrected on site, aide POC updated. Patient 4: The current aide POC contains the following tasks with no frequencies: record BM, change patient linens, turn and reposition. Corrected on site, aide POC updated. Patient 5: The current aide POC contains the following task with no frequency: record BM. Corrected on site, aide POC updated.”

“Upon patient record review 4 of 19 (Patient #2,3,7,13) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 2: The aide POC has ordered to dress patient every visit. The aide did not dress the pt on 11/25/25. No evidence of refusal or communication with RN. Patient 3: The POC 12/3/25 contains an order for aides twice a week, the aide did not visit the week of admission, they started 12/9/25. There was no missed visit documentation or evidence of refusal. Patient 7: The POC contains an order for Aide twice weekly beginning 11/14/25. The aide did not start seeing patient until 11/17/25 which is in the next Medicare week. Patient 13: The POC contains an order for aide twice weekly. The aide made 1 visit the week of 11/23-11/29/25 with no evidence of refusal or missed visit documentation.”

“Upon patient record review, 11 of 19 (Patient #1,3,4,6,7,8,9,10,11,12,18) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient 1,3,4,6,7,8,9,10,11,12,18: The Admission CTI only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement.”

“Upon patient record review, 5 of 19 (Patient #5,12,14,15,16) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient 5: The CTI’s/face to face encounters completed on 11/8/25 and 9/9/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 12: The recert CTI only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 14: The recert CTI/face to face on 9/18/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 15: The Recert CTI on 9/2/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement. Patient 16: The recert CTI on 3/27/25 only included a statement by physician of the life expectancy less than 6 months and patient history in nursing section typed in by nurse and did not contain evidence of a physician’s brief narrative explanation of the clinical findings that supports the life expectancy statement.”

“Upon patient client record review, 1 of 19 (Patient #2) did not have evidence that each patient record contains: Patient 2: The notification of the individual’s (or representative’s) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual’s terminal illness and related conditions and would not be covered by the hospice area was not marked yes or no to indicate whether or not the individual wanted a copy of the addendum and the addendum was not sent.”

“Upon patient client record review, 17 of 19 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 1: The hospice election form contains information that the patient does not wish to choose an attending physician then the facility medical director’s name was written in. The hospice medical director is the attending. All of the documentation by the SN, aide, and MSW are not appropriately authenticated and dated. Patient 2: the aide, nurse, MSW, SC did not authenticate and date any of their visits. Patient 3: The MSW has not appropriately authenticated and dated their note on 12/8/25 and the SC has not appropriately authenticated their note on 12/4/25. The election form has marked “I do not wish to choose an attending “ then the facility doctor’s name is written in the blank. Patient 4,8,12,14,15,16: The SN, MSW, SC and Aide notes from admission to current are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 5,11: The Aide notes from admission to current are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 6,9,10: The SN, SW, Aide visits are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 7: The aide visit notes are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 13: The SN notes on 11/25/25, 11/6/25, 11/4/24 are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 14: The aide visit notes from admission to current and the SN notes on 11/6/25, 11/5/25, 11/4/25, 9/23/25 have not been appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 17: The SN notes on 1/25/25, 1/24/25, 1/20/25 are not appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice.”

“Upon patient record review, 2 of 19 (Patient #7,8) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patient 7: The SN documented in the narrative on 11/26/25 receiving order from MD to cleanse the wound area and leave open to air. There was no order transcribed for wound care. Patient 8: The SN documented on 11/4/25 in the narrative: patient with blood clots, called MD and received order that if this persists to insert a foley and bladder irrigations using NS will be initiated as needed. This order was never transcribed into the medical record.”

“Upon client record review, 2 of 19 (Patient #3,4) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 3: The SN documented 12/4/25, 12/8/25 wound care to right toe as “treatment Betadine” there is no evidence the order was followed. The order was to cleanse with NS, pat dry and leave open to air. SN documented on 12/4/25, 12/8/25 for right heel wound care “treatment skin prep”, there is no evidence the order was followed. Order was to cleanse with NS, pat dry apply skin prep and leave open to air. Patient 4: The SN documented on 11/10/25 “RN Flushed bladder with 60ml of NS” there is no order in place to flush irrigate the bladder until 12/10/25. SN documented on 12/1/24 “Patient’s bladder was flushed with NS until blood clots resolved and irrigation showed clear”. There is no order until 12/10/25 and there is no specifics of how much NS was used. Corrected on site, orders updated for continued use.”