Aloria Healthcare

“It is required that each patient’s individualized written plan of care reflects patient and family goals and 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 3 of 14 (21%) clinical records reviewed, the agency did not ensure the plan of care included patient and family goals and planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The initial nursing assessment dated 11/15/2025 included documentation in the narrative portion that the patient had bladder and bowel incontinence. The plan of care dated 11/15/2025 did not include goal(s) and intervention(s) for the patient’s assessed bladder and bowel incontinence. CLINICAL RECORD 9: The patient elected the hospice benefit on 11/19/2025 with diagnosis of senile degeneration of the brain. The initial nursing assessment dated 11/19/2025 included in the narrative portion that the patient had bladder and bowel incontinence. The plan of care dated 11/19/2025 did not include goal(s) and intervention(s) for the patient’s assessed bladder and bowel incontinence. CLINICAL RECORD 10: The patient elected the hospice benefit on 11/14/2025 with diagnosis hypertensive heart disease without heart failure. The initial psychosocial assessment dated 11/17/2025 included documentation that the Social Worker would see the patient one time per month. The initial spiritual assessment dated 11/16/2025 included documentation that the Spiritual Counselor would see the patient one time per month. The plan of care did not include goal(s) and intervention(s) for the Social Worker and the Spiritual Counselor. During an interview and joint clinical record reviews on 02/18/2026, the Licensed Vocational Nurse, the Director of Patient Care Services Designee, and the Alternate Administrator stated they agreed the plans of care for clinical records 4 and 9 lacked specific goals and interventions for bladder and bowel incontinence that were identified on the initial nursing assessments. They also agreed the plan of care for clinical record 10 was missing specific goals and interventions for the social worker and the spiritual counselor that had planned frequency of visits once a month.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician 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 4 of 4 (100%) clinical records reviewed for patients that revoked the hospice benefit, the agency did not ensure a copy of the hospice discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 4: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient and family revoked the hospice benefit on 02/12/2026 to pursue curative treatment. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient’s attending physician. CLINICAL RECORD 5: The patient elected the hospice benefit on 01/22/2026 with diagnosis of hypertensive heart disease with heart failure. The patient and family revoked the hospice benefit on 02/11/2026 to leave the country. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient’s attending physician. CLINICAL RECORD 6: The patient elected the hospice benefit on 11/15/2025 with diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. The patient and family revoked the hospice benefit on 02/04/2026 to pursue curative treatment. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient’s attending physician. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/14/2025 with diagnosis of heart failure. The patient and family revoked the hospice benefit on 01/09/2026 to relocate. There was no documented evidence in the clinical record that the agency forwarded the discharge summary to the patient’s attending physician. During an interview and joint clinical record reviews on 02/18/2026, the Licensed Vocational Nurse, the Director of Patient Care Services Designee, and the Alternate Administrator stated they agreed the clinical records for the patients/families that revoked the hospice benefit did not include documentation that the discharge summaries were forwarded to the patient’s attending physician.”