Alc Palliative and Hospice Care Inc.

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any), the patient or patient representative, if any of them so desire, and the primary caregiver in accordance with the patient’s needs, if any of them so desire. This standard was not met as evidenced by clinical record review and interview. In 1 of 9 (11%) Clinical records reviewed in which a patient had a wound, the agency did not ensure that the physician ordered plan of care was followed for documentation of the wound care frequency. CLINICAL RECORD 8: The physician order effective 02/18/2025 and additional orders dated 04/10/2025 and 05/15/2025 for wound care to the ear and right forearm stated, “Hospice SN (skilled nurse) to change the dressings twice a week. FSN (Facility skilled nurse) may change dressing PRN (as needed) soiling”. The dressing was documented as changed by the hospice nurse on 04/21/2025, 04/24/2025, 05/01/2025, 05/08/2025, then 05/12/2025, and twice a week after that. For a two-week period, there was no documentation that the plan was followed for the twice-a-week dressing change, or who changed the dressing the second time during those two weeks. The wound did document improvement and did eventually heal. During the interview with the director of nursing who reviewed the record on 06/04/2025, it was stated that the documentation did not document the twice-a-week changes and that the facility nurse changed the dressing in between but agreed that this was not documented.”

“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, document review and interview. In 2 of 19 (11%) clinical records reviewed, it was revealed that the agency did not ensure that the plans of care documented all interventions for the care of the patients. Agency Policy: No.9-017 [revised April 2019], titled, The Plan of Care, stated in part, “The written plan of care will contain, but will not be limited to, the following: Individualized intervention to assist with end-of-life care.” CLINICAL RECORD 6: The plan of care was dated 01/25/2024 documented the following interventions, “Observe patient as he/she stands up from a chair without using his/her arms, walks several paces, turns, returns to chair, and sits down to assess patient fall risk. This continued to be documented every two weeks to the last updated plan of care dated 05/26/2025, though the patient was documented on 01/24/2025 as standing with help for short periods only, and on 07/29/2025 documented as became a Hoyer transfer as increasingly unsteady and unable to support self.” The intervention was not updated as the patient’s assessment was updated. Additionally, the updated Interdisciplinary Group meeting (IDG) dated 02/27/2024 documented the patient was using an Ensure supplement due to decreased oral intake. The updated IDG on 05/21/2025 documented the patient was eating less and using 3 bottles of Ensure a day. There were no documented interventions or goals related to this identified nutritional need. CLINICAL RECORD 8: The physician order dated 02/18/2025, documented “Rinse left ear with wound cleanser, pat dry, apply medihoney, cover with border gauze dressing. Hospice SN to change dressing twice weekly. Facility SN to change/reinforce dressing PRN soiling or dislodgement.” The physician order dated 04/10/2025 stated, “Cleanse left ear with wound cleanser, pat dry, apply medihoney cover with bordered gauze dressing. Hospice SN to change dressing twice weekly, FSN to change/reinforce dressing PRN soiling, dislodgement. 05/15/2025 right forearm rinse with wound cleanser, pat dry, cover with bandage, Hospice SN to change dressing twice weekly. FSN to change, reinforce/dress PRN soiling. The plans of care from 02/18/2025, updated every 2 weeks, did not document any interventions or goals for skin integrity. The IDG meeting minutes dated 4/8/2025, 04/23/2025, 05/06/2025, and 05//20/2025 updates documented that the dressings were changed and on 05/06/2025 documented non-healing wounds but no interventions or goals were documented. During the interview with the director of nursing on 06/05/2025, who reviewed the records, it was stated that the interventions were missing from the plan of care, but that the orders were present.”

“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 as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. 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 and interview. In 3 of 19 (16%) clinical records reviewed, it was revealed that the agency did not ensure that there were documented goals for all problems that were documented. CLINICAL RECORD 2: The need for volunteer services was identified 10/09/2023 and family was called by the coordinator. The volunteer visit was dated 01/20/2025. There was no reason for the long delay documented in the IDG documentation dated 10/10/2023, 10/24/2023, and 11/07/2023 of what was being pursued for the volunteer need identified. CLINICAL RECORD 3: The need for pet therapy was identified and documented on a volunteer assessment completed 01/20/2025. The IDG notes documented 01/28/2025, 02/11/2025, and 02/25/2025 did not include any updates for the pet therapy and no notes that documented it was provided or why it might not have been. CLINICAL RECORD 14: The nursing assessments documented 2 times a week visits documented the wound status and the unstageable wound with measurements and the dressing change but the updates to progress or lack of progress was not documented on the IDG meetings.”

“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. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IID (intermediate care facility/Individuals with Intellectual Disabilities) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered, and the frequency of service delivery. This standard was not met as evidenced by clinical record review, document review and interview. In 2 of 3 (66%) clinical records reviewed in which bereavement services would have been provided, it was revealed that the agency did not ensure there was documentation of a bereavement plan of care with the frequency of interventions to be provided. Agency Policy: Policy No. 1-021 [revision date 12/2018] titled Bereavement Assessment, stated in part, “After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow up assessment. The Bereavement Coordinator will develop a plan of intervention based on the findings of the bereavement follow-up assessment. The Bereavement Coordinator or Volunteer will document the family bereavement interventions.” CLINICAL RECORD 16: The patient died on 10/15/2024. A phone call was made to triage by the bereavement coordinator on 10/16/2024 and spoke to the daughter, who was a low bereavement risk, and documented in part, “Letters to continue in the mail contact as needed. There was no documented bereavement plan, and the mailings are not defined by frequency. A sympathy card was documented as sent on 10/22/2024, and on 02/12/2025, the #2 Newsletter was documented as sent to the daughter. It was documented that continuation of the plan of care would be followed, but there was no documented plan of care. CLINICAL RECORD 17: The patient died on 12/12/2024. A phone call was made from the social worker on 12/15/2024 and documented in part, “Spoke with daughter. Bereavement to follow up and update POC accordingly. On 12/16/2024, a documented email was sent to reach out to the family. On 02/12/2025, the family was sent newsletter # 1. There was no documented bereavement plan with interventions or frequency of bereavement services to be provided. During the interview with the administrator and director of nursing, who stated that the bereavement plan was not documented. There was no documented bereavement plan with interventions or frequencies.”

“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 are prepared by an RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed in which a hospice aide was accepted, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 5: The hospice aide’s plan of care was documented on 05/09/2025 with an aide visit frequency of 2 times a week—no updates were documented for the aide plan. The hospice aide documented on 05/29/2025 the completion of the assigned task of a shower every visit. The visits on 05/12/2025 and 05/29/2025 documented that TED (antiembolism hose) hoses were worn bilaterally. (These would require removal and reapplied if a shower were provided). The hospice aide visit note dated 05/22/2025 documented that TED hoses were applied. The visit note dated on 05/20/2025 documented that the TED hose were not available. The aide documented each visit, updating the hospice RN and the facility nurse. The hospital aide’s plan with assigned tasks did not assign a task to apply the TED hose, as of the review date, 06/03/2025. During interview with the Director of Nursing on 06/03/2025 it was stated that the TED hose should have been documented on the aide care plan.”

“It is required that volunteers be used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care, and documented in the patient record, including the time spent. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records reviewed, of patients that accepted a volunteer, it was revealed that the agency did not ensure that the volunteer’s assigned visits were documented. CLINICAL RECORD 2: The documented need for a volunteer was identified on 10/09/2023, on a social work assessment visit, and the family was called by the volunteer coordinator. The volunteer visit was dated 01/20/2025. There was no reason documented for the long delay in providing the service. CLINICAL RECORD 3: The documented need for a volunteer was identified, and the volunteer assessment was documented on 01/20/2025 with the need for PET therapy. There was no documentation as of the date of review 06/05/2025, that the PET therapy was provided or a reason why it was not, or communication with the patient and family as to why it was not provided. During interview with the administrator and the volunteer coordinator on 06/05/2025, the volunteer coordinator (in her role for less than six months), stated that as she entered the position some rebuild of the program was necessary and that the volunteer who provided PET therapy disappeared and could not be reached so documentation was not obtained. Efforts were made but the resolution was not documented in the clinical record.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The hospice documents the cost savings achieved through volunteers. Documentation includes: The identification of each position that is occupied by a volunteer; The work time spent by volunteers occupying those positions; Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1 and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Review of the documented hospice volunteer cost savings for the calendar year 2024 was 3.1%. The volunteer coordinator had achieved cost savings of 3% year to date, 2025 and had also been working on recruitment opportunities. During the interview with the Quality Director and the Volunteer Coordinator on 06/06/2025 they stated that the volunteer program had an active process improvement plan in place. Review of hospice volunteer cost savings for 2024 was 3.1%. The volunteer coordinator has achieved cost savings of 3% so far in 2025, but has also been working on recruitment and opportunities.”