All Care Hospice Inc.

“Based on interview and document review, the agency failed to ensure care and services were provided in accordance with the plan of care for 4 patients (#3, #11, #19 and #9), out of a total sample of 19 patients.Findings include: 4. For Patient #9, the agency failed to ensure Home Health Aide (HHA) visits were provided as ordered.Patient #9 was admitted to the agency in September 2025 with diagnosis of malignant neoplasm of the lung.Review of Patient #9’s physician ordered plan of care for certification period 9/22/25 through 12/20/25, included an addendum physician’s order dated 9/25/25, for HHA visits 2 times a week to begin 9/29/25.Review of the clinical record indicated only 1 HHA visit was documented as being completed on 10/9/25, 11 days after the physician’s order indicated.During an interview on 10/16/25 at 11:15 A.M., the Director of All Care Resources confirmed Patient #9 received only 1 HHA visit on 10/9/25. She said the expectation would be for HHA services to be scheduled within 48 hours of the physician order and the HHA scheduler missed the order. Review of the agency policy, titled, Communication with Physician, reviewed on 3/6/25, included the following:The physician is notified in writing a minimum of every 60 days and as needed. Physicians will be notified in the interim but not limited to: changes in the plan of care; when there is any problem implementing the plan of care.1.) For Patient #3, the agency failed to provide Home Health Aide (HHA) visits as ordered.Patient #3 admitted to the agency in August 2025 with a diagnosis of Alzheimer’s Disease.Review of the physician ordered plan of care for certification period 8/8/25 to 11/5/25 included an order for a Home Health Aide (HHA) 5 times per week.Review of the clinical record indicated that for the weeks of 8/17/25 and 8/25/25 a HHA was provided 4 times, not 5 times as ordered.During an interview on 10/15/25 at 1:40 P.M., the Vice President of Hospice Services said that an HHA was not provided 5 times as ordered for the weeks of 8/17/25 and 8/25/25. She said the scheduler should have notified the case manager so that the case manager could notify the physician that there was a problem implementing the plan of care.2.) For Patient #11, the agency failed to provide Physical Therapy (PT) visits as ordered.Patient #11 admitted to the agency in November 2024 with a diagnosis of cerebral infarction (stroke).Review of the physician ordered plan of care for the certification period 11/5/24 to 2/2/25 included an order for Physical Therapy (PT) 1 time a week for 11 weeks.Review of the clinical record indicated that PT was provided 1 time the week of 12/15/25. The record failed to indicate that PT was provided as ordered the weeks of 11/24/24, 12/1/24, 12/8/24 or 12/22/24. The order was discontinued 12/31/24.Review of Missed Visit Notes dated 11/26/24, 12/6/24 and 12/13/24 were blank. The notes failed to indicate the reason the visit was not made and failed to indicate that the physician was notified.During an interview on 10/16/25 at 10:10 A.M., Clinical Manager #1 said that the PT should have documented the reason the visits were not made per the plan of care, and the physician should have been notified of the missed visits.3.) For Patient #19, the agency failed to provide Home Health Aide (HHA) visits as ordered.Patient #19 admitted to the agency in October of 2024 with a diagnosis of Alzheimer’s Disease.Review of the physician ordered plan of care for certification period 9/23/25 to 11/21/25 included an order for HHA 3 times per week.Review of the clinical record indicated that HHA visits were provided 2 times per week, not 3 as ordered for the weeks of 8/31/25, 9/7/25, 9/14/25, 9/21/25, 9/28/25 and 10/5/25.During an interview on 10/15/25 at 12:15 P.M., the Vice President of Operations said that as of 9/1/25 the HHA who visits Patient #19 was no longer able to visit 3 times per week. She said the scheduler offered another HHA and the family requested to have 2 visits per week with the current HHA. She said the scheduler did not tell the case manager so that the case manager could notify the physician of the change in the plan of care.”

“Based on interview and document review, the agency failed to ensure the physician was notified when the plan of care was not implemented as ordered for 4 patients (#3, #11, #19 and #9), out of a total sample of 19 patients.Findings include: 4. For Patient #9, the agency failed to ensure the physician responsible for the plan of care (POC) was notified of the Home Health Aide (HHA) missed visits.Patient #9 was admitted to the agency in September 2025 with diagnosis of malignant neoplasm of the lung.Review of Patient #9’s physician ordered POC for certification period 9/22/25 through 12/20/25, included an addendum physician’s order dated 9/25/25, for HHA visits 2 times a week to begin 9/29/25.Review of the clinical record indicated only 1 HHA visit was documented as being completed on 10/9/25, 11 days after the physician’s order indicated.Further review of the clinical record failed to include documentation the physician was notified of the missed HHA visits, as required.During an interview on 10/16/25 at 11:15 A.M., the Director of All Care Resources confirmed Patient #9 received only 1 HHA visit on 10/9/25. She said the scheduler should have notified the primary clinician, who would have notified the physician of the missed visits, however there was no documentation that the clinician/physician was notified. Review of the agency policy, titled, Communication with Physician, reviewed on 3/6/25, included the following:The physician is notified in writing a minimum of every 60 days and as needed. Physicians will be notified in the interim but not limited to: changes in the plan of care; when there is any problem implementing the plan of care.1.) For Patient #3, the agency failed to ensure the physician responsible for the plan of care (POC) was notified of home health aide missed visits.Patient #3 admitted to the agency in August 2025 with a diagnosis of Alzheimer’s Disease.Review of the physician ordered plan of care for certification period 8/8/25 to 11/5/25 included an order for a Home Health Aide (HHA) 5 times per week.Review of the clinical record indicated that for the weeks of 8/17/25 and 8/25/25 a HHA was provided 4 times, not 5 times as ordered.During an interview on 10/15/25 at 1:40 P.M., the Vice President of Hospice Services said that an HHA was not provided 5 times as ordered for the weeks of 8/17/25 and 8/25/25. She said the scheduler should have notified the case manager so that the case manager could notify the physician that there was a problem implementing the plan of care.2.) For Patient #11, the agency failed to ensure the physician responsible for the plan of care (POC) was notified of missed physical therapy visits.Patient #11 admitted to the agency in November 2024 with a diagnosis of cerebral infarction (stroke).Review of the physician ordered plan of care for the certification period 11/5/24 to 2/2/25 included an order for Physical Therapy (PT) 1 time a week for 11 weeks.Review of the clinical record indicated that PT was provided 1 time the week of 12/15/25. The record failed to indicate that PT was provided as ordered the weeks of 11/24/24, 12/1/24, 12/8/24 or 12/22/24. The order was discontinued 12/31/24.Review of Missed Visit Notes dated 11/26/24, 12/6/24 and 12/13/24 were blank. The notes failed to indicate the reason the visit was not made and failed to indicate that the physician was notified.During an interview on 10/16/25 at 10:10 A.M., Clinical Manager #1 said that the PT should have documented the reason the visits were not made per the plan of care, and the physician should have been notified of the missed visits.3.) For Patient #19, the agency failed to ensure the physician responsible for the plan of care was notified of missed Home Health Aide (HHA) visits.Patient #19 admitted to the agency in October of 2024 with a diagnosis of Alzheimer’s Disease.Review of the physician ordered plan of care for certification period 9/23/25 to 11/21/25 included an order for HHA 3 times per week.Review of the clinical record indicated that HHA visits were provided 2 times per week, not 3 as ordered for the weeks of 8/31/25, 9/7/25, 9/14/25, 9/21/25, 9/28/25 and 10/5/25.During an interview on 10/15/25 at 12:15 P.M., the Vice President of Operations said that as of 9/1/25 the HHA who visits Patient #19 was no longer able to visit 3 times per week. She said the scheduler offered another HHA and the family requested to have 2 visits per week with the current HHA. She said the scheduler did not tell the case manager so that the case manager could notify the physician of the change in the plan of care.”

“Based on review of quality assessment and performance (QAPI) records and staff interview, it was determined the hospice failed to implement and maintain documentation of performance improvement projects (PIPS) being conducted, the reasons for conducting these projects, and any measurable progress achieved on these projects. This deficient practice had the potential to affect all patients who were currently receiving hospice services and future hospice patients.Findings include: Review of the agency policy, titled Quality Assessment and Performance Improvement Program, reviewed 3/6/25, indicated the following:Policy: The agency will evaluate, monitor, and improve the quality of patient/client care as evidenced by the improvement of specific data-driven indicators.Performance Measurement (Data Collection)For each process selected for measurement, a systematic process will be sued to collect data to:a. Design and assess new processes.b. Assesses the dimension of performance relevant to functions, processes, and outcomes.c. Measure the level of performance and stability of important existing processes.d. Identify areas for possible improvement of existing processes; and, e. Determine whether changes improved the process.A review of QAPI documents for April 24, 2025, included a PIP with a date of April 1, 2025, for Clinician Missed Visit Documentation. The PIP indicated monthly audits would be conducted to ensure that the agency was following the policy and documenting appropriately. No audits or documentation was done as stated. No audits were provided to the surveyor during the survey.During the recertification survey, during the record review, it was identified that 4 of 19 records had concerns with missed visits.During an interview on October 16, 2025, at 10:30 A.M., the Vice President of Hospice (VP) said that the concern around documentation of missed visits was identified back in the spring of 2025, and a PIP was implemented on April 1, 2025. She said that due to the upcoming initiation of the Hope program (new assessment tool for Hospice) the agency failed to continue the PIP as planned. The VP said the missed visit audits took a back seat.”

“Based on interview and document review, the agency failed to ensure supervision of the Home Health Aide (HHA) was provided no less frequently than every 14 days for 1 patient (#19), out of a total of 19 patients.Findings include: Review of the agency policy, titled, Hospice Aide Supervision, undated, included the following:A registered nurse (RN) makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by Interdisciplinary Group and provided by the hospice aide are meeting the patient’s need.The supervisory visits are documented in the patient’s clinical record every two weeks and include notations regarding the aid’s competency, whether the aide is following the patient’s plan of care and is satisfactory to the patient/family.Patient #19 was admitted to the agency in October of 2024 with a diagnosis of Alzheimer’s Disease.Review of the Physician ordered Plan of Care for certification period 9/23/25 to 11/21/25 included an order for a Home Health Aide (HHA) 3 times per week.Review of the clinical record on 10/14/25 indicated that HHA was provided 2 times per week for the weeks of 8/31/25, 9/7/25, 9/14/25, 9/21/25, 9/28/25 and 10/5/25. Further review indicated that an RN Supervisory visit was last conducted on 9/5/25. The medical record failed to include any supervisory visits between 9/5/25 and 10/14/25 (39 days).During an interview on 10/15/25 at 12:20 P.M., the Vice President of Hospice and Clinical Manger #1 said that supervisory visits should be completed at least every 14 days, but they were unable to find documentation in the medical record to indicate that one had been conducted since 9/5/25.”

“Based on document review and staff interview, the agency failed to provide volunteers in a day-to-day administrative and/or direct patient care service position in an amount that, at a minimum, equals five (5) percent of the total patient care hours of all paid hospice employees and contract staff. Findings include: Review of the Volunteer Cost Savings Report between August 2024 and August 2025 indicated the following:8/2024 - Cost Savings 3% 9/2024 - Cost Savings 3% 10/2024 - Cost Savings 3%11/2024 - Cost Savings 2%12/2024 - Cost Savings 3%1/2025 - Cost Savings 3%2/2025 - Cost Savings 2.5%3/2025 - Cost Savings 2.5%4/2025 - Cost Savings 2%5/2025 - Cost Savings 2%6/2025 - Cost Savings 2.5%7/2025 - Cost Savings 2%8/2025 - Cost Savings 2%Total Cost Savings last 12 months: 2.7% During an interview on 10/14/25 at 1:00 P.M, the Volunteer Coordinator said the agency has not been able to meet the requirement of 5% for volunteers. During an interview on 10/16/25 at 10:30 A.M. with the Vice President of Hospice, she said that the volunteer cost savings program does not meet the 5% requirement but that they continue to reach out in the surrounding communities and team up with bereavement services to try to gain more volunteers.”