Allied Hospice, LLC

“Based on record review and interview, the hospice failed to ensure completion of an initial assessment within 48 hours from receipt of referral for hospice services for two (Patients #2 and 12) of 14 patients. Findings: Patient #2A review of the clinical record showed a referral for hospice services on 10/03/25 and showed an initial assessment with a date of election of 10/06/25 (three days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the referring physician and no change in orders. Patient #12A review of the clinical record showed a referral for hospice services on 10/06/25 and showed an initial assessment with a date of election of 10/09/25 (three days from receipt of the referral). The clinical record showed no patient or caregiver refusal or request to delay hospice services, no communication with the referring physician and no change in orders. On 07/08/26 from 1:25 p.m. to 1:46 p.m., Staff A stated the initial assessments for hospice services on patients #2 and 12 were not completed within 48 hours of receipt of the referrals.”

“Based on record review and interview, the hospice failed to ensure the POC was fully developed to include:All services necessary for the palliation and management of the terminal illness for one (Patient #3) of 14 patients.Included hospice aide interventions and goals for nine (Patients #4, 5, 6, 7, 8, 9, 10, 11 and #13) of 14 patients. Findings: Patient #3A plan of care dated 05/26/26 to 08/23/26 and plan of care updates dated 05/27/26, 06/10/26 and 06/23/26 failed to include interventions and goals necessary for the palliation and management of the terminal illness neuroendocrine tumor. On 07/08/26 at 1:30 p.m., Staff A stated the POC for patient #3 failed to include interventions and goals for endocrine tumor. Patient #4A plan of care dated 05/15/26 to 08/12/26 and plan of care updates dated 05/27/26, 06/10/26 and 06/23/26 failed to include interventions and goals for hospice aide services. Patient #5A plan of care dated 05/15/26 to 08/12/26 and plan of care updates dated 05/27/26, 06/24/26 failed to include interventions and goals for hospice aide services. Patient #6A plan of care dated 05/15/26 to 08/12/26 and plan of care updates dated 05/27/26, 06/24/26 failed to include interventions and goals for hospice aide services. Patient #7A plan of care dated 06/12/26 to 08/10/26 and plan of care update dated 06/24/26 failed to include interventions and goals for hospice aide services. Patient #8A plan of care dated 05/20/26 to 07/18/26 and plan of care updates dated 05/27/26, 06/10/26 and 06/23/26 failed to include interventions and goals for hospice aide services. Patient #9A plan of care dated 06/16/26 to 09/13/26 and plan of care update dated 06/24/26 failed to include interventions and goals for hospice aide services. Patient #10A plan of care dated 05/03/26 to 07/01/26 and plan of care updates dated 05/27/26, and 06/24/26 failed to include interventions and goals for hospice aide services. Patient #11A plan of care dated 12/02/25 to 01/30/26 and plan of care updates dated 12/10/25, 12/24/25, 01/07/26 and 01/21/26 failed to include interventions and goals for hospice aide services. Patient #13A plan of care dated 07/04/25 to 07/14/25 and plan of care updates dated 07/09/25 failed to include interventions and goals for hospice aide services. On 07/08/26 from 1:32 p.m. to 1:50 p.m., Staff A stated the POC for patient #3 failed to include hospice aide interventions and goals for patients #4, 5, 6, 7, 8, 9, 10, 11 and #13.”

“Based on record review and interview, the hospice failed to ensure IDG meetings to update and revise individualized patient care plans were conducted every 15 days for three (Patients #1, 5 and #6) of 14 patients. Findings:Patient #1A review of a POC date of 05/05/26 to 07/03/26 showed IDG meeting dates of 05/13/26, 05/27/26 and 06/24/26. The clinical record showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services from 05/27/26 through 06/24/26 (28 days). On 07/08/26 at 1:20 p.m., Staff A patient #1 did not have an IDG meeting every 15 days. Patient #5A review of a POC date of 05/15/26 to 08/12/26 showed IDG meeting dates of 05/27/26 and 06/24/26. The clinical record showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services from 05/27/26 through 06/24/26 (28 days). Patient #6A review of a POC date of 05/15/26 to 08/12/26 showed IDG meeting dates of 05/27/26 and 06/24/26. The clinical record showed no other IDG meeting documentation and no coordination of care communications with the physician related to hospice services from 05/27/26 through 06/24/26 (28 days). On 07/08/26 from 1:20 p.m. to 1:37 p.m., Staff A patients #1, 5 and 6 did not have an IDG meeting every 15 days.”

“Based on record review and interview, the hospice failed to ensure hospice services were provided in accordance with the plans of care frequency for two (Patients #11 and #13) of 14 patients. Findings: Patient #11A review of the plan of care dated 12/02/25 to 01/30/26 ordered MSW visits at a frequency of one time a month. The clinical record showed from 12/02/25 to 01/28/26 an MSW visit was missed on 12/31/25 (two visits ordered, no visits conducted). The clinical record showed no attempts to reschedule the visit, no patient or family refusal of visits and no changes in the ordered frequency for the MSW. On 07/08/26 at 1:43 p.m., Staff A stated social work visit frequency was not followed as ordered. Patient #13A review of the plan of care dated 07/04/26 to 07/14/26 ordered SN visits at a frequency of seven times a week. The clinical record showed from 07/04/26 to 07/14/26 an SN visits were conducted on 07/07/26, 07/10/26, 07/11/26 and on 07/14/26 (11 visits ordered, four visits conducted). The clinical record showed no missed visits, no patient or family refusal of visits and no changes in the ordered frequency for the SN. On 07/08/26 at 1:43 p.m., Staff A stated SN visit frequency was not followed as ordered.”

“Based on record review and interview, the hospice failed to ensure on-site aide supervisory visits were completed every 14 days for one (Patient #11) of 14 patients. Findings: Patient #11A review of the POC dated 12/02/25 to 01/30/26 showed a home health aide visit frequency of one time per week and showed hospice aide visits conducted on 12/24/25 and 12/31/25. The clinical record showed supervisory visits were conducted on 12/22/25 and on 01/07/26 (16 days). On 07/08/26 at 1:45 p.m., Staff A stated supervisory aide visits were not conducted every 14 days.”

“Based on record review and interview, the hospice failed to ensure volunteers provided services in an amount that equaled 5% of the total patient care hours of hospice employees for calendar years 2024 and 2025 for all patients, caregivers and employees. Findings: A review of volunteer records and hours for calendar years 2024 and 2025 showed volunteer utilization rates of 2.9% in calendar year 2024 and 3.3% in calendar year 2025. On 07/08/26 at 10:30 a.m., Staff D stated the hospice did not meet required volunteer use in 2024 and 2025.”

“Based on record review and interview, the hospice failed to ensure a physician certificate of terminal illness for subsequent certification periods for two (Patients #1 and #7) of 14 patients. Findings: Patient #1A review of a plan of care dated 05/05/26 to 07/03/26 showed no certificate of terminal illness for the certification period. Patient #7A review of a plan of care dated 06/12/26 to 08/10/26 showed no certificate of terminal illness for the certification period. On 07/08/26 from 1:20 p.m. to 1:38 p.m., Staff A stated patients #1 and #7 had no certificate of terminal illness for the subsequent certification periods.”

“Based on record review and interview, the hospice failed to ensure provision of a completed summary of care to the physician after revocation and discharge from hospice services for two (Patients #11 and #12) of 14 patients. Findings: Patient #11A review of the clinical record showed the patient revoked and was discharged from hospice services on 01/28/26. The clinical record showed no discharge summary was provided to the physician. Patient #12A review of the clinical record showed the patient revoked and was discharged from hospice services on 01/22/26. The clinical record showed no discharge summary was provided to the physician. On 07/08/26 at 1:45 p.m., Staff A stated the hospice did not provide completed summary of cares to the physician for patients #11 and #12.”

“Based on record review and interview, the hospice failed to ensure completion of the initial bereavement assessment no later than 5 calendar days after the election of hospice care for one (Patient #7) of 14 patients. A review of the clinical record showed an election of the hospice benefit on 02/29/24 with no completion of the initial bereavement assessment from 02/29/24 to 04/18/24 (49 days after the election of the hospice benefit) with no documentation of patient or caregiver refusal of the initial bereavement risk assessment. On 04/18/24 at 1:00 pm., Staff C stated the initial bereavement assessment was not completed for Patient #7.”

“Based on record review and interview, the hospice failed to ensure a timely review of medications for five (Patient #1, 3, 6, 7 and 11) of 14 patients. Patient #1 A review of the plan of care dated 01/22/24 to 03/21/24 included interventions to administer oxygen as ordered (no ordered flow rate was included). Documentation showed no addition of oxygen to the medication profile. Patient #3 A review of the plan of care dated 01/19/24 to 04/17/24 included interventions to administer oxygen as ordered (no ordered flow rate was included). Documentation showed no addition of oxygen to the medication profile. Patient #6 A review of the plan of care dated 01/31/24 to 04/29/24 included interventions to administer oxygen as ordered (no ordered flow rate was included). Documentation showed no addition of oxygen to the medication profile. Patient #7 A review of the plan of care dated 02/29/24 to 05/28/24 showed no addition of any medications to the medication profile. Patient #11 A review of the plan of care dated 03/13/24 to 05/11/24 included interventions to administer oxygen as ordered (no ordered flow rate was included). Documentation showed no addition of oxygen to the medication profile. On 04/18/24 at 1:35 pm, Staff C stated oxygen was not added to the medication profile for Patients #1, 3, 6 and 11 and no medications were added to the medication profile for Patient #7.”

“Based on record review and interview, the hospice failed to ensure 1. skilled nurse visits were provided in accordance with the plan of care for two (Patients #3) of 14 patients; 2. hospice aide visits were provided in accordance with the plan of care for one (Patient #4) of 14 patients; and 3. social worker visits were provided in accordance with the plan of care for one (Patient #9) of 14 patients. 1. Patient #3 A review of the plan of care dated 01/19/24 to 04/17/24 and plan of care updates dated 01/21/24, 02/14/24, 02/23/24 and 03/13/24 showed a skilled nurse frequency of two visits per week for. A review of the clinical record showed the following: A skilled nurse missed visit note date 03/05/24 documented the reason for the missed visit was due the patient being “out with family” for the week of 03/03/24 to 03/09/24 (one of two completed visits for this week). Documentation showed no patient or family refusal of visits, no change in the ordered frequency and no attempts to reschedule the missed visit. 2. Patient #4 A review of the plan of care dated 02/02/24 to 04/01/24 and plan of care updates dated 02/14/24, 02/28/24, 03/13/24 and 03/27/24 showed a hospice aide frequency of two visits per week. A review of the clinical record showed the following: A hospice aide missed visit note dated 03/28/24 documented the reason for the missed visit as being informed by the social worker that the patient would not be “home tomorrow” for the week of 03/17/24 to 03/23/24 (only one of two completed visits for this week). Documentation showed no patient or family refusal of visits, no change in the ordered frequency and no attempts to reschedule the missed visit. Patient #9 A review of the plan of care dated 01/07/24 to 04/05/24 and plan of care updates dated 01/07/24 and 01/17/24 showed a social worker frequency of one to two visits per month. A review of the clinical record showed the following: A social worker visit dated 01/10/24 documented a missed visit (no visits were completed for the month of January). Documentation showed no patient or family refusal of visits, no change in the ordered frequency and no documentation of attempts to reschedule the missed visit.On 04/18/24 at 1:10 pm., Staff B stated: 1. the skilled nurse frequency was not followed as ordered for Patient #3; 2. the hospice aide frequency was no followed as ordered for Patient #4 and 3. the social worker frequency was not followed as ordered for Patient #9.”

“Based on record review and interview, the hospice failed to ensure an individualized plan of care was fully developed to include all services necessary for the palliation and management of the terminal illness for nineteen (Patients #1, 4 and 5) of 14 patients reviewed. Patient #1 A plan of care dated 01/22/24 to 03/21/24 documented a primary diagnosis of senile degeneration of the brain and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #4 A plan of care dated 02/02/24 to 04/01/24 documented a primary diagnosis of cancer of overlapping sites of stomach and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. Patient #5 A plan of care dated 02/19/24 to 04/18/24 documented a primary diagnosis of Alzheimer’s disease and showed no individualized plan of care development for the services necessary for the palliation and management of the terminal illness. On 04/18/24 at 1:35 pm, Staff C stated the plans of care for Patients #1, 4 and 5 failed to include services necessary for the palliation and management of the terminal illness.”