Allstate Hospice LLC

“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 observation and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the individualized plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 1: The patient elected the hospice benefit on 09/11/2024. The skilled nurse documented on the initial nursing assessment dated 09/11/2024, that the patient had a G-tube [gastrostomy tube]. The plan of care dated 09/11/2024 to 12/09/2024 did not include planned interventions addressing assessment and care of the G-tube. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/28/2025. The skilled nurse documented on the nursing assessment dated 04/09/2025, that the patient had a urinary tract infection. The plan of care dated 03/28/2025 to 06/25/2025 did not include planned interventions related to the patient’s urinary tract infection. CLINICAL RECORD 11: The patient elected the hospice benefit on 11/07/2024. The skilled nurse documented on the nursing assessment dated 12/04/2024, that the patient had a stage 2 wound to the coccyx and the facility was providing wound care. The plan of care dated 11/07/2024 to 02/04/2025 did not include planned interventions related to the patient’s wound identified during the nursing assessment. During an interview on 06/24/2025, the Director of Nursing (Personnel Record 7) stated she would have the nurse update the plan of care and they will be doing additional education regarding updating the plan of care.”

“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 document review, clinical record review, and interview. In 3 of 3 (100%) clinical records reviewed with bereavement services provided, the agency did not ensure the bereavement plan of care included the types of bereavement services offered and the frequency of service delivery. Agency policy PC.130 Bereavement, last reviewed 090124, required in part, “The bereavement coordinator will complete a follow-up assessment and develop a bereavement POC [plan of care] for bereavement services based on the re-assessment and the family and/or caregiver’s willingness to receive services.” CLINICAL RECORD 15: The patient elected the hospice benefit on 01/05/2024 and the date of death was 06/24/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and multiple phone calls were also completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 16: The patient elected the hospice benefit on 10/29/2024, and the date of death was 11/01/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and multiple mailings were also completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. CLINICAL RECORD 17: The patient elected the hospice benefit on 11/15/2024, and the date of death was 11/18/2024. Clinical record review revealed a post-death bereavement assessment had been completed, a sympathy card was sent, and one phone call had been completed post death. There was no documented evidence in the clinical record that a bereavement plan of care had been developed that included the types of bereavement services to be offered and the frequency of service delivery. During an interview the Bereavement Coordinator/Chaplain (Personnel Record 4) was able to verbalize the bereavement process and stated that she had been adding the task into the electronic medical record, but that she had not been generating a bereavement plan of care. She stated that she would review and update the process.”

“It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and ensure that services ordered by the hospice Interdisciplinary Group (IDG) meet the patient’s needs. The hospice aide does not need to be present. This standard was not met as evidenced by clinical record review and interview. In 1 of 15 (7%) clinical records reviewed with hospice aide services provided, the agency did not ensure the hospice aide was supervised by the Registered Nurse no less frequently than every 14 days. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/18/2025 with a diagnosis of senile degeneration of the brain. The plan of care dated 02/18/2025 to 05/18/2025 included an order for hospice aide visits one time per week. Clinical record review revealed an aide supervisory visit was completed on 03/26/2025 and the next aide supervisory visit was dated 05/01/2025, a total of 36 days after the 03/26/2025 visit and 22 days outstanding. During an interview and record review on 06/25/2025, the Director of Nurses (Personnel record #7) stated she cannot believe an aide supervisory visit was missed. She explained that the agency has been focusing on monitoring that aide supervisory visits are done timely.”

“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. This standard was not met as evidenced by document review and interview. The hospice did not ensure 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 hospice employees and contract staff. During a review of the agency’s hospice volunteer program, a review of the volunteer hours report revealed that the agency percentage of volunteer hours for the most recent 12 months was 2.88%. During an interview and review of the volunteer program on 06/26/2025, the Volunteer Coordinator stated that they are increasing the recruitment efforts and have recently been able to connect with some of the local college programs for potential short-term volunteers. During a review of the volunteers hours it was found that the agency did not ensure that the volunteer percentage was above 5%. The volunteer hours report documented that for the average for the most recent 12 months was 2.88%.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record may be maintained electronically or on paper. Each patient’s record includes, at minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure documentation of physician orders. CLINICAL RECORD 6: The patient elected the hospice benefit on 03/28/2025 with a diagnosis of malignant neoplasm of the colon. The clinical record review revealed the nurse documented on the nursing assessment dated 04/09/2025 that Ertapenem (Invanz) 1g reconstituted with 3.1 ml lidocaine was ordered for the patient. The clinical record did not include a physician order for Ertapenem. CLINICAL RECORD 11: The patient elected the hospice benefit on 11/07/20024 with a diagnosis of Alzheimer’s disease. The clinical record review revealed the Licensed Vocational Nurse documented on the nursing assessment dated 11/13/2024 that the patient is receiving Flagyl IV [intravenous] for urinary tract infection. The clinical record did not include a physician order for Flagyl. During an interview and record review on 06/25/2025, the Director of Nursing (Personnel record #7) stated she did not know what happened, but that education would be provided soon to the clinical staff.”