Alpha Omega Hospice

“Upon patient record review, 3 of 19 (Patient #5,6,9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 5: The RN documentation indicated that the patient was using oxygen at 4LNC and 2.5LNC. The active medication list has an order for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes 4LNC or 2.5LNC and no evidence that the current order includes a titration order to increase when needed. COS-Active medication list updated during survey Patient 6: The active medication profile has an entry for acetaminophen rectal supp 650 mg PRN every 6 hours for constipation. COS - active medication profile list to remove constipation as the PRN reason for use. Patient 9: Active medication list has MiraLAX, Colace, and Dulcolax all listed as PRN for constipation. No evidence that the active medication list included instructions on which medication to give first in the event of constipation. COS - new order written to update the active medication list during survey.”

“Upon patient record review, 1 of 19 (Patient #13) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days assessments. Patient 13: No evidence that a comprehensive assessment was completed by the RN every 15 days between 01/31/2025 and 02/20/2025. 20 days between assessments.”

“Upon patient record review, 5 of 19 (Patient #1,3,5,7,12) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The clinical documentation indicated that the patient was a risk for falls. No evidence of problems, goals, and interventions related to risk for falls included in the current plan of care. COS - New order written to update the plan of during survey. Patient 3: The medical record indicated that the patient currently takes Xarelto for blood thinner. No evidence of problems, goals, and interventions related to risk for bleeding included in the current plan of care. COS - New order written to update the plan of during survey. Patient 5: The medical record also indicated that the patient has a related diagnosis of depression. No evidence of problems, interventions, and goals related to depression included in the current plan of care. COS- New order written to update the plan of during survey. Patient 7: The patient has Humalog PRN and insulin pen daily for DM2. Diabetes listed as a related diagnosis. No evidence of problems, goals, and interventions related to DM/Endocrine on the current plan of care. COS - New order written to update the plan of care during survey. Patient 12: The medical record indicated that the patient/caregiver accepted social services at the time of admission. The plan of care has active orders for the social worker to visit monthly. No evidence of problems, interventions, and goals related to social services included in the current plan of care. COS - New order written to add social services to the plan of during survey.”

“Upon patient record review, 3 of 19 (Patient #5,6,9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5: The RN documentation indicated that the patient was using oxygen at 4LNC and 2.5LNC. The active medication list has an order for oxygen 2LNC PRN for shortness of breath. No evidence that the active medication list includes 4LNC or 2.5LNC and no evidence that the current order includes a titration order to increase when needed. COS-Active medication list updated during survey Patient 6: The medical record has an active order for acetaminophen rectal supp 650 mg PRN every 6 hours to given for constipation. COS - new order written to remove constipation as the PRN reason for use and add that it is to be used for mild pain. Patient 9: Active medication list has MiraLAX, Colace, and Dulcolax all listed as PRN for constipation. No evidence that the order included instructions on which medication to give first in the event of constipation. COS - new order written to add instructions during survey.”

“Upon patient record review, 2 of 19 (Patient #1,5) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 1: The clinical documentation indicated that the patient currently uses a wheelchair due to weakness and impaired mobility. No evidence that the wheelchair was added to the current plan of care DME list. COS- Plan of care DME list updated during the survey. Patient 5: The medical record indicated that the patient used a rolling walker daily due to shuffled gait and impaired mobility. No evidence that the rolling walker was added to the current plan of care DME list. COS- Plan of care DME list updated during the survey.”

“Upon patient record review, 3 of 19 (Patient #4,5,12) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. current level of care during survey. Patient 4: The clinical documentation indicated that the patient does not currently have an active wound. Active wound care orders remain on the current plan of care. COS - New orders written to remove wound care orders removed from the active plan of care during survey. Patient 5: The medical record indicated that patient requested to end aide services on 06/24/2025. Active orders for the aide to perform visits once a week remain on the current plan of care - new benefit period started on 07/08/2025. COS - new order written to remove the aide orders from the active plan of care during survey. Patient 12: The medical record indicated that patient requested to end chaplain services on 02/24/2025. Problems, interventions, and goals related to spiritual care remain on the current the plan of care - new benefit period started on 05/22/2025. COS - new order written to remove the spiritual care plan from the plan of care during survey.”

“Upon patient record review 5 of 19 (Patient #5,6,7,8,9) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 5: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated “Accepts volunteer services. Placed on the list for next available volunteer.” Second benefit period started on 08/01/2025. Patient 6: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated “Accepts volunteer services. Placed on the list for next available volunteer.” Second benefit period started on 08/01/2025. Patient 7: The RN documentation indicated that the patient/caregiver accepted volunteer services at the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated “Accepts volunteer services. Placed on the list for next available volunteer.” Patient 8: The medical record indicated that the patient/POA accepted volunteer services at the time of admission on 2/03/2025. No evidence of volunteer coordination follow-up or that a visit was completed by a volunteer at the time that the chart was surveyed. Patient 9: The RN documentation indicated that the patient/caregiver accepted volunteer services as the time of admission. No evidence that follow-up occurred past the initial note entered by the VC which stated “Accepts volunteer services. Placed on the list for next available volunteer.””

“Upon patient record review, 3 of 19 (Patient #2,4,6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: The clinical documentation indicated that the patient has a related diagnosis of dysphagia and was identified as a risk for aspiration. No evidence that the aide plan of care included instructions for related risk for aspiration. COS - new order written to add to those instructions to the aide plan of care during survey. Patient 4: The aide plan of care includes instructions for patient to take a bath or shower 3 times a week patient was not cognitively able to choose per diagnosis and baseline confusion. COS - new order written to update aide plan of care during survey. Patient 6: The aide plan of care includes task to “change linens when soiled”. No evidence that a frequency was included. COS - new order written to add frequency to linen changes on the aide plan of care during survey.”

“Upon patient record review 1 of 19 (Patient #10) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 10: The aide plan of care included instructions to notify the RN when task are refused by the patient. The patient refused task on visits that occurred on 07/15 (shampoo), 07/18 (all task refused), 07/22 (nail care), 07/23,07/24, 07/30, 08/06 (shave). No evidence that the aide notified the RN that the task was refused.”

“Upon patient record review 3 of 19 (Patient #8,13,14) did not have evidence documentation in the patient record that a Registered Nurse made 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 to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient 8: No evidence that a registered nurse made an aide supervisory visit every 14 days between 04/23/25- 05/09/25 (16 days) and 05/20/2025-06/14/2025 (15 days). Patient 13: No evidence that a registered nurse made an aide supervisory visit every 14 days between 02/05/25- 04/01/25 (23 days) and 05/28/2025-06/17/2025 (22 days), 06/17/2025-07/09/2025 (22 days), and 07/22/2025-08/06/2025 (15 days). Patient 14: No evidence that a registered nurse made an aide supervisory visit every 14 days between 12/30/25-01/29/25 (30 days) again between 03/06/2025-04/02/2025 (16 days), 05/13/2025 - 07/15/2025 (64 days), and again between 07/15/2025- 08/06/2025 (22 days).”

“Upon patient record review, 1 of 19 (Patient #2) did not have evidence that a written hospice plan of care is established and maintained in consultation with SNF/NF or ICF/IID representatives. All hospice care provided is in accordance with this hospice plan of care. Patient 2: The plan of care has volunteer frequency ordered as twice a month for the months of Feb/March/April 2025. No evidence that the patient received 2 visits for the months of February 2025, March 2025, or April 2025. No evidence that the visit was missed at the request of the family or that an order was received to change the visit frequency for the month.”