Allumine Hospice

“Upon patient record review 2 of 14 (Patient #3, 8) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #3:The comprehensive assessment dated 01/25/26 indicated the patient had pain, but the comprehensive pain assessment was incomplete as evidenced by no description/character of pain, no duration and no side effects documented. However, the HOPE documentation indicated it was completed. Patient #8: The comprehensive assessment by the SN dated 07/18/25 indicated the patient had a chronic wound to the L foot. However, the wound measurements or assessment were not documented on the comprehensive assessment.”

“Upon patient record review, 1 of 14 (Patient #8) 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: • Actual or potential drug interactions • Effectiveness of drug therapy • Drug therapy currently associated with laboratory monitoring Patient #8: Oxygen 2 Liters per NC was noted on the initial RN assessment dated 07/18/25 and the initial plan of care. However, oxygen was not listed on the medication profile.”

“Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1: The Bereavement assessment was completed on 02/05/26 which was greater than 5 days after the admission date of 01/30/26.”

“Upon client record review, 2 of 14 (Patient #2,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2:Wound care was ordered per the plan of care 3 x week. During the week of 01/18/26 through 01/24/26, the wound care was documented as “not addressed” on 01/23/26. Patient #9:The plan of care dated 10/22/25 showed safety interventions included a “volunteer to provide support, socialization, and respite”. However, there was no volunteer provided. Documented in the SN comprehensive assessment at admission was that the patient transferred hospices in order to receive a PT consult. Additionally, a PT visited the patient on 10/21/26 and 11/18/25, but there was no evidence of an order for PT or that PT was part of the plan of care.”

“Upon patient record review, 4 of 14 (Patient #2,#3,#7,#8) did not have evidence in the patient record that hospice aide assignments and duties are: • 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 On the aide care plan dated 12/31/25 the duties of make bed, change linens, transfer and reposition were assigned “as needed.”. Patient #3 The aide care plan dated 01/25/26 had assigned tasks of shower every visit and “bed bath as needed if too weak to shower.” Aide is not able to make decision if patient is “too weak”. Additionally, assist with bedside commode was assigned as needed. Patient #7 The aide care plan written 01/14/26 listed assigned duties of shave, make bed, and assist with transfer as “as needed”. Patient #8 The aide care plan written 07/18/25 listed duties of making bed, change linens, and incontinent care as “PRN”.”

“Upon patient client record review, 2 of 14 (Patient #5, #12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5:The consent, dated 01/23/26, was not signed by the patient and there was no evidence the relationship of the signatory was documented. Additionally, there was no evidence a request or declination for receipt of the Patient Notification of Non-Covered Services was documented. Patient #12: On the Admission Consent signed 05/05/25, there was no evidence the Notification of non-covered services was addressed as evidenced by the request or declination not checked.”

“Upon patient client record review, 2 of 14 (Patient #8,9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #8: Wound care was ordered on the plan of care dated 01/14/26 specifically to, “clean the wound with WC, pat dry, apply calcium alginate and cover with a foam dressing”. However, there was no evidence the SN followed the individualized plan of care due to lack of detailed documentation as evidenced by documentation on 01/15/26, “wound cleaned and new dressing placed on bottom foot”, on 01/22/26, “wound care completed to L foot”, and on 01/29/26, “wound care completed.” Patient #9:A pain screening was completed as part of the SN comprehensive and HOPE assessment on 10/19/25 and documented as, “No pain reported”. However, the PAINAD was also completed and pain was rated 4/10, but there was no other evidence the patient was experiencing pain.”