Alpha Hospice

“Based on document review and interview, the agency failed to provide a patient Bill of Rights that is in compliance with the Washington Administrative Code 246-335-635, Hospice Bill of Rights.Failure of the agency to update the patient’s Bill of Rights places the patient at risk of being unaware of their rights pertaining to their care.Reference:WAC 246-335-635 Bill of rights.A hospice agency at the time of admission must provide each patient, designated family member, or legal representative with a written bill of rights affirming each patient’s right to:(8) The name of the individual within the hospice agency responsible for supervising the patient’s care and the manner in which that individual may be contacted. Findings included:1. Document review of the agency’s policy titled, “Patient Bill of Rights,” (Policy #2-002.1, Revised: February 2020) showed that the patient will be informed of the individual within the hospice agency responsible for supervising the patient’s care and the manner in which that individual may be contacted. 2. Document review of the agency’s Hospice admission booklet in Section 3: Patient Rights and Responsibilities showed the agency failed to include the name of the individual within the hospice agency responsible for supervising the patient’s care and the manner in which that individual may be contacted. 3. On 08/27/25 at 2:00 PM, the Surveyor interviewed the agency’s Chief Executive Office & Executive Director (Staff #113) regarding the missing patients’ Bill of Right. Staff #113 acknowledge the finding and was unable to provide documentation of the patients’ Bill of Right showing the name of the individual responsible for supervising the patient’s care and the manner in which that individual may be contacted ..”

“Based on document review, record reviews, and interview, the agency failed to ensure bereavement risk assessments were completed as part of the initial comprehensive assessment for 6 of 17 Patients (Patient #101, Patient #102, Patient #108, Patient #111, Patient #113, and Patient #116) (Item #1) and failed to ensure bereavement risk assessment was completed timely for 5 of 14 Patients (Patient #104, Patient #106, Patient #110, Patient #117, and Patient #118) (Item #2).Failure to complete a bereavement risk assessment and to complete it timely puts the patient’s family and others at risk of not able to address their ability to cope with the patient’s death. Findings included:Item #1 - Initial Bereavement Assessment1. Document review of the agency’s policy titled, “Bereavement Services,” (Policy # 4-006.1, (Revised: February 2020) showed that a bereavement risk assessment will be completed by the hospice social worker upon the admission. 2. Record review of Patient #101, Patient #102, Patient #108, Patient #111, Patient #113, and Patient #116 showed:a. Patient #101 signed the Hospice Election statement on and was admitted on 11/12/24. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment.b. Patient #102 signed the Hospice Election statement on and was admitted on 03/24/25. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment.c. Patient #108 signed the Hospice Election statement on and was admitted on 06/27/25. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment.d. Patient #111 signed the Hospice Election statement on and was admitted on 08/13/25. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment.e. Patient #113 signed the Hospice Election statement on and was admitted on 07/09/24. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment.f. Patient #116 signed the Hospice Election statement on and was admitted on 08/13/25. Documentation of the initial bereavement risk assessment was not present in the patient record. There was no documentation to explain the absence of the bereavement risk assessment. 3. On 08/28/25 at 10:00 AM, the Surveyor interviewed the agency’s Director of Clinical Services (Staff #114) regarding the lack of initial bereavement risk assessments. Staff #114 acknowledged the issues regarding the late bereavement assessments and stated that they were unable to provide documentation related to the missing bereavement assessments. Item #2 - Timely Completion of Initial Bereavement Risk Assessment1. Document review of the agency’s policy titled, “Comprehensive Assessment,” (Policy #4-042.1, Revised: February 2020) showed that a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days including the bereavement assessment.2. Record review of Patient #104, Patient #106, Patient #110, Patient #117, and Patient #118 showed:a. Patient #104 signed the Hospice Election statement on and was admitted on 03/21/25. The initial bereavement risk assessment was completed on 03/30/25, but there was no documentation to explain the delay of the bereavement risk assessment.b. Patient #106 signed the Hospice Election statement on and was admitted on 03/28/25. The initial bereavement risk assessment was completed on 04/05/25, but there was no documentation to explain the delay of the bereavement risk assessment.c. Patient #110 signed the Hospice Election statement on and was admitted on 09/23/22. The initial bereavement risk assessment was completed on 09/30/22, but there was no documentation to explain the delay of the bereavement risk assessment.d. Patient #117 signed the Hospice Election statement on and was admitted on 09/19/24. The initial bereavement risk assessment was completed on 09/27/24, but there was no documentation to explain the delay of the bereavement risk assessment.e. Patient #118 signed the Hospice Election statement on and was admitted on 09/26/24. The initial bereavement risk assessment was completed on 10/11/24, but there was no documentation to explain the delay of the bereavement risk assessment 3. On 08/28/25 at 10:00 AM, the Surveyor interviewed the agency’s Director of Clinical Services (Staff #114) regarding the late completion of the initial bereavement risk assessment. Staff #114 acknowledged the issues regarding the lack of bereavement assessments as part of the patient’s comprehensive assessment, and stated that they were unable to provide documentation related to the bereavement assessments..”

“Based on document review, record reviews, and interview, the agency failed to notify the patient’s physician of missed Hospice Aide services resulting in changes to the patient’s plan of care in 3 of 14 active patients (Patient #102, Patient #105, and Patient #112). Failure to communicate with the patient’s physician of changes to the plan of care may potentially have a clinical impact on the patient’s medical needs. Findings included:1. Document review of the agency’s policy titled, “The Plan of Care,” (Policy #4-027.1, Revised: February 2020) showed the plan of care include the detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.2. Record review of patient records of Patient #102, Patient #105, and Patient #112 showed:a. Patient #102 was admitted on 03/24/25. Hospice Aide (HA) Services were ordered with frequencies of 1 time a week for 13 weeks starting 03/25/25. There was no documentation as to why there were no HA visits made during the Medicare week of 04/06/25 to 04/12/25, and no physician notification of the missed HA visit. b. Patient #105 was admitted on 07/22/24. HA services were ordered with frequencies of 2 times a week for 8 weeks starting 07/17/25. There was no documentation as to why only 1 of 2 HA visits were made during the Medicare week of 08/10/25 to 08/16/25, and no physician notification of the missed visit. c. Patient #112 was admitted on 07/07/25. HA Services were ordered with frequencies of 1 time a week for 13 weeks starting 07/08/25. There was no documentation as to why there were no HA visits made during the Medicare week of 07/20/25 to 07/26/25, and no physician notification of the missed HA visit.3. On 08/28/25 at 10:00 AM, the Surveyor interviewed the agency’s Director of Clinical Services (Staff #114) regarding the lack of documentation and physician notification of the missed HA services. Staff #114 acknowledged the findings and stated that they were unable to provide documentation of why the missed services occurred and why the patient’s physicians were not notified..”

“Based on document review, record review, and interview, the agency failed to follow the plan of care (POC) relative to hospice aides (HA) visit frequencies and failed to notify the patient and/or their representatives of HA missed visits for Patient #108.Failure to follow the POC and communicate with the patient and/or their representatives of changes to the POC may potentially have a clinical impact on the patient’s wellbeing. Findings included:1. Document review of the agency’s policy titled, “Plan of Care”, (Policy # 4-027.1, Revised Date: February 2020) showed that the POC identifies the patient’s needs and the scope and frequency of services necessary to meet the patient and family needs. 2. Record review of Patient #108 showed that hospice services started on 06/27/25. Hospice aide services were ordered with frequencies of 2 visits every week for 12 weeks starting 06/25/25. The following hospice aide missed visits showed:a. On 07/01/25, missed visit documentation showed Certified Nursing Assistant was sick.b. On 07/25/25, missed visit documentation showed Certified Nursing Assistant was sick.There was no other documentation to show the hospice aide missed visits were communicated to the patient and their representative. 3. On 08/28/25 at 10:30 AM, the Surveyor interviewed the agency’s Director of Clinical Services (Staff #114) regarding the reasons for the HA missed visit. Staff #114 acknowledged the findings and stated that the hospice aide caring for the Patient #108 required education on appropriate missed visit documentation. In addition, Staff #114 stated that they were unable to provide documentation to show that the patient and their representative were contacted regarding the missed visits.”