Every finding on record at Ang Hospice Inc

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review the agency 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. Unable to abate due to the agency has not admitted new patients since their compliance date.

Upon patient record review, the agency 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. Unable to abate due to the agency has not admitted new patients since their compliance date.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. No evidence of QAPI minutes or activities for 2023, 2024, 2025 and 1st qtr 2026.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology and volunteers.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There is no evidence of core and non-core services/staff available to patients such as volunteer, physical, occupational, speech language therapy and lack of active QAPI program. In addition, the agency cannot provide short-term inpatient care is provided for pain control, symptom management and respite purposes. The agency Administrator nor governing body has implemented any plan of corrections to abate condition level findings from survey in February 2026.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • volunteer • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care

Upon contract review agency did not have evidence of a therapy agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. There is no evidence when the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director.

Upon observation agency cannot provide short-term inpatient care. During survey, it was noted agency has no evidence of a contract to provide inpatient care and respite care.

Upon observation, there was no evidence of a contract for short term inpatient care for pain control and symptom management with a Medicare certified hospice, if applicable.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare certified hospice, if applicable.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare or Medicaid certified nursing facility, if applicable.

Condition of Participation: Personnel Qualifications.

Upon personnel record review agency did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review agency did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, agency did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, agency did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. There is no evidence of therapy personnel files.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 8 (Patient #1,2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 1: Patient was admitted on 12/24/25. There is no evidence of a psychosocial comprehensive assessment. Patient 2: Patient was admitted on 01/07/26. There is no evidence of a psychosocial comprehensive assessment.

Upon patient record review 4 of 8 (Patient #1,2,3,4) 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 1: Patient was admitted on 12/24/25. There is no evidence of a psychosocial comprehensive assessment. Patient 2: Patient was admitted on 01/07/26. There is no evidence of a psychosocial comprehensive assessment. Patient 3: Patient admitted 02/05/26. There is no evidence of a spiritual or psychosocial comprehensive assessment. Patient 4: Patient admitted 02/12/26. There is no evidence of a spiritual or psychosocial comprehensive assessment.

Upon patient record review, 3 of 8 (Patient #2,3,4) 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 2: Current medication record includes orders for MiraLAX powder. Order does not include a diluent. Patient 3: Current medication record includes orders for MiraLAX powder. Order does not include a diluent. Patient 4: Current medication record includes orders for Polyethylene glycol powder. Order does not include a diluent.

Upon patient record review, 4 of 8 (Patient #1,2,3,4) 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 1,2,3,4,: There is no evidence that an initial comprehensive bereavement assessment was completed.

Upon patient record review, 4 of 8 (Patient #5,6,7,8) did not have evidence in the patient record that the written plan of care is developed by the IDG, in consultation with the patient's attending physician, which specifies the services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as it relates to the terminal illness and related conditions. Patient 5: Patient death 01/28/26, there is no evidence of a bereavement plan of care. Patient 6: Patient death 12/30/25, there is no evidence of a bereavement plan of care. Patient 7: Patient death 08/17/25, there is no evidence of a bereavement plan of care. Patient 8: Patient death 01/02/26, there is no evidence of a bereavement plan of care.

Upon patient record review, 3 of 8 (Patient #2,3,4) 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 2: Current POC includes orders for MiraLAX powder, order does not include a diluent. Patient 3: Current POC includes orders for MiraLAX powder, order does not include a diluent. Patient 4: Current POC includes orders for Polyethylene glycol powder, order does not include a diluent.

Upon patient record review, 2 of 8 (Patient #1,3) 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. Patient 1: Current POC includes orders for aspirin. There is no evidence of a risk for bleeding care plan that includes appropriate goals and interventions. Patient 3: Current POC includes orders for aspirin. There is no evidence of a risk for bleeding care plan with appropriate goals and interventions.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. Agency was not able to produce data from years of 2023, 2024 or 3 quarters of 2025.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. Agency was not able to provide evidence of QAPI activities for 2023,2024 and 3 quarters of 2025

Upon observation, there was no evidence the program must use quality indicator data, including patient care, and other relevant data, in the design of the program.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence QAPI activities focus on high risk ,high volume, or problem prone areas.

Upon observation, there was no evidence Quality Assessment and Performance Improvement activities focus on high risk, high volume or problem-prone areas by considering incidence, prevalence, and the severity of problems.

Upon observation, there was no evidence the hospice investigates all adverse events, incidents, accidents, variances or unusual occurrences that involve patient care and develops a plan of correction to prevent the same or similar event from occurring again.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon observation, there was no evidence in the QAPI reports that the hospice maintains a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. The agency was not reporting or tracking any infections.

Upon personnel record review, the agency did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Medical social services

Upon observation, there was no evidence the hospice provides medical social services as a core service. Upon review agency does not currently have a Social Worker employed or a plan to cover psychosocial needs and assessment. Recruitment efforts in place and new hire in process.

Upon patient record review, 4 of 8 (Patient #Patient 5,6,7,8) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient(s) 5,6,7,8 did not show evidence of development or implementation of a bereavement plan of care.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all non-core services which includes physical therapy, occupational therapy and speech-language pathology and volunteer services.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Agency was not able to provide a current active contract for PT/OT/ST. They did believe at time of purchase that all contracts were valid.

Upon patient record review, 2 of 8 (Patient #2,3) 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: Current Aide plan of care does not include frequencies for feeding assistance, record bowel movement or turn and reposition. Patient 3: Current Aide plan of care does not include frequencies for record bowel movement or turn and reposition.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by lack of core and non-core services/staff available to patients such as counseling, volunteer, physical, occupational, speech language therapy and lack of active QAPI program.

Upon contract review, the agency did not have evidence of a therapy agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care

Upon observation, there was no evidence the hospice designates a physician to serve as Medical Director which includes: • The Medical Director must be a doctor of medicine or osteopathy who is an employee or is under contract. • When the Medical Director is not available, a physician designated by the hospice assumes the same responsibilities and obligations as the Medical Director. Agency does not currently have an Alternate Medical Director.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Agency was not able to provide medical records prior to purchase 6/2025.

There is not evidence that patient records have been maintained for 6 years. Agency was not able to produce medical records prior to agency purchase date (June of 2025). At the time of survey agency was not able to produce medical records for patients on service prior to purchase 6/2025.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, the agency did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, the agency did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, the agency did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, the agency did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions.

Upon personnel record review, the agency did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. No therapy contract, therefore no therapy personnel records.

Upon personnel record review, the agency did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. No MSW or volunteer personnel.

Upon patient client record review, 1 of 10 (Patient #1) 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 #1 was admitted to the hospice on 10/18/22 with a diagnosis of Liver Disease, Diabetes Mellitus and dysphagia. Review of RN visit note dated 10/21/22 revealed that the patient was not taking any medications. Review of IDG notes dated 11/4/22, 11/18/22 and 12/2/22 indicated that medication indicators, allergies, adverse reactions and contraindications were discussed with patient and family. Review of plan of care revealed patient was not taking any prescribed or OTC medications.