Every finding on record at Angel Bright Hospice, Inc.

Observed in Record Review. In 2 of 5 patient records reviewed, During RR# 1 and RR# 5's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals. For example: review of RR# 1's updated plan of care, dated approximately 11 days prior to the surveyor review of the record, revealed RR# 1’s terminal diagnosis was Pulmonary Heart Disease and was on 5 LPM via nasal cannula. However, further review of RR# 1’s updated plan of care revealed no goals for the oxygen intervention. Review of RR# 5’s updated plan of care dated approximately four days prior to the surveyor review of the record, revealed documentation of a pain assessment that included worst pain level of 8/10 and acceptable pain level at 1/10. However, review of RR# 5’s plan of care revealed no goal for pain. This was reviewed, discussed, and validated with the Executive Director.

Observed in Record Review. In 2 of 5 patient records reviewed, During RR# 4's patient record review it was noted the organization had not ensured the plan of care included interventions to manage symptoms. For example: review of RR# 4's plan of care revealed RR# 4 had a PEG tube with dysphagia and unable to swallow food liquids by mouth. However, review of the RR# 4's plan of care revealed no aspiration precautions. This was reviewed, discussed, and validated with the Executive Director.

Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 3's patient record review it was noted the organization had not ensured the plan of care included all the treatments necessary to meet the needs of the patient. For example: review of RR# 1's patient record revealed RR# 3's updated plan of care, dated approximately 11 days prior to the surveyor review of the record, revealed RR# 3 had an indwelling foley catheter with the intervention to change the foley catheter monthly. However, further review of the updated plan of care revealed not documentation on the size, type, or balloon size. This was reviewed, discussed, and validated with the Executive Director.

Observed in Record Review. In 3 of 5 patient records reviewed, the written plan of care was not based on the patient’s goals and time frames, settings, and services required to meet those goals, for example in review of the medical record for RRNHV #2 the patient had three documented wounds (left buttocks, right buttocks and right lower extremity, however there was only one problem identified on the care plan with no specific and measurable goals or interventions for each wound. In review of RRNHV # 3 there was a physician order to update the plan of care with specific wound care orders to the arterial ulcer of the left 1st toe, 4th toe and 5th metatarsal however there was no evidence of a skin integrity/wound care problem with goals and interventions on the plan of care. Additionally for RRNHV #3 the patient had a PEG tube and there were physician orders to update the plan of care with Jevity feedings and flushes however there was no evidence on the plan of care of a nutritional problem, goals or interventions. This was also observed in review of RRNHV #5 where the plan of care problems and goals were broad and not specific and measurable. and validated with the Hospice Director.

Observed in Record Review. In 1 of 5 patient records reviewed, In 1 of 14 active patient records reviewed. The plan of care had not been updated to include the wound care provided. Example: During review of HOSv#2. The plan of care had not been updated to include specific wound care orders. For example in review of RRNHV #2 the patient had three documented wounds (left buttocks, right buttocks and right lower extremity, however there was only one problem identified on the care plan with no specific and measurable goals and interventions for each wound. The plan of care included the problem: Deficit related to skin/membrane integrity AEB sacral wound and skin breakdown. Goal: sacral wound will remain free from s/s of infection and will not show signs of further progression over the next 30 days. The medical record did include Physician orders for wound care which were followed on each visit, however the plan of care had not been updated with the orders.

Observed in Record Review. In 1 of 5 patient records reviewed, the record had not documented progress towards goals. For example in review of RRNHV #2 the patient had an incision from surgery for a right leg fracture which nursing notes documented dressing changes and removal of staples.. There were care plan updates on 11/22/2024, 11/25/2024, 11/27/2024 and 12/2/2024 which included skilled nurse will provide wound care and dressing changes at each visit however the care plan updates did not include specific orders for RLE incision care or removal of staples.. The EMR did include Physician orders for wound care which were followed on each visit, however those updates were not included on the care plan. The goal remained unchanged throughout the patient's care without documentation to reflect any progression to the goal. This was validated with the Hospice Director.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the organization had not implemented their plan of correction and staff education to address non compliant standards and the governing body/leadership did not ensure that the following Conditions of Participation were met; 418:56. This was discussed with the Hospice Director.

Observed in Individual Tracer. In 2 of 14 patient records reviewed and confirmed by the Director of Operations. The comprehensive assessment had not been completed within 5 days. During review of HOSv#3 the MSW had not completed a patient assessment . Example: The MSW had attempted to phone the patient with no answer, but there had not been any further attempt to contact the patient or family. During review of HOSrr#3 the MSW had been accepted by the patient during the initial assessment . The MSW had not provided an assessment within 5 days and there had not been any contact or refusal by the patient documented.

Observed in Individual Tracer. During observation of the Interdisciplinary team meeting it had been identified that the MSW had been absent from the meeting. During discussion with the Director of Nursing and the Director of operations they identified that the full time MSW had moved out of the area several months ago. The current MSW had been employed on an as needed basis. The prn MSW had been unable to attend the IDG due to other employment. The Director of Operations had been actively recruiting to replace the full time position.

Observed in Individual Tracer. In 2 of 14 patient records reviewed, Confirmed by the Director of Nursing . Patient goals had not been measurable. Example: During review of HOSv#2 care had not documented a measurable goal specific for the healing of a wound. the goal had documented the patient will achieve and maintain optimal skin integrity. During review of HOSrr#1 the goal for personal care had documented that the patient will have safe and effective bathing.

Observed in Individual Tracer. In 1 of 14 active patient records reviewed. The plan of care had not been updated to include the wound care provided. Example: During review of HOSv#2. The plan had documented that the wound care would be provided per physician orders.

Observed in Individual Tracer. In 1 of 14 active patient hospice records reviewed. Confirmed by the Director of Nursing. The patient record had not documented the progress to goal. Example: During review of record HOSv#1 the goal had identified that patient had been restless at night and agitated and to be relieved in 1 week. The goal remained unchanged for several months without documentation to reflect any progression to the goal.

Observed in Individual Tracer. In 1 of 14 active hospice records reviewed. Social work services had not been provided based on the patient and family needs. Example: During review of HOSrr#2 the RN had identified, in the plan of care, the need for psychosocial services to be provided to the family for further education for end of life and the hospice philosophy. The frequency had stated for MSW 1xmonth prn for changes and needs. The MSW had not provided visits to the patient and family to address the need. This had been confirmed by the Director of Operations.

Observed in Individual Tracer. In 3 of 3 patient records reviewed, for the Bereavement Program and confirmed by the Bereavement Coordinator and the Director of Operations . A Bereavement plan of care that specified the kind of bereavement services and the frequency of the service delivery had not been developed. Example: During discussion with the Bereavement Coordinator it had been confirmed that a complete plan had not been maintained other than general information to include the deceased patient name , the survivor information and periodically hand written notes if needed.

Observed in Individual Tracer. The organization leaders had not assured that the provision of all hospice services be available to include all core services. Example: During observation of the Interdisciplinary team meeting , it was identified that the MSW had not been participating. Discussion with the Director of nursing and the Director of Operations had confirmed that the current MSW had been employed on a per diem basis but unavailable for the team meetings as required.

Observed in Building Tour. During the Hospice inpatient document review, it had been identified that the documentation for the inpatient medication refrigeration temperature levels had not been documented consistently, Example: During the month of April the medication refrigerator had not documented the temperature for half of the month, Weekends had been missed in May over the weekends . The agency policy had not documented a plan based on manufacturer, state, federal or Pharmacy input as to the proper temperature logs to be maintained for Promethazine and Tylenol suppositories. This had been confirmed by the Director of operations per policy to be completed daily.

Observed in Record Review. In 2 of 13 patient records reviewed, the surveyor found that the organization had not conducted the psychosocial assessment of comprehensive assessment. A psychosocial assesment was not found for RR3 or RR10. In RR3, there were initial communication notes from the social worker indicating that attempts at contacting the family had been made but no documentation that the family had refused the service or the visit. Other services had made contact and were in place.

Observed in Patient Home. In 1 of 2 home visits conducted, the surveyor found that the organization had not completed a comprehensive review of the medications that the patient was taking with each recertification and update to the comprehensive assessment. For example, during the home visit for HV2, a patient that had been on services for over 12 months, the nurse conducted a review of the medications being taken by the patient and what was on the current medication profile. In discussion with the caregiver, the nurse found that the patient was no longer utilizing the Duoneb treatments, Nystatin, prednisone eye drops and Lasix. The caregiver stated the patient had not used those medications within the past year. It was also found that the comfort kit had not been in the home for approximately the same amount of time.

Observed in Record Review. In 13 of 13 patient records reviewed, the surveyor found that the organization had not consistently identified outcomes that were measurable and time limited for issues identified in the initial and updated comprehensive assessment. For example, in HV1, the pain control goal was 0 (on 0-10 scale) but there was no time frame specified to achieve this. For the patient's respiratory status the goal was that the patient would have improved respiratory status. There was no identification of what would indicate an improved respiratory status nor a time frame to achieve it. In HV2, the patient goals included multiple problems where the goal was that symptoms would be managed and a goal for adequate nutrition as desired by patient. There was no identification of what would indicate symptoms were managed nor a time frame to achieve this. In HV3 the goal was that the Pt/Cg will verbalize having elimination need meet at an acceptable level. There was no identification of what would indicate an acceptable level nor a time frame to achieve this. There were similar findings in all other records (RR1, RR2, RR3, RR4, RR5, RR6, RR7, RR8, RR9, RR10) reviewed.

Observed in Record Review. In 4 of 13 patient records reviewed, the surveyor found that the plan of care did not include individualized and/or specific interventions to manage pain and symptoms. For example, in review of the medical record for RR2, the patient was admitted with oxygen at 15lpm via a nonrebreather mask but the initial plan of care had the standardized order for 2-5lpm via NC prn. In review of the medical record for RR4 and RR6, the patient was admitted with a previously placed indwelling foley catheter 16fr. The initial plan of care had the standardized order of foley catheter 14-18fr prn. In review of the medical record for RR8 the same finding was observed except that the patient was admitted with an18fr foley catheter. In review of the medical record for RR4 and RR6, it was evident that staff were performing dressing changes on wounds but the plan of care did not contain the specific interventions for the wound care just that staff could follow orders from the facility.

Observed in Record Review. In 8 of 13 patient records reviewed, the surveyor noted that the organization had not individualized the patient's plan of care related to medications being taken. For example, in HV 2, Cipro did not specify a route of administration. In RR1, levsin PRN, did not specify an indication for use. In RR3, ondansetron and albuterol were PRN but did not specify an indication for use. In RR4, Humalog did not specify a dose, but only had that it was sliding scale. In RR5, Gentamicin eye drops did not specify which eye other than the affected eye. In RR7, Dulcolax PRN did not specify an indication for use. In RR8, Bisacodyl, lorazepam and hyoscyamine were PRN but did not specify an indication for use. In RR9, Phenergan, Lorazepam, Tylenol and Bisacodyl were PRN but did not specify an indication for use. Route of administration, dosage and indication for use of PRN medications were required as per organization policy PC.17, Medication Administration.

Observed in Tracer Activities. In 1 of 13 patient records reviewed, the surveyor noted that the organization had not provided care according to the patient's individualized plan of care. For example, during the home visit HV2, the surveyor observed that the patient had a 16fr/10ml foley catheter in place. In review of the most recent plan of care, the order was for a 20fr foley catheter.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor observed lapses in hand hygiene. For example, during the home visit for HV1 and HV2, the surveyor observed multiple glove changes where hand hygiene was not completed. In HV3, one staff member did not perform hand hygiene with a glove change. Organization policy IC.3 required hand hygiene be completed after removing gloves and after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. During HV3, the second staff member was observed 'waving her hands to dry them instead of rubbing them together until the product had dried as required by the manufacture's instructions for use of the alcohol based hand sanitizer. Observed in Patient Home. In 2 of 2 home visits conducted, where reusable medical equipment was utilized, the surveyor observed that the organization did not clean the equipment per manufacturer's instructions. For example, during the home visit for HV1 and HV2, the staff member utilized a pulse oximeter and temporal thermometer. The manufacturer's instructions required the devices be cleaned with isopropyl alcohol. During each visit the devices were cleaned with a either a Clorox wipe or a benzalkonium chloride wipe. Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed that the staff member did not follow organization policy IC.12, Bag Technique. For example, during the home visit for HV1 and HV2, the surveyor observed the staff member enter the equipment bag multiple times without first performing hand hygiene. It was also noted that the staff member returned the cleaned reusable medical equipment to the bag without first performing hand hygiene. The policy required that hand hygiene be performed on initial entry to the bag and again if additional items are retrieved from the bag during the visit. Hand hygiene was also to be completed prior to returning cleaned reusable equipment to the bag.

Observed in Record Review. In 4 of 10 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found that the aide plan of care was not specific for the patient. For example, in review of the medical record for RR1, the aide care plan required external catheter care, measure catheter output and empty drainage bag. This patient did not have an external catheter in place. In review of the medical record for RR4, the patient had multiple wound dressings in place, a g-tube and the potential for seizures. There were no instructions on the aide care plan related to this. In review of the medical record for RR6, the patient had a wound dressing in place. There were no instructions on the aide care plan related to this. In RR10, the patient was on continuous oxygen, used a walker and was a fall risk. There were no instructions on the aide care plan related to this.

Observed in Tracer Activities. In 2 of 2 home visits conducted, where medications were reviewed, the surveyor noted that the organization's medication profile was not consistent with the medications the patient was taking. For example, during the home visit for HV1, the facility medication administration record included Roxanol, Bisacodyl, docusate but these medications were not present on the organization's medication profile. During the home visit for HV2, the profile indicated that duoneb, nystatin, prednisone eye drops, Lasix and comfort kit medications were present. The caregiver stated that most of those medications had not been present in the home for approximately a year.

Observed in Building Tour. During the building tour of the hospice inpatient unit, the surveyor observed that the corridor fire extinguisher cabinet that was mostly recessed and not visible. There was no signage to indicate the location of the extinguisher when looking down the length of the corridor. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the building tour for the hospice inpatient unit, the surveyor observed dirty sprinkler heads in room 100 and room 102. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. During the building tour of the hospice inpatient unit, the surveyor observed the automatic sprinkler piping being used as a support. For example, in the space above access panel1, sprinkler piping was supporting cabling and ducting. In the space above access panel 2, sprinkler piping was seen to be supporting cabling and wooden planks. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Record Review. In 1 of 1 patient records reviewed, for patient in a skilled nursing facility, the surveyor noted that the plan of care did not identify which provider was responsible for performing the functions that were included in the plan of care. For example, in HV1, the plan of care did not specify who was responsible for care such as suctioning and management of pain and/or other symptoms.