Every finding on record at Angel Heart Hospice, LLC

Upon patient record review, 2 of 19 (Patient #1,13) 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 1: The medication profile has entry for Zinc capsule with an alternate route listed to be given via nasal cannula. Patient 13: RN documentation on 05/04 indicated that the patient uses oxygen at 5LNC. No evidence that medication profile has an entry for oxygen at 5LNC. The current oxygen order on the medication profile is for 2-4L as needed via NC.

Upon patient record review, 1 of 19 (Patient #9) 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 9: No evidence that the initial bereavement assessment was completed within 5 days of election of hospice. The patient was admitted on 03/23/2026. The bereavement risk assessment was completed on 03/30/2026.

Upon patient record review, 2 of 19 (Patient #5,7) 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 5: The medical record indicated that the patient currently takes Eliquis. No evidence that the problems, goals, and interventions related to risk for bleeding on the current plan of care. Patient 7: The medical record indicated that the patient currently smokes daily. No evidence that the problems, goals, and interventions related to smoking/fire safety on the current plan of care.

Upon patient record review, 2 of 19 (Patient #6,7) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 6: Initial plan of care has SW orders as 1 PRN. No evidence of routine visits on plan of care. Patient 7: Initial plan of care has SW orders as 1 PRN. No evidence of routine visits on plan of care.

Upon patient record review, 2 of 19 (Patient #1,13) 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 1: The medication profile has entry for Zinc capsule with an alternate route listed to be given via nasal cannula. Patient 13: RN documentation on 05/04 indicated that the patient uses oxygen at 5LNC. No evidence that an order was received for oxygen at 5LNC. The current oxygen order is for 2-4L as needed via NC.

Upon client record review, 2 of 19 (Patient #9,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 9: The medical record indicated that the patient had a foley catheter placed by hospice on 04/28/2026. No evidence that a physician order was placed before the start of survey that included the foley catheter size and maintenance instructions. Patient 13: The medical record indicated that the patient had a foley catheter that was both removed and replaced on 04/24/2026 by hospice. No evidence that a physician order was placed before the start of survey that included the patient foley catheter size and maintenance instructions.

Upon observation during 1 of 4 home visits, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 3: The RN placed her tablet on the patient's bedside table without a barrier of any sort.

Upon patient record review 2 of 19 (Patient #2,9) 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 2: No evidence that a registered nurse made an aide supervisory visit every 14 days between 02/05/26 and 02/20/26. Patient 9: No evidence that a registered nurse made an aide supervisory visit every 14 days between 04/21/26 and 05/13/26.

Upon patient client record review, 3 of 19 (Patient #1,11,13) 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: On face-to-face documentation that occurred on 3/25/26, NP documented that the patient was a DNR. The medical record and PCM confirmed that the patient is full code. Patient 11: The medical record indicated that the authorization to release PHI form uploaded to the chart missing the reason why the patient did not sign the form herself. Patient 13: The medical record indicated that the SN placed a 16FR foley on 04/24/2026. The physician order placed during survey indicated that the catheter size is 18FR and the SN actually placed an 18FR foley and not a 16FR foley.

Upon patient record review 1 of 19 (Patient #13) 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 #13: There was no evidence that a spiritual comprehensive assessment was complete at time of survey.

Upon patient record review, 3 of 19 (Patient #1, #9, #14) 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 #1: The medication profile included gentamicin topical cream without evidence of specific area(s) for application. COS Patient #9: The medication profile included oxygen 2-4lpm through bipap however, there was no indication patient was using bipap. Agency confirmed patient does not have a bipap and using oxygen via nasal cannula. COS Patient #14: The medication profile included oxygen 2-4lpm PRN SOB however, there was no route specified. COS

Upon patient record review, 2 of 19 (Patient 8, #11) 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 #8: The patient admitted 03/24/2022 however, the bereavement assessment was completed 07/19/2022. Patient #11: The patient admitted 02/25/2023 however, the bereavement assessment was completed 03/06/2023.

Upon patient record review, 1 of 19 (Patient #4) 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 #4: The patient admitted with lung cancer however, there was no evidence of respiratory problems/interventions/goals. COS

Upon patient record review, 3 of 19 (Patient #1, #9, #14) 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 #1: The order for gentamicin topical cream did not contain evidence of specific area(s) for application. COS Patient #9: The order for oxygen 2-4lpm through bipap however, there was no indication patient was using bipap. Agency confirmed patient does not have a bipap and using oxygen via nasal cannula. COS Patient #14: The order for oxygen 2-4lpm PRN SOB however, there was no route specified. COS

Upon client record review, 1 of 19 (Patient #6) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #6: The plan of care update occurred 4/26 and then 5/24 was the next documented update.

Upon patient record review, 2 of 19 (Patient #13, #14) 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. Patients #13: The record indicated patient went on respite 05/19-05/23/2023 however, there were no problems/intervention/goals updated to the plan of care. Patients #14: The record indicated patient went on respite 05/25-05/30/2023 however, there were no problems/intervention/goals updated to the plan of care.

Upon client record review, 2 of 19 (Patient #2, #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: The visit frequency for the chaplain and social worker ordered 05/24/23 2M2 however, there was no evidence of visits in May. COS Patient #8: The nurse visit frequency on 03/19/2023 was ordered 2/week and 4 PRN however, the week of 04/30 and 05/14 there was only evidence of one visit each week.

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. Patients #11 and #12: There was documentation of infection in the month of May however, there was no evidence these were reported for hospice to investigate. COS

Upon patient record review 1 of 19 (Patient #8) 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 #8: The aide visit frequency was ordered 03/19 3/week however, the week of 05/14 there was only evidence of 2 visits completed.

Upon patient client record review, 1 of 19 (Patient #9) 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 #9: The patient requested addendum for non-covered items however, there was no evidence of receipt.

Upon patient client record review, 1 of 19 (Patient #19) 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 #19: The chart indicated patient discharged on 12/06/2022 however, the Notice of Medicare Non-Coverage was dated 12/07/2022.

Upon client record review, 1 of 19 (Patient #16) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #16: There was no evidence a discharge summary was sent to attending.

Upon patient record review, 2 of 19 (Patient #3, #4) did not have evidence that the hospice provided the following information to the SNF: • The most recent aide hospice plan of care specific to each patient • Hospice election form specific to each patient • Physician certification and recertification of the terminal illness specific to each patient • Names for hospice personnel involved in hospice care of each patient