Every finding on record at Angel of God Hospice and Palliative Care, Inc.

Observed in Tracer Activities. During tracer review the hospice surveyor noted that the organization failed to develop an all hazards vulnerability assessment, thus mitigation activities were not defined by the organization. This was reviewed and validated by the DPCS. Observed in Tracer Activities. The hospice surveyor noted that the organization failed to complete a hazard vulnerability analysis, therefore there is no evidence that the organization had prioritized their identified potential emergencies. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. the hospice surveyor noted that the organization failed to develop a continuity of operations plan as it did not complete a hazard vulnerability analysis. This was reviewed and validated by the DPCS.

Observed in Record Review. In 3 of 14 patient records reviewed, the hospice surveyor noted in HOSRRDC #2 where the bereavement assessment was completed 21 days after the comprehensive assessment, in HOSRRBR #1 the bereavement assessment was done 6 days after the comprehensive assessment, and in HOSRRNHV #6 the bereavement assessment was done 10 days after the comprehensive assessment. Per the organizational policy the Initial Assessment/Comprehensive Assessment the bereavement assessment should be completed at the time of the comprehensive assessment. This was reviewed and validated with the DPCS.

Observed in Patient Home. In 11 of 14 patient records reviewed, the surveyor noted in HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRDC #1, and HOSRRBR #2 that the patient was on aspirin 81 mg and the POC for the home health aide did not include safety precautions such as bleeding. Additionally, HOSRRNHV #2 has apixaban ordered and the aide care plan does not include safety precaution for bleeding. HOSRRNHV #3 has an order for Eliquis and the Home health aide care plan does not include bleeding precautions. In HOSRRNHV #7 the patient is on aspirin and apixaban and the aide care plan does not include bleeding precautions. In HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRDC #1, HOSRRDC#2, HOSRRBRV1, HOSRRBR#2, HOSRRNHV #2 oxygen order for 2 L of oxygen via NC prn for SOB. May slowly titrate 2-5 L for comfort. There was no documentation on how to titrate the oxygen on the order. Additionally their Medication Orders policy states that range orders are not permitted. This was reviewed with the DPCS and she states that this will be found in all of the charts as they order oxygen for all patients at SOC. The DPCS stated that she had the supervisor go into the patient charts and update the oxygen orders on all of the patients.In HOSRRHV #1 the surveyor noticed duplicate orders for Loperamide Hydrochloride 2 mg caplets 1 caplet by mouth every 4 hours as needed for pain. There was not a stop date for one or the other. The Medication Orders policy states all orders that look alike will be verified. This was reviewed and validated with the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the hospice surveyor noted that the medication orders did not state when to take one as needed medication over the other. In HOSRRHV #2 the patient had both Ativan 2mg/ml concentrated solution 0.5 ml by mouth/sublingual every 6 hours as needed for agitation, and she also had Haloperidol 0.5mg tablet 1 tablet, three times a day as needed for agitation. It is not clear which of the medications the patient should take for agitation. In HOSRRHV #3 the patient had orders for both Polyethylene Glycol 3350 17 gm by mouth once a day as needed for constipation and Dulcolax suppository 10 mg per rectum as needed if no BM in 3 days. The orders are not clear if one or both of these medications should be used if no BM. This was reviewed and validated with the DPCS. Observed in Record Review. In 2 of 14 patient records reviewed, the hospice surveyor noted that the organization failed to plan the patient's care. In HOSRRNHV#2 and HOSRRNHV #3 where the patients are on an anticoagulant and there was no bleeding precautions care plan entered. This was reviewed and validated with the DPCS.

Observed in Record Review. In 2 of 14 patient records reviewed, the hospice surveyor noted on HOSRRDC #1 that there was a missed visit and the provider was not notified and HOSRRNHV #1 the patient had two missed visits over 2 months and the provider was not notified. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. During tracer activity the hospice surveyor noted that the governing body did not review and revise the QAPI program in 2024 or for 2025, however the data continued to be collected and analyzed and improvements shown with documented improvements in outcomes. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. The organization failed to develop a performance improvement plan. The organization could not provide the nurse surveyor with a written copy of the QAPI plan, denoting what was going to be monitored, when and for how long. This was reviewed and validated with the DPCS. Observed in Tracer Activities. During tracer activity the hospice surveyor noted that the hospice had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. This was reviewed and validated with the DPCS.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to follow manufacturer's recommendations for cleaning vital sign equipment purchased by staff. During HOSRRHV #1 and HOSRRHV #3 the home health aide and the RN purchased their own equipment. The home health aide was using an Omron cuff from CVS and a Safety thermometer which was infrared. She cleaned both with McKesson wash clothes, This is not an approved cleaner for the pulse oximeter which should have been cleansed with ETOH wipes. The RN in HOSRRHV #3 attests that he bought his sphygmomanometer cuff, thermometer, and pulse oximeter from Amazon about 1 year ago. He was cleaning all his equipment with Clorox wipes, which is not an approved cleaner for the equipment, the sphygmomanometer should have been cleansed with soap and water and the thermometer and pulse oximeter should have been cleansed with an ETOH wipe per manufacturer's guidelines.. This was reviewed and validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, in 1 of 3 home visits conducted where the CHHA was observed the hospice surveyor noted in HOSRRHV #1 that the CHHA performed a shower on the patient and she used the same pair of gloves for washing the clean and dirty areas e.g. washing the patients bottom. The aide then dressed the patient using the same gloves. The aid failed to follow the organization's Hand Hygiene Policy and Compliance Program. Thus the organization failed to implement activities for the prevention and control of infections and communicable diseases. This was reviewed and validated with the DPCS.

Observed in Tracer Activities. During the survey the hospice surveyor noted there was no evidence that the organization's infection control program had been reviewed by the governing body as part of the hospice's QAPI program. This was reviewed and validated by the DPCS.

Observed in HR File Review. In 7 of 9 HR files reviewed, the nurse surveyor noted during the HR tracer that there was no evidence that staff had competencies documented every 3 years, per policy Staff Competency Program and regulation. Per the policy the patient care staff should have their competency assessed every three years and the hospice aide should have her competency assessed at least annually. This was observed in the RN CM who did not have a competency done from his hire date of 2021. The Home Health aide had the last competency done in 2022. The MSW had her last competency done in 2021. The medical director and the alternate medical director both had their last competencies done in 2021, and the volunteer coordinator and bereavement coordinator had her last competency performed in 2021. This was reviewed and validated with the RN Supervisor.

Observed in HR File Review. In 1 of 1 HR files reviewed, where a home health aide was reviewed the hospice surveyor noted that there were only 8 hours of inservice education in the last 12 months documented for the Home Health Aide. This was reviewed and validated with the RN supervisor.

Observed in Pharmacy. In 1 of 1 home visits conducted, where the hospice surveyor observed a home health aide the surveyor noted that the aide failed to provide peri care, brush the patient's teeth, and take vital signs as instructed in POC. Home Health aide removed ace wrap to left ankle and blew dry the patient's hair and both were not on plan of care. This was reviewed and validated with the DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, the hospice surveyor noted in HOSRRDC #1 that the organization failed to send the discharge summary to the community provider after a live discharge. This was reviewed and validated with the DPCS.

Observed in Document Review. Review of governing body meeting minutes from the second quarter of 2022 revealed that establishing priorities for performance improvement was mentioned, however there was no documentation of the discussion, nor a plan to address the requirement for improvement and how new processes for the QAPI program would be created and implemented. Additionally, this topic was mentioned during an in-service a month after the survey, but there was no documentation of the content of the meeting, nor what education was provided. QAPI meeting minutes from the second quarter of 2022 did not include required topics, and, opportunities for improvement identified by hospice leaders.

Observed in Document Review. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.58.

Observed in Individual Tracer. In 3 of 11 patient records reviewed, the hospice comprehensive care plan did not reflect all interventions required based on the assessment to manage the patient's symptoms. RR#1 had dysphagia, was on a mechanically soft diet, had a high Braden score and had a Foley. The care plan did not reflect specifics related to diet, or interventions related to high Braden score. The size of the catheter was indicated however not the balloon size or the frequency of change. RR#2 required a liquid diet based on the assessment and this diet restriction was not included on the care plan. RR#3 was bed bound, had contractures was incontinent and as a result had a high Braden score. The comprehensive care plan of RR#3 did not identify any interventions related to these issues. RR#4 had spasm that resulted in his jaw breaking and ultimately he was admitted to the hospital. His spasms were being treated with medication however the comprehensive care plan did not reflect this problem nor did it include any interventions to manage this symptom. These observations were discussed with the assistant director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice comprehensive care plan did not reflect the medications needed to meet the patient's needs. RR#1 had multiple medications listed on the care plan that the patient no longer was given. These medications included an antibiotic, a medication for the prostate, and a medication to treat restlessness. These observations were discussed with the assistant director .

Observed in Individual Tracer. In 2 of 11 patient records reviewed, the interdisciplinary care plan was not updated based on changes after admission to the program. RR#1 had the following services/treatments added after admission to the program; volunteer and Foley. The interdisciplinary care plans after these changes were implemented did not describe the new treatments or the effectiveness of these interventions. RR#3 also had volunteer services add after admission and the interdisciplinary care plan was not updated. These observations were discussed with the assistant director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not provide care based on the assessed patient needs. RR#1 had a Foley Catheter and was being treated for a urinary track infection. The care plan/orders did not specify the frequency of the catheter changes however based on discussions with the assistant director, Foleys are typically changed at least monthly. Based on a review of RR#1 visit notes,, his Foley had not been changed in over 3 months.

Observed in Data Tracer. The data collected based on the Quality Assessment Performance Improvement plan (QAPI) for 2021 and 2020 did not reflect the complexity of services provided or incorporated information on relevant HIS indicators. The hospice scored significantly below the national average on certain HIS indicators and this data was not addressed in the QAPI data. Additionally, the hospice provided some services under contract, provided bereavement and volunteer services and data related to these services were not reported and or analyzed as part of the QAPI. These observations were discussed with the assistant director and the administrator.

Observed in Infection Control System Tracer. Hand hygiene compliance was not assessed while doing patient care in 2021. The staff was observed washing their hands in the office. This observation was confirmed with the assistant director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the hospice aide care plan did not reflect all of the interventions required to meet the patient's needs. RR#1 required a Hoyer lift and had a Foley. The hospice aide care plan did not reflect precautions/instructions related to these two devices. This observation was discussed with the assistant director.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, the Hospice did not supervise the hospice aide in the home at least every 14 days. There was no documentation in RR#1 for over a 1 month period of the supervision of the hospice aide. The aide provided services during this time and the RN also made visits during this time. This observation was discussed with the assistant director.

Observed in Data Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100, 418.56, 418.58.

Observed in Individual Tracer. In 2 of 5 patient records reviewed, the comprehensive care plan did not identify which provider would be responsible for performing certain interventions. RR#7 resided in a nursing home and had multiple decubiti requiring daily care. RR#8 also resided in a nursing home and had both a Foley and multiple wounds. The comprehensive care plans did not identify which entity would perform the wound care. These observations were discussed with the assistant director.