Every finding on record at Angel's Smile Hospice Inc

Upon patient record review, 4 of 14 (Patient #2,5,6,7) 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 #2-The medication profile dated 09/15/25 lists an oxygen concentrator as DME but there is no medication order listed for oxygen. #5-The medication profile dated 08/18/25 lists an oxygen concentrator 5L, 2-4 LPM via NC as DME, but there is no medication order listed for oxygen. #6-The medication profile dated 07/03/25 includes Diclofenac 1% topical gel twice daily as needed for mild pain on affected area. The affected area is not identified. #7-The medication profile dated 06/30/25 lists fiber powder 1 tsp for suspension daily. There are no instructions included for reconstitution.

Upon patient record review, 4 of 14 (Patient #2,5,6,7) 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. #2-The plan of care dated 09/15/25 lists an oxygen concentrator as DME but there is no medication order listed for oxygen. #5-The plan of care dated 08/18/25 lists an oxygen concentrator 5L, 2-4 LPM via NC as DME, but there is no medication order listed for oxygen. #6-The plan of care dated 07/03/25 includes Diclofenac 1% topical gel twice daily as needed for mild pain on affected area. The affected area is not identified. #7-The plan of care dated 06/03/25 lists fiber powder 1 tsp for suspension daily. There are no instructions included for reconstitution.

Upon patient record review, 9 of 11 (Patients #1,#2,#3,#4,#5,#6,#7,#8,#9) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient client record review, 1 of 11 (Patient #6) 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 #6: Upon medical record review, the RN documented 8-8-22 "SN provided with teaching cg regarding". There is no evidence the note was completed.