Every finding on record at Angel Wings Hospice Services, LLC

Observed in Record Review. The HCO failed to conduct and document a patient-specific comprehensive assessment as evidenced by in RR#6 there was no assessment for aspiration risk for a mechanical soft diet for a CVA patient, this was validated and discussed with Assistant Director of Nursing and Administer Observed in Record Review. In 2 of 12 patient records reviewed, The surveyor noted (ARR#10) that the initial social worker assessment indicated that the primary caregiver was experiencing burnout; however, it did not indicate the severity of the stress or an assessment of the need for a different level of care/respite. This was confirmed with the administrator.

Observed in Record Review. In 3 of 12 patient records reviewed, The HCO failed to provide education and training to the patient caregiver based on the patient's assessed needs as identified in RRHV#2 , patients spouse informed the surveyor that when needed the patients son provides wound care and in chart review there was no education provided to son or identified on plan of care that son would do the wound care. In RR#6 and RR#8, orders were present for Oxygen 2-4 litres via N/C PRN but no education was provided to family on how to dose oxygen. This was discussed and validated with Assistant Director of Nursing and Administrator.

Observed in Record Review. In 4 of 12 patient records reviewed, The HCO failed to implement an individualized plan of care based on problems identified as in RR #4 aggression and hallucinations identified at SOC but there was no goals for managing symptoms. RR#5 IDG note identified disturbance in sleep patterns, but no goals identified. In RR #6, patient had orders for mechanical soft diet for a CVA patient, but no goal identified for aspiration precautions and in RR#7 patient had nausea 8/10 as identified in the Palliative scale and no goals for assessment or improvement of symptoms. This was discussed and validated with Assistant Director of Nursing and Administrator Observed in Record Review. The surveyor noted (ARR#10) that the plan of care goals on the initial plan of care did not include reasonable time frames for achieving outcomes. All goals were to be met at the end of the certification period. This was confirmed with the administrator.

Observed in Record Review. The surveyor noted (ARR#10) that there were no interventions to manage the goal: caregiver emotional challenges. The plan of care issue was identified; however, there were no intervention for assisting the caregiver to manage burnout and exhaustion as indicated in the assessment. There were no outcome expectation or time frames for managing the caregiver stress. The goal was to provide support throughout the benefit period. The frequency for the social worker was monthly, as it was for everyone. This was confirmed with the administrator. Observed in Record Review. In 5 of 12 patient records reviewed, The HCO failed to implement the plan of care to include all services needed for the palliation and management of the terminal illness and related conditions as seen in RRHV#2 the SN to prefill the medication box weekly was not on the plan of care. RRHV#2 when HHA was getting the patient out of bed to bathe, the surveyor observed a dressing on patients lt upper buttock, when asked the HHA stated that she would change the dressing following the patients shower, in record review there was no order for wound care. In RRHV#3 there was no instructions on the care plan as to who was administering the pre filled medication in the syringes. In RR#5 patient had a g-tube but there was no order for g-tube site care or what measures to take if g-tube falls out. RR#7 orders for oxygen was 3 liter's via N/C continuous or PRN, no indication identified. This was discussed and validated with Assistant Director of Nursing and Administrator

Observed in Individual Tracer. In 5 of 12 patient records reviewed, The HCO failed to implement measurable outcomes anticipated from implementing and coordinating the plan of care as identified in record review. In RRHV#1 goals for pain was to remain at a tolerable level and no timeframe identified. RRHV#3 constipation was identified goal was for elimination needs to be at an acceptable level and the goal for the wound had an appropriate measure but not a reasonable time frame as documented: will decrease in size by 50% by end of cert. An additional goal identified in RR#3: anxiety but measure was to inform of reduced symptoms. In RR #9 initial plan of care, pain and dyspnea was identified as a symptom but time frames were for end of cert.This was discussed and validated with Assistant Director of Nursing and Administrator

Observed in Record Review. In 1 of 12 patient records reviewed, The HCO failed to revise plan of care based on new information as identified in RRHV#1, Social worker identified a new POA but there was no plan of care revisions made to discuss advance directives with the POA. This was discussed and validated with the Assistant Director of Nursing and Administrator.

Observed in Individual Tracer. In 3 of 3 home visits conducted, The HCO failed to implement the infection prevention and control activities: to perform hand hygiene consistent with policy as evidenced during HV #1 it was observed that the Chaplain did not perform hand hygiene during the home visit, minimally at start and end of visit. During HV#2 the HHA used a bar of soap that was in the bathroom, she turned off the faucet with her hands and did not have any paper towels to dry her hands. During HV#3 the RN did not use hand sanitizer when entering her medical bag after performing vital signs and assessment. This was validated with the Assistant Director of Nursing who was also present for both visits.

Observed in Record Review. In 1 of 12 patient records reviewed, The HCO failed to provide written patient care instructions for the hospice aide as identified in RRHV#2, The Home Care Aide Care Plan did not include wound care instructions, as required by policy. This was discussed and validated with the Assistant Director of Nursing and Administrator.

Observed in HR File Review. In 1 of 9 HR files reviewed, The HCO failed go maintain a completed competency assessment as evidenced by Chaplain personnel file review: incomplete competency as none of the individual competencies were identified, only signatures were documented at the bottom of the page, this is a new hire since 8/01/24. This was discussed and validated with the Administrator

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor noted that the plan of care had not been individualized for each patient with measurable outcomes. For example, in HV1, outcomes that were not measurable included: Pt will maintain pain controlled at an acceptable level for Pt/CG; Pt/CG will understand disease process (no time frame); Aspiration risk minimized during certification period. In HV2, outcomes that were not measurable included: Pt will maintain pain controlled at an acceptable level for Pt/CG; Pt/CG will understand disease process and endurance limits; Will have adequate food and fluids as tolerated to maintain comfort. In HV3, outcomes that were not measurable included: Pt will have food and fluids as tolerated to maintain comfort; Family will verbalize understanding of disease process. In RR1, RR2, RR3, RR4, RR5, RR6, RR7 and RR8, also contained outcomes that were not measurable. This observation was discussed with the Administrator/DON and the alternate Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor noted that the frequency identified for services was not consistent between the order for the services and the comprehensive plan of care. For example, in review of the medical record for HV2, the organization had two orders for the aide to visit 2 times per week. The Plan of Care contained visit frequencies for the aide at 3 times per week on each of the updates. The aide consistently provided services 3 times per week. This same inconsistency related to aide frequency was also found in RR3.

Observed in Record Review. In 2 of 11 patient records reviewed, the surveyor noted that the organization had not specified the medications and/or treatment necessary to meet the needs of the patient. For example, in review of the medical record for HV3, wound care was being completed by the nurse but the plan of care did not provide the specific elements of the wound care to be completed (cleansing, dressing type, etc). In review of the medical record for RR4, the medication ibuprofen was ordered as needed without an indication for use. This was discussed with the Administrator/DON and Alternate Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the surveyor observed that the staff member did not follow organization policy on bag technique. For example, in HV2 and HV3, the staff member cleaned the reusable medical equipment and immediately replaced it in the equipment bag without performing hand hygiene after cleaning the equipment and before replacing it in the bag. Organization policy titled Equipment Bag Technique section M requires that the staff member perform hand hygiene and then return the equipment to the bag and close the bag. This was discussed with the Administrator/DON and Alternate Administrator.. Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor observed that the staff member did not follow accepted standards of practice when performing hand hygiene. For example, during the home visit for HV1, the surveyor observed the staff member wash her hands at the sink. She retrieved a clean cloth towel from the patient's bedroom, turned the faucet off and continued to dry her hands with the towel. In HV2, the surveyor observed the staff member wash her hands at the kitchen sink and close the faucet with her bare hand. In HV3, the surveyor observed the staff member wash her hands at the sink, close the faucet with her bare hand and then retrieve a cloth towel from her equipment bag to dry her hands. She then replaced the towel in her equipment bag in the same compartment as contained her reusable medical equipment. This same staff member was observed waving her hands to dry them after applying alcohol based hand gel. In discussion with Administrator, he stated the organization follows CDC guidelines for hand hygiene. CDC hand hygiene recommendations included in IB state the following when washing hands with soap and water: Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. IB states the following when using an alcohol based hand gel: … apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. This observation was discussed with the Administrator/DON and Alternate Administrator. Observed in Patient Home. In 2 of 2 home visits conducted, where reusable medical equipment was cleaned, the surveyor observed that the staff member did not follow manufacture's instructions related to use of the cleaning wipe. In HV2 and HV3, the staff member wiped the reusable medical equipment with a alkyl dimethylbenzyl ammonium chloride wipe. Instructions for use required a wet contact time of 10 seconds for sanitizing and 4 minutes for disinfection. During both visits, the equipment was wiped down and placed immediately back in the equipment bag without ensuring the required wet contact time. Additionally, in both visits, a pulse oximeter was utilized and also cleaned with a alkyl dimethylbenzyl ammonium chloride wipe. Manufacturer's instructions required the device be cleaned with 70% isopropyl alcohol. This observation was discussed with the Administrator/DON and Alternate Administrator.

Observed in Record Review. In 2 of 8 patient records reviewed, where the patient had hospice aide services ordered, the surveyor found the RN had not provided the hospice aide with specific instructions for the patient. For example, in review of the medical record for RR3, the patient had a foley catheter in place but the aide was not provided specific instructions related to this device. In review of the medical record for RR7, the patient had wound dressings in place through multiple benefit periods. The aide plan of care was updated during the benefit periods but did not specify how these wound dressings were to be cared for (keep clean and dry, watch for dislodgment, etc.). In each case there were also no instructions on when to notify the nurse related to these specific situations. This observation was discussed with the Administrator/DON and the Alternate Administrator.

Observed in Record Review. In 1 of 8 patient records reviewed, where the patient had hospice aide services, the surveyor noted that the aide did not provide all services required. For example, in review of the medical record for HV3, the aide careplan included shaving the patient. There were multiple visits during the 4th benefit period where this was not completed and no documentation to indicate the patient had refused. This observation was discussed with the Administrator/DON and Alternate Administrator Observed in Patient Home. In 1 of 1 home visits conducted, with the hospice aide, the surveyor observed that the aide did not provide care as required by the aide care plan. For example, in HV1, the aide was observed shaving the patient and applying miconazole cream. These tasks were not listed on the aide care plan. This observation was discussed with the Administrator/DON.

Observed in Record Review. In 1 of 8 patient records reviewed, where hospice aide services were ordered, the surveyor noted that the aide had not completed appropriate documentation related to the care provided. For example, in review of the medical record for RR2, multiple notes during the third benefit period were initiated with a time in and out and last bowel movement but all other information had not been documented. These was discussed with and verified by the Administrator/DON.

Observed in Patient Home. In 1 of 2 home visits conducted, where medication reconciliation was completed, the surveyor noted that the medication profile was not consistent with the ordered medications in the home. For example, in HV2, the medication in the home (MS Contin) was ordered prn but the medication profile listed the medication as having a scheduled, round the clock dose. The caregiver verbalized he gave the medication only as needed. This was discussed with the staff member at the time of the visit.