Every finding on record at Angelic Health of Sc, LLC

Upon patient record review 1 of 14 (Patient #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Pt #10 - Admitted 4/2/24. No evidence of psychosocial assessment until 04/17/24

Upon patient record review, 2 of 14 (Patient #8, 9) 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 Pt #8 - Order for O2 in chart, not on med profile. (Corrected on site) Pt # 9 - No evidence that Calamine skin protectant is listed on medication profile but on facility record, (Corrected on site)

Upon patient record review, 1 of 14 (Patient #9) 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. Pt # 9 - Facility MAR states patient is receiving Calazime skin protectant to buttock q shift: may leave at bedside and administer per HHA. No evidence of order in pt hospice record. (Corrected on Site)

Upon patient record review 1 of 14(Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Pt #2 - SC made assessment visit 3/25/24. Note read - "chaplain was asked to call in a week or 2 to schedule a follow up visit." No evidence of follow up until missed visit TC 4/30/24 - no answer and then the next contact was 5/31/24 where the pt requested a later date.

Upon patient record review 2 of 14 (Patient #3, 10) 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 Pt #3- Visit frequency is 5Xwk. No evidence of visits 5/24, 5/27, 5/28 . (Corrected on site) Pt #10 - Visit frequency 5xwk. No evidence of visit 5/27/24. 5 X wk visit order. (Corrected on site)

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Annual 2023 report states volunteer hours were at 3%