Every finding on record at Angels Caring Hands Hospice Care

Upon patient record review, 1 of 7 (Patient #2) 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 2:The medical record includes documentation that the patient requires oxygen therapy at 3 liters per minute via nasal cannula as needed for shortness of breath. There is no evidence that the plan of care includes the intervention of oxygen therapy to manage dyspnea.

Upon patient record review, 1 of 7 (Patient #2) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2:The aide plan of care includes use of Hoyer lift for transfers. As noted during home visit and conversation with SN, there is no evidence that the patient requires a Hoyer lift for transfers.

Upon patient client record review, 1 of 7 (Patient #1) 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:The medical record includes an order for Eliquis for anticoagulation therapy which is profiled on the medication profile. The plan of care includes a intervention for the problem of risk of bleeding that notes anticoagulation therapy as Aspirin.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by review of clinical records and interview. 5 of 5 (100%) of clinical records reviewed revealed the hospice did not ensure an initial comprehensive assessment was completed no later than five (5) calendar days after the election of hospice care. Clinical Record #12492; Patient elected hospice services on 2/8/2022 with a primary diagnosis of chronic kidney disease. Review of the clinical record revealed the spiritual assessment was not completed within 5 days of election of hospice. Clinical Record #76234; Patient elected hospice services on 11/25/2022 with a primary diagnosis of breast cancer. Review of the clinical record revealed the spiritual assessment was not completed within 5 days of election of hospice. Clinical Record #94254; Patient elected hospice services on 4/4/2022 with a primary diagnosis Alzheimer’s Disease. Review of the clinical record revealed the spiritual assessment was not completed within 5 days of election of hospice. Clinical Record #38583; Patient elected hospice services on 4/4/2022 with a primary diagnosis of congestive heart failure. Review of the clinical record revealed the spiritual assessment was not completed within 5 days of election of hospice. Clinical Record #37092; Patient elected hospice services on 4/13/2022 with a primary diagnosis of cerebrovascular disease. Review of the clinical record revealed the spiritual assessment was not completed within 5 days of election of hospice. During an interview on 6/9/2022 the administrator confirmed this finding and stated completion of the spiritual assessment was overlooked and the team will be educated about the requirement to complete the spiritual assessment within 5 days of election to hospice.

It is required that the hospice infection control program includes education of employees in infection control. This standard was not met as evidenced by review of personnel records, and interview. 8 of 8 (100%) personnel records reviewed revealed the hospice did not ensure infection control education was completed per agency hospice policy. Personnel Record #22385 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #34717 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #87596 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #92452 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #69127 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #98737 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Personnel Record #34100 was reviewed and identified the date of hire was 6/08/2021. Documentation in the personnel record did not contain evidence of monthly hand hygiene observations. Hospice Infection Control policy states, in part, “proper hand hygiene procedures are to be observed monthly and be documented as completed correctly on the hand hygiene form.” During an interview with the administrator on 6/9/2022, the administrator confirmed hand hygiene observations did not occur per policy. The administrator stated she “was unaware of the policy requirement and the hand hygiene form.”

It is required that all hospice professionals always keep their qualifications current. This standard was not met as evidenced by review of personnel records and interview. 1 of 1 (100%) personnel records reviewed that require current prescription authority revealed, the hospice did not ensure prescription authority by the drug enforcement administration (DEA) was current. Record #34100 was reviewed and identified the date of hire was 6/08/2021. Review of the record revealed the hospice medical director did not have documentation of a current DEA license. During an interview on 6/8/2022, the administrator confirmed this finding, stating “this was overlooked, the MD has current authority, and that documentation of current authority will be placed in the personnel record as soon as possible.” At the conclusion of the on-site survey the documentation was not yet in the personnel record.