Every finding on record at Angels Heart Hospice Inc

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that the patient chooses a health care provider, including an attending physician. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence of the appropriate documentation for release of confidential information This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that the patient received information about the services covered under the hospice benefit. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 5 of 5 (Patient #1-5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Upon patient record review, 5 of 5 (Patient #1-5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. This agency has had no patients since previous survey. There are no active patients on services at this time. No records produced for review.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency does not have any current patients, staff other than Administrator recently hired, alternate administrator.

Condition of Participation: Patient’s Rights. L500

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence of the appropriate documentation for release of confidential information. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon patient record review,1 of 5 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 5 (Patient #1,2) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patients #1,#2: No evidence of a physical or comprehensive assessment.

Upon patient record review, 2 of 5 (Patient #1,2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #1,#2: No evidence of a physical or comprehensive assessment.

Upon patient record review, 3 of 5 (Patient #2,#3,#4) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2: SN notes 11/8 and 11/11/2024 identify SOB with congestion, orders received for nebulizer and antibiotics. No evidence POC undated with these findings or problem/goals/interventions for respiratory/infection. Patient #3: SN notes 11/28/2024 identify episodes of nausea and vomiting, orders received for Zofran. No evidence POC undated with these findings. Patient #4:SN identifies wound to rt heel, with dressing changes and debridement prior week. No evidence in updated POC with these findings.

Upon client record review, 5 of 5 (Patient #1,#2,#3,#4,#5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Frequency orders dated at SOC 9/6/2024 included SW 2x QRT, visits were made 5x September, October and 3 x December. SC ordered 1 X per month, visits made 2x September and October. Patient #2: Frequency orders dated at SOC included SW 2x month, visits were made 3x September and 1x November. SC ordered 2x month, visits were made 1x November and none in December. Patient #3: Frequency orders dated at SOC included SW 1x month, visits were made 5x September, 3x October. No orders for SC visits were made 1x September and October, 2 x November. SN ordered weekly no SN visit week of 10/20/2024. Patient #4:Frequency orders dated at SOC included SW and SC no visits ordered, SW visited 4x September, 3x October and 1x November and December. SC made visits 1x September, 2x October and November. Patient #5: Frequency orders dated at SOC included SW 1x week. SW week of 10/20,10/27 and 11/24/2024 no visits, week of 11/3/2024 2 visits. SC 1x Qtr made visits 1x October, 2x November.

Upon observation, there was no evidence the hospice measures, analyzes, and tracks quality indicators, including adverse patient events and other aspects of performance that enable the hospice to assess processes of care, hospice services, and operations. New Service being utilized for QAPI is QAPI Plus- they have no evidence of any adverse events, incidents, accidents, variances or unusual occurrences since December. Per Operating Manger none existed prior.

Upon patient record review, 3 of 5 (Patient #2,#3,#4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #2: No CTI for BP#9. Patient #3: No CTI for BP #3. Patient #4: No CTI BP #5.

Upon patient client record review, 1 of 5 (Patient #3) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #3: No evidence of admission and informed consent, signed copy of pt. rights, EOB, release of info and other documents for protected health information.

Upon client record review, 4 of 5 (Patient #1,#2,#4,#5) did not have evidence that the discharge summary includes all required information. Patients #1,#2,#4,#5: No evidence of a discharge summary.

Upon patient record review, 5 of 5 (Patients #1, 2, 3, 4 and 5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #1: The CTI benefit period duration has incorrect time period for 1st benefit period. The start of care is listed as 6/29/23. The agency benefit period reads 6/29/23 to 9/27/23. The 1st benefit should read 6/29/23 to 9/26/23(90 days). Patient #2: The CTI benefit period duration has incorrect time period for 1st benefit period. The start of care is listed as 6/30/23. The agency benefit period reads 6/30/23 to 9/30/23. The 1st benefit should read 6/30/23 to 9/27/23 (90 days). Patient #3: The CTI benefit period duration has incorrect time period for 1st benefit period. The start of care is listed as 6/30/23. The agency benefit period reads 6/30/23 to 9/29/23. The 1st benefit should read 6/30/23 to 9/27/23 (90 days). Patient #4: The CTI benefit period duration has incorrect time period for 1st benefit period. The start of care is listed as 1/12/23. The agency benefit period reads 1/12/23 to 4/12/23. The 1st benefit should read 1/12/23 to 4/11/23 (90 days). Patient #5: The CTI benefit period duration has incorrect time period for 1st benefit period. The start of care is listed as 2/3/23. The agency benefit period reads 2/3/23 to 5/4/23. The 1st benefit should read 2/3/23 to 5/3/23 (90 days).