Every finding on record at Angels Hospice Inc

Observed in Patient Home. In 1 of 1 home visits where a Comprehensive Assessment was being completed to update the plan of care, the Registered Nurse (RN) did not follow the organizational Policy No. 2-031.1,2-Ongoing Comprehensive Assessment. For example, observed in HV#2, the RN completed the medication reconciliation, vital signs, pain assessment, auscultated heart, lung, and bowel sounds, but failed to assess G) skin integrity, L) oxygen safety, N) spiritual issues, and O)psychosocial issues, all listed in the organizational policy as required components of the ongoing comprehensive assessment. This was reviewed and validated by the Administrator and Director of Patient Care Services.

Observed in Patient Home. Observed in 2 of 2 home visits where reusable medical equipment was utilized during the patients' assessments, the clinician did not follow the organizational Policy No. 9-0014.1,2 Bag Technique: 5) When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, . . . , A.) Stethoscope, bell and diaphragm - alcohol; . . . C) Reusable tourniquet-soap and water and/or alcohol; D) Thermometer-soap and water; E) Blood pressure cuff will be cleaned in accordance wit the manufacturer's guidelines such as with soap nd water t frequency recommended by the cuff manufacture . . . For example, in HV#1, and HV#2, the Registered Nurse used Member Mark disinfecting wipes to clean the wrist blood pressure cuff, infrared thermometer, stethoscope, and pulse oximeter. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. The Surveyor identified that the organization had no documentation of volunteer recruitment efforts over the past 3 quarters. This was reviewed and validated with the Administrator.

Observed in Record Review. In 3 of 3 active patient records reviewed, there were no verbal authorization documented for hospice eligibility at the time of recertification, and the Medical Director failed to provide a written signature on the certificate of terminal illness (CTI) at the time of recertification in accordance with the organizational Policy No. 2-025.2-Certification of Terminal Illness- 5) . . . the hospice Medical Director must compose and sign the narrative based on a review of the patent's medical record . . .A verbal or written certification statement must be obtained from the Medical Director . . .no more than fifteen calendar days prior or two calendar days after the first day of each period. For example, in the record review for HV#1: the CTI for benefit period two was signed 86 days after the start of the benefit; the CTI for benefit period four was signed 63 days after the start of the benefit; and the CTI for benefit period five, remained unsigned at the time of survey 10 days post start of the benefit. In review of the record for HV#2, the CTI for benefit period two was signed 81 days after the start of the benefit; in benefit period four, the CTI was signed 59 days after the start of the benefit; and in benefit period 5, the CTI remained unsigned at the time of survey 7 days post start of the benefit. In the review of the record for RR#1 the CTI for benefit period two was signed 113 days after the start of benefit; the CTI for benefit period 3 was signed 23 days after the start of the benefit; the CTI for benefit 4 was signed 91 days after the start of the benefit; and, the CTI for benefit period 5 was signed 31 days after the start of the benefit. This was reviewed and validated with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 2 home visits where a medication reconciliation was completed with the patients' medication list, the organization did not ensure that the medication profile was accurate. For example, during HV#2, the medications Paxlovid-1tablet by mouth 2x each day for 5 days, ordered approximately 2 1/2 months prior remained active on the medication list; and, Mupirocin 2% topical ointment, 1 application, 2x day until resolved, ordered 2 months prior remained active on the medication list beyond the date when the skin infection was resolved. This was reviewed and validated with the Administrator and Director of Patient Care Services.