Every finding on record at Angels of Peace Hospice, Inc

Upon patient record review, 10 of 14 records reviewed (Patient #1-#10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10: There was no evidence in the record the patient chose a health care provider including an attending physician.

Upon patient record review 7 of 14 charts reviewed (Patient #1, #2, #3, #5, #7, #9, #10) 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. Patient #1, #2, #3, #5, #7, #9, #10: There was no evidence in the chart the spiritual comprehensive assessment was completed at the time of the survey.

Upon patient record review, 10 of 14 records reviewed (Patient #1-#10) 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 Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10: Each patient had multiple medications listed on the medication profile. There was no evidence in the chart the medications were reviewed to include effectiveness of therapy, actual or potential drug interaction, duplicate therapy and or drug therapy currently associated with laboratory monitoring.

Upon patient record review, 1 of 14 records reviewed (Patient #4) 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 #4: The record indicated the goal for pain will remain less than 5/10 on a pain scale within 48 hours and on an ongoing basis. The assessment revealed the patient's self identified threshold was a "2", this plan was not individualized. COS.

Upon patient record review 1 of 14 (Patient #4) 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. Patient #4: The record indicated the patients pain on admission on 10/01/24 had a pain score of "5" and the self identified threshold was a "2". The next assessment on 10/03/24 the pain was assessed and it was a "3". The next visit was on 10/12/24 and the pain was a "4". There was no evidence of meeting the patient needs with pharmacological or non-pharmacological interventions for self identified threshold.

Upon patient client record review, 10 of 14 charts (Patient #1-#10) 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 #1, #2, #3, #4, #5, #6, #7, #8, #9, #10: There was no evidence the patient was offered to received a copy of the non covered items, services, and / or drugs at the start of care that the hospice has determined to be unrelated to the patients terminal illness, this was not part of the hospice election addendum. In addition, there was no evidence patient given opportunity to select an attending physician.

Upon patient client record review, 1 of 14 records reviewed (Patient #5) 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 #5: The record indicated the comprehensive assessment had 14 pages. The patients full name and or medical record number was not written on pages 2-14. COS.

Upon patient record review, 1 of 5 (Patient #3) 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 equipment and supply needs. Patient #3: This patient had a cane to ambulate. This item was not included on the Plan of Care.