Every finding on record at Angels Palm LLC

Upon patient record review, 1 of 11 (Patient #2) 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 Patient 2: In the patient medication administration profile, the patient had Lasix and potassium discontinued, the hospice profile still listed the medications as active. Also, the hospice has Zofran listed on the profile, the patient medication profile is missing the medication.-Corrected on site.

Upon patient record review, 1 of 11 (Patient #2) 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. Patient 2: In the facility chart, the patient had Lasix and potassium discontinued on 04/29/25, the hospice did not have discontinue order for these medications.-corrected on site.

Upon patient record review, 8 of 11 (Patients #1, #2, #3, #4, #5, #6, #7, #8) 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 1: In the admission note, it was identified that patient needs an air mattress, there is no order for air mattress found. Patient 2: In the admission note, it was identified that patient has air mattress, bed, table, and oxygen concentrator, there is no order found for equipment. Patient 3: In the admission note, it was identified that patient has a walker in home, there is no order found for equipment. Patient 4: In the admission note, it was identified that patient has a walker, hospital bed, and bedside table in home, there is no order found for equipment. Patient 5: In the admission note, it was identified that patient has a cane, walker, wheelchair, shower chair in home, there is no order found for equipment. Patient 6: In the admission note, it was identified that patient has a hospital bed, bedside table, cane, walker, wheelchair, shower chair, and commode in home, there is no order found for equipment. Patient 7: In the admission note, it was identified that patient has a walker, wheel chair, shower chair, oxygen concentrator, there is no order found for equipment. Patient 8: In the admission note, it was identified that patient has a hospital bed, bedside table, walker, shower chair, commode in home, there is no order found for equipment.

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. The hospice has zero direct patient care hours from the annual report of 2024.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon observation and patient record review, 1 of 8 (Patient#7) there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #7: On 5/29, 6/12, 6/26/24, the IDG meetings have no MSW or SC signatures. There is notation that services were declined. There is no evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient.

Upon patient record review, 3 of 8 (Patient #1, 2, 5) 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 #1: Medications include Levetiracetam for Seizures with no evidence of related problems/goals/interventions. Patient #2: Medications include Divalproex for Seizures with no evidence of related problem/goal/intervention. Patient #5: Medications include Levetiracetam for Seizures with no evidence of related problems/goals/interventions.

Upon patient record review, 3 of 8 (Patient #4, 5, 8) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #4. On 8/15/25 order for SN 1x/week and as needed. POC includes MSW and SC frequency of 1x upon admission and as needed for psychosocial and spiritual assistance respectively. No evidence of a PRN frequency. Patient #5: On 8/6/25 order for MSW and SC once upon admission and as needed for psychosocial needs and spiritual assistance respectively. No evidence of a PRN frequency. Patient #8: On 8/5/24 order for MSW and SC 1x upon admission and as necessary for psychosocial needs and spiritual assistance respectively. SN x1 visit every week and as necessary for symptom management. No evidence of a PRN frequency.

Upon patient record review, 2 of 8 (Patient #2,3) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #2: There is no SC note and no SC signature at the 2/27/24 IDG meeting. There is no MSW note and no MSW signature. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #3: There is no SC note and no SC signature at the 2/27/24 IDG meeting. The disciplines were actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 3 of 8 (Patient #4, 5, 8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The 8/15/24 order for SC 1x upon admission and as needed for spiritual assistance. IDG POC includes 8/15/24 order for MSW and SC frequency of 1x upon admission and as needed for psychosocial and spiritual assistance respectively. In addition to initial assessment, MSW made monthly visits thru November. In addition to initial assessment, SC saw patient for each recert period. Patient #5: SC and MSW frequency once upon admission and as needed. Patient was seen monthly by both disciplines. Patient #8: SC and MSW frequency once upon admission and as needed. Patient was seen monthly by both disciplines.

Upon patient record review, 1 of 8 (Patient #5) 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 #5: The patient is on medication for seizure disorder, but there is no reference to seizure precautions for hospice aide assignment.

Upon patient record review 2 of 8 (Patient #4, 7) 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 Patient #4: Hospice aide frequency ordered 2x week. Only 1 visit documented week of 11/4/24. Patient #7: Hospice aide frequency ordered 3x week. Only 2 visits week of 6/3/24 and 6/24/24; 4 visits documented week of 6/17/24

Upon patient record review, 2 of 8 (Patient #2, 6) 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 #2: CTI narrative only lists age, diagnosis, KPI 60, ADL 2/6 with patient functional and clinical decline. Patient #6: CTI narrative only lists age, diagnosis and that patient was on hospice 2 days (prior to revocation).

Upon patient record review, 3 of 8 (Patient #2, 4, 8) 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 #2: In initial IDG Meeting note 1/16/25, MSW documents last saw patient 1/2/25, but visit note dated 1/4/25. Patient #4: MSW visits were ordered and made monthly, but in initial assessment 8/19 and follow up visit 11/12/24, MSW documented plans to see patient weekly. Patient #8: Report of Death and Disposal of Controlled Drugs form (includes clinician visit at time of death) is not authenticated with clinician's name/signature and credentials. DC summary is completed, but no signature.

Upon patient record review, 1 of 8 (Patient #7) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient #7: DC summary narrative states gave patient Plan of Care and Med List and POLST and she will contact PCP.

Upon patient record review, 4 of 8 (Patient #4, 5, 6, 7) did not have evidence that the discharge summary includes all required information. Patients #4, 5, 6, 7: Discharge Summary does not include comprehensive account of patient stay.

Upon personnel record review, 1 of 12 (Personnel #10 ) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #10: No criminal background check from PT available by the end of survey.