Every finding on record at Angels Protection Hospice Inc.

Upon patient record review, 2 of 10 (Patient: #2 and #4) did not contain evidence in the patient record that the patient chooses a health care provider, including an attending physician. Patient #2: Attending Physician declined the Role as Attending Physician. Record revealed no evidence of Patient/CG Choice of Attending Physician Role was offered. Patient #4: Recertification signed by Physician with no evidence of affiliation and not by patient/family choice of Attending Physician. Record revealed no evidence of Patient/CG Choice of Attending Physician Role was offered.

Upon patient record review, 2 of 10 (Patient #9 and #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 #9 and #10: Medical record did not show evidence of oxygen 2L via NC as needed for shortness of breath on medication profile.

Upon patient record review, 1 of 10 (Patient #7) 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 # 7: documentation of SW Initial Assessment stated that no SW goals were needed due to residing in Board and care home, despite documentation stating Patient declining fast and needs continued support.

Upon patient record review, 2 of 10 (Patient #9 and #10) 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 #9 and #10: Medical record did not show evidence of order for oxygen 2L via NC as needed for shortness of breath.

Upon patient record review, 1 of 10 (Patient #7) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #7: Record indicated documentation of MSW of family requesting Chaplain/Bereavement support and daughter exhibiting difficulty coping with patient death on 07/12/23 with no evidence of follow up for Bereavement services.

Upon patient record review, 5 of 10 (Patient #1, #3, #5, #6, #7) did not have evidence in the patient record that hospice aide assignments and duties are: Upon record review, Home health Aide Care Plans did not have evidence of specific frequencies in which to perform tasks assigned. • 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 #1. #3, #5 , #6, #7: Aide plan of care did not contain evidence of specified task frequency in medical record.

Upon patient record review 1 of 10 (Patient #8) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #8: Medical Record did not indicate Supervisory visit complete by RN (LVN documentation of Aide Supervisory visit completed on 06/06/23)

Upon patient record review, 1 of 10 (Patient #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 #4 Recertification Order on 12/30/23 was not signed by Medical Director involved in case. Signed by another Provider who was not an agency designee or involved in case.

Upon patient client record review, 1 of 10 (Patient #2) 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: The Recertification of patient for 7th Benefit Period contains inconsistent dates, signed by Physician with no affiliation to patient on 01/01/24 and RN signed 09/07/23.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.

Upon observation, there was not evidence that all patient records are retained for a minimum of six years from the date of the most recent discharge or the death of the patient, unless state law stipulates a longer period of time. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.

Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.