Every finding on record at Guardian Angels Hospice Care, LLC

Upon patient record review, 4 of 7 (Patient #1,2,3,4) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,3,4 do not have evidence that imminently dying was assessed in the admission comprehensive assessment(s) or visit summary.

Upon patient record review, 1 of 7 (Patient #4) 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 4:The current medication record contains orders for Acetaminophen 325 (2) tabs prn for pain/fever. There is no frequency listed. Corrected on site, POC updated.

Upon patient record review, 2 of 7 (Patient #1,4) 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 1: The current POC for skin integrity does not include directions for wound care, who will complete wound care, frequency or site of wound care. Corrected on site, POC updated. Patient 4:The current POC contains orders for Acetaminophen 325 (2) tabs prn for pain/fever. There is no frequency in the order listed. Corrected on site, POC updated.

Upon observation, there was no evidence the Emergency Preparedness plan: • Is based on and includes a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach • Includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. There was no evidence the agency completed an All Hazard Risk Assessment.

Upon observation, there was no evidence of contracts/agreements with other facilities/agencies/hospices to receive patients in the event the hospice cannot provide care to their patients during an emergency.

Condition of Participation: Patient’s rights The patient has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1-5: There is no evidence the patient or caregiver was provided verbal or written information of notice of patient's rights and responsibilities. All medical records reviewed contained a typewritten name for the patient/PCG. There was no signature by the patient or PCG that indicated they received verbal or written notice.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1-5: There is no evidence the patient or caregiver acknowledged the receipt of verbal or written information of notice of patient's rights and responsibilities. All medical records reviewed contained a typewritten name for the patient/PCG. There was no signature by the patient or PCG that indicated they received verbal or written notice.

Upon observation, there is not evidence that the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. All patient consents are not signed by patient or representative.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1-5: All medical records reviewed contained a typewritten name for the patient/PCG. There was no signature by the patient or PCG that indicated they received verbal or written notice.

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patient #1-5: There is no evidence the patient/family was involved in the development of their care plan. All medical records reviewed contained a typewritten name for the patient/PCG. There was no signature by the patient or PCG that indicated they received verbal or written notice.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #1,2,3,4,5: There was no evidence in the medical record the patient chose an attending physician. All medical records reviewed contained a typewritten name for the patient/PCG where the signature was needed. There was no signature by the patient or PCG that indicated a choice.

Upon patient record review, 5 of 5 (Patient ##1,2,3,4,5) did not have evidence of the appropriate documentation for release of confidential information. Patient #1-5: There was no evidence of the appropriate documentation for release of confidential information. All medical records reviewed contained a typewritten name for the patient/PCG where a signature was needed. There was no signature by the patient or PCG that indicated receipt of information.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #1-5: There was no evidence that the patient/PCG received information about the services covered under the hospice benefit. All medical records reviewed contained a typewritten name for the patient/PCG where a signature was needed. There was no signature by the patient or PCG that indicated receipt of information.

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1-5: There was no evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. All medical records reviewed contained a typewritten name for the patient/PCG where a signature was needed. There was no signature by the patient or PCG that indicated receipt of information.

Condition of participation: Initial and Comprehensive assessment of the patient The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions.

Upon patient record review 5 of 5 (Patient #1,2,3,4,5) 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. Patient #1-5: There was no evidence in the patient record of a complete psychosocial assessment was completed. Patient #5 also did not have a spiritual needs assessment.

Upon patient record review, 4 of 5 (Patient #2,3,4,5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients #2-5: There was no evidence of consideration of the imminence of death.

Upon patient record review, 1 of 5 (Patient #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. Patient #2: There was no evidence of an initial bereavement assessment.

Upon client record review, 1 of 5 (Patient #1) 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 #1: There is no evidence of IDG meeting on 4/22/25.

Upon client record review, 1 of 5 (Patient #4) 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 visit frequency was RN 1xwk. There was no visit the week of 5/4/25.

Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. Agency was not able to provide evidence of ability to provide occupational or speech-language pathology. Agency was able to obtain OT contract during survey but not a contract for ST.

Condition of participation: Hospice aide and homemaker services. All hospice aide services must be provided by individuals who meet the personnel requirements specified in paragraph (a) of this section. Homemaker services must be provided by individuals who meet the personnel requirements specified in paragraph (j) of this section.

Upon patient record review, 2 of 5 (Patient #3,4) 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 #3: No aide plan of care was developed for the patient. Patient #4: There was an aide plan of care but it did not contain tasks.

Upon patient record review 2 of 5 (Patient #3,4) 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 #3: Aide visits ordered one time per week however, there was no evidence this was completed. Patient #4: Aide visits ordered one time per week however, there was no evidence this was completed.

Condition of Participation: Organization and administration of services. The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions.

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. Upon initiation of survey, the agency was unable to provide evidence of ability to provide all levels of care-specifically short-term inpatient care (GIP, respite). Agency did obtain contract during survey. In addition, agency unable to provide evidence of ability to provide occupational and speech-language pathology. Able to obtain OT contract prior to end of survey but unable to produce HR documents required such as license, criminal background, etc. All patient admission documents missing actual signature of patient and/or authorized representative. Overall agency is unable to display knowledge and ability needed for a fully compliant operational hospice agency.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance Upon arrival for the survey, the agency was unable to provide evidence of ability to provide short-term inpatient care, occupational or speech-language pathology services.

Upon patient client record review, 5 of 5 (Patient #1,#2,#3,#4,#5) 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 Patients 1-5: Election of benefit forms not signed by patients or authorized representative.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5: The discharge summary did not contain summary of the stay, current POC, physician orders or post discharge continuity of care.

Upon client record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1-5: There is no evidence management of controlled drugs was provided or discussed. All medical records reviewed contained a typewritten name for the patient/PCG. There was no signature by the patient or PCG that indicated they received verbal or written notice.

Upon observation, there was no evidence of a contract to provide inpatient care for respite purposes in a Medicare certified hospice, if applicable. The agency was not able to provide evidence of ability to provide inpatient for respite at the start of survey. Corrected on site

Condition of participation: Personnel qualifications

Upon personnel record review, 1 of 8 (Personnel #7) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel #7: There was no license available for the Occupational Therapist.

Upon personnel record review, 2 of 8 (Personnel #7, #8) 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 #7, No OT file provided. Personnel#8 no evidence of background check.