Every finding on record at Heart of Angel Hospice and Palliative, Inc

Upon patient record review, 1 of 11 (Patient 1) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1: The EOB does not contain evidence that the patient chose a health care provider including attending physician.

Upon patient record review 5 of 11 (Patient 1,2,9,10,11) 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: The comprehensive assessment by the RN does not include a spiritual care assessment and the SC did not make a visit as the pt refused SC. Patient 2: The comprehensive assessment by the RN does not include a spiritual care assessment and the SC did not make a visit as the pt refused SC. Patients 9,10,11: The comprehensive assessment by the RN did not include a spiritual care or Psychosocial assessment and the SC documented in all 3 records the Pt's caregivers requesting later visits than within the first 5 days but the SC and MSW have no documentation in the record that visits were made at all.

Upon patient record review, 1 of 11 (Patient 1) 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: Patient 1: The POC contains an order for Tylenol Q8 hours prn, the medication profile has Tylenol Q4 hours prn. Corrected on site.

Upon patient record review, 3 of 11 (Patient #9,10,11) 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 Patients 9,10,11: The medical records of these patients do not include a bereavement assessments being completed upon admission.

Upon patient record review, 3 of 11 (Patient 9,10,11) did not have evidence in the patient record that the comprehensive assessment is updated including and by: Patients 9,10,11: The medical records do not contain: Changes that have taken place since the initial assessment, Information on the patient's progress toward desired outcomes, Reassessment of the patient's response to care, The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.

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

Upon patient record review, 4 of 11 (Patient 1,2,3,8,) 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: The nursing care plan includes Alteration of nutrition and hydration with intervention of assessing the tube feeding site includes assessments of an NG and the patient does not have an NG. Pt has a G tube. Corrected on site. Patient 2: The nursing care plan includes a Bladder disturbance goal with an intervention to maintain the catheter. The patient does not have a catheter. Patient 3: The nurse care plan included an intervention for choking and tube dislodgement. The patient does not have any tubes. Patient 8: The nurse care plan included an intervention for foley catheter care. The patient does not have a foley.

Upon patient record review, 1 of 11 (Patient #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 treatment. Patient 4: The POC 1/28/23 contains a Foley order with no size and the order is written to "irrigate 1-2" no frequency. The pt has a G tube and there are no orders for site care.

Upon patient record review, 3 of 11 (Patient 1,4,6) 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: The POC does not contain DME supply orders. It is documented pt has a G tube with continuous tube feedings and a foley. Corrected on site. Patient 4: The POC 1/28/23 does not contain DME orders. The medical record contains evidence of pt having a hospital bed, suction equipment, oxygen. Patient 6: The POC 5/27/23 does not contain DME orders. The medical record contains evidence of pt having oxygen.

Upon client record review, 3 of 11 (Patient 9,10,11) 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. Patients 9,10,11: The medical records do not contain evidence of 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.

Upon patient record review, 3 of 11 (Patient 9,10,11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patients 9,10,11: There is no evidence in the patient record that a revised plan of care includes information from the patient's updated comprehensive assessment or note the patient's progress towards outcome/goals from the plan of care.

Upon client record review, 7 of 11 (Patient 1,2,4,6,9,10,11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The nurse documents on 10/30/23 "Foley catheter changed per physician order" There is no evidence the nurse followed the order and the documentations does not state how the pt tolerated the procedure. The SN documents on 11/27/23 "IV administered as ordered". Patient 2: The SN documented on 1/10/23 "IV hydration continues as ordered". There is no evidence the IV is running as ordered. SN documented 1/10/23 "wound care performed". There is no evidence the SN followed the POC order for wound care. Patient 4: The SN documented on 1/29/23 "IV hydration provided per MD order" There is no evidence the order was followed. Patient 6: The POC 5/27/23 contains an order for SN 1 time per week. The medical record contains evidence of SN visits twice the week of 5/28/23-6/3/23 on 5/30 and 6/3. Both visits are documented at routine visits. Patients 9,10,11: The medical records contained no visits documented past the admission date. The POC contains orders to be seen once a week by nursing. There were no IDG meetings documented. In addition, there was documentation by the MSW that the patients' caregivers requested their comprehensive assessment be completed later than 5 days but there is no evidence there were any visits completed by the MSW.

Upon patient client record review, 3 of 11 (Patient 9,10,11) did not have evidence that each patient record contains:(this references that the documentation is part of the patient record. Patients 9,10,11: The medical records did not have evidence of any signed and dated progress notes, updated comprehensive assessments, updated POC.

Upon patient client record review, 3 of 11 (Patient 1,5,6) did not have evidence that each patient record contains: Patient 1: The EOB has multiple blank spaces not filled in and has patient's signature. Patient 5: The EOB has a blank line where the pt is informed of the Medicare coverage. Patient 6: The EOB has a blank line where the pt is informed of the Medicare coverage.

Upon patient client record review, 3 of 14 (Patient #9. 10, 11) did not evidence that each patient record contains physician orders. Patient 9,10,11: There were no further visits past admission on these patients despite having visit orders for all disciplines. There was no discharge orders written on any of these patients.

Upon patient client record review, 1 of 11 (Patient 1) 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 1: The SN documented "F/C" for foley catheter. This is not an approved abbreviation.

Upon client record review, 3 of 11 (Patient 9,10,11) did not have evidence that the discharge summary includes all required information. Patients 9,10,11: There were no further visits performed on these patients and no discharge summaries documented.

Upon SNF/NF contract review, 1 of 3 (Heritage Manor) did not have evidence that it is the hospice's responsibility to provide services at the same level and to the same extent as those services would be provided if the SNF/NF resident were in his or her own home.

Upon client record review, 1 of 11 (Patient 2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 2: The POC 1/5/23 contains wound care orders but does not state who is to perform the wound care.

Upon observation, there was no evidence the hospice provides orientation to personnel of a SNF/NF or ICF/IID regarding the policies and procedures of the provision of care/service including all required content.