Every finding on record at Heavenly Angel Hospice Inc

Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial assessment for one of three sampled patients (Patient 1), when one of Patient 1’s medications, which was listed on the Medication Profile (MP — a current list of all medications prescribed for a specific patient), was stored unsafely, being exposed, open to air, and readily available for use. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy, which could place Patient 1’s health and safety at risk. Findings: A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of August 27, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of August 27, 2025, to October 25, 2025.  Patient 1 had diagnoses that included Atherosclerotic heart disease of native coronary artery without angina pectoris (a condition that the blood vessels in the heart are getting narrow or blocked because of plaque build-up, but it doesn't cause chest pain) and paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days).During an observation on September 3, 2025, at 11:00 AM, during Patient 1's home visit, with a Licensed Vocation Nurse (LVN 1) and in the presence of Patient 1’s caregiver, an unidentified, unlabeled medication was found inside the first drawer of a bedside mesh wire four-compartment drawer, which was located at Patient 1’s bedroom. The medication was oval-shaped and bright pink in color, with a total of 92 pills. The pills were not stored in a bottle or bag but were loose inside an open drawer organizer. During an interview on September 3, 2025, at 11:10 AM, with Patient 1’s caregiver, she stated she was not aware that the medication needed to be kept in its original bottle for identification purposes. Patient 1’s caregiver stated “the medication was placed in the drawer organizer about two months ago, around July, and the last time she [Patient 1] took the medication was last night [September 2, 2025]” During an interview on September 3, 2025, at 11:20 AM, with LVN 1, LVN 1 stated all medications should be stored in their original bottle or bag. LVN 1 further stated that the nurse should have checked and reviewed all medications during the home visit to ensure that all medications were stored safely, but this was not done.During an interview on September 3, 2025, at 3:00 PM, with Director of Patient Services (DPCS), the DPCS stated, “It was her and/or visiting nurse responsibility using the medication profile to teach purpose of medication, dosages, routes, administration times, including potential side effects, and contraindications. The DPCS further stated "the nurses should have been ensuring each medication labeled and store safely on their visits".During a concurrent interview and record review on September 3, 2025, at 3:10 PM, the DPCS reviewed the agency’s policy and procedure titled “Medication Profile,” revised May 2023, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient's current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE. 1. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time of administration… 3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. B. Using the medication profile to teach purpose of medication, …”. The DPCS stated the agency did not follow the policy.

Observed in Record Review. In 5 of 5 patient records reviewed, During HV#1-3 and RR#1-2, although there were IDG meetings documented every 14 days, it was noted the MSW did not update the psychosocial/emotional assessments. The MSW documentation within the response to teaching, symptom management, treatment and service/progress toward targeted outcomes section of the note was the same at multiple IDG meeting. During HV#1 and RR#1-2 it was noted the Spiritual Counselor (SC) did not update the spiritual assessments during IDG meetings. The SC documentation within the response to teaching, symptom management, treatment and service/progress toward targeted outcomes section of the note was the same at multiple IDG meeting. This was discussed with the Administrator/DPCS.