Every finding on record at Pro Angels Inc

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. Review of the governing body minutes for the year 2024 did not contain documentation that the Board of Directors approved the frequency and detail of the data collection for the QAPI program indicators.

Upon patient record review, 1 of 14 (Patient # 14) 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 # 14: Upon review of patients Hospice Aide POC dated 5/31/2024 the aide duties of "nail cleaning" and "nail filing" were ordered PRN.

Upon patient record review 1 of 14 (Patient # 2) 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 # 2: Review of the hospice aide supervisory visits by the RN demonstrated a supervisory visit was made 11/18/2024 and was followed by the next supervisor visit on 12/06/24. In addition, an RN supervisor visit completed 01/03/2025 and was followed by the next supervisor visit on 01/22/2024.

Upon patient record review, 1 of 5 records (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. Patient 4: The medication profile contained Haloperidol/acetate 2mg/ml every 4 hours prn for agitation and restlessness. There was no evidence of a dose. The medication profile contained Morphine sulfate 20mg/ml every 2 hours as needed for pain or shortness of breath with no evidence of dose.