Every finding on record at United Angels Hospice Inc.

Upon patient client record review, unable to abate this deficiency as there has been no admissions since previous survey.

Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient's clinical record in confidential manner. Agency does not have prior patient records to ensure confidentiality maintained.

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.

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

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees • Entities providing services under arrangement • Patients' physicians • Other hospices

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years.

Upon patient record review, 2 of 6 (Patients #1,#2) 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 1: The medication profile contained diclofenac and Nitro Bid topical medication with no area defined for administration. Corrected on site with clarification order received and instructions added to the medication profile. Patient 2: The medication profile contained oxygen without a frequency of as needed or continuous.

Upon patient record review, 1 of 6 (Patient #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • 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 Patient 2: There was no evidence of an RN assessment from 10/25/24 to 11/25/24 and 12/26/24 to 1/17/25.

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

Upon patient record review, 4 of 6 (Patients #2,#3,#4,#6) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 2: The medical record contained an order for social work visits every recert and as needed. There was no quantity of PRN visits outlined. Patient 3,6: The medical record contained an order for social work visits every recert and as needed, and spiritual care as needed. There was no evidence of scheduled spiritual care and there was no quantity of PRN visits outlined. Patient 4: The medical record contained an order for social work visits as needed. There was no evidence of a scheduled need and there was no quantity of PRN visits outlined. The record also contained an order for aide visits twice weekly and one PRN.

Upon patient record review, 2 of 6 (Patients #1,#2) 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 medical record contained orders for diclofenac and Nitro Bid topical medication with no area defined for administration. Corrected on site with clarification order received. Patient 2: The medical record contained an order for oxygen with no frequency of as needed or continuous.

Upon patient record review, 4 of 6 (Patients #1,#2,#3,#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 medical record contained nursing documentation upon admission identifying patient use of a hospital bed, air mattress, walker, wheelchair, shower chair, Hoyer lift, and suction machine. Upon home visit, the patient also had half rails on the bed. There was no evidence of orders for the DME included in the plan of care. Corrected on site with orders received to update the plan of care. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of a cane, walker, and nebulizer. There was no evidence of orders for the DME included in the plan of care. Patient 3: The medical record contained nursing documentation upon admission identifying patient use of a cane and walker. There was no evidence of orders for the DME included in the plan of care. Patient 6: The medical record contained nursing documentation upon admission identifying patient use of a walker and shower chair. There was no evidence of orders for the DME included in the plan of care.

Upon client record review, 4 of 6 (Patient #2,3,4,6) 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 2: There was no evidence of social work and spiritual care involvement for IDG 1/21/25. Patient 3: There was no evidence of RN, social work and spiritual care involvement for IDG 2/4/25; social work and spiritual care involvement 1/21/25; and spiritual care involvement 1/7/25. Patient 4: There was no evidence of social work and spiritual care involvement for IDG 2/18/25. Patient 6: There was no evidence of social work and spiritual care involvement for IDG 1/21/25 and 2/4/25.

Upon client record review, 1 of 6 (Patient #3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The medical record contained an order for RN visits once every two weeks and an order stating patient declined LVN visits. The patient was receiving weekly LVN visits without an order.

Upon observation, there was no evidence licensed professionals participate in the hospice's QAPI program. Agency was unable to provide evidence of QAPI meetings conducted with attendance records.

Upon observation, there was no evidence in-service training for Hospice Aides are supervised by a Registered Nurse.

Upon patient record review 2 of 6 (Patients #1,#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 Patient 1: The aide care plan contained bathing task of a shower and 2 person transfers. The aide performed a bed bath 7/7/25, 7/9/25, 7/21/25, and 7/23/25; and transfer with a Hoyer lift 7/14/25 without evidence of instructions from the hospice RN. Patient 4: The aide care plan contained bathing task of a shower. The aide performed a bed bath 2/13/25 without evidence of instructions from the hospice RN.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon personnel record review, 1 of 10 (Personnel #7) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 1 of 10 (Personnel #7) did not have evidence that the hospice employees have received orientation on their specific job requirements.

Upon patient record review, 1 of 6ectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 4: The written certification of terminal illness was signed 2/13/25 with admission 2/10/25. There was no evidence of a verbal authorization received.

Condition of Participation: Clinical Records.

Upon patient client record review, 5 of 6 (Patients #1,#2,#3,#4,#5) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 1: There was no evidence of documentation to identify if the patient or responsible party elected to receive the Notification of Hospice Non-Covered items. Patients 2,3: The election form identified that the patient elected to receive the Notification of Hospice Non-Covered Items. There was no evidence the hospice provided the BFCC-QIO information to the patient or provided the notification on request. Patient 4: There was no evidence the patient received information regarding their right to receive the Notification of Hospice Non-Covered Items. Patient 5: There was no evidence of documentation to identify if the patient or responsible party elected to receive the Notification of Hospice Non-Covered items and there was no evidence the hospice provided the BFCC-QIO information to the patient.

Upon patient client record review, 1 of 6 (Patient #1) did not have evidence that each patient record contains Advance Directives. Patient 1: The plan of care identified the patient as DNR. The POLST in the record was incomplete and contained a signature but the patient identify portion of the form was empty.

Upon patient client record review, 2 of 6 (Patients #1,#4) 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 1,4: The medical record contained a signed revocation form with uploaded consents. The revocation did not identify a date of signature or effectiveness.

Upon observation and administrator interview, the agency reported the license is now under its third owners. The agency was unable to provide any patient records from the previous owners.

Upon client record review, 1 of 6 (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 5: There was no evidence the agency provided written policies and procedures for managing controlled drugs. The patient had orders 12/22/24 for haloperidol and morphine.

Upon patient record review, 1 of 6 (Patient #1) did not have evidence that the hospice provided the following information: • Physician certification and recertification of the terminal illness specific to each patient • Names and contact information for hospice personnel involved in hospice care of each patient Patient 1: Upon home visit observation, there was no evidence of names for hospice personnel involved with care of the patient and physician certification and recertification of the terminal illness.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. The agency provided a notification of change in administrator, DPCS, administrator designee, DPCS designee, and medical director to the California Department of Public Health on 6/22/25. Hire dates for the administrator, administrator designee, DPCS and DPCS designee were 12/15/24, and the medical director was 3/15/25. The agency also stated that there was a change in ownership in August of 2024, however they could not produce communication to the appropriate authorities regarding the change in ownership.