Every finding on record at White Angels Hospice, Inc.

Upon patient record review, 2 of 14 (Patient #1,#7,#10,#11) 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 - Patient medication profile showed evidence of patient taking Senna and Colace prn for constipation. There was no evidence of directions for when to take one versus the other or if these can be taken together. (corrected onsite). Patient #7 - Patient medication profile showed evidence of patient taking docusate scheduled daily, and Dulcolax, fleets enema, and Milk of Magnesium prn for constipation. There was no evidence of directions for when to take one versus the other or if these can be taken together. (corrected onsite). In addition, medication profile lists Tylenol 325 mg - take 2 tabs Q4hr PRN; Tylenol suppository 650 mg Q6 hr PRN. There was no evidence of a daily maximum dose of acetaminophen listed for this medication. Patient #10 - The patient medication profile listed patient is on Tylenol 500 mg Q4-6 hrs PRN and Hydrocodone 5/325 take 1 PO Q 4-6 hrs PRN. There was no evidence of a daily maximum dose of acetaminophen listed for these medications. Patient #11 - The patient medication profile listed patient is on Tylenol 650 mg Q6 hr PRN along with hydrocodone 5/325 take 1 PO Q4 hr PRN for pain management. There was no evidence of a daily maximum dose of acetaminophen listed for these medications.

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

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #5 - The record indicates an MD order dated 12/16/24 for wound care to the stage 4 sacrococcyx wound. SN frequency ordered 3x/week which LVN completed these visits and documented the wound care following the original order. This was done from the date of the order to the patients death. The RN completed assessments on 12/11/24, 12/25/24, 1/2/25, 1/8/25, 1/22/25, 2/5/25, 2/11/25, 2/19/25, and 3/5/25 and documented under the skin integrity section "no skin breakdown, skin remains intact with no issues observed." There was no evidence or documentation of wound assessment or measurements by the RN.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,10,11,12,13) 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 -Nursing Comprehensive assessed patient a 12 on the Braden Skin risk assessment (high risk) - there was no evidence of problems, goals or interventions; patient also taking ASA as a blood thinner and there was no evidence of problems, goals or interventions; patient taking Glipizide - no endocrine problem outlining problems, goals and interventions (all corrected onsite). Patient #2 - The medication profile showed patient was on nebulized medications for shortness of breath. There was no evidence of problems, goals or interventions (corrected onsite). Patient #3 - The patient's advanced directives indicated patient wishes were to be a full code. There was no evidence of problems, goals or interventions listed. The patient profile indicated patient is taking aspirin as a blood thinner. There was no evidence of problems, goals or interventions related to the bleeding risk (corrected onsite). Patient #4 - The medication profile indicated patient taking Eliquis as a blood thinner. There was no evidence of bleeding risk goals, problems, or interventions listed in patient plan of care. Patient medication list also contained Januvia and Ozempic and there was no evidence that the Endocrine problem, goals and interventions were added to the patient plan of care (all corrected onsite). Patient #10 - The medication profile indicated patient was utilizing nebulized medications for shortness of breath. There was no evidence of goals, problems or interventions. Patient #11 - Patient's medication profile showed patient taking Metformin for diabetes management. There was no evidence of endocrine goals, problems, or interventions. Patient #12 -Patient's mediation profile showed patient was taking metformin for diabetes management. There was no evidence of endocrine problems, goals or interventions; the same medication profile also showed patient was on ASA for blood thinning. There was no evidence of bleeding risk goals, problems or interventions. Patient #13 - On patient profile and in patient advance directives, it was documented that patient had chosen to be a full code. There was no evidence of problems, goals or interventions related to that full code status.

Upon patient record review, 4 of 14 (Patient #1,#7, #10, #11) 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-Orders present for both Senna and Colace prn for constipation. There was no evidence of directions for when to take one versus the other or if these can be taken together. (corrected onsite). Patient #7 - Orders present for docusate scheduled daily, and Dulcolax, fleets enema, and Milk of Magnesium prn for constipation. There was no evidence of directions for when to take one versus the other or if these can be taken together. (corrected onsite). In addition, orders for Tylenol 325 mg - take 2 tabs Q 4hr PRN; Tylenol suppository 650 mg Q6 hr PRN. There was no evidence of a daily maximum dose of acetaminophen listed for this medication. Patient #10 - Orders present for Tylenol 500 mg q 4-6 hrs PRN and Hydrocodone 5/325 take 1 PO Q 4-6 hrs PRN. There was no evidence of a daily maximum dose of acetaminophen listed for these medications. Patient #11 - Orders present for Tylenol 650 mg Q6 hr PRN along with hydrocodone 5/325 take 1 PO Q4 hr PRN for pain management. There was no evidence of a daily maximum dose of acetaminophen listed for these medications.

Upon patient record review, 2 of 14 (Patient #1, #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 patient medication profile listed patient is on oxygen. There was no evidence that the oxygen supplies needed were listed on the plan of care (corrected onsite). Patient #6 - The patient medication profile listed the patient is utilizing nebulized medication for symptom management. The patient medication profile also listed oxygen for shortness of breath prn. There was no evidence that the supplies required for the nebulizer and oxygen were listed on the patient plan of care.

Upon patient record review, 2 of 14 (Patient #5,6) 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. Patient #5 - The medical record indicated the patient was placed on continuous care on 03/09/25. There was no evidence of goals, problems or interventions related to that level of care change. Patient #6 - The medical record indicated the patient was placed on continuous care between 01/16/25-01/23/25. There was no evidence of problems, goals or interventions related to that level of care change.

Upon patient record review, 1 of 14 (Patient #6) 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 #6 - The medical record showed aide service was being provided 2 times per week starting on 05/17/24 through 01/20/25 as evidenced by completed aide visit notes in the patient record. There was no evidence of a frequency order. The IDG's conducted during that timeframe had no frequency ordered, and the aide assignment plan had tasks listed, but no frequency of visits.

Upon patient record review 1 of 14 (Patient #6) 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 #6 - After review of the medical record, there was no evidence that a registered nurse made supervisory visits for the aide every 14 days between 06/11/24 and 08/06/24.

Upon observation, there was no evidence the Emergency Plan communication plan includes a primary and alternate means for communicating with hospice's employees.

Upon patient client record review, 1 of 5 (Patient #5) 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 5: The medical record contains revocation paperwork signed by the patient and dated 3-14-22. Pt was admitted 3-14-22 and revoked services on 3-30-22.