Angel of God Hospice and Palliative Care Inc.

“Based on record review and interview, the hospice agency failed to ensure the patient-specific skin assessment for patient 6 was accurately documented.This failure had the potential to compromise patient care. Findings:During the Home Visit observation and interview on 7/14/26, at 1:00 p.m. with the Registered Nurse LN 1), LN 1 was observed assessing Patient 6’s left arm multiple purplish skin discoloration, dry scab on the right elbow, and redness on Patient 6’s right ankle.During a review of Patient 6’s RN visit notes (RVN) skin assessment, dated 7/14, the RVN had no documentation addressing Patient 6’s multiple purplish skin discoloration on the left arm and the Patient 6’s right ankle redness.During a concurrent interview and record review on 7/15/26 at 2:25 p.m. with the LN 1, Patient 6’s POC were reviewed. LN 1 stated that the left arm discoloration was identified as new skin condition, and the right elbow started on 6/30 as a skin tear during Patient 6’s fall incident and the redness on the right ankle redness had an onset date as 7/3. LN 1 acknowledged gaps in the plan of care (POC), specifically noting that there was no documented POC addressing the right ankle redness and the multiple skin discoloration on the left arm for Patient 6.During a review of the facility’s policy and procedure (P&P) titled “Initial Assessment/Comprehensive Assessment,” dated 2/2024, the P&P indicated that in part, “…2. Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patient’s need for Hospice care and services and identify the patient’s need for:…Support with activities of daily living.””

“Based on record review and interview, the hospice agency (HA) failed to ensure that one (patient 5) of the three sampled patients for home visit had an accurate and up-to-date list of all medications they were taking (comparing the patient’s medication list with the medications they were currently receiving). This failure had the potential to lead to medication errors, such as omissions, duplications, improper dosages, and or drug interactions. During a home visit for patient 5 with the licensed nurse (LN3) on 7/14/26 at 10:45 am, LN3 was observed giving care for patient 5. After the care, LN3 discussed the care with the caregiver. LN3 did not ask to see the medication list and compared it with the hospice medication list. During an interview with the director of patient care services (DPCS) designee on 7/15/26 at 3;35 pm, the DPCS designee acknowledges medication reconciliation was not done, DPCS designee indicated medication profile should be checked every visit. The facility policy and procedures titled “Medication Profile” dated June 2019 indicates “The nurse will add all new/changed medication(s) to the medical profile. Discontinued medications will be documented and dated. The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the IDG.””

“Based on record review and interview, the hospice agency (HA) failed to ensure the written visit schedule and frequency of visits provided to the patient were consistent with the most recent plan of care (POC) for five of 14 sampled patients (Patient 7, Patient 13, Patient 6, Patient 5, and Patient 1) when:1. One of two hospice aide services did not occur in week two on 7/10/26 for patient 7. 2. Hospice aide visit was missed in week from 7/5/26 to 7/11/26 for patient 13. 3. The skin issues care plan for patient 6 was not implemented by a hospice nurse. 4. One of two skilled nurse routine visits including the supervisory visits were missed on dates 5/26/26 and 6/9/26 for patient 5. 5. Spiritual Counselling monthly visit for patient 1 was missed in October 2025. These failures had the potential of not fulfilling patient’s needs as scheduled which may result in poor patient outcomes. 4. Review of patient 5’s health records on 7/15/26 at 11:05 am, records indicate skilled nursing had a frequency visit order of 2 times a week for certification period of 4/14/26 to 7/12/26. On 5/26/26 and 6/9/26 the licensed nurse was scheduled to visit the patient. No missed visit documentation was located. During an interview with the director of patient care services designee (DPCS designee) on 7/15/26 at 3:35 pm, the DPCS designee acknowledged visit was missed. 5. Review of patient 1’s health records on 7/15/26 at 10 am, records indicate the chaplain (SC) had an order for visit frequency for once a month for the certification period of 10/12/25 to 1/9/26. For the month of October the SC did not visit the patient. During an interview with the DPCS designee on 7/15/26 at 3:35 pm, the DPCS designee acknowledged missed visit. The facility policy and procedure titled “Provision of Care, Treatment and Services, Missed Visit Policy” no date, indicates “When a scheduled visit cannot be completed, the hospice shall document the reason for the missed visit, assess the patient’s immediate needs, determine whether visit is clinically indicated, notify appropriate supervisory personnel, and reschedule services as appropriate. Documentation shall accurately reflect all communication and action taken.” 2.During a review of Patient 13’s Admission Comprehensive Nursing Assessment (ACNA), dated 5/19, the ACNA indicated that Patient 13 was admitted to hospice care with the diagnosis of cerebral infarction (blood vessel supplying blood and oxygen (air) to the brain is blocked), had very limited mobility and required maximum to complete assistance with activities of daily living (ADL) such as a walking, toileting, transfer, dressing, feeding and bathing. The ACNA further indicated that Patient 13 required personal care & support needs for a hospice aide and was communicated to the attending physician, and the interdisciplinary team (IDT) and the care plan (POC) were initiated.During a review of Patient 13’s Physician’s Certification for Hospice Benefit (CTI), certification period dated 5/19/26 to 8/16/26, the CTI was signed by the attending physician on 5/19/26.During a review of Patient 13’s Physician’s Order (PO) dated 5/19/26, the PO indicated a doctor’s order for Patient 13 to be visited by Certified Hospice Aid (CHA) two times a week to assist with ADLs.During a review of Patient 13’s HA visit, the CHA visit indicated that Patient 13 was only visited one time the week of 7/5 to 7/11.During a review of Patient 13’s POC/IDG (Interdisciplinary Group – team of professional individuals that are involve for developing and maintaining patient’s plan of care), dated 5/28, 6/11, 6/25 and 7/9, the POC/IDG indicated that Patient 13’s POC for CHA visit was two times a week.During a concurrent interview and record review on 7/15/26, at 2:45 p.m. with the Registered Nurse (LN 1). The POC and CHA visit were reviewed. LN 1 stated that documentation must be completed the same day or the following day of the visit. LN 1 stated that the POC was not followed and acknowledged the missed HA visit. LN 1 was unable to provide additional documentation for the missed visit.The facility policy and procedure titled “Provision of Care, Treatment and Services, Missed Visit Policy” no date, indicates “When a scheduled visit cannot be completed, the hospice shall document the reason for the missed visit, assess the patient’s immediate needs, determine whether visit is clinically indicated, notify appropriate supervisory personnel, and reschedule services as appropriate. Documentation shall accurately reflect all communication and action taken.”3. During the Home Visit observation and Interview on 7/14/26, at 1:00 p.m. with the registered nurse (LN 1), LN 1 was observed assessing Patient 6’s left arm multiple purplish skin discoloration, dry scab on the right elbow, and redness on Patient 6’s right ankle.During a concurrent interview and record review on 7/15/26 at 2:25 p.m. with the LN 1, Patient 6’s registered nurse visit notes (RNV) dated 7/14 and POC dated 7/9 were reviewed. LN 1 stated that the left arm discoloration was identified as new skin condition, and the right elbow started on 6/30 as a skin tear during Patient 6’s fall incident now almost healed and the redness on the right ankle redness had an onset date as 7/3. LN 1 acknowledged gaps in the plan of care (POC), specifically noting that there was no documented POC addressing the right ankle redness and the multiple areas of skin discoloration on the left arm for Patient 6.During a review of the P&P titled, “IDG Care Planning Process,” dated 2/2024, the P&P indicated in part, “…2. The care of plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment…A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Visit ranges may be used: The Plan of care includes a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient…There will be documentation in the record…” 1.During a concurrent record review and interview on 7/16/26 at 2:00 PM, with the Registered Nurse (LN1), patient 7’s “Plan of Care (POC),” dated 5/18/26, 6/11/26, 6/25/26 and 7/9/26 were reviewed. The “POC” indicated Patient 7 was to receive hospice aide (cha) visits “CHA 2x /week.” Review of Patient 7’s clinical record indicated, only one CHA visit was made the week from 7/5/26-7/11/26 instead of two visits as indicated in the POC. There was no documentation in Patient 7’s clinical record regarding the missed visit. The LN1 acknowledged that Patient 7 received only one CHA visit from 7/5/26-7/11/26, rather than the ordered frequency of two visits.During a review of the agency’s P&P titled, “IDG Care Planning Process” revised 2/2024, the P&P indicated, “…All care and services furnished to patients…follows an individualized plan of care…””

“Based on record review and interview, the hospice agency’s interdisciplinary group (IDG – team of professional individuals that are involve for developing and maintaining patient’s plan of care) failed to update the plan of care (POC) for Patient 6’s mobility issues related to fall with injury.This failure to address Patient 6’s changes in mobility related to fall increases Patient 6 likelihood of repeated falls thereby placing Patient 6 at risk for further injury. Findings:Findings:During a review of Patient 6’s incident report, dated 7/4, the incident report indicated that Patient 6 had fallen while ambulating sustaining bruising on the right arm.During a review of Patient 6’s POC, dated 7/9, the POC did not address Patient 6’s recent fall incident with right arm bruising.During a concurrent interview and record review on 7/15/26 at 2:00 p.m. with the Registered Nurse (LN 1), Patient 6’s incident report and POC were reviewed. LN 1 acknowledged the missing POC and was not able to provide an updated POC related to fall incident on 7/4.During a review of the P&P titled, “IDG Care Planning Process,” dated 2/2024, the P&P indicated in part, “…2. The care of plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment…A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Visit ranges may be used: The Plan of care includes a range of visits and PRN orders for visit frequencies to ensure the most appropriate level of service is provided to the patient…9. The IDG (in collaboration with the patient’s attending physician…reviews, revises, and documents the individualized plan as frequently as the patient’s condition requires…””

“Based on record review and interview, the hospice agency failed to ensure a healthcare professional (LCSW-licensed clinical social worker) meet the appropriate qualification in accordance with applicable state and local laws. As of July 2026, the LCSW’s basic life support (BLS) card expired since January 2026.This failure is a potential breach of patient safety protocols. During a review of the employee files on 7/13/26 at 2:45 pm, employee files indicated the licensed clinical social worker (LCSW) basic life support (BLS) certification has expired on 1/25/26.During an interview with the director of patient care services (DPCS) on 7/13/26 at 3:10 pm, the DPCS acknowledged the BLS certificate was expired since 1/25/26.The facility policy and procedure titled “License,Registration or Certification Requirements” dated June 2019 indicates “When current licensure, certification and or registration are required by law and/or regulation to practice a profession, Hospice verifies such credentials with the primary source at time of hire and prior to or upon expiration of credentials.””

“Based on record review and interview, the hospice agency (HA) failed to ensure bereavement services were available to the family following the patient’s death for one of two patients in the sample. (Patient 3)This failure had the potential to deprive patient 3’s family of essential bereavement support following the patient’s death.” During a review of Patient 3’s clinical record (CR) and a concurrent interview with LN1 on 7/16/26 at 2 PM, it was discovered that the post-death bereavement action plan, which included sending letters and cards after one month, three months, six months, and nine months, had not been provided, because no documents could be found to prove that the letters or cards were sent to the bereaved family. The LN1 acknowledged and confirmed the aforementioned findings.During a review of the agency’s P&P titled “Bereavement Services” revised 2/2022, the P&P indicated, “…Within a month of death, a twelve-month bereavement mailing program will be initiated for designated family members…which may include letters and cards…””

“Based on record review and interview, the hospice agency (HA) failed to ensure that two hospice aides (CHA 1 and CHA 2) received 12 hours of in-service training during a 12-month period.This failure had the potential to result in hospice aides credentials not being updated. During a review of the agency’s monthly in-service training sign-in sheets with the Registered nurse (LN1) on 7/16/26 at 3:00 PM, the in-service training sign-in sheets indicated that CHA1 did not attend the in-services training in July and October 2025. Furthermore, CHA2 did not attend the in-services training from March to June 2026. During a concurrent interview, LN1 acknowledged that CHA1 and CHA2 had not completed the required 12 hour in-service training, which they should have.During a review of the hospice agency’s policy and procedures (P&P) titled “Inservice Education” revised 2/2021, the P&P indicated, “…Each Hospice Aide must receive at least 12 hours of in-service training during each 12-month period. Hospice may fulfill the annual 12-hour in-service training requirement on…a rolling 12 month basis as long as each aide meets this in-service training requirement…””

“Observed in Patient Home. In 11 of 14 patient records reviewed, the surveyor noted in HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRDC #1, and HOSRRBR #2 that the patient was on aspirin 81 mg and the POC for the home health aide did not include safety precautions such as bleeding. Additionally, HOSRRNHV #2 has apixaban ordered and the aide care plan does not include safety precaution for bleeding. HOSRRNHV #3 has an order for Eliquis and the Home health aide care plan does not include bleeding precautions. In HOSRRNHV #7 the patient is on aspirin and apixaban and the aide care plan does not include bleeding precautions. In HOSRRHV #1, HOSRRHV #2, HOSRRHV #3, HOSRRDC #1, HOSRRDC#2, HOSRRBRV1, HOSRRBR#2, HOSRRNHV #2 oxygen order for 2 L of oxygen via NC prn for SOB. May slowly titrate 2-5 L for comfort. There was no documentation on how to titrate the oxygen on the order. Additionally their Medication Orders policy states that range orders are not permitted. This was reviewed with the DPCS and she states that this will be found in all of the charts as they order oxygen for all patients at SOC. The DPCS stated that she had the supervisor go into the patient charts and update the oxygen orders on all of the patients.In HOSRRHV #1 the surveyor noticed duplicate orders for Loperamide Hydrochloride 2 mg caplets 1 caplet by mouth every 4 hours as needed for pain. There was not a stop date for one or the other. The Medication Orders policy states all orders that look alike will be verified. This was reviewed and validated with the DPCS.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the hospice surveyor noted that the medication orders did not state when to take one as needed medication over the other. In HOSRRHV #2 the patient had both Ativan 2mg/ml concentrated solution 0.5 ml by mouth/sublingual every 6 hours as needed for agitation, and she also had Haloperidol 0.5mg tablet 1 tablet, three times a day as needed for agitation. It is not clear which of the medications the patient should take for agitation. In HOSRRHV #3 the patient had orders for both Polyethylene Glycol 3350 17 gm by mouth once a day as needed for constipation and Dulcolax suppository 10 mg per rectum as needed if no BM in 3 days. The orders are not clear if one or both of these medications should be used if no BM. This was reviewed and validated with the DPCS. Observed in Record Review. In 2 of 14 patient records reviewed, the hospice surveyor noted that the organization failed to plan the patient’s care. In HOSRRNHV#2 and HOSRRNHV #3 where the patients are on an anticoagulant and there was no bleeding precautions care plan entered. This was reviewed and validated with the DPCS.”

“Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to follow manufacturer’s recommendations for cleaning vital sign equipment purchased by staff. During HOSRRHV #1 and HOSRRHV #3 the home health aide and the RN purchased their own equipment. The home health aide was using an Omron cuff from CVS and a Safety thermometer which was infrared. She cleaned both with McKesson wash clothes, This is not an approved cleaner for the pulse oximeter which should have been cleansed with ETOH wipes. The RN in HOSRRHV #3 attests that he bought his sphygmomanometer cuff, thermometer, and pulse oximeter from Amazon about 1 year ago. He was cleaning all his equipment with Clorox wipes, which is not an approved cleaner for the equipment, the sphygmomanometer should have been cleansed with soap and water and the thermometer and pulse oximeter should have been cleansed with an ETOH wipe per manufacturer’s guidelines.. This was reviewed and validated with the DPCS. Observed in Patient Home. In 1 of 3 home visits conducted, in 1 of 3 home visits conducted where the CHHA was observed the hospice surveyor noted in HOSRRHV #1 that the CHHA performed a shower on the patient and she used the same pair of gloves for washing the clean and dirty areas e.g. washing the patients bottom. The aide then dressed the patient using the same gloves. The aid failed to follow the organization’s Hand Hygiene Policy and Compliance Program. Thus the organization failed to implement activities for the prevention and control of infections and communicable diseases. This was reviewed and validated with the DPCS.”

“Observed in HR File Review. In 7 of 9 HR files reviewed, the nurse surveyor noted during the HR tracer that there was no evidence that staff had competencies documented every 3 years, per policy Staff Competency Program and regulation. Per the policy the patient care staff should have their competency assessed every three years and the hospice aide should have her competency assessed at least annually. This was observed in the RN CM who did not have a competency done from his hire date of 2021. The Home Health aide had the last competency done in 2022. The MSW had her last competency done in 2021. The medical director and the alternate medical director both had their last competencies done in 2021, and the volunteer coordinator and bereavement coordinator had her last competency performed in 2021. This was reviewed and validated with the RN Supervisor.”