Angels Protection Hospice, Inc.

Rights of the patient (42 CFR 418.52(c)(4))

“Upon patient record review, 2 of 10 (Patient: #2 and #4) did not contain evidence in the patient record that the patient chooses a health care provider, including an attending physician. Patient #2: Attending Physician declined the Role as Attending Physician. Record revealed no evidence of Patient/CG Choice of Attending Physician Role was offered. Patient #4: Recertification signed by Physician with no evidence of affiliation and not by patient/family choice of Attending Physician. Record revealed no evidence of Patient/CG Choice of Attending Physician Role was offered.”

Rule L0515. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c)(6))

Rule L0530. Standard-level.

Content of plan of care (42 CFR 418.56(c))

Rule L0545. Standard-level.

Content of plan of care (42 CFR 418.56(c)(4))

“Upon patient record review, 2 of 10 (Patient #9 and #10) 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 #9 and #10: Medical record did not show evidence of order for oxygen 2L via NC as needed for shortness of breath.”

Rule L0549. Standard-level.

Counseling services (42 CFR 418.64(d)(1))

Rule L0596. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1))

“Upon patient record review 1 of 10 (Patient #8) 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 #8: Medical Record did not indicate Supervisory visit complete by RN (LVN documentation of Aide Supervisory visit completed on 06/06/23)”

Rule L0629. Standard-level.

Recertification of the terminal illness (42 CFR 418.102(c))

“Upon patient record review, 1 of 10 (Patient #4) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient #4 Recertification Order on 12/30/23 was not signed by Medical Director involved in case. Signed by another Provider who was not an agency designee or involved in case.”

Rule L0668. Standard-level.

Authentication (42 CFR 418.104(b))

“Upon patient client record review, 1 of 10 (Patient #2) 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 # 2: The Recertification of patient for 7th Benefit Period contains inconsistent dates, signed by Physician with no affiliation to patient on 01/01/24 and RN signed 09/07/23.”

Rule L0679. Standard-level.

Protection of information (42 CFR 418.104(c))

“Upon observation, there was no evidence the organization follows their policies and procedures to maintain the the patient’s clinical record in confidential manner. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.”

Rule L0680. Standard-level.

Retention of records (42 CFR 418.104(d))

“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. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.”

Rule L0681. Standard-level.

Retrieval of clinical records (42 CFR 418.104(f))

“Upon observation, there was no evidence the patient record, whether hard copy or in electronic form, is made readily available on request by an appropriate authority. The unduplicated admission number for the past year was 10. The agency changed ownership in Dec 2022. Surveyors requested to review records from the time prior to the past year and/or prior to the CHOW. The administrator/DPCS who was on site for the survey could not produce these records.”

Rule L0685. Standard-level.