Angels Care Hospice

“Based on review of the Emergency Preparedness Plan (EPP), policy review, document review, and interview, the Hospice failed to ensure the EPP included a complete list of the names and contact information for all hospice staff, patients’ physician, contracted facilities, and other hospices. Failure to ensure a comprehensive list of contacts places patients at risk for unmet care needs during an emergency. Findings Include: Review of the Hospice EPP policy titled “Emergency Management Plan” [EMP] last revised November 2021, showed “The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: … Names and contact information for the following: … Staff … Entities providing services under arrangement … Patients’ physician … Other Hospices”. Review of the Hospice EPP document titled “Office Responsibilities for EMP” with no listed review date showed “Components of Emergency Preparedness Program Manual … Compliance is dependent on maintenance of the manual … Office responsibility toward the program: … Add lists of employees, physicians, hospitals, emergency shelters that are specific to your area to the manual. … Keep all aspects of the program together in the manual … At the end of the year, remove all items and store, make copies of program forms as required and begin a new year.” Review of the Hospice EPP showed “Each office will keep and maintain a current list of contact information for staff and emergency contacts, vendors, emergency services, hospitals, and other appropriate community resources.” Review of the Hospice EPP book dated “2025” showed no contact list for current hospice employees, contracted facilities, Patients’ physician, and other regional hospices. Review of the Hospice EPP book dated “2024” showed no contact list for contracted facilities, patients’ physician, and other regional hospices. Review of the Hospice EPP book dated “2023” showed no contact list for contracted facilities and other regional hospices. During an interview on 06/04/25 at 2:50 PM, Staff A, Executive Director (ED), stated that when the EPP is activated the call tree is activated and the listed staff are notified by email or text. Staff A, ED, stated that the EPP plan and contact list is reviewed and updated annually with any changes. The Hospice failed to provide a current contact list including the names and numbers of all current hospice staff, contracted facilities, patient physicians, and other regional hospices.”

“Based on review of the Emergency Preparedness Plan (EPP), policy review, document review, and interview, the Hospice failed to provide evidence of an additional full-scale exercise, mock disaster drill, or a tabletop exercise or workshop every 2 years. Failure to perform routine exercises to test the EPP places all patients at risk for unmet care needs during an emergency. Findings Include: Review of the Hospice EPP policy titled “Emergency Management Plan” [EMP] last revised November 2021, showed “… Hospice will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise. … The Agency conducts an additional exercise every two (2) years … the additional exercise may include, but is not limited to: … A second full scale exercise … A mock disaster drill … A table top exercise or workshop that is led by a facilitator and includes group discussion using a narrated, clinically-relevant emergency scenarios, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. … All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical and support staff.” Review of the Hospice EPP document titled “Office Responsibilities for EMP” with no listed review date showed “Components of Emergency Preparedness Program Manual … Compliance is dependent on maintenance of the manual … Office responsibility toward the program: … Keep all aspects of the program together in the manual including job descriptions, in-services, training, and testing … Document all annual testing and notification requirements.” Review of the Hospice EPP book dated “2025” showed a document titled “INSERVICE/EXERCISE SIGN IN LIST” dated 05/21/25 showed “Emergency Preparedness and Response Plan … Agency policy on Emergency Preparedness and Response plan reviewed.” with unmarked check boxes for “Full-Scale Community-Based Exercise … Individual Facility-Based Exercise … Tabletop Exercise”. The 2025 EPP book showed no evidence of a full-scale exercise, mock disaster drill, or a tabletop exercise testing of the EPP. Review of the Hospice EPP book dated “2024” showed a document titled “Emergency Plan Evaluation” dated 01/05/24 and noted activation of the EPP for a winter storm. The 2024 EPP book showed no evidence of a full-scale exercise, mock disaster drill, or a tabletop exercise testing the EPP. Review of the Hospice EPP book dated “2023” showed a document titled “INSERVICE SIGN-IN SHEET … Fire Drill/ EPP training … of Emergency Preparedness” dated 03/27/23 showing no evidence that the content of the EPP training included a full-scale exercise, a mock disaster drill, or a tabletop exercise testing the EPP. During an interview on 06/04/25 at 2:50 PM, Staff A, Executive Director (ED), stated that training is done for staff on an annual basis regarding the EPP program. Staff A, ED, stated that prior to taking over the ED role in on 07/15/24, some type of training occurred in 2023 with the hospice and fire department or emergency department. Staff A, ED, stated that communication about the meeting were documented, however the activities performed during the meeting were unknown. The Hospice failed to provide evidence of testing of the EPP with an additional full-scale exercise, mock disaster drill, or a tabletop exercise or workshop every 2 years.”

“Based on policy review, record review, and interview the Hospice failed to update the comprehensive assessment at least every 15 days for 1 (Patient 1) of 14 patients sampled. Failure to routinely update the comprehensive assessment places the patient at risk for unmet care needs and negative outcomes. Findings Include: Review of the Hospice policy titled “THE PLAN OF CARE” last revised November of 2024, showed “… The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days … based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the of the plan of care will be documented in the clinical record.” Patient 1 Review of Patient 1’s record showed a 74-year-old admitted to hospice services on 12/16/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. Review of Patient 1’s plan of care (POC) dated 12/16/24 showed a skilled nursing visit frequency of 2 times weekly. Review of Patient 1’s RN visit notes showed the initial Start of Care (SOC) comprehensive assessment visit performed by an RN on 12/16/24. The next RN comprehensive assessment visit was performed on 01/17/25, a gap of 31 days between RN on-site visits. During an interview on 06/05/25 at 3:30 PM, Staff G, Vice President of Operations, RN, stated that an RN should perform an on-site comprehensive visit at least every 15 days for each patient. Staff G, confirmed with review of Patient 1’s record that a comprehensive assessment was not performed by an RN between 12/16/24 and 01/17/25.”

“Based on policy review, record review, and interview, the Hospice failed to ensure that the interdisciplinary group (IDG) reviewed each patient’s plan of care (POC) at least every 15 days for 1 (Patient 1) of 14 patients sampled. Failure to have the IDG routinely review each patient POC places the patient at risk for unmet care needs. Findings Include: Review of the Hospice policy titled “THE PLAN OF CARE” last revised November of 2024, showed “The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days … The written plan of care will contain, but will not be limited to, the following: … Drugs and treatments.” Review of the Hospice policy titled “INTERDISCIPLINARY GROUP MEMBERSHIP AND RESPONSIBILITIES” last revised November of 2024 showed “The interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. … The interdisciplinary group responsibilities include but are not limited to: … Participation in the establishment of the plan of care … Participation in the periodic review and updating of the plan of care for each patient …” Patient 1 Review of Patient 1’s record showed a 74-year-old admitted to hospice services on 12/16/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. Review of Patient 1’s visit notes showed the initial start of care comprehensive assessment visit performed by an RN on 12/16/25. Review of Patient 1’s IDG notes showed the first IDG meeting was performed on 01/02/25, a gap of 17 days before an IDG reviewed Patient 1’s POC. During an interview on 06/05/25 at 3:30 PM, Staff G, Vice President of Operations, RN, stated that an IDG review of each patient should occur at least every 15 days for each patient. Staff G, confirmed with review of Patient 1’s record that an IDG meeting did not occur between 12/16/25 and 01/02/25.”

“Based on policy review, record review, and interview, the Hospice failed to ensure that medications were reconciled and updated by the registered nurse (RN) within the plan of care (POC) and with the facility for 2 (Patient 2 and 9) of 14 patients sampled. Failure to ensure that medications are current and accurate between the hospice and non-hospice caregivers places patients at risk for unmanaged symptoms and negative outcomes. Findings Include: Review of the Hospice policy titled “THE PLAN OF CARE” last revised November of 2024, showed “The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days … The written plan of care will contain, but will not be limited to, the following: … Drugs and treatments.” Review of the Hospice policy titled “INTERDISCIPLINARY GROUP MEMBERSHIP AND RESPONSIBILITIES” last revised November of 2024 showed “The interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan of care. … The interdisciplinary group responsibilities include but are not limited to: … Participation in the establishment of the plan of care … Participation in the periodic review and updating of the plan of care for each patient …” Patient 2 Review of Patient 2’s record showed a 46-year-old admitted to hospice on 07/01/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. Review of Patient 2’s POC dated 06/02/25 showed “NEED FOR FACILITY STAFF CARE COORDINATION … REVIEWED HOSPICE PLAN OF CARE WITH FACILITY STAFF … CONTINUITY OF CARE AMONG PROVIDERS IS ACHIEVED”. Review of Patient 2’s medications showed the following: The hospice POC “Client Medication Record” showed Entresto 24 milligram (mg) -26 mg, give 1 tab by mouth (PO) daily for heart failure. The residing facility’s medication record dated 06/04/25 showed Entresto 24-26 mg, give 1 tab PO 2 times daily for heart failure. The hospice POC “Client Medication Record” showed potassium chloride ER 10 milliequivalents (MEQ), give 1 tab PO daily for electrolyte balance. The residing facility’s medication record dated 06/04/25 showed Klor-Con (potassium chloride) 10 MEQ, give 1 tab PO 2 times a day for low blood potassium. The hospice POC “Client Medication Record” showed spironolactone 25 mg, give 1 tab PO daily for fluid retention. The residing facility’s medication record dated 06/04/25 showed 50 mg, give 1 tab PO daily for hypertension (high blood pressure). The hospice POC “Client Medication Record” showed budesonide suspension 0.5 mg per 2 milliliters (ml), give by nebulizer (a device that turns liquid into mist) 3 times daily for chest congestion. The residing facility’s medication record dated 06/04/25 showed budesonide suspension 0.5 mg per 2 ml, give by nebulizer every 12 hours as needed (PRN) for congestion. The hospice POC “Client Medication Record” showed 2% miconazole powder, apply topically to skin folds daily PRN for yeast infection. The residing facility’s medication record dated 06/04/25 did not list 2% miconazole powder as an active medication. The hospice POC “Client Medication Record” showed Toprol extended release (XL) 50 mg, give 1 tab PO daily for hypertension. The residing facility’s medication record dated 06/04/25 did not list Toprol XL as an active medication. The hospice POC “Client Medication Record” showed fluconazole 200 mg, give 4 tabs PO for 1 day for yeast (fungal) infection, then 2 tabs daily PO for 7 days then stop medication. The residing facility’s medication record dated 06/04/25 did not list fluconazole as an active medication. The residing facility’s medication record dated 06/04/25 showed acetaminophen 325 mg, give 2 tabs PO 2 times daily and PRN every 8 hours for pain. The hospice POC “Client Medication Record” failed to list acetaminophen as an active medication. The residing facility’s medication record dated 06/04/25 showed amiodarone HCl 200 mg, give 1 tab PO daily for atrial fibrillation (irregular heartbeat). The hospice POC “Client Medication Record” failed to list amiodarone HCl as an active medication. The residing facility’s medication record dated 06/04/25 showed Imodium A-D 2 mg, give 1 tab PO every 6 hours PRN for diarrhea. The hospice POC “Client Medication Record” failed to list Imodium A-D as an active medication. The RN and interdisciplinary group (IDG) failed to ensure medications were reconciled and updated within the POC and with the facility from 07/01/24 through 06/04/25. Patient 9 Review of Patient 9’s record showed an 83-year-old admitted to hospice services on 03/12/25 with a primary diagnosis of senile degeneration of the brain (memory loss with a state of mental, emotional, and social decline). Review of Patient 9’s POC dated 06/02/25 showed “… NEED FOR MEDICATION MANAGEMENT AND INSTRUCTION … NEED FOR FACILITY STAFF CARE COORDINATION”. Review of Patient 9’s medications showed the following: The hospice POC “Client Medication Record” showed Miralax 17 grams (gm), 1 cap full dissolved in water daily PRN for constipation. The residing facility’s medication record dated 06/04/25 did not list Miralax as an active medication. The hospice POC “Client Medication Record” showed Morphine oral concentrate 20 mg per 1 ml, give 0.25 ml PO every 4 hours PRN for pain or shortness of air. The residing facility’s medication record dated 06/04/25 did not list Morphine concentrate as an active medication. The hospice POC “Client Medication Record” showed Hyoscyamine 0.125 mg, 1 tab by mouth every 1-hour PRN for secretions. The residing facility’s medication record dated 06/04/25 did not list hyoscyamine as an active medication. The residing facility’s medication record dated 06/04/25 showed amlodipine 5 mg, 1 tab PO daily for hypertension. The hospice POC “Client Medication Record” failed to list amlodipine as a current medication. The residing facility’s medication record dated 06/04/25 showed acetaminophen 325 mg, 2 tabs PO every 4 hours PRN for fever or pain. The hospice POC “Client Medication Record” failed to list acetaminophen as a current medication. The residing facility’s medication record dated 06/04/25 showed Robitussin dextromethorphan (DM ) syrup, 10 ml PO every 6 hours PRN for cough. The hospice POC “Client Medication Record” failed to list Robitussin DM syrup as a current medication. The residing facility’s medication record dated 06/04/25 showed Tusnel extended release (EX) liquid, 100 mg per 5ml, 10 ml PO every 6 hours PRN for cough. The hospice POC “Client Medication Record” failed to list Tusnel EX liquid as a current medication. The residing facility’s medication record dated 06/04/25 showed lorazepam 0.5 mg, 1 tab PO every 4 hours PRN for anxiety. The hospice POC “Client Medication Record” failed to list a PRN dose of lorazepam as a current medication. The residing facility’s medication record dated 06/04/25 showed Haldol 0.5 mg, 1 tab PO every 4 hours PRN for agitation. The hospice POC “Client Medication Record” failed to list a PRN dose of Haldol as a current medication. The RN and IDG failed to ensure medications were reconciled and updated within the POC and with the facility from 03/12/25 through 06/04/25. During an interview on 06/04/25 at 3:00 PM, Staff B, Patient Care Manager, RN, stated that every patient medication record and POC is reviewed and updated during visits and at each IDG review of the patient. Staff B confirmed that review of Patient 2’s and Patient 9’s records did not show a reconciliation of all current medications.”

“Based on policy review, record review, and interview, the Hospice failed to ensure that a registered nurse (RN) made an on-site visit for the supervision visit of the hospice aide at least every 14 days for 1 (Patient 1) of 14 patients sampled. Failure of the RN to provide routine supervisory visits places the patient at risk for unmet care needs. Findings Include: Review of the Hospice policy titled “RESPONSIBILITIES/SUPERVISION OF CLINICAL SERVICES” last revised November 2024, showed “Hospice aide supervisory visits will be conducted on site at least every two (2) weeks by a hospice registered nurse.” Review of the Hospice policy titled “HOSPICE AIDE SUPERVISORY VISITS” last revised November of 2024, showed “The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days.” Patient 1 Review of Patient 1’s record showed a 74-year-old admitted to hospice services on 12/16/24 with a primary diagnosis of hypertensive (high blood pressure) heart disease with heart failure. Review of Patient 1’s Plan of Care (POC) dated 12/16/24 showed a frequency for the home health aide (HHA) of 1 time weekly for week of 12/16/24, then increase to 2 times weekly for 12 weeks starting the week of 12/22/24. Review of Patient 1’s HHA visit notes showed missed visit notes on 12/19/24, 12/23/24, 12/26/24, 12/30/24, 01/03/25, 01/06/25, 01/08/25, 01/11/25, and 01/15/25. Further review showed a HHA visit made on 01/13/25. Review of Patient 1’s RN visit notes showed the initial Start of Care (SOC) visit performed by an RN on 12/16/25. The next RN supervisory visit was performed on 01/17/25, a gap of 31 days between RN on-site visits. During an interview on 06/05/25 at 3:20 PM, Staff B, Patient Care Manager, RN, stated that an RN should perform an HHA supervisory visit at least every 14 days and review of Patient 1’s record did not find an RN supervisory visit between the initial RN admission visit on 12/16/24 and subsequent RN supervisory visit performed on 01/17/25.”