Only Angels Hospice LLC

“It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including the following: A detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review and interview. In 4 of 8 (50%) clinical records reviewed, the agency did not ensure the individualized plan of care included the scope and frequency of services to be provided. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/28/2024 with a diagnosis of memory deficit with cardiovascular disease. The patient was recertified for multiple episodes of care. Clinical record review revealed the Medical Social Worker (MSW) documented visits were provided to the patient on 11/13/2024, 12/11/2024, 01/08/2025, 03/24/2025, 05/01/2025, 05/16/2025, and 05/22/2025, and the Chaplain documented visits were provided to the patient on 04/22/2025, 04/29/2025, 05/05/2025, 05/12/2025, 05/27/2025, and 05/29/2025. The plans of care for the benefit periods dated from the start of care through the current benefit period dated 05/23/2025 included the statements “Social work visit frequency _____ [left blank]” and “Spiritual care visit frequency _____ [left blank].” The plans of care did not include the scope and frequency of services for the MSW and Chaplain services. CLINICAL RECORD 2: The patient elected the hospice benefit on 05/05/2025 with diagnosis of stage IV prostate cancer. Clinical record review revealed the MSW documented visits to the patient on 05/05/2025 and 05/21/2025, and the Chaplain documented visits were provided to the patient on 05/05/2025, 05/14/2025, and 05/28/2025. The plan of care dated 05/05/2025 included the statements “Social work visit frequency _____ [left blank]” and “Spiritual care visit frequency _____ [left blank].” The plan of care did not include the scope and frequency of services for the MSW and Chaplain services. CLINICAL RECORD 3: The patient elected the hospice benefit on 06/07/2024 with diagnosis of chronic obstructive pulmonary disease. The patient was recertified for multiple episodes of care. Clinical record review revealed the MSW documented visits were provided to the patient on 04/15/2025, 05/16/2025, and 05/29/2025 and the Chaplain documented visits were provided to the patient on 04/09/2025, 04/23/2025, 05/09/2025, and 05/23/2025. The plan of care dated 04/03/2025 to 06/01/2025 did not include the scope and frequency of services for the MSW and Chaplain services. CLINICAL RECORD 4: The patient elected the hospice benefit on 02/21/2024 with diagnosis of dementia. The patient died on 04/19/2024. Clinical record review revealed the Chaplain documented visits were provided to the patient on 02/23/2024, 04/18/2024, and 04/19/2024. The plan of care dated 02/21/2024 to 04/19/2024 did not include the scope and frequency for Chaplain services. During an interview on 05/30/2025, the Administrator/Director of Nursing stated “they (MSW and Chaplain) know they can go once a week, twice a week, every other week or as often as the patient needs. I didn’t add their frequency in the (EMR), I am still learning the system.””

“It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record reviewed with volunteer services provided, the agency did not ensure volunteer services were included in the plan of care. CLINICAL RECORD 1: The patient elected the hospice benefit on 05/28/2024 with diagnosis of memory deficient with cardiovascular disease. The patient was recertified for multiple episodes of care. Clinical record review revealed the Volunteer provided visits twice a month starting on 01/14/2025 through the date of record review on 05/30/2025. The plans of care dated 01/23/2025 to 03/23/2025 and 03/24/2025 to 05/22/2025 did not include an order for volunteer frequency of visits, and did not include goals and interventions related to volunteer services. During an interview and review of the record on 05/30/2025 with the Administrator/Director of Nursing and the Volunteer Coordinator, the Volunteer Coordinator, stated she did not realize volunteer goals on interventions needed to be included in the plan of care. The Administrator/Director of Nursing also stated, “we didn’t know that, but we can start adding volunteers to the plans of care.””