Angela Hospice Home Care, Inc.

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The hospice EP training program includes EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 17 (6%) personnel records reviewed, it was revealed that the agency did not ensure that the volunteer received emergency preparedness training as required by the agency’s policy. POLICY AND PROCEDURES: The agency policy, no. 4-001, last reviewed 01/30/2025, titled, Emergency Management Plan, stated in part, “The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable” and “The training is provided annually.” PERSONNEL RECORD 17: The volunteer, who enrolled with the agency on 03/09/2023 and who provided care in both the home setting and the inpatient unit, received written evidence of training on emergency preparedness during the volunteer’s initial orientation process in March of 2023. There was no additional documented evidence of emergency preparedness trainings completed by this volunteer in the personnel record. During an interview with the Director of Supportive Care on 06/26/2025, she stated that the emergency preparedness trainings were assigned for this volunteer in 2024 and 2025 but had not been completed.”

“It is required that the hospice Interdisciplinary Group, in consultation with the individual’s attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 7 of 27 (26%) clinical records reviewed, it was revealed that the agency did not ensure that a comprehensive assessment was completed within five calendar days after the election of the hospice benefit. POLICY AND PROCEDURES: Agency Policy No 1-020, last revised 07/24/2019 titled, Spiritual Assessment, read in part, “4. The in-depth spiritual assessment will be performed by the Chaplain: A. In the patient’s residence.” CLINICAL RECORD 12: The patient was admitted on 06/06/2025 with a diagnosis of left breast cancer. The clinical record contained a note dated 06/12/2025 that read, “SCC (Spiritual Care Coordinator) has made one attempt for spiritual care (SC) assessment and left a detailed voicemail at contact number. Writer has not heard back from (name) or family and will follow up.” As of 06/25/2025, the clinical record contained no further follow up related to completing the spiritual care assessment. CLINICAL RECORD 17: The patient elected hospice on 06/11/2025. The SN assessment was completed on 06/11/2025. The spiritual care assessment was not completed until 06/18/2025, 11 days after admission. CLINICAL RECORD 6: The patient elected the hospice benefit on 02/14/2025. On the initial RN comprehensive assessment dated 02/14/2025, no documented spiritual assessment was done. There was no documented comprehensive spiritual assessment on the initial social work assessment dated 02/17/2025. The chaplain made a phone call for a telephone assessment on 02/17/2025. There was no in-person chaplain visit made until 02/21/2025, 7 days after admission. CLINICAL RECORD 19: The patient elected the hospice benefit on 05/07/2025. On the initial plan of care dated 05/07/2025 there was an order for Spiritual Care: (PRN) 1 visit starting 05/07/2025 (week 1) Reason for PRN: Spiritual Evaluation Start Date:05/07/2025 End Date: 08/04/2025. On the initial RN comprehensive assessment dated 05/07/2025, no documented spiritual assessment was done. There was no documented comprehensive spiritual assessment on the initial social work assessment dated 05/08/2025. The chaplain made a phone call for a telephone assessment on 05/09/2025. There has been no in-person chaplain visit made to date. CLINICAL RECORD 20: The patient elected the hospice benefit on 04/24/2025. On the initial RN comprehensive assessment dated 04/24/2025, no documented comprehensive spiritual assessment was done. There was no documented comprehensive spiritual assessment on the initial social work assessment dated 04/28/2025. The chaplain made a phone call for a telephone assessment on 05/02/2025. An in-person visit was made by the chaplain on 06/18/2025 CLINICAL RECORD 21: The patient elected the hospice benefit on 02/14/2025. On the initial plan of care dated 02/14/2025 there was an order for Spiritual Care: (PRN) 1 visits starting 05/07/2025 (week 2) Reason for PRN: Spiritual Evaluation Start Date:02/14/2025 End Date: 05/14/2025. On the initial RN comprehensive assessment dated 02/14/2025, no documented comprehensive spiritual assessment was done. There was no documented comprehensive spiritual assessment on the initial social work assessment dated 02/18/2025. The chaplain made a phone call for a telephone assessment on 02/17/2025. No other visits were made for spiritual care. CLINICAL RECORD 22: The patient elected the hospice benefit on 05/07/2025. On the initial RN comprehensive assessment dated 05/07/2025, no documented comprehensive spiritual assessment was done. There was no documented comprehensive spiritual assessment on the initial social work assessment dated 05/09/2025. The chaplain made a phone call for a telephone assessment on 05/12/2025. No other visits were made for spiritual care. In an interview with the Quality improvement specialist on 06/26/2025 it was confirmed that the comprehensive spiritual assessments were not completed in person by any members of the interdisciplinary team.”

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by clinical record review and interview. In 5 of 27 (19%) clinical records reviewed it was revealed that the agency did not ensure that the medication profile was updated when new medication was added or changes were made to the existing medication. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/18/2025. On 05/08/2025 at 1603, triage received a call from the facility stating, “She noted a large softball-sized abscess on the patient’s right iliac crest, reddened, with the center of the wound open, draining with foul-smelling pus.” The facility RN stated, “Spoke with the doctor there and patient was started on Doxycycline”. The medication profile in the clinical record was not updated to include Doxycycline. The Director of Quality confirmed, that there was no documented evidence of the medication Doxycycline being added to the patient’s medication profile during joint review on 06/24/2025. CLINICAL RECORD 10: The patient elected hospice on 05/15/2025 with a diagnosis of unspecified diastolic heart failure. The plan of care included Oxygen 2 liters per nasal cannula as a treatment. The medication profile did not include oxygen. CLINICAL RECORD 11: Patient admitted to hospice 06/13/2022 with a diagnosis of chromosomal abnormality. The skilled nursing comprehensive reassessment dated 05/16/2025 revealed that the patient had oxygen 2 liters per nasal cannula PRN. The plan of care for the benefit period 18, beginning 05/28/2025, included an oxygen concentrator effective 08/27/2024 and oxygen precautions to start 08/27/2024. The medication profile did not include oxygen. CLINICAL RECORD 12: The plan of care dated 06/06/2025, the first benefit period, included orders for an oxygen concentrator, effective 06/06/2025, and intervention orders to initiate oxygen flow at 2 liters per minute effective date 06/06/2025. Oxygen was not included on medication list on the plan of care or on the medication profile. CLINICAL RECORD 14: The patient was admitted on 04/23/2025 with a diagnosis of Chronic Obstructive Pulmonary Disease. The clinical record includes an order to initiate oxygen flow at 2 liters per minute effective 06/12/2025. Oxygen was not added to the medication profile. The quality improvement specialist confirmed in an interview and chart review that oxygen was not included on the medication list and reported that the software did not include oxygen as a medication, and oxygen has to be listed as a treatment under the medication profile within the software. On 06/25/2025 Health information manager reported that he can manually add oxygen to the database if the software does not update the database quickly.”

“It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care, ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review and interview. In 1 of 27 (4%) clinical records reviewed it was revealed that the agency did not ensure that a designated member of the IDG provided coordination of care and ensure the implementation of the interdisciplinary plan of care. CLINICAL RECORD 17: The patient was admitted on 06/11/2025 with a diagnosis of malignant neoplasm of the bladder. The initial skilled nurse assessment dated 06/11/2025 revealed that a hospice aide was requested to assist with a shower. As of 06/26/2025 the clinical record did not include documentation of care coordination or notification to the physician or team, that an aide had been requested. During the interview and further review of the clinical record on 06/25/2025, the Director of Quality and Quality Improvement Specialist, confirmed the finding.”

“It is required that each patient’s individualized written plan of care include all medical supplies necessary to meet the needs of the patient. This standard was not met as evidenced by clinical record review and interview. In 4 of 27 (15%) clinical records reviewed it was revealed that the agency did not ensure that the individualized plan of care included all of the medical supplies needed to meet the needs of the patient. CLINICAL RECORD 7: The patient elected hospice on 05/28/2025. The SN assessment on 05/28/2025 revealed that the patient had an ileostomy on the left abdomen and a healing site of an old ostomy on the right abdomen. The plan of care dated 05/28/2025 did not include dressing supplies or ileostomy/stoma supplies. CLINICAL RECORD 8: The patient elected hospice on 06/07/2025. The SN assessment on 06/07/2025 revealed that the patient had a feeding tube and an ileal conduit. The medication profile revealed that tube feedings were administered via a pump. The plan of care dated 06/07/2025 did not include the feeding pump or the ileal stoma supplies. CLINICAL RECORD 17: The patient elected hospice on 06/11/2025 with a diagnosis of malignant neoplasm of the bladder. The skilled nursing assessment on 06/11/2025 revealed that the patient had an indwelling catheter that required flushes multiple times per day. Indwelling catheter supplies were not included in the plan of care. CLINICAL RECORD 23: The patient admitted on 04/20/2024 with a diagnosis of nonspecific abnormal finding of the lung field. The plans of care for the benefit periods, with dates 04/20/2024 - 07/18/2024, 07/19/2024 - 10/16/2024, and 10/17/2024 through 10/31/2024 did not include medical supplies. Skin nurse assessment on 04/20/2025 revealed that the patient required incontinence briefs. Director of Quality and Health Information stated in an interview on 06/24/2025, “Ok, we really have focused on listing the big DME items not the small supplies.””

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 17 (6%) personnel record reviewed, it was revealed that the agency did not ensure that all employees and volunteers received training in infection control as required by the agency’s policy. POLICY AND PROCEDURES: The agency policy no. 7-001, last reviewed on 09/06/2024 titled, Infection Control Plan, stated in part, “[The agency] will educate all personnel on infection control policies, procedures, and their responsibilities for implementation,” and that “Infection control in-services will be scheduled no less than annually.” PERSONNEL RECORD 17: A review of the personnel record for this patient care volunteer, who enrolled with the agency on 03/09/2023 and had provided patient related volunteer work in both the home setting and in the inpatient unit, included written evidence of training on infection control during the initial orientation process, in March of 2023. There was no additional documented evidence of infection control trainings completed by this volunteer in the personnel record. During an interview with the Director of Supportive Care on 06/26/2025, she stated that the infection control trainings were assigned for this volunteer in 2024 and 2025 but had not been completed.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 11 (36%) clinical records reviewed of patients that received home health aide services it was revealed that the agency did not ensure that the RN responsible for the aide’s supervision wrote specific patient care instructions for the hospice aide. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/06/2025 with a diagnosis of combined heart failure. The initial comprehensive assessment dated 06/06/2025 documented that the patient was admitted with multiple open pressure ulcers located on the coccyx, left ischial, right ischial, left heel, and right heel. Skin tears are located on the right upper arm, the right lower leg, and the left lower leg. The aide plan of care did not include documented instructions for the aide concerning specific instructions for wounds or suprapubic catheter. During an interview with the Director of Quality on 06/24/2024, he agreed that the instructions should be on the aide plan of care. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/18/2025. The clinical record noted a large, softball-sized abscess on the patient’s right iliac crest, reddened, with the center of the wound open, draining with foul-smelling pus on 05/08/2025. The aide care plan was not updated to include information for the aide related to how to manage care of the wounds and bandages while providing personal care. CLINICAL RECORD 7: The patient elected hospice on 05/28/2025. The SN assessment completed on 05/28/2025 revealed that the patient had an ostomy closed on the right abdomen and an ileostomy created on the left side. An aide care plan was developed on 06/13/2025 for an aide to provide personal care 1 time per week. The aide care plan did not include any information related to the patient’s ileostomy. CLINICAL RECORD 8: The patient elected hospice on 06/07/2025 with a diagnosis of malignant neoplasm of the head, face, and neck. The SN assessment dated 06/07/2025 documented the use of oxygen and a feeding tube with an enteral pump, and the patient had an ileus. The aide plan of care was developed on 06/09/2025 for an aide visit 1 time per week. The aide plan of care included fall precautions but did not include oxygen precautions or mention of the patient’s use of oxygen. The aide plan of care did not include information to the aide related to care of the feeding tube or the ileus. The Director of Quality and Health Information reviewed charts 2, 4, 7, and 8 on 06/25/2025 and confirmed that the aide care plans did not include required information.”

“It is required that a patient clinical record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum, physician orders. This standard was not met as evidenced by clinical record review and interview. In 4 of 27 (15%) clinical records reviewed it was revealed that the agency did not ensure that the patient’s record included physician orders for all treatments and medications. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/18/2025. On 05/08/2025 at 1603 hours, triage received a call from the facility stating, “She noted a large softball-sized abscess on the patient’s right iliac crest, reddened, with the center of the wound open, draining with foul-smelling pus.” The facility RN stated, “Spoke with the doctor there and the patient was started on Doxycycline. The RN made a visit on 05/08/2025, and documented, “Right iliac crest pressure ulcer/injury, open, stage 3, 3.5cmx2cmx7cm, red, granular, weeping, serosanguineous drainage, no odor.” The RN also documented, “Wound cleansed with wound cleanser and mepilex dressing placed over wound.” During the joint review of the clinical record and interview on 06/24/2025 with the Director of Quality, there were no documented physician’s order for Doxycycline and no orders for interventions to manage the patients wound on the patient’s plan of care. CLINICAL RECORD 11: The pediatric patient with a date of birth of 09/09/2021, and a diagnosis of chromosomal abnormality, was admitted to hospice on 06/13/2022. The eighteenth benefit period was 05/28/2025 through 07/26/2025. The plan of care for the episode 05/28/2025 included an intravenous solution Alyglo 10% 2.5 Gram every month for 24 months through 06/24/2026. The plan of care did not include an order for the infusion rate or indicate if the drug was infused via gravity or pump. The patient was also receiving enteral feedings. The plan of care noted the diet was enteral feeding of whole food blends and Pediasure, continuous as tolerated. The plan of care did not include any orders for the rate of the enteral feeding, or flushes of the feeding tube. CLINICAL RECORD 15: The patient elected hospice on 06/20/2025 with a diagnosis of Malignant neoplasm of the pancreas with secondary diagnosis of malignant neoplasm of the liver. The patient had a pleurex drain placed during her most recent hospital stay and had 6.1 liters removed on 06/16/2025. The plan of care did not include orders for care of the pluerex site, and there were no orders related to draining the Pluerex. CLINICAL RECORD 17: The patient elected hospice on 06/11/2025 with a diagnosis of malignant neoplasm of the bladder. The skilled nursing assessment on 06/11/2025 revealed that the patient had an indwelling catheter that required flushes multiple times per day. The plan of care dated 06/11/2025, did not include orders for catheter care, or catheter flushes. The initial nurse assessment documented that an additional foley kit was provided to the patient upon admission. There was no documentation or physician orders to indicate the size of the catheter or the size of the balloon. The quality team confirmed each finding with a review of the clinical record on 06/24/25 and 06/25/25 and voiced agreement that the plans of care did not include the orders as noted above.”

“It is required that hospice care of the patient/resident is stated in a written plan of care established and maintained in consultation with SNF/NF or ICF/IID representatives. The hospice plan of care identifies the care and services that are needed and specifies which provider is responsible for performing the functions that are agreed upon and included in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 27 (7%) clinical records reviewed it was revealed that the agency did not ensure that the hospice plan of care identified specifics on which provider was responsible for performing the functions that were agreed upon and included in the plan of care. CLINICAL RECORD 2: The patient elected the hospice benefit on 06/06/2025 with a diagnosis of combined heart failure. The patient resided in a skilled nursing facility (SNF). The initial comprehensive assessment dated 06/06/2025 documented that the patient was admitted with multiple open pressure ulcers located on the coccyx, left ischial, right ischial, left heel, and right heel. Skin tears were located on the right upper arm, the right lower leg, and the left lower leg. The plan of care dated 06/06/2025 had multiple orders for wound care that did not include who was responsible for changing the wound dressing. The hospice RN assessed and documented characteristics of the wounds on the initial comprehensive assessment dated 06/06/2025, however, there was no documented evidence in any other RN documentation of wound assessments. In an interview with the RN case manager on 06/25/2025 she stated, “The facility was responsible for changing the dressings.” This information was not documented in the patient’s clinical record. CLINICAL RECORD 4: The patient elected the hospice benefit on 03/18/2025. On 05/08/2025 triage received a call from the SNF stating “Noted today a large, softball sized abscess on patient’s iliac crest, reddened, with center of wound open, draining with foul smelling pus. SNF RN stated she spoke with the doctor at the SNF and patient was started on doxycycline. Patient is in pain, and SNF RN asking for visit to assess patient. RN made a visit on 05/08/2025 documented “Right illiac crest pressure ulcer/injury, open, stage 3, 3.5cmx2cmx7cm, red, granular, weeping, serosanguineous drainage, no odor.” RN also documented “wound cleansed with wound cleanser and mepilex dressing placed over wound.” During a joint review of the clinical record and interview with the quality improvement specialist on 06/24/2025 it was found and agreed that there was no documented evidence on the plan of care of who was responsible for wound care.”