Angel Bright Hospice Inc.

“Observed in Record Review. In 2 of 5 patient records reviewed, During RR# 1 and RR# 5’s patient records review it was noted the organization had not ensured the plan of care was based on the patient’s goals. For example: review of RR# 1’s updated plan of care, dated approximately 11 days prior to the surveyor review of the record, revealed RR# 1’s terminal diagnosis was Pulmonary Heart Disease and was on 5 LPM via nasal cannula. However, further review of RR# 1’s updated plan of care revealed no goals for the oxygen intervention. Review of RR# 5’s updated plan of care dated approximately four days prior to the surveyor review of the record, revealed documentation of a pain assessment that included worst pain level of 8/10 and acceptable pain level at 1/10. However, review of RR# 5’s plan of care revealed no goal for pain. This was reviewed, discussed, and validated with the Executive Director.”

“Observed in Record Review. In 1 of 5 patient records reviewed, During RR# 3’s patient record review it was noted the organization had not ensured the plan of care included all the treatments necessary to meet the needs of the patient. For example: review of RR# 1’s patient record revealed RR# 3’s updated plan of care, dated approximately 11 days prior to the surveyor review of the record, revealed RR# 3 had an indwelling foley catheter with the intervention to change the foley catheter monthly. However, further review of the updated plan of care revealed not documentation on the size, type, or balloon size. This was reviewed, discussed, and validated with the Executive Director.”

“Observed in Record Review. In 3 of 5 patient records reviewed, the written plan of care was not based on the patient’s goals and time frames, settings, and services required to meet those goals, for example in review of the medical record for RRNHV #2 the patient had three documented wounds (left buttocks, right buttocks and right lower extremity, however there was only one problem identified on the care plan with no specific and measurable goals or interventions for each wound. In review of RRNHV # 3 there was a physician order to update the plan of care with specific wound care orders to the arterial ulcer of the left 1st toe, 4th toe and 5th metatarsal however there was no evidence of a skin integrity/wound care problem with goals and interventions on the plan of care. Additionally for RRNHV #3 the patient had a PEG tube and there were physician orders to update the plan of care with Jevity feedings and flushes however there was no evidence on the plan of care of a nutritional problem, goals or interventions. This was also observed in review of RRNHV #5 where the plan of care problems and goals were broad and not specific and measurable. and validated with the Hospice Director.”

“Observed in Record Review. In 1 of 5 patient records reviewed, In 1 of 14 active patient records reviewed. The plan of care had not been updated to include the wound care provided. Example: During review of HOSv#2. The plan of care had not been updated to include specific wound care orders. For example in review of RRNHV #2 the patient had three documented wounds (left buttocks, right buttocks and right lower extremity, however there was only one problem identified on the care plan with no specific and measurable goals and interventions for each wound. The plan of care included the problem: Deficit related to skin/membrane integrity AEB sacral wound and skin breakdown. Goal: sacral wound will remain free from s/s of infection and will not show signs of further progression over the next 30 days. The medical record did include Physician orders for wound care which were followed on each visit, however the plan of care had not been updated with the orders.”

“Observed in Record Review. In 1 of 5 patient records reviewed, the record had not documented progress towards goals. For example in review of RRNHV #2 the patient had an incision from surgery for a right leg fracture which nursing notes documented dressing changes and removal of staples.. There were care plan updates on 11/22/2024, 11/25/2024, 11/27/2024 and 12/2/2024 which included skilled nurse will provide wound care and dressing changes at each visit however the care plan updates did not include specific orders for RLE incision care or removal of staples.. The EMR did include Physician orders for wound care which were followed on each visit, however those updates were not included on the care plan. The goal remained unchanged throughout the patient’s care without documentation to reflect any progression to the goal. This was validated with the Hospice Director.”

“Observed in Individual Tracer. In 2 of 14 patient records reviewed and confirmed by the Director of Operations. The comprehensive assessment had not been completed within 5 days. During review of HOSv#3 the MSW had not completed a patient assessment . Example: The MSW had attempted to phone the patient with no answer, but there had not been any further attempt to contact the patient or family. During review of HOSrr#3 the MSW had been accepted by the patient during the initial assessment . The MSW had not provided an assessment within 5 days and there had not been any contact or refusal by the patient documented.”

“Observed in Individual Tracer. In 1 of 14 active hospice records reviewed. Social work services had not been provided based on the patient and family needs. Example: During review of HOSrr#2 the RN had identified, in the plan of care, the need for psychosocial services to be provided to the family for further education for end of life and the hospice philosophy. The frequency had stated for MSW 1xmonth prn for changes and needs. The MSW had not provided visits to the patient and family to address the need. This had been confirmed by the Director of Operations.”

“Observed in Building Tour. During the Hospice inpatient document review, it had been identified that the documentation for the inpatient medication refrigeration temperature levels had not been documented consistently, Example: During the month of April the medication refrigerator had not documented the temperature for half of the month, Weekends had been missed in May over the weekends . The agency policy had not documented a plan based on manufacturer, state, federal or Pharmacy input as to the proper temperature logs to be maintained for Promethazine and Tylenol suppositories. This had been confirmed by the Director of operations per policy to be completed daily.”