Every finding on record at Gimag Healthcare

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 8: Medication profile contained MiraLAX with no evidence of instructions for diluent.

Upon patient record review, 5 of 14 (Patient #1,#3,#4,#5,#7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1,4,5,7: Patient on anticoagulant therapy; however, no evidence of problems, goals and interventions for risk for bleeding. Patient 3: RN drains pleural fluid via PleurX drain every week with no evidence of problems, goals and interventions. Patient 4: On admission and consecutive visits, there was documented difficulty managing pain; however, there was no evidence of care plan for pain. Patient 5: Patient identified as having dysphagia and risk for aspiration with no evidence of problems, goals and interventions.

Upon patient record review, 2 of 14 (Patient #1,#8) 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 1: Patient refused to have foley catheter reinserted and medical director notified. No evidence of order to discontinue catheter. Patient 8: Medical record contained order for MiraLAX with no evidence of instructions for diluent.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 2: No evidence of any open care plans at time of survey, there were no progress towards goals with no problems/goals/interventions documented. 5 care plans were expired and 1 was inactive.

Upon patient record review 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient 4: SW documented daughter of the patient was experiencing caregiver role strain and opened a care plan for respite care. No evidence of follow up or discussion with daughter to offer respite services.

Upon patient record review, 5 of 14 (Patient #4,#5,#8,#9,#14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient 4,9,14: No evidence of bereavement plan of care developed. Patient 5: No evidence of following bereavement care plan after 08/03/2025, and no evidence of documentation regarding why bereavement had ceased. Patient 8: No evidence of updates to bereavement care plan after 08/19/2025, and no evidence of documentation regarding why bereavement had ceased.

Upon patient record review 2 of 14 (Patient #1,#8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 1: Aide frequency is 2x/week with no evidence of aide visit week of 03/30/2026. Patient 8: Aide frequency is 3x/week with no evidence of aide visit week of 08/11/2025.

Upon patient client record review, 3 of 14 (Patient #4,#9,#12) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 4,9,12: Date not entered in blank for the effective date of election on the election statement.

Upon patient record review, 1 of 14 (Patient #6) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6 medication profile includes “Acetaminophen 325mg oral tab 3 tabs po every 4 hours prn moderate to severe pain” with no daily dosage limit.

Upon patient record review, 1 of 14 (Patient #6) 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 #6 plan of care includes “Acetaminophen 325mg oral tab 3 tabs po every 4 hours prn moderate to severe pain” with no daily dosage limit.

Upon patient record review, 4 of 15 (Patient #3, #5, #6 and #12) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3, #6 and #12 did not show evidence indicating what tasks are to be done by the Aide and the frequency of these tasks. Vital signs (B/P, T, P, R) were to be taken as identified on the hospice care plan with no frequency indicated. Patient #5 There was no Hospice Aide care plan for current benefit period.