Every finding on record at Gold Star Hospice LLC

Upon patient record review 5 of 14 (Patient #1,4,6,8,9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #1: There is evidence in the medical record on 11/26/25 of a note by the Social worker of a phone call stating there was no answer. There is no evidence of a follow up contact for the psychosocial assessment. Patient #4: There is evidence in the nursing assessment "daughter declined MSW evaluation and Chaplain assessment". The RN did not provide psychosocial and spiritual assessment. Patient #6: There is evidence of an order 10/22/25 "MSW and SC visit declined. Will continue to re-offer services". There was no assessment by the RN for psychosocial and spiritual assessment after the services declined. Patient #8: There is evidence of a note by the chaplain on 5/14/25 "Chaplain called family who declined spiritual counseling". There was no spiritual assessment by the RN after the services were declined. Patient #9: There is evidence of a note by the MSW on 10/6/25 "MSW called family who declined psychosocial assessment". There was no psychosocial assessment by the RN after the services were declined.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: There is evidence the patient is on Eliquis 2.5 mg BID. The initial plan of care did not include risk of bleeding.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #5: There is evidence the nursing frequency order is 2x week and 6 PRN for changes in condition. The PRN frequency is too high.

Upon patient record review, 1 of 14 (Patient #1) 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: There is evidence on 11/26/25 of a wound order: "Cleanse right chest wall wound with NS, pat dry, apply Xeroform dressing, secure with tape. Change dressing daily." Order does not include who will change the dressing.

Upon patient record review, 2 of 14 (Patient #3,10) 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: There was an order on 1/19/26 for Thick it and aspiration precautions. Aspiration precautions were not on the aide plan of care. Patient #10: There is evidence on the Aide plan of care 12/16/25, for shampoo and nail care: "as needed". Aide tasks must be specific.

Upon patient record review 1 of 14 (Patient #3) 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 #3: There is evidence on the Aide plan of care to complete a shower every visit. On 1/20/26 the aide completed a bed bath. There was no documentation the patient was cognitively able to make their own decisions regarding a shower.

Based on observation, interview, and record review, the agency failed to ensure an individualized plan of care established by the hospice interdisciplinary group (IDG, the team responsible for the development and review of the hospice beneficiary's plan of care) for one of three sampled patient (Patient 2) when the physician order was not followed for oxygen (a chemical element found in the air as a colorless odorless tasteless gas that is necessary for life) at 2 liters continuously. This failure had the potential to insufficient care provided to Patient 2. Findings: A review of Patient 2's IDG physician order with a start of care of 7/14/2022 indicated to give oxygen at 2 liters continuously for shortness of breath and comfort. During a home visit observation for Patient 2 on 8/29/2022 at 2:30 p.m., it was observed the Director of Patient Care Services (DPCS) was providing care and Patient 2 do not have oxygen. During an interview with the DPCS on 8/30/2022 at 10:40 a.m., she confirmed Patient 2 did not have an oxygen and physician order should have been followed. Review of the agency's policy and procedure dated 10/2019, "Verification of Physician Orders", indicated orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients.

2. During an observation on 8/29/22 at 9:42 a.m., the medical supplies cabinet was inspected, and the following medical supplies were found to be expired: a. 21 pieces (pcs) non adherent dressing (dressing that does not stick to the wound) with expiry date 3/2022; b. Five pcs anti-septic towelette (used to cleanse wound) with expiry date 4/2021; c. One povidone iodine pad (solution used into wounds to prevent infections) with expiry date 6/2021; d. Four surgical lubricants (solution that reduces friction) with expiry dated 2/28/22; e. Two monofilament foot screen test (device used to assess loss of protective sensation) with expiry date 12/2021; f. One centurion dressing (used to secure intravenous catheters [hollow tube use to deliver fluids in the body]) with expiry date 12/2018. During an interview with the Administrator/Director of Patient Care Services (ADMIN/DPCS) on 8/29/22 at 10:11 a.m., she stated she was responsible in maintaining the medical supplies cabinet. The ADMIN/DPCS then threw all the expired medical supplies. During additional interview with the ADMIN/DPCS on 9/1/22 at 9:58 a.m., she stated she was responsible in maintaining the medical supplies cabinet and should have thrown the expired medical supplies. Review of the agency's undated policy, "SUPPLY", the ADMIN/DPCS should maintain the medical supply cabinet monthly. Based on observation, interview, and record review, the agency failed to follow infection control precautions when 1) Registered Nurse (RN) and the Director of Patient Care Services (DPCS) failed to do hand hygiene, change gloves in between procedures, and practice infection control procedures during home visits for two (2) out of three (3) home visit patients; and 2) expired medical supplies were found in the medication supply closet. These failures put patients at risk for infections and cross contamination. Findings: 1. During a home visit on 8/30/2022 at 2:00 p.m. to Patient 3 with Registered Nurse A (RN A), RN A prepared 2 chucks, one was placed on top of the chair where she placed her nursing bag beside her personal handbag. Another one was placed on top of the table where she placed her medical equipment and a can of wet wipes. RN A did hand hygiene and put on new gloves. RN A then assessed and take Patient 3's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). RN A took out a wet wipe then cleaned the thermometer and took Patient 3's temperature, then cleaned the thermometer with same wet wipe she was holding in her left hand and placed the cleaned thermometer in her nursing bag. Next, she took the pulse oximeter (a device to check the oxygen saturation in the body), cleaned it with same wet wipe, then proceeded to take Patient 3's pulse and oxygen saturation. Afterwards, with same wet wipe in her left hand, she cleaned the pulse oximeter and returned it to her nursing bag. RN A was wearing the same gloves and she proceeded to clean the digital blood pressure (BP, the force of the blood against the artery walls) machine (a device to check the BP) and applied the cuff on Patient 3's left arm. While the BP machine was pumping and wearing the same gloves, RN A reached inside her nursing bag and took out a note pad, then without changing gloves and wearing the same gloves, RN A reached inside her personal handbag and took out a pen. She then proceeded to record the vital signs on her notepad, then placed the notepad on top of her pocketbook and the pen on top of the table. Afterwards, RN A proceeded to remove the BP machine from Patient 3's left arm and cleaned it with a wet wipe while the BP machine was laying on top of patient's linen and chucks next to the patient's condom catheter tubing. During an interview with RN-A on 8/30/2022 at 3:55 p.m.. RN A confirmed the above observations. Review of RN A's training records indicated she last attended infection control and bag technique training on 2/3/2022. Review of agency's Standards Precautions Policy (Policy No. 7-007) dated October 2019 indicated: PROCEDURE: Hand Hygiene-1. Hand hygiene will be performed to prevent cross-contamination between the patient and personnel ... Personnel Protective Equipment 1. Gloves - C. Gloves are changed: 1. Between tasks and procedures on the same patient. Review of agency's Hand Hygiene Policy No. 7-009 dated October 2019 indicated the hand decontamination using an alcohol-based hand rub should be performed: and after contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient). After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. During a home visit conducted for Patient 2 on 8/29/2022 at 2:35 p.m., the Director of Patient Care Services (DPCS) check the Patient 2's vital signs with her gloves, took her phone, and notebook to document the vitals signs with the same gloves. DPCS removed her gloves and put the used gloves beside the home health bag. During an interview with the DPCS on 8/29/2022 at 3:30 p.m., she confirmed she did not remove her gloves when she documented Patient 2 vital signs. DPCS stated she did not have a trash can when she removed her dirty gloves and put it beside her home health bag. Review of agency's policy and procedure dated 10/2019, "Standard Precaution", indicated gloves are to be changed during in between tasks and procedures on the same patient. Review of agency's policy and procedure dated 10/2019, "Bag Technique", indicated to maintain a clean nursing bag/computer bag and preventing cross-contamination.

Based on interview and record review the agency failed to maintain a current medication profile for one (1) out of three (3) home visit patients (Patient 3). This failure puts Patient 3 at risk for adverse medication side effects. Findings: During a home visit on 8/30/22 at 2:00 p.m. with Patient 3 and Registered Nurse A (RN A), a medication review of Patient 3's current medications was conducted. The medication list printed on 8/29/22 was reviewed with the patient's care giver (CG 3), with RN A and with the medication list in the home. The following medications and supplements had discrepancies: Concurrent interviews with both RN A and CG 3 confirmed these discrepancies. a. Ambien 5 milligrams (mg, a unit of measure) oral tablets started on 8/13/22 was not on the home medication list. This was confirmed by RN A. b. Medihoney Wound/Burn Dressing External Gel started on 8/6/22. CG 3 stated medication was no longer used and they still have the medication at home. RN A stated this was for a wound on patient's back, but Patient 3 had no wound at the back. c. Tramadol 50 mg oral tablets started on 4/21/2022. RN A stated he had it before, but he does not need it, Patient 3 gets Gabapentin now. CG 3 did not want to keep it. d. Zinc Oxide External Ointment started on 3/13/2022. RN A stated this was for Patient 3's rash on the scrotum which resolved. Both RN A and CG 3 stated this was not used and it was only for 7 days. e. Ensure can and CG 3 stated she also gives Patient 3 Ensure 2 cans per day, but this was not on the list. f. Multivitamins (MVI) and CG 3 stated she also gives MVI to Patient 3 but it was not on the list. Concurrent interviews with both the CG 3 and RN A on 8/30/22 both confirmed the above observation and record review. Review of agency's Medication Profile Policy No. 2-004 dated October 2019, indicated the medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.