Every finding on record at Golden Age Hospice, Inc.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure the clinical record was complete, promptly and accurately documented. For example: on review of RRHV#1 the LVN narrative documentation on the most recent visit noted the patient with tachycardia, yet the heart rate was documented as 71. Another LVN note documented tachycardia in the narrative, but the pulse was documented to be 78. In review of RRNHV#8 there was documentation in the RN narrative in September stating that the patient had O2 at 2 liters per nasal cannula as needed yet other documentation noted the patient continued to refuse oxygen and there were no O2 orders. In review of RRHV#2 the clinical and IDG documentation noted that the patient had pain that was controlled with Acetaminophen as needed, however the patient's medication profile noted that the patient was taking oxycodone 4 times a day scheduled. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 4 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#4 it was noted that the patient was being seen by the MSW and Spiritual Care yet there were no psychosocial or spiritual care plans to guide the care. Further, in the initial comprehensive assessment there was documentation of a stage 2 to the sacrum yet there was no skin integrity care plan at the time of survey. In RRHV#1 and RRNHV#8 the patient was being seen by the MSW and Chaplain yet there were no psychosocial or spiritual care plans established. In RRHV#3 there were visits recorded from the Chaplain but no spiritual care plan to guide the care. These observations were reviewed with the CEO/Administrator and the Administrator Designee.

Observed in Record Review. In 6 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. For example: in review of RRNHV#8 the patient was diabetic and required insulin. The insulin order on the medication profile for Humalog and Levemir were ordered to be given per sliding scale, yet the order failed to specify the parameters of the sliding scale and when to give which dosage. Further, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRHV#2 all were noted in the record to be diabetic that were doing blood glucose monitoring, yet there were no orders as part of the plan of care to specify when monitoring was to be conducted and by whom. In RRNHV#8 there were orders specifying the SN may assess blood glucose level as needed for signs and symptoms of hypo/hyperglycemia yet there were no orders to specify when and who was to check the patient's blood glucose for the sliding scale insulin. In RRNHV#4 the patient had a documented wound, but there were no wound care treatment orders noted on the plan of care. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to provide patient with care, treatment, and services according to the patient's individualized plan of care. For example: on review of RRNHV#9 the Chaplain was ordered to visit the patient per the IDG plan of care 1 time every three months, yet was documentation noted the patient was receiving spiritual care visits monthly. In RRNHV#4 the patient was documented to have a stage 2 wound to the sacrum. Multiple nursing notes documented that wound treatments were provided yet there were no wound treatment orders per the plan of care. These observations were reviewed with the Administrator Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure that written patient care instructions for the hospice aide were prepared by a registered nurse. For example: on review of RRNHV#4 the aide plan of care prepared by the RN noted vital signs to be taken every visit, however there were no parameters to guide the aide when to notify the nurse of abnormal findings. This observation was reviewed with the Administrator/CEO and Administrator Designee.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aides, the organization failed to ensure an RN make an annual on-site visit to the location where a patient is receiving care to observe and assess each aide while performing care. On review of HR#6, for the CHHA, it was noted that annual competencies with direct observation was documented, however the aide was observed by another aide and not a Registered Nurse as required. This observation was reviewed with the Administrator/CEO and Administrator Designee.

Observed in HR File Review. In 1 of 1 HR files reviewed, for CHHA, the organization failed to ensure the supervising nurse assess the aides ability to demonstrate continued satisfactory performance in meeting outcome criteria. On review of the HR file for the CHHA, HR#6, it was noted that annual competencies with direct observation was documented, however the aide was observed by another aide and not a Registered Nurse as required. This observation was reviewed with the Administrator/CEO and Administrator Designee.

Observed in Record Review. In 2 of 2 HR files reviewed, The organization failed to ensure it make available physician services 24 hours a day 7 days a week, and all other covered services available on a 24-hour basis when necessary to meet the needs of a patient and family. On review of the HR file for the Medical Director and Associate Medical Director, it was noted that the Contract noted the MD would be available from 8:00 - 4:30 Monday - Friday for on-call consultation, assistance and decisions regarding patient care. The Administrator Designee states that physicians are available 24/7 yet the signed contract did not reflect around the clock availability as required.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization failed to ensure that before the recertification period for the patient, the medical director reviews the patient's clinical information. For example: on review of RRNHV#5 the CTI for benefit period #2 did not contain a physician narrative, attestation, or signature. This observation was reviewed with the Administrator Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, The organization failed to ensure the patient record contain all information to reflect the patient's care treatment or services. For example: on review of RRNHV#4 all RN documentation since the initial comprehensive (August and September) were noted to have a time in and out but all further documentation was left blank and not documented per organization policy. In RRHV#3 the patient medication profile noted the patient to be ordered Admelog yet in the patient home the insulin present and the patient confirmed she was taking was Novolog. This observation was reviewed with the Administrator/CEO and Administrator Designee. Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the patient medical record contain all information that reflects the patient's, care treatment, or services. For example: on all active patient records reviewed there was no patient history and physical leading up to the hospice admission noted on the record. This observation was reviewed with the Administrator Designee.

Observed in Record Review. In 7 of 10 patient records reviewed, the organization failed to ensure that all entries were legible, clear, complete, and appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. For example: on review of RRNHV#4 the initial comprehensive assessment for the MSW and SC were not authenticated in the records. Further, most all visit notes were noted to be entered in the record but were not authenticated by the author. In RRNHV#5, RRNHV#9 and RRNHV#10 there were multiple visit notes on the record in September that had not been authenticated by author. In RRHV#2 and RRHV#3 the initial RN comprehensive assessment was not signed and dated. These observations were reviewed with the Administrator/CEO and the Administrator Designee.

Observed in Record Review. In 4 of 4 patient records reviewed, the surveyor observed that the social worker nor the chaplain documented patients progress toward goals and only documented that they would continue to monitor goals. The surveyor also found that the nurse on 2/4 records had not documented patients progress toward goals. This issue was discussed and confirmed with organization leaders.