Every finding on record at Golden Ages Palliative and Hospice Care Inc

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #3 SOC 11/26/23. All admission forms signed 11/27/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #3 SOC and Initial Comprehensive Assessment documented as 11/26/23. All admission forms signed 11/27/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence of the appropriate documentation for release of confidential information. Patient #3 SOC and Initial Comprehensive Assessment documented as 11/26/23. All admission forms signed 11/27/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #3 SOC and Initial Comprehensive Assessment documented as 11/26/23. All admission forms signed 11/27/23.

Upon patient record review, 1 of 14 (Patient #3) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #3 SOC and Initial Comprehensive Assessment documented as 11/26/23. All admission forms signed 11/27/23.

Upon patient record review, 1 of 14 (Patient #4) did not have evidence that each patient and family received education and training provided as appropriate to their responsibilities for the care and services identified in the plan of care. Patient #4: Communication Notes 12/20/23 710 pm RN documented received call from daughter that patient seems more restless and requested SN visit. Scheduled SN tomorrow." 12/21/23 communication note by same RN. SN visited and the patient appears to be in sharp decline.. Patient was moaning and restless. Ordered ekit to have on standby." No evidence of follow up on delivery and related education regarding the comfort kit.

Upon patient record review, 3 of 14 (Patient #3, 4, 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 #3: SOC 11/26/23 MSW visits order Initial eval within 5 days from admission, depending on need, once monthly visit for support and counseling to provide psychosocial support to patient and family. Patient #4,5 : Frequency of Visit SC 1 as needed.

Upon client record review, 4 of 14 (Patient #1, 2, 3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SOC 9/30/23. 9/30/23 Order written that Vol. was declined, but service assigned and provided weekly beginning 11/28/23. Patient #2 . SOC 11/21/23 with 11/21/23 order that volunteer was declined. Service was however, assigned and provided weekly beginning 11/28/23. Patient 3 SOC 11/26/23 with 11/26/23 order that volunteer was declined. Service was however, assigned and provided weekly beginning 12/5/23. Patient #1,2,3,4: There is an initial order for nursing frequency, but IDG POC every 2 week updates exclude order for SN. SN visits provided weekly.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #1, 3: LVN wore mask under his nose during both visits. Patient #2: when setting up bath water, the HA turned off faucet with same gloves she approached patient wearing - and held patients hand with same glove. Education provided

Upon personnel record review, 1 of 14 (Personnel # 5) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #5: Competency skills check off list utilized by agency does not include sink, tub, bed type shampoos, but simply shampoo. Therefore, competency in all 3 is not documented.

Upon patient record review 1 of 14 (Patient #1) 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: 12/18/23 HA Visit note. Non-ambulatory section: HA marked tasks completed for bed rails up, objects within reach, bed in low position, turn and reposition, although not assigned by RN. Feeding Instructions section: HA marked tasks completed for aspiration precaution, feeding assistance, encourage fluids as tolerated, although tasks not assigned by RN.

Upon personnel record review, 1 of 12 (Personnel #9) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #9: There is no skills competency assessment list documented in personnel file for volunteer.

Upon patient record review, 8 of 14 (Patient #4, 5, 7, 8, 9, 10, 11, 12) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient #4, 5: CTIs for subsequent benefit period 12/4/23-2/1/24 lack narrative statement. Patient #7, 8: SOC 12/6/23 for both patients and CTI for both lack physician narrative statement. Patient #9: SOC 12/7/23, CTI lacks physician narrative statement. Patient #10 SOC 12/16/23, admitted in 11th HMB. The CTI does not include verbal certification within 48 hours and does not include physicians narrative statement. Patient #11: SOC 12/7/23. CTI does not include physician's narrative statement. Patient #12: CTI for recertification benefit period #3 4/15/23-6/23/23, lacks physician narrative statement.

Upon patient client record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) 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 #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14: Election Statement has no space prompting or specifying effective or beginning date. There is a date in the header and a date at bottom for signature, but not specifying/clarifying start date. Patient #3 in addition is being cited related to SOC 11/26/23. All admission forms signed 11/27/23.

Upon patient client record review, 3 of 14 (Patient #2, 4, 5) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: SOC 11/21/23. Initial psychosocial assessment 11/25/23. The MSW documented that "Patient continues to reside at "Golden Ages Hospice Facility". The home is a private group home and CEO clarifies that Golden Ages has no ownership. Patient #4: Patient admitted in 12th benefit period. RN summary for initial assessment 12/1/24 says "Dr. Barreintos has certified for the 1st 90 day benefit period that patient has terminal illness with life expectancy of six months or less ....." Patient #5: Patient admitted in 12th benefit period. RN summary for initial assessment 12/1/24 says "Dr. Barreintos has certified for the 1st 90 day benefit period that patient has terminal illness with life expectancy of six months or less ....."

Upon client record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14: Admission information, handbook and/or acknowledgement form did not include agency policy on disposal of controlled medications.

Upon observation, there was no evidence the hospice has the appropriate licenses/permits required by state or local rules and regulations. The posted hospice license expired 12/08/23. The agency presented copy of renewal application packet submitted 12/18/23.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel.