Every finding on record at Golden Angel Hospice Inc

Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #1, Patient SOC 9.18.24, initial MSW assessment completed on 12.13.24. No evidence of initial assessment completed within 5 calendar days.

Upon patient record review, 8 of 14 (Patient #1,2,5,6,7,8,9,10) 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 #1,2,5,6,7,8,9,10, Oxygen therapy 2-5L/min via nasal canula as needed was documented under treatment. No evidence of oxygen documented on medication profile. COS Patient #8, SN note documents patient rated their pain at 5 and patient had taken analgesic one hour prior to visit. No evidence of analgesic noted on medication profile. COS

Upon patient record review, 1 of 14 (Patient #7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #7, Bereavement assessment dated 3.13.25 documented in narrative assessment complete. No evidence of assessment was documented within note.

Upon patient record review, 8 of 14 (Patient #1,4,5,6,7,8,9,10) 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, Patient was a full code and had no funeral home identified. No evidence psychosocial interventions and goals for full code or funeral home. Patient was admitted on 6.1.25. No evidence of initial care plans documented. COS Patient #5, Patient is on glipizide 10mg 2x/day and metformin 1000mg 2x/day. No evidence of endocrine interventions and goals for diabetic medications. COS. Patient #6, Patient was admitted on 5.22.25 for terminal diagnosis of COPD. No evidence of respiratory interventions and goals. No evidence of psychosocial interventions and goals for no funeral home identified. COS Patient #7, No evidence of psychosocial interventions and goals for no funeral home identified. COS Patient #8, Patient documented on admission with pain. No evidence of pain interventions and goals. COS Patient #9, Patient admitted on 11.13.24. No evidence of a care plan documented until 12.18.24 only for spiritual care. Then on 1.1.25 a care plan was initiated for MSW and Nursing care plans not initiated until 3.12.25. Patient #10, No evidence psychosocial interventions and goals for full code status. COS

Upon patient record review, 8 of 14 (Patient #1,2,5,6,7,8,9,10) 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 #1,2,5,6,7,8,9,10, Oxygen therapy 2-5L/min via nasal canula as needed was documented under treatment. No evidence of oxygen order documented on POC orders. COS Patient #8, SN note documents patient rated their pain at 5 and patient had taken analgesic one hour prior to visit. No evidence of analgesic noted on POC orders. COS

Upon patient record review, 5 of 14 (Patient #1,3,5,6,7) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, IDG note dated 1.20.24, 3.12.25, 5.21.25, no evidence of RN signature. Patient #3, IDG note dated 3.12.25, 5.24.25, no evidence of SC signature. IDG note on 6.4.25, no evidence of RN or SC signature. Patient #5,6, IDG note dated 5.22.25, no evidence of SC signature. Patient #7, IDG note dated 3.12.25, no evidence of SC signature.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #9, Physician order for SC frequency states every recertification. Patient visit on 11/15/24 and 11/20/24. No evidence of order for additional visit.

Upon personnel record review, 1 of 13 (Personnel #1) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1, Administrator education is a Bachelor of Art in Mass Communication, job description states Bachelor in Business Administration or nurse. No evidence Administrator met job description. COS, job description changed.

Upon patient record review, 2 of 14 (Patient #11,12) did not have evidence that the discharge summary includes all required information. Patient #11, 12, No evidence of the patient stay was documented in discharge summary. Discharge summary contained admission diagnosis and the reason for discharge.

Observed in Record Review. In 4 of 5 patient records reviewed, the agency failed to document an initial bereavement assessment as part of the initial comprehensive assessment. In RR#1 the initial bereavement assessment was done three months after admission. In RR#2 there was a bereavement assessment documented in the initial five days but it was incomplete and did not identify the bereaved. In RR#4 and RR#5 there was no bereavement assessment documented. This was validated with the DPCS.

Observed in Record Review. A review of 1 of 6 patient records, revealed that the organization did not ensure that comprehensive assessment updates included all required elements. For example, during a review of the medical record for RR#6 it was noted that the provision of hospice care review did not include a description of the patient's response to care, treatment, and services since the last comprehensive assessment.

Observed in Record Review. In 5 of 5 patient records reviewed, the plan of care did not include individualized goals with time frames to meet those goals. In RR#1, RR#2, RR#3, RR#4 and RR#5 most goals were very general and generic such as reaching optimal comfort. All goals had target dates that coincided with the end of the certification period and were automatically changed to the end of the next cert period at recertification. There was therefore no documentation that time frames to achieve goals were assessed and determined and the patient care plan failed to identify those short term goals that should be met early on in care to insure patient safety. This was validated with the DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the agency failed to deliver care and services in accordance with the plan of care. In RR#1 the plan of care called for weekly visits for MSW and Spiritual Care but actual care delivered was at recertification only. In RR#2 aide services were ordered 3 times per week but there were 3 weeks in which only 2 aide visits were provided without explanation in the record.

Observed in Record Review. In 1 of 5 patient records reviewed, the agency failed to document a spiritual assessment as part of the comprehensive assessment within the first 5 days of care. In RR#1 the spiritual care assessment was done on day 6 and was incomplete. The entire assessment documented was: patient did not express any concerns over the visit, pain was zero, there was no patient caregiver anxiety present, no spiritual distress and I prayed for patient. comforted with bible scripture. Patient was left in a comfortable state. This was validated with the DPCS.

Observed in Record Review. In 2 of 4 patient records reviewed, for patients with oxygen, the agency failed to document teaching on oxygen risk based on the findings of the oxygen safety assessment. In RR#2 and RR#3 the oxygen safety assessment identified open flames as an issue in the home but there was no associated teaching documented to address this risk. This was validated with the DPCS.