Every finding on record at Golden Care Hospice, LLC

Upon patient record review, 7 of 14 (Patient #1,2,4,7,8,9,10) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1,2,4,7,8,9,10: On the RN comprehensive assessment the RN does not take into consideration the imminence of death.

Upon patient record review, 2 of 14 (Patient #2, 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 2: The patient's caregiver state the patient is not taking Atorvastatin 40mg daily, Vitamin D3, Nutiva Coconut oil 1 tsp 125mcg daily, NAC 600mg daily, Advil as needed, Tramadol 50mg two times daily, Diclofenac Cream three times daily, Voltaren three times daily as needed and amitriptyline 25mg one tab at night these medications are listed on medication profile. Patient 6: The patient states he is not taking Atorvastatin that is on the medication profile, and started taking Saw Palmetto 450mg 2 months ago which is not on the medication profile.

Upon patient record review, 7 of 14 (Patient #3,4,5,6,7,8,10) 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 3: On the RN initial assessment the RN state the patient is incontinent, there is not a risk for skin break down on the plan of care with goals and interventions. Patient 4: On the RN assessment there is evidence the patient is incontinent and has difficulty swallowing, there is not a risk for skin break down or risk of aspiration on the plan of care with goals and interventions. Patient 5: On the RN assessment there is evidence the patient is incontinent of bowel, there is not a risk for skin break down with goals and interventions on the plan of care. Patient 6,7,8: On the plan of care there is an order for aspirin 81mg daily, there is not a risk of bleeding with goals and interventions on the plan of care. Patient 10: On the RN assessment the RN documented the patient is incontinent, there is not a risk for skin break down on the plan of care with goals and interventions.

Upon patient record review, 2 of 14 (Patient #2, 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 2: The patient's caregiver state the patient is not taking Atorvastatin 40mg daily, Vitamin D3, Nutiva Coconut oil 1 tsp 125mcg daily, NAC 600mg daily, Advil as needed, Tramadol 50mg two times daily, Diclofenac Cream three times daily, Voltaren three times daily as needed and amitriptyline 25mg one tab at night these medications are ordered on the plan of care. Patient 6: The patient states he is not taking Atorvastatin that is on the plan of care, and started taking Saw Palmetto 450mg 2 months ago which is not on the plan of care.

Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,8,9,10) 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 1: On the recent aide plan of care there is an order to complete bed bath, complete shower, light housekeeping, make bed, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 2: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, light housekeeping, change linen, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 3: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, light housekeeping, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 4: On the recent aide plan of care there is an order to change linen, make bed, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 5,6,8,9,10: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, the frequency of these orders is as needed and more than one form of bathing is not permitted.

Upon patient record review, 1 of 11 (Patient #5) 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 5: Missing patient representative and hospice representative signature on "Patients Bill of Rights".

Upon patient record review, 1 of 11 (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 4: It was not acknowledge who the patient wanted to choose as attending physician on hospice election statement. Corrected on site.

Upon patient record review 2 of 11 (Patient #2,#4) 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 2: Admitted on 1/16/23, Psychosocial assessment completed late on 01/25/2023. Patient 4: Admitted on 2/13/23, Psychosocial assessment completed late on 03/09/2023.

Upon patient record review 1 of 11 (Patient #11) 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 11: No evidence spiritual initial assessment was completed.

Upon patient record review, 4 of 11 (Patient #1,9,10,11) 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 1: Admitted on 10/1/22, Bereavement assessment completed late on 03/09/2023. Patient 9: No evidence that the bereavement risk assessment was completed. Patient 10: No evidence that the bereavement risk assessment was completed. Patient 11: No evidence that the bereavement risk assessment was completed.

Upon client record review, 2 of 11 (Patient #6,#9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 6: No evidence of an order on current plan of care for volunteer services. Volunteer documented that she saw the patient on 02/15/2023. Plan of care updated to include volunteer services during survey. Patient 9: Volunteer ordered for monthly on plan of care, no evidence that visits were completed monthly in October and November.

Upon patient record review 1 of 11 (Patient #9) 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 9: Aide visits ordered as twice a week on plan of care at SOC. Aide had one missed visit note for 10/18/2022. No evidence that any visits were made between 10/18/2022 and the time of discharge 12/13/22. No order to d/c aide services.

Upon patient client record review, 4 of 11 (Patient #2,3,4,5) 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 2: Missing signature by hospice representative on "Hospice Election Statement" and "Notice of non-covered items, services, and drugs". Corrected on site Patient 3: Missing signature by hospice representative and caregiver representative on Hospice election statement. Correct on site. Patient 4: "Notice of non-covered items, services, and drugs" not addressed at time of admission. It was not acknowledge who the patient wanted to choose as attending physician on hospice election statement. Corrected on site. Patient 5: No caregiver representative signature on "Hospice Election Statement".

Upon client record review, 1 of 11 (Patient #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed.