Every finding on record at Golden Coast Hospice and Palliative Care, Inc.

Upon patient record review, 1 of 4 (Patient #2) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 02: The updated comprehensive assessment was not completed by the RN for 28 days. The patient received an RN visit on 11/12/23 and 12/10/23, visits were made by the LVN on 11/16/23, 11/20/23, 11/27/23, 11/30/23, and 12/5/23.

Upon client record review, 1 of 4 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 04: Orders for SN visits entered on 11/22/23 are ordered for 2 visits per week and 3 prn for symptom management. The patient received 1 SN visit the week of 11/20/23 and 1 SN visit the week of 11/26/23.

Upon patient record review, 1 of 4 (Patient #1) 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 01: The patient was admitted on 12/8/23, the patient takes Xarelto (a blood thinner) daily, the hospice aide plan of care does not include bleeding precautions.

Upon patient record review 1 of 4 (Patient #4) 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 04: The hospice aide order indicates 2 times weekly, the patient received 1 visit during the week of 11/26/23.

Upon patient record review 1 of 4 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 02: The patient receives hospice aide services 2 times per week, a supervisory visit was made on 11/12/23 with no additional supervisory visit until 12/10/23.

Upon patient record review, 2 of 14 (Patient #2 and 13) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 2: Pt chose an attending physician upon admission. There is no evidence the Attending was consulted regarding the IDG POC. Patient 13: The Election of Benefits form has a section where the pt chooses an attending physician. The section was left blank. There is no evidence the pt was able to choose an attending physician.

Upon patient record review 1 of 14 (Patient #6) 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 6: The pt was admitted 1/28/22 the SC initial assessment was not completed until 2/13/22.

Upon patient record review, 12 of 14 (Patient #1,2,4,5,6,7,8,9,10,11,12,13) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 8 of 14 (Patient #1,2,5,6,8,10,11,13) 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: Patient 1,2,5,8: Triple Antibiotic cream is on the POC but is not included on the medication profile. Patient 5: The medication profile contains: Lorazepam intensol with no dose, Imodium with no dose or frequency, "May have O2 administration if needed for SOB or CP" with no dose. Patient 6: The medication profile contains Milk of magnesia with no frequency. Patient 10: The medication profile contains an order for Acetaminophen with a dose of 1 liquid BID, Benadryl with dose of 1 sol QHS prn, Lorazepam 2mg/ml 1 sol for dose. Patient 11: The medication profile contains Lorazepam intensol with a dose of 0.25 sol. Patient 13: The medication profile contains an order for Lorazepam Intensol with a dose of 1 sol.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 9 of 14 (Patient #2,4,7,8,10,11,12,13,14) 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 2,4,7,8,10,11,12,13,14: The POC contains orders for SC and MSW once a month and PRN with no number of allowed PRN visits.

Upon patient record review, 11 of 14 (Patient #1,2,4,5,6,8,9,10,11,12,13) 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: The POC contains an order "May use Triple ATB ointment for skin tears". There is no frequency. The POC contains an order for wound care treatment with no frequency. Patient 2: The POC contains an order "May use Triple ATB ointment for skin tears" and "May use Vitamin A&D cream to reddened area if needed. There is no frequency. Patient 4: The POC contains an order for flush suprapubic catheter with 50ml NS if needed for hematuria or obstruction. There is no frequency. Patient 5: The POC contains: "O2 administration if needed for SOB or CP", "May use Triple ATB ointment for skin tears", Lorazepam intensol with no dose, Imodium with no dose or frequency. The SN documented on 11/6/23 the facility staff will begin applying ice and elevating the extremity. There is no order for this modality. Patient 6: The POC contains Milk of magnesia with no frequency, may use barrier cream as needed and Vitamin A&D cream with no frequency. Order for Foley catheter reads "Insert Foley catheter Fr. 18ml for wound care management". No frequency, size, flush orders. Patient 8: The medical record contains evidence pt has a G tube requiring site care with no orders on the POC for site care. The POC contains an order "May use Triple ATB ointment for skin tears". There is no frequency or dose. Patient 9: The POC contains conflicting orders of SN 1 time per week and LVN 1x/week and RN 1 time per week. The POC contains wound care orders, on 2/27/23 the SN documented the wound is healed. The nurse did not update the POC to discontinue the wound care orders. Patient 10: The POC contains an order for Acetaminophen with a dose of 1 liquid BID, Benadryl with dose of 1 sol QHS prn, Lorazepam 2mg/ml 1 sol for dose. Patient 11: The POC contains Lorazepam intensol with a dose of 0.25 sol. Patient 12: The POC contains an order to flush the Foley catheter weekly with 50-100cc of NS. There is no order to change the foley or any foley care. Patient 13: The POC contains an order for Lorazepam Intensol with a dose of 1 sol.

Upon patient record review, 2 of 14 (Patient #8,12) 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 equipment and supply needs. Patient 8: The POC does not list the DME and there is evidence pt has oxygen and is bed bound. Patient 12: SN documented "pt has FWW" 4/12/23 the walker is not listed on the POC.

Upon client record review, 11 of 14 (Patient #1,2,4,6,7,8,9,10,11,12,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The POC 4/16/23 SN 1 time per week. The SN made visits on 10/8/23 & 10/11/23 no order to increase visits,no evidence second visit was PRN. The POC has order to cleanse wound with wound cleanser, 9/11/23, documented by the wound care company the wound was cleansed with Betadine. The SN documented on 8/23/23 "wound care done as ordered" and 8/30/23 "Tx done as ordered". No evidence the nurse followed the POC. The POC order for SN to take a picture of the patients wound each visit, there is not evidence the pictures are being taken at every visit. Patient 2: The SN documented 10/17/23 "wound cleansed and provided wound care". There is no order for wound care. Patient 4: The POC order for SN 2 times per week. Pt was seen by SN 1 time the week of 7/2/23-7/8/23. SN documented 7/15/23 "Left heel dressing removed, cleansed with NS and new dressing applied. No evidence the SN followed the POC. 7/17/23 SN documented Left hand skin tear, cleansed with NS applied foam dressing, left heel dressing removed, cleansed with NS, reapplied clean dressing. No evidence the POC was followed. The week of 7/9/23-7/15/23 the patient was seen 3 times by the SN 7/11,7/13,7/15 with an order for SN visits twice weekly. No evidence the third visit was PRN and no order to increase visits. SN documented 7/19/23 "Dressing on insertion site of suprapubic removed, cleansed with NS and reapplied". There is no order for this wound care. Patient 6: POC order 1/14/23 is for SN 1x week. Pt seen 3/26/23 & 3/29/23 the week of 3/26-4/1 no order to increase visits or evidence the visit was PRN. No visit made by SN the week of 4/9-4/15, no missed visit documentation. The MSW is seeing pt bimonthly the POC has orders for monthly. POC orders for SC monthly, SC did not see pt past the initial assessment. Patient 7: The POC contains order for SN 1x/week starting 1/14/23. Pt admitted 11/21/22. Pt was seen by SN weekly after admission without orders until 1/14/23. There are missed visits the week of 2/12/23-2/18/23, 4/9/23-4/15/23. There were 2 visits performed the week of 5/14/23-5/20/23 on 5/15 and 5/19 with no order to increase visits or evidence the second visit was prn. Patient 8: POC 4/4/23 contains order for SN 1x/week there was no visit made the week of 4/9-4/15/23. No Missed visit documentation. SN documented on 4/30/23 "G tube site dressing removed, cleansed with wound cleanser, pat dry, applied triple ATB ointment, covered with dry dressing", on 4/23/23 & 4/16/23 SN documented "G tube dressing removed, cleaned, dried, applied barrier cream, applied clean dressing". There is no evidence of an order for care of the G tube site. Patient 9: SN documents 12/5/22 "upper rt coccyx wound cleansed and foam dressing applied". No evidence the order was followed. POC order SN1x/week, no visit performed 4/9-4/15/23, no missed visit documentation. Patient 10: POC RN 1x/week & LVN 1x/week, RN saw 12/14, 12/16 (12/11-12/17/22). Patient 11: POC contains order for SN 2x/week, pt seen by SN on 6/6,6/7,6/9 with no evidence of visits being prn or order to increase visits. Patient 12: POC order for SN 2x/week seen 3/28 only the week of 3/23-3/29. The week of 4/2-4/8 The pt was seen 4/2,4/5,4/8. The POC contains order to flush foley weekly with 50-100cc NS. The SN documents flushing the foley 4/8 with Sterile water, flushed again 4/2 100ml NS but no order to flush the second time that week, on 4/16 foley flushed with 30cc saline. Order is for 50-100cc. Patient 13: POC SN 2x/week. Pt seen 2/13,2/14,2/15,2/16. Visits not PRN & no order to increase visits.

Upon patient record review 1 of 14 (Patient #11) did not have evidence documentation in the patient record that a hospice aide provides services that are: Patient 11: The POC contains orders on 6/6/23 for aide visits 2 times per week. The aide saw pt once the week of 6/4-6/10/23 on 6/9/23. There is no communication of why the visit was missed.

Upon patient record review, 1 of 14 (Patient #10) 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 10: The record 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. There is no documentation the physician considered: 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. Agency did not bill for this pt.

Upon patient client record review, 8 of 14 (Patient #4,7,8,9,10,11,12,13) 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 4,7,8,9,10,11,12: The consents signed indicate the patient requested a copy of the Notification of non covered items, services and drugs. There is no evidence the pt received the copy. Patient 4: The election statement does not indicate payor source and there is no election date documented. Patient 9: The election statement does not contain the date of election of hospice. Patient 12 & 13: The Election of Benefits form does not have the type of insurance (Medicare,Medicaid, private insurance) filled out Patient 13: The Election of Benefits form has a section where the pt chooses an attending physician. The section was left blank.

Upon patient client record review, 2 of 14 (Patient #2 and 13) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 2: The medical record contains evidence the pt chose their primary care physician to be their attending for hospice. The primary care physician is the physician that referred the pt to hospice as well. The chosen attending did not complete a CTI, the medical director completed both CTI's. Patient 13: The Election of Benefits form has a section where the pt chooses an attending physician. The section was left blank. The referring physician signed the CTI and stated they did not wish to follow for hospice care. The Medical Director took over for pt care.

Upon patient client record review, 3 of 14 (Patient #1,9,12) 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 1: The medical record contains consents signed by the patient 9/15/22, the agency representative signed the consents on 9/17/22 which is the SOC date instead of dating the signature as 9/15/22 when the documents were signed. Patient 9: The comprehensive assessment has marked pt is uncomfortable because of pain and then the SN narrative states pt denies pain and has no s/sx of pain. Communication note on 2/27/23 SN documented "LMM" and on 2/27/23 visit note Coccyx PI healed". There is not evidence these are approved abbreviations. Patient 12: SN documented on 4/29/23 "Patient atonal breathing, appears pale/jaundice. Mottling beginning on toes and fingers. Unable" It appears the nurse did not complete the documentation and this was the death visit.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested Patient 4: Patient revoked Hospice and there is no evidence a copy of the hospice discharge summary was sent to the attending physician.

Upon client record review, 5 of 14 (Patient #4,6,7,8,9) did not have evidence that the discharge summary includes all required information. Patients: 4,6,7,8,9: The discharge summary did not include: Pt's current plan of care, latest physician orders.

Upon SNF/NF contract review, 1 of 3 (contract Advanced rehab) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.

Upon client record review, 3 of 14 (Patient # 4,6,9) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient 4,6,9: The POC contains orders for wound care though does not state who will be performing the wound care.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that the hospice provided the following information to the SNF: Patient 1: There was no evidence that the Hospice election form or the Physician certification and recertification of the terminal illness were provided to the SNF.

Upon personnel record review, 3 of 13 (Personnel #7,8,9) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Corrected on site.

Upon personnel record review, 4 of 13 (Personnel #1,4,12,13) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Corrected on site.