Every finding on record at Golden Heart Hospice LLC

Upon patient record review, 3 of 9 (Patients #1,2,3) 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: Timolol 0.5% solution, Sertraline 50 mg, Lasix 20 mg, Aripiprazole 10mg and Lamotrigine 25 mg are duplicated on the medication profile. Additionally, Vitamin D was listed on ALF medication profile and not listed on the hospice medication profile. Patient #2: The hospice medication profile indicated Acetaminophen 325mg/Chlorpheniramine maleate 2mg/Dextromethorphan 10mg/Phenylephrine Hydrochloride 5mg, give 2 tabs per pack. The ALF medication profile did not have these medications listed on their profile. Additionally, the following were listed on ALF medication profile and not on Hospice medication profile (on RXNT only): Omeprazole 40 mg, Seroquel 25 mg and Trazadone 50mg. Patient #3: ASA 81mg, Digoxin 0.125 mg, Eliquis 2.5 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Jakafi 15 mg and Sertraline 100mg were listed on ALF medication profile and not listed on hospice medication profile (on RXNT only). Note- There seems to be a data integration failure between the RXNT module and the Hospice Tools EMR medication profile. When medications are entered correctly in the RXNT tab of the Hospice EMR, they fail to transfer to the EMR's medication profile.

Upon patient record review, 3 of 9 (Patients #1,2,5) 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 #1: This patient had a bed, boots, wedge pillow, APP mattress, fall mat, walker and shower chair. These were not included on the Plan of Care. Patient #2: This patient had a rollator walker. This item was not included on the Plan of Care. Patient #5: The record reflected that this patient had a nebulizer treatment. The nebulizer equipment was not included on the Plan of Care.

Upon personnel record review, 1 of 13 (Personnel #9) 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.) Personnel #9: The Aide did not have the following as an observed task (verbal only): ·Normal range of motion and positioning

Upon patient record review, 3 of 9 (Patients #3,6,7) 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 #3: The Aide Care plan (9/5/25) indicated to "shower patient if she allows due to increase agitation." No clear instruction listed for the aide of task to be performed. Patient #6: The Aide Care plan (9/6/25) indicated to "provide bed bath 1X per week, if patient refuses shower." This is an ALF patient in the Memory Care unit. No clear instruction listed for the aide of task to be performed. Patient #7: The Aide Care plan (9/4/25) indicated to "shampoo 1X per week, with additional instructions to shampoo as needed." This is an ALF patient in the Memory Care unit. No clear instruction listed for the aide of task to be performed.

Upon patient record review 1 of 9 (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 (POC) Patient #4: The POC listed Aide visit frequency of, 3 X's per week. For the first benefit week there was only 1 visit made on 7/18/25.

Upon patient record review, 6 of 9 (Patients #2,3,4,7,8,9) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #2: The signed Election of Benefit form indicated 8/2/25 as the effective date. The patients start of care began on 7/27/24. Patients #3, 4, 9: The Election of Benefit form did not have effective date filled in on the space provided on the form. Patient #7: The Election of Benefit form did not have witness/hospice signature filled in on the space provided on the form. Patient #8: The Election of Benefit form did not have effective date filled in on the space provided on the form. Additionally, the Election statement does not provide BFCC-QIO contact information or Notice of Non Coved Items addendum information.