Every finding on record at Golden Hospice & Healthcare Services LLC

Upon observation, there was no evidence of emergency preparedness training and testing program that is based on the emergency plan, policies and procedures and the communication plan. There have been no documented training drills or actual events since March 2021.

Upon patient record review, 2 of 12 (Personnel #7,8) did not have evidence Emergency Preparedness training including: • Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles • Demonstrate staff knowledge of emergency procedures • Provide emergency preparedness training at least annually • Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others • Maintain documentation of all emergency preparedness training Personnel #7,8: There are no personnel files/documents.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. There have been no documented training drills or actual events since March 2021.

Condition of Participation: Patient’s Rights. L500

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #2: Admission Forms including Consent, Patient Rights and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian/health care proxy.

Upon patient record review, 1 of 4 (Patient #2) 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 #2: Admission Forms including, but not limited to, Consent, Advanced Directives and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian /health care proxy.

Upon patient record review, 1 of 4 (Patient #2) 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 #2: Admission Forms including, but not limited to Consent, Patient Rights and Hospice Election are signed by personal care home owner. The medical record does not include documentation to support she is legal guardian/health care proxy.

Upon patient record review, 1 of 4 (Patient #2) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #2: Admission Forms including, but not limited to Consent, Patient Rights and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian/health care proxy.

Upon patient record review, 1 of 4 (Patient #2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: Admission Forms including, but not limited to, Consent and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian/health care proxy.

Upon patient record review, 1 of 4 (Patient #2) did not have evidence of the appropriate documentation for release of confidential information. Patient #2: Admission Forms including, but not limited to, Consent, Release of Info and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian /health care proxy.

Upon patient record review, 1 of 4 (Patient #2) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #2: Admission Forms including, but not limited to Consent and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian/health care proxy for the patient.

Upon patient record review, 1 of 4 (Patient #2) 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 #2: Admission Forms including, but not limited to Consent and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian/health care proxy for the patient.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review 2 of 4 (Patient #2,3) 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. Patients #2,3 did not have evidence of psychosocial assessments.

Upon patient record review, 3 of 4 (Patient #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: Clonidine listed on hospice medication profile, but patient says he does not take this medication. The following medications were missing from hospice medication profile: Varenicline, KLC, Mirtayapin, Fluroxetine, Mirtayapin, Sertraline, Quetiapine, Levothyroxine, Carvedilol, Clopidogrel Bisulfate, Famotodine, Resperidone, Prazosin HCL, Furosemide, Lisinopril, Rivastigmine Tartrate. Patient #2: Amlodipine 5mg daily listed on hospice medication profile, but patient has Amlodipine 2.5 mg daily. The following medications were missing from hospice medication profile: Quetiapine Fumarate, Sertraline, Cyclobenzaprine. Patient #3: Melatonin 3 mg 2 tabs, 1/day on hospice medication profile, but patient does not take. The following medications were missing from hospice medication profile: Mirthzaphine (Started 8/2/24), Chloramazine,

Upon patient record review, 2 of 4 (Patient #1,4) 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, 4: There is no evidence of initial bereavement assessment within 5 days or thereafter.

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

Upon client record review, 4 of 4 (Patient #1, 2, 3, 4) did not have evidence that the hospice follows the individualized plan of care developed in in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. Patients #1, 2, 3, 4: There is no documented evidence of Plan of Care to review and validate collaboration and/or compliance.

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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. Patients 1,2,3,4: There are no specific problems/goals/interventions identified and individualized for each patient, although there is a very broad grouping of general interventions in a document titled "Care Plan". There is no documented evidence of specific services to be provided.

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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 #1,2,3,4: There is no evidence of physician ordered frequency for visits for any discipline although nursing and other discipline visits were provided for all patients.

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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 measurable outcomes are anticipated from implementing and coordinating the plan of care for each patient by using data elements identified by the hospice and is used as part of the Hospice's QAPI program.

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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. Patients #1,2,3,4: There is no documented Plan of Care orders provided to surveyor for review in any of the records provided; therefore, compliance cannot be verified for any medications. Patient #1, 4: Hospice aide care plan includes Oxygen. There is no documented evidence of physician order at all to include dosage and frequency.

Upon patient record review, 4 of 4 (Patient #1,2,3,4) 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 #1,4: Patients have oxygen available per caregiver, but no oxygen equipment listed on plan of care. Patient #2: Medical record includes receipt for purchase of rollator walker/stroller at Walmart with equipment not listed on plan of care and no orders. Patient #3: Medical record includes receipt for purchase of gloves, pull ups and bed pads 8/1/24 purchased from Walmart with no evidence of listing on plan of care.

Upon client record review, 4 of 4 (Patient #1, 2, 3, 4) did not have evidence that the plan of care included IDG's documentation of the patient's or families level of understanding, involvement and agreement with the plan of care. Patients #1, 2,3,4: There is no documented evidence of Plan of Care to validate compliance.

Upon client record review, 4 of 4 (Patient #1, 2, 3, 4 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, 2, 3, 4: There is no documented evidence of IDG Plan of Care review and updates no less frequently than every 15 calendar days.

Upon client record review, 4 of 4 (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. Patients #1,2,3,4: There is no documented evidence of Plan of Care to review and validate compliance. There is evidence that multi-discipline services were provided to all patients with no documented evidence of physician's authorization of disciplines and/or frequencies. Patient #1,4: Nursing, MSW, SC services provided with no ordered frequency and orders are not included in the EMR. Patient #2,3: Nursing services provided with no ordered frequency and orders are not included in the EMR. Patient #1,2,3,4: Clinical records contain no physician orders verbal/written or signed. Upon interview with multiple staff and physician, it is determined that agency uses HIPPA compliant phone app to request, receive, authorize physician orders. There is no interface and no process to upload, input orders to EMR.

Upon patient record review, 4 of 4 (Patient #1, 2, 3, 4) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patients #1,2,3,4: There is no documented Plan of Care or Care Plan provided to surveyor as evidence of information sharing on an ongoing basis.

Upon observation, there was no evidence the organization develops, implements, and maintains an effective, on-going, organization wide Quality Assessment and Performance Improvement (QAPI) program. Upon observation, the reports available to surveyor are not definitive regarding the effectiveness or lack of effectiveness of initiatives. The QAPI program did not have measurements to demonstrate effectiveness of PIPs and goals. The owner/CEO/Administrator were unable to verbalize a current QAPI initiative.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement Upon observation, the reports available to surveyor are not definitive regarding the effectiveness or lack of effectiveness of initiatives. The QAPI program did not have measurements to demonstrate effectiveness of PIPs and goals. The owner/CEO/Administrator is unable to verbalize a current QAPI initiative.

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 Visits#1, 2: The nurse had no hand sanitizer solution to use after direct patient contact and did not wash her hands after direct patient contact. Patient Visit #3: The nurse performed hand washing and failed to use paper towel when turning off faucet. The nurse had physical contact with patient skin, when performing BLLE assessment and palpating pulses, but failed to hand sanitize afterwards. The nurse did not clean reusable equipment (stethoscope and blood pressure cuff) following use on the patient.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 12 (Personnel #4) 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 #4: The competency form utilized by the agency includes "shampoo" only and does not specify/verify that the aide has demonstrated competency in all (3) types of shampoo.

Upon patient record review, 2 of 4 (Patient #1, 4) 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 Patients #1, 4: The aide care plan includes Oxygen, but oxygen precautions not listed on the aide care plan.

Upon patient record review 2 of 4 (Patient #1, 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 Patients #1, 4: There is no documented Plan of Care orders provided to surveyor for review to verify frequency of aide visits; no frequency orders present; therefore, compliance cannot be verified.

Upon patient record review 2 of 3 (Patient #1,4) 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 #1,4: RN documented supervisory visits 5/23/24 and 6/6/24 and none since that time.

Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel #7: There is no identified Volunteer Coordinator included in organizational chart, personnel listing, and no employee personnel file available to surveyor with Volunteer Coordinator Job Description and/or Competency.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. There is no documented evidence of recruiting in calendar year 2024.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice provides care directly or under contract that optimizes comfort and dignity of the patient and is consistent with the patient/ family needs and goals. The patient needs and goals are a priority. Patients #1, 2, 3, 4: The patient/family needs and goals are not clearly documented in a care plan that is available to surveyor at time of survey, and therefore, compliance can not be validated.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. There was no evidence for patients on service of a Plan of Care, Updates to the Plan of Care, Physician orders, Certifications and Recertifications for Terminal Illness for all benefit periods, IDG scheduled meetings every 15 days, a QAPI Program, and an ongoing Emergency Preparedness planning/training. In addition, for personnel there was no currently licensed Physical Therapist/Occupational Therapist and Speech Therapist contracted or a Hospice Aide contract and there was not a Volunteer Coordinator and Volunteer as part of the hospice program.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services • Medical social services • Physician services • Counseling services, including spiritual counseling, dietary counseling and bereavement counseling • Hospice aide, volunteer, homemaker services • Physical therapy, occupational therapy, speech-language pathology services • Short-term inpatient care • Medical supplies (including drugs and biologicals) and medical appliance There is no evidence that the agency can provide a volunteer at this time. No personnel file included Volunteer job description and/or competency.

Upon contract review, 1 of 5 (contract Gertrude Christian, HA) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient's plan of care Gertrude Christian, HA is identified as contracted employee with W9 on file. There is no corresponding contractual agreement available to surveyor during survey.

Upon personnel record 2 of 12 (Personnel #7,8) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personnel #7,8: There are no personnel files/documents.

Upon personnel record review, 3 of 12 (Personnel #6,7,8) did not have evidence that the hospice employees have received orientation on their specific job requirements. Personnel #6: The personnel file includes a job description altered to read Spiritual Counselor/Bereavement Counselor, when in fact, the policy manual has separate job descriptions specific to each job title. The job description on file is consistent with content of Spiritual Counselor. Therefore, the personnel file lacks signed job description for Bereavement Counselor. Personnel #7,8: There are no personnel files/documents.

Upon personnel record review, 2 of 12 (Personnel #7, 8) 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 #7, 8: There are no personnel identified as volunteer coordinator or volunteer, and therefore, no verified competency for the roles

Condition of Participation: Medical Director.

Upon patient record review, 3 of 4 (Patient #1,2,3) 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 #1,2,3 no evidence of a CTI for the initial episode of care.

Upon patient record review, 1 of 4 (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: Clinical record does not include CTI's for all recertification benefit periods. Only CTI documented was from 2/24/24-5/24/24.

Condition of Participation: Clinical Records.

Upon patient client record review, 4 of 4 (Patient #1,2,3,4) 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 Patients #1,2,3,4: The patient chose yes to receive election addendum. The agency provided the addendum, but there is no information regarding what is covered and/or what is not covered. Both sections are blank. Patient #2: Admission Forms including Consent and Hospice Election are signed by personal care home owner. The clinical record does not include any documentation to support she is legal guardian /health care proxy.

Upon patient client record review, 2 of 4 (Patient #1, 4) did not have evidence that each patient record contains Advance Directives Patients 1,4: Identified as DNR with POLST on file; however, there is no evidence of such included in medical record.

Upon patient client record review, 4 of 4 (Patient #1,2,3,4) 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. Patients #1,2: Clinical records include signed copy of Revocation form and signed copy of Transfer form on file with admission consent forms. The patient signatures are not dated. Patient #3: Clinical record includes signed Revocation form with signature dated 6/22/24, the same date as SOC however, the patient is an active patient. Patient #4 : Clinical Record includes signed Transfer form, but there is no date for the patient signature. When surveyor made home visit, found demographics to inadvertently include address of Patient #1, 2, not the current patient address. Also, for patient #4, the paper binder record provided to surveyor includes comprehensive nursing assessment forms, with hand written notations such as "Readmission 5th Benefit Period" and "Readmission 7th Benefit Period". The record also includes (2) signed Revocation forms dated 2/23/24 and 5/14/24. There is no other documentation otherwise regarding separation of admissions, consent forms, elections, discharge summaries etc. When spoke with administrator, he confirmed there had been discharges/readmissions, but was unable to offer any additional explanation.

The agency did not list or allow access to records other than current (4) patients with SOC dating back to back to 11/25/23. The agency only included current patients in listing, although surveyor repeatedly questioned regarding all patient records since start of business, therefore there is not evidence that records are maintained for minimum of 6 years.

Upon patient record review, 1 of 4 (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: Client record presented to surveyor includes admission/consent forms dated 11/25/23. The record further includes Revocation statements dated 2/23/24 and 5/14/24. There is no documented explanation of revocation and no related discharge summaries.

Condition of Participation: Drugs and Biologicals, Medical Supplies, and Durable Medical Equipment.

Upon patient record review, 4 of 4 (Patient #1, 2, 3, 4) did not have evidence that if a drug order is verbal or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, pharmacist, physician or other licensed individuals as designated by state regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. Patients #1, 2, 3, 4: There is no documented orders in any of the records provided to the surveyor. Upon interview, the staff report using HIPPA compliant phone app to request and receive physician orders. Upon further questioning, it is confirmed that there is no interface with EMR and there is no process for staff to enter the orders into EMR.

Upon patient record review, 4 of 4 (Patient # 1, 2, 3, 4) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patients #1, 2, 3, 4: There is no documented Plan of Care provided to surveyor for review in any of the records provided; therefore, compliance cannot be verified.

Upon client record review, 1 of 4 (Patient #2) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #2: Admission Forms including, but not limited to, Consent and Hospice Election are signed by personal care home owner. The medical record does not include any documentation to support she is legal guardian /health care proxy.

Upon observation, there was no evidence that when the hospice provides durable medical equipment under contract, then the DMEPOS provider is accredited by a CMS approved accreditation organization. The accreditation certificate on file has HHQA dated survey as 10/10/20 which is expired.

Condition of Participation: Personnel Qualifications.

Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state's Speech-Language Pathology Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel Files #12: Professional license expired and was not updated by end of survey. There is no documented evidence of therapy visits being provided.

Upon personnel record review, 1 of 12 (Personnel #11) did not have evidence all Occupational Therapy Services are provided by a qualified licensed Occupational Therapist (OT) in accordance with the state's Occupational Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel Files #11 Professional license expired and was not updated by end of survey. There is no documented evidence of therapy visits being provided.

Upon personnel record review, 1 of 12 (Personnel #10) did not have evidence all Physical Therapy Services are provided by a qualified licensed Physical Therapist (PT) in accordance with the state's Physical Therapy Practice Act and the hospice's policies and procedures and/or job descriptions. Personnel Files #10: Professional license expired and was not updated by end of survey. There is no documented evidence of therapy visits being provided.

Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence the hospice obtained a criminal background check, OIG exclusion list and national sex offender registry checks on all contracted individuals who have direct patient care and access to patient records. Personnel#4: There is no evidence a criminal background check, OIG exclusion list and national sex offender registry check was completed. Criminal Background check obtained prior to end of survey. COS.

Upon personnel record review, 2 of 12 (Personnel #7,8) did not have evidence of criminal background checks, OIG exclusion list and national sex offender registry 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. Personnel #7,8: There are no personnel files/documents.