Every finding on record at Golden Hospice, Inc

Upon patient record review, 3 of 14 (Patient #1,2,7) 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 Duplicate orders of Jardiance 10mg daily on 12/26/24 and 1/23/25, corrected on site. On 1/24/25 SN notes Quetiapine 25mg BID was discontinued and increased to 50mg BID, however both orders remain active on medication profile. Patient #2 Duplicate orders for Tylenol 500mg Q6 PRN on 11/21/24 and 1/17/25 on medication profile. corrected on site. Patient #7 Duplicate orders for Docusate Sodium QHS on 11/15/24 and 1/13/25 on medication profile. corrected on site.

Upon patient record review, 1 of 14 (Patient #1) 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 On 4/8/24 Warfarin 2.5mg tablet daily with no evidence of bleeding precautions in place.

Upon patient record review, 1 of 14 (Patient #5) 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 #5 Spiritual Care frequency is ordered as "PRN only" without indication of specific frequency.

Upon patient record review, 3 of 14 (Patient #1,2,7) 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 Duplicate orders of Jardiance 10mg daily on 12/26/24 and 1/23/25, corrected on site. On 1/24/25 SN notes Quetiapine 25mg BID was discontinued and increased to 50mg BID, however both orders remain active. Patient #2 Duplicate orders for Tylenol 500mg Q6 PRN on 11/21/24 and 1/17/25. Duplicate orders for wound care on 1/28/25 and 2/13/25, both deficiencies corrected on site. Patient #7 Duplicate orders for Docusate Sodium QHS on 11/15/24 and 1/13/25, this was corrected on site.

Upon patient record review, of X (Patient #) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2 LVN frequency ordered 1x/week, during the week of 12/22/24 visits were made on 12/22/24 and 12/28/24 both indicating they are scheduled visits. Patient #3 LVN frequency ordered 1x/week, no visit made the week of 2/9/25. Patient #5 LVN frequency ordered 1x/week, no visit made the week of 1/26/25. Patient #6 Spiritual Care frequency is ordered 1x/month and no visits have been made since 12/26/25, no evidence of visits in January 2025. Patient #7 LVN frequency ordered 1x/week, SN frequency ordered 2x/week and RN frequency ordered for 1x/2 weeks, orders not followed as there are too many orders in place for visit frequency. This was corrected on site. Patient #9 1/20/25 There are no frequency orders in place for MSW as requested by family.

Upon patient record review 2 of 14 (Patient #2,8) 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 #2 Aide visit completed 11/4/24 and 1/17/25 indicates a mechanical lift is in place, however patient does not have a mechanical lift. Aide visits completed 12/27/24, 1/17/25, 1/24/25, 1/31/25 and 2/7/25 aide indicates task for aspiration precautions in place, however it is not an ordered task on the aide care plan. Patient #8 Aide visit on 2/17/25, the aide did not complete the task for transfer as ordered on the aide care plan. Aide visits on 1/31/25, 2/3/25, 2/5/25, 2/7/25 and 2/10/25 Aide did not complete the tasks for Special mouth care, Precautions, and Oxygen as ordered on the aide care plan.

Upon patient record review, 1 of 14 (Patient #1) 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 RN completed an aide supervisory visit on 2/7/25, however there was not an aide assigned to the patient.