Every finding on record at Golden Road Hospice Inc.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary and alternate means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies. The hospice communication plan for emergency management did not contain evidence of a primary and alternate means of communication with a federal agency.

Upon patient record review, 7 of 14 (Patients # 1, 2, 3, 7, 9, 10, 14) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patients # 1, 2, 3, 7, 9, 10, 14: The comprehensive assessment in the patients' medical records did not contain evidence that during the comprehensive assessment the imminence of death was taken into consideration.

Upon patient record review, 1 of 14 (Patient # 3) 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 # 3: The patient's plan of care contained order for the MSW as needed for psychological support of family. There was no indication of the quantity of visits.

Upon client record review, 5 of 14 (Patients # 1, 2, 3, 6, 7) 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, 6, 7: Patient IDG meeting dated 12/2/25 did not contain evidence of the chaplain's signature. Patient # 2: Patient IDG meetings dated 10/25/25, 11/4/25, and 12/2/25 did not contain evidence of the chaplain's signature. Patient # 3: Patient IDG meeting dated 12/2/25 did not contain evidence of the chaplain or MSW signatures.

Upon personnel record review, 1 of 12 (Personnel # 8) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel # 8: The employee's file did not contain evidence of competencies for, a) communication skills including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff, and b) shampoo, sink, tub, and bed.

Upon patient record review, 9 of 14 (Patients # 2, 3, 4, 5, 6, 7, 11, 13, 14) 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 # 2: The patient's aide plan of care dated 9/24/25 contained instructions to turn and reposition,, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 3: The patient's aide plan of care dated 11/3/25 contained instructions to empty collection bag, exercise equipment as specified in RN instructions, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 4: The patient's aide plan of care dated 10/30/25 contained instructions to turn and reposition, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 5: The patient's aide plan of care dated 10/30/25 contained instructions to turn and reposition, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 6: The patient's aide plan of care dated 9/29/25 contained instructions to turn and reposition, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 7: The patient's aide plan of care dated 9/25/25 contained instructions to turn and reposition, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 11: The patient's aide plan of care dated 1/27/25 contained instructions to turn and reposition, record bowel movements, empty collection bag, measure urine output. There was no indication of the frequency for the task to be performed by the aide. Patient # 13: The patient's aide plan of care dated 8/8/25 contained instructions to turn and reposition, record bowel movements, measure urine, empty collection bag, and change the linens. There was no indication of the frequency for the task to be performed by the aide. Patient # 14: The patient's aide plan of care dated 9/13/25 contained instructions to turn and reposition,, record bowel movements, and change the linens. There was no indication of the frequency for the task to be performed by the aide.

Upon patient record review, 1 of 5 (Patient #2) 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: Medication profile included Miralax 17 Gms orally 2x/day for no BM >3 days. There is no mention of diluent. There is no instruction in regards to the duration of 2x/day dosage.

Upon patient record review, 1 of 5 (Patient #2) 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: Admitted 9-10-22. Initial POC with order for Miralax 17 Gms orally 2x/day for no BM >3 days. There is no mention of diluent. There is no instruction in regards to the duration of 2x/day dosage.

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 #1: RN had no antiseptic wipes to clean equipment after use. She used Purell hand gel. She did allow to dry and replaced in bag. Patient #2: RN had personal hygiene wipes with no antiseptic/alcohol to use for equipment disinfecting.

Upon personnel record review, 1 of 1 applicable (Personnel #5) 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 #5: HA Competency list utilized by agency states Bed Shampoo/Hair Shampoo, sink, tub, bed. Hair shampoo is circled. It is not clear that HA demonstrated competency in sink, tub and bed shampoos.

Upon patient client record review, 1 of 5 (Patient #2) 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 #2: Visit note documentation implies extended periods of no BM. Administrator/DPCS identifies last BM dates as typo. 9/19/22 Visit note: Last BM recorded as 7/22/22. 9/26/22 Note, Last BM recorded as 7/31/22. "Patient on Miralax twice a day". 10/3/22 Note, last BM recorded as 8/17/22. 10/10 Note, last BM recorded as 10/9/22.