Every finding on record at Golden Seasons Hospice, Inc.

Observed in Record Review. In 3 of 10 patient records reviewed, the plan of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care. For HV #1 the Plan of Care (POC) included a problem for Cardiovascular including edema to bilateral lower extremities with a goal: prevent discomfort due to increasing edema, hypotension -Achieve and maintain peripheral circulation for patient comfort. -patient/caregiver will verbalize/express understanding of medication /treatment orders and side effects and did not include measurable goals such as edema will decrease from 7-10 to 3-5. Also, for HV #2 the POC included a problem for pain with a goal: Patient/Family/Facility will verbalize understanding of pain management, when to take pain medications, nonpharmacological pain management, and when to call hospice and did not include measurable goals. Additionally, for HV #3 the surveyor noted that the POCincluded Psychosocial problem for Emotional Support and Socialization in the SNF with the goal: The daughter will express feelings and emotions related to possible discharge from hospice and have an increased ability to maintain relationships and positive coping in her life. The patient will experience increased socialization and comfort in the SNF. The goal did not include measurable outcomes for example, the patient will participate in social activities at the SNF 2-3 times per month. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the plan of care did not include treatments necessary to meet the patient’s needs. During the home visit for HV #2 the RN was observed to provide wound care to the lower left leg/shin which included cleansing with wound care cleaner, application of triple antibiotic ointment and covering with a foam dressing however in review of the medical record the surveyor noted that the physician order for the wound care had a stop date of 04/8/2026 and had not been renewed. in the medical record or on the plan of care until after the SNV on this date. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization had not collaborated in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In review of the medical record for RR #1 the care plan included a frequency of social worker visits 1x month plus 1 prn visit beginning in the month of November however there was no evidence that a visit was made in the month of December, February and March and no documentation that the physician was notified of the missed visits. This was validated by the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to perform hand hygiene at times required by standard precautions CDC guidelines and organizational policy no,9-009.1 Hand Hygiene as evidenced by the Hospice Aide failed to perform a glove change and perform hand hygiene after cleaning fecal material on the patient during a bed bath for HV #1. The Hospice Aide continued to provide care and complete the patient's care with contaminated gloves. This was validated by the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, with hospice aides, the hospice aide did not provide care in accordance with the plan of care. For HV #1 the HA Assignment included apply lotion and deodorant every visit and clean nails every visit which were not observed during the bed bath for HV #1 additionally, the hospice aide stated that she applies A&D ointment if the patient needs it which was not included on the HA Assignment. This was validated by the Director of Patient Care Services.

Observed in Tracer Activities. Volunteers did not provide at least 5% of the total patient care hours of all paid hospice employees and contract staff. In review of the organization's cost savings documents and in conversation with the Volunteer Coordinator and Director of Patient Care Services the surveyor noted the following cost savings; 2024 = 1.86% and 2025 3.74%.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the Hospice did not assess pain per policy # 2-032.1. RR#10 was on continuous care for pain management. The RN visit note reflected that the patient had a pain level of 7/10. There was no other descriptors as per policy such as location, quality, alleviating and aggravating factors. This observation was discussed with the director .

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice did not update the IDG after patient changes. RR#8 was placed a new medication for GERD and was given an Enema for constipation. The subsequent IDG(s) did not address the effectiveness of these two medication changes. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 11 patient records reviewed, the hospice comprehensive care plan did not have individualized target date goals. HV#1 list of problems included being oxygen dependent, a wound, and was at risk for falls and aspiration. All of the target dates of the goals related to these problems were either within 3 weeks or by the end of the certification period. This observation was discussed with the director.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the Hospice Care Plan/Medication profile did not reflect the medications that the patient was taking. Based on a review of the medications given/available in the home of HV#2 and discussions with the caregiver, the patient was not taking a supplement and was not able to locate a medication utilized to decrease saliva in the home. Both of these medications were listed as active on the care plan. The medications listed on the profile/care plan provided to the surveyor for HV#1 did not match the medication administration record of the assisted living facility. The discrepancies included 2 inhalers, aspirin, 2 pain meds, a water pill, and eye drops. Per the director, these medications were on hold and subsequently were discontinued.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the Hospice staff did not follow the hand hygiene policy #9-009.1. The RN in HV#1 was observed washing his hands with the ALF's bar soap, drying his hands off on a terry cloth towel, and turning the faucet off with his forearm. The RN in HV#2 was observed entering and re-entering her nursing bag to retrieve various pieces of equipment (ie BP cuff, a bottle of normal saline, thermometer etc) after assessing the patient and without disinfecting and or washing her hands. The RN in HV#2 cleaned off each piece of equipment after use and placed them in her nursing bag as she finished utilizing them. The RN did not clean her hands after disinfecting each piece of equipment and or before entering her nursing bag. Finally, the RN in HV#2 was observed taking off the patient's soiled dressing (this patient had colonized MRSA in the wound) she then removed her gloves and retrieved an item from her bag. She did not disinfecting and or wash her hands immediately after the removing her gloves or prior to entering her nursing bag. These observations were discussed with the director. Observed in Individual Tracer. In 1 of 3 home visits conducted, the hospice staff did not comply with the bag technique policy #9-014.1. The RN in HV#2 was observed placing her nursing bag directly on the floor. This bag had no wheels nor did the nurse utilize a barrier. This observation was discussed with the director.

Observed in Individual Tracer. In 2 of 4 patient records reviewed, the hospice aide care plan did not reflect all of the interventions/precautions required based on the patient assessment. Hv#1 was on aspirin therapy and had a wound. The hospice aide care plan did not include precautions related to bleeding and or wound. The aide care plan of RR#3 did not include seizure precautions as per the nursing assessment. These observations were discussed with the director.