Every finding on record at Golden Touch Hospice Care, Inc.

Upon patient record review, 2 of 14 records reviewed (Patient #3, 10) 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 #3: During the home visit the patient had a filled prescription on 12/06/24 by the hospice medical director for D3 25mcg one po daily, there was no evidence of this medication on the medication profile. The Administrator confirmed it was called in and was not put in the EMR system at the time the order was given and called into the pharmacy. COS. Patient #10: The record indicated on the medication profile Lidocaine 4% patch topical one every 12 hours as needed for lower back pain. There was no evidence of where to place the patch. COS.

Upon patient record review, 5 of 14 records reviewed (Patient #1, #2, #3, #4, #9) 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: The record indicated the start of care was 12/12/24. The patient was a full code. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS. Patient #2: The record indicated the start of care was 11/14/24. The patient was a full code. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS. Patient #3: The record indicated the start of care was 11/13/24. The patient was a full code. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS. Patient #4: The record indicated the start of care was 10/23/24. The patient was receiving Humulin 70/30 100U/ml SQ BID with meals and a glucometer was provided. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions to include blood sugar checks and how often and what to report based on the blood sugar reading. COS. Additionally, the patient was a full code on hospice admission. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS. Patient #9: The record indicated the start of care was 07/31/24. The patient was a full code. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS. Additionally on the initial assessment it was noted the patient is blind and could not sign legal documents. There was no evidence of an individualized written plan of care for the problem that reflected the patient/family goals and interventions. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #10) 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 #10: The physician order for was noted to be written as Lidocaine 4% patch topical one every 12 hours as needed for lower back pain. There was no evidence of where to place the patch. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #1) 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: The record indicated the following was ordered on 12/12/24: Oxygen Concentrator, Nebulizer Machine, E Tanks, CPAP, Four Point Cane, Rollator with Seat, and adult diapers. There was no evidence of these DME/supply items listed in the plan of care. COS.

Upon patient record review, 1 of 14 (Patient #5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #5: The record indicated the start of care was 08/10/24. The patient was a full code. The care plan goal on 08/11/24 stated a DNR will be completed in two weeks. There was no evidence of the patient's progress towards the desired outcome at the time of the survey. COS.

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 #3: During the home visit the hospice aide placed her bag on a barrier, removed the equipment from the bag, cleaned the pulse oximeter, she did not clean any other equipment and did not wash her hands or use hand sanitizer prior to the removal of these items. She did not follow the Bag Policy No. 9-014.1 The policy states handwashing will always be completed before opening the nursing bag.

Upon patient record review, 1 of 14 (Patient #5) 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 Patient #5: The patient's legals for the Election of Hospice and consent for treatment has only initials, there was no signature or signature log for the initials. COS.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not informed the patient of limitations regarding the scope of services available to the patient. For example, in review of the medical record for HOS 1 a 92 year old woman who had been admitted over 6 months ago the Comprehensive Nursing Assessment and subsequent skilled nursing visit notes consistently documented that the patient experienced shortness of breath on exertion, chest pain, dizziness and syncopal episodes. During the survey visit the surveyor questioned the patient if a home health aide would be helpful to her for bathing and personal cares and the patient stated she was unaware of the home health aide services and that she would like to have the assistance with bathing and personal cares. The RN present during the survey visit reported that the organization only had a male home health aide and did not have a female home health aide employed to meet the needs of the patient. This was validated by the Admin/DPCS.

Observed in Document Review. The organization failed to define assessment and reassessment criteria. For example, the organization's policy 9.6.2 Initial Assessment/Comprehensive Assessment states that the RN must complete an initial assessment within 48 hours after election of Hospice care and the policy then identifies the assessment criteria. However, the organization has not defined criteria for the psychosocial assessment completed by the social worker or criteria for the spiritual assessment completed by the chaplain. This was validated with the Admin/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to complete the comprehensive assessment no later than five calendar days after the election of hospice care. For example, in review of the medical record for HOS 2 who had declined to have the Chaplain visit there was no documentation to support that the RN had discussed her initial evaluation with the Chaplain and that they collaboratively decided that the spiritual assessment by the Chaplain was not necessary based on the patient’s clinical presentation. This was also observed in review of the medical record for HOS 3. This was validated by the Admin/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the IDG team did not collaborate on the bereavement plan of care. For example, in review of the medical record for HOS 1 the Bereavement Coordinator/MSW completed the Bereavement Assessment and developed goals that the patient and family bereavement needs will be met and that the patient/family will verbally express grief however there is no evidence in the medical record that the IDG team had approved the Bereavement Plan. This was also observed in review of the medical records for RR 1 and RR 2. This was validated by the Admin/DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, with home visits, the information in the patient record did not reflect the patient's care and treatment. For example, in review of the skilled nursing visit note that was conducted during the survey for HOS 1 the RN documented a weight of 140 lbs, that a head to toe assessment was done, that the patient ambulates with a walker 15 feet, that the RN educated family on proper techniques to assist patient with ADLs, that the caregiver was administering medications as prescribed, that the patient and caregiver states that chronic pain is currently controlled, that the plan of care was reviewed with the patient and the caregiver and that the caregiver expressed confidence in providing care. The surveyor noted that the patient was not weighed during the visit, a head to toe assessment was not completed with the RN obtaining vital signs, heart, lung and bowel sounds and assessing for pedal edema. Skin integrity was not assessed, patient's ability to ambulate was not assessed and the patient remained sitting on the couch for the duration of the visit. The patient's son/caregiver was not present for the visit. This was validated with the Admin/DPCS.