Every finding on record at Golden Touch Hospice, Inc

Upon patient record review, 2 of 5 (Patient #1, 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 1 MAR included Voltaren gel 1% topical 3x day for joint pain and did not specify the location to be applied. Patient 2 MAR included ABHR 125/110mg/ml topical Q6h prn agitation/anxiety and did not specify the location to be applied.

Upon patient record review, 2 of 5 (Patient #1, 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 1 order for Voltaren gel 1% topical 3x day for joint pain and did not specify the location to be applied. Patient 2 order for ABHR 125/110mg/ml topical Q6h prn agitation/anxiety and did not specify the location to be applied.

Upon patient record review, 1 of 5 (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 had over bed table, nebulizer, suction machine, O2 tank and concentrator, no order for these DME items.

Upon client record review, 2 of 5 (Patient #3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3 order for spiritual care visits 1x month and 1 prn. Spiritual care visits completed 5/5/24 and 5/20/24. Patient 4 social work visit completed on 5/8/24, no order for social work visit.

Upon patient record review, 1 of 12 (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, No evidence of receipt of Bill of Rights was completed.

Upon patient record review, 1 of 12 (Patient #6) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #6, No evidence of identifying attending MD, both yes and no boxes left empty.

Upon patient record review 1 of 12 (Patient #2) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #2, POA signed admission paperwork on 1/22/24, Initial assessment completed on 1/31/24. No evidence of initial assessment within 48 hours.

Upon patient record review 1 of 12 (Patient #2) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #2, POA signed admission paperwork on 1/22/24, Initial assessment completed on 1/31/24. No evidence of all disciplines completing comprehensive assessment within 5 days.

Upon patient record review, 5 of 12 (Patient #2,3,5,10,11) 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 #2,3,5,10,11 Oxygen 2-4 LPM via n/c as needed for shortness of breath or oxygen less than 90%. No evidence of oxygen order on the medication sheet. Oxygen written on treatment sheet.

Upon patient record review, 2 of 12 (Patient #2,7) 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 #2, POA signed admission paperwork on 1/22/24, Initial assessment completed on 1/31/24. No evidence of bereavement assessment completed within 5 days of admission paperwork signed. Patient #7, No evidence bereavement assessment completed within 5 days. Patient was admitted on 3/19/22, assessment completed on 4/20/22.

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

Upon patient record review, 1 of 12 (Patient #2) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #2, No evidence of wound assessment except for initial nursing assessment.

Upon patient record review, 5 of 12 (Patient #2,4,6,8,9)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 #2, No evidence of problems/goals/interventions related to neuro, pain, ADL's, skin, or psychosocial, Care plans current were GI, sleep , spiritual. Patient #4, No evidence of problems/goals/interventions related to psychosocial or ADL problems/goals/interventions. Patient #6, No evidence of problems/goals/interventions related to spiritual care or wound care orders on integumentary/skin problems/goals/interventions. Patient #8,9, No evidence of problems/goals/interventions related to psychosocial.

Upon patient record review, 1 of 12 (Patient #1) 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, MSW frequency 1 as needed by phone only. SC frequency 1 initial assessment and PRN per family request.

Upon patient record review, 1 of 12 (Patient #8) 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 #8, No evidence of order for oxygen. On initial assessment documented oxygen 2-4 l/m via nc PRN, oxygen listed in care plan.

Upon patient record review, 1 of 12 (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 equipment and supply needs. Patient #2, No evidence of DME completed on Plan of Care. Patient has hospital bed.

Upon patient record review, 1 of 12 (Patient #8) 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 #8, Patient was admitted on 4/8/22, SN note on 5/6/22 noted foley 20f 30cc inserted. No update noted on care plan.

Upon client record review, 5 of 12 (Patient #1,2,3,4,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, MSW frequency 1 as needed by phone only, patient seen on 3/9/24 in person Patient #2,3,4, MSW frequency 1x/month and 1 PRN, no evidence of visit made in March 2024. Patient #8, SN frequency 2x/week and 1 PRN ordered 4/8/22, No evidence of SN visit the first week.

Upon patient record review 5 of 12 (Patient #1,2,4,8,9) 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 #1, Aide frequency 3x/week, no evidence patient was seen 3x the first week. Only 1 visit on 3/8/24. Patient #2, Aide frequency 3x/week, no evidence 3 visits were completed the first week. Only one visit completed the first week. Patient #4,Aide frequency 2x/week, no evidence that visits were completed the first week. Patient #8, Aide frequency 3x/week, no evidence that visits were completed the first week. Patient #9, Aide care plan instructs incontinence, no evidence task was completed on aide note of 5/27/21.

Upon patient client record review, 2 of 12 (Patient #2,6) 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 #2,6, No evidence of hospice election date was completed. Patient #6, No evidence of identifying attending MD, both yes and no boxes left empty.

Upon patient client record review, 1 of 12 (Patient #2) did not have evidence that each patient record contains Advance Directives. Patient #2, No evidence of Advance Directive filled out.

Upon patient client record review, 1 of 12 (Patient #10) did not evidence that each patient record contains physician orders. Patient #10, No evidence of order to discharge from Hospice. Patient was a live discharge.

Upon patient client record review, 4 of 12 (Patient #1, 5, 9, 11) 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 #1,5, MSW documentation within narrative states; needs addressed by family, Morning Star hospice and care givers. This agency is Golden Touch Hospice. No evidence of using correct name of agency. Patient #9, RN note on 6/7/21, incomplete. LPN note on 4/2/21, incomplete. No evidence of completed notes. Patient #11, Discharge note states revocation however, patient was discharged for extended prognosis.