Every finding on record at Golding Care Hospice, Inc

Upon patient record review, 1 of 5 (Patient #4) 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 4: POC has orders for Oxygen. There was no oxygen care plan with problems, goals or interventions. Corrected on site.

Upon personnel record review, 1 of 4 (Personnel #3) 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.) Personnel 3: The aide competency does not include the following tasks: sponge bath, sink, tub and bed shampoo.

Upon patient record review, 5 of 14 (Patient #1, 2, 6, 9, 10) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1, 2, 6, 9, 10 elected the hospice MD to be the attending, there is a CTI from the referring physician who was not chosen as the attending.

Upon patient record review 9 of 14 (Patient #1, 3, 6, 7, 8, 9, 11, 12, 13) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1, 3, 6, 7, 8, 9, 11, 12, 13 declined spiritual care support, there was no evidence of an initial spiritual assessment completed. Patient 7 no evidence of an initial psychosocial assessment completed as of the time of the survey.

Upon patient record review, 3 of 14 (Patient #1, 4, 9) 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 medication profile included Clotrimazole topical for 7 days with a start date of 1/9/24 and it remained active on the medication profile. Patient 4 medication profile included Bengay topical cream and did not specify the location to be applied. Patient 9 medication profile included Systane Balance eye drops and did not specify which eye(s) to apply.

Upon patient record review, 2 of 14 (Patient #6, 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.

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

Upon patient record review, 2 of 14 (Patient #3, 4) 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 3 no documented wound care assessment or measurements from 1/5/24 to current. Hospice and outside agency are providing wound care. Patient 4 no evidence of a documented wound care assessment or measurements 4/2/24 to current, unsure of the last assessment and measurements.

Upon patient record review, 10 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) 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 has oxygen ordered prn, identified as high fall risk and aspiration risk. No evidence of a care plan to include problems, goals and interventions for respiratory, oxygen or oxygen safety, aspiration or fall precautions. Patient 2 taking Eliquis, no evidence of bleeding precautions. Patient 3 has oxygen ordered prn, identified as high risk for aspiration, no evidence of a care plan to include problems, goals, and interventions for respiratory, oxygen or oxygen safety, or aspiration precautions. Patient 4 taking aspirin and Plavix, no evidence of bleeding precautions. Also taking Vaproic Acid for seizures, no evidence of seizure precautions. Patient 5 has oxygen ordered prn, terminal diagnosis is protein calorie malnutrition, and is high risk for aspiration. No evidence of a care plan to include problems, goals, and interventions for respiratory, oxygen, nutrition, or aspiration. Patient 6, 7 oxygen ordered prn. No evidence of a care plan problems, goals or interventions for respiratory or oxygen. Patient 8 oxygen ordered prn. No evidence of a care plan problems, goals or interventions for respiratory or oxygen. Patient identified to have constipation and taking docusate scheduled, no evidence of a care pan for constipation. Patient 9 oxygen ordered prn and RN visit on 4/21/24 documented dyspnea. No evidence of a care plan problems, goals or interventions for respiratory or oxygen. Patient identified to have constipation and taking Senna scheduled and Bisacodyl prn, no evidence of a care pan for constipation. Patient 10 oxygen ordered prn and RN visit on 3/24/24 documented dyspnea with exertion. No evidence of a care plan problems, goals or interventions for respiratory or oxygen. Patient identified to have constipation and taking Senna scheduled and Bisacodyl prn, no evidence of a care plan for constipation.

Upon patient record review, 3 of 14 (Patient #4, 8, 9) 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 4 order for Bengay topical cream, did not specify the location to be applied. Patient 8 RN visit on 5/10/24 documented patient using Glucerna both orally and for PEG feedings, no order for Glucerna. Patient 9 order for Systane Balance eye drops, did not specify which eye(s) to apply.

Upon client record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 9, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1, 2, 3, 4, 5, 9, 10 Initial plan of care and updated plans of care included RN frequency of assess and evaluate at initial and recertification, RN every 14 days for aide supervision, RN every 30 days for LVN supervision, and RN every 15 days for care plan updates. RN visits were not made every 14 days, every 15 days and every 30 days. Patient 2 initial plan of care included an order to assess MAC every visit, RN visit on 4/22/24 and LVN visit on 4/23/24 did not document the MAC. Patient 4 wound care is ordered to be performed every 2-3 days, SN visits on 4/16/24, 4/30/24, 5/14/24 do not document any wound care being performed, no wound measurements.

Condition of Participation: Quality Assessment and Performance Improvement.

Upon observation, there was no evidence the program shows measurable improvement in indicators related to improved palliative outcomes and hospice services. QAPI meeting April 2024 documents 10 patient charts were audited but no results of the audit are documents. Last patient audits were January 2023 4 charts were audited. No actions or improvement plans were implemented as a result of the audits and no measurable improvements. No projects to demonstrate palliative outcome improvements.

Upon observation, there was no evidence the QAPI program uses quality indicator data, including patient care and other relevant data in the design of its program. The hospice must use the data collected to: • Monitor the effectiveness and safety of services and quality of care • Identify opportunities and priorities for improvement

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice's population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice's services and operations. The agency did not have any current performance improvement projects, and did not have any projects for 2023 or 2024. The agency was tracking data and pulling reports from the EMR (such as demographics and patient reports) but did not have any projects or assessments of the data they pulled from the reports.

Upon observation, there was no evidence the hospice documents what QAPI projects are being conducted, the reasons for conducting these projects, and the measurable progress achieved on these projects.

Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program. There was no evidence that the hospice's governing body is responsible for ensuring that an ongoing program for quality improvement and patient safety is: • Defined • Implemented • Maintained • Evaluated annually

Upon observation, there was no evidence the hospice's governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.

Upon home visit 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, the MSW did not have any hand sanitizer during the visit and did not wash her hands during the visit.

Upon personnel record review, 5 of 14 (Personnel #4, 5, 6, 8, 9) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Nursing • Medical social services • Counseling Personnel 4, 5, 6, 8, 9 were contracted 1099 staff. The administrator corrected this on day one of the survey and these staff are now W-2 employees.

Condition of Participation: Hospice Aide and Homemaker Services. L607

Upon personnel record review, 1 of 14 (Personnel #7) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. The following tasks on the aide competency were completed verbally and not with a patient prior to the aide providing care independently: ·Positioning ·Shampoo, sink, tub, and bed ·Nail and skin care ·Toileting and elimination

Upon patient record review, 8 of 14 (Patient #1, 2, 3, 4, 5, 6, 9, 10) 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 1 no evidence of oxygen or aspiration precautions. Patient 2 no evidence of bleeding precautions, patient on Eliquis. Turn and reposition is on the aide care plan without a frequency. Patient 3, 6, 9 no evidence of aspiration precautions. Turn and reposition is on the aide care plan without a frequency. Aide care plan includes street clothes as the type of clothing but does not include a frequency for dressing the patient. Patient requires assistance with all ADLs. Patient 4 no evidence of bleeding or seizure precautions. Turn and reposition is on the aide care plan without a frequency. Aide care plan includes street clothes as the type of clothing but does not include a frequency for dressing the patient. Patient requires assistance with all ADLs. Patient 5 no evidence of aspiration precautions. Patient 10 Turn and reposition is on the aide care plan without a frequency. Aide care plan includes street clothes as the type of clothing but does not include a frequency for dressing the patient. Patient requires assistance with all ADLs.

Upon patient record review 2 of 14 (Patient #1, 6) 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 ordered 3x week, visits on 5/2/24 and 5/4/24, no evidence of a third visit or refusal this week. Patient 6 aide ordered 2x week, visit on 5/16/24, no evidence of a second visit or refusal this week.

Upon patient record review 3 of 14 (Patient #2, 3, 5) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 2 aide supervisory visit was completed on 4/22/24 and the next one was completed on 5/21/24, there was a nursing visit on 5/7 but no aide supervision was documented on this visit. Patient 3 aide supervisory visits were completed on 3/28/24, 4/12/24, 4/26/24, and 5/11/24. Patient 5 aide supervisory visits were completed on 4/17/24 and 5/2/24.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The agency did not have evidence that the board of directors/governing body ensured the appointed administrator was qualified based on agency job description, performed appropriate criminal background checks on personnel, and provided oversight that there was a Quality Assessment/Performance Improvement program in place and active.

Upon observation, there was no evidence the hospice is primarily engaged in providing the following care and services: • Nursing services Patient 3 medical record documented weekly wound care being provided by an outside wound care agency. The administrator confirmed that the hospice is not paying the wound care company for this routine wound care and that the wound care company is billing the patient's insurance. The wound care is routine wound care and not a specialized wound care.

Upon personnel record review, 1 of 14 (Personnel #12) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy.

Upon personnel record review, 1 of 14 (Personnel #8) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel 8 SW competency on 7/20/23 was performed by the spiritual care provider.

Condition of Participation: Clinical Records.

Upon patient client record review, 4 of 14 (Patient #3, 7, 10, 11) 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 3 elected to receive the notice of non-covered items at admission on 12/12/23 and it was provided on 12/19/23. Patient 7 election of benefit does not have an effective date, it was signed on 5/9/24 and start of care was 5/11/24. The election also had a box to check that the patient received a copy of the patient rights, this box was not checked. Patient 10 elected to receive the notice of non-covered items at admission on 2/28/24 and it was provided on 3/5/24. Patient 11 election of benefit was signed on 3/26/24 with an effective date of 3/25/24.

Upon patient client record review, 1 of 14 (Patient #4) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient 4 elected an attending physician (CL) and there was not a certification of terminal illness from the attending.

Upon patient client record review, 3 of 14 (Patient #3, 4, 6) 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 3 SN visits on 3/28/24, 4/12/24, 4/17/24, 4/23/24, and 4/26/24 documented wound care performed ordered and did not include the details of the wound care or how the patient tolerated the wound care. Patient 4 LVN visits in April/May document the wound is healing, RN visits in May document the wound size is increasing. Patient 6 election of benefit has effective date of 5/14/24, hospice care did not start until 5/15/24.

Upon client record review, 2 of 14 (Patient #11, 12) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon SNF/NF contract review, 1 of 3 (Pacific Haven SNF contract) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.

Upon personnel record review, 2 of 14 (Personnel #7, 11) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. The agency performed a check through a search engine that had a disclaimer that it could not be used for criminal background checks for employment purposes.

Upon personnel record review, 9 of 14 (Personnel #1, 2, 3, 4, 5, 6, 8, 9, 10) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. The agency performed a check through a search engine that had a disclaimer that it could not be used for criminal background checks for employment purposes.