Every finding on record at Goldstar Hospice, Inc.

Observed in Patient Home. In 1 of 3 home visits conducted, the nurse surveyor noted the following medication was missing from the plan of care and on the medication list in the patient's home. For RRHV#1, there was no evidence of an updated order for the following medication, Docusate-Senna 8.6-50mg once a day. This was discussed with the DCPS.

Observed in Record Review. In 1 of 4 patient records reviewed, the organization did not ensure the patient record was completed, promptly and accurately documented. For example in RRHV#3, the nurse documented wound care was completed in the narrative note, however there was no documentation of a wound in the wound care assessment area of the clinical note, nor was there evidence of wound care orders in the plan of care or additional physician orders. This was discussed with the DCPS.

Observed in Record Review. In 4 of 4 patient records reviewed, the surveyor noted in RRHV#1, RRHV#2, RRHV#3, RRHV#4, the goals in the plan of care were to all be achieved by the last day of the benefit period, for example early detection of upper respiratory infection, lungs to be clear, healing road to peace, able to cope. This was discussed with the DPCS.

Observed in Record Review. In 1 of 3 patient records reviewed, the nurse surveyor noted in RRHV#3, the prn visits were quantified but no additional information was provided on the plan of care to determine what qualifies as a prn visit or the reason for the prn visit to be made. This was discussed with the DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, the orders were not clarified. For example, for RRHV#1, RRHV#2, RRHV#3, the order stated for SN to check oxygen saturation level via fingerstick every visit and notify MD if it is less than 90%. Oxygen saturation is not monitored via fingerstick, In addition, for RRBR#1, Insulin lispro 100/ml for injection was instructed to be administered via intracavernous route, which is not the route for insulin. This was discussed with the DCPS.

Observed in Record Review. In 1 of 4 patient records reviewed, the nurse surveyor noted that in RRHV#3 the patient verbalized new respiratory symptoms and a reassessment was not performed. For example, on several nursing visits, the nursing documentation showed evidence the patient's oxygen saturation was declining from 86% to 84% in the course of three subsequent visits. In addition, on one visit notE the nurse stated an order for oxygen was not received yet and no further follow up was completed on the next few nursing visits. This was discussed with the DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, the nursing assessment showed evidence of a wound to the lower leg, however in RRBR#1 record review, there was documentation of wound care performed, but did not specify the wound care provided. This was discussed with the DCPS.

Observed in Record Review. In 4 of 10 patient records reviewed, there not evidence of a nursing signature at the completion of the clinical note. For example, RRHV#1, RRHV#2, RRHV#3, RRNHV#3, the nurse completing the clinical documentation did not sign or date the clinical notes. This was discussed with the DCPS.

Observed in Record Review. During HV#1 record review it was noted lack of a documented bereavement assessment completed within 5 days of the RN initial comprehensive visit in June 2021.

Observed in Record Review. During HV#3 record review it was noted in the middle of March 2022 documentation by an SN that the physician ordered nitroglycerin SL for the patient for chest pain. The IDG RN summary during the IDG meeting the end of March 2022 lacked documentation of the c/o chest pain with an update to the POC.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV#1 record review it was noted the MSW summary during the recent IDG the middle of June 2022, documented the patient used her oxygen for SOB. Oxygen therapy is not included on the POC under DME, medication profile or as an intervention on the POC.

Observed in Record Review. During HV#1 and #3, RR#1-9, it was noted the bereavement POC goal after the initial bereavment assessment was completed were not individualized and were the same in each patient record: Healing road to peace in 2-3 weeks. Coping and acceptance of death by Family/PCG in 2-3 weeks.

Observed in Record Review. During RR#4 it was noted a frequency for the chaplain of every month on the IDG/POC. The POC lacked spiritual issues identified with interventions and goals.

Observed in Record Review. During HV#3 record review it was noted on the IDG summary for the RN the beginning of March 2022 there was lack of documentation of any patient clinical assessment findings from the prior 2 weeks. The IDG summary included only what the SN instructed on during the 2 week time period.

Observed in Individual Tracer. In 1 of 2 home visits conducted, During HV#1 it was noted the SN did not disinfect the equipment used during the visit with a disinfectant that had direction on a wet to dry contact time. The SN used alcohol prep pads to disinfect the stethoscope, BR cuff, and pulse oximetry device.

Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted lack of a goal that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The plan stated limiting the spread of infection associated with the use of medical equipment, devices and supplies.. Observed in Infection Control System Tracer. During review of the organization infection control plan it was noted lack of a goal that included limiting unprotected exposure to pathogens. The plan stated discussing the prevention of each risk by limiting exposure to pathogens. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include a goal for limiting the spread of infections associated with procedures. The 2022 Infection Control Plan stated Limiting the spread of infection associated with procedure.

Observed in Record Review. In 5 of 6 patient records reviewed, who had hospice aide services ordered on the POC. During RR#3 it was noted lack of documentation of the hospice aide supervision every 14 days. The aide supervision visits were completed by the RN on day 21 after the aide services were initiated and after each 21 day interval. During RR#4, RR#5, RR#8 and RR#9 it was noted the aide supervisory visits were not documented every 14 days. The documentation of supervision was every 21 days. There was no documentation in the records to indicate the reason the RN staff were not able to visit the patients due to the PHE. Staff ordered on each POC were able to visit the patient either by phone of in person for records reviewed.

Observed in Document Review. During review of the pharmacy contract it was noted the contract lacked a stipulation that the contracted service will complete criminal background checks on employees who provide direct patient care or have access to patient records. In addition, the contract lacked the manner in which the contracted service will be coordinated, supervised, and evaluated by the hospice.