Every finding on record at Goodwill Health Care LLC

Upon patient record review 1 of 5 (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 - Patient was admitted to hospice service on 05/14/25. The medical record showed the social worker comprehensive assessment was not completed until 05/20/25.

Upon patient record review, 1 of 5 (Patient #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 #2 - the medication profile noted patient taking Miralax for constipation. There was no evidence of a diluent to be added with this medication included in the instructions. This was corrected onsite

Upon patient record review, 3 of 5 (Patient #1,2,4) 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 #1 - The patient medical record showed evidence of advance directives indicating patient is choosing to be full code status. There were no problems, goals or interventions listed on patients plan of care. This was corrected onsite. Patient #2 - The nurse comprehensive assessment dated 05/14/25 indicated the patient was assessed as high risk for impaired skin integrity as indicated by scoring an eleven on the Braden Scale. There was no evidence of problems, goals or interventions related to impaired skin integrity. This was corrected onsite. Patient #4 - The patient medication profile indicated the patient was utilizing oxygen for shortness of breath. There were no problems, goals or interventions related to oxygen use on patients plan of care. The comprehensive assessment dated 05/07/25 indicated patient was on a mechanical soft diet. There were no problems, goals or interventions related to this diet on the plan of care. The medication profile also indicated patient was on aspirin and Plavix as blood thinners. There was no evidence of problems, goals, or interventions related to the bleeding risk while taking these medications listed on the plan of care.

Upon patient record review, 1 of 5 (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 medications and treatments. Patient #2 - There was an order for Miralax 17 gm daily for constipation. There was no evidence of a diluent added to order.

Upon patient record review, 1 of 5 (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 - Medication profile showed Zofran was initiated on 05/21/25 for a new symptom of nausea/vomiting. There was no evidence of problems, goals, or interventions related to nausea/vomiting control initiated.

Upon patient record review, 3 of 5 (Patient #1,3,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1 - The IDG notes from 05/26/25 - 07/16/25 indicated a frequency order for bereavement coordinator visits 1 per week. There was no evidence of weekly pre bereavement visits or assessments noted in the medical record. Patient #3 - The IDG notes from 05/07/25 - 07/16/25 indicated a frequency order for bereavement coordinator visits 1 per week. There was no evidence of pre bereavement visits or assessments noted in the medical record. Patient #4 - The IDG notes from 05/07/25 - 06/18/25 indicated a frequency order for bereavement coordinator visits 1 per week. There was no evidence of pre bereavement visits or assessments noted in the medical record.

Upon observation and home visits, 2 of 3 (Patient #2,#3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2 - This patient was a home visit scheduled with the CNA. The policy no 6-013.1 under bag technique section 1, states "the bag will be placed on a clean surface and that surface can easily disinfected." The aide was noted to walk into patient's room and set her work bag on a recliner which belonged to the patient's roommate and sitting on that recliner it was noted to contain a disposable chux pad that appeared to have been used. Patient #3 - This patient was a home visit with the MSW. It was noted the social worker carried a bag into the home of the patient and set it on the patient's floor in the living room. There was no evidence of cleaning the bag prior to or after the visit.

Upon patient record review, 2 of 5 (Patient #4,#5) 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 Patient #4 - Patient was discharged from hospice due to pursuing hospitalization related to a fall on 06/01/25. A discharge summary was completed however there was no evidence that the summary was sent to attending physician for review or documentation that this summary was sent. Patient #5 - Patient was discharged from hospice due to pursuing hospitalization related to a chest pain episode. A discharge summary was completed however there was no evidence that the summary was sent to attending physician for review or documentation that the summary was sent.