Every finding on record at Goodwill Healthcare Services Inc.

Upon patient record review, 1 of 19 record reviewed (Patient #4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: The start of care was on 05/07/24. There was no evidence on the chart that the patient choose an attending physician at the time of the survey. COS.

Upon patient record review 3 of 19 records reviewed (Patient #2, #4, #13) 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: The record indicated the patients start of care was 12/28/23. The psychosocial comprehensive assessment was not completed until 01/08/24. Patient #4: The record indicated the patients start of care was 05/07/24. The spiritual comprehensive assessment was not completed until 05/17/24. Patient #13: The record indicated the patients start of care was 07/31/24. The psychosocial comprehensive assessment was not completed until 08/06/24.

Upon patient record review 3 of 19 records reviewed (Patient #1, #2, #3) 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: The record indicated the start of care was 02/20/24. There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #2: The record indicated the start of care was 12/28/23. There was no evidence of a spiritual comprehensive assessment completed at the time of the survey. Patient #3: The record indicated the start of care was 11/03/23. There was no evidence of a psychosocial comprehensive assessment being completed at the tie of the survey.

Upon patient record review, 2 of 19 (Patient #1, #2) 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 #1: The start of care was 02/20/24. There was no evidence of the initial bereavement assessment at the time of the survey. Patient #2: The start of care was 12/28/23. The bereavement risk assessment was not completed until 01/08/24.

Upon patient record review, 3 of 19 records reviewed (Patient #7, #12, #17) 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 #7: There was an order for a right hip X-ray and right wrist X-ray on 08/27/24 and the X-ray was obtained 8/30. The RN follow up visit on 08/31/24 was 4 days after the hip and wrist X-ray was ordered. Patient #12: There was an order for a CBC with diff on 8/30/24. There was no evidence of the follow up for results on the chart at the time of the survey. COS. Patient #17: The record indicated the patient was transitioning on 1/26/24 with a BP of 76/56 while having dysphagia and was not seen until again until 4 days later on 1/30/24 which the patient was unresponsive with large amounts of sputum.

Upon patient record review, 3 of 19 records reviewed (Patient #6,7,9) 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. Patients #6: The record indicated an order on 8/12/24 for Speech Therapy to assess swallowing and for pocketing food. There was no evidence of an individualized written plan of care that reflected the patient/family goals and interventions for the Speech Therapy that was ordered. COS. Patient #7: The record indicated the patient had a right hip X-Ray and right wrist X-Ray on 8/30/24. There was no update to the plan of care including the patient's progress towards outcomes and goals. COS. Patient #9: The record indicated an order on 8/23/24 for podiatry in reference toenail trimming due to pain / discomfort. There was no evidence of an individualized written plan of care that reflected the patient/family goals and interventions for the Podiatry referral that was ordered. COS.

Upon client record review, 1 of 19 records reviewed (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The record indicated on 6/1/24 the visit frequency for the RN was Q2Weeks and 1 SN visit per week. There was only one RN visit for a three week period on 9/5/24, 9/9/24, and 9/17/24 and no evidence visits made according to orders. COS.

Upon patient record review, 1 of 19 records reviewed (Patient #7) 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 #7: The record indicated the patient was receiving hospice aide services. There was no plan of care update to the hospice aide care plan regarding the hip fracture diagnosed from the hip X-ray on 8/30/24 to ensure the patients was bedbound. COS.

Upon personnel record review, 2 of 16 (Personnel #8, #10) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. There was no evidence of competency skills assessments for #8, #10.

Upon patient client record review, 1 of 19 (Patient #4) 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 #4: The start of care was on 05/07/24. There was no evidence election statement identified an attending physician at the time of the survey. COS.

Upon patient client record review, 2 of 19 (Patient #6, #14) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #6: The record indicated the initial CTI with a start of care date 01/18/24 needed to be signed by the patients choice of attending. This was not signed at the time of the survey. COS. Patient #14: The record indicated the initial CTI with a start of care date 05/25/24 needed to be signed by the patient choice of attending. This was not signed at the time of the survey. COS. Agency policy is for orders to be signed within 30 days.

Upon patient client record review, 3 of 19 records reviewed (Patient #1, #3, #4) 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: The record indicated documentation was required for Advance Directives. There was no evidence on the chart at the time of the survey the assessment of these documents were completed, the area for the assessment on the NOE were blank. Patient #3: The record indicated an IDG meeting was held on 06/20/24. There was no evidence the MD signature and or the Social Worker signature was on file for this meeting. COS. Patient #4: The record indicated documentation was required for Advance Directives. There was no evidence on the chart at the time of the survey the assessment of these documents were completed, the area for the assessment on the NOE were blank.