Every finding on record at Old Is Gold Hospice Care Inc

Upon patient record review, 1 of 16 (Patient #10) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #10: Patient discharged/revoked related to hospitalization. SN Notes 7/1, 7/15 and 7/27/25 leading up to 8/2/25 hospitalization are incomplete; therefore, no evidence of comprehensive assessment at minimum of every 15 days, unable to validate continued assessment and intervention related to patient needs and symptom management leading up to hospitalization.

Upon patient record review, 7 of 16 (Patient #2, 4, 6, 8, 9, 11, 12) 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 #2: SN 1/week and 3 prn visits per week, ordered nursing frequencies are not individualized and prn visits are too broad. Patient #4: SN 2/week and 2 prn / week, ordered nursing frequencies are not individualized and prn visits are too broad. Patient #6: SN 1/week and 2 prn /week, ordered nursing frequencies are not individualized and prn visits are too broad. Patient #8: SN 1/week and 2 prn visits/week. RN 1 every 14 days and 2 prn visits /week, ordered nursing frequencies are not individualized and prn visits are too broad. Patient #9: SN 1/week and 2/week prn. RN every 14 days and 2 prn/week, ordered nursing frequencies are not individualized and prn visits are too broad. Patient #11: SN 2/week for 2 week and 2 prn/wk. RN every 14 days and 2/week prn, ordered nursing frequencies are not individualized and prn visits are too broad. patient #12: SN 1/week and 2 prn per week RN 1/mo. and 2 prn / week, ordered nursing frequencies are not individualized and prn visits are too broad.

Upon patient record review, 1 of 16 (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: SN visit 8/4/25. Order for in and out catheterization for urine specimen. Order did not specify size of catheter to use.

Upon patient record review, 2 of 16 (Patient #3, 7) 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 #3: 7/31/25 order: Abrasion to right hip ... cleanse with normal saline, pat dry, apply triple antibiotic ointment to wound bed. Apply zinc oxide to surrounding area. Cover with bordered gauze dressing. Change daily and as needed when soiled,dislodged. 8/1/25 communication note says Abrasion to right hip 2x4 cm by LVN. Dr. Alam informed with new order for : Cleanse with NS, pat dry, apply Medihoney gel to wound bed, apply zinc oxide to surrounding area. Cover with Optifoam dressing daily for 30 days. Order carried out. IDT and daughter informed. However, 8/4/25 IDG says skin remains intact and clean with no reference to new treatment orders since prior IDG. Problems, goals and interventions include 7/31/25 ordered treatment for triple antibiotic and zinc, and not updated with Medihoney. Patient #7: Patient discharged related to administrative discharge. There is no evidence of IDG discussion and updates to problems/goals/interventions to prepare patient/family/caregivers for discharge.

Upon client record review, 3 of 16 (Patient #3, 4, 10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: 8/8/25 and 8/15/25 RN visit notes have time in and out, but notes are incomplete, for sections for supervisory, care provided, visit check list (that says complete every visit) and no narrative. The note is not authenticated with clinician signature. Visits required to meet frequency ordered. Patient #4: 6/10/25 and 6/30/25 RN visit notes have time in and out, but are incomplete, and not authenticated with signature. Visits required to meet frequency ordered. Patient #10: RN Note 6/27/25 is not authenticated with signature. SN notes July 1, 15, 27 have time in and out, but are incomplete with no authenticating signatures. Visits required to meet frequency ordered.

Upon personnel record review, 1 of 12 (Personnel #5) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5: The form utilized by agency does not include various types of shampoo and there are no related notations to validate all competencies were demonstrated.

Upon personnel record review, 2 of 12 (Personnel #1, 2) did not have evidence that the administrator is a hospice employee and possesses the education and experience required by the governing body. Personnel #1: Administrator agency job description qualifications require a bachelors degree in business administration, masters degree in related field preferred. Resume notes academic degree in Linguistics and intercultural communications, specialization English language and international journalism. Personnel #2: There is no signed job description for Alternate Administrator, only DPCS on file. Job description was provided by end of day.

Upon patient record review, 6 of 16 (Patient #3, 6, 7, 8, 9, 12) did not have evidence that a hospice that provides hospice care to a Medicare or Medicaid beneficiary does not discontinue or reduce care because of the beneficiary's inability to pay. Patients #3, 6, 7, 8, 9, 12: Patient discharge summary and/or physician orders refer to reason for discharge as Administrative Discharge. Interview with staff describe process to educate patients that services provided are no longer being covered by insurance/CMS and therefore, agency offered option to transfer to another provider, revoke participation in hospice Medicare benefit or to pay services privately. Patient/CG cited above reportedly chose not to transfer or revoke and were not able or willing to pay services privately. Completed NOMNC, DENC, ABN provided to surveyor Day 2. These forms were not available in EMR Day 1 of survey, but were uploaded to EMR Day 2.

Condition of Participation: Clinical Records.

Upon patient client record review, 5 of 16 (Patient #2, 3, 4, 8, 13) did not have evidence that each patient record contains Advance Directives. Patient #2: EMR identifies patient code status as DNR. POLST on file checked Attempt CPR/with full treatment and no artificial means of nutrition, including feeding tubes. The form is not signed by MD/PA/NP. Patient #3, 13: EMR identifies code status as DNR, however there was no supportive documentation for initial review day 1. Patient #4: EMR identifies code status as DNR. POLST on file checked Attempt Resuscitation/CPR, Comfort focused care, trial period of artificial nutrition. Patient #8: POLST on file with date form prepared 11/29/24, but MD signature is 11/13/24.

Upon patient client record review, 1 of 16 (Patient #7) did not evidence that each patient record contains physician orders. Patient #7: Patient discharged related to administrative discharge. There is no documented physician order.

Upon patient client record review, 7 of 16 (Patient #2, 3, 4, 7, 8, 10, 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 #2: SN visit 8/4/25. Order for in and out catheterization for urine specimen. Documentation is not complete as size not specified. Patient #3: 8/8/25 and 8/15/25 RN visit notes have time in and out, but notes are incomplete, for sections for supervisory, care provided, visit check list (that says complete every visit) and no narrative. The note is not authenticated with clinician signature. Patient #4: 6/10/25 and 6/30/25 RN visit notes have time in and out, but are incomplete, and not authenticated with signature. Patient #7: 4/14/25 Initial bereavement assessment by MSW identifies first name as a sister. No actual name, no other names/contact info. Patient #8: SC assessment visit note 5/24/25 not authenticated with signature. Patient #10: RN Note 6/27/25 is not authenticated with signature. SN notes July 1, 15, 27 have time in and out, but are incomplete with no authenticating signatures. Patient #11: DC summary not authenticated with signature.

Upon client record review, 5 of 16 (Patient #7, 8, 9, 10, 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 Patient #7, 8, 9, 10: There is no evidence of discharge summary completed and/or forwarded in clinical record review Day 1. The discharge summary form had been opened with reason for discharge listed only. Patient #12: There is no evidence that discharge summary was forwarded.

Upon client record review, 4 of 16 (Patient #7, 8, 9, 10) did not have evidence that the discharge summary includes all required information. (none have signatures - just date and reason) Patient #7, 8, 9, 10: Upon surveyors initial clinical record review Day 1 of survey, there is no evidence of discharge summary completed other than #7, 8, 9 had reason for discharge "Administrative Discharge" and #10 reason for discharge as Hospitalization. No other documentation on form.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #6: Personnel file includes diploma for masters degree in psychology. There is no other social worker on staff for supervision.

Observed in Patient Home. In 3 of 3 home visits conducted, and in review of the home folder provided to patients, the agency provided generic information on advanced directives but did not provide information on the company policy on advance directives. This was validated with the nursing supervisor.

Observed in Record Review. In 1 of 5 contracts reviewed, the agency failed to include a stipulation that requires the contractor to do criminal background checks on any employee who has patient contact or access to the patient's medical record. In Contract #5 for transportation there was no such stipulation. This was validated with the nursing supervisor.