Golden Care Hospice, LLC

“Upon patient record review, 2 of 14 (Patient #2, 6) 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 patient’s caregiver state the patient is not taking Atorvastatin 40mg daily, Vitamin D3, Nutiva Coconut oil 1 tsp 125mcg daily, NAC 600mg daily, Advil as needed, Tramadol 50mg two times daily, Diclofenac Cream three times daily, Voltaren three times daily as needed and amitriptyline 25mg one tab at night these medications are listed on medication profile. Patient 6: The patient states he is not taking Atorvastatin that is on the medication profile, and started taking Saw Palmetto 450mg 2 months ago which is not on the medication profile.”

“Upon patient record review, 7 of 14 (Patient #3,4,5,6,7,8,10) 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 3: On the RN initial assessment the RN state the patient is incontinent, there is not a risk for skin break down on the plan of care with goals and interventions. Patient 4: On the RN assessment there is evidence the patient is incontinent and has difficulty swallowing, there is not a risk for skin break down or risk of aspiration on the plan of care with goals and interventions. Patient 5: On the RN assessment there is evidence the patient is incontinent of bowel, there is not a risk for skin break down with goals and interventions on the plan of care. Patient 6,7,8: On the plan of care there is an order for aspirin 81mg daily, there is not a risk of bleeding with goals and interventions on the plan of care. Patient 10: On the RN assessment the RN documented the patient is incontinent, there is not a risk for skin break down on the plan of care with goals and interventions.”

“Upon patient record review, 2 of 14 (Patient #2, 6) 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: The patient’s caregiver state the patient is not taking Atorvastatin 40mg daily, Vitamin D3, Nutiva Coconut oil 1 tsp 125mcg daily, NAC 600mg daily, Advil as needed, Tramadol 50mg two times daily, Diclofenac Cream three times daily, Voltaren three times daily as needed and amitriptyline 25mg one tab at night these medications are ordered on the plan of care. Patient 6: The patient states he is not taking Atorvastatin that is on the plan of care, and started taking Saw Palmetto 450mg 2 months ago which is not on the plan of care.”

“Upon patient record review, 9 of 14 (Patient #1,2,3,4,5,6,8,9,10) 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: On the recent aide plan of care there is an order to complete bed bath, complete shower, light housekeeping, make bed, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 2: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, light housekeeping, change linen, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 3: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, light housekeeping, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 4: On the recent aide plan of care there is an order to change linen, make bed, the frequency of these orders is as needed and more than one form of bathing is not permitted. Patient 5,6,8,9,10: On the recent aide plan of care there is an order to complete bed bath, partial bath/shower, the frequency of these orders is as needed and more than one form of bathing is not permitted.”