Every finding on record at Altadena Hospice Care, Inc

Upon patient record review 6 of 14 (Patient #1,3,4,5,8,10) 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 #1,3,4,5,8,10 MSW declined. No evidence of RN initial assessment completed a psych social assessment.

Upon patient record review, 2 of 14 (Patient #9,10) 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 #9, Primary bereaved name is daughter Maria. Bereavement assessment narrative documents spoke to care giver Guadalupe who declined services. No evidence of bereavement risk completed on daughter. Patient #10, Primary bereaved name is daughter Anna. Bereavement assessment narrative documents spoke to care giver Mark, who declined services. No evidence of bereavement risk completed on daughter.

Upon patient record review, 1 of 14 (Patient #2) 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 #2, No evidence of g-tube care updated on care plan.

Upon patient record review, 1 of 14 (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, tube feeding documented under treatment as tube feeding flush with 30 ml warm water before and after bolus tube feeding. Give 1000 ml of water daily. No evidence of tube feeding bolus order.

Upon patient record review 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #1,2,3,4,5,6,7,8,9,10, RN initial assessment documented requested hospice to contact local clergy. No evidence of local clergy was contacted.

Upon patient record review, 3 of 14 (Patient #6,7,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #6, CTI for certification period 7/28/24-10/25/24 had no evidence of MD narrative or MD signature and verbal CTI not present in record. Patient #7,10, CTI for certification period 7/2/24-8/30/24 had no evidence of MD narrative or MD signature and verbal CTI not present in record.