Every finding on record at Around the Clock Hospice

Upon observation, there was no evidence the Emergency Plan communication plan includes: • A method for sharing information and medical documentation for patients under the hospice's care, as necessary, with other health care providers to maintain the continuity of care • A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii) • A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4) There was not evidence of a patient list with patient information for sharing with other health care providers.

Upon patient record review, 1 of 14 (Patient #4) 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 #4: The visit frequency for the RN was once every 14 days. The record indicated that the last visit by the RN was 4/18/25.

Upon patient record review, 2 of 14 records (Patient #1,#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 visit frequency for the LVN was 1x/week. There was not evidence of a visit for the week of 4/27/25-5/3/25. Patient #4: The visit frequency for the LVN was 1x/week. The record indicated 2 routine visits by the LVN on 4/29/25 (7:00 am and 10:30 am). In addition, the visit frequency for the RN was once every 14 days. The record indicated that the last visit by the RN was 4/18/25.

Upon inpatient contract review, 1 of 5 contracts (Los Palos Post Acute) did not have evidence of a provision that the hospice supplies the inpatient provider with a copy of the patient's plan of care and specifies the inpatient services to be furnished. Corrected on site.

Upon inpatient contract review, 1 of 5 contracts (Los Palos Post Acute) did not have evidence of a provision that the hospice patient's inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge. Corrected on site.