Every finding on record at Avery Care Hospice Inc.

Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient's Rights and Responsibilities in a language and manner that the patient understands. Patient #9: During patient visit, it was noted that patient and husband primary language is Chinese. Patient admission handbook documents provided in English language. Upon interview with Alt Admin/DPCS, it was reported that resources are not available to print forms in different languages. She stated that daughter speaks English and able to translate. Daughter was not in home at time of observed patient visit.

Upon patient record review, 14 of 14 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients 1-14: The Consent for Primary Care Physician form is ambiguous and not clear for patient's right to choose attending physician. The form includes (3) options: --- I wish to continue my primary care with my current physician, I would prefer Avery Care Hospice Medical Director to attend to my care needs, I would prefer Avery care hospice medical direct to intercede for only my terminal illness treatment needs and pain management. In some cases, the patient/responsible party checked 2 of 3 items. It is not clear who the patient was choosing to be the attending physician.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: During visit, noted patient to have 1000 I.U. Vitamin D in home. Vitamin D order and hospice medication profile do not specify units. Patient has physician order and medication profile listing for Prolia 60 mg/ml solution for injection subcutaneously every 6 months for RA (Rheumatoid Arthritis). During home visit, the nurse reports that patient receives in clinic. This is not specified in the order or on med profile. Patient has physician order and medication profile listing for Orencia Clickject 125 mg/ml auto injector solution for injection subcutaneously once a week for RA. During visit, nurse reports that hospice agency administers this injection weekly. This is not clear in the order or on the med profile.

Upon patient record review, 1 of 14 (Patient # 2) 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 #2: Wound treatment orders for (4) different wounds dated 7/9 and 7/10/24. There is no evidence of wound assessment and/or effectiveness of current treatment documented in subsequent visit notes July 12th and 15th.

Upon patient record review, 3 of 14 (Patient #3, 4, 5) 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. Patients #3, 4, 5: Patient has MSW/SC disciplines ordered monthly and each recert, but there are no problems, goals interventions related to psychosocial and spiritual needs.

Upon patient record review, 1 of 14 (Patient #10) 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 #10: During visit, noted patient to have 1000 I.U. Vitamin D in home. Vitamin D order does not specify units. Patient has physician order for Prolia 60 mg/ml solution for injection subcutaneously every 6 months for RA (Rheumatoid Arthritis). During home visit, the nurse reports that patient receives in clinic. This is not specified in the order. Patient has physician order for Orencia Clickject 125 mg/ml auto injector solution for injection subcutaneously once a week for RA. During visit, nurse reports that hospice agency administers this injection weekly. This is not in the order.

Upon client record review, 6 of 14 (Patient #1, 2, 5, 6, 7, 12) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: SN Missed Visit Report, 6/7/24 with time in 330-445 pm. Note that patient was not home after scheduled visits was made. Patient left phone inside the house. Will leave a message. No evidence office or MD was notified of missed visit. SC frequency included visit within 5 days of SOC, monthly and every cert. No visits were made other than initial phone visits when patient declined further visits. SC frequency was not updated. Patient #2: MSW frequency order within 5 days of SOC, monthly and every cert. No June visit or documented contact. Patient #5: SOC 4/26/24. MSW frequency order within 5 days of SOC, monthly and every cert. MSW initial assessment was 5/8/24 with no indication that patient refused earlier visit. Patient #6: SOC 4/26/24. MSW frequency order within 5 days of SOC, monthly and every cert. MSW initial assessment was 5/3/24 with no indication that patient refused earlier visit. Patient #7: SOC 4/22/24. MSW frequency order within 5 days of SOC, monthly and every cert. MSW initial assessment was 4/25/24. There was no May visit or contact documented. Patient #12: SOC 1/30/24. MSW frequency order w/in 5 days and every cert. MSW initial assessment was 2/8/24, with no indication that patient refused earlier visit.

Upon patient record review, 7 of 14 (Patient #1, 2, 3, 4, 5, 8, 12) 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 #1, 2, 3, 4, 5, 8, 12: Patient requested addendum of coverage/non-coverage, but no evidence the addendum was provided.

Upon patient record review, 3 of 14 (Patient #3, 4, 5) did not have evidence that each patient record contains Physician certification and recertification of terminal illness. Patient #3, 4, 5,elected referring MD as attending. There is no certification statement by the chosen physician for the initial 90 day benefit period..

Upon client record review, 3 of 14 (Patient #8,9,10) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient 8, 9, 10: There is no documented acknowledgement that the policy was provided or discussed, although it was observed in home setting.

Upon client record review, 1 of 14 (Patient #2) did not have evidence that the hospice plan of care identifies the care and services that are needed and specifically identify which provider (nursing facility or hospice) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care. Patient #2: Wound treatment orders for (4) different wounds dated 7/9 and 7/10/24. It is specified that hospice, patient caregiver and/or SNF may perform wound care but is not specific for who is to provide the wound care and when in order, to ensure care is provided as ordered.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. It is reported that the Director of Patient Care Services resigned April 12, 2024. The Alternate DPCS is present and acting in vacancy. The agency reports that they have been unable to fill the vacancy. The acting DPCS (Alt DPCS) reports that she communicated the vacancy to CDPH via phone, but had no written evidence that it was reported.