Every finding on record at Blessed Hospice California Inc

Upon patient record review, 1 of 5 (Patient #3) 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: The patient is on Anticoagulants. There are no interventions or goals for bleeding/anticoagulants in the POC

Upon patient record review, 7 of 14 (Patient #1,2,3,4,6,8,9) 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 #1, 2, 3, 4, 6, 8, 9 - The patient had oxygen noted in the nursing comprehensive assessment and the DME list. The oxygen was not included on the patient medication profile.

Condition of participation: Interdisciplinary group, care planning, and coordination of services. The hospice must designate an interdisciplinary group or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. The plan of care must specify the hospice care and services necessary to meet the patient and familyspecific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions.

Upon patient record review, 7 of 14 (Patient #1,2,3,4,8,9,10) 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 #1, 8 - The medical record noted patient was listed as a full code. The record showed no evidence on patients POC that problems, goals, or interventions related to that full code status were outlined. Patient #2, 3, 9 - The medication profile listed the use of Zofran for nausea or vomiting. There was no evidence of problems, goals, or interventions related to nausea/vomiting. Patient #4 - The nursing comprehensive completed 12/06/24, showed evidence that patient was placed on aspiration precautions. The documentation also indicated that the patient has a related diagnosis of Type 2 Diabetes. There was no evidence of problems, goals or interventions related to the endocrine system as well as the aspiration precautions. Patient #10 - The medication profile listed the use of a nebulized medications. There was no evidence of problems, goals, or interventions related to that medication.

Upon patient record review, 4 of 14 (Patient #4,5,6,10) 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 #4 - IDG notes and orders between 2/24/24 to current, have a prn order for the MSW. There is no evidence of any routine visits. Patient #5 - IDG notes and orders between 12/10/24 to current, have a prn order for the MSW. There is no evidence of any routine visits. Patient #6 - IDG notes and orders between 12/24/24 to current, have a prn order for the MSW. There is no evidence of any routine visits. Patient #10 - IDG notes and order between 01/07/25 to current, have a prn order for the MSW. There is no evidence of any routine visits.

Upon patient record review, 1 of 14 (Patient #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 #6 - The nursing comprehensive dated 07/04/24, showed evidence in the narrative portion, that the patient was using a nebulizer. There was no evidence of an order outlining instructions for use and dosage of this medication.

Upon patient record review, 6 of 14 (Patient #1,2,3,4,5,6) 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 equipment and supply needs. Patient #1 - The nursing comprehensive dated 05/23/25, documented that the patient was incontinent and utilizing oxygen for comfort. There was no evidence that oxygen supplies or incontinent supplies were included on the supply list on patient's POC. Patient #2 - The nursing comprehensive dated 04/02/25, documented that the patient was incontinent and utilizing oxygen for comfort. There was no evidence that oxygen supplies or incontinent supplies were included on the supply list on patient's POC. Patient #3 - The nursing comprehensive dated 02/10/25, documented that the patient was incontinent and utilizing oxygen for comfort. There was no evidence that oxygen supplies or incontinent supplies were included on the supply list on patient's POC. Patient #4 - The nursing comprehensive dated 12/06/24, documented that the patient was incontinent and utilizing oxygen for comfort. There was no evidence that oxygen supplies or incontinent supplies were included on the supply list on patient's POC. Patient #5 - The nursing comprehensive dated 11/15/24, documented that the patient was incontinent of bowel and bladder. There was no evidence of incontinent supplies included on the supply list on patient's POC. Patient #6 - The nursing comprehensive dates 07/04/24, documented that the patient utilizes a nebulizer machine. There was no evidence that the nebulizer was included on the supply list on patient's POC.

Upon patient record review 4 of 14 (Patient #1,3,4,10) 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 - The nursing comprehensive assessment dated 05/23/25, noted the need for volunteer services. There was also documentation that the volunteer need for this patient could be provided by the "SNF staff." There was no evidence that a volunteer evaluation was ordered or completed. Patient #3 - The nursing comprehensive assessment dated 04/02/25, noted the need for volunteer services. There was also documentation that that volunteer need could be provided by the "SNF staff." There was no evidence that a volunteer evaluation was ordered or completed. Patient #4 - The nursing comprehensive showed evidence that a referral was made for a volunteer evaluation to assess for need. There is no evidence in the record that a volunteer evaluation was completed. Patient #10 - The spiritual comprehensive completed 01/07/25 had included a narrative note by the spiritual care coordinator which stated "patient has requested continued chaplain visits throughout his hospice journey." Upon review of the admission IDG note dated on 01/07/25, the same spiritual care coordinator documented "patient declined spiritual care." There was no other evidence in the record of a different conversation with the patient to where they declined spiritual care.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 7 - The agencies policy on bag technique revision date of 05/11/25, under 4.1.10, states "the use of paper towels or other barrier such as plastic , underpad, etc., must be used while performing various patient functions". Upon home observation, noted RN entered the home and set her bag on the patient's bedside table without a barrier between the table and the bag.

Upon personnel record review, 1 of 13 (Personnel #8) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #8 - The agency job description for bereavement coordinator outlines qualifications to be "bachelor's degree or equivalent theological degree from college or university. Experience with families/caregivers and patients through death/dying issues - OR - Master's degree in Social Work with qualifications of experienced clinical grief counseling". There is evidence listed on her resume of a Bachelor Degree in Science and Nutrition and nine months of experience in a SNF.

Upon patient record review 1 of 14 (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #4 - The aide plan of care 05/27/25 contained an aide frequency order for 2x/week. Patient was seen the week of 6/1/25 on 6/1/25; 6/2/25; and 6/4/25 without evidence of an order for extra visit.

Upon patient record review, 2 of 5 records (Patients #1,#4) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 1 and 4: The election of benefit forms did not have the section completed for choice to elect an attending physician.

Upon patient record review, 2 of 5 records (Patients #3,#4) 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. Patient 3: The medication profile contained diclofenac gel with no instructions of area for application. Corrected on site. Patient 4: The medication profile contained dulcolax suppository and milk of magnesia with frequencies listed as needed. There was no evidence of defined frequency required between administrations.

Upon patient record review, 1 of 5 records (Patient #1) 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 1: There was no evidence of an initial bereavement assessment completed.

Upon patient record review, 3 of 5 records (Patients #2,#3,#4) 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 equipment and supply needs. Patient 2: The medical record contained nursing documentation upon admission identifying patient use of walker and wheelchair and a shower chair referral to the DME supplier. There was no evidence of the walker, wheelchair and shower chair included on the plan of care. Corrected on site. Patient 3: The medical record contained nursing documentation upon recertification identifying patient use of wheelchair. There was no evidence of the wheelchair included on the plan of care. Corrected on site. Patient 4: The medical record contained nursing documentation upon admission identifying patient use of hospital bed, wheelchair and oxygen. There was no evidence of the bed, chair, and oxygen included on the plan of care.

Upon client record review, 2 of 5 (Patient #2 and 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 2: The medical record also contained social worker visits completed 2/23/22 and 3/23/22. There was no evidence of an order for social worker frequency included in the plan of care. Corrected on site. Patient 3: The medical record contained social worker visits completed 2/24/22 and 3/29/22 as well as spiritual care visit completed 4/6/22. There was no evidence of orders for social work and spiritual care frequencies included in the plan of care. Corrected on site.

Upon patient record review 1 of 5 (Patient #1) did not have evidence in the patient record that the hospice has provided spiritual counseling in accordance with the patient/family's desires. Patient 1: The initial spiritual assessment was condensed and completed by nurse to address religious affiliation, current concerns addressed and if spiritual care was needed. The documentation identified that spiritual care was needed but did not address the nature and scope of spiritual concerns or needs. No evidence that spiritual care services were provided as identified.

Upon patient record review, 2 of 4 applicable (Patient #1 and 2) 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 The aide care plan also contained an assigned task for monitoring of oxygen that was a data entry error by the nurse. The patient did not use oxygen. Patient #2: The medical record contained nursing documentation 4/10/22 identifying patient request to discontinue aide services. There was no evidence of an order to discontinue aide services in the medical record.

Upon patient record review 1 of 4 applicable records (Patient #3) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient 3: The medical record contained an order frequency for aide visits once weekly. There was no evidence of an aide visit completed the week of 5/15/22.

Upon patient record review, 1 of 5 records (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 5: There was no evidence of a CTI completed for the patient. Corrected on site.

Upon patient client record review, 4 of 5 records (Patients #1,#2,#4,#5) did not have evidence that each patient record contains signed election statement in accordance with 418.24 Patient 1, 2, 4 and 5: Patient elected to receive notice of non-covered hospice items. There was no evidence the patients received the notification. Patient 1 and 4: The election of benefit forms did not have the section completed for choice to elect an attending physician.

Upon patient client record review, 2 of 5 records (Patients #1,#4) 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 1: The plan of care had conflicting nursing frequencies listed as twice weekly in one order section and once weekly in the frequency section. Corrected on site. Patient 4: The transfer form had an effective date of 1/19/22. The medical record had discharged date of 1/21/22.