Every finding on record at Coastal Hospice of Socal Inc

Upon patient record review, 1 of 5 (Patient #5) 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 5: The Plan of Care contained MSW frequency orders, "Initial assessment and evaluation at SOC, every recertification period, and as needed for psychosocial management." Also, the Plan of Care contained SC frequency orders, "Initial assessment and evaluation at SOC, every recertification period, and as needed for spiritual counseling." There was no further evidence of the amount of PRN visits that would be permitted before reevaluation of visit frequency was indicated to ensure the scope and frequency of services rendered meet the specific patient and family needs.

Upon patient record review, 2 of 5 (Patient #2, 3) 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 RN summary for the IDG meetings on 8/1/25 and 7/3/25 and nursing visits for 6/27/25 and 7/26/25 indicated use of a wheelchair. There was no documented evidence found of a wheelchair contained in the plan of care. Patient 3: The RN recertification visit dated 7/17/25 indicated the use of a hospital bed, over bed table, and shower chair. There was no evidence of these DME items contained in the plan of care.

Upon patient record review, 3 of 14 (Patient #4,5,7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #4: There is no evidence that the patient or caregiver right to choose their attending physician was honored. The record indicated the patient start of care was on 10/07/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice. Patient #5: There is no evidence that the patient or caregiver right to choose their attending physician was honored. The record indicated the patient start of care was on 01/10/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice. Patient #7: There is no evidence that the patient or caregiver right to choose their attending physician was honored. The record indicated the patient start of care was on 10/07/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice.

Upon patient record review 4 of 14 records reviewed (Patient #5, #6, #7, #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 #5,10: There was no evidence of the spiritual or psychosocial comprehensive assessment being completed at the time of the survey. Patient #6: There was no evidence of the psychosocial comprehensive assessment being completed at the time of the survey. Patient #7: There was no evidence of the spiritual comprehensive assessment being completed at the time of the survey.

Upon patient record review, 2 of 14 records reviewed (Patient #2, #7) 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 record indicated Nystatin 100,000 U/g one application apply to affected area two times a day, there was not an amount or site location listed. COS. Patient #7: Lidocaine 2% apply thin layer to affected area Q6hours prn pain, there was no specific site location. COS.

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 observation, there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patient #10: There was no evidence of the Chaplain and or Social Worker attending the IDG on 07/30/24. No evidence the IDG was composed of all individuals to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient.

Upon patient record review, 3 of 14 records reviewed (Patient #3, #8, #12) 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 record indicated the patient was on Plavix 75mg via G Tube every day, there was no individualized written plan of care to address bleeding precautions to reflect patient/family goals and interventions based on the problem. COS. Patient #8: The record indicated the patient and patients spouse spoke Spanish only, the daughter spoke English. There was no individualized plan or care to address how the staff would communicate when the daughter wasn't present there were no patient/family goals and interventions based on this problem. Patient #12: The record indicated the patient was discharged on 04/15/25 for extended prognosis, there was no individualized planning to reflect the patient and or family goals and interventions.

Upon patient record review, 7 of 14 records reviewed (Patient #1, #2, #3, #5, #6, #7, #8) 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 #1: The Spiritual Care visits were order to be done initially and prn. There was no scope and frequency. COS. Patient #2,5,6,8: The Spiritual Care visits and Social Worker were both ordered for initial, recert and prn. There was no scope and frequency. COS. Patient #3,7: The Social Worker care visits were ordered initial, recert and prn. There was no scope and frequency. COS.

Upon patient record review, 2 of 14 charts reviewed (Patient #2, #7) 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 record indicated orders for Nystatin 100,000 U/g one application apply to affected area two times a day, there was not an amount or site location listed. COS. Patient #7: Lidocaine 2% apply thin layer to affected area Q6hours prn pain, there was no specific site location.

Upon patient record review, 2 of 14 records reviewed (Patient #1, 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 equipment and supply needs. Patient #1: The record indicated an order may suction excessive oral secretions with yankauer tip as needed. There was no suction machine listed on the plan of care. COS. Patient #10: The record indicted an order for Oxygen 2 LPM via NC as needed for SOB, wheezing, respiratory distress and comfort, may increase to 4 LPM for respiratory distress, there was no oxygen concentrator on the plan of care.

Upon patient record review, 2 of 14 records reviewed (Patient #2, #5) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #2: Levaquin was ordered on 05/28/25 for a respiratory infection, there was no individualized written plan of care that reflected the patient and family goals and interventions based on the infection. COS. Patient #5: The Social Worker assessment on 05/06/25 stated the patient was "confused", the plan of care was not updated based off the comprehensive assessment due to the intervention stated the social worker would allow the patient to verbalize feelings, but the patient was unable to do so. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #2) 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 Social Worker visit orders were initially, recert and prn. The Social Worker made visits on 11/25/24, 12/19/24, 01/17/25, 02/20/25, 03/27/25, 04/19/25 and 05/19/25 and was making monthly visits since the start of 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. During the home visit the nurse did not use a barrier to place the nursing bag on and did not have a clean barrier for the equipment. Once the equipment was used the dirty equipment was placed on the corner of the table and cleaned with alcohol then placed in the bag there was no time allowed for the equipment to dry.

Upon patient record review, 1 of 14 records reviewed (Patient #3) 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 #3: The record indicated the patient was on Plavix 75mg via G Tube every day, there was no evidence of bleeding precautions on the hospice aide care plan. COS.

Upon patient record review 1 of 14 (Patient #10) 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 #10: An order for the aide to make a visit 1 X W was ordered on 07/30/24, there was no visit made during 07/30/24 to 08/04/24.

Upon patient record review 1 of 14 records reviewed (Patient #3) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #3: There was no evidence of a supervisory visit by an RN for the hospice aide between 04/07/25 to 04/23/25.

Upon patient record review, 3 of 14 (Patient #2,3,4) 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 #2: There was no evidence of a narrative for the first benefit period from 11/24/24 -02/21/25. Patient #3: There was no evidence of a narrative for the first benefit period from 10/27/24 - 01/24/25. Patient #4: There was no evidence of a narrative for the first benefit period from 10/07/24 - 01/04/25.

Upon patient record review, 5 of 14 (Patient #1,2,3,4,5) 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 #1: There was no evidence of the physician narrative on the CTI and or an addendum for the 2nd benefit period from 04/18/25 - 07/16/25. Patient #2: There was no evidence of the physician narrative on the CTI and or an addendum for the 2nd benefit period from 02/22/24 - 05/22/25 and the 3rd benefit period from 05/23/25 - 07/21/25. Patient #3: There was no evidence of the physician narrative on the CTI and or an addendum for the 2nd benefit period from 01/25/25 - 04/24/24 and the 3rd benefit period from 04/25/25 - 06/23/25. Patient #4: There was no evidence of the physician narrative on the CTI and or an addendum for the 2nd benefit period from 01/05/25 - 04/04/25, 3rd benefit period from 04/05/25 - 06/03/25 and the 4th benefit period from 06/04/25 - 08/02/25. Patient #5: There was no evidence of the physician narrative on the CTI and or an addendum for the 3rd to the 9th benefit period: 3rd benefit 05/12/24 to 07/10/24, 4th benefit 07/11/23 to 09/08/24, 5th benefit 09/09/25 to 11/07/24, 6th benefit 11/08/25 to 01/06/25, 7th benefit period from 01/07/25 to 03/07/25, 8th benefit 03/08/25 to 05/06/25 and the 9th benefit 05/07/25 to 07/05/25.

Upon patient record review, 3 of 14 records reviewed (Patient #4, #5, #7) did not have evidence 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 #4: The record indicated the patient start of care was on 10/07/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice. Patient #5: The record indicated the patient start of care was on 01/10/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice. Patient #7: The record indicated the patient start of care was on 10/07/24 and they did not choose a health care provider including an attending, this was left blank on the election of hospice.

Upon patient record review, 1 of 14 charts reviewed (Patient #2) did not have evidence that each patient record contains Advance Directives. Patient #2: There was no evidence on the chart Advance Directives were discussed and or reviewed with patient and or family.

Upon patient record review, 2 of 14 records reviewed (Patient #1, #2) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1,2: There was no evidence in the record that the hospice provided information and discussed the policies and procedures for managing controlled drugs. The form was left blank.

Observed in Patient Home. In 1 of 2 skilled nursing visits, the organization did not assess and reassess its patients for medication effectiveness and/or potential problems. During HV#2, it was noted the skilled nurse did not reassess/reconcile the patient's medications. When asked how often the patient's medications were reassessed/reconciled, the nurse indicated monthly medication reconciliations were performed. Upon review with the Director of Patient Care Services (DPCS), it was confirmed the organization's policy and standard outlined medications were to be reassessed/reconciled every skilled nursing visit. This was reviewed/verified with the DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not assess/reassess its patients by conducting and documenting a patient-specific comprehensive assessment that included survivor bereavement risk factors before the death. In RR#1, the bereavement assessment section of the RN's initial comprehensive assessment was blank. It was also noted the MSW's and Spiritual Care Counselor's initial assessments did not include a bereavement risk assessment. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Pharmacy. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned, including practicing standard precautions. In HV#2, the skilled nurse did not follow the organization's policy and procedure/CDC standards when performing hand hygiene. It was confirmed the nurse wore artificial nails longer than 1/4 inch in length, and did not apply friction to the nail areas/cuticles according to policy and procedure/standards when using hand gel. This was reveiwed and verified with the Director of Patient Care Services.

Observed in Record Review. In 1 of 5 patient records reviewed, the organization did not ensure the hospice aide provided services as ordered in accordance with the plan of care. In RR#1, the aide care plan indicated the aide was to reposition the patient, change bed linens, make the bed, and straighten the patient's room every visit. These tasks were not completed, and were unchecked on several aide visit notes. This was reveiwed and verified with the Director of Patient Care Services.

Observed in HR File Review. In 3 of 8 HR files reviewed, the organization did not ensure staff were competent to perform their responsibilities by assessing and documenting competence as part of orientation. In HR#3, the Spiritual Care Counselor's competencies were documented by a past college instructor who indicated the competency assessment was based on training/instruction provided 10 years prior. In HR#7, (hospice aide) and HR#8 (LVN), the Initial Competency Skills Assessment/Checklist was blank for most skills, with competency assessed verbally on those skills that were documented by RN. This was reveiwed and verified with the Administrator and Director of Patient Care Services.