Every finding on record at Crescenta Hospice Care Inc.

Upon patient record review, 1 of 14 (Patient #6) 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 #6, RN assessment completed on 7/21/25 then 8/15/25. No evidence of comprehensive assessment no less frequently than every 15 days.

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 #1, 10, IDG meeting dated 11/10/25,11/24/25, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #4, IDG meeting dated 8/5/25, 8/18, 9/1,9/15, 9/29, 10/13, 10/27, 11/10, 11/24, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #5, IDG meeting dated 10/13/25,10/27,11/10,11/24, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #6, IDG meeting dated 11/24/25, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #7,8,IDG meeting dated 10/27/25, 11/10, 11/24, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care. Patient #9, IDG meeting dated 7/7/25, 7/21, 8/4, 8/18, 9/1,9/15, 9/29, 10/13, 10/27, 11/10, 11/24, missing signatures of MSW. The disciplines were actively involved with the patient therefore there was no evidence the IDG reviewed/revised the plan of care.

Upon patient record review, 8 of 14 (Patient #1,2,3,4,5,6,7,9) 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 #1,7, Patient is a full code status. No evidence of goals and interventions related to full code status. Bereavement assessment documents caregiver has having anticipatory grief. No evidence of goals and interventions related to anticipatory grief. Patient #2,5,6,MSW initial assessment does not identify funeral home. No evidence of goals and interventions related to funeral home arrangement status. Bereavement assessment documents caregiver has having anticipatory grief. No evidence of goals and interventions related to anticipatory grief. Patient #3,4,9 Bereavement assessment documents caregiver has having anticipatory grief. No evidence of goals and interventions related to anticipatory grief.

Upon client record review, 3 of 14 (Patient #4,8,9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4, MSW frequency documented as eval only. No evidence of additional orders. MSW visits completed 9/5, 10/4, 11/2, 12/1/25 without order for additional visits. Patient #8, MSW frequency documented as every recertification. MSW visits completed monthly 10/15, 11/13/25 without order for additional visits. Patient #9, MSW frequency documented as eval only. No evidence of additional orders. MSW visits completed 9/6, 10/5, 11/3/25, without order for additional visits.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) 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 #1,2,3,4,5,6,7,8,9,10, No evidence of clinical documentation in CTI documented by Medical Director.

Upon patient client record review, 1 of 5 (Patient #3) 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. Patient #3: RN SOC Comprehensive Assessment narrative documents "Currently taking Donepezil Hydrochloride 5 mg tablet 1 tab daily as needed for anxiety management." The order is written for daily at bedtime, rather than as needed. Verified during home visit.