Every finding on record at Delta Hospice of Inland Valley, Inc.

It is required that each patient’s individualized written plan of care reflects patient and family goals, and Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview in which 3 of 11 (27%) records revealed the plan of care (POC) lacked goals and interventions for relevant treatment. Record #62909: The patient was admitted 10/8/21. The initial nursing assessment narrative dated 10/8/21 states the patient is incontinent to bowel and bladder functions. The POC dated 10/8/21 lacked a goal and interventions for bowel and bladder incontinence. Record# 24000: The patient was admitted 7/24/20. The frequency for both the social worker and the chaplain is 1x/month and 1 prn/month for increased psychosocial or spiritual needs. The POC dated 3/9/21 lacked a goal and interventions for the social worker and the chaplain. Record #76790: The patient was admitted 7/1/21. The face-to-face dated 9/29/21 stated that stents failed, and the patient had bilateral nephrostomy tubes. The POC dated 9/29/21 lacked a goal and interventions for the nephrostomy tubes. Policy #9-017, "The Plan of Care", states in part, "The care provided to the patient must be in accordance with the POC. The POC will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group . . .". The DPCS who was interviewed, reviewed and agreed with the above findings. L-545 | §418.56(c)

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 41.I and the patient’s record, if requested. This standard was not met as evidenced by clinical record review and document review in which 2 of 2 (100%) records reviewed for a patient that transferred to another hospice, and a patient who revoked hospice to seek aggressive treatment, and was taken to the hospital, revealed the record lacks evidence that the discharge summary, and required components were sent to the hospital. Record #24000: The patient was admitted 7/24/20. The patient was transferred to another hospice on 4/7/21. The record lacks evidence that the discharge summary and required components being sent to the receiving Hospice. Record #56211: The patient was admitted 4/19/21. The family revoked hospice on 7/21/21 because the patient was taken to the hospital to pursue aggressive treatment. The record lacks evidence that the discharge summary and required components being sent to the receiving Hospital. Policy #1-022, "Transfer Information", states in part, "Procedure: 2. The transferring clinician will provide a verbal report to the receiving organization with a preliminary report on the patient. 4. Completed transfer summaries will be given to a clinical records clerk who will send a copy to the receiving organization within 72 hrs of transfer and file the original in the clinical record." The DPCS who was interviewed, reviewed and agreed with the findings. L-682 | §418.104(e)(1)