Every finding on record at Encinitas Hospice Care, Inc

Upon patient record review of 19 (Patient #10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #10 - SOC 08/14/24, psychosocial assessment not complete initial visit until 08/21/24.

Upon patient record review, 14 of 19 (Patient #6,7,8,9,10,11,12,13,14,15,16,17,18,19) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death.

Upon patient record review, 2 of 19 (Patient #7, 15) 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 #7 - RN completed assessment on 10/22/24 then again on 11/08/24 -17 days between RN assessment visits. Patient #15 - RN completed assessment on 10/21/24 then again on 11/07/24 -17 days between RN assessment visits.

Upon patient record review, 3 of 19 (Patient #6, 12, 19) 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 - Wound care ordered on 10/06/24 did not contain wound site. Patient #12 - Wound care ordered on 11/17/24 did not contain wound care frequency. Patient #19 - wound care ordered on 11/18/24 did not contain wound care frequency.

Upon client record review, 1 of 19 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10 - SN visit not on 10/14/24 SN documented "cleaned wound with wound cleanser, applied bacitracin ointment and covered with Optifoam dressing. - no order for this wound care.

Upon patient record review 5 of 19 (Patient #6, 10, 11, 16, 17) 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 #6 - Aide visit on 09/13/24 and 09/18/24 Aide documented bed bath completed but shower was ordered on care plan. Patient #10 - Aide visit on 09/16/24 and 09/19/24 Aide documented shaved patient but task shaving was not ordered on care plan. Patient #11 - Aide visit on 10/25/24 and 10/31/24 Aide documented bed bath completed but shower was ordered on care plan. Patient #16 - Aide visit on 10/09/24, 10/11/24, 10/28/24 and 11/31/24 Aide documented bed bath completed but shower was ordered on care plan. Patient #17 - Aide visit on 09/10/24 and 09/17/24 Aide documented bed bath completed but shower was ordered on care plan.

Upon patient record review 2 of 19 (Patient #7, 15) 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 #7 - Aide supervisory visit completed on 10/22/24 then again on 11/08/24 -17 days between supervisory visits. Patient #15 - Aide supervisory visit completed on 10/21/24 then again on 11/07/24 -17 days between supervisory visits.

Upon client record review, 2 of 19 (Patient #9, 12) 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 #9 - Order written on 08/07/24 regarding wound care did not 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 #12 - Order written on 11/07/24 regarding wound care did not 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.

Based on interview and record review, the agency failed to update the plan of care to match the ordered visit frequency for one of eleven sampled patients (10). As a result, there was the risk of Patient 10 not receiving the ordered care and services. Findings: Per the agency's Plan of Care, dated 3/2/22, certification period 2/12/22 through 5/12/22, Patient 10's start of care was on 2/12/22, with a primary diagnosis of lung cancer. Per the Plan of Care, the ordered frequency of Skilled Nurse (SN) visits was one time per week, plus three as needed. Per the agency's Current Treatment / Medication / DME (Durable Medical Equipment) List, there was an order on 2/18/22 for the SN to visit Patient 10 two times per week plus three as needed. On 3/3/22 at 10:30 A.M., a concurrent interview and record review was conducted with the Director of Patient Care Services (DPCS). The DPCS found the latest order for Patient 10's SN frequency was two times per week on 2/18/22, but the Plan of Care listed the SN frequency at one time per week. The DPCS stated, the Plan of Care needed to be updated manually by the Case Manager (CM) when they received a new order, and it was an oversight that they didn't match. On 3/3/22 at 11:05 A.M., a telephone interview was conducted with the CM. The CM stated, when she received a new order for a patient, it was not her responsibility to update the Plan of Care. On 3/3/22 at 11:10 A.M., an interview was conducted with the DPCS. The DPCS stated, the CM should have known it was her responsibility to update the Plan of Care when she received a new order. Per the facility's policy, titled Entries Into the Clinical Record, revised April 2017, "...A clinical record will be initiated and maintained for each patient receiving care or services... and will include... updated plans of care..."