Every finding on record at Encino Valley Hospice, Inc.

Upon patient record review, 1 of 14 (Patient #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 #10: There is evidence in the record the Chaplain visit frequency is "as needed to provide spiritual support to the patient and family" which does not contain a detailed statement for scope and frequency.

Upon patient record review, 5 of 14 (Patient #1, #3, #6, #8, #10) 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 #1: There is evidence in the record that on 5/4/24 the Plan of Care identified Psychosocial Problem: Knowledge deficit advanced directives, funeral planning and lacks coping skills. There is no documented follow up on the IDG discussion/Updated comprehensive Assessment Review on 5/13/24, 5/27/24, 6/10/24 and 6/24/24 and 7/8/24. Patient #3: There is evidence in the record that on 5/5/24 recertification, the Plan of Care identified Psychosocial Problem: Potential knowledge deficit a related to Hospice philosophy and risk potential for psychological distress related to patients terminal diagnosis. Funeral Planning. There is no documented follow up on the IDG discussion/Updated comprehensive Assessment Review on 5/13/24, 5/27/24, 6/10/24 and 6/24/24 and 7/8/24. Patient #6: There is evidence in the record that the initial plan of care on identified Psychosocial Problem: Knowledge deficit related to patients terminal diagnosis. There is no documented follow up on the IDG discussion/Updated comprehensive Assessment Review on 4/15/24, 4/29/24, 5/13/24, 5/27/24, and 6/10/24. Patient #8: There is evidence in the record that on 4/1/24, the Plan of Care identified Spiritual Problem: Risk of spiritual distress related to patients terminal diagnosis. There is no documented follow up on the IDG discussion/Updated comprehensive Assessment Review on 4/15/24, 4/29/24, 5/13/24, and 5/27/24. Patient #10: There is evidence in the record that on 4/15/24, the Plan of Care identified Spiritual Problem: Risk of spiritual distress related to patients terminal diagnosis. There is no documented follow up on the IDG discussion/Updated comprehensive Assessment Review on 4/29/24, 5/13/24, and 5/27/24, 6/10/24, and 6/24/24.