Every finding on record at Glendale Hospice Inc.

Upon patient record review, 1 of 14 charts reviewed (Patient #5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #5: The initial bereavement assessment was not fully complete, there was no last name of the bereaved. COS.

Upon patient record review 4 of 14 charts reviewed (Patient #2, #3, #8, #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 #2: The record indicated the patient was taking Janumet 50mg/500mg one po BID. The individualized care plan on the start of care did not include what to report and to whom when the blood sugar was high and or low, there were no defined parameters listed in the interventions. COS. Patient #3: The patient was on Eliquis 2.5mg po BID at the start of care. There were no bleeding precautions on the plan of care. COS. Patient #8: The record indicated the patient was on Eliquis 5mg 1/2 tab po BID at the start of care. There were no bleeding precautions on the plan of care. Patient #9: The patient was on Humalog 100U/ml 5 U SC if BS is 200 and below, 8U if the BS is 201 or above, Lantus 100U/ml 15U SQ at bedtime and Jardiance 25mg po daily before breakfast, the individualized care plan on the start of care did not include what to report and to whom when the blood sugar was high and/or low. COS.

Upon patient record review, 2 of 14 charts reviewed (Patient #7,8) 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 #7,8: There was not a complete order for the ensure, the order did not have the amount and the specific time period i.e. 1-2 cans per day. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4: The social worker made a visit on 02/12/25 and there was no order for this visit. COS.

Upon patient record review 1 of 14 records reviewed (Patient #3) 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 #3: The patient was on Eliquis 2.5mg po BID at the start of care. There were no bleeding precautions on the Hospice Aide plan of care. COS.

Upon patient record review, 1 of 14 records reviewed (Patient #4) 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 elected to receive a copy of non covered items on admission. There was no evidence this was provided within 5 days. In addition, the patient chose an attending physician, but there was no physician name listed on the election of benefit. COS.

Upon patient record review, 1 of 5 (Patient #1) 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. Patient #1: A 5L Oxygen concentrator was listed as part of the patient's plan of care. Oxygen was not listed on the medication profile.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. Patient #1: Agency unable to evidence a care plan which identified the problems identified at the initial assessment. There were orders for the patient's care and clinical notes did evidence that care plan problems had been developed (as evidenced by care plan problems on the clinical note) but the agency could not produce the care plan itself for review during survey.

Upon patient record review 1 of 1 applicable patients (Patient #4) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #4: Aide did not complete the following ordered tasks on the 8/24/21 visit nor did the aide document why the tasks were not completed: bed bath, combing hair, shampoo, applying lotion, peri-care or visualizing skin.

Upon patient record review, 3 of 5 (Patient #1,2,3) 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. Patient #1: There was no evidence of a physician narrative on the certification of terminal illness or elsewhere in the documentation. Patient #2 and #3: Both narratives by the MD in the certification of terminal illness documented that the patients were to be admitted to a different Hospice name.