Every finding on record at Hillhurst Hospice Inc.

Upon patient record review, 5 of 5 (Patient 1-5) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1-5: No evidence in record that the comprehensive assessment took into consideration the imminence of death. Section left blank in each patient's comprehensive assessment.

Upon patient record review, 1 of 5 (Patient #5) 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 5 no update to the comprehensive assessment by the RN from 2/23/23 to 3/27/23.

Upon client record review, 1 of 5 (Patient 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: The visit frequency for the skilled nurse was indicated on plan of care orders as "SN 1x week and 2 prn visits for symptom management. There is no evidence of any SN visits for weeks 3/12/23 and 3/19/23.

Upon patient record review 1 of 5 (Patient 5) 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 5: Plan of care orders for aide services state a frequency of "HHA 2x week". Documentation in medical record of aide services being provided for week of 3/12/23 with 1 Aide visit on 3/14/23; and no visits for weeks of 3/19/23 and 3/26/23.