Every finding on record at La County Hospice, Inc

Upon patient record review, 3 of 14 (Patient #1, 5, 6) 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 01:Patient was admitted on 7/26/23 and is identified as a full code, the plan of care does not include a problem statement with interventions and goals to address the full code status. Patient 05:Patient was admitted on 7/28/23 and is identified as a full code, the plan of care does not include a problem statement with interventions and goals to address the full code status. Patient 06:Patient was admitted on 7/28/23 and is identified as a full code, the plan of care does not include a problem statement with interventions and goals to address the full code status.

Upon client record review, 7 of 14 (Patient #2, 4, 5, 7, 8, 9, 11) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 02: The plan of care includes orders for MSW visits to be performed monthly, there is no evidence in the patient record of a visit for September 2023. Patient 04: The patient was admitted on 9/4/23. The plan of care includes frequencies for MSW and SC visits one time per benefit period however visits were made by MSW on 10/10/23 and SC visit was made on 10/3/23 in addition to the initial evaluation performed within 5 days of admission. Patient 05: The plan of care includes order for SC visit to be performed monthly, there is no evidence in the patient's record of a visit for August 2023. Patient 07: The plan of care includes orders for MSW visits to be performed monthly, there is no evidence in the patient record of a visit for July 2023. Patient 08: The plan of care includes orders for MSW visits to be performed monthly, there is no evidence in the patient record of a visit for May and June 2023. Patient 09: The plan of care includes orders for MSW visits to be performed monthly, there is no evidence in the patient record of a visits for March and May 2023. The plan of care includes orders for SC to be performed monthly, there is no evidence in the patient record of a visit in June 2023. Patient 11: The plan of care includes orders for MSW visits to be performed monthly, there is no evidence in the patient record of a visit for June, July and August 2023.

Upon patient record review, 4 of 14 (Patient #4, 5, 7, 9) 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. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patient 04: The certification of Terminal illness for benefit period starting 9/4/23 does not include subjective and objective clinical findings, information regarding patient's conditions, or supportive data for the terminal condition. Patient 05: The certification of Terminal illness for benefit period starting 7/28/23 does not include subjective and objective clinical findings, information regarding patient's conditions, or supportive data for the terminal condition. Patient 07: The certification of Terminal illness for benefit period starting 7/13/23 does not include subjective and objective clinical findings, information regarding patient's conditions, or supportive data for the terminal condition. Patient 09: The certification of Terminal illness for benefit period starting 5/19/23 and 7/18/23 does not include subjective and objective clinical findings, information regarding patient's conditions, or supportive data for the terminal condition.

Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 08: MSW visits was performed on 9/15/22 and 5/10/23 that was not properly authenticated with a signature.