Every finding on record at La Crescenta Hospice Care, Corp.

Upon patient record review, 6 of 14 (Patients #1,3,5,7,8,10) 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 Patients #1,7,8,10: BC/SC and MSW indicated 1 extra visit per request. This frequency did not include a baseline visit frequency for the SC/BC or MSW. Patients #3,5: BC/SC indicated 1 extra visit per request. This frequency did not include a baseline visit frequency for the SC/BC.

Upon patient record review, 3 of 14 (Patients #2,3,5) 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 equipment and supply needs. Patient #2: This patient had a cane and walker. These were not included on the Plan of Care. Additionally, Hospital Bed was indicated on POC, per daughter this was picked up as patient would not use. Patient #3: This patient had a cane, walker and wheel chair. These were not included on the Plan of Care. Patient #5: The record reflected that this patient had a Albuterol and Duo-Neb inhalation solutions. The Nebulizer machine was not included on the Plan of Care.

Upon personnel record review, 1 of 12 (Personnel #8) did not have evidence in the personnel file that the Aide's initial competency assessment was observed with a patient or pseudo patient for the following: · Normal range of motion and positioning · Toileting and elimination

Upon patient record review 3 of 14 (Patients # 4,6,8) 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 Patient #4: The POC listed Aide Visit's 2X's per week. During 1st Benefit week there was one visit made by the aide on 1/4/24 only. Patient #6: The POC listed Aide Visit's 2X's per month. During month of August there were three visits made on 8/1, 8/15 and 8/29/23 Patient #8: The POC listed Aide Visit's 2X's per week. There have been no visits by Aide from 6/28/23 to date.

Upon patient client record review, 9 of 14 (Patients #2,3,5,6,7,8,11,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients 2,3,5,6,7,8,11: Elected to receive addendum “Patient Notification of Hospice Non-Covered Items, Services, and Drugs”. The agency processed timely through EMR. However, did not get addendum countersigned by patient/family at admission or 5 days thereafter. Agency corrected on site with current patients and obtained a countersigned signature during this survey (with exception of patient #11 who was not current and discharged). Patients #13,14: Agency has older form for these patients that do not include BFCC-QIO information or request for addendum as required.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) 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, 2, 3, 4, 5: The records indicated the patient was using oxygen. Oxygen did not appear on the medication list. (corrected onsite for active patients) Patient 2: There was no evidence of the patient's comfort pack on the medication list. The SN note dated 10.14.2021 indicated the alprazolam from the comfort pack had been used to control anxiety. The SN notes dated 10.13.2021 and 10.20.2021 indicated the Bisacodyl from the comfort pack had been used to control constipation. The SN notes dated 10.13.2021 and 10.27.2021 indicated the acetaminophen from the comfort pack had been used to control pain/discomfort. (corrected onsite)

Upon patient record review, 1 of 1 applicable (Patient #5) did not have evidence in the patient record that hospice aide assignments and duties indicate what tasks are to be done by the Aide and the frequency of these tasks. Patient 5: The hospice aide care plan, dated 08.13.2021, did not contain evidence of a frequency for the assigned aide tasks. Tasks assigned to the aide included providing a bed bath and shampoo for the patient.

Upon patient record review, 1 of 5 (Patient #4) 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 4: There was no evidence of a physician's narrative statement as part of the certification of terminal illness form.

Upon patient client record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that each patient record contains a signed election statement in accordance with 418.24 Patient 1, 2, 3, 4, 5: The election statement did not contain evidence of the required updates, effective 10.01.2020, providing patients notification of noncovered services and remediation via the BFCC-QIO.