Every finding on record at La Elder Hospice and Palliative Care, Inc.

Upon observation, there was no evidence the agency has conducted exercises to test the emergency plan every two years. During 01/07/2025 wildfires, hospice personnel documented communication with hospice patients directly in their charts per expectations. After the emergency was over, there was no evidence of emergency preparedness summary, plan update, or staff meeting documented. COS

Upon patient record review 6 of 14 (Patient #2,3,4,5,6,9) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 2: Patient admitted 11/10/2023. Initial spiritual assessment documented 02/08/2024, which is outside the initial 5 days of care. Patient 3: Patient admitted 11/15/2024. Initial psychosocial assessment documented 11/21/2024, which is outside the initial 5 days of care. Patient 4: Patient admitted 01/03/2025. Initial psychosocial assessment documented 01/16/2025, which is outside the initial 5 days of care. Patient 5: Patient admitted 05/16/2024. Initial spiritual assessment documented 01/20/2025, which is outside the initial 5 days of care. Patient 6: Patient admitted 12/16/2024. Initial psychosocial assessment documented 12/28/2024, which is outside the initial 5 days of care. Patient 9: Patient admitted 11/14/2024. Initial psychosocial assessment documented 11/20/2024, which is outside the initial 5 days of care.

Upon patient record review 9 of 14 (Patient #1,2,5,7,8,9,10,12,14) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1,9,10,14: There is no evidence of initial spiritual assessment in the medical record. Patient 2,5,8,12: There is no evidence of initial psychosocial assessment in the medical record. Patient 7: There is no evidence of initial psychosocial or spiritual assessment in the medical record.

Upon patient record review, 3 of 14 (Patient #1,3,4) 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. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Medication list digoxin 125mcg by mouth daily. There is no evidence of administration parameters on the medication list. COS Patient 3: medication list diclofenac 1 percent. Apply pea size to knee twice daily as needed for knee pain. There is no evidence to application site on the medication list. COS Medication list for Salonpas Patch. Apply one patch to lower back daily as needed for pain. There is no evidence of dosage or on/off instructions on the medication list. COS Patient 4: Medication list Lamisil 1 percent. Apply peasize amount topically twice daily for 14 days. There is no evidence of application site on the medication list. COS

Upon patient record review, 1 of 14 (Patient #12) 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 12: Patient admitted 12/01/2023. Initial bereavement assessment documented 12/18/2023, which is outside the initial 5 days of care.

Upon patient record review, 2 of 14 (Patient #1,3) 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 1: Physician’s SN visit frequency order is twice weekly. The most recent SN visit documented in patient’s chart is 02/18/2025, no evidence of comprehensive assessment completed as the condition of patient requires, but no less frequency than every 15 days. Patient 3: The physician’s visit frequency order for SN is weekly and 2PRN. The most recent SN visit documented in the medical record is dated 01/29/2025. There is no evidence of SN visit between 1/11/25 and 1/22/25. no evidence of comprehensive assessment completed as the condition of patient requires, but no less frequency than every 15 days.

Upon patient record review, 4 of 14 (Patient #1,3,4,7) 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 1: Identified needs without problems, goals, interventions on the plan of care: high risk for skin breakdown. Patient 3: Identified needs without problems, goals, interventions on the plan of care: pain, oxygen, confusion, high risk for skin breakdown. Patient 4: Identified needs without problems, goals, interventions on the plan of care: high risk for skin breakdown, bleeding precautions. Patient 7: Identified needs without problems, goals, interventions on the plan of care: oxygen, confusion.

Upon patient record review, 6 of 14 (Patient #1,2,3,8,9,11) 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 1,3,11: Physician’s visit frequency order for spiritual care and for social work: X1, then PRN. There is no evidence of ordered scheduled visits or a quantifier for PRN visits. Patient 2: Physician’s visit frequency order for spiritual care: X1, then PRN. There is no evidence of ordered scheduled visits or a quantifier for PRN visits. Patient 8: Physician’s visit frequency order for spiritual care: X1PRN. There is no evidence of ordered scheduled visits. Patient 9: Physician’s visit frequency order for social work: X1, then PRN. There is no evidence of ordered scheduled visits or a quantifier for PRN visits.

Upon patient record review, 3 of 14 (Patient #1,3,4) 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 1: Plan of care with order for digoxin 125mcg by mouth daily. There is no evidence of administration parameters on the plan of care. COS Patient 3: plan of care with order for diclofenac 1 percent. Apply pea size to knee twice daily as needed for knee pain. There is no evidence to application site on the plan of care. COS Plan of care with order for Salonpas Patch. Apply one patch to lower back daily as needed for pain. There is no evidence of dosage or on/off instructions on the plan of care. COS Patient 4: Plan of care with order for Lamisil 1 percent. Apply peasize amount topically twice daily for 14 days. There is no evidence of application site on the plan of care. COS

Upon patient record review, 2 of 14 (Patient #4,7) 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 4: There is no evidence of DME on the plan of care, despite identified need: walker. Patient 7: There is no evidence of DME on the plan of care, despite identified need: suction machine.

Upon client record review, 4 of 14 (Patient #4,5,6,8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 4: IDG dated 02/13/2025 is blank. Patient 5,8: In all IDG notes, social worker documents “MSW for initial visit then one visit/month for emotional and psychosocial support,” in all IDG notes. There is no evidence of social worker plan of care review or update. Patient 6: Patient’s initial IDG 12/16/2024, which is day of admission. The next IDG is dated 01/02/2025, which is 17 days.

Upon client record review, 6 of 14 (Patient #1,2,3,6,7,8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Physician’s SN visit frequency order is twice weekly. The most recent SN visit documented in patient’s chart is 02/18/2025. Patient 2: Physician’s visit frequency order for social work: once monthly and 1PRN. Documented visits: 11/13/23, 2/8/24, 5/8/24, 7/5/24. This is less than the once monthly frequency ordered by the physician. Patient 3: There are 2 scheduled SC visits documented in the medical record, on 12/16/24 and 1/15/25. Physician’s visit frequency order for SC is X1, then PRN. There is no evidence of order for these scheduled visits. The physician’s visit frequency order for SN is weekly and 2PRN. The most recent SN visit documented in the medical record is dated 01/29/2025. There is no evidence of SN visit between 1/11/25 and 1/22/25. Patient 6: Patient has 2 visit frequency orders for SN, both written on date of admission (12/16/24). Order 1 is weekly and order 2 is every other week. From 1/28/25 to present, patient has been seen by SN every other week. Patient 7: There are 2 PRN visits made by social work on 11/13/24, and 11/15/24. There is no evidence of a physician’s order for these visits in the medical record. Patient 8: SC has visited patient once every recertification period. There is no evidence of physician’s order for these visits, as order reads: X1PRN. SC visited the patient 1/18/25. There is no evidence of physician’s order for this visit in the medical record.

Upon patient record review, 3 of 14 (Patient #1,4,7) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 1: Assigned aide tasks without assigned frequency: turn/reposition; change patient’s linen. COS Patient 4: Assigned aide tasks without assigned frequency: turn/reposition; street clothes; feeding assist; change patient’s linen. COS Patient 7: Assigned aide tasks without assigned frequency: turn/reposition; street clothes; pajamas/gown; record bowel movement; transfer per 1-assist and mechanical lift; feeding assist; change patient’s linen. COS

Upon patient record review 3 of 14 (Patient #1,4,7) 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 1: Aide visit frequency order is twice weekly. Most recent aide visit documented in the medical record is dated 02/14/2025. Patient 4: Aide visit frequency order is three times weekly. Most recent aide visit documented in the medical record is dated 02/07/2025. Patient 7: Aide visit frequency order is three times weekly. Most recent aide visit documented in the medical record is dated 02/06/2025. Additionally, patient was seen by aide only twice this week. Tasks not documented as completed: Feeding section of care plan on 12/21/24, 12/26/24,1/3/25, 1/6/25,1/10/25,1/14/25,1/23/25. Patient status/additional care section of care plan on 1/10/25. Tidy patient room, empty trash, light housekeeping on 1/3/25. Diet as tolerated on 1/8/25.

Upon patient record review 3 of 14 (Patient #1,4,7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient 1: Aide visit frequency order written 12/10/24. Only documented aide supervisory visit in medical record dated 1/20/25. Patient 4: There is no evidence of aide supervisory visit 1/23/25-2/9/25, which is 17 days. Patient 7: Most recent aide supervisory visit documented on 1/11/25.