Every finding on record at La Patient Care Hospice

Upon patient record review 1 of 14 (Patient #8) 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 #8-Patient admitted 2/11/25 with visit frequency orders 1x/month, 1st SC visit with spiritual assessment made 3/16/25, no evidence of reason visit was not completed in 5 calendar days.

Upon patient record review, 1 of 14 (Patient #8) 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 #8-SOC 2/11/25, bereavement assessment not completed until 3/16/25.

Upon client record review, 1 of 14 (Patient #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 #8-SOC 2/11/25, Initial IDG not completed until 3/13/25.

Upon client record review, 5 of 14 (Patient #1,2,3,4,6) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1-SC visit frequency orders 1x/month, visits made 6/1/25 and 6/28/25 with no evidence of visit in 7/2025 or order for additional visit in 6/2025. Patient #2-SC visit frequency orders 1x/month, 5/2025 had 2 visits (5/2 and 5/27) with no evidence of order for additional visit. No SC visits were made 7/2025, no evidence of order to miss visit. Patient #3-LVN visit frequency order states "LVN_____ per week for changes in condition effective 8/1/25", no evidence of actual visit frequency number. LVN visits were made 8/1, 8/8, 8/15 and 8/22/25 with no evidence of order. MSW visits were made 1/4 and 3/27/25, no evidence of visit frequency orders in place. Patient #4-RN visit frequency orders for 1x/2 weeks, visit made 7/30/25with no evidence of next RN visit until 8/19, due 8/13. RN visit made on 8/19 and next visit due 9/5/25, no evidence of visit completed. Patient #6- POC for visit frequency for MSW 1x/recert period. MSW visits were made 8/1, 8/15, 8/29 and 9/12, no evidence of order for visit.

Upon patient record review 1 of 14 (Patient #2) did not have evidence that the IDG ensures that the care and services provided are based on all assessments of the patient and family needs. Patient #2-Labs ordered 5/7/25 and 6/2/25 with no evidence physician notified of lab results, no evidence of follow up with patient/family following labs.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #2-Labs ordered 5/7/25 and 6/2/25 with no evidence of results in patient record from lab.

Upon patient record review, 2 of 14 (Patient #6,8) 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 #6-Aide care plan 2/12/25 is incomplete with no evidence of what tasks are to be completed. Patient #8-Aide care plan 2/12/25 is incomplete with no evidence of what tasks are to be completed.

Upon patient record review 3 of 14 (Patient #3,6,8) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #3-Aide care plan task for checking patient vitals was not completed 9/4, 9/8, 9/11 and 9/15, no evidence of why POC was not followed or discussed with RN. Patient #6 and #8-Aide visits being made 1x/week since 3/2/25 with no evidence of POC.

Upon patient record review 1 of 14 (Patient #1) 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 supervisory visit completed 6/2/25, no evidence of supervisory visit until 8/1/25.

Upon observation, there was no evidence volunteers are used in day to day administrative and/or direct patient care roles.

Upon observation, there was no evidence the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel.

Upon patient record review, 1 of 14 (Patient #8) 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 #8-Patient transferred from another hospice with SOC 2/11/25, no evidence of CTI for BP 1 from previous hospice.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1-CTI for BP #4 has no evidence of physician signature.

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. 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: The initial comprehensive assessment and physician's CTI indicate that the patient is incontinent of urine and an insulin dependent diabetic. However, there have not been a care plans initiated or developed related to the patient's GU status, risk for skin breakdown, or endocrine status. (corrected onsite)

Upon patient record review, 1 of 5 (Patient #3) 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 3: The initial comprehensive assessment and physician's CTI indicate that the patient utilizes a Foley catheter. The IPOC indicates that the patient is supplied with a Foley catheter and related supplies. However, there is no evidence of a treatment order for the Foley. (corrected onsite)