Every finding on record at Los Feliz Hospice Healthcare

Upon patient record review, 2 of 14 (Patients #1, 9) 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:Polyethylene Glycol order (7/7/23) with no diluent ordered. Corrected on Site. Patient# 9: Nebulizer machine listed in DME Section of POC. No Nebulizer meds ordered or on medication list.

Upon patient record review, 1 of 14 (Patient #6) 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 #6: There is no initial bereavement assessment completed to date. Start of care is 8/23/23. Corrected on Site.

Upon patient record review, 2 of 14 (Patient #2, 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 equipment and supply needs. Patient #2: This patient had a wheel chair and BST. This was not included on the Plan of Care. Corrected on Site. Patient #3: This patient had a wheel chair, hospital bed and BST. This was not included on the Plan of Care. Corrected on Site.

Upon client record review, 1 of 14 (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 POC listed volunteer visit frequency of, 1 X per month. For the month of August there were no visits made by the volunteer. Coordination note from volunteer of one attempted visit for the month of August.

Upon personnel record review, 1 of 13 (Personnel #10) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient. Personnel #10: The Aide Initial Competency was not verified for Normal Range of Motion.

Upon patient record review 4 of 14 (Patients #5,6,7,8) 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 #5: The POC listed Aide visit frequency of, 2 X's per week. There were no visits made by the aide on the first benefit week as ordered. Patient #6: The POC listed Aide visit frequency of, 2 X's per week. There were no visits made by the aide on the first benefit week as ordered. Patient #7: The POC listed Aide visit frequency of, 2 X's per week. There were no visits made by the aide on the first benefit week as ordered. Patient #8: The POC listed Aide visit frequency of, 2 X's per week. There were no visits made by the aide on the first or second benefit week as ordered.

Upon patient client record review, 12 of 14 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1, 2, 3, 4, 5, 6, 7, 10, 11,13: The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” information on EOB did not have a choice for patient/caregiver to elect or decline this. Patients #8, 12: The “Patient Notification of Hospice Non-Covered Items, Services, and Drugs” information on EOB did not have a choice for pt/cg to elect or decline this. Additionally, there is no election/start of care date filled in on space provided on form.