Upon patient record review 6 of 14 (Patient #1, 2, 4, 6, 9, 10) 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. Patients 1, 2, 4, 6, 10: There is no evidence that a comprehensive assessment has been completed to assess the patient's spiritual needs. Patient 9: There is no evidence that a comprehensive assessment has been completed to assess the patient's psychosocial needs.
Every finding on record at Loving Soul Hospice
Van Nuys, California · CCN B21774
3 findings across 1 survey, in the inspector's own words.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Survey of July 17, 2024
3 findingsUpon client record review, 5 of 14 (Patient #3, 4, 5, 7, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 3: The plan of care indicates that a skilled nurse will visit the patient one time weekly. However, during the week of 06.02.2024, a SN made 2 visits to the patient's home on 06.04.2024 and 06.07.2024. Additionally, during the week of 06.16.2024 a SN also made 2 visits to the patient's home on 06.18.2024 and 06.21.2024. Patient 4: The plan of care indicates that a skilled nurse will visit the patient one time weekly. However, during the week of 06.16.2024 there was no evidence that a SN visited the patient. Patient 5: The plan of care indicates that a skilled nurse will visit the patient two times weekly. However, during the week of 05.05.2024, a SN made 3 visits to the patient's home on 05.06.2024, 05.07.2024, and 05.10.2024. Additionally, during the week of 06.16.2024 a SN only made 1 visit to the patient's home on 06.17.2024. Then during the week of 06.30.2024, a SN made 3 visits to the patient's home on 06.30.2024, 07.02.2024, and 07.05.2024. Patient 7: The plan of care indicates that a skilled nurse will visit the patient one time weekly. However, during the week of 06.02.2024, a SN made 2 visits to the patient's home on 06.04.2024 and 06.08.2024. Patient 9: A lab order was entered in the patient record on 07.11.2024 and duly signed by the physician. However, there is no evidence of how this order originated or if it has been carried out to date. (Only two business days have passed since the order was entered into the patient record and there is no indication that it is related to an acute need or care concern.) There is no mention in the nursing notes, during the IDT meeting discussion, or in coordination with the patient & family relating to the lab order.
Upon patient client record review, 1 of 14 (Patient #2) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient 2: The signed election statement does not include the effective date for the initiation of hospice services.
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Federal survey findings only. State licensure findings for hospices are not shown.
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