Every finding on record at Pinnacle Care Hospice Inc

Upon patient record review, 1 of 14 (Patient #1) 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 #1: Documentation indicated there was no family . The patient record indicated there was an IHSS worker involved but no bereavement assessment completed.

Upon patient record review 2 of 14 (Patient #2, 14) 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 #2:The POC listed Aide visit frequency of 3x per week of 6/1/24. There were no visits made by the Aide the first Benefit Week. Patient #14: Aide services were ordered for 2 X's per week to begin 1/7/24. However, the Aide visited prior to order date on 1/3/24 and 1/5/24.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #1: The BFCC-QIO contact information was not included on Election Statement form. Per agency this was an older version of the EOB.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. 6 of 14 (Patients #1,4,6,7,12,14) patients did not have evidence in their file that this document was provided to patient or patient representative. Patient #1: There was no evidence the copy of Policies and Procedures for Controlled Drugs was provided. Patients # 4,6,7,12,14: There was no evidence the copy of Policies and Procedures for Controlled Drugs was provided.

Upon patient record review, 6 of 14 (Patients #1, 4, 6, 7, 12, 13) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient #1: There was no evidence the copy of Policies and Procedures for Controlled Drugs was provided and discussed. Patients #4,6,7,12,13: There was no evidence the copy of Policies and Procedures for Controlled Drugs was provided and discussed.