Every finding on record at Topanga Hospice Care, Inc

Upon patient record review, 1 of 14 (Patient #2) 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 #2: The Bereavement Initial Assessment was not completed within 5 days of SOC (3/24/23). During survey, this assessment was entered into patient record on 7/19/23.

Upon patient record review, 1 of 14 (Patient #1) 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. Patient #1: The oxygen was not included on medication/treatment on the Plan of Care. This was added/updated on POC during survey.

Upon patient record review, 5 of 14 (Patients #1, 5, 7, 9 and 11) 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 #1: Had shower chair and rollator that was not included on Plan of Care. This was COS/Updated with late entry during survey. Patient #5, 7, 9, 11: The record reflected that this patient had oxygen concentrator. This was not included on the Plan of Care. This was COS/Updated with late entry during survey.

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.

Upon personnel record review, 1 of 14 (Personnel #8) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include--Tub Bath. Personnel #8: The Aide Initial Competency had verbal verification for tub bath and range of motion. These competencies were not observed/demonstrated as required.

Upon patient record review 2 of 14 (Patients #2 and #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 Patient #2: The Aide was visiting 2x week from SOC to 6/6/23. However, the Aide frequency and visits were not included on Plan of Care. Patient#7: The Aide was visiting starting 5/1/23. However, these visit frequencies were not evident on Plan of Care until 6/1/23 update.

Upon patient record review, 1 of 14 (Patient #1) 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 #1: The physician narrative explanation of terminal illness did not include patient diagnosis or subjective/objective findings.

Upon patient client record review, 1 of 14 (Patient #12) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patient #12: The Election of Benefit form did not have the hospice start of care/effective date written/typed on this form.