Every finding on record at Unique Care Los Angeles Hospice, Inc.

Observed in Record Review. In 3 of 3 applicable patient records reviewed, the plan of care did not include psychosocial and/or spiritual interventions. Upon review of RR#1, it was noted the psychosocial assessment and spiritual assessment indicated support was to be provided; however, on review of the plan of care, there were no psychosocial or spiritual interventions established. Upon review of RR#2 and RR#3, it was noted the spiritual assessment indicated support was to be provided; however, on review of the plan of care, there were no spiritual interventions established. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 3 applicable patient records reviewed, the visit frequency established on the plan of care was not in accordance with the patient’s needs. Upon review of RR#1, it was noted the plan of care indicated an aide frequency of twice a week; however, on review of nursing documentation, the daughter had declined aide services, therefore no visit frequency was needed. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 3 applicable patient records reviewed, the plan of care did not include all equipment to meet the patient’s needs. Upon review of RR#1, it was noted nursing documentation indicated the patient had a hospital bed, air mattress, over-the-bed table, and a hoyer lift; however, on review of the plan of care, equipment needs were not addressed. This was reviewed and validated with the Administrator.

Observed in Record Review. In 1 of 3 applicable patient records reviewed, the plan of care was not revised to reflect changes from the updated comprehensive assessment. Upon review of RR#3 and the updated comprehensive assessment, it was noted the patient was started on continuous care due to pain and agitation with daily nursing visits; however, on review of the revised plan of care, the visit frequency for nursing was documented as weekly and was not revised to reflect the change to daily nursing visits. This was reviewed and validated with the Administrator.

Observed in Emergency Management Session. The surveyor noted the emergency operations plan did not include a delegation of authority plan that described the decisions and policies that could be implemented by authorized successors during an emergency and criteria or triggers that initiate the delegation. This was confirmed with the DON/administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization did not inform the patient in advance of furnishing care the estimated patient's responsibility for payment. In RR #1, the surveyor noted the payment and authorization of assigned benefits section was blank on the consent form. This was confirmed with the DON/administrator. In RR #2, RR #5 and RR #6, the surveyor noted the organization provided the patient with a percentage of their responsibility for payment and not a specific dollar amount. This was confirmed with the DON/administrator. In RR #5 and RR #6, the surveyor noted the organization did not provide the patient with the hospice election of benefit addendum that provided information on non-covered items. There was no documentation of refusal of this information. This was confirmed with the DON/administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not respect the patient's right to elect and revoke hospice care.In RR #1, the surveyor noted the patient signed the revocation documentation on admission to hospice services. This was confirmed with the DON/administrator.

Observed in Record Review. In 3 of 11 patient records reviewed, the assessment did not include the severity of symptoms. In RR #1, the surveyor noted the patient was identified as having dysphagia and agitation; however, the assessment did not include the severity of these symptoms. This was confirmed with the DON/administrator. In RR #4, the surveyor noted the patient was identified as having agitation; however, the assessment did not include the severity of this symptom. This was confirmed with the DON/administrator. In RR #5, the surveyor noted the patient was identified as having dysphagia and depression; however, the assessment did not include the severity of this symptoms. This was confirmed with the DON/administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the patient record did not contain IDG documentation to be used in individual patient care planning and in the coordination of services. In RR #5, the surveyor noted the IDG documentation of the discussion did not change for the entire certification period. In discussion with the leadership, the documentation was prepopulated from one IDG meeting to the next for nursing, chaplain and medical social worker. There was no documentation of discussion of a pressure ulcer development in the fourth week of service in the IDG meeting minutes. This was confirmed with the DON/administrator. In HV #1, the surveyor noted the IDG documentation for chaplain indicated Chaplain will arrange to visit for spiritual assessment within 5 days of admission; there was no change to this documentation in the IDG notes through the the first certification period. This was confirmed with the DON/administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the written plan of care was not based on the patient's goals and the time frames to meet those goals. In RR #2, the surveyor noted the plan of care included inappropriate time frame of four months for the following goals: Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects - and early detection of upper respiratory infection. PCG will verbalize understanding of the aspiration precautions instructions. This was confirmed with the DON/administrator. In RR #5 and HV #1, the surveyor noted the plan of care included inappropriate time frame of three months for the following goal: Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. This was confirmed with the DON/administrator. In HV #2 and RR #8, the surveyor noted the plan of care included the following non-measurable goal: MSW to Establish trusting relationship with PCG. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the plan of care included an inappropriate time frame for goal: Patient family will verbalize understanding of dying process for patient imminently dying in 3 months; however, the patient was identified as imminently dying and therefore the goal of 3 months would be inappropriate. This was confirmed with the DON/administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In RR #1, the surveyor noted the patient was identified as having agitation, dysphagia, skin breakdown risk and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In RR #2, the surveyor noted the patient was identified as being at risk for skin breakdown and falls; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In RR #3, the surveyor noted the patient was identified as having constipation, fall risk and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In RR #4, the surveyor noted the patient was identified as having edema, skin break down risk and fall risk; however, the plan of care did not include interventions to address this identified needs. This was confirmed with the DON/administrator. In RR #5, the surveyor noted the patient was identified as having constipation, skin breakdown risk and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In RR #6, the surveyor noted the patient was identified as having edema, fall risk, and skin breakdown risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In RR #7, the surveyor noted the patient was identified as having dysphagia, skin breakdown risk, and fall risk; however, the plan of care did not include interventions to address these risks. This was confirmed with the DON/administrator. In HV #1, the surveyor noted the patient was identified as having depression, dysphagia, shortness of breath, skin breakdown risk, and fall risk; however, the plan of care did not include interventions to address this identified needs. This was confirmed with the DON/administrator. In HV #2, the surveyor noted the patient was identified as having pain, shortness of breath, dysphagia, fall risk and skin breakdown risk; however, the initial plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator. In HV #3, the surveyor noted the patient was identified as having depression, dysphagia, skin break down risk and fall risk; however, the initial plan of care did not include interventions to address these identified needs in the first certification period. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the patient was identified as having pain, agitation, anxiety, pitting edema, constipation, skin breakdown risk and fall risk; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the DON/administrator.

Observed in Record Review. In 8 of 11 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In RR #1, the surveyor noted the visit frequency on the plan of care indicated LVN: 1 per Week +3 PRN Visits, MSW: 1 per Month + 1 PRN Visits, RN: 1 per 2 Week +3 PRN Visits:; however, there was no indication given for the PRN visits. In addition, the patient was receiving hospice aide services; however, the plan of care did not include the visit frequency for the hospice aide. This was confirmed with the DON/administrator. In RR #3, the surveyor noted the visit frequency on the plan of care indicated: MSW: 1 per Month + 1 PRN Visits, RN: 1 per Week +3 PRN Visits; however, there was no indication given for the PRN visits. This was confirmed with the DON/administrator. In RR #4, the surveyor noted the visit frequency on the plan of care indicated: MSW: 1 per Month +2 PRN Visits, RN: 2 per Week +3 PRN Visits, SC: 1 per Month +2 PRN Visits; however, there was no indication given for the PRN visits. This was confirmed with the DON/administrator. In RR #5, the surveyor noted the plan of care included the following visit frequencies: MSW 1 per Month + 1 PRN Visits, RN: 1 Daily until further orders, SC: 1 per Month + 1 PRN Visits; however, there was no indication given for the PRN visits. This was confirmed with the DON/administrator. In RR #6, the surveyor noted the plan of care included the following visit frequencies: MD: 1 per Month +3 PRN Visits, MSW: 1 per Month +3 PRN Visits, RN: 1 - one per week + three as needed per week, SC: 1 per Month + 1 PRN Visits; however, there was no indication given for the PRN visits. This was confirmed with the DON/administrator. In HV #1, the surveyor noted the plan of care included the following visit frequencies: LVN: 3 per Week +3 PRN Visits, MSW: 1 per Month + 1 PRN Visits, RN: 1 per Week +3 PRN Visits, SC: 1 per Month + 1 PRN; however, there was no indication given for the PRN visits. In addition, the plan of care visit frequency was not updated to reflect actual LVN visit frequency of twice per week in the second certification period. This was confirmed with the DON/administrator. In HV #2, the surveyor noted the plan of care included the following visit frequencies: LVN: 1 per Week +3 PRN Visits, MSW: 1 per Month + 1 PRN Visits, RN: 1 per Week +3 PRN Visits, SC: 1 per Month + 1 PRN Visits; however, there was no indication given for the PRN visits. In addition, the initial plan of care did not include a frequency for the hospice aide. The aide visit frequency was not added to the plan of care until 7 days after the first aide visit was made. This was confirmed with the DON/administrator. In HV #3, the surveyor noted the plan of care included PRN visits for SN, MSW and SC; however, there was no indication given. In addition, the patient was seen by the hospice aide for two months last year; however, there was no visit frequency on the plan of care or supplemental orders obtained for the aide services. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the plan of care included the following visit frequency: MSW: 1 per Month + 1 PRN Visits, RN: 1 per Week +3 PRN Visits, SC: 1 per Month + 1 PRN Visits; however, the plan of care did not include specific indications for PRN visits. This was confirmed with the DON/administrator.

Observed in Record Review. In 9 of 11 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In RR #2, the surveyor noted the patient was identified as having a wound on the left foot, a peripheral IV site and on oxygen; however, the plan of care did not include specific treatment orders for these identified needs. In addition, the plan of care did not include a specific diet type for the patient. This was confirmed with the DON/administrator. In RR #4, the surveyor noted the plan of care did not include a specify diet type for the patient. In addition, the patient had a peripheral IV; however, the plan of care did not include specific treatment orders such as site care and frequency change. Also, the plan of care included the following incomplete medication orders: Sarna 1% - Apply to affected areas topically 3-4 times a day and as needed. Triamcinolone 0.1% - Apply to affected areas topically 2 times a day and as needed. This was confirmed with the DON/administrator. In RR #3, RR #5, RR #6, RR #8, HV #1 and HV #2, the surveyor noted the plan of care did not include a specific diet type for the patient. This was confirmed with the DON/administrator. In RR #5, the surveyor noted the patient was identified as having a PICC line; however, the plan of care did not include interventions to address PICC line care. In addition, the nurse documented wound care performed in the fourth week of service; however, the plan of care was not updated to include this intervention. This was confirmed with the DON/administrator. In HV #1 and HV #3, the surveyor noted the patient had wound care performed on the admission visit; however, there were no wound care orders obtained. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the patient was identified as having a peripheral IV inserted the second day of service, a condom catheter, and 6 pressure ulcers on admission; however, the plan of care did not include interventions to address these identified needs such as wound care orders, condom catheter care/frequency change, IV insertion order/site care. This was confirmed with the DON/administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the plan of care did not include the medical supplies and appliances necessary to meet the needs of the patient. In HV #1, the surveyor noted the plan of care DME and supplies section were blank; however, the patient had a walker, oxygen, and wound care supplies in the home. This was confirmed with the DON/administrator.

Observed in Record Review. In 5 of 11 patient records reviewed, the organization did not provide the patient with the care, treatment or services according to the patient's individualized plan of care. In RR #6, the surveyor noted the plan of care included a visit frequency of RN 1 x per week; however, the LVN saw the patient every other week. There was no visit frequency for the LVN. This was confirmed with the DON/administrator. In HV #1, the surveyor noted the plan of care aide visit frequency was 2 x's per week; however, there was a missed aide visit the 11th week of service in the first certification period. There was no documentation as to why the visit was missed. In addition, the visit frequency for the LVN in the first certification period was three times per week; however, the LVN only saw the patient twice per week for the first certification period. This was confirmed with the DON/administrator. In HV #2, the surveyor noted the plan of care visit frequency for skilled nursing was separated into RN 1 x week and LVN 1 x week; however, the RN saw the patient every other week and the LVN saw the patient on the opposite week every other week and therefore did not following the plan of care. This was confirmed with the DON/administrator. In HV #3, the surveyor noted the current plan of care SC visit frequency was one time per month on current plan of care; however, the patient was not seen by the chaplain in the past three months. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the plan of care visit frequency indicated RN 1 x/week and did not include LVN; however, the patient was seen by the LVN daily throughout patient's services. This was confirmed with the DON/administrator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #2, the surveyor noted the hospice aide donned and doffed gloves four times without performing hand hygiene in between glove changes as required by organization policy while cleaning equipment and performing vital signs . This was discussed with the CEO.

Observed in Record Review. In 2 of 5 patient records reviewed where the patient received hospice aide services, the registered nurse did not prepare written patient care instructions for the hospice aide. In RR #5, the surveyor noted the aide provided care to the patient on the second day of service; however, the aide plan of care was not created until the 8th day of service. This was confirmed with the DON/administrator. In RR #6, the surveyor noted the aide plan of care indicated vital signs were to be performed at each visit; however, the aide plan of care did not specify parameter for when the aide should contact the nurse for the vital signs. This was confirmed with the DON/administrator.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and 418.52, 418.56, 418.116.

Observed in HR File Review. In 1 of 8 HR files reviewed, the hospice did not provide an initial orientation for each employee. In HR #5, the surveyor noted the organization did not provide orientation to the medical director upon hire to include relevant policies and procedures and their specific job duties as evidenced by the organization was not able to produce this documentation at the time of survey. This was confirmed with the DON/administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record did not contain all clinical information.In RR #8, the surveyor noted the nurse documented second day of service Skilled nursing placed a peripheral IV on left forearm secured by transparent tape. patient tolerated well, sharps/needles disposed in sharp container as per agency policy.; however, the documentation did not specify the size of the IV catheter. This was confirmed with the DON/administrator.

Observed in Record Review. In 3 of 3 discharge records reviewed, the attending physician was not notified of the availability of the discharge summary or the discharge summary did not include the care, treatment, and services the patient received. In RR #5 and RR #6, the surveyor noted the organization completed a discharge summary; however, the organization did not notify the attending physician of its availability. There was no documentation that the discharge summary was faxed to the attending physician. This was confirmed with the DON/administrator. In RR #8, the surveyor noted the discharge summary was not a summary of the care, treatment and services the patient received. The discharge summary only indicated This is a case of 90 year old male patient with diagnosis of Alzheimer`s disease. Patient was seen by hospice staff as ordered and condition has been changed. Patient`s son has notified hospice they have decided to revoke hospice services as of 5/09/2021. PCP/IDT made aware of discharge. This was confirmed with the DON/administrator.

Observed in Record Review. In 2 of 2 discharge records reviewed, the hospice did not provide the patient with the appropriate advanced beneficiary notice. In RR #5 and RR #6, the surveyor noted the patient was discharged from hospice services due to status improved; however, the Notice of Non Medicare Coverage was signed by the RN and not the patient/patient representative. This was confirmed with the DON/administrator.