Every finding on record at Van Nuys Hospice Inc.

Upon patient record review 1 of 14 (Patient #4) 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. Patient #4 There was no evidence of initial psychosocial assessment.

Upon client record review, 4 of 14 (Patient #11,12,13,14) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #11 last documented IDG was 07/30/24. Patient revoked hospice care on 08/21/24. Patient #12 last documented IDG was 08/13/24. Patient revoked hospice care on 09/01/24. Patient #13 last documented IDG was on 07/30/24. Patient passed 08/27/24. Patient #14 last documented IDG was on 09/10/24. Patient passed 09/20/24.

Upon client record review, 1 of 14 (Patient #4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #4 admission order for SW Eval within 5 days. There was no evidence of the evaluation or any contact.

Upon patient record review, 2 of 14 (Patient #13,14) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #13 contained no evidence that the bereavement assessment was updated at the time of death. The "Post Death Bereavement Assessment" dated 08/29/24 was blank. No bereavement plan of care. Mailings, showed "letter #1" as "overdue" with a due date of 09/27/24. Patient #14 had a "Post Death Bereavement Assessment dated 10/03/24, with a narrative note stating the bereaved was "struggling". Stated "Will provide a follow-up call in 3 weeks". There was no further documentation of a follow-up call. No Bereavement plan of care. Mailings showed "letter #1" as "overdue" with a due date of 10/30/24.

Upon personnel record review, 1 of 14 (Personnel #5) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #5 competency included "Shampoo", and did not specify all 3 methods, Sink, Tub, bed. Competency included "Bath shower/tub", not specific for Sponge, tub and shower.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1 Aide plan of care instructed the following: "Assist with medications as per RN instruction". There were no further instructions and this could also be outside the scope of practice for the aide. There was no documentation of the aide assisting with medications. Under "additional instructions" were the following: "Report SBP greater than 160 and less than 90". "Report DBP greater than 90 and less than 50". Report RR less than 10 or greater than 22 per cycle". However; there was not a task for the aide to assess any vital signs.

Upon patient client record review, 14 of 14 (Patient #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. (IDT notes missing MD Signatures &/or SW signature.) Patient #1 IDG Meeting note and update to plan of care not signed by a Social Worker. All dates, 7/924-11/05/24. Patient #2 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 8/17/24-11/05/24. Patient #3 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 07/10/24-11/05/24. Not signed by MD 10/08/24,10/22/24,11/02/24. Patient #4 IDG Meeting note and update to plan of care not signed by a Social Worker 10/26/24, 11/05/24. Not signed by MD 11/05/24. Patient #5 IDG Meeting note and update to plan of care not signed by a Social Worker or MD 10/22/24. Patient #6 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 09/20/24-11/05/24. Not signed by MD all dates between 09/24/24-11/05/24. Patient #7 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 09/18/24-11/05/24. Not signed by MD all dates between 09/24/24-11/05/24. Patient #8 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 8/22/24-11/05/24. Not signed by MD 11/05/24. Patient #9 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 8/01/24-11/05/24. Not signed by MD 11/05/24. Patient #10 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 7/10/24-11/05/24. Not signed by MD 10/08/24 , 11/05/24. Patient #11 IDG Meeting note and update to plan of care not signed by a Social Worker or MD. All Dates, 06/07/24-07/30/24. (last documented IDG 7/30/24,patient didn't Revoke Hospice until 08/21/24.) Patient #12 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 5/07/24-08/15/24. (last documented IDG 08/15/24, patient didn't Revoke Hospice until 09/01/24) Patient #13 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 06/10/24-07/30/24. (last documented IDG 07/30/24, patient didn't pass until 08/27/24.) Patient #14 IDG Meeting note and update to plan of care not signed by a Social Worker. All Dates, 07/30/24-09/10/24. (last documented IDG 09/10/24, patient didn't pass until 09/30/24.)

Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. The patient information binder had incongruent information to voice grievances and complaints. To report grievance/complaint the insert had another hospice name (LC Hospice) instead of their own name. Additionally, the telephone had an extra digit that read (818) 9800-6200.

Upon patient record review, 3 of 5 (Patient #1, #2 and #4) 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 SOC 10-27-21 and Bereavement risk assessment completed on 11-9-21. Patient # 2 SOC 11-1-21 there was no evidence that a Bereavement risk assessment was completed. Patient # 4 SOC 10-14-21 there was no evidence that a Bereavement risk assessment was completed.

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. The policy insert in patient binder was from LC Hospice and not the agency specific policy.