Every finding on record at Van Nuys Serenity Hospice and Palliative Care, Inc

Upon patient record review, 1 of 11 (Patient # 9) 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, including a detailed scope and frequency of services necessary to meet the specific patient and family needs. Patient #9: MSW frequency was ordered as needed only without a routine frequency

Upon client record review, 1 of 11 (Patient #10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #10: Order for LVN 1x/week, patient seen twice on 12/19/21 and 12/21/21 both for routine visit without additional order for visits. Patient also seen twice on 1/3/22 and 1/8/22 both for routine visits without additional orders.

Upon patient record review 3 of 4 applicable (Patient #4,6,9) did not have evidence documentation in the patient record that a hospice aide provides services that are ordered by the IDG and included in the plan of care. Patient #4: 4/8/22 missed documentation of street clothes per care plan. Patient #6: 3/19/22 missed documentation of street clothes, walker and dress per care plan. 3/22/22 missed documentation of walker, pj/gown and dress per care plan. Patient #9: 3/5/22, 3/7/22, and 3/9/22 missed documentation of street clothes, dress per care plan.

Upon patient client record review, 6 of 11 (Patient #1,2,3,4,6,8) did not have evidence that all entries are complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient #1: missing signature for MSW on IDG form for dates 3/21/22 and 3/30/22. Patient #2: missing LVN signature on incomplete note for dates 4/9/22 and 4/2/22. IDG note on 4/13/22 missing RN and MSW signature. Patient #3: missing LVN signature on LVN note for 4/11/22 and 4/4/22. IDG note missing MSW signature on 11/21/21, Missing MD signature on 11/24/21, 12/8/21, 12/22/21. Patient #4: missing LVN signature on visit note for 4/6/22. Missing MD signature on 11/18/21, 11/24/21. Missing RN signature on 4/13/22 for IDG note, Missing MSW signature on 11/20/21 and 4/13/22 on IDG note. Patient #6: missing MSW signature on 1/29/22 on IDG note. Patient #8: missing MSW signature on IDG note 1/28/22, 2/1/22, 2/2/22, 2/16/22, 3/2/22, 3/16/22, 3/30/22, 4/13/22. Missing RN signature on IDG note on 4/13/22.