Calstro Hospice Orange County

Notice of rights and responsibilities (42 CFR 418.52(a)(1))

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0502. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(2))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0503. Standard-level.

Notice of rights and responsibilities (42 CFR 418.52(a)(3))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0504. Standard-level.

Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(3))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0507. Standard-level.

Rights of the patient (42 CFR 418.52(c)(4))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0515. Standard-level.

Rights of the patient (42 CFR 418.52(c)(5))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence of the appropriate documentation for release of confidential information. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0516. Standard-level.

Rights of the patient (42 CFR 418.52(c)(7))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0518. Standard-level.

Rights of the patient (42 CFR 418.52(c)(8))

“Upon patient record review, 1 of 14 (Patient #8) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0519. Standard-level.

Timeframe for completion of assessment (42 CFR 418.54(b))

“Upon patient record review 1 of 14 (Patient # 10) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #10: Patient was admitted on 05/02/23, the initial comprehensive psychosocial assessment was completed on 05/23/23.”

Rule L0523. Standard-level.

Content of comprehensive assessment (42 CFR 418.54(c))

“Upon patient record review 1 of 14 (Patient #11) 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 #11: Patient was admitted 06/04/23, spiritual care services were declined, but the patient did not receive a spiritual care assessment by the RN or MSW within 5 days or by date of discharge.”

Rule L0524. Standard-level.

Content of plan of care (42 CFR 418.56(c)(5))

Rule L0550. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(1))

Rule L0625. Standard-level.

Hospice aide assignments and duties (42 CFR 418.76(g)(2))

Rule L0626. Standard-level.

Supervision of hospice aides (42 CFR 418.76(h)(1))

“Upon patient record review 1 of 14 (Patient # 6) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient#6: The patient receives hospice aide services, there are no supervisory visits in the record between 10/09/23 and 10/30/23.”

Rule L0629. Standard-level.

Content (42 CFR 418.104(a)(2))

“Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0673. Standard-level.

Content (42 CFR 418.104(a)(6))

“Upon patient client record review, 1 of 14 (Patient #8) did not have evidence that each patient record contains Advance Directives. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0677. Standard-level.

Label dispose storage drugs (42 CFR 418.106(e)(2)(i)(C))

“Upon client record review, 1 of 14 (Patient #8) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patient # 8: Patient admitted on 08/13/22 with a comorbidity of vascular dementia and senile degeneration of the brain with noted evidence of confusion and behavior disturbances. Patient signed her election of benefit, consent for service and POLST.”

Rule L0697. Standard-level.