Providence at Home With Compassus Hospice and Palliative Care Napa Valley

“It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, interview, and observation. In 2 of 19 (11%) clinical records reviewed and home visits, the organization did not ensure that each patient’s individualized written plan of care identified all planned interventions. CLINICAL RECORD 10: The patient elected the hospice benefit on 08/18/2026, effective through 11/15/2026, with primary and pertinent secondary diagnoses that included malignant neoplasm of connective and soft tissue of the head, face, and neck, secondary malignant neoplasm of the lung, dysphagia, disorders of the subcutaneous skin related to radiation, thrombocytopenia, and stage 2 pressure ulcer of coccyx. The clinical record was reviewed, and the RN Hospice Start of Care Nursing Summary note indicated that the patient had a “percutaneous endoscopic gastrostomy tube, 24 French, with Jevity feedings- 300cc-four times/day.” During a clinical record review and interview on 09/11/2026, the Administrator and Directors of Patient Care Services (DPCS) acknowledged that the Plan of Care (POC), effective 08/18/2026, and the only Interdisciplinary Group (IDG) POC Update, documented on 09/02/2026, did not include the documented intervention for Jevity feedings to be administered through the patient’s gastrostomy tube. A DPCS confirmed that the most recent skilled nursing visit notes indicated that the patient was still receiving Jevity feedings through the gastrostomy tube, managed independently by the patient’s family, and that the patient was taking in no food, liquids, or medication by mouth. The Administrator acknowledged the need for a gastrostomy tube feeding intervention documented as a physician’s order specifying the amount of feeding to be administered through the patient’s gastrostomy tube, by gravity or pump with flow rate specified, including the amount of water that should be flushed before and after the feeding (or total amount of water required daily) for hydration, as appropriate. CLINICAL RECORD 12/HOME VISIT 4: The patient elected the hospice benefit on 07/22/2023. Benefit Period 18, effective 07/06/2026 through 09/03/2026, and Benefit Period 19, effective 09/04/2026 through 11/02/2026, were reviewed. The patient’s primary and pertinent secondary diagnoses included chronic hepatic failure without coma, cirrhosis of the liver, hepatorenal syndrome, severe protein-calorie malnutrition, Type 2 diabetes mellitus, metabolic encephalopathy, hypothyroidism, and immune thrombocytopenic purpura. During the home visit # on 09/10/2026 with the Registered Nurse (RN) (Personnel Record 10), the RN asked the patient’s niece to review the patient’s daily blood glucose log to ensure that it had been “within range” since the patient’s Insulin Glargine 300 units/ml to be administered nightly at bedtime had been decreased to 20 units (ordered 4/17/2026). During a joint clinical record review and interview on 09/11/2026, the Administrator and DPCS(s) acknowledged that the RN visit note documented on the 9/10/2026 visit included a summary note confirming: “Niece administers 20 units of insulin at night. Blood sugars have been within normal limits.” The Administrator and DPCS acknowledged that the patient’s POC’s effective 07/06/2026 and 09/04/2026 and IDG POC updates did not include an intervention for the patient’s caregiver to monitor and log daily blood sugar levels. The Administrator agreed that because the caregiver had been educated to monitor and log daily blood sugar levels, and the RN was checking the blood sugar log during skilled nursing visits, the intervention should be included on the POC.”

“It is required that a qualified Administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The hospice Administrator has the education and experience as required by the governing body. If the Administrator is not available, another individual is assigned the Administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 2 (100%) personnel records reviewed for the Administrator and Administrator designee, the governing body did not ensure the individuals appointed to these roles had the education required by organizational policy. The organization’s policy titled Governing Body-Number HOS-AO4- Revision Date 06/30/2026; Review Date 07/22/2026 stated in part, “...(State): A hospice agency shall have an Administrator, Administrator designee, Director of Patient Care Services (DPS), DPS designee, Medical Director (MD) or Contracted MD, and MD designee shall submit to the following information for each individual on an initial application. Vacancies will be filled within 60 days. The Administrator or designee appointed must: 1. Have a baccalaureate degree or higher in a health-related field. 2. +2 years supervisory experience in hospice/home health/primary care clinic/health facility in the past 5 years as evidenced on resume or other supporting documents. ...” PERSONNEL RECORD 1: The Administrator was employed at the time of the joint venture acquisition on 10/01/2025 as Director of Patient Care Services (RN) Designee. The organization’s Governing Board appointed her Administrator in March 2026, and the State Department of Public Health was notified of the appointment on 08/20/2026. During a joint review of the Administrator’s personnel file and interview on 09/10/2026, the Administrator confirmed that she had earned an associate’s degree in nursing. The Administrator stated that a FLEX Waiver 15318, Flexibility in Administration, had been submitted to the State Department of Public Health on 07/21/2026 because the role of Administrator required a baccalaureate degree or higher in a health-related field, according to the organization’s policy, effective 06/30/2026. Before the exit conference on 09/11/2026, the organization’s leadership confirmed that the Flex Waiver remained in “under review” status and had not been approved by the state. PERSONNEL RECORD 2: The Administrator Designee, a non-clinical associate, was hired by the organization on 01/20/2026. The organization’s Governing Board appointed him Administrator Designee in March 2026, and the State Department of Public Health was notified of the appointment on 08/20/2026. During a joint review of the Administrator Designee personnel file’s resume and interview on 09/11/2026, the Administrator confirmed that the Administrator Designee had earned a Bachelor of Arts in Political Science, a non-health-related degree. The Administrator stated that a FLEX Waiver 15318, Flexibility in Administration, was submitted to the State Department of Public Health on 07/21/2026 because the Administrator Designee role required a baccalaureate degree or higher in a health-related field, according to the organization’s policy, effective 06/30/2026. The organization’s leadership confirmed before the exit conference on 09/11/2026 that the Flex Waiver remained in “under review” status and had not been approved by the state. State Hospice Emergency regulations: Title 22. Social Security Division 5. Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies, Chapter 6.5. Hospice. Adopt section 74876 to read as follows: Section 74876. Administrator. (a) The hospice governing body must appoint an Administrator in writing. (b) The Administrator must have a baccalaureate degree or higher in a health-related field and a minimum of two years of full-time supervisory or managerial experience in a hospice, home health agency, primary care clinic, or health facility within the last five years. (c) The Administrator must appoint a Designee in writing who meets the requirements of subdivision (b) that will assume the responsibilities and obligations of the Administrator if the Administrator is not available.”

“It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) discharged clinical records reviewed in which the patient revoked services, the organization did not ensure that a discharge summary was forwarded to the patient’s attending physician. CLINICAL RECORD 15: The patient elected the hospice benefit on 02/16/2026 with a primary terminal diagnosis of diastolic (congestive) heart failure and revoked services to seek aggressive treatment on 03/02/2026. During a joint clinical record review and interview on 09/11/2026, the Administrator and Directors of Patient Services confirmed that they never sent a discharge summary to the patient’s primary practitioner. The Administrator stated that the organization discovered in July (2026) that discharge summaries were not being automatically faxed to the primary practitioners of patients discharged alive from hospice services as required by regulations. The Administrator stated, “After our acquisition, we were told that our live discharge summaries would be faxed to primary practitioners. We learned recently that our Team Coordinators were responsible for this process. They have been taught to send all Discharge/Transfer Summary Reports to Primary Care physicians and skilled nursing facilities as of July of this year. That’s why this patient’s discharge was not sent to the patient’s physician.””