Crossroads Home Health & Hospice

“Based on record review, interview, and document review, the hospice agency failed to thoroughly investigate a grievance for one of 14 sampled patients (Patient (P) 12). This resulted in P12’s family member feeling unsupported during P12’s death. Findings include: Review of P12’s “Patient Profile” located under the “View” tab in the electronic medical record (EMR) revealed P12 was admitted to hospice services on 11/18/24 with the terminal illness of senile degeneration of the brain. Review of the hospice agency’s “Grievance Log” revealed on 04/16/25 “Hospice RN [Registered Nurse] was informed by son/daughter that no one showed up to death visit, so he/she went to the death visit this am [morning].” The investigation revealed, “On call runner [name of Licensed Vocational Nurse (LVN) 2] stated verbally and in a teams [sic] messenger to DCPS [Director of Patient Care Services] that he/she indeed do [sic] the death visit. Death visit documentation was done late. RNCM [RN Case Manager] and DCPS spoke to the patient’s son/daughter, and he/she was very clear that no nurse from our team visited on the evening of 04/15 [04/15/25] for the death visit. He/she [Family Member (FM) 1] stated he/she called Triage, spoke to nurse who said that another nurse was coming for the death visit and to assist with post-mortem care but that no one showed up.” The investigation outcome indicated “Likely substantiated given that there were 3 [sic] death visits back to back in 2 [sic] evenings that had to be done by 1 [sic] LVN runner. 2 [sic] of them were in East Bay and this patient was in SF [San Francisco].” Resolution indicated that the “family was satisfied with apology [name of hospice agency] and our promise that such will never occur again. Clinician was counseled.” Review of P12’s “RN-Skilled Nursing Visit” located under the “Nursing” tab in the EMR and dated 04/14/25 at 11:48 AM indicated, “Pt. [patient] was asleep in bed upon arrival. Pt. was sleeping so deeply and soundly that myself and the pt’s [patient’s] son stopped and stood by the pt’s bed waiting for signs of life…” Review of P12’s “Discharge-Death” located under the “Nursing” tab in the EMR and dated 04/15/25 at 12:30 AM indicated under the section “Medication Disposal: teaching provided regarding disposal of medication disposal [sic] and family verbalized understanding.” Under the section “Medication Disposal Witness: family will drop off medications at the nearest pharmacy” was documented. Further review of the “Discharge-Death” note indicated, “Upon arrival at the patient’s residence, patient was found in bed, unresponsive, without signs of respiration or pulse. Pupils fixed and non-reactive to light. Skin was cool to touch, with mottling noted throughout extremities. Time of death was verified at 0030 [12:30 AM] per hospice on call nurse assessment. Post-mortem care was provided per hospice protocol… and prepared for funeral home, which was contacted per family’s request… Emotional support and bereavement support was offered to family… Family… expressed gratitude for hospice support. NO signs of trauma or need for coroner involvement. Death appears consistent with the patient’s known terminal illness.” During a phone interview on 12/17/25 at 2:30 PM, FM1 stated, “My dad/mom [P12] had received a nurse visit that day [04/15/25] and things were not looking good for him/her, and we thought that he/she would be passing. The nurse explained that if anything happens, to please call this phone number and they showed me the number to call and explained that a nurse would come out and make sure things were taken care of. The nurse stated the nurse on call would get my dad’s/mom’s body ready for the funeral home before they came to pick my dad’s/mother’s body up. When he/she passed, I called my aunt to tell her about my dad/mom and then I called the number that I was instructed to call. I spoke to a nurse that asked me questions and then he/she stated she would call the funeral home and they would be coming. I was shocked to feel that I was left alone since I was told that a nurse would come to the house when my dad/mom passed. My grandmother and I were the only people at the house when this happened.” During an interview on 12/17/25 at 2:00 PM, the Director of Patient Care Services (DPCS) stated, “I had received a phone call from the patient’s case manager and he/she stated that he/she wasn’t sure but the [FM1] had contacted him/her and told him/her that when his/her mother [P12] had passed away that a nurse [LVN2] from the agency had not come out to the home when the family called to let him/her know the patient had passed away. He/she stated that [FM1] had called the phone number and talked to a nurse, but he/she did not come out to the house. I called the nurse [LVN2] and asked if he/she had made a death visit for [P12]. He/she admittedly told me that he/she had made the visit and performed postmortem care and then the body was picked up by the funeral home.” During an interview on 12/18/25 at 3:30 PM, the Director of Patient Care Services (DPCS) was notified of the above documented phone interview with FM1 of P12. The DCPS stated, “Oh, no. He/she [LVN2] told me he/she made this death visit. I feel so bad now. I should have investigated this further. I had tried to call the [FM1], but I left messages each time. He/she [FM1] never returned my call.” Asked to clarify that the DCPS did not speak to FM1 as documented on the “Grievance Log” and the DCPS stated, “No, I called him/her [FM1] twice and had to leave messages.” Asked if DCPS had documented these phone calls when they were made and the DCPS stated, “I don’t know if I did or not.” Both the RNCM and LVN2 were no longer employed at the facility and were not available for interviews. Review of the hospice agency’s policy “Complaint/Grievance process” dated May 2023 indicated, “… The organization will investigate complaints regarding treatment of care… The organization shall be responsible for asking the necessary questions to determine cause…””

“Based on interview, record review and policy review, the agency failed to ensure one out of 14 patients (Patient (P) 4) was assessed comprehensively to identify physical, psychosocial, emotional, and spiritual needs related to the terminal illness upon admission to hospice. This created the potential for P4 to not receive the full array of hospice care and services to promote well-being, comfort, and dignity. Findings include: Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P4 was admitted to hospice on 08/18/25 with a primary diagnosis of hypertensive heart disease with heart failure. Review of the “Physician’s Order” dated 08/18/25 in the EMR under the “Orders” tab revealed P4 was to be assessed by the Chaplain for services. Review of the “Chaplain/Counselor” tab under the “IDG/POC (Interdisciplinary Group/Plan of Care) Benefit Period Manager” dated 08/18/25 – 11/15/25 in the EMR revealed a Chaplain assessment had not been completed. During an interview on 12/16/25 at 3:52 PM, the Director of Patient Care Services (DPCS) stated P4 was not interested in chaplain services and that was why the Chaplain Assessment was not completed upon admission. The DPCS stated she would look for documentation to support this; however, no documentation was provided prior to the survey exit on 12/18/25. During an interview on 12/17/25 at 3:56 PM, Chaplain1 stated P4 had never been assigned to him in his hot box. Chaplain1 explained that he received notification when he needed to assess or make visits to patients via the hot box (electronic notification system) and without this notification he did not know an assessment was needed. The Chaplain stated the requirement was to see and assess patients for Chaplain services within the first five days of admission to the hospice as part of the comprehensive assessment. The Chaplain stated if a patient was not interested in Chaplain services and expressed this prior to an assessment being completed, there should be documentation of this. During an interview with the DPCS on 12/18/25 at 5:27 PM, she stated there should be documentation of the refusal of a Chaplain Assessment documented in an initial note or in a communication note. Review of the hospice’s “Initial Assessment” policy dated 05/2023 and provided by the hospice revealed, “Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during the initial assessment. A. Nursing and bereavement sections will always be identified.””

“Based on record review and interview the hospice agency failed to ensure that the required individuals (physician, registered nurse (RN), social worker, and/or chaplain) had documented signatures to indicate they attended the Interdisciplinary Group (IDG) meetings for five of 10 patients (Patient (P) 2, P5, P6, P3, and P4) out of a total sample of 14. This failure had the potential for the staff not to have knowledge of the patient’s plan of care. Findings include: 1. Review of P2’s “Patient Profile” located under the “View” tab in the EMR revealed P2 was admitted to hospice services on 08/07/25 with the terminal illness of malignant neoplasm of right bronchus or lung. Review of P2’s agency provided “EB [East Bay Hospice IDG Mtg [Meeting]” indicated on 10/07/25 there was no evidence that the medical director and social worker attended this meeting. There was no documented evidence that the Chaplain attended the 11/04/25 meeting. Continued review revealed there was no documented evidence the Social Worker nor the Medical Director attended the 11/18/25 meeting. Additionally, there was no documented evidence that the Medical Director nor the Chaplain attended the 12/02/25 meeting. 2.Review of P5’s “Patient Profile” located under the “View” tab in the EMR revealed P5 was admitted to hospice services on 08/18/25 with the terminal illness of Alzheimer’s Disease. Review of P5’s agency provided “EB [East Bay Hospice IDG Mtg [Meeting]” indicated on 10/07/25 there was no documented evidence that the Medical Director nor the Social Worker attended the IDG meeting. There was no documented evidence that the Chaplain attended the 11/04/25 meeting. Continued review revealed there was no documented evidence that the Social Worker nor the Medical Director attended the 11/18/25 meeting. Additionally, there was no documented evidence that the Medical Director nor the Chaplain attended the 12/02/25 meeting. 3. Review of P6’s “Patient Profile” located under the “View” tab in the EMR revealed P5 was admitted to hospice services on 03/14/25 with the terminal illness of Alzheimer’s Disease. Review of P6’s agency provided “EB [East Bay Hospice IDG Mtg [Meeting]” indicated on 10/07/25 there was no documented evidence that the Medical Director nor the Social Worker attended the IDG meeting. There was no documented evidence that the Chaplain attended the 11/04/25 meeting. Continued review revealed there was no documented evidence that the Social Worker nor the Medical Director attended the 11/18/25 meeting. Additionally, there was no documented evidence that the Medical Director nor the Chaplain attended the 12/02/25 meeting. 4. Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P3 was admitted to hospice on 10/03/25 with a primary diagnosis of malignant neoplasm of the breast. P3 was a patient in the San Francisco office. Review of P3’s “SF [San Francisco] Hospice IDT [Interdisciplinary Team] Mtg [Meeting]” log of participants attending dated 10/29/25 and provided by the hospice revealed the Medical Director /Physician and Social Worker did not attend the IDG meeting in which P3 was reviewed. 5. Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P4 was admitted to hospice on 08/18/25 with a primary diagnosis of hypertensive heart disease with heart failure. Review of P4’s “SF [San Francisco] Hospice IDT [Interdisciplinary Team] Mtg [Meeting]” log of participants attending dated 09/03/25 and provided by the hospice revealed the Medical Director /Physician did not attend the IDG (Interdisciplinary Group) meeting in which P4 was reviewed. Review of the “SF [San Francisco] Hospice IDT [Interdisciplinary Team] Mtg [Meeting]” log of participants attending dated 10/01/25 and provided by the hospice revealed the Medical Director /Physician did not attend the IDG meeting in which P4 was reviewed. Review of the “SF [San Francisco] Hospice IDT [Interdisciplinary Team] Mtg [Meeting]” log of participants attending dated 10/29/25 and provided by the hospice revealed the Medical Director /Physician and Social Worker did not attend the IDG meeting in which P4 was reviewed. During an interview on 12/17/25 at 1:02 PM, the Business Office Manager (BOM) stated the Log of participants provided as attending the IDG meetings were from the Zoom call in logs. The BOM stated sometimes staff called into the meetings; however, the Zoom records did not include those individuals. The BOM stated he would look for additional information. No additional documentation was provided for the meetings held on 09/03/25, 10/01/25, or 10/29/25 to show the additional required IDG members attended. During an interview on 12/18/25 at 4:56 PM, the Director of Patient Care Services (DPCS) stated all patients of the San Francisco office were reviewed at every San Francisco IDG meeting (at least every 15 days). The DPCS stated she facilitated the IDG meetings and all the required members attended (physician, nurse, social worker, and chaplain). The DPCS verified there was no additional information to confirm full attendance of all required IDG members for the meetings listed above for hospice patients of the San Francisco office. During an interview on 12/18/25 at 5:30 PM, the Social Worker stated, “I usually attend these meetings by calling in on my phone. I don’t remember if I missed any meetings.””

“Based on interview, record review, and policy review, the agency failed to ensure all visits specified in the Plan of Care were completed for two out of 14 sampled patients e patients (Patient (P) 6 and P10). This failure created the potential for P6 and P10 to experience changes in condition that otherwise could have been recognized earlier. Findings include: 1. Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P10 was admitted to hospice on 06/30/25 with a primary terminal diagnosis of malignant neoplasm of the pancreas. Review of the “Plan of Care Order” dated 09/28/25 in the Electronic Medical Record (EMR) under the “IDG/POC [Interdisciplinary Group/Plan of Care]” tab revealed P10 was to receive two chaplain visits per month for “spiritual crisis.” Review of the “Benefit Period Manager: View Chaplain/Counselor” dated 09/28/25 – 12/26/25 in the EMR under the “Chaplain/Counselor” tab revealed P10 had not received any chaplain visits from 09/28/25 up through 12/17/25. During an interview on 12/17/25 at 4:06 PM, Chaplain1 stated there had been a change in the person who was doing the scheduling about two or three months ago. Chaplain1 stated he/she had noticed some patients had dropped off his/her schedule including P10. Chaplain1 stated scheduling for P10 had not come to his/her hot box (electronic scheduling notification system). Chaplain1 stated P10 had enjoyed his/her visits; he/she verified that he had not seen P10 during the current benefit period (09/28/25 – 12/17/25). 2. Review of P6’s “Patient Profile” located under the “View” tab in the EMR revealed P5 was admitted to hospice services on 03/14/25 with the terminal illness of Alzheimer’s Disease. Review of P6’s “Plan of Care” located under the “IDG [Interdisciplinary Group]/POC [Plan of Care]” in the EMR and dated for the certification period of 11/09/25 to 01/07/26 revealed the Chaplain was to make visits one time a month to provide spiritual guidance. Review of P6’s “Chaplain Visits” located under the “Chaplain” tab in the EMR revealed there was no documentation of a visit made or of a missed visit for the month of November 2025. During an interview on 12/18/25 at 4:56 the Director of Patient Care Services (DPCS) stated the scheduler was responsible for putting the frequency of the Physician’s Order for visits into the hot box for the specified discipline/individual. The DPCS stated she and the clinical manager had been doing the scheduling after the previous scheduler left until the new scheduler started a month ago. The DPCS stated the scheduler did not enter the visits and that was why the Chaplain did not complete the visits for either patient. The DPCS verified visits should be conducted in accordance with the Plan of Care. Review of the facility’s policy titled “The Plan of Care” dated 05/2023 and provided by the agency revealed, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided must be in accordance with the plan of care.””

“Based on interview, record review, and policy review, the agency failed to ensure the goals on the care plans were measurable for 10 of14 10 sampled patients reviewed (Patient (P)1, P2, P3, P4, P5, P6, P7, P8, P9, and P10). This failure created the potential that outcomes would not be achieved. Findings include: 1. Review of the undated “Patient Profile” located in the EMR under the “View” tab revealed P3 was admitted to hospice on 10/03/25 with a primary diagnosis of malignant neoplasm of the breast. Review of P3’s “Plan of Care” dated 10/03/25 – 12/31/25 and provided by the agency revealed a problem of weight loss with a goal of “Patient maintains adequate nutrition and hydration.” The goal was not measurable. 2. Review of the undated “Patient Profile” located in the EMR under the “View” tab revealed P4 was admitted to hospice on 08/18/25 with a primary diagnosis of hypertensive heart disease with heart failure. Review of P4’s “Plan of Care” dated 11/16/25 – 02/13/26 and provide by the agency revealed a problem of ankle edema with a goal of “Patient maintains adequate cardiac/circulatory function.” The goal was not measurable. 3. Review of the undated “Patient Profile” located in the EMR under the “View” tab revealed P7 was admitted to hospice on 05/13/25 with a primary diagnosis of Alzheimer’s disease. Review of P7’s “Plan of Care” dated 11/09/25 – 01/07/26 and provided by the agency revealed a problem of patient talking baby talk with a goal of “Patient might need comfort, reassurance, or comfort.” The goal was not measurable. 4. Review of the undated “Patient Profile” in the EMR located under the “View” tab revealed P8 was admitted to hospice on 07/08/25 with a primary diagnosis of severe protein calorie malnutrition. Review of P8’s “Plan of Care” dated 10/07/25 – 01/04/26 and provided by the agency revealed a problem of quality of life with a goal of “Patient and caregiver have enhance daily life through enjoyment of mutually satisfying activities.” The goal was not measurable. 5. Review of the undated “Patient Profile” located in the EMR under the “View” tab revealed P10 was admitted to hospice on 06/30/25 with a primary terminal diagnosis of malignant neoplasm of the pancreas. Review of P10’s “Plan of Care” dated 09/08/25 – 12/26/25 and provided by the agency revealed a problem of possible caregiver problem with a goal of “Care giver will provide care to extent possible.” 6. Review of P1’s “Plan of Care” located under the “IDG/POC [Interdisciplinary Group/Plan of Care] tab in the EMR, indicated the Registered Nurse (RN) started P1’s care plan on 07/25/25. The care plan indicated that P1 was at risk for injury related to falls, at risk for skin breakdown, and fluid overload as evidenced by edema and shortness of breath. The Social Worker (SW) started P1’s care plan on 07/25/25 and indicated that P1 had no advanced directive. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals for the RN and the SW. 7. Review of P2’s “Plan of Care” located under the “IDG/POC” tab in the EMR revealed the RN started P2’s care plan on 11/13/25 and indicated that P2 was at risk for personal injury and/or a house fire related to the unsafe use of oxygen. The SW started P2’s care plan on 11/13/25 and indicated that P2 expressed anxiety related to imminent death. 8. Review of P5’s “Plan of Care” located under the “IDG/POC” tab in the EMR revealed the RN started P2’s care plan on 11/13/25 and indicated that P5/care giver had knowledge deficit and/or barrier with the use of pain medication and patient had an actual wound. The SW started P5’s care plan on 11/13/25 and indicated for patient/family needing assistance with funeral of their choice. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals for the RN and the SW. 9. Review of P6’s “Plan of Care” located under the “IDG/POC” tab in the EMR revealed the RN started P6’s care plan on 03/20/25 and indicated that P6 had urinary incontinence, risk of injury related to high risk pan medication, and altered bowel elimination. The SW started P6’s care plan on 03/15/25 and indicated that P6 had no advanced directive. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals for the RN and the SW. 10. Review of P9’s “Plan of Care” located under the “IDG/POC” tab in the EMR revealed the RN started P9’s care plan on 12/02/25 and indicated that P9/care giver had knowledge deficit and/or barrier with the use of pain medication, patient had actual wounds to left buttock stage two and was at risk for skin breakdown. The SW started P9’s care plan on 12/04/25 and indicated that P6/family needed assistance with funeral/burial of their choice. The care plan did not include measurable data elements to monitor the progress toward the expected outcomes and goals for the RN and the SW. During an interview on 12/18/25 at 4:56 PM, the Director of Patient Care Services (DPCS) stated care plans should include a time/data element for the goal and should be measurable. During an interview on 12/18/25 at 5:30 PM, the SW stated, “After our conversation with this, those goals are not measurable. I will start adding that to the goals.” During an interview on 12/18/25 at 6:30 PM, the Director of Patient Care Services (DPCS) was asked if the goals for the patients were measurable and the DCPS confirmed the goals did not contain data elements to be measured. During an interview on 12/18/25 at 6:40 PM, the RN confirmed the patient’s goals were not measurable. Review of the facility’s policy titled “The Plan of Care” dated 05/2023 and provided by the agency revealed, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program…Each patient will be monitored for his/her response to care or services provide against established patient goals and patient outcomes to evaluate progress toward goals... “”

“Based on interview, document review, and policy review, the hospice agency failed to have volunteer hours that equaled five percent of total patient hours. This had the potential to cause 14 out of 14 active patients to have unmet needs. Findings include: Review of the hospice agency’s document titled, “Hospice Volunteer Hour Report Percentage,” revealed the agency’s monthly volunteer hour percentages were: December 2024 – 3.7%January 2025 – 3.2%February 2025 – 3.0%March 2025 – 3.1%April 2025 – 6.2%May 2025 – 5.3%June 2025 – 4.5%July 2025 – 6.6%August 2025 – 6.1%September 2025 – 6.5%October 2025 – 6.2%November 2025 – 6.8% This was an average volunteer hour percentage of 4.7% for December 2024 through November 2025. During an interview on 12/18/25 at 4:00 PM, the Executive Director stated, “We have had this position vacated for approximately two to three months. We were unaware that we were not meeting five percent that is required until I was putting this report together. It was just a few hours missing here and there that would have given us the requirement of meeting the five percent. We have been talking about how to correct this moving forward.” Review of the hospice agency’s policy “Volunteer Hours” dated May 2023 indicated, “… The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% [percent] [sic] of the total patient hours of paid and contracted hospice personnel…””

“Based on interview, record review, and policy review, the hospice agency failed to ensure medical records were complete for two of 14 sample patients (Patient (P) 13 and P14). Specifically, P13 and P14 were reviewed for hospice revocation and neither of their medical records contained signed hospice revocation forms. The failure to ensure the medicals records were complete created the potential for a lack of care and services to be provided. Findings include: 1. Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P13 was admitted to hospice on 09/18/25 with a primary diagnosis of Alzheimer’s disease. Review of P13’s “Live Discharge Form” dated 10/19/25 and provided by the agency revealed P13 was sent to the hospital for aggressive wound care treatment with hospice being revoked on this date. Review of P13’s EMR revealed there was no hospice revocation record signed by the Patient or Patient Representative and Hospice Representative. On 12/18/25, a request was made for P13’s hospice revocation record and P13’s “Hospice Revocation” form was provided by the agency. The effective date of the revocation was 10/19/25 with the desire to discontinue hospice services due to the patient desiring a higher level of care. 2. Review of the undated “Patient Profile” located in the electronic medical record (EMR) under the “View” tab revealed P14 was admitted to hospice on 05/05/25 with a primary diagnosis of malignant neoplasm of upper lobe right lung. Review of P14’s “Revocation Statement” dated 05/13/25 and provided by the agency revealed P14’s family member called and informed the nurse P14 could not swallow pills and her pain was out of control. The family called an ambulance and had P14 transferred to the hospital. The family member stated he wanted to revoke hospice. This was not the signed revocation form. Review of P14’s EMR revealed there was no hospice revocation record signed by the Patient or Patient Representative and Hospice Representative. On 12/18/25, a request was made for P14’s hospice revocation record and P14’s “Hospice Revocation” form was provided by the agency. The effective date of the revocation was 05/13/25 with the reason documented, “admitted to the hospital.” During an interview on 12/18/25 at 1:10 PM, the Director of Patient Care Services (DPCS stated the revocation forms were not in the EMRs for P13 and P14. The DPCS stated she looked in “Teams” meetings and found them there. The DPCS stated the revocation forms should be located in the EMRs.”