Hospice of Imperial Valley

“Based on record review and interview, the facility did not provide Social Work services as directed by the Plan of Care for one of 13 sampled patients (Patient 12). This failure resulted in Patient 12 not having social service care as directed. Findings:Per the Plan of Care dated 3/29/2025, Patient 12 was admitted to service on 3/29/2025 with a diagnosis of frontotemporal neurocognitive disorder (a brain disorder causing changes in behavior, personality, and language ability).During a review of Patient 12’s plan of care, the record indicated Social Service visits were to be made once a month. Further review of Patient 12’s medical record indicated that no Social Service visits were documented.During an interview with the Director of Patient Care Services (DPCS) on 12/18/2025 at 3:45 P.M., the DPCS stated that if visits were not documented then they were not completed. The DPCS further stated that the visits were ordered so “we were not following the plan of care.”Per the agency’s policy titled Interdisciplinary Plan of Care Development and Management dated 1/01/25, the policy indicated “…Clinical Staff deliver care in accordance with the plan of care…Document services provided…””

“Based on observation, interview, and record review, the agency failed to ensure the Director of Patient Care Services (DPCS) performed hand hygiene after handling soiled items for the 1 of 1 home visits conducted (Patient 2). This failure increased the risk of infection. Findings: Per the agency’s Plan of Care (POC) for the certification period dated 9/19/25 through 12/17/25, Patient 2 was admitted to the agency on 9/19/25 with diagnoses that included prostate cancer (abnormal cell growth in the male reproductive system). Per the POC, Patient 2 was to be seen by the HA twice a week for personal care and assistance. On 12/17/25 at 1 P.M., a joint home visit was conducted with the DPCS. Patient 2 had soiled a brief with urine and bowel movement. The DPCS was observed with gloved hands, cleaned Patient 2. After the pericare, the DPCS applied cream on Patient 2’s buttocks and lotion on Patient 2’s legs and back without changing to new gloves. After the home visit, a follow-up interview was conducted with the DPCS. The DPCS stated he should have removed the soiled gloves and applied the new ones before applying the lotion and cream to prevent cross-contamination. Per the agency’s policy and procedure, dated 1/1/25, titled Infection Control Policy, indicated “...Hand Hygiene before and after patient contact with potentially contaminated surfaces, and after removal of PPE [Personal Protective Equipment]...””

“Based on interview and record review, the agency failed to ensure the post-bereavement (loss) assessment and services were available for 7 of 7 death records reviewed (Patient 7, 8, 9, 10, 11, 12, and 13). This failure had the potential for the family members or loved ones not to receive assistance from the patient’s death. Findings: On 12/17/25, a review of the agency’s Patient Discharge List was conducted. Per the list, the following data were entered:Patient 7 died on 12/12/25Patient 8 died on 5/12/25Patient 9 died on 11/6/25Patient 10 died on 8/26/25Patient 11 died on 10/23/25Patient 12 died on 3/29/25Patient 13 died on 9/23/25 A review of the patient’s clinical record was conducted, and there was no documented evidence of the completed post-bereavement assessment. On 12/18/25 at 2 P.M., a joint interview and record reviews were conducted with the Director of Patient Care Services (DPCS). The DPCS stated the chaplain was responsible for performing the post-bereavement assessment, and all the documentation must be in the patient’s medical electronic record. The DPCS stated it was not documented, and it was not done. The Chaplain was not available for an interview. Per the agency’s policy and procedure, dated 4/2012, titled Bereavement Services, “...After the death occurred, the bereavement assessment will be updated, and the family/caregiver needs will be discussed...””

“Based on interview and record review, the agency failed to ensure a qualified registered nurse made supervisory visits to evaluate staff performance, patient care, and adherence to hospice policies provided by the hospice aide (HA) for 2 of 13 sampled patients (Patient 2, and 7), when the Director of Patient Care Services (DPCS) served concurrently as the HA, and the DPCS performed a self-supervision performance evaluation. As a result, there was no independent oversight of performance evaluations for these patients. Findings: 1. Per the agency’s Plan of Care (POC) for the certification period dated 9/19/25 through 12/17/25, Patient 2 was admitted to the agency on 9/19/25 with diagnoses that included prostate cancer (abnormal cell growth in the male reproductive system). Per the POC, Patient 2 was to be seen by the HA twice a week for personal care and assistance. A review of Patient 2’s clinical record was conducted on 12/16/25, and it was noted in the HA note that the HA that provided care to Patient 2 was the Director of Patient Care Service (DPCS). A further review of Patient 2’s clinical record was conducted, in the RN [Registered Nurse] Visit Note, dated 9/21/25, 9/22/25, 9/29/25, 10/6/25, 10/13/25, 10/20/25, 10/27/25, 11/3/25, 11/10/25, 11/17/25, 11/24/25, 12/1/25, and 12/8/25 under Supervisory Note, indicated that the DPCS and the HA were the same individual. Per the notes, the DPCS was effectively supervising and evaluating his own clinical work. 2. Per the agency’s Plan of Care (POC) for the certification period dated 11/19/25 through 2/16/26, Patient 7 was admitted to the agency on 11/19/25 with diagnoses that included malignant neoplasm of the overlapping sites of rectum, anus, and anus canal (cancer that starts in or spreads across the rectal area). A review of Patient 7’s clinical record was conducted on 12/17/25, and it was noted in the HA note that the HA provided care to Patient 7 was the DPCS. A further review of Patient 7’s clinical record was conducted in the RN Visit Note, dated 11/21/25, 11/24/25, and 12/1/25, under Supervisory Note, the DPCS performed a self-supervision performance evaluation. On 12/18/25 at 2 P.M., during an interview, the DPCS stated that because the agency did not employ a hospice aide, he performed the HA visits himself. The DPCS also stated that he did not realize the conflict of interest when completing the supervisory notes. Per the agency’s policy and procedure, dated 1/1/25, titled Clinical Supervision and Oversight, indicated “[the agency] provides ongoing supervision of all hospice personnel to ensure that patient care is delivered consistent with the Plan of Care, scope of practice, and hospice policies.””

“Based on the interview and record review, the agency failed to ensure the clinical records were accurate and complete for 2 of 13 sampled patients (Patient 3 and 7), when (1) there was a documentation of supervisory assessment was performed but Patient 3 was not receiving HA visits, and (2) there was no documented evidence of the HA visit for Patient 7. These failures had the potential to result in unverified care delivery and inadequate coordination of services. Findings: 1. Per the agency’s Plan of Care (POC) for the certification period dated 10 /27/25 through 12/25/25, Patient 3 was admitted to the agency on 10/27/25 with malignant melanoma (skin cancer) of the face. Per the POC, Patient 3 declined HA services. A review of Patient 3’s clinical record was conducted. Per the Registered Nurse (RN) Visit Note, dated 11/3/25, 11/10/25, and 11/17/25, indicated that supervisory assessments were performed, even though, Patient 3 was not receiving an HA services. On 12/18/25 at 1:52 P.M., an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated Patient 3 did not have an HA service, and the supervisory visit assessment was inaccurate. The DPCS further states that patients’ medical records should be accurate. 2. Per the agency’s Plan of Care (POC) for the certification period dated 11/19/25 through 2/16/26, Patient 7 was admitted to the agency on 11/19/25 with diagnoses that included malignant neoplasm of the overlapping sites of rectum, anus, and anus canal (cancer that starts in or spreads across the rectal area). Per the POC, Patient 4 was to be seen by the HA twice a week for personal care and assistance. A review of Patient 7’s clinical record was conducted. For the week of 12/7/25 through 12/13/25, there was no documented evidence that the HA visited Patient 7. On 12/18/25 at 2 P.M., a joint interview and record review was conducted with the DPCS. The DPCS stated his visit schedule with Patient 7 as HA was every Monday and Thursday. The DPCS further stated he forgot to document his HA visit, but he recalled visiting Patient 7 home for the HA service. The DPCS stated that the patients’ medical records should be complete with the HA visit note. Per the agency’s policy and procedure, dated 1/1/25, titled Required Contents of the Clinical Record, indicated, “...Entries are completed in a timely manner and authenticated by the author. All documentation reflects services provided in accordance with the Plan of Care...””