Mission Hospice Services of Los Angeles LLC

“It is required that each patient’s individualized written plan of care includes measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review and interview. 3 of 14 (21%) clinical records reviewed revealed that the agency did not ensure that the patient’s plans of care included patient-specific measurable goals for the care and treatment of identified patient problems. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023, with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain. During the Interdisciplinary Group Meeting (IDG) on 11/06/2025, the nurse noted the patient was experiencing worsening weakness and contractures in her left arm and leg, which caused pain and necessitated increased doses of Norco and Voltaren Arthritis Gel. The patient’s medication list included Hydrocodone/Acetaminophen 5mg-325mg, prescribed as 1 tablet every morning and at bedtime, and 1-2 tablets every 4 hours as needed for pain, and Voltaren Arthritis Pain 1% Topical Gel: 4 inches every 6 hours for pain. A review of the patient’s plans of care for the benefit periods from 09/14/2025 to 11/12/2025 and 11/13/2025 to 01/11/2026 identified pain as a significant issue. The intervention documented included educating the patient and caregiver on prescribed pain management techniques. However, the only goal was for the patient and caregiver to teach back the pain management techniques, with no specific goal related to the patient’s actual pain management documented. CLINICAL RECORD 7: The patient elected the hospice benefit on 03/22/2024.On 11/10/2025, the nurse noted evidence of dysphagia in the gastrointestinal assessment and included that it had been 4 days since the patient had passed a bowel movement. A physician’s order dated 11/06/2025 included Senna-S 8.6mg/50mg: 2 capsules twice daily for constipation; Lactulose 20 g/30ml: 20 g three times daily for constipation; and Dulcolax 10mg daily as needed for constipation. A review of the patient’s plans of care for the benefit periods from 09/13/2025 to 11/11/2025 and 11/12/2025 to 01/10/2026 identified a problem: altered gastrointestinal status. The intervention included educating the patient and caregiver on the medications used to manage constipation. The goal identified for the treatment of the patient’s constipation was to relieve or control it; however, the specific criteria for what constituted “relieved/controlled” constipation were not defined in the plan of care, rendering this goal unmeasurable. CLINICAL RECORD 10: The patient elected the hospice benefit on 09/02/2025 with a diagnosis of Parkinson’s Disease and with a comorbid condition of chronic pain syndrome. During the start of care visit documented by the Registered Nurse on 09/02/2025, she noted the patient had aching lower extremity pain that varied according to the time of day and affected her mobility and sleep/rest. The nurse documented that the patient’s stated pain goal was 0/10. On 11/18/2025, the nurse noted the patient’s pain score was 2/10 and that her Norco dose frequency has had to be increased. The patient’s medication list included Gabapentin 100mg at bedtime for pain, Hydrocodone/Acetaminophen 5mg - 325mg: 2 tablets twice daily for pain, and Hydrocodone/Acetaminophen 10mg - 325mg: 1 tablet twice daily as needed for pain. A review of the plans of care for the benefit periods from 09/02/2025 to 11/30/2025 and 12/01/2025 to 02/28/2025 included the identified problem of pain management/altered comfort with the intervention that the nurse would educate the patient and her caregiver on when to report changes in the patient’s pain and how to report those changes to the hospice. The goal for the patient’s identified pain was for the patient and caregiver to understand the need to report changes in the patient’s pain level to the hospice staff. There was no goal identifying the patient’s pain goal, listed on admission as a goal of 0/10. During a review of the clinical record findings and an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) on 12/12/2025, she confirmed that she was working with the clinical staff to individualize the patient’s problems, interventions, and goals in the plan of care. A Performance Improvement Project (PIP) for care plan specificity and measurability was initiated on 09/22/2025 with a care plan refresher class with the Registered Nurses, done on 11/20/2025. The evidence that was included in the findings was obtained after the initiation of the PIP.”

“It is required that the Interdisciplinary Group, in collaboration with the individual’s attending physician (if any), reviews, revises, and documents the individualized care plan. A revised plan of care includes information from the patient’s updated comprehensive assessment. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed that the agency did not ensure updates to the patient’s plans of care to reflect newly identified or worsening problems, interventions, or goals based on data from the comprehensive assessments. CLINICAL RECORD 5: The patient, who resided at home, elected the hospice benefit on 10/15/2024. During the Registered Nurse’s (RN) visit on 10/14/2025, the patient’s anxiety score was documented as a 5/10, with the patient reporting her anxiety goal of 1/10. Her sleeplessness was scored as 7/10, with a reported goal of 0/10. Also included was that “...Daughter reports patient is becoming more agitated and easily angered with ADLs. Lorazepam given 1-2x daily, increased insomnia. New med order...Klonopin...” The patient’s medication list included Lorazepam 2mg/ml oral concentrate: 0.25ml every 6 hours PRN for anxiety as of 10/15/2024, and Klonopin 0.5mg orally at bedtime for agitation/insomnia added on 10/14/2025. Klonopin 0.5mg orally at bedtime for agitation/insomnia. The patient’s plan of care for the benefit period from 10/10/2025 to 12/08/2025 was reviewed and revealed that it was not updated to reflect the identified problems of anxiety/agitation and insomnia or any intervention or patient-specific goals addressing the patient’s new/worsening anxiety, agitation, and insomnia requiring a new medication. CLINICAL RECORD 6: The patient elected the hospice benefit on 07/27/2023, with diagnoses including malignant neoplasm of the lung and secondary malignant neoplasm of the brain. During a RN visit on 11/20/2025, the patient reported daily nausea before dinner, stating, “I am nauseous right now.” The RN administered a PRN dose of Zofran, which was effective after 20 minutes. New orders were received to initiate Ondansetron 4mg daily at 4 PM for nausea management. The patient’s medication list included Ondansetron 4mg every 6 hours as needed for nausea, with the daily Ondansetron 4mg disintegrating tablet added on 11/20/2025. While reviewing the patient’s plan of care for the benefit period from 11/13/2025 to 01/11/2026, it was noted that the identified problem of altered nutrition and hydration had been added on 11/09/2025. However, there were no documented interventions or goals included to address the patient’s worsening nausea. During a review of the clinical record findings and an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) on 12/12/2025, she confirmed that she was working with the clinical staff to individualize the patient’s problems, interventions, and goals in the plan of care. A Performance Improvement Project (PIP) for care plan specificity and measurability was initiated on 09/22/2025 with a care plan refresher class with the RNs, done on 11/20/2025. The evidence that was included in the findings was obtained after the initiation of the PIP.”

“The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. 4 of 8 (50%) personnel records reviewed pertaining to employee infection control education, it was found that the agency failed to provide documentation confirming that all employees received the required annual or on-hire infection control training. AGENCY POLICY: The agency’s policy, “Training/Inservice Education No. 1-033,” included in part that, “The written plan for annual inservices will include...infection control...” PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025 revealed that there was no infection control education documented upon hire. PERSONNEL RECORD 4: A review of the personnel record for the Registered Nurse hired on 04/18/2022 revealed that there was no documentation of infection control education for the year 2024. PERSONNEL RECORD 5: A review of the personnel record for the Social Worker hired on 10/25/2021 revealed that there was no documentation of infection control education for the year 2024. PERSONNEL RECORD 6: A review of the personnel record for the Chaplain/Bereavement Coordinator hired on 08/19/2019 revealed that there was no documentation of infection control education for the year 2024. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025 confirmed there was no documentation of infection control education provided at hire for personnel record 2, or of annual infection control education in 2024 for personnel records 4, 5, and 6. She stated that the Clinical Education team is responsible for clinical education. She noted that turnover at the corporate level in the clinical education department leadership, along with a switch to educational platforms in 2024, likely contributed to these gaps.”

“It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by document review, interview and personnel record review. 1 of 1 (100%) Hospice Aide (HA) personnel files reviewed revealed that the agency did not ensure that an annual HA supervisory visit by a Registered Nurse (RN) was documented. AGENCY POLICY: The hospice’s policy “Home Health Aide Supervisory Visits No. 1-036” read in part, “...Semi-annually the registered nurse shall make an on-site visit to the location where each patient is receiving care in order to observe and assess each home health aide....” PERSONNEL RECORD 7: Upon reviewing the personnel file for the Hospice Aide (HA) hired on 09/25/2023, it was found that there was no documented annual on-site supervisory visit by a RN for 2024 or to-date 2025. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, no RN-HA Supervisory Visit for 2024 or 2025 was located in the HR file. She explained that HA supervision is conducted by the local agency, which is responsible for uploading the reports to the HA’s personnel file. Due to turnover in both local clinical leadership and the corporate education team, there was no one available from the 2024 or early 2025 period to consult regarding this matter. Additionally, during an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) and the Clinical Manager (Personnel Record 11), it was stated that the previous DPCS is no longer with the agency. They could not locate any documented HA supervisory visit by a RN for 2024 and confirmed that, while a local Skills Lab Competency was completed, it did not include direct observation of the HA by a RN performing hands-on skills with a patient or pseudo-patient, nor was it conducted at the site of patient care.”

“It is required that hospice volunteers provide day-to-day administrative or direct patient care services in an amount that, at a minimum, equals five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. This standard was not met as evidenced by document review and interview. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 9) on 12/11/2025, it was found that the agency’s average volunteer percentage rate was 0.89% for 2024 and 0.81% to-date for 2025. These figures fall significantly below the targeted 5% of total patient care hours for all paid hospice employees and contract staff, prompting the initiation of a Performance Improvement Project (PIP) on 04/30/2025. The Volunteer Coordinator indicated Volunteer Coordinators from all corporate hospice locations meet monthly to assess ongoing activities and progress towards the volunteer engagement goal. Documented recruitment strategies include outreach via online volunteer recruitment platforms, senior fairs, health expos, and organizations such as the Lions Club and the Rotary Club. To maintain consistent engagement with current volunteers, the agency employs various methods, including calls and texts, thank-you cards, holiday and birthday greetings, and an annual gift basket or goodie bag for Volunteer Appreciation Week in April. The PIP has not yet demonstrated improvement. During the review of the Volunteer Program documents and an interview with the Volunteer Coordinator (Personnel Record 9) on 12/11/2025, it was found that the agency’s average volunteer percentage rate was 0.89% for 2024 and 0.81% for 2025. These figures fall significantly below the targeted 5% of total patient care hours for all paid hospice employees and contract staff, prompting the initiation of a Performance Improvement Project on 04/30/2025. The Volunteer Coordinators from all corporate hospice locations meet monthly to assess ongoing activities and progress towards the volunteer engagement goal. Documented recruitment strategies include outreach via online volunteer recruitment platforms, senior fairs, health expos, and organizations such as the Lions Club and the Rotary Club. To maintain consistent engagement with current volunteers, the agency employs various methods, including calls and texts, thank-you cards, holiday and birthday greetings, and an annual gift basket or goodie bag for Volunteer Appreciation Week in April.”

“It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties and includes the needs and concerns of patients and families coping with a terminal illness. This standard was not met as evidenced by document review, interview and personnel record review. In 3 of 4 (75%) personnel records reviewed for employees onboarded in 2023, 2024, or 2025, it was found that the agency failed to document hospice orientation. AGENCY POLICY: “Orientation No. 1-027 states in relevant parts, “...All personnel and volunteers will be required to attend an orientation program upon employment...The orientation content for all personnel/volunteers will include...General company orientation including the organization’s mission, policies and procedures, environmental safety program, etc...infection prevention and control...HIPAA regulations...Emergency management plan...A Personnel Orientation Checklist will be completed for all new personnel. New personnel will sign and date when their orientation has been completed. The supervisor will sign and date the checklist when new personnel have completed the required activities....” PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025, revealed that there was no documentation of the completion of an initial orientation. PERSONNEL RECORD 7: A review of the personnel record for the Hospice Aide (HA) hired on 09/25/2023, revealed that there was no documentation of the completion of an initial orientation. PERSONNEL RECORD 9: A review of the personnel record for the Volunteer Coordinator hired on 04/24/2023, revealed that there was no documentation of the completion of an initial orientation. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, hospice orientation documents for personnel records 2, 7, and 8 could not be found, despite her outreach to the Clinical Education team, who is tasked with clinical education and orientation. She noted that there had been turnover at the corporate level in the leadership of the clinical education department.”

“It is required that the hospice assesses the skills and competencies of all individuals providing care. This standard was not met as evidenced by document review, interview and personnel record review. In 6 of 6 (100%) applicable personnel records of clinical staff due for an annual evaluation of skills competency reviewed, it was found that the agency did not conduct the required annual evaluations of patient care staff skills, as stipulated by the agency’s policy. AGENCY POLICY: The hospice’s policy, “Competency Program No. 3-001,” included in relevant parts, “...The organization will establish and annually evaluate a group of specific skills related to patient care/service responsibilities and complexity of care/service provided by personnel...Specific competencies will clearly identify and define the skills, which are essential to observe for determination of competence, for each job category...the essential skills will be demonstrated upon hire and annually thereafter...competency will be monitored annually...as part of the annual evaluation process....” PERSONNEL RECORD 2: A review of the personnel record for the Director of Patient Care Services hired on 03/17/2025 revealed that there was no initial Registered Nurse Competency Assessment documented upon hire. PERSONNEL RECORD 4: A review of the personnel record for the Registered Nurse hired on 04/18/2022 revealed that there was no Registered Nurse Competency Assessment documented for 2024. PERSONNEL RECORD 5: A review of the personnel record for the Social Worker hired on 10/25/2021 revealed that there was no Social Work Competency Assessment documented for 2024. PERSONNEL RECORD 6: A review of the personnel record for the Chaplain/Bereavement Coordinator hired on 08/19/2019 revealed that there was no Chaplain or Bereavement Coordinator Competency Assessment documented for 2024. PERSONNEL RECORD 7: Upon reviewing the personnel file for the Hospice Aide (HA) hired on 09/25/2023, it was found that an initial HA skills competency assessment was completed via direct observation by a RN on 10/05/2023. However, no completed HA skills competency assessment for 2024 was located. While a General Skills Lab Competency for all staff was documented on 09/10/2025, there was no evidence of the HA successfully performing grooming, hygiene, or range of motion/patient transfers under the direct observation of an RN with a patient or pseudo-patient. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, no HA skills competency was found in the HR file, nor could it be located following her request for the Clinical Education team to search their records. She explained that there had been staff turnover at the corporate level within the clinical education department, and the process required those staff completing the HA competencies to send them to the appropriate staff to be uploaded into the HR files. Additionally, during an interview with the Director of Patient Care Services (DPCS) (Personnel Record 2) and the Clinical Manager (Personnel Record 11), it was confirmed that the previous DPCS is no longer with the agency. They could not locate a skills competency assessment for 2024 and verified that the locally completed Skills Lab Competency did not include any direct observation by an RN of hygiene, grooming, or transfer techniques utilized with a patient or pseudo-patient. PERSONNEL RECORD 8: A review of the personnel record for the Licensed Vocational Nurse hired on 02/22/2021 revealed that there was no Licensed Vocational Nurse Competency Assessment documented for 2024. During a joint personnel file review and interview with the Senior Vice President of Human Resources (SVHR) on 12/12/2025, it was confirmed that no 2024 competency assessments were located in the HR file for personnel records 4, 5, 6, or 8, and no on-hire competency assessment was completed for personnel record 2. She explained that the previous individual in charge of the corporation’s clinical education left the organization and is not available to answer questions or retrieve any documentation that may not have been scanned into the agency’s electronic human resources system.”