Inland Valley Hospice

“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 and interview. In 3 of 19 (16%) clinical records reviewed, the agency did not ensure the plan of care included planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 5: The patient elected the hospice benefit on 12/16/2025 with diagnoses of cerebral infarction, urinary tract infections, chronic constipation, and sigmoid volvulus. Clinical record review revealed at the time of admission, and continuing to the present, the patient had an indwelling Foley (indwelling urinary catheter used to drain urine from the bladder) catheter (16 Fr with a 30cc balloon) in place due to a neurogenic bladder. The patient’s plan of care dated 12/06/2025 did not include identification of the patient’s genitourinary status and interventions related to management of the Foley catheter. CLINICAL RECORD 7: The patient elected the hospice benefit on 11/07/2025 with diagnoses of Parkinson’s disease, repeated falls, convulsions, tremors, and hypertension. The patient is currently prescribed Phenytoin 100 mg, four tablets daily, for seizure management. The plan of care dated 11/07/2025 did not include interventions related to the patient’s neurological status and seizure activity. CLINICAL RECORD 19: The patient elected the hospice benefit on 10/11/2025 with diagnoses of Tay-Sachs disease, chronic respiratory failure, and seizures. Clinical record review revealed documentation that at the time of admission, the patient was mechanically ventilated and was scheduled for a compassionate extubation by respiratory therapy later that same day. The patient had an existing tracheostomy (a surgical hole in the windpipe that helps with breathing when the usual way is blocked or reduced) and, after extubation on 10/11/2025, was transitioned to 2–5 liters of oxygen via the tracheostomy. The plan of care did not include interventions to address care and management of the tracheostomy. The clinical record also included documentation that the patient had a gastrostomy tube (an artificial external opening into the stomach for nutritional support and gastric decompression). The plan of care included an order for feedings to be administered per the G-tube; however, the plan of care did not include interventions for care and management of the G-tube. Following a joint review of the records and interview with the Director of Clinical Operations and the Vice President of Clinical Operations on 01/22/2026, they agreed the plans of care did not include interventions that corresponded to management of medical equipment and patient symptoms documented on nursing assessments.”

“It is required that a revised plan of care includes information from the patient’s updated comprehensive assessment and record of the patient’s progress toward the outcomes and goals specified in the plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the revised plan of care included updated information from the patient’s comprehensive assessment. CLINICAL RECORD 8: The patient elected the hospice benefit on 10/25/2025 with diagnoses of systemic lupus, atherosclerotic heart disease, and chronic obstructive pulmonary disease. Clinical record review revealed the interdisciplinary team (IDT) meeting documentation by the Registered Nurse Case Manager did not include updates to the plan of care in accordance with the patient’s reported symptoms. Review of nursing visit notes revealed, the nurse documented on the nursing visit note dated 11/24/2025: The patient reported morning nausea and heartburn, noting episodes of vomiting yellow bile daily. On the nursing visit note dated 01/05/2026, the nurse documented: The patient continued to report nausea and decreased oral intake, though Zofran (medication) provided some relief. The nurse documented on the nursing visit note dated 01/26/2026: The patient reported symptoms consistent with a possible lupus flare, including generalized swelling, heaviness, and joint pain. The IDT documentation from 11/25/2025, 12/23/2025, 01/06/2026, and 01/20/2026 included the following nursing update: “SN (skilled nurse) in agreement with current plan of care.” There was no documented evidence that the nurse had updated the patient’s plan of care to address the patient’s evolving symptoms. CLINICAL RECORD 4: The patient elected the hospice benefit on 01/06/2026 Alzheimer’s disease, lower back pain, and major depressive disorder. Clinical record review revealed the IDT meeting documentation by the Registered Nurse Case Manager did not include updates to the plan of care in accordance with the patient’s reported symptoms and clinical needs. Review of nursing visit notes revealed, the nurse documented on the nursing visit note dated 01/15/2026: the patient was observed moaning, and the hospice nurse contacted the patient’s son, who authorized administration of morphine for pain, with effective relief noted. Additionally, wounds were identified on the patient’s right ear and coccyx. The IDT documentation included the following nursing update: “SN in agreement with current plan of care.” There was no documented evidence that the nurse had updated the patient’s plan of care to address the patient’s evolving symptoms and assessment findings. Following a joint record review and interview with the Vice President of Clinical Services and the Director of Clinical Services on 01/23/2026, both leaders agreed that IDT documentation must reflect updates identified during comprehensive assessments.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 16 (25%) clinical records reviewed with hospice aide services provided, the agency did not ensure the Registered Nurse developed patient specific care instructions for the Hospice Aide. CLINICAL RECORD 10: The patient elected the hospice benefit on 10/22/2025 with diagnoses of chronic obstructive pulmonary disease, ventricular tachycardia, and type 2 diabetes mellitus. The plan of care included an order for hospice aide services twice weekly. Clinical record review revealed the patient had an indwelling Foley (indwelling urinary catheter used to drain urine from the bladder) catheter and two unstageable pressure injuries, one located on the sacrum and one on the right ankle. The pressure ulcers required wound care every other day. The hospice aide plan of care dated 10/26/2025 did not include instructions for the aide related to Foley catheter care or instructions for how to care for the wounds/wound dressings while providing care to the patient. CLINICAL RECORD 16: The patient elected the hospice benefit on 08/29/2025 with diagnoses of senile degeneration of the brain, heart failure, hypertension, chronic pain, and cerebral vascular accident. The patient was ordered to receive hospice aide services three times per week. The hospice aide plan of care dated 09/19/2025 assigned the aide the task of bed bath. However, the registered nurse’s additional comments documented, “bed bath/shower 3x weekly MWF (Monday, Wednesday, Friday).” The hospice aide plan of care did not identify who was responsible for determining whether the patient should receive a bed bath or a shower. CLINICAL RECORD 17: The patient elected the hospice benefit on 10/25/2024 with diagnoses of malignant neoplasm of the brain, weakness, insomnia, edema, and seizures. The patient was ordered to receive hospice aide services three times per week. The hospice aide plan of care dated 10/25/2024 did not include information to the aide related to the patient’s history of seizures. CLINICAL RECORD 19: The patient elected the hospice benefit on 10/11/2025 with diagnoses of Tay-Sachs disease, chronic respiratory failure, and seizures. The hospice aide plan of care dated 10/11/2025, included information that the patient had a tracheostomy (a surgical hole in the windpipe that helps with breathing when the usual way is blocked or reduced) through which oxygen was being administered. However, the aide care plan did not include instructions to the aide related to care of the tracheostomy while providing care to the patient. The hospice aide plan of care instructed the aide to follow the current physician’s dietary orders, including feeding the patient 1/3 teaspoon at a time, allowing adequate time to chew and swallow, instructing the patient not to talk while eating, and monitoring for coughing. Clinical record review revealed a physician order dated 10/11/2025 that ordered the patient to be NPO (nothing by mouth) and noted that the patient was unresponsive. The hospice aide care plan was not updated to instruct the aide that the patient was NPO. Following joint clinical record reviews and interview conducted on 01/22/2026, the Vice President of Clinical Services and the Director of Patient Care Services, agreed that the hospice aide plans of care had not been updated to reflect the patient’s identified care needs as required following completion of the comprehensive assessment.”