Mission Hospice of Ventura, LLC

“It is required that the documented comprehensive assessment includes a drug profile that contains the patient’s current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following, the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, observation and interview. 1 of 4 (25%) observed home visits and clinical records reviewed revealed the agency did not ensure a medication reconciliation was completed and medications updated to the medication profile when there were changes. HOME VISIT 3/CLINICAL RECORD 14: The date of election was 06/13/2025. The patient resided in a skilled nursing facility. The hospice medication profile, printed on 08/18/2026, listed haloperidol lactate 2 mg/ml oral concentrate, take 0.5ml (1mg) orally or under the tongue every 6 hours as needed for intractable nausea/vomiting or terminal agitation dated 06/14/2025; Senna Lax 8.6 mg tablet, take 1 tablet 2 times daily oral dated 07/29/2026; Senna Plus 8.6 mg-50 mg tablet, take 1 tablet 2 times daily oral dated 12/22/2025; and Valium 10 mg tablet, take valium 10mg suppository 1 rectally at 1st sign of seizure may repeat every 20-30 minutes no more than 3 doses dated 08/19/2025. During the observed home visit on 08/19/2026 with the Registered Nurse (Personnel Record 7), the medication list in the facility revealed MOM concentrate suspension (Magnesium Hydroxide - milk of magnesia) give 30 cc by mouth every 24 hours as needed constipation. Give daily in AM prn dated 6/17/2025; Multiple Vitamins-Minerals Capsule, one capsule by mouth in the evening for supplement wound healing dated 11/15/2025; Tylenol tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for mild pain 1-3/10 NTE (not to exceed) 3 grams acetaminophen in 24 hours dated 02/05/2026; Tylenol tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for temp 100.5 degrees Farenheit and above and call MD NTE 3 grams acetaminophen in 24 hours dated 06/17/2025; and Sennasoides oral tablet 17.2 mg, give 1 tablet by mouth two times a day for bowel management dated 06/17/2025. The facility nurse stated that the Valium had “fallen off the MAR (medication administration record)” on 02/05/2026 and there was no record of an order for haloperidol. Valium was not available in the facility in the event the patient had a seizure. The agency’s medication record had two orders for senna, while the facility had an order for sennasoids 17.2 mg tablet. The agency’s medication record did not list oral Tylenol, MOM, and Multiple Vitamins-Minerals. The record lacked evidence that medication reconciliation occurred when a new medication was added or when changes were made to existing medications. During a joint record review and interview on 08/19/2026, the Director of Patient Care Services confirmed that there was no documented evidence that medications were reconciled when new medications were added or when changes were made to existing medications.”

“It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment. This standard was not met as evidenced by document review, interview and observation. 1 of 4 (25%) home visit observations revealed the agency did not ensure the staff followed accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, for hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment. Agency Policy: Hand Hygiene Policy No. 7-009, approved 07/25/2026, stated in part, “Hand decontamination with an alcohol-based hand rub... Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patient; before donning sterile gloves when performing sterile procedures; before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices; after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient); after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated; when moving from a contaminated body site to a clean body site during patient care; after contact with inanimate objects (including medical equipment) in the immediate vicinity or the patient; and after removing gloves. At any time, personnel may choose to wash their hands with soap and running water in addition to using the alcohol-based hand rub, especially if personnel feel there is a “build-up” on the hands after repeated used of the alcohol-based hand rub. Hand Washing with Soap and Water: Equipment: paper towels and liquid soap; if water and liquid soap are not available, waterless hand-washing products will be used. Wet hands and apply the soap and rub hands together vigorously; avoid use of hot water because repeated exposure to hot water may increase risk of dermatitis. Wash hands for at least fifteen (15) seconds covering all surfaces of the hands and fingers. Rinse with warm water and dry the hands with a disposable towel from the fingers toward the forearm. Use a dry disposable towel to turn off faucet.” HOME VISIT 1: During the observed home visit on 08/19/2026 with the Hospice Aide (HA - Personnel Record 9), the HA was observed washing her hands using soap and water, turned off the faucet with wet hands, and dried her hands with a paper towel. The HA filled the basins with water, gathered soap, and donned gloves. The HA cleaned the patient’s face, arms, torso, and legs. A cup that was used to rinse the hair fell on the floor. The HA picked up the cup and placed it on a table. The HA cleaned the patient’s peri area, removed the gloves, took out another pair of gloves from the HA’s pants pocket, and donned the gloves. The HA cleaned the patient’s back and buttocks using new washcloths and disposable wipes. Without changing the gloves and decontaminating her hands, the HA removed a brief from the filing cabinet (which held supplies), removed barrier cream from the patient’s bag, used the barrier cream, and replaced the cream tube back into the patient’s supply bag. The HA removed another container of cream, used the cream on the patient’s back and replaced the container into the patient’s bag. The HA placed the brief on the patient and put the package of wipes back into the patient’s bag. The HA applied lotion to the patient’s face and body. The HA changed her gloves, dressed, and repositioned the patient. The HA combed the patient’s hair and placed the comb back in the bag. The bag remained in the patient’s room. The HA removed her gloves and washed her hands with soap and water. The HA turned off the faucet with wet hands and then dried them with paper towels. The HA’s hands were not dried before turning off the water faucet. The HA’s hands were not disinfected between glove changes. The HA’s hands were not decontaminated after moving from a dirty to clean area of the body and entering clean areas where supplies were kept. The items kept in the patient’s bag were not disinfected prior to replacing them in the bag after use. During an interview on 08/19/2026, the Director of Patient Care Services agreed the HA did not follow accepted standards of practice (or agency policy) to prevent the transmission of infections and communicable disease, including the use of standard precautions, for hand hygiene; use of gloves, mask, eye protection, or face shield depending on anticipated exposure; safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids; and safe handling of soiled items in the patient’s care environment.”

“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. The hospice documents the cost savings achieved through volunteers. Documentation includes the identification of each position that is occupied by a volunteer, the work time spent by volunteers occupying those positions, estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions noted in Item 1, and for the durations noted in Item 2. This standard was not met as evidenced by document review and interview. Upon reviewing the Volunteer Program, the documentation revealed that volunteer administrative and direct care services accounted for less than 5% of the total patient care hours of all paid hospice employees and contract staff for 2024 (0.70%), 2025 (1.51%), and to date in 2026 (0.81%). A performance improvement project was created in 2024 for volunteer hours below 5%. During a discussion, the Director of Patient Care Services reported that a part-time Volunteer Coordinator left in 2025 and several volunteers also left, resulting in a significant decrease in the number of volunteers and hours. A new Volunteer Coordinator was interviewed and offered the position but never showed up. The current Volunteer Coordinator started on 04/20/2026. Since starting, the Volunteer Coordinator has onboarded 4 new volunteers. When discussing different volunteer-hour opportunities, the agency reported that a volunteer had been making memory bears for specific patients’ families without recording the hours toward the total volunteer hours. During a joint review of the Volunteer Program records and an interview on 08/20/2026, the Volunteer Coordinator confirmed that the agency did not meet the required 5% of volunteer hours for 2024 and 2025. During a joint review of the Volunteer Program records and an interview on 08/20/2026, the Director of Patient Care Services confirmed that the agency did not meet the required 5% of volunteer hours for 2024 and 2025. Upon reviewing the volunteer program, the documentation revealed that volunteer administrative and direct care services accounted for less than 5% of the total patient care hours of all paid hospice employees and contract staff for 2024 (0.70%), 2025 (1.51%), and to date in 2026 (0.81%). A performance improvement project was created in 2024 for volunteer hours below 5%. During a conversation, the Director of Patient Care Services reported that a part-time Volunteer Coordinator left in 2025 and several volunteers also left, resulting in a significant decrease in the number of volunteers and hours. A new Volunteer Coordinator was interviewed and offered the position but never showed up. The current Volunteer Coordinator started on 04/20/2026. Since starting, the Volunteer Coordinator has onboarded 4 new volunteers. When discussing different volunteer-hour opportunities, the agency reported that a volunteer had been making memory bears for specific patients’ families without recording the hours toward the total volunteer hours.”