California Mission Hospice, LLC

“Based on interview and record review, the hospice failed to ensure individualized care plans were developed for one of three sampled patients (Patient 3). This failure had the potential to result in inconsistent delivery of care, which could lead to a decline or lack of improvement in the patient’s health condition. Findings: Review of the hospice’s P&P titled the Plan of Care undated, showed 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 to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. Review of Patient 3’s clinical record was initiated on 8/24/26. The clinical record showed the SOC was 3/30/26. The patient was certified for hospice services during the certification periods from 3/30/26 to 06/27/26 and 6/28/26 to 9/25/26.Review of the medication profile for the certification periods from 6/28/26 to 9/25/26, showed the following:-administer oxygen via nasal cannula at 3 liters per minute for shortness of breath.-albuterol sulfate hydrofluoroalkane (bronchodilator) inhalation aerosol solution 108 micrograms (equivalent to 90 micrograms of albuterol base) per actuation two puffs via inhalation four times a day for shortness of breath.-Breo Ellipta Inhalation Aerosol Powder Breath Activated (combination of steroid and bronchodilator) 100-25 mcg per actuation Take one inhalation once daily at the same time every day for asthma-Flonase Allergy Relief Nasal Suspension (allergy symptom reliever) 50 mcg/act one spray in each nostril twice a day for nasal congestion/sinus congestion/allergy.-acetylcysteine inhalation solution (mucolytic) 20 % 3 ml four times a day via nebulizer for respiratory secretions/airway congestion -Ipratropium-Albuterol Inhalation Solution (brochodilator) “0.5-2.5 (3) MG/3ML” one vial via nebulizer every four hours as needed for cough or shortness of breath. The Interdisciplinary Team Plan of Care Updated Review dated 7/23, 8/6, and 8/20/26, showed the Plan of Care for respiratory function was ongoing; however, there was no documented evidence the Interdisciplinary Group had developed an individualized plan of care to address Patient 3’s respiratory needs. On 8/27/26 at 1530 hours, an interview and concurrent clinical record review were conducted with the DPCS Designee. The DPCS Designee stated all medications listed above were still active orders. The DPCS designee acknowledged and confirmed the findings.”

“Based on interview and record review, the hospice failed to ensure the Interdisciplinary Group reviewed and revised the patients’ plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for one of 3 sampled patients (Patient 1). This failure had the potential to result in this patients not receiving appropriate, consistent, and quality hospice care. Findings: The hospice’s P&P titled Interdisciplinary Group Meeting undated showed the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient’s plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires. Grievances and issues of ethical concern will be discussed.Review of Patient 1’s closed clinical record was initiated on 8/24/26. The clinical record showed the SOC was 6/21/26. The patient was certified for hospice services during the certification periods from 6/21/26 to 9/18/26. Patient 1 was expired on 6/29/26Review of the Physician Order dated 6/28/26, showed the following:-At 1130 hours, the family member called and expressed concern regarding the patient’s prolonged end-of-life decline. The family member reported the patient was intermittently unresponsive and stated that patient appeared to be ‘lingering.’ The family member requested guidance regarding the dying process, expected changes, and appropriate comfort measures. Documentation showed the IDT was informed.-At 1330 hours, the intervention for the Plan of Care included continue comfort-focused hospice care due to significant terminal decline and increased unresponsiveness; and educated family/facility staff regarding expected end-of-life changes and recognition of pain, respiratory distress, agitation, or other symptoms requiring hospice intervention. Family verbalized understanding. Facility/family to contact hospice 24/7 for any further change in condition or uncontrolled symptoms. The RN follow-up visit was planned for the following day to reassess patient’s condition and evaluate effectiveness/tolerance of newly ordered medication and overall symptom-management plan.* However, the care plan was not updated specifically to address Patient 1’s concern. O8/25/26 at 1400 hours, an interview was conducted with the LVN 1. LVN 1 stated on 6/28/26, the family called several times and expressed a concern regarding Patient 1 transitioning and wanted to “speed up the process.” They also requested information regarding Death with Dignity. In addition, the family had concerns about the frequency of bathing and the episode of agitation. LVN 1 stated the staff from the long‑term care facility did not notify him of the episode on 6/27/26. LVN 1 stated when he visited Patient 1 on 6/28/26, the patient was calm and not agitated. The facility staff did not inform him that the patient had experienced increased agitation, or the administration of the medication had been ineffective to manage agitation. On 8/27/26 at 1530 hours, an interview and concurrent clinical record review were conducted with the DPCS designee. The DPCS designee was informed Patient 1 had concerns regarding death with dignity, bathing frequency, and the episode of agitation. The DPCS designee acknowledged that the care plan should have been revised to specifically educate the family and address their concerns. The DPCS designee verified the findings.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the patient-specific comprehensive assessment and reassessment identified the patient’s need for hospice care and services. On review of RRHV#3 the patient had a history of Type 2 Diabetes yet there was no assessment of the endocrine system completed in the record. In RRNHV#9 the patient had a history of diabetes and on two types of injectable hypoglycemic medication yet there was no assessment of the endocrine system noted in the record. These observations were reviewed with the DPCS Designee, and Administrator.”

“Observed in Record Review. In 10 of 10 patient records reviewed, the organization failed to ensure the written plan of care reflect patient and family goals that are individualized, specific, measurable and time-bound. On review of all clinical records the goals established were noted to be non-specific and not individualized to the patient. The same goals were repeated from patient to patient throughout all the records. An example of a non-specific goal in RRHV#1 was Patient will be able to meet needs while neurological changes are being managed until ### this same goal could be seen in most patient records. In RRNHV#6 a goal was Patient will be able to cope with activity intolerance and participate in daily activities while signs and symptoms are being managed until ###, again the same goal could be noted throughout the records. In RRNHV#8 a non-specific goal was Patient will be able to gain optimal hygiene and maintain self-esteem until ###. These observations were reviewed with the DPCS Designee, Administrator, and Alt Administrator.”

“Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to ensure the plan of care include all services needed for the palliation and management of the terminal illness and related conditions. On review of RRHV#3 the patient was on multiple diabetic medications including insulin yet there was no endocrine care plan to guide the care. There were no physicians order for blood glucose monitoring although the caregiver noted on home observation that she was performing monitoring in the home. Further, the order for insulin on the medication profile was incomplete or incorrect as it noted a dose of 300 units. The formulation was 300 units per ml. The caregiver stated she gave 10 and demonstrated how to give 10 on the insulin pen. In RRNHV#9 the patient was also diabetic and was on two types of injectable hypoglycemics up to 3 times a day. There were no orders for blood glucose monitoring nor was there a care plan for the diabetes to guide the care. These observations were reviewed with the RN, and Administrator.”

“Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to ensure services were provided per the established plan of care. On review of RRHV#2 the plan of care noted volunteer services at 1 time a month yet on discussion with the leadership the were no volunteer services being provided as the family had declined. in RRHV#3 the plan of care specified the aide to visit 2 times a week yet per the documentation the aide was visiting 1 time a week. In RRNHV#5 there was an order for physical therapy noted on the plan of care but there was no documentation that the therapy was provided to the patient. These observations were reviewed with the DPCS designee.”

“Observed in Patient Home. In 5 of 10 patient records reviewed, with aide services provided, the organization failed to ensure the registered nurse provide written patient care instructions for the hospice aide. On home observation for RRHV#1 the patient required shampoo hair care and two person transfer yet these skills were not assigned on the aide plan of care. On review of RRNHV#4 the patient had multiple wounds yet no specific instructions on how the aide was to handle the wounds while providing care. In RRNHV#5 there was documentation of skin tears with wound treatment yet no instructions for the aide on how to handle the wounds. In RRNHV#9 the patient was on oxygen as needed but the aide assigned plan of care did not indicate the presence of oxygen or oxygen precautions. In RRNHV#10 the patient was on continuous O2 but the aide assignment did not specify whether the O2 could be removed for bathing or to remain in place and failed to indicate oxygen and bleeding precautions as the patient was on Eliquis. These observations were reviewed with the RN and Administrator.”