Wellhouse Care Inc.

“Based on interview and record review, the agency failed to implement an alternate office site to ensure business operations will continue during an actual emergency, which was necessary for ensuring the continuity of care in a universe of nine patients, when staff members were unable to provide information regarding the agency’s Emergency Preparedness Plan of the designated alternate office site during emergency event. This failure had the potential to disrupt the agency’s ability to maintain continuous care, placing the agency’s patients at risk, and compromising their safety and quality of care during an emergency event. Findings: During an interview on September 16, 2025, at 10:30 AM, with Chaplain (a trained professional who provides spiritual and emotional support to patients and their families during end-of-life care), Chaplain stated uncertainty regarding the timing of the agency’s Emergency Preparedness Plan in-services and the last one might have been around March 2025, approximately six months ago. Chaplain further stated that he does not recall the location of the alternate office site in case of an emergency. During an interview on September 16, 2025, at 12:30 PM, with Certified Nursing Assistant/Hospice Aid (CNA/HA), CNA/HA stated the last time the agency’s Emergency Plan in-services were provided to her was last month which is August 2025. CNS/HA further stated the alternate office site during emergencies will be the office parking lot. During an interview on September 16, 2025, at 1:30 PM, with Registered Nurse (RN), RN stated that the agency’s Emergency Preparedness Plan in-services were provided to the staff monthly, with the most recent session conducted in August 2025. RN further stated that she was not sure about the location of the alternate office site during an emergency, but her best guess was that it would be in the office parking lot. During an interview on September 18, 2025, at 10:30 AM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), the Admin stated that he was responsible for the agency’s Emergency Preparedness Plan and confirmed that the agency’s Emergency Preparedness Plan in-services were conducted monthly, but he did not recall if he mentioned the alternate office site during these sessions to all staff. During a follow-up interview on September 18, 2025, at 11:05 AM, with the Admin and DPCS, the Admin acknowledged the importance of all staff being aware of the alternate office site during an emergency to ensure the continuity of essential functions. The Admin stated that this information should have been included in the agency’s monthly Emergency Preparedness Plan in-services but was not. During a concurrent interview and record review, on September 18, 2025, at 11:15 AM, with the Admin and DPCS, the agency’s policy and procedure titled, “Emergency Operation Plan”, reviewed on March 5, 2025, was reviewed. The P&P indicated, “POLICY. It is the policy of [Name of the Hospice agency] to have an Emergency Management Plan in place to ensure that the organization will be able to respond to a disaster. An emergency in the hospice organization or its community could suddenly and significantly affect the ability to provide hospice services. The goal is to develop processes for establishing the means and methods to continue care, treatment, and services during and after the potential emergencies. … The Administrator is ultimately responsible for assuring continuation of service. If cell phones are not available and all land lines are down, or for the requirement of an indoor command post to support additional functions at the original site or in case the original site is incapacitated, all hospice personnel should report to the home of the Administrator/DPCS. Emergency supplies will be available (refer to the Emergency Kit section below). The address is as follows: [Admin name] 10984 Harris Dr. Loma Linda, CA 92354 …” Both Admin and DPCS stated the agency did not follow the policy.”

“Based on interview and record review, the agency failed to ensure that the current patient roster contained the required acuity level (a system of classifying patients according to the urgency of their medical needs during an emergency situation) for each patient, was readily available to support continuity of care during an emergency in accordance with the agency’s policy. This failure had the potential to impact the agency’s ability to adequately assess and address the needs of the patients to implement immediate intervention during emergencies, compromising the safety and well-being of nine patients at risk. Findings: A review of the agency’s “Emergency Operation Plan” (EOP) binder for the period from June 1, 2024, to September 18, 2025, indicating that a patient roster with required acuity levels was not readily available to ensure adequate support and maintain continuity of care during an emergency. During a concurrent interview and record review on September 18, 2025, at 11:30 AM with the Administrator (Admin) and Director of Patient Care Services (DPCS), the Admin stated that he was responsible for the agency’s Emergency Preparedness Plan including updating the patient roster. Upon reviewing the agency’s EOP binder, the Admin was unable to provide an explanation as to why the patient roster, containing the required acuity levels, was not implemented in accordance with the agency’s policy. During a sequent concurrent interview and record review on September 18, 2025, at 11:40 AM, with the Admin and DPCS, the agency’s policy and procedure titled, “Emergency Operation Plan”, reviewed on March 5, 2025, was reviewed. The P&P indicated, “POLICY. It is the policy of [Name of the Hospice agency] to have an Emergency Management Plan in place to ensure that the organization will be able to respond to a disaster. An emergency in the hospice organization or its community could suddenly and significantly affect the ability to provide hospice services. The goal is to develop processes for establishing the means and methods to continue care, treatment, and services during and after the potential emergencies… CATEGORIES OF PATIENT CARE [name of the agency]… The hospice will identify patients at risk and the types of services the hospice has the ability to provide in the event of emergency. Hospice will maintain a list of patients with acuity level established. The list will be updated weekly and the Administrative person on-call maintains the list. …”. The Admin stated he was not aware the patient roster needed to be updated weekly as per the agency’s P&P. The Admin further stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to ensure a medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking) was conducted during the initial and recertification assessment for one of nine sampled patients (Patients 3) when one medication Patient 3 was taking was not on the Medication Profile (MP-a current list of all medications prescribed for a specific patient) and was available to use after the expiration date. This failure had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: A review of Patient 3’s demographic (a document that gives a summary of patient’s information), indicated a start of care date of May 2, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of July 31, 2025, to October 28, 2025. Patient 3 had diagnoses that included chronic obstructive pulmonary disease (COPD is a term for lung and airway diseases that restrict your breathing) and hypertension (high blood pressure). During an observation at the home visit on September 16, 2025, at 1:45 PM, with Registered Nurse (RN), an observation of Patient 3’s actual medications, available in the home, were compared with Patient 3’s most current MP. During a concurrent observation and interview on September 16, 2025, at 1:50 PM, with RN, RN checked a bottle of Enulos solution (lactulose is prescription medication used to treat chronic constipation [a problem with passing stool]) 10 g (gram-a unit of measure)/15 ml (milliliter -a unit of measure). RN reviewed Patient 3’s MP, and she acknowledged that there was no indication of the order for Enulos and it was not part of Patient 3’s MP. Further observation on September 16, 2025, at 1:55 PM, with RN, indicated the Enulos solution expiration date was June 2025. The RN verified Patient 3’s bottle of Enulos solution had passed the expiration day (three months expired) and was available to use for Patient 3. During an interview on September 16, 2025, at 2:00 PM, with Patient’s 3, Patient 3 stated that he had been taking Enulos since the beginning of starting hospice and his doctor is aware of it. Furthermore, Patient 3 stated that the last time he [Patient 3] took the medication was two nights ago [September 14, 2025]. A follow-up interview on September 16, 2025, at 2:05 PM, with RN, RN stated that the medication reconciliation should have been completed, and the MP updated during each visit, but it had not been done. During an interview on September 18, 2025, at 10:30 AM, with the Director of Patient Care Services (DPCS), the DPCS stated, “It was Case Manager Nurse responsibility to update Medication Profile when there’s any new order or changes. Nurses should have been reviewing and updating medication profile on their visits.” During a concurrent interview and record review on September 18, 2025, at 10:35 AM, with the DPCS, the agency’s policy and procedure (P&P) titled, “Medication Profile,” revised 2009, was reviewed. The P&P indicated, “POLICY Hospice provides a mechanism for documentation of patient prescriptions, nonprescription ( over-the-counter) medications and home remedies, including vitamins and herbs. PROCEDURE. 1. The initial assessment performed by the RN includes a review of all medications that the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicative drug therapy and non compliance with drug therapy.… 5. The RN or LPN reviews the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effects, storage and administration of all medications …”. The DPCS stated the agency did not follow the policy. During a concurrent interview and record review on September 18, 2025, at 10:40 AM, with the DPCS, the agency’s P&P titled, “Initial Assessment/Comprehensive Assessment,” revised 2009, was reviewed. The P&P indicated, “POLICY. Each patient admitted by Hospice will have an appropriate initial assessment and comprehensive. Procedure… Each patient’s comprehensive assessment includes a review of all medications the patient is currently taking (prescription, non-prescription, herbs, home remedies, other alternative treatments, etc.) to identify: assessment performed and documented. • Drug effectiveness. • Side effects. • Actual or potential drug interactions. • Noncompliance with medications. • Duplicate therapy. • Ineffective therapy. • Potential adverse effects. • Medication reactions.• Drug therapy associated with lab monitoring… “. The DPCS stated the agency did not follow the policy.”

“Based on observation, interview, and record review, the agency failed to follow its policy and procedure to develop and maintain a system of communication and integration for three out of nine sampled patients (Patient 1, 2 and Patient 3), when the patients’ home clinical record binders did not contain their current care plans (a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care) including their most current Medication Profile (MP-a current list of all medications prescribed for a specific patient). This failure had the potential to result in ineffective care coordination, unmanaged symptoms, and medication errors (mistakes with medicines that can cause harm or stop proper treatment), which could place Patient 1, 2 and Patient 3’s safety, comfort, and overall well-being at serious risk in his end-of-life care. Findings: 1. A review of Patient 1’s demographic (document that gives a summary of patient’s information), indicated, a start of care date of October 4, 2023 with a certification period (a specific timeframe during which a patient is eligible to receive hospice (medical care for people who are expected to live six months or less) services) of July 25, 2025 to September 22, 2025. Patient 1 had primary diagnoses that included multiple sclerosis (is a condition that affects nerves in your central nervous system) During a concurrent observation and interview at the home visit on September 16, 2025, at 10:45 AM, with Chaplain (a trained professional who provides spiritual and emotional support to patients and their families during end-of-life care), in the presence of Patient 1’s brother, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both Chaplain and Patient 1’s brother confirmed that these essential documents were not available. 2. A review of Patient 2’s demographic, indicated, a start of care date of January 13, 2025 with a certification period of September 10, 2025 to November 8, 2025. Patient 2 had primary diagnoses that included congestive heart failure (a long-term condition that happens when your heart can’t pump blood well enough to give your body a normal supply) and included Chronic obstructive pulmonary disease (COPD is a term for lung and airway diseases that restrict your breathing) and hypertension (high blood pressure). During a concurrent observation and interview at the home visit on September 16, 2025, at 12:45 PM, with Certified Nursing Assistant/Hospice Aid (CNA/HA), in the presence of Patient 2, a review of Patient 2’s home clinical record binder and the surrounding area was conducted. Patient 2’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both CNA/HA and Patient 2 confirmed that these essential documents were not available. 3. A review of Patient 3’s demographic, indicated a start of care date of May 2, 2025, with a certification period of July 31, 2025 to October 28, 2025. Patient 3 had diagnoses that included COPD and hypertension (high blood pressure). During a concurrent observation and interview at the home visit on September 16, 2025, at 2:10 PM, with Registered Nurse (RN), in the presence of Patient 3, a review of Patient 3’s home clinical record binder and the surrounding area was conducted. Patient 3’s current care plan including the most recent MP were not found in the binder or anywhere in the house. Both RN and Patient 3 confirmed that these essential documents were not available. During an interview and record review on September 18, 2025, at 10:45 AM, with the Administrator (Admin) and Director of Patient Care Services (DPCS), both Admin and DPCS stated that it is the responsibility of the visiting nurse and case manager to ensure that the current care plan including the most recent Medication Profile (MP), and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the Admin stated the current care plan including the most recent MP were crucial for maintaining effective care coordination, proper medication management, timely clinical responses and to facilitate continuity of care. During a concurrent interview and record review on September 18, 2025, at 10:50 AM, with the Admin and DPCS, the agency’s policy and procedure (P&P) titled, “Medication Profile,” revised 2009, was reviewed. The P&P indicated, “POLICY Hospice provides a mechanism for documentation of patient prescriptions, nonprescription ( over-the-counter) medications and home remedies, including vitamins and herbs. PROCEDURE…6. The original medication record will be filled in the patients’ record. A copy may be placed in the patient’s home…”. Both Admin and DPCS stated the agency did not follow the policy. During a concurrent interview and record review on September 18, 2025, at 10:55 AM, with the Admin and DPCS, the agency’s P&P titled, “Patient Record Content,” revised 2009, was reviewed. The P&P indicated, “POLICY. Hospice will provide an accurate and current patient record for every patient seen by hospice. The record weather hard copy or electronic form , will be made readily available… Procedure… 3. Each patient record will contain the following as applicable: … initial assessment. Comprehensive assessment. Updates to comprehensive assessment… A current medication profile to include medication/allergies/sensitivities and every medication, dose, frequency and route of administration for prescription and non-prescription medications, herbal products and home remedies…. “Both Admin and DPCS stated the agency did not follow the policy.”