Alta Loma Hospice, Inc.

“Based on interview and record review, the facility failed to ensure that the Governing Body (GB), (a group of people with the authority to manage and control an organization or institution) provided adequate oversight to meet quality care standards and aligned with the agency strategic goals, when the Quality Assessment and Performance Improvement (QAPI - program that monitors care and use data to identity and address problems in patient care and quality of life) was not documented in the GB minutes from August 1, 2024 through August 31, 2025. This failure had the potential to cause missed opportunities for quality improvement and quality of care to go unaddressed and continue in a universe of 31 patients. During a concurrent interview and record review on September 4, 2025, at 3:15 PM, with the Administrator (Admin) and Director of Patient Care Services (DPCS) regarding the data collection from the QAPI committee not being given to or presented in the meetings of the Governing Body, and for the QAPI reports to be approved in the Governing Body meeting minutes. Both the Admin and DPCS stated they had not given any of the data to the Governing Body.During a record review of the facility’s Governing Body (GB) binder, undated, it indicated the GB meets monthly, but there was no documented evidence that the QAPI report was discussed or approved.During a concurrent interview and record review on September 5, 2025, at 1:00 PM, with the Admin and DPCS, the facility’s Policy and Procedure (P&P), titled, “Performance Improvement,” undated, was reviewed. The P&P indicated, “The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually. PROCEDURE: … 4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis.” The Admin and DPCS stated the policy was not followed.During a concurrent interview and record review on September 5, 2025, at 1:05 PM, with the Admin and DPCS, the facility’s Policy and Procedure (P&P), titled, “Governing Body,” undated, was reviewed. The P&P indicated “…5A. Relevant findings of performance improvement activities are consistently provided to 5B. the Governing Body…6. The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide quality assessment and performance improvement program (QAPI). Information related to the performance improvement program will be provided to the Governing Body on a quarterly basis. 7. The Governing Body must ensure that the QAPI program: …F. Approves the frequency and detail of the QAPI data collection and included in the Board minutes.” The Admin and DPCS stated the policy was not followed.”

“Based on interview and record review, the agency failed to ensure seven of seven Certified Home Health Aides (CHHA 1, 2, 3, 4, 5, 6, and 7) received the required 12 hours of annual in-service training, which is necessary for maintaining staff competency. This failure had the potential to result in a decline in the quality of care, leading to provision of below-standard services by the agency, which may affect the health and safety of patients receiving care from CHHA. During a concurrent interview and record review on September 5, 2025, at 11:00 AM, with the Director of Patient Care Services (DPCS), the DPCS reviewed the “In-Services” binder. The required 12-hour in-services for all seven CHHAs (CHHA 1, 2, 3, 4, 5, 6, and 7), had not been completed and no documentation was available to verify their participation. The DPCS stated, “we rely on the aides to get their in-services hours for licensure.” The DPCS further stated the CHHAs do their in-services for their state certification, but the documentation is not in the binder.During a record review of the facility’s Policy and Procedure, titled, “Performance Improvement”, undated, it indicated: “I. The program shall provide or make provision for at least quarterly in-service education program to its employees and volunteers who have direct patient contact.” The DPCS stated that the policy was not followed.During a record review of the CHHA’s Job Description”, undated, it indicated, “POSITION QUALIFICATIONS: 1. Meets the training requirements of the State of California. 2. Effective august 14, 1990, a person who has successfully completed a state established or other training program that meets the requirements of S 484.36 (a) and a competency evaluation program, or state licensure program that meets the requirements of S 484.36 (b), or a competency evaluation program or state licensure program that meets the requirements of S 484.36 (b).” The DPCS stated the job description and requirements for licensure was not followed.”