Bristol Hospice - Inland Valley LLC

“Based on interview and record review, the agency failed to ensure the comprehensive assessment (a thorough, in-person evaluation of a patient to understand their medical, physical, emotional, social, and spiritual needs) identified and addressed the physical needs related to the terminal illness for one of eight sample patients (Patient 8), when the open wound identified during the assessment did not have a physician treatment order in place.This failure had the potential to result in the inability to manage and monitor the patient’s wound effectively, which could impact the Patient 8’s overall comfort and well-being. During a review of Patient 8’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of May 13, 2025, 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 June 13, 2025, to July 13, 2025. Patient 8 had primary diagnoses that included senile degeneration of the brain (a neurological disorder that is tied to cognitive decline, memory impairment, and changes in behavior).During a concurrent interview and record review on November 19, 2025, at 2:38 PM, with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 8’s IDT Notes (each discipline is required to have an IDT note to talk about their plan of care for the patient), dated May 15, 2025. The IDT Notes indicated Patient 8 had a stage 4 pressure injury (a severe, full-thickness wound with damage extending to muscle, tendon, or bone) located at the sacral right buttock area (the region at the base of the spine and the upper, inner part of the right buttock), and heels. The DPCS stated Patient 8 had wounds.During a concurrent interview and record review on November 19, 2025, at 2:45 PM, with the DPCS, the DPCS reviewed Patient 8’s plan of care (a comprehensive, individualized document that outlines the medical, emotional, and spiritual support for a terminally ill patient and their family), with a certification period of June 13, 2025, to July 13, 2025. The DPCS could not find documented evidence that a treatment order was in place for Patient 8’s identified wounds. DPCS stated Patient 8’s wound care orders were not included in the plan of care.During a concurrent interview and record review on November 19, 2025, at 3:00 PM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P), titled, “The Plan of Care,” dated, September 09, 2024, which indicated, “PURPOSE: To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues… POLICY: 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 member of the interdisciplinary group. PROCEDURE: …9. The plan of care will be reviewed and revise as frequently as deemed necessary, … with input from the attending physician, the patient, and the family/caregiver. Review the plan of care will be documented in the clinical record… 12. The written plan of care can contain, but will be not be limited to, the following:… S. Drugs and Treatments (including allergies) … T. Physician-directed instruction to patient and family/caregiver.” The DPCS confirmed that the policy was not followed.”

“Based on interview, and record review, the agency failed to ensure the Registered Nurse, as a member of the interdisciplinary group (IDT - a team of healthcare professionals who collaborate to create and manage a patient’s care plan, ensuring holistic support for both the patient and their family), provided appropriate coordination of care and ongoing assessments for one of eight sample patients (Patient 5), when three identified wounds did not have documented measurements for Patient 5.This failure had the potential to result in an inability to evaluate the effectiveness of the treatment and to coordinate appropriate care for Patient 5. During a review of Patient 5’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of August 27, 2025, 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 September 12, 2025, to November 12, 2025. Patient 5 had primary diagnoses that included atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). During a concurrent interview and record review on November 18, 2025, at 11:00 AM, with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 5’s comprehensive assessment (a thorough, in-person evaluation of a patient to understand their medical, physical, emotional, social, and spiritual needs), indicated a certification period of September 12, 2025, to November 12, 2025. The comprehensive assessment indicated Patient 5 had 3 sites pressure injuries (a sore that develops when skin and the underlying tissue are damaged from constant pressure): right heel, right great toe and posterior lumbar area (coccyx), treatment orders indicated “…Cleanse affected area with soap and water or no-rinse cleanser, if available… 2. Gently pat dry and apply protective ointment such as petroleum jelly or zinc… 4. Cover with plastic wrap… 5. Repeat after each episode of incontinence.” The DPCS could not find documented evidence that Patient 5’s three identified wounds were measured by the Registered Nurse in the comprehensive assessment. DPCS stated the Registered Nurse should have measure Patient 5’s wounds upon admission and on a weekly basis.During a review of Patient 5’s clinical records, there is no documented evidence that Patient 5’s wounds were measured in the IDT Notes (each discipline is required to have an IDT note to talk about their plan of care for the patient), dated August 28, 2025, September 11, 2025, and September 25, 2025.During an interview on November 18, 2025, at 12:40 PM, with Registered Nurse (RN2), the RN stated that wounds must be measured at admission and weekly.During a concurrent interview and record review on November 18, 2025, at 4:00 PM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P) titled, “Wound Care” dated September 2021, which indicated, “PURPOSE. To provide guidelines for wound assessment and treatment. POLICY: To provide wound care treatments/services based on evidence-based standards of care under direction of a physician. PROCEDURE:… 3. The admitting registered nurse will document each wound status including, location and etiology, measurement of length, width, and depth, undermining and tunneling, if present, description of the wound bed, drainage, signs and symptoms of infection, healing and peri wound skin condition. …5. The admitting registered nurse, in conjunction with the patient and caregiver, will develop an appropriate plan of care based on the patient’s needs and the assessment findings… 7. The hospice nurse will provide wound care instruction to the patient/caregiver/facility at each visit…CONTINUED/ONGOING TREATMENT… 3. At least every week, the wound assessment and documentation will include measurement of length, width, depth and undermining and tunneling if present. The DPCS confirmed that the policy was not followed.During a concurrent interview and record review on November 18, 2025, at 4:25 PM, with the DPCS, the DPCS reviewed the agency’s “Job Description for Registered Nurse Case Manager”, dated February 26, 2025, which indicated,…Administer medications and treatments as prescribed by the physician in the physician’s plan of care…Provide health care instructions to the patient, as appropriate, per assessment and plan…to coordinate patient care for assigned caseload”. The DPCS confirmed that the job description was not followed.During a concurrent interview and record review on November 19, 2025, at 2:38 PM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P), titled, “Interdisciplinary Group Meeting”, dated, May 2020, which indicated, “PURPOSE: To define the process for interdisciplinary group meetings and documenting patient status in the clinical record. POLICY: 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. PROCEDURE: …3. Level of services will be reviewed for new and ongoing patients based on hospice team assessments. The group will approve recommendation for a change in the level of care…6…I will note changes, response to treatment and progress toward targeted outcomes, which may include: …B. An increase or decrease in symptoms or acuity…3. Condition of skin/presence/status of pressure ulcers. The DPCS confirmed that the policy was not followed.”

“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; [and] 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; [and] drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and, as appropriate, preventive measures are implemented to manage the side effects. 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. In 2 of 19 (10%) clinical records reviewed and home visits observed, the agency did not ensure the comprehensive assessment included a review of the patient’s medications to identify actual or potential drug interactions. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 06/20/2024 with a diagnosis of senile degeneration of the brain. The patient resided in a skilled nursing facility (SNF). During the home visit with the Social Worker (SW) [Personnel Record 5] on 11/12/2024, the hospice medication profile (printed on 11/11/2024) was compared to the SNF medication profile (printed on 11/12/2024). The hospice medication profile documented the following medications that were not documented on the SNF medication profile: Lorazepam 0.5 mg tablet, one (1) tablet by mouth every 6 hours as needed for anxiety, effective 06/20/2024; Duoneb 3mg/0.5mg/3ml, one (1) inhalation every 4 hours as needed for shortness of breath. Additionally, the hospice medication profile documented Acetaminophen 650 mg suppository as needed for fever, and Milk of Magnesia 15 ml po, and the SNF medication profile documented Acetaminophen 500 mg tablet as needed for fever, effective 06/21/2024, and Milk of Magnesia 30 ml po. Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 02/05/2024 for a diagnosis of hypertensive chronic kidney disease. The patient resided in a skilled nursing facility (SNF). During the home visit with the Registered Nurse [Personnel Record 4[ on 11/12/2024, the hospice medication profile (printed on 11/11/2024) was compared to the SNF medication profile (printed on 11/12/2024). The SNF medication profile documented the following medications that were not documented on the hospice medication profile: Fleet enema, insert one (1) dose rectally every 24 hours as needed for constipation if Dulcolax suppository ineffective, effective 02/05/2024; Milk of Magnesia 1200 mg/15ml, give 30 ml by mouth every 24 hours as needed for constipation; Ready Care Supplement, give 60 ml 3 times a day by mouth with med pass, effective 02/27/2024; Norco 5/325 mg, give one (1) tablet by mouth every 6 hours as needed for severe pain, effective 09/23/2024; and Keppra 750 mg, give one (1) tablet 2 times a day by mouth, effective 06/27/2024. The hospice medication profile documented Keppra 500 mg. Additionally, the hospice medication profile documented the following medications that were not documented in the SNF medication profile: Loperamide 2 mg, give one (1) tablet daily as needed for loose stools, effective 02/05/2024; Acetaminophen 650 suppository, insert rectally every 6 hours as needed for fever greater than 100.5; and Lorazepam 2mg/ml concentrate, give 0.25 ml by mouth every 6 hours as needed for anxiety or restlessness. There was no evidence that the Fleet enema, Milk of Magnesia, Ready Care Supplement, and Norco had been reviewed during the comprehensive assessment. During an interview and a joint review of the medication profiles on 11/13/2024, the Regional Director of Operations, Branch Director, and Clinical Leader agreed the lists had differences during the time of printing and the site visit.. The Clinical Leader advised that they “Visited the SNF and reconciled the lists, but it was after the site visit.””

“It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, observation, and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the Registered Nurse provided coordination of care to ensure the implementation of the plan of care. Clinical Record 4/Home Visit 4: The patient elected hospice care on 08/02/2024 with a diagnosis of hypertensive heart disease. The plan of care ordered Hospice Aide services two (2) times a week. The patient was a resident of a board and care facility. During the home visit with the Hospice Aide (HA) [Personnel Record 7], the HA care plan dated 10/04/2024 assigned the HA the relevant tasks: “apply heel protectors every visit and emergency call light near patient every visit.” The patient did not have heel protectors in place, nor did the bed or room have an emergency call light system. A review of the HA visit notes revealed the HA documented that the patient did not have heel protectors or an emergency call light, and the RN was notified. There was no evidence the RN coordinated care with the HA regarding the heel protectors. During the interview, the HA contacted the nurse regarding the heel protectors and was advised that “maybe they had not arrived.””

“It is required that medical social services are provided by a qualified social worker: based on a psychosocial assessment; according to the patient’s and family’s needs and acceptance of these services; per the plan of care; and under the direction of a physician. This standard was not met as evidenced by clinical record review and interview. In 3 of 19 (16%) clinical records reviewed, the organization did not ensure that medical social services were provided per the plan of care. Clinical Record 2: The patient elected the hospice benefit on 02/05/2024. The initial plan of care ordered Social Worker (SW) services one (1) time a month. In April 2024, the SW documented one (1) phone call to the patient. There was no documented SW patient visit. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. Clinical Record 6: The patient elected the hospice benefit on 08/29/2023. The initial plan of care (POC) ordered Social Worker services one (1) time a month. There was no evidence of SW visits documented in April 2024, May 2024, June 2024, July 2024, or August 2024. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. The SW visit frequency was discontinued on Sept 21, 2024. Clinical Record 9: The patient elected the hospice benefit on 07/26/2023. The initial POC ordered Social Worker services one (1) time a month. In March 2024 and April 2024, the SW documented phone calls to the patient instead of visits. In May 2024 and June 2024, the SW did not document phone calls or visits to the patient. There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. During an interview on 11/12/2024, the Regional Director of Operations confirmed the SW visits were not provided as ordered, and in clinical records 6 and 9, there were several months of undocumented visits.”

“It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (10%) clinical records reviewed, the organization did not ensure that spiritual counseling was provided in accordance with the patient’s and family’s acceptance of the services. Clinical Record 2: The patient elected the hospice benefit on 02/05/2024. The initial plan of care ordered Spiritual Counselor (SC) services twice monthly. The SC documented a visit on 09/19/2024. There was documentation by the SC that the second visit was “missed due to it being a duplicate..” There was no documented evidence of refusal of visits by the patient/caregiver or change in the POC visit frequency. Clinical Record 3: The patient elected the hospice benefit on 08/31/2024. The plan of care documented a change of SC visits to 1 time a week for 8 weeks, effective 10/01/2024, and “The patient has been alienated from the community of faith and needs spiritual interventions.” A clinical record review revealed no SC visit documented the week of 10/27/2024 or documentation of the patient’s refusal of services. During an interview on 11/12/2024, the Regional Director of Operations confirmed the findings and stated there should have been a second visit for the Spiritual Counselor in September 2024.”

“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, interview, and observation. In 1 of 17 (6%) clinical records reviewed in which Hospice Aide (HA) services were accepted, the agency did not ensure the Registered Nurse (RN) provided specific written instructions for the Hospice Aide. Clinical Record 6: The patient elected hospice care on 08/29/2023 with a diagnosis of Parkinson’s disease. The patient resided at home. The HA care plan dated 10/22/2024 assigned the HA the relevant tasks to be performed three times weekly: turn the bed exit alarm on and assist with ambulation using a walker. The HA visit notes dated 10/29/2024 and 11/05/2024 documented, “Bed exit alarm on. Not required: No bed exit alarm in place.” There was a note to notify the nurse. This patient lived in a home and did not have a bed exit alarm. During an interview and a joint record review on 11/12/2024, the Regional Director of Operations agreed the Registered Nurse did not provide the Hospice Aide with specific written instructions for the care plan.”

“It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum: physician orders. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #6-022 “Clinical/Service Data Collection” (revised Feb 2023) stated in part, “A clinical/service record will be initiated and maintained for each patient receiving care or services according to hospice policies found in this manual and will include at a minimum: J. Reasons for interruptions in the provision of care and services...7. Entries into the electronic medical record (EMR) should be done the same day care is rendered. Electronic documentation will be transmitted from the clinician’s device to the EMR user database per auto-sync updates every 15 minutes when connected to the internet. Data entered in “offline” status (in remote areas or otherwise compromised situations where internet connectivity is not available or poor quality) will auto sync immediately when connection is re-established.” In 1 of 19 (5%) clinical records reviewed, the agency did not ensure the clinical record contained physician orders for hospice care and services. Clinical Record 11: The Hospice Aide care plan dated 11/21/2023 and updated on 1/14/2024 documented Hospice Aide (HA) services 3 x weekly. A clinical record review revealed no HA visits documented from 10/30/2024 to 11/11/2024. Additionally, the documentation revealed the patient had traveled out of the country to Mexico. An order to update the plan of care was documented as obtained by the Registered Nurse. The order was not entered into the EMR by the Registered Nurse as per the policy. During a joint record review and interview on 11/14/2024, the Regional Director of Operations revealed the physician’s order to hold the aide visits for 1 week while the patient was out of town had not been entered per agency policy.”