Mission Hospice Services of Rancho Mirage, LLC

“Based on interview and record review, the agency failed to ensure the individualized plan of care (POC) was reviewed and revised when Patient 1 was transferred from the Assisted Living Facility (ALF) to a Board and Care (B&C) facility for one of three patients reviewed (Patient 1).This failure had the potential for Patient 1 not to receive the necessary care and services indicated in the POC. Findings:On May 28, 2025, Patient 1’s record was reviewed. Patient 1 was admitted to the agency with the start of care (SOC) date of November 12, 2022, with diagnoses which included chronic obstructive pulmonary disease (COPD - lung disease), abdominal aortic aneurysm (an enlargement of the main blood vessel that delivers blood to the body, can be life-threatening if it burst) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).A review of the Physician’s Certification of Terminal Illness (CTI) for the certification period from 12/31/2024 to 2/28/2025, indicated Patient 1 was sleeping 16-18 hours per day, eating 40% - 50% of her meals, with episodes of paranoia (a condition characterized by an irrational and persistent belief that others are trying to harm her/ him or suspicious of you) accusing staff of spying on her. Patient was started on oxygen, oral antibiotic and breathing treatment due to congestion. Patient 1 was declining.A review of the Registered Nurse re-certification assessment dated 12/16/2024, for the certification period from 12/31/2024 to 2/28/2025, indicated “...Patient 1 was a 98 year old female who resides at the board and care facility, with increased paranoia, accusing staff of wanting to throw her in the pool and poisoning her...Appears thin, frail with protruding bones...Sleeps with the head of the bed elevated due to orthopnea (discomfort when breathing while lying down flat) ...” The assessment indicated Patient 1 had intact skin, dry callous to the right outer ankle, right heel and left outer foot treated with betadine.Medications included the following: - “Haloperidol (used for mental disorder)) 1 milligram (mg - a unit of measurement) every four hours sublingual for paranoia order date of 6/5/24; and - Betadine Swab stick 10%, 1 swab daily topical for wound care order date 9/30/2024; and - Dermal wound Cleanser for wound/skin cleansing, order date of 5/11/2023...”A review of Patient 1’s POC for the certification period from 3/6/2024 to 5/4/2024, at the Assisted Living Facility (ALF) indicated the following: “...CALENDAR FREQUENCY OF VISIT...SN (Skilled Nurse, can be Licensed Vocational Nurse or Registered Nurse) effective 03/06/2024, 2WK9, (two visits per week for 9 weeks), 4 PRN (as needed) for symptom management, MSW (medical social worker) effective 03/06/2024 1M2 (one visit per month for 2 months, 3 PRN for psychological support, HHA (Hospice Aide) effective 03/06/2024, 1WK9 (1 visit per week for 9 weeks) FOR ADL CARE, CL (clergy) DECLINED...”A review of Patient 1’s POC for the certification period from 5/5/2024 to 7/3/2024, at the Board and Care Facility indicated the following:”...CALENDAR FREQUENCY OF VISIT...SN EFFECTIVE 05/05/2024, 3WK8 (three visits a week for 8 weeks), 2WK1 (two visits a week for 1 week), 4 PRN FOR SYMPTOM MANAGEMENT, MSW EFFECTIVE 05/05/2024, 1M2 (1 visit a month for two months), 4PRN FOR PSYCHOLOGICAL SUPPORT, HHA EFFECTIVE 05/05/2024 1WK9 (1 visit a week for 9 weeks)...”The Registered Nurse (RN) visit note dated 04/01/2024, indicated Patient 1 continued to have increased weakness and fatigue, short of breath (SOB) with any exertion, and relocating to (name of the Board & Care) on 04/02/2024.The visit note by the MSW dated 04/03/2024, indicated Patient 1 was transferred from the Assisted Living Facility (ALF) to a board and care facility. The note indicated Patient 1 likes her new surroundings. A routine visit on 04/03/2024, was conducted by the SN. The note indicated wound care was provided as ordered, no signs and symptoms of infection.The POC for the certification period from 3/6/2024 to 5/4/2024, indicated Patient 1 was at the ALF. The POC for the certification period from 5/5/2024 to 7/3/2024, indicated Patient 1 was at the Board and Care facility.There was no documented evidence the POC was reviewed and revised when Patient 1 was transferred to the Board and Care facility on 04/02/2024.The POC was developed on 5/5/2024, 32 days after Patient 1 was transferred to the B&C facility. The POC for the certification period from 12/31/2024 to 2/28/2025, indicated the frequency of visit as follows: - Skilled Nurse (SN) effective 12/31/2024, 1WK1 (one visit per week), 2WK8 (Two times a week for eight weeks), 8 PRN (as needed) for symptoms management; - Medical Social Worker (MSW) effective 01/01/2025 1M2 (one per month for 2 months), 2 PRN FOR PSYCHOSOCIAL SUPPORT; and - HHA (Home Health Aide) effective 12/31/2024 1WK9 (one visit a week for nine weeks).A review of IDG (Interdisciplinary Group - a collaborative approach where professionals from different disciplines work together to address patient’s needs) dated 1/10/2025, indicated “...Infection : none in the last 2 weeks...Wounds: none...”A review of the SN visit dated 01/02/2025, indicated integumentary (skin) assessment was conducted by RN. No documentation of any findings.A review of the Hospice Aide visit dated 01/02/2025, indicated Patient 1 received bath (shower), shampoo, perineal care and hair care...” No identified skin problem.A review of the RN visit dated 01/07/2025, indicated integumentary assessment was conducted by the RN. The RN note indicated “...Heel assessed during visit. Instructed (name of care giver) to continue to administer Iodine and leave...air out...Message sent to (name of family member) updating her patient visit...” A review of the RN visit dated 1/14/2025, indicated integumentary assessment with scab on the right outer foot. RN note indicated, “...Scab on the right foot...instructed (CG) to continue to apply Iodine twice a day...leave to air...and apply band-aid bedtime...”A review of the RN visit dated 1/16/2025, indicated, “...Wound on the right edge foot assessed...Obtained new orders to cleanse with saline solutions, apply bacitracin to wound bed twice day and cover with non-adherent gauze. Cover with Kerlix. Care Givers and SN to perform wound care...Message sent to (name of the family member) updating her patient visit...” A review of the physician’s order dated 1/16/2025, indicated “...Bacitracin Ointment apply to wound on the right foot twice a day, Clean the area with normal saline, pat and dry, apply Bacitracin Ointment, cover with Non adherent gauze, wrap with kerlix twice a day. Hospice SN or Caregiver to perform wound care...”On May 29, 2025, at 1:50 p.m., a concurrent interview and record review was conducted with the Clinical Manager and the Director of Patient Care Services (DPCS), and the Vice President of Operation/ Director of Quality (VP/ QA). The DPCS stated Patient 1’s POC should have been reviewed and revised when Patient 1 was transferred from the ALF to a B&C facility.The VP of Operation/ QA acknowledged that Patient 1’s POC should have been reviewed and revised when Patient 1 was transferred from the ALF to a private B&C facility. A review of the agency’s policy and procedure titled, “THE PLAN OF CARE, “ dated March 2024, indicated, “...to ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues...the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than 15 days, by the interdisciplinary group...””

“It is required that each patient’s individualized written plan of care: reflects patient and family goals; [and] identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 19 (11%) clinical records reviewed, the agency did not ensure the patient’s plan of care (POC) reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Clinical Record 3: The patient elected hospice care on 07/22/2024 with a diagnosis of cerebral atherosclerosis. The initial nursing assessment dated 07/22/2024 documented, “According to the patient’s paid caregiver, over the last 2 months she has had an increase in agitation. She was reported to have episodes of striking out, scratching, and biting her caregiver during care, and has a tendency to kick and flail her arms hitting the bed rails when she becomes agitated.” The interdisciplinary group (IDG) POC did not document goal(s) and intervention(s) for the patient’s identified agitation and combativeness. Clinical Record 11: The patient elected hospice care on 12/27/2024 with a diagnosis of anoxic brain damage not elsewhere specified. The initial nursing assessment dated 12/27/2024 documented the patient had bladder and bowel incontinence. The IDG POC dated 12/27/2024 did not document goal(s) and intervention(s) for the patient’s identified bladder and bowel incontinence. In an interview on 02/06/2025, the Administrator/Director of Patient Care Services confirmed that the POC did not reflect patient and family goals and interventions based on problems identified in the initial comprehensive assessment.”

“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 and interview. In 3 of 16 (19%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Registered Nurse (RN) provided the Hospice Aide (HA) with specific written patient care instructions. Clinical Record 1: The patient elected hospice care on 01/21/2025 with a diagnosis of cerebrovascular disease, unspecified. The interdisciplinary group (IDG) plan of care (POC) dated 01/21/2025 ordered HA services two (2) times a week and skilled nursing to “Cleanse right medial calf with NSS, pat dry, cover with calcium alginate with silver and secure with bordered dressing 2x/week and prn for soilage of dislodgement. Cleanse right 4th lateral toe with wound cleanser, pat dry, cover with calcium alginate with silver, and secure with bordered dressing 2x/wk and prn for soilage or dislodgement.” The HA visit notes dated 01/28/2025, 02/03/2025, and 02/05/2025 documented “Bed bath...Completed - Y.” The HA visit notes did not include documentation of how the aide managed the patient’s right medial calf and right 4th lateral toe dressings during the bed bath. The HA care plan dated 01/21/2025 did not provide the HA with instructions regarding how to manage and what to report related to the toe and calf dressings should they become wet, soiled, or dislodged during the bed bath. Clinical Record 3: The patient elected hospice care on 07/22/2024 with a diagnosis of cerebral atherosclerosis. The plan of care ordered HA services two (2) times a week. The initial nursing assessment dated 07/22/2024 documented, “According to the patient’s paid caregiver, over the last 2 months she has had an increase in agitation. She was reported to have episodes of striking out, scratching, and biting her caregiver during care and has a tendency to kick and flail her arms, hitting the bed rails when she becomes agitated.” Per the nurse, the patient’s Seroquel was recently increased to help manage her agitation. The HA visit note dated 07/31/2024 documented, “Patient combative during visit caregiver assisted.” The HA care plan dated 07/22/2024 did not include patient-specific instructions and alert the HA of the patient’s potential for agitation and combative behavior during personal care and bathing. Clinical Record 11: The patient elected hospice care on 12/27/2024 with a diagnosis of anoxic brain damage not elsewhere specified. The POC ordered HA services two (2) times a week. The initial nursing assessment dated 12/27/2024 documented, “The patient receives gastrostomy (g-tube) tube feeding and has a tracheostomy.” The HA visit note dated 02/03/2025 documented the assigned task: “Bed bath...Completed ... Y” and did not document how the HA managed the patient’s g-tube and tracheostomy sites while performing the bed bath. The HA care plan dated 01/21/2025 did not provide the HA with instructions regarding how to manage and what to report related to the g-tube and tracheostomy sites during personal care. In an interview on 02/06/2025, the Administrator/Director of Patient Care Services and Clinical Manager confirmed that the hospice RN did not provide the aide with clear and accurate patient-specific written care instructions on the HA care plan.”

“It is required that hospice aides must report changes in the patient’s medical, nursing, rehabilitative, and/or social needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 2 of 8 (25%) clinical records reviewed of patients who received Hospice Aide services with changes related to the care plan, the agency did not ensure that the HA reported changes in the patient’s needs to the Registered Nurse (RN). Clinical Record 4: The patient elected hospice care on 01/31/2025 with a diagnosis of cerebral atherosclerosis. The plan of care ordered HA services two (2) times per week. The HA care plan dated 01/31/2025 assigned the HA the tasks assist with bedpan, assist with feeding, and bathing (bed bath) every visit. The HA visit note dated 02/04/2025 documented, “Completed: N...Task already completed” for the assigned tasks, which included assisting with bedpan, feeding, and bathing (bed bath). A clinical record review revealed no evidence that the HA reported changes in the patient’s needs related to the care plan to the RN. Clinical Record 12: The patient elected hospice care on 12/23/2023 with a diagnosis of Alzheimer’s Disease. The plan of care ordered HA services two (2) times per week. The HA care plan dated 12/17/2024 assigned the HA the tasks of oral care and change linens every visit. The HA visit note dated 12/20/2024 documented, “Completed: N...Task already completed” for the “oral care” task. The HA visit notes dated 12/20/2024 and 01/29/2025 documented “Completed: N...Task already completed” for the “change linens” task. A clinical record review revealed no evidence that the HA reported changes in the patient’s needs related to the care plan to the RN. In an interview on 02/06/2025, the Administrator/Director of Patient Care Services and Clinical Manager confirmed that the HA did not report changes in the patient’s needs to the RN as the changes related to the HA care plan.”

“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. This standard was not met as evidenced by document review and interview. The agency did not ensure that hospice volunteers provided 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 review of the “2024 Volunteer Hours/Percentage Report” revealed the volunteer percentage of hours worked for 2024 was 0.69%. In an interview on 02/06/2025, the Administrator/Director of Patient Care Services and Volunteer Coordinator confirmed that volunteers did not provide the required minimum of five percent (5%) of the total patient care hours of all paid hospice employees and contract staff. The review of the “2024 Volunteer Hours/Percentage Report” revealed the agency did not ensure that volunteers provided day-to-day administrative or direct patient care services in an amount that, at a minimum, equaled five percent (5%) of the total patient care hours of all paid hospice employees and contract staff.”