American River Hospice Services

“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; other alternative treatments that could affect drug therapy. 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, interview, and observation. In 2 of 4 (50%) home visits revealed the agency did not ensure the drug profile contained the patient’s current prescription and over-the-counter (OTC) drugs; supplements; herbal remedies; and other alternative treatments that could affect drug therapy. Home Visit 1: The patient elected the hospice benefit on 11/24/2024 for a diagnosis of protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the home visit(Home Visit 1) with the Hospice Aide (Personnel Record 7) on 01/29/2025, the hospice medication profile (printed on 01/28/2025) was compared to the facility medication profile (printed on 01/29/2025). The hospice medication list documented the following medications that were not documented on the facility medication profile: Order dated 11/25/2025 Apply Calmoseptine to the pressure ulcer on coccyx twice daily and as needed. There was no documented evidence that the facility medication profile was updated when the new medication was ordered. Home Visit 3: The patient elected the hospice benefit on 12/04/2024 for a diagnosis of progressive supranuclear ophthalmoplegia. The patient resided in a group home facility. During the home visit(Home Visit 3) with the Spiritual Counselor (Personnel Record 6) on 01/29/2025, the hospice medication profile (printed on 01/28/2025) was compared to the facility medication profile (printed on 01/29/2025). The hospice medication list documented the following medications that were not documented on the facility medication profile: Acetaminophen 500 mg. Give one tablet routinely every night for pain. Ordered on 12/19/2024. The following discrepancies were also found: Hospice list had Bisacodyl 10 mg take 1 suppository daily as needed and facility had two times a day as needed; hospice had Hyoscyamine 0.125 mg tablet take 1-3 tablets every 2 hours as needed and facility had every 4 hours as needed; hospice list had Trazadone 100 mg 1 tablet at bedtime scheduled and facility had as needed; hospice had Benztropine 0.5 mg take 1 tablet by mouth every night at bedtime and facility had 2 tablets. There was no documented evidence that the facility medication profile was updated when the new medication was ordered or that the hospice medication profile was reconciled with the facility. These medication lists were reviewed, and an interview was conducted on 01/30/2025 with the VP of Clinical Services. It was agreed there were differences, and the lists needed to be reconciled.”

“It is required that each patient’s individualized written plan of care 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 revealed the agency did not ensure the patients individualized written plan of care identified planned interventions based on problems identified in the initial and updated comprehensive assessments. CLINICAL RECORD 14: The patient elected the hospice benefit 05/21/2024 with a diagnosis of Secondary malignant neoplasm of other parts of nervous system. The patient resided in an assisted living facility (ALF). The initial spiritual assessment dated 05/22/2024 stated the following: “Patient expressing sadness in our visit regarding her conversion from Jewish to Christian. Rejected from her family. She then shared she wants for her children to find God. SC (spiritual counselor) provided supportive, active listening and reminded it was because of her prayers and sharing Christ with them that made them start reading their bible and not to be discouraged.” Visit frequency after the initial assessment was set at twice monthly, and it was noted further interventions: “per plan of care.” A spiritual plan of care with problems, goals, and interventions was not added. Spiritual visits continued twice monthly until September 2024, when the patient declined further visits. Each visit note included the statement, “the plan for the next visit was per plan of care.” CLINICAL RECORD 17: The patient elected the hospice benefit on 08/05/2024 for the diagnosis of malignant neoplasm of the pancreas. The initial social worker assessment noted the patient and wife “had three children, wife needed financial paperwork and FMLA for work.” The initial spiritual counselor assessment noted “weekly visits for support and prayer of anointing needed.” A problem for pain was added to the plan of care on 08/08/2024 but was not updated throughout the time on hospice. There were medication adjustments, visits made, and additional interventions identified in the comprehensive assessments. The social worker, spiritual counselor did not have problems, interventions, or goals in the plan of care. The pain problem was not updated. During an interview and joint clinical record review, the VP of Clinical Services agreed the plans of care needed to be updated. He also advised “they had begun working with the team, especially spiritual counselors and social workers on updating plans of care.””

“It is required that 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 2 of 17 (12%) clinical records reviewed in which hospice aide services were accepted revealed the agency did not ensure the registered nurse provided specific written instructions for the hospice aide. CLINICAL RECORD 1: The patient elected the hospice benefit on 11/24/2024 with a diagnosis of Protein calorie malnutrition. The hospice aide care plan(s) dated 11/24/2024 included the following relevant tasks: bathing via shower, dressing, hair care, peri care, foot care, and notify nurse of any new skin changes every visit. Aide frequency of twice weekly. A nursing visit dated 11/25/2024 included a physician’s order for wound care and to add heel protectors. The heel protectors remained in place until the order was discontinued on 01/10/2025. The aide plan of care was not updated with specific instructions for the heel protectors during tasks. CLINICAL RECORD 8: The patient elected the hospice benefit on 01/21/2025 with a diagnosis of Malignant neoplasm of lower lobe. The hospice aide care plan(s) dated 01/21/2025 included the following relevant tasks: bathing via bed bath, shave, shampoo, inspect skin, check pressure areas. call nurse if pressure areas noted every visit. Aide frequency of twice weekly. A nursing visit dated 01/22/2025 noted a “Stage I PU (pressure ulcer) to coccyx covered with bordered foam dressing and right shoulder skin tear covered with gauze.” The visit also noted the patient was on “6 liters per minute of continuous oxygen.” The aide plan of care was not updated to provide the aide with specific instructions for the wound(s) or oxygen during tasks. A joint clinical record review and interview was conducted with the VP of Clinical Services on 01/29/2025, it which it was agreed the aide care plans had not been updated with specific instructions to include the heel protectors, wounds, or oxygen.”

“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 revealed during the interview with the Volunteer Coordinator and Administrator on 01/30/2025 and document review of the Volunteer Requirement Report revealed the year-to-date percentage was below the 5% requirement at 0.09% average for the last 12 months. In a joint interview with the Administrator and Volunteer Coordinator on 01/30/2025 the volunteer cost savings of 0.09% was confirmed. The Volunteer Coordinator is “bringing new volunteers on board and working on getting them to commit to more hours.” Proof of recruitment and retention was provided. An interview with the Volunteer Coordinator and Administrator on 01/30/2025 and document review of the Volunteer Requirement Report revealed the year to date percentage was below the 5% requirement at 0.09% average for the last 12 months. Jan 2024 patient hours 1878, volunteer hours 10.5, Feb 2024 patient hours 1798.25, volunteer hours 21, Mar 2024 patient hours 1929.5, volunteer hours 25.3, Apr 2024 patient hours 2085.5, volunteer hours 25.5, May 2024 patient hours 2085.5, volunteer hours 23, June 2024 patient hours 2150.25, volunteer hours 6.5, July 2024 patient hours 2412.25, volunteer hours 12.8, Aug 2024 patient hours 2309.50, volunteer hours 30.75, Sept 2024 patient hours 2268.75, volunteer hours 20, Oct 2024 patient hours 2268.75, volunteer hours 31.75, Nov 2024 patient hours 2634.25, volunteer hours 28.5, Dec 2024 patient hours 2276.75, volunteer hours 26.5.”