Moonlight Hospice Care, Inc.

“Upon patient record review, 1 of 5 (Patient #1) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: 11/3/25 Visit note, SN documented Plan of care includes continuation of Bactrim DS 800 mg-160 mg tablet for urinary tract infection as prescribed. Actual order on 10/16/25 x 7 days. Med profile had not been updated to reflect completed and/or continue, but was updated during survey to reflect treatment completed.”

“Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Upon review, there is no evidence that hospice admitted patient(s) since prior survey to demonstrate compliance.”

“Upon patient record review, 3 of 5 (Patient #3, 4, 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3: LVN 1/wk for changes in condition. RN 1/2wk for changes in condition. Provided education that this qualification is applicable more to PRN visits, rather than base frequency. Patient #4: SN one per week for changes in condition. Provided education that this qualification is applicable more to PRN visits, rather than base frequency. Patient #5:LVN 1/wk for change in condition. RN 1 every 2 wk for change in condition. Provided education that this qualification is applicable more to PRN visits, rather than base frequency.”

“Upon patient record review, 1 of 5 (Patient #3) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient #3: 11/06/25 RN Note documents patient has an incision opening in the middle of her abdominal area, post surgery over 15 years ago. Order is to keep area clean and dry. Cleanse with NS. Pat dry with gauze and cover with dry gauze and apply tape. There is no update to the problems, goals and interventions.”

“Upon client record review, 2 of 5 (Patient #2,3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: MSW visit 11/13/25 and SC visit 11/3/25. 11/5/25 MSW narrative note says frequency monthly, but there is no update to ordered visit frequency. There are no MSW, SC orders beyond the initial orders 9/17/25 for initial assessment within 5 days. Patient #3: RN frequency 1 every 14 days for changes in patient condition. RN visits documented 11/5/25 and 11/6/25. There is reference to LVN absence related to car issues, but no clarifying order. Orders are written for LVN and for RN separately/exclusively, not for SN. Education provided.”

“Upon patient client record review, 2 of 5 (Patient #2,3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #2: RN assessment visit 11/12/25 notes that HA is 3x/wk. Assignment sheet and orders are for 2x/wk since 9/17/25 order and no physician ordered frequency changes. Unclear/confusing documentation. Patient #3: 11/6/25 SN note documents ostomy bag is to be replaced TID however, order is colostomy care daily and change colostomy bag every 3rd day and as needed for leakage. Unclear/confusing documentation.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure every member of the interdisciplinary group (IDG- hospice Medical Director and all hospice interdisciplinary group members, including volunteers, social workers and attending physician) participated in the interdisciplinary group meeting for four of nine sample patients (Patient 3, Patient 8, Patient 10, and Patient 16). This deficient practice had the potential risk for patient care needs and plan of care not effectively assessed and updated. d. During a review of Patient 16’s clinical record, the clinical record indicated a SOC of 9/25/25, with diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities), essential hypertension (HTN-high blood pressure), weakness, and full incontinence of feces (involuntary loss of stool). During an interview with the DPCS on 11/7/2025, at 12:08 p.m., the DPCS stated the weekly POC/IDG Review forms are signed by the attendees the same day as the IDG meeting.During a concurrent interview and record review on 11/7/2025, at 1:41 p.m. with the DPCS, Patient 16’s “POC/IDG Review – Nov 05, 2025 – Cert# 1”, dated 11/5/2025, was reviewed. The POC/IDG Review – Nov 05, 2025 – Cert# 1 indicated the MSW’s signature block was blank. The DPCS stated the MSW should have signed the POC/IDG Review form, and without full participation of the IDG there is no assurance that all aspects of the patients’ needs – physical, emotional, and spiritual – are assed, coordinated, and incorporated into the patients’ POCs. There was no documented evidence that the MSW participated in the IDG meeting on 11/5/2025.During a review of the facility’s policies and procedures (P&P) titled, “Interdisciplinary Group Meeting, Policy No. 4-032.1,” undated, the P&P indicated, “… all hospice interdisciplinary group members will be present…” b. During a review of Patient 8’s clinical record indicated a start of care date (SOC) of 7/16/2025, with diagnosis of with diagnosis of malignant neoplasm of anal canal (a type of cancer that develops in the anal canal, the lower part of the rectum).During a review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 11/05/2025, indicated the Master of Social Work (MSW) and Chaplain signatures were blank.There was no documented evidence the MSW and Chaplain participated in the IDG meeting.c. During a review of Patient 10’s clinical record indicated a start of care date (SOC) of 6/16/2025, with diagnosis of with diagnosis of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs).During a review of Patient 8’s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) Review form dated 11/05/2025, indicated the Master of Social Work (MSW) signature was blank.There was no documented evidence that the MSW participated in the IDG meeting.During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 11/7/2025 at 12:09 p.m., the DPCS stated that an IDG meeting is done every two weeks that the staff that attended the IDG sign attendance the same day the IDG meeting is conducted. DPCS stated that it is important to sign the day of the IDG meeting to confirm that staff attended the meeting. During a review of the agency’s policy and procedure titled “Interdisciplinary Group Meeting,” undated, indicated that the hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The policy and procedure indicated that members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. a. During a review of Patient 3’s clinical record, the clinical record indicated a Start of Care (SOC) of 2/21/25, with diagnosis of hypertensive heart disease without heart failure (a condition of when the blood pressure is elevated without resulting in heart pumping function loss). During a concurrent interview and record review on 11/7/2025, at 12:15 p.m. with the DPCS, Patient 3’s “POC/IDG Review, Nov 05, 2025 – Cert#12”, dated 11/5/2025, was reviewed. The POC/IDG Review Nov 05, 2025 – Cert# 12 indicated the MSW’s signature block was blank. The DPCS stated the MSW should have signed the POC/IDG Review form, and without full participation of the IDG there is no assurance that all aspects of the patients’ needs – physical, emotional, and spiritual – are assed, coordinated, and incorporated into the patients’ POCs. There was no documented evidence that the MSW participated in the IDG meeting on 11/5/2025. When asked when are IDG members supposed to sign the IDG meeting Review forms, DPCS stated the weekly POC/IDG Review forms are signed by the attendees the same day as the IDG meeting.”

“Based on interview and record review, the facility failed to ensure an individualized plan of care (POC, a comprehensive document that outlines a patient’s health status, goals, and the coordinated services and treatments needed to achieve those goals) was developed for two of nine sampled patients (Patient 3, Patient 4) by failing to: 1.Ensure Patient 3’s POC included the endocrine system (a network of glands that produce secret hormones) to address blood sugar monitoring and medication use for Diabetes Mellitus (DM, a condition that the blood sugar levels are elevated). 2.Ensure Patient 4’s physician’s orders for oxygen therapy not specifying the oxygen dose and not addressed in Patient 4’s POC. This deficient practice had the potential to result in Patient 3’s health condition not being monitored and Patient 4 not receiving effective oxygen therapy. Findings:During a review of Patient 4’s clinical record, the clinical record indicates Patient 4’s Start of Care (SOC) of 2/21/25, with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart and affects its ability to pump blood).During a concurrent interview and record review on 11/7/25 at 1:41 p.m. with the Director of Patient Care Services (DPCS), Patient 4’s “Current Treatment/Medication/DME (Durable Medical Equipment, equipment that is medically necessary for long-term use to help with a health condition, injury, or disability) List”, undated, was reviewed. The Current Treatment/Medication/DME List indicated an order for oxygen starting 8/20/2025, and did not contain an order for an oxygen concentrator or e-tank. The DPCS stated the L/min (liters per minute, flow rate of oxygen) should be indicated for the oxygen order, the DPCS missed that [L/min] and the physician will be contacted immediately to correct it [L/min]. The DPCS stated there should be an order for an oxygen concentrator (a medical device that takes in ambient are, filters out nitrogen, and delivers concentrated, purified oxygen) an e-tank (portable compressed cylinder of oxygen), and without those items the patient has no oxygen and may experience respiratory distress.During a concurrent interview and record review on 11/7/25 at 1:41 p.m. with the DPCS, Patient 4’s “POC/IDG Review”, dated 10/22/2025 and 10/8/2025, were reviewed. Both of the POC/IDG Reviews indicated “Oxygen therapy” and “Oxygen as ordered via _____ at _____L/min.” The DPCS stated the L/min (liters per minute) fields are blank and should be indicated for the oxygen order. During a record review of the facility’s policy and procedure (P&P) titled, “The Plan of Care, Policy No. 4-027.1” undated, the P&P indicated, “…The written plan of care will contain, but not be limited to, the following: … M. Frequency/Amount/Duration and type of services.” During a record review of the facility’s policy and procedure (P&P) titled, “Medication Profile, Policy No. 4-050.1” undated, the P&P indicated, “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. “During a record review of the facility’s P&P titled, “Care/Service Coordination, Policy No. 4-099.1”, undated, the P&P indicated, “…6. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes.” During a review of Patient 3’s clinical record, the clinical record indicated a Start of Care (SOC) of 2/21/25, with diagnosis of hypertensive heart disease without heart failure (a condition of when the blood pressure is elevated without resulting in heart pumping function loss). During a record review of Patient 3’s clinical record document titled “Current Treatment/Medication/DME (Durable Medical Equipment, equipment that is medically necessary for long-term use to help with a health condition, injury, or disability) List”, undated, was reviewed. The document indicated Metformin Hydrochloride (a medication for blood sugar control) 1000mg 1 tablet oral twice a day. The document further indicated, “Finger stick blood sugar check once a day via glucometer (a device which checks patient blood sugar levels) by caregiver…”During a record review of Patient 3’s clinical document titled, “POC/IDG Review”, dated 10/22/2025 and 10/8/2025, were reviewed. There was no evidence of endocrine care plan addressing the blood sugar monitoring or blood sugar control medication in the POC/IDG discussions”During an interview on 11/6/2025 at 12:50 p.m. with PCG 3 at Patient 3’s residence, PCG 3 stated, “We give Patient 3 only one tablet of Metformin a day. We have noticed when we used to give her two pills of Metformin a day she would get cool and clammy and disoriented.” When asked if the there is a blood sugar monitoring log, or how often Patient 3’s blood sugar is being monitored, PCG 3 stated, “we haven’t been monitoring her blood sugar levels for a while, Patient 3 is not really diabetic, Patient 3 is pre diabetic. We used to take her blood sugar levels, but they were normal so we stopped.”During an interview on 11/7/2025 at 2:47 p.m. with DPCS, the DPCS stated, “Nurses are supposed to do medication reconciliation on every visit to see if there are any missing medications, or expired medication, they use the current medication list to check the medications, if there are any missing medications or the patient is not taking it they need to contact the physician and discontinue or modify the order, this will be discussed in the IDG/POC meetings. I see there is no evidence that the metformin dosage was discussed during the IDG meeting for Patient 3. If the patient doesn’t have DM then they don’t need to be on the medication, this was missed. The is no care plan for endocrine system in the POC/IDG flagged. We needed to update the records and get a new doctors order to reflect what the patient is taking, and add endocrine to Patient 3’s POC or discontinue diabetes parameters and medications if the patient is not diabetic. This should have been caught.” During a record review of the hospice agency’s policy and procedure, titled, “Plan of Care”, revised November 2021, the policy and procedure indicated, “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 members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions. The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care. This plan of care must be initiated at start of care.””

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure patient care was provided in accordance with the plan of care for one of nine sampled patients (Patient 3). The failure resulted in Patient 3 not receiving skilled nursing services in accordance with the plan of care. During a review of Patient 3’s clinical record, the clinical record indicated a Start of Care (SOC) of 2/21/25, with diagnosis of hypertensive heart disease without heart failure (a condition of when the blood pressure is elevated without resulting in heart pumping function loss). During an interview on 11/6/2025 at 12:15pm, with Patient Care Giver 1 (PCG 1), at Patient 3’s residence, PCG 1 stated that Patient 3 did not receive nursing visits from the HA for a few weeks. During a concurrent interview and record review on 11/7/2025 at 12:35 pm, with the Director of Patient Care Services (DPCS), Patient 3’s clinical record was reviewed. Patient 3’s clinical record indicated that no skilled nursing visit notes for the week of 10/12/2025 to 10/18/2025 and 10/26/2025 to 11/04/2025, and no documentation of physician notification. The DPCS confirmed that there was no skilled nurse visit for the week of 10/12/2025 to 10/18/2025 and 10/26/2025 to 11/04/2025, and no documentation of physician notification in Patient 3’s clinical record. The DPCS stated missed nursing visits should be reported to the physician and attempts to send another nurse should be documented. The DPCS stated it is important to provide patient care in accordance with their plan of care for better management of patient’s health conditions. During a review of the hospice agency’s policy and procedure titled “Missed Visits”, dated 11/ 2021, the policy and procedure indicated “Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will:A. Notify the I DG and clinical supervisor of the missed visit and reason for missed visitB. Document in the patient’s clinical record the following information:1. Patient name.2. Date and type of visit that was missed.3. Reason for the missed visit.4. Description of any unmet needs and how the patient’s needs were met.5. Any other follow-up needed.6. Other person(s) that were notified of the missed visit.7. Signature of staff member reporting the information.””

“Based on observation, interview and record review the Hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure an effective communication of care between hospice agency, patient caregiver, and Durable Medical Equipment (DME) company for one of nine sampled patients (Patient 3). The deficient practice resulted in Patient 3 not been able to use newly delivered equipment for necessary care and to optimize daily activities. During a review of Patient 3’s clinical record, the clinical record indicated a Start of Care (SOC) of 2/21/25, with diagnosis of hypertensive heart disease without heart failure (a condition of when the blood pressure is elevated without resulting in heart pumping function loss). During a review of a document titled “Deliver Order”, dated 10/22/2025, indicated on 10/22/2025 at 11:47 pm, a delivery was made to Patient 3’s residence and the following equipment were delivered: full electric bed, manual patient lift, medium sling, 5 liter oxygen concentrator, a tank (an oxygen delivering canister), tank cart, regulator (gauge, a device that attached to an oxygen tank to reduce and control the high pressure of the gas), over bed table, suction unit, suction supply kit, oxygen supply kit, standard wheelchair and nebulizer unit (a medical device that turns liquid medication into a fine, breathable mist for direct delivery into the lungs) with supply kit. The check box on Deliver Order for “Service technician has provided training in safe/proper use and maintenance of all medical equipment” was left blank and did not mark as completed. During an observation on 11/06/2025 at 12:20 pm, in Patient 3’s residence, several medical equipment were observed in their original packaging, unopened, including a Hoyer lift (a device to lift bedbound patients out of bed), a nebulizer (a device used to deliver breathing treatments), a suction canister and machine (a device used to suction liquids from mouth) and an oxygen concentrator with a humidifying chamber ( a device used to deliver oxygen through tubes for patients with respiratory problems with water chamber used for humidifying the oxygen). During an interview on 11/6/2025 at 12:30 pm, with Patient Care Giver 1(PCG 1), at Patient 3’s residence, PCG 1 stated “All equipment were delivered a few weeks ago, we don’t know how to use it so we never opened it. They did not educate us on how to use any of the devices; they just dropped it off and left. I haven’t been able to use the Hoyer lift to move Patient 3 and I let the hospice agency know but so far nothing has been done. We haven’t used the oxygen machine, the suction machine, or the breathing treatment machine. Registered Nurse 2 (RN 2) has come to the house twice since the equipment was delivered, but RN 2 didn’t provide education, we were under the impression that the other nurse, that hasn’t been coming, will come and provide education.” During an interview on 11/6/2025 at 12:45 pm, with RN 2, RN 2 stated “I was not aware Patient 3 and family have not received education on the new equipment. The hospice agency did not communicate that information with me.” During an interview on 11/7/2025 at 11:35 am, with the HA’s Office Staff (OS), OS stated “we were under the impression that the DME (durable medical equipment) company educated Patient 3’s family on use of all medical devices delivered.” During a review of Patient 3’s Plan of Care/Interdisciplinary Group (POC/IDG, a team of healthcare professionals who collaborate to create and manage a patient’s plan of care), dated 10/22/2025, the POC/IDG indicated there was no documentation regarding DME training, Patient 3 and family concerns regarding the medical equipment. During a record review of hospice agency’s policy and procedure titled “Care/Service Coordination”, dated 11/2021, the policy and procedure indicated “Timely and ongoing communication is the responsibility of each team member and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. The clinician/technician will be responsible for facilitating communications about changes in the patient’s status among the assigned personnel. Organization personnel will communicate changes in a timely manner via telephone, one­on-one meetings, case conferences, and home visits. Documentation of all communications will be included in the clinical record on a communication note, case conference summary, or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication. When the patient requires more than one (1) service from the organization, the Case Manager will be responsible for cooperative care planning in order to assure that goals, actions, and the interrelationship of services is not duplicated and to minimize the potential for missed or conflicting services. Written evidence of care coordination may be found in the plan of care/service, case conference summary forms, clinical notes in the patient’s clinical record or interdisciplinary group meeting notes. All organization personnel involved in patient care/service, including those providing contracted services, will have access to the plan of care/service and all other relevant patient information to ensure coordination and continuity. All personnel will be knowledgeable regarding patient needs, goals of care, and services. Contract organization personnel will participate in preparation of the plan of care/service; submit weekly documentation of services provided including clinical notes, schedule of visits, and patient evaluations/assessments; and participate in multidisciplinary (interdisciplinary group) case conferences when a patient in their caseload is being discussed.””

“Upon observation, there was no evidence that during the initial assessment visit in advance of furnishing care, the hospice provided the patient and/or family with verbal (meaning spoken) and written notice of the Patient’s Rights and Responsibilities in a language and manner that the patient understands. Patient 6: Primary language identified as Spanish Speaking and Consents provided in English only, patient/family requested a choice to choose their primary physician. There is no evidence of primary attending physician being selected on the form. Patient 9: On 8/28/25 SN documents “I called patient to make a visit to him, but patient stated that he wants to refuse my visit. He stated that he wants a Spanish speaking nurse to visit him. Agency and CM informed to find patient a new nurse.” There is no indication that a translation service was offered to patient or that a different nurse was offered. There are no documented RN visits since patient refused RN on 8/28/25.”

“Upon patient record review, 2 of 14 (Patient # 6,9) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 6: Primary language identified as Spanish Speaking and Consents provided in English only, patient/family requested a choice to choose their primary physician. There is no evidence of primary attending physician being selected on the form. Patient 9: Primary language identified as Spanish and Consents signed in English at SOC on 4/23/25 and do not contain choice of attending physician. Spanish consents were re-signed with patient’s sister on 8/29/25 following state survey.”

“Upon patient record review 2 of 14 (Patient # 3,7) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual’s attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient 3: There is no evidence of SCP visit and comprehensive assessment 02/27/25 completed within 5 days of SOC on 2/21/25. The initial SCP comprehensive assessment was completed on 02/27/25. Patient 7: There is no evidence of SCP visit and completion of comprehensive assessment completed within 5 days of SOC on 7/16/25. The initial SCP comprehensive assessment was completed on 8/1/25.”

“Upon patient record review, 8 of 14 (Patient # 1,2,3,4,6,7,8,9) did not have evidence in the patient record that the comprehensive assessment takes into consideration the imminence of death. Patient 1: There is no evidence of imminence of death documentation at SOC on 07/17/25. Patient 2: There is no evidence of imminence of death documentation at SOC on 02/21/25. Patient 3: There is no evidence of imminence of death documentation at SOC on 02/21/25. Patient 4: There is no evidence of imminence of death documentation at SOC on 09/25/25. Patient 6: There is no evidence of imminence of death documentation at SOC on 7/22/25. Patient 7: There is no evidence of imminence of death documentation at SOC on 07/16/25. Patient 8: There is no evidence of imminence of death documentation at SOC on 09/16/25. Patient 9: There is no evidence of imminence of death documentation at SOC on 04/23/25.”

“Upon patient record review, 3 of 14 (Patient # 1,2,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: The agency medication list contains orders for Tamsulosin and Folic Acid and patient/caregiver report patient is no longer taking these medication and medications are not located at Board and Care home. COS with new medication orders. Patient 2:The agency medication list contains duplicate orders for Hydrochlorothiazide patient reports taking once every AM and an order for potassium that patient reports he is not taking. COS with new medication orders. Patient 3: The agency medication list contains orders for Macrobid, Mucinex and Azithromycin that caregiver reports patient is no longer taking, COS with new medication orders.”

“Upon patient record review, 1 of 14 (Patient # 7) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient’s family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient’s death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 7: There is not evidence of completion of an initial bereavement assessment at SOC on 07/16/2025.”

“Upon patient record review, 2 of 14 (Patient # 5, 9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual’s attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient’s progress toward desired outcomes • Reassessment of the patient’s response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient 5: SOC 9/17/25, no evidence of RN visits since initial comprehensive assessment was completed. Patient 9: On 8/28/25 SN documents “I called patient to make a visit to him, but patient stated that he wants to refuse my visit. There are no documented RN visits since patient refused RN on 8/28/25.”

“Upon patient record review, 1 of 14 (Patient # 5) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient’s plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient 5: SOC is 9/17/25 and there no evidence of visit frequency for any disciplines (nursing, aide, MSW, spiritual care) in the record.”

“Upon patient record review, 3 of 14 (Patient # 1,2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The updated POC 9/24/25 contains orders for Tamsulosin and Folic Acid and patient/caregiver report during home visit patient is no longer taking these medication and medications are not located at Board and Care home. COS with updated orders to POC. Patient 2:The updated POC 9/24/25 contains duplicate orders for Hydrochlorothiazide patient reports during home visit taking once every AM and an order for potassium that patient reports he is not taking. COS with updated orders to POC. Patient 3: The updated POC 9/24/25 contains orders for Macrobid, Mucinex and Azithromycin that caregiver reports during home visit patient is no longer taking, COS with updated orders to POC.”

“Upon patient record review, 2 of 14 (Patient #1,5) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient’s condition requires but no less frequently then every 15 calendar days. Patient 1: The IDG meeting review on 7/30/25 does not have evidence of a signature by the RN and on 8/13/25 IDG meeting dose not have evidence of a signature and date by RN or SCP. Patient 5: The Initial POC 9/17/25 and IDG meeting review does not include any input by nursing. The IDG meeting notes are not signed by RN and MSW.”

“Upon patient record review, 3 of 14 (Patient # 1,10,12) did not have evidence that a revised plan of care includes information from the patient’s updated comprehensive assessment and must note the patient’s progress towards outcome/goals from the plan of care. Patient 1: The POC on 07/17/25 does not include target dates for all of the problems/interventions/goals. The IDG meeting review on 7/30/25 does not have evidence of a signature by the RN and on 8/13/25 IDG meeting date did not have evidence of a signature and date by RN or SCP. Patient 10: The updated POC on 9/24/25 contains target dates that have not been updated with problems/goals and interventions to be met by target date 9/11/25. Patient 12: 7/21/25 Patient is being discharged due to decline in authorization of payment. Patient was discharged from services for inability of financial means without evidence of discharge planning documented in the plan of care.”

“Upon patient record review, 2 of 14 (Patient # 1,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: Visit note following SOC on 7/21/25 SCP completed a bereavement assessment within a visit note and documentation indicates no actual visit was completed and bereavement assessment is completed via phone call and not visit. Patient 10: The updated POC 8/13/25 at recertification contains orders for LVN visit frequency once weekly. Last documented LVN visit completed on 9/12/25 with no evidence of LVN visits during the week of 9/14, 9/21, and 9/28/25.”

“Upon personnel record review, 1 of 13 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide. The competency evaluation form does not allow space for each individual task to be signed and dated with each patient observation as competency assessment is performed by aide.”

“Upon patient record review, 4 of 14 (Patient # 2,3,6,9) did not have evidence that each patient record contains: Patient 2: The start of care date 02/21/25 is missing from the EOB. The non covered items addendum form is not completed, it is left blank for elect to receive or not to receive addendum. Patient 3: The start of care date 02/21/25 is missing from the EOB and the name of hospice is not completed. There is no identified certification period noting which certification patient is signing at SOC on consent forms. The non covered items addendum form is not completed, it is left blank for elect to receive or not to receive addendum. Patient 6: Primary language identified as Spanish Speaking and Consents provided in English only, patient/family requested a choice to choose their primary physician. There is no evidence of primary attending physician being selected on the form. Consents are signed by self and patient indicated desire to receive non-covered items at SOC 07/22/25. There is not evidence of non covered items form completion or patient receiving non covered items addendum. Patient 9: Primary language identified as Spanish and Consents signed in English at SOC on 4/23/25 and do not contain terminal diagnosis, name of hospice agency, effective SOC date, choice of attending physician. Spanish consents were re-signed with patient’s sister on 8/29/25 following state survey.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP, a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Interdisciplinary Group were met as follows: 1. The Medical Director (MD) did not discuss the option for PleurX (long-term chest tube to drain fluid from the abdomen) as a treatment for the ascites to Patient 1 and/or the patient’s caregiver. 2. The Interdisciplinary Team (IDT) failed to communicate to Patient 1 and/or the patient caregiver regarding what hospice services would be provided for the management of Patient 1’s ascites 3. The IDT team failed to discuss the desire of Patient 1 to stop the hospice services in the event Patient 1’s ascites would not be treated. This failure placed Patient 1 at increased risk of suffering from reduced quality of life, increased distress which could then lead to emergency hospitalization contributing to an avoidable traumatic death. Patient 1 and the patient’s family are also likely to experience difficulty in coping with the patient’s illness and dying with dignity.Refer to L554The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written rules or laws) mandated compliance with the Federal regulations for Interdisciplinary Group to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14who were assessed to receive hospice care services.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP, a conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Quality Assessment and Performance Improvement (QAPI, a structured approach that hospice organizations use to continuously monitor, assess, and improve the quality of patient care and services), were met as follows: The HA failed to demonstrate a process and provide documented evidence of measuring, analyzing, and tracking of quality indicators (specific, quantifiable metrics that can be tracked over time) that enable the facility to assess processes of care, hospice services (end of life care that provides comfort, support, and medical assistance) and the agency’s operations for fourteen out of fourteen sampled patients. (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 receiving inadequate quality of care, unsafe patient care and increased risk of medical errors and adverse events that can lead to emergency hospitalizations and may contribute to an avoidable traumatic death. (Refer to: L562). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written rules or laws) mandated compliance with the Federal regulations for Quality Assessment & Performance Improvement to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14who were assessed to receive hospice care services.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organizational Environment were met as follows: The HA failed to demonstrate a process and provide documented evidence of measuring, analyzing, and tracking of quality indicators (specific, quantifiable metrics that can be tracked over time) that enable the facility to assess processes of care, hospice services (end of life care that provides comfort, support, and medical assistance) and operations for fourteen out of fourteen sampled patients. (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 receiving inadequate quality of care, unsafe patient care and increased risk of medical errors and adverse events that can lead to emergency hospitalizations and may contribute to an avoidable traumatic death. (Refer to L651) The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written rules or laws) mandated compliance with the Federal regulations for Organizational Environment to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 who were assessed to receive hospice care services.”

“Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (COP, conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Clinical Records was met as follows: The HA failed to ensure that three of fourteen sampled patients (Patient 2, Patient 3, and Patient 4) had the necessary Re-Certification of Terminal Illness (CTI, requirements is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) completed as part of their medical records. The agency’s Medical Director (MD) did not perform a face-to-face encounter (an in person visit by a hospice physician with a patient before the third and subsequent Medicare benefit periods to confirm continued eligibility for hospice care and a life expectancy of six months or less) prior to signing the CTI no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.This failure resulted in Patient 2, Patient 3, and Patient 4 not having complete clinical records that could potentially not meeting the recertification of terminal illness eligibility requirement and identify the patients’ current health conditions and affect the care and services of Patient 2, Patient 3, and Patient 4 received that could lead to hospitalization and death.Refer to L676The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written law) mandated compliance with Federal regulations for Clinical Records to ensure patients’ clinical records were complete and reflect patients’ current health status.”

“Based on interviews and record review, the facility failed to ensure two of four sampled patients (Patient 1 and Patient 5), and their representatives, received rights and responsibilities as hospice patients in their preferred language. This failure resulted in Patient 1 and Patient 5, and their representatives to sign a consent without understanding the rights and responsibilities they had as a hospice patient and had the potential to mis their opportunity to make informed decisions about their care. Findings:During an interview, on 8/26/2025 at 4:31 pm., with Patient 1, during the joint home visit with Licensed Vocational Nurse 1 (LVN 1) at Patient 1’s home, Patient 1 stated he speaks Spanish only. Patient 1 stated he was referred to Hospice Agency by his primary physician and that the Registered Nurse 1 (RN 1) came to the admission visit and had him sign the Hospice consent in English. Patient 1 stated RN 1 did not explain the services that the Hospice offered in a language he understood. During an interview on 8/26/2025 at 4:45 with Patient 1’s Care Giver (PCG 1), PCG 1 stated that she didn’t understand all the services the hospice provides because she only speaks Spanish.During an interview on 8/27/2025 at 11:11 a.m. with RN 1, RN 1 stated she (RN1) asked LVN 1 to translate for Spanish speaking patients. RN 1 was not sure if the facility has a Spanish consent form and it is important to have an interpreter so patients know what they are consenting to. During an interview on 8/27/2025 at 12:59 p.m. with Director of Patient Care Services (DPCS) DPCS stated LVN 1 speaks Spanish so they use him to translates for patients who speak Spanish. DPCS stated the facility should use a language interpreter service and document when services are used. During an interview on 8/27/2025 at 3:00 p.m. with Administrator (ADM), ADM stated that the staff rely on other staff to help translate since they no longer have an interpreter service.During an interview on 8/27/2025 at 3:34 p.m. with LVN 1, LVN 1 stated that he has been asked by RN 1 to translate between her and Patient 1. LVN stated he did it once but does not speak Spanish very well and is uncomfortable at times speaking Spanish. During an observation on 8/27/2025 at 5:15 p.m. during an Inter Disciplinary Group meeting (IDG) RN 5 stated she speaks a little Spanish, Patient 5 speaks Spanish only and PCG 5 speaks Spanish and a little bit of English enough were she feels like PCG 5 understands. During an interview on 8/28/2025 at 9:23 a.m. with RN 5, RN 5 stated that she did the initial assessment and had PCG 5 sign consent in English. During an interview on 8/28/2025 at10:25 a.m. with PCG 5, PCG 5 stated she understands RN 5 about basic care but did not fully understand when RN 5 was explaining about hospice services, patient rights and signing of consent. During a review of the facility’s policy and procedure titled, The Patient Bill of Rights/Responsibilities, dated 11/2021, indicated the patient bill of rights/responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.During a review of the facility’s policy and procedure titled, Informed Consent/Refusal of Treatment, dated 11/2021, indicated, Upon admission and throughout the course of care/service, the patient and family/caregiver will be: Given information, in an understandable language, to make informed decisions regarding the care/service being provided.During a review of the facility’s policy and procedure titled, Facilitating Communication, dated 11/2021, indicated, To assure that patients, visitors, and personnel with speech, vision, or hearing impairments, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance and other aids at no cost to patient(s) being served.”

“Based on interview and record review, the Hospice Agency (HA, (HA, agency providing care to terminally ill patients who have six months or less to live), failed to provide a direct phone number for 14 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) to file a complaint or grievance when the facility did not have a system in place for patients or family members to submit complaints.This failure had the potential to result in patients’ needs not being met and poor standards of care. Findings:During a review of Patient 1’s Face Sheet (admission record) the Face Sheet indicated Patient 1’s Start of Care (SOC) date was 4/23/2025, with primary diagnosis of alcoholic cirrhosis of liver with ascites (severe and irreversible damage to the liver caused by long-term excessive alcohol consumption, leading to buildup of fluid in the abdomen). During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 2/20/2025, with primary diagnosis of malignant neoplasm of prostate (a cancerous growth of cells that develops in the prostate gland, a small organ located below the bladder in men). During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/17/2025, with primary diagnosis of hypertensive heart disease without heart failure.During a review of Patient 5’s Face Sheet, the Face Sheet indicated Patient 5’s SOC date was 8/1/2025, with primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 6’s Face Sheet, the Face Sheet indicated Patient 6’s SOC date was 7/22/2025 with primary diagnosis of heart disease (a range of conditions that affect the heart).During a review of Patient 7’s Face Sheet, the Face Sheet indicated Patient 7’s SOC date was 7/17/2025 with primary diagnosis of Alzheimer’s disease.During a review of Patient 8’s Face Sheet, the Face Sheet indicated Patient 8’s SOC date was 7/16/2025 with primary diagnosis of malignant neoplasm of anal canal (a rare type of cancer that occurs in the lower part of the rectum).During a review of Patient 9’s Face Sheet, the Face Sheet indicated Patient 9’s SOC date was 7/4/2025 with primary diagnosis of chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly during the filling phase, leading to reduced blood volume in the heart).During a review of Patient 10’s Face Sheet, the Face Sheet indicated Patient 10’s SOC date was 6/16/2025 with primary diagnosis of chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing).During a review of Patient 11’s Face Sheet, the Face Sheet indicated Patient 11’s SOC date was 3/26/2025 with primary diagnosis of end stage renal disease (irreversible kidney failure).During a review of Patient 12’s Face Sheet, the Face Sheet indicated Patient 12’s SOC date was 2/21/2025 with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart and affects its ability to pump blood).During a review of Patient 13’s Face Sheet, the Face Sheet indicated Patient 13’s SOC date was 8/8/2025 with primary diagnosis of cerebral infarction (loss of blood flow to a part of the brain).During a review of Patient 14’s Face Sheet, the Face Sheet indicated Patient 14’s SOC date was 1/17/2025 with primary diagnosis of Alzheimer’s disease.During a concurrent interview and record review on 8/29/2025 at 11:50 a.m. with the Administrator (ADM), the “Patient/Family Bill of Rights,” given to newly admitted hospice patients was reviewed. The Patient/Family Bill of Rights indicated patients are instructed to call the State of California Home Health Hotline or Accreditation Commission for Health Care (ACHC) phone number to lodge a complaint. The Patient/Family Bill of Rights did not indicate the facility’s phone number. The ADM stated they do not have a system for patients to call the facility directly to file a complaint or grievance.During a review of the facility’s policy and procedure (P&P) titled, “Complaint/Grievance Process,” revised 11/2021, the P&P indicated, “…The organization staff member receiving the complaint will discuss, verbally and in writing, the grievance with a supervisor within five (5) days of the alleged grievance… All complaints will be logged, tracked, trended, and filed in the performance improvement office…””

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to involve three of 14 sampled patients (Patient 1, Patient 2, and Patient 3) and their family members in developing the plan of care when Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 2 did not educate the patients and their family members of their right to be involved in developing the plan of care.This failure had the potential to result in Patient 1, Patient 2, Patient 3, and their family members mis opportunity to participate with their plan of care and experiencing ineffective communication from HA regarding the hospice care and services being provided. . Findings:During a review of Patient 1’s Face Sheet (admission record) the Face Sheet indicated Patient 1’s Start of Care (SOC) date was 4/23/2025, with primary diagnosis of alcoholic cirrhosis of liver with ascites (severe and irreversible damage to the liver caused by long-term excessive alcohol consumption, leading to buildup of fluid in the abdomen). During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 2/20/2025, with primary diagnosis of malignant neoplasm of prostate (a cancerous growth of cells that develops in the prostate gland, a small organ located below the bladder in men). During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During an observation on 8/26/2025 at 12:30 p.m. in Patient 3’s home, RN 2 was observed conducting a home visit with Patient 3 and Patient 3’s Caregiver (PCG 3). RN 2 did not discuss Patient 3’s Plan of Care document (care plan) with Patient 3 or PCG 3.During an interview on 8/26/2025 at 1:25 p.m. with PCG 3, PCG 3 stated he has never seen Patient 3’s care plan since Patient 3’s SOC (2/21/2025). PCG 3 stated he was never educated on what the care plan is or how it affects Patient 3’s care. PCG 3 stated he was not informed of his right to be involved in the development or updating of the care plan.During an interview on 8/26/2025 at 3:15 p.m. with Patient 2 and Patient 2’s Caregiver (PCG 2), PCG 2 stated she has never seen Patient 2’s care plan since Patient 2’s SOC (2/20/2025). Patient 2 stated the care plan was dropped off to their house the day prior (8/25/2025). PCG 2 stated hospice staff never discussed the care plan with her. PCG 2 stated she was not informed of her right to be involved in the development of the care plan.During an interview on 8/26/2025 at 3:20 p.m. with LVN 1, LVN 1 stated the care plan was dropped off to Patient 2’s house on 8/25/2025. During an interview on 8/26/2025 at 4:30 p.m. with Patient 1 and Patient 1’s Caregiver (PCG 1), PCG 1 stated she has never seen Patient 1’s care plan since Patient 1’s SOC (4/23/2025). Patient 1 stated hospice staff never discussed the care plan with him. PCG 1 stated she was not informed of her right to be involved in the development of the care plan. During an interview on 8/29/2025 at 3:56 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated it is the visiting RN’s responsibility to discuss the care plan in detail with the patients and their caregivers. The DPCS stated it was important to ensure patients and their caregivers were aware of the care being provided.During a review of the facility’s policy and procedure (P&P) titled, “Patient Bill of Rights/Responsibilities,” revised 11/2021, the P&P indicated, “…Each patient will be an active, informed participant in his/her plan of care…”During a review of the facility’s P&P titled, “The Plan of Care,” revised 11/2021, the P&P indicated, “…The patient and family/caregiver will be encouraged to participate in the development of and continued updating of the plan of care.…””

“Based on interview and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to explain about the care and services covered under the hospice benefit when Registered Nurses (RN) had Patient 1 and Patient Care Giver 5 (PCG) sign a hospice consent without explaining the services to Patient 1 and PCG5.This failure had the potential for lack of information about the hospice care and services that could prevented the patient from making fully informed decisions regarding their care. Findings:During an interview on 8/26/2025 at 4:31 p.m., with Patient 1, Patient 1 stated RN 1 did not explain the services that the hospice offered. Patient 1 stated, he (Patient 1) only signed the consent because he thought that hospice would help him feel better but no one really explain the services and his prognosis. Patient 1 stated that the admission and consent were conducted in English when he only speaks Spanish. During an interview on 8/26/2025 at 4:45 p.m., with PT1’s Care Giver (PCG 5), PCG 5 stated that she (PCG5) did not understand all the services the hospice provides because she only speaks Spanish. During an interview on 8/27/2025 at 4:02 p.m. with Medical Director (MD), MD stated, that hospice services being provided should be explained to patients during the initial visit and it should be done by the most qualified staff which is him. During an interview on 8/28/2025 at 9:23 a.m. with RN 5, RN 5 stated that she did the initial assessment for Patient 5 and had PCG 5 sign consent in English with PCG 5’s daughters translating for PCG 5.During an interview on 8/28/2025 at10:25 a.m. with PCG 5, PCG 5 stated she understands RN 5 about basic care but did not fully understand when RN 5 was explaining about hospice services, patient rights and signing of consent. During an interview on 8/27/2025 at 11:11 with RN 1, RN 1 stated that she did not use a Spanish consent form for patient 1 and unsure if the facility has a Spanish consent form available. During a review of the facility’s Policy and Procedure (P&P) titled, Hospice Community Education, dated 11/2021, P&P indicated, Moonlight Hospice Care, INC will provide community education reflective of the Organization’s philosophy, mission, and purpose, with the goal of making the community aware of hospice services for end-of-life care.During a review of the facility’s P&P titled, Admission Criteria and Process, dated 11/2021, P&P indicated, The patient must desire hospice services, and be aware of the diagnosis and prognosis.During a review of the facility’s P&P titled, Hospice Election Statement, dated 11/2021, P&P indicated, The patient and family/caregiver, or his/her legal representative will be asked to sign the hospice election statement which acknowledges the following: A full understanding of the palliative, rather than curative nature of hospice care.”

“Based on interview and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to explain the scope of services covered under the hospice benefit when Patient 1 and Patient Care Giver (PCG) 1 were not fully informed of physical, psychosocial, practical, and spiritual needs that would be provided for Patient 1.This deficient practice had a potential for Patient 1 and Patient 1’s care giver of lack of information about the hospice care and services that could prevented Patient 1 from making fully informed decisions regarding their care. Findings:During an interview on 8/26/2025 at 4:31 p.m., with Patient 1, Patient 1 stated Registered Nurse (RN) 1 did not explain the services that the hospice services offered. Patient 1stated, he signed the consent because he thought that the hospice agency would help him feel better but no one really explain the services and his prognosis. Patients 1 stated his goal was to get a catheter placed in his abdomen so he can drain the excess fluid from his abdomen himself instead of having to go to the hospital every time he is in discomfort. During an interview on 8/26/2025 at 4:45 p.m., with Patient1’s Care Giver (PCG 1), PCG 1 stated she has only a little understanding of what hospice is because her husband was receiving hospice services. PCG 1 stated that she didn’t understand all the services the hospice would be able to provide Patient 1.During an interview on 8/27/2025 at 11:11 a.m. with RN 1, RN 1 stated that she was the RN that conducted the admission, explained what hospice was and had Patient 1 sign consent. RN 1 stated that she did not use a Spanish consent form or and interpreter as they seem to understand. During an interview on 8/27/2025 at 4:02 p.m. with Medical Director (MD), MD stated he had suggested Patient 1 get a Pleurx (a tube placed in the chest to drain excess fluid in the abdomen) and asked LVN 1 to explain to Patient 1 and PCG 1 but did not get a response. MD stated that he did not get a response because Patient 1 and PCG 1 probably did not understand the procedure. MD stated that the admitting RN should be explaining to patients hospice services but he would be the most qualified to explain to Patient 1 and PCG 1 the hospice services, prognosis and Pleurx procedure to Patient 1 and PCG 1. During a review of the facility’s policy and procedure titled, Hospice Community Education, dated 11/2021, indicated, Moonlight Hospice Care Inc will provide community education reflective of the organization’s philosophy, mission, and purpose, with the goal of making the community aware of hospice services for end-of-life care. Examples of educational content may include: Admission criteria and scope of services.During a review of the facility’s policy and procedure titled, Scope of Services, dated 11/2021, indicated, Moonlight Hospice Care Inc provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of hospice patients and families/caregiver.During a review of the facility’s P&P titled, Hospice Election Statement, dated 11/2021, P&P indicated, The patient and family/caregiver, or his/her legal representative will be asked to sign the hospice election statement which acknowledges the following: A full understanding of the palliative, rather than curative nature of hospice care.”

“Based on an interview and record review the the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) failed to update Patient 1’s comprehensive assessment when Patient 1 returned from the emergency room following a paracentesis (removable of excess fluid in the abdomen) procedure.This deficient practice had the potential for Patient 1 not to receive care and services necessary to meet care goal needs and the ability to monitor and adjust treatment plans effectively. During a concurrent observation and interview, on 8/26/2025 at 4:31 PM with Patient 1, Licensed Vocational Nurse 1 (LVN 1) was observed conducting a home visit to Patient 1. Patient 1 stated that about two and a half months ago he had to go into the ER for a paracentesis because he was feeling more discomfort and Short of Breath (SOB) when he laid on his back. Patient stated that he was not seen by his nurse after returning from the ER and was not contact by hospice. Patient 1’s Visit Notes, dated 5/4/2025, authored by LVN 1, indicated Patient 1’s belly was filled with fluid due to his stomach being firm. The Visit Note indicated Patient 1 could not breathe well during the night because he feels out of breath if he lays down on his back and he cannot sleep on his stomach without hurting. Patient 1’s Visit Notes, dated 5/14/2025, authored by LVN 1, indicated Patient 1 had been to the doctor to have “10 cups” of fluid removed and was feeling better because it was easier to breath. Patient 1’s Nursing Update Assessment, dated 5/21/2025 at 10:00 a.m. authored by RN 1, indicated “There is SOB with mild exertion, lung sounds were diminished.”During an interview on 8/27/2025 at 11:11 a.m. with RN1, RN 1 stated that she completes comprehensive assessment during the recertification process and was unaware that she need to complete a comprehensive assessment after an ER visit. RN 1 stated that it’s the RNs responsibility to reassess the patient after ER and to give Interdisciplinary Group (IDG) an update on the patients reevaluation. During an interview on 8/27/2025 at 12:59 p.m. with DPCS, DPCS states that the RN should be reassessing the patients when there is a change of condition or had an ER visit. DPCS stated that if there is a delay in reassessments patients can be in discomfort or end up in the hospital. DPCS stated that LVN 1’s notes dated 5/7 were not discussed during IDG and it was her responsibility to follow up. DCPS also stated that PT 1’s visit to the ER was not documented during IDG but the team was aware Patient 1 had a paracentesis. During a review of the facility’s Policy and Procedure (P&P) titled, Interdisciplinary Group Meeting, dated 11/2021 indicated, the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient’s condition requires.During a review of the facility’s P&P titled, Comprehensive assessment, dated 11/202, P&P indicated, If there has been a change in the patient’s condition/status, then the comprehensive assessment must be updated.”

“Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), that LVN 1 did not communicate with the Inter Disciplinary Group meeting (IDG) when he omitted Patient 1’s wishes to terminate his hospice service. This deficient practice had the potential for violating Patient 1’s rights and receiving unwanted care. During a concurrent observation and interview, on 8/26/2025 at 4:31 PM with Patient 1, Licensed Vocational Nurse 1 (LVN 1) was observed conducting a home visit to Patient 1. Patient 1 stated he thought hospice was going to help him get a catheter placed in his chest to help him remove the excess fluid to get better. Patient 1 stated that if hospice was not going to do this for him he wished to terminate his hospice services. During an observation on 8/27/2025 at 5:15 p.m. during an IDG meeting LVN 1 did not communicate with the group Patients 1 not wanting to keep receiving hospice services due to patient 1 not receiving the outcome he desired. During an interview on 8/27/2025 at 5:25 p.m. with Patient 1, Patient 1 stated he did not want hospice anymore and did not want to be called anymore in regard to hospice services. During a review of the facility’s Policy and Procedure titled, “Hospice Nursing Care,” revised 11/2021, the P&P indicated, “...Duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group...” During a review of the facility’s P&P titled, “Patient Bill of Rights/Responsibilities,” revised 11/2021, the P&P indicated, The Patient Bill of Rights/Responsibilities statement defines the right of the patient to: Voice grievances regarding treatment or care that is (or fails to be) furnished…”

“Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to provide an individualized plan of care for four of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 15) when the care plans did not include interventions and goals for how to manage their medical diagnoses.This deficient practice had the potential to result in insufficient and ineffective interventions to maintain the quality of life for Patient 1, Patient 2, Patient 3, and Patient 15 and an undignified death. Findings:During a review of Patient 1’s Face Sheet (admission record) the Face Sheet indicated Patient 1’s Start of Care (SOC) date was 4/23/2025, with primary diagnosis of alcoholic cirrhosis of liver with ascites (severe and irreversible damage to the liver caused by long-term excessive alcohol consumption, leading to buildup of fluid in the abdomen). During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC date was 2/20/2025, with primary diagnosis of malignant neoplasm of prostate (a cancerous growth of cells that develops in the prostate gland, a small organ located below the bladder in men). During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During a review of Patient 15’s Face Sheet, the Face Sheet indicated Patient 15’s SOC date was 3/6/2025 and End of Care (EOC) date was 5/2/2025, with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart and affects its ability to pump blood). During a review of Patient 15’s Plan of Care/IDG Review, dated 4/9/2025, the POC/IDG Review indicated Patient 15 had a PleurX catheter (a tube inserted into the abdomen used to drain recurrent fluid buildup, often due to liver disease) in his left abdomen.During a concurrent observation and interview on 8/26/2025 at 12:30 p.m. with Patient 3’s Caregiver (PCG 3) in Patient 3’s home, Patient 3 was wincing and complaining of bilateral (affecting both sides) shoulder pain. PCG 3 stated Patient 3 has had chronic bilateral shoulder pain for years.During a concurrent observation and interview on 8/26/2025 at 3:15 p.m. with Patient 2’s Caregiver (PCG 2) in Patient 2’s home, Patient 2 walked out of his front door with a walking stick. PCG 2 stated Patient 2 had glaucoma in both eyes and could not see.During a concurrent interview and record review on 8/29/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS), Patient 15’s Plan of Care (care plan), dated 4/9/2025, was reviewed. The care plan did not indicate goals for monitoring for infection control or shortness of breath (SOB) related to Patient 15’s PleurX catheter. The DPCS stated patients with a PleurX catheter should include measurable goals and interventions for infection control and monitoring for SOB. The DPCS stated it was the primary RN’s, Medical Director (MD), and DPCS’ responsibility for ensuring the care plan included infection control and SOB. The DPCS stated Patient 15 could develop an infection or experience SOB and discomfort from not including infection control and monitoring for SOB in the care plan.During a concurrent interview and record review on 8/29/2025 at 12 p.m. with the DPCS, Patient 1’s care plan, dated 8/25/2025, was reviewed. The care plan did not indicate goals for monitoring Patient 1’s diagnosis of alcoholic cirrhosis of liver with ascites. The DPCS stated the care plan did not indicate how Patient 1’s diagnosis would be managed. The DPCS stated Patient 1’s care plan should have included assessments for SOB, measurements of abdominal girth, daily weights, and monitoring for increased confusion.During a concurrent interview and record review on 8/29/2025 at 4:06 p.m. with the DPCS, Patient 2’s care plan, dated 8/25/2025, was reviewed. The care plan did not indicate goals for monitoring Patient 2’s glaucoma. The DPCS stated the care plan did not indicate how Patient 2’s glaucoma would be managed. The DPCS stated Patient 2 could fall and injure himself because his glaucoma was not included in the care plan.During a concurrent interview and record review on 8/29/2025 at 4:10 p.m. with the DPCS, Patient 3’s care plan, dated 8/25/2025, was reviewed. The care plan did not indicate goals for monitoring Patient 3’s shoulder pain. The DPCS stated the care plan did not indicate how Patient 3’s shoulder pain would be managed. The DPCS stated Patient 3 could be experiencing uncontrolled pain because her shoulder pain was not included in the care plan.During a review of the facility’s P&P titled, “The Plan of Care,” revised 11/2021, the P&P indicated, “…A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program… The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.””

“Based on observation, interview, and record review, the facility failed to help manage pain for one of 14 sampled patients (Patient 3) when Patient 3 had uncontrolled shoulder pain and the interdisciplinary team (IDT) did not include the use of alternative therapies to manage it.This failure resulted in unmanaged pain and discomfort for Patient 3, which increased the risk of developing agitation that could lead to emergency hospitalization and, subsequently, an avoidable traumatic and undignified death. Findings:During a review of Patient 3’s Face Sheet (admission record), the Face Sheet indicated Patient 3’s Start of Care (SOC) date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During a concurrent observation and interview on 8/26/2025 at 12:30 p.m. with Patient 3’s Caregiver (PCG 3) and Registered Nurse (RN) 2 in Patient 3’s home, Patient 3 was wincing and complaining of bilateral (affecting both sides) shoulder pain. Patient 3 could not extend both arms up past her shoulders. PCG 3 stated Patient 3 has had chronic bilateral shoulder pain for years. RN 2 stated Patient 3 takes pain medication to help manage it, but Patient 3During an interview on 8/27/2025 at 4:32 p.m. with the Medical Director (MD), the MD stated he was not made aware of Patient 3’s constant shoulder pain. The MD stated if he knew the prescribed pain medication was not working, he would have ordered a Physical Therapy (PT) evaluation. The MD stated Patient 3’s shoulder pain and alternative therapies should be discussed during IDT meetings.During an observation on 8/27/2025 at 5:06 p.m. in the conference room, the facility’s IDT meeting was observed. RN 2 and the MD did not bring up Patient 3’s shoulder pain or alternative therapies.During a review of the facility’s P&P titled, “Pain Assessment,” revised 11/2021, the P&P indicated, “Nonpharmacological interventions will be considered for the treatment of pain.”During a review of the facility’s P&P titled, “Interdisciplinary Group Meeting,” revised 11/2021, the P&P indicated, “An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. It will note changes, response to treatment and progress toward targeted outcomes, which may include…Pharmacotherapeutic effectiveness of symptom management outcomes.””

“Based on interview and record review the facility failed to ensure that the frequency of License Vocational Nurse (LVN) and Registered Nurse (RN) visits was ordered for Patient 1 when the Plan of Care (POC) did not contain visit intervals to address Patient 1 needs. This failure had the potential to significantly impact the quality of care provided to Patient 1, as the absence of clearly defined visit intervals might have led to inconsistent or inadequate attention to patient needs. Patient 1’s Plan of Care dated 4/23/2025 authored by Director of Patient Care Service (DPCS), indicated, “Frequency of Visit: Home aide: declined, Social Worker: 1 per month-for support and counseling.”During an interview on 8/27/2025 at 12:59 p.m. with DPCS, DPCS stated that RN visits should be every 14 days or as needed and every week for LVN. DPCS stated the frequency of visits for Patient 1 is missing from Patient 1’s POC. During an interview on 8/27/2025 at 4:02 p.m. with Medical Director (MD), MD stated he reviews and signs the orders that are discussed in IDG meetings. During a review of the facility’s Policy and Procedure titled, “The Plan Of Care,” revised 11/2021, the P&P indicated, The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient’s and family/caregiver’s needs, goals and outcome achievement.”

“Based on interview and record review, the facility failed to provide medical supplies necessary for two of 14 sampled patients (Patient 3 and Patient 15) when the facility did not provide a suction machine for Patient 3 and did not provide enough vacuum bottle drainage (bottles used to drain fluid buildup from the abdomen or lungs) kits for Patient 15.This failure resulted in unmanaged discomfort and poor symptom management for Patient 3 and Patient 15 that could lead to emergency hospitalization and contribute to an avoidable undignified death. Findings:During a review of Patient 3’s Face Sheet (admission record), the Face Sheet indicated Patient 3’s Start of Care (SOC) date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During a review of Patient 15’s Face Sheet, the Face Sheet indicated Patient 15’s SOC date was 3/6/2025 and End of Care (EOC) was 5/2/2025, with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure damages the heart and affects its ability to pump blood).During a concurrent interview and record review on 8/26/2025 at 1:15 p.m. with Patient 3’s Caregiver (PCG 3), Patient 3’s “Current Treatment/Medication/Durable Medical Equipment (DME) List”, undated, was reviewed. The Current Treatment/Medication/DME List indicated there was an order for a suction machine (a medical device that uses negative pressure to remove fluid from the body) starting 2/21/2025. PCG 3 stated they have never received a suction machine and does not know what it is.During a concurrent interview and record review on 8/29/2025 at 11:30 a.m. with the Director of Patient Care Services (DPCS), Patient 15’s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 4/9/2025, was reviewed. The POC/IDG Review indicated Patient 15 had a PleurX catheter (a tube inserted into the abdomen used to drain recurrent fluid buildup, often due to liver disease) in his left abdomen. The POC/IDG Review also indicated Patient 15 had increased abdominal distention (a feeling of fullness or swelling due to an accumulation of fluid in the abdomen) and needed two PleurX drainage bottles daily. The POC/IDG Review did not indicate how Patient 15’s increased abdominal distention and need for two PleurX drainage bottles daily would be addressed by the IDG. The DPCS stated POC/IDG Review indicated, Patient 15’s “abdominal distention was getting worse.” The DPCS stated Patient 15’s need for two PleurX drainage bottles daily was not discussed with the IDG. The DPCS stated if Patient 15’s abdominal fluids were not drained, it could lead to increased shortness of breath, infection, discomfort, and possible hospitalization.During a concurrent interview and record review on 8/29/2025 at 11:50 a.m. with the DPCS, Patient 15’s Order Confirmation Forms, dated April 2025, were reviewed. The Order Confirmation Forms indicated the facility delivered 1000 milliliter (ml, a unit of measurement) vacuum bottle drainage kits (drainage bottles that connect to a patient’s PleurX catheter to drain and contain bodily fluids) on 4/9/2025, 4/17/2025, and 4/28/2025. The DPCS stated Patient 15 did not receive enough vacuum bottle drainage kits to meet his needs based on the order confirmation forms. The DPCS stated Patient 15 was hospitalized because of increased shortness of breath due to the buildup of fluid in his abdomen.During a review of the facility’s P&P titled, “Scope of Services,” revised 11/2021, the P&P indicated, “…An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which will include, as appropriate, the following services… Durable medical equipment related to the hospice patient’s terminal diagnosis.”During a review of the facility’s P&P titled, “Medicare Hospice Benefit,” revised 11/2021, the P&P indicated, “…To be provided by hospice as needed by patient:Durable medical equipment (DME) from Medicare-certified contracted vendorsMedical supplies by selected vendors…””

“Based on interview and record review, the facility failed to ensure that the patient or caregiver was involved, understood, and agreed with the care plan (an outline of the patient’s specific needs, treatment goals and actions needed to reach those goals) for two of three sampled patients (Patient 1 and Patient 2). This failure had the potential to result in the patient needs and preferences not being addressed, lack of adherence to interventions, and potential compromise of health outcomes. Findings: During a review of Patient 1’s Facesheet (Admission Record), the Facesheet indicated Patient 1, a 70- year-old male, had a Start of Care (SOC) that was initiated on 4/23/2025, with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a severe and irreversible damage to the liver caused by long-term excessive alcohol consumption with fluid buildup in the abdominal cavity). During a review of Patient 1’s care plan, dated 8/25/2025, the care plan was not patient specific and did not indicate Patient 1 had alcoholic cirrhosis of the liver with ascites and did not address goals or interventions for the diagnosis.During a concurrent interview and record review on 8/26/2025 at 4:35 p.m. with Patient 1, a binder containing a medication list and care plan was reviewed. Patient 1 stated Licensed Vocational Nurse 1 (LVN 1) had dropped off a binder but he did not know what was inside of the binder. Patient 1 stated the documents in the binder had not been reviewed with him. During an interview on 8/29/2025 at 12:00 p.m. with Director of Patient Care Services (DPCS), DPCS stated she and the visiting nurse were in charge of developing the care plan. DPCS stated the patient’s diagnosis had not been included in the care plan and symptoms of shortness of breath, abdominal girth (the measurement around the stomach area used to check for changes in swelling or fluid buildup), daily weights and change of condition should be included in the care plan. During a review of Patient 2’s Facesheet (Admission Record), the Facesheet indicated Patient 2, an 85-year-old male, had a SOC that was initiated on 2/20/2025, with a primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland, a small walnut-shaped organ located below the bladder in men).During a review of Patient 2’s care plan, dated 8/25/2025, the care plan was not patient specific, there was no documentation that Patient 2 had visual impairment and there was no documentation that the care plan had been discussed with Patient 2 and caregiver. During an interview on 8/26/2025 at 3:15 p.m. with Patient 2 and Patient 2’s Caregiver (PCG 2), Patient 2 and PCG 2 stated the care plan had been dropped off the day prior on 8/25/2025 and that hospice staff had not discussed the care plan with them. During an interview on 8/26/2025 at 3:20 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the care plan along with the medication list had been dropped off to Patient 2’s house on 8/25/2025. During an interview on 8/29/2025 at 3:56 p.m. with DPCS, DPCS stated she was aware that Patient 2 wears glasses and that the patient has glaucoma (an eye disease that causes vision loss and blindness by damaging the nerve in the back of the eye). DPCS stated there was nothing mentioned in the patient’s care plan in regard to glaucoma and that it should be included as it can be a safety concern for falls. DPCS stated the registered nurse discusses the care plan upon admission and the follow up nurses are to review the care plan with the patient and caregiver. DPCS stated the expectation was that the care plan was explained in detail. During a review of the facility’s policy and procedure (P&P) titled, “Job Description-Registered Nurse”, dated 11/2021, the P&P indicated the Registered Nurse’s essential job functions and responsibilities are to “Develop a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and family in the planning process”.”

“Based on interview and record review the facility failed to update and individualize Patient 1’s Plan of Care (POC) according to his diagnosis and change of condition when his POC did not identified problems, goals, and interventions.The failure resulted in a generalized POC that led to Patient 1’s receiving the wrong type of care and worsening health condition. Patient 1’s Visit Notes, dated 5/4/2025, authored by LVN 1, indicated Patient 1’s belly was filled with fluid due to his stomach being firm. The Visit Note indicated Patient 1 could not breathe well during the night because he feels out of breath if he lays down on his back and he cannot sleep on his stomach without hurting. Patient 1’s Visit Notes, dated 5/14/2025, authored by LVN 1, indicated Patient 1 had been to the doctor to have “10 cups” of fluid removed and was feeling better because it was easier to breath. Patient 1’s Nursing Update Assessment, dated 5/21/2025 at 10:00 a.m. authored by RN 1, indicated “There is SOB with mild exertion, lung sounds were diminished.”Patient 1’s POC/IDG Review dated 5/21/2025, 6/4/2025, and 6/18/2025 at 4:00 p.m., authored by DPCS indicated, no update to POC. During a concurrent observation and interview, on 8/26/2025 at 4:31 PM with Patient 1, Licensed Vocational Nurse 1 (LVN 1) was observed conducting a home visit to Patient 1. Patient 1 stated that about two and a half months ago he had to go into the ER for a paracentesis. During an interview on 8/27/2025 at 12:59 p.m. with Director of Patient Care Services (DCPS), DPCS stated the Plan of Care (POC) is discussed during Interdisciplinary Group (IDG) meeting only when there is a new order. During a concurrent interview and record review on 8/29/2025 at 12:00 p.m. with DPCS, Patient 1’s POC, dated 5/7/2025 was reviewed. DPCS stated she is responsible for creating POCs for all the hospice patients. DPCS stated the POC should focus on Patient 1’s ascites (excessive fluid in abdomen) and include how the facility can manage abdominal distention, daily weights, Shortness of breath (SOB), pain, increase confusion and any other change in condition. During a review of the facility’s Policy & Procedure (P&P) titled, “Clinical Record Review,” revised 11/2021, P& P indicated, Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered is reliable, timely, valid, and accurate. All records will be reviewed using a clinical record review tool to: Determine the adequacy of the plan of care and to determine if further service is necessary and appropriate.During a review of the facility’s P&P titled, “Clinical Record Review,” revised 11/2021, P& P indicated, 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 be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions.”

“Based on observation, interview and record review the facility failed to ensure that the Interdisciplinary Group (IDG or Interdisciplinary Team [IDT], a team of professionals who collaborate to provide comprehensive physical, medical, social, emotional, and spiritual care for patients and their families facing a terminal illness) supervised, coordinated and communicated with Patient 1 and/or Patient 1’s representatives regarding hospice services, care plan and alternative treatment plan, as recommended by the physician, to manage Patient 1’s (excess fluid accumulation in the abdomen cavity) by failing to: 1. The Medical Director (MD) did not discuss the option for PleurX (long-term chest tube to drain fluid from the abdomen) as a treatment for the ascites to Patient 1 and/or the patient’s caregiver. 2. The Interdisciplinary Team (IDT) failed to communicate to Patient 1 and/or the patient caregiver regarding what hospice services would be provided for the management of Patient 1’s ascites 3. The IDT team failed to discuss the desire of Patient 1 to stop the hospice services in the event Patient 1’s ascites would not be treated. This failure placed Patient 1 at increased risk of suffering from reduced quality of life, increased distress which could then lead to emergency hospitalization contributing to an avoidable traumatic death. Patient 1 and the patient’s family are also likely to experience difficulty in coping with the patient’s illness and dying with dignity. On 8/28/2025 at 4:33 p.m., while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, and death of a resident) regarding the failure of the IDG/IDT to supervise and communicate with Patient 1 and/or Patient 1’s representatives the hospice services, care plan, and alternative treatment to manage patient 1’s ascites. The survey team notified the Administrator (ADM) of the IJ situation.On 9/2/2025 4:59 p.m., the IJ was removed in the presence of the ADM after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present.The IJ Removal Plan dated 8/29/2025 at 2:01 p.m., included the following:1. On 8/29/2025, the MD held a face-to-face conference with Patient 1 and family, with a certified medical interpreter through LanguageLine® Personal Interpreter. The MD explained disease status, palliative (refers to type of care that focuses on relieving symptoms, pain, and stress caused by serious illness) options (intermittent paracentesis [a medical procedure where fluid is periodically removed from the abdomen to relieve symptoms caused by ascites] versus tunneled peritoneal catheter [a thin, flexible tube that is inserted under the skin and into the abdomen cavity to allow ongoing drainage of fluid, typically ascites), risks and benefits, expected frequency, and hospice coordination for orders and home care. Documentation of discussion, consent or declination, and updated goals of care was entered in the Electronic Medical Record (EMR) within 24 hours (8/29/2025) and included in the Plan of Care (POC) and IDG minutes.2. On 8/29/2025, the Registered Nurse Case Manager (RNCM) re-issued Spanish-language patient rights, hospice philosophy, services and non-covered services, and levels of care to Patient 1 and representative. Education was reviewed in detail with the patient and family using certified medical interpreters through LanguageLine® Personal Interpreter. Patient signed the acknowledgment in Spanish and filed in the EMR.3. On 8/29/2025 RNCM performed an urgent reassessment. MD orders were obtained for symptom management and updated in the POC. All change-of-condition reports now trigger immediate Registered Nurse (RN) assessment, same-day call to MD for orders, documentation in EMR within 24 hours, IDG notification, and log entry on Same-Day MD Notification Log.4. On 8/29/2025, the MD, RNCM, and certified medical interpreter through LanguageLine® Personal Interpreter reviewed Patient 1’s right to revoke hospice at any time. Patient 1’s preference to stay in hospice service was documented in the EMR and presented in the updated plan of care dated 8/29/2025.5. Effective 8/29/2025, License Vocational Nurse (LVN) staff are prohibited from interpreting. Agency contracts exclusively with certified medical interpreters through LanguageLine® Personal Interpreter, which supplies certified, medically trained interpreters. Interpreter session ID numbers are documented in the EMR for verification.6. Verification of Qualifications: The agency maintains an active Business Associate Agreement (BAA) with LanguageLine® Personal Interpreter, ensuring compliance with HIPAA (Health Insurance Portability and Accountability Act) and HITECH (Health Information Technology for Economic and Clinical Health Act) privacy and/or security standards. Human Resources and Compliance Department keeps annual verification of interpreter credentialing, provided directly by LanguageLine® Personal Interpreter. Interpreters are trained in confidentiality, security, and Protected Health Information (PHI) standards. LanguageLine® Personal Interpreter uses secure, encrypted telephonic and video platforms that meet HIPAA standards. No call recordings or transcripts are stored by LanguageLine® Personal Interpreter preserving patient confidentiality.7. By 8/29/2025, the Director of Patient Care Services (DPCS) audited all active patients for: Preferred language and interpreter needs; presence of language-appropriate rights/consents; documentation of physician-led discussion of major palliative options; evidence of patient/family participation in the POC; documentation of whether any patient expressed intent to revoke and how it was addressed; any change-of-condition in the last 30 days that lacked same-day physician notification and POC update8. Audit Results: Results of the census-wide audit will be finalized and available by close of business today, 8/29/2025. Findings will be reviewed by the DPCS and submitted to the Quality Assurance and Performance Improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) Committee for trending, corrective actions, and ongoing monitoring.9. Effective 8/29/2025 Any identified deficits will be corrected same day, including: re-issuing consents in the preferred language with LanguageLine® Personal Interpreter support; documenting interpreter session ID numbers in the EMR; conducting physician-led palliative care discussions and updating the POC accordingly; immediate MD notification for any change-of-condition not previously addressed, with orders obtained and POC revised; documentation of revocation discussions in EMR and IDG minutes; 10. By 8/30/2025 the DPCS will provide a written summary of the audit results to the QAPI Committee. Findings will be trended, and any repeated or systemic issues will trigger a Performance Improvement Project (PIP) under QAPI governance.11. Documentation Tools Implemented effective 8/29/2025: New IDG template section “Goals/Preferences & Revocation.”; Same-Day MD Notification Log (monitored weekly); Palliative Procedure Checklist to ensure counseling, consent, supplies and POC updates. DPCS audits weekly to ensure compliance.12. On 8/29/2025, a Staff Education/In-Service was held, topics covered: monitoring/reporting change-of-condition, physician services, hospice nursing/IDG coordination, language access (1557 compliance, patient rights/revocation and clinical records.13. Effective 8/29/2025, monitoring & QAPI oversight audits of admissions & active census, POC/IDG, change-of-condition, and clinical records completeness. Findings:During a review of Patient 1’s Face Sheet (admission record), the Face Sheet indicated Patient 1’s Start of Care (SOC) was 4/23/2025 with primary diagnosis of alcoholic cirrhosis of liver with ascites (a severe and irreversible damage to the liver caused by long-term excessive alcohol consumption with fluid buildup in the abdominal cavity). During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC was 2/20/2025 with primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland, a small walnut-shaped organ located below the bladder in men.) During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC was 2/21/2025 with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without causing the heart to pump inefficiently heart failure).During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC was 1/17/2025 with primary diagnosis of hypertensive heart disease without heart failure.During a review of Patient 5’s Face Sheet, the Face Sheet indicated Patient 5’s SOC was 8/1/2025 with primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 6’s Face Sheet, the Face Sheet indicated Patient 6’s SOC was 7/22/2025 with primary diagnosis of heart disease (a range of conditions that affect the heart). During a review of Patient 7’s Face Sheet, the Face Sheet indicated Patient 7’s SOC was 7/17/2025 with primary diagnosis of Alzheimer’s disease.During a review of Patient 8’s Face Sheet, the Face Sheet indicated Patient 8’s SOC was 7/16/2025 with primary diagnosis of malignant neoplasm of anal canal (a rare type of cancer that occurs in the anal canal, the lower part of the rectum). During a review of Patient 9’s Face Sheet, the Face Sheet indicated Patient 9’s SOC was 7/4/2025 with primary diagnosis of chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly during the filling phase [diastole], leading to reduced blood volume in the heart). During a review of Patient 10’s Face Sheet, the Face Sheet indicated Patient 10’s SOC was 6/16/2025 with primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) During a review of Patient 11’s Face Sheet, the Face Sheet indicated Patient 11’s SOC was 3/26/2025 with primary diagnosis of end stage renal disease (an irreversible kidney failure).During a review of Patient 12’s Face Sheet, the Face Sheet indicated Patient 12’s SOC was 2/21/2025 with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure [hypertension] damages the heart muscle, leading to impaired pumping function and heart failure). During a review of Patient 13’s Face Sheet, the Face Sheet indicated Patient 13’s SOC was 8/8/2025 with primary diagnosis of cerebral infarction (loss of blood flow to a part of the brain)During a review of Patient 14’s Face Sheet, the Face Sheet indicated Patient 14’s SOC was 1/17/2025 with primary diagnosis of Alzheimer’s disease.During a concurrent observation and interview, on 8/26/2025 at 4:31 p.m. PM with Patient 1, Licensed Vocational Nurse 1 (LVN 1) was observed conducting a home visit to Patient 1. Patient 1 stated he speaks only Spanish. Patient 1 stated he was referred to hospice by his primary physician. Patient 1 stated that Registered Nurse 1 (RN 1) came (to his home) to complete the admission and had him sign the hospice consent in English. Patient 1 stated RN 1 did not explain the services that the hospice agency offered in a language he understood.During the interview, on 8/26/2025 at 4:31 p.m. with LVN 1 present, Patient 1 stated he thought the hospice agency would help him get a catheter (a thin flexible tube) in his abdomen to drain the fluids, so that he does not need to go to the Emergency Department (ED) for the procedure. Patient 1 stated he feels discomfort and short of breath when fluids build up in his abdomen, which was why he needed to go to ED to have it drained.During the interview, on 8/26/2025 at 4:31 p.m. with LVN 1 present, Patient 1 stated he did not want hospice services if they would not help him in placing the tube in his abdomen. LVN 1 heard Patient 1’s statement regarding stopping the hospice services. During an interview on 8/26/2025 at 4:41 p.m., with LVN 1, LVN 1 stated he was aware Patient 1 wanted the catheter placed but it was denied because Patient 1 was under hospice services. LVN 1 stated he did inform Patient 1 about the denial. During an interview on 8/27/2025 at 11:11 a.m. with RN 1, RN 1 stated she was not contacted by LVN 1 regarding the patient’s stomach being firm, difficulty breathing, or stomach pain on 5/4/2025. RN 1 stated this would have been considered a change of condition for Patient 1. RN 1 stated if LVN 1 reported those symptoms to her (RN 1), she would have notified the DPCS, who then would have notified the MD. RN 1 stated the symptoms would have been discussed during the IDG/IDT meeting and Patient 1’s plan of care would be adjusted. RN 1 stated Patient 1’s goal was for the hospice agency to help remove the fluids in his abdomen. RN 1 stated she notified the DPCS regarding Patient 1’s goal because it was something that should be addressed.During a concurrent interview and record review, on 8/27/2025 at 1:20 p.m. with the DPCS, Patient 1’s IDT notes were reviewed. The IDT notes did not indicate Patient 1 was being assessed for ascites, shortness of breath, or stomach discomfort, and visit to the ED. The DPCS stated the assessment of his symptoms should have been documented in Patient 1’s IDT meeting notes as well as the patient’s visit to the ED. The DPCS stated there should have been documentation of MD notification regarding Patient 1 wanting paracentesis. The DPCS stated she does not speak Spanish and that she had the nurse discuss with Patient 1 that receiving paracentesis was not part of the “hospice philosophy” (a compassionate, holistic approach to end-of-life care that focuses on comfort, dignity, and quality of life rather than curing illness). During an interview on 8/27/2025 at 3:34 p.m. with LVN 1, LVN 1 stated that he had been asked by RN 1 to translate between her (RN 1) and Patient 1. LVN stated he did it once, but he does not speak Spanish very well and he is uncomfortable at times speaking Spanish. During an interview on 8/27/2025 at 4 p.m., with the MD, the MD stated he was aware Patient 1 had abdominal distention from his ascites and had considered performing paracentesis but that it was not feasible because Patient 1 would require a paracentesis every two weeks. MD stated he had asked RN 1 and LVN 1 to talk to the patient’s family regarding taking the patient to the hospital to place a PleurX to help drain the fluid in the abdomen, so that the hospice nurse could drain the fluid during home visits. MD stated he was not aware of what the family had decided regarding the PleurX catheter and that he did not follow up. MD stated he is the most qualified to explain to Patient 1 and family about the treatment plan that included paracentesis and placement of PleurX catheter and that the LVN 1 should not be the one to explain this to the patient and family. MD stated he had not had a face to face with Patient 1 and the family regarding care and believed it was the duty of the admitting nurse to explain to the patient and family the patient’s terminal illness and length of life. During an observation on 8/27/2025 at 5:15 p.m. during an IDG meeting, LVN 1 was observed not mentioning to the group Patient 1’s desire to not continue with hospice services since he was not getting the treatment he needed. During a review of Patient 1’s Nursing Assessment dated 4/23/2025 authored by RN 1, the Nursing Assessment indicated Patient 1 complained of frequent fluid buildup in the abdomen which needed to be drained out.During a review of Patient 1’s Visit Notes, dated 5/4/2025, authored by LVN 1, the Visit Notes indicated Patient 1’s belly (abdomen) was filled with fluid due to his stomach being firm. The Visit Note indicated Patient 1 could not breathe well during the night because he felt out of breath if he lay down on his back, and he could sleep on his stomach without hurting.During a review of Patient 1’s Visit Notes, dated 5/14/2025, authored by LVN 1, the Visit Notes indicated Patient 1 had been to the doctor to have “10 cups” of fluid removed and was feeling better because it was easier to breath. During a review of Patient 1’s Nursing Update Assessment, dated 5/21/2025 at 10 a.m. authored by RN 1, the Nursing Update Assessment indicated “There is SOB (shortness of breath) with mild exertion, lung sounds were diminished.”During a review of Patient 1’s IDG Discussion/Updated Comprehensive Assessment review, dated 5/21/2025 at 4 p.m., the IDG Discussion/Updated Comprehensive Assessment indicated “The patient denies SOB (shortness of breath). The patient reports no discomfort. Patient complains that they have frequent ascites.” The IDG did not mention Patient 1’s visit to the emergency room.During a review of Patient 1’s Nursing Update Assessment, dated 6/4/2025, authored by RN 1, the Nursing Update Assessment indicated the patient’s abdomen was distended due to ascites, and the patient was recommended to get the fluid drained out in the ER.During a review of Patient 1’s Nursing Update Assessment, dated 7/16/2025, authored by RN 1, the Nursing Update Assessment indicated, “Patient complains that they have frequent ascites build up in the abdomen which needs to be drained out.”During a review of the facility’s policy and procedure (P&P) titled, “Monitoring Patient’s Response/Reporting to Physician,” revised 11/2021, the P&P indicated “...The hospice Medical Director will be contacted on the same day when any of the following occur: Changes in the patient’s condition... Changes occur regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions, and limitations)...” During a review of the facility’s P&P titled, “Physician Services – Attending Physician’s Role,” revised 11/2021, the P&P indicated, “The attending physician will inform the patient and family/caregiver about the prognosis of six (6) months or less and about the hospice program. The physician will make known to the patient and family/caregiver that the goals of the hospice program are palliative, not curative, and that no care will be provided to artificially prolong life.” During a review of the facility’s P&P titled, “Hospice Nursing Care,” revised 11/2021, the P&P indicated, “...Duties will include the responsibility for coordination of care and fostering communication between the patient and the interdisciplinary group...””

“Based on interview and record review, the facility failed to show measurable improvement in indicators in the current (QAPI, a data driven approach to continuously improve care and services) projects to improve palliative outcomes and hospice services. This failure had the potential to result in the inability to identify if corrective actions are effective which can lead to compromised patient care. Findings:During a review of the facility’s Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) for Quarter 1, dated 1/1/2025 to 3/31/2025, it indicated 13 out of 17 patients reported being uncomfortable because of pain. The QAPI report did not indicate what interventions were done for the patient experiencing pain or what tool was used to measure improvement indicators. The QAPI report indicated there were 3 infections out of 1367 care days and the action plan was to educate patients, caregivers, and staff regarding hand hygiene (washing of hands to prevent the spread of germs). The QAPI report did not include data regarding percentage of staff, patients or caregivers that performed hand hygiene. During a review of the facility’s “QAPI Quarter 2”, dated 4/1/2025 to 7/31/2025, the QAPI report indicated 4 out of 7 patients reported being uncomfortable because of pain. The QAPI report did not indicate what interventions were done for the patient experiencing pain or what tool was used to measure improvement indicators. The QAPI report indicated the infection rate was 1.82 out of 1,000 care days and the action plan was to educate patients, caregivers, and staff regarding hand hygiene (washing of hands to prevent the spread of germs). The QAPI report did not include data regarding percentage of staff, patients or caregivers that performed hand hygiene.During an interview on 8/30/2025 at 9:58 a.m. with the Administrator (ADM), the ADM stated she was the one responsible for collecting data and the necessity of gathering data and presenting quantifiable results. During an interview on 8/30/2025 at 1:41 p.m. with Director of Patient Care Services (DPCS), DPCS stated she has no data documentation of her audits and analysis of the pain management and that it should have been included in the QAPI report.During an interview on 8/30/25 at 1:43 p.m. with the Director of Patient Care Services (DPCS), DPCS stated patients were interviewed over the phone on how to perform hand washing and there was no documentation that it was done or to monitor. DPCS stated it was important to document and track to be able to improve the outcomes and reinforce patient and caregiver teaching if needed.During a review of the facility’s policies and procedure (P&P) titled, “Improving Organizational Performance”, no date, the P&P indicated the purpose is “To establish a performance improvement framework, which integrates activities to improve organizational performance, improve patient outcomes, improve patient safety, and reduce the risks for acquisition and transmitted of infections…The problem-solving approach will stress the interrelationship of quality services provided, management activities, and sound business practices as applicable to the organization’s activities related to patient care and patient safety focusing on high risk, high volume and problem prone areas, data collection and analysis (measured and documented in a systematic and retrievable way), and identify and set specific outcomes for measurable improvement among palliative care and hospice services”.”

“Based on interview and record review, the Hospice agency (HA, an agency providing care to terminally ill patients) failed to demonstrate a process and provide documented evidence of measuring, analyzing, and tracking of quality indicators (specific, quantifiable metrics that can be tracked over time) that enable the facility to assess processes of care, hospice services (end of life care that provides comfort, support, and medical assistance) and operations for fourteen of fourteen sampled patients. (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 receiving inadequate care, unsafe patient care, and increased risk of medical errors and adverse events that can lead could lead to hospitalizations and death. On 8/30/2025 at 3:49 p.m., while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) for failing to demonstrate a process and provide documented evidence of measuring, analyzing, and tracking of quality indicators, and the agency’s operations for fourteen of fourteen sampled patients. (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14).On 9/2/2025 the agency submitted an IJ removal plan(includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely), reviewed and was accepted. On 9/2/2025 at 5:54 p.m., the accepted written IJ Removal Plan were verified and confirmed onsite of the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present. The IJ Removal Plan dated 9/2/2025 at 12:30 p.m. included the following:1. On 9/2/2025 immediate corrective action included halt and review of quality assessment and performance improvement (QAPI, a data driven approach to continuously improve care and services).b. On 9/2/2025 the Administrator, Director of Patient Care Services (DPCS), and QAPI coordinator held an emergency meeting to address deficiencies. c. On 9/2/2025, removed inaccurate staff from QAPI committee roster (Registered Nurse 1 and Licensed Vocational Nurse 1) and verified with employee acknowledgment.d. On 9/2/2025, an in-service education was given to all staff on QAPI principles, including performance indicators, root cause analysis, and their role on QAPI. 2. On 8/30/2025 and 9/2/2025 new members who were appointed based on clinical roles and availability, signed acceptance and a role understanding.b. Effective 9/2/2025, the QAPI committee membership includes Administrator, DPCS, Medical Director and RN Case Manager. c. Effective 9/2/2025, chart audits conducted by the DPCS and RN Case Manager monthly using a standardized audit tool. Results will be compiled into a quarterly summary report.d. Effective 9/2/2025, incident reports are collected in real time by Administrator and RN Case Manager. Each incident is logged, trended, and presented to the QAPI committee during quarterly meetings. e. Effective 9/2/2025, Patient/Family complaints will be logged by DPCS and Administrator, categorized by type and reviewed monthly. Trends are corrective actions are tracked and reported quarterly. f. Effective 9/2/2025, Infection Control Logs are maintained by DPCS and RN Case Manager and data is aggregated quarterly and reviewed for trends, corrective action and reporting to the QAPI committee. g. Effective 9/2/2025, Standardized Root Cause Analysis (RCA) Protocol is used and includes data validation, staff interviews, chart audit evidence, and identified systemic contributors. h. Effective 9/2/2025, the DPCS is responsible for preparing and submitting quarterly QAPI reports and reports will contain measurable indicators, numerator/denominator calculations, analysis narrative, identified root cause, corrective actions, and follow up tracking column.i. Effective 9/2/2025, the DPCS and Administrator will have meeting sign in sheets and filed in QAPI log and minutes will reflect discussion summaries, data reviewed, actions approved, and assignments made. j. Effective 9/2/2025, the DPCS and Administrator are responsible for QAPI outcomes and lessons learned that include monthly staff meetings, field staff newsletters, and required quarterly QAPI education module. 3. Effective on 9/2/2025, the DPCS and Administrator are responsible for monitoring and tracking effectiveness monthly QAPI documentation audit, performing a quarterly review to verify QAPI adherence and impact on clinical care, and feedback surveys sent to QAPI committee members and randomly selected clinical staff to assess engagement and comprehension. 4. Effective on 9/2/2025, the Administrator is responsible for ensuring overall compliance and enforcement. The DPCS is responsible for overseeing clinical indicators and RCA documentation. The RN Case Manager is responsible for maintaining QAPI log, schedule meetings and collecting audits. The Medical Director is responsible for reviewing clinical indicators relevance and outcomes. Findings:During a review of Patient 1’s Facesheet (Admission Record), the Facesheet indicated Patient1’s Start of Care (SOC) date was 4/23/2025, with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a severe and irreversible damage to the liver caused by long-term excessive alcohol consumption with fluid buildup in the abdominal cavity). During a review of Patient 2’s Facesheet (Admission Record), the Facesheet indicated Patient 2’s SOC date was 2/20/2025, with a primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland, a small walnut-shaped organ located below the bladder in men).During a review of Patient 3’s Facesheet (Admission Record), the Facesheet indicated Patient 3’s SOC date was 2/21/2025, with a primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without causing the heart to pump inefficiently).During a review of Patient 4’s Facesheet (Admission Record), the Facesheet indicated Patient 4’s SOC date was 1/17/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without causing the heart to pump inefficiently heart failure). During a review of Patient 5’s Facesheet (Admission Record), the Facesheet indicated Patient 5’s, SOC date was 8/1/2025, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 6’s Facesheet (Admission Record), the Facesheet indicated Patient 6’s SOC date was 7/22/2025, with a primary diagnosis of heart disease (a range of conditions that affect the heart). During a review of Patient 7’s Facesheet (Admission Record), the Facesheet indicated Patient 7’s SOC date was 7/17/2025, with a primary diagnosis of Alzheimer’s disease (disease characterized by a progressive decline in mental abilities). During a review of Patient 8’s Facesheet (Admission Record), the Facesheet indicated Patient 8’s SOC date was 7/16/2025, with a primary diagnosis of malignant neoplasm of anal canal (a rare type of cancer that occurs in the anal canal, the lower part of the rectum). During a review of Patient 9’s Facesheet (Admission Record), the Facesheet indicated Patient 9’s SOC date was initiated on 7/4/2025, with a primary diagnosis of chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly during the filling phase, leading to reduced blood volume in the heart). During a review of Patient 10’s Face Sheet (admission record) the Face Sheet indicated Patient 10’s SOC date was 6/16/2025 with primary diagnosis of Chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) During a review of Patient 11’s Facesheet (Admission Record), the Facesheet indicated Patient 11’s SOC date was 3/26/2025, with a primary diagnosis of end stage renal disease (irreversible kidney damage). During a review of Patient 12’s Facesheet (Admission Record,) the Facesheet indicated Patient 12’s SOC date was 2/21/2025,a with a primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure [hypertension] damages the heart muscle, leading to an impaired pumping function). During a review of Patient 13’s Facesheet (Admission Record), the Facesheet indicated Patient 13’s SOC date was 8/8/2025,a with a primary diagnosis of cerebral infarction (loss of blood flow to a part of the brain). During a review of Patient 14’s Facesheet (Admission Record), the Facesheet indicated Patient 14’s SOC date was 1/17/2025, with a primary diagnosis of Alzheimer’s disease (disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 8/30/2025 at 9:19 a.m., with the Administrator (ADM), the QAPI dated March 2025 and June 2025, were reviewed. The March 2025 QAPI did not indicate there was a sign in sheet for the QAPI members. The June 2025 QAPI did not indicate there was a sign in sheet for the QAPI members. The ADM stated the QAPI members included the Medical Director (MD), the ADM, the Director of Patient Care Services (DPCS), and a staff nurse. The ADM stated they met quarterly but there was no sign in sheet when the QAPI meeting was conducted quarterly for March 2025 and June 2025. During a concurrent interview and record review on 8/30/2025 at 9:24 a.m., with the ADM, the quarter 1 QAPI, dated 1/1/2025 to 3/31/202, and quarter 2 QAPI, dated 4/1/2025 to7/31/2025, were reviewed. Quarter 1 QAPI indicated the topics discussed were pain, infection control, and fall reduction. Quarter 2 QAPI indicated the topics discussed were pain, infection control, and fall reduction. The ADM stated pain, infection control, and fall reduction were the only topics discussed during their QAPI meetings and that her only source for gathering data was Hospice MD (electronic record). The ADM stated Hospice MD did not include data that shows nurses’ performance, the quality of care the nurses provide, and patients’ issues and or concerns. The ADM stated there is no documentation addressing nurses’ performance, quality of care or patient concerns. During an interview on 8/30/2025 at 9:28 a.m. with the ADM, the ADM stated the QAPI meeting results were communicated to the nurses while they were in office or via a phone call. During an interview on 8/30/2025 at 11:00 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN stated he was not familiar with QAPI and had not attended any meetings. LVN 1 stated he had never been updated on QAPI data results. During an interview on 8/30/2025 at 11:59 a.m. with Registered Nurse 1 (RN 1), RN 1 stated she was not aware of QAPI projects or what the meetings included. RN 1 stated she makes patient home visits and that she was not part of the QAPI committee. During a concurrent interview and record review on 8/30/2025 at 1:41 p.m. with DPCS, the “QAPI-Pain Management,” dated 1/1/2025 and 4/1/2025, were reviewed and it indicated the following:· 13 patients were uncomfortable because of pain· The root cause (an underlying reason to why a problem, event of failure occurred), indicated it was a delayed physician notification for uncontrolled pain and inconsistent reassessment/documentation of pain at follow up visits.· Monthly chart audits (10 random charts) and quarterly trending reports for QAPI committee would be tracked and monitored for pain. The DPCs stated the only source used by the facility’s QAPI for quality indicators were the data collected from Hospice MD as it has become a practice of the facility. The DPCS stated she does not remember how the pain management root cause was obtained, and she has no data documentation of her audits and analysis of the pain management and that it should have been included in the QAPI report. During a concurrent interview and record review on 8/30/2025 at 1:41 p.m. with DPCS, the “QAPI-Infection Control,” dated 1/1/2025 and 4/1/2025, were reviewed and it indicated the following: · Infection remained clustered in wound and respiratory problems.· The root cause was the variation in wound care practices and inconsistent reinforcement of hand hygiene with caregivers.The DPCS stated the root cause for Infection Control was gathered verbally through the nurses which is why they do not have documentation. DPCS stated they did not use quality indicators, but they should have and the QAPI results were discussed with staff that are involved and not the entire Hospice staff. The DPCS stated that it is important for staff to be informed of QAPI results for better patient outcomes and for the staff to understand the QAPI principles. During a review of the facilities policy and procedure (P&P) titled, “Patient Focused Performance Improvement,” no date, the P&P indicated, “As part of the organization-wide performance improvement process, patient outcomes will be identified through continuous measurement of patient satisfaction survey results, clinical/service record review, monitoring of incidents and infection control reports and adverse event outcome reports. The QAPI committee is responsible for evaluating and prioritizing QAPI activities based on the aggregation of analysis of data collected. Under the direction of the QAPI coordinator, the committee issues a quarterly report summarizing QAPI activities and results taken.” During a review of “Quality Assessment and Performance Improvement (QAPI),” no date, the P&P indicated, “A) The hospice QAPI Plan is to provide a strategy for the systemic organization wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services. B) The QAPI plan is operated through a committee structure that ensures that the QAPI program follows regulatory requirements. The QAPI coordinator examines results from ongoing quality control activities to identify trends that will need follow-up action by the QAPI Committee. C) Resources will be made available to employees to assist them in gaining a basic understanding of QAPI principles. In-services will be held periodically to reinforce the knowledge base.””

“Based on interview and record review, the facility failed to ensure their Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) program used quality indicator data to track and monitor patient care, missed home visits and nurse clinical notes, and assess if patients and families are aware of how to file a grievance (formal complaint or concern). This failure had the potential to result in patients not receiving high quality care, having unmanaged symptoms, and experiencing feelings of not having their concerns heard. Findings:During a review of the facility’s Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) for Quarter 1, dated 1/1/2025 to 3/31/2025, the QAPI report did not indicate data for missed home visits, clinical notes and patients filing grievances was collected and tracked. During a review of the facility’s “QAPI Quarter 2”, dated 4/1/2025 to 7/31/2025, the QAPI report did not indicate data for missed home visits, clinical notes and patients filing grievances was collected and tracked.During an interview on 8/30/2025 at 9:58 a.m. with the Administrator (ADM), the ADM stated patient reported nurses were having to reschedule home visits and that she was aware of clinical notes not being documented. Administrator stated there was no documentation or log to show the amount of home visits that were being missed or how often home visits were being missed. ADM stated there was no documentation of how missed clinical notes were being tracked and that data needs to be gathered to show that this issue is being addressed. During an interview on 8/30/2025 at 10:00 a.m. with the ADM, ADM stated Hospice MD (electronic health record) is the only tool used to collect data but Hospice MD does not show patient grievances. ADM stated patient could express their concerns to the visiting nurse and the nurse would then report to the facility but there was no written grievance form that could be provided to the patients and their families. The ADM stated Hospice MD does not show the nurses’ performance or how effectively patient care is provided. The ADM stated meetings are held with the nursing staff and discuss concerns mentioned but there was no sign in sheet to indicate who attends the meetings or documentation indicating the concerns were addressed.During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, no date, the P&P indicated the objectives was “To show measurable improvement in indicators that demonstrate an improvement in patient outcomes…To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, hospice services and operations…To collect data to monitor the effectiveness and safety of services and quality of care as well as to identify opportunities for improvement”.”

“Based on interview and record review, the facility failed to collect and document data to monitor effectiveness for pain management, infection control and quality of care. This failure had the potential to result in increased errors and unsafe practices that can put patients at risk. Findings:During a review of the facility’s “Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) for Quarter 1, dated 1/1/2025 to 3/31/2025, the QAPI report did not indicate data was collected to monitor quality of care, monitor effectiveness for pain management and infection control. During a review of the facility’s “QAPI Quarter 2”, dated 4/1/2025 to 7/31/2025, the QAPI report did not indicate data was collected to monitor quality of care, monitor effectiveness for pain management and infection control. During an interview on 8/30/3035 at 9:24 a.m. with the Administrator (ADM), the ADM stated pain, infection control, and fall reduction were the only topics discussed during their QAPI meetings and that her only source for gathering data was Hospice MD (electronic record). The ADM stated the pain management plan was not done and there was no documentation addressing quality of care.During an interview on 8/30/2025 at 1:41 p.m. with Director of Patient Care Services (DPCS), DPCS stated the only source used by the facility’s QAPI for quality indicators were the data collected from Hospice MD as it has become a practice of the facility. The DPCS stated she has no data documentation of her audits and analysis of the pain management and that it should have been included in the QAPI report.During an interview on 8/30/2025 at 1:41 p.m. with DPCS, DPCS stated patients were interviewed over the phone on how to perform hand washing. DPCS stated it was verbal and there was no documentation that it was done or to monitor. DPCS stated it was important to document and track to be able to improve the outcomes and reinforce patient and caregiver teaching if needed. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, no date, the P&P indicated the objective is “To show measurable improvement in indicators that demonstrate an improvement in patient outcomes…to collect data to monitor the effectiveness of and safety of services and quality of care…””

“Based on interview and record review, the facility failed to track and document adverse patient events.This failure had the potential to result in the hospice agency (HA, an agency providing care to terminally ill patients) not identifying harm such as medication errors or delays and patients experiencing inconsistent or substandard care. Findings:During a review of the facility’s Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) for Quarter 1, dated 1/1/2025 to 3/31/2025, the QAPI report did not indicate data for patient adverse events was collected. During a review of the facility’s “QAPI Quarter 2”, dated 4/1/2025 to 7/31/2025, the QAPI report did not indicate data for patient adverse events was collected. During an interview on 8/30/2025 at 1:41 p.m. with Director of Patient Services (DPCS), DPCS stated that in their QAPI meetings, the only topics discussed are pain management, infections control and falls as this has become their practice. During an interview on 8/30/2025 at 3:34 p.m. with the Administrator (ADM), the ADM stated there was no log or documentation for adverse events. The ADM stated the nursing staff would input any adverse events into Hospice MD (electronic health record) but there was log and no way to track how many adverse events have occurred within the year. During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, no date, the P&P indicated the objective is “To measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care, hospice services and operations”.”

“Based on interview and record review, the facility failed to ensure their Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) program had a process to monitor performance improvement, implementation and success.This failure had the potential for the facility to not meet patients needs and systemic issues can continue without resolution, leading to repeated errors. Findings:During a review of the facility’s Quality Assessment and Performance Improvement (QAPI, a data driven approach to continuously improve care and services) for Quarter 1, dated 1/1/2025 to 3/31/2025, it indicated that monthly chart audits would be used for monitoring for pain management and infection control, an ongoing infection log, and chart audits for fall risk education documentation. During a review of the facility’s “QAPI Quarter 2”, dated 4/1/2025 to 7/31/2025, the QAPI report indicated that monthly chart audits would be used for monitoring for pain management and infection control, an ongoing infection log, and chart audits for fall risk education documentation.During an interview on 8/30/2025 at 9:58 a.m. with the Administrator (ADM), the ADM stated there was a lack of documentation to show data collected or how topics were addressed.During an interview on 8/30/2025 at 1:41 p.m. with Director of Patient Care Services (DPCS), DPCS stated she had no data documentation of her audits and analysis of the pain management and that it should have been included in the QAPI report.During a review of the facility’s policy and procedure (P&P) titled, “Quality Assessment and Performance Improvement (QAPI) Plan”, no date, the P&P indicated the objective is “To conduct Performance Improvement Projects aimed at performance improvement and to track performance to ensure that it is sustained and to document QAPI activities including reasons for Performance Improvement Projects and progress achieved on these projects”.”

“Based on interview and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the HA’s Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) demonstrate and provide evidence of their GB knowledge and involvement in the agency’s Quality Assessment Performance Improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to ensure ongoing care assessments of patient health status and delivery of hospice services to Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14. This failure had the potential to result in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 receiving inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse events that can lead to emergency hospitalization and may contribute to an avoidable traumatic death. On 9/2/2025 at 12:54 p.m., while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, and death of a resident) regarding the failure of the agency to demonstrate and provide evidence of a GB. The survey team notified the Administrator (ADM) of the IJ situation.On 9/2/2025 5:46 p.m. the IJ was removed in the presence of the ADM after the facility submitted an acceptable IJ Removal Plan and the surveyor verified and confirmed onsite the facility’s implementation of the IJ Removal Plan and that the IJ situation was no longer present.The IJ Removal Plan dated 9/2/2025 at 4:23 p.m., included the following:1.On 9/2/2025, an emergency meeting was held by the GB that consisted of the ADM, Director of Patient Care Services (DPCS), Medical Director (MD), and Register Nurse Case Manager (RNCM). The agenda included QAPI findings, risks identified by CDPH, corrective actions, and monitoring plan.2. On 9/2/2025, all clinical and administrative staff were reeducated on the purpose and responsibilities of the GB, QAPI program functions and reporting and documentation requirements.3. Effective 9/2/2025, GB oversight policy was updated. ADM will ensure GB meetings occur and all oversight duties are documented. ADM will also ensure any missed items are corrected within seven (7) days.4. Effective 9/2/2025, GB must meet quarterly (January, April, July, October). Each meeting must include QAPI review, corrective actions, and outcomes. Minutes must include attendance, agenda, action items, and follow-up.5. Effective 9/2/2025, Registered Nurse (RN) 1 was removed from the listed members in the GB roster. Findings: During a review of Patient 1’s Face Sheet (admission record), the Face Sheet indicated Patient 1’s Start of Care (SOC) was 4/23/2025 with primary diagnosis of alcoholic cirrhosis of liver with ascites (a severe and irreversible damage to the liver caused by long-term excessive alcohol consumption with fluid buildup in the abdominal cavity). During a review of Patient 2’s Face Sheet, the Face Sheet indicated Patient 2’s SOC was 2/20/2025 with primary diagnosis of malignant neoplasm of prostate (a cancerous tumor that develops in the prostate gland, a small walnut-shaped organ located below the bladder in men.) During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC was 2/21/2025 with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without causing the heart to pump inefficiently heart failure).During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC was 1/17/2025 with primary diagnosis of hypertensive heart disease without heart failure.During a review of Patient 5’s Face Sheet, the Face Sheet indicated Patient 5’s SOC was 8/1/2025 with primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 6’s Face Sheet, the Face Sheet indicated Patient 6’s SOC was 7/22/2025 with primary diagnosis of heart disease (a range of conditions that affect the heart). During a review of Patient 7’s Face Sheet, the Face Sheet indicated Patient 7’s SOC was 7/17/2025 with primary diagnosis of Alzheimer’s disease.During a review of Patient 8’s Face Sheet, the Face Sheet indicated Patient 8’s SOC was 7/16/2025 with primary diagnosis of malignant neoplasm of anal canal (a rare type of cancer that occurs in the anal canal, the lower part of the rectum). During a review of Patient 9’s Face Sheet, the Face Sheet indicated Patient 9’s SOC was 7/4/2025 with primary diagnosis of chronic diastolic heart failure (a condition where the heart muscle is unable to relax properly during the filling phase [diastole], leading to reduced blood volume in the heart). During a review of Patient 10’s Face Sheet, the Face Sheet indicated Patient 10’s SOC was 6/16/2025 with primary diagnosis of Chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing).During a review of Patient 11’s Face Sheet, the Face Sheet indicated Patient 11’s SOC was 3/26/2025 with primary diagnosis of end stage renal disease (ESRD, an irreversible kidney failure).During a review of Patient 12’s Face Sheet, the Face Sheet indicated Patient 12’s SOC was 2/21/2025 with primary diagnosis of hypertensive heart disease with heart failure (a condition where prolonged high blood pressure [hypertension] damages the heart muscle, leading to impaired pumping function and heart failure). During a review of Patient 13’s Face Sheet, the Face Sheet indicated Patient 13’s SOC was 8/8/2025 with primary diagnosis of cerebral infarction (loss of blood flow to a part of the brain) During a review of Patient 14’s Face Sheet, the Face Sheet indicated Patient 14’s SOC was 1/17/2025 with primary diagnosis of Alzheimer’s disease. During a review of the GB agenda and minutes dated 1/6/2025, the minutes did not have the documented evidence that QAPI report was discussed. The GB agenda included the members listed were: The Administrator (ADM), The Director of Patient Care Services (DPCS), the Medical Director (MD) and Registered Nurse 1 (RN 1) and the attendees for the GB meeting for 1/6/2025 were the ADM and the DPCS. During an interview on 8/30/2025 at 11:59 a.m. with RN 1, RN 1 stated she did not know what a GB was and that she only performed patient house visits and was not involved in GB meetings or discussions. During an interview on 8/30/2025 at 1:11 p.m. with ADM, the ADM stated the GB meets quarterly but there was no documentation regarding GB meeting and minutes since 1/6/2025. The ADM stated the only topic discussed on 1/6/2025 was the budget for the year 2024 and there was no documentation that the facility’s QAPI was discussed. The ADM stated the lack of an effective GB could affect the agency and there was more room for mistakes. During an interview on 8/30/2025 at 1:41 p.m., the DPCS stated the members of the GB were the same as the members of the QAPI (ADM, DPCS, and MD). The DPCS stated the GB would conduct informal meetings and there was no sign-in sheet to show an in-person GB meeting was conducted. The DPCS stated the GB met when there was a need or every six months and she was not able to recall when the last meeting was held. The DPCS stated there were no documented minutes to show when their last meeting was held and that the QAPI was discussed in the GB meetings. The DPCS stated it was important to document what had been discussed in prior meetings to be able to review and resolve issues that were discussed. During a review of the facility’s policy and procedure (P&P) titled “Governing Body”, the P&P indicated, “The Governing Body will assume full legal authority, responsibility, decision-making and accountability for its quality assessment and performance improvement (QAPI) program…The process and documentation will reflect that: A)Relevant findings of performance improvement activities are consistently provided to the Governing Body. B) Other information relevant to the quality of patient care (i.e. unusual occurrences in care delivered) is also consistently provided through a defined process. The Governing Body will comply with the organization’s bylaws in relation to: A) Frequency of meetings. B) Appointment of officers and terms of office. C) Attendance requirements at meetings and quorum determination. All actions taken by the GB will be documented in meeting minutes. Minutes will minimally include attendance records, summaries of agenda items and action taken, and motions documented as stated and acted upon.””

“Based on interview and record review, the facility failed to ensure nurse visit notes were input into Hospice MD (electronic health record) for four of fourteen sampled patients (Patient 1, Patient 5, Patient 6, and Patient 10). This failure had the potential to result in missed, updated patient information such as a change of condition, patient reported symptoms or medication issues which can delay interventions. Findings: During a review of Patient 1’s Facesheet (Admission Record), the Facesheet indicated Patient 1, a 70- year-old male, had a Start of Care (SOC) that was initiated on 4/23/2025, with a primary diagnosis of alcoholic cirrhosis of the liver with ascites (a severe and irreversible damage to the liver caused by long-term excessive alcohol consumption with fluid buildup in the abdominal cavity). During a review of Patient 1’s monthly visit calendar, dated 6/15/2025 to 7/19/2025, the monthly visit calendar did not indicate Patient 1 had scheduled visits from the Licensed Vocational Nurse 1 (LVN 1) once a week.During a review of Patient 1’s Visit Log In Sheet, the Visit Log In Sheet did not indicate the LVN had made home visits for the month of July 2025. During a review of Patient 5’s Facesheet (Admission Record), the Facesheet indicated Patient 5, a 98-year-old male, had a SOC that was initiated on 8/1/2025, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities). During a review of Patient 5’s LVN 1 visit note, dated 8/1/2025, the note did not indicate documentation was done. During a review of Patient 5’s LVN 1 visit note, dated 8/21/2025, the note did not indicate documentation was done. During a review of Patient 6’s Facesheet (Admission Record), the Facesheet indicated Patient 6, an 88-year-old female, had a SOC that was initiated on 7/22/2025, with a primary diagnosis of heart disease (a range of conditions that affect the heart). During a review of Patient 6’s care plan, dated 8/29/2025, the care plan indicated Patient 6 had a Licensed Vocational Nurse (LVN) visit frequence of once per week effective 7/25/2025. During a review of Patient 6’s electronic health record, it indicated there were no visit notes from LVN after 7/25/2025. During a review of Patient 10’s Face Sheet (admission record) the Face Sheet indicated Patient 10, a 71-year-old male, SOC was 6/16/2025 with primary diagnosis of Chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) During a review of Patient 10’s electronic health record, it indicated there were no visit note from LVN after 7/31/2025. During an interview on 8/27/2025 at 3:34 p.m. with LVN 1, LVN 1 stated he did not have a computer to chart his visit notes. LVN 1 stated he was charting his visit notes on a paper format. During an interview on 8/27/2025 at 4:01 p.m. with Office Staff (OS), OS stated the paper charting had been dropped off that day. During an interview on 8/27/2025 at 4:05 with Medical Director (MD), the MD stated patients should be seen once a week by nurses and if they are not seen once a week then patients may develop new symptoms related to their illness. During an interview on 8/28/2025 at 9:29 a.m. with Registered Nurse 3 (RN 3), RN 3 stated it is important for the LVN to make the home visits and make sure the patients’ needs are being met. RN 3 stated it’s unacceptable to not document after a visit and that if there is no documentation then it could be possible the home visit was not done. RN 3 stated it’s important for the nurses to documents in a timely manner to no forget the important findings during a home visit. During an interview on 8/29/2025 at 3:56 p.m. with Director of Patient Care Services (DPCS), DPCS stated the LVN should be documenting their home visit notes within 48 hours after visit, but some nurses are not documenting within the required timeframe. DPCS stated it was important for documentation to be done so that issues or concerns that were identified, the Director of Nursing (DON) and physician can address those issues and concerns. During a review of the facility’s policy and procedure (P&P) titled, “Job Descriptions-Licensed Practical/Vocational Nurse”, dated 2021, the P&P indicated the responsibilities of an LVN is to “Provide accurate and timely documentation of patient services to reflect the plan of care”.”

“Based on interview and record review, the facility failed to ensure that three of fourteen sampled patients (Patient 2, Patient 3, and Patient 4 had the necessary Re-Certification of Terminal Illness (CTI, requirements is the narrative summary, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) completed as part of their medical records. The agency’s Medical Director (MD) did not perform a face-to-face encounter (an in person visit by a hospice physician with a patient before the third and subsequent Medicare benefit periods to confirm continued eligibility for hospice care and a life expectancy of six months or less) prior to signing the CTI no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care.This failure resulted in Patient 2, Patient 3, and Patient 4 not having complete clinical records that could potentially not meeting the recertification of terminal illness eligibility requirement and identify the patients’ current health conditions and affect the care and services of Patient 2, Patient 3, and Patient 4 received that could lead to hospitalization and death.On 8/29/2025 at 1:23 p.m., the California Department of Public Health (CDPH) called an Immediate Jeopardy (IJ, a situation in which the provider’s noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a patient), in the presence of the agency’s Administrator (ADM), for failure to ensure the MD conducted a face to face encounter for Patient 2, Patient 3, and Patient 4 prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification of terminal illness eligibility requirement and identify the patients’ current health conditions. On 9/2/2025 the HA submitted an IJ removal plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation), and the team reviewed and accepted.The IJ Removal Plan dated 8/29/2025 at 5 p.m., included the following:1. On 8/29/2025 and 8/30/205, the MD conducted in-person face-to-face visits with Patient 2, Patient 3, and Patient 4, the patients identified in the IJ findings. During each visit, the MD performed a direct physical assessment, reviewed symptoms, verified clinical findings, and confirmed ongoing hospice eligibility.2. Effective 8/29/2025, the MD will conduct all face-to-face recertification encounters within 30 days prior to the start of the 3rd and subsequent benefit periods and prior to signing any CTI. No CTI will be signed without direct patient assessment by MD in the EMR.3. The Electronic Health Record (EHR) tracking system now generates an alert 30 days in advance of each patient’s recertification period. The DPCS is responsible for monitoring the alerts, notifying the Medical Director, and confirming completion of the face-to-face visit before the CTI is signed.4. On 8/29/2025, the Director of Patient Care Services (DPCS) provided written and verbal instruction to all staff regarding the CMS and CDPH requirements for face-to-face recertifications. Staff were informed that failure to follow this requirement results in noncompliance and potential harm to patients.5. All completed face-to-face visits will be entered into the EHR on the same day of the encounter, with date, time, and physician signature. Compliance with this standard will be verified daily by the DPCS until sustained adherence is demonstrated.6. The agency’s policy “Certification of Terminal Illness” was reviewed during the inservice provided on 9/2/2025. The policy will clearly state that a face-to-face encounter must be completed by the MD within 30 days prior to the start of the 3rd and subsequent benefit periods.7. On 9/2/2025, a mandatory training was conducted for all clinical staff and physicians, covering facility’s policy and procedure (P&P) titled, “Certification of Terminal Illness.” Attendance will be tracked, and staff who miss the session will be required to complete make-up training within 7 days.8. Beginning 9/2/2025, the Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) Committee will review 100% of recertifications for the next 90 days to ensure compliance. Ongoing monthly audits of 10% of all recertifications will continue after the 90-day corrective action period.9. The Medical Director has signed an attestation of responsibility to ensure timely completion of face-to-face encounters.10. A tracking and alert system has been implemented in the EHR to notify the DPCS and MD 30 days in advance of each patient’s recertification period. The DPCS will monitor adherence monthly and report findings to leadership and Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities).On 9/2/2025 at 4:32 p.m., while onsite, the survey team verified the implementation of the accepted IJ removal plan. The IJ was removed in the presence of the Administrator. Findings:During a review of Patient 2’s Face Sheet (admission record), the Face Sheet indicated Patient 2’s Start of Care (SOC) date was 2/20/2025, with primary diagnosis of malignant neoplasm of prostate (a cancerous growth of cells that develops in the prostate gland, [a small organ located below the bladder in men]). During a review of Patient 2’s Physician’s Certification for Hospice Benefit, dated 8/19/2025, the Physician’s Certification for Hospice Benefit (a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician), indicated the MD signed an attestation on 8/19/2025 that stated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”During an interview on 8/26/2025 at 3:15 p.m. with Patient 2’s caregiver (PCG 2), PCG 2 stated the MD has not seen or visited Patient 2 since the start of care, 2/20/2025.During a review of Patient 3’s Face Sheet, the Face Sheet indicated Patient 3’s SOC date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During a review of Patient 3’s Physician’s Certification for Hospice Benefit, dated 8/20/2025, the Physician’s Certification for Hospice Benefit indicated the MD signed an attestation on 8/20/2025 that stated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”During an interview on 8/26/2025 at 1:20 p.m. with Patient 3’s caregiver (PCG 3), PCG 3 stated the MD has not seen or visited Patient 3 since the start of care, 2/21/2025. During a review of Patient 4’s Face Sheet, the Face Sheet indicated Patient 4’s SOC date was 1/17/2025, with primary diagnosis of hypertensive heart disease without heart failure.During a review of Patient 4’s Physician’s Certification for Hospice Benefit, dated 7/16/2025, the Physician’s Certification for Hospice Benefit indicated the MD signed an attestation on 7/16/2025 that stated, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”During an interview on 8/27/2025 at 3:44 p.m., with Registered Nurse (RN) 2, RN 2 stated the MD does not always answer his (MD) phone call when visiting RN (in general) conduct a home visit with a patient (in general) for an upcoming recertification period. RN 2 stated if the MD would not answer his phone call, RN 2 would call the MD after a home visit (in general) to tell him (MD) of the assessment.During an interview on 8/27/2025 at 6 p.m., with the MD, the MD stated the hospice agency’s office staff would notify him (MD) of the coming certification period and would arrange a phone call between the visiting Registered Nurse (RN) and him (MD). The MD stated the visiting RN would complete their own assessment and would call him (MD) while onsite with the patient (in general). The MD stated he (MD) would get updates from the visiting RN regarding the patient (in general) and will determine if the patients (in general) eligible for hospice care and services based on their (visiting RN) assessment.During a concurrent interview and record review on 8/27/2025 at 6:07 p.m., with the MD, Patient 2’s CTI dated 8/19/2025 and Patient 3’s CTI dated 8/20/2025 were reviewed. Patient 2’s and Patient 3’s CTIs indicated the certifications were based on face-to-face encounters by having check marks on the “Face-to-Face Encounter” boxes. The MD stated he (MD) has not conducted Patient 2’s face-to-face assessment for recertification period #3 (8/19/2025 to 10/17/2025). The MD stated he (MD) has not conducted Patient 3’s face-to-face assessment for recertification #11 (8/20/2025 to 10/18/2025). The MD stated he (MD) signed Patient 2’s and Patient 3’s CTIs and planned to conduct his face-to-face assessments at a later date. The MD stated he (MD) has 30 days after the third recertification period to conduct a face-to-face assessment for hospice patients.During a concurrent interview and record review on 8/29/2025 at 8:35 a.m., with the MD, Patient 4’s CTI dated 7/16/2025 was reviewed. Patient 4’s CTI indicated the certification was based on a face-to-face encounter by having a check mark on the “Face-to-Face Encounter” box. The MD stated he (MD) has not conducted Patient 4’s face-to-face assessment for recertification period #3 (7/19/2025 to 9/13/2025). The MD stated he has not seen Patient 4 in person.The MD stated the importance of conducting a face-to-face assessment with patients (in general) to establish their hospice eligibility by checking to see if their reported symptoms are real and ensure documentation of RN assessments were accurate. During an interview on 8/29/2025 at 8:42 a.m. with RN 1, RN 1 stated she (RN 1) would only contact the MD when needed and when conducting a home visit with a patient (in general) for an upcoming recertification period. RN 1 stated she (RN 1) primarily reports to the Director of Patient Care Services (DPCS) with her (RN 1) assessments and findings. During a review of the hospice agency’s policy and procedure (P&P) titled, “Certification of Terminal Illness,” revised 11/2021, the P&P indicated “...A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period...””

“Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled patients (Patient 3) had a physician’s order for albuterol (a medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, and coughing) when Patient 3’s caregiver (PCG 3) administered it to Patient 3 without an order from the Medical Director (MD).This failure resulted in incomplete clinical records. Findings:During a review of Patient 3’s Face Sheet (admission record), the Face Sheet indicated Patient 3’s Start of Care (SOC) date was 2/21/2025, with primary diagnosis of hypertensive heart disease without heart failure (a condition where prolonged high blood pressure damages the heart without affecting its ability to pump blood).During an interview on 8/26/2025 at 1:15 p.m. with Patient 3’s Caregiver (PCG 3), PCG 3 stated he administered albuterol to Patient 3 with a nebulizer (a machine that delivers a fine, steady mist of medicine through a mouthpiece or mask) when Patient 3 had shortness of breath.During an interview on 8/27/2025 at 6:07 p.m. with the MD, the MD stated patients should only take physician-ordered medications that are listed in the Current Treatment/Medication/DME List. The MD stated Patient 3 could experience adverse side effects from taking albuterol without a physician order.During a review of Patient 3’s “Current Treatment/Medication/Durable Medical Equipment (DME) List”, the Current Treatment/Medication/DME List did not indicate an order for a nebulizer.During a review of the facility’s P&P titled, “Medication Profile,” revised 11/2021, the P&P indicated, “Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.”

“Based on interview and record review the facility failed to ensure that the signed consent form was authenticated by the correct Registered Nurse (RN) who conducted the admission for Patient 5. This failure has the potential risk for inaccuracy of patient records and affecting patient care. During a review of Patient 5’s Consent form Dated 8/1/2025, the date “1” has been altered. Consent form signed by RN 4.During a concurrent interview and record review on 8/28/2025 at 9:23 a.m. with RN 3, Patient 5’s consent form, dated 8/1/2025 was reviewed. The consent indicated, RN 4 was present when Patient 5 signed consent and the date had been altered. RN 3 stated, she was the RN that was present when PCG 5’s caregiver signed the consent. During an interview on 8/28/2025 at 10:47 a.m. with RN 3, RN 3 stated she did not remember doing the admission for Patient 5 on 8/1/2025 and the last time she saw Patient 5 was earlier this year. During an interview on 8/28/2025 at 11:00 a.m. with Administrator (ADM), ADM stated that RN 4 was supposed to admit Patient 5 but RN 3 end it up going since she lived closer to Patient 5. ADM stated that it is unacceptable to alter consent forms because its against the law.During an interview on 8/28/2025 at 11:40 a.m. with Office Staff (OS), OS stated that she was the one to have altered the date on the consent form and handed to surveyors. OS stated it was a mistake on their part.During a review of the facility’s Policy and Procedure (P&P) titled, “Contents of Clinical Record” revised 11/2021, P& P indicated, A clinical record will be maintained for each patient receiving care… The following information will be available in the clinical record as applicable to care and services provided: Consent and authorization formsDuring a review of the facility’s P&P titled, “Safeguarding/Retrival of Clinical/Service Record,” revised 11/2021, the P&P indicated, The organization will safeguard the clinical/service record against loss, destruction, tampering, or unauthorized use through the development of processes, policies and procedures. The clinical/service record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements.During a review of the facility’s P&P titled, “Clinical Record Review,” revised 11/2021, P& P indicated, Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered is reliable, timely, valid, and accurate.”