Cherry Blossom Hospice

“Based on observation, interview, and record review, the agency failed to ensure patients’ rights were protected when the state’s free home health hotline, its contact information, hours of operation and its purpose to receive complaints were not provided to two of four sampled patients (Patients 1 and 2). This failure had the potential to limit Patients 1 and 2’s ability to lodge a complaint, which could have resulted in the agency continuing to provide substandard care. Findings:1.A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of March 19, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of March 14, 2026, to May 12, 2026. Further review indicated Patient 1 had primary diagnoses that included chronic obstructive pulmonary disease (acute) with exacerbation (a sudden, severe flare-up of a long-term lung disease that makes it extremely hard for a person to breathe) and hypertensive heart diseases without heart failure (a condition when blood pressure is high for a long time and heart has to work harder than normal, but it still manages to pump enough blood around the body).During an interview on May 5, 2026, at 11:45 AM, with Patient 1’s son, Patient 1’s son confirmed he had signed consent upon admission. He stated that he received Patient 1’s home clinical record, but he was not informed that it included the state’s free home health hotline. He further stated he did not know he has the right to file a complaint with the state. 2.A review of Patient 2’s face sheet indicated a start of care date of October 23, 2025, with a certification period of March 22, 2026, to May 20, 2026. Further review indicated Patient 2 had primary diagnoses that included chronic pain syndrome (long term pain) and hypertension (high blood pressure).During an interview on May 5, 2026, at 11:45 AM with Patient 2’s sister, Patient 2’s sister confirmed consent was signed upon admission . She stated that he received Patient 2’s home clinical record, but she was not informed that it included the state’s free home health hotline. She further stated she did not know she has the right to file a complaint with the state.During an interview on May 6, 2026, at 11:45 AM, with the Director of Patient Care Services/Administrator (DPCS/Admin), the DPCS/Admin stated upon admission, the admitting nurse should have explained to the patients and their families that the home clinical record folder, left in the patient’s home, included the hotline information. The DPCS/Admin further stated, “I do not know why it is not.”During a concurrent interview and record review on May 6, 2026, at 1:10 PM, with the DPCS/Admin, the agency’s undated policy and procedure (P&P) titled, “Patient/Family Bill of Right” was reviewed. The P&P indicated,” Each hospice patient/family shall be assured of quality care about participating in the hospice program. Care is offered to any person regardless of age, sex handicap, diagnosis, color, race, religion, national origin, or sexual orientation. The Right and responsibly of both hospice and patient/family are as follows: As patient you have the right to: • Documentation of receipt and understanding of information is placed in the patient record. This is done prior to care/treatment being provided. This evidence is provided by obtaining signatures of the patient and/or family. • To be fully informed prior to or at the time of admission …. • I have read the following Patient/Family Bill of Rights. I further understand that if a problem arises regarding the services of hospice care I should notify the Director of Patient Services Or to lodge a complaint with the State of California Home Health “Hotline.” The telephone number and hours of operation to receive complaints and answer questions each day, are 7 days per week, 8:30 am to 6:00 pm. The address and numbers are San Bernardino District Office Department of Health Services. 464 W 4th Street, Suite 529. San Bernardino, CA 92401. 1(909) 383-4777…”. The DPCS/Admin stated the agency did not follow the P&P.During a concurrent interview and record review on May 6, 2026, at 1:20 PM, with the DPCS/Admin, the agency’s P&P titled, “Rights and Responsibilities” revised April 2016, was reviewed. The P&P indicated,” … P. The right to voice a complaint/concern (grievance) regarding care or service without fear of reprisal for exercising this right. (See “Complaint/Grievance Process” Policy No. 1-010.) The availability of other sources to receive questions and complaints and assist in resolution.… ” The DPCS/Admin stated the agency did not follow the P&P.”

“Based on observation, interview, and record review, the agency failed to ensure the plan of care for two of two sampled patients (Patients 1 and 2) reviewed for medication management included drugs and treatments necessary to meet their needs when Patients 1 and 2’s Medication Profile (MP) did not accurately reflect the patients’ current medication regimen.This failure had the potential to result in medication errors (any preventable mistake that causes, or could cause, harm when taking medicine), omitted medications, and ineffective symptom management placing Patients 1 and 2’s health and safety at risk. Findings: 1.A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of March 19, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of March 14, 2026, to May 12, 2026. Further review indicated Patient 1 had primary diagnoses that included chronic obstructive pulmonary disease (acute) with exacerbation (a sudden, severe flare-up of a long-term lung disease that makes it extremely hard for a person to breathe) and hypertensive heart diseases without heart failure (a condition when blood pressure is high for a long time and heart has to work harder than normal, but it still manages to pump enough blood around the body).During a home visit on May 5, 2026, at 10:30 AM, with a Licensed Vocational Nurse (LVN), in the presence of Patient 1 and Patient 1’s son, Patient 1’s home medications were compared with Patient 1’s most current MP. During a concurrent observation and interview on May 5, 2026, at 10:35 AM, with LVN, LVN reviewed Patient 1’s MP, which indicated Patient 1 had an order for nitroglycerin tablet. (a prescription medication used to treat or prevent chest pain by relaxing and widening blood vessels to improve blood flow to the heart) 0.4 mg (milligrams, a unit of measure) one tablet sublingual (placing medication under the tongue to dissolve) as needed for chest pain and albuterol sulfate inhalation (a prescription medication used to relax airway muscles and improve breathing for conditions such as wheezing or shortness of breath) inhalation (administration of medication via the respiratory tract, allowing it to enter directly into the lungs). LVN verified that neither medication was available for Patient 1’s use.During an interview on May 5, 2026, at 10:40 AM, with Patient’s 1 son, Patient 1’s son stated Patient 1 had not been taking nitroglycerin tablet and albuterol sulfate inhalation for more than three months.During a follow up interview on May 5, 2026, at 10:45 AM, with LVN, LVN stated, “The printed MP should have been updated.”2. A review of Patient 2’s face sheet indicated a start of care date of October 23, 2025, with a certification period of March 22, 2026, to May 20, 2026. Further review indicated Patient 2 had primary diagnoses that included chronic pain syndrome (long term pain) and hypertension (high blood pressure).During a home visit on May 5, 2026, at 11:30 AM, with LVN and MSW (Medical Social Worker), in the presence of Patient 2 and Patient 2’s sister, Patient 2’s home medications were compared with Patient 2’s most current MP. During a concurrent observation and interview on May 5, 2026, at 11:35 AM, with LVN, LVN inspected Patient 2’s home medications, which included a bottle of amlodipine besylate (a prescription medication used to treat high blood pressure and chest pain by relaxing blood vessels and improving blood flow) 5 mg one tablet by mouth daily. LVN reviewed Patient 2’s MP and verified Amlodipine besylate was not listed in Patient 2’s MP.During an interview on May 5, 2026, at 11:40 AM, with Patient 2’s sister, Patient 2’s sister stated Patient 2 had been taking amlodipine besylate since February 2026, (3 months ago), and his doctor was aware of it.During an interview on May 5, 2026, at 11:45 AM, with LVN, LVN stated, “The printed MP should have been updated.”During an interview on May 6, 2026, at 11:00 AM, with Director of Patient Care Services/Administrator (DPCS/Admin), DPCS/Admin stated, “It was the Case Manager’s responsibility to update MP when there’s any new order or changes. Nurses should have been reviewing and updating MP on their visits.”A review of agency’s policy and procedure (P&P) titled, “Plan of Care,” which indicated, “ PURPOSE. To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY. A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program… Procedure…12. The written plan of care will contain, but will not be limited to, the following:… T. Drug and treatment… 14. Care provided to the patient will be accordance with the plan of care.”During a concurrent interview and record review on May 5, 2026, at 2:00 PM, the DPCS/Admin reviewed the agency’s P&P titled, “Medication Profile,” revised 2013, which indicated, “PURPOSE To define the use of the medication profile in evaluating a patient’s current medication regimen. POLICY Patients receiving medications administered by hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. PROCEDURE… 2. The admitting nurse will initiate a medication profile to document the current medication regiment… 5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. …”. The DPCS/Admin stated the agency did not follow their P&P.”

“Based on observation, interview, and record review, the agency failed to follow its policy and procedure (P&P) to develop and maintain a system of communication and integration for one out of two sampled patients (Patient 1), when Patient 1’s home clinical record did not contain their current Plan of Care (POC is a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their comfort and care). This failure had the potential to result in ineffective care coordination, unmanaged symptoms, which could place Patient 1’s safety, comfort, and overall well-being at serious risk in his end-of-life care. Findings: A review of Patient 1’s face sheet (document that gives a summary of patient’s information) indicated a start of care date of March 19, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) of March 14, 2026, to May 12, 2026. Further review indicated Patient 1 had primary diagnoses that included chronic obstructive pulmonary disease (acute) with exacerbation (a sudden, severe flare-up of a long-term lung disease that makes it extremely hard for a person to breathe) and hypertensive heart diseases without heart failure (a condition when blood pressure is high for a long time and heart has to work harder than normal, but it still manages to pump enough blood around the body).During a home visit on May 5, 2026, at 10:30 AM, with License Vocational Nurse (LVN), in the presence of Patient 1 and Patient 1’s son, a review of Patient 1’s home clinical record binder and the surrounding area was conducted. Patient 1’s current POC were not found in the binder or anywhere in the house. Both LVN and Patient 1‘s son confirmed that these essential documents were not available.During an interview on May 7, 2026, at 10:45 AM, with the Director of Patient Care Service/Administrator (DPCS/Admin), the DPCS/Admin stated, “It is the responsibility of the visiting nurse and case manager to ensure that the current POC and other essential documents are left at the patient’s location and are easily accessible.” Furthermore, the DPCS/Admin stated the current POC was crucial for maintaining effective care coordination, proper medication management, timely clinical responses and to facilitate continuity of care.During a concurrent interview and record review on May 7, 2026, at 11:00 AM, with the DPCS/Admin, the DPCS/Admin reviewed the agency’s policy and procedure (P&P) titled, “Contents of the Clinical Records,” revised April 2020, which indicated, “PURPOSE. To outline the requirements for and components of a clinical record. POLICY. A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe patient problems/needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. PROCEDURE: … M. Record and findings of initial, comprehensive and updated comprehensive assessments. N. Every dose of medication administered by organization personnel, patient response and any adverse drug reaction…. S. Care planning activity (initial and updated POCs) based on the patient’s problem and needs …”. The DPCS/Admin stated the agency did not follow the P&P.”