Optima Care Hospice

“Based on observation, interview and record review the HA failed to ensure the comprehensive assessment included the revision of the patient’s medication profile to reflect the current medication regimen including the dosage of the medication administered or taken for one of fourteen sampled patients (Patient 9). This failure had the potential to put the patient at risk for medication errors and adverse drug reactions. During a review of Patient 9’s Personal Information sheet (face sheet, admission record), the Personal Information sheet indicated a Start of Care (SOC) date of 10/24/2025, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 9’s Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/7/2025 for certification #1 indicated an order for Skilled Nurse visits 1 time a week plus 2 as needed visits for change in condition for clinical care, pain and symptom management and provide comfort measures, and Home aide (HA) visit 3 times a week plus 1 as needed visit for personal care, home making, hygiene and to promote comfort per Registered Nurse’s assignment sheet instructions.During a review of Patient 9’s current treatment/ medication/ durable medical equipment (DME) List, undated, the list indicated an order for medication Guaifenesin (medication for the cough) 100 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) / 5 milliliters (ml- metric unit of measurement, used for medication dosage and/or amount) solution, to take 20 ml’s orally every 4 to 6 hours as needed for cough/congestion.During a joint home visit on 11/19/2025 at 11:04 a.m., with Licensed Vocational Nurse 1 (LVN1) at Patient 9’s residence at a board and care, Patient 9’s medications were reviewed. During a reconciliation (review) of Patient 9’s medication bottles, it was noted that the bottle for the medication Guaifenesin indicated on the front label to take 10 ml orally every 6 hours as needed for cough and congestion. During a review of Patient 9’s medication list, the order for the medication Guaifenesin indicated to take 20 ml orally every 4 to 6 hours as needed for cough and congestion. LVN1 stated and confirmed that the dosage for the medication Guaifenesin on the bottle did not match the dosage on the medication list. LVN1 stated that the Director of Patient Care Services (DPCS) had received the order for medication and typed it into the system. LVN1 placed a call to the DPCS to clarify the order. LVN1 stated the DPCS clarified the order and the correct dosage ordered for Guaifenesin was 10 ml, what read on the medication bottle, and not 20 ml, and that the DPCS had made a typo. LVN1 stated that she reviews the patient’s medications during every home visit, and she had missed the difference in dosage on the bottle and list.During a concurrent interview and record review on 11/20/2025 at 2 p.m. with the DPCS stated, Patient 9’s medication list was reviewed. The DPCS stated and confirmed that Patient 9’s medication list indicated an order for Guaifenesin 100 milligrams / 5 milliliters solution, to take 20 ml’s orally every 4 to 6 hours as needed for cough/congestion. The DPCS stated she had received the order from the doctor and input the order into the system. The DPCS stated she typed in the incorrect dosage of 20 ml’s on the medication list, and that the correct dose ordered by the doctor was 10 ml’s which was the dosage that was indicated on the bottle. The DPCS stated she does monthly audits for the patient’s chart and missed that mistake. The DPCS stated medication review should be done at every home visit by the visiting nurses and as well as when the Registered Nurse (RN) visits every two weeks for supervisory visits. The DPCS stated it is important to verify all medication orders before in putting them on the medication list and sending it to the pharmacy, especially the dosage, because the patient might receive a dosage too high or too often that can cause bad side effects like overdose.During a review of the HA’s Policy and Procedure (P&P) titled Medication Profile, revised on May 2024, the P&P indicated that a drug regimen will be performed at the time of the initial and comprehensive assessment. The P&P also indicated that during subsequent hospice visits the medication profile will be used as a teaching guide by the nurse to ensure the patient and family/caregiver understand the medication, dosage, purpose of use, frequency of use, side effects and also evaluate how the medication is being used in the home.”

“Based on interview and record review the HA failed to complete and submit an initial bereavement assessment, to provide bereavement counseling in accordance with the patient/family’s needs, within five days of Start of Care (SOC) for one of 14 sampled patients (Patient 2).This failure had the potential for the Patient 2’s family bereavement (grief and mourning after death) needs to be unmet and result in emotional distress. Findings:During a review of Patient 2’s admission record indicated the hospice agency (HA) admitted Patient 2 with the start of care (SOC) date of 9/5/2025. The primary diagnosis included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and secondary diagnoses, including but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty swallowing).During an interview of 11/20/2025 at 1:25 pm., with the Director of Patient Care Services (DPCS). The DPCS stated the bereavement assessment should be completed within five days from the SOC and should be completed by the Bereavement Coordinator (SC), which is also the HA’s chaplain and spiritual counselor. The DPCS stated it was important to assess patient and family’s bereavement to determine if they need more spiritual and bereavement support, and if not completed patient and/or family may become depressed.During a concurrent interview and record review on 11/20/2025 at 1:41 pm., with the DPCS of Patient 2’s “POC/IDG” (Plan of Care/Interdisciplinary Group (the team responsible for the holistic care of the hospice beneficiary)), dated 9/5/2025 stated the admission orders and frequency visit indicated “Bereavement Coordinator to assess and evaluate bereavement and grieving risk factors within 5 days of Admission”.During a concurrent interview and record review on 11/20/2025 at 1:50 pm., with the DPCS of Patient 2’s “History of Bereavement Assessment”, for the certification period of 9/5/2025 to 10/12/2025, stated there was no documentation that the initial bereavement assessment was completed.During an interview on 10/21/2025 at 11:57 a., with SC stated part of his responsibility was to complete the initial bereavement assessment for patients and family within five days of the start of care and complete a plan of care for bereavement. SC stated he must have not completed the bereavement assessment for Patient 2 for the certification period of 9/5/2025 to 10/12/2025. SC stated the bereavement assessment identifies the risk for spiritual and emotional preparedness of the patient and family when it comes to impending loss of your loved one. SC stated patient and family members may experience emotional distress and/or loneliness when bereavement concerns were not addressed.During a review of HA’s policies and procedure (P&P) titled “Comprehensive Assessment”, dated May 2024. The P&P indicated, but not limited to, the following:- “A comprehensive assessment will be performed by the hospice IDG no later than five calendar days after the election of hospice care.”- “During the comprehensive patient assessment, all baseline date … including at least the following:X. A bereavement assessment of the needs of the patient’s family and other individuals focusing on:1. The nature of the relationship to the patient2. Circumstances surrounding the illness/prognosis3. Behaviors prior to and after the illness/prognosis4. Survivor needs (social, spiritual and cultural) that may impact coping skills5. Potential for pathological grief reactions”During a review of HA’s policies and procedure (P&P) titled “Bereavement Assessment”, dated May 2024. The P&P indicated, but not limited to, the following:- “On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator”- “The Bereavement Coordinator will review the bereavement to determine potential needs of the survivor.””

“Based on interview and record review, the HA failed to reassess the patient and family/caregiver spiritual, emotional and religious needs at every recertification by the bereavement counselor as ordered, for one of fourteen sampled patients (Patient 11).This failure had the potential to provide the patient and/or family/caregiver with the proper guidance and support needed to cope with the patient’s condition and death. During a review of Patient 11’s Personal Information (face sheet, admission record), the Personal Information sheet indicated a Start of Care (SOC) date of 11/4/2024, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 9’s Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated 11/7/2025 for certification #6 indicated an order for Skilled Nurse visits 2 times a week and 2 as needed visits for assessment and to provide comfort measures and symptom control management, Home aide (HA) visit 2 times a week and 1 as needed visit to assist with personal care, home making and to promote comfort per Registered Nurse (RN) assignment, Medical Social Worker (MSW) visit once per month and 1 as needed visit for psychosocial, emotional and counseling needs, Bereavement Coordinator (BC) visit 1 per certification period, and Spiritual Counselor (SC) visit once per month and 1 as needed visit for spiritual, emotional counseling and support needs.During a review of Patient 11’s Electronic Medical Record (EMR), Patient 11’s EMR indicated that the BC did not submit or complete notes or bereavement assessments during every recertification period, as specified in the POC/IDG Review dated 11/7/2025.During an interview on 11/21/2025 at 11:56 a.m., with the Chaplain, the Chaplain stated his responsibilities include Bereavement Coordinator and Spiritual Counselor. The Chaplain stated that within 5 days of admission, he is to contact and visit the patient to complete a spiritual assessment and initial bereavement assessment. The Chaplin stated that a bereavement assessment can also be completed at every recertification if ordered by the physician to reassess the patient and/or family/caregiver’s level of bereavement and assess their coping needs. The Chaplain stated if a patient does have an order for the Bereavement Coordinator to assess the patient at every recertification period, then it is his responsibility to complete that and document his assessment in the patients EMR. The Chaplain stated if his assessment is not in the EMR under the section Bereavement for each recertification period then he did not do it.During a concurrent interview and record review on 11/21/2025 at 12:56 p.m., with the Director of Patient Care Services (DPCS), Patient 11’s IDG/POC Review dated November 7, 2025, was reviewed. Patient 11’s POC/IDG Review indicated an order for the BC to visit 1 per certification period. The DPCS stated that a physician order in the POC/IDG Review should be followed, especially frequency of visits because it is what the patient needs. The DPCS stated and confirmed that the order for the BC to visit once a certification period was not followed as Patient 11’s EMR does not indicate documentation of the assessment to validate the visit was completed. The DPCS stated the Chaplain is the Bereavement Coordinator and it was his responsibility to visit the patient every certification period and document the visit. The DPCS stated and confirmed that Patient 11’s POC/IDG was not followed by the Chaplain to visit the patient once a certification period, as ordered by the physician.During a concurrent interview and record review on 11/21/2025 at 1 p.m., with the DPCS, Patient 11’s EMR was reviewed. The DPCS stated and confirmed that Patient 11’s EMR did not indicate documented evidence of a completed bereavement assessment for every certification period, was submitted by the Chaplain. The DPCS stated the documentation should be found under the Bereavement section and not in a note, but that Patient 11’s EMR had a note or assessment documented. The DPCS stated it was important that the Chaplain follow the order of doing a bereavement assessment for Patient 11 during every certification period because that patient was not coping well with her diagnosis and had verbalized to the nurse that she was scared of dying and required more assistance with her coping needs and assessing what other services the patient might need to also assist her with her spiritual needs. The DPCS stated that was the responsibility of the Chaplain, who is the HA’s Bereavement Coordinator and Spiritual Counselor. During a review of the HA’s Policy and Procedure (P&P) titled Bereavement Assessment, revised on May 2024, the P&P indicated that the Bereavement Coordinator will reassess the bereavement needs during each contact and all bereavement documentation will be submitted for filing in the patient’s permanent clinical record.During a review of the HA’s P&P titled Bereavement Services, revised May 2024, the P&P indicated that the program would provide bereavement services to the family/caregivers of the hospice patients before and after the patient’s death, in accordance with the plan of care. The P&P also indicated that depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact and/or provide supportive counseling to the patient and family/caregiver prior to the patient’s death, to facilitate a normal grieving process and identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses.”

“Based on interview and record review the HA failed to ensure a social worker and a spiritual counselor attended their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) to meet the psychosocial, emotional, and spiritual needs for one of 14 sampled patients (Patient 13). This failure had the potential to result in Patient 13 and/or family/caregiver not being provided with the care and services required and needed during the patient’s end-of-life process. During a review of Patient 13’s Personal Information sheet (face sheet, admission record), the Personal Information sheet indicated a Start of Care (SOC) date of 1/10/2025 with a primary diagnosis of Leukemia (cancer of the blood forming tissues, such as bone marrow [soft, fatty substance in the bones in which blood cells are produced] that causes overproduction of abnormal white blood cells), and an End of Care (EOC) date of 11/3/2025.During a concurrent interview and record review on 11/20/2025 at 1:39 p.m., with the Director of Patient Care Services (DPCS), Patient 13’ s EMR section for Interdisciplinary Group (IDG) was reviewed. Patient 13’s EMR section for IDG indicated the following:POC/IDG Review dated 9/12/2025 with electronic signatures from the Medical Director (MD), the DPCS, the Medical Social Worker 2 (MSW2), and no signature from the Spiritual Counselor (SC).POC/IDG Review dated 9/26/2025 with electronic signatures from the MD, the DPCS, the MSW2, and no signature from the SC.POC/IDG Review dated 10/10/2025 with electronic signatures from the MD, the DPCS, the MSW2, and no signature from the SC.POC/IDG Review dated 10/24/2025 with electronic signatures from the MD, the DPCS, and no signatures from the SC and the MSW2.POC/IDG Review dated 11/7/2025 with electronic signatures from the MD, the DPCS, and no signatures from the SC and the MSW2.The DPCS stated the HA IDG members are the MD, the DPCS, the SC and the MSW. The DPCS stated the IDG meetings are every other Friday either in person or via zoom call. The DPCS stated all IDG members must be part of every IDG meeting and the staff members that are optional to join are the licensed nurses. The DPCS stated and confirmed that Patient 13’s POC/IDG Review dated 9/12/2025, 9/26/2025, 10/10/2025, 10/24/2025, and 11/7/2025 did not have documented evidence of the SC’s signature, and the POC/IDG Reviews dated 10/24/2025 and 11/7/2025 also did not have documented evidence of the MSW’s signature. The DPCS stated there was no sign-in sheet for IDG meetings other than each IDG member documenting their portion on the POC/IDG Review and electronically signing it. The DPCS stated the IDG members must complete and sign the POC/IDG Review right away after the meeting was completed within 24 hours. The DPCS stated the MSW2 assigned to Patient 13 was a second social worker the agency contracted to assist with patient visits in orange county, but when she left, she did not submit all her work. The DPCS stated the importance of having all IDG members present at every patient meeting is if there is an issue occurring with the patient then all disciplines can be aware of it and discuss how each can help the patient identify what they need and include the family as well. The DPCS stated if an IDG member was absent from a meeting then it can cause a break in the continuity of care.During a telephone interview on 11/21/2025 at 12:07 p.m., with the Chaplain, the Chaplain stated he was a member of the IDG. The Chaplain stated the IDG held meetings every other Friday in person or via zoom and discussions were about the patient’s health and well-being, and if he has any concerns regarding the patient’s spiritual aspect, he will share it with the team. The Chaplain stated he would document on the POC/IDG review for each patient discussed and electronically sign it right after each meeting. The Chaplain stated if his signature was not on the POC/IDG Review then it would mean he did not attend. The Chaplain stated he had missed some meetings due to being out on the field visiting patients and families. The Chaplain stated it was important for him to make sure he was present during every IDG meeting to hear his colleagues’ concerns about the patients and see if there was need for his help, and for him to share with the team the patient’s emotional and spiritual status. The Chaplain stated it was also important to sign every POC/IDG Review he was part of, to verify his assessment and validate his attendance.During a telephone interview on 11/21/2025 at 12:33 p.m., with the Medical Social Worker (MSW1), MSW1 stated she is a member of the IDG and the IDG meets every other Friday. MSW1 stated the IDG meetings were held in person or via zoom. MSW1 stated it was important that all members of the IDG should attend the meetings so that all disciplines can share their assessment of the patient and all aspects of care for the patient were discussed as a team. MSW1 stated if there is no signature from a discipline then it means that person was not part of the meeting.During a review of the HA’s Policy and Procedure (P&P) titled Interdisciplinary Group membership and responsibilities, revised May 2024, the P&P indicated the interdisciplinary team/group members will include at a minimum the physician, registered nurse, social worker, and pastoral or other counselor. The P&P also indicated the interdisciplinary group will participate in establishing the plan of care for each patient admitted to hospice services, do periodic review and update the plan of care for each patient and family receiving hospice services, provide and/or supervise coordinate hospice care and services, and review and resolve conflict of care and ethical issues.During a review of the HA’s P&P titled Interdisciplinary Group meeting, revised May 2024, the P&P indicated that the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and update plan of care no less frequently than every 15 days or more frequently if the patient’s condition requires. The P&P also indicate that the members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor.During a review of the HA’s P&P titled Entries into the clinical record, revised May 2024, the P&P indicated that clinical notes will include the care provided, treatment and/or invasive procedures performed, patient response to treatment and/or procedures, the date the service was provided (month, day, year), and signature of the clinician and his/her credentials. The P&P also indicated that the signature authorization of clinical documentation will include the staff member’s name and credentials.”

“Based on interview and record review the HA failed to follow all orders in the individualized Plan of Care (POC [documents the process of identifying a patient’s needs and facilitating complete care and ensures collaboration among nurses, patients, and other healthcare providers]) for two of fourteen sampled patients (Patient 2, and Patient 11).This failure had the potential to result in Patient 2 and Patient 11 not receiving the needed services and treatments as prescribed by the physician, that could potentially affect the patients’ health and well-being. During a review of Patient 11’s Personal Information (face sheet, admission record), the Personal Information sheet indicated a Start of Care (SOC) date of 11/4/2024, with a primary diagnosis of Alzheimer’s disease (a disease characterized by a progressive decline in mental abilities).During a review of Patient 9’s Plan of Care/ Interdisciplinary Group (POC/IDG) Review dated November 7 2025 for certification #6 indicated an order for Skilled Nurse visits 2 times a week and 2 as needed visits for assessment and to provide comfort measures and symptom control management, Home aide (HA) visit 2 times a week and 1 as needed visit to assist with personal care, home making and to promote comfort per Registered Nurse (RN) assignment, Medical Social Worker (MSW) visit once per month and 1 as needed visit for psychosocial, emotional and counseling needs, Bereavement Coordinator (BC) visit 1 per certification period, and Spiritual Counselor (SC) visit once per month and 1 as needed visit for spiritual, emotional counseling and support needs.During a review of Patient 11’s Electronic Medical Record (EMR), Patient 11’s EMR indicated that the BC did not submit or complete notes or bereavement assessments during every recertification period, as specified in the POC/IDG Review dated November 7, 2025.During an interview on 11/21/2025 at 11:56 a.m. with the Chaplain, the Chaplain stated his responsibilities include Bereavement Coordinator and Spiritual Counselor. The Chaplain stated that within 5 days of admission, he is to contact and visit the patient to complete a spiritual assessment and initial bereavement assessment. The Chaplin stated that a bereavement assessment can also be completed at every recertification if ordered by the physician to reassess the patient and/or family/caregiver’s level of bereavement and assess their coping needs. The Chaplain stated if a patient does have an order for the Bereavement Coordinator to assess the patient at every recertification period, then it is his responsibility to complete that and document his assessment in the patients EMR. The Chaplain stated if his assessment is not in the EMR under the section Bereavement for each recertification period then he did not do it.During a concurrent interview and record review on 11/21/2025 at 12:56 p.m. with the Director of Patient Care Services (DPCS), Patient 11’s IDG/POC Review dated November 7, 2025, was reviewed. Patient 11’s POC/IDG Review indicated an order for the BC to visit 1 per certification period. The DPCS stated that a physician order in the POC/IDG Review should be followed, especially frequency of visits because it is what the patient needs. The DPCS stated and confirmed that the order for the BC to visit once a certification period was not followed as Patient 11’s EMR does not indicate documentation of the assessment to validate the visit was completed. The DPCS stated the Chaplain is the Bereavement Coordinator and it was his responsibility to visit the patient every certification period and document the visit. The DPCS stated and confirmed that Patient 11’s POC/IDG was not followed by the Chaplain to visit the patient once a certification period, as ordered by the physician.During a concurrent interview and record review on 11/21/2025 at 1 p.m. with the DPCS, Patient 11’s EMR was reviewed. The DPCS stated and confirmed that Patient 11’s EMR did not indicate documented evidence of a completed bereavement assessment for every certification period, was submitted by the Chaplain. The DPCS stated the documentation should be found under the Bereavement section and not in a note, but that Patient 11’s EMR had a note or assessment documented. The DPCS stated it was important that the Chaplain follow the order of doing a bereavement assessment for Patient 11 during every certification period because that patient was not coping well with her diagnosis and had verbalized to the nurse that she was scared of dying and required more assistance with her coping needs and assessing what other services the patient might need to also assist her with her spiritual needs. The DPCS stated that was the responsibility of the Chaplain, who is the HA’s Bereavement Coordinator and Spiritual Counselor.During a review of the HA’s Policy and Procedure (P&P) titled The Plan of Care, revised May 2024, the P&P indicated that the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by the members of the Interdisciplinary group and the plan of care must be initiated at the start of care. The P&P indicated that the plan of care must state in detail the scope and frequency of services needed to meet the patient’s and family/caregiver needs. The P&P also indicated that the care provided to the patient will be in accordance with the plan of care and each patient will be monitored for his/her response to services being provided.During a review of the HA’s P&P titled Bereavement Services, revised May 2024, the P&P indicated that the program will provide bereavement services to the family/caregivers of the hospice patients before and after the patient’s death, in accordance with the plan of care. The P&P also indicated that depending on the patient and family/caregiver needs identified in the bereavement assessment, bereavement counselors may need to contact and/or provide supportive counseling to the patient and family/caregiver prior to the patient’s death, to facilitate a normal grieving process and identify and appropriately refer those persons who may be experiencing pathological grief reactions that may interfere with the eventual resolution and integration of their losses. During a review of Patient 2’s admission record, undated. The admission record indicated the HA admitted Patient 2, a 76 year-old female, with SOC on 9/5/2025 with primary diagnosis of heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and secondary diagnoses, including but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty swallowing).During a concurrent interview and record review on 11/20/2025 at 1:41 pm with the DPCS. Patient 2’s “POC/IDG” (Plan of Care/Interdisciplinary Group (the team responsible for the holistic care of the hospice beneficiary)), dated 9/5/2025 was reviewed. The DPCS stated the admission orders and frequency visit indicated “Bereavement Coordinator to assess and evaluate bereavement and grieving risk factors within 5 days of Admission”. The DPCS stated the plan of care for bereavement and spiritual needs to address to ensure families are grieving appropriately and the HA is providing the support they needed.During a concurrent interview and record review on 11/20/2025 at 1:50 pm with the DPCS. Patient 2’s “History of Bereavement Assessment”, for the certification period of 9/5/2025 to 10/12/2025 was reviewed. The DPCS stated there was no documentation that the initial bereavement assessment was completed.During an interview on 10/21/2025 at 11:57 am with SC. The SC stated part of his responsibility is to complete the initial bereavement assessment for patients and family within five days of the start of care and complete a plan of care for bereavement. The SC stated he must have not completed the bereavement assessment for Patient 2 for the certification period of 9/5/2025 to 10/12/2025.The SC stated the bereavement assessment identifies the risk for spiritual and emotional preparedness of the patient and family when it comes to impending loss of your loved one. The SC stated patient and family members may experience emotional distress and/or loneliness when bereavement concerns were not addressed.During a review of HA’s policies and procedure (P&P) titled “The Plan of Care”, date May 2024. The P&P indicated, but not limited to, the following:- “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 plan of care”- “Care decisions and services to be provided will ne made as a result of the care planning process, analysis of initialDuring a review of HA’s policies and procedure (P&P) titled “Interdisciplinary Group Coordination of Care”, date May 2024. The P&P indicated, but not limited to, the following:- “The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessment regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions.During a review of HA’s P&P titled “Bereavement Services”, dated May 2024. The P&P indicated, but not limited to:- “The program will provide bereavement services to the family/caregivers of the hospice patients, before and after the patient’s death, in accordance with the plan of care.”- “Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.”- “After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed.””

“Based on interview and record review, the HA failed to develop and implement a plan of care for bereavement (grief and mourning after death) and spiritual needs of the family/caregivers that includes established goals and individualized interventions for one of 14 patients (Patient 2).This failure had the potential for the Patient 2’s family bereavement (grief and mourning after death) needs to be unmet and result in emotional distress. Findings:During a review of Patient 2’s admission record indicated the HA admitted Patient 2 with SOC on 9/5/2025. The primary diagnosis included heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and secondary diagnoses, including but not limited to, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and dysphagia (difficulty swallowing).During a concurrent interview and record review on 11/20/2025 at 1:41 pm., with the DPCS of Patient 2’s “POC/IDG” (Plan of Care/Interdisciplinary Group (the team responsible for the holistic care of the hospice beneficiary)), dated 9/5/2025, stated there were no POC interventions and goals regarding Patient 2 and their family. The DPCS stated the plan of care for bereavement and spiritual needs to address to ensure families are grieving appropriately and the HA is providing the support they needed.During a review of Patient 2’s “POC/IDG”, dated 9/12/2025, 9/26/2025 and 10/102025. The “POC/IDG” did not indicate a plan of care that reflects goals and interventions related to Patient 2 and their families’ bereavement and spiritual needs/concerns.During an interview on 11/21/2025 at 11:57 am., with the Bereavement Coordinator (SC), SC stated part of his responsibility is to complete the initial bereavement assessment for patients and family within five days of the start of care and creating a plan of care for bereavement and spiritual assessment based on the assessment completed. The SC stated all patients should have a plan of care for spiritual and bereavement. The SC stated part of his interventions to address the patient’s, and families’ bereavement and spiritual needs includes assessing their faith and emotional well-being, praying with them, listening with their concerns and overall being present for them. The SC stated patient and family members may experience emotional distress and/or loneliness when bereavement and spiritual concerns were not addressed.During a review of HA’s policies and procedure (P&P) titled “The Plan of Care”, date May 2024. The P&P indicated, but not limited to, the following:- “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 identify the patient’s needs and services to meet those needs…It must state, in detail, the scope and frequency of services needed to meet the patient’s family/caregiver’s needs.”- “The written plan of care will contain, but will not be limited to, the following:J. Frequency and type of servicesK. …referrals as needed for counseling, additional disciplines, volunteers and adjunctive services.L. Individualized interventions to assist with the end-of-lifeT. Measurable outcomes anticipated from implementing and coordinating the plan of careV. Anticipated discharge and bereavement care needs of the family.”During a review of HA’s P&P titled “Spiritual Care Counseling Services”, dated May 2024. The P&P indicated, but not limited to, the following:- “The chaplain will be a member of the [IDG] and will participate in the development, implementation and revision of the plan of care”- “The Hospice chaplain will develop an individualized spiritual/pastoral plan of care, which will demonstrate an effort to…provide spiritual support.”During a review of HA’s P&P titled “Bereavement Services”, dated May 2024. The P&P indicated, but not limited to:- “The program will provide bereavement services to the family/caregivers of the hospice patients, before and after the patient’s death, in accordance with the plan of care.”- “Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care.”- “After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed.””

“Based on observation, interview, and record review, the hospice agency (HA, agency that provides specialized care and support for people with serious illness and nearing the end of life) failed to ensure the administrator and/or another individual is available to fulfill his or her assigned duties and responsibilities, in accordance with the hospice’s established policies and procedures. This deficient practice had the potential for the HA to not operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. During a concurrent interview and record review on 11/20/2025 at 10:50 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), The HA’s “Certificate of Accreditation (a formal recognition that a healthcare organization meets rigorous, independent standards for quality and safety, as set by the non-profit Accreditation Commission for Health Care which a process involves a detailed review of policies and operations, followed by an on-site survey, to ensure compliance with the ACHC’s criteria for performance and care delivery)” from the ACHC (Accreditation Commission for Health Care, an organization that provides accreditation to healthcare facilities and providers to ensure they meet quality and safety standards, it acts as a third-party evaluator, verifying that healthcare organizations, such as hospice agencies, consistently provide excellent patient care) was reviewed. The HA’s “Certificate of Accreditation” from the ACHC indicated an effective date from 8/5/2021 through 8/5/2024. The ADM/DPCS stated and confirmed that the ACHC Certificate of Accreditation issued to the HA has an expiration date of 8/5/2024 and was no longer active. During an interview on 11/20/2025 at 11 a.m., with the ADM/DPCS, the ADM/DPCS stated and clarified the HA had deemed status (means that the HA has been accredited by a private, national organization that is officially recognized by the federal government (specifically, the Centers for Medicare & Medicaid Services, or CMS (is a federal agency that administers the nation’s major healthcare programs)) and has not been recertified for a year since August of 2024. The ADM/DPCS stated that the ACHC (Accreditation Commission for Health Care, an organization that provides accreditation to healthcare facilities and providers to ensure they meet quality and safety standards, it acts as a third-party evaluator, verifying that healthcare organizations, such as hospice agencies, consistently provide excellent patient care) surveyor (is a trained, independent professional (often a nurse or another experienced healthcare expert) who assesses a healthcare organization’s compliance with national quality and safety standards set by the ACHC) came around August of 2024, but did not want to wait for the DPCS arrival. The ADM/DPCS stated that the volunteer staff was in the HA office and opened the door for the ACHC surveyor. The ADM/DPCS stated that she got into the HA office about an hour after she spoke with ACHC surveyor. The ADM/DPCS stated the ACHC surveyor told her that ACHC has a policy of only waiting for an hour and if the in-charge person does not show up then the ACHC surveyor will have to leave. The ADM/DPCS stated that days after, she received a telephone call from the CDPH (The California Department of Public Health, collaborates with the state’s county public health office to oversee a variety of research, response and prevention programs to protect the health of the people​) staff that the ACHC called their office to inform them that recertification survey was not done. The ADM/DPCS stated expiration of accreditation was 8/5/2024.The ADM/DPCS stated that when the ACHC surveyor came, she was out on the field to do home visits for patients and stated she did have a DPCS Designee in her absence but was not able to come to office either during that time. The ADM/DPCS stated that she spoke to the ACHC surveyor over phone and told her she can only wait for an hour. The DPCS stated that during the time when the ACHC surveyor came, the HA has only one field registered nurse and 2 field licensed vocational nurses (LVN) with a census of 10 to 12 patients. The ADM/DPCS stated that the DPCS Designee was not available when the ACHC surveyor came, and she was at her other job. The ADM/DPCS stated she called the DPCS Designee to come to office to assist the ACHC surveyor, but she was not able to go because she was the only one at the office at her other job. The ADM/DPCS stated the same day after ACHC surveyor went to the HA, stated she received a call from an account manager from ACHC to inform her that they would mark the HA down as refusal of service. The ADM/DPCS stated she did not attempt to call the ACHC surveyor once she arrived at the HA office because the ACHC surveyor already informed her she would leave within the hour. The ADM/DPCS stated she arrived 5 to 10 minutes after the ACHC surveyor had left the HA office. The ADM/DPCS stated she is responsible for the day-to-day operations of the HA as she is also the Administrator. The ADM/DPCS stated during that situation when the ACHC surveyor came, it was not manageable to be an Administrator (ADM), DPCS and a visiting RN at the same time. The DPCS stated that it is important that the DPCS/ADM or designee to be in the office within a timely manner, especially if the HA is in waiting period to be accredited, to assist the accreditation process to what it needs and to represent for the HA. The DPCS stated that during that day when the ACHC surveyor came, stated that she was the only RN, and she should be waiting for the recertification survey and preparing by being in office all the time. The DPCS stated she could have also called the HA’s Chief Financial Officer (CFO), who could have helped the ACHC surveyor to start the process by getting documents that the ACHC surveyor needed for the mean time until she arrived at the HA office. The DPCS stated that it is important for the HA to be recertified to continue to provide services to patients and for the HA to be compliant with the federal/state regulations. The ADM/DPCS stated that the HA applied to the Joint Commission (non-profit organization that evaluates and accredits healthcare organizations, like hospice agencies, to ensure it meets specific standards for quality and patient safety) in September of 2025 and waits for the recertification survey. The DPCS stated she received an email from CDPH staff sometime around last quarter of 2024 and then she proceeded to call the CDPH staff to speak over the telephone to which she mentioned to CDPH staff that the HA will opt to do recertification survey through CDPH, and she stated that the HA would be under CDPH and will wait for the recertification survey. The ADM/DPCS stated that she should have stayed in the office to oversee the day to day administrative and clinical operation of the HA and accommodated the ACHC surveyor as they anticipated a recertification survey from them and to ensure that the HA follows the federal and state regulations. During a review of the HA’s job description for “Clinical Director/Director of Patient Care Services” with a revised date of May 2024, the HA’s job description for Clinical Director (CD)/Director of Patient Care Services (DPCS) indicated that the CD/DPCS is responsible for the overall direction of hospice clinical services, establishes, implements and evaluates goals, objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy, and essential job functions/responsibilities which include: 18. Assures compliance with all local, state, and federal laws regarding licensure and certification of organization personnel and maintains compliance to the Joint Commission Home Care standards.”

“Based on interview and record review, the Hospice Agency (HA, agency that provides specialized care and support for people with a serious illness and nearing the end of life) failed to maintain an authenticated clinical record based on accepted standards of practice and regulations followed by failing to ensure that the Interdisciplinary Group (IDG, meeting where the Registered Nurse [RN], Master of Social Work [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) meetings were signed by all IDG members for one of fourteen sample patients (Patient 13). This failure resulted in Patient 13’s clinical record being inaccurate and incomplete, which could lead to non-continuity of care and services provided to this certified hospice patient. During a review of Patient 13’s Personal Information sheet (face sheet, admission record), the Personal Information sheet indicated a Start of Care (SOC) date of 1/10/2025. The primary diagnosis included Leukemia (cancer of the blood forming tissues, such as bone marrow [soft, fatty substance in the bones in which blood cells are produced] that causes overproduction of abnormal white blood cells), and an End of Care (EOC) date of 11/3/2025.During a concurrent interview and record review on 11/20/2025 at 1:39 p.m., with the Director of Patient Care Services (DPCS), Patient 13’ s EMR section for Interdisciplinary Group (IDG) was reviewed. Patient 13’s EMR section for IDG indicated the following:POC/IDG Review dated 9/12/2025 with electronic signatures from the Medical Director (MD), the DPCS, the Medical Social Worker 2 (MSW2), and no signature from the Spiritual Counselor (SC).POC/IDG Review dated 9/26/2025 with electronic signatures from the MD, the DPCS, the MSW2, and no signature from the SC.POC/IDG Review dated 10/10/2025 with electronic signatures from the MD, the DPCS, the MSW2, and no signature from the SC.POC/IDG Review dated 10/24/2025 with electronic signatures from the MD, the DPCS, and no signatures from the SC and the MSW2.POC/IDG Review dated 11/7/2025 with electronic signatures from the MD, the DPCS, and no signatures from the SC and the MSW2.The DPCS stated the HA IDG members were the MD, the DPCS, the SC and the MSW. The DPCS stated the IDG meetings were conducted every other Friday either in person or via zoom call. The DPCS stated all IDG members must be part of every IDG meeting and the staff members that are optional to join are the licensed nurses. The DPCS stated and confirmed that Patient 13’s POC/IDG Review dated 9/12/2025, 9/26/2025, 10/10/2025, 10/24/2025, and 11/7/2025 did not have documented evidence of the SC’s signature, and the POC/IDG Reviews dated 10/24/2025 and 11/7/2025 also did not have documented evidence of the MSW’s signature. The DPCS stated there was no sign-in sheet for IDG meetings other than each IDG member documenting their portion on the POC/IDG Review and electronically signing it. The DPCS stated the IDG members must complete and sign the POC/IDG Review right away after the meeting is completed within 24 hours. The DPCS stated the MSW2 assigned to Patient 13 was a second social worker the agency contracted to assist with patient visits in Orange County, but when she left, she did not submit all her work documents. The DPCS stated the importance of having all IDG members present at every patient meeting is if there is an issue occurring with the patient then all disciplines can be aware of it and discuss how each can help the patient identify what they need and include the family as well. The DPCS stated if an IDG member was absent from a meeting then it can cause a break in the continuity of care.During a telephone interview on 11/21/2025 at 12:07 p.m., with the Chaplain, the Chaplain stated he was a member of the IDG. The Chaplain stated the IDG held meetings every other Friday in person or via zoom and discussions are about the patient’s health and well-being, and if he has any concerns regarding the patient’s spiritual aspect, he will share it with the team. The Chaplain stated he will document in the POC/IDG review for each patient discussed and electronically sign it right after each meeting. The Chaplain stated if his signature was not on the POC/IDG Review then it would mean he did not attend. The Chaplain stated he has missed some meetings due to being out on the field visiting patients and families. The Chaplain stated it was important for him to make sure he was present during every IDG meeting to hear his colleagues’ concerns about the patients and see if there was need for his help, and for him to share with the team the patient’s emotional and spiritual status. The Chaplain stated it was also important to sign every POC/IDG Review he was part of to verify his assessment and validate his attendance.During a telephone interview on 11/21/2025 at 12:33 p.m., with the Medical Social Worker (MSW1), MSW1 stated she was a member of the IDG and the IDG would meet every other Friday. MSW1 stated the IDG meetings were held in person or via zoom. MSW1 stated it is important that all members of the IDG attend the meetings so that all disciplines can share their assessment of the patient and all aspects of care for the patient are discussed as a team. MSW1 stated if there was no signature from a discipline then it means that person was not part of the meeting.During a review of the HA’s Policy and Procedure (P&P) titled Interdisciplinary Group membership and responsibilities, revised May 2024, the P&P indicated the interdisciplinary team/group members will include at a minimum the physician, registered nurse, social worker, and pastoral or another counselor. The P&P also indicated the interdisciplinary group will participate in establishing the plan of care for each patient admitted to hospice services, do periodic review and update the plan of care for each patient and family receiving hospice services, provide and/or supervise coordinate hospice care and services, and review and resolve conflict of care and ethical issues.During a review of the HA’s P&P titled Interdisciplinary Group meeting, revised May 2024, the P&P indicated that the interdisciplinary group would meet on a regular basis to discuss patient and family/caregiver changes and progress and update plan of care no less frequently than every 15 days or more frequently if the patient’s condition requires. The P&P also indicate that the members of the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor.During a review of the HA’s P&P titled Entries into the clinical record, revised May 2024, the P&P indicated that clinical notes will include the care provided, treatment and/or invasive procedures performed, patient response to treatment and/or procedures, the date the service was provided (month, day, year), and signature of the clinician and his/her credentials. The P&P also indicated that the signature authorization of clinical documentation will include the staff member’s name and credentials.”