California Healthcare and Hospice

“Upon patient record review, 4 of 14 (Patient #2,3,4,5) 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 #2: Duoneb 3mg-0.5mg/3mL is listed on medication profile and not in patient home. Per visiting nurse, this is a discontinued medication. Patient #3: Docusate Sodium 50 mg, liquid solution in patient home and not on current medication profile. Additionally, Miralax listed on medication profile(s) with no diluent. Patients #4, #5: Miralax listed on medication profile with no diluent. Ordered on 7/5/23. Corrected on site-agency updated medication profile.”

“Upon patient record review, 1 of 14 (Patient #10) 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 #10: There is no initial bereavement risk assessment completed to date on this patient.”

“Upon patient record review, 4 of 14 (Patients #1,2,4,5) 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. Patients #1, 2: The MSW and SC visit frequency indicated 1x month as needed. There was no baseline visit frequency. Patients #4, #5: The MSW and SC visit frequency indicated 1x month as needed. There was no baseline visit frequency.”

“Upon patient record review, 4 of 14 (Patients #10,12,13,14) did not have evidence the hospice offers bereavement counseling that includes: • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #10, #12: There is no bereavement plan of care in these patient records. Patient #13, #14: These patients both passed in June 2025. There is no record of the one-month letter being sent per plan of care(s).”

“Upon personnel record review, 1 of 13 (Personnel #10) 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.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·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 ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #10: The Initial Skills Competency for the Aide showed all tasks observed/demonstrated as indicated. However, there was no signature of Supervising RN in the space provided on this document.”

“Upon patient record review 6 of 14 (Patient #1,2,3,5,8,14) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care Patient #1: The POC listed aide visit frequency of 2 X’s per week (6/15/25). The aide visited this patient prior to start date on 6/14/25. Patient #2: The POC listed aide visit frequency of 2 X’s per week (7/20/25). For benefit week 7/27/25 there were no visits documented for aide services. Patient #3: The POC listed aide visit frequency of 2 X’s per week (5/29/25). The IDG listed aide visit frequency of 3X’s per week (5/29/25). There were no documented aide visits until 6/24/25. Patient #5: The POC listed aide visit frequency of 2 X’s per week (6/17/25). The first benefit week the Aide visited 1X on 6/19/25 only. Patient #8: The POC listed aide visit frequency of 3 X’s per week (8/25/24). The first benefit week the aide visited 2X on 8/28/24 and 8/30/24. The second benefit week the aide visited 1 X on 9/5/24. Patient #14: The POC listed aide visit frequency of 2 X’s per week (5/26/25). There are no documented aide visits to date.”

“Upon contract review, 3 of 5 (Medical Director Contract, Alt Medical Director Contract, Hospice Aide Contract) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: • Authorized by the hospice • Furnished in a safe and effective manner by qualified personnel • Delivered in accordance with the patient’s plan of care Contracts 1,2,5: The Medical Director, Medical Director Designee and Aide contract did not have all CMS requirements as follows: • Furnished in a safe and effective manner by qualified personnel/organization”