Medicalone Health
A hospice in Antioch, California 94509
3240 Lone Tree Way, Suite 203, Antioch, California 94509. (925) 436-3155.
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The short answer
Record last released by CMS on Oct 23, 2026. We couldn’t read Centers for Medicare & Medicaid Services’ list since Oct 27, 2026: qcor.cms.gov now refuses our reader. This record is as of then.
- 57 deficiencies cited in the last three years
- Not rated family caregiver rating
- Not available CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
- Condition-level deficiency
- For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.
What did inspectors find?
57 deficiencies cited in the last three years
The middle of the 44 hospices serving ZIP code 94509 had 6.
The last inspection on record was on Oct 29, 2025: a follow-up inspection by the Accreditation Commission for Health Care.
8 deficiencies at condition level, the more serious of CMS’s two levels
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
57 deficiencies in 2 months of the last 36. Last cited Sep 2025. Most serious: Condition-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Sep 11, 2025: follow-up inspection by the Accreditation Commission for Health Care22 deficiencies
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Core services (42 CFR 418.64)
“Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #6, Upon reviewing HR file, the spiritual care provider had completed a W-9 form and there was no evidence of a W-4 form in the chart.”
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Organizational environment (42 CFR 418.100)
“Condition of Participation: Organization and Administration of Services.”
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Clinical records (42 CFR 418.104)
“Upon patient record review 1 of 5 (Patient #5) did not have evidence a patient record maintained for each hospice patient. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Notice of rights and responsibilities (42 CFR 418.52(a)(1))
“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 #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Notice of rights and responsibilities (42 CFR 418.52(a)(2))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Notice of rights and responsibilities (42 CFR 418.52(a)(3))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the hospice obtained the patient’s or representative’s signature confirming that they received a copy of the Patient’s Rights and Responsibilities. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(1)(iii))
“Upon observation, there was no evidence the patient has the right to voice grievances/complaints regarding treatment or care that is (or fails to be) furnished and lack of respect of property by anyone who is furnishing care/service on behalf of the hospice. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Exercise of rights/respect for proprty/person (42 CFR 418.52(b)(3))
The inspectors’ words, 91 words
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient’s rights to the extent allowed by state law. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Rights of the patient (42 CFR 418.52(c)(2))
“Upon client record review, 1 of 5 (Patient #5) did not have evidence that the plan of care included IDG’s documentation of the patient’s or families level of understanding, involvement and agreement with the plan of care. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Rights of the patient (42 CFR 418.52(c)(4))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Rights of the patient (42 CFR 418.52(c)(5))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence of the appropriate documentation for release of confidential information. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Rights of the patient (42 CFR 418.52(c)(7))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Rights of the patient (42 CFR 418.52(c)(8))
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Initial assessment (42 CFR 418.54(a))
“Upon patient record review 1 of 5 (Patient #5) did not have evidence that the hospice Registered Nurse must complete an initial assessment within 48 hours after the election of hospice care in accordance with §418.24 Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
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Performance improvement projects (42 CFR 418.58(d)(1))
“Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice’s population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice’s services and operations. No evidence of the number and scope of distinct QAPI projects conducted annually.”
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Executive responsibilities (42 CFR 418.58(e)(2))
“Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness. Agency added a QAPI program that is completely empty. No evidence governing body addressed priorities for improved quality of care and patient safety.”
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Hospice aide instructor qualifications (42 CFR 418.76(e))
“Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. Personnel #2, No evidence the DPS possesses a minimum of 2 years nursing experience.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(2))
The inspectors’ words, 153 words
“Upon patient record review 4 of 5 (Patient #1,2,3,4) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, Aide care plan directed these cares: ambulatory, w/c, bathroom, incontinence care. No evidence these items were completed by aide note on 8/30/25. Patient #2, Aide care plan directed these cares: dress, diet as tolerate, aspiration precaution. No evidence these items were completed by aide note on 8/23/25. Patient #3, Aide care plan directed these cares: dress, aspiration precaution. No evidence these items were completed by aide note on 8/26/25. Patient #4, Aide care plan directed these cares: dress, regular diet, aspiration precaution. No evidence these items were completed by aide note on 8/18/25.”
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Governing body and administrator (42 CFR 418.100(b))
“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by no evidence of the governing body appointed the administrator, employed qualified Director of Clinical Services per agency job description, provided employees for core services as the spiritual care/bereavement coordinator is contract, and ensured Administrator oversight of hospice meeting policies and regulations by ensuring contracts in place and patient care and management oversight.”
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Professional management responsibility (42 CFR 418.100(e))
The inspectors’ words, 109 words
“Upon contract review, 1 of 3 (No LCSW 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 LCSW has a W 9 for service for supervision of Social worker however, there was no evidence of contract between agency and LCSW.”
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Initial certification of terminal illness (42 CFR 418.102(b))
The inspectors’ words, 115 words
“Upon patient record review, 1 of 5 (Patient #5) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient’s life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient’s conditions unrelated to the terminal illness Patient #5, No evidence of verbal certification or written CTI completed and signed by MD. Patient was admitted on 9/8/25. CTI is blank.”
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Content (42 CFR 418.104(a)(2))
“Upon patient client record review, 1 of 5 (Patient #5) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #5, Patient was admitted on 9/8/25. Policy for documentation states all charting will be completed in 48 hours. Upon review of this chart, no documentation was completed. The chart was completely empty with a few items documented in the initial nursing assessment.”
Jul 31, 2025: reaccreditation inspection by the Accreditation Commission for Health Care35 deficiencies
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Quality assessment & performance improvement (42 CFR 418.58)
“Condition of Participation: Quality Assessment and Performance Improvement.”
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Phys, occupnl therapy & speech-lang pathology (42 CFR 418.72)
“Upon observation, there was no evidence the hospice ensures that non-core services are provided to hospice patients and their families according to applicable laws and regulations. Non-core services include Physical Therapy, Occupational Therapy and Speech-Language Pathology. The agency did not have employed non-core personnel nor an executed contract for these services.”
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Hospice aide and homemaker services (42 CFR 418.76)
“Condition of Participation: Hospice Aide and Homemaker Services. L607”
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Organizational environment (42 CFR 418.100)
“Condition of Participation: Organization and Administration of Services.”
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Personnel qualification (42 CFR 418.114)
“Condition of Participation: Personnel Qualifications.”
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Timeframe for completion of assessment (42 CFR 418.54(b))
“Upon patient record review 1 of 14 (Patient #5) 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 #5: There is evidence the patient was admitted on 5/17/25. The spiritual assessment was completed on 5/29/25. Greater than 5 calendar days.”
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Content of comprehensive assessment (42 CFR 418.54(c))
“Upon patient record review 1 of 14 (Patient #1) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. Patient #1: There is evidence the patient was admitted on 7/18/25. The spiritual assessment was not completed.”
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Content of comprehensive assessment (42 CFR 418.54(c)(6))
The inspectors’ words, 291 words
“Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,8) 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: Upon observation of the nursing facility medication record, Quetiapine fumarate 25 mg. BID was listed on the Facility Medication Record but Not on the hospice medication record. (Corrected on site, order obtained from medical director.) Patient #2: There is evidence in the medical record on 7/7/25 an order for Moxifloxacin 0.5%, each eye TID for 5 days. The medication is still on the medication record. Patient #3: There is evidence in the medical record on 6/23/25 of an order for MiraLAX 17 g. daily. The medication instructions do not indicate to dilute the powder with fluid. Patient #5: Upon observation of the facility medication record, Depakote ER 250 mg daily was Not listed on the Facility Medication Record but was on the hospice medication record. Patient #6: There is evidence in the medical record on 7/1/25 an order for Macrobid 100 mg BID for 5 days. The medication is still on the medication record. Additionally, on 5/6/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record. Patient #8: There is evidence in the medical record on 5/22/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record.”
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Content of comprehensive assessment (42 CFR 418.54(c)(7))
The inspectors’ words, 120 words
“Upon patient record review, 2 of 14 (Patient #1,5) 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. Patient #1: There is evidence the patient was admitted on 7/18/25. A bereavement assessment was not completed in 5 days. Patient #5: There is evidence the patient was admitted on 5/12/25. A bereavement assessment was completed on 5/29/25. Greater than 5 days.”
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Update of comprehensive assessment (42 CFR 418.54(d))
The inspectors’ words, 134 words
“Upon patient record review, 1 of 14 (Patient #7) 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 #7: There is no evidence in the medical record that the RN visited the patient from 5/6/25 to 6/3/25. The patient is in an ALF and there was not visit by a RN for coordination and implementation of the plan of care.”
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Content of plan of care (42 CFR 418.56(c))
The inspectors’ words, 153 words
“Upon patient record review, 2 of 14 (Patient #5,7) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #5: There is evidence in the medical record on the Nursing initial assessment 5/12/25 “family want/need funeral plans”. MSW was declined by the family. There was no Problem/Intervention/Goal opened to assist family with funeral plans. Patient #7: There is evidence in the medical record on the Nursing initial assessment 5/5/25 “family want/need funeral plans” and “patient has extreme anxiety about diagnosis”. MSW was declined. There was no Problem/Intervention/Goal opened for anxiety or to assist with funeral plans.”
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Content of plan of care (42 CFR 418.56(c)(4))
The inspectors’ words, 257 words
“Upon patient record review, 6 of 14 (Patient #1,2,3,5,6,8) 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: Upon observation of the nursing facility medication record, Quetiapine fumarate 25 mg. BID was listed on the Facility Medication Record but Not on the hospice . (Corrected on site, order obtained from medical director.) Patient #2: There is evidence in the medical record on 7/7/25 an order for Moxifloxacin 0.5%, each eye TID for 5 days. The medication is still on the medical record. Patient #3: There is evidence in the medical record on 6/23/25 of an order for MiraLAX 17 g. daily. The medication instructions do not indicate to dilute the powder with fluid. Patient #5: Upon observation of the facility medication record, Depakote ER 250 mg daily was Not listed on the Facility Medication Record but was on the hospice medical record. Patient #6: There is evidence in the medical record on 7/1/25 an order for Macrobid 100 mg BID for 5 days. The medication is still on the medical record. Additionally, on 5/6/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medical record. Patient #8: There is evidence in the medical record on 5/22/25 the medication Permethrin 5% topical cream, apply and repeat in 7 days. Report if condition persists, Scabies. The medication is still on the medication record.”
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Review of the plan of care (42 CFR 418.56(d))
The inspectors’ words, 131 words
“Upon client record review, 3 of 14 (Patient #2,3,4) 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 #2,4: There is no evidence in the medical record the IDG on 7/14/25 that the Chaplain participated in the meeting. There is no signature by the chaplain, the hospice does not keep a record of staff participating in IDG. Patient #3: There is no evidence in the medical record the IDG on 7/14/25 that the Chaplain or MSW participated in the meeting. There is no signature by the chaplain or by the MSW, the hospice does not keep a record of staff participating in IDG.”
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Program data (42 CFR 418.58(b)(3))
“Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection.”
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Performance improvement projects (42 CFR 418.58(d)(1))
“Upon observation, there was no evidence the number and scope of distinct QAPI projects conducted annually is based on the needs of the hospice’s population and internal organizational needs and must reflect the scope, complexity, and past performance of the hospice’s services and operations.”
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Executive responsibilities (42 CFR 418.58(e)(1))
“Upon observation, there was no evidence of involvement of the governing body and organizational leaders in the Quality Assessment/Performance Improvement (QAPI) program.”
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Executive responsibilities (42 CFR 418.58(e)(2))
“Upon observation, there was no evidence the hospice’s governing body is responsible for ensuring that the hospice-wide Quality Assessment and Performance Improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness.”
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Hospice aide instructor qualifications (42 CFR 418.76(e))
“Upon personnel record review, 1 of 12 (Personnel #2) did not have evidence that the RN who supervises classroom and practical training possesses a minimum of 2 years nursing experience, at least 1 year of which must be in home care. The RN graduated from nursing school in December 2023. He began working for the hospice in December 2024. He did not have any supervisory experience.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(1))
The inspectors’ words, 192 words
“Upon patient record review, 2 of 14 (Patient #3,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #3: There is evidence in the medical record 6/23/25 of an order for Divalproex 375 mg at HS for seizures. The home health aide plan of care does not indicate seizure precautions. Patient #10: There is evidence in the medical record 11/19/24 of an order for Pradaxa 150 mg BID as a blood thinner. The home health aide plan of care does not indicate bleeding precautions.”
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Hospice aide assignments and duties (42 CFR 418.76(g)(2))
“Upon patient record review 1 of 14 (Patient #2) 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 • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: There is evidence in the medical record of an order on 6/30/25 for Aide visit 1X week. There have not been aide visits since admission.”
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Supervision of hospice aides (42 CFR 418.76(h)(1))
The inspectors’ words, 132 words
“Upon patient record review 2 of 14 (Patient #4,7) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient’s needs. Patient #4: There is evidence in the medical record that the aide visited the patient on 6/23/25 and 6/26/25. There was a supervisory visit by the RN on 7/12/25, but no supervisory note was completed by the RN. Patient #7: There is evidence in the medical record that the aide visited the patient on 5/16/25. There was no supervisory visit/note by the RN between 5/6/25 and 6/4/25.”
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Governing body and administrator (42 CFR 418.100(b))
“Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice as evidenced by the agency is unable to provide all non-core services (PT/OT/SLP) due to none of these disciplines employed and no evidence of an executed contract. In addition, Director of Clinical Services is not qualified based on California regulations and ACHC standards.”
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Professional management responsibility (42 CFR 418.100(e))
The inspectors’ words, 105 words
“Upon contract review, 1 of 3 (Non-core therapy) 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 The agency did not have an executed contract for therapy (PT/OT/SLP) services as it had not been signed nor dated.”
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Recertification of the terminal illness (42 CFR 418.102(c))
The inspectors’ words, 196 words
“Upon patient record review, 2 of 14 (Patient #6,10) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient’s clinical information and provide written documentation that it is anticipated that the patient’s life expectancy is 6 months or less. Patient #6: There is evidence in the medical record the physician did not document a life expectancy of 6 months or less for recertification of benefit period #10 beginning 7/5/25. The physician narrative in the Certification of Terminal Illness stated: “Patient’s general condition is now plateauing with no further decline. Patient can be transferred to HHC, f/u with PCP, reassessed for hospice care if her condition deteriorating in the future.” (Hospice has not billed for July.) Patient #10: There is evidence in the medical record the physician did not document a life expectancy of 6 months or less for recertification of benefit period #3 beginning 5/18/25. The physician narrative in the Certification of Terminal Illness stated: “Discussed with staff can be discharged to HHC, f/u with PCP, reassessed for hospice care if her condition deteriorating in the future.” ( Hospice billed 27 days in May.)”
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Content (42 CFR 418.104(a)(2))
“Upon patient client record review, 3 of 14 (Patient #1,4,6) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #1,4,6: There is evidence on the Election Statement the effective date of hospice services was left blank.”
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Authentication (42 CFR 418.104(b))
“Upon patient client record review, 10 of 14 (Patient #1-10) 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 #1-10: There is evidence on the Hospice Election Statement that staff signed the election statement with first name and last initial with out credentials.”
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Inpatient care provided under arrangements (42 CFR 418.108(c)(3))
“Upon inpatient contract review, 1 of 3 (Vacaville) did not have evidence that the hospice patient’s inpatient clinical record includes a record of all inpatient services furnished and events regarding care that occurred at the facility; that a copy of the discharge summary be provided to the hospice at the time of discharge; and that a copy of the inpatient clinical record is available to the hospice at the time of discharge.”
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Written agreement (42 CFR 418.112(c)(2))
“Upon SNF/NF contract review, 1 of 3 (Vacaville) did not have evidence that specifies the provision of hospice services in the facility, including: A provision that the SNF/NF or ICF/IID immediately notifies the hospice if: • When a need to transfer a patient from the SNF/NF or ICF/MR arises, and the hospice makes arrangements for, and remains responsible for, any necessary continuous care or inpatient care necessary related to the terminal illness and related conditions • A patient dies”
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Written agreement (42 CFR 418.112(c)(3))
“Upon SNF/NF contract review, 1 of 3 (Vacaville) did not have evidence of a provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.”
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Written agreement (42 CFR 418.112(c)(8))
“Upon SNF/NF contract review, 1 of 3 (Vacaville) did not have a provision stating that the hospice reports all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice to the SNF/NF administrator within 24 hours of the hospice becoming aware of the alleged violation.”
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Written agreement (42 CFR 418.112(c)(9))
“Upon SNF/NF contract review, 1 of 3 (Vacaville) did not have a delineation of the responsibilities of the hospice and the SNF/NF to provide bereavement services to SNF/NF personnel.”
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Personnel qualification (42 CFR 418.114(b)(3))
“Upon personnel record review, 1 of 12 (Personnel #4) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state’s Social Work Practice Act, the hospice’s policies and procedures and/or job descriptions. There is no evidence of an MSW was serving as an active advisor since 12/1/24 to the BSW.”
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Personnel qualification (42 CFR 418.114(b)(4))
“Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence that all Speech Therapy Services are provided by a qualified licensed Speech-Language Pathologist (SLP) or Audiologist in accordance with the state’s Speech-Language Pathology Practice Act and the hospice’s policies and procedures and/or job descriptions. No evidence of SLP HR file available.”
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Criminal background checks (42 CFR 418.114(d)(1))
“Upon personnel record review, 1 of 12 (Personnel #12) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. No SLP HR file available.”
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Criminal background checks (42 CFR 418.114(d)(2))
“Upon personnel record review, 1 of 12 (Personnel #7) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Oct 29, 2025 | Follow-up inspection by the Accreditation Commission for Health Care | No deficiencies cited |
| Sep 11, 2025 | Follow-up inspection by the Accreditation Commission for Health Care | 22 deficiencies cited |
| Jul 31, 2025 | Reaccreditation inspection by the Accreditation Commission for Health Care | 35 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Jul 30, 2022.
- CMS doesn’t list its type of ownership.
- Cited at For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. in the last three years: it didn’t meet a whole condition of Medicare’s rules.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- CMS hasn’t published nursing time from Medicare claims for this hospice.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 58% at home, 42% in assisted living.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
Who owns it?
- 3 owners or officers are people: Victoria N Nwokochah (owns 5% or more directly, 100%); Victoria N Nwokochah (corporate officer, 100%); Victoria N Nwokochah (managing employee (on the payroll), 100%).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- CMS gives no family caregiver survey rating: “The number of cases is too small to report Star Ratings.”
- CMS gives no Hospice Care Index for this hospice.
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
How does it compare nearby?
- Of the 44 hospices CMS’s data show serving patients in ZIP code 94509, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 6; this one had 57.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Sacred Hands Hospice Home Care, LLC | 1 |
| Medicalone Health This hospice | 57 |
| Aura Hospice LLC | 6 |
| Hospice of the East Bay | 7 |
| Kaiser Foundation Hospital Hospice - Martinez | 2 |
| Sutter Care at Home | 3 |
| Hope Hospice | 5 |
| Hospice of the Foothills | 6 |
| Vitas Healthcare Corporation of California | 1 |
| Vitas Healthcare Corporation of California | 8 |
| Prohealth Home Care, Inc. | 2 |
| Ace Home Health Care & Hospice, Inc. | 5 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
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Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.