Alpha Hospice Care Inc.

“Observed in Tracer Visit. In 5 out of 5 records, the agency did not have individualized plan of care goals for each patient. Examples: RRHV#1 Goals not individualized. Reorienting to person, time, place and event. Discussing techniques on prevention of potential infections associated with bladder disturbance. RRHV#2 Communicating empathy or understanding of Patient’s experience. Facilitating and creating sense of support for adaptation. RRHV#3 Reorienting to person, time, place and event. RRHV#4 Reporting pain is at or below acceptable level ____. This was confirmed by the DON. Observed in Record Review. In RRNHV#2, the plan of care included wound goals. However, the patient did not have a wound. This was confirmed by the DON.”

“Observed in Record Review. In 2 of 9 patient records reviewed, it was noted that the patient record was inaccurate. For example, RRHV#2 in the admission assessment there was documentation that the patient declined the volunteer, but in another section for the same visit it stated that the patient requested volunteer visits. In RRHV#3 on the admission the nurse’s narrative stated 2. Supervisory visit completed today and below the narrative the nurse checked the box No supervision at this time. Also, RRHV#3 the recertification assessment was incomplete with 1 page of the 6 page assessment left blank and the Nurse Recertification Assessment 2 page document left blank. This was confirmed and discussed with the DON.”

“Observed in Record Review. During discussion with the Administrator and DON it was noted that the patient clinical record had not been retained for 7 years as required by California. They reported that since December 2025 they have had 9 admissions and the hospice had no patients in 2025 prior to December and no patients in 2024 and 2023. The Surveyor requested to see the 5 patient records from the hospice’s initial survey in 2023. The organization was only able to provide 4 of the 5 original records. This was confirmed and discussed with the Administrator and DON who were hired in December 2025 and January 2026.”

“Observed in Record Review. In 9 of 9 patient records reviewed, it was noted that the hospice had not developed an individualized plan of care for each patient. For example in record RRHV#1 the Care Problems section of the record included goals such as: Verbalizing a plan to eliminate health and safety hazards. Displaying hemodynamic stability, e.g., blood pressure, cardiac output, peripheral pulse, renal perfusion. Discussing techniques on prevention of potential infections associated with bladder disturbance. These goals were not individualized. For example, RRHV#2 the Care problems section goals were not individualized, Providing safe measures to prevent injuries. Facilitating creation of support system. Record RRHV#3 the Care problems section goals were not individualized, Displaying hemodynamic stability, e.g., blood pressure, cardiac output, peripheral pulse, renal perfusion. In RRNHV#1 the Care problems section goals wer not individualized, Demonstrating proper feeding techniques. Records RRNHV#2,3 and 4 and RRDC#1 and 2 included similar issues with goals. This was confirmed and discussed with the DON.”

“Observed in Record Review. In 1 of 9 patient records reviewed, it was noted that there was no documentation that the interdisciplinary group had reviewed or revised the plan of care.. For example in RRHV#1 documentation the was no documentation for the initial IDG meeting. This was confirmed and discussed with the DON present. Observed in Record Review. In 1 of 9 patient records reviewed, it was noted that the interdisciplinary group did not document its review and revision of the patient’s plan of care. For example in RRHV#1 the only documentation for 2 IDG meetings was a sign in sheet. This was confirmed and discussed with the DON present.”

“Observed in Record Review. In 5 of 9 patient records reviewed, it was noted that the organization had not provided the patient with care and service according to the patient’s individualized plan of care. For example in record RRHV#2 the hospice aide did not follow the ordered frequency of visits. The admission order was for weekly aide visits and the first aide visit was documented 5 weeks after the admission date. In record RRHV#1 the nurse frequency was ordered weekly and 2 weeks over 2 months there was no visit or missed visit documented. In record RRHV#3 the nurse visit frequency was ordered weekly and 3 weeks over 2 months there were 2 visits documented. In records RRNHV#3 and RRMHV#4 it was noted that there was no documentation of visit frequency for the nurse; not on IDG, the admission order or nurse notes. As a result unable to evaluate if the frequency was followed. This was confirmed and discussed with the Administrator and DON present.”

“Observed in Data Tracer. During the Data session it was noted that the hospice had not developed a data-based performance improvement program and did not have any active patients 2023, 2024, and 2025 January to December, hence leadership did not set priorities for data collection. This was confirmed and discussed with the DON present. Observed in Tracer Activities. During the Leadership and Data session the hospice was not able to provide an organization wide performance improvement for 2023, 2024 and 2025 January through November. This was confirmed and discussed with the DON present.”

“Observed in Tracer Activities. During review of the Volunteer program and discussion with the volunteer coordinator it was noted that the volunteer cost savings, positions occupied, work time spent occupying positions, and estimated dollar costs were not documented. For example, the organization did not have any patients in 2023 or 2024 and in 2025 admitted the first patient 12/6/26. There was no documentation of volunteer hours, the type of volunteer services, time worked and no percentage of the total patient care hours for December 2025. This was discussed with the Administrator and DON present.”

“Observed in Tracer Activities. During review of the Volunteer program and discussion with the volunteer coordinator it was noted that the volunteer had not provided at least 5% of the total patient care hours of all paid hospice employees and contract staff. For example, the organization did not have any patients in 2023 or 2024 and in 2025 admitted the first patient 12/6/26. There was no documentation of volunteer hours, the type of volunteer services, time worked and no percentage of the total patient care hours for December 2025. The Volunteer Coordinator stated during discussion that the total patient care hours for January 2026 was 7%. On review of the documented data, the data stated 5% of the total patient hours for the month was completed by a volunteer, however the math had been done incorrectly and the number was below 5%. This was discussed with the Administrator and DON present.”

“Observed in HR File Review. During review of HR files it was noted that staff did not participate in ongoing education and training to maintain their competency. For example, in files HRMSW and HRSC there was no documentation of annual or triannual education in the files. This was confirmed and discussed with the Administrator and DON present. Observed in HR File Review. In 3 of 12 HR files reviewed, it was noted that the staff competency was not assessed as part of orientation. For example, the volunteer’s file did not include an initial competency documented as part of orientation. RN file the competency document was only signed by the employee with no Qualified observer signature. The LVN file’s competency document stated that the LVN was competent to provide IV, IV medication and central line care. Upon discussion with the DON this was a mistake. In the This was confirmed with the Administrator present.”

“Observed in Record Review. In 9 of 9 patient records reviewed, it was noted that the patient record documentation was incomplete. For example RRHV#1 there were no medications or medication list included on 2 of 4 IDG notes, there was no narrative documented by anyone of the hospice core team (MD, RN, MSW, or SC) on 4 of 4 IDG notes, there was no POC with goals and interventions documented on 4 of 4 IDG notes and there was no visit frequency documented on 4 of 4 IDG notes. In RRHV#2 there were no narratives documented by anyone of core team on 2 of 4 IDG notes and on 2 of 4 notes only by RN documented, there was no POC with goals and interventions documented on 4 of 4 IDG notes, and there was no visit frequency documented on 4 of 4 IDG notes. In RRHV#3 there were no narratives documented by any core team on 1 of 7 IDG notes and on 3 of 7 IDG notes only the RN documented, there was no POC with goals and interventions on 5 of 7 IDG notes. and there were no visit frequency documented on 7 of 7 IDG notes. in RRNHV#1 there were no narratives documented, all areas left blank, by the core hospice team on 2 of 2 IDG notes, There were no medications or medication list on 2 of 2 IDG notes, and no visit frequencies on 2 of 2 IDG notes. Record RRNHV#2, #3, and #4 had similar findings. This was confirmed and discussed with the DON.”