Every finding on record at Accentcare Home Health of California, Inc.

It is required that the written Patient Bill of Rights includes the right to: be informed about the scope of services the hospice provides and any specific limitations on those services. This standard was not met as evidenced by clinical record review and interview. In 4 of 19 (21%) clinical records reviewed, the agency did not ensure that the patient was informed about the scope of services the hospice provided and any specific limitations on those services. Clinical Record 3: A review of the patient's Election of Benefits signed 04/29/2024, revealed no documented start of care date. The start of care (SOC) date was left blank, documenting: "I want my election of the Medicare/Medicaid hospice benefit to be effective on ________." Clinical Record 4: A review of the patient's Election of Benefits signed 06/29/2023, revealed a documented start of care date of 06/29/2023. However, the actual SOC was on 06/30/2023. Clinical Record 10: The patient elected the hospice benefit on 06/04/2025. The patient was provided the advanced beneficiary notice (ABN) upon start of care stating: "GIP general inpatient care level ABN. Reason Medicare may not pay: Usually, GIP ...is a non coverage of GIP level. If care of patient is clinically appropriate for routine level of care. Estimated cost $979.11 day." The patient signed this ABN on 06/04/2025. Clinical Record 17: A review of the patient's Election of Benefits signed 06/02/2025, did not have a documented start of care date. The family signed on 06/02/2025, and the hospice representative signed on 06/03/2025. The start of care (SOC) date was left blank, documenting: "I want my election of the Medicare/Medicaid hospice benefit to be effective on ________." The start of care date was 06/03/2025. During joint clinical record reviews and interviews on 06/10/2025, 06/11/2025, and 06/12/2025, the Director of Clinical Operations, Executive Director/Administrator, and Regional Director of Clinical Operations agreed "the start of care date needs to be included, but this usually happens with hospital discharges that don't come out the same day." For Clinical Record 10, the ABN was "supposed to specify that the room and board would not be paid without a discharge plan from a facility if they didn't qualify for GIP."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs; supplements; herbal remedies and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by clinical record review, observation, and interview. In 3 of 19 (16%) clinical records reviewed and home visits observed, the agency did not ensure that the patient's drug profile contained the patient's current medications. Clinical Record 1/Home Visit 1: The patient elected the hospice benefit on 05/01/2025 with a diagnosis of chronic obstructive pulmonary disease. The patient resided in a group home. During the home visit with the Hospice Aide (HA) [Personnel Record 7] on 06/10/2025, the hospice medication profile (printed on 06/09/2025) and the group home medication list (printed 06/10/2025) were reviewed. The hospice medication profile documented the following medications that were not included on the group home medication list: ciclodan 8% topical cream, apply to affected areas daily (ordered 05/02/2025); Combivent 25 mcg, inhale two (2) puffs daily (ordered 05/02/2025); hyoscyamine 0.125 mg, take one (1) tablet every six hours as needed (ordered 05/02/2025); and DuoNeb 3 mg, inhale one (1) vial every 6 hours as needed (ordered 05/02/2025). Clinical Record 2/Home Visit 2: The patient elected the hospice benefit on 12/20/2024 with a diagnosis of protein-calorie malnutrition. The patient resided in a skilled nursing facility (SNF). During the home visit with the Spiritual Counselor (SC) [Personnel Record 6] on 06/10/2025, the hospice medication profile (printed on 06/09/2025) and the SNF medication list (printed 06/10/2025) were reviewed. The hospice medication profile documented the following medications that were not listed on the SNF medication list: prochlorperazine 10 mg, take one (1) tablet by mouth every 6 hours as needed (ordered 12/20/2024); and omeprazole 40 mg, take one (1) capsule daily (ordered 12/24/2024). Additionally, the hospice medication profile documented, "Haldol 2mg/ml, give 0.5 ml every 6 hours (ordered 05/12/2025), and the SNF medication list documented "Haldol 2mg/ml, give 0.5 ml every 4 hours as needed (ordered 03/03/2025). Clinical Record 3/Home Visit 3: The patient elected the hospice benefit on 05/01/2024 with a diagnosis of Alzheimer's disease. The patient resided in a SNF. During the home visit with the Registered Nurse (RN) [Personnel Record 4] on 06/10/2025, the hospice medication profile (printed on 06/09/2025) and the SNF medication list (printed 06/10/2025) were reviewed. The hospice medication profile documented the following medications that were not listed on the SNF medication list: acetaminophen 25 mg, give one (1) tablet every 6 hours as needed (ordered 05/02/2024); antifungal cream, apply under breasts daily (ordered 04/14/2025); lorazepam 0.5 mg, give one (1) tablet every 6 hours as needed (ordered 05/02/2024); and hyoscyamine 0.125, give one (1) tablet every 4 hours as needed (ordered 05/02/2024). The SNF medication list documented, "Robitussin DM 100-10, give 10 ml every 3 hours as needed (ordered 02/23/2025). During a joint clinical record review and interview on 06/11/2025, the Director of Clinical Operations confirmed the findings and stated, "The medication updates are faxed to the facilities, but the nurses need to check them as well during every visit."

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires. This standard was not met as evidenced by clinical record review and interview. In 1 of 19 (5%) clinical records reviewed, the agency did not ensure that the individualized plan of care was updated as frequently as the patient's condition required. Clinical Record 12: The patient elected hospice care on 01/03/2025 with a diagnosis of malignant neoplasm of the rectosigmoid junction. The Plan of Care (POC) dated 03/25/2025 documented "Problem and Goals: Pain will be at an acceptable level of less than 5" and ordered skilled nursing (SN) services once weekly. The SN visit note dated 04/09/2025 documented "increase in Methadone related to pain of 7." The SN visit note dated 04/23/2025 documented "pain rated at 7. Worst pain in last 24 hours rated at 10. Increase Methadone." On 05/22/2025, the physician ordered an increase in the Methadone. A clinical record review revealed the next SN visit dated 05/27/2025. Throughout the medication increases due to the patient's increased pain, the POC was not updated with new interventions, goals, and the nursing visit frequency remained the same at once weekly. During joint clinical record reviews and interviews on 06/11/2025 and 06/12/2025, the Director of Clinical Operations, Executive Director/Administrator, and Regional Director of Clinical Operations agreed that the POC should have been updated and the patient should have documented evidence of follow-up to these pain issues."

It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 4 of 16 (25%) clinical records reviewed of patients who received Hospice Aide services, the agency did not ensure that the Hospice Aide (HA) received written patient instructions to meet the patient's needs. Clinical Record 4: The patient elected hospice care on 06/29/2023 with a diagnosis of malignant neoplasm of the endometrium. The HA care plan dated 12/12/2024 assigned the HA the relevant tasks: "bed bath every visit and partial sponge bath when requested by patient." The HA visit frequency was twice weekly. The initial nursing assessment dated 06/29/2023 documented, "patient has cognitive deficits and is unable to sign her consents." The HA care plan did not specify the type of bath the patient was to receive, considering the patient had cognitive deficits and was unable to choose their bath type. Clinical Record 5: The patient elected hospice care on 12/05/2024 with a diagnosis of malignant neoplasm of the bladder. The HA care plan dated 12/05/2024 assigned the HA the relevant tasks: "bed bath and shower-seated every visit." The HA visit frequency was twice weekly. The HA care plan did not specify the type of bath the patient was to receive. Clinical Record 14: The patient elected hospice care on 03/25/2025 with a diagnosis of Parkinson's disease. The HA care plan dated 03/25/2025, and updated on 04/05/2025, 04/09/2025, and 05/07/2025, assigned the HA the relevant tasks: "Bed bath-every visit and turn and position in bed-every visit." The HA visit frequency was twice weekly. The initial skilled nursing (SN) assessment dated 03/25/2025 documented, "Stage II on coccyx, apply tegaderm for wound care. Cover with island dressing-gluteal crevice." The HA care plan did not alert the HA of the wound and did not provide the HA with any instructions for managing the dressing during the bath or to notify the SN if the wound dressing became soiled, dislodged, or wet. Clinical Record 19: The patient elected hospice care on 02/16/2024 with a diagnosis of chronic respiratory failure with hypoxia. The HA care plan dated 02/19/2024, and updated on 02/21/2024, 03/08/2024, 03/12/2024, 04/04/2024, and 06/27/2024, assigned the HA the following relevant tasks: "skin care-lotion to back, arms, and legs-every visit; bed bath-every visit; peri care-apply thick layer of barrier cream to sacral area-every visit." The HA care plan, updated on 02/21/2024, added the relevant task: "Use Hoyer to transfer the patient every visit." The HA visit frequency was twice weekly. The initial SN assessment, dated 02/16/2024, documented that the patient had a "Gastrostomy tube (G-Tube) and an unstageable PU (pressure ulcer) on the coccyx covered with Mepilex." The SN visit note dated 04/04/2024 documented: "wound still present." The SN visit note dated 04/22/2024 documented "wound no longer present." The HA care plan and the updated HA care plans did not alert the HA of the wound and did not provide the HA with any instructions for managing the dressing during the bath or to notify the SN if the wound dressing became soiled, dislodged, or wet. The HA care plans did not include notification or specific instructions for the HA regarding the G-Tube. During interviews and joint clinical record reviews on 06/10/2025, 06/11/2025, and 06/12/2025, the Director of Clinical Operations, Executive Director/Administrator, and Regional Director of Clinical agreed that the "aides needed to be provided with one bath type and specific instructions when the patients had a wound."

It is required that a registered nurse makes an annual on-site visit to the location where a patient is receiving care in order to observe and assess each hospice aide while he or she is performing care per the hospice’s policies and procedures. This standard was not met as evidenced by interview and personnel record review. In 1 of 1 (100%) personnel record review of a Hospice Aide (HA), the agency did not ensure that a Registered Nurse (RN) made an annual on-site visit to the location where a patient was receiving care to observe and assess the Hospice Aide performing care. Personnel Record 7: The Hospice Aide was hired on 10/09/2006. A personnel record review revealed no evidence of an annual on-site visit for 2024. During the joint personnel record reviews and interviews on 06/11/2025 and 06/12/2025, the Director of Clinical Operations, Executive Director/Administrator, and Regional Manager of Business Operations confirmed they were "unable to locate documentation of an aide supervisory visit for 2024."

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review, document review, and interview. Agency policy #HOS 2-083 "Discharge Summary" (effective 01/01/2013) (revised 09/12/2023) stated in part: "All patients discharged from hospice service shall have a discharge summary completed and filed in the clinical record." Agency policy #HOS 2-082 "Discharge from Hospice Program" (effective 01/01/2013) (revised 11/08/2024) stated in part: "The case manager shall ensure that all necessary paperwork is completed during the discharge visit, including Discharge or Transfer Summary..." In 1 of 2 (50%) clinical records reviewed of discharged patients, the agency did not ensure that the discharge summary included a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. Clinical Record 16: The patient elected the hospice benefit on 05/15/2024 and revoked their hospice benefit on 06/14/2024 to "seek aggressive treatment in the hospital." A review of the clinical record revealed no evidence of a documented discharge summary. During joint clinical record reviews and interviews on 06/10/2025, 06/11/2025, and 06/12/2025, the Director of Clinical Operations, Executive Director/Administrator, and Regional Director of Clinical Operations confirmed the finding, stating, "It should have been documented but might have been missed as the patient went to the hospital."

It is required that the hospice designates a registered nurse member of the IDG to: provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed revealed that medical social services was not provided as ordered on the plan of care. Clinical Record 3: The patient elected the hospice benefit on 10/22/2021. There was no visit frequency for the social worker documented on the plan of care for Benefit Period 7/12/2022 - 8/1/2022. A visit was documented as missed on 8/18/2022 and a phone visit was documented by the social worker on 8/26/2022. The Administrator was interviewed on 8/30/2022 and agreed that the plan of care did not include visit frequencies for the social worker. He had no additional information to provide.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan: as frequently as the patient's condition requires; but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed revealed that the Interdisciplinary Group did not document the review of the individualized care plan every 15 days. Clinical Record 8: The patient elected the hospice benefit on 6/9/2020. The clinical record evidenced that the plan of care was reviewed on 5/4/2022 and 6/1/2022. There was no evidence that a review occurred on 5/18/2022. The Administrator was interviewed on 8/30/2022 and agreed that the plan of care for this patient was not reviewed on the indicated date. He had no additional information to provide.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 1 of 13 (8%) clinical records reviewed revealed that hospice aide services were not provided as ordered in the plan of care. Clinical Record 3: The patient elected the hospice benefit on 10/22/2021. The plan of care for Benefit Period 5, which began on 8/18/2022, ordered the Hospice Aide visit frequency at two times each week. There was no visit documented on 8/19/2022 and there was no documentation stating why the visit was missed. The Administrator was interviewed on 8/30/2022 and agreed that there was no documentation to explain why the visit was not completed. He had no additional information to provide.