Every finding on record at Alpha Hospice Care, Inc.

Observed in Tracer Visit. In 1 out of 1 home visits conducted with the LVN, the medication assessment was not accurately completed and did not meet policy requirements. During the visit, the LVN was prompted several times to review the labels and validate caregiver knowledge when discrepancies were noted. During the visit, the LVN did not use the revised agency tool for medication reconciliation in the home. This was confirmed by the DON.

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 Tracer Visit. In 1 out of 1 home visits, the medication profile within the medical record was not accurate, as evidenced multiple outdated entries remaining on the medication profile in the medical record. For example, Vitamin B, Triple Antibiotic ointment, Seroquel 25 mg (morning), Seroquel 25 mg (evening), Norvasc, and Hydrocortisone cream had all been discontinued three weeks prior; however, these medications were still listed as active on the medication profile within the medical record. This was confirmed by the DON.

Observed in Record Review. In 5 of 9 patient records reviewed, it was noted that the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. For example in record RRHV#3 there was no spiritual assessment documented and no documentation that the patient/family declined. In RRNHV#1, #2, #3 and #4 there was no spiritual or social work assessment documented. This was confirmed and discussed with the DON and Administrator.

Observed in Patient Home. In 2 of 2 home visits conducted, with the hospice nurse, it was noted that she failed to conduct a medication assessment. For example during visits RRHV#1 and RRHV#3 the LVN did not perform a medication assessment as required by policy. This was confirmed and discussed with the DON.

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 to no documentation and was unable to demonstrate operation of a program 2023, 2024 and 2025 January to December.  This was confirmed and discussed with the DON and Administrator present. Observed in Data Tracer. During the Data session it was noted that the hospice did not have a quality assessment and improvement program in place for 2023, 2024 and 2025 January to December.  This was confirmed and discussed with the 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 Record Review. In 2 of 2 patient records reviewed, it was noted that the RN had not effectively supervised the hospice aide. For example, in record RRHV#2 the aide service was ordered and did not begin for 5 weeks. During the 5 weeks the RN documented 2 aide supervision visits that stated that the aide had provided care, performed duties and Staff member visits on time. This was confirmed and 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 hospice had not documented efforts to recruit or retain volunteers. The Volunteer Coordinator reported that he had started with the organization 3 months ago and that there was no documentation of a volunteer program on his arrival. He also stated that he plans to develop flyers for recruitment, but had not yet. This was confirmed with the Volunteer Coordinator and Administrator 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 Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services. The hospice did not manage the implementation of policies and procedures as evidenced by- condition level findings at 418.114, 418.113, 418.54, 418.78, 418.100, 418.102, 418.56, 418.76, 418.104, and 418.58.

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 3 of 9 patient records reviewed, it was noted that the Medical Director did not review clinical information or sign the initial certificate of terminal illness. For example in records RRHV#1, RRHV#2 and RRNHV#1 the initial CTI documentation was not completed, left blank. This was confirmed and discussed with the DON and Administrator present.

Observed in Record Review. In 2 of 9 patient records reviewed, it was noted that the Medical Director failed to review the clinical information and sign the CTI prior to recertification. For example in record RRHV#2 and RRHV#3the CTI was not completed prior to recertification, it was blank. This was confirmed and discussed with the Administrator and DON present.

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. 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.

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 HR File Review. During review of human resource files it was noted that the organization had not verified a license upon hire. For example in HRHHA2 file there was a document that stated it was a primary source of license, however there was no date of when the hospice received the document. This was confirmed and discussed with the DON and Administrator present.

Observed in HR File Review. During HR file review it was noted that the criminal background check was not conducted or documented per policy. For example in the HRMed Director file the employee start date was 3/25/2020 and the criminal background check in the file was dated 1/6/2017. This was confirmed and discussed with the Administrator and DON present.

Observed in Record Review. In 4 of 5 patient records reviewed, The HCO did not ensure patient reassessments by the registered nurse(RN) take place at required intervals. For example, the surveyor noted on HV #1/RR #1, there were no RN reassessments between: 09/16/22 and 10/12/22, 11/25/22 and 12/21/22, 01/20/23 and 02/15/23, and none after 03/15/23 to present, on HV #2/RR #2, none between: 06/06/22 and 06/23/22, 09/15/22 and 10/11/22, 11/24/22 and 12/20/22, 01/19/23 and 02/14/23, and none after 03/15/23 to present, on HV #3/RR #3, none between 08/01/22 and 08/27/22, 10/24/22 and 11/14/22, 01/02/23 and 01/28/23, and 02/27/23 and 03/25/23, and on RR #5, none between 08/24/22 and 09/19/22. Standards require patient reassessment/updates take place at least every fifteen day intervals. These findings were reviewed, discussed, and validated by the Administrator/DPCS.

Observed in Record Review. In 1 of 5 patient records reviewed, The HCO did not ensure an initial comprehensive assessment was completed within five days of the patient electing the hospice benefit. For example, the surveyor noted on RR #4, the initial spiritual care assessment was completed on 08/23/2022, although the patient’s start of care date was 08/15/2022. There was no documentation or orders addressing the delay. Standards require a comprehensive assessment, including spiritual care, be completed within five days of a patient electing hospice care. These findings were reviewed, discussed, and validated with the Director of Patient Care Services and the Assistant Director of Quality.

Observed in Record Review. In 3 of 5 patient records reviewed, The HCO did not ensure patient care plan goals were attainable, measurable, realistic, and appropriately timed. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, and HV #3/RR 3, the patient’s care plan goals included statements such as: “ In 1-2 weeks and onwards, hand hygiene will be observed by all providers resulting to zero occurrence of communicable infections., In 1-2 weeks and onwards, Pt will remain free of injury resulting from decreased mentation, related to Alzheimer’s/dementia episodes of confusion., In 1-2 weeks and onwards, family will provide adequate social support through visits, calls, cards, expressions of concern or actual care, ,In 1 - 2 weeks, patient / PCG/ family will verbalize understanding re: occurrence or recurrent infection, including: pneumonia, sepsis, pyelonephritis, or other forms of UTI, that it is a part of disease process., In 1 - 2 weeks, patient / PCG/ family will verbalize understanding re: occurrence or recurrent infection, including: pneumonia, sepsis, pyelonephritis, or other forms of UTI, that it is a part of disease process.” These stated goals do not contain information that can be accurately measured to assist organizational staff in determining whether the patient is progressing towards achieving their goals and were not updated from one certification period to the other. These findings were reviewed, discussed, and validated with the Director of Patient Care Services and the Quality Coordinator.

Observed in Record Review. In 4 of 5 patient records reviewed, The HCO staff failed to provide patient care at the ordered frequency. For example, the surveyor noted on HV #1/RR #1, HV #2/RR #2, HV #3/RR #3, and RR #5, the hospice aide visits did not take place at the ordered frequency for many weeks. There were no communication, documentation, or physician orders, addressing the deviations. Standards require patient care be provided according to the patient’s individualized plan of care. These findings were reviewed discussed and validated with the Director of Patient Care and Quality Director.

Observed in Record Review. In 4 of 5 patient records reviewed, The organization did not ensure the registered nurse complete hospice aide supervisory visits as required. For example, the surveyor on HV #1/RR #1, HV #2/RR #2, HV #3/RR #3 and RR #5 there was no documentation of aide supervisory visits. Standards require the registered nurse supervise the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. These findings were reviewed, discussed, and validated by the Director of Patient Care Services and Quality Director.