Every finding on record at Cp Sonoma N-Ca Hospice, LLC

Observed in Record Review. In 7 of 18 patient records reviewed, The surveyor observed that the patient wounds had not been measured weekly as required by HCO policy. The surveyor observed that multiple patients in SNFs the hospice staff had documented wound care completed by SNF staff and hospice staff had not documented any wound measures for multiple weeks some exceeding 3 weeks and two records the surveyor observed that wound had not been measured on admit and greater than one week before wounds were measures. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 9 of 18 patient records reviewed, The surveyor observed that the plan of care goals had not been measurable the organization had changed their EMR in late 2025 and the new system generated more generic non measurable goals that clinicians had been using. The issue was discussed and confirmed with organization.

Observed in Record Review. In 1 of 18 patient records reviewed, the hospice surveyor noted that the organization did not make sure that the plan of care included treatments necessary to meet the patient’s needs. For example, in HOSRRHV#4, the wound care order did not include a complete wound order describing what the wound should be cleansed with, only stating clean area with, providing no detail. This was reviewed and discussed with leadership. Observed in Individual Tracer. In 1 of 6 home visits conducted, The surveyor observed in observing review of medications with RN in HOSHV#1 that two symptom management PRN medications without indication for when to take which medication. For example the surveyor observed that the patient had two medications for pain without indications as to when to take which medication. The issue was discussed and confirmed with organization leadership.

Observed in Patient Home. In 2 of 6 home visits conducted, the hospice surveyor noted that the organization did not make sure that clinicians followed infection control activities that support the use of standard precautions and hand hygiene practices. for managing infection control practices. For example, in HOSRRHV#4, the clinicians did not perform hand hygiene consistent with the organization;s policy Infection Control: Bag technique for in Home Care and Standard Precautions. The clinician did not perform hand hygiene after gloves were removed and before donning new gloves to change from cleaning the wound to then applying the clean dressing. Additionally, she did not perform hand hygiene after removing gloves at the end of wound care. She then used her tablet and left the patient residence without performing hand hygiene. This was reviewed and discussed with leadership.

Observed in Patient Home. In 1 of 6 home visits conducted, The surveyor observed that the organization had not given the family a copy of organization policy on the management and disposal of controlled drugs. The issue was discussed and confirmed with organization leadership.

Observed in Record Review. In 7 of 18 patient records reviewed, the organization did not complete a comprehensive assessment In accordance with their policy: Initial and Comprehensive Assessments which states the Chaplain will complete a spiritual assessment including spiritual concerns and practices important to the patient and family that influence care, treatment and services or needs identified by the patient or family and desire for involvement of a religious group. In review of the medical record for HOS 1, HOS 4 and RR 9 the spiritual assessment was completed by the social worker, for HOS 2 and, RR 3 and RR 10 there was no evidence in the medical record that a spiritual assessment had been completed, and for HOS 3 the spiritual assessment had been completed by the RN on admission.. This was validated by the Support Services Manager.

Observed in Record Review. the organization did not complete the comprehensive assessment no later than five calendar days after the election of hospice care. For example, in review of the medical record for HOS 1 the surveyor noted that the spiritual counselor did not complete an initial assessment of the patient's need for spiritual care. There was a note entered in the record on the 7th day following the election of hospice benefits however the spiritual assessment had not been completed. This was validated with the Support Services Manager.

Observed in Patient Home. The organization had not assessed potential medication-related problems. During the survey visit for HOS 1 the hospice nurse reviewed and reconciled the hospice medication list with the MAR from the Skilled Nursing Facility when it was noted that the hospice medication list included Seroquel 25mg take one tablet by mouth nightly and take 12.5 mg one time a day, however the MAR from the SNF only included Seroquel 25 mg take one tablet by mouth nightly. The hospice nurse discussed the medications with the facility nurse and was informed that they had started tapering the medication 22 days ago. Additionally, the hospice medication included the medication Remeron 15 mg by mouth nightly however the MAR from the facility indicated that the patient is receiving 1/2 tablet and had been on that dose for more than six months prior to admission to the hospice program indicating that the medication had not been documented correctly on admission to the hospice program. This was validated by the Clinical Manager.

Observed in Record Review. In 4 of 18 patient records reviewed, a registered nurse had not supervised the hospice aide during an on-site visit to the patient’s home no less frequently than every 14 days. In review of the medical record for RR 1 there was no evidence that supervision of the hospice aide had occurred. Additionally, in review of RR 8 there was a supervisory visit missed when it was noted that there had been 21 days between supervisory visits by the RN, in review of RR11 there was a period of 7 weeks when there was no documentation of supervision of the hospice aide and in review of RR 12 there was a period of 16 days between supervision of the hospice aide. This was validated with the Clinical Director.