Every finding on record at Faithful Hospice Care, Inc.

Based on record review and interview, the hospice agency's interdisciplinary group (IDG - team of professional individuals that are involve with patient's plan of care) failed to update the plan of care (POC) to reflect changes in patient 14's skin condition. This failure had the potential to leave patient 14’s skin condition untreated, resulting in further skin deterioration and discomfort. --- Findings:During an observation of Patient 14’s home visit conducted on 4/28 at 12 p.m., Patient 14’s care with the hospice aide (HA) was observed. While providing care, the HA discovered a purplish skin discoloration on Patient 14’s right and left upper arms. The HA verbalized the skin condition was new and would be reported to the nursing supervisor.During a review of HA visit notes dated 4/28, the notes indicated Patient 14’s bilateral upper‑arm bruising.During a review of Patient 14’s registered nurse (RN) visit notes dated 4/28, the RN visit notes indicated the RN assessed Patient 14 and confirmed the HA’s findings of skin bruising on both upper arms.During a review of Patient 14’s Plan of Care (POC) Interdisciplinary Group (IDG) Review dated 4/29, no POC was found addressing Patient 14’s bilateral upper‑arm skin discoloration.During a concurrent interview and record review on 4/30 at 2:54 p.m. with the RN/case manager (CM), Patient 14’s clinical record was reviewed. The CM acknowledged the missing POC for Patient 14’s new skin condition on the bilateral upper arms and stated the POC should have been initiated but was not.During a review of the P&P titled “The Plan of Care,” dated April 2021, the P&P indicated: “A written individualized patient and family caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care…The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis…12. The written plan of care will contain…B. Identification of patient and family/caregiver needs, including physical, psychosocial…spiritual…J. Frequency and type of services…14. Care provided to the patient will be in accordance with the plan of care.”

Based on record review and interview, the hospice agency failed to ensure care and services were provided in accordance with the Plan of Care (POC) for seven of the 14 patient records reviewed (Patient 14, Patient 12, Patient 3, Patient 9, Patient 6, Patient 11, and Patient 13).For Patient 14, Spiritual Counselor (SC) frequency of visit was not fulfilled, and the Medical Social Worker (MSW) missed the visit for 3/2026.For Patient 12, the SC visit was not fulfilled.For Patient 3, the hospice aide (HA) visit was incomplete, and the SC visit was not fulfilled.For Patient 9, the Skilled Nursing (SN) visit was missed for the week of 4/12/26–4/18/26.For Patient 6, no SC visit was provided.For Patient 11, no SC visit was provided.For Patient 13, no SC visit was provided.These failures had the potential to result in unmet patient needs as outlined in the POC, which may contribute to poor patient outcomes. --- 5. During a review of patient 6’s health records on 4/29/26 at 3:30 pm, the plan of care indicated the Chaplain (SC) had a visit frequency of one per month, for the certification period of 3/5/26 to 6/2/26. On 3.9.26 the SC documented the patient refused SC services, the plan of care was not updated and still indicates SC visit is one per week and no SC visits documented.During an interview with the director of patient care services designee (DPCSD) on 4/29/26 at 3:50 pm, the DPCSD acknowledged plan of care should have been updated. 6. During a review of patient 11’s health records on 4/29/26 at 3:38 pm, the plan of care indicated the Chaplain (SC) had a visit frequency of one per month, for the certification period of 1/2/26 to 4/1/26. On 1/5/26 the SC documented the patient refused SC services, the plan of care was not updated and still indicates SC visit is one per week and no SC visits documented. During an interview with the director of patient care services designee (DPCSD) on 4/29/26 at 3:50 pm, the DPCSD acknowledged plan of care should have been updated. 7. During a review of patient 13’s health records on 4/29/26 at 3:45 pm, the plan of care indicated the Chaplain (SC) had a visit frequency of one per month, for the certification period of 1/13/26 to 3/13/26. On 7/18/25 the SC documented the patient refused SC services, the plan of care was not updated and still indicates SC visit is one per week and no SC visits documented. During an interview with the director of patient care services designee (DPCSD) on 4/29/26 at 3:50 pm, the DPCSD acknowledged plan of care should have been updated. During a review of the P&P titled, “The Plan of Care,” dated April 2021, the P&P indicated, “A written individualized patient and family caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care…The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis…2. The Case Manager (or admitting  registered nurse) will then notify the attending physician and core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs…12. The written plan of care will contain…B. Identification of patient and family/caregiver needs, including physical, psychosocial…spiritual…J. frequency and type of services…14. Care provided to the patient will be in accordance with the plan of care.” Findings: 1.During a review of the registered nurse (RN) recertification assessment, dated 2/2/26, indicated an RN referral for MSW and SC visit. During a review of Patient 14’s clinical record, review period 2/7/26 – 4/7/26, Patient 14’s Interdisciplinary Group (IDG – team of professional individuals that are involve in patient's plan of care) Review, dated 2/4 and 2/18, the POC for a MSW visit was one (1) per month during initial evaluation then monthly follow up visit and as needed while the SC visit on initial evaluation to assess the need for spiritual support then monthly follow up visit and as needed.Further review of Patient 14’s clinical record indicated a missing MSW visit for the month of March 2026, and SC visit after the initial SC assessment. No documentation was found why the POC for MSW and SC were not followed.2.During a review of RN recertification assessment, dated 12/9/26, indicated an RN referral for an SC visit. During a review of Patient 12’s clinical record, review period 12/16/25 – 3/15/26, Patient 12’s IDG Review, dated 12/10, the POC for SC visit during initial evaluation to assess the need for spiritual support then monthly follow up visit and as needed.Further review of Patient 12’s clinical record, no SC follow up visit documentation was found after Patient 12's initial visit by the SC.3. During a review of RN comprehensive nursing assessment, dated 12/11/25, indicated an RN referral for an SC visit and the need for HA visit. During a review of Patient 3’s clinical record, review period 12/11/25 – 3/10/26, Patient 3 was admitted on 12/11/25 for hospice services due to Chronic Obstructive Pulmonary Disease (COPD – a type lung condition), the IDG Review, dated 12/11, indicated that the POC for an SC visit during initial evaluation to assess the need for spiritual support then monthly follow up visit and as needed and HA visit two times per week to assist with personal care, home making and to provide comfort.Further review of Patient 3’s clinical record, no follow up visit was made after the initial SC visit and HA visit record indicated Patient 3 was only visited one time the week of 12/24/25 to 12/20/25 when the POC HA visit was twice a week. No additional documentation was found why the POC was not followed. 4.During a review of Patient 9’s clinical record, review period 1/24/26 to 4/23/26, Patient 9 was admitted for hospice services on 1/24/26 due unspecified Heart disease (heart problems), the POC for the SN visit for indicated that Patient 9 is to be visited by a registered nurse (RN) 1 visit per week to do initial evaluation then weekly visit thereafter for ongoing comprehensive assessment. Further review of Patient 9’s clinical record indicated no RN visit was found the week of 4/12/26 to 4/18/26. Patient 9’s clinical record had no documentation about the reason for the RN missed visit.During an interview and record review on 4/30, at 2:54 p.m. with the Case Manager (CM). Patient 14, 12, 3 and 9's clinical record were reviewed. The CM was unable to provide additional documentation and acknowledged that Patient 14, 12, 3 and 9"s POC was not followed. During a review of the facility’s policy and procedure (P&P) titled, “Missed Visits,” dated April 2021, the P&P indicated in part, “…1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for the missed visit. B. Document in the patient’s clinical record the following information: 1. Patient name. 2. Date and type of visit that was missed. 3. Reason for the missed visit. 4. Description of any unmet needs and how the patient’s needs were met. 5. Other follow up needed. 6. Other person(s) that were notified of the missed visit…”During a review of the P&P titled, “The Plan of Care,” dated April 2021, the P&P indicated, “A written individualized patient and family caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care…The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis…2. The Case Manager (or admitting  registered nurse) will then notify the attending physician and core member of the interdisciplinary group of the initial assessment findings, the identification of patient needs and the recommended services to meet those needs…12. The written plan of care will contain…B. Identification of patient and family/caregiver needs, including physical, psychosocial…spiritual…J. frequency and type of services…14. Care provided to the patient will be in accordance with the plan of care.”

Based on personnel file review and interview, the hospice agency failed to ensure that two hospice aides (HA 1 and 2) received 12 hours of in-service training during a 12-month period.This failure had the potential to result in hospice aides’ credentials not being updated. --- Review of the hospice agency’s policy and procedures (P&P) titled  “Personnel Administration-Hospice Aide Training” revised 4/2021, the P&P indicated, “…Hospice will offer 12 hours of inservice training per year to be used to meet the annual inservice requirements.”During a review of the agency’s monthly in-service training sign-in sheets with the case manager (CM) on 4/30/26 at 4:00 PM, the in-service training sign-in sheets indicated that HA1 did not attend the in-services training in January and February 2026. Furthermore, HA2 did not attend the in-services training from January to August 2025.     During a concurrent interview, CM acknowledged that HA 1 and 2 had not completed the required 12 hour of in-service training, which they should have.

Based on record review, policy review, and interview, the hospice agency’s Governing Body (GB) failed to ensure:That Patient 4’s and Patient 2’s family member (FM) or advocate received written notification explaining the investigation steps, results, resolution, and date of completion for each filed grievance. This deficient practice had the potential to affect any patients or representatives filing grievances.That the grievances identified in the agency’s “QAPI Summary‑2026” were transferred into a Performance Improvement Project (PIP) for monitoring. This failure had the potential to prevent tracking the effectiveness of remedial steps performed.That one of the two social workers (SW 2) providing direct patient services maintained a current license. This failure had the potential to undermine the hospice agency’s compliance with federal and state regulations.That two hospice aides (HA 1 and HA 2) received 12 hours of in‑service training during a 12‑month period.This failure had the potential to result in hospice aides’ credentials not being updated. --- 1.Review of the agency’s policy and procedure (P&P) titled, “Complaint/Grievance Process” revised 4/2021, the P&P indicated, “…Resolution information will be communicated in writing to the patient or his/her representative filing the complaint.”During a review of  grievances submitted by family member (FM) or advocates on behalf of Patient 4 on 02/26/26 and Patient 2 on 4/11/26 about hospice patient care. The grievance submitted indicated that no written notification of resolution (letter) was issued to the FM or advocates of patients 4 and 2, explaining how the investigation was conducted, the results of that investigation and the action taken or findings.During an interview on 4/30/26 at 3:18 PM, the administrator (ADM) verbalized that “she communicated the grievance investigation results to the complainants over the phone, and she acknowledged that she had not provided written notification of the resolution to patients, patient’s families, or patient advocates for the grievances filed on behalf of Patient 4 and Patient 2. The ADM concurred that any grievances should be followed up with patients and patient advocates in writing, in accordance with the agency’s policies and procedures.2.Review of the agency’s document “Governing Body Meeting” dated 1/21/2026, the document indicated, “…The Governing Body approved the…data to be collected on a quarterly basis:…patient complaints…The Governing Body reviewed the Performance Improvement Project (PIP) projects that the hospice continues to be monitoring…”A review of the agency’s “Quality Assessment and Performance Improvement (QAPI) summary 2026” indicated, in part, the findings or percentages of grievances received in the first quarter of 2026.A review of the agency’s “Performance Improvement Project (PIP)” for the first quarter (Q1) of 2026 indicated no documented evidence that the complaints issue was addressed in the PIP program. During an interview on 04/30/26 at 3:18 PM, the administrator confirmed that the agency’s issues with complaints they received for the Q1-2026 were not included in the PIP program and should be. 3.) During a review of SW 2’s employee records, it was found that SW 2’s registration/license as an Associate Clinical Social Worker (ASCW) has been expired since 1/31/25.  This was verified on the California Department of Consumer Affairs (DCA) website using the License Search online tool (https://search.dca.ca.gov).  The licensing details for SW 2 also indicated a primary status of “cancelled.”During a concurrent interview and record review conducted on 4/29/26 at 2 p.m. with the agency’s Case Manager (CM), it was noted that SW 2’s registration/license had expired. CM stated that attempts to contact SW 2 to verify whether a renewal was in process had been unsuccessful.  CM also stated that SW 2 continues to conduct independent patient home visits as documented in the agency report titled, "All Visit Reports," dated 2/2025 through 4/2026, which summarizes all home visit dates conducted by SW 2 for this specific period.  The “California Business and Professions Code (BPC) 4996.14.2(b),” which requires that "individuals practicing clinical social work, as defined in Section 4996.9, maintain an active license or registration while working in nonexempt settings," was reviewed with CM. CM acknowledged that SW 2’s registration/license should have been renewed after it expired.During a review of the agency’s “Job Description” titled “Social Services Supervisor,” revised 4/2021, the job description indicated in part, “ESSENTIAL JOB FUNCTIONS/ RESPONSIBILITIES… 2) Ensures compliance with all state, federal, and Joint Commission (an accreditation organization) social service regulatory requirements….” 4.) Review of the hospice agency’s policy and procedures (P&P) titled  “Personnel Administration-Hospice Aide Training” revised 4/2021, the P&P indicated, “…Hospice will offer 12 hours of inservice training per year to be used to meet the annual inservice requirements.”During a review of the agency’s monthly in-service training sign-in sheets with the case manager (CM) on 4/30/26 at 4:00 PM, the in-service training sign-in sheets indicated that HA1 did not attend the in-services training in January and February 2026. Furthermore, HA2 did not attend the in-services training from January to August 2025.     During a concurrent interview, CM acknowledged that HA 1 and 2 had not completed the required 12 hour of in-service training, which they should have.

Based on record review and interview, the hospice agency failed to fulfill the professional licensing mandate for social worker. --- The CONDITION OF PARTICIPATION was not met when:The hospice agency (HA) failed to ensure its direct-hired social worker (SW2) professional providing services directly to hospice patients had maintained an active license in accordance with applicable state, local, and federal laws. (Refer to L784) The cumulative effects of these systemic problems resulted in the hospice’s inability to ensure the provision of quality health care and inability to comply with the Conditions of Participation 42 CFR 418.114 Personnel Qualification.

Based on record review and interview, the hospice agency failed to ensure one of its two employed social workers (SW 2) maintained an active State registration/licensure.This failure had the potential for the agency to face regulatory penalties or sanctions for non-compliance with State licensure requirements.Findings: --- During a review of SW 2’s employee records, it was found that SW 2’s registration/license as an Associate Clinical Social Worker (ASCW) has been expired since 1/31/25.  This was verified on the California Department of Consumer Affairs (DCA) website using the License Search online tool (https://search.dca.ca.gov).  The licensing details for SW 2 also indicated a primary status of “cancelled.”During a concurrent interview and record review conducted on 4/29/26 at 2 p.m. with the agency’s Case Manager (CM), it was noted that SW 2’s registration/license had expired. CM stated that attempts to contact SW 2 to verify whether a renewal was in process had been unsuccessful.  CM also stated that SW 2 continues to conduct independent patient home visits as documented in the agency report titled, "All Visit Reports," dated 2/2025 through 4/2026, which summarizes all home visit dates conducted by SW 2 for this specific period.  The “California Business and Professions Code (BPC) 4996.14.2(b),” which requires that "individuals practicing clinical social work, as defined in Section 4996.9, maintain an active license or registration while working in nonexempt settings," was reviewed with CM. CM acknowledged that SW 2’s registration/license should have been renewed after it expired.During a review of the agency’s “Job Description” titled “Social Services Supervisor,” revised 4/2021, the job description indicated in part, “ESSENTIAL JOB FUNCTIONS/ RESPONSIBILITIES… 2) Ensures compliance with all state, federal, and Joint Commission (an accreditation organization) social service regulatory requirements….”

Observed in Record Review. In 2 of 12 patient records reviewed, The hospice nurse surveyor noted (ARR#4) that the patient was admitted with a terminal diagnosis of CHF and a secondary diagnosis of IDDM prescribed both Farxiga and Metformin. There was no evidence that a severity of the patient's diabetes was completed including any blood glucose levels or an assessment of the patient's ability to manage blood glucose monitoring. Also, the patient was also just admitted to a new board and care and there was no documentation of an evaluation of the caregiver's ability to manage diabetes. The organization received a call from the board and care reporting that the patient's blood glucose level was 57, less than two weeks later. In (ARR#5) the patient was admitted with a secondary diagnosis of IDDM and prescribed routine and sliding scale insulin. Also, the patient had recently had two toes amputated and had two wounds. The surveyor noted that there was no documentation to confirm that an assessment of the patient's diabetic symptoms was assessed nor an assessment of the patient or caregiver's ability to manage the routine and sliding scale insulin and blood glucose monitoring. Also, there was no assessment of the patient/caregivers ability to manage the prescribed wound care. This was confirmed with the director of clinical services.

Observed in Record Review. In 2 of 14 patient records reviewed, The hospice nurse surveyor noted that (ARR#4), there was no evidence that the patient or board and care staff were educated about diabetes management, glucose monitoring, medication use, and complications. In (ARR#5) the surveyor noted that there was no documentation to confirm that the patient and board and care staff where provided any diabetes education, glucose monitoring and insulin administration or education about how to perform the ordered wound care. This was confirmed with the director of clinical services.

Observed in Record Review. In 2 of 12 patient records reviewed, The hospice nurse surveyor noted In (ARR#4) that there was a goal for diabetes; however it did not include any intervention for assessing the patient/caregivers management of blood glucose monitoring. Also, in (ARR#5) that there was no plan of care goals and interventions to manage the patient's insulin dependent diabetes. Also, there were no measurable outcomes for managing the diabetes. The surveyor noted that there were orders on file to cleanse the wound with cleanser and pat dry with gauze. Apply skin prep (car stock) to the peri-wound and apply Tetracyte and medical grade honey to the wound bed, followed by hydrogel and oil emulsion gauze. Cover with bordered gauze 3x weekly and PRN for soiled or loose dressing. The care plan did not specify who was to perform the wound care or when, for this patient in a board and care setting. The patient was also being followed by a wound specialist and that was not indicated in the plan of care. This was confirmed with the director of clinical services.

Observed in Individual Tracer. The hospice nurse surveyor noted (HOSHV#3) that the Home Health Aide removed the patient's oxygen prior to and it remained off while she provided a bed bath including a shampoo. She also, instructed the patient to lift himself up to remove his lower body garments, thus fatiguing the patient. The aide care plan did not include any instructions to remove the oxygen during the bath. The surveyor noted that the most recent order from January for oxygen read: patient on routine oxygen at 2 liters per minute continuously via nasal cannula. This was confirmed with the director of clinical services.

Observed in Document Review. In 1 of 4 contracts reviewed, The hospice nurse surveyor noted that the DME contract did not include language requiring criminal background checks. This was confirmed with the administrator.

Observed in Record Review. In 4 of 11 patient records reviewed, the organization had not determined how staff function within the organization in compliance with CMS standards. For example in RR1, RR3, RR5, RR6 and the records associated with HV2 and HV3, the Certified Home Health Aide care plans were initiated by the Licensed Vocational Nurse instead of the standard directed Registered Nurse. This was confirmed by the Administrator.

Observed in Individual Tracer. In 3 of 3 home visits conducted, the organization had not ensured the patient's record information that reflects the patient's care, treatment, or services. For example, during the three home visits conducted all home records failed to have information about the plan of care, medication list or copy of the advance directive (DNR/ Power of Attorney) since the time of admission. All patients were on service with a staff member visiting at least weekly and a supervisory visit every two weeks. This was confirmed by the Nurse performing the visits.