Every finding on record at Grace Palliative and Hospice Care

Upon patient record review, 1 of 5 (Patient #3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #3: Patient admitted 10/3/25 with Foley catheter in place. Patient pulled Foley out 10/4/25 and SN made PRN visit. SN unsuccessfully attempted to insert new Foley. Visit note included documented to leave the Foley out per MD. However, there were no documented related problems goals and interventions for the Foley while in place and/or regarding being discontinued. No documented evidence that IDG was updated related to prn visit and Foley change in subsequent IDG 10/15, 10/29/25.

Upon patient record review, 1 of 5 (Patient #1) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: Patient admitted 10/9/25 with multiple wounds. Initial treatment orders for heels and thigh to cleanse with NS or wound spray at each skilled nursing visit. Pat dry. Apply Xeroform dressing to wound bed. Cover with Kerlix and secure with tape as ordered. Instruct PCG on proper wound reinforcement technique and how to identify dressing that is soiled, wet or dislodged. Frequency of wound care orders should be specific and indicate who is to perform wound care on the non SN visit days.

Upon patient record review, 2 of 5 (Patient #1, 3) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: Patient admitted 9/9/25 with 9/9/25 physician order for Referral to wound care specialty group related to multiple wounds. Initial wound care generally included Xeroform. Patient was seen by wound care specialty group 10/18/25, with recommendation for change in treatment to Calcium Alginate for heels and Iodoform for thigh. Changes were transcribed to physician orders. However, subsequent visit notes (10/23 and 10/28/25) continued to document Xeroform dressing, with no reference to updated orders. (Wound group had also documented visits 10/25 and 11/01/25 with recommendations to continue Calcium Alginate treatment.) Patient #3: Patient admitted 10/3/25 with Foley catheter in place. Patient pulled out catheter 10/4/25. SN made prn visit and unsuccessfully attempted to replace Foley catheter. Although there was documented correspondence with physician, there was no documented verbal orders related to catheter, including replacement and/or discontinuing.

Upon patient record review 3 of 5 (Patient #2,4,5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #2,4,5, No evidence of comprehensive assessment for spiritual and psychosocial and no evidence in RN initial assessment of psychosocial or spiritual assessment completed.

Upon patient record review, 2 of 5(Patient #1,3) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1,3, No evidence of order for oxygen under medication profile. DME has document oxygen concentrator and E tanks with the oxygen order connected to the DME.

Upon patient record review, 3 of 5 (Patient #1,2,4) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #1, No initial bereavement assessment completed. Assessment blank. Patient #2,4, No initial bereavement assessment completed. MSW documented in note as declined.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 3 of 5 (Patient #1,2,3) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1, RN initial assessment documented patient declined any further MSW, documented patient has extreme anxiety and history of emotional illness. SC documented as no further spiritual care. RN documented mild distress for both MSW and SC. No evidence of care plan addressing these concerns. Patient #2, No care plans identified on IDG dated 8/14/25 and 8/20/25. Patient #3, No problems, goals, interventions on care plans identified for MSW with frequency of monthly visits.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #3, MSW frequency monthly, every certification and as needed to evaluate which is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2, No evidence of DME documented on plan of care. RN initial assessment documents patient has his own bed, overbed table, walker, shower chair.

Upon client record review, 2 of 5 (Patient #1,2) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #1, 2, No evidence of MD participation /sign in note in EMR on 8/8/25, 8/20/25.

Upon client record review, 3 of 5 (Patient #1,2,4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1, RN frequency every 14 days. Patient seen by RN 8/8, 8/20 which is 12 days. SN frequency 1x/week. No evidence of weekly visits completed by SN. MSW made a visit on 8/9 without an order,  SC made a visit on 8/12 without an order. Patient #2, MSW declined, 8/15/25 assessment note documents in person, unscheduled visit that is declined. No evidence of order for visit or telephone visit. SC declined, 8/19/25 telephone scheduled visits documented as decline. No evidence of order for visit or telephone visit. Patient #4, SN frequency 1x/week, No evidence of SN visit the first week of 9/1/25.

Upon patient record review, 2 of 5 (Patient #3,5) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. No evidence in records of sharing of information from wound care agency.

Upon patient record review 4 of 5 (Patient #1,2,3,5) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1, Aide frequency 3x/week effective 8/8/25. First Aide visit completed 8/11/25, which is the 2nd week of the frequency. No missed visits noted. Patient #2, Aide frequency 3x/week effective 8/14/25. First Aide visit completed 8/18/25, which is the 2nd week of the frequency. No missed visits noted. Patient #3, Aide care plan directions for Aspiration precaution. No evidence this was completed as it was left blank on 9/16/25 note. Aide frequency 2x/week effective 8/31/25. First aide visit documented on 9/16/25 without any missed visits documented. Patient #5, Aide frequency 2x/week effective 9/8/25. No aide visits documented in the chart and no missed visits noted.

Upon patient record review 1 of 5 (Patient #2) did not have evidence documentation in the patient record that a Registered Nurse made an on-site visit to the patient's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group meet the patient's needs. Patient #2, No evidence of aide supervisory visit completed. RN visit note on 9/12/25 is blank.

Upon observation and request, there was no evidence the Medical Director or physician designee has the responsibility for the medical component of the hospice's patient care program as the Medical Director and Alternate were both unavailable to as they were both in surgery.

Upon patient record review, 1 of 14 (Patient #14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #14: Patient on service 9/11/24-11/17/24. Patient's election statement in patient file on start of survey which was signed 9/11/24 had a blank patient choice to choose or not choose attending physician. Agency presented a completed one the next day after informed however, was not in patient chart originally.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 4 of 14 (Patient #1, 8, 9, 10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: 7/12/25 order for oxygen 2l/min PRN. Problems, goals, interventions includes administer supplemental oxygen as prescribed to maintain desired oxygen saturation levels. Desired oxygen saturation levels are not defined in POC/Orders. Patient #8: 6/6/25 order for oxygen 2l/min PRN. Problems, goals, interventions includes administer supplemental oxygen as prescribed to maintain desired oxygen saturation levels. Desired oxygen saturation levels are not defined in POC/Orders. Patient #9: 6/10/25 order for oxygen 2l/min PRN. Problems, goals, interventions includes administer supplemental oxygen as prescribed to maintain desired oxygen saturation levels. Desired oxygen saturation levels are not defined in POC/Orders. Patient #10: 3/7/25 order for oxygen 2l/min PRN. Problems, goals, interventions includes administer supplemental oxygen as prescribed to maintain desired oxygen saturation levels. Desired oxygen saturation levels are not defined in POC/Orders.

Upon patient record review, 2 of 14 (Patient #8,9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #8: MSW frequency monthly, as needed and in every recertification to evaluate which is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. Patient #9: MSW and SC frequency within 5 days of SOC, monthly, as needed and in every recertification which is not a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs.

Upon patient record review, 7 of 14 (Patient #2,3,4,7,10,12,14) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #2: 7/2/25 order to provide Foley catheter care including placement every SN visit. Patient #3, 4, 7, 10, 12: Patient with wounds and services of specialized wound are service. Wound care orders in hospice plan of care include perform wound care every SN visit. The specific frequency ordered for wound care (including other participants - caregiver and/or wound care contractor)- is not clear, but necessary for coordination and compliance with treatment plan. Patient #14: 9/11/24 Order may drain indwelling pleural catheter 1x/weekly and as needed. As needed is not qualified.

Upon client record review, 2 of 14 (Patient #7,10) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #7: SOC 6/5/25 with MSW services ordered/provided. IDG meetings 6/25, 7/9/25: No evidence of MSW participation, sign in or note in (EMR). 7/23/25 IDG: No evidence of MD participation /sign in or note in EMR. No evidence of MSW participation, sign in or note in EMR Patients #10: 7/23/25 IDG No evidence of MD or MSW participation via signature. No MSW note. 7/6, 6/25/25: No evidence of MSW participation, sign in or note in EMR. A hard copy of attendance roster was provided to surveyor that includes above attendees, although not evident in EMR.

Upon client record review, 8 of 14 (Patient #1,3,4,9,10,11,12,14) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: 7/12/25 order for PT eval. PT recommended 1wk5. 1 additional visit note was documented 7/24/25. No evidence of order obtained for for follow up visit based on PT recommendation. Patient #3: Wound Savers wound care visit reports throughout service documented plan for wound care to be performed 3x/week, with wound care staff performing 1/wk and hospice staff 2/wk and PRN for wound dressing changes. Hospice orders/Plan of Care include wound care to be performed every RN/SN visit, but SN visit frequency is ordered 1/wk. (except for 7/1/25 order for SN 2/wk. week of 7/1-7/5, then 1/week.) Patients #4, 10, 12: Wound Savers wound care visit reports throughout service documented plan for wound care to be performed 3x/week, with wound care staff performing 1/wk. and hospice staff 2/wk. and PRN for wound dressing changes. Hospice orders/Plan of Care include wound care to be performed every RN/SN visit, but SN visit frequency is ordered 1/wk. Patient #9: SOC 6/10/24. Frequency written as monthly, as needed and every recert. Patient was seen monthly except no May 2025 visit. Patient #11: SOC 5/13/25. 5/14/25 MSW initial assessment narrative concludes with plan to visit patient monthly. Order for MSW monthly, as needed and in every recertification to evaluate ... There was no MSW visit in June. No evidence it was refused. Patient #14: SOC 9/11/24. MSW assessment is grossly blank/incomplete, dated 9/13/24 with time in and time out, therefore no evidence visit was actually made.

Upon patient record review, 4 of 14 (Patient #3,4,10,12) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. There is no documented evidence that the IDG reviewed and discussed Wound Saver of America recommendations in a coordinated plan of care.

Upon personnel record review, 1 of 13 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6: Hospice Aide competency for shampoo does not specify competency for sink, tub and bed types, but generalized shampoo.

Upon patient record review, 4 of 14 (Patient #1,8,9,10) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient#1: POC order 7/12/25 for oxygen 2lpm. Hospice Aide assignment includes no related reference to oxygen flow rate or safety precautions. Oxygen section blank. Patient #8: POC order 6/6/25 for oxygen 2lpm. Hospice Aide assignment includes no related reference to oxygen flow rate or safety precautions. Oxygen section blank. POC includes 6/6/25 order for mechanical soft diet, thin liquids and aspiration precautions. Hospice Aide assignment says diet as tolerated and other is checked. There is no specification for "other" including consistency ordered. Assignment also includes task to encourage fluids as tolerated if not contraindicated leaving decision making to aide, this needs to be more specific. Patient #9: POC order 6/10/25 for oxygen 2lpm. Hospice Aide assignment includes no related reference to oxygen flow rate or safety precautions. Oxygen section blank. Assignment includes task to encourage fluids as tolerated if not contraindicated. Patient on Plavix with no related bleeding precautions (blank) and medication and history of seizures with no related precautions (blank). Patient #10: POC order 5/28/25 for oxygen 2lpm. Hospice Aide assignment includes no related reference to oxygen flow rate or safety precautions. Includes task to encourage fluids if not contraindicated. Patient has sacral and heel wounds/dressings with no reference in Hospice Aide assignment to notify RN if soiled or bleeding or dislodged.

Upon personnel record review, 1 of 13 (Personnel #2) did not have evidence the alternate administrator's personnel record verifies that: • The employee has appropriate education and experience requirements • There is a signed job description for this role • The employee has been orientated to this role Personnel #2: Date of Hire 11/3/23. Job description requires 3-5 years in healthcare management experience. Application and resume do not support this requirement is met. Resume includes positions as Case manager (Nov 22-present); LVN Treatment nurse (May 23-Sept 2023); LVN Treatment nurse/ADON at LTCF May 2022-May 2023.

Upon patient client record review, 1 of 14 (Patient #14) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #14: Patient on service 9/11/24-11/17/24. Patient's election statement in patient file on start of survey which was signed 9/11/24 had a blank date of election and blank patient choice to choose or not choose attending physician. Agency presented a completed one the next day after informed however, was not in patient chart originally.

Upon patient client record review, 3 of 14 (Patient #3,10,12) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: SN note 7/29/25: "IDT withheld". Upon interview staff inadvertently meant IDT held. Patient #10, 12: Upon review of Wound Savers of California contract, 2a. includes that All Wound Specialist is a duly licensed Nurse practitioner and is authorized to perform.... Contractor visit reports include name only for visiting staff, no credentials to verify.

Upon personnel record review, 3 of 13 (Personnel #11, 12, 13) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #11,12,13: There was no criminal background check from contractor available to surveyor by end of survey.

Upon observation, there was no evidence the organizational chart matches the hospice's information submitted to CMS and/or State licensing agencies for ownership and management personnel. DPCS has hire date of 12/19/24. No evidence of update to CDPH was available to surveyor at time of survey.

Upon client record review, 1 of 5 (Patient #5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 5: On SOC orders MSW and SC visit frequencies were evaluation and monthly thereafter. There was no evidence of SC or SW visits in the months of March or April.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient 1: After care of patient placed safety barrier from under nursing bag back into clean space. Patient 3: After taking patients vitals placed dirty thermometer into clean bag, and placed dirty BP cuff into clean bag.