Every finding on record at Graceful Care Hospice, Inc.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization did not have a completed contractual agreement with the Alternate Medical Director which included the expectations in writing to the provider of the contracted services.

Observed in Record Review. In 1 of 2 patient records reviewed, During RR2 it was noted the POC was not updated to reflect pain level increase to 8/10 the end of October 2025. The POC was not updated to reflect this change in condition. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 2 patient records reviewed, During RR#1 it was noted the clinical SN notes, IDG POC updates and physician orders since the last survey, failed to include orders for a stage 2 coccyx pressure ulcer, oxygen at 7liters/min, and Foley catheter (F/C) change orders and care. During RR2 it was noted on the physician orders, to instruct on blood sugar monitoring however there is lack of documentation of a dx of diabetes on the RN initial assessment and CTI documentation. This was discussed with the administrator and quality staff.

Observed in Record Review. In 1 of 2 patient records reviewed, During RR1 it was noted an order for the SN to instruct pt. to monitor the patient blood sugars. The SN notes lack documentation of BS results by the patient/PCG as ordered. This was discussed with the organization leadership..

Observed in Document Review. There was lack of evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by conditional level findings in 418.102 and 418.56. This was discussed with the organization leadership.

Observed in Regulatory Review. During discussion with the DPCS it was noted the organization does not employ or contract with a physician to act as a designated alternate when the Medical Director is unavailable. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, the agency failed to obtain orders after the initial comprehensive assessment was completed. For ex,ample in NHV#3 the clinical documentation shows the patient has a foley catheter, a stage 2 sacral pressure ulcer, nasogastric tube and oxygen 6L NC and there are no physician orders for the treatment of foley and catheter care, or nasogastric tube. In addition the clinical note shows evidence of wound care and catheter care being performed without orders. For RRNHV4, comprehensive assessment on admission shows oxygen 2L NC, however no physician orders were obtained or on plan of care after. No orders were received during the entire first certification for RRNHV#3 and RRNH#4. This was discussed with the administrator and quality staff.

Observed in Leadership Session. the organization failed to provide all services that met the patient's needs. During tracer activities for the volunteer program, the hospice nurse surveyor observed the volunteer program had no current volunteers and there were no recruitment efforts for years 2023 or 2024. This was discussed with the administrator, chaplain and quality staff.

Observed in Tracer Activities. The nurse surveyor noted the organization was not able to show cost savings through the use of volunteers. The agency was unable to provide documentation of cost savings achieved. This was discussed with the Chaplain, administrator and quality staff.

Observed in Tracer Activities. The surveyor noted the agency did not provide at least 5% of patient care hours of all paid hospice employees and contracted staff. The agency percentage rate was 0%. The agency currently has not volunteer staff. This was discussed with the administrator and quality staff.

Observed in Record Review. In 2 of 14 patient records reviewed, the medical director or the physician member of the interdisciplinary team did not provide written certification that the patient's life expectancy is six months or less if the illness runs its normal course. For example, for RRNHV#1 and RRNHV#2, there was no evidence of documentation of a signed certificate of terminal illness (CTI) in the patients record. This was discussed with the CEO and administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, the clinical record must be legible, clear and appropriately authenticated. In review of RRNHV#1 and RRNHV#2, the documents were signature, but did not include the clinician's title. This was discussed with the administrator and CEO.

Observed in Leadership Session. he organization was not licensed in accordance with California law and regulation. Change of ownership occurred in June of 2025. At the time of survey the organization was not able to provide documentation to show that the Change of Ownership was approved by CMS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure the plan of care goals were based on the time frames, settings, and services required to meet those goals. For example: on review of all clinical records reviewed most all goals were noted to contain non-specific time frames and most all target dates were set to the end of the certification period. In review of RR#2 an example of a goal was patient will verbalize increase strength/energy for optimal functional activities thru the cert period. In RR#3 a goal stated in 2-3 weeks and throughout the cert period, Pt will take blood pressure mediation in a timely and regular manner resulting to a controlled blood pressure within range limit of 110/60 to 140/90. Further, throughout all records reviewed there were goals that read in 5-7 days and throughout cert , in 1-2 weeks and onwards and similar. Most target dates were noted to be set for the end of the certification period. On conversation with the current DPCS the org's practice is to change target dates to the next benefit period for any unresolved goals. This observation was reviewed with the current DPCS, the new oncoming DPCS and the Administrator.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1,and RR#4, the hospice nurse surveyor observed not all items needed for the palliation and management of the terminal illness and related conditions were included on the plan of care. For example: in HV#1, the patient had documentation of an eye infection with orders for antibiotics, but it was not addressed on the POC. In RR#4, the patient had multiple wound care changes as wound were documented as healed, and changes to the Tylenol dosage but they were not addressed in the care plans. This observation was reviewed with the DPCS and Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During review of all records and after conversation with the Administrator, the hospice nurse surveyor observed the Chaplain was not attending IDG and the SW was intermittently attending IDG. The administrator stated she was unaware of this requirement. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to plan the patient's care. During record review for all patients, the hospice nurse surveyor observed all timeframes for all patient's and all goals were the last day of the certification period. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to plan the patient's care. During record review for RR#3, RR#4 and BR#1, the hospice nurse surveyor observed not all items needed for the palliation and management of the terminal illness and related conditions were included on the plan of care. For example: in RR#3, the patient had multiple medication changes for pain but it was not addressed on the POC. In RR#4, the patient had a new wound and anxiety and depression with medication changes but they were not addressed on the plan of care and with BR#1, the patient was placed on Continuous Care but it was not addressed on the Plan of Care. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During record review for HV #2, the hospice nurse surveyor observed documentation from 6/11 by the LVN of a new cough, congested lungs and no BM for 4 days but no documentation of notification to the physician or the RN. This was discussed and reviewed with the Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#1 and HV#2, the hospice nurse surveyor observed the LVN fail to follow the organization's hand hygiene policy. During both visits the LVN did hand hygiene, put gloves on and then continued to go into her nursing bag throughout care without further hand hygiene. This was discussed and reviewed with the Administrator. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During HV#2, the hospice nurse surveyor observed the LVN fail to perform hand hygiene consistent with the organizational policy. The LVN washed her hands in the facility sink with soap and water, dried with a paper towel and then used the same paper towel to turn off the faucet. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to set goals to minimize the possibility of spreading infections. During tracer activities for Data Management, the hospice nurse surveyor observed the organization did not document a written infection and control plan that included goals or prioritized risks. The organization was collecting infection data but had not documented a plan on how to use the data. No goals were documented. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. In 1 of 1 HR files reviewed, the organization failed to have a registered nurse make an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. During HR file review, the hospice nurse surveyor observed the HHA had an initial competency in 2018 but none documented for 2019, 2020, 2021 or 2022. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The organization failed to provide all services that met the patient's needs. During tracer activities for the Volunteer Program, the hospice nurse surveyor observed the volunteer program had no current volunteers and there were no recruitment efforts for 2020, 2021 and 2022. This was discussed and reviewed with the Administrator.

Observed in Tracer Activities. The governing body/ leadership team did not ensure that the following Conditions of Participation were met as determined through observation, documentation, and staff interviews: §418.60, §418.56. §418.100, §418.116, §418.76, §418.108 and §418.114. This was discussed and reviewed with the Administrator.

Observed in HR File Review. In 4 of 4 HR files reviewed, the organization failed to document staff competence. During HR file review, the hospice nurse surveyor observed HR file #1, HR#2, HR#5 and HR#6 did not have documentation of the annual competency as required by organizational policy. HR#1, 2, 4 had not had competencies since hire in 2018 and HR#5 had no competency for 2020, 2021 or 2022. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed, the organization failed to provide for planned scope and level of care, treatment, or services. During record review for RR#1, the hospice nurse surveyor observed a note with request from son for respite for the patient due to a weekend vacation. The SW note stated hospice does not pay for respite. No further documentation of conversation or events lead by the SW to assist the family. Multiple conversations with the Hospice leadership team involving how much respite costs, the fact that SNFs require a deposit and the team continued to state the son was given options but no documentation of this was provided. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to determine how staff should function within the organization. During record review for RR#7, BR#1 and BR#2, the hospice nurse surveyor observed the LVN had pronouncing death and there was no documentation of collaboration with an MD. After discussion with the hospice leadership team, they noted that the LVN would then notify via JNCloud the physician but there was no documentation the LVN was calling the physician from the home for death notification. The Owner/ Administrator did not appear to know that LVN's could not pronounce in California. This was discussed and reviewed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to comply with law and regulation. During record review for RR#5 and RR#6, the hospice nurse surveyor observed the patients had not been given the notice of non-coverage at least 48 hours prior to discharge, they had not been given it at all. During discussion with the owner, she was unaware of this requirement. This was discussed and reviewed with the Administrator.