Every finding on record at Kaiser Foundation Hospital - Riverside Hospice

Based on interview and record review, the agency failed to ensure Medical Social Worker (MSW) Services were provided for seven of nine patients reviewed for Core Services (Patients 2, 3, 4, 5, 6 , 7, and 9).This failure has the potential for unmet social services needs for the patients and their families. --- Findings:On October 13, 2025, at 12:24 p.m., an unannounced visit was conducted at the agency regarding two complaints involving MSW services.On October 13, 2025, at 1:45 p.m., the Director of Patient Care services (DPCS) was interviewed. The DPCS stated she was not aware of any patient or family complaints in relation to MSW services, but was aware of some staff complaints regarding MSW workload issues. The DPCS stated she received approval for posting and eventual hiring for a full time MSW position, although the two current fulltime and one per diem MSWs were sufficient to fulfill and complete MSW assignments, with assistance from palliative care MSW, since they have low census. The DPCS stated the Bereavement Assessments (BA) were to be conducted within 10 days of the patient’s death.On October 17, 2025, at 11:40 a.m., during a follow up onsite visit, the DPCS stated MSWs were averaging one visit per day, maybe two. On October 22, 2025, at 11:33 a.m. during a telephone interview, the DPCS stated initial assessments by the different disciplines was to be done within the first 48 hours and the comprehensive assessment should be done within the first five (5) days.On October 22, 2025, at 11:39 a.m., MSW 1 was interviewed. MSW 1 stated she is a full time MSW for home based palliative care (focuses on improving the quality of life of patients with serious illnesses, regardless of their prognosis. It aims to manage symptoms, provide emotional support, and coordinate care across different discipline) and had been helping out to conduct hospice MSW assessment since there was a shortage of MSWs for hospice. MSW 1 stated some of her patients and family members had complained that they were not getting MSW services at the frequency that they preferred, or an initial assessments conducted but no follow up visits.On October 22, 2025, at 12:16 p.m. MSW 2 was interviewed. MSW 2 stated in the last three years, two full time (FT) MSWs have left the agency, leaving only two full time MSWs from four FT MSWs. MSW 2 stated those positions have not been filled since then. MSW 2 further stated the census had actually increased since the last MSW retired, with the census being greater now than when there were four FT MSWs.On October 22, 2025,  at 1:57 p.m., MSW 3 was interviewed. MSW 3 stated the remaining two FT MSWs covered the south territory of their service area, and the retired MSWs previously covered the north territory. MSW 3 stated the remaining 2 FT MSWs now covered the agency’s entire coverage area. MSW 3 stated if both FT MSWs had 25 active each and there were 80-100 patients, that would leave 40-50 other patients that would potentially not be seen. MSW 3 stated with this increased workload, the required MSW Initial Assessments (IA) and Bereavement Assessments (BA) at the time of patient’s’ deaths were not in compliance with federally mandated guidelines. MSW 3 stated the assistance from the MSWs from other departments were limited to IAs and the follow ups and BAs would fall on the two FT MSWs.On October 22, 2025, at 3:24 p.m., MSW 4 was interviewed. MSW 4 stated the MSWs have a written agreement with the hospice agency, signed by the hospice agency’s Administrator, indicating each MSW workload was capped at 25 active patients. MSW 4 stated the two FT MSWs had more than 25 active patients in their areas alone, and so would have to “delay those patients” who were beyond the 25 patients on their active workload, leading to the inability to meet IA and BA deadlines.A review of sample patients’ records was conducted and indicated the following:1. Patient 2 was admitted to the agency on May 24, 2025, with diagnoses including severe protein calorie malnutrition, and died on June 6, 2025.A review of the tree-view of agency staff encounters (a listing of agency staff encounters including assessments, home visits, telephone encounters, staff communication notes regarding the patient) indicted IA was not conducted by the MSW for Patient 2.A review of the physician’s order dated May 30,2025, indicated, “…Delay in SOC (start of care) for social services due to low staffing and inability to complete IA within five 5 of admission. Management aware…”2. Patient 3 was admitted to the agency on June 15, 2025, with diagnoses which included Alzheimer’s Disease (memory loss), and expired on June 26, 2025.A review of the tree-view of staff encounters did not indicate any MSW encounters with the patient occurred, and there was no documented evidence an IA or BA was conducted for Patient 3 by the MSW.3. Patient 4 was admitted to the agency on June 19, 2025, with diagnoses which included Glioblastoma Multiforme (a form of brain cancer), and expired on June 30, 2025.A review of the tree-view for staff encounters indicated there were no MSW encounters for Patient 4. In addition, there was no documented evidence an IA or BA was conducted for Patient 4 by the MSW.4. Patient 5 was admitted to the agency on May 30, 2025 with diagnoses which included end stage kidney disease, and expired on Jul 4, 2025.A review of the tree-view for staff encounters, as well as the “MSW Telephone Bereavement” note indicated the MSW conducted a BA on July 16, 2025, 12 days after Patient 5’s death.5. Patient 6 was admitted to the agency on May 26, 2025 with diagnoses which included small lymphocytic B-cell lymphoma ( a type of cancer), and expired on July 1, 2025.A review of the physician’s order, dated May 28, 2025, indicated, “…Delay in SOC for social services due to low social work staff and writer's inability to complete IA within 5 days. Management aware…”A review of the tree-view for staff encounters indicated an IA was conducted by the MSW for Patient 6 on June 6, 2025, 11 days from Patient 6’s admission to the agency.A review of the tree-view of staff encounters, as well as the “MSW Telephone Bereavement,” note by the MSW, indicated the BA was conducted on August 7, 2025, 37 days after Patient 6’s death.6. Patient 7 was admitted to the agency on June 18, 2025, with diagnoses which included melanoma metastatic (skin cancer which had spread) to brain and neck, and expired on July 17, 2025.A review of the “Hospice Case Communication,” dated July 14, 2025, by the MSW indicated, “…Declined SW assessment at this time…”A review of the tree-view of staff encounters indicated there were no other MSW encounters with Patient 7 before or after the communication note dated July 14, 2025.There was no documented evidence an IA or BA were conducted by the MSW for Patient 7.7. Patient 9 was admitted to the agency on May 6, 2025, with diagnoses which included cancer which had spread to the bone, and revoked hospice services on July 23, 2025.A review of the physician’s order dated May 12, 2025, indicated, “…Delay in SOC for social services due to inability of staff to complete IA within 5 days. Low staffing; management aware…”A review of the tree-view of staff encounters indicated an IA was conducted by the MSW on May 24, 2025, 21 days after Patient 9’s admission to the agency.A review of the agency’s policy and procedure titled, “Initial Assessments,” reviewed April 2025, indicated, “…An initial assessment will be performed and competed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative…Admitting registered nurse assesses for problems and to establishes of the patient’s physical, psychosocial, and emotional status…Admitting registered nurse will determine the need for other disciplines to complete the appropriate sections for the comprehensive assessment based on identified problems and needs during this initial assessment…If the comprehensive assessment is completed during the admission visit, the initial assessment will be included as part of the comprehensive assessment…”A review of the agency’s policy and procedure titled, “Psychosocial Assessment,” reviewed April 2025, indicates, “…An in-depth psychosocial assessment will be completed by a qualified social worker…The assessment includes, but is not limited to…coping with and adjusting to the patient’s terminal illness…making final arrangements…reaction to the terminal illness and subsequent bereavement needs…Social and financial needs…Procedure…A social work contact will be made either by a home visit or by telephone based on the family’s needs and acceptance of the service…A psychosocial assessment by the qualified social worker will be performed at the initial meeting of patient and family/caregiver…In the patient’s residence…The assessment will be completed and submitted within 48 hours…”A review of the agency’s policy and procedure titled, “…Bereavement Assessment,” reviewed April 2025, indicates, “…On admission, the Social Worker will complete a bereavement risk assessment. If the Hospice Social Worker is unable to complete the  initial bereavement risk assessment within 5 days, the Registered Nurse will complete the initial bereavement risk assessment  (Low, Med, High)…Within 10days following the patient’s death, the Social Worker will complete a post death bereavement risk assessment and re-evaluate the risk level. Social worker will attempt to contact the bereaved twice. If Social Worker is unable to complete the post bereavement risk assessment within 10 days, the assessment can be completed by the Registered Nurse, Spiritual Counselor, or Bereavement Coordinator. Unsuccessful attempts will be recorded in the bereavement section of the chart..."

Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan of care included safety precautions. For example: review of RR# 1's patient record revealed a terminal diagnosis of amyotrophic lateral sclerosis (ALS) with documentation RR# 1 had decided to discontinue Total Parental Nutrition and IV fluids. Review of RR# 1's registered nurse start of care comprehensive assessment revealed documentation that RR# 1 had aspiration precautions. Review of RR# 1's initial Plan of Care and subsequent Plan of Care Updates revealed no aspiration precautions. This was reviewed, discussed, and validated with the Director of Patient Care Services. Observed in Record Review. In 1 of 16 patient records reviewed, During RR# 1's patient record review it was noted the organization had not ensured the plan of care included safety precautions. For example: review of RR# 1's patient record revealed a terminal diagnosis of amyotrophic lateral sclerosis (ALS) with documentation RR# 1 had decided to discontinue Total Parental Nutrition and IV fluids. Review of RR# 1's registered nurse start of care comprehensive assessment revealed documentation that RR# 1 had aspiration precautions. Review of RR# 1's initial Plan of Care and subsequent Plan of Care Updates revealed no aspiration precautions. This was reviewed, discussed, and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 16 patient records reviewed, During RRHV# 3's patient record review it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of RRHV# 3's recertification Certificate of Terminal Illness (CTI) revealed physician documentation with physician signature and date. Further review of the recertification CTI revealed a RN verbal order dated five days after the physician signature. This was reviewed, discussed, and validated with the Director of Patient Care Services and the Hospice Service Line Administrator. Observed in Record Review. In 1 of 16 patient records reviewed, During RRHV# 3's patient record review it was noted the organization had not ensured it maintained the security and integrity of health information. For example: review of RRHV# 3's recertification Certificate of Terminal Illness (CTI) revealed physician documentation with physician signature and date. Further review of the recertification CTI revealed a RN verbal order dated five days after the physician signature. This was reviewed, discussed, and validated with the Director of Patient Care Services and the Hospice Service Line Administrator.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice agency failed to follow its policies on patient assessments. In RR#5 the first full wound assessment of a sacral wound was done on day 18 of hospice care. Wound care had been done by the family with no documentation that nurse has assessed that the family was doing the wound care correctly. There was also a toe wound that had care provided but there was no evidence of any assessment of a toe wound at any time during care to date (over two months of care). Policy #2-043.1 Patient Education Process requires that the clinician describe what was taught, the patient's response to teaching including the level of understanding and the ability to repeat or demonstrate what was taught. Per agency leadership, the assessment of wounds is to include type of wound, wound bed, odor, drainage, measurements, signs of infection are required every visit. This was validated with the internal nurse consultant assisting the surveyor with chart review.

Observed in Record Review. In 13 of 13 patient records reviewed, the hospice agency failed to establish target dates for goals that would prioritize the plan of care to communicate which goals should be met in the short term to insure patient safety. For example in HOHV#1 some goals that were targeted for 3 weeks after admission included understanding safe use of oxygen, and understanding of medication administration. All goals had the same target dated and goal target dates were consistently automatically updated from one IDG meeting to the next IDG meeting. The same pattern was repeated in all of the remaining charts reviewed.This was validated with the internal nursing consultant that assisted the surveyor with chart review.

Observed in Record Review. In 2 of 13 patient records reviewed, the hospice plan of care did not address all issues identified in the comprehensive assessment. In HORR#1 the social worker assessed no funeral arrangements but did not address funeral plans in the plan of care. Funeral arrangements were currently in place at time of survey (7 months into hospice care) per MSW note but no indication of where the arrangements are. In HORR#4 the social worker identified financial concerns and gave family applications but no plan to follow up before 3 weeks later without explanation. This was validated with the internal nurse consultant assisting the surveyor with medical record review.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice agency failed to provide services according to the plan of care. In RR#5 the documented wound care provided to a toe wound did not follow the plan of care. Wound orders on the plan of care for the toe were to cleanse with NS, pat dry and cover with adhesive dressing. The nurse documented that the family wanted the wound left open to air. The nurse documented following patient family wishes but there was no documented notification to IDG to change orders until two months later. This was validated with the internal nurse consultant assisting the surveyor with chart review.