Every finding on record at Mediq Hospice and Palliative Care

Observed in HR File Review. In 2 of 8 HR files reviewed, there was no documentation to validate staff were provided emergency management training at least every 2 years. On HR #1 and HR #7, it was noted that there has been no emergency training in the last two year. This was validated with the DCPS.

Observed in Data Session. Review of the agency’s Complaint Log revealed no documented complaints for calendar year 2025. However, review of QAPI meeting minutes showed there had been complaints during multiple quarters in 2025. Agency Complaints policy (1-010.1), states all complaints are to be addressed within 5 days of receipt using a complaint form, with a documented response completed within 10 days. Upon further inquiry by the surveyor regarding whether complaint forms had been completed, staff retrieved the complaint log and returned approximately one hour later with entries completed. The newly documented entries indicated that complaint forms had not been completed within the required 5-day timeframe, and responses were not documented within the required 10-day timeframe. The Complaint Log for 2025 had previously been blank at the time of initial review, demonstrating a failure to maintain timely and accurate documentation of complaints in accordance with agency policy. This finding was reviewed with the DCPS.

Observed in Record Review. In 2 of 14 patient records reviewed, the organization did not complete a bereavement risk assessment. On RRNHV #1, it was noted that a bereavement assessment was not completed on the admission from 2 months ago. On RRBR #1, it was noted that the patient did not have a bereavement risk assessment completed. This finding was reviewed and validated with the DCPS.

Observed in Record Review. In 7 of 10 live discharge records reviewed, the organization did not educate the patient on discharge instructions when they were discharged from service. On RRDC #2 and RRDC #6, the patient was discharged for extended prognosis, there was no documentation that the patient was given discharge instructions. On RRDC #3, RRDC #4, RRDC #5, RRDC #7 and RRDC #8, the patient was discharged due to revocation but there was no documentation that discharge education was provided to the patient. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 of 2 patient records reviewed with aide services ordered, the organization did not have orders for aide services. On RRDC #9, it was noted that aide was seeing patient 2 times a week and there was no orders for frequency of those services on the plan of care. This finding was reviewed with the DCPS.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not update the plan of care based on the patients needs. On RRBR #2, it was noted that during course of service, the patient had DuoNeb therapy added for congestion but the care plan had not been updated to reflect the current issue. This finding was reviewed and validated with the DCPS.

Observed in Record Review. In 2 of 14 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV # 1 and RRHV #2, the physician's orders in the plan of care documented duplicate PRN medication therapy for constipation of Senna and Docusate with no indication of how to handle the duplicate therapy. This finding was reviewed and validated with the DCPS.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not provide care according the individualized plan of care. On RRBR #2, it was noted that the one month bereavement mailing was due 3 weeks ago. This finding was reviewed and validated with the DCPS.

Observed in Record Review. In 1 of 2 live discharged records reviewed for extended prognosis, the organization did not coordinate care and services with the interdisciplinary team. On RRDC #2, it was not discussed with the IDG team regarding discharging patients from service because they didn't qualify for Hospice as evidenced by no documentation of this discussion in the IDG notes. This finding was reviewed with the DCPS.

Observed in Data Session. During review of the organizations data and QAPI plan, although the organization was collecting data, the frequency and detail of that data collection had not been approved by the governing body for 2026. In addition for 2024 and 2025 the governing body did not approve the frequency of the data collection. This was reviewed and validated with the DCPS.

Observed in Data Session. On review of the Hospice QAPI program, the program had not been evaluated annually over the last 3 years. This finding was reviewed with the DCPS.

Observed in Patient Home. in 1 of 2 home visit conducted, the nurse did not follow the organization's bag technique policy. The organization's Bag Technique policy (9-014.1) states that the nurse will have a clean and dirty designation in the bag and that equipment will be cleaned with alcohol or soap and water. On RRHV #2, it was noted that the nurse's bag did not have two separate areas in the bag. In addition, equipment was cleaned using Lysol instead of alcohol. This finding was reviewed and validated with the DCPS.

Observed in Data Tracer. During the data management session, it was noted that the organization had established a performance improvement goal related to hand hygiene. However, there was no supporting statistical data collected to substantiate this goal, such as documented observation audits or monitoring results. The absence of measurable data indicated that the organization was unable to demonstrate how the goal was developed or to evaluate progress toward improvement. This finding was reviewed with the DCPS.

Observed in HR File Review. In 5 of 8 HR files reviewed, the surveyor noted the organization failed to provide annual infection control and Blood Borne Pathogen training annually as required by the organization's policy. In HR #1 and HR #7, there was no evidence of infection control and annual blood borne pathogen training for the past 2 years. On HR #3, there was no documented evidence that infection control and blood borne pathogen training was done in 2025. On HR #6, there was no documented evidence that infection control and blood borne pathogen training was done in 2024. On Volunteer #1, it was noted that the orientation for blood borne training was blank and unsigned. This was reviewed and validated with the DCPS.

Observed in Record Review. In 1 of 3 bereaved records reviewed, the organization did not develop a bereavement plan that specifies the type and frequency of services. On RRBR #1, it was noted that there was no bereavement care plan developed on a patient that passed away a month ago. This finding was reviewed and validated with the DCPS.

Observed in HR File Review. In 1 of 2 Home Health Aide HR records reviewed, 12 hours of yearly in-service education was not completed annually. On HR#3, the Home Health Aide completed 1 hours of in-service education in 2024 and 3 hours in 2025. This was reviewed and validated with the DCPS.

Observed in Tracer Activities. On review of the organizations volunteer program, there was no documentation to validate cost savings had been achieved using volunteers. During discussion, they were able to show me the cost savings for 2026 and 2025 but did not have 2024 information. This was reviewed and validated with the Administrator and DPCS.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no documentation of volunteer hours for 2024 and as a result there is no calculation of percent of volunteer hours for that year. This was reviewed and validated with the Administrator and DPCS.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level findings at §418.104, §418.52, §418.56, §418.60. This finding was reviewed with the DCPS.

Observed in Patient Home. In 2 of 2 home visits conducted, the organization failed to ensure the medical record contained information to accurately reflect the patient's medications. On RRHV #1, it was noted that the medication in the home did not match the medication list in the medical record. The home list had Morphine, acetaminophen and atropine but this was not reflected in the medical record. In addition the medical record listed Aspirin which was not on the home medication list. On RRHV #2, it was noted that the medication list in the home from admission 3 days ago was blank. Agency Medication Profile policy states admitting clinician will initiate medication profile to document current medication regimen. This finding was reviewed and validated with the DCPS.

Observed in Record Review. In 4 of 14 patient records reviewed, all entries were not appropriately completed, authenticated and dated in accordance with hospice policy and currently accepted standards of practice. Agency policy for Entries into the Clinical Record (5-006.1) state that notes are entered on same day and notes are signed by the clinician. In RRHV #2, it was noted that the nursing note from 3 days ago had not been electronically signed. On RRNHV#1, it was noted that the LVN visit note from 9 days ago was not completed. In RRBR #1, it was noted that nursing note from death visit a month ago has not been authenticated as evident by no electronic signature on the record for the visit. On RRBR #2, it was noted that visit notes from the spiritual counselor for visits 3 and 6 months ago had not been authenticated with an electronic signature. This was reviewed and confirmed with the DPCS.

Observed in Record Review. In 7 of 10 patient records reviewed that were live discharges, the organization failed to provide a written discharge summary to the service provider who will provide care after discharge. On review of RRDC#2, the Hospice Nurse Surveyor observed the discharge summary was written and signed off by the DCPS designee but there was no tracking or documentation that the summary was sent to the receiving provider or notification that it was available on request. In addition on RRDC #3, RRDC #4, RRDC #5, RRDC #6, RRDC#7,and RRDC #8, the discharge summaries were completed but there was no documentation that receiving provider was notified it was available or sent to the receiving provider. This finding was reviewed with the DCPS.

Observed in HR File Review. in 1 of 8 HR files reviewed, it was noted there was no documentation in the HR file that a criminal background check was obtained on hire. On HR #5, it was noted that employee was hired just over 2 years ago and there was no criminal background check in their employee file. This was reviewed and confirmed with the DCPS.

Observed in Record Review. In 2 of 5 patient records reviewed, the Surveyor noted the patient medical record contained conflicting patient information. For example: HOS HV #1, the Surveyor noted the patient Medical Record (MR) had 2 physician signed CTI’s that were dated for the same day with the same patient identifiers but contained different patient clinical information. One CTI reported “patient 64 YO female at home routine level of care with diagnosis of end stage hypertensive heart disease.” The second CTI reported “patient is 75 YO female residing at home routine level of care with diagnosis of senile degeneration of brain.” HOS RR #5, the patient had a discharge summary on the HCO letterhead that stated Patient discharge from hospice services. patient is moving out of service area with his wife. Patient/Family are aware of the risk during travel from S. Sacramento to Tennessee. Patient is Discharge today […] from Anaiah Hospice care INC. Due to Geographical Relocation. The HCO being surveyed is located in Los Angeles, and the name identified is not the HCO. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 5 patient records reviewed, the Surveyor noted the California Physician Orders for Life Sustaining Treatment (POLST) had been incomplete. For example, in HOS RR #4, the patient medical record had a POLST signed by the patient and the Medical Director; however, document sections A, B, C, D, AND E, which identified patient treatment choices had been blank. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the Surveyor noted the medication profile in the Medical Record had not been updated to reflect the medications the patient was currently being administered. For example: HOS HV #1, the patient had been taking Meclizine 25 mg 1 tab every 8 hours since early March; however, this medication had not been included in the medical record. HOS HV #2, the patient medical record had incorrect mg doses for Meclizine 12.5 mg and Ibuprofen 800 mg, incorrect frequency for Vitamin D3 and Omega 3, and had been missing Montelukast 10mg, all started prior to Hospice admission. HOS HV #3, the medical record had been missing the medication Cyclosporin ophthalmic drops the patient had been prescribed prior to hospice admission. This was validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 5 patient records reviewed, the patient had a California Physician Orders for Life-Sustaining Treatment (POLST) that had not been appropriately authenticated per California Regulation from the Emergency Medical Services Authority (EMSA ) that states 'the approved POLST form must be signed and dated by a physician, […]. HOS HV #3, the patient had a POLST that had not been dated by the physician. This was validated with the Director of Patient Care Services.