Every finding on record at Metro Hospice West Valley Inc

Based on interview and record review, the facility failed to ensure that the Governing Body (GB), (a group of people with the authority to manage and control an organization or institution) provided adequate oversight to meet quality care standards and aligned with the agency strategic goals, when the Quality Assessment and Performance Improvement (QAPI - program that monitors care and use data to identity and address problems in patient care and quality of life) was not documented in the GB minutes from August 1, 2024 through August 31, 2025. This failure had the potential to cause missed opportunities for quality improvement and quality of care to go unaddressed and continue in a universe of 31 patients. --- During a concurrent interview and record review on September 4, 2025, at 3:15 PM, with the Administrator (Admin) and Director of Patient Care Services (DPCS) regarding the data collection from the QAPI committee not being given to or presented in the meetings of the Governing Body, and for the QAPI reports to be approved in the Governing Body meeting minutes.  Both the Admin and DPCS stated they had not given any of the data to the Governing Body.During a record review of the facility’s Governing Body (GB) binder, undated, it indicated the GB meets monthly, but there was no documented evidence that the QAPI report was discussed or approved.During a concurrent interview and record review on September 5, 2025, at 1:00 PM, with the Admin and DPCS, the facility’s Policy and Procedure (P&P), titled, “Performance Improvement,” undated, was reviewed. The P&P indicated, “The Governing Body is responsible for ensuring that the performance improvement program is defined, implemented, maintained and evaluated annually.  PROCEDURE: … 4. Senior management will report the results of QAPI activities to the Governing Body on a quarterly basis.”  The Admin and DPCS stated the policy was not followed.During a concurrent interview and record review on September 5, 2025, at 1:05 PM, with the Admin and DPCS, the facility’s Policy and Procedure (P&P), titled,  “Governing Body,” undated, was reviewed. The P&P indicated “…5A. Relevant findings of performance improvement activities are consistently provided to 5B. the Governing Body…6. The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide quality assessment and performance improvement program (QAPI).  Information related to the performance improvement program will be provided to the Governing Body on a quarterly basis.  7. The Governing Body must ensure that the QAPI program: …F. Approves the frequency and detail of the QAPI data collection and included in the Board minutes.”  The Admin and DPCS stated the policy was not followed.

Based on interview and record review, the agency failed to ensure seven of seven Certified Home Health Aides (CHHA 1, 2, 3, 4, 5, 6, and 7) received the required 12 hours of annual in-service training, which is necessary for maintaining staff competency.  This failure had the potential to result in a decline in the quality of care, leading to  provision of below-standard services by the agency, which may affect the health and safety of patients receiving care from CHHA. --- During a concurrent interview and record review on September 5, 2025, at 11:00 AM, with the Director of Patient Care Services (DPCS), the DPCS reviewed the “In-Services” binder. The required 12-hour in-services for all seven CHHAs (CHHA 1, 2, 3, 4, 5, 6, and 7), had not been completed and no documentation was available to verify their participation. The DPCS stated, “we rely on the aides to get their in-services hours for licensure.” The DPCS further stated the CHHAs do their in-services for their state certification, but the documentation is not in the binder.During a record review of the facility’s Policy and Procedure, titled, “Performance Improvement”, undated, it indicated: “I. The program shall provide or make provision for at least quarterly in-service education program to its employees and volunteers who have direct patient contact.”  The DPCS stated that the policy was not followed.During a record review of the CHHA’s Job Description”, undated, it indicated, “POSITION QUALIFICATIONS: 1. Meets the training requirements of the State of California. 2. Effective august 14, 1990, a person who has successfully completed a state established or other training program that meets the requirements of S 484.36 (a) and a competency evaluation program, or state licensure program that meets the requirements of S 484.36 (b), or a competency evaluation program or state licensure program that meets the requirements of S 484.36 (b).” The DPCS stated the job description and requirements for licensure was not followed.

Based on interview and record review, the hospice agency failed to conduct an initial bereavement assessment for six of 11 sampled patients (Patient 6, 7, 8, 9, 10 and 11). This deficient practice resulted in patients not receiving bereavement assessments. Findings: a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 4/24/2021, with a diagnosis of Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 8/17/2022 to 10/15/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 6's clinical record indicated there was no initial bereavement assessment conducted. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 12/11/2020, with a diagnosis of Alzheimer's disease. A review of Patient 7's Plan of Care for the certification period of 8/3/2021 to 10/1/2021, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 7's clinical record indicated there was no initial bereavement assessment conducted. c. A review of Patient 8's clinical record indicated a start of care date (SOC) of 4/14/2021, with a diagnosis of Alzheimer's disease. A review of Patient 8's Plan of Care for the certification period of 8/7/2022 to 10/5/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 8's clinical record indicated there was no initial bereavement assessment conducted. d. A review of Patient 9's clinical record indicated a start of care date (SOC) of 10/19/2021, with a diagnosis of Alzheimer's disease. A review of Patient 9's Plan of Care for the certification period of 8/15/2022 to 10/13/2022, indicated a Skilled Nurse (SN) is scheduled to visit the patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 9's clinical record indicated there was no initial bereavement assessment conducted. e. A review of Patient 10's clinical record indicated a start of care date (SOC) of 10/22/2021, with a diagnosis of Alzheimer's disease. A review of Patient 10's Plan of Care for the certification period of 8/18/2022 to 10/06/2022, indicated a Skilled Nurse (SN) is scheduled to visit patient one time a week and Certified Home Health Aide (CHHA) is scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 10's clinical record indicated there was no initial bereavement assessment conducted. f. A review of Patient 11's clinical record indicated a start of care date (SOC) of 3/21/2022, with a diagnosis of chronic atrial fibrillation (an irregular and often very rapid heart rhythm). A review of Patient 11's Plan of Care for the certification period of 3/21/2022 to 6/18/2022, indicated a Skilled Nurse (SN) and Certified Home Health Aide (CHHA) are scheduled to visit the patient two times a week and was receiving routine care. A review of Patient 11's clinical record indicated there was no initial bereavement assessment conducted. During an interview with the Administrator (ADM) on 9/12/2022, at 2:15 p.m., he stated the social worker does not complete an initial bereavement assessment and only does a post death assessment. A review of the agency's undated policy and procedure titled "Bereavement Assessment," indicated the purpose of the policy and procedure is to provide guidance for the assessment and reassessment of the bereavement needs of the family/caregivers. The policy and procedure further indicated that on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator.

Based on interview and record review, the hospice agency failed to have every member of the interdisciplinary group (IDG) participate in the interdisciplinary group meeting for three of 10 sample patients (Patient 1, 4 and 6). This deficient practice had the potential for members of the IDG not to contribute to the patient's comprehensive and ongoing assessments and care planning process. Findings: c. A review of Patient 6's clinical record indicated a start of care date (SOC) of 07/22/2020, with diagnosis of alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 07/12/2022 to 09/09/2022, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and was receiving routine care. A review of Patient 6's Interdisciplinary Group Meeting dated 03/15/22, 03/29/2022, 04/12/2022, 04/26/2022 and 08/09/2022 indicated that the physician's signature was blank. During an interview with the Director of Patient Care Services (DPCS) on 08/29/2022, at 3:15 p.m., she stated that the IDG is done every two weeks and the members include the Medical Director, Social Worker, Chaplain and Registered Nurse. DPCS stated that a signature of the individual is the verification of attendance and that the members of the IDG sign the same day the IDG meeting is conducted. A review of the agency's policy and procedure titled "The IDG (interdisciplinary group)," undated, indicated that the agency designates an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. The policy and procedure further indicated that the interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services.

Based on interview and record review, the hospice agency failed to develop, implement and update their COVID-19 (corona virus disease - highly contagious respiratory disease caused by a virus that can spread from person to person) policy and procedure. The deficient practice had the potential to put the patients and staff at risk for infection. Findings: A review of the of the agency's Governing Body Meeting dated 02/21/2020 indicated that the meeting will be regarding COVID-19 and adding a policy and procedure under the Infection Control policy. During an interview with the Administrator (ADM) on 08/24/2022, at 1:12 p.m., she stated that the governing body meeting dated 02/21/2020 regarding COVID-19 and the documents Healthcare Infection Prevention and Control FAQs for COVID-19 and Healthcare Professionals: Frequently Asked Questions and Answers were all last updated on 02/21/2020. The Administrator further stated that there was no other recent COVID-19 policy and procedure available.

Based on interview and record review, the hospice agency failed to provide volunteer training to the volunteer coordinator. This deficient practice resulted in the volunteer coordinators not having training. Finding: On 9/8/2022, a review of the Administrator Designee (ADMD) employee records indicated that the ADMD was also the Volunteer Coordinator. However, there was no certificate of training on file. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 2:31 p.m., she stated the only training she received regarding being a volunteer coordinator was what was taught to her by the Administrator. The Administrator Designee further stated that she does not have a certificates or proof of documentation regarding the training. A review of the agency undated policy and procedure titled "Volunteer Services," indicated the purpose of the policy and procedure is to ensure that qualified volunteers provide appropriate services in accordance with the plan of care and hospice program needs.

Based on interview and record review, the hospice agency failed to ensure that the patient's skilled nursing and hospice aide notes where signed after submission for three of ten sample patients (Patient 6, 7 and 8). The deficient practice had the potential to cause inaccurate information, lack of continuity and delay of treatment, care, and services to the patients. Findings: a. A review of Patient 6's clinical record indicated a start of care date (SOC) of 07/22/2020, with diagnosis of alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 6's Plan of Care for the certification period of 07/12/2022 to 09/09/2022, indicated that a skilled nurse (SN) and hospice aide (HA) is scheduled to visit patient two times a week and was receiving routine care. A review of Patient 6's clinical record indicated that the skilled nursing and hospice aide notes for the certification period of 07/12/2022 to 09/09/2022 were not signed by the SN or HA. b. A review of Patient 7's clinical record indicated a start of care date (SOC) of 03/04/2021, with diagnosis of alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Patient 7's Plan of Care for the certification period of 08/31/2021 to 10/29/2021, indicated that a skilled nurse (SN) and hospice aide (HA) is scheduled to visit patient two times a week and was receiving routine care. A review of Patient 7's clinical record indicated that the hospice aide notes for the certification period of 08/31/2021 to 10/29/2021 were not signed by the HA. c. A review of Patient 8's clinical record indicated a start of care date (SOC) of 03/04/2021, with diagnosis of cirrhosis of the liver (disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged) A review of Patient 8's Plan of Care for the certification period of 09/03/2021 to 12/01/2021, indicated that a skilled nurse (SN) is scheduled to visit patient two times a week and hospice aide (HA) is scheduled to visit patient three times a week and was receiving routine care. A review of Patient 8's clinical record indicated that the hospice aide notes for the certification period of 09/03/2021 to 12/01/2021 were not signed by the HA. During an interview with the Director of Patient Care Services (DPCS) on 08/29/2022, at 3:15 p.m. and 3:45 p.m., she stated that the SN and HA notes should be signed within two weeks of visit. DPCS further stated that the SN and HA notes are not officially submitted until it is signed. A review of the agency's policy and procedure titled "Clinical/Service Data Collection," undated, indicated that all skilled nurse (SN)/certified home health aide (CHHA) visit notes must be submitted as soon as possible and no later than two weeks. The policy and procedure further indicated that the clinical/service note will include the date the service was provided and signature of clinician/technician and his/her credentials.

Based on interview and record review, the hospice agency failed to update and implement their coronavirus (COVID-19 - highly contagious respiratory disease caused by a virus that can spread from person to person) employee vaccination policies and procedures to ensure a process of documenting an employee's approval for medical or religious exemption for two of 20 agency employees (Licensed Vocational Nurse [LVN 1] and Certified Home Health Aide [CHHA 1]). This deficient practice resulted in the agency not having an updated policy and procedure for COVID-19 employee vaccination and two employees not having proof that religious exemption was approved. Findings: On 09/08/2022 and 09/12/2022, a review of the agency's COVID-19 policy and procedure and COVID-19 employee vaccination list was conducted. The COVID-19 vaccination list indicated that there were two (LVN 1 and CHHA 1) out of 20 employees who did not receive the COVID-19 vaccine and that they each submitted a COVID-19 Vaccine Exemption/Declination Form. During an interview with the Administrator Designee (ADMD) on 09/12/2022, at 12:55 p.m. and 2:03 p.m., she stated all employees were fully vaccinated except for LVN 1 and CHHA 1. Administrator Designee (ADMD) further stated that both LVN 1 and CHHA 1 submitted declination forms but no other document regarding the approval of the religious exemption. A review of the agency's undated policy and procedure titled "COVID-19 Policy and Procedure," indicated that the organization will comply with all applicable CMS (Centers for Medicare and Medicaid Services) and CDC (Centers for Disease Control and Prevention) recommendations for SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2).