Every finding on record at Sacramento River Healthcare LLC

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Plan of Care (POC) was followed for two of 19 sampled patients (Patient 10 and Patient 6) when:Chaplain (CH) visits were missed for Patient 10; and,Medical Social Worker (MSW) visits were missed for Patient 6.These failures had the potential to affect Patient 10 and Patient 6’s quality of life and overall health and well-being. --- 2.  A review of Patient 6's clinical record indicated Patient 6 had a Start of Care (SOC) date with the HA on 11/8/23 for multiple diagnoses including heart failure (weakened heart muscle does not pump blood efficiently), failure to thrive (inability to sustain weight leading to progressive decline in health), and chronic kidney disease (kidneys lose the ability to filter waste products from the blood).A review of Patient 6's Plan of Care (POC) for recertification period 7/10/25 to 9/7/25 indicated "...Calendar Frequency: ...MSW EFFECTIVE 07/10/2025 1M1 [1 VISIT FOR 1 MONTH], 2M1 [2 VISITS FOR 1 MONTH] ...FOR PSYCHOSOCIAL NEEDS..."       A review of Patient 6's "Client Calendar Report" for 7/3/25 to 9/3/25, indicated Patient 1 had only 1 visit in the month of August 2025 on 8/4/25.      A review of Patient 6's "Visit Note Report" and "Client Coordination Note Report," both dated 8/4/25, indicated "...MSW UPDATED PATIENT DTR [DAUGHTER] AND RNCM [REGISTERED NURSE CASE MANAGER] ON VISIT.  PATIENT DOESN'T INTERACT MUCH DURING VISITS.  FREQUENCY TO BE REDUCED TO 1XWEEK..."During a concurrent interview and record review on 10/9/25 at 3:00 p.m. with the Director of Patient Care Services (DPCS), reviewed that Patient 6 had a missed MSW visit the month of August 2025.  The DPCS acknowledged that the POC indicated that two MSW visits for August 2025 visits were ordered per Patient 6's POC but only one visit was provided.  The DPCS stated that Patient 6's "Visit Note Report" and "Client Coordination Note Report" on 8/4/25 indicated that MSW visits would be reduced to once a month but acknowledged that there was no physician order to change the frequency of the MSW visits.  The DPCS stated, "There should be an order or a missed visit note."A review of the HA's Policy and Procedure (P&P) titled "The Plan of Care," not dated, indicated "...To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues...A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process...The written plan of care will contain...Frequency/Amount/Duration and type of services...Care provided to the patient will be accordance with the plan of care..."        A review of the HA's P&P titled "Missed Visits," not dated, indicated "...To ensure that missed visits are documented and does not affect the quality of patient care...If a visit is missed and not rescheduled the clinician will: ... Notify the IDG (Interdisciplinary Group) and the clinical supervisor of the missed visit and the reason for missed visit..."  Findings:1. Patient 10 had a start of care (SOC) date of 3/8/25 and diagnoses included cerebral atherosclerosis (a condition where the arteries in the brain become narrowed and hardened due to the accumulation of fats).A review of Patient 10’s Plan of Care (POC), dated 8/19/25 for the recertification period 9/4/25 to 11/2/25 indicated, “…Calendar Frequency:…CH EFFECTIVE 09/04/2025 2M2 [twice a month for two months]…FOR SPIRITUAL NEEDS…”During a review of Patient 10’s Client Calendar Report for September 2025, the report did not indicate that chaplain visits were done for the month of September 2025.During a concurrent interview and record review of 10/9/25 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the DPCS confirmed the physician order for Patient 10’s chaplain visits and verified that there were no visits done by the chaplain for the month of September 2025. The DPCS further confirmed that there was no documented evidence on why the visits were missed. The DPCS stated, “…there should be a phone call or note, and the care plan should be followed…”During a review of the agency’s policy and procedure (P&P) titled “Spiritual Care Counseling Services,” undated, the P&P indicated, “Hospice will provide spiritual care counseling in keeping with the patient’s/family’s/caregiver’s belief system and practice, and in accordance with the plan of care…”

Based on interview and record review, the agency failed to ensure the Plan of Care (POC) for one of 19 sampled patients (Patient 16) included Patient 16's pressure injury (PI- partial-thickness loss of skin, presenting as a shallow open wound) to patient's tailbone and the treatment ordered by the physician.These failures placed Patient 16 at risk for inadequate wound monitoring and care. --- Findings:A review of Patient 16's admission record indicated the patient was admitted to the agency in the summer of 2025 with multiple diagnoses which included pancreatic and liver cancer.A review of Patient 16's clinical record contained a physician order dated 7/18/25, which indicated, "Coccyx [tailbone] stage 2 pressure injury, cleanse with wound cleanser...pat dry...apply skin prep...cover wound barrier cream, cover with foam dressing twice weekly and as needed."A review of the clinical record for Patient 16 included a "Hospice Certification and Plan of Care," for the  certification period from 7/17/25 through 10/14/25. The document indicated physician's order directing skilled nurse (SN) to observe/assess Patient 16's skin status for early identification of complications. The "Hospice Certification and Plan of Care" did not contain documentation that Patient 16 had a PI stage 2 on her tailbone and did not include physician's order for treatment to the patient's tailbone wound.During a concurrent interview and record review with Director of Patient Care Services (DPCS) on 10/10/25, at 12:10 p.m., the DPCS acknowledged that Patient 16's POC was not revised and not updated with physician's order for tailbone PI treatment. The DPCS reviewed Patient's 16's Interdisciplinary Group (IDG) meeting dated 7/24/25 and stated that the patient's PI was not addressed during the meeting.A review of the agency's undated policy titled, "The Plan of Care," indicated, "A written individualized patient...plan of care will be established and maintained for each individual admitted to the hospice program...The plan of care will be based on...comprehensive and ongoing...assessment...and will be reviewed on a regular basis...The plan of care will identify the patient's needs and services to meet those needs...The individualized plan of care will be reviewed by the...interdisciplinary group within two (2) days of start of care."

Based on observation, interview, and record review the Hospice Agency (HA) failed to provide an accurate medication profile for one of nineteen sampled patients (Patient 4) when Patient 4's medication profile did not correlate with the medications that were in Patient 4's home environment.This failure resulted in medications not being administered as ordered per the Plan of Care (POC) potentially causing Patient 4's symptoms to not be treated adequately. --- A review of Patient 4's clinical record indicated Patient 4 had a Start of Care (SOC) date with the HA on 5/11/25 for multiple diagnoses including Alzheimer's disease (type of dementia that destroys memory and thinking abilities), urinary tract infection, and chronic kidney disease (kidneys lose the ability to filter waste products from the blood).A review of Patient 4's POC for certification period 8/9/25 to 11/6/25 indicated order "...SN [SKILLED NURSE] EFFECTIVE 08/10/2025 2WK12 [2 TIMES A WEEK FOR 12 WEEKS, 1WK1 [ONCE A WEEK FOR 1 WEEK] ..."A review of Patient 4's "Client Medication Report [Medication Profile]," printed 10/8/25, indicated multiple medications including:"Atropine 1% Eye Drops [medication to reduce saliva production] ...2 Drops...Every 4 hours...Sublingual...Instructions: Place 2 drops under tongue every 4 hours as needed for excessive oral secretions at the end of life...""Buspirone [anti-anxiety medication]15 mg [milligrams]...1 tablet...2 times a day...""Olanzapine [antipsychotic medication to treat mental health condition] 2.5 mg...1 tablet...daily...""Pantoprazole [medication to reduce stomach acid] 40 mg tablet, delayed release...1 tablet...2 times daily..."A review of Patient 4's "Medication Administration Record [MAR]," for 10/1/25 to 10/31/25, from the Assisted Living Facility where she resides, indicated;Atropine 1% eye drops PRN (as needed) but had not been given,Buspirone 5 mg was being given two times a day,Olanzapine 2.5 mg was not on the MAR, andPantoprazole 40 mg was being given one time a day.       During a home visit for Patient 4 conducted on 10/9/25, beginning at 8:50 a.m. with Skilled Nurse (SN) 2, SN 2 stated she does a medication reconciliation monthly.  SN 2 stated she was not sure what the HA policy was for medication reconciliation.  SN 2 conducted medication reconciliation with facility's med tech staff present.  During the medication reconciliation it was found that Patient 4's Atropine 1% eye drops, Buspirone 15 mg tablets, and Olanzapine 2.5 mg tablets were not available in the medication cart.  It was also found that Patient 4's medication card and Patient 4's MAR indicated Pantoprazole 40 mg was given one time a day.  SN 2 acknowledged that Patient 4's medication profile did not match the medications that Patient 4 was receiving at the Assisted Living Facility.  SN 2 stated the expectation is that the medication profile matches the facility's medications.  SN 2 stated she had not done a medication cart check but now will start.  SN 2 stated, "Will be a good practice.  Have been more of a 'stickler' for accuracy with home patients."  During a concurrent interview and record review on 10/9/25 at 3:00 p.m. with the Director of Patient Care Services (DPCS), reviewed Patient 4's medication profile with the Assisted Living Facility's MAR and what was in the medication cart at the facility.  The DPCS acknowledged that Patient 4's medication profile did not match Patient 4's medications in the facility. The DPCS stated her expectation is that medication reconciliation be done at least every two weeks.   A review of the HA Policy and Procedure 's (P&P) titled "Medication Profile," not dated, indicated "...To determine the use of the medication profile in evaluating a patient's regimen...Patient's receiving medications administered by the organization will have a current accurate medication profile in the clinical record. The medication profile will be updated for each change to reflect current medications, and new and/or discontinued medications...During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure the patient and family/caregiver, as well as other clinicians, understand the medication regimen...Using the medication profile to evaluate the use of the drugs in the home setting. The medication profile includes...date prescribed, name of medication, dose, frequency, drug classification, and date discontinued. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications.  Using the medication profile as a communication tool for other clinicians involved in care... Based on review of the medication profile as well as the written material, changes in the plan of care may be required...Deviations from taking medications as ordered will be documented in clinical notes, and the physician...will be notified..."   A review of the HA P&P titled "The Plan of Care, " not dated, indicated "...The written plan of care will contain...Drugs and treatments...Care provided to the patient will be in accordance with the plan of care..."

Based on interview and employee personnel file review, the agency failed to ensure performance evaluations were done annually for one of 10 sampled Home Health Aides (HHA 1).This failure increased the potential for HHA 1 to provide inadequate care to patients. --- Findings:During a concurrent interview and personnel file review with Human Resources Specialist (HRS) on 10/10/25, at 10 a.m., HHA 1 file revealed a hire date of 3/11/24. The HRS stated that the Annual Performance Evaluation (APE) should be completed every year around the date the employee was hired. The HRS was unable to locate the APE for HHA 1.During a follow up interview and personnel file review for HHA 1 on 10/10/25 at 11:45 a.m., the Director of Patient Care Services (DPCS) provided a document titled "Annual Performance Evaluation" which contained HHA 1 name. The DPCS validated that APE document was not acknowledged and not signed by HHA 1. The DPCS stated the performance evaluations should be completed annually on the employees' anniversary date and should be acknowledged by the employee that APE was done.A review of the undated facility's policy titled, "Performance Evaluations," indicated, "All organizational personnel will be evaluated...by their supervisor...to determine strengths and areas requiring performance improvement...performance evaluations will be completed...annually...Performance evaluations will be documented on the applicable form, signed by the person completing the evaluation of the employee."

Based on observation, interview. and record review, the Hospice Agency failed to ensure home health aide (HHA) assignments and duties were provided based on the Plan of Care (POC) for one of 19 sampled patients (Patient 10) when Patient 10’s oral care (practices aimed at maintaining the health and cleanliness of the mouth, teeth, and gums) was not provided as ordered and was not documented accurately on Patient 10's medical record.This failure had the potential to affect Patient 10’s overall health and well-being. --- Findings:Patient 10 had a start of care (SOC) date of 3/8/25 and diagnoses included cerebral atherosclerosis (a condition where the arteries in the brain become narrowed and hardened due to the accumulation of fats).A review of Patient 10’s “Aide Care Plan Report,” effective 5/9/25, indicated, “…Care Plan Category/Service:…ORAL CARE…Frequency:…EVERY VISIT…”During an observation on 10/9/25 at 6:53 a.m. with HHA 2, HHA 2 was observed providing bed bath, hair care, skin care, and perineal care to Patient 10 but oral care was not observed during the care as indicated on Patient 10’s POC.During an interview on 10/9/25 at 7:59 a.m. with HHA 2, HHA 2 confirmed oral care was not done for Patient 10 during the visit. HHA 2 stated HHAs use little sponges in providing oral care, and HHA 2 stated she did not see the sponges in the supply storage. HHA 2 stated providing oral care to patients was important to prevent infection. HHA 2 further stated it was important to follow the POC because “…It’s a checklist to do our due diligence…”A review of Patient 10’s “Visit Note Report,” dated 10/9/25, indicated, “…SERVICE: ORAL CARE…COMPLETED: Y [Yes]…”During a concurrent interview and record review on 10/9/25 at 2:10 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that the expectation was for all staff to follow the POC and for HHAs to complete all the tasks indicated on the POC. The DPCS confirmed HHA 2’s visit on 10/9/25 indicated all care was provided to Patient 10 in contrary to the observation and interview with HHA 2.During a review of the agency’s policy and procedure (P&P) titled, “HOSPICE AIDE SERVICES,” revised 5/2024, the P&P indicated, “…3. Hospice Aide assignments, plan of care, and interventions will be documented and included in the patient’s clinical records. 4. Hospice Aide duties include: A. Assisting with personal hygiene…5. Hospice aide will document care provided in accordance with the hospice aide assignment…”During a review of the agency’s P&P titled “THE PLAN OF CARE,” undated, the P&P indicated, “…4. The plan of care will identify the patient’s needs and services to meet those needs…14. Care provided to the patient will be in accordance with the plan of care…”

Based on interview and record review, the agency failed to provide nursing services consistent with accepted standards of practice for one of 19 sampled patients (Patient 15), when there was no documented evidence that Patient 15's death was pronounced (a formal declaration that a person has died; a legal process essential for obtaining a death certificate) by the physician. This failure had the potential to delay communication about the Patient 15's death and had the potential to result in critical aspects of postmortem details being missed. --- A review of Patient 15’s Plan of Care (POC) indicated Patient 15 had a Start of Care (SOC) of 7/6/24 with diagnoses that included dementia (a progressive state of decline in mental abilities).During a review of Patient 15’s document titled “Visit Note Report,” dated 10/25/24, the document indicated Patient 15 died on 10/25/24 and the death visit was provided by Skilled Nurse (SN 1) who was a Licensed Vocational Nurse (LVN). SN 1 documented, "Upon arrival pt [patient] absent of all vs [vital signs - measurements of the body's most basic functions, which include heart rate, respirations, blood pressure and temperature]." SN 1 documented that Patient 15's daughter and funeral home were notified. The document did not indicate that Patient 16's death was pronounced by the physician.A review of the agency's undated policy titled, "Death at Home," indicated the purpose of the policy was to follow the process when a patient died. The policy indicated, "Following notification of a patient's...death, the nurse will notify the attending physician...It will be the attending physician's responsibility to pronounce death...The nurse will document in the clinical record...significant information regarding the death."During a concurrent interview and record review on 10/10/25 at 11:40 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that per agency's policy, patient's death should be pronounced by physician or registered nurse. The DPCS stated that it was not within a scope of practice (activities and duties legally permitted to perform) for a Licensed Vocational Nurse to pronounce the patient's death. The DPCS explained that if LVN conducted visit upon patient's death, LVN was to call the physician, provide the assessment and the physician pronounced death based on LVN's assessment. The DPCS acknowledged that she was not able to find any record that the physician pronounced Patient 15's death.A review of the agency's undated policy titled, "Hospice Nursing Care," indicated, " Nursing services will be provided in accordance with accepted standards of practice...The hospice nurse will play a key role...in initiating communication with the interdisciplinary group...Licensed...vocational nurses will supplement the nursing care needs of the patient...Providing services in accordance with organizational policies and procedures."

Based on observation and interview, the Hospice Agency (HA) failed to remain in compliance with Federal, State, and local laws when the HA was certified under a non-operational Home Health Agency (HHA) as required by State law. This failure resulted in the HA not maintaining a State license, which had the potential to impact care of its hospice patients and the services to the community. Findings: During the State recertification survey for the HA, Department entered agency on 11/9/22 at 9:28 a.m. for a Change of Ownership licensing survey for the HHA. The Director of Patient Care Services (DPCS) stated the agency had no home health patients. The DPCS stated the Administrator (ADM) was on his way and suggested to wait for him. During an interview with the ADM and the DPCS on 11/9/22 at 10:00 a.m., the ADM stated they were both hired on 6/6/21 when the agency was bought by new owners. The ADM stated the former owners had no home health patients and the new owners had no plans to operate home health services. The DPCS indicated the new owners understanding at the time the agency was purchased, was the hospice agency was licensed to operate under the 'old school' using the home health agency license. The ADM and the DPCS reported they do not have medical records in paper or electronic form, staff, policies and procedures, supplies or contracted staff or services for home health care patients, just for hospice patients. The ADM stated the space dedicated for home health care by the former owners was still intact and part of the agency. The ADM stated the agency does not have plans to provide any home health care services. The DPCS provided hospice census of 94 patients. A determination was made to deny a renewal of the HHA State license due to its the non-operational status, which consequently had the HA in noncompliance with State law according to T22 (Title 22)-74671(b)(3) Statute that states the Agency must be licensed and the HHA must be operational.