Every finding on record at Sacramento River Healthcare, LLC

Based on interview and record review, the Hospice Agency failed to follow the individualized plan of care for one out of 14 sampled patients (Patient 6) when Patient 6's order for Skilled Nursing (SN) daily visit was not followed.This failure had the potential for Patient 6 to experience change in condition and uncontrolled symptoms that the hospice agency would not be aware of, and for Patient 6 to not receive required skilled nursing services negatively affecting Patient 6's comfort and well-being. --- Findings: A review of Patient 6’s clinical records indicated Patient 6 had a Start of Care (SOC) date with the Hospice Agency on 10/6/25 and had diagnoses that included senile degeneration of the brain (a progressive decline in mental abilities that occurs with aging), and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities).A review of Patient 6's physician's order, dated 10/11/25, indicated, "CONTINUE DAILY SKILLED NURSE VISITS X [for] 3 DAYS FOR SYMPTOM MANAGEMENT." A review of Patient 6's Registered Nurse visit note, dated 10/11/25, indicated, "...PATIENT PLACED ON DAILY SKILLED NURSE VISTS DUE TO DECLINE AND SYMPTOMMANAGEMENT..."During a concurrent interview and record review on 10/15/25 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 6's clinical records were reviewed. The DPCS confirmed that Patient 6 was not visited by any hospice agency staff on 10/13/25 and that Patient 6's order for SN daily visit was not followed. The DPCS stated that physician's order should have been followed. The DPCS also stated there was no communication note about why Patient 6 was not visited on 10/13/25. The DPCS further stated there was a risk for Patient 6 to have a change in condition and uncontrolled symptoms that hospice staff would not be aware of.A review of the Centers for Medicare & Medicaid Services (CMS- the federal agency in the United States that provides health coverage) online publication titled, "Hospice", dated 11/6/24, indicated, "All hospice care and services offered to patients and their families must follow an individualized written plan of care (POC) that meets the patient’s needs. The hospice interdisciplinary group establishes the POC together with the attending physician (if any), the patient or representative, and the primary caregiver." (https://www.cms.gov/medicare/payment/fee-for-service-providers/hospice#:~:text=Hospice%20is%20a%20comprehensive%2C%20holistic,terminal%20illness%20and%20related%20conditions)

Based on interview and record review, the Hospice Agency failed to ensure provision of bereavement (the period of grieving and adjustment following a significant loss) services in accordance with the facility's policy and procedures (P&P) and bereavement plan of care for one out of 14 sampled patients (Patient 9) when:1. Patient 9's family was not sent an initial sympathy letter within 7 days after Patient 9's death; and,2. There was no bereavement assessment done to Patient 9's family after the Patient 9's death.These failures had the potential for Patient 9's family to not receive needed support and/or counseling services after Patient 9's death. --- Findings:A review of Patient 9’s clinical records indicated Patient 9 had a Start of Care (SOC) date with the Hospice Agency on 8/3/25 and had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), and breast cancer.A review of Patient 9’s clinical document titled “Client Coordination Note Report”, dated 8/4/25, indicated Patient 9 died on 8/4/25 at 4:48 p.m.A review of Patient 9’s clinical records revealed there was no documented evidence that Patient 9's family was sent an initial sympathy letter within 7 days after Patient 9's death. There was also no documented bereavement assessment done to Patient 9's family after the Patient 9's death.During a concurrent interview and record review on 10/15/25 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 9's clinical records were reviewed. The DPCS confirmed that there was no documented evidence that Patient 9's family was sent an initial sympathy letter within 7 days after Patient 9's death and stated it was part of the care plan, and the hospice agency had to follow it. The DPCS further confirmed that there was no documented bereavement assessment done to Patient 9's family after the Patient 9's death and stated the assessment should have been done because the bereavement risk of the family could be different after the patient's death.A review of the facility's P&P titled, "BEREAVEMENT SERVICES", undated, indicated, "8. Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved...10. Within three (3) to five (5) weeks after the patient's death, a bereavement assessment...will be completed by the bereavement counselor following the family/caregiver. This assessment will note and observe the bereaved for symptoms related to grief. The bereavement counselor will render a professional judgment as to whether the bereaved is experiencing normal grief, moderate grief, or a severe grief reaction."

Based on interview and record review, the hospice failed to ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid hospice employees and contract staff for a census of 63. This failure resulted in the hospice not optimizing the cost savings of volunteer activities. --- During a concurrent interview on 10/15/25 at 11:11 a.m. with the Volunteer Coordinator and review of the hospice document titled “Hospice Volunteer Requirement Report, dated 10/14/25 indicated from October 2024  to October 2025 the hospice did not ensure volunteers provided day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals five percent of the total patient care hours of all paid hospice employees and contract staff. The Volunteer Coordinator confirmed the percentages were below five percent from October 2024 to October 2025.Review of the hospice’s undated policy and procedure titled, “Volunteer Services,” indicated, “The Volunteer Coordinator will track the use of volunteers, the cost savings achieved, and that the hours of volunteer services will exceed 5% of the total patient care hours of paid and contracted hospice personnel. The Volunteer Coordinator will provide an annual report to the Governing Body to demonstrate the cost savings of volunteer activities.

Based on interview and record review, the agency failed to provide nursing services and physician services that are consistent with accepted standards of practice for one of 14 sampled patients (Patient 9) when there was no documented evidence that Patient 9's death was pronounced (a legal process of declaration that a person has died which is essential for obtaining a death certificate) by a physician.This failure had the potential to delay communication about the Patient 9's death and had the potential to result in critical aspects of postmortem (occurring or performed after death) details being missed. --- Findings:A review of Patient 9’s clinical records indicated Patient 9 had a Start of Care (SOC) date with the Hospice Agency on 8/3/25 and had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions causing memory loss and confusion), and breast cancer.A review of Patient 9’s clinical document titled “Client Coordination Note Report”, dated 8/4/25, indicated Patient 9 died on 8/4/25 at 4:48 p.m. and the death visit was provided by Licensed Nurse (LN) 2 who was a Licensed Vocational Nurse (LVN). The document did not indicate that Patient 9’s death was pronounced by a physician. The document also did not indicate that a physician was notified of Patient 9’s death.During a concurrent interview and record review on 10/15/25 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 9's clinical records were reviewed. The DPCS confirmed that there was no documentation that Patient 9’s death was communicated to and was pronounced by a physician. The DPCS stated that a patient's death should be pronounced by a Physician or could also be a Registered Nurse (RN). The DPCS also stated that it was not within the scope of practice (activities and duties legally permitted to perform) for an LVN to pronounce a patient's death. The DPCS further stated that LN 2 should have notified the physician, provided the assessment and the physician would have pronounced Patient 9's death based on LN 2's assessment. A review of the facility's policy and procedure (P&P) titled, "DEATH AT HOME", undated, indicated, "2. The nurse will assist the family/caregiver at the home with notification of the attending physician…4. The nurse will notify the attending physician of the patient’s death. It will be the attending physician’s responsibility to pronounce death…The physician will routinely accept hospice’s description or report of the absence of vital signs when assuming this responsibility."

Based on interview and record review, the Hospice Agency failed to follow the agency's policy and procedures (P&P) for discharge for one out of 14 sampled patients (Patient 7) when Patient 7's discharge summary was not forwarded to his attending physician after Patient 7's discharge from hospice program.  This failure had the potential for Patient 7 to not continuously receive needed care and services, which could affect Resident 7's comfort and well-being. --- Findings:A review of Patient 7’s clinical records indicated Patient 7 had a Start of Care (SOC) date with the Hospice Agency on 2/20/25 and had diagnoses that included senile degeneration of the brain (a progressive decline in mental abilities that occurs with aging), and dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities).A review of Patient 7’s clinical document titled "Discharge-Transfer Summary Report", dated 5/14/25, indicated, "...DISCHARGE TO HOME OR SELF CARE / Reason: CLIENT [Patient 7] NO LONGER REQUIRES SKILLED CARE..." A review of Patient 7’s clinical records revealed there was no documented evidence that Patient 7's discharge summary was forwarded to his attending physician after Patient 7's discharge from hospice program.During a concurrent interview and record review on 10/15/25 at 11:05 a.m. with the Director of Patient Care Services (DPCS), Patient 7's clinical records were reviewed. The DPCS confirmed that there was no documented evidence that Patient 7's discharge summary was forwarded to his attending physician after Patient 7's discharge from hospice program. The DPCS stated the agency's policy is to send the patient's discharge summary to the patient's physician or to the referring doctor for continuity of care.A review of the facility's P&P titled, "DISCHARGE FROM HOSPICE PROGRAM", undated, indicated, "7. A copy of the discharge summary will be sent to the attending physician...."