Every finding on record at Uni Hospice, Inc.

Observed in Record Review. In 3 out of 4 patient records reviewed, the organization failed to plan the patient’s care with measurable and time specific goals. On RRNHV #1, it was noted that goals were not measurable and specific with examples of “patient will maintain blood pressure within target range as prescribed by MD” and “patient will maintain therapeutic anticoagulation” On RRNHV #3, goals not measurable and specific with example of “patient will maintain stable blood pressure within the target” and there is no ordered target. On RRDC #1, it was noted that goals had not been developed to be measurable and specific prior to discharge with examples of “patient’s hypertension will be controlled by medication”, “maintain adequate nutritional intake”, and no timeframe for “Patient to apply for the Friendly Visitor Program for increased socialization”. This was discussed and reviewed with the DCPS designee.

Observed in Record Review. In 3 of 4 patient records reviewed, the organization failed to ensure the plan of care was updated based on the patient’s reassessment and progress toward goals. In RRNHV #2 the plan of care had not been updated to reflect the current assessment, achieving goals that had been achieved. For example, every teaching goals were unaltered for IDG to IDG since admission 2 months ago with no change or update to their progress. On RRNHV #3 the plan of care has not been updated to reflect goals that have been achieved based on assessment, patient has goal for altered skin to be healed but the recent assessments don’t document that the patient has any altered skin. On RRDC #1, the plans of care were reviewed prior to discharge, and the Plan of care had not been updated to reflect achieved goals with teaching goals present throughout the entire length of stay. This finding was reviewed with the DCPS designee.

Observed in Record Review. In 1 of 3 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRNHV # 1 the physician’s orders in the plan of care documented MiraLAX PRN for constipation and Colace PRN for constipation; however, there was no indication how to handle the duplicate PRN therapy. This was discussed with the DCPS designee.

Observed in Record Review. On 1 of 3 bereavement records reviewed, the organization did not follow the plan of care. On RRBR #2, the bereavement plan of care called for a mailing to be sent at one month but there is no documentation to indicate that letter was sent. This finding was reviewed with the DCPS designee.

Observed in Emergency Management Session. The organization had not conducted exercises to test the emergency plan at least annually. On review of the organizations Emergency Plan they did not have documentation of a drill for 2024. This was reviewed with the DCPS designee.

Observed in Record Review. In 3 of 3 discharge records reviewed, the patient discharged from service without the completion of a Notice of Medicare Non Coverage (NOMNC) completed prior to discharging patient from service. On review of RRDC #1, RRDC #2 and RRDC #3, the agency did not have record that the NOMNC was completed prior to discharging the patient from service. This finding was reviewed and discussed with DCPS designee.

Observed in Record Review. In 2 out of 3 active patient records reviewed, the organization failed to plan the patient's care with measurable and time specific goals. On RRHV #2, it was noted that goals were not time specific with examples of No fall episode and Altered skin will heal for patient comfort. On review of RRHV #3, it was noted that goals were not measurable and specific with examples of Pt will have adequate food and fluids as tolerated or desired and Pt will have adequate food and fluids to maintain comfort. This was discussed and reviewed with the DCPS designee.

Observed in Record Review. In 2 of 3 discharged records reviewed, the organization did not get a physician order for discharge. On review of RRDC #2 and RRDC #3, it was noted that the administrator called both patients and notified them Medicare was not covering care and they were being discharge with no physician order obtained for the discharge. This finding was reviewed and discussed with DCPS designee.

Observed in Record Review. In 1 of 3 active patient records reviewed, the hospice nurse surveyor noted medication orders were not clear and accurate. On RRHV # 3 the physician's orders in the plan of care documented Tylenol 500 mg cap Q6prn for mild pain and Tylenol 650mg suppository Q 6 PRN mild pain; however, there was no indication how to handle the duplicate therapy. This was discussed with the DCPS designee.

Observed in Record Review. On 2 of 3 live discharged records reviewed, the organization did not coordinate care and services with the interdisciplinary team. On RRDC #2 and RRDC #3, it was not discussed with the IDG team regarding discharging patients from service because they didn't qualify for Medicare. This finding was reviewed with the DCPS designee

Observed in Data Session. On review of the QAPI program, the hospice had no documentation of ongoing, hospice wide, date driven quality assessment process improvement program for the last three years. In discussions with the organization, they have recognized the issue and have done an assessment of the organization but have not had the meeting yet to set up the program. This was reviewed by the DCPS designee. Observed in Data Session. On review of the QAPI program, the hospice program did not have a quality assessment and improvement program in place for the last three years. This was reviewed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, the hospice did not include issues related to palliative outcomes in their QAPI program because they had not set up their program. This was reviewed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, the hospice did not use quality indicator data in the design of its QAPI program because they had not set up a program. This was reviewed by the DCPS designee.

Observed in Data Session. On review of the organizations QAPI program, the organization had not been collecting data until August 2025 so it could not be analyzed or used to identify performance trends or variances. This was confirmed by the DCPS designee. Observed in Data Session. On review of the organizations QAPI program, the agency had been collecting data but it was not being aggregated, trended or analyzed so therefore it was not being utilized to identify areas for process improvement. This was confirmed by the DCPS designee.

Observed in Data Session. During review of the organizations QAPI program, it was noted the organization did not specify the detail and frequency the organization would collect data and have the governing board approval for that frequency. This was confirmed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, leadership had not established any performance improvement activities that affect palliative outcomes, safety or quality of care. This was reviewed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, the organization did not collect data on adverse patient events, prior to August 2025. This was confirmed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, the hospice had not identified any performance improvement projects and therefore had no documentation for reasons to conduct the project or measurable progress. This was reviewed by the DCPS designee.

Observed in Data Session. On review of the QAPI program, the agency had not collected data to be analyzed and had no performance improvement plans in place to have any improvement. This was reviewed by the DCPS designee. Observed in Data Tracer. On review of the QAPI program, the hospice had not developed a data-based performance improvement program, hence leadership did not set priorities for data collection. The organization has recognized the deficit and started an assessment and collecting data in August of 2025. This was reviewed by the DCPS designee.

Observed in Infection Control System Tracer. On review of the organization Infection control, the organization failed to implement activities for infection surveillance. On review of the organization's QAPI and Infection control program there was no data for infections collected data prior to August 2025. This was reviewed with the DCPS designee.

Observed in Infection Control System Tracer. During QAPI session, it was noted the organization did not have documented hand hygiene goals for 2025, 2024 and 2023 and subsequently, no data regarding improvements in hand hygiene compliance. They have started collecting data as of August 2025. This was reviewed with the DCPS designee.

Observed in Record Review. The surveyor found from January 2025 to August 2025 there had been no evidence of functional bereavement program that was addressing the care of the bereaved clients. The prior leadership decided to stop seeing patients and there was a gap in services being performed and the follow-up for bereavement was not done. This gap in services was discovered during the survey process, when on review of charts and discussion with leadership and the current bereavement coordinator, patient are not receiving the follow-up. The agency has hired a new bereavement coordinator as of August 2025 but on discussion with him during the survey he was just assigned the role and had no tools to do bereavement yet. This was reviewed with the DCPS designee.

Observed in Tracer Activities. During review of the Volunteer program, there was no documentation to validate cost savings had been achieved using volunteers. In discussion with the Volunteer Coordinator, there was a gap without a volunteer coordinator and the reports were not completed. They have recognized the deficit and have the cost savings report for the last two months. This was reviewed and validated with the DPCS designee.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, the organizing is not providing volunteers that equals 5% of the total patient care hours of all paid hospice employees and contract staff. There is no documentation of volunteer hours prior to August 2025 and currently they are only at 2.5 % for their hours. This was reviewed and validated with the DPCS designee.

Observed in Tracer Activities. The organization failed to implement policies and procedures. During tracer activities the Hospice Nurse Surveyor observed the organizational leaders did not implement policies and procedures which results in non-compliance with 418.58, 418.116 and 418.100. This finding was reviewed with DCPS designee.

Observed in Record Review. In 3 of 3 patient records reviewed that had a live discharge, the organization failed to provide a written discharge summary in accordance with their policy. Agency policy (4-076) states that a discharge summary will be sent to attending physician. On RRDC #1, the discharge summary was created but there is no record of it being sent to the physician. On review of RRDC #2 and RRDC #3, it was noted that the discharge summary was not sent to the physician when the patient was discharged. This finding was reviewed and discussed with DCPS designee.

Observed in Tracer Activities. On review of the organizations controlled substance policy and procedures, the organization did not have a process in place for the disposal of controlled substances for the family, the section of the policy manual was a page from the vendor stating insert organizations drug disposal instructions here and there was no insert. This finding was reviewed with the DPCS designee.

Observed in Tracer Activities. On review of the admission packet and controlled substance policy and procedures, the organization did not provide a copy of the organizations written policy and procedure. The organization has been giving instructions that have been developed in their admission binder on the disposal of controlled drugs but it did not match a policy or procedure. This finding was reviewed with the DPCS designee.

Observed in Record Review. In 1 out of 2 patient records reviewed where patient death occurred, the organization failed to ensure that the patient's pronouncement follow agency policy and California statute. Agency Death Policy (4-069) states that the attending physician will pronounce death. On RRBR #2, the LVN note stated SN declared patient time of death at 11:15 am, there was no documentation that the LVN contacted the physician to pronounce death. This is not in compliance with agency policy, or California law and regulations. This was discussed and verified with the DPCS designee. Observed in Leadership Session. On review of leadership, the organization had a 49% ownership change this year and the organization did not notify California Department of Health of this change. This finding has been reviewed with agency leadership.