Every finding on record at Casa De La Paz Hospice

Based on observations, interviews, record review, and agency policy review, the Hospice agency failed to provide personal care in a manner to prevent cross contamination for two of four patients (Patient (P) 1 and P2) observed during home visits out of a total sample of 19. This had the potential to increase the risk of infection for the patients.  Findings include: Review of agency policy titled, "Hand Hygiene," revised 03/01/21, indicated, "To help prevent the spread of microorganisms and infection by cross-contamination and to provide practice guidelines…Procedure…8. Other Aspects of Hand Hygiene: …b. Change gloves during patient care if moving from a contaminated body site to a clean body site."1. Review of P1's "Patient Information Report," provided by the agency, indicated that P1 was admitted to hospice on 04/07/23 with a diagnosis of atrial fibrillation.  During a home visit on 12/16/25 at 10:45 AM, Home Health Aide (HHA) 1 was observed completing a bed bath for P1. HHA1 placed his/her gloves on and went out of the room to return with a basin with soapy water and one washcloth. Wearing the same gloves, he/she removed P1's clothing from his/her upper body and placed them on the floor. HHA1 took the washcloth and washed P1's upper body. After washing P1, HHA1 dried P1 with the same gloves put fungal powder under each breast, then lotion on both arms, and washed P1's face. HHA1 placed a new shirt on P1. Without changing his/her gloves, HHA1 assisted P1 to lay down in bed. HHA1 removed soiled clothing along with soiled brief. HHA1 washed P1's right leg, then his/her left leg and dried them both. HHA1 put lotion on P1's legs and then washed and dried P1's vaginal area. HHA1 assisted P1 in rolling over to his/her left side where HHA1 washed and dried P1s buttocks which visually had bowel movement (BM). After drying P1, but with the same gloves, HHA1 looked through P1's dresser and nightstand until HHA1 found cream for P1's buttocks. HHA1 placed cream and new brief on P1, with the same gloves. Afterwards, he/she removed his/her gloves and did not perform hand hygiene.  2. Review of P2's "Patient Information Report," provided by the agency, indicated that P2 was admitted to hospice on 10/25/24 with a diagnosis of congestive heart failure. During a home visit on 12/16/25 at 2:00 PM, HHA1 was observed completing a bed bath for P2. HHA1 donned his/her gloves and went into the kitchen to return with a round green Tupperware bowl of soapy water and one washcloth. HHA1 washed P2's face then his/her hair. HHA1 removed P2's clothing from his/her upper body and washed and dried P2's chest and arms. With the same gloves, HHA1 washed P2's right leg, then left leg, cleaned P2's vaginal area, and assisted P2 in rolling over to his/her right side. HHA1 washed and dried P2's back and buttocks. Afterwards, HHA1 with the same gloves, put cream on P2's buttocks and placed a new brief on P2. HHA1, then put new clothing on P2, and he/she put a clean fitted sheet that had been sitting on the floor on P2's bed long with a clean pillow. Afterwards, he/she removed his/her gloves; however, the HHA did not perform hand hygiene after he/she removed his/her soiled gloves. During an interview on 12/16/25 at 3:00 PM, HHA1 confirmed he/she should have changed his/her gloves when he/she went from a dirty area to a clean area. During an interview on 12/17/25 at 10:00 AM, the Executive Director (ED) confirmed that gloves should be changed when going from a dirty area to a clean area.