Every finding on record at Hospice of San Joaquin

Based on observation, interview, and record review, the agency failed to ensure influenza vaccines that expired on 6/2025 were disposed of and not available for use, for a census of 6.This failure had the potential for patients admitted to the Hospice House to receive ineffective vaccines which could cause decreased protection against the current strain of the influenza virus. --- During a concurrent  observation and interview, in the Hospice House medication room, on 9/16/25, at 10:09 AM, with Licensed Nurse (LN) 1, LN 1 confirmed there were 59 vials of influenza vaccine in the active medication refrigerator with an expiration date of 6/2025. LN 1 stated the expired medications should have been removed from the refrigerator to prevent accidental use. LN 1 further stated the expired vaccines should have been placed in a separate storage area until they could  be destroyed by two licensed nurses. LN 1 stated expired vaccine could be ineffective or cause an adverse reaction and should not be administered to patients.During an interview on 9/19/25, at 9:26 AM, with the Consultant Pharmacist (CP), the CP stated expired medications should not be stored with active medications due to the possibility of a mix up. The CP further stated the expired medication should have been disposed of immediately.A review of an online article, accessed on 9/23/25, from the Center for Disease Control and Prevention (CDC) website, Hesse EM, Hibbs BF, Cano MV. Notes from the Field: Administration of Expired Injectable Influenza Vaccines Reported to the Vaccine Adverse Event Reporting System- United States, July 2018- March 2019, indicated, “…Vaccination with an expired influenza vaccine might not protect against influenza infection because different virus strains can be included in the vaccine each year…protection against viruses included in the vaccine could wane if vaccine potency decreases over time…”https://www.cdc.gov/mmwr/volumes/68/wr/mm6823a3.htmA review of a facility policy titled, “Destruction of Discontinued, Expired, Damaged or Contaminated Medications,” dated, 6/14/16, indicated, “…Hospice House residents’ medications supplied by prescription that have been discontinued and/or those which remain in the facility after the patient’s death or discharge will be destroyed by the facility…Discontinued expired, damaged or contaminated medications will be removed from patient care areas immediately and stored separately from medications available for administration…”

Based on observation, interview, and record review, the facility failed to ensure food, and food preparation equipment were stored in a sanitary environment, for a census of six, when:1. A waffle maker was stored in a kitchen cabinet containing a yellowish substance around the cooking surfaces and on the cabinet shelf the waffle maker was stored on. 2. Two bottles of expired olive oil were in the pantry;3. Two opened boxes of cereal were stored in the pantry;4. One opened package of sugar was stored in the pantry; and5. Four blackened bananas were stored in the pantry.These failures had the potential to attract pests such as ants, cockroaches, mice, and had the potential to cause foodborne illness in patients residing in the facility. --- During a concurrent observation and interview, in the kitchen and in the pantry, with the Chief Clinical Officer (CCO), on 9/16/25, between 9:45 AM and 9:50 AM, in a kitchen storage cabinet, a waffle maker was stored containing a yellowish dough like substance around the edges, which was easily removeable, and yellowish dough like substance was stuck to the bottom of the shelf the waffle maker was on. The CCO confirmed the above and stated the waffle maker should have been clean prior to it being stored. In the kitchen pantry the following items were noted:-an opened, uncovered box of rice.-two opened, uncovered boxes of cereal.-one opened, uncovered bag of sugar.-two expired bottles of olive oil, one opened with an expiration date of 10/11/22, one sealed with an expiration date of 2/19/24.-four dark brown and soft bananas.The CCO confirmed the above items and stated they should not be available for use. The CCO explained the opened items could encourage pests.A review of the facility policy titled, “Dietetic Service – Food Storage,” dated 6/14/16, indicated, “… food for use … will be stored, prepared, distributed and served using proper sanitation, temperature, light, moisture, ventilation and security to keep it clean and fresh and to protect it from contamination … Foods held in refrigerated or other storage areas shall be covered … Spoiled and contaminated food shall not be served an will be properly disposed of.”

Based on interviews and record review, the agency failed to provide care and services according to the plan of care (POC) for 2 of 16 sampled patients (Patient 3 and Patient 16) when: 1. Skilled Nursing (SN) home visit was missed for Patient 3, and 2. Patient 16's plan of care did not include a signed physician's order for Home Health Aide (HHA) and frequency of HHA visits to meet patient's needs and HHA visits were missed between 8/31/21 and 9/14/21. These failures placed the residents at risk for unmet care needs. 1. Patient 3 had the Start of Care (SOC) date on 9/23/21 with diagnoses included dementia with an advanced age. Review of the clinical record, "Physician's Orders/Plan of care from 09-23-21 to 12-21-21," indicated Patient 3 had a physician order, dated 9/23/21, for SN to visit the patient home two times for the first week of SOC, "SN 09-23-21, 2 x week x 1 week". Review of Patient 3's clinical record indicated SN made the first visit on 9/23/21 and no other visit was made for the week. There was no documented evidence SN contacted the attending physician or informed the IDG (Interdisciplinary Group, a group of professionals working together for the patient) regarding the missed visit to ensure the IDG was aware of the patient's up to date health status. There was no documented evidence the missed visit was rescheduled. Review of the Agency's October, 2915 policy and procedure, Missed Visits, stipulated, "Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." In an interview on 11/17/21 at 1:55 p.m., the Chief Clinical Officer (CCO) verified the SN visit order for Patient 3 and the missed visit. The CCO stated there should have been a missed visit note in order to update the patient's plan of care. The CCO acknowledged the communication with the IDG regarding the patient health status was important to ensure quality of patient care. 2. According to Patient 16's POC, she was admitted to the hospice agency with a start of care (SOC) date of 8/31/21 with a terminal diagnosis of lung cancer. A review of Patient 16's Plan of Care from 8/31/21 to 11/28/21 indicated an order for Skilled Nursing and Medical Social Worker visits. The POC was electronically signed by the physician on 9/10/21. The POC did not include the order for HHA services. A review of Patient 16's clinical records indicated the HHA visits were made on 9/17, 9/22, 9/24, 9/28, 10/5, 10/8, 10/12, 10/19, 10/21, 10/26, 10/29, 11/2, 11/5, 11/9, 11/13, and 11/16/21. During a concurrent interview and record review with Chief Clinical Officer (CCO) on 11/17/21, at 3:40 p.m., the CCO confirmed the agency provided HHA services with personal care for Patient 16 on 9/17, 9/22, 9/24, 9/28, 10/5, 10/8, 10/12, 10/19, 10/21, 10/26, 10/29, 11/2, 11/5, 11/9, 11/13, and 11/16/21. The CCO reviewed Patient 16's clinical record including the POC and was not able to find a a physician's order for HHA services. A review of Patient 16's clinical records revealed no HHA visits were made from 8/31/21 until 9/14/21 which indicated that patient had four missed visits. The clinical records did not contain any documentation explaining why the visits were missed. During a continuing concurrent interview and record review with the Chief Clinical Officer (CCO) on 11/17/21, at 3:40 p.m., the CCO acknowledged the HHA services were not provided for Patient 16 for two weeks. The CCO stated she was not aware Patient 16 had four missed visits. On 11/18/21, at 10:05 a.m., the CCO provided an unsigned physician's order for Patient 16 titled, "Supplemental Orders from 8/13/21 to 11/27/21," which indicated the HHA was to visit patient twice a week for 11 weeks. The CCO stated although the order was not signed by the physician, the agency followed the order and provided HHA services for Patient 16. The CCO explained the order for HHA was not included in Patient 16's POC because it was not signed. The CCO stated it should have been signed by physician within 30 days of receiving the order and the POC should have been updated to reflect the HHA services and it frequency. During continued interview with the CCO on 11/18/21 at 10:05 a.m., the CCO confirmed that there was no documentation in Patient 16's record why the four visits were not made. The CCO stated the reason for the missed visits should have been communicated to the clinical supervisor or case manager and documented in the clinical record. When the CCO was asked if Patient 16's physician had to be notified of missed visits and services not provided, the CCO stated, "I don't know." Review of the agency's policy titled, "Verification of Physician Orders," dated 4/21, indicated, "Orders will be obtained from a licensed physician ...for care and services to be provided to hospice patients ...The ...order will be delivered to the physician ...for his/her signature ...Signed orders will be placed in the clinical records within 30 days of initiation of the order." Review of the agency's policy titled "The Plan of Care," dated 6/14, indicated, "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 written plan of care will contain ...frequency and type of services ...physician (or other authorized licensed independent practitioner) orders ...Care provided to the patient will be in accordance with the plan of care." Review of the agency's policy titled, "Missed Visits," dated 6/16, indicated,"Purpose: To ensure that missed visits are documented and do no affect the quality of patient care ...Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting ...If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained ....Missed visits will be documented in the clinical record."

Based on observation, interview and record review, the agency failed to ensure drugs to manage symptoms associated with terminal illness were readily available and not expired for one of 4 sampled patients who received home visits (Patient 6) when compazine (used for nausea and vomiting) was expired and bisacodyl (used for constipation) suppositories were not available. This failure had the risk for end of life symptoms to not be managed. Findings: According to Patient 6's Plan of Care (POC) dated 11/7/21 through 1/5/22, the agency admitted her with a terminal diagnosis of breast cancer. Patient 6 resided in an Assisted Living Facility (ALF). During a home visit on 11/17/21, starting at 11 a.m., accompanied by Skilled Nurse (SN 1), SN 1 was observed as she verified Patient 1's supply of medications with a medication technician. The medications were stored in the medication cart. The medication technician handed SN 1 a bubble pack containing compazine which had expired on 10/8/21, which was 10 days before the patient was recertified for hospice care. SN 1 asked the medication technician if Patient 1 had a supply of bisacodyl suppositories and she stated there was none after checking inside the medication cart and the medication room. During a concurrent interview with SN 1, on 11/17/21 at 11:15 a.m., she validated the compazine for Patient 1 was expired and the patient had no supply of bisacodyl suppositories. SN 1 stated she had visited Patient 1 on 11/15/21 and did not check her supply of medication because she could not locate the medication technician. SN 1 further stated that prior to 11/15/21, the Registered Nurses were assigned to visit Patient 1. A review of the agency's "MEDICATION PROFILE" policy dated 10/2015 indicated, "The admitting nurse will ... review the medications with the patient or their representative and determine the relationship of the medication to the patient's terminal illness and related conditions that contribute to the terminal prognosis ... Related to the terminal illness or related conditions (hospice pays for the medication)." Review of another agency 'IDENTIFICATION OF MEDICATION FOR ADMINISTRATION' policy dated 10/2015 indicated, "All medications will be checked for stability by visually examining the medication and observing for ... Expiration date." An interview conducted with the Chief Clinical Officer (CCO) on 11/17/21, at 1:30 p.m., she stated the nurses who visited Patient 6 should have ensured she had a supply of bisacodyl suppositories and her compazine was removed from the ALF medication cart when it expired.