Every finding on record at Kaiser Foundation Hospital Hospice-Santa Clara

Based on observation, interview, and record review, the hospice agency failed to ensure medications were reviewed and checked regularly for one of six home visit sampled patients (Patient 2) when, the lorazepam (controlled medication used to treat anxiety or excessive worrying disorders and symptoms, sleeping problems and seizures) tablets of Patient 2 were already expired and needed to be replaced. This failure had the potential to create adverse effects to the patient. --- Findings: During the home visit observation of Patient 2 in the assisted living facility (ALF, a residential setting that provides housing, personal care, and support services for older adults or people with disabilities who need assistance with daily tasks but not full-time skilled nursing care), with registered nurse case manager E (RNCM E), on 10/15/25 at 12:25 p.m., RNCM E reviewed and checked the current medications of Patient 2, including the medications in his comfort kit (C-Kit, contains prescribed medications used to treat end-of-life symptoms, such as pain, anxiety, nausea or urge to vomit and shortness of breath). Patient 2's lorazepam 0.5 milligram (mg, unit of mass) tablets in the comfort kit were already expired, on 9/16/25.  Review of Patient 2's clinical records indicated, his hospice start of care was 11/14/24 with the primary diagnosis of adenocarcinoma of the rectum (type of cancer that originates in the glandular cells lining in the rectum).  Review of Patient 2's hospice plan of care (HPOC, personalized document that outlines the medical, emotional, psychosocial, and spiritual needs of a terminally ill patient and their family) updated on 9/24/25 indicated, Patient 2 had an order of lorazepam 0.5 mg oral tablet, take 1 tablet by mouth or under the tongue every 6 hours as needed for anxiety or sleep, started on 7/2/25.   During the interview with RNCM E on 10/15/25 at 12:55 p.m., RNCM E verified the expired lorazepam 0.5 mg tablets and stated that they should have been replaced already. RNCM E further verified that patient medications should have been reviewed and checked weekly or every nursing visit and would have the lorazepam 0.5 mg tablets replaced.  During the interview with the registered nurse manager D (RNM D) on 10/15/25 at 1:05 p.m., RNM D verified that patients' medications should have been reviewed and checked regularly and the expired lorazepam 0.5 mg tablets of Patient 2 should not be there and should have been replaced already. RNM D then stated that she would remind nurses about this.  Review of the hospice agency's policy and procedure titled, "Comfort Kits (C-Kit)," revised 12/18/24 indicated, "Medication Management: The Hospice RN will regularly inspect the C-Kit to ensure unauthorized use has not occurred, to assess for expiration dates, and to ensure that patient and/or caregiver/s are educated to its use, as needed."

Based on interview and record review, the hospice agency failed to ensure an individualized plan of care (POC) established by the interdisciplinary group (IDG, the team responsible for development and review of the hospice beneficiary’s plan of care) was followed when the hospice home health aide (HHA) missed the scheduled home visit for one of 23 sampled patients (Patient 15). This failure could lead to insufficient care rendered to Patient 15. --- Findings:During a concurrent interview with both registered nurse quality coordinator A (QC A), in person, and registered nurse quality coordinator B (QC B), thru a video call, and record review of Patient 15’s POC and the calendar for each disciplines home visits on 10/20/2025 at 11:32 a.m., the QC A confirmed Patient 15’s POC indicated a start of care on 8/9/2025 and the diagnosis was multiple myeloma (a cancer of plasma cells [white blood cells that produce antibodies to help fight infections], which are found in the bone marrow [a soft, spongy tissue found inside the hollow center of most bones] and are a part of the immune system). The QC A further confirmed Patient 15’s POC for HHA visit should have been three visits every week for 13 weeks from 8/10-11/6/2025. The QC A stated the POC for HHA visit was to assist Patient 15 with personal care and bed bath. The QC B confirmed there was a missed HHA visit on 9/10/2025 for the week of 9/7/2025 – 9/13/2025, and there was no documentation of the reason for the missed visit, nor notifications to the case manager and Patient 15’s physician. QC B stated the HHA should have notified the case manager for Patient 15’s missed visit, for the case manager to notify the physician. Both QC A and QC B stated the notification should have been documented.During a review of the hospice agency’s undated policy and procedure titled, “Provision of Care, Treatment and Service, Policy No. 2-031.3,” indicated, “The physician must be notified if a scheduled visit is not completed. The reason for the missed visit and notification of the physician must be documented in the medical record.”

Based on interviews and record reviews, the hospice agency failed to have a clear and accurate visit frequency of clinician services for one of twenty-three sampled patients (Patient 23), when the previous visit frequency order for the certified hospice aide (CHA) of Patient 23 was not discontinued after getting a new order. This failure had the potential to result in unnecessary clinician services or lack of it that could result in not meeting the specific patient and family needs. --- Findings: Review of Patient 23's clinical records indicated, his hospice start of care was 2/26/25 with the primary diagnosis of adenocarcinoma metastatic to bilateral lungs (cancer originating elsewhere in the body and has spread to both lungs). Review of Patient 23's hospice plan of care (HPOC, personalized document that outlines the medical, emotional, psychosocial, and spiritual needs of a terminally ill patient and their family) updated on 9/17/25 for the third benefit period (sixty-day time-limited period of care for terminally ill patients), from 8/25/25 to 10/23/25 indicated, Patient 23 had a visit frequency order for certified hospice aide (CHA) of 1 visit every week for 9 weeks from 8/24/25 to 10/23/25. He had a new order of 2 CHA visits every week for 6 weeks from 9/14/25 to 10/23/25. HIs previous order of 1 CHA visit every week for 9 weeks from 8/24/25 to 10/23/25 was not discontinued.  During the concurrent review of Patient 23's HPOC for the third benefit period, from 8/25/25 to 10/23/25 and interviews with quality coordinator F (QC F) and quality coordinator G (QC G) on 10/20/25 at 1:44 p.m., both QC F and QC G verified that the CHA visit frequency order of Patient 23 was not specific. They further verified that the previous order of 1 visit every week for 9 weeks from 8/24/25 to 10/23/25 should have been discontinued when they got the new CHA visit frequency order, to make it clear and accurate and would check and update it.  During the interview with the area quality director (AQD) on 10/20/25 at 1:50 p.m., AQD acknowledged that Patient 23's previous CHA visit frequency order of 1 visit every week for 9 weeks from 8/24/25 to 10/23/25 should have been discontinued when they got a new CHA visit frequency order and would have it updated.  Review of the hospice agency's policy and procedure titled, "The Plan of Care," revised 12/18/24 indicated, "The frequency and duration of visits will be written in a manner which clearly indicates the number of visits needed per week with a prescribed duration.........."

Based on interview and record review, the hospice agency failed to ensure a patient’s change in condition was communicated to the physician in a timely manner for one of 23 sampled patients (Patient 9). This failure had the potential to compromise Patient 9’s comfort. --- Findings:During a concurrent interview with both registered nurse quality coordinator F (QC F), and registered nurse quality coordinator G (QC G) and a record review of Patient 9’s plan of care (POC) and documentation of visits for benefit period number 13 (3/22/2025 – 5/20/2025) on 10/20/2025 at 4:00 p.m., QC G confirmed Patient 9’s start of care was on 9/23/2024 with diagnosis of major neurocognitive disorder due to Alzheimer’s disease (a progressive decline in brain function, most often characterized by memory loss, confusion, and difficulty with thinking and reasoning that interferes with daily life), unspecified severity, with mood disturbance (when a person experiences persistent, intense, and often inappropriate emotional states that interfere with daily life). QC F and QC G confirmed Patient 9 had an after hour visit by a registered nurse (RN) on 4/19/2025 at 9:46 p.m. due to a popped blister (a fluid-filled bubble on the skin that has been broken exposing the tender skin underneath) on Patient 9’s right buttock (one of two rounded part of the human body that you sit on), and there was no documentation that the physician was notified about Patient 9’s new skin issue.During an interview with the area quality director (AQD) on 10/20/2025 at 4:15 p.m., the AQD confirmed their hospice agency has an after-hour program called Continuous Care Advance Program (CCAP) that consists of registered nurses, leaderships and physicians. The AQD stated, RNs should notify the after-hour physician for a patient’s change in condition.During a review of the hospice agency’s policy and procedure titled, ’24-HOUR ACCESS TO CARE,” date revised 10/29/2020, indicated, “PURPOSE To define the access to after-hours care for assuring 24-hour coverage of services.”

Based on observation, interview and record review, the hospice agency failed to follow standard precautions and maintain proper infection control practices to prevent transmission of infection when the certified hospice aide C (CHA C) did not observe hand hygiene (the practice of cleaning hands to remove dirt, germs and bacteria) and proper infection control and prevention, after she contaminated her gloved hands.This failure had the potential to expose the patient to infectious diseases (illnesses caused by microorganisms, known as pathogens, that invade and multiply in the body). --- Findings: During the home visit observation of Patient 1 in the assisted living facility (ALF, a residential setting that provides housing, personal care, and support services for older adults or people with disabilities who need assistance with daily tasks but not full-time skilled nursing care), with the certified hospice aide C (CHA C) on 10/15/25 at 10:35 a.m., CHA C was giving Patient 1, a bed bath (bathing a patient who is confined to bed and can't have the physical and mental capability of self-bathing). After preparing everything for the bed bath, she sanitized her hands and put on clean pair of gloves and proceeded to give Patient 1, his bed bath. CHA C was preparing to reposition Patient 1, with the assistance of two ALF caregivers, when she touched and moved the garbage container at the side of the bed first with her gloved hands, before she moved Patient 1 to his left side with the help of the two ALF caregivers, then wiped and cleaned his buttocks, without removing the dirty gloves, sanitizing her hands and putting on clean gloves.  During the interview with CHA C on 10/15/25 at 11:05 a.m., CHA C verified that she should have changed her dirty gloves, sanitized her hands and put on clean gloves, after she touched and moved the garbage container at the side of the bed and would not do it next time.  During the interview with the registered nurse manager D (RNM D) on 10/15/25 at 11:07 a.m., RNM D verified the above concern and would remind CHA C about hand hygiene and infection control and prevention. Review of the hospice agency's policy and procedure titled, "Infection Prevention and Control: Hand Hygiene," revised 10/23/24 indicated, "Personnel providing care in the home setting will follow hand hygiene provisions established in this policy based on the World Health Organization (WHO)... 5 moments of hand hygiene... After contacting/touching patient surroundings..."

Based on interview and record review, the hospice agency failed to ensure the bereavement services were provided to the bereaved (a person who is greatly saddened by the loss of a loved one through death) of one out of 3 sampled patients (Patient 9). This failure had the potential to result in unmet needs of Patient 9’s bereaved. --- Findings:During a concurrent interview with both registered nurse (RN) quality coordinator F (QC F), and RN quality coordinator G (QC G) and a record review of Patient 9’s plan of care (POC) on 10/20/2025 at 4:00 p.m., QC G confirmed Patient 9’s start of care was on 9/23/2024 with diagnosis of major neurocognitive disorder due to Alzheimer’s disease (a progressive decline in brain function, most often characterized by memory loss, confusion, and difficulty with thinking and reasoning that interferes with daily life), unspecified severity, with mood disturbance (when a person experiences persistent, intense, and often inappropriate emotional states that interfere with daily life).During a concurrent interview with RN quality coordinator A (QC A), in person and RN quality coordinator B (QC B), thru a  video call, and a record review of Patient 9’s POC in Benefit Period number 14 (5/21/2025 – 7/19/2025) on 10/20/2025 at 5:00 p.m., QC A and QC B confirmed Patient 9’s death notification was on 6/13/2025. QC B stated the medical social worker (MSW) completed a Post Death assessment and made a phone call to Patient 9’s bereaved (did not answer) on 6/17/2025. Both QC A and QC B confirmed there was no documentation that bereavement services were provided to the Patient 9’s bereaved, like a follow up call after 6/17/2025 or scheduled mails.During an interview with the area quality director (AQD) on 10/20/2025 at 5:15 p.m., the AQD confirmed there was no documentation that bereavement services were provided to Patient 9’s bereaved after 6/17/2025.During an interview with the bereavement coordinator (BC) on 10/20/2025 at 5:25 p.m., the BC confirmed there were no documented follow up calls to Patient 9’s bereaved after 6/17/2025. She confirmed that she just called Patient 9’s bereaved on 10/20/2025 (four months after Patient 9’s death).During a review of Patient 9’s MSW POC Notes dated 6/19/2025, it indicated the MSW called Patient 9’s bereaved and left a message. Further review indicated, “MSW will remain available for resources and support as requested by family. A sympathy card will be sent as well as seven bereavement mailings…Additional phone calls will be made as appropriate by hospice staff. Bereavement services to be provided for a period of up to 13 months…referred to bereavement department.”During a review of the hospice agency’s policy and procedure titled, “BEREAVEMENT SERVICES,” date revised 10/29/2020, indicated, “The program will provide bereavement services to the family/caregivers/others of hospice patients, before and after the patient’s death… As defined by the agency’s bereavement program, after the death of a patient, a sympathy card will be sent to the bereaved. As defined by the agency’s bereavement program, a bereavement letter will be sent to the bereaved, offering support and outlining the hospice bereavement services… A bereavement clinical record will be maintained on each family/caregiver unit of care. Each record will contain the following information…E. All bereavement clinical notes.”

Based on interview and record review, the agency failed to implement the policy and procedure related to allegation of abuse for one of 20 sampled patients (Patient 13) when the patient allegation of abuse was not reported immediately by the hospice supervisor (HS B) to the hospice administrator. This failure had the potential to cause psychological distress to the patient and family. Findings: Patient 13 was admitted to the agency on 7/30/2021 with diagnoses of Parkinson's disease (a progressive nervous system disorder that affects movement) and diastolic heart failure (condition where the lower left chamber of the heart (left ventricle) was not able to fill properly with blood). Review of Patient 13's nurse's note dated 8/3/2021, indicated Patient 13 was an 88 year old female with Parkinson's disease, bed bound for three years and declined over the last several days. Review of Patient 13's situation, background, assessment and recommendation (SBAR, a mechanism which provides a framework for communication between members of the health care team about a patient's condition) dated 10/25/2022, indicated the HS B had a home visit on 10/11/2021 for Patient 13. Patient 13's responsible party (RP, the individual who makes decisions) was suffering from caregiver burnout and Patient 13 was transferred to a skilled nursing facility (SNF, an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) for respite care (temporary care provided to caregiver). The SBAR indicated the RP was unhappy regarding rough handling at the SNF which caused bruising to Patient 13. The SBAR also indicated Patient 13's RP was charged on his credit card in advance for the extra days Patient 13 planned to stay at the SNF. Review of the complaint risk report for Patient 13 dated 10/25/21, indicated the caller stated the agency referred his wife to the skilled nursing facility (SNF). The caller stated after the first day she was maltreated and the service was really bad. Caller stated his wife had a bruise on her arm after going to the facility and the caller paid out of pocket money for an extra five days. The caller also stated the SNF did not give her medication and she had a wet diaper on for more than a day. During an interview with HS B on 2/16/2022 at 4:40 p.m., HS B stated she went on a home visit on 10/11/2021 for Patient 13. During the home visit, the RP was angry due to the SNF staff who caused the bruising and rough handling for Patient 13. HS B stated she completed the SBAR report on 10/25/2022 and she should have reported the allegation of abuse sooner. During an interview with the Service Director (SD) on 2/17//2022 at 4 p.m., the SD confirmed HS B should have immediately evaluated the abuse allegation for reporting. Review of the Agency policy dated 10/29/2020, "Assessment and Reporting of Suspected Abuse/Neglect", indicated all alleged violation involving maltreatment, neglect, mental, sexual, physical abuse, including injuries of unknown source, and misappropriation of patient property by anyone furnishing services on behalf of the hospice are reported immediately by the hospice employee and the contracted staff to the hospice administrator. Reports must continue to be made by telephone immediately or as soon as practically possible. A written report must be submitted within two (2) working days to the appropriate agency.

Based on interview and record review, the agency failed to ensure an individualized plan of care established by the interdisciplinary group (IDG, the team responsible responsible for development and review of the hospice beneficiary's plan of care) was not followed when the skilled nurse (SN) missed the scheduled home visit for one of 20 sampled patients (Patient 9). This failure could lead to insufficient care rendered to Patient 9. Findings: A review of Patient 9's plan of care (POC) with a start of care date of 8/19/21 indicated primary diagnosis included multiple myeloma (a cancer of the plasma cell. Normal plasma cells are a type of white blood cell that helps make up your immune system). Review of the POC established by the IDG for benefit period two and period reviewed from 11/17/2021 to 2/14/2022, indicated SN visits two times a week and five visits as needed for symptom management. Review of SN visit schedule indicated the SN missed a home visit the week of 12/19/2021 through 12/25/2021. During a concurrent interview and record review on 2/17/2022, at 11:20 a.m., with the quality coordinator (QC), she reviewed the SN home visit schedule and confirmed the SN missed one scheduled home visit. The QC further stated she did not know the reason the home visit was missed because there was no SN note. The QC acknowledged the physician should be notified if a home visit was missed. The QC confirmed she could not find proof the physician was notified. Review of the agency's policy and procedure, "Comprehensive Assessment" revised 10/29/2020, indicated "The reason for the missed visit and notification of the physician must be documented in the medical record."

Based on observation, interview, and record review, the agency failed to follow the standards of practice to prevent the spread of infection for 2 of 4 home visit patients (Patients 20 and 18) when: 1. Home health aide C (HHA C) did not perform hand hygiene after she touched the inside of the trash can and continued to provide care for Patient 20; 2. Physical Therapist (PT) left the home health bag exposed and it was next to the garbage can; 3. PT did not change disposable gloves before beginning a different task. These failures had the potential to expose the patients to infectious disease. Findings: 1. During a home visit conducted for Patient 20 on 2/15/2022 at 11:30 a.m., it was observed HHA C provided a bed bath for Patient 20 with her gloves, then HHA C wiped Patient 20 on the left shoulder, held the inside of the trash can, placed it at the end of the bed, HHA C did not perform hand hygiene, and continued to wiped Patient 20 with a towel. HHA C wiped Patient 20's buttocks with gloves, held the inside of the trash can full of dirty gloves, wiped Patient 20 on the buttocks area, and did not perform hand hygiene. During an interview with the Site Manager (SM) on 2/15/2022 at 2:18 p.m., she confirmed HHA C touched the trash can and did not perform hand hygiene. During an interview with HHA C on 2/15/2022 at 2:20 p.m., HHA C stated she did not perform hand hygiene after she held the trash can. Review of the CDC website https://www.cdc.gov/handhygiene/providers/index.html indicated, "Perform hand hygiene before touching a patient." 1. During an observation on 2/15/2022 at 1:01 p.m., PT put the home health bag on the floor next to the garbage can with garbage inside and left the bag exposed. During an observation on 2/15/2022 at 1:43 p.m., the PT put the home health bag on the floor next to the garbage can with garbage inside and left the bag exposed. 2. On 2/15/2022 at 1:46 p.m., PT checked Patient 18's colostomy bag, checked her lower extremities, put a pillow between the Patient 18's knees and touched her left hand without changing gloves or removing gloves and performing hand hygiene. During an interview on 2/15/2022 at 2:02 p.m., with the PT, she acknowledged the above observation. During an interview on 2/15/2022 at 2:03 p.m., with HS A she confirmed the above observation and stated it was an infection control issue. Review of the CDC website https://www.cdc.gov/handhygiene/providers/index.html indicated, "Perform hand hygiene before touching a patient." Review of CDC website https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html indicated Handle patient- care equipment and instruments/devices according to Standard Precautions.