Every finding on record at Madrone Hospice, Inc

Based on interview, and record review, the agency failed to ensure the plan of care (a personalized, doctor approved roadmap outlining the specific medical services, goals, and treatments a patient receives at home) was followed for one of 19 sampled patients (Patient 4), when Patient 4 did not receive a skilled nursing (SN, services performed by or under the supervision of a licensed nurse, and included assessment of patient condition, monitoring for signs of infection, and addressing patient concerns) visit as ordered by the physician. This failure had the potential to cause a delay in needed services, which could lead to negative clinical outcomes and poor symptom management for end of life care. --- Findings:  During a review, of the agency’s policy and procedure (P&P) titled “Implementing Care and Treatment,” dated 9/1/24, the P&P indicated, when the provision of care/treatment cannot be implemented as established on the Plan Of Care (POC), the patient’s physician will be notified. The appropriate documentation will be completed and submitted by the assigned discipline. The Clinical Manager (CM) will be notified as appropriate.  Patient 4’s clinical record was reviewed. Patient 4 was admitted for hospice (end of life care) services on 10/2/25, for diagnoses that included chronic obstructive  pulmonary disease (COPD, a progressive lung disease that makes it hard to breathe), sleep apnea (a common, serious disorder when breathing repeatedly stops and starts during sleep), mild cognitive impairment (a slight decline in memory, thinking process and decision making such as planning and judgement), acquired absence of cervix and uterus (surgical removal of female reproductive organs due to cancer or other complications), carpal tunnel syndrome of bilateral upper limbs (common, painful condition caused by compression of nerves in the hands or wrists that can include numbness, tingling, and weakness in the thumbs and fingers), and spinal stenosis (narrowing of the spinal region that puts pressure on the spinal cord and nerves, causing pain, numbness, tingling and muscle weakness).   During a record review, a document titled, “Hospice Plan of Care,” dated, 10/2/25, indicated that the frequency ordered for Patient 4 was SN to complete two visits weekly through 12/20/25, and six as needed visits for complications or support.  During a record review, of Patient 4’s clinical record, there was only one SN visit completed for week of 10/12/25, completed on 10/15/25, but no other SN visits completed, and no documentation of a SN visit attempted, or that the physician was updated of a missed visit per the POC.  During an interview, on 5/5/26 at 4:42 pm, the Clinical Manager (CM) confirmed, that Patient 4 missed a SN visit the week of 10/12/25, and the POC was not followed, and the physician had not been updated of this change. CM stated, “Usually there is a note for communication, but I cannot find any documentation the visit was attempted, or the physician was notified of the change in frequency for Patient 4.”

Based on observation, interview, and record review, the facility failed to ensure that all aspects of the Infection Control Program were carried out when five out of ten reviewed employee files did not contain documentation that staff had completed infection control orientation training, two of ten employee files did not contain documentation of up to date tuberculosis (a highly contagious respiratory disease) testing, and the medical supplies closet contained two catheters (tube inserted into the bladder to remove urine) that were expired.  These failures had the potential to place patients at increased risk for infections, which could lead to negative clinical outcomes. --- The facility's policy titled, "Equipment and Supply Maintenance," dated 2/1/26, indicated that the hospice may choose to obtain and store a limited amount of supplies for staff and patient use on the facility site. Supplies will be checked for expiration date prior to use.  If out of date, the supplies will be discarded. During a concurrent observation, and interview, with the Executive Director (ED) on 5/7/26 at 10:50 am, in the medical supply closet two items were confirmed expired.  One Bardex Foley Catheter, expired 10/19/24, and one Magic3 coude catheter expired 3/28/26.  The ED confirmed that both items were expired, and in supplies that staff would utilize for patient care.  The ED stated that all employees are responsible for ensuring that expired supplies are not utilized. The facility's policy titled, "Selection of Agency Staff," dated 9/26/23, indicated that the initial health examination will include a tuberculosis screening.  Tuberculosis screening will occur annually thereafter. During a concurrent interview, and record review, with Human Resources (HR) on 5/6/26 at 3 pm, employee files were reviewed.  HR confirmed that Licensed Nurse (LN) K did not have documentation indicating she had completed the facility's infection control orientation training.  HR confirmed that, the Clinical Manager did not have documentation indicating she had completed the facility's infection control orientation training. During a concurrent interview, and record review, with ED on 5/7/26 at 2:20 pm, employee files were reviewed.  ED confirmed, that Speech Therapist (ST)'s employee file indicated her last TB test was 5/30/23, and Physical Therapist (PT)'s employee file indicated her last TB test was on 12/21/22.  ED reviewed the employee file for for herself, and confirmed her employee file did not contain documentation that she had completed the facility's infection control training.  ED reviewed the employee file for ST's and confirmed her employee file did not contain documentation that she had completed the facility's infection control training.  ED reviewed the employee file for PT and confirmed her employee file did not contain documentation that she had completed the facility's infection control training.  ED confirmed that the facility's expectation is for all staff to complete the infection control orientation training, and to have a TB test upon hire, and then annually.

Based on interview, and record review, one of nine employees failed to have a criminal background check within three months of the date of their employment. This failed action had the potential to have an unfit employee care for the agency's patients which could endanger their safety and wellbeing leading to negative clinical outcomes. --- Findings: During a review of nine employee personnel files with the facility's Human Resource Manager (HRM) on 5/18/23 at 2:15 pm. There was no documented evidence that Contracted Staff (CS) A had a background check conducted within three months of the date of their employment. CS A's date of hire was 2/11/2022. During an interview, with the Director of Patient Care Services (DPCS) on 5/18/23 at 10:30 am, she stated it is a standard practice of the agency to do the criminal background check on all employees before they are hired, and prior to having first patient contact. A policy on background checks was requested but not provided by the end of the survey. On 5/19/23 at 11:09 am, HRM stated that CS A never had a background check, and was hired greater than three months ago.

Based on interview, and review of nine employee health records, the agency failed to ensure their infection control program monitored and screened staff annually for Tuberculosis (TB, an infectious bacterial disease that mainly affects the lungs), and ensure that all employees were offered a Hepatitis B vaccine (a virus contracted through bloodborne means) when; Two Contracted Staff (CS) had no evidence of annual TB screening. One CS had no documented evidence that they had been offered, or declined the Hepatitis B vaccine. Three CS, and two employees failed to have documented evidence they had a health exams conducted within six months of their first day of work. These failed actions had the potential for the spread of infection to patients, and their families, and employees to not be able to safely care for patients which could lead to negative clinical outcomes. --- Findings: During a review, of nine employee health records with the Human Resource Manager (HRM) on 5/18/23 at 2:15 pm, the following was identified: Contracted Staff (CS) B who was hired on 1/13/22, had no evidence of an initial TB testing, or annual testing. CS B's file also failed to contain information related to the Hepatitis B vaccine to indicate if they had been offered, declined, or received the vaccination. CS C was hired on 2/22/22, and their file indicated that they had received a TB test on 2/22/22, but had no evidence of a current annual testing. CS C's file also failed to contain information related to the Hepatitis B vaccine to indicate if they had been offered, declined, or received the vaccination. Additionally CS A, (hired on 2/11/22), CS B (hired on 1/13/22), CS C (hired on 2/22/22), Employee D (hired on 4/26/21) and Employee E (hired on12/29/09), failed to have annual health exams in their personnel records. The facility's undated policy titled, "Health/Physical Requirements," was reviewed, and indicated that all employees and volunteers are required to provide documented evidence of a TB screening prior to patient contact. All employees and volunteers are required to complete a PPD (purified protein derivative, a skin test to diagnose tuberculosis) test if it has been more than a year since their last test had been given. All patient care staff members are offered the Hepatitis B series at the time of hire. If the employee wishes to take the series arrangements are made for the administration at no cost to the employee. All patient care employees and volunteers must complete the Hepatitis B Vaccine information form indicating their decision to accept or decline the vaccine. Additionally the policy directs that all employees who work directly with patients and family must provide documented evidence of a medical examination performed by a qualified physician within six months of the first day of work. During an interview, with the Director of Patient Care Services (DPCS) on 5/18/23 at 10:46 am, she stated she was technically the one that manages the agencies infection control program. The DPCS stated, that when she was hired she was told that the agency Human Resource Department took care of the TB screening, and the Hepatitis B vaccination information. On the same day at 3 pm, the DPCS stated the agency has never done the health exams, but have always required TB screening when hired, and then annually. On 5/18/23 at 3:18 pm, during an interview, with HRM she confirmed the above findings in the personnel records. The HRM stated, that the agency had never done health exams on their volunteers. On 5/19/23 at 9 am, the DPCS acknowledged that the, "Health/Physical Requirements," policy direction that all employees who work directly with patients, and family must provide documented evidence of a medical examination performed by a qualified physician within six months of the first day of work.