Every finding on record at Pathways Home Health and Hospice

Based on observation, interview and record review, the hospice agency (HA), failed to ensure, the family member of patient was informed of the toll-free hotline telephone number of the California Department of Public Health (CDPH, a state department responsible for public health in California which enforces some of the laws in the California Health and Safety Codes, notably the licensing of hospice agencies), in order to file grievance or complaint, in one of four home visit patients (Patient 9), when the family member AA (FM AA) of Patient 9 and the visiting registered nurse A (RN A) did not know the toll-free hotline number of the CDPH.This failure had the potential to delay the complaint process and compromise the patients' rights. --- Findings: During the home visit observation of Patient 9 on 3/27/26 at 11:10 a.m., Patient 9 was sitting in the dining area eating lunch. Patient 9 was alert, calm, comfortable and verbally responsive. During the concurrent review of Patient 9’s admission packet and interview with registered nurse A (RN A) on 3/27/26 at 11:21 a.m., RN A acknowledged that she did not know the toll-free hotline telephone number of CDPH. RN A further acknowledged that she did not know as well, where it could be found in the admission packet of Patient 9. She then stated that she would remember the number next time and where, it could be found in the admission packet. During the interview with the family member AA (FM AA) of Patient 9 on 3/27/26 at 11:25 a.m., FM AA of Patient 9 verified that she did not know the toll-free hotline telephone number of CDPH, to report complaints and then asked for the number and then wrote it. During the concurrent interviews with hospice director of clinical services (HDCS) and hospice clinical services manager (HCSM) on 4/27/26 at 1:55 p.m., HDCS and HCSM, both verified that visiting nurses or staffs should know the toll-free hotline telephone number of CDPH and where it could be found in the admission packet, so they could remind the patients and family members about it. They further verified that family members of patients should be reminded of the CDPH number, in case they have concerns to report and they would remind and educate the staffs about these issues. Review of the hospice agency’s policy titled, “Bill of Rights and Responsibilities,” last revised on 9/10/2025 indicated, “……….Patient Rights – Filing a Grievance……….Be advised of the telephone number and hours of the state’s toll-free hotline, which receives complaints or questions about local agencies. The hotline also receives complaints concerning the implementation of advance directive requirements. The patient or representative also has the right to be advised of the address to submit written complaints or questions……….”

Based on observation, interview, and record review, the hospice agency failed to follow accepted standards of practice to prevent the spread of infection for one of four home visit patients (Patient 9) when the foley catheter bag of Patient 9 was just left on the floor without placing it in a basin or protective container and after registered nurse A (RN A) checked it.This failure had the potential for Patient 9 to acquire infection. --- Findings:During the home visit observation of Patient 9 with registered nurse A (RN A) on 3/27/26 at 11:36 a.m., RN A assessed Patient 9. She checked the foley catheter bag of Patient 9 and the urine was clear, draining well from Patient 9’s foley catheter and with no odor. Patient 9 appeared calm and comfortable. RN A then placed back the foley catheter bag on the floor after checking it, without putting it in a basin or protective container. During the interview with RN A on 3/27/26 at 11:38 a.m., RN A confirmed that the foley catheter bag should have been placed on the floor. RN A then asked for a plastic basin from the caregiver and she then placed the foley catheter bag in the plastic basin. During the concurrent interviews with hospice director of clinical services (HDCS) and hospice clinical services manager (HCSM) on 4/27/26 at 1:55 p.m., HDCS and HCSM, both verified that RN A should have placed the foley catheter bag of Patient 9 in a basin or a protective container and it should not leave it on the floor.Review of the hospice agency’s policy titled, “Infection Control Plan,” last revised on 1/5/2025 indicated, “……….Activities to be performed by the company to prevent and control the spread of infection include; but not limited to:……….Protocols for addressing patient care issues and prevention of infection related to……….urinary tract care……….”

Based on interview and record review, the hospice agency failed to ensure bereavement counseling services were provided in a timely manner, to the family members (FM) of one out of three reviewed patients that passed away (Patients 3), when the bereavement service follow up of Patients 3 was not provided after more than a month of his passing. This failure had the potential for family members and loved ones of patients that passed away, to be not receiving the appropriate bereavement services that meet their needs. --- Findings: Review of Patient 3’s clinical records indicated, Patient 3’s hospice start of care was 9/22/25 with the diagnosis of hypertensive heart disease with heart failure (critical condition where long-term high blood pressure or hypertension causes the heart muscle to thicken, stiffen, or weaken, resulting in the heart’s inability to pump blood efficiently). Patient 3 passed away at home on 10/24/25. Review of Patient 3’s bereavement follow-ups indicated, the hospice agency first contacted two of the family members (FM BB and FM CC) of Patient 3 on 12/10/25 via telephone. FM BB picked up the call and they left a message with FM CC. The hospice agency did another telephone call follow-up of FM CC on 1/7/26. During the concurrent review of the clinical records of Patient 3 and interview with the hospice clinical services manager (HCSM) on 4/1/26 at 1:15 p.m., HCSM confirmed that the bereavement follow-ups of the family members of Patient 3 were not done right away. They were done, more than a month, from Patient 3’s passing. HCSM further confirmed that the bereavement follow-up should have been done within a month of his passing. Patient 3 passed away at home on 10/24/25 and the first bereavement follow-up by the hospice agency was done on 12/10/25.Review of the hospice agency’s policy titled, “Bereavement Services,” last revised on 1/17/2023 indicated, “……….Bereavement will be provided for up to 13 months following the death of the patient. The frequency and intensity of the interventions are determined by the needs of the caregivers and family. Contact is made at one (1) month, and every three (3) months thereafter and documented on the bereavement file. This schedule would apply to uncomplicated or low risk bereavement situations……….”

Based on interview and record review, the hospice agency failed to ensure that their hospice aides were assessed by a registered nurse every fourteen days to evaluate the care provided to patients in one out of nineteen patients reviewed, (Patient 7), when there were two missed supervisory visits for Patient 7.This failure had the potential to compromise the provision of quality care to patients by the agency. --- Findings:Review of Patient 7’s clinical records indicated, Patient 7’s start of care with the hospice agency was on 8/6/25 with the diagnosis of unspecified Alzheimer’s disease (a progressive irreversible brain disorder that slowly destroys memory, thinking skills, and eventually the ability to perform daily tasks).During the concurrent review of Patient 7’s client schedule report (a critical tool of the hospice agency for ensuring patient care continuity, compliance with frequency orders, and real-time visibility into staff activities) and interview with hospice clinical services manager (HCSM) on 4/1/26 at 2:30 p.m., HCSM acknowledged that Patient 7 had two missed registered nurse (RN) supervisory visits with the hospice aide (HA) on 2/19/26 and 3/5/26. HCSM further acknowledged that she would follow up on this concern.Review of the hospice agency's policy titled, “Supervision of Home Health Aides,” last revised on 3/10/2026 indicated, “……….If the patient receives skilled nursing care, the registered nurse (RN), or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days………. If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual must make an on-site visit to the location where the patient is receiving care in order to observe and assess the aide while he or she is performing care……….”

Based on observation, interview, and record review, the hospice agency (HA) failed to provide, the correct toll-free hotline telephone number of the California Department of Public Health (CDPH) to report complaints, in the patients' hospice admission packets or binders for three of three patients visited (1, 2 and 7), when their admission packets or binders did not have the state's toll-free hotline telephone numbers or did not have the correct state's toll-free hotline telephone numbers. These failures had the potential to delay the complaint process and compromise the patients' rights. --- 1. Review of Patient 1's admission information binder during a home visit on 12/20/2022 at 9:20 a.m. there was no California Department of Public Health (CDPH) San Jose District Office hospice toll- free hotline telephone number. During a concurrent interview and record Review on 12/20/22 at 9:30 a.m., with the licensed vocational nurse (LVN) and Program Director (PD) both reviewed Patient 1s hospice clinical records binder and confirmed that there was no CDPH San Jose District Office hospice toll- free hotline telephone number. Both LVN and PD stated they were no CDPH hotline telephone number for filing complaints and grievances for Patient 1. LVN and PD also stated the hospice agency should have provided the toll-free hotline telephone number 2. Review of Patient 7's admission information booklet during a home visit on 12/20/2022 at 12:40 p.m., indicated the CDPH Richmond District Office's toll-free hotline telephone number was in the patient's community resources guide. The family member (FM) and registered nurse (RN) confirmed it was the CDPH Richmond District Office toll-free hotline telephone number on Patient 7's admission booklet during the home visit. Review of California Hospice and Palliative Care Association Standards of Quality Hospice Care, 2005 Section 6.6 "Patient/Family Rights and Responsibilities" indicated the patient has the right to be informed by the licensee of the provisions of the law regarding complaints and procedures for registering complaints confidentially, including, but not limited to, the address and telephone number of the local district office of the CDPH department. During a concurrent skilled nursing facility (SNF) visit observation and interview with home health aide A (HHA A) of Patient 2 (Pt 2) on 12/20/22 at 10:40 a.m., there was no toll-free hotline number of CDPH to report complaints, in pt 2's hospice and facility binders. HHA A verified that there was no state's toll-free hotline number in Pt 2's hospice and facility binders. HHA further stated that he did know the state's toll-free hotline number. During an interview with the facility director of nursing (FDON) on 12/20/22 at 10:45 a.m., she verified that there was no state's toll-free hotline number in Pt 2's hospice and facility binders. During an interview with hospice director of clinical services (HDOCS) on 12/20/22 at 1:40 p.m., HDOCS verified that Pt 2's admission packets or binders should have the state's toll-free hotline number and she also said that HHA A should have known the state's toll-free hotline number. HDOCS further stated that she would have an in-service with HHA A about the state's toll-free hotline number and update the hospice admission packets and binders of the patients. Review of Pt 2's clinical record indicated, Pt 2 was an eighty-five year old male, admitted to health agency's (HA's) care on 4/3/22, with diagnoses including, chronic obstructive pulmonary disease (COPD, long-term lung disease that causes airflow blockage, making it hard to breathe) with acute exacerbation (sudden worsening), hypertension (high blood pressure), gastritis (irritation of the stomach lining) without bleeding, abnormal weight loss and dependence on supplemental oxygen (colorless gas that exists in large quantities in the air). Review of the HA's policy and procedure entitled, "Admission for Care and Services," revision date, 11/21/19 and reviewed, 11/21/22, indicated, "During the admission visit, the qualifying clinician would verify and document the physician's verbal order in the electronic record and will provide the patient with the following information, types of care and services available: care and service limitations, charges or patient responsibility for care and service, eligibility criteria, hours of operation, including on-call availability, contact information and referral procedures and other care and services available in the community."

Based on interview and record review, the hospice agency (HA) failed to ensure, care and services were provided in accordance with the plan of care for five of thirteen sampled patients (1, 4, 6, 8 and 13), when the number of skilled nursing (SN), medical social worker (MSW) and home health aide (HHA) visits did not meet the number of visits ordered by the physician in the plan of care. These failures had the potential to compromise patient care. --- 1. Review of Patient 1's clinical record indicated she was admitted to the hospice agency on 4/24/22 with a diagnosis of Alzheimers disease (a progressive disease that destroys memory and mental functions) with late onset.A review of Patient 1's POC included physician orders for skilled nursing (SN) (Hospice aid) visits 2 times a week for 12 weeks beginning 7/24/2022. Patient 1's record indicated that no SN visits (Hospice aid) were made the week of 7/29/22, and 9/6/22. Review of clinical record notes had no documentation for the missed (Hospice aid) SN visit on 9/6/22 and responsible party (RP) was not notified by the hospice staff for the missed (Hospice aid) SN visit on 7/29/22. During a concurrent interview and record review with the Hospice manager of clinical services (HMOCS) on 12/22/22 at 10:58 a.m., she stated there was no documentation in the clinical record as to why the (Hospice aid) SN visits was not made for patient 1 on 9/6/22. She acknowledged the missed visit and the SN should have made those visit as ordered for patient 1. HMOCS stated that RP should have been notified with the missed visit on 7/29/22.2. Review of Patient 4's clinical record indicated she was admitted to the hospice agency on 5/10/22 with a diagnosis Myocardial infarction (A heart attack that was a deadly medical emergency where your heart muscle begins to die.) Patient 4's clinical record was reviewed for the certification period of 11/6/22 through 1/4/23. A review of Patient 4's POC included physician orders for SN visits (Hospice aid) 3 times a week for 8 weeks beginning 5/10/2022. Patient 4's record indicated that no hospice aid (SN) visits were made the week of 9/26/22 and 12/9/22. Review of clinical record notes had no documentation note for the missed SN visits. During a concurrent interview and record review with the HMOCS on 12/22/22 at 2:28 p.m., she stated there was no documentation in the clinical record as to why the SN hospice aid visits were not made for Patient 4. HMOCS acknowledged the missed visits and stated the SN should have made those visits as ordered for Patient 4. 3. Review of Patient 6's clinical record indicated she was admitted to the hospice agency on 11/24/21 with a diagnosis of senile degeneration of brain not elsewhere classified.A review of Patient 6's POC included physician orders for skilled nursing (SN) (Hospice aid) visits 3 times a week for 8 weeks beginning 11/24/2021. Patient 6's record indicated that no SN visits (Hospice aid) was made the week of 12/9/22. During a concurrent interview and record review with the HMOCS on 12/22/22 at 3:21 p.m., she reviewed Patient 6s clinical record notes and she acknowledged no documentation by the hospice staff that the responsible party (RP) was not notified about the missed (Hospice aid) SN visit on 12/9/22. 4. Review of Patient 8's clinical record indicated she was admitted to the hospice agency on 5/17/22 with a diagnosis of chronic obstructive pulmonary disease (COPD- a disease that affects airflow in the lungs and makes it difficult to breathe) Patient 8's clinical record was reviewed for the certification period of 11/13/22 through 1/11/23. A review of Patient 8's POC included physician orders for MSW once every two weeks times 2 months beginning 5/17/2022. Patient 8's clinical record indicated that no MSW visit was made the week of 12/5/2022. During a concurrent interview and record review with the HMOCS on 12/22/22 at 10:10 a.m., she reviewed Patient 8s clinical record notes and confirmed that there was no home visit documentation for the MSW on 12/5/22 and she further stated that MSW should have followed the physician order for home visit and documented the missed visit note. The facility's policy number 33.103 title, "Missed Visit or Shift ", revised 02/16/2022, indicated to comply with the Conditions of Participation regarding physician and if indicated, allowed practitioner notification of a missed visit or shift ordered on the plan of Care. If physician or allowed practitioner ordered frequency cannot be met, a Missed Visit Notification coordination note would have been completed in the Patient Medical record and the physician and if indicated, allowed practitioner will be notified by fax. The facility's undated policy, "Missed Visit Process in HCHB- Home Health/Hospice", indicated the clinician will select the Miss option in Poincare and then select the reason for the visit being missed. A missed Visit Notification Note template will open and prompt the clinician to complete. Upon completion of the note, clinician will sync their tablet to send the visit back to the office....... Scheduler will process the" Process Missed Visit" task or will open the task and view the Missed Visit Report to determine reason for the visit being missed. Review of the clinical record of Patient 13 (Pt 13) indicated, he was a ninety-four year old male, admitted to HA's care on 6/21/22 with diagnoses including, moderate protein-calorie malnutrition (second degree of inadequate protein and calorie intakes), dysphagia (difficulty swallowing), abnormal weight loss, mild cognitive impairment (early stage of memory loss), hypertension (high blood pressure) and history of malignant neoplasm of prostate (history of prostate cancer). Review of Pt 13's plan of care (POC) for his second hospice benefit period, 9/19/22 to 12/17/22, indicated, orders for SN visits effective 9/19/22 were once per week for thirteen weeks plus three as needed visits. Then effective 11/20/22, order for SN visit was once per week for four weeks and effective 11/27/22, SN visit order was now, once every two weeks for two weeks and once per week for one week. During the concurrent record review and interview of the client calendar report of Pt 13 on 12/23/22 at 11:35 a.m., with the hospice manager of clinical services (HMOCS), Pt 13 had one SN missed visit for week thirteen of his second hospice benefit period, 12/11/22 to 12/17/22. HMOCS verified that Pt 13 had one SN missed visit for week thirteen of his second hospice benefit period, 12/11/22 to 12/17/22. She further stated that there was no missed visit notification coordination note and the missed visit was not rescheduled. Review of the HA's policy and procedure entitled, "Missed Visit," with the revision date, 2/16/22 indicated, "In the event that a patient or an employee cancels a scheduled visit ordered by the physician or the allowed practitioner, the visit would have been rescheduled, if possible, to comply with the physician or allowed practitioner order within Medicare week. If the visit cannot be rescheduled in compliance with the physician or allowed practitioner order, the physician or allowed practitioner will be notified. If physician or allowed practitioner ordered frequency cannot be met, a missed visit notification coordination note will be completed in the patient medical record and the physician and if indicated, allowed practitioner will be notified by fax."

Based on observation, interview and record review, the hospice agency (HA) failed to follow standard precautions and to maintain proper infection control practices to prevent transmission of infection when: 1. The gray barrel with used sharp red containers was overflowing in the biohazard room in the facility and 2. Home health aide B (HHA B) did not change her gloves in between tasks. These failures had the potential to expose the patients to infectious disease. --- 1. During an initial tour inside the facility on 12/19/2022 at 9:44 a.m., with the director of administrative services (DOAS) inside the biohazard room there was one gray barrel overflowing with used sharp red containers. During a concurrent observation and interview on 12/19/22 at 9:45 a.m., with the DOAS, she acknowledged the above observation and stated that the red sharp containers with used sharps inside should have been covered by the gray barrel cover and should have not been overflowing. Review of agency's revised policy number 33.148 dated 03/10/2022 titled, "Disposal and Removal of Regulated Waste", indicated all sharps waste generated by the agency would have been contained in a sharps container immediately after use and disposed of in the bio-hazardous waste container in the Agency Office and to ensure proper and legal handling of regulated waste for the prevention of transmission of infectious disease..... In the office, the sharps containers should be placed in a secondary box or contaminated devices provided by the biomedical waste hauler, or in another appropriate container labeled with the biohazard symbol or color- coded. 2. During a home visit observation with Patient 1, a home health aide B (HHA B) on 12/20/22 at 9:10 a.m., HHA B was wearing pair of gloves and she touch the shoes, put it on to Patient 1s feet. Using the same gloves HHA B was assisting Patient 1 to be transferred to the shower chair for shower using the Hoyer lift (device to lift the patient) with the help of the assisted living staff and HHA B was touching the shoulder, arms, incontinent pad, sweater and white shower linen blanket of Patient 1. HHA B did not change her gloves in between tasks. Review of facility's revised policy number 33.900 dated 08/10/2022 titled, "Hand Hygiene", indicated Standard and Universal Precautions should have been followed in determining use of gloves.... Change gloves between tasks and procedures on the same patient to prevent cross contamination.

Based on interview and record review the hospice agency (HA) failed to follow their policy and procedure for appropriate patient transfer and discharge for one of 2 sampled patients (Patient 15). This failure resulted in lack of the ability for staff to follow an outlined process for communicating with the physician and legal representatives or designated family members. --- Review of Patient 15's discharged clinical record indicated she was admitted to the hospice agency on 4/5/22 with a diagnosis of chronic kidney disease (also called chronic kidney failure, describes the gradual loss of kidney function) with heart failure (the heart muscle is unable to pump enough blood through to meet the body's needs for blood and oxygen, the heart can't keep up with its workload) and was discharged to acute hospital on 11/19/2022. During a concurrent interview and record review on 12/23/2022 at 10:15 a.m., with the Hospice manager of clinical services (HMOCS) on 12/23/22 at 10:15 a.m., she confirmed that Patient 15 was discharged to acute hospital on 11/19/2022 without a physicians order. The family member notified the HA on 11/19/2022 regarding the transfer to acute hospital but there no written physician order obtained. During a concurrent interview and record review on 12/23/2022 at 1:25 p.m., with the HMOCS, she reviewed the policy and procedure of the hospice agency title ";Transfer and Discharges- Hospice" revised date 12/19/2022, policy number 86.07 indicated the Clinician or Agency will ...... Prior to transferring or discharging a patient, the Hospice will obtain a physicians written order from the hospice Medical Director, after team consultation that includes the Patients attending physician.