Every finding on record at Prohealth Home Care, Inc

Based on interview and record review, the hospice agency failed to ensure that the correct mailing address of the California Department of Public Health (CDPH) was provided and patients and their family members were instructed on how to report complaints to CDPH’s toll free number for two of three home visit patients (Patients 2 and 3), when their care packets did not have the correct CDPH address and they were not aware on how to file a grievance to CDPH.The incorrect mailing address and not being informed of their right to make complaints to the department had the potential to delay the complaint process and compromise the patients' rights. --- Findings:2.During a concurrent interview with Patient 3’s family member (FM AA) and document review of the hospice agency’s care packet on 10/28/2025 at 3:21 p.m., Patient 3 stated, “Oh, I don’t know (about CDPH toll free number). All I know is their (hospice agency’s) after hour number.” Patient 3’s FM AA confirmed she did not know where to find the department’s toll-free number and stated she did not know the importance of it. Patient 3’s FM AA further stated that the nurse who admitted Patient 3 did not instruct her on how to file a complaint to the department, and she was just instructed to call the hospice agency’s after hour number for any emergency.During a concurrent interview with the clinical coordinator for hospice (CCFH) and operations manager (OM) and document review of the hospice agency’s care packet on 10/29/2025 at 9:50 a.m., the CCFH stated the admission nurse should discuss the care packet to the patient or their family member and should provide instruction on how to file a grievance to CDPH toll free number. Both the CCFH and OM confirmed that the department’s toll-free number could be found in the patient’s rights section of the care packet, and both confirmed the CDPH address was not the correct one. OM confirmed their care packet still indicated CDPH San Jose District’s old office address: 100 Paseo De San Antonio, Suite 235, San Jose, CA 95113.During a review of the hospice agency's undated policy and procedure titled, "RIGHTS/RESPONSIBILITIES," indicated, "The patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of:...The right to voice a complaint/concern (grievance) regarding care, treatment or services that are (or fail to be) provided or are provided inconsistently or inappropriately without fear of reprisal for exercising this right. The right to voice grievances regarding lack of respect for property...The availability of other sources to receive questions and complaints and assist in resolution." 1.During a concurrent home visit observation of Patient 2 and interview with medical social worker B (MSW B) on 10/28/25 at 2:06 p.m., MSW B was doing a routine visit of Patient 2, checking the patient and asking the caregiver for any concerns. Asked the MSW B, the toll-free hotline number of CDPH to report complaints, if she knew about it and if she reminded the family member and caregiver of Patient 2 about it as well. MSW B acknowledged that she did not know that there was a toll-free hotline number of CDPH to report complaints. MSW B further acknowledged that she would ask the office about the number and be familiar with it.During an interview with the family member BB (FM BB) of Patient 2 on 10/28/25 at 2:14 p.m., she verified that she did not know about the toll-free hotline number of CDPH. FM BB further verified that nobody from the hospice agency, told her about the number.Review of Patient 2’s profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 2’s start of care with the hospice agency was on 3/31/25 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).During the interview with the clinical coordinator for hospice (CCFH) on 10/30/25 at 11:20 a.m., CCFH verified that MSW B should know the toll-free hotline number of CDPH. CCFH further verified that FM BB should be informed or be reminded of the toll-free hotline number of CDPH, in case they wanted to report complaints. CCFH then stated that she would follow up on these concerns. CCFH also acknowledged the incorrect mailing address of CDPH in the hospice agency’s care packet and she would have it corrected.

Based on interview and record review, the hospice agency failed to ensure, the individualized plan of care (POC, comprehensive, individualized document that outlines the medical, emotional, psychosocial, and spiritual support for a terminally ill patient and their family) established by the interdisciplinary group (IDG, the team responsible for development and review of the hospice beneficiary’s plan of care) was followed for the 11 of 15 sampled patients (Patients 2, 7, 12, 13, 14, 3, 4, 8, 9, 10 and 15) when:1. the clinicians of Patients 2, 7, 12, 13, 14, 3, 4, 8, 9, and 10 missed their scheduled home visits and there were no evidences that the physician was notified;2. the clinicians of Patients 9, 10, and 8 had no documentation of the missed visits nor reasons for the missed visits; and3. the clinicians of Patient 15 did not sign the documentation of their missed visits.These failures could lead to insufficient care and services rendered to patients and families, (see L543).The hospice agency failed to ensure the communication and coordination of care for missed home visits were maintained for 11 of 15 sampled patients (Patients 2, 7, 12, 13, 14, 3, 9, 10, 8, 4, and 15) which resulted in patients’ individualized plan of care, not being followed, which could lead to poor care and services, (see L554).The hospice agency failed to ensure, care and services were provided in accordance with the plan of care for three of fifteen sampled patients (Patients 1, 6 and 13), when the number of skilled nursing (SN) visits did not match with the number of visits ordered by the physician in the plan of care and these had the potential to compromise patient care, (see L555).  The cummulative effect of these systemic problems impeded the hospice agency's ability to provide quality of care and services, in accordance with established POCs. --- See the findings in L543, L554 and L555.

Based on interview and record review, the hospice agency failed to ensure, the individualized plan of care (POC, comprehensive, individualized document that outlines the medical, emotional, psychosocial, and spiritual support for a terminally ill patient and their family) established by the interdisciplinary group (IDG, the team responsible for development and review of the hospice beneficiary’s plan of care) was followed for the 11 of 15 sampled patients (Patients 2, 7, 12, 13, 14, 3, 9, 10, 8, 4 and 15) when:1.The clinicians of Patients 2, 7, 12, 13, 14, 3, 9, 10, 8, and 4 missed their scheduled home visits and there were no documented evidence that the physician was notified;2.The clinicians of Patients 9, 10, and 8 had no documentation of the missed visits nor reasons for the missed visits; and3.The clinicians of Patient 15 did not sign the documentation of their missed visits.These failures could lead to insufficient care and services rendered to patients and families. --- 1f. During an interview with the clinical coordinator for hospice (CCFH) on 10/30/2025 at 9:36 a.m., CCFH stated when their clinicians had missed visits with their assigned patients, they should notify their case managers, their director of patient care services (DPCS), and the patient’s physician. The CCFH further stated the missed visits should be discussed during their IDG meeting to check if they could be re-scheduled and they would allow each clinician to complete their documentation in 48 hours.During a concurrent interview with the CCFH and operations manager (OM) and record review of Patient 3’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 9:41 a.m., CCFH confirmed Patient 3’s start of care was on 10/21/2025 and had a diagnosis of malignant neoplasm (a cancerous tumor, an abnormal growth of cells that have the ability to invade surrounding tissues and spread to other parts of the body) of right female breast. The CCFH further confirmed Patient 3’s POC for home health aide (HHA) visit should have been two home visits per week. Both the CCFH and OM confirmed there was a missed HHA home visit on 10/24/2025 and there was no documentation until 10/28/2025. The CCFH further confirmed there was no evidence the clinical manager and Patient 3’s physician were notified of the missed visit.1g. During a concurrent interview with the CCFH and record review of Patient 9’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 9:55 a.m., CCFH confirmed Patient 9’s start of care was on 6/24/2025 with diagnosis of atherosclerotic heart disease of native coronary artery (a condition where plaque builds up in the two major blood vessels, narrowing them and reducing blood flow to the heart) without angina pectoris (chest pain). The CCFH stated the POC for Patient 9’s HHA visit should have been two home visits per week to assist with personal care, activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and light housekeeping. CCFH confirmed there was no HHA visit with Patient 9 in Week 1 (6/24/2025 – 6/28/2025) and there was only one HHA visit in Week 2 (6/29/2025 – 7/5/2025). CCFH further confirmed there was no evidence that the physician was notified of the missed visits.1h. During a concurrent interview with the CCFH and record review of Patient 10’s POC for benefit period #1 (7/28/2025 – 10/25/2025) and the calendar of each clinician’s home visits on 10/30/2025 at 10:09 a.m., CCFH stated Patient 10’s start  of care was on 7/28/2025 with diagnosis of malignant neoplasm of the right breast. CCFH confirmed Patient 10’s POC for skilled nursing visit should have been two home visits per week and there was only one documented registered nurse (RN) visit in week 7 (9/7/2025-9/13/2025). CCFH further confirmed there was no evidence the physician was notified of the missed skilled nursing visit.1i. During a concurrent interview with the CCFH and record review of Patient 8’s POC for benefit period #7 (8/19/2025-10/17/2025) and the calendar of each clinician’s home visits on 10/30/2025 at 10:16 a.m., CCFH stated Patient 8’s start of care was on 6/20/2025 with diagnosis of unspecified severe protein-calorie malnutrition (poor health resulting from not getting enough calories or the right balance of nutrients, which can be caused by under-eating, over-eating unhealthy food, or not getting enough vitamins and minerals). CCFH confirmed Patient 8’s POC for skilled nursing visits should have been two home visits per week from 8/19/2025 until 10/17/2025 and there was only one RN documented home visit in week 7 (9/28/2025-10/4/2025) and in week 8 (10/5/2025-10/11/2025). CCFH further confirmed there was no evidence the physician was notified about the two missed visits by nurses.1j. During a concurrent interview with the CCFH and record review of Patient 4’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 10:29 a.m., CCFH stated Patient 4’s start of care was on 5/21/2025 with diagnosis of liver cell carcinoma (cancer of the liver). CCFH confirmed Patient 4’s POC for HHA visit should have been 2 home visits per week to assist with personal care, ADLs, and light housekeeping from 5/21/2025-8/18/2025. CCFH further confirmed there were two documented HHA missed visits on 5/27/2025 and 5/29/2025 and there was no evidence Patient 4’s physician was notified.During a review of the agency's undated policy and procedure titled, " MISSED VISITS," indicated, "If a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit."2a. During a concurrent interview with the CCFH and record review of Patient 9’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 9:55 a.m., CCFH confirmed there was no documentation of HHA missed visits in Week 1 (6/24/2025-6/28/2025)  and in Week 2 (6/29/2025-7/5/2025).  CCFH further confirmed there was no documentation to support the HHA missed visits in Week 1 and 2 nor the reason for the missed visits.2b. During a concurrent interview with the CCFH and record review of Patient 10’s POC for benefit period #1 (7/28/2025 – 10/25/2025) and the calendar of each clinician’s home visits on 10/30/2025 at 10:09 a.m., CCFH confirmed there was no documentation of  Patient 10’s one missed skilled nursing visit in Week 7 (9/7/2025-9/13/2025). CCFH stated there should have been a documentation of the skilled nursing missed visit to indicate the reason.2c. During a concurrent interview with the CCFH and record review of Patient 8’s POC for benefit period #7 (8/19/2025-10/17/2025) and the calendar of each clinician’s home visits on 10/30/2025 at 10:16 a.m., CCFH confirmed  there was no documentation of the skilled nursing missed visits in Week 7 (9/28/2025-10/4/2025) and in week 8 (10/5/2025-10/11/2025). CCFH further confirmed there was no documentation to support the reason for skilled nursing missed visits in Week 7 and 8.During a review of the facility's undated policy and procedure titled, "MISSED VISITS," indicated, "To ensure that missed visits are documented and does not affect the quality of patient care...Document in the patient's clinical record the following information: 1. Patient name. 2. Date and type of visit that was missed. 3. Reason for the missed visit. 4. Description of any unmet needs and how the patient's needs were met. 5. Any other follow-up needed. 6. Other person(s) that were notified of the missed visit..."3. During a concurrent interview with the CCFH and record review of Patient 15’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 3:12 p.m., CCFH confirmed Patient 15’s start of care was on 7/23/2025 with diagnosis of acute  (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypercapnia (a condition in which there is an excessive amount of carbon dioxide in the blood). CCFH stated Patient 15’s POC for skilled nursing should have been two home visits per week and she confirmed there were one RN missed visits on 7/31/2025 and 8/7/2025. CCFH further confirmed the documentation for RN missed visits on both days did not have the clinician’s signature. CCFH stated the missed visits’ documentation should have been signed to complete it.During a review of the facility's undated policy and procedure titled, "MISSED VISITS," indicated, "Missed visits will be documented in the clinical record...Document in patient's clinical record the following information:...Signature of staff member reporting the information.". 1a. Review of Patient 2’s profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 2’s start of care with the hospice agency was on 3/31/25 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). Review of Patient 2’s hospice plan of care for the second benefit period (specific timeframe during which hospice care is covered), from 6/29/25 to 9/26/25, indicated, Patient 2 had a skilled nursing visit frequency order of one time per week for seven weeks, from 8/10/25 to 9/26/25. Review of Patient 2’s schedule of clinician visits with the actual visits done for the second benefit period indicated, that the licensed vocational nurse missed the visit for Patient 2 on 8/30/25 and there was no documentation that the physician was notified. The missed visit was not discussed as well in the interdisciplinary group (IDG, a mandatory, bi-weekly conference in hospice care where a team of professionals collaborates to review and update a patient’s plan of care) meeting. During the concurrent review of Patient 2’s clinical records for the second benefit period from 6/29/25 to 9/26/25 and interview with the clinical coordinator for hospice (CCFH) on 10/30/25 at 11:20 a.m., CCFH checked Patient 2’s schedule of clinician visits and the actual visits done and confirmed that she had a missed visit by the licensed vocational nurse on 8/30/25. CCFH reviewed the hospice plan of care for the second benefit period, from 6/29/25 to 9/26/25 and verified that Patient 2 had a visit frequency order for nurses of once per week for seven weeks, from 8/10/25 to 9/26/25 and there was no visit by a hospice nurse for the week of 8/24/25 to 8/30/25. CCFH further verified that there was no documentation that the physician was notified of the missed visit by the nurse on 8/30/25 and it was not discussed during the IDG meeting of Patient 2.1b. Review of Patient 7’s profile indicated, Patient 7’s start of care with the hospice agency was on 8/16/24 with the primary diagnosis of senile degeneration of brain (age-related cognitive decline or gradual decline in cognitive function that occurs with aging), not elsewhere classified.Review of Patient 7’s hospice plan of care for the fourth benefit period, from 4/13/25 to 6/11/25, indicated, Patient 7 had a hospice aide visit frequency order of twice per week, from 4/13/25. Review of Patient 7’s schedule of clinician visits with the actual visits done for the fourth benefit period indicated that the hospice aide missed one visit for the weeks 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25. There was no documentation that the physician was notified, and the missed visits were not discussed in the IDG meeting. During the concurrent review of Patient 7’s clinical records for the fourth benefit period from 4/13/25 to 6/11/25 and interview with CCFH on 10/30/25 at 11:40 a.m., CCFH reviewed Patient 7’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed one visit for the weeks of 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25.  CCFH reviewed the hospice plan of care for the fourth benefit period and verified that Patient 7 had a visit frequency order for hospice aide of twice per week from 4/13/25 and only one hospice aide visit was done for the weeks of 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits by the hospice aide and they were not discussed during the IDG meeting of Patient 7.1c. Review of Patient 12’s profile indicated, Patient 12’s start of care with the hospice agency was on 9/24/25 with the primary diagnosis of malignant neoplasm of lower third of esophagus (type of cancer that develops in the lower portion of the esophagus, the tube that connects the throat to the stomach).Review of Patient 12’s hospice plan of care for the first benefit period, from 9/24/25 to 12/22/25, indicated, Patient 12 had a hospice aide visit frequency order of twice per week for thirteen weeks, from 9/24/25 to 12/20/25.Review of Patient 12’s schedule of clinician visits with the actual visits done for the first benefit period indicated that the hospice aide missed visits on 9/29/25, 10/1/25, 10/6/25, 10/9/25, 10/14/25 and 10/21/25. There was no documentation that the physician was notified, and the missed visits were not discussed in the IDG meeting.During the concurrent review of Patient 12’s clinical records for the first benefit period from 9/24/25 to 12/22/25 and interview with CCFH on 10/30/25 at 12:00 p.m., CCFH reviewed Patient 12’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visits on 9/29/25, 10/1/25, 10/6/25, 10/9/25, 10/14/25 and 10/21/25. CCFH reviewed the hospice plan of care for the first benefit period and verified that Patient 12 had a visit frequency order for hospice aide of twice per week for thirteen weeks, from 9/24/25 to 12/20/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits by the hospice aide and they were not discussed during the IDG meeting of Patient 12. 1d. Review of Patient 13’s profile indicated, Patient 13’s start of care with the hospice agency was on 2/20/25 with the primary diagnosis of malignant neoplasm of unspecified main bronchus (a cancerous tumor that originates in the main or largest airway of the lung, but the specific location within the bronchus is not specified).Review of Patient 13’s hospice plan of care for the third benefit period, from 8/19/25 to 10/17/25, indicated, Patient 13 had a hospice aide visit frequency order of twice per week for nine weeks, from 8/19/25 to 10/17/25. Patient 13 also had a skilled nursing visit frequency order of twice per week for nine weeks, from 8/19/25 to 10/17/25.Review of Patient 13’s schedule of clinician visits with the actual visits done for the third benefit period indicated that the hospice aide had a missed visit on 8/30/25. There was also a skilled nursing missed visit on 9/17/25. There was no documentation that the physician was notified of the missed visits and they were not discussed in the IDG meeting.During the concurrent review of Patient 13’s clinical records for the third benefit period from 8/19/25 to 10/17/25 and interview with CCFH on 10/30/25 at 12:10 p.m., CCFH reviewed Patient 13’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visit on 8/30/25. CCFH also confirmed that there was missed skilled nursing visit on 9/17/25. CCFH reviewed the hospice plan of care for the third benefit period and verified that Patient 13 had a visit frequency order for the hospice aide of twice per week for nine weeks, from 8/19/25 to 10/17/25 and the skilled nursing visit frequency order was also twice per week for nine weeks, from 8/19/25 to 10/17/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits and they were not discussed during the IDG meeting of Patient 13. 1e. Review of Patient 14’s profile indicated, Patient 14’s start of care with the hospice agency was on 9/22/25 with the primary diagnosis of Parkinson’s disease (progressive neurological disorder that affects movement, balance, and coordination) with dyskinesia without mention of fluctuations (involuntary and uncontrollable muscle movements were not documented).Review of Patient 14’s hospice plan of care for the first benefit period, from 9/22/25 to 12/20/25, indicated, Patient 14 had a hospice aide visit frequency order of twice per week for thirteen weeks, from 9/22/25 to 12/20/25.Review of Patient 14’s schedule of clinician visits with the actual visits done for the first benefit period indicated that the hospice aide missed visit on 10/15/25. There was no documentation that the physician was notified, and the missed visit of the hospice aide and it was not discussed in the IDG meeting of Patient 14.During the concurrent review of Patient 14’s clinical records for the first benefit period from 9/22/25 to 12/20/25 and interview with CCFH on 10/30/25 at 12:26 p.m., CCFH reviewed Patient 14’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visit 10/15/25. CCFH reviewed the hospice plan of care for the first benefit period and verified that Patient 14 had a visit frequency order for hospice aide of twice per week for thirteen weeks, from 9/22/25 to 12/20/25. CCFH further verified that there was no documentation that the physician was notified of the missed visit by the hospice aide and it was not discussed during the IDG meeting of Patient 14. Review of the hospice agency’s undated policy and procedure titled, “Missed Visits” indicated, “Missed visits will be communicated to the Interdisciplinary Group at the IDG meeting……….Missed visits will be documented in the clinical record……….If a patient is routinely refusing visits, the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director.”

Based on interview and record review, the hospice agency failed to ensure the communication and coordination of care for missed home visits were maintained for 11 of 15 sampled patients (Patients 2, 7, 12, 13, 14, 3, 9, 10, 8, 4, and 15). These failures resulted in patients’ individualized plan of care (POC – comprehensive, individualized document that outlines the medical, emotional, psychosocial, and spiritual support for a terminally ill patient and their family), not followed, which could lead to insufficient care and services rendered to patients and families. --- 6. During an interview with the clinical coordinator for hospice (CCFH) on 10/30/2025 at 9:36 a.m., CCFH stated when their clinicians had missed visits with their assigned patients, they should notify their case managers, their director of patient care services (DPCS), and the patient’s physician. The CCFH further stated the missed visits should be discussed during their interdisciplinary group (IDG – the team responsible for development and review of the hospice beneficiary’s plan of care which consist of the required core members: physician, registered nurse [RN], social worker [SW], and a chaplain or spiritual counselor) meeting to check if they could be re-scheduled and they would allow each clinician to complete their documentation in 48 hours.During a concurrent interview with the CCFH and operations manager (OM) and record review of Patient 3’s POC and the calendar of each clinician’s home visits on 10/30/2025 at 9:41 a.m., CCFH confirmed Patient 3’s start of care was on 10/21/2025 and had a diagnosis of malignant neoplasm (a cancerous tumor, an abnormal growth of cells that have the ability to invade surrounding tissues and spread to other parts of the body) of right female breast. The CCFH further confirmed Patient 3’s POC for home health aide (HHA) visit should have been two home visits per week. Both the CCFH and OM confirmed there was a missed HHA home visit on 10/24/2025 and there was no documentation until 10/28/2025. The CCFH further confirmed there was no evidence the clinical manager, the IDG and Patient 3’s physician were notified of the missed visit.7. During a concurrent interview with the CCFH and record review of Patient 9’s POC, IDG minutes, and the calendar of each clinician’s home visits on 10/30/2025 at 9:55 a.m., CCFH confirmed Patient 9’s start of care was on 6/24/2025 with diagnosis of atherosclerotic heart disease of native coronary artery (a condition where plaque builds up in the two major blood vessels, narrowing them and reducing blood flow to the heart) without angina pectoris (chest pain). The CCFH stated the POC for Patient 9’s HHA visit should have been two home visits per week to assist with personal care, activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and light housekeeping. CCFH confirmed there was no HHA visit with Patient 9 in Week 1 (6/24/2025 – 6/28/2025) and there was only one HHA visit in Week 2 (6/29/2025 – 7/5/2025). CCFH further confirmed there was no evidence that the physician was notified of the missed visits and these were not discussed in Patient 9’s IDG meetings held on 7/1/2025 and 7/15/2025.8. During a concurrent interview with the CCFH and record review of Patient 10’s POC for benefit period #1 (7/28/2025 – 10/25/2025), IDG minutes, and the calendar of each clinician’s home visits on 10/30/2025 at 10:09 a.m., CCFH stated Patient 10’s start of care was on 7/28/2025 with diagnosis of malignant neoplasm of the right breast. CCFH confirmed Patient 10’s POC for skilled nursing visit should have been two home visits per week and there was only one documented registered nurse (RN) visit in week 7 (9/7/2025-9/13/2025). CCFH further confirmed there was no evidence the physician was notified of the missed skilled nursing visit nor was it discussed in their IDG meeting held on 9/9/2025 and 9/23/2025. 9. During a concurrent interview with the CCFH and record review of Patient 8’s POC for benefit period #7 (8/19/2025-10/17/2025), IDG minutes and the calendar of each clinician’s home visits on 10/30/2025 at 10:16 a.m., CCFH stated Patient 8’s start of care was on 6/20/2025 with diagnosis of unspecified severe protein-calorie malnutrition (poor health resulting from not getting enough calories or the right balance of nutrients, which can be caused by under-eating, over-eating unhealthy food, or not getting enough vitamins and minerals). CCFH confirmed Patient 8’s POC for skilled nursing visits should have been two home visits per week from 8/19/2025 until 10/17/2025 and there was only one RN documented home visit in week 7 (9/28/2025-10/4/2025) and in week 8 (10/5/2025-10/11/2025). CCFH further confirmed there was no evidence the physician was notified about the two missed visits by nurses nor was it discussed during their IDG meeting held on 10/7/2025.10. During a concurrent interview with the CCFH and record review of Patient 4’s POC, and the calendar of each clinician’s home visits on 10/30/2025 at 10:29 a.m., CCFH stated Patient 4’s start of care was on 5/21/2025 with diagnosis of liver cell carcinoma (cancer of the liver). CCFH confirmed Patient 4’s POC for HHA visit should have been 2 home visits per week to assist with personal care, ADLs, and light housekeeping from 5/21/2025-8/18/2025. CCFH further confirmed there were two documented HHA missed visits on 5/27/2025 and 5/29/2025 and there was no evidence the Patient 4’s physician nor the IDG were notified.11. During a concurrent interview with the CCFH and record review of Patient 15’s POC, IDG minutes and the calendar of each clinician’s home visits on 10/30/2025 at 3:12 p.m., CCFH confirmed Patient 15’s start of care was on 7/23/2025 with diagnosis of acute  (severe, or intense, often referring to something with a sudden onset and relatively short duration) and chronic (lasting for a long time or recurring frequently) respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypercapnia (a condition in which there is an excessive amount of carbon dioxide in the blood). CCFH stated Patient 15’s POC for skilled nursing should have been two home visits per week and she confirmed there were one RN missed visits on 7/31/2025 and 8/7/2025. CCFH further confirmed the RN’s two missed visits were not discussed in the IDG meeting held on 8/12/2025.During a review of the facility's undated policy and procedure titled, "MISSED VISISTS," indicated, "Missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible...If a visit is missed for any reason, the clinician should attempt to reschedule if for the same week so that the physician ordered frequency is maintained...If a visit is missed and not rescheduled the clinician will Notify the IDG and clinical supervisor of the missed visit and reason for missed visit...the clinician and the IDG should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and Medical Director."  1. Review of Patient 2’s profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 2’s start of care with the hospice agency was on 3/31/25 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). Review of Patient 2’s hospice plan of care for the second benefit period (specific timeframe during which hospice care is covered), from 6/29/25 to 9/26/25, indicated, Patient 2 had a skilled nursing visit frequency order of one time per week for seven weeks, from 8/10/25 to 9/26/25. Review of Patient 2’s schedule of clinician visits with the actual visits done for the second benefit period indicated, that the licensed vocational nurse missed the visit for Patient 2 on 8/30/25 and there was no documentation that the physician was notified. The missed visit was not discussed as well in the interdisciplinary group (IDG, a mandatory, bi-weekly conference in hospice care where a team of professionals collaborates to review and update a patient’s plan of care) meeting. During the concurrent review of Patient 2’s clinical records for the second benefit period from 6/29/25 to 9/26/25 and interview with the clinical coordinator for hospice (CCFH) on 10/30/25 at 11:20 a.m., CCFH checked Patient 2’s schedule of clinician visits and the actual visits done and confirmed that she had a missed visit by the licensed vocational nurse on 8/30/25. CCFH reviewed the hospice plan of care for the second benefit period, from 6/29/25 to 9/26/25 and verified that Patient 2 had a visit frequency order for nurses of once per week for seven weeks, from 8/10/25 to 9/26/25 and there was no visit by a hospice nurse for the week of 8/24/25 to 8/30/25. CCFH further verified that there was no documentation that the physician was notified of the missed visit by the nurse on 8/30/25 and it was not discussed during the IDG meeting of Patient 2. CCFH then stated that the missed nursing visit of Patient 2 should have been discussed in the IDG meeting for any recommendations or clarifications.2. Review of Patient 7’s profile indicated, Patient 7’s start of care with the hospice agency was on 8/16/24 with the primary diagnosis of senile degeneration of brain (age-related cognitive decline or gradual decline in cognitive function that occurs with aging), not elsewhere classified.Review of Patient 7’s hospice plan of care for the fourth benefit period, from 4/13/25 to 6/11/25, indicated, Patient 7 had a hospice aide visit frequency order of twice per week, from 4/13/25. Review of Patient 7’s schedule of clinician visits with the actual visits done for the fourth benefit period indicated that the home health aide missed one visit for the weeks 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25. There was no documentation that the physician was notified, and the missed visits were not discussed in the IDG meeting. During the concurrent review of Patient 7’s clinical records for the fourth benefit period from 4/13/25 to 6/11/25 and interview with CCFH on 10/30/25 at 11:40 a.m., CCFH reviewed Patient 7’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed one visit for the weeks of 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25.  CCFH reviewed the hospice plan of care for the fourth benefit period and verified that Patient 7 had a visit frequency order for hospice aide of twice per week from 4/13/25 and only one hospice aide visit was done for the weeks of 4/13/25 to 4/19/25; 4/20/25 to 4/26/25; 4/27/25 to 5/3/25 and 5/4/25 to 5/10/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits by the hospice aide and they were not discussed during the IDG meeting of Patient 7. CCFH then stated that the missed hospice aide visits of Patient 7 should have been discussed in the IDG meeting for any recommendations or clarifications.3. Review of Patient 12’s profile indicated, Patient 12’s start of care with the hospice agency was on 9/24/25 with the primary diagnosis of malignant neoplasm of lower third of esophagus (type of cancer that develops in the lower portion of the esophagus, the tube that connects the throat to the stomach).Review of Patient 12’s hospice plan of care for the first benefit period, from 9/24/25 to 12/22/25, indicated, Patient 12 had a hospice aide visit frequency order of twice per week for thirteen weeks, from 9/24/25 to 12/20/25.Review of Patient 12’s schedule of clinician visits with the actual visits done for the first benefit period indicated that the hospice aide missed visits on 9/29/25, 10/1/25, 10/6/25, 10/9/25, 10/14/25 and 10/21/25. There was no documentation that the physician was notified, and the missed visits were not discussed in the IDG meeting of Patient 12.During the concurrent review of Patient 12’s clinical records for the first benefit period from 9/24/25 to 12/22/25 and interview with CCFH on 10/30/25 at 12:00 p.m., CCFH reviewed Patient 12’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visits on 9/29/25, 10/1/25, 10/6/25, 10/9/25, 10/14/25 and 10/21/25. CCFH reviewed the hospice plan of care for the first benefit period and verified that Patient 12 had a visit frequency order for hospice aide of twice per week for thirteen weeks, from 9/24/25 to 12/20/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits by the hospice aide and they were not discussed during the IDG meeting of Patient 12. CCFH then stated that the missed hospice aide visits of Patient 12 should have been discussed in the IDG meeting for any recommendations or clarifications.4. Review of Patient 13’s profile indicated, Patient 13’s start of care with the hospice agency was on 2/20/25 with the primary diagnosis of malignant neoplasm of unspecified main bronchus (a cancerous tumor that originates in the main or largest airway of the lung, but the specific location within the bronchus is not specified).Review of Patient 13’s hospice plan of care for the third benefit period, from 8/19/25 to 10/17/25, indicated, Patient 13 had a hospice aide visit frequency order of twice per week for nine weeks, from 8/19/25 to 10/17/25. Patient 13 also had a skilled nursing visit frequency order of twice per week for nine weeks, from 8/19/25 to 10/17/25.Review of Patient 13’s schedule of clinician visits with the actual visits done for the third benefit period indicated that the hospice aide had a missed visit on 8/30/25. There was also a skilled nursing missed visit on 9/17/25. There was no documentation that the physician was notified of the missed visits and they were not discussed in the IDG meeting of Patient 13.During the concurrent review of Patient 13’s clinical records for the third benefit period from 8/19/25 to 10/17/25 and interview with CCFH on 10/30/25 at 12:10 p.m., CCFH reviewed Patient 13’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visit on 8/30/25. CCFH also confirmed that there was missed skilled nursing visit on 9/17/25. CCFH reviewed the hospice plan of care for the third benefit period and verified that Patient 13 had a visit frequency order for the hospice aide of twice per week for nine weeks, from 8/19/25 to 10/17/25 and the skilled nursing visit frequency order was also twice per week for nine weeks, from 8/19/25 to 10/17/25. CCFH further verified that there was no documentation that the physician was notified of the missed visits and they were not discussed during the IDG meeting of Patient 13. CCFH then stated that the missed visits by the hospice aide and skilled nurse of Patient 13 should have been discussed in the IDG meeting for any recommendations or clarifications.5. Review of Patient 14’s profile indicated, Patient 14’s start of care with the hospice agency was on 9/22/25 with the primary diagnosis of Parkinson’s disease (progressive neurological disorder that affects movement, balance, and coordination) with dyskinesia without mention of fluctuations (involuntary and uncontrollable muscle movements were not documented).Review of Patient 14’s hospice plan of care for the first benefit period, from 9/22/25 to 12/20/25, indicated, Patient 14 had a hospice aide visit frequency order of twice per week for thirteen weeks, from 9/22/25 to 12/20/25.Review of Patient 14’s schedule of clinician visits with the actual visits done for the first benefit period indicated that the hospice aide missed visit on 10/15/25. There was no documentation that the physician was notified, and the missed visit of the hospice aide and it was not discussed in the IDG meeting of Patient 14.During the concurrent review of Patient 14’s clinical records for the first benefit period from 9/22/25 to 12/20/25 and interview with CCFH on 10/30/25 at 12:26 p.m., CCFH reviewed Patient 14’s schedule of clinician visits and the actual visits done and confirmed that the hospice aide missed the visit on 10/15/25. CCFH reviewed the hospice plan of care for the first benefit period and verified that Patient 14 had a visit frequency order for hospice aide of twice per week for thirteen weeks, from 9/22/25 to 12/20/25. CCFH further verified that there was no documentation that the physician was notified of the missed visit by the hospice aide and it was not discussed during the IDG meeting of Patient 14. CCFH then stated that the missed hospice aide visit of Patient 14 should have been discussed in the IDG meeting for any recommendations or clarifications.

Based on interview and record review, the hospice agency failed to ensure, care and services were provided in accordance with the plan of care (POC, comprehensive, individualized document that outlines the medical, emotional, psychosocial, and spiritual support for a terminally ill patient and their family) for three of fifteen sampled patients (Patients 1, 6 and 13), when the number of skilled nursing (SN) visits did not match with 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 profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 1’s start of care with the hospice agency was on 10/29/24 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).Review of Patient 1’s hospice plan of care for the fifth benefit period, from 8/25/25 to 10/23/25, indicated, Patient 1 had a skilled nursing visit frequency order of twice per week for eight weeks, from 8/25/25 to 10/18/25. There was no as needed visits for the skilled nurse.Review of Patient 1’s schedule of clinician visits with the actual visits done for the fifth benefit period indicated that the skilled nurse had one extra visit for the week of 9/28/25 to 10/4/25. During the concurrent review of Patient 1’s clinical records for the fifth benefit period from 8/25/25 to 10/23/25 and interview with clinical coordinator for hospice (CCFH) on 10/30/25 at 10:51 a.m., CCFH reviewed Patient 1’s schedule of clinician visits and the actual visits done and confirmed that the skilled nurse had one extra visits for the week of 9/28/25 to 10/4/25. CCFH further confirmed that Patient 1 had no as needed skilled nursing visit order, hence the skilled nursing care and services provided were not in accordance with Patient 1’s POC. CCFH then stated that she would follow up on this concern.2. Review of the profile of Patient 6 indicated, her start of care with the hospice agency was on 4/15/25 with the primary diagnosis of malignant neoplasm of unspecified site of right female breast.Review of the hospice plan of care of Patient 6 for the second benefit period, from 7/14/25 to 10/11/25, indicated, Patient 6 had a skilled nursing visit frequency order of one time per week and three as needed visits for thirteen weeks.Review of the schedule of clinician visits of Patient 6 with the actual visits done for the second benefit period indicated that the skilled nurse did not do a visit of Patient 6 for the week of 7/20/25 to 7/26/25. There was no documentation that the skilled nursing visit was done for that weekDuring the concurrent review of Patient 6’s clinical records for the second benefit period from 7/14/25 to 10/11/25 and interview with CCFH on 10/30/25 at 11:28 a.m., CCFH reviewed Patient 6’s schedule of clinician visits and the actual visits done and confirmed that the skilled nurse did not do a visit of Patient 6 for the week of 7/20/25 to 7/26/25. CCFH further confirmed that Patient 6’s POC was not followed by the skilled nurse. CCFH then stated that she would follow up on this concern.3. Review of Patient 13’s profile indicated, Patient 13’s start of care with the hospice agency was on 2/20/25 with the primary diagnosis of malignant neoplasm of unspecified main bronchus (a cancerous tumor that originates in the main or largest airway of the lung, but the specific location within the bronchus is not specified).Review of Patient 13’s hospice plan of care for the third benefit period, from 8/19/25 to 10/17/25, indicated, Patient 13 had a skilled nursing visit frequency order of twice per week for nine weeks, from 8/19/25 to 10/17/25. There was no as needed visits for the skilled nurse.Review of Patient 13’s schedule of clinician visits with the actual visits done for the third benefit period indicated that the skilled nurse had two extra visits for the week of 9/21/25 to 9/27/25 and one extra visit for the week of 10/5/25 to 10/11/25. During the concurrent review of Patient 13’s clinical records for the third benefit period from 8/19/25 to 10/17/25 and interview with CCFH on 10/30/25 at 12:10 p.m., CCFH reviewed Patient 13’s schedule of clinician visits and the actual visits done and confirmed that the skilled nurse had two extra visits for the week of 9/21/25 to 9/27/25 and one extra visit for the week of 10/5/25 to 10/11/25. CCFH further confirmed that Patient 13 had no as needed skilled nursing visit order, hence the skilled nursing care and services provided were not in accordance with Patient 13’s POC. CCFH then stated that she would follow up on this concern.Review of the undated hospice agency’s policy and procedure titled, “The Plan Of Care,” 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. This plan will focus on identified problems, goal, and interventions……….”

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 three home visit patients (Patient 3) when the home health aide A (HHA A) failed to change disposable gloves and perform hand hygiene (HH – the practice of cleaning one’s hands to remove dirt, bacteria, and viruses that can spread infection) before donning (putting on) a new pair of disposable gloves to begin a new task.This failure had the potential to expose Patient 3 to infectious disease. --- Findings:During a home visit conducted for Patient 3 on 10/28/2025 at 2:09 p.m., it was observed  HHA  A prepared the materials needed for Patient 3’s bed bath. HHA A brought a basin with water from the bathroom, placed it on top of Patient 3’s overbed table, and moved the overbed table closer to the bed with her bare hands. HHA A donned a new pair of disposable gloves without hand hygiene and started to reposition Patient 3 with the used of the bed remote and touched Patient 3 to move to her side. At 2:15 p.m., HHA A observed to have pulled out Patient 3’s pants and removed gloves performed hand hygiene. HHA A touched her bag and took out a plastic bag for Patient 3’s dirty clothes. HHA A donned a new pair of gloves without hand hygiene. At 2:22 p.m., HHA A placed some chux (disposable absorbent pads or under pads) under Patient 3’s head, upper body, buttocks’ area and lower legs. HHA A pulled out Patient 3’s right and left socks with some dried skin spread on Patient 3’s chux. HHA A placed both used socks inside the plastic bag with dirty clothes. She started to wash Patient 3’s face and hair without changing her gloves.During an interview with HHA A on 10/28/2025 at 3:30 p.m., HHA A confirmed above observations and stated she did not realize she forgot to perform hand hygiene before she donned a new pair of gloves. HHA stated she should have performed hand hygiene prior to donning a new pair of gloves and she should have changed her gloves after she removed Patient 3’s used socks, performed hand hygiene and donned a new pair of gloves prior to washing Patient 3’s face and hair.During an interview with the clinical coordinator for hospice (CCFH) on 10/30/2025 at 9:50 a.m., the CCFH stated hand hygiene should be performed before donning a new pair of gloves and the clinician should have changed gloves every time they touched a dirty area to begin a new task.During a review of the Centers for Disease Control and Prevention’s (CDC) guidelines and recommendations titled, “Clinical Safety: Hand Hygiene for Healthcare Workers,” dated 2/27/2024, indicated, “Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings…When to change gloves and clean hands…If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs.”

Based on interview and record review, the hospice agency failed to ensure, the patients’ clinical notes were completed in a timely manner for one of fifteen sampled patients, (Patient 2), when clinicians were late in signing their visit notes for Patient 2. This failure could delay the care and services to be provided to the patient or family, which could affect the patient’s quality of care. --- Review of Patient 2’s profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 2’s start of care with the hospice agency was on 3/31/25 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).Review of Patient 2’s schedule of clinician visits with the actual visits done for the third benefit period, from 9/27/25 to 11/25/25 indicated, that hospice aide C (HA C) visited Patient 2 on 10/2/25 and 10/16/25. Patient 2 was also visited by licensed vocational nurse D (LVN D) on 10/3/25 and 10/23/25. Review of Patient 2’s clinician visit notes for the third benefit period indicated, HA C signed her 10/2/25 visit note on 10/6/25 and her 10/16/25 visit note, on 10/20/25. LVN D signed her 10/3/25 visit note on 10/7/25 and her 10/23/25 visit note on 10/27/25.During the concurrent review of Patient 2’s clinical records for the third benefit period and interview with the clinical coordinator for hospice (CCFH) on 10/30/25 at 11:20 a.m., CCFH checked Patient 2’s schedule of clinician visits with the actual visits done and confirmed that Patient 2 was visited by HA C on 10/2/25 and 10/16/25 and Patient 2 was also visited by licensed vocational nurse D (LVN D) on 10/3/25 and 10/23/25. CCFH verified that HA C and LVN D were late in signing or completing their clinical visit notes of Patient 2. CCFH stated that HA C signed her 10/2/25 and 10/6/25 visit notes, after 96 hours or 4 days after the visit and LVN D also signed her 10/7/25 and 10/23/25 visit notes, after 4 days of the visit as well. CCFH further verified that clinician visit notes should be signed after the patient visit or within 48 hours after the visit was done. CCFH then stated that she would follow up on these concerns.Review of the hospice agency’s undated policy and procedure titled, “Entries Into The Clinical Record,” indicated, “Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided……….Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned into the office within 48 hours. The clinical note will include:……….Signature of clinician and his/her credentials……….”

Based on interview and record review, the hospice agency failed to ensure, the patient’s clinical record was signed and completed in a timely manner for one of fifteen sampled patients (Patient 1), when the initial plan of care (POC, comprehensive, individualized document that outlines the medical, emotional, psychosocial, and spiritual support for a terminally ill patient and their family) or plan of treatment of Patient 1 was signed late, by the hospice medical director and the registered nurse (RN). This failure had the potential to jeopardize prompt rendition of care and services that could affect the patient's quality of care. --- Review of Patient 1’s profile (comprehensive record of a person’s health-related information, including their clinical data, medical history, and personal details) indicated, Patient 1’s start of care with the hospice agency was on 10/29/24 with the primary diagnosis of unspecified Alzheimer’s disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).Review of Patient 1’s clinical records indicated, her initial plan of care or plan of treatment was not signed on time by the clinicians. Patient 1’s start of care and initial POC date was 10/29/24. The hospice medical director signed the initial POC of Patient 1 on 4/25/25, while the registered nurse signed it on 12/17/24.During the concurrent review of Patient 1’s initial POC and interview with the clinical coordinator for hospice (CCFH) on 10/30/25 at 10:51 a.m., CCFH checked Patient 1’s initial POC and confirmed that Patient 1’s start of care and initial POC date was 10/29/24. CCFH also confirmed that the hospice medical director signed the initial POC of Patient 1 on 4/25/25 and the registered nurse signed it on 12/17/24. CCFH verified that the clinicians were late in signing and completing the initial POC of Patient 1. She further verified that the registered nurse should have signed it within 48 hours from the date of the initial POC and the hospice medical director should have signed it, within a month. CCFH then stated that she will follow up on this concern.Review of the hospice agency’s undated policy and procedure titled, “The Plan of Care,” indicated, “To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues……….The individualized plan of care will be reviewed by the rest of the interdisciplinary group (IDG, the team responsible for development and review of the hospice beneficiary’s plan of care) within two (2) days of start of care……….” Review of the hospice agency’s undated policy and procedure titled, “Verification of Physician Orders,” indicated, “……….A copy of the order will be kept in the patient’s clinical record. The original order will be delivered to the physician (or other licensed practitioner) for his/her signature. Signed order will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation……….”

Based on observation, interview, and record review, the hospice agency failed to ensure the correct California Department of Public Healths' (CDPH) toll-free hotline telephone number to report complaints was included in the patient information booklet under rights and responsibilities for one home visit patient (Patient 3). The incorrect hotline number has the potential to delay the complaint process. Findings: Review of Patient 3's admission information booklet during a home visit on 2/2/2022 at 10:00 a.m. indicated the CDPH Richmond District Office's toll-free hotline telephone number was in the patient's rights and responsibilities section. This was confirmed by both registered nurse (RN-A) and the Board and Care administrator (B&C ADMIN) who were present during the home visit. During an interview with the acting clinical director (ACD) and the operations manager (OMAN) on 2/2/2022 at 4:45 p.m., both were shown a picture of page 5 (item 19) of Patient 3's admission booklet at the board and care, listed the CDPH Richmond District Office's toll-free hotline telephone number instead of the CDPH San Jose District Office. The ACD stated "it was not updated' and indicated they were going to correct the admission booklet and replace the copy in the patient home. Review of the current updated/unused sample admission packet provided to the surveyor indicated "Patient Rights and Responsibilities: As a patient of Pro Health Home Care, Inc., you have the right to: 24. Report complaints about Pro Health Home Care Inc. to the California Department of Public Health [San Jose District Office], 24-hour hotline. The regular business hours are Monday to Friday from 8 AM to 5 PM. After hours you may leave a message. __ SAN JOSE 800-554-0348"

Based on observation, interview and record review, the hospice agency failed to ensure a thorough review of patients' medications, including all prescribed and over-the-counter medications when the medication profile was not updated for 1 home visit patient (Patient 3). Failure to review and update the medication profile had the potential for ineffective drug therapy. Findings: During a medication reconciliation during a home visit with Patient 3 on 2/2/22 at 10:07 a.m. with registered nurse A (RN-A) and the board and care administrator (B&C ADMIN), the medication profile copy from the agency did not match the medication list copy at the board and care (B & C), nor the medications administered at the B & C. The Hospice Medication Profile from the Agency indicated and included the following: 1. Ventolin HFA (breathing treatment) Inhalation 90 micrograms (mcg, unit of measurement) /act; two puffs four times per day as needed, purpose shortness of breath (SOB). [Ventolin is brand name for: Albuterol Sulfate, medication for bronchospasm] 2. Oxybutynin Chloride (medication for bladder and urinary condition) Oral 5 milligrams (mg, unit of measurement) one tab Daily, purpose frequent urination. 3. Seroquel Oral (antipsychotic medication) 25 mg one tab every night at bedtime, purpose restlessness. Upon reconciliation at the board and care; 1. The medication for Ventolin indicated, "Albuterol Sulfate 108 mcg/act AER (means by air), Inh(alation) two puffs by mouth Q4 PRN (every four hours as needed)" 2. Oxybutynin Chloride was on the medication list at the B & C, but during a concurrent interview with RN-A, he stated this medication was discontinued on 11/5/21. 3. The B&C medication list as well as the actual medication bottle indicated: Seroquel oral 25 mg 1 tab Twice per day (every morning and night at bedtime), purpose restlessness. Review of agency's policy titled, "Safe/Effective Use of Medications" revised November 2020, indicated Purpose: To provide guidelines for the instruction of patients and family/caregivers regarding the safe, effective use of medication. To promote correct administration of medication by patients and family/caregivers ....Procedure: 6. Documentation of patient and family/caregiver instruction in the clinical record will include... E. Updating medication profile.

Based on observation, interview and record review, the hospice agency (HA) failed to follow accepted standards of practice to prevent the spread of infection when: A. The medical supply room contained supply items with expired 'use by' dates (the date the manufacturer determines a medical supply item is no longer guaranteed sterile or safe to use) and B. During a home visit, Registered Nurse A (RN A) failed to change disposable gloves and perform hand hygiene before beginning a different task. These failures had the potential to expose patients to infectious disease. Findings: A. During an observation and concurrent interview with the clinical supervisor (CS) on 1/31/2022 at 9:40 a.m., in the medical supply room, the following expired items were identified: 1. Six bottles of Curad iodoform (treatment supply) packing strip expired 3/2021; 2. One thick it (instant food and beverage thickener) expired 12/2018; 3. Two bottles of Dakin's solution (treatment solution) expired 3/2021 and 1 bottle of Dakin's solution expired 12/2021; 4. Six bottles of Tincture of benzoin (treatment supply)pre spray expired 4/2018; 5. One bottle of Brava adhesive (treatment supply) remover expired date 11/16/2020; 6. Two tubes of eakin (conva tec) cohesive paste expired 10/1/2020; 7. 70 pairs large latex gloves expired 10/2016 and 80 pairs powder free latex exam gloves expired 1/2012; 8. Six boxes of alcohol pre pads (100 counts per box) expired 10/22/2020; 9. Two boxes coflex TLC (2-layer compression bandage system expired 11/2021; 10. Two boxes eakin (convatec-10 pieces per box) expired 8/2016; 11. Three boxes Hollister (treatment supply) skin barrier (five units per box) expired 1/2017; 12. Ten pieces of coloplast-high output pouch expired 8/2015; 13. 10 pieces Hollister (colostomy bag) expired 10/2016; 14. Seven tubes silvasorb gel (treatment) expired 6/2017; 15. One kerra cel gelling fiber silver dressing expired 11/30/2019; 16. One promogram matrix wound dressing expired 8/2020; 17. One optifoam gentle expired 12/2020; 18. One Coagu check XS PT test code 301 expired 5/31/2019, one bottle expired 12/31/19 and one bottle expired 1/4/2010; 19. 27 Curad triple antibiotic packets ointments expired 8/2018; 20. 144 packets pap test lubricating jelly carbomer free expired 4/2021; 21. 11 packets E-Z lubricating jelly expired 1/2010; 22. 1 & 1/2 boxes of Lemon Glycerin swabsticks expired 9/20/21; 23. 9 boxes Pure Gentle Enema expired 5/2020 and 2 boxes expired 10/2017; 24. 1 Piston Irrigation Tray expired 6/25/21; 25. 1 bottle EpiClenz Hand Antiseptic Sanitizer expired 9/2021; 26. 2 boxes of Dressing Change Tray with CHLOR expired 11/30/2021 and, 27. 6 pieces Sureprey Protective Wipe expired 7/2021. During a concurrent interview, the CS confirmed the above observation and stated the expired items should be separated from the non-expired items and removed from the supply room. Review of the agency's policy and procedure dated 11/2020, titled "Environmental of Care- Storage," indicated Personnel must regularly check the expiration date of any disposable supplies kept in the supply room. Expired supplies should be disposed as per waste management regulation. B. A home visit conducted for Patient 3 at her board and care home on 2/2/2022 at 9:45 a.m. During this home visit observation Registered nurse A (RN A) performed care on Patient 3 and RN-A performed the following: He applied a pair of gloves, then used PDI (disposable, germicidal wipes) to clean the oximeter (used to determine the oxygen saturation of arterial blood), the Blood Pressure (BP) cuff, thermometer, and the stethoscope. RN-A without changing gloves or removing gloves and doing hand hygiene checked Patient 3's temperature, cleaned the thermometer, checked Patient 3's heart rate with a stethoscope, oxygen saturation level, blood pressure, checked for lower extremities for edema, buttocks, coccyx, measured the arm diameter and recorded the results. Without changing gloves and without performing hand hygiene RN-A was touched his N-95 mask with the same pair of gloves that was used from the start of care, during blood pressure taking, writing, and cleaning the BP cuff, thermometer, tape measure and the stethoscope. During an interview on 2/2/2022 at 11:00 a.m., RN-A confirmed the above observations and stated he should have changed gloves before the beginning of each task and should have performed hand hygiene. Review of the agency's policy and procedure dated 11/2020, titled "Infection Prevention and Control Plan," indicated to delineate an infection control plan to meet the following goals: Guide organization personnel in the care and services they provide in relation to infection control practices ... Set goals to limit the spread of infections associated with procedures and the use of medical equipment, devices and supplies. Review of the CDC website https://www.cdc.gov/handhygiene/providers/index.html indicated, "Perform hand hygiene before touching a patient."