Kaiser Foundation Hospital - Hospice

“Based on interview and record review, the agency failed to ensure services were administered per plan of care for 2 of 23 sampled patients (Patient 1 and Patient 2).This failure reduced the agency’s potential to provide care needed for Patient 1 and Patient 2. Findings:Patient 1 had a start of care (SOC) date of 5/20/25 and diagnosis of Adenocarcinoma-tail of pancreas (cancer of a part of the pancreas).During a review of Patient 1’s Plan of Care (POC) for the certification period 5/20/25-8/18/25 indicated orders for skilled nurse (SN) visits one time a week for twelve weeks and medical social worker (MSW) visits one visit every month and five as needed.During a review of Patient 1’s clinical record on 9/4/25 at 11:10 a.m. indicated no skilled nurse’s visits were made for the week of 5/25/25.Patient 2 had a SOC date of 2/26/25 and diagnosis of Parkinson’s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements).During a review of Patient 2’s POC for the certification period of 2/26/25-3/12/25 indicated orders for home health aide (HHA) visits two visits every week for one week and one visit every week for nine weeks.During a review of Patient 2’s clinical record on 9/4/25 at 11:30 a.m. indicated no HHA visit were made for the week of 4/20/25.During a concurrent interview and record review on 9/4/25 at 11:45 a.m. with the Hospice Supervisor (HS), the HS confirmed that no SN visit was made the week of 5/25/25 for Patient 1. The HS further confirmed that no HHA visit was made for week of 4/20/25 for Patient 2 and verified that there was no documentation addressing reason why the visit was missed and that the physician was notified for both Patient 1 and Patient 2.During an interview on 9/4/25 at 3:10 p.m. with the Director Patient Care Services (DPCS), the DPCS stated that her expectation would be that the Licensed Nurse (LN) should have attempted to reschedule the visit. If the LN could not reschedule the visit, the reason and notification to the physician should be documented in the patient’s clinical record.Review of the agency’s policy and procedure (P&P) titled, “Comprehensive Assessment” revised 10/29/20, the P&P indicated, “The physician must be notified if a scheduled visit is not completed. The reason for the missed visit and notification of the physician must be documented in the medical record.”

“Based on interview and record review, the facility failed to ensure criminal background checks were done when no documented evidence of background checks in their personnel files for three out of seven sampled staff members.This failure has a potential risk to endanger the health and safety of the vulnerable patients receiving direct patient care on hospice. FINDINGS:During a concurrent interview and record review via zoom on 9/5/25 at 10 a.m. with Human Resources (HR)1, HR1 stated that Home Health Aide (HHA) 1, HHA 2, and Licensed Nurse (LN) 1 did not have any evidence that a background check was available upon request. There was no evidence that a background check was performed when HHA1 was hired and started working for Hospice in 2014. HR1 further stated, HHA 2 and LN1 did not have a background check available in their personnel file.During a concurrent interview and record review via zoom on 9/5/25 at 12:15 p.m. with HR 2, HR 2 confirmed and stated, HHA1, HHA 2 and LN1 did not have any documented evidence of background checks in their personnel file.During a review of facility’s policy and procedure titled, “Employment Screening,” dated 5/14/2025, the P&P indicated, “…Federal Criminal records search…to determine the presence of a case (s) which involves offences pertaining to a federal law…jobs that require a federal Criminal Record search are all…. Home Health, and Hospice….””

“Based on interview and record review, the Hospice Agency (HA) failed to provide Hospice Aide (HAide) services according to the Plan of Care (POC) for two of three sampled patients (Patient 1, Patient 3), when Patient 1 and Patient 3 did not receive bathing services two times a week. This failure had the potential for Patient 1 and Patient 3 to have skin breakdown not identified and to have decreased self- esteem and comfort. Findings: A review of Patient 1’s POC for benefit period 1/27/24 to 3/26/24, indicated Patient 1 had Start of Care (SOC) date with the HA on 6/1/23 for diagnosis of Alzheimers dementia (progressive brain disorder that causes loss of memory and other mental functions). The POC indicated “Assistance with bed bath as tolerated and safe per wife request...inspect skin for signs of pressure or irritation...Planned Visits as of 1/29/2024 Home Health Aide...2 visits every week for 9 weeks...” A review of Patient 1’s POC for benefit period 3/27/24 to 5/25/24, indicated “”Assistance with bed bath as tolerated and safe per wife request...inspect skin for signs of pressure or irritation...Planned Visits as of 4/12/2024 Home Health Aide...1 visit every week for 1 week...2 visits every week for 8 weeks...” A review of Patient 1’s “Schedule Visit Set,” for 1/28/24 to 5/25/24, indicated Hospice Aide missed visits on 2/9/24, 2/16/24, 5/14/24, and 5/21/24. A review of Patient 3’s POC for benefit period 5/1/24 to 7/29/24, indicated Patient 3 had SOC date with the HA on 5/1/24 for diagnoses including Alzheimers dementia and CHF (congestive heart failure- the heart does not pump blood as well as it should). The POC indicated “Assistance with bed bath...Inspect for signs of pressure or irritation...Planned Visits as of 5/17/2024 Home Health Aide...2 visits every week for 12 weeks...1 visit every week for 1 week...” A review of Patient 3’s “Schedule Visit Set,” for 5/5/24 to 5/25/24, indicated Hospice Aide missed visit on 5/18/24. During a telephone interview on 5/24/24 at 8:43 a.m. with Patient 1’s Family Member (FM), the FM stated Patient 1 was supposed to have HAide two times a week for bathing. FM stated that HAide did not come on 5/14/24 and 5/21/24. The FM stated she was not notified that the HAide was not coming. The FM stated a few months ago, Patient 1 had missed HAide visits also. During a concurrent interview and record review on 5/24/24 at 12:43 p.m. with the Quality Coordinator (QC), the QC acknowledged that Patient 1 had missed HAide visits on 2/9/24, 2/26/24, 5/14/24, and 5/21/24. The QC confirmed that there were no “Missed Visit” notes for 2/9/24, 2/26/24, 5/14/24, and 5/21/24. The QC acknowledged that there was no documentation indicating family or physician was notified of missed visits. During an interview on 5/24/24 at 1:07 p.m. with the Service Director for Home Health and Hospice (SDHHH), The SDHHH acknowledged that Patient 1 had missed HAide visits on 2/9/24, 2/26/24, 5/14/24, and 5/21/24. The SDHHH stated, “The expectation is that “Missed Visit” notes are completed and that the family is notified of missed visits.” The SDHHH stated the HAide should document the conversation with the family regarding the missed visit in the “Missed Visit” note. The SDHHH stated the expectation is that the HAide or the supervisor would notify the family if the HAide visit will be missed. The SDHHH stated the nurse case manager or supervisor would be the one to notify the physician of the missed visit and document the notification. During an interview on 5/24/24 at 1:15 p.m. with the Quality Director for Home Health and Hospice (QDHHH), the QDHHH stated the HA process is to communicate missed visits with the family. The QDHHH further stated, “There is not a policy, but it is our process to contact the family.” During a subsequent concurrent interview and record review on 5/24/24 at 1:25 p.m. with the QC, the QC confirmed Patient 3 had HAide missed visit on 5/18/24. The QC confirmed there was not a “Missed Visit” note for 5/18/24. During a subsequent interview on 5/24/24 at 1:42 p.m. with the SDHHH, the SDHHH stated missed visits were due to not having enough staff. The SDHHH stated, “Staff did not follow the process. Scheduling should have gone to the case manager and called the family to figure out an alternate plan. The “Missed Visit” notes that were not completed were due to staff not following the process.” During a telephone interview on 5/24/24 at 1:43 p.m. with HAide, the HAide stated if Patient 1 had a missed visit, the information would be documented in a “Missed Visit” note and communicated to the case manager and supervisor. The “Missed Visit” note is then sent to the physician to notify them of the missed visit. If the HAide was unable to make the visit or patient refused, she would contact the supervisor and would expect the supervisor to call the family. During a subsequent interview on 5/24/24 at 3:05 p.m. with QDHHH, the QDHHH stated, “The HAide should notify the case manager and supervisor of schedule issues. Patient and family need to be aware of any missed visits.” The QDHHH further stated, “It is the agency process to notify the MD [Medical Doctor] and patient.” A review of the HA Policy and Procedure (P&P) titled “Hospice Aide Services,” revised 3/7/23, indicated “...Hospice aide services may be included for routine care on an intermittent basis when personal care is needed. Services provided by an aide include bathing...These activities, in accordance with the interdisciplinary plan of care and physician’s orders, will be assigned and supervised by a hospice registered nurse...Hospice Aide Services exist for the provision of personal care services under the direction and supervision of the RN [Registered Nurse] in accordance with the Plan of Care. The duties of the Hospice aides include...Assisting patients with bathing...Completing concise and accurate records of care and services provided...” A review of the HA P&P titled “Comprehensive Assessment,” revised 10/29/20, indicated “...The assessment should determine...Type of services, frequency, and duration needed to meet patient care needs...The frequency and duration of visits will be written in a manner which clearly indicates the number of visits per week with a prescribed duration...The physician must be notified if a scheduled visit is not completed. The reason for the missed visit and notification of the physician must be documented in the medical record...” A review of the HA P&P titled “Hospice Nursing Care,” revised 10/29/20, indicated “...The hospice nurse will...Ensure communication between the hospice and other health care providers involved in the patient’s care...The hospice RN is responsible for the hospice aid [sic] care plan...””