Hospice of the East Bay

“It is required that the hospice maintains an emergency preparedness training program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. The training program is reviewed and updated at least every two (2) years. The hospice EP training program includes the following: For all new hospice employees and those providing services under arrangement, initial training in EP policies and procedures consistent with their expected roles; EP training of all hospice employees and individuals providing services under arrangement at least every two (2) years. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 12(17%) personnel records reviewed revealed the agency did not ensure that staff and volunteers were trained in emergency preparedness as per agency policy. Agency Policy: Agency policy number 3.20, “Incident Command System”, effective 12/2000 and revised 5/2025, stated in part that, “(Agency Name) assures the ability to respond to an internal or external emergency/disaster situation in all locations”. Orientation and education on emergency preparedness will be coordinated by senior leadership and will include: 1) General orientation upon hire, and 4) annual competencies. PERSONNEL RECORD 2: A review of the personnel record for the registered nurse (RN) (Personnel Record 2) with a hire date of 09/07/2025 revealed that the RN did not complete emergency preparedness training in 2023 or 2024. PERSONNEL RECORD 11: A review of the personnel record for the Volunteer (Personnel Record 12) (hired 03/19/2024) revealed that the volunteer did not have initial emergency preparedness training, or any annual emergency preparedness training. There was no documented education on hire in 2024 or as of the site visit for 2025. Interview with Human Resources director on 8/21/2025 where she agreed that the RN noted in personnel record 2 and the volunteer in personnel record 11 did not have documentation of emergency preparedness training. During interview with the Chief Clinical Officer on 8/21/2025 she agreed that emergency preparedness training should be added to the initial volunteer orientation as well as annual volunteer training requirements as per policy. Interview with Human Resources director on 8/21/2025 where she agreed that the RN noted in personnel record 2 and the volunteer in personnel record 11 did not have documentation of emergency preparedness training. During interview with the Chief Clinical Officer on 8/21/2025 she agreed that emergency preparedness training should be added to the initial volunteer orientation as well as annual volunteer training requirements as per policy. Agency policy number 3.20, “Incident Command System”, effective 12/2000 and revised 5/2025, states in part that, “Hospice East Bay assures the ability to respond to an internal or external emergency/disaster situation in all locations”. Orientation and education on emergency preparedness will be coordinated by senior leadership and will include: 1) General orientation upon hire, and 4) annual competencies.”

“It is required that the hospice designates a registered nurse member of the IDG to: Provide coordination of care; Ensure continuous assessment of each patient’s and family’s needs; Ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by: The hospice IDG in collaboration with the attending physician (if any); The patient or patient representative if any of them so desire; The primary caregiver in accordance with the patient’s needs if any of them so desire. This standard was not met as evidenced by clinical record review, document review, and interview. In 1 of 13 (8%) Clinical records reviewed of patients with wounds in the community program, the agency did not ensure that wound measurements were documented as defined by agency approved wound care management and the plan of care. Agency Approved Process.: Wound Care Management [last updated 12/27/2023] “Identify and address all issues that may impact and potentially delay healing document and evaluate wound for location, length, width and depth weekly.” CLINICAL RECORD 9: The updated plan of care dated 07/03/2025 was for wound care for a stage 2 wound and one of the interventions was to measure weekly. Weekly measurements were documented weekly, except from 07/16/2025 thru 07/28/2025 which was 11 days and left the week of 7/20/2025 - 07/26/2025 with no wound measurements. During interview on 08/21/2025 the Chief Compliance Officer who stated that the wound had not been documented as measured weekly.”

“It is required that each patient’s individualized written plan of care: Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review and interview. In 2 of 6 (33%) clinical records in which the patient had a Foley catheter, the agency did not ensure that the plan of care documented individualized detail for the catheter. CLINICAL RECORD 13: The initial comprehensive assessment documented on 08/08/2025 a Foley catheter that was a 20 French/ 30cc balloon with a large drainage bag. The hospice plan of care initiated 08/08/2025 and updated every 2 weeks documented a catheter to maintain patency but did not include the size, potential flushing, or care of large drainage bag or if it could be changed. CLINICAL RECORD 26: The initial comprehensive assessment documented on 08/01/2025 for a patient on GIP (general inpatient) documented that the patient had a Foley catheter. The initial plan of care dated 08/01/2025 and updated every 2 weeks documented a catheter to maintain patency but did not include the size, potential flushing, or care of the large drainage bag. During interview with the Chief Compliance Officer on 08/20/2025, the Chief Compliance Officer stated that the individualized direction for the catheters was not documented.”

“It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview, and personnel record review. In 2 of 12(17%) of personnel records reviewed, the agency did not ensure that staff were educated in infection control procedures annually. Agency Policy: Agency policy number 7.62, “Team Member Development and Education” effective 8/1997 and revised 1/2024 stated in part that, “Hospice (Agency Name) will provide for team member development including but not limited to: continuing education, in-services, training sessions, and one on one mentoring. Documentation of attendance will be requested and filed in team members’ records.” “Each clinical, administrative, and clerical staff must complete the following programs each year. The mandatory in-services includes A: Hand hygiene and C: Infection control” PERSONNEL RECORD 7: A review of the personnel record for the Bereavement Coordinator (hire date 06/06/2011) revealed that the Bereavement Coordinator did not complete Infection Control education during the 2024 calendar year or for 2025 as of the personnel record review on 08/21/2025. PERSONNEL RECORD 10: A review of the personnel record for the Medical Director (hire date of 08/07/2023) revealed that the Medical Director did not complete Infection Control education during the 2024 calendar year or for 2025 as of the personnel record review on 08/21/2025. During interview with the Bereavement Coordinator (Personnel Record 7) on 8/21/2025 where he agreed that he had not completed the required infection control education. He noted that it had not been assigned to him, and they would look into the education program for errors which may have contributed to the training not being assigned to the Bereavement Coordinator and the Medical Director.”

“It is required that hospice aides are assigned to a specific patient by a registered nurse who is a member of the Interdisciplinary Group. Written patient care instructions for a hospice aide are prepared by a RN who is responsible for the supervision of the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 6 of 18 (33%) clinical records reviewed, of patients that accepted the hospice aide in the community program, the agency did not ensure that the registered nurse prepared a hospice aide plan of care that contained clear and specific instructions for the patient’s required care. CLINICAL RECORD 1/HOME VISIT 1: The patient elected the hospice benefit on 08/07/2024 with a diagnosis of congestive heart failure. The hospice aide care plan dated 05/22/2025 included the bath task of sponge bath as needed and continued was continued until 03/05/2025 when the bath was changed to shower every visit. The nurse documented that the patient was forgetful. During the home visit (Home Visit1) with the hospice aide (Personnel Record 1) on 08/19/2025 the aide stated that only a sponge bath has been given for several months as the patient was too tired and short of breath to shower but plan of tasks left shower as an option. She stated the patient kind of decides but the observed behavior during the visit, was minimal from the patient. There was no identified decision maker documented. CLINICAL RECORD 2: The patient elected the hospice benefit on 07/01/2025 with primary diagnosis was atherosclerotic disease. The hospice aide care plan dated 07/01/2025 included the task to “apply topical cream ointment A & D (specify location). There was no identified location to apply the cream The hospice aide documented each visit that the cream was applied but not the location. CLINICAL RECORD 9: The patient elected the hospice benefit on 07/02/2025 with a diagnosis of Parkinson Disease. The hospice aide care plan dated 07/02/2025 included the task to “apply topical cream ointment A & D (specify location). There was no identified location to apply the cream. The hospice aide documented each visit that the cream was applied but not the location. CLINICAL RECORD 11: The patient elected the hospice benefit on 07/04/2025 with a diagnosis of degenerative nervous system. The nursing clinical documentation was that the patient was confused and forgetful. The hospice aide care plan dated 07/04/2025 included the task bed bath every visit as patient request and the task of shower every visit as patient requested. There was no identified decision maker. CLINICAL RECORD 13: The patient elected the hospice benefit on 08/08/2025 with a diagnosis of Degenerative nervous system. The patient was admitted with a foley catheter 20 FR/30cc. The hospice aide care plan dated 08/14/2025 included a task assigned for perineal care. This patient was admitted 08/08/2025 with a Foley catheter 20 French/ 30cc but the aide plan did not include a task for cleaning around the catheter or emptying the drainage bag. CLINICAL RECORD 15: The patient elected the hospice benefit on 07/10/2025 with a diagnosis of CVA. The hospice aide care plan dated 08/18/2025 included a task for bed bath every visit and shampoo in shower every visit. The patient is bed bound and confused and has had some falls. During interview with the Chief Compliance Officer on 08/21/2025, the Chief Compliance Officer stated that the aide care planning process will be reviewed, and education needed for the care plan details.”

“It is required that hospice aides must report changes in the patient’s, nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. This standard was not met as evidenced by clinical record review and interview. In 1 of 18 (6%) clinical records reviewed in which a hospice aide was accepted in the community program, the agency did not ensure that the aide notified the nurse when the tasks assigned on the aide plan were not completed. CLINICAL RECORD 1: The patient elected the hospice benefit on 08/07/2024 with a diagnosis of congestive heart failure. The hospice aide care plan dated 03/05/2025 included the bath task of sponge bath as needed and continued until 05/22/2025 when the bath was changed to a shower every visit. The following dates, 06/26/2025, 07/15/2025, 07/22/2025, 08/07/2025 and 8/18/2025 the shower was refused however there was no documented evidence that the aide reported this to the registered nurse. During interview with the Chief Compliance Officer on 08/20/2025, the Chief Compliance Officer stated that the notification was not documented.”

“It is required that the designated IDG member provides the SNF/NF or ICF/IID with the following information for each patient/resident: Physician certification and recertification of the terminal illness. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 1 (100%) Observed visits at a skilled nursing facility, the agency did not ensure that the agency binder with hospice information included documentation of the initial physician certification or the recertification of terminal illness. Agency Policy: Agency Policy #6.24 “Hospice Care For skilled Nursing Facility (SNF) Residents/Patients [revision dated 05/2025] stated in part: “The RN Case Manager or designee will provide the following information to the SNF (skilled nursing facility) for inclusion in the SNF Medical Records: most current hospice plan of care, Hospice election form and any advanced directives, Physician certification and recertification of the terminal illness, names and contact information of hospice personnel involved in the care of the resident/patients, instructions on how to access the agency 24 hour on call system, hospice medication information specific for each resident/patient, hospice physician and attending physician orders. HOME VISIT 3: observed visit on 08/20/2025 with the registered nurse (PR 3) at a skilled nursing facility. The patient information binder included all required items except the physician certification and recertification of terminal illness. The hospice benefit of election was 11/15/2024 and the current benefit period began 07/13/2025., There was no initial or current certification CTI (certificate of terminal illness) in the agency binder located at the skilled facility. During interview with the Chief of Clinical Services and the Chief Compliance Officer on 08/21/2025, they stated that the CTI had not been on their list.”