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……….””