Angel Valley Hospice LLC

“Based on observation, record review and interview, the agency failed to follow accepted standards of practice addressing infection control including the prevention of the spread of infectious and communicable disease with 1 of 17 of the agency’s Patients reviewed (Patient #2), in that: 1. RN B failed to ensure prevention of transmission of infection during a routine urinary catheter change procedure on Patient #2. This failure placed the agency’s patients at risk for infection transmitted by an employee. Findings included:During a home observation for Patient #2, on 7/29/2026 at 2:00 p.m., RN B was scheduled to replace Patient #2’s urinary catheter (a hollow tube that is inserted into the bladder to drain urine into a bag found outside the body). Further observation revealed that RN B placed medical supplies such as catheter changing supplies onto the patient’s living room table. The items placed on the table were sterile (supplies that are free of harmful bacteria). RN B was observed contaminating the gloves she was wearing while touching Patient #2’s skin prior to the catheter’s insertion.During an interview on 7/29/2026 at approximately 2:30 p.m. RN B said she should have taken off her gloves, sanitized and re-gloved using sterile technique after contaminating the gloves she had on. RN B further stated that she was nervous during the visit.During a record review of RN B’s employee record revealed a date of hire on 3/10/2026 and infection control education completed on 3/10/2026.During record review of Patient #2 clinical record revealed a start of care date of 6/5/2026, with a certification period of 6/5/2026-9/2/2026, and a terminal diagnosis of hypertensive heart disease (a heart problem caused by long-term high blood pressure). Further record review revealed Patient #2 received skilled nursing visits twice weekly, Chaplain visits once weekly, and social worker visits bi-weekly. Further record review revealed Patient #2 required monthly urinary catheter replacements to prevent urinary infections. During a joint interview with the Administrator and DON on 7/30/2026 at 1:00 p.m. the processes for infection prevention were discussed. The DON stated that staff received training on proper techniques to prevent the spread of infection. The DON stated she accepted responsibility for the failure because infection control was important requirement during urinary catheter replacement procedures in order to prevent urinary infections among hospice patients.During record review of agency policy “Infection Control Program” last reviewed 1/1/2025 read in part… “The Hospice will follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of [infection control measures] ...” Further record review of the Agency’s policy revealed, “... Implementing appropriate preventive procedures... Implementing appropriate measures to control infection...””

“Based on record review and interview, the agency failed to provide volunteer services in an amount that equals 5 percent of the total patient care hours of all paid hospice employees for 2024 and 2025. This failure could place Agency patients at risk of inadequate care by not ensuring that Agency’s volunteers are being adequately staffed for the Agency’s hospice patients. During a record review of the agency’s volunteer activities, it was revealed there were no volunteer hours for the years 2024 and 2025. In an interview with the Administrator on 7/29/2026 at 12:00 p.m., the Administrator was informed of the above findings for the Agency during the years 2024 and 2025. The Administrator acknowledged responsibility for the requirement of volunteer hours in the care of the Agency’s hospice patients. The administrator also acknowledged that the volunteer program is a vital component of the hospice agency. The administrator further acknowledged that he is responsible for this as the volunteer coordinator. Record review of the Agency’s policy titled, “Volunteers” dated 10/1/2021, revealed in part, “III. The Agency will provide volunteer services to be used in day-to-day administrative and/or direct patient care roles, in an amount that, at a minimum, equals five percent of the total patient care hours of all paid Hospice employees and contract staff.” Further record review of the Agency’s policy revealed,” The hospice will document and demonstrate viable and ongoing efforts to recruit and retain volunteers.””