Every finding on record at Affinity Care of Virginia LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review, interview, and observation. Agency policy "Hand Hygiene" (effective date of 3/1/2019) stated in relevant parts, "When hands are not visibly soiled, they should be washed using an alcohol-based hand rub for routinely decontaminating hands... Hand decontamination using an alcohol-based hand rub should be performed: D. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. E. When moving from a contaminated body site to a clean body site during patient care. G. After removing gloves." In 1 of 3 (33%) home visits observed, the agency did not ensure personnel performed hand hygiene to prevent the transmission of infections and communicable disease per the agency policy. Home Visit 2: During the home visit with the Registered Nurse (RN) [Personnel 6] on 1/23/2024, the RN was observed three times during assessment and care of the patient to doff their gloves and don new gloves without first performing hand hygiene. Once was after changing the patient's soiled incontinence brief. During an interview on 1/23/2024, the Clinical Director confirmed that the RN [Personnel 6] did not follow standard precautions and established agency policy for hand hygiene.

Based on staff interview and document review, it was determined the hospice failed to appoint an administrator responsible for the day-to-day operation of the hospice. Specifically, the hospice's Administrator was unable to fulfill the obligations of day-to-day operations and failed to appoint a qualified alternate to carry out the Administrator's duties. --- Two (2) surveyors arrived at the agency on 12/12/23 at 11:18 AM. Two (2) staff members (staff members' 2 and 3) were present in the office upon surveyor arrival. A surveyor asked staff member #3 if the hospice's Administrator was available. Staff member #3 replied ";no." The surveyors requested for hospice staff to notify the Administrator of the surveyors arrival and complaint investigation in progress. Staff member #1 then called the surveyors to advise they were en route to another separately certified hospice located approximately four (4) hours from the agency. The surveyor asked staff member #1 who was designated to act in their absence and the staff member confirmed there was not another person to act on their behalf in the event of their absence. Staff member #1 requested surveyors email a list of required information needed for the survey. Staff member #1 arrived at the agency approximately 2.5 hours after entrance. The surveyors requested an organizational chart from staff member #1. The organizational chart was provided and reviewed. The undated document listed another staff member, staff member #11 as the agencys Administrator. Staff member #1 confirmed staff member #11 was the agency Administrator and stated that staff member #11 was currently in Florida and split their time between Virginia and Florida locations. Surveyors confirmed staff member #11 was appointed by the governing body as the agencys Administrator. Staff member #1 provided surveyors with a document, Designation of Individual in Absence of Administrator. Staff member #1s name was listed on the form. The form was not dated and not signed by anyone. The form also contained a field for the Qualified Nurse acting in absence of the Administrator and this field was also blank. An interview was conducted with staff member #12 on 12/13/23. Staff member #12 has been employed by the agency for over two years. The staff member denied ever speaking to or meeting the agencys Administrator and stated that staff member #1 is responsible for day-to-day activities of the agency. An interview was conducted with the agencys Administrator (staff member #11) on 12/13/23 at 1:05 PM. Staff member #11 confirmed that they were the Administrator of the agency. The staff member stated they were currently in Florida acting as a hospice director at another certified agency. The Administrator stated they were currently the Administrator at five (5) separately certified hospice agencies to include four (4) Virginia locations. Staff member #11 confirmed staff member #1 was the agencys alternate Administrator and that staff member #11 had regional duties to include assisting a new Clinical Director at another separately certified hospice.