Every finding on record at Angelic Heart Hospice

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 and safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids. This standard was not met as evidenced by document reviews and observation on home visits. 1 of 3 (33%) visits revealed the staff did not follow agency policy for handwashing prior to returning clean equipment to bag. Agency Policy #7-016 Bag Technique [revision day May 2020], "Hands will be decontaminated prior to returning clean equipment to bag." Home Visit 1: This RN [Staff 7] was observed during the home visit on 9/27/2022. Hand hygiene was performed on arrival at the home and before the physical assessment. The nurse cleaned used equipment, a blood pressure cuff, pulse ox, and stethoscope and returned the items to the equipment bag without handwashing.

It is required that the Organization defines a process to ensure that nationally recognized infection prevention and control guidelines intended to mitigate the transmission and spread of COVID-19 are implemented and followed. This standard was not met as evidenced by a review of personnel records, document review, and interviews. In 2 of 13 (15%) personnel records reviewed, the agency did not ensure COVID testing prior to patient visits for staff exempt from vaccination per agency policy. Agency Policy 1-046 HR COVID 19 Vaccination [revised May 2022] states in part, "If staff have been granted an exemption, either medical, religious or job responsibility, to the COVID 19 vaccination requirement, they must submit to weekly COVID 19 testing. Test results shall be provided to the hospice for documentation. Unvaccinated staff are required to wear masks and /or respirators, PPE and follow appropriate precautions outlined by the organization." Staff 4: This Nurse Practitioner, who had a documented exemption from COVID vaccination, was hired on 02/14/2022. There was no documented evidence of weekly COVID testing prior to the patient visit. Staff 1: The Executive Director, who had a documented exemption from COVID vaccination, was hired on 05/23/2022. Two death visits had been conducted since the time of hire by this staff member. There was no documented evidence of weekly COVID testing prior to the patient visits. An interview with the Executive Director revealed that no COVID testing had been completed prior to conducting the patient death visits. An interview with the Nurse Practitioner revealed that no COVID testing was completed prior to the one patient visit. Both staff members stated that they have rare patient-to-staff contact in their defined roles.