Every finding on record at Bluebird Hospice LLC

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical record review and interview. In 1 of 10 (10%) clinical records reviewed revealed that the agency did not ensure that the hospice Interdisciplinary Group completed an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. Clinical Record 3: The patient was admitted to hospice services on 08/28/2024 and the psychosocial assessment was completed on 10/01/2024 (33 days). In an interview with the Executive Director (ED) on 12/17/2024, after reviewing the clinical record, the executive director (ED) stated that the MSW must have forgotten to enter a note about the late assessment.

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 interview and observation. In 1 of 3 (33%) home visit observations and interviews revealed, that the agency did not ensure accepted standards of practice, hand hygiene, was used to prevent the transmission of infections and communicable diseases. Document 1: The agency's policy read in part, " When the visit is completed, reusable equipment will be cleaned using alcohol, soap, and water, or other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. Hands will be decontaminated before returning clean equipment to bag." (Bag Technique) (November 2023). Home Visit 1: A home visit was made on 12/18/2024 to observe the Registered Nurse (RN) (Personnel Record 1). After the vital signs were obtained, the RN sanitized her hands. Then, she cleaned the equipment and put it back into the bag one piece at a time without sanitizing her hands. In an interview with the RN, she stated she did not set up correctly for bag technique and that threw her off for hand hygiene.