Every finding on record at Bristol Hospice - State College, 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; [and] use of gloves, mask, eye protection, or face shield depending on anticipated exposure. This standard was not met as evidenced by clinical record review, document review, and observation. Agency policy #7-009 "Hand Hygiene" (revised 09/2024) read in part, "Hand decontamination using an alcohol-based hand rub should be performed: G. After removing gloves." In 1 of 3 (33%) home visit observations, the agency did not ensure that hand hygiene was performed when indicated per the agency's policy. Home Visit 3: The patient elected hospice care on 03/07/2025 with a diagnosis of senile degeneration of the brain. During the home visit with the Registered Nurse (RN) [Personnel Record 3] on 03/18/2025, the RN pulled the adhesive dressing from the patient's sacral wound to assess and observe the wound and reapplied the dressing after completing the assessment. The RN removed their gloves and began documenting the visit findings on their tablet. The RN did not perform hand hygiene after removing their gloves per agency policy. During an interview on 03/18/2025, the Director of Patient Care Services (DPCS) confirmed that the RN's hands should be cleansed after glove removal, stating, "She (the RN, Personnel Record 3] just called me about the home visit. She said she thinks she messed up."