Every finding on record at C V Hospice Care, Inc.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy”. For example, during RRHV#1 the skilled nurse did not perform hand hygiene after she finished cleaning her equipment and put it back in her bag. During RRHV#2 the hospice aide washed her hands, turning the sink off with her bare hands and did not perform hand hygiene again during the visit. During RRHV#3 the Social Worker helped the patient put up her “toothpicks”, then touched the patient’s hands, then moved the overbed table closer to the patient prior to leaving the room all without hand sanitizing. Findings were verified by the Administrator who was present during the visits. Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the nurse surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Bag Technique Policy”. During RRHV#1 the skilled nurse set her bag down on an upholstered bag next to the kitchen table without a barrier. During RRHV#2, the hospice aide set her bag down on the bathroom counter without a barrier, then put it down on the bathroom floor. Findings were validated by the Administrator who was present on during the visit. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per the “Bag Technique Policy”. During RRHV#1 the skilled cleaned her equipment with alcohol then fanned each piece of equipment in the air before placing it in her bag. Findings were verified by the Administrator who was present during the visit.

Observed in Record Review. In 6 of 10 patient records reviewed, of active patients, it was noted by the nurse surveyor that for RRHV#1,RRHV#2, RRHV#3, RRNHV#2, RRNHV#6and RRNHV#7, the hospice aide care plan did not address whether the patient’s oxygen could be removed for the patient’s bath/shower if it was on at the time of the hospice aide’s visit. Additionally, for RRNHV#2, the hospice aide care plan did not address that the patient had a coccyx wound dressing or what to do regarding it during the patient bed bath. Findings were verified by the Director of Patient Care Services and the QAPI Assistant.

Observed in Individual Tracer. In 2 of 4 patient records reviewed, HV1, HV2, during home visit and record review, the surveyor noted the organization failed to conduct an initial bereavement risk assessment. The Bereavement risks were not documented on the assessment form, in any subsequent clinical or IDG notes or on the plan of care. This was validated by the DPCS.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, HV1, HV2 RR3, RR4 during record review the surveyor noted the Interdisciplinary group meeting notes did not document decline, progress, revisions to plans of care and goals. There was no documentation of the changes since initial assessment, patient’s progress toward desired outcomes and/or a reassessment of the patient’s response to care. For example, in all records, there were IDG narrative summary notes that were brief, incomplete and not reflective of progress or decline in patient condition. For example HV2, the patient received intravenous normal saline, but there was no documentation regarding response to therapy or reason for the therapy; there was no documentation of condition, progress/decline in condition. The notes in the summary were brief and were repetitive over several IDG meetings from admission and throughout the course of care. This was discussed at length with the DPCS and validated by the DPCS.

Observed in Individual Tracer. In 2 of 2 home visits conducted, HV1, HV2, the surveyor noted the organization failed to implement its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. For example, HV1, the nurse did not change gloves or perform hand hygiene prior to accessing the nurse bag. In addition, she cleaned her equipment with Clorox disinfectant wipes but did not allow equipment to dry prior to replacing them in the bag; HV2, the aide place her bag directly upon the bed without a barrier, linens were dropped on the floor and then used them to change patient bedding. This was not compliant with the organization's Nurse Bag Policy and Infection Control policies. This was validated by the Administrator and DPCS. Observed in Individual Tracer. In 2 of 2 home visits conducted, HV1, HV2, the surveyor noted the organization failed to demonstrate it used standard precautions, including the use of personal protective equipment, to reduce the risk of infection, including hand hygiene. For example, during HV1, the nurse and HV2, the aide failed to change gloves and perform hand prior to and after direct patient contact. This was not compliant with the organization's Hand Hygiene policy and validated by the Administrator and DPCS. Observed in Individual Tracer. In 1 of 2 home visits conducted, HV2, during the home visit the surveyor noted the organization failed to demonstrate it had implemented infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For example HV2, the nurse used disinfectant wipes from an unlabeled plastic bag stating that they were Clorox wipes. She cleaned her reusable equipment with the unlabeled disinfectant wipes and immediately placed them into the bag without allowing dry time. This was not compliant with the organization Nurse Bag technique which states equipment should be cleaned with alcohol and/or according to manufacturer guidelines. This was validated by the Administrator and DPCS.

Observed in Individual Tracer. In 4 of 4 patient records reviewed, HV1, HV2, BR3, BR4 during the record review the surveyor noted the organization failed to develop a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example, there was no initial bereavement risk assessments, no care plans developed, documented or implemented. BR3, BR4 there was no post death bereavement assessment, no bereavement plan developed and no evidence the organization had implemented bereavement program or support for the survivor. This was validated by the DPCS.

Observed in Individual Tracer. In 1 of 2 home visits conducted, During HV1, the surveyor observed the patient record did not contain the following clinical information:A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. For example, HV1 during the medication reconciliation, it was noted the patient was taking OTC supplement Culturelle Probiotic capsules 1 tablet daily since admission November, 2021. This medication was not on the care plan or medication list; in addition, the caregiver reported she stopped administering Senna over a week prior to the survey visit due to regular bowel movement however it remained on the medication list; the caregiver stated she was crushing medications due to patient's difficulty swallowing; however there were no instructions or indications on the medication profile that identified medications to be crushed. This was not compliant with the organization's medication management policies and validated by the DPCS.

Observed in HR File Review. In 2 of 3 HR files reviewed, HR2,HR3 during personnel file review, the surveyor noted the organization failed to demonstrate criminal background checks were conducted as required by law and regulation. For example, HR2, HR3 did not have criminal background checks documented in the personnel files. This was validated by the Administrator.

Observed in Infection Control System Tracer. During Infection Control Session/Leadership session, the surveyor noted the organization failed to show evidence it had policies, processes or procedures established regarding staff vaccination for the COVID 19 virus by February 28, 2022. The organization was able to demonstrate a tracking log that reflected 90.9% vaccination compliance of current employees, however no policies had been developed or established. This was validated by the Administrator and DPCS.