Every finding on record at Delmar Gardens of Omaha, L.L.C.

Based on record review, policy and procedure review, observation of provision of cares, and staff interview, 1 of 3 staff (Staff B) observed during the provision of cares to 1 of 3 patients (Patients 2), failed to follow the hospice's infection control policies and procedures for proper hand hygiene and glove use. The census was 12. --- Findings are: A. Review of the hospice's policy and procedure titled Infection Control- Standard Precautions revealed staff were to: 1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items. 2. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients or environments. 3. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. 4. Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. 5. Put on clean gloves just before touching mucous membranes and non-intact skin. 6. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. B. Review of Patient 2's Hospice Plan of Care for the certification period of 2/7/24 through 5/6/24, included orders for Hospice Aide (HA) 1-2 times per week to assist with bathing, dressing, grooming, incontinent cares, hair, nail, and foot care, as well as room cleaning tasks. C. The observation of the provision of a shower and grooming tasks to Patient 2, on 3/26/24 at 9:00 AM, revealed Staff B failed to: 1. Remove gloves and wash hands after performing frontal perineal care (cleansing of the genital area) and prior to cleaning the patient's lower body. 2. Remove gloves and wash hands after washing patient and prior to drying patient. 3. Remove gloves and wash hands after performing posterior perineal care and prior to applying lotion to the patients body. D. During an interview on 3/26/24 at 1:30 PM, the Administrator confirmed Staff B failed to follow the hospice's policy and procedure for proper hand washing and glove use when Staff B failed to change gloves and wash hands between clean and dirty tasks during the provision of a shower and grooming tasks for Patient 2.

Based on review of volunteer records, policy and procedure review, and staff interview, the hospice failed to ensure volunteers provide at a minimum five percent of the total patient care hours of all paid hospice employees and contracted staff. The census was 12. --- Findings are: A. Review of the hospice's policy and procedure titled, Volunteers- Recordkeeping, last reviewed 1/2024, revealed the hospice was to document monthly volunteer activity, and summarize annually, to demonstrate the services provided by hospice volunteers equals or exceeds five percent of the total patient care hours of all paid hospice employees and contracted staff. B. Review of the Volunteer Roster revealed the hospice had 3 volunteers. C. Review of the hospice's 2024 Cost Savings Report revealed the hospice's volunteers provided 0.03 percent for January, 0.05 percent for February, and 0.02 percent for March, of the hospice's total patient care hours of all paid hospice employees and contracted staff, utilizing two volunteers each of those months. D. During an interview on 3/26/24 at 2:00 PM, the Volunteer Coordinator confirmed the hospice failed to ensure, for January, February, and March in 2024, their volunteers provided the minimum five percent of the total patient care hours of all paid hospice employees and contracted staff.

Based on record review, policy and procedure review, and staff interview, the hospice interdisciplinary team (IDT) failed to determine the patient/caregiver's ability to safely self-administer medications during the plan of care review for 11 of 14 clinical records reviewed (Patient 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). The census was 12. --- Findings are: A. Review of the hospice's policy and procedures titled, Interdisciplinary Group Meeting, last reviewed 1/2024, revealed: 1. The IDT reviews each patient's plan of care every 15 days or more frequently if needed to continually monitor the care and services provided to the patient. 2. The focus of the IDT meeting was reviewing and revising the patient's plan of care based on the patient's reassessment information. 3. The hospice's policy failed to include the regulatory requirement for the IDT to determine the patient/caregiver's ability to safely self-administer medications during the plan of care review. B. Review of the hospice's policy and procedure titled Medications- Administration, last reviewed 1/2024, revealed it failed to include the regulatory requirement for the IDT to determine the patient/caregiver's ability to safely self-administer medications during the plan of care review. C. Review of clinical records revealed: 1. Patient 2's start of care was 2/7/24. The Interdisciplinary Group Meeting notes (notes from the IDT plan of care review), dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 2. Patient 3's start of care was 11/13/23. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 3. Patient 4's start of care was 2/14/24. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 4. Patient 5's start of care was 10/20/23. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 5. Patient 6's start of care was 12/29/23. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 6. Patient 7's start of care was 11/10/23. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 7. Patient 8's start of care was 3/31/22. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 8. Patient 9's start of care was 8/3/22. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 9. Patient 10's start of care was 1/13/23. The Interdisciplinary Group Meeting notes dated 3/7/24 and 3/21/24, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. 10. Patient 11's start of care was 10/15/22. The Interdisciplinary Group Meeting notes dated 9/27/23 and 10/5/23, failed to include the IDT's determination of the patient/caregivers' ability to safely self-administer medications. 11. Patient 12's start of care was 1/18/23. The Interdisciplinary Group Meeting notes dated 5/4/23 and 5/18/23, failed to include the IDT's determination of the patient/caregiver's ability to safely self-administer medications. D. During an interview on 3/28/24 at 2:30 PM, the Administrator confirmed the IDT does not determine the patient/caregiver's ability to safely self-administer medications as part of the group's review of each patient's plan of care.