Every finding on record at Hestia in Home Support LLC

Based on interview and record review, the agency failed to ensure after-action reviews were completed and documented after annual emergency plan testing exercises; the agency failed to show necessary improvements determined during the annual emergency plan testing exercises. This deficient practice had the potential to affect all agency staff and patients receiving care from the agency. Findings include: --- Review of the agency's annual emergency plan exercises from 1/8/22 through 1/4/23, showed a mock disaster drill and a full-scale community based emergency plan test. The agency did not complete or document an after-action plan review for the two completed drills. During an interview on 3/15/23 at 1:40 p.m., staff member A stated they were not aware an after-action review needed to be completed for the drills.

Based on interview and record review, the agency failed to ensure interventions to manage pain were included in the plan of care for 1 (#15) of 18 sampled patients. Findings include: --- Review of the agency's policy and procedure titled, Care of the Dying Patient, showed, "...Hospice will develop an individualized plan of care and cooperation with the patient, family or caregiver, attending physician and interdisciplinary team members that facilitate: ...Pain management (control or alleviate) according to physician orders that may include analgesia and non-invasive and non-pharmacological interventions." Review of patient #15's Initial Assessment, dated 11/25/22, showed, "...Family reports patient has history of low back pain. They treat with liquid tylenol [sic] or [over the counter] lidocaine patch..." Review of patient #15's Initial Plan of Care, dated 11/25/22, showed the agency failed to include interventions to manage pain was included on the patient's plan of care. Review of patient #15's IDG Meeting Note and updated POC, dated 12/8/22, failed to identify and establish interventions to manage the patient's pain were included in the updated POC. Review of patient #15's IDG meeting note and Recertification POC, dated 2/15/23, failed to identify and establish interventions to manage pain symptoms were included in the recertification POC. During an interview on 3/14/23 at 3:00 p.m., staff member A stated it was the expectation that pain management was addressed on the patient's POC. She stated they had not included the pain management on patient #15's POC.

Based on observation, interview, and record review, the agency staff failed to perform hand and equipment hygiene for preventing the spread of infections among patients for 2 (#s 1 and 2) of 18 sampled patients. Findings include: --- During an observation on 3/15/23 at 9:55 a.m., staff member H entered patient #2s room without performing hand hygiene. She proceeded to place her bag of nursing equipment on the patients bed. Staff member H took out the thermometer, blood pressure cuff, stethoscope and oximeter, and proceeded to check the patient's vitals. The staff member then donned gloves, without performing hand hygiene, and provided 3 dressing changes for patient #2. Staff member H left the patients room to access an oral medication and returned to room without performing hand hygiene. Staff member H left the patient's room to obtain mouth swabs. Oral care was provided to the patient without gloves or hand hygiene. Staff member H washed her hands at the end of the visit with patient #2. During an observation and interview on 3/15/23 at 11:00 a.m., staff member H assisted a patient down the hall by holding her hands. She returned to patient #1s room and proceeded to retrieve her nursing equipment from the bag. During an interview at 11:10 a.m., staff member H was asked about the agencys practice for sanitizing equipment. Staff member H stated, "Thanks for the reminder," and sprayed her equipment with a sanitizing solution. No hand hygiene was performed prior to obtaining patient #1s vitals. Staff member H stated the agency would need to refocus on infection control practices. Review of the hospice agency's Infection Control Policy showed the staff should wash hands thoroughly before and after all patient care, and upon arrival and departure from the patients' home/room. "Scrub hands for at least 15 seconds. Clean equipment with a disinfectant spray and allow to air dry."

Based on interview and record review, the agency failed to ensure the infection control and prevention program data was routinely reviewed and monitored as part of the agency's quality assessment and performance improvement program; failed to establish policy and procedures to ensure surveillance data was routinely reviewed and monitored by the QAPI program; and, failed to establish protocols to ensure appropriate corrective actions were performed based on program data analysis of the agency's QAPI program. This deficient practice had the potential to affect all staff and patient's receiving services from the agency. Findings include: --- Review of the agency's policy and procedure titled, Employee Health, showed, "Responsibilities: Hospice Director:...Monitors employee infections, infection related injuries, exposures to communicable diseases, employee absence reports and tuberculin skin test conversions. Provides information to the QAPI team as needed." Review of the agency's established policy and procedures related to infection control failed to establish additional policy and procedures to ensure surveillance data for patients was reviewed and monitored and corrective actions established by the agency's QAPI program. Review of the agency's IFC program and QAPI program failed to include a process which ensured the agency's IFC program was integrated into their QAPI program. During an interview on 3/15/23 at 2:15 p.m., staff member A stated she was responsible for oversight of the IFC and QAPI programs. She stated she was not aware the IFC program needed to be integrated into their QAPI program. Staff member A stated they currently were not addressing any corrective actions in the agency's QAPI program related to surveillance data of infections.

Based on observation, interview, and record review, the agency failed to attempt oral care for comfort, without cueing from the state agency for 1 (#2) of 4 sampled patients. Findings include: --- During an observation and interview on 3/15/23 at 10:20 a.m., patient #2's mouth and lips were coated with a sticky mucous. The patient had not been eating or drinking adequately for a few days, per staff interview. The patient's upper teeth had a brown film. Patient #2 was picking dried matter off her lips. Staff member H offered the patient fluids to drink, but did not offer oral care. The surveyor asked if oral care might make the patient more comfortable, and the patient was able to say "definitely." Oral care was provided, and the patient smiled. Review of patient #2's hospice aide care plan showed oral hygiene would be completed 5 times per week.

Based on interview and record review, the agency failed to ensure a discharge summary was completed for 2 (#s 17 and 18) of 18 sampled patients upon their transfer of care to another participating hospice. Findings include: --- 1. Review of patient #17's Live Discharge Note, dated 11/17/22, showed, "Patient is transferring to [Hospice Agency]." Review of patient #17's Notice of Hospice Patient Change, dated 11/17/22, showed the patient elected to be transferred/change of hospice provider. Review of patient #17's EMR did not show a discharge summary was completed for patient #17 at the time of their discharge from the agency. 2. Review of patient #18's Live Discharge Note, dated 9/19/22, showed, "Patient requested to transfer [Hospice Agency] for increased services in the area... They are being admitted to [Hospice Agency] 9/20/22. Review of patient #18's Notice of Hospice Patient Change, dated 9/19/22, showed the patient elected to be transferred/change of hospice provider. Review of patient #18's EMR did not show a discharge summary was completed for patient #18 at the time of their discharge from the agency. During an interview on 3/13/23 at 10:00 a.m., staff member B stated a discharge summary was not completed other than items from the patients' record were sent to the receiving agency.

Based on interview and record review, the agency failed to ensure discharge summaries were completed which included a summary of the patient's stay including treatments, symptoms, and pain management, the current plan of care, and the patient's latest physician orders for 2 (#s 17 and 18) of 18 sampled patients. Findings include: --- 1. Review of patient #17's Live Discharge Note, dated 11/17/22, showed, "Patient is transferring to [Hospice Agency]." Review of patient #17's EMR did not show a discharge summary was completed for patient #17 at the time of their discharge from the agency. 2. Review of patient #18's Live Discharge Note, dated 9/19/22, showed, "Patient requested to transfer [Hospice Agency] for increased services in the area... They are being admitted to [Hospice Agency] 9/20/22. Review of patient #18's EMR did not show a discharge summary was completed for patient #18 at the time of their discharge from the agency. During an interview on 3/13/23 at 10:00 a.m., staff member B stated when a patient was a live discharge to another hospice agency, they would send the last IDG meeting notes, recent POC, medication list, and any other notes requested by the agency. Staff member B stated a discharge summary was not completed other than the items addressed from the patient's record.

Based on interview and record review, the agency failed to ensure background checks were obtained within three months of the date of hire for a volunteer. This deficient practice has the potential to affect all patients receiving volunteer services. Findings include: --- Review of staff member I's date of hire was 9/27/22, staff member I signed a consent for the agency to complete a background check on 9/27/22. Review of staff member I's criminal background check, showed the document was created on 3/13/23 and completed on 3/14/23. Review of staff member I's Volunteer Visit Note, dated 2/16/23, showed staff member I provided volunteer services for a patient on 2/28/23. During an interview on 3/15/23 at 11:55 a.m., staff member B stated volunteers after being hired complete the on-boarding paperwork and then criminal background checks are completed prior to the volunteer providing services for the patients. Staff member B stated the reason the background check for staff member I showed it was completed on 3/14/23, was related to the fact that the background check system did not show the original date the background check was requested and received, it only showed the date the background check was printed.