Every finding on record at Highland Hospice, Inc.

Observed in Record Review. In 1 of 1 home visits conducted where the patient was receiving supplemental oxygen therapy, the organization had not maintained a complete and accurate patient record. Observed during the home visit conducted for RRHV#1, the patient was receiving oxygen therapy via nasal cannula at 7 liters per minute supplied by a 10 liter stationary concentrator. Identified during the record review for RRHV#1, documentation states oxygen therapy 2 liters to 5 liters as needed provided by a 5 liter stationary concentrator. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 10 active patient records reviewed, the organization did not provide the patient with treatment according to the patient's individualized plan of care. Observed in the home visit conducted for RRHV#2, the Registered Nurse cleansed the patient's facial wound (squamous cell carcinoma) with a hydrogen peroxide solution and povidone iodine solution. In reviewing the patient's record, the plan of care states: Gently cleanse the wound with saline solution and pat dry with gauze. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. Observed in RRHV#1 and RRHV#3, the clinicians did not perform hand hygiene in accordance with organizational policy 5.7.1-3. Observed in RRHV#!, the Hospice Aide began washing her hands by applying liquid soap to her dry hands and rubbing the soap into the both surfaces of her hands prior to turning on the running water. After rinsing her hands, she turned off the faucets with her hands before drying them with a paper towel. In RRHV#3, the Licensed Vocational Nurse was observed, turning off the faucets with his cleansed hands before drying them with a paper towel. This was reviewed and validated with the Administrator. Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement its infection prevention and control activities to minimize, reduce, or eliminate the risk infection. Observed in RRHV#1, the Hospice Aide did not change gloves in accordance with organizational policy 5.6.1. Upon beginning the bed bath, the Hospice Aide double gloved prior to placing barriers under the patient. Following barrier placement, she removed the top gloves and retrieved the bath water still wearing the bottom gloves, returned to the patient and removed the patients soiled gown, and then continued without changing gloves. During the bath, the Hospice Aide made multiple water changes, repositioned the patient, assisted the patient with her oxygen and CPAP, and removed the patients socks, all without changing gloves. This was reviewed and validated with the Administrator.

Observed in Infection Control System Tracer. Identified during the Infection Control Session, there was no evidence that the organization had completed an Infection Risk Analysis during the past three years based on its geographic location, community and population served; the care, treatment, or services it provides; or, the analysis of its surveillance activities and other infection control data. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Infection Control System Tracer. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by Condition Level findings at 418.60: Infection Control. This was reviewed and validated with the Administrator.

Observed in Regulatory Review. In 2 of 2 patient record reviews where the patient revoked hospice services, the organization did not provide a written discharge summary to the patient's physician or other licensed practitioner in accordance with law and regulation and in accordance with organizational policy 9.29.1-2. Identified during the review of LiveDC#1, and LiveDC#2, the patients revoked hospice services to see alternate care. There was no evidence in the patient record that the patients' primary physicians or receiving practitioners were offered or provided a discharge summary of the hospice episode of care. This was reviewed and validated with the Administrator.