Every finding on record at Horisun Hospice, Inc.

Based on record review, policy and procedure review, the observation of the provision of cares, and staff interview, 3 of 5 staff (Staff-E, -G, and -H) observed during the provision of cares to 3 of 4 patients (Patient 1, 2, and 3) failed to perform appropriate hand hygiene, glove use, and/or use of clean bag technique according to the agency policies and procedures to prevent the potential for cross contamination and home care acquired infections. The total sample size was 19. The census was 56. --- Findings are: A. Review of the agency policy and procedure titled Infection Control, Hand Hygiene, undated, revealed staff were to perform hand hygiene before and after patient contact. B. Review of the agency policy and procedure titled Infection Control, PPE [(personal protective equipment)]/Gloving, undated, revealed staff were to perform hand hygiene prior to donning [(applying)] and removing gloves, and after touching the patient or their surroundings. C. Review of the agency policy and procedure titled Home Care Bag Technique, undated, revealed staff were to wash hands prior to removing any equipment from the bag, remove all necessary equipment from the bag at the start of the visit, and enter the bag as few times as possible. D. Review of Patient 1's clinical record revealed: 1. Recertification and Plan of Care for the certification period of 10/31/24 through 12/29/24 included orders for Hospice Aide (HA) services 1 time per week for 8 weeks. 2. The Hospice Aide Plan of Care dated 12/3/24, included tasks of bathing and personal cares. E. Review of Patient 2's clinical record revealed: 1. Recertification and Plan of Care for the certification period of 11/5/24 through 1/3/25 included orders for Skilled Nurse (SN) 2 times per week for 9 weeks, for patient assessment. 2. The Comprehensive Plan of Care dated 10/29/24 included orders for SN to perform wound care. F. Review of Patient 3's Initial Plan of Care for the certification period of 9/23/24 through 12/21/24 included orders for SN 1 time per week for 12 weeks, for patient assessment. G. The observation of the provision of HA services on 12/4/24 at 9:00 AM, by Staff-E to Patient 1, revealed Staff-E failed to perform hand hygiene when removing gloves and prior to applying clean gloves, and between clean and dirty tasks on four occasions while providing a bed bath to the patient. H. The observation of the provision of SN services and wound care on 12/4/24 at 10:45 AM, by Staff-G to Patient 2, revealed Staff-G failed to sanitize hands: 1. after removing a soiled dressing from the patient's right heel wound and prior to applying clean gloves; and 2. after placing a barrier under the patient's foot wound, removing gloves, and prior to applying clean gloves. I. The observation of the provision of SN services on 12/5/24 at 10:45 AM, by Staff-H to Patient 3, revealed the Staff-H failed to sanitize hands after touching the patient and the patient's surrounding during the SN assessment, and prior to entering the clean supply bag to retrieve equipment on four separate occasions. J. During an interview on 12/10/24 at 8:00 AM, the Administrator confirmed Staff-E, -G, and -H failed to perform appropriate hand hygiene, glove use, and/or use of clean bag technique according to the agency policies and procedures, to prevent the potential for cross contamination and home care acquired infections.