Every finding on record at Hospice Angels LLC

It is required that each patient’s individualized written plan of care. Identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met by review of clinical records, document review and interview that in 1 of 5 (20%) records failed to document all problems identified in the initial comprehensive assessment. Agency Policy, “Comprehensive Assessment” (Revised September 2021), #2-031.2 stated in part, “Based on the assessment, the plan of care – including problems, needs goals and outcomes – identified.” Record #72534: Plan of Care reviewed, 01/11/2021 documented primary diagnosis of Alzheimer’s. No problem on the initial care plan (dated 10/282021) for Alzheimer's Disease. Review of all updated plans of care on 01/13/2022 did not include the problem, intervention, or goals for Alzheimer’s Disease. Interview with Administrator on 01/12/2022 stated that Alzheimer’s Disease should have been care planned.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as: Hand Hygiene. This standard is not met as evidenced by observation, interview, and review of policy and procedure, that in 2 of 3 (66%) observed visits Agency Policy for hand hygiene was not followed. Agency Policy, # 9-009.1 "Hand Hygiene" (Revised September 2021), stated in part, " Hand decontamination using an alcohol-based hand rub should be performed : After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated and After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient". Agency Policy #9-014.1," Bag Technique" (Revised September 20210, stated in part, " Hands will be decontaminated prior to reentering the bag." Record: #72545, RN (registered nurse), observed, provided care 01/12/2022, sanitized hands with an alcohol hand gel, then removed equipment from bag. Nurse observed with unmasked patient who was coughing on nurse and equipment, evaluated taking blood pressure, temperature and auscultation of cardiac system. No hand hygiene preformed moving from body areas with equipment. Record: # 56618, RN observed, provided care on 01/12/2022, sanitized hands with alcohol gel, then removed equipment from bag. Nurse observed and provided physical assessment of heart sounds and lung sounds, blood pressure and temperature. No hand hygiene performed after assessment or prior to return of equipment to bag. Interview with Administrator and observed RN on 01/12/2022 stated that the nurse was nervous and missed some steps of hand hygiene