Every finding on record at Hospice of Lenawee, Inc

It is required that the hospice provides an initial orientation for each employee that addresses the employee’s specific job duties, including infection control and organization procedures and policies and procedures on advance directives. This standard was not met as evidenced by document review, interview and personnel record review. In 1 of 5 (20%) personnel records reviewed of staff hired after 07/22/2021, it was revealed that the agency did not ensure that policy for orientation upon hire was followed. Document 4: Agency's Orientation and Competency of Team Members policy number 203.1, version 2 (reviewed on 12/2023) stated in part, "Orientation will consist of general orientation and job specific training individualized for each staff member". Personnel Record 2: The Spiritual Care Counselor was hired on 12/10/2022. The personnel record did not contain documentation of completion of the orientation process. The orientation document that was present in the personnel record and used to validate the successful completion of the orientation process was incomplete and blank in several areas of the hospice-specific education and unsigned by the designated reviewer. During interview with Director of Human Resources, she stated that she was unable to provide documentation of satisfactory completion of the orientation process, though she was confident that it was completed.

It is required that hospice inpatient facilities provide a sanitary environment by following current standards of practice, including nationally recognized infection control precautions, and avoiding sources and transmission of infections and communicable diseases. This standard was not met, as evidenced by an interview and observation. A tour of the inpatient facility on 06/05/2024, including the medication room, revealed expired supplies in the supply cabinet. The expired supplies included: 1 (one) Enteral extension expired on 04/20/2024; 1 (one) scalp vein needle expired on 05/20/2024; 2 (two) mini spikes expired 02/29/2024 and the other on 12/31/2023. During an interview with the Patient Resident Manager on 06/05/2024, she stated that she would take the supplies for education. A tour of the in-patient facility on 06/05/2024 including the medication room revealed expired supplies in the supply cabinet. The expired supplies included: 1 (one) Enteral extension expired on 04/20/2024; 1 (one) scalp vein needle expired on 05/20/2024; 2 (two) mini spikes expired 02/29/2024 and the other on 12/31/2023. During an interview with the Patient Resident Manager on 06/05/2024 stated that she would take the supplies for education.