Every finding on record at Integrated Senior Care Hospice

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by clinical record review and interview. In 2 of 14 (14%) clinical records reviewed it was revealed that the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 5: The Election of Benefits form was dated 6/10/2022. The need for a spiritual care (SC) evaluation was documented in the comprehensive assessment. The chaplain documented their initial visit on 6/23/2022 (13 days after the election of hospice care). There was no documentation as to why the assessment was not completed within 5 calendar days after the election of hospice care. Clinical Record 6: The Election of Benefits form was dated 9/1/2023. The need for a spiritual care (SC) evaluation was documented in the comprehensive assessment. There was no evidence of documentation that the chaplain performed a spiritual care assessment within 5 calendar days after the election of hospice care. The Clinical Director who reviewed records with the site visitor on 10/16/2023 stated that she did not know why the comprehensive assessments were not completed within 5 calendar days after the election of hospice care. In 2 of 14 (14%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care.

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 was not met as evidenced by document review, interview and observation. In 1 of 3 (33%) home visit observations it was revealed that the hospice organization did not ensure adherence to agency infection prevention and control policies and procedures. Document 1: Agency policy no.7-009 titled Hand Hygiene (revision date 4/2020), read in relevant parts, "Hand decontamination using an alcohol-based hand rub should be performed after contact with inanimate objects and before having direct contact with patients." Home Visit 1: The Election of Benefits form was dated 6/4/2023. During a home visit on 10/17/2023 at 1200, infection control technique was observed by the RN. With gloves on, the RN took off a dressing that was on the patient's right shin. The RN then reached into the visit bag twice without first removing gloves and cleansing hands, once to get gauze pads and wound cleanser and the second time to get a new dressing. The RN then cleansed the shin area and placed a new dressing on the patient's shin. The RN did not cleanse hands prior to providing wound care. The Clinical Director, RN was interviewed on 10/18/2023 at 0900 and acknowledged the RN should have washed his hands after reaching into his visit bag and before direct contact with the patient. She stated they will be re-educating the staff. In 1 of 3 (33%) patients who received a home visit with observation of handwashing, revealed the hospice organization did not ensure adherence to agency infection prevention and control policies and procedures.