Every finding on record at Join II, LLC

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. 1 of 4 (25%) home visit observations revealed the organization did not ensure that clinical staff followed the hand hygiene policy. Agency Policy: Hand Hygiene Policy No. 7-009, last updated 01/01/2025, stated in part, "Apply alcohol-based hand rub product to the palm of one (1) hand and rub hands together, covering all surfaces of hands and fingers (including under nails) until hands are dry. The volume of product needed to reduce the number of bacteria on hands will vary by product, so product directions must be followed. Hand decontamination using an alcohol-based hand rub should be performed. Before having direct contact with patients. Before donning sterile gloves when performing sterile procedures. Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices. After contact with a patient's intact skin (when taking a pulse, blood pressure or lifting a patient). After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings, if hands are not visibly contaminated. When moving from a contaminated body site to a clean body site during patient care. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After removing gloves. At any time, personnel may choose to wash their hands with soap and running water in addition to using the alcohol-based hand rub, especially if personnel feel there is a "build-up" on the hands after repeated used of the alcohol-based hand rub." HOME VISIT 3: During the observed home visit on 12/17/2025 with the Registered Nurse (RN - Personnel Record 6), the RN was observed placing cleaning wipes, a disposable trash bag, gloves, alcohol, and assessment equipment on the barrier on the over-the-bed table. The RN donned gloves and began the assessment. The RN used alcohol on the gloves each time after using the pulse oximeter, thermometer, and blood pressure machine. The RN used alcohol on the gloves and then used the stethoscope to auscultate the patient. The RN used alcohol on the gloves and then completed the assessment. Then the RN removed the gloves and used alcohol on the hands. During an interview on 12/17/2025, the Regional Compliance Director agreed the RN did not follow the hand hygiene policy.

It is required that each patient’s individualized written plan of care reflects patient and family goals, identifies planned interventions based on problems identified in the initial and updated comprehensive assessments, includes all services necessary for the palliation and management of the terminal illness including intervention to manage pain and symptoms and measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 11 (18%) records reviewed revealed the hospice did not ensure the plans of care reflected patient and family goals with outcomes that were defined and measurable. Record 1: The patient’s date of election was 8/29/2022 with a primary diagnosis of Alzheimer’s disease, and a co-morbidity of chronic pain syndrome. The registered nurse assessment on 11/12/2022 documented the patient's pain level at 6/10. The medication profile listed Hydrocodone 5mg-Acetaminophen 325mg 2 tablets every 6 hours as needed for pain, effective 11/11/2022. The plan of care dated 11/11/2022-2/8/2023 included the problem: altered comfort, start date 11/11/2022 and a goal stating "Patient/Caregiver will understand the pain scale, how to manage pain and report changes to hospice". There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. Record 2: The patient’s date of election was 10/14/2022 with a primary diagnosis of senile degeneration of the brain. The registered nurse assessment on 10/14/2022 documented the patient's pain level at 5, and "yes pain is an active problem". The registered nurse assessment on 2/8/2022 documented the patient's pain level at 3, the pain frequency was daily, and that the pain was associated with a wound. The medication profile listed 8-hour pain reliever 650mg tablet extended release every 4 hours as needed for fever/pain effective 11/10/2022. The plan of care dated 10/14/2022-2/8/2023 included the problem: altered comfort, start date 11/11/2022 and goal stating "Patient/Caregiver will understand the pain scale, how to manage pain and report changes to hospice". There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. The Regional Director of Clinical Operations was interviewed on 2/9/2023 and agreed, the plans of care reviewed did not include patient and family goals that were defined and measurable. Record 1: The patient’s date of election was 8/29/2022 with a primary diagnosis of Alzheimer’s disease, co morbidity chronic pain syndrome. The registered nurse assessment on 11/12/2022 revealed pain 6/10. The medication profile revealed Hydrocodone 5mg-Acetaminophen 325mg 2 tablets every 6 hours as needed for pain, effective 11/11/2022. The plan of care between 11/11/2022-2/8/2023 was reviewed. Problem: Altered Comfort, start date 11/11/2022. Goal: Patient/Caregiver will understand the pain scale, how to manage pain and report changes to hospice. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. Record 2: The patient’s date of election was 10/14/2022 with a primary diagnosis of senile degeneration of the brain. The registered nurse assessment on 10/14/2022 revealed pain of 5, yes pain is an active problem. The registered nurse assessment on 2/8/2022 revealed pain of 3, pain frequency daily, pain associated with wound: YES. The medication profile revealed 8-hour pain reliever 650mg tablet extended release every 4 hours as needed for fever/pain effective 11/10/2022. The plan of care between 10/14/2022-2/8/2023 was reviewed. Problem: Altered Comfort, start date 11/11/2022. Goal: Patient/Caregiver will understand the pain scale, how to manage pain and report changes to hospice. There was no documented evidence the plan of care reflected patient and family goals with measurable outcomes for the pain. The Regional Director of Clinical Operations was interviewed on 2/9/2023 and agreed, the plan of cares reviewed did not include patient and family goals that were defined and measurable.

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 reviews and observation on home visits. 1 of 3 (33%) observed home visits revealed the hospice did not ensure adherence to the agency's infection control policies and procedures for hand hygiene and bag technique. Agency Policy # 7-009 [effective date October 2019, revised 5/11/2020] titled "Hand Hygiene", states in part, “Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients, after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient), when moving from a contaminated body site to a clean body site during patient care, after contact with non-intact skin, and wound dressings. Agency Policy #7-016 [effective date October 2019, revised 5/11/2020] titled "Bag Technique", states in part, “reusable equipment will be cleaned, hands will be washed, and equipment and supplies will be returned to the bag; hands will be decontaminated prior to returning clean equipment to the bag; handwashing will always be completed before opening the bag.” Home Visit 3 (Clinical Record 2): During the home visit on 2/8/2023, the Registered Nurse (RN) (Staff 5) was observed performing vital signs and wound care on the patient. The RN performed vital signs on the patient using a pulse oximeter, tape measure and thermometer, then typed on a tablet keyboard at the bedside, sanitized the pulse oximeter, tape measure and thermometer, and returned to the nursing bag. The RN did not perform hand hygiene before sanitizing the reusable equipment after direct patient contact or before returning to the nursing bag. While performing wound care to a stage 3 pressure ulcer on the patient's right buttock, the RN entered the nursing bag multiple times to pull out scissors, skin prep and gloves without first performing hand hygiene. The RN was not observed performing hand hygiene before applying a clean dressing to the wound. Agency Policy # 7-009 [effective date October 2019, revised 5/11/2020] titled Hand Hygiene, stated in part, “Hand decontamination using an alcohol-based hand rub should be performed: before having direct contact with patients, after contact with a patient’s intact skin (when taking a pulse, blood pressure or lifting a patient), when moving from a contaminated body site to a clean body site during patient care, after contact with non-intact skin, and wound dressings. Agency Policy #7-016 [effective date October 2019, revised 5/11/2020] titled Bag Technique, stated in part, “reusable equipment will be cleaned, hands will be washed, and equipment and supplies will be returned to the bag; hands will be decontaminated prior to returning clean equipment to the bag; handwashing will always be completed before opening the bag.” During observation of Home Visit #3 on 2/8/2023, the Administrator (Staff 1) was present for intermittent periods during the visit. The Registered Nurse (RN) (Staff 5) was observed performing vitals and wound care on the patient (Record 2) residing at home. The RN performed vitals on the patient using a pulse oximeter, tape measure and thermometer, then typed on a tablet keyboard at the bedside, sanitized the pulse oximeter, tape measure and thermometer, and returned to the nursing bag. The RN did not perform hand hygiene before sanitizing reusable equipment after the direct patient care contact or before returning to the nursing bag. While performing wound care to stage 3 pressure ulcer on right buttocks, the RN was observed entering the nursing bag multiple times to pull out scissors, skin prep and gloves from inside the nursing bag without first performing hand hygiene. The RN was not observed performing hand hygiene before applying the clean dressing to the stage 3 right buttocks wound.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary, the patient's record, if requested. This standard was not met as evidenced by a review of clinical records and interviews. 2 of 2 (100%) records of patients discharged from the hospice revealed the hospice did not ensure that the discharge summaries were sent to the attending physician(s). Record 8: The patient’s date of election was 12/28/2022. The patient signed revocation paperwork on 12/30/2022. There was no documented evidence the discharge summary was sent to the attending physician. Record 9: The patient’s date of election was 5/21/2022. The patient was discharged, due to a failure to decline on 12/27/2022. There was no documented evidence the discharge summary was sent to the attending physician. The Regional Director of Clinical Operations was interviewed on 2/9/2023 and agreed, there was no documented evidence the discharge summaries were sent to the attending physicians. Record 8: The patient’s date of election was 12/28/2022. The discharge was reviewed and revealed the patient signed revocation paperwork on 12/30/2022. There was no documented evidence the discharge summary was sent to the attending. Record 9: The patient’s date of election was 5/21/2022. The discharge was reviewed and revealed the patient was discharged, failure to decline on 12/27/2022. There was no documented evidence the discharge summary was sent to the attending. The Regional Director of Clinical Operations was interviewed on 2/9/2023 and agreed, there was no documented evidence the discharge summary was sent to the attending physician.