Every finding on record at Light Days Hospice, Inc.

Observed in Record Review. During review of patient record of HOS RR#2 the nurse surveyor observed that the organization had not assessed the patient. There was no documented evidence that the chaplain had completed an initial assessment and no documented evidence of any rationale.

Observed in Patient Home. During HOS HV#1 the nurse surveyor observed that the hospice had not followed the accepted standard of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions. The nursing bag was placed on the floor along with a box of gloves and antimicrobial wipes with no barrier. In discussion with the QAPI Director, this is not consistent with the organization's expected practices.

Observed in Data Session. During discussion in Data Session and review of patient packet a copy of the organization's written policy and procedures on the management and disposal of controlled drugs had not been provided to the patient representative and family. This was discussed with management.

Observed in Record Review. During review of patient record for HOS HV#3 the nurse surveyor observed that the organization had not provided patient education and training based on each patient’s needs and abilities. The patient's son had reported that he had been administering insulin to the patient several times a day. There was no documented evidence in the patient record that the patient or family had been educated or observed in the safe disposal of medical supplies associated with insulin administration. This was discussed with QAPI Manager.