Every finding on record at Lighthouse Community Hospice, The

Based on facility document reviews, and staff interview, it was determined that the facility failed to provide day to day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. --- The Findings include: Review of facility document ";VOUNTEER Cost Saving Repot revealed that January through October 2024, the Monthly Service % was less than 5% each month. The hospice agency failed to provide day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff. On 11/23/2024 at 11:30 a.m. an interview was conducted with the Administrator and the owner who acknowledged that the records of day-to-day administrative direct patient care services in an amount minimum equal to five percent of the total patient care hours of all paid hospice employees and contract staff, were not met.

Based on observation, staff interviews, and review of agency policy and procedures, it was determined that the hospice agency staff failed to follow standard precautions to prevent the transmission of infectious and communicable diseases during the home visit as evidenced by staff placing nursing bag on the floor at patients home for one patient (P) (P#2) of 13 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, P#13). --- The findings include: On 7/27/2023 at 1:20 p.m., during a home visit at an assisted living facility in a memory care unit, surveyor along with another surveyor observed Registered Nurse (RN) AA enter the room of P#2 and place her nursing bag on the floor without a protective barrier underneath. A nursing assessment was then performed by RN AA. Nursing bag remained on the floor throughout the visit. RN AA then exited the building and placed the bag in the trunk of the car. On 7/24/23 at 1:35 p.m., an interview with RN AA confirmed that the nursing bag was placed on the floor without a protective barrier between the bag and the floor. RN AA verbalized nervousness during the visit. During an interview on 7/24/2023 at 3:00 p.m., the Administrator acknowledged the RN AA did not follow acceptable standards for infection control to prevent transmission of infectious and communicable diseases. The hospice agency policy for bag technique was not available.

Based on record review, staff interviews, and review of agency policy and procedures, it was determined that the agency failed to ensure that the criminal background check was included in the contract agreement between hospice agency and the pharmacy company that the agency uses for durable medical equipment (DME) for 13 of 13 sampled patients (P#1, P#2, P#3, P#4, P#5, P#6, P#7, P#8, P#9, P#10, P#11, P#12, and P#13). --- The findings include: Review of hospice agency contract binder revealed that the agency has a contract agreement with pharmacy for DME signed on March 1, 2020. Criminal background check failed to be mentioned or written in the agreement. An interview 7/24/2023 at 10:45 a.m., with the Director of Nursing (DON), revealed that she was not aware the criminal background checks were missing in the contract agreement with pharmacy used for DME. An interview 7/24/2023 at 12:23 p.m., with the Administrator revealed she was not aware the criminal background checks were missing in the contract agreement with pharmacy used for DME. Agency policy was not available upon exit.