Every finding on record at Loyal Way Hospice and Palliative Care Inc

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%) patients who received a home visit with observation of handwashing, revealed that the hospice organization did not ensure adherence to agency hand hygiene policy. The agency policy "Hand Hygiene" No 9-009.1 revised October 2020 states in relevant parts "Use a dry disposable towel to turn off faucet." Home Visit 3: During the home visit on 11/15/23 with the Registered Nurse (Staff #5), the Registered Nurse (RN) was observed during the handwashing procedure to turn off the faucet with his bare hands. During an interview with the Administrator/DPCS (Staff # 1) on 11/16/2023, she acknowledged that the RN should have followed the hand hygiene policy. 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.

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. This standard was not met as evidenced by clinical record review and interview. In 1 of 1 (100%) clinical record in which a patient revoked the election of hospice care revealed that the hospice did not ensure that a copy of the discharge summary was sent to the patient's attending physician. Clinical Record 12: The patient’s benefit election was dated 3/27/2023. The patient's date of discharge (revocation) was dated 4/26/2023. There was no documented evidence in the record that a copy of the discharge summary was forwarded to the patient’s attending physician. An interview with the Administrator/DPCS (Staff1) on 11/17/2023 confirmed this finding. In 1 of 1 (100%) clinical record in which a patient revoked the election of hospice care revealed the hospice did not ensure that a copy of the discharge summary was sent to the patient's attending physician.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care or to the patient’s community attending physician upon hospice discharge includes at least a summary of the patient’s hospice stay, including treatments, symptoms, and pain management. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records reviewed in which a discharge summary was required revealed that the hospice did not ensure that the discharge summary information provided to the receiving facility contained a summary of the patient's hospice stay. Clinical Record 12: The patient’s benefit election was dated 3/27/2023. The patient's date of discharge (revocation) was dated 4/26/2023. The discharge summary stated the patient wanted to be on home health so she could be treated for her lung cancer. There was no documented evidence that the discharge summary included a summary related to diagnosis, symptoms, pain management and the extent to which goals were met and/or not met. An interview with the Administrator/DPCS (Staff 1) on 11/16/2023 confirmed this finding. In 1 of 2 (50%) clinical records reviewed in which a discharge summary was required revealed the hospice did not ensure that the information provided to the receiving facility contained a summary of the patient's hospice stay.