Every finding on record at Lumicare Health Az1 LLC

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions, such as hand hygiene. This standard was not met as evidenced by document review and observation. In 1 of 3 (33%) home visit observations, it was revealed that the agency did not ensure that the registered nurse (RN) followed the procedure for hand hygiene as stated in the policy during patient care. Document 1: Policy No 7-009 Hand Hygiene stated in part, "Hand decontamination using an alcohol-based hand rub should be performed after removing gloves and after contact with inanimate objects in the immediate vicinity of the patient." Home Visit 3: After a dressing change, the registered nurse was observed not using hand sanitizer in between removing her gloves and donning a new pair of gloves and putting her equipment back in her nursing bag before touching the patient.

It is required that hospice aides are supervised by a registered nurse who makes an on-site visit to the patient’s home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide. This standard was not met as evidenced by clinical record review and interview. In 1 of 14 (7%) records reviewed of patients that received aide services, it was revealed that the agency did not ensure the registered nurse assessed the aide services no less frequently than every 14 days. Clinical Record 2: Aide services were ordered by the RN on 12/29/22 to be provided twice a week. The aide visited twice a week through 04/19/23 and 06/14/23 to provide care to the patient. There was no documentation of aide supervision by the registered nurse from 04/19/23, until 06/14/23, seven weeks without an aide supervisory assessment. The Regional Director of Clinical Support and Education was interviewed on 6/28/23 and agreed there was no supervisory documentation between 4/19/23 and 6/14/23.