Every finding on record at Luminary Hospice of Ohio, 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. In 1 of 3 (33%) home visit observations revealed the organization did not ensure the staff followed the hand hygiene policy. Document 1: Agency Policy: Hand Hygiene Policy No. 7-009, not dated, stated in part, "Hand decontamination using alcohol-based hand rub should be performed after removing gloves." Home Visit 1: During the home visit (Clinical Record 5) on 08/07/2024 with the Hospice Aide (Personnel Record 7), the aide was observed washing the hands, setting out the necessary supplies, and filling the wash basins with water. The aide donned gloves and washed the upper and lower body. The aide removed the gloves, picked up the wash basins with used water, and took them to the bathroom to throw out the water and fill them with fresh water. The wash basins were placed on the over-the-bed table along with other supplies for the bath. The aide then sanitized the hands and donned a new pair of gloves. The perineal area was washed. The aide removed the gloves, sanitized the hands, and donned a new pair of gloves. The aide turned the patient and washed the back. The aide removed the gloves, picked up the used wash basins, and emptied them into the toilet. The aide was not observed performing hand hygiene after removing gloves. During a joint document review and interview on 10/26/2024, the Administrator/Director of Clinical Services confirmed the staff did not follow the hand hygiene policy.