Every finding on record at Northstar Home Hospice, LLC

It is required that the hospice implements emergency preparedness (EP) policies and procedures, based on the emergency plan, the risk assessment, and the communication plan. The policies and procedures address development and inclusion of a plan for each hospice patient during a natural or man-made disaster as part of a patient/family comprehensive assessment and the documented discussion of the plan provided to the patient/family and maintained by the hospice. This standard was not met as evidenced by clinical record review, interview and observation. In 12 of 12 (100%) clinical records reviewed, the agency did not develop an individualized emergency plan for each patient during the comprehensive assessment that addressed actions to be taken in the event of a natural or man-made disaster as outlined in the agency's policy. Agency Policy, Emergency Preparedness Plan (Dated 03/2025), stated in part, "Individualized plans for patients during a natural or man-made disaster will be included as part of the comprehensive patient assessment." CLINICAL RECORD 1: The initial comprehensive assessment that was documented on 02/27/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 2: The initial comprehensive assessment that was documented on 03/03/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 3: The initial comprehensive assessment that was documented on 03/14/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 4: The initial comprehensive assessment that was documented on 02/24/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 5: The initial comprehensive assessment that was documented on 03/20/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 6: The initial comprehensive assessment that was documented on 03/19/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 7: The initial comprehensive assessment that was documented on 02/05/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 8: The initial comprehensive assessment that was documented on 03/23/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 9: The initial comprehensive assessment that was documented on 02/17/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 10: The initial comprehensive assessment that was documented on 03/08/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 11: The initial comprehensive assessment that was documented on 02/25/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. CLINICAL RECORD 12:The initial comprehensive assessment that was documented on 02/08/2025 did not contain documented evidence of an individualized plan for the patient in the event of a natural or man-made disaster, as indicated in the agency's policy. The Alternate Administrator was interviewed on 03/25/2025 and stated, "The comprehensive assessment does not contain an area for the clinician to document an individualized emergency plan for each patient. We will reach out to the [software vendor] to find out how we can document this." The patients were assigned triage levels which were documented in the clinical record, but there was nothing documented in the comprehensive assessments regarding an individualized plan.

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 observation visits, the agency did not ensure the clinician’s performed hand hygiene in accordance with the agency policy. Agency Policy, Exposure Control (Dated 03/2025), stated in part, "Handwashing: Employees shall wash their hands with soap and running water or a hand sanitizer that contains at least 60% alcohol...After the removal of gloves or other personal protective equipment." HOME VISIT 2: A home visit was conducted with the Registered Nurse (RN) (Personnel Record 6) on 03/25/2025. During the visit, the RN was observed in several instances removing gloves without sanitizing hands before putting on a new pair of gloves. The RN was interviewed during the visit and stated, "I know I forgot to clean my hands a few times after taking off my gloves." The Alternate Administrator (Personnel Record 2) was interviewed on 03/25/2025 and stated, "The nurse did not follow our policy for hand washing."