Every finding on record at Passionate Care Hospice and Palliative Care, LLC

Based on observation, staff interviews, and review of agency policy titled, ";Specific Procedures for Employee and Patient Infection Control Training", 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 by failing to wash hands between glove changes for one patient (P) (P#1) of 2 sampled patients with home visits. (P#1, P#3) --- Findings include: Review of the agency policy titled, ";Specific Procedures for Employee and Patient Infection Control Training", revised Jan. 2nd 2022, revealed the following: Procedure Staff 1. All employees who come into contact with blood, body fluids, tissue, solids or any moist body part or substance of any patient will use the following specific procedures in compliance with Standard Precautions procedures: • Apply gloves before contact with any moist body site, fluids or solids, including mucous membranes, (e.g., when examining patients with bleeding or open lesions, large abrasions or dermatitis) and when handling items soiled with body fluids or substances. • Wear gloves for all patient care if employee's hands are chapped or if employee has any open skin areas on hand. • Wear gloves for phlebotomy and fingerstick procedures and during all invasive procedures. • Wear gloves when changing soiled lines. • Wash hands before and after wearing gloves. • Change gloves and wash hands between patients. Standard Precautions Using Gloves 5. Perform hand hygiene after removing gloves. (Note: Gloves do not replace handwashing.) Hand Hygiene Policy and Compliance Program Procedure 1. Indications for hand hygiene are: • Before and after direct patient care. • Before and after each procedure. At approximately 12:00 p.m., on July 31, 2023 during a home visit with P#1, who resides at a skilled nursing facility (SNF), surveyor along with another surveyor, observed Certified Nursing Assistant (CNA) AA performing a bed bath for P#1. CNA AA removed the initial disposable gloves at the beginning of the bed bath and then removed them during the procedure and donned new gloves. However, CNA AA failed to sanitize or wash hands in between the glove exchange. During an interview on July 31, 2023 at approximately 12:00 p.m., CNA AA verbalized nervousness during the visit because of surveyor presence. At approximately 4:30 p.m., on July 31, 2023, during an interview with surveyor along with another surveyor, the Administrator verbalized understanding for the potential infection control breech by CNA AA failing to wash hands between glove exchange. Administrator further revealed that CNA AA has been trained to use infection control techniques and has observed CNA AA use these techniques properly during direct patient care. The agency failed to follow their policy titled, "Specific Procedures for Employees and Patient Infection Control Training".

Based on observation, staff interviews, and review of agency policy and procedures, it was determined that the hospice agency staff failed to use appropriate and safe techniques in performing personal hygiene and thus failed to provide a safe environment for one patient (P) (P#1) of 2 sampled patients with home visit (P#1, P#3) --- Findings include: At approximately 12:00 p.m., on July 31, 2023, during a home visit with P#1, who resides at a Skilled Nursing Facility (SNF), surveyor along with another surveyor observed CNA AA performing a bed bath for P#1. Surveyors observed that the CNA failed to lock the bed before the bed bath was initiated. Additionally, surveyors observed that the CNA failed to raise the side rail before P#1 was turned to that side of the bed during the bath. During an interview on July 31, 2023 at approximately 12:00 p.m., CNA AA verbalized nervousness during the visit because of surveyor presence. At approximately 4:30 p.m., on July 31, 2023, during an interview with surveyor along with another surveyor, the Administrator verbalized understanding for the potential safety issues by CNA AA failing to lock the wheels of the bed as well as raise the side rail during personal hygiene and turning the patient. Administrator further reveals that CNA AA has been trained to utilize appropriate safety measures and has observed CNA AA use these techniques properly during direct patient care. Administrator acknowledged that Passionate Care Hospice has a policy and procedure for safety but failed to locate it. Administrator failed to produce a policy or procedure on patient safety for surveyor review.