Every finding on record at Precision Care Hospice

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control. This standard was not met as evidenced by document review, interview and personnel record review. In 8 of 10 (80%) personnel record review revealed the agency did not ensure that employees received infection education annually. Document 1: The agency policy named Precision Care Hospice Infection Control Plan and program states in part, “every staff member and independent contractor will receive policies and procedures on Hepatitis, its control, and precautions on orientation and annually thereafter as part of the annual competency". Personnel Record 1: The CEO/Hospice Medical Director was hired on 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 2: The date of hire for the MSW/Bereavement Coordinator was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 3: The date of hire for the CHHA was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 4: The date of hire for the Chaplain was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 5: The hire date for the RN/DPCS/Clinical manager of patient services/administrator was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 8: The hire date for the CFO/Alternate Administrator/Volunteer Coordinator was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 6: The Office manager/Volunteer was hired on 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. Personnel Record 7: The secretary's date of hire was 12/07/2020. The personnel record reviewed revealed that bloodborne infection education was received at the time of hire; however, the personnel record did not contain evidence of annual infection education. During an interview with the consultant on 12/05/2024, she stated she did not realize that the education the staff received for the year did not contain infection education annually.