Every finding on record at Presbyterian Manors, Inc.

Based on nationally-recognized standards, policy review, observation, and interview the hospice provider failed to ensure that proper glove use and hand hygiene were performed in one of four home visits conducted (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the Centers for Disease Control (CDC) policy titled, "Hand Hygiene Guidance," dated 01/30/2022, showed healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: - Immediately before touching a patient; - Before performing an aseptic task; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient's immediate environment; - After contact with blood, body fluids, or contaminated surfaces; and - Immediately after glove use. Review of the providers policy titled, ";Hand Hygiene," dated 2016, showed in part the following: - Hand hygiene is to occur: * Before and after patient contact; * After removing and disposing of gloves and other protective equipment; * After contact with blood, body fluids, mucous membranes, non-intact skin, and wound dressings; * Moving from contaminated patient body site to clean site during patient care; * After contact with inanimate objects or medical equipment close to patient; and * When there has been a potential exposure to spore-forming organisms. - Alcohol based hand rubs are preferred for decontaminating hands if hands are not visibly soiled or if running water and soap is not available in the home; and - Gloves are not a substitute for hand hygiene: * Use gloves before contact with blood and body fluids, mucous membranes and non-intact skin; * Remove gloves after contact with each patient and avoid reuse of gloves; and * Change or remove gloves if moving from contaminated to clean patient site or the environment. RECORD/PATIENT #2: Observation on 03/04/2024 beginning at 1:45 PM, during the patients home visit, showed the following: - Registered nurse A (RN-A) entered the home and set all equipment out on a barrier on the bedside table; - Applied gloves and took the patients vital signs (temperature, blood pressure, pulse, and oxygen saturation); - Touched his/her computer screen to input vital signs; - Completed a head-to-toe assessment on the patient; - Inspected the dressing on the patients buttocks; - Removed the dressing from the patients buttocks; - Removed his/her gloves and failed to complete hand hygiene; - RN-A then applied new gloves and opened a new dressing for the patients buttocks and applied the dressing; - Touched the patients gown and blankets with contaminated gloves; and - Removed his/her gloves and completed hand hygiene. After returning to the room from performing hand hygiene RN-A applied new gloves, removed the patients socks, and checked the skin of the patients feet; - Removed gloves and failed to complete hand hygiene; - Applied new gloves and cleaned his/her equipment; and - Removed his/her gloves and failed to complete hand hygiene prior to using his/her computer for documentation. Prior to leaving the patients room the patient complained that his/her mouth was dry and RN-A cleaned the patients mouth with a pink swab and failed to apply gloves or complete hand hygiene before or after swabbing the patients mouth. During an interview on 03/06/2024, beginning at 10:20 AM, the administrator stated that he/she would expect that the hand hygiene and glove use policy be followed when providing care.

Based on policy review, clinical record review, and interview the hospice provider failed to ensure that clinical documentation was signed in a timely manner in one of five full charts reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the providers policy titled, ";Submission of Patient Documentation," dated 2016, showed in part, to ensure timely and accurate submission of patient documentation to the medical record ongoing visitation documentation will be documented on the day of the visit and must be submitted to the provider within 2 (two) days. RECORD/PATIENT #3: Review of the clinical record showed the following: - The registered nurse (RN) initial assessment was dated 08/10/2023 and signed on 08/18/2023 (8 (eight) days later); - The chaplain initial assessment was dated 08/11/2023 and signed on 08/14/2023 (3 (three) days later); - An RN visit was dated 01/25/2024 and signed on 01/28/2024 (3 days later); - A home health aide (HHA) visit was dated 02/09/2024 and signed on 02/13/2024 (4 (four) days later); - An HHA visit was dated 02/16/2024 and signed on 02/20/2024 (4 days later); and - An RN visit was dated 02/22/2024 and signed on 02/26/2024 (4 days later). During an interview on 03/05/2024 at 2:40 PM, the administrator stated that he/she would expect documentation to be signed sooner than three or four days.

Based on policy review, contract review, and interview, the hospice provider failed to ensure that the facility respite contract contained the verbiage that a copy of the discharge summary and/or clinical record is to be supplied to hospice at the time of discharge in one of one respite contract reviewed. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Contractual Agreements," dated 2016, showed, in part, that a copy of the discharge summary be provided to [named hospice] at the time of discharge and that a copy of the inpatient clinical record is available to [named hospice] at the time of discharge. Review of the respite facility contract failed to contain the verbiage that a discharge summary and/or clinical record is to be supplied to the hospice at the time of discharge. During an interview on 03/06/2024 at 10:20 AM, the hospice administrator stated that he/she would expect the contracts to contain the items that were missing. He/she then stated that the lawyers had already been contacted to start revising the contracts.

Based on policy review, contract review, and interview, the hospice provider failed to ensure that the respite facility contract contained that the respite facility provided a home like atmosphere, space for private patient and family visiting, accommodations for family members to remain with the patient throughout the night, space for family privacy after a patient's death, and visitors at any hour including infants and small children in one of one respite contract reviewed. This deficient practice has the potential to affect all patients served by the provider. --- Findings included: Review of the provider's policy titled, "Contractual Agreements," dated 2016, showed the policy failed to contain information regarding the requirements for patient areas. Review of the respite facility contract failed to contain the following elements that the hospice must provide: - A home like atmosphere; - Space for private patient and family visiting; - Accommodations for family members to remain with patient throughout the night; - Space for family privacy after a patient's death; and - Visitors at any hour, including infants and children. During an interview on 03/06/2024 at 10:20 AM, the hospice administrator stated that he/she would expect the contracts to contain the items that were missing. He/she then stated that the lawyers had already been contacted to start revising the contracts.