Every finding on record at Prisma Health D/B/A Prisma Health Hospice of the Foothills

Observed in Patient Home. In 3 of 6 home visits conducted, it was observed by the nurse surveyor that the organization did not implement the infection prevention and control activities it had planned per policy “Hand Hygiene Policy”. During RRHV#3 the hospice nurse did not hand sanitize prior to donning gloves per policy. During RRHV#4, the hospice nurse did not perform hand hygiene per policy when moving from the patient to documenting, to touching her phone. During RRHV#6, the chaplain hand sanitized upon leaving his vehicle, but did not hand sanitize again upon opening the facility door, knocking on the patient’s door, or upon entry into the patient’s room. Findings were verified by the Assistant Manager for Home Hospice who was present on the home visits.

Observed in Building Tour. Cottingham Hospice House, it was noted by the surveyor that the second set of fire doors on the first patient hallway just past the nurses’ station had greater than a 1/8 space between the doors. Finding was verified by the Facility staff who were present on the tour. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission. Observed in Building Tour. Cottingham Hospice House, the nurse surveyor noted that signage on a designated EXIT door leading to the Electrical/Housekeeping hallway said Authorized Personnel Only, thus confusing the means of egress. Finding was verified by the Facility Staff present on the tour. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Based on review of the the hospice's Emergency Preparedness Program (EPP) and interview, the hospice failed to provide a tabletop staff training for the hospice within the past 2 years. The finding includes: On 4/22/2022 at 10:20 AM, review of the hospice's EPP data and program revealed the hospice had no documentation that a tabletop exercise for EPP training was conducted with hospice staff for the past 2 years. On 4/22/2022 at 11:10 AM, the Hospice Director revealed "Training was done through the hospital with hospice managers, but not with the hospice staff."

Based on record reviews and interviews, the hospice failed to ensure documentation of attendance for all Interdisciplinary Team (IDT) core members who are present for IDT meetings for care planning for 15 of 16 patients' needs. (Patient #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, and #16). The Finding includes: Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15 and #16 On 4/19/2022 through 4/20/2022, review of Patient #1's, #2's, #3's, #4's, #5's, #6's, #7's, #8's, #10's, #11's, #12's, #13's, #14's, #15's, and #16's charts revealed no attendance documentation for core IDT members at any of the IDT's meetings. On 4/19/2022 at 9:15 AM, the Hospice Director revealed "Since it's an order, we only have the physician sign electronically. Been doing this for a while." When asked how the hospice demonstrates proof of attendance for those IDT members attending the meetings, the Hospice Director revealed "We don't have a sign in sheet. ...We know they are in attendance. We're all there."

Based on observations, patient record reviews, and interview, the hospice leadership failed to ensure the Skilled Nurse (SN) updated the patient's Plan of Care (POC) for 7 of 12 patient charts. ((Patient #3, #5, #6, #7, #8, #11 and #16) The findings include: Patient #3 On 4/19/2022 at 2:52 PM, review of Patient #3's chart revealed the SN was ordered 2 visits each week for 8 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 1:55 PM, the Hospice Director verified the findings. Patient #5 On 4/20/2022 at 12:50 PM, review of Patient #5's chart revealed SN ordered 1 visit 1 week, and then, 2 visits each week for 13 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 1:25 PM, the Hospice Director verified the findings. Patient #6 On 4/20/2022 at 3:06 PM, review of Patient #6's chart revealed SN ordered visits for 2 visits each week for 12 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 12:45 PM, the Hospice Director verified the findings. Patient #7 On 4/20/2022 at 2:23 PM, review of Patient #7's chart revealed the RN ordered visits for 1 visits each week for 12 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 1:17 PM, the Hospice Director verified the findings. Patient #8 On 4/20/2022 at 3:27 PM, review of Patient #8's chart revealed SN ordered 1 visits each week for 12 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 3:07 PM, the Hospice Director verified the findings. Patient #11 On 4/19/2022 at 12:08 PM, review of Patient #11's chart revealed SN ordered visits for 1 visit each week for 13 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/21/2022 at 2:42 PM, the Hospice Director verified the findings. Patient #16 On 4/20/2022 at 1:25 PM, review of Patient #16's chart revealed SN ordered 2 visits for 1 week, and 2 visits each week for 12 weeks with 10 Pro Re Nata (PRN) visits. The number of PRN visits is not individualized to meet the patient's specific needs. On 4/22/2022 at 8:47 AM, the General Inpatient (GIP) Director verified the finding.

Based on observations, patient record reviews, and interview, 3 of 4 patient's Plan of Care (POC) did not include all services necessary for management of the patient's care. (Patient #3, #5, and #11) The findings include: Patient #3 Observations during a home visit on 4/18/2022 at 4:00 PM revealed to Patient #3's home revealed the patient is bed bound with a pressure wound of the coccyx and a foam dressing on the right heel. On 4/18/2022 at 4:20 PM, the Certified Nurse Assistant (CNA) #2 reported the foam to right heel is to prevent "pressure sores". On 4/19/2022 at 2:52 PM, review of Patient #3's chart revealed there was no documentation for integumentary goals or interventions for this episode dated 3/27/2022 to 5/25/2022. There were no wound care orders for coccyx pressure ulcer or the right heel. No wound measurements were documented in the Skilled Nursing(SN) notes. On 4/21/2022 at 1:55 PM, the Hospice Director verified the findings. Patient #5 On 4/20/2022 at 12:50 PM, review of Patient #5's chart revealed the SN charted on 3/5/2022 the patient "has a skin tear" of unknown site. There was no documentation for integumentary goals or interventions in the IDT notes dated 3/9/2022, no wound care orders for the skin tear, and no wound measurements in the skilled nursing notes. Review of the SN note dated 3/9/2022 had no further follow-up documentation for the skin tear. On 4/21/2022 at 1:25 PM, the Hospice Director verified the findings. Patient #11 On 4/19/2022 at 12:08 PM, review of Patient #11's chart revealed the patient elected the hospice benefit on 2/21/2022 with diagnosis of Cancer of oral cavity with draining wounds of chin and a pressure ulcer of the coccyx. There was no documentation for integumentary goals or interventions in the patient's POC for the episode dated 2/21/2022 through 4/19/2022 (death), no wound care orders documented for the chin and coccyx wounds, and no wound measurements in the skilled nursing notes for the chin wound. On 4/21/2022 at 2:42 PM, the Hospice Director verified the findings.