Every finding on record at Pruitthealth Hospice, Inc.

Based on record reviews and staff interviews it was determined that the agency failed to maintain an agency-wide infection control program that includes implementing the appropriate actions expected to result in improvement and disease prevention. --- The findings include: Review of records revealed the agency failed to reveal documentation of measurable disease prevention and control of the infections. Furthermore, the agency failed to reveal documentation of the agencys Quality Assessment and Performance Improvement (QAPI) program involvement to any measurable disease prevention and control including the reviewing, monitoring, and corrective actions needed to be taken based on the analysis of the infections for the months of October 2023, November 2023, December 2023, January 2024 and February 2024. On 3/4/24 at 1:30 p.m., an interview with the Director of Health Services revealed the agency had a computerized program for documentation of the infections, but the computerized program was not capable of calculating any percentages for further evaluation. She further stated discussion of the infections were not discussed with hospice leaders in QAPI. She stated the agency did not document any monitoring or corrective actions for the infection trends, and . She was unable to provide any education or corrective actions for prevention regarding the documented infection trends for the months of October 2023, November 2023, December 2023, January 2024 or February 2024.