Every finding on record at Roze Room Hospice of the Valley, Inc.

Observed in Individual Tracer. In 6 of 6 home visits conducted, The Hospice surveyor noted that the organization did not follow accepted standard precautions for hand hygiene. For example, in HV 1 the LVN did not gel her hands after glove removal. In HV 2, the RN did not gel his hands after handling his computer. In HV 3, changed her gloves 3 times but did not gel her hands after glove removal. In HV 4, the RN scrubbed to the elbow but dried from his elbow to his hands. In HV 5, the RN washed his hands but then turned off the faucet with his bare hands and no towel. In HV 6, the LVN assessed the patient head to toe, then opened the diaper and then assessed the upper back without gloves after touching the diaper. This was validated in a discussion with and observation by the Team Leader and the Regional Director of Clinical Operations.

Observed in Data Session. The Hospice surveyor noted that the organization did not collect data for the past year on the surveillance of hand hygiene during home visits. This was validated in a discussion with and observation by the VP of Operations.

Observed in Record Review. In 1 of 4 patient records reviewed, of active patients, it was noted by the hospice nurse surveyor that for RR#4, the bereavement risk assessment was not completed as part of the comprehensive assessment. This was confirmed with the VP of Operations.

Observed in Patient Home. In 1 of 2 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. For example, during HV#2/RR#2 with a skilled nurse, proper hand technique was broken. The nurse washed his hands in the patient’s bathroom sink using proper technique but upon leaving the room he turned the light off with his bare clean hand. He did not hand sanitize after touching the light switch, he then proceeded to get the dressing supplies together in preparation of providing wound care. Once set up the skilled nurse donned gloves without hand sanitizing. The rest of the dressing change was performed following the policy. The Team Leader was present during the visit and also observed the breaks in technique per agency policy.

Observed in Record Review. In 1 of 4 patient records reviewed, for active patients with the hospice aide. The nurse surveyor noted that for RR#3, the initial Hospice Aide Supervisory visit was completed 17 days after the hospice aide started to provide care, not the 14 days as required by regulation. Finding was verified with the VP of Operations.