Every finding on record at Saint Jude Associates LLC

Upon observation, there was no evidence the board of directors/governing body approves the frequency and detail of the data collection. The governing body meeting minutes did not contain evidence of governing body approval of the frequency and detail of the data collection for 2024.

Upon observation, there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient # 2) Upon entry to patient's home RN placed equipment/supply bag on the floor without a barrier. MED-PASS Policy, "Specific Procedures for Employee and Patient Infection Control Training", approved by agency was not followed.

Upon personnel record review, 1 of 13 (Personnel # 9) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. ·Reading and recording temperature, pulse, and respiration ·Safe transfer techniques and ambulation. ·Normal range of motion and positioning ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(A) Bed bath ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed ·(D) Nail and skin care ·(E) Oral hygiene ·(F) Toileting and elimination The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #9) Following review of the personnel record, there was not evidence the following required competencies were performed. 1) Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other hospice staff. 2) Reading and recording temperature, pulse, and respiration.

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. Upon review of the Volunteer Cost Savings report, the cost savings demonstrated was 0.5% for 2024.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. Personnel # 8) Upon review of personnel records, MSW services are being provided through a contract with Primo Care Services LLC, with a start date of 03/18/2022. Corrected on site Personnel # 11) Upon review of personnel records, SC/BC services are being provided through a contract with Presence Services LLC, with a start date of 02/01/2025. Corrected on site

Upon observation, 2 of 3 applicable (Patient 2 and 3) there was no evidence the hospice follows acceptable standards of practice to prevent the transmission of infections and communicable diseases, including standard precautions. Patient #2: The chaplain did not have paper towels in order to shut off the faucet and dry hands after hand washing and proceeded to shake hands to air dry and then wipe them off on clothing. Patient #3: The aide did not have paper towels in order to shut off the faucet and dry hands following hand washing. Patient had to go to kitchen to obtain paper towels for the aide. The hospice's Hand Hygiene Policy states "Handwashing with soap and water. Wet hands first, wash thoroughly, rinse, dry with disposable towel and use towel to turn off faucet"

Upon patient record review, 2 of 6 (Patient #1, #3) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: There was no evidence that vital sign parameters (temperature, respirations, pulse, blood pressure) were indicated on the aide care plan with the orders to obtain complete vital signs; therefore the aide could not ascertain when to report vitals to the registered nurse. Corrected on-site Patient #2: There was no evidence that blood pressure parameters were assigned on the aide care plan; therefore the aide could not ascertain when to report a blood pressure to the registered nurse. Corrected on-site.