Every finding on record at Seasons of Life Hospice, LLC

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not use standard precautions, to reduce the risk of infection. Staff did not follow the organization's Hand Hygiene Policy No. 9.109.1 and Standard Precautions Policy No. 9.107.1 for HOS 1 the nurse was observed to glove and remove gloves several times throughout the visit without performing hand hygiene in accordance with the organization's policy. For example, during the medication reconciliation process the nurse gloved her hands however failed to perform hand hygiene before gloving and also changed gloves without performing hand hygiene. Additionally, in observation of the home visit for HOS 2 the nurse was observed to assess the patient including a comprehensive skin integrity assessment of the patient's buttock and sacral area and then following that assessment continued the visit without sanitizing her hands and for HOS 3 the hospice aide did not change gloves and perform hand hygiene after washing the patient's perineal area and buttocks but continued to bathe the patient. This was discussed with the Owner/Administrator. Observed in Patient Home. In 2 of 2 home visits conducted, with nursing staff the organization did not implement its infection prevention and control activities to minimize, reduce, or eliminate the risk of infection. In observation of the visit for HOS 1 the nurse did not follow the organization's Bag Technique Policy No. 9.114.1 which requires hands to be decontaminated prior to entering the bag. The nurse entered the nursing bag multiple times throughout the visit to retrieve supplies and gloves without first decontaminating her hands as required by the organization's policy. Also, for HOS 2 the nurse was observed entering the nursing bag multiple times throughout the visit to retrieve supplies and gloves without first decontaminating her hands as required by the organization's policy. Additionally, the nurse did not place her tablet on a barrier for either home visit or clean the tablet before leaving the home. This was discussed with the Owner/Administrator.

Observed in HR File Review. In 1 of 2 HR files reviewed, for hospice aides there was no evidence that the organization had met the required 12 hours of in-service/education.. In review of the personnel record for the Hospice Aide HR 3 the surveyor noted that for 2020 there were only 9 hours of in-service education documented and for 2021 there were only 4 hours of in-service education documented. This was verified with the Office Manager and Owner/Administrator.