Every finding on record at Spanish Cove Housing Authority

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, use of gloves, mask, eye protection, or face shield depending on anticipated exposure, safe handling of equipment in the patient’s care environment if it is likely to have been contaminated with body fluids, safe handling of soiled items in the patient’s care environment, other requirements of applicable state and federal law and regulation. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 3 (33%) home visit observations, the agency did not ensure that accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as hand hygiene, were followed. DOCUMENT 2: Agency Policy Section 6.0 "Infection Prevention & Control in the Home Setting" stated, in part, "Hand hygiene shall be performed at a minimum: A. After contact with the patient's immediate environment." "Alcohol-based products shall be the preferred recommended hand hygiene technique used when there is no visible soiling of hands. CLINICAL RECORD 1/HOME VISIT 1: This patient elected the hospice benefit on 05/09/2025 with a terminal diagnosis of senile degeneration of the brain. The patient resided in an assisted living facility (ALF). During on 10/29/2025 performed in an assisted living facility to observe the Hospice Aide (Personnel Record 1), the Hospice Aide was observed placing her gloves on without sanitizing her hands when beginning her visit. She stated that she would have used hand sanitizer but there was none available in the facility. The Aide was observed reaching down and attempting to unclog the shower drain with her gloved hands and then continued the patient's shower without removing dirty gloves and sanitizing hands. The Patient Care Coordinator was interviewed on 10/29/2025 and stated that the agency policy for hand hygiene was not followed. It was stated that the agency provided hand sanitizer in the office and that the Hospice Aide would be educated to obtain hand sanitizer from the agency.

It is required that the hospice discharge summary provided to a facility receiving a hospice patient for care—or to the patient’s community attending physician upon hospice discharge—includes at least the following: the patient’s current plan of care. This standard was not met as evidenced by clinical record review and interview. In 2 of 2 (100%) clinical records reviewed in which a patient was a live discharge, the agency did not ensure that the hospice discharge summary provided to the patient’s community attending physician upon hospice discharge included the patient’s current plan of care. CLINICAL RECORD 6: This patient elected the hospice benefit on 05/14/2025 with a terminal diagnosis Alzheimer's Disease and was discharged on 08/06/2025. There was no documented evidence in the clinical record review that hospice discharge summary provided to the patient’s community attending physician upon hospice discharge included the patient’s current plan of care. CLINICAL RECORD 7: This patient elected the hospice benefit on 07/03/2025 with a terminal diagnosis of metabolic encephalopathy and was discharged on 09/15/2025. There was no documented evidence in the clinical record review that hospice discharge summary provided to the patient’s community attending physician upon hospice discharge included the patient’s current plan of care. During a joint clinical record review and interview on 11/29/2025, the Patient Care Coordinator stated that the patient's current plan of care was not sent with the discharge summary.