Every finding on record at Spirit Healthcare Hospice, Inc.

Observed in Individual Tracer. In 11 of 11 patient records reviewed, It was found on review of 11 of 11 records reviewed that PRN visits for all disciplines were on the POC however there was no indication as to why these visits would be necessary which was required by Joint Commission standards..

Observed in Individual Tracer. In 1 of 3 home visits conducted, It was observed on HV#1 that the nurse cleaned her equipment used during patient care with a Super Sani-Cloth and placed them back in her bag. She was not following the instruction on the package. The package directions stated: to disinfect nonfood contact surfaces only and allow surface to remain wet for a full 2minutes. The nurse immediately put the equipment into her bag with out leaving it wet for 2 minutes. This was verified with the DON.

Observed in Leadership Session. It was found during orientation to the organization that the agency has no aides on staff. All of the patients are in assisted living facilities and the hospice utilizes the aides at the facility to provide care. These aides are not employees of Hospice. In the three years since purchasing the organization has never had a patient in their own home. Conditions of Participation require that a Hospice provide aide, volunteer and homemaker services. This was discussed with the DON and Administrator.

Observed in Document Review. It was found during the interview with the Bereavement Coordinator she stated that most of their patient families did not want follow-up after the death of their loved one. If the family did not express a need for follow up nothing more was done. She stated she still had some communication (text or emails) from several families on occasion however she had not documented these communications.

Observed in Individual Tracer. It was observed on HV#1 that the patient's backup oxygen tank was stored in a closed closet in a stand surrounded by clothes and other items. The assisted living facility where the patient resides likes it stored there per the visiting nurse statement, however oxygen should never be stored in a closed area. Further education needs to be provided to the staff at the assisted living. This was verified with the DON.