Every finding on record at Summerwind Hospice, Inc.

Observed in HR File Review. In 1 of 1 HR files reviewed, During HR# 1's file review it was noted the organization had not ensured the alternate medical director completed a competence assessment on hire by another physician. This was reviewed, discussed, and validated with the Administrator.

Observed in Emergency Management Session. During Document Review the Hospice surveyor noted that the HVA for 2023 was blank. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Emergency Management Session. During the EM plan review, the hospice surveyor noted that the organization had not defined in its plan how how they will inform state and local officials of any on-duty staff or patients that they are unable to contact. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Emergency Management Session. During Document Review the Hospice surveyor noted that there were no emergency management drills for 2021, 2022 and 2023 that stressed the plan down to the level of the patient with the appropriate after action evaluations. There was one in office fire drill only. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, During the Document Review, the Hospice surveyor noted that there was no explanation of the 5 day respite benefit. For example patient information packet under the explanation of Hospice benefit there was description of GIP and continuous care but no definition of respite. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Document Review. During the document review, the hospice surveyor noted that falls risk assessment was only assessed on admission according to organization policy. The falls policy stated that falls would be assessed on admission but did not include that it would be reassessed on recertification, after a fall, and in a change of condition or location. this was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Tracer Visit. In 3 of 3 tracers conducted, During HV 1, 2 and 3, the Hospice surveyor noted that there was no consistency in the cleaning of equipment after use and with what product. For example, in HV 1 the RN appeared to not clean the equipment and placed it directly back in the bag. In HV 2, the LVN used alcohol to clean his equipment but used the patient's BP cuff but did not clean if after use. In HV 3 the HHA took the patients VS and used a wet paper towel to clean the equipment but it was not clear what she used to wet the paper towel. This was validated in a discussion with and observation by the Administrator/DPCS. Observed in Tracer Visit. In 3 of 3 home visits conducted, During HV 1, 2 and 3, the Hospice surveyor noted that there were multiple lapses in hand hygiene technique. For example, in HV 1 the RN removed her gloves but did not gel her hands and then proceeded to retrieve wound care supplies from a box and her nursing bag. In addition, she used and touched her phone multiple times and did not gel her hands after use. In HV 2 the LVN change his gloves 6 times and never gelled his hands after removing the gloves or before donning another pair. Also, during the assessment he went from assessing the buttocks area and then the back without changing cloves. In HV 3 the HHA used an unidentified soap at the kitchen sink (blue in an unlabeled tub) to wash her hands. She also removed her gloves during the shower but had no gel to use before donning another pair. She only used one washcloth during the shower and finished the leg area after the buttocks area. This was validated in a discussion with and observation by the Administrator/DPCS. Observed in Individual Tracer. In 3 of 3 tracers conducted, During HV 1, 2 and 3, the Hospice surveyor noted that there were multiple lapses in bag technique and staff were not following agency policy for Bag Technique. For example, two of the bags were tote bags with no zipper to close and no clean and dirty dividers. The LVN had a zippered bag with clean and dirty dividers. All 3 practitioners entered the bags multiple times with out proper hand hygiene. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Infection Control Tracer. During Document Review the Hospice surveyor noted that there was no infection control assessment performed annually for the last 2 years. In addition the verbiage was copied word for word from the standard but did not specify the risks based its geographic location, community, and population served : The care, treatment, or services it provides : and the analysis of its surveillance activities and other infection control data. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Leadership Session. The hospice surveyor noted that the leadership did not insure that policies and procedures were implemented. This resulted in condition level deficiencies at 418.60 and 418.113. This was validated in a discussion with and observation the Administrator/DPCS.

Observed in HR File Review. In 1 of 10 HR files reviewed, During the HR file review, the hospice surveyor noted in MD2 that there was no documented competency performed on hire by another MD. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in Record Review. In 14 of 14 patient records reviewed, During Document Review the Hospice surveyor noted that there was no individualized emergency plan of care that addressed all the needs of the patient as required. This was validated in a discussion with and observation by the Administrator/DPCS.

Observed in HR File Review. In 5 of 6 licensed file, During the HR file review, the hospice surveyor noted in HR1 there was no PSV on hire 3/3/20 until 6/28/23. In HR 2 there was no license verification on hire 6/12/19 until 4/13/22 but it expired 10/31/22 and was not rechecked until 5/23/23. In HR 3 there was no license verification on hire 2/12/19 and that expired 6/25/23 and not verified until 9/25/23. In HR 4 there was no license verification on hire 6/26/22. In the HR5 the MSW was hired on 6/6/23and there has been no license verification. The organization was not able to show the surveyor a completed PSV for HR#5 before the end of survey. This was validated in a discussion with and observation by the Administrator/DPCS.