Every finding on record at Three Oaks Hospice Dallas, Inc.

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. This standard was not met as evidenced by document review, interview and observation. In 1 of 6 (17%) home visits observed the agency did not ensure that the staff member used standard precautions such hand hygiene that followed accepted standards of practice and agency policy. Document 1: The agency's policy titled, Hand Hygiene, IC.15, last reviewed 12/12/22 stated in relevant parts, " Policy: All Hospice staff providing patient care will perform hand hygiene in accordance with Center for Disease Control (CDC) recommendations. Procedure: II. Hand Hygiene with an Alcohol-based Hand Rub, D. Staff may use an alcohol-based hand run for routinely decontaminating hands in clinical situation described below: 4. After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings and supplies (PPE) if hands are not visibly soiled. 7. After contact with blood, body fluids and contaminated surfaces. 8. After removing gloves." Home Visit 6: A home visit was conducted with staff #14, a Registered Nurse (RN), on 2/8/24. The RN was providing wound care to the patient, and it was observed that the RN doffed their gloves twice and donned new gloves without first performing hand hygiene, once after cleansing the patient's wound and once after packing the wound. In an interview conducted with the Director of Clinical Services (DCS) on 2/8/24 they did confirm that the RN, staff #1 did not follow standard precautions and established agency policy for hand hygiene.

It is required that the designated IDG member provides the SNF/NF or ICF/IDF with the following information for each patient/resident, the hospice election form and physician certification and recertification of the terminal illness. This standard was not met as evidenced by interview and observation. In 2 of 2 (100%) home visits conducted in a Skilled Nursing Facility (SNF) the agency did not ensure that the designated IDG member provided the SNF with the patient's Election of Benefit (EOB) and Certification/ Recertification of Terminal Illness (CTI). Home Visit 1: A home visit was conducted on 2/7/2024 with the Hospice Aide to a patient (clinical record 13) residing in a SNF. The patient's hospice record maintained in the SNF was reviewed and lacked evidence that the patient's EOB and CTI had been provided to the facility. Home Visit 2: A home visit was conducted on 2/7/2024 with the Registered Nurse (RN) to a patient residing in a SNF (clinical record 14). The patient's hospice record maintained in the SNF was reviewed and lacked evidence that the patient's EOB and CTI had been provided to the facility. Personnel Record 15: In an interview conducted with the RN (case manager), for the patients (records 13 and 14) managed in the SNF they did state that they were "unsure what documents were required to be provided to the SNF for hospice patients". In an interview conducted with the Director of Clinical Services (DCS) on 2/7/24 they did confirm that the EOB and CTI had not been provided to the SNF and should have been.