Every finding on record at Valhalla Hospice LLC

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by document review, interview and observation. In 2 of 3 (67%) home visit observations revealed that the agency did not ensure that bags and equipment taken into the patient environment were handled according to the agency's policy. Document 1: The agency policy, "Bag Technique" (Policy No. 9-014.1) with the revised date of October 2022, read, "The bag will be placed on a clean dry surface (i.e., a surface that can be easily disinfected) in the car and in the home...The bag will contain a designated clean and dirty area. The clean area carries unused or clean supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.). Further, the policy stated, "When the visit is completed, reusable equipment will be cleaned using alcohol and/or soap and water as appropriate, hands will be washed, and equipment and supplies will be returned to the bag...Hands will be decontaminated prior to returning equipment to bag." Home Visit 1: The patient elected the hospice benefit on 7/8/2023. During the home visit observation on 8/30/2023, it was noted that the staff member placed her bag on the stuffed fabric couch beside where she sat down without placing any barrier underneath the bag. After the visit, she did not clean or disinfect the bag. Home Visit 2: The patient elected the hospice benefit on 5/15/2023. During the home visit observation on 8/30/2023, it was noted that the staff member, wearing gloves, took the patient's blood pressure, picked up the thermometer, and took the patient's temperature. After the temperature reading, the staff member placed the thermometer back into the small bag without disinfecting the thermometer or taking off her gloves and sanitizing her hands. Personnel Record 1: In an interview with the Director of Patient Care Services on 8/30/2023, she confirmed that staff bags taken into the patient environment should be placed on a barrier or a disinfected/cleaned surface. She further confirmed that hands and equipment should be cleaned prior to re-entry into the "clean" area of the bag.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. Each patient’s record includes, at a minimum signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 6 (50%) clinical records reviewed revealed that the agency did not ensure that the signed hospice election statements included the effective date for the start of hospice care. Document 1: The agency policy, "Hospice Election Statement" (Policy No. 2-2024.1) with the revised date of October 2022 stated, "The date on the hospice election statement will be the official service start date." Clinical Record 1: The patient elected the hospice benefit on 7/8/2023. The effective date for the beginning of hospice services was left blank on the top of page two of the Informed Consent and Treatment Authorization form. No date appeared on pages one, two, or three. On page four (of four), the patient's representative signed with the date of 7/8/2023. Clinical Record 4: The patient elected the hospice benefit on 8/29/2023. The effective date for the beginning of hospice services was left blank on the top of page two of the Informed Consent and Treatment Authorization form. No date appeared on pages one, two, or three. On page four (of four), the patient's representative signed with the date of 8/29/2023. Clinical Record 5: The patient elected the hospice benefit on 5/22/2023. The effective date for the beginning of hospice services was left blank on the top of page two of the Informed Consent and Treatment Authorization form. No date appeared on pages one, two, or three. On page four (of four), the patient's representative signed with the date of 5/22/2023. Personnel Record 1: On 8/31/2023, during an interview with the Director of Patient Care Services, she confirmed that the area for the effective start of hospice care date was not completed.