Every finding on record at Wellspring Hospice

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by clinical record review and interview. 2 of 14 (14%) clinical records reviewed revealed the hospice did not ensure that the interdisciplinary group completed the initial bereavement risk assessment. Clinical Record 6: Patient’s hospice benefit election was dated 6/28/22. There was no documented evidence in the clinical record that an initial bereavement assessment was completed by the interdisciplinary group. Clinical Record 8: Patient’s hospice benefit election was dated 10/1/22. There was no documented evidence in the clinical record that an initial bereavement assessment was completed by the interdisciplinary group. The DPCS was interviewed on 5/3/23. She stated that she did not know why the initial bereavement assessment was not completed.

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. 2 of 3 (67%) patients who received a home visit with observation of handwashing, revealed the hospice organization did not ensure adherence to agency infection prevention and control policies and procedures. Document 1: Agency policy titled, "Hand Hygiene Policy and Compliance Program", revised June 2019, stated in relevant parts, “Lather hands well…. wash between fingers, wash area around and under nails” and “Using a clean paper towel, dry hands thoroughly and turn off water faucet using towel.” Home Visit 1: During the home visit on 5/3/23 (Record 12), the registered nurse (RN), [Staff 6] was observed during the handwashing procedure. Observation revealed the RN, (Staff 6) did not lather his hands well, wash between his fingers or wash the area around and under his fingernails. The faucet was then turned off with his bare hands. Home Visit 3: During a home visit on 5/3/23 (Record 14), the Licensed Vocation Nurse (LVN) [Staff 9] was observed during the handwashing procedure. Observation revealed the LVN (Staff 9) washed her hands then dried her hands and turned the faucet off with a towel that was hanging up in the patient’s bathroom. In an interview after the home visits on 5/3/23, the Director of Patient Care Services acknowledged that [Staff 6 and 9] should have followed the agency hand hygiene policy.