Saad Hospice Services

“Based on observation, the facility failed to maintain the required means of egress per the requirements of: 2012 NFPA 101, 19.2.10.1, and 7.10.8.3 This deficiency affects 1 of 1 non exits. Findings include: During a tour of the facility, the surveyor observed on the 1st floor level of the Back Stairwell of the North Wing, a door leading to the Kitchen roof that could be mistaken for an exit and was not identified with a sign that reads, “No Exit”. A member of the maintenance staff was present when this deficiency was identified. .”

“Based on observation, the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet per the requirements of: 2012 NFPA 101, 19.3.5.1, 9.7.1.1, and 9.7.7 2010 NFPA 13, 6.2.9.7, and 6.2.9.7.1 This deficiency affects all of the sprinkler system. .Finding Include:During a tour of the facility, the surveyor observed the facility failed to post a list of sprinklers installed in the property at the sprinkler cabinet. The list shall include the following:(1) Sprinkler identification number; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating(2) General description(3) Quantity of each type to be contained in the cabinet(4) Issue or revision date of the list A member of the maintenance staff was present when this deficiency was identified..”

“Based on observation, the facility failed to maintain smoke barriers that would provide at least a half hour fire resistance rating and restrict the movement of smoke per the requirements of: 2012 NFPA 101, 19.3.7.3, 8.5.1, 8.5.6.2, and 8.5.6.3 This deficiency affects 1 smoke barrier. Findings include: During a tour of the facility, the surveyor observed an unsealed penetration (the inside of the conduit) of a ¾” EMT conduit used as a chase for 2 blue cables, above the ceiling of the smoke barrier between the Bereavement Room/People Development Room 1 and the North Wing. A member of the maintenance staff was present when this deficiency was identified. .”

“Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure the comprehensive assessments were completed within five days. This deficient practice affected four of 27 MR reviewed including MR # 11, MR # 21, MR # 5, MR # 14, and had the potential to negatively affect all patients admitted to this agency. Findings include: Agency Policy: Interdisciplinary Team Meeting ProcedurePolicy Number: 2A0225Reviewed: 6/25Section 1: Purpose/Objective1.1. To implement and maintain a process of coordinated patient communication to ensure continuity of care from admission through discharge/death...Section 4: Procedure4.1. A Care Plan and Assessment meeting will be completed within 5 days of admission...4.3. Patient information will include at a minimum:...b. Frequencies for all disciplinesc. Current issue/Concern/Problemd. MSW (Master of Social Work) Sectione. Chaplain Section...g. Volunteer Section 4. MR # 14 was admitted on 8/14/25 with a diagnosises of Parkinson’s Disease without Dyskinesia, without mention of fluctuations and Ataxia, unspecified.Review of the HCPOC dated 8/14/25 revealed physician’s orders for SN two visits per week for thirteen weeks, MSW one visit per week for one week, HHA two visits per week for twelve weeks.Review of the MSW VNR dated 8/20/25 revealed the MSW assessment was not completed until six days after admission. An interview was conducted on 9/18/25 at 4:23 PM with EI # 1 who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days. 3. MR # 5 was admitted to the agency on 7/29/25 with a primary diagnosis of Alzheimer’s Disease, Unspecified.Review of the HCPOC dated 7/29/25 revealed physician’s order for SN two visits a week for thirteen weeks, MSW one visit per week for one week, HHA one visit for one week then three visits for twelve weeks, and Chaplain one visit for one week. Review of the MR revealed the initial chaplain assessment dated 8/5/25 was not completed until eight days after admission.An interview was conducted on 9/18/24 at 3:19 PM with EI # 1 who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days. 2. MR # 21 was admitted on 2/5/25 with a primary diagnosis Malignant Neoplasm of Rectum.Review of the HCPOC dated 2/5/25 revealed physician orders for SN three visits per week for one week and two visits a week for 12 weeks, and MSW one visit per week for one week.Review of the MSW VNR dated 2/11/25 revealed the MSW assessment was not completed until 6 days after admission. An interview was conducted on 9/18/25 at 4:06 PM with EI # 1, Clinical Director, who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days. 1. MR # 11 was admitted on 7/31/25 with a primary diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery with Angina Pectoris. Review of the Hospice Certification and Plan of Care (HCPOC) dated 7/31/25 revealed physician orders for Skilled Nurse (SN) two visits per week for 13 weeks, MSW one visit per week for one week, Home Health Aide (HHA) two visits per week for 13 weeks, and Chaplain (CH) one visit per week for one week. Review of the CH Visit Note Report (VNR) dated 8/7/25 revealed the CH assessment was not completed until seven days after admission. Review of the MSW VNR dated 8/13/25 revealed the MSW assessment was not completed until 13 days after admission. An interview was conducted on 9/18/25 at 3:30 PM with Employee Identifier (EI) # 1, Clinical Director, who confirmed the agency failed to ensure the comprehensive assessment was completed by all required disciplines within five days.”

“Based on medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure volunteer services were offered as requested. This deficient practice affected four of 27 MR reviewed including MR # 14, Home Visit (HV) # 6, HV # 3, MR # 12, and had the potential to negatively affect all patients admitted to this agency.Findings include:Agency Policy: Volunteer ProgramPolicy Number: NoneReviewed: 7/21Purpose/Objective: 1.1 Saad Hospice Volunteer Program exists to place trained volunteer personnel as adjunct members to the hospice patient care team.Policy: Services of volunteers are provided on an as needed basis or by inclusion in the patient’s plan of care. 4. MR # 12 was admitted to the agency on 5/2/25 and recertified for care on 7/26/25 with a primary diagnosis of Cerebral Infarction, Unspecified.Review of the Hospice Recertification Plan of Care Update dated 7/16/25 revealed physician’s orders for SN three visits per week for one week, seven visits per week for twelve weeks, and three visits per week for one week. MSW one visit every month for three months and HHA two visits per week for one week, five visits per week for twelve weeks, and two visits per week for one week.Review of the MSW Client Coordination Report dated 8/26/25 revealed MSW reviewed Volunteer Services with patient. Patient and caregiver requested volunteer services and request was sent to Volunteer Coordinator. There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 3:44 PM with EI # 1, who confirmed the staff failed to provide volunteer services. 3. HV # 3 was admitted on 9/5/25 with a primary diagnosis of Senile Degeneration of Brain. Review of the HCPOC dated 9/5/25 revealed physician’s orders for SN two visits per week for 13 weeks then one visit per week for one week, MSW one visit for one week, and HHA three visits per week for 12 weeks then two visits per week for one week. Review of the MSW Client Coordination Note Report dated 9/8/25 revealed the MSW documented the patient/caregiver had requested volunteer services and the request had been sent to Volunteer Coordinator. There was no documentation volunteer services were provided. An interview was conducted on 9/18/25 at 4:00 PM with EI # 1 who confirmed volunteer services were not provided as requested. 1. MR # 14 was admitted on 8/14/25 with diagnoses including Parkinson’s Disease without Dyskinesia, without mention of fluctuations and Ataxia, unspecified.Review of the Hospice Certification and Plan of Care (HCPOC) dated 8/14/25 revealed physician orders for Skilled Nurse (SN) two visits a week for thirteen weeks, Masters in Social Work (MSW) one visit a week for one week, and Hospice Aide (HA) two visits a week for twelve weeks, then one visit a week for one week.Review of the MSW Client Coordination Note Report dated 8/20/25, revealed patient/caregiver requested volunteer services.There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 4:23 PM with Employee Identifier (EI) # 1, Clinical Director, (CD) who confirmed the staff failed to provide volunteer services.2. HV # 6 was admitted on 7/30/35 with diagnoses including Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation.Review of the HCPOC dated 7/30/25 revealed physician orders for SN two visits a week for thirteen weeks, then one visit a week for one week, MSW one visit a week for one week, HA three visits a week for one week, five visits a week for twelve weeks, then one visit a week for one week, and Chaplain (CH) one visit a week for one week.Review of the MSW Client Coordination Note Report dated 8/28/25, revealed patient/caregiver requested volunteer services.There was no documentation of a volunteer visit.An interview was conducted on 9/18/25 at 4:17 PM with EI # 1, who confirmed the staff failed to provide volunteer services.”

“Based on observation, agency policies and procedures, Centers for Disease Control (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers, and staff interviews, it was determined the agency failed to ensure staff: 1. Performed hand hygiene per agency policy, and CDC Guidelines. 2. Followed the agency’s bed bath protocol. 3. Followed agency policy for medical equipment cleaning. 4. Followed agency policy for barrier protection/bag technique. These deficient practices did affect three of seven home visits (HV) conducted including HV # 1, HV # 4 and HV # 6, and had the potential to negatively affect all patients served by the agency.Findings include:Agency Policy: Hand Washing IndicationsPolicy Number: 2B1230Date Reviewed: 01/25Section 1: Purpose/Objective 1.1. To prevent the spread of infection among the staff, visitors, and patients of Saad Hospice...Section 2: Policy 2.1. All employees will follow CDC hand washing recommendations for preventing the spread of infection...Section 4: Procedure 4.3. Employees should always sanitize their hands before and after touching wounds. 4.4. Employees should sanitize their hands before and after situations during which microbial contamination of hands is likely to occur, especially those involving contact with mucous membranes, blood, or bodily fluids, secretions, excretions... 4.6. Employees should sanitize their hands before and after touching inanimate sources that are likely to be contaminated...Agency Policy: Complete Bed Bath Procedure Policy Number: Not ListedDate Reviewed: 08/25Section 1: Purpose/ObjectiveTo remove dirt and odors...and help prevent skin breakdown in hospice patients...Section 4: Procedure 4.1. Use Universal Precautions... 4.3. Sanitize hands by washing...Apply gloves... 4.27. Wash patients back and buttocks...4.29. Wash Hands, and apply gloves...Agency Policy: Medical equipment CleaningPolicy Number: 2B1219Date Reviewed: 12/23 Section 1: Purpose/Objective 1.1. To provide clean equipment for patient use and reduce the risk of the spread of infection.Section 2: Policy 2.1. All equipment used for assessing patient vitals will be cleaned... between use on each patient...Agency Policy: Barrier Protection for Non-Disposable Medical SuppliesPolicy Number: 2A124Date Reviewed: 02/22Section 1: Purpose/Objective 1.1. To prevent and control infections in the home care setting.Section 2: Policy 2.1. All staff will be responsible for using recommended precautions... 2.5. Linen, laundry, or any other surface in direct contact with the patient or any other surface in the patient’s home where contamination is possible should be considered contaminated...Section 4: Procedure...4.2. Prior to replacing any non-disposable medical equipment or storage container for medical supplies on a surface in the patient’s home, the hospice staff member will place a fluid impermeable, disposable barrier material on the surface. The equipment can then be placed on top of the barrier. The barrier for the bag is divided into a clean half and a dirty half. The clean and dirty barrier equipment are not to be intermingled. 4.3. ...Once the non-disposable supplies have been used, they will be cleaned..., allowed to dry for the allotted time... and returned to the appropriate place within the work bag. CDC Clinical Safety: Hand Hygiene for Healthcare Workers.February 27, 2024Recommendations:Know When to Clean Your Hands: a. Immediately before touching a patient... c. Before moving from work on a soiled body site to a clean body site on the same patient. d. After touching a patient or patient’s surroundings... e. After contact with blood, body fluids, or contaminated surfaces. f. Immediately after glove removal...Know When to Wear ( and change) Gloves.Gloves are not a substitute for hand hygiene. a. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or patient’s surroundings. b. Always clean your hands after removing gloves... 3. HV # 6 was admitted to the agency on 7/30/25 with a primary diagnosis of Hypertensive Heart Disease without Heart Failure and Paroxysmal Atrial Fibrillation.Review of the HCPOC dated 7/30/25 revealed physician’s order for SN visits two per week for thirteen weeks, MSW visits one time per week for one week, HHA visits three times per week for one week, then five times per week for twelve weeks, and CH visits one time per week for one week.A HV was conducted on 9/17/25 at 8:47 AM to observe wound care provided by EI # 5, RN.EI # 5 placed a barrier on a bedside table and a second barrier on a chair.EI # 5 performed hand hygiene, donned gloves, and obtained HV # 6’s blood pressure, temperature, oxygen saturation, and heart rate. EI # 5 placed the used equipment on the clean half of the barrier.EI # 5 then cleaned the blood pressure cuff, placed the used equipment back on the barrier with the dirty equipment, allowed the equipment to dry, and returned the equipment back to his/her bag.An interview was conducted on 9/18/25 at 4:17 PM with EI # 2, Inpatient Unit Director who confirmed staff did not follow the agency policies for cleaning of equipment or barrier protection/bag technique. 1. HV # 1 was admitted to the agency on 1/6/25 and recertified for care on 7/20/25 with the primary diagnosis Senile Degeneration of Brain, not Elsewhere Classified.Review of the Hospice Recertification Plan of Care Update (HRPOCU) dated 7/20/25 revealed physician’s order for Skilled Nurse (SN) visits one per week for nine weeks, Master of Social Work (MSW) visits one per month for two months, Home Hospice Aide (HHA) visits five per week for eight weeks, Chaplain visits one per month for three months.A HV was conducted on 9/16/25 at 1:08 PM to observe care provided by Employee Identifier (EI) # 7, HHA , to provide a bed bath for HV # 1.EI # 7 washed and rinsed HV # 1’s buttocks then his/her back and legs. Wearing the same pair of dirty gloves, EI # 7 dried his/her buttocks, back and legs with a towel, changed linen, Chux, and draw sheet, turned patient from side to side, dressed him/her with a clean shirt, pulled head of bed into a sitting position and pulled his/her sheet and blanket up to his/her chin without changing out of the dirty gloves.An interview was conducted on 9/18/25 at 4:02 PM with EI # 1, Clinical Director, who confirmed staff did not follow the agency’s hand hygiene policy or bed bath protocol. 2. HV # 4 was admitted to the agency on 12/27/24 and recertified for care on 8/9/25 with a primary diagnosis of Cerebral Infarction, Unspecified.Review of the HRPOCU dated 8/9/25 revealed physician’s order for SN visits two per week for eight weeks, MSW visits for one per month for two months.A HV was conducted on 9/17/25 at 9:27 AM to observe wound care provided by EI # 8, Registered Nurse (RN).EI # 8 placed a barrier on a bedside table and his/her work bag at the end of the barrier, and a second barrier on a short stool. EI # 8 donned gloves without performing hand hygiene and obtained HV # 4’s blood pressure. EI # 8 removed the used blood pressure cuff and placed it on the clean half of the barrier with the unused thermometer and pulse oximeter, contaminating the clean side of the barrier.During the HV, EI # 8 removed his/her dirty gloves five times and without performing hand hygiene, donned clean gloves, including before wound care was provided.EI # 8 cleaned the reusable equipment and placed them back on the now contaminated clean side of the barrier.An interview was conducted on 9/18/25 at 4:10 PM with EI # 1 who confirmed staff did not follow the agency policies for hand hygiene, cleaning of equipment or barrier protection/bag technique.”

“Based on observation, Centers for Disease Control (CDC) Injection Safety: Preventing Unsafe Injection Practices, and staff interviews, it was determined staff failed to date multidose vials (MDV) of medication when opened.This deficient practice had the potential to negatively affect all patients served by this agency.Findings include:CDC Injection Safety: Preventing Unsafe Injection PracticesDate: March 26,2024Key PointsUnsafe injection practices put patients and healthcare providers at risk. This harm is preventable...Why it mattersSafe injection practices are every provider’s responsibility...Key Points for MDVOnce a MDV is opened (ergo, needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial... A tour of the Saad Hospice inpatient hospice facility at Providence Hospital was conducted on 9/16/25 at 9:16 AM.An observation of the medication room revealed the following open MDVs without a date when medication was opened and available for patient use: a. One 10 milliliter (ml) vial of Versed 5 milligrams (mg). b. One 10 ml vial of Lorazepam 20 mg.Employee Identifier (EI) # 2, Inpatient Unit Coordinator, confirmed at the time of the observation staff failed to date the MDVs when opened, and were available for patient use.”