Affinity Hospice

“Based on observations, agency policy and procedure, medical record review, Potter and Perry Fundamentals of Nursing and interviews, it was determined the agency failed to ensure patient and caregiver (CG) education was provided for oxygen safety to include signage in the home. This affected one of four Home Visit (HV) patients with oxygen in use, including HV # 3, and had the potential to negatively affect all patients admitted to this agency. Findings Include: Agency Policy: Safe/Effective Use of Equipment and Supplies Policy Number: 4-086.1 Date Revised: November 2018 Purpose To provide guidelines for the instruction of patients and family/caregivers regarding the safe, effective use of medical equipment and/or supplies. Policy Patients will receive information regarding the safe and effective use of home medical equipment (HME)...When medical equipment is supplied by another organization, hospice personnel will be supportive in the patient teaching role. Procedure ...5. Hospice will maintain generic patient teaching tools from the company for common pieces of HME found in the home, including but not limited to: A. Oxygen 6. Specific operational information related to these items will be obtained from the company providing the equipment. This will include such information as: ...D. Safety precautions and warnings... Reference: Potter and Perry Fundamentals of Nursing Fifth Edition. Copyright: 2001 ...page 1176... Safety Precautions with Oxygen Therapy... With increasing use of home oxygen therapy, clients... must be aware of the dangers of combustion. The nurse should promote safety by using the following measures: “No Smoking” signs should be placed on the client’s room door and over the bed. The client, visitors and roommates, and all personnel should be informed that smoking is not permitted in areas where oxygen is in use... 1. HV # 3 was admitted on 2/23/23 and recertified for care from 4/18/24 to 6/16/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Cerebral Infarction, Unspecified. A review of the Hospice Plan of Care Update dated 4/30/24 revealed orders for the Hospice Nurse to instruct in safe use of Oxygen and monitor its effectiveness. A HV was conducted on 6/11/24 at 2:08 PM to observe care provided by Employee Identifier (EI) # 6, Hospice Aide. During the HV on 6/11/24, Oxygen via nasal cannula was observed in the patients bedroom available for patient use. The patient said he/she occasionally needed to use the oxygen but not all the time. There were no “No Smoking” signs in the room or on the door indicating oxygen was available for use. An interview was conducted on 6/12/24 at 4:15 PM with EI # 2, Executive Director of the Pell City branch, who confirmed there was no documentation to confirm education was provided for Oxygen safety to include signage in the home.”

“Based on medical record (MR) review, agency policy, and interviews, it was determined the agency failed to ensure the staff completed the ordered frequency and communicated with the physician regarding any missed visits. This affected two of 19 MRs reviewed including MR # 11, Home Visit (HV) # 1, and had the potential to negatively affect all patients admitted to this agency. Findings Include: Agency Policy: Missed Visits Policy Number: 4-101.1 Revised: November, 2018 Purpose: To ensure that missed visits are documented and does not affect the quality of patient care. Policy: Missed visits will be communicated to the Interdisciplinary Group (IDG) at the IDG meeting. A missed visit will be rescheduled the same week, if possible. Missed visits will be documented in the clinical record... 2. HV # 1 was admitted to hospice on 5/21/24 with diagnoses including Malignant Neoplasm of the Head, Neck and Face and Parkinson’s Disease. A review of the Plan of Care dated 5/21/24 revealed an ordered frequency for the Hospice Aide (HA) of one time a week for one week and three times a week for twelve weeks. A review of the HA visit note report for week one beginning 5/21/24, revealed no HA visits were completed. There was no documentation of a missed visit note. A review of the HA visit note report for the week of 5/26/24, revealed one visit and one missed visit completed. There was no documentation of a missed visit for the third visit ordered. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 5/28/24 revealed no documentation the missed visits were communicated to the IDG. An interview was conducted on 6/13/24 at 1:31 PM with EI # 1, who confirmed that the ordered frequency was not followed, and the physician was not notified of the missed visits. 1. MR # 11 was admitted to hospiice on 4/28/24 with diagnoses including Other Malignant Neuroendocrine Tumors and Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. Review of the Hospice Certification and Plan of Care dated 4/28/24 revealed orders for Skilled Nurse (SN) seven times a week for 12 weeks then six times a week for one week. Review of the SN Visit Note Reports (VNRs) for the week of 4/28/24, revealed three of the seven ordered SN visits were completed. There was no documentation of missed visit notifications. Review of the SN VNRs for the week of 5/5/24, revealed five of the seven ordered SN visits were completed. There was no documentation of the missed visit notification for 5/5/24. Review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 5/12/24 revealed no documentation the missed visits were communicated to the IDG. An interview was conducted on 6/13/24 at 2:00 PM with Employee Identifier (EI) # 1, Executive Director, Birmingham, who confirmed the agency failed to ensure the visit frequency was followed and failed to notify the IDG of the missed visits.”

“Based on observations, agency policy and procedure and interviews, it was determined the agency failed to ensure staff performed hand hygiene (HH) per policy. This had the potential to negatively affect all patients and staff of the hospice agency and did affect one of four Home Visits (HV), including HV # 3. Findings Include: Agency Policy: Hand Hygiene Policy Number: 6-006.1 Date Revised: November 2018 Purpose To prevent cross-contamination and home-acquired infections Policy Personnel providing care in the home setting will regularly wash their hands, per the most recently published CDC (Center for Disease Control) regulations and guidelines for hand hygiene in healthcare settings... Procedure Hand decontamination with an alcohol-based hand rub ...3. Hand decontamination using an alcohol-based hand rub should be performed: ...E. When moving from a contaminated body site to a clean body site during patient care. 1. HV # 3 was admitted to the agency on 2/23/23 and recertified for care 4/18/24 to 6/16/24 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Cerebral Infarction, Unspecified. A HV was conducted on 6/18/24 at 1:50 PM to observe care provided by Employee Identifier (EI) # 3, Hospice Aide. During the bed bath, EI # 3, washed and rinsed the patient’s buttock, dried the patient with a towel, applied lotion, deodorant, assisted the patient to get dressed and cleaned the wash basin all while wearing the same pair of contaminated gloves. An interview was conducted on 6/12/24 at 4:15 PM with EI # 2, Executive Director of the Pell City branch, who confirmed staff failed to perform HH per the agency policy.”

“Based on medical record (MR) review, agency policy and procedure, and interview, it was determined the agency failed to ensure the Hospice Aide (HA) was supervised at least every 14 days. This affected one of 15 MRs reviewed of patients receiving HA services including MR # 12, and had the potential to negatively affect all patients receiving HA services. Agency Policy: Responsibilities/Supervision of Clinical Services Policy Number: 1-027.1 Revised: November, 2018 Purpose: To ensure that there is a process for the selection of a qualified individual for overseeing all clinical care and services. Policy: Nursing and hospice aide services will be under the supervision of a registered nurse... Procedure: 7...Hospice aide supervisory visits will be conducted on site at least every two (2) weeks by a hospice registered nurse... 1. MR # 12 was admitted to hospice on 5/25/23 with diagnoses including Unspecified Severe Protein-Calorie Malnutrition and Chronic Obstructive Pulmonary Disease, Unspecified. Review of the Hospice Certification and Plan of Care dated 5/25/23 revealed orders for HA one time a week for one week, three times a week for twelve weeks, then one time a week for one week and Skilled Nurse (SN) three times a week for two weeks, two times a week for eleven weeks, then one time a week for one week. Review of the HA Visit Note Reports (VNR) from 6/2/23 to 7/10/23 revealed 16 HA visits were completed. Review of the SN VNRs dated 6/1/23 to 7/10/23 revealed an Aide Supervisory Vist was completed on 6/1/23 and on 7/10/23. Further review of the SN VNs dated 6/13/23, 6/15/23, 6/20/23, 6/22/23, 6/27/23, 6/29/23, 7/4/23, 7/5/23, 7/7/23. 7/8/23, and 7/9/23 revealed the SN documented in each note the supervisory function was not completed and not applicable to the visit. The SN failed to document HA supervision for 40 days of HA service. An interview was conducted on 6/13/24 at 1:37 PM with Employee Identifier # 1, Executive Director, Birmingham, who confirmed the agency failed to ensure the HA supervision was conducted at least every 14 days.”