Delaware Hospice, Inc. Southern Division

“Based on review of policies, documents, and staff interview, it was determined that the agency failed to provide training in emergency preparedness policies and procedures to all new and existing hospice employees consistent with their expected roles. Findings include: Agency policy titled, “;Emergency Preparedness and Response (EPRP) Plan” updated 12/2022 stated, “;Hospice ensures that all employees...are trained and oriented about their responsibilities in the agencys EPRP upon initial implementation, upon hire and with any updates to the plan...” Review of educational content provided to staff titled “DHI Emergency Preparedness Survey Readiness” dated October 2023, did not include content related to the employee’s responsibilities during an emergency. Content included information for leadership but failed to include information specific for other roles within the organization. During an interview on 12/07/23 at 12:00 PM with Employee # 4, the above finding was confirmed. Per Employee # 4, the education provided was a leadership education that was “tweaked” to be used for all staff, including home care and the inpatient staff. It was confirmed that although some policy numbers for additional information were listed in the education, no links were embedded in the online education that would have allowed staff to review the information relevant to their specific roles. Staff were not required to review any job specific policies related to emergency preparedness during their annual emergency preparedness education.”

“Based on observation, record review, policy review, and staff interview, it was determined that the agency failed to conduct complete nursing assessments for 1 out of 18 active homecare patients (Patient #22) in the sample. Findings include: Agency policy titled “;Admission Visit” reviewed 5/23, stated, “;...Admission completed by an RN [registered nurse]...The medications are reconciled...” Agency policy titled “;Medication administration and Management – Home Care” reviewed 11/23 stated, “;...Medication Reconciliation – On all admissions...the nurse...Reconcile all medications (those currently being administered and those that are in the home and have been administered in the past)...” During an observation of home visit for Patient #22 by Employee #6 on 12/6/23 from 10:00 to 11:30 AM, the patients wife questioned if Patient #22 would continue to take Riluzole and Radicava [medications] while on hospice. Employee #s 6 and 4 reviewed the electronic medical record and found no evidence that either medication was documented in the Medication Administration Record (MAR) included for medication reconciliation at time of admission. Review of the medical record of Patient #22 revealed: Patient admitted on 12/2/23. “;Patient Medication Profile” dated 12/6/23 at 8:53 PM documents, Riluzole 50 mg tablet, 1 two times a day starting 12/6/23 (not covered) and Radicava ORS 105mg/5 ml, 5 ml one time daily starting 12/6/23 (not covered). During an interview on 12/6/23 at 3:45 PM, Employee #1 confirmed Riluzole and Radicava were not placed in the MAR of Patient #22 upon admission.”

“Based on policy review, document review, and staff interview, it was determined the Agency failed to ensure their performance improvement activities focused on high risk and problem-prone areas which impacts all inpatient unit patients and Delaware Hospice Southern Division staff. Findings include: Agency policy titled “;Quality Assessment Performance Improvement (QAPI) Program” reviewed 12/22 stated, “;Performance Improvement activities focus on high risk, high volume or problem prone area that affect patient safety...Performance activities track adverse patient events, analyze their causes and implement preventive actions...” I. Patient falls in Inpatient Unit (IPU) Review of Agency IPU log of incident events revealed 26 documented patient falls between 12/20/22 and 12/1/23. Review of Agency document titled “;Annual Board of Trustees Meeting” dated 9/28/23 stated, “;...Patient Falls Safety Data...Beginning October 2023...We are analyzing falls, the reason, use of medication and other precipitating events...” Nine falls were reported in the inpatient unit between April 2023 to June 2023. Review of Agencys QAPI Steering meeting minutes for 1/25/23 and 9/27/23 revealed no evidence of reporting or discussion of patient falls. Review of Agencys QAPI Steering meeting minutes for 3/22/23, 5/23/23, and 7/26/23 revealed tracking and trending of patient falls without evidence of analysis of the causes or planned preventive actions. During an interview on 12/7/23 at 11:45 AM, Employee #4 confirmed there is no evidence in the 2023 QAPI minutes of discussion of increased falls in the inpatient unit. II. Positive Legionella findings Review of Agency document titled “;Delaware Hospice Center – Legionella Mitigation Plan” dated 11/5/21 stated, “;...Kurita engaged to do Legionella samples...quarterly...reported to Leadership and Safety Committee...” Review of results of Kuritas “;Environmental Culture Test-Legionella” revealed: -Testing dated 1/18/22 showed all samples were negative for Legionella. -Testing dated 4/19/22 showed all samples were negative for Legionella. -Testing dated 10/27/22 showed all samples were negative for Legionella. -Testing dated 1/23/23 showed all samples were negative for Legionella -Testing dated 4/26/23 showed all samples were negative for Legionella -Testing dated 7/13/23 shows “;Cooling Tower #1” sample was positive for Legionella rubrilucens. -Testing dated 8/4/23 shows “;Cooling Tower #1” sample with no Legionella detected. -Testing dated 11/2/23 shows “;B-Wing Coffee Area” and “;C-Wing Kitchen” samples were positive for Legionella feeleii. Surveyor requested copy of Safety Committee meeting minutes documenting report of Legionella quarterly samples. Employee #4 provided a copy of the 7/14/22 Safety Committee meeting minutes which stated, “;...updated to water...testing...last quarters testing...were all negative...” Employee #4 stated there no other 2022 Safety Committee minutes where the Legionella test results were discussed. Employee #4 stated the Legionella results are reported only if there were positive results. Surveyor requested copy of Safety Committee minutes for the meeting following the 7/13/23 positive Legionella results for Cooling Tower #1, Employee #4 provided a copy of Safety Committee minutes dated 10/10/23. Review of Safety Committee Minutes dated 10/10/23 showed no evidence that the 7/13/23 positive Legionella results for the sample from Cooling Tower #1 was reported to the Safety Committee. Review of QAPI Steering Committee minutes for the year of 2023 (1/25/23, 3/22/23, 5/23/23, 7/26/23, and 9/27/23) revealed no evidence of reports or discussions about ongoing Legionella mitigation or the 7/13/23 positive Legionella results for the sample from Cooling Tower #1. During an interview on 12/7/23 between 10:45 to 11:22 AM, Employee #4 confirmed 1) the only Safety Committee Meeting minutes that documents reporting of quarterly Legionella sample results was the 7/14/22 meeting; 2) there is no evidence that the 7/13/23 positive Legionella results for the sample from Cooling Tower #1 was reported to the Safety Committee or QAPI Steering Committee.”

“Based on observation, policy review, and staff interview, it was determined the Agency failed to ensure staff followed accepted standards of practice to prevent the transmission of infections and communicable diseases. Findings include: Agency policy titled “;Supply Bag Technique/Homecare Equipment and Supplies” reviewed 8/23 stated, “;...When the visit is completed, reusable, noncritical supplies/equipment are cleaned and sanitized or disinfected, and returned to the bag...” CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) stated, “;...Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devises...4.b. Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA [Environmental Protection Agency] registered hospital disinfectant using the labels safety precautions and use directions...” PDI Sani-Hands instant hand sanitizing wipes label states, “;...Use to decrease bacteria on the skin...” No evidence of product being an EPA registered hospital disinfectant. Employee #8 During observation of Patient #24 care provided by Employee #8 on 12/6/23 from 11:45 AM to 12:10 PM, the following was observed: -at end of care Employee #8 opened “;PDI Sani-Hands Instant Hand Sanitizing Wipe” package -cleaned blood pressure cuff and placed in equipment bag -cleaned stethoscope and placed in equipment bag During interview on 12/6/23 at 12:10 PM, Employee #s 4 and 8 stated the hand sanitizing wipes are provided by the Agency. Upon request on 12/6/23, Agency was not able to provide evidence that PDI Sani-Hands Instant Hand Sanitizing Wipes is approved for sanitizing noncritical medical equipment prior to survey exit on 12/7/23 at 1:45 PM. Upon request on 12/7/23, Agency was not able to provide documentation of research Agency Educator completed to determine the effectiveness of use of “;PDI Sani-Hands Instant Hand Sanitizing Wipes” for sanitizing noncritical medical equipment prior to survey exit on 12/7/23 at 1:45 PM. The finding of no evidence that “;PDI Sani-Hands Instant Hand Sanitizing Wipes” are approved or effective for sanitizing noncritical medical equipment was confirmed with Employee #4 on 12/7/23 at 11:45 AM.”

“Based on review of polices, record review, and interview with staff, it was determined that for 1 of 3 active inpatient unit patients (patient #6) in the sample, the hospice failed to provide infection control education to the patient. Policy titled “Patient/Caregiver Education Process” reviewed 12/22 stated, “All patients and/or families/caregivers receive education and training specific to the patient’s needs and as appropriate to the care, treatment and services provided...all patients...receive verbal and, as appropriate, written instructions using the teach back method when indicated, in...infection control...patient education documentation in the narrative section of assessments by each discipline in EMR consists of: describing what was taught to the patient...describing the patient’s response to the teaching...” Policy titled “Implementation of transmission-based precautions” reviewed 8/23 stated, “...the nurse implements infection precautions...the nurse provides education to the patient...”. Review of patient record revealed: Patient # 6 Patient was admitted on 12/4/23 for IV antibiotic treatment related to an infection. Ordered was placed on 12/5/23 at 11:15 AM for contact isolation precautions for ESBL in urine. Review of clinical documentation revealed no evidence of patient education being provided related to contact isolation for ESBL. During an interview on 12/07/23 at 09:24 AM with Employee # 2, it was confirmed that education was not provided to the patient regarding infection control after the patient was placed on contact isolation precautions. test.....”

“Based on document review and staff interview, it was determined the Agency failed of ensure hospice aides received at least 12 hours of in-service training in the last 12-months for 3 of 3 CNAs (Employee #s 7, 11, and 12) sampled. Findings include: Agency policy titled Certified Nursing Assistant Training/Certification and Continuing Education” reviewed 8/22 stated, “;...During...yearly evaluation periods, the CNA [certified nursing assistant], with the Clinical Supervisor reviews the continuing education website to ensure the CNA is meeting requirements...” Review of Agencys Human Resources file revealed: -Employee #7 (CNA) completed 2 in-service hours in the last 12-month period. -Employee #11 (CNA) completed 1 in-service hour in the last 12-month period. -Employee #12 (CNA) completed 8 in-service hours in the last 12-month period. During an interview on 12/7/23 at 12:15 PM, Employee #3 confirmed the finding and stated the Agency does not keep track of the CNAs training.”

“Based on observation, policy review, medical record review and staff interview, it was determined that hospice aide services were not consistent with hospice aid training for 1 of 18 active home care patients (Patient #20) sampled. Findings include: Agency policy titled “;Certified Nursing Assistant Duties and Responsibilities” reviewed 12/22 stated, “;...Certified Nursing Assistants [CNA] provide certified nursing assistant services...maintaining a...safe environment...” During observation of Employee #7 providing care to Patient #20 on 12/6/23 from 8:20 to 8:55 AM, Employee #7: -Raised bed and washed patient, covered patient with towel. -Lowered bed and left bedside to empty water basin in bathroom. -Returned with clean water and raised bed. -Walked away from raised bed to retrieve a disposable adult diaper. -Returned to raised bed, turned patient towards wall to remove old diaper, returned patient to their back. -Walked away from raised bed to get towels. -Returned to bedside and draped patient and performed perineal care and put on new diaper. -Lowered patient’s bed. During an interview on 12/6/23 at 8:55 AM, Employee #s 4 and 7 confirmed Employee #7 left patient #20s bedside while it was in a raised position during patient care putting the patient at risk for injury.”

“Based on policy review, document review, and staff interview, it was determined that the Agency failed to ensure competencies were assessed for 1 of 1 contracted registered nurse (Employee #13) sampled. Findings include: Agency policy titled New Hire Orientation Program – Clinical Staff” reviewed 8/22 stated, “;Delaware Hospice, Inc. (DHI) provides a comprehensive orientation program for all new patient care staff, whether employed by Delaware Hospice or provided through contract. Prior to providing services independently, DHI staff demonstrate core competency skills...Required documentation...All necessary training...is completed before the end of the staff member’s six-month probation period. Core skills...may not be practiced independently until competency is demonstrated...New Hire Skills Checklist applicable to position, with demonstration of all core competencies initialed by field preceptor...” Employee #13 Review of Human Resources staff documentation revealed: -Date of hire 1/9/23. -No evidence nursing competencies were assessed. During an interview on 12/7/23 at 12:15 PM, Employee #10 stated the Agency does not assess competencies for agency staff and confirmed there is no evidence of competencies being assessed for Employee #13 prior to providing patient care services.”

“Based on staff interviews and document review, the Agency failed to ensure that orientation and training regarding hospice philosophy, including methods of comfort, pain control, and symptom management were performed for all staff providing care to the patients residing at 2 of 2 nursing facilities. Findings include: Agency document titled “;Nursing Facility Services Agreement” between Delaware Hospice, Inc. and Nursing Facility #1 dated 1/14/19 stated, “;...Responsibilities of Hospice...Hospice Care Training. The Hospice retains the responsibility for ensuring that the required training of personnel who will be providing Hospice Patient care in the Facility has been provided and that a description of the training and the names of those giving the training are documented...” Agency document titled “;Nursing Facility Services Agreement” between Delaware Hospice, Inc. and Nursing Facility #2 dated 5/1/18 stated, “;...Responsibilities of Hospice...Hospice Care Training. The Hospice retains the responsibility for ensuring that the required training of personnel who will be providing Hospice Patient care in the Facility has been provided and that a description of the training and the names of those giving the training are documented...” Upon request on 12/7/23, the Agency was unable to provide documentation that personnel at Nursing Facilities #1 and #2 caring for Hospice patients received Hospice orientation. During an interview on 12/7/23 at 12:15 PM, Employee #s 1 and 4 confirmed they had no evidence personnel at Nursing Facilities #1 and #2 caring for Hospice patients received Hospice orientation.”