Solace Healthcare

“Based on IDG observation and staff interviews, it was determined the hospice failed to ensure the IDG included all disciplines, specifically, a chaplain or counselor. This failure had the potential to interfere with the quality of patient care and not meet all patient needs. Findings include: Surveyors attended and observed the IDG meeting on 2/05/25 beginning at 8:30 AM. In attendance were the Medical Director, Social Worker, DON and RN case manager. There was no Chaplain present. The DON was interviewed on 2/05/25 at 2:30 PM. When asked if the hospice had a chaplain, she stated they did not. When asked how long they have been without a chaplain, she stated it had been about 6 months. The Administrator was interviewed on 2/05/25 at 2:45 PM. He was asked if they were currently searching for a chaplain. He stated they were not. The hospice agency did not have the ability to provide spiritual support to its patients and had the potential to affect all patients.”

“Based on direct observation, staff interview, and hospice policy and procedures, it was determined the hospice failed to ensure proper infection control was maintained during 2 of 3 observational patient visits (Patients #2, Patient #3) conducted by surveyors. This had the potential to affect all hospice patients should proper infection control methods not be maintained. Findings include: A hospice policy titled “Hand Hygiene, Ref #4006” was reviewed. The policy stated: “All staff will use the hand-hygiene techniques, as set forth in the following procedure. The CDC has recommended guidelines on when to use...after coming in contact with patient’s intact skin, i.e., taking a patient’s blood pressure, pulse...always after removing gloves.” This policy was not followed. A hospice policy titled “Hospice Aide Bag, Ref #4016” was reviewed. The policy stated: “After hand cleansing, the supplies and/or equipment needed for the visit will be removed from the bag...when the visit is completed, reusable equipment will be cleaned, hands will be cleansed, and equipment and supplies will be returned to the bag.” This policy was not followed. A hospice policy titled “Nursing Bag, Ref #4015” was reviewed. The policy stated: “the bag should be placed on a barrier...after hand cleansing, all the clean supplies and equipment needed for the visit are removed from the bag...when the visit is completed...reusable equipment is cleaned using alcohol...hands are washed prior to returning clean equipment and supplies to the bag.” This policy was not followed. Examples include: 1.An HHA observation visit was conducted on 2/05/25, beginning at 11:30 AM with Patient #2. Patient #2 was an 87 year old male on hospice services with a terminal diagnosis of congestive heart failure. The HHA was observed to take the patient’s blood pressure, pulse, and oxygen saturation. The HHA then returned the used equipment of blood pressure cuff and pulse oximeter to her aide bag without cleaning the equipment or her hands. The HHA then assisted Patient #2 to the bathroom, donned gloves, and assisted patient to prepare for the shower. The HHA did not use hand sanitizer prior to donning gloves. The HHA was interviewed on 2/05/25, at 12:30 PM, after the observation visit. She confirmed she did not follow hand hygiene policy. She confirmed she neglected to perform proper hand hygiene before donning gloves and did not clean her equipment after use on patient. 2. An RN observation visit was conducted on 2/05/25, beginning at 1:00 PM with Patient #3. Patient #3 was an 82 year old male on hospice services with a terminal diagnosis of lung cancer. The RN was observed to remove a blood pressure cuff and pulse oximeter from her jacket pocket and take the vital signs of Patient #3. The RN then placed the used blood pressure cuff and pulse oximeter back into her jacket pocket. She then removed a stethoscope from around her neck and proceeded to listen to patient #3’s lung sounds. The RN then placed the stethoscope around her neck again. The RN did not carry a nursing bag into the patient home and did not clean her equipment after use. The RN was interviewed on 2/05/25, at 1:45 PM, after the observation visit. The RN stated she did not like to bring her nursing bag into the patient home if it was not needed. The RN stated she cleans the used equipment in her pocket when she returns to her vehicle. When asked if she considered her jacket pockets to be a clean area, she agreed they were not. The DON was interviewed on 2/05/25, beginning at 4:00 PM. The observation findings were reviewed with her. The DON confirmed the HHA and the RN did not follow the hospice policies for bag technique and hand hygiene. Infection control policies were not followed.”

“Based on Hospice Policy, IDG observation and staff interviews, it was determined the hospice failed to ensure the spiritual needs of patient were being assessed or met. This failure had the potential to interfere with the quality of patient care and not meet all patient needs. Findings include: A hospice policy titled “Spiritual Care Services, Ref #9112” was reviewed. The policy stated, “Hospice provides spiritual support in keeping with the patient’s belief system and practice and as developed by the interdisciplinary team’s plan of care...The Hospice Chaplain/Spiritual Care Coordinator provides direct support and coordinates spiritual care...The Chaplain provides spiritual services or coordinates a referral.” This policy was not followed. The DON was interviewed on 2/05/25 at 2:30 PM. When asked if the hospice had a chaplain, she stated they did not. When asked how long they have been without a chaplain, she stated it had been about 6 months. The Administrator was interviewed on 2/05/25 at 2:45 PM. He was asked if they were currently searching for a chaplain. He stated they were not. The hospice did not follow follow their policy of providing patient spiritual support via Hospice Chaplain/Spiritual Care Coordinator which had the potential to affect all patients.”