SSM Hospice of Illinois

“Observed in Record Review. In 2 of 14 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. In review of the medical record for HOSRRHV #1 it was noted that the psychosocial assessment was completed on the 6th day following the election of the hospice benefit. Additionally in review of the medical record from the branch office for HOSRRHV #4 it was noted that the psychosocial assessment was completed on the 6th day following the election of the hospice benefit. This was validated with the Hospice Manager.”

“Observed in Record Review. In 12 of 12 patient records reviewed, the initial bereavement assessment was not completed as required by the organization’s policy; Assessment of Patient and Client and the policy Bereavement Services states that a bereaved risk assessment shall be completed at the time the psychosocial assessment is completed. In review of the medical record for HOSRRHV #1 HOSRRHV #2, HOSRRHV #3, HOSRRHV #4 and 9 additional hospice patient records there was no evidence that the bereavement risk assessment had been completed at the election of the hospice benefit. Additionally, in review of 13 of 13 medical records for hospice patients there was no evidence that the organization had assessed and documented the need for volunteer services. This was validated by the Hospice Supervisor.”

“Observed in Patient Home. In 3 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. For HOSRRHV #2 the hospice aide did not follow the organization’s hand hygiene/standard precautions policy when it was observed that the hospice aide changed gloves 5 times throughout providing care however failed to perform hand hygiene between glove changes. Also, for HOSRRHV #3 the RN failed to perform hand hygiene during wound care when she removed a glove and entered the clinical bag without performing hand hygiene. Finally, for the home visit from the branch office for HOSRRHV #4 the surveyor observed the RN enter the clinical bag without performing hand hygiene first and wearing dirty gloves. This was validated by the RN/Scribe. Observed in Patient Home. In 2 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. the organization did not implement their infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For HOSRRHV #1 the medical social worker did not follow contact time (wet time) of two minutes when cleaning the tablet with a Sani-wipe as specified by the manufacturer’s instructions for use.. Also for the patient visit from the branch office patient HOSRRHV #4 the surveyor observed the RN clean the blood pressure cuff and wipe the case and then put the equipment into the clinical bag (no dwell time) This was validated by the RN/Scribe.”

“Observed in Patient Home. In 3 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. For HOSRRHV #2 the hospice aide did not follow the organization’s hand hygiene/standard precautions policy when it was observed that the hospice aide changed gloves 5 times throughout providing care however failed to perform hand hygiene between glove changes. Also, for HOSRRHV #3 the RN failed to perform hand hygiene during wound care when she removed a glove and entered the clinical bag without performing hand hygiene. Finally, for the home visit from the branch office for HOSRRHV #4 the surveyor observed the RN enter the clinical bag without performing hand hygiene first and wearing dirty gloves. This was validated by the RN/Scribe. Observed in Patient Home. In 2 of 4 home visits conducted, the organization had not implemented their infection prevention and control activities. the organization did not implement their infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. For HOSRRHV #1 the medical social worker did not follow contact time (wet time) of two minutes when cleaning the tablet with a Sani-wipe as specified by the manufacturer’s instructions for use.. Also for the patient visit from the branch office patient HOSRRHV #4 the surveyor observed the RN clean the blood pressure cuff and wipe the case and then put the equipment into the clinical bag (no dwell time) This was validated by the RN/Scribe.”