Reid Health

“Based on record review and interview, the agency failed to develop and maintain an individualized Emergency Preparedness Plan for 1 of 1 agency reviewed with the potential to affect all patients. Findings include: During an interview on 11/8/2023 at 12:30 PM, the Family Care Coordinator presented a one-page laminated sheet detailing a code plan response for active shooters, fire alarms, Thunderstorm/Tornados, Mass Casualty, Winter Weather, Missing/Abducted Child or Adult, and a Hazardous Spill and asked surveyors if this was what was requested in regard to their Emergency Preparedness Program that was requested during the entrance conference. Surveyors indicated to the Family Care Coordinator and Administrator needing to review all information the Hospice agency had on their Emergency Preparedness Plan, including but not limited to their policies, risk analysis, and tabletop and or real community exercises required by CMS (Centers for Medicare/Medicaid Services). The Family Care Coordinator and Administrator indicated this was all they had on Emergency Preparedness but would reach out to Entity 1’s Manager of Emergency Operations & Safety to obtain requested information and set up a date and time for them to bring the information and answer all of our questions. During an interview on 11/9/2023 at 2:00 PM, Entity 1’s Manager of Emergency Operations & Safety indicated that the emergency preparedness program encompasses all of Entity 1’s facilities located in Indiana and Ohio and does not have policies specific to the Hospice agency. Indicated that approximately a year and half ago when he/she onboarded it was found that each facility, including the Hospice agency encompassed a mass amount of policies and in an attempt to downsize this burden, the policies specific to the Hospice agency were archived and new policies for all Entity 1’s facilities were consolidated. Agreed that Hospice agency no longer had agency specific policies. Entity 1’s Manager of Emergency Operations & Safety indicated that during the last community disaster in April of 2023, a hazardous fire requiring patient evacuations from their homes, was implemented. Entity 1’s Manager of Operations & Safety reached out the Hospice agency to request who, if any, employees would be available to assist if needed, however, the hospice patients were not identified as those at risk. This error was noted in their emergency plan documentation along with an additional facility after recognizing this error. During an interview on 11/9/2023 at 2:05 PM, the Administrator indicated the Emergency Preparedness Program is all encompassed by Entity 1 and does not have an individualized Emergency Preparedness program, including policies, that are specific to the Hospice Agency. Indicated the Hospice agency does not complete real and/or tabletop exercises as required by CMS (Center for Medicare/Medicaid Services), nor have identified Hospice Agency specific risks. Indicated that invitations are sent to attend the Emergency Preparedness Meetings, however, to date, have been unable to attend. The Administrator indicated that during the April 2023 community disaster, the Hospice agency did reach out to each patient to identify risk and determined that no patient’s were located in an area that required evacuation. A document titled “;Hazard Vulnerability Assessment Tool – Reid Health – Richmond, 1100 Reid Parkway, Richmond” was provided by the Manager of Emergency Operations and Safety on 11/9/2023 at 2:41 PM. The Manager of Emergency Operations and Safety indicated the document identified the probability of specific hazards affecting Reid Health Hospital and did not include the assessment of hazards affecting Reid Health Hospice.”

“Based on record review and interview, the agency failed to ensure a review of patients’ prescription and over-the counter medications were reviewed, accurate, and up-to-date in 1 of 4 home visits completed. (Patient 3) Findings Include: A record review was completed for Patient 3 on 11/9/2023, for the benefit election period starting 09/14/2023--11/12/2023. The medication profile for Patient 3 was provided by the Administrator on 11/8/2023 at 4:19 PM and failed to include the following medication: Heparin (a medication used to prevent clotting of blood) 500 units/5ml [milliliter] every 6-8 weeks via Port-A-Cath (catheter placed under the skin to administer medications and complete blood draws). The medication profile for Patient 3 included the following medications Patient 3 was no longer taking: Cholecalciferol (Vitamin D3) 125 microgram tablet by mouth daily and Cyanocobalamin (Vitamin B-12) 2,500 microgram sublingual tablets, 2 tablets under the tongue by mouth daily. A physician order dated 01/06/2023, for Patient 3, titled, “Standing Order Protocol” was provided by the charge nurse on 11/9/2023 at 1:00 PM. The document indicated but was not limited to, “Flush port with 500units/5 ml Heparin every 6-8 weeks. Dx [Diagnosis] Port-A-Cath in place”. During an interview on 11/9/2023 at 10:40 AM, RN 3 (Registered Nurse) indicated that Patient 3 was no longer taking Cholecalciferol (Vitamin D) and Cyanocobalamin (Vitamin B-12) and thought she/he had removed those orders from the medication profile. RN 3 also indicated that Patient 3 has a port located at right upper chest that is being flushed with Heparin every other month. Indicated no other medications or treatments are being completed with port at this time. During an interview on 11/9/2023 at 1:25 PM, the charge nurse indicated that each patients’ medications should be reconciled at each visit to ensure a complete and accurate list of medications for each patient are available in the EMR (electronic medical record). A policy approved on 10/03/2018 and titled “;Hospice Visit Policy” was provided by the Administrator on 11/09/2023 at 12:35 PM. The policy indicated but was not limited to: “;... the guidelines to follow when completing a hospice visit...f. Hospice RN will complete full comprehensive assessment weekly (see Hospice How to Guide for documentation requirements) ...l. review of patients medication to be completed at least weekly by Hospice RN...” An untitled document was provided by the RN Charge Nurse on 11/13/2023 at 2:39 PM. The RN Charge Nurse indicated the document was the Hospice How to Guide referenced in the “;Hospice Visit Policy.” The document indicated but was not limited to: “;...Medication list should be reviewed with each visit make sure that you (sic) adding all new medications when you activate or start them. As well if you have a change in dose of medication or it pt is to stop taking them...””

“Based on observation, record review, and interview the agency failed to follow infection control standards of practice for 2 of 4 home visit patients (Patient #1, #2). Findings include: During an observation on 11/13/2023 at 9:00 AM, RN 1 was completing a head-to-toe assessment on Patient 1 located in a skilled nursing facility while sitting in a wheelchair. Shortly after beginning the assessment, RN 1, indicated to surveyor that Patient 1 requires a Hoyer lift (mechanical device used to transfer non-weight bearing patients) to stand and/or transfer with need to assess buttocks due to increased risk of pressure ulcers. RN 1 then removed gloves, noted to be visibly soiled, left Patient 1’s room without washing/sanitizing hands to retrieve a nurse to assist with standing Patient 1 up. Once returning to Patient 1’s room with the long-term care nurse, RN 1 then sanitized hands, donned new gloves and assisted the skilled nursing facility’s nurse with standing Patient 1 up and removing adult diaper to continue the assessment. Once assessment was completed, RN 1 then removed soiled gloves failed to wash and/or sanitize hands after glove removal before charting in the Hospice binder that would be left at the skilled nursing facility’s nurse’s station. RN 1 then picked up personal cell phone and attempted to call Patient 1’s family for update on patient. RN 1 failed to follow standard of practice in regard to hand hygiene practices. During an observation on 11/13/2023 at 11:00 AM, RN 2, (Registered Nurse) set up sterile field to complete suprapubic catheter (a flexible catheter used to drain urine from the bladder) in the home of Patient 2. RN 1 verbalized forgetting to bring in a syringe from supplies located in his/her car to deflate the balloon anchoring the catheter in the bladder prior to removing it. RN 2 then removed gloves, did not wash/sanitize hands, and exited the home to retrieve the syringe from his/her car. RN 2 then returned to Patient 2, sanitized hands, donned new gloves, and resumed the procedure of changing the suprapubic catheter. RN 2 failed to follow standard of practice in regard to hand hygiene practices. During an interview on 11/13/2023 at 1:24 PM, the charge nurse indicated that standard of practice in regard to hand hygiene is to wash and/or sanitize hands after removing soiled gloves. A webpage titled “;Hand Hygiene Guidance,” was reviewed at https://www.cdc.gov on 11/13/2023 and printed on 11/15/2023, indicated but was not limited to: “;The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in the healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: After touching a patient or the patients immediate environment...Immediately after glove removal...Require healthcare personnel to perform hand hygiene in accordance with the Centers for Disease Control and Prevention (CDC) recommendations...””