Hosparus, Inc.

“Based on interview and facility document review, the facility failed to protect the patients rights to voice complaints/grievances by failing to ensure the admission packet contained the correct number to the State Survey Agency to file a complaint/grievance. This deficient practice affected all patients who received care from the facility. The findings include: Review of the facility document titled, “;Care Guide,” revised 12/2024, revealed “;This booklet was written to answer some of the questions people ask once they have chosen hospice services.” Per the Care Guide, “;The Compliance Hotline: If you have concerns about patient care or safety, report your concerns to the Compliance Hotline at [telephone number].” On 01/27/2025 at 8:48 AM and 01/29/2025 at 11:14 AM, the Surveyor called the telephone number listed in the Care Guide and the telephone number was not in service. During an interview on 01/29/2025 at 1:20 PM, the Executive Director of Quality and Survey Excellence stated the number to file a complaint was listed in the admission packet (Care Guide). During an interview on 01/30/2025 at 2:45 PM, the Medical Director stated she would expect the admission packet to contain the correct telephone number for a patient to file a complaint.”

“Based on observation, interview, and facility policy review, the facility failed to ensure 2 (Registered Nurse [RN] #1 and RN #2) of 2 observed staff removed their gloves after disinfecting equipment and performed hand hygiene as per facility policy. Observation revealed Registered Nurse (RN) 1 and RN 2 they failed to remove their gloves after disinfecting their stethoscopes and failed to perform hand hygiene before they assessed a patients heart, lungs, and abdomen. The findings include: Review of the facility policy titled, “;Hand Hygiene” reviewed 08/19/2024, revealed, “;Hand hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to handwashing, antiseptic handwashing, antiseptic hand rubbing, and surgical hand asepsis.” Per policy review, the hands were the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Continued review revealed because of this, hand hygiene was the single most important procedure to prevent infection and to protect patients from health care-associated infection, hand hygiene “;must be” performed routinely and thoroughly.” Review revealed the policy specified, “;Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or proven, and after using the restroom.” Further policy review revealed an alcohol-based hand rub was “;appropriate for decontaminating the hands: before direct patient contact, putting on gloves, or inserting an invasive device - when moving from a contaminated body site to a clean body site during patient care - after contact with a patient or with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings (if hands arent visibly soiled) - after contact with inanimate objects in the patients environment - after removing gloves.” During an observation on 01/28/2025 at 11:11 AM, RN #1 performed hand hygiene prior to the application of gloves. Per observation, RN #1 then obtained a stethoscope from a patients bedside table and disinfected the stethoscope with a disinfectant wipe. Further observation revealed while wearing the same gloves she wore to disinfect the stethoscope, RN #1 assessed the patients heart, lungs, and abdomen with the stethoscope, without removing the gloves and performing hand hygiene as required. During an interview on 01/28/2025 at 11:20 AM, RN #1 stated she had received infection control training regarding personal protective equipment had been received. RN #1 stated she was expected to remove the gloves she wore to disinfect the stethoscope, perform hand hygiene, and put on a clean pair of gloves before she assessed the patient. During an observation on 01/28/2025 at 11:43 AM, RN #2 performed hand hygiene, put on gloves, and administered intravenous medication to a patient. Continued observation revealed RN #2 then removed a stethoscope from around her neck and disinfected the stethoscope with a disinfectant wipe. Further observation revealed while wearing the same gloves she wore to disinfect the stethoscope, RN #2 assessed the patients lung with the stethoscope, without removing the gloves and performing hand hygiene as required. During an interview on 01/28/2025 at 12:00 PM, RN #2 stated she received training on infection control and was expected to remove her gloves and perform hand hygiene before she moved from a dirty task to a clean task.”

“Based on interview, record review, and facility policy review, the facility failed to ensure the family of 1 (Patient #6) of 3sampled patients sampled for bereavement received bereavement services after the patients death (Patient (P) 6). The findings include: Review of the facility policy titled, “;Grief Counseling Center-Services” effective 05/17/2022, indicated revealed, “;2. [Facility name] Grief Counseling Center provides anticipatory grief services, as well as bereavement services at no charge for up to thirteen months following a hospice patients death.” Review of the facility policy titled, “;Bereavement-Mailings and Initial Contact,” effective 01/01/2025, revealed, “;bereavement services were offered through mailings and telephone calls to family members, caregivers and significant others of deceased [facility name] patients. Per review, anyone identified by the interdisciplinary group as being at risk for complicated grief or as needing immediate attention by a bereavement counselor “;is contacted within 72 hours or three business days if prior to holiday or weekend by bereavement services.” Continued review revealed the policy specified, “;4. Bereavement mailings (individualized letter with grief support handouts and current programming material) are sent at four weeks, three months and six months to anyone admitted to bereavement with correct mailing addresses.” Review of the, “;Patient Information Report” revealed the facility admitted Patient #6 on 06/25/2020. According to additional review of the Patient Information Report, the patient expired on 06/26/2020. Review of #P6s medical record revealed no evidence to indicate a bereavement risk assessment, a phone call or the mailing of a bereavement letter had been completed for the patients family after the patients death. During an interview on 01/30/2025 at 9:39 AM, the Executive Director of Counseling Services stated a nurse or member of the interdisciplinary group would call a patients family after the death of a patient and, in a week after the patients death, the chaplain would offer the patients family bereavement services. The Executive Director of Counseling Services stated at one, three, and six month intervals, a letter would be mailed to the patients family. During an interview on 01/30/2025 at 5:25 PM, the Medical Director stated she expected the facility to send out information related to group services offered by the Grief Counseling Center to the patients families.”

“Based on observation, interview, and facility document review, the facility failed to ensure preventative maintenance of a blood pressure machine was conducted on a blood pressure machine. The failure to follow the equipments service manual instructions had the potential for equipment malfunction, which could negatively impact the safety and well-being of the 10 inpatient hospice patients who received care at the facility. The findings include: Review of the “;M3 Vital Signs Monitor Service Manual,” dated 08/2008, revealed, “;Routine Check: The overall check of the monitor, including the functional safety check, must be performed by qualified personnel once every 6 to 12 months or each time after fixing up.” Per review, all checks that were needed to open the monitor enclosure “;must” be performed by qualified service personnel. Further review revealed “;Warning: If the hospital or agency does not follow a satisfactory maintenance schedule when using monitor, the monitor may become invalid, and the human health may be endangered.” Observation of the personal protective equipment (PPE) room on 01/28/2025 at 10:55 AM, revealed a blood pressure machine with no preventative maintenance sticker to indicate when preventative maintenance had last been performed on the machine. During an interview on 01/28/2025 at 11:05 AM, the Director of Inpatient Services stated she was unsure if preventative maintenance was required for the equipment. During an interview on 01/30/2025 at 9:17 AM, the Director of Facilities stated the facility had equipment that was used for patients that preventative maintenance had not been performed. The Director of Facilities stated the facility had no policies and procedures on preventative maintenance in place, and he was not sure what the expectation to perform it was. During an interview on 01/30/2025 at 5:05 PM, the Medical Director stated the expectation had always been that the facility followed the patient equipment manual for preventative maintenance.”