Pennyroyal Hospice

“Based on review of the agency’s “Emergency Operations Plan (EOP),” interview, and review of the Agency’s policy, the facility failed to conduct exercises to test the “Emergency Plan” at least annually. This had the potential to affect all 41 current patients, staff, or visitor during a potential emergent event. The findings include: Review of the undated agency policy titled, ’’Emergency/Disaster Management,’’ indicated ’’...Procedures...7. Components of the Emergency/Disaster Management Plan were the subject of rehearsals and drills on an annual basis.’’ Review of facility provided ’’EOP,’’ dated10/02/23, indicated there was no evidence of any annual rehearsals and/or drills conducted in the last year. During an interview on 07/26/24 at 7:25 AM, with the Executive Director (ED), he/she stated they did not have any annual exercises conducted for the past year. The Clinical Director also confirmed this.”

“Based on review of QAPI (quality assessment and performance improvement) records, interview, and review of the agency policy, the agency failed to implement and maintain documentation of performance improvement projects (PIPs) being conducted currently, the reasons for conducting these projects, and any measurable progress achieved on these projects. Failure to develop performance improvement projects has the potential to allow agency problems to remain unidentified and does not enable the hospice to reflect improved outcomes. This deficient practice had the potential to affect the 41 patients who were currently receiving hospice services and all future hospice patients. The findings include: A review of QAPI documents revealed there was no documented evidence of ongoing PIPs. During an interview on 07/26/2024 at 1:30 PM, the Clinical Director, who was responsible for the QAPI program, acknowledged this finding and stated, “We have not yet started any specific PIPs for the hospice program.” These findings were also confirmed by the Executive Director who was present at the QAPI review. Review of the agency policy titled “;QAPI – Performance Improvement Activities and Projects,” undated, revealed “;The QAPI Committee makes recommendations for potential performance improvement activities and projects that reflect areas of weakness, as identified through data analysis and the needs of the organization. The planning, development, and implementation of performance improvement activities and projects is comprehensive and collaborative. All performance improvement projects conducted, the reasons for selecting specific projects and the measurable progress achieved of all activities and projects are documented in QAPI Committee meeting minutes.””

“Based on observation, interview, and review of the agency’s policy the agency failed to implement accepted standards of practice to prevent the potential of transmission of infections and communicable diseases in two of four home visits with (Registered Nurse (RN)5 and (Home Hospice Aide HHA5). This deficient practice had the potential to affect all 41 patients who were currently receiving hospice services. The findings include: 1. During a joint home visit on 07/25/2024 at 11:00 AM, RN5 was observed placing the equipment bag on the floor of Patient (P)2’s bedroom without any type of barrier to protect the cleanliness of the bag. RN5 used a plastic barrier on the bedside table to place several pieces of equipment used during the home visit, including the blood pressure cuff, stethoscope, and thermometer. At the conclusion of the visit, RN5 wrapped the equipment in the contaminated barrier and placed the entire package in the equipment bag prior to leaving the home. Review of the agencys policy titled “;Infection Control – Bag Technique,” undated, indicated “;Upon arrival at the patients home, the bag is placed on a clean surface utilizing newspaper, paper towels, and /or a liner as a barrier. Clean and dirty items are kept separate within the bag. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag.” 2. During a joint home visit on 07/25/2024 at 8:30 AM HHA5 was observed completing vital signs for P1. HHA5 used a plastic barrier on the bedside table to place the required equipment needed during the visit, including the blood pressure cuff, stethoscope, and thermometer. HHA5 donned clean gloves and completed the vital sign readings. After the conclusion of the vital signs, and without changing the contaminated gloves, HHA5 proceeded to clean all the used equipment with alcohol. HHA5 then placed the equipment back in the clean supply bag prior to leaving the facility. At the end of the visit, when HHA5 was asked when changing gloves was appropriate, HHA5 stated, “;I guess I forgot to change gloves after I did vital signs.” During an interview on 07/25/2024 at 5:00 PM, these findings were discussed with the Clinical Director who responded, “HHA5 should have changed gloves before cleaning the equipment, which is what our policy requires.” The Clinical Director acknowledged that HHA5 failed to maintain the cleanliness of the equipment bag and its contents. At this time, the Clinical Director was asked for a written policy that outlined agency expectations for glove changing, however was unable to provide said policy stating that “;all we have is a handwashing policy – and it doesnt talk about when glove changing is required.””

“Based on personnel file review, interview, and review of agency policy, the hospice agency failed to ensure that an initial hospice orientation and competency evaluation addressing the employee’s specific duties had been documented for each professional staff member providing patient care services in three of three professional files, (Registered Nurse (RN) 1, RN 2, and Medical Social Worker (MSW) reviewed. This could potentially allow employees who had not been oriented to their specific job responsibilities to fail to be responsive to the hospice needs of the patient/family. This had the potential to affect the 41 patients who were currently receiving hospice services and all future hospice patients. The findings include: Review of the agency policy titled “Competency Assessment,” undated, revealed “The hospices governing body is ultimately responsible for assuring that all individuals who provide patient and family care and services on the hospices behalf are competent to do so. As a component of the orientation process, new staff complete a competency evaluation prior to providing care.” 1.Review of the personnel file for RN1 revealed the RN was hired on 07/07/2007. There was no evidence of a completed orientation or competency assessment that addressed the employee’s specific job duties in the personnel file provided. 2.Review of the personnel file for RN2 revealed the RN’s date of hire was 05/16/2024. There was no evidence of a completed orientation or competency assessment that addressed the employee’s specific job duties in the personnel file provided. 3.Review of the personnel file for MSW revealed the MSW hire date was 10/22/2018. There was no evidence of a completed orientation or competency assessment that addressed the employee’s specific job duties in the personnel file provided. During an interview on 07/24/2024 at 4:30 PM, the Clinical Director verified these findings and stated, “We transition our employees into their hospice roles but do not have documentation of a completed hospice orientation or competency evaluation.” The Clinical Director acknowledged that per agency policy, each employee was required to complete orientation appropriate to their job functions... and that documentation of successful completion of the orientation program should be retained in the employee’s personnel file.”

“Based on review of personnel files and staff interview, it was determined the hospice agency failed to maintain documentation that a criminal background check had been completed for each hospice employee providing patient care in two of five personnel files (Registered Nurse (RN)1 and Home Hospice Aide (HHA)5 reviewed. This had the potential to negatively affect the employees and the 41 patients who were currently receiving hospice services and all future hospice patients / patient family units. The findings include: 1.Review of RN1’s personnel file revealed a hire date of 07/09/2007. There was no documentation that a criminal background check had been obtained for the employee. 2.Review of HHA5’s personnel file revealed a hire date of 12/20/2021. There was no documentation that a criminal background check had been obtained for the employee. During an interview on 07/24/2024, at 4:00 PM, the Human Resources Manager (HRM) was questioned about the missing criminal background checks. The HRM stated that hospice policy required background checks on all employees to be done at hire and would attempt to locate the missing background checks. During an interview on 07/25/2024 at 12:10 PM the HRM revealed there was no documentation to show that criminal background checks were completed for RN1 or for HHA5. During an interview on 07/25/2024 at 1:00 PM these findings were discussed with the Clinical Director. The Clinical Director confirmed that the agency’s hospice policy required background checks on all employees to be done at hire and acknowledged the failure to obtain criminal background checks on RN1 and HHA5, stating “;they must have been missed.””