Anvoi Hospice

“Based on observation, interview and record review the agency failed to ensure the hospice staff followed accepted standards of practice to prevent the transmission of infections for 1 (Patient #3) of 4 patients observed during home visits. Findings: Observation on 03/02/2026 at 2:30PM revealed S4Registered Nurse performed hand hygiene and applied gloves to her hands. With gloved hands, S4Registered Nurse positioned Patient #3 and removed Patient #3’s soiled bandage from her sacral wound, discarded the soiled bandage, and without removing her gloves or performing hand hygiene, S4 Registered Nurse reached into an open multiuse gauze packet and removed the clean gauze. Further observation, revealed, S4 Registered Nurse then picked up a wound cleanser bottle and sprayed the clean gauze, with the same gloved hands. S4Registered Nurse then cleaned and measured Patient #3’s sacral wound. S4 Registered Nurse then removed her gloves, performed hand hygiene and redressed Patient #3’s sacral wound. After completion of wound care to Patient #3’s sacral wound, S4Registered Nurse removed Patient #3’s brief, repositioned Patient #3 to expose her left hip wound, removed her gloves and performed hand hygiene. S4Registered Nurse then applied clean gloves, pushed the bed table to left side of the bed, with gloved hand and removed Patient #3’s soiled left hip dressing and discarded it. With the same gloved hand, S4Registered Nurse reached in to the open multiple use gauze packet and removed the clean gauze, sprayed wound cleanser on the gauze, cleaned and measured the left hip wound, prepared clean dressing and redressed the wound. In an interview on 03/03/2026 at 4:00PM, S1Director of Nursing confirmed S4Registered Nurse should have changed her gloves and performed hand hygiene after removing the patient’s soiled dressing, before obtaining clean gauze and after cleaning the Patient #3’s wounds, prior to redressing the wounds.”

“Based on interview and record review the agency failed to ensure a registered nurse made an on-site visit to the patient’s home no less frequently than every 14 days for 1(Patient #1) of 17 patients reviewed for hospice aide supervisory visits. Findings: Patient #1Review of Patient #1’s hospice plan of care for certification period 12/11/2025 to 3/10/2026 revealed Patient #1 was to receive hospice aide services three - five days a week. Review of Patient #1’s record revealed the hospice aide provided services in part: 12/12/2025, 12/15/2025 – 12,19/2025, 12/22/2025, 12/23/2025, 12/26/2025, 12/29/2025 – 12/31/2025, 01/02/2026, 01/05/2026, 01/07/2026, 01/12/2026, 01/14/2026, 01/16/2026, 01/19/2026, 01/21/2026, 01/23/2026, 01/26/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/13/2026, 02/16/2026, 02/18/2026, 02/20/2026, 02/23/2026, 02/25/2026, and 02/27,2026. Further review revealed no documented evidence the registered nurse performed an on-site hospice aide supervisory visit. In interview on 03/02/2026 at 1:28PM, S2Director of Nursing indicated hospice aide supervisory visits were not completed on-site every 14 days. S2Director of Nursing further indicated she was not aware hospice aide supervisory visits were required to be on-site, that it was the agency’s standard practice to conduct the supervisory visits via telephone call.”

“Based on interview and record review, the agency failed to ensure volunteers provided administrative and/or direct patient care service, which equaled 5 percent or greater of the total patient care hours of all hospice contract and employed staff. Findings: Review of the agency’s volunteer binder revealed the percentage of volunteer hours for December 2025 was 4.12%, for November 2025 was 1.1%, for October 2025 was 1.24%, for September 2025 was 2.98% and for August 2025 was 3.23%. Review of the agency’s quarterly Volunteer Hour Report revealed the third quarter of 2025 total patient care hours were 2875.70, the total volunteer hours were 104.92, and the percent of volunteer hours for the quarter was 3.52; the fourth quarter of 2025 total patient care hours were 3,151.70, the total volunteer hours were 72, and the percent of volunteer hours was 2.23. Further review revealed the total patient care hours provided for 2025 were10853.63, the total volunteer hours for 2025 was 451.92, percent of volunteer hours for 2025 was 4.16. In an interview on 03/04/2026 at 1:22PM, S1Administrator stated the agency did not have 5% or greater involvement of hospice volunteers for 2025 as required. S1Administrator confirmed the total percentage for 2025 was 4.16 percent.”