Ethos Hospice

“Based on review of the Hospice Agency’s Emergency Preparedness Program (EPP) and staff interview, the agency failed to include documentation of efforts to contact and collaborate with state and federal emergency preparedness officials/agencies for 1 of 1 emergency preparedness plan reviewed. Failure to develop and maintain a comprehensive emergency plan including an integrated response with state and federal agencies, limited the agencys ability to prepare for potential emergency situations and ensure all patients’ safety in the event of an emergency. This deficient practice had the potential to affect 309 patients in the past 12 months who received or are currently receiving services from the agency. Findings include: Review of the agency’s EPP, which includes the emergency plan, occurred on the morning of 01/10/24. The emergency plan lacked evidence the agency contacted state and federal emergency preparedness officials and, when applicable, of its participation in collaborative and cooperative planning efforts. During an interview on the morning of 01/10/24, an administrative staff member (#1) confirmed the agency failed to contact and collaborate with state and federal emergency preparedness officials or agencies in development of the emergency preparedness plan.”

“Based on review of the Hospice Agencys Emergency Preparedness Program (EPP) and staff interview, the agency failed to maintain a current list of contact information, specifically state and federal emergency preparedness officials/agencies, in their communication plan (part of the EPP). This failure had the potential to affect 309 patients in the past 12 months who received or are currently receiving services from the agency by delaying the agency’s ability to contact all levels of assistance with the potential to prevent state and federal sources of assistance from providing services to the agency and its patients during an emergency event. Findings include: Review of the agency’s EPP communication plan revealed a lack of emergency contact information for state and federal emergency preparedness officials or agencies. During an interview on the morning of 01/10/24, an administrative staff member (#1) confirmed the communication plan did not include contact information for the state or federal officials or agencies.”

“Based on observation, policy and procedure review, and staff interview, the Hospice failed to follow standards of infection control for 1 of 4 patients (Patient #1) during a home visit. Failure to practice infection control standards related to multi-use equipment and a supply bag has the potential to spread infection to patients, family, visitors, and staff. Findings include: Review of the agency policy titled “;Bag Technique” occurred on 01/11/24. This undated policy, stated, “;. . . Principals and bag technique have been developed and will be utilized to manage control infection. Procedures: . . . Upon entering the home/facility, place the bag on a hard surface, chucks pad, or hang from chair/hook on wall; ensure only touching hard surface. . . . . Remove all items which will be needed for the visit. Place items on a clean surface. Close the bag and give the patient care. If additional items are needed after care has started, wash hands before re-entering bag. Clean any visibly soiled items which will be returned to the bag. Wash hands and return equipment to the bag; close bag. . . .” Observation during a home visit on 01/08/24 at 1:30 p.m. showed the staff member (#3) placed her supply bag on a bench next to Patient #1s bed. The staff member removed a stethoscope and pulse oximeter from the supply bag, placed the pulse oximeter on the patients finger, and used the stethoscope to auscultate lung and abdomen sounds. After patient care completed, the staff member placed the stethoscope and oximeter back into the supply bag. The staff member failed to place a surface barrier under the supply bag and failed to disinfect the multi-use equipment items before placing them into the supply bag. During an interview on 01/11/24 at 12:00 p.m., two administrative staff members (#1 & #2) stated they expected staff to place a surface barrier under the supply bag and disinfect the multi-use equipment items prior to placing them into the supply bag.”

“Based on observation, record review, policy review, and staff interview, the Hospice failed to ensure the hospice aide received specific patient care instructions for 2 of 14 active patient (Patient #2 and #9) records reviewed receiving hospice aide services. Failure to ensure the aide care plan included instructions specific for each resident related to methods of transfer has the potential to cause injury to the patient and/or aide. Findings include: Review of the facility policy titled “Comprehensive Assessment - Updates” occurred on 01/11/24. This undated policy stated, “. . . Information from the updated comprehensive assessment is reviewed by the IDG [interdisciplinary group] at care planning meetings and is used to revise the patient’s plan of care as needed. . . .” - Observation on the afternoon of 01/08/24 showed a hospice aide (#4) and a second certified nurse aide (CNA) from the skilled nursing facility transferred Patient #2 from a wheelchair to a shower chair using a full-body mechanical lift. Following the shower, the hospice aide and a second CNA transferred the patient to the toilet using the same mechanical lift. The hospice aide (#4) when asked how she knew a patient’s care and transfer needs, stated her tablet (electronic charting device) contained the patient’s care plan created by the nurse. She stated the “safety measures” area listed how to transfer the patient. Review of Patient #2’s medical record occurred on January 8-10, 2024. The record indicated the hospice aide visited twice weekly and provided assistance with activities of daily living (ADLs). The aide care plan for mobility stated, “Pt [patient] tx [transfer] with SBA [standby assistance] x1 [with one staff] with ADLs and ambulation.” The IDG meeting notes, dated 09/20/23, stated in a nurse’s entry, “. . . Downgraded to Hoyer [full-body mechanical] lift, facility staff report patient shows increased weakness. . . .” During an interview on 01/11/24 at 8:30 a.m., a nurse administrator (#2) confirmed Patient #2 transferred with a Hoyer lift and they needed to update the aide care plan. - Review of Patient #9’s medical record occurred on 01/11/24. The record showed Patient #9’s aide care plan failed to include a method of transfer.The nurses’ notes, dated 12/15/23, under functional assessment stated Patient #9 “transfers bed to chair with maximal assistance.” The IDG meeting notes, dated 12/27/23, stated in a nurse’s entry, “. . . Patient extensive assist x2 [with 2 staff] with sit to stand lift . . .” During an interview on 01/11/24 at 10:40 a.m., a nurse administrator (#2) stated Patient #9’s level of transfer assistance varies from maximal assist to use of a sit to stand lift and confirmed the transfer method should be on the aide care plan.”

“Based on record review, policy and procedure review, and staff interview, the Hospice Agency failed to ensure a registered nurse (RN) performed an on-site home health aide supervisory visit every 14 days for 2 of 14 active patient records reviewed (Patient #3 and #17) receiving aide services for more than two weeks. Failure to perform supervisory visits limited the Hospices ability to assess the adequacy of aide services, in relation to the needs of the patient and family, and to ensure the aides furnished the appropriate care identified in the patient’s plan of care. Findings include: Review of the facility policy titled “Hospice Aide Supervision” occurred on 01/11/24. This undated policy stated, “. . . A registered nurse makes an on-site visit to the patient’s home no less frequently than every 14 days to ensure that the services ordered by the IDG [interdisciplinary group] and provided by the hospice aide are meeting the patient’s need. . . . The supervisory visits are documented in the patient’s clinical record every two weeks. . . .” - Review of Patient #3s active medical record occurred on 11/09/24. The record identified a certification period of 11/17/23 to 02/14/24, and the physicians orders included skilled nurse visits weekly and aide visits weekly. The record showed a RN supervisory visit completed on 12/14/23 and on 01/02/24 (19-day span). The record lacked evidence of a RN supervisory visit on or before 12/28/23, which resulted in a missed supervisory visit. During an interview on 01/09/24 at 4:15 p.m., an administrative staff member (#2) confirmed the RN failed to complete a supervisory visit every 14 days for Patient #3. - Review of Resident #17’s medical record occurred on January 10-11, 2024. The record identified a start of care date of 10/10/23, weekly skilled nurse visits, and weekly hospice aide visits. The record identified a RN supervisory visit completed on 10/20/23 and 11/07/23 (over 14 days). During an interview on the morning of 01/11/24, an administrative staff member (#2) confirmed the RN failed to complete a supervisory visit within 14 days.”