Caring Hospice of South Jersey

“Based on observations, staff interviews, and a review of facility policies and documents, it was determined that the facility failed to maintain and document an effective infection control program as evidenced by: 1.) failure to ensure that facility policies were followed to prevent the transmission of infections and communicable diseases during the care of two of three patients (Patient (P) 2 and P3) (L0679); 2.) failure to develop and implement a coordinated program for infection control and prevention at the facility (L0580). Cross Reference: 418.60 (a) Infection Control: Prevention 418.60 (b) Infection Control: Control”

“Based on the review of the emergency preparedness plan, staff interview, and review of facility documents, it was determined the facility failed to develop and implement a process to inform state and local officials about patients in need of evacuation during an emergency. Findings include: The facility’s Emergency Preparedness Plan was reviewed on 9/4/2024. The Emergency Preparedness Plan did not identify a process to inform state and local officials concerning patients in need of evacuation during an emergency. During an interview conducted on 9/6/2024 at 12:35 PM with Staff (S)1, Manager, it was confirmed that State and Local officials were not informed and stated, “No they are not informed, we don’t inform them, they don’t have any prior awareness before an emergency evacuation happens.” A review of the facility policy titled, “Emergency/Disaster Management” last revised 4/21/23, states, “...Procedures:..2... b. Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation.””

“Based on patient interviews, staff interviews, and a review of facility documents, it was determined the facility failed to ensure arrangements with other facilities are in place to provide continuation of services in the event of evacuation or cessation of operations. Findings include:On 9/4/2024, a review of the facility’s Emergency Preparedness Plan revealed the facility did not have a policy in place to address arrangements with other facilities and providers to receive patients in the event of limitations or cessation of operations. On 9/4, 9/5 and 9/6, S1 and S2 were requested to provide copies of transfer agreements, documented arrangements with other facilities and providers, but were unable to provide documentation of any arrangements with other facilities. On 9/5/24, upon review of Patient (P) 3 and P4’s medical records, the “Patient Specific Emergency Plan” evacuation site was listed as “TBD” [To be determined]. P3 and P4 were homebound patients. On 9/5/24, a home visit was conducted to observe P3’s care. An interview with P3’s daughter was conducted at 2:00 PM. When questioned about emergency evacuation plans, P3’s daughter stated, “The facility never told us where we are supposed to evacuate [P3] to.” On 9/6/2024 at 12:37 PM, during an interview with Staff (S) 1, Manager, it was stated that in the event of an emergency, all home patients would be “sent to the local hospital.” When questioned if local hospitals were informed of the facility’s plan, S1 stated, “we would call the hospitals at the time of the emergency.” A review of the facility policy titled, “Emergency/Disaster Management” revised 4/21/23, states, “... Procedures: ... 6. Information related to emergency preparedness is included in the materials provided to patients and their caregivers when they are admitted...””

“Based on observations, staff interviews, and a review of facility documents, it was determined that the facility failed to ensure that facility policies were followed to prevent the transmission of infections and communicable diseases during the care of two of three patients (Patient (P) 2 and P3). On 9/5/24 at 2:08 PM, S6, a RN, was observed providing care for P3. At 2:10 PM, S6 placed a barrier pad on P3’s floor and placed his/her nursing bag on the barrier pad. S6 then placed a barrier pad in this inside of his/her nursing bag. At 2:12 PM, S6 began collecting vital signs on P3. S6 used a plastic, retractable tape measure to assess P3’s arm circumference. After collecting vital signs, S6 placed dirty vital sign equipment inside his/her nursing bag. At 2:30 PM, S6 completed P3’s assessment and picked up his/her nursing bag and ended the visit. P3 then walked to his/her car, opened the trunk, laid a barrier pad down, and placed his/her nursing bag on the driveway. S6 then proceeded to pull the dirty equipment out from the nursing bag to wipe down with Clorox Hydrogen Peroxide disinfectant wipes. S6 cleaned the plastic, reusable tape measure and then immediately allowed it to retract without allowing any dry time. The equipment was then placed on the barrier pad in S6’s car. An interview was conducted with S1, Manager, on 9/6/24 at 12:31 PM, regarding proper placement of the nursing bag. S1 stated, “the nursing bag should be placed on a clean, hard surface. It is not allowed on the ground.” Findings include: On 9/4/24 at 12:33 PM, Staff (S) 7, a Registered Nurse (RN), was observed providing care for P2. At 12:39 PM, S7 placed a barrier pad on P2s bed and placed the nursing bag on the barrier pad. S7 placed his/her tablet on P2s bed without using a barrier pad. At 12:40 PM, S7 began collecting vital signs on P2. S7 used a plastic, retractable tape measure to assess P2s arm circumference. After collecting vital signs, S7 placed dirty vital signs equipment back on the barrier pad with the nursing bag. At 12:45 PM, S7 finished collecting P2s vital signs and began cleaning the equipment with a Chlorox Hydrogen Peroxide disinfectant wipe. After using the disinfectant wipes on the vital sign equipment (stethoscope, pulse oximeter, sphygmomanometer, and blood pressure cuff), S7 placed the equipment immediately back into the nursing without allowing any dry time. S7 failed to disinfect the retractable tape measure and the tablet before leaving P2s room. At 12:49 PM, the visit with P2 was completed and the surveyor asked S7 to wait in the lobby of the facility while an interview was conducted with a staff member at the assisted living facility. At 12:55 PM, an interview with S7 was conducted. When questioned about the policy for cleaning tablets, S7 stated “;You just missed it. I just cleaned the tablet with a disinfectant wipe while you were interviewing the facility staff member.” When questioned about the dry time for the disinfectant wipes, S7 stated “;I have to be honest, I dont know.” S7 was unable to provide a package of the disinfectant wipes to determine the dry time. On 9/5/24 at 1:48 PM, S1, the Manager / Nursing Supervisor, provided surveyors with a package of Chlorox Hydrogen Peroxide disinfectant wipes used by nurses at the facility for review. Directions on the package stated, “;1 minute contact (dry) time.” On 9/5/24 at 2:08 PM, S6, a RN, was observed providing care for P3. At 2:10 PM, S6 placed a barrier pad on P3’s floor and placed his/her nursing bag on the barrier pad. S6 then placed a barrier pad in this inside of his/her nursing bag. At 2:12 PM, S6 began collecting vital signs on P3. S6 used a plastic, retractable tape measure to assess P3’s arm circumference. After collecting vital signs, S6 placed dirty vital sign equipment inside his/her nursing bag. At 2:30 PM, S6 completed P3’s assessment and picked up his/her nursing bag and ended the visit. P3 then walked to his/her car, opened the trunk, laid a barrier pad down, and placed his/her nursing bag on the driveway. S6 then proceeded to pull the dirty equipment out from the nursing bag to wipe down with Clorox Hydrogen Peroxide disinfectant wipes. S6 cleaned the plastic, reusable tape measure and then immediately allowed it to retract without allowing any dry time. The equipment was then placed on the barrier pad in S6’s car. On 9/6/24 at 12:31 PM, an interview was conducted with S1 When questioned about the policy for placement of the nursing bag during a home visit, S1 stated, “the nursing bag should be placed on a clean, hard surface. It is not allowed on the ground.” When questioned about the policies for cleaning equipment, S1 stated that “;equipment should be cleaned as soon as it is done being used. All equipment should be cleaned before it leaves the patients home and before it goes back into the nursing bag. After using disinfectant wipes, the nurses should let equipment dry for 30 seconds to one minute before placing it back in the bag.” Facility policy titled, “;Cleaning and Disinfecting Equipment”, states “;The agency will orient all personnel to their Infection Control Policies and Procedures on an annual basis and as deemed necessary... Reusable instruments can be disinfected in the home for procedures requiring clean technique.” 8:42C - 10.2(b)”

“Based on staff interviews and a review of facility documents, it was determined that the facility failed to develop and implement a coordinated program for infection control and prevention at the facility. Findings include: On 9/4/24 at 9:50 AM, an entrance conference was conducted with Staff (S) 1, the Nursing Supervisor; S2, the Chief Operating Officer; and S3, the Regional QAPI Coordinator. When questioned about the infection control program, S2 stated that there was a regional infection control professional (ICP) but was unsure who the day-to-day ICP would be in the facility. S2 stated that the day-to-day ICP would probably be S1. On 9/6/24 at 11:30 AM, a review of S1s personnel file was conducted. S1s personnel file did not contain any additional training, education, or certification for infection control. S1s job description did not contain any information about being the day-to-day infection control lead. S1s resume did not list any experience related to infection control. On 9/6/24 at 11:53 AM, during an interview, S2 confirmed that S1 did not have any additional training in infection control beyond the annual infection control training provided to all the staff at the facility. On 9/6/24 at 12:20 PM, an interview was conducted with S1. S1 confirmed that he/she does not have any training in infection control other than the basic training provided to staff. S1 stated that he/she conducts the training for staff on bag technique and hand hygiene and supervises the annual competencies for staff infection control practices at the facility. 8:42C – 10.1(b) On 9/4/24 at 9:50 AM, during the entrance conference, S1, S2, and S3 were questioned about the infection control committee members. S2 and S3 stated that the infection control committee members would be the same as the IDG (interdisciplinary group) members and that the infection control committee would be a part of QAPI (Quality Assurance and Performance Improvement). On 9/4/24 at 12:00 PM, during the review of the facility’s Infection Control Plan and QAPI documents, there was no documented evidence of an infection control meeting minutes in either document. Upon request, S1 and S2 were unable to provide documentation of meeting minutes for an infection control committee. On 9/6/24 at 12:20 PM, upon interview, S1 confirmed that there was no infection control committee for the facility because “;it is a small office.” 8:42C – 10.2(a)”

“Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure the medical records were completed within 48 hours in four of 14 medical records reviewed (Patient (P) 2, 3, 4, 8, and 10). On 9/5/24 at 3:30 PM, P10s medical record was reviewed. The review of P10s medical record revealed three nursing assessments that were documented greater than 48 hours after the clinician visit. On 7/26/24 at 3:30 PM, P10 was seen in-home by a hospice nurse. The documentation of this nursing assessment was signed on 8/4/24 at 9:07 PM. On 8/21/24 at 10:06 AM, P10 was seen in- home by a hospice nurse. On 9/5/24 at 3:45 PM, the nursing assessment for 8/21/24 was listed as “;pending” and the documentation only included P10s temperature. The documentation of this nursing assessment was completed and signed on 9/6/24 at 10:55 AM. On 8/30/24 at 4:34 PM, P10 was seen in- home by a hospice nurse. On 9/5/24 at 3:45 PM, the nursing assessment for 8/30/24 was listed as “;pending” and the documentation was blank. The documentation of this nursing assessment was completed and signed on 9/6/24 at 11:21 AM. On 9/6/24 at 12:51 PM, Staff (S) 1, Patient Care Manager, explained that clinicians are expected to write and upload notes 48 hours after patient visit. S1 confirmed that when a clinician signs the documentation, it is considered complete. S1 verified that the date and timestamp listed at the bottom of documentation is when a clinician signs the document as complete. Facility policy titled, “;Clinical Record Guidelines for EMR [Electronic Medical Record]” states, “;...Procedures: ... 3. Entries must be accurate, relevant, timely and complete. 4. Notes must be completed, reviewed, and synchronized to the clinical record as soon as possible after the visit. This will occur within forty-eight hours after the visit, but no less often than weekly...” On 9/5/24, P3’s medical record was reviewed. The review of P3’s medical record revealed two nursing assessments that were documented greater than 48 hours after the clinician visit. On 8/15/24 at 12:17 PM, P3 was seen in-home by a hospice nurse. The documentation of this nursing assessment was signed 9/3/24 at 9:09 PM. On 8/21/24 at 12:41 PM, P3 was seen in-home by a hospice nurse. The documentation of this nursing assessment was signed 9/3/24 at 9:30 PM. On 9/5/24, P4’s medical record was reviewed. The review of P4’s medical record revealed two nursing assessments that were documented greater than 48 hours after the clinician visit. On 8/13/24 at 3:05 PM, P4 was seen in-home by a hospice nurse. The documentation of this nursing assessment was signed on 8/26/24 at 11:14 AM. On 8/15/24 at 2:01 PM, P4 was seen in-home by a hospice nurse. The documentation of this nursing assessment was signed on 8/26/24 at 12:07 PM. On 9/6/24, P8’s medical record was reviewed. The review of P8’s medical record revealed two nursing assessments that were documented greater than 48 hours after the clinician visit. On 8/12/24 at 10:51 AM, P8 was seen by a hospice nurse. The documentation of this nursing assessment was signed on 9/4/24 at 10:19 AM. On 8/21/24 at 10:21 AM, P8 was seen by a hospice nurse. The documentation of this nursing assessment was signed on 9/5/24 at 11:15 AM.”

“Based on a review of medical records, staff interview, and review of facility documents, it was determined that the facility failed to document in the patient’s medical record that a written copy of policies and procedures for the management and disposal of controlled drugs was provided to two of two patients (Patient (P) 3 and 4) receiving care at their home. Findings include: On 9/5/24, a medical record review was conducted for P3 and P4. The medical records for P3 and P4 lacked documentation that the hospice provided a copy of the hospice’s policies and procedures for the safe management and disposal of controlled drugs to the patient or the patient’s representative. An interview was conducted with Staff (S) 1, Manager, on 9/6/24 at 12:45 PM. S1 stated that comfort packs (medicine kits that may contain controlled substances such as Morphine and Ativan) are given to every homebound patient. Education on the comfort packs is provided to patients and “should be written in the nursing documentation notes.” Upon request, S1 was unable to provide evidence of this documentation for P3 and P4. A review of facility policy titled, “Medications - Use and Disposal of Controlled Substances”, last reviewed 3/30/18, states, “... Procedures: 1. At the time when controlled substances are first ordered, the hospice nurse: ... c. documents in the patient’s clinical record that written policies and procedures for managing controlled drugs were provided and discussed.””