Greenwood House Hospice Services Inc.

“Based on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that the facility’s emergency preparedness plans are in collaboration with local hospitals, police, fire department, and EMS (emergency medical services). Findings include: On 5/24/24 at 12:30 PM, a review of facility documents titled “Patient Evacuation Plan” revealed that five out of five patients (P1, P2, P3, P10, and P13) had an evacuation plan which identified in the event of an emergency or natural or man-made disaster the patient would “evacuate with assistance of emergency officials. Call 911 for emergency transportation.” On 5/24/24 at 1:00 PM, an interview was conducted with Staff (S) 6, Director of Nursing. When questioned about the emergency preparedness plans, S6 stated that the facility had not had any discussions with nearby hospitals about receiving patients in the event of an emergency. S6 also stated that the facility had not discussed their emergency plan with the local police, fire department, or EMS. S6 stated that the “;on-call nurses would need training” on how to coordinate with local, state, and federal officials in the event of an emergency. Facility policy titled, “;Emergency Preparedness/Disaster Plan”, last reviewed on February 1, 2020, states “;Policy: Greenwood House Hospice is committed to providing needed services to patients during times of emergencies. It is Greenwood House Hospices goal in an emergency to maintain patient care with minimal disruption of services... Procedure: 1. Overview to Emergency Preparedness Plan, Policies and Procedures: ... B. Greenwood House Hospices emergency policies and procedures include, but are not limited to: ... ii. Procedures to inform state and local officials about hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patients medical and psychiatric condition and home environment. ...v. The development of arrangements with other hospices and other providers to receive patients in the event of limitations or cessation of operations in order to maintain the continuity of services to hospice patients...””

“Based on a review of facility documents and staff interviews, it was determined that the facility failed to measure, analyze, and track quality indicators in monitoring of its infection control program. Findings include: On 5/24/24 at 11:30 AM, the facilitys Quality Assessment/Performance Improvement (QAPI) Plan was reviewed. The facility document titled, “;Quality Assessment/Performance Improvement Plan Year: 2024-2025” stated “; ... The QAPI activities and reports for 2024-2025 include the following: ... 2. Infection Control: ... B. Evaluation of handwashing technique and compliance of hospice staff and volunteers with a target of 100% compliance...” On 5/24/24 at 12:00 PM, an interview was conducted with S6, Director of Nursing. S6 stated that hand hygiene monitoring consisted of observing the handwashing technique for all staff and volunteers in the office once a year. S6 stated that all staff and volunteers passed the handwashing technique competency observation in 2023 and 2024. During the interview, S6 confirmed that the facility evaluated handwashing techniques but did not measure staff and volunteer compliance with handwashing in a patient care setting.”

“Based on three of three home visit observations of patients(P) (#1, #2, and #3), staff interviews, and a review of facility policy and procedure, it was determined the facility failed to implement acceptable standards of practice for cleaning and disinfecting reusable equipment, storage of sterile equipment, hand hygiene, and clinical bag technique. On 5/22/24 at 11:56 AM, a home visit was observed for Patient (P) 1. Staff (S) 2, Hospice Registered Nurse (RN), entered the facility where P1 resides carrying his/her equipment bag on his/her shoulder carrying a white disposable pad in hand. The equipment bag on S2s shoulder was unzipped. At 11:58 AM, S2 entered P1s room and performed hand hygiene using soap and water for 26 seconds. At 12:01 PM, S2 placed one white disposable pad on the overbed table and placed the equipment bag onto the pad. S2 removed equipment from the bag and placed clean equipment onto the white pad. S1s equipment bag remained sitting on the table, unzipped. At 12:05 PM, upon completion of the assessment of P1, S2 placed dirty equipment next to clean equipment on the white pad. At 12:08 PM, S2 went into the bathroom to perform hand hygiene. During this time, S2s bag fell off of the table onto the floor. S2 returned to the patients bedside and found the bag on the floor. He/she used hand sanitizer and then picked the bag off of the floor and placed the bag back onto the white pad without cleaning the bag. He/she performed hand hygiene again with hand sanitizer. At 12:10 PM, S2 used “;SaniCloth” wipes to clean the thermometer, he/she then held the clean thermometer in his/her left hand while wiping down the bag with his/her right hand. At this time, S2 placed a new “;SaniCloth” wipe on the table and placed the cleaned thermometer on it. S2 now had both hands free to clean the equipment bag. He/she wiped down one side of the equipment bag with a “;SaniCloth” wipe. He/she then flipped the bag over and placed the cleaned side onto the white pad to clean the opposite side. At 12:12 PM, S2 removed his/her gloves and performed hand hygiene with hand sanitizer. He/she placed the thermometer back into the equipment bag. S2 cleaned the remainder of the equipment, and he/she placed the equipment onto the white pad to dry, in the same area it sat after it was used on P1. At 12:17 PM, S2 states that after cleaning with “;SaniCloth” wipes, equipment must be left to “;air dry.” On 5/23/24 at 9:30 AM, an interview with S6, Director of Nursing (DON) was conducted. S6 states that all staff are provided with and equipment bag upon hire for use in the field. The bag has a zipper, and separate areas for clean and dirty sections. According to S6, staff can use their own bags as long as it has a zipper, is cleanable, and has sections for clean and dirty. Facility policy titled, “;Clinical Bag Technique” reviewed on February 1, 2022, states, “;...Procedure: 1. Adhere to Standard Universal Safety and Infection Control Precautions. 2. Select a flat secure work surface to place bag and set up work area...Keep bag closed when not in use. 3. Place a barrier (paper towels, clean newspapers, or other appropriate material) on a flat surface before setting bag down...7. Following care: clean, reusable items (for example, blood pressure cuff or stethoscope, etc.) are returned to the bag...9. Soiled reusable items must be cleaned and disinfected prior to returning to the bag. Alcohol wipes are the preferred method for cleaning items...” Findings include: 1. During a home visit for P2, on 5/22/24 at 1:06 PM, the following was observed as Staff (S) 7, registered nurse (RN), provided care for the patient: At 1:06 PM, S7 setup clean area by placing a barrier cloth on the table. At 1:07 PM, S7 performed hand hygiene using hand sanitizer for 6 seconds and then shook hands out to air dry with wet sanitizer still on hands. S7 then placed blood pressure cuff, stethoscope, thermometer, and pulse ox on clean barrier. At 1:08 PM, S7 took P2s vital signs. Dirty vital sign equipment, (blood pressure cuff, thermometer, pulse ox, and stethoscope) was then placed on the clean barrier, thus contaminating barrier. At 1:11 PM, S7 attempted to clean blood pressure cuff using alcohol swab. S7 cleaned sensor area only. S7s blood pressure cuff had fabric armband and S7 was unable to clean fabric material. S7 then placed clean blood pressure cuff on the dirty barrier. S7 then proceeded to clean the rest of his/her equipment and placed back on the dirty barrier. S7 placed vital sign equipment into his/her clinical bag. At 1:12 PM, S7 performed hand hygiene. 2. At 1:27 PM, a trunk inspection of S7’s car was conducted in the presence of S7. The following was observed: S7 had one clear tote that contained patient supplies including sterile gauze, foley catheters, gloves, sani-wipes and bandages. The foley catheters were stored bent in half. The condition of the tote was dirty, with visible dirt and debris collecting at the bottom of the tote as well as on the patient supplies. The tote lid was stored underneath the tote and had accumulated dust and debris. The tote was stored next to S7’s personnel items including dirty outdoor lawn chairs. 3. On 5/23/24 at 09:58 AM, a trunk inspection of S1’s car was conducted in the presence of S1. The following was observed: S1 had two tote bins; one for dirty supplies and the other that contained patient supplies including sterile gauze, foley catheter, foley catheter insertion kits, and bandages. When asked about the storing of sterile equipment in the car, S1 stated he/she, “has two patients with foleys. I will use these foleys (indicating the foleys kept in the car) or will use the extra one in the home.” S1 indicated he/she did not date the foleys kept in the car and did not know how long they had been stored in the car. 4.During a home visit for P3, on 5/23/24 at 10:05 AM, the following was observed as S1, RN, provided care for the patient: At 10:05 AM, S1 setup clean area by placing two barrier clothes on the table. S1 placed her bag on the first barrier. At 10:06 AM, S1 reached into her bag to take the patients blood pressure. S1 then placed blood pressure cuff on barrier. At 10:08 AM, S1 reached into her bag with dirty hands to retrieve thermometer. S1 placed thermometer on clean barrier and hand sanitized. S1 took P3s temperature. 10:09 AM, S1 reached into her bag with dirty hands to retrieve stethoscope and pulse ox. S1 used equipment and placed them on the barrier. 10:11 AM, S1 cleaned equipment with dirty hands and placed equipment back into his/her clinical bag. S1 and S7 failed to prevent the transmission of infectious agents to the clean reusable equipment via improper bag technique. S1 and S7 failed to protect the integrity of sterile equipment by storing sterile equipment in a non-temperature regulated environment. S7 also failed to prevent the transmission of infectious agents by utilizing a blood pressure cuff with porous, uncleanable surfaces and improper hand hygiene. Facility policy, titled, “;Clinical Bag Technique”, last revised 02/01/22, states, “;...Greenwood House Hospice has a program developed to prevent contamination of the clinical bag and equipment to avoid cross-contamination and to establish a clean work area; proper bag technique is required in the home environment... 4. Perform hand hygiene according to universal precautions. 5. Removed needed items from bag and place on a clean barrier. 6. Decontaminate hands prior to re-entering bag for any reason... Facility policy, titled, “;Hand Washing”, last revised 02/01/22, states, ...2. Decontaminate hands with alcohol hand rubs when hands are NOT visibly soiled, before direct patient contact, before putting on gloves or taking off gloves, and after contact with objects located in the patients environment, and between nursing procedures...A. Apply product to palm of one hand. B. Follow the manufacturers recommendations regarding the volume of product to use. C. Rub hands together. D. Cover all surfaces of hands and fingers. E. Rub until hands are dry.” Facility policy titled, “;Sterile Technique” effective 2/1/2022, states, “;...2. Provided the packaging is not damaged, wet, soiled, discolored, or stained, the item will be considered sterile indefinitely unless there is a specific expiration date noted on the item. 3. Storage of sterile items must be in a clean, dry, dust-free environment to prevent contamination of the supply when opening the package. 4. Such items could include dressings, IV supplies, catheters and catheter supplies, tubing, solutions for feeding, intravenous, wound care, irrigation, etc...” In an interview conducted with S6, Director of Nursing, on 5/23/24 at 12:07 PM, he/she confirmed the facility follows CDC guidelines. The CDC guideline, titled, “;Hand Hygiene for Patients in Healthcare Settings”, written, 2/27/24, states, “;...How to clean hands with an alcohol-based hand sanitizer: 1. Put product on hands and rub together. 2. Cover all hands until hands feel dry. 3. This should take around 20 seconds...”. An interview was conducted with S6, on 5/23/22, at 11:02 AM that discussed the proper contents of the nurses clinical bag. S6 stated the nurses should have, “;hand sanitizer, wipes, towels, equipment and a small garbage bag.” The nurses are, “;allowed to use their own personal supplies as long as they are kept neat and tidy.” Per S6, there are no requirements for the blood pressure cuff, “;they should use whatever is comfortable for the patient.” The equipment should be cleaned “;using the purple sani-clothes.” Upon inspection, packaging on the “Super Sani-Cloth” states the product is to be used on “hard, nonporous surfaces.” When asked about the contents of the nurses’ trunk supply, S6 stated, “the staff should have equipment in the trunk to allow for the separation of dirty and clean. The trunks are checked two times a year for content of supplies and to make sure nothing is expired.” When asked about storing foley catheters and other sterile supplies in the trunk, S6 stated, “I do encourage the staff to keep them in the back of their trunk in case of an emergency.” At 11:06 AM, S6 stated that staff have a copy of the key for the building incase they need to get more supplies and that S6 does not encourage staff to bring their trunk supplies in and out of the house. Packaging on the “MEDLINE urinary foley catheter” states the product is, “;...sterile in unopened, undamaged package. Do not resterilize. Store product away from direct exposure to light at room temperature...” NJAC 8:42C-10.3(a)4 NJAC 8:42C-10.2b”