Avera @ Home

“Based on observation, interview, record review, and policy review, the provider failed to follow standard infection prevention practices when transporting reusable supplies and equipment in a nursing bag for one of four sampled hospice patients (1) during a home visit.Findings include: 1. Observation on 6/10/25 at 2:10 p.m. of registered nurse (RN) D during a hospice home visit at an assisted living center conducted in the community room with patient 1 revealed:*She greeted patient 1 who was sitting in a chair in front of the television in the community room with several other residents, family members, and staff present. She removed the backpack style nursing bag from her back, sat in a chair next to the patient, placed the nursing bag on her lap, removed and placed a disposable square piece of wax paper as a barrier on a foot stool located in front of her and next to the patient, removed her laptop computer from the nursing bag and placed it on top of the wax paper barrier on the foot stool. She then placed her nursing bag on the floor in front of her next to the foot stool without a barrier under it.*She completed hand hygiene, opened the nursing bag, and removed the following reusable equipment items: stethoscope, thermometer, and an oximeter (a non-invasive device that measures the percent of oxygen in the blood). She placed the stethoscope around her neck and placed the thermometer and oximeter items on the keyboard of the open laptop computer.*She then picked the equipment items up off the open laptop computer and used them on the patient to obtain the patient’s temperature, pulse, and oxygen saturation (level of oxygen in the blood), and then sat them back down on the open laptop computer. She then removed the stethoscope from around her neck and listened to the patient’s heart, lungs, and bowel sounds with the stethoscope.*When her visit was completed, she cleaned those equipment items with an alcohol wipe before returning them to her nursing bag and disposed of the wax paper barrier that her laptop computer had been placed on.2. Interview on 6/10/25 at 2:30 p.m. with RN D regarding infection prevention after the hospice home visit with patient 1 revealed:*She had worked at the hospice agency for approximately one year and four months.*She was trained on infection prevention and proper bag technique to maintain infection control during new hire orientation and received additional infection prevention training from the agency.*She agreed that placing her nursing bag on the floor without a barrier and then using it to transport reusable supplies and equipment into other patients’ homes did not follow standard infection prevention practices. 3. Interview on 6/11/25 at 2:45 p.m. with nursing manager A regarding infection prevention revealed:*Nurses received infection prevention and nursing bag technique/infection control training as part of their new hire orientation and ongoing during their employment with the agency.*The agency had a Home Health/Hospice RN Orientation Competency Check List form that was completed and signed off by a preceptor/trainer during a nurse’s new hire orientation, that included nursing bag technique/infection control.*RN D had received the nursing bag technique/infection control training and completed a validation competency with a preceptor/trainer during her orientation.*She agreed that the nursing bag placed on the floor without a barrier by RN D during the observed hospice home visit had not followed infection prevention standards, or the provider’s Bag Technique policy and posed an infection risk to patients.4. Review of RN D’s employee file with training revealed:*Her hire date was 1/8/2024.*Her Avera@Home Registered Nurse-Hospice & Home Care Orientation Skills Check List, dated as completed between 1/8/24 and 4/5/24, included the nursing bag technique/infection control training as completed with her and her preceptor’s initials on 1/13/24.5. Review of the provider’s Bag Technique Policy with a 7/1/2013 origination date, a 9/18/19 last revised date, and a 5/20/25 last approved date revealed:*”PURPOSE:Describe the procedure for maintaining a clean nursing bag/computer bag and preventing cross-contamination.*POLICY:As part of the infection/exposure control plan, Avera@Home personnel will consistently implement principles to maximize efficient use of the patient’s care supply bag when used in caring for patients.”“Bag Technique:1. The bag needs to be placed on a barrier between the surface in the patient’s home and the computer, bag, or any other equipment that goes from home to home. The barrier is to be disposed of after each use. The barrier can be any of the following approved items: wax paper, newspaper, plastic bag, or a disposable chux [underpad].””

“Based on interview, record review, and policy review, the provider failed to ensure that volunteers are providing administrative and direct patient care hours equal to or exceeding 5% of the total patient care hours provided by paid hospice employees and contract staff as required by Medicare Condition of Participation at 42 CFR Part 418 (§418.78).Findings include: 1. Interview on 6/11/25 at 2:45 p.m. with Nurse Manager A revealed:*The provider was well below the required 5% of volunteer hours.*They had tried to recruit volunteers last fall by putting up posters, making a brochure, and asking at churches. *She felt that the amount of required volunteer training hours kept people from being interested in volunteering, as it included eight hours of online modules as well as tasks and tests before they could begin one on one training with Social Worker C.*Social Worker C was responsible for volunteer coordination, and was also responsible for bereavement coordination, admissions, and the social work role. *She stated that Social Worker C “wore a lot of hats” which did not leave much time for recruitment activities. 2. Interview on 6/11/25 at 3:30 p.m. with Social Worker (MSW) and Volunteer Coordinator C revealed:*She was responsible for social work, bereavement, and volunteer coordination duties for the agency. *They were not near the 5% requirement for volunteer hours and thought they had been at about 0.5% “pretty much forever”.*They had tried to recruit volunteers last fall with a brochure and in church bulletins, and a Certified Nurse Aide with the provider had made and posted some bulletin board posters around town but she would have to look back in her records to find the date that occurred.*Her job duties did not allow her time to complete many volunteer recruitment activities.*Following the interview, she provided a copy of the bulletin board poster and brochure with October 2024 handwritten at the top.*She confirmed they tried to recruit volunteers in October 2024, but had no documentation of further recruiting after that time. 3. Review of the provider’s monthly volunteer hour data collection form for the Medicare Condition of Participation 5% match revealed:*For calendar year 2023, monthly percentages ranged from 0.63% to 2.81%. *For calendar year 2024, 11 of 12 monthly percentages ranged from 1.16% to 2.12%. The month of June had a percentage of 4.71% as they held their annual remembrance ceremony. *For January 2025 through May 2025, monthly percentages ranged from 0.00% to 0.65%.*No months met the required volunteer hours equal to a minimum of 5% of staff hours. 4. Review of the provider’s Volunteer Information Sheet revealed a total of four volunteers:*One started in 2020.*One started in 2023.*Two started in 2024. 5. Review of the provider’s Hospice Volunteer Staff policy last approved on 8/16/23 revealed:*Purpose: Ensure that qualified volunteers are available to assist with the provision of hospice services.*Policy: Volunteers will be utilized in defined roles to support ancillary, administrative, and/or patient care services.*There will be active and ongoing efforts to recruit, train, and retain volunteers. *All efforts will be documented.”