Gentle Shepherd Hospice Inc.

“Based on observation, interview, and policy review, the Hospice Agency failed to ensure that standard precautions were maintained during and after direct patient care for one of three patients (Patient (P) 7) observed during home visit out of a total sample of 19. This deficient practice had the potential to adversely affect all 77 patients receiving care from the hospice agency.Findings include: Review of the agency’s undated policy titled, “Bag Handling Techniques” revealed, “To prevent the contamination of the healthcare bag and to protect patients, family members, and healthcare workers from the spread of infection . . . In the home, identify a clean and safe area for the healthcare bag. Never set the healthcare bag on the floor. Always choose a place to set the bag that gives you enough workspace, is close to the patient, has a source of water, and is away from children and pets . . . Spread an impervious barrier on the surface before setting the bag down . . .”Review of the Healthecareers website at https://www.healthecareers.com/nurse-resources/nursing-patient-care/proper-bag-technique revealed, “. . . Once in the patient’s home, select a clean, flat, hard surface to place bag and set up work area . . . (Note: Use a barrier under bag to help prevent the transmission of infections, McGoldrick, 2009) . . .”Review of the facility policy titled, “Infection Control / Monitoring Performance and Infection Control Practices,” revised 01/2025, revealed, “. . . Any contaminated equipment should be wiped down with a disinfectant.”During an observation home visit on 07/09/25 at 11:35 AM, Registered Nurse (RN) 2 entered the home of P7, walked through to the family room / kitchen area, and placed his/her healthcare supply bag on the floor of the family room area. As RN2 retrieved equipment from the bag (pulse oximeter, stethoscope, blood pressure cuff), he/she cleaned each with an alcohol wipe before use. After using the items, they were laid on the top of the bag and cleaned with an alcohol wipe prior to being put into the bag. During an interview post visit on 07/09/25 at 11:50 AM, RN2 confirmed he/she cleaned his/her equipment with alcohol wipes but was not sure what the policy was regarding disinfection, stating, “I would have to check the policy for what to use.” When queried about a barrier under the bag, RN2 confirmed there was no barrier under her bag. RN2 was asked what the agency’s policy was regarding using a barrier. He/She stated, “Again, I would have to check.”During an interview on 07/09/25 at 2:45 PM, the Chief Executive Officer (CEO) confirmed a barrier should be under the bag but was unsure if the policy for infection control identified a disinfectant product.”

“Based on observation, interview, and policy review, the Hospice Agency failed to ensure that supplies kept for patient use were not expired. This had the potential to negatively affect 77 of 77 patients receiving services. Expired products may not perform as intended, leading to ineffective treatment, and/or increase the risk of infection. Findings include: Review of the facility policy titled “Medical Supply Expiration Date Auditing Policy,” dated 07/08/25, revealed, “To ensure the safe and effective use of medical supplies by regularly auditing expiration dates to prevent the use of expired products and minimize the risk of harm to patients . . . Expired products will be immediately removed from active supplies and will be disposed of according to hospice policy and procedure and healthcare regulations. Expired products will be reported to [name of employee] in case there is a need to order additional products . . .”Observation of the facility supply closets on 07/08/25 at 5:07 PM, accompanied by the Chief Executive Officer (CEO) revealed:38 blue top vacutainer tubes expired 07/01/25, confirmed by the CEO at 5:10 PM, stating, “just expired”6 Bard urinary leg bags with a “Use by” date of 03/31/2531 – 3 milliliter (ml) 21-gauge (g) x 1.5-inch (“) needles with an expiration date of 05/20/243 – 5 ml 20g x 1” needle with an expiration date of 11/2019 10 – 10ml 21g x 1” needle with expiration date of 10/15/23 4 – 1ml 27g x 0.5” expired 12/25/226 – 5ml 21g x 1.5” expired 11/30/234 – 1ml 27g x 0.5” expired 05/20202 – bottles of Iodoform wound packing expired 10/27/24Silvasorb Gel 1.5oz tubes –1 expired 7/20202 expired 02/20244 expired 12/20221 expired 01/2021 expired 11/2021 During the observation, the CEO confirmed the quantities and expiration dates of all the expired products.During an interview on 07/08/25 at 5:30 PM, the CEO stated an expectation that expired products would not be available for patient use.”