Hope Hospice and Palliative Care

“Based on record review and interview the agency failed to document a risk assessment based on all-hazards approach in 1 of 1 Emergency Preparedness programs reviewed. Findings include: Review of agency policy/procedure titled “Emergency / Disaster Management, Policy Number: AD.E10” last reviewed on 01/30/2024 revealed no documentation of a completed facility or community based all-hazards risk assessment. During an interview with Director A on 12/04/2024 at 9:30 AM, Director A stated, “We don’t have that” and was unaware that they (Agency) needed a risk assessment. Director A stated that the agency works with the community to determine risks and participates in community exercises. Director A was unable to provide documentation of a community based risk assessment.”

“Based on observation, record review, and interview agency staff failed to properly disinfect reusable equipment prior to returning it to the nursing bag in 1 of 1 RN (Registered Nurse) observation visit out of a total of 3 observation visits (RN B). Findings include: Review of policy “;Infection Control-Bag Technique” policy number: PC.I10, last revised 12/2020 revealed in part, “;5. All items that might be used with other patients (for example, stethoscopes) are cleaned with the appropriate disinfectant after each use and before being returned to the bag. 7. Disinfect reusable items before returning them to the bag: c. Allow items to dry before putting back in the bag.” Review of disinfectant wipes label for use revealed “;1. Wipe surface with enough wipes for treated surface to remain visibly wet for 4 minutes. 2. Let the surface dry.” An observation visit was performed with RN B at the residence of Patient #2 on 12/3/2024 at 1:15 p.m. At the conclusion of the visit, RN B used a disinfectant wipe to wipe down equipment that was used during the visit. RN B placed the equipment directly into a plastic bag and returned it to the nursing bag, without allowing the items to remain wet for 4 minutes. During an interview on 12/4/2024 at 12:30 p.m. with Director A, Director A was asked what the expectation is for staff disinfecting equipment. Director A stated that staff should follow the instructions on the label.”

“Based on record review and interview the Hospice agency failed follow agency policies and procedures and to maintain and document an effective infection control program that protects patients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases in 1 of 1 Infection Control Programs reviewed. Findings include: Review of agency policy and procedure tilted, “Infection Control - Program Policy Number: PC.I40” Last reviewed on 12/2020 revealed, “Procedures: 2. As an integral component of the hospice’s quality assessment and performance improvement program (QAPI), infection control data is collected and analyzed to determine trends and areas in need of improvement to minimize the risk of infections. Data collected may include, but not limited to; a. identification of targeted infections; b. identification of unusual/undesirable trends and factors contributing to those trends; c. monitoring staff compliance with infection control policies and procedures; and d. reportable employee or patient illnesses and infections. 3. A summary of all infection control activities performed as well as results of aggregated surveillance data analysis is provided by the QAPI committee and included in reports to the hospice’s leaders.” Review of the agency’s Infection Control program revealed no documentation of identifying infectious and communicable disease or any surveillance data that was reviewed or monitored. Review of the agency’s QAPI program revealed no documentation of an integrated infection control program. No infection control data was found. During an interview with Director A on 12/04/2024 at 9:40 AM, Director A stated the agency does not track specific patient / employee infection control data. She stated that she does monitor the CDC website for disease trends. When asked if the agency had a policy related to screening employees for communicable disease, Director A stated, “We don’t have a policy related to employees and communicable diseases.””

“Based on record review and interview, agency staff failed to ensure that the hospice plan of care identified which provider was responsible for performing their respective functions in 7 of 7 patients residing in an SNF (Skilled Nursing Facility) or an ALF (Assisted Living Facility) out of a total of 13 records reviewed (Patients #1, #2, #3, #5, #9, #10, and #13). Findings include: Review of policy “;Plan of Care (POC)” policy number PC.P40, last revised 12/2020 revealed in part, “;6. For hospice patients who reside in a skilled nursing facility, community based residential setting, or other contracted residential facility (referred to as facility): c. The hospice plan of care identifies the care and services that are needed and specifically identifies which provider (hospice, facility staff) is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care.” Review of Patients #1, #2, #3, #5, #9, #10, and #13 medical records revealed that these patients resided in a SNF or ALF. Review of the Plans of Care for these patients revealed no identification of which provider was responsible for performing their respective functions. During an interview conducted on 12/4/2024 at 1:00 p.m. with Director A, Director A was asked what the expectation is for plans of care of patients who reside in a facility. Director A stated that the plan of care should identify who is responsible for doing what.”