DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
491526 A. BUILDING __________
B. WING ______________ 		10/03/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
PERSONAL TOUCH HOME CARE & HOSPICE-NEWPORT NEWS 11817 CANON BLVD, SUITE 300, NEWPORT NEWS, VA, 23606
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0523      
27661 Based on interviews and a review of clinical records it was determined the agency staff failed to complete a comprehensive assessment within five (5) days of the start of care for three (3) of eight (8) patients in the survey sample reviewed during the initial certification period (patient #'s 4, 6, and 10). The findings were: Clinical records were reviewed in the agency from 9/30/19 through 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. 1. The clinical record of patient #4 with a documented election of hospice/start of care date of 7/03/19 was reviewed for the certification time frame of 7/03/19-9/30/19. The social worker and chaplain failed to complete the psychosocial and spiritual portion of the comprehensive assessment until 7/11/19, nine (9) days after the start of care. 2. The clinical record of patient #10 with a documented election of hospice/start of care date of 8/17/19 was reviewed for the certification time frame of 8/17/19-11/14/19. The social worker failed to complete the psychosocial portion of the comprehensive assessment until 9/04/19, nineteen (19) days after the start of care. 3. The clinical record of patient #6 with a documented election of hospice/start of care date of 07/20/19 was reviewed for the time frame of 07/20/19 to 10/01/19. The clinical record contained physician's orders for a Chaplain one (1) to two (2) times a month times three (3) months. The first Chaplain visit documented was on 08/06/19; 18 days after the start of care. The administrator provided a policy on assessments on 9/30/19 at 1:40 pm titled "Assessment and Development of The Plan of Care". The policy failed to specify who was responsible for conducting the comprehensive assessment. An interview with staff member #2 on 10/01/19 related to the completion of the comprehensive assessment revealed the "skilled nurse does the comprehensive assessment but we like all the disciplines to be in within the first 5 days". The agency failed to provide evidence the skilled nurse had the necessary training and skills or acted within the nursing scope of practice to complete the psychosocial and spiritual part of the assessment. 36944
L0531      
27661 Based on interviews and a review of clinical records it was determined the agency staff failed to complete a bereavement assessment within five (5) days of the start of care for four (4) of eight (8) patients in the survey sample reviewed during the initial certification period (patient #'s 4, 6, 8, and 10). The findings were: Clinical records were reviewed in the agency from 9/30/19 through 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. 1. The clinical record of patient #4 with a documented election of hospice/start of care date of 7/03/19 was reviewed for the certification time frame of 7/03/19-9/30/19. No initial bereavement assessment was completed. 2. The clinical record of patient #10 with a documented election of hospice/start of care date of 8/17/19 was reviewed for the certification time frame of 8/17/19-11/14/19. No initial bereavement assessment was completed. 3. The clinical record of patient #6 with a documented election of hospice/start of care date of 07/20/19 was reviewed for the time frame of 07/20/19 to 10/01/19. The clinical record failed to contain documentation of an initial bereavement assessment. 4. The clinical record of patient #8 with a documented election of hospice/start of care date of 08/07/19 was reviewed for the time frame of 08/07/19 to 10/01/19. The clinical record failed to contain documentation of an initial bereavement assessment conducted as part of the comprehensive assessment. The initial bereavement was documented on 08/20/19 by the Medical Social Worker; 12 days after the start of care. An interview with staff member #1 on 10/02/19 at 8:30 am revealed the social worker and chaplain are responsible for completing the bereavement assessment. An interview with staff member #1 on 10/03/19 at 8:55 am confirmed "there is none" in reference to the initial bereavement assessment for patients #4 and 10. 36944 Select Agency Policy Review: A copy of the agency's bereavement policy was provided on 10/01/19 at 1:00 p.m. to the MFI (Medical Facilities Inspector). The policy was titled, "BEREAVEMENT SERVICES-Hospice" a select portion read as follows: "A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice".
L0533      
27661 Based on an interview and review of clinical records it was determined the agency staff failed to update the comprehensive assessment at least every 15 days for thirteen (13) of thirteen (13) patients in the survey sample (patients #1-13). The findings were: Clinical records were reviewed in the agency from 9/30/19 through 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. 1. The clinical record for patient #4 with a start of care date of 7/03/19 was reviewed for the certification period of 07/03/19 through 9/30/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 2. The clinical record for patient #5 with a start of care date of 7/29/19 was reviewed for the certification period of 07/29/19 through 10/26/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 3. The clinical record for patient #7 with a start of care date of 5/24/19 was reviewed for the recertification period of 8/22/19 through 11/19/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 4. The clinical record for patient #9 with a start of care date of 6/13/19 was reviewed for the recertification period of 09/11/19 through 12/09/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 5. The clinical record for patient #10 with a start of care date of 8/17/19 was reviewed for the certification period of 08/17/19 through 11/14/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 6. The clinical record for patient #11 with a start of care date of 5/31/19 was reviewed for the recertification period of 08/29/19 through 11/26/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 7. The clinical record for patient #13 with a start of care date of 6/06/19 was reviewed for the recertification period of 09/04/19 through 12/12/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 36944 8. The clinical record of patient #1 with a documented election of hospice/start of care date of 06/14/19 was reviewed for the time frame of 06/14/19 to 07/15/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment. 9. The clinical record of patient #2 with a documented election of hospice/start of care date of 04/26/18 was reviewed for the recertification time frame of 04/21/19 to 06/19/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 10. The clinical record of patient #3 with a documented election of hospice/start of care date of 05/30/19 was reviewed for the time frame of 05/30/19 to 08/22/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 11. The clinical record of patient #6 with a documented election of hospice/start of care date of 07/20/19 was reviewed for the time frame of 07/20/19 to 10/01/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 12. The clinical record of patient #8 with a documented election of hospice/start of care date of 08/07/19 was reviewed for the time frame of 08/07/19 to 10/01/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. 13. The clinical record of patient #12 with a documented election of hospice/start of care date of 07/26/19 was reviewed for the time frame of 07/26/19 to 10/01/19. The record failed to contain evidence of an identifiable update to the comprehensive assessment after the initial assessment was completed on admission. An interview with staff member #2 on 10/01/19 at 1:25 pm revealed "the computer really doesn't show the update, it is part of IDG (interdisciplinary group) meetings. A review of IDG meetings failed to clearly identify updates to the comprehensive assessment were being completed.
L0536      
27661 Based on staff interview, observations made during a home visit and clinical record review it was determined the agency failed to: - Ensure all members of the Interdisciplinary groupt attended care plan meetings (L541) - Follow the plan of care, specifically wound care, foley irrigation and visit frequency (L543) - Ensure the plan of care contained a detail statement of the scope and frequency of services (L547) - Ensure the plan of care contained measureable outcomes (L548) - Document progression towards goals (L553) The cumulative effect of systematic problems exist and may be placing patients at risk.
L0541      
36946 Based on document review and staff interview it was determined the agency failed to ensure the interdisciplinary group (IDG) contained the required members to include a doctor, a registered nurse, a social worker, and a pastoral or other counselor. Findings: The interdisciplinary team meeting notes were reviewed in the agency on 10/2-3/19 for the months of July, August, and September 2019. The sign in sheet for the interdisciplinary team meeting conducted 7/23/19 failed to contain the signature of a social worker. The documentation provided by the agency indicated that 32 active patients were reviewed in this meeting to review care for the period of 7/9/19-7/23/19. The agency failed to provide documentation that a social worker was present or provided input in this meeting to update the comprehensive assessment of the 32 patients discussed as a member of the IDG. The sign in sheet for the interdisciplinary team meeting conducted 6/11/19 failed to contain a signature of an MD. The meeting notes indicated that 31 patients were reviewed during that meeting. The hospice was unable to provide evidence that a medical doctor was present during the meeting to discuss these patients. On 10/02/19 at 2:00 p.m. the MFI (Medical Facilities Inspector) asked staff member #1 why there was no signature of the physician for the IDG meeting of 06/11/19. Staff member #1 stated, he/she was probably on vacation out of the country. The MFI asked if there was a documented teleconference for the physician for this time frame and staff member #1 shook his/her head no. On 10/03/19 at approximately 8:50 am, the MFI was presented with a document titled, "Dr. [name redacted] time off." The document indicated that the physician was off of work from 6/10-19/2019. The agency was unable to provide evidence that another doctor participated in the IDG group meeting on 6/11/19.
L0543      
36944 Based on review of clinical records, home visit observations and staff interview, it was determined the agency failed to ensure staff provided care according to the patient's plan of care. Specifically, the agency staff failed to follow wound care orders per physician's order for four (4) of six (6) clinical records for whom wound care was applicable. Additionally, agency staff failed to ensure the patient's received the ordered frequency of services for the disciplines for two (2) of 13 clinical records reviewed in the survey sample (Clinical records: #2, #3, #11, and #12). The findings: Clinical records were reviewed in the agency 09/30/19, 10/01/19 and 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. 1. The clinical record of patient #2 with a documented election of hospice/start of care date of 04/26/18 was reviewed for the recertification time frame of 04/21/19 to 06/19/19. The clinical record contained a physician's order for SN (Skilled Nurse) to perform wound care as follows: Measure wound first visit of the week, sacral stage 4 pressure ulcer (wound extending to the muscle or bone): cleanse w/wnd (with wound) cleanser or SNS (sterile normal saline), pack maxorb (dressing that absorb moderate to heavy drainage) saturated w/silvasorb (with silvasorb-a gel that helps reduce the amount of infectious bacteria), cover w/optifoam (with optifoam-waterproof dressing for high fluid capacity) or equiv (equivalent). Change packing 3x/wk (three times a week), outer dressing as needed, caregiver can change on non-nursing days. The clinical record failed to contain documentation of wound care being provided per physician orders by the SN as follows: Specific Details: - 04/24/19 SN did not document use of silvasorb during the wound care according to the clinical note. - 04/26/19 SN did not document use of Silvasorb during the wound care according to the clinical note. - 04/29/19 SN did not document use ofSilvasorb during the wound care according to the clinical note. - 05/01/19 SN did not document use of Silvasorb during the wound care according to the clinical note. - 05/03/19 SN did not document use of Silvasorb during the wound care according to the clinical note. - 05/17/19 SN documented neosporin (ointment to decrease the risk of infections that contains three antibiotics) applied to right inner thigh with no physician order. - 05/22/19 SN documented medihoney (gel that removed dead skin tissue and aids in wound healing) applied to right inner thigh with no physician order. - 05/31/19 SN documented medihoney applied to right ear with no physician order. - 06/02/19 to 06/08/19 No wound measurement for week 7. - 06/14/19 SN documented aquacel AG (moisture holding dressing with a silver supplement) applied to the sacral wound with no physician order. In addition, on 06/07/19 a physician's order regarding a foley catheter (tube passed into the bladder) read as follows: SN irrigate catheter with 50 cc sterile water or normal saline every SN visit. The clinical record failed to contain documentation of the SN irrigating the patient's catheter for the subsequent ordered visits of 06/07/19, 06/10/19, 06/12/19, 06/14/19, 06/17/19 and 06/19/19. On 10/01/19 at 1:10 p.m. during the electronic medical record review staff member #1 acknowledged the agency staff failed to follow wound care orders and irrigate the patient's foley catheter as ordered for the above patient. 2. The clinical record of patient #3 with a documented election of hospice/start of care date of 05/30/19 was reviewed for the time frame of 05/30/19 to 08/22/19. The clinical record contained a physician's order for SN to perform wound care as follows: Measure wound first visit of the week, perform wound care cleanse with DWC (dermal wound cleanser), pat dry, apply Calazime (skin protectant) to affected area. The clinical record failed to contain documentation of wound care being provided per physician orders by the SN as follows: Specific Details: - 07/14/19 SN documented applied medihoney to sacral wound and optifoam with no physician order. - 07/22/19 SN documented applied medihoney to sacral wound and optifoam with no physician order. The clinical record failed to contain documentation of wound care per physician orders. 3. The clinical record of patient #12 with a documented election of hospice/start of care date of 07/26/19 was reviewed for the time frame of 07/26/19 to 10/01/19. The clinical record contained a physician's order for SN to perform wound care as follows: Measure wound first visit of the week, perform wound care 3xweekly prn (as needed) R & L (right and left) buttock stage 2 wound cleanser, pay dry, medihoney, optifoam dsg (dressing). Specific Details: - 09/03/19 SN documented right and left buttock healed, however the SN documented a new wound to the sacral crevice. The SN documented the same above wound order to the new sacral crevice wound without a physician's order. In addition, the clinical record contained a physician orders for SN two (2) times a week for 11 weeks effective 08/03/19. The clinical record contained documentation of only one (1) SN visit the week of 09/21/19 through 09/27/19 (week 10). The clinical record also contained a physician orders for Hospice Aide services two (2) times a week for one (1) week effective 07/31/19. The clinical record contained documentation of zero (0) Hospice Aide service/visit the week of 07/31/19 through 08/02/19 (week 1). During the home visit on 10/01/19 at approximately 11:05 a.m., the MFI (Medical Facilities Inspector) observed the SN performing hand hygiene with an alcohol wipe, donning clean gloves and partially removing the dressing from the patient's sacral area. The SN pulled the soiled dressing away from the skin, exposing the wound. The SN performed a visual assessment of the wound, measured the wound, and touched the wound with his/her gloved fingers. The SN removed his/her gloves and donned new clean gloves without performing hand hygiene and replaced the used, soiled dressing back over the wound. The SN then covered the dressing with an antiseptic pad as directed by the patient's caregiver. The dressing reapplied to the patient's wound was described by the caregiver as a medihoney sheet that the caregiver purchased from CVS. The box of those types of dressings was observed on the bedside table by the MFI at the time of the home visit. The SN failed to perform wound care with medihoney and an optifoam dressing as ordered in the plan of care during the home visit. Additionally, the clinical record failed to contain an order for the antiseptic pad the nurse placed over the dressing. On 10/02/19 at 11:25 a.m. the MFI conducted a phone interview with the SN who was observed at the home visit on 10/01/19. He/she stated that the family picks up different supplies for wound care and likes to try different things. When the dressing is changed by the RN (Registered Nurse), it is changed using medihoney and optifoam. 27661 4. The clinical record of patient #11 with a documented election of hospice/start of care date of 5/31/19 was reviewed for the recertification time frame of 8/29/19 to 11/26/19. The plan of care contained physician's orders for home health aide (HHA) services one (1) time per week for one (1) week and two (2) times per week for thirteen (13) weeks. The week of 9/08/19, the HHA only made one visit. The week of 9/15/19, the HHA documented one visit was refused and the record failed to contain evidence the second visit was made or refused by the patient or caregiver. The above noted findings related to staff not providing care according to the patient's plan of care was reviewed with staff member #1 and staff member #2 prior to and during the exit conference on 10/03/19 at 9:30 a.m.
L0548      
36944 Based on review of clinical records and staff interview it was determined the hospice agency failed to ensure the documentation of measurable outcomes for problems documented on the plans of care for 13 of 13 patients in the survey sample (Clinical records: #1 - #13). The findings: Clinical records were reviewed in the agency 09/30/19, 10/01/19 and 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. The clinical records for the patients listed below failed to contain measurable goals/outcomes on the plans of care. 1. The clinical record of patient #1 with a documented election of hospice/start of care date of 06/14/19 was reviewed for the time frame of 06/14/19 to 07/15/19. The plan of care failed to contain measurable goals/outcomes. 2. The clinical record of patient #2 with a documented election of hospice/start of care date of 04/26/18 was reviewed for the recertification time frame of 04/21/19 to 06/19/19. The plan of care failed to contain measurable goals/outcomes. 3. The clinical record of patient #3 with a documented election of hospice/start of care date of 05/30/19 was reviewed for the time frame of 05/30/19 to 08/22/19. The plan of care failed to contain measurable goals/outcomes. 4. The clinical record of patient #6 with a documented election of hospice/start of care date of 07/20/19 was reviewed for the time frame of 07/20/19 to 10/01/19. The plan of care failed to contain measurable goals/outcomes. 5. The clinical record of patient #8 with a documented election of hospice/start of care date of 08/07/19 was reviewed for the time frame of 08/07/19 to 10/01/19. The plan of care failed to contain measurable goals/outcomes. 6. The clinical record of patient #12 with a documented election of hospice/start of care date of 07/26/19 was reviewed for the time frame of 07/26/19 to 10/01/19. The plan of care failed to contain measurable goals/outcomes. 27661 7. The clinical record for patient #4 with a start of care date of 7/03/19 was reviewed for the certification period of 07/03/19 through 9/30/19. The plan of care failed to contain measurable goals/outcomes. 8. The clinical record for patient #5 with a start of care date of 7/29/19 was reviewed for the certification period of 07/29/19 through 10/26/19. The plan of care failed to contain measurable goals/outcomes. 9. The clinical record for patient #7 with a start of care date of 5/24/19 was reviewed for the recertification period of 8/22/19 through 11/19/19. The plan of care failed to contain measurable goals/outcomes. 10. The clinical record for patient #9 with a start of care date of 6/13/19 was reviewed for the recertification period of 09/11/19 through 12/09/19. The plan of care failed to contain measurable goals/outcomes. 11. The clinical record for patient #10 with a start of care date of 8/17/19 was reviewed for the certification period of 08/17/19 through 11/14/19. The plan of care failed to contain measurable goals/outcomes. 12. The clinical record for patient #11 with a start of care date of 5/31/19 was reviewed for the recertification period of 08/29/19 through 11/26/19. The plan of care failed to contain measurable goals/outcomes. 13. The clinical record for patient #13 with a start of care date of 6/06/19 was reviewed for the recertification period of 09/04/19 through 12/12/19. The plan of care failed to contain measurable goals/outcomes. In an interview with staff member #1 on 10/02/19 at 1:40 p.m. this MFI (Medical Facilities Inspector) asked if he/she realized none of the above goals were measurable for the above patient plans of care. Staff member #1 stated, "Yes, I see that". The lack of measurable goals in the above noted patient plans of care was discussed with staff member #1 prior to and during the exit conference on 10/03/19 at 9:30 a.m.
L0553      
36944 Based on review of clinical records and staff interview it was determined the agency failed to ensure their interdisciplinary group (IDG) documented the patient's progress toward outcomes and goals specified in the plans of care for six (6) of 13 patients in the survey sample (Clinical records: #2, #3, #4, #5, #11 and #12). The findings: Clinical records were reviewed in the agency 09/30/19, 10/01/19 and 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. The clinical records for the patients below failed to contain evidence of IDG documentation of the patient's progress toward outcomes and goals specified in the plans of care. 1. The clinical record of patient #2 with a documented election of hospice/start of care date of 04/26/18 was reviewed for the recertification time frame of 04/21/19 to 06/19/19 and failed to contain evidence of IDG documentation of the patient's progress toward outcomes and goals specified in the plans of care. 2. The clinical record of patient #3 with a documented election of hospice/start of care date of 05/30/19 was reviewed for the time frame of 05/30/19 to 08/22/19. The IDG documented: "progressing toward goals" for all the IDG meetings for the above noted time frame. 3. The clinical record of patient #12 with a documented election of hospice/start of care date of 07/26/19 was reviewed for the time frame of 07/26/19 to 10/01/19. The IDG documented: "progressing toward goals initiated at SOC (start of care)" for the IDG meetings dated 08/20/19 and 09/17/19. 27661 4. The clinical record for patient #4 with a start of care date of 7/03/19 was reviewed for the certification period of 07/03/19 through 9/30/19. The IDG (interdisciplinary group) failed to document progression towards goals. 5. The clinical record for patient #5 with a start of care date of 7/29/19 was reviewed for the certification period of 07/29/19 through 10/26/19. The IDG failed to document progression towards goals. 6. The clinical record for patient #11 with a start of care date of 5/31/19 was reviewed for the recertification period of 08/29/19 through 11/26/19. The IDG documented: "slow decline" for progression towards goals. The lack of documentation by the agency's IDG regarding the patient's progress toward outcomes and goals specified in the plans of care for the above noted patient's was discussed with staff member #1 on 10/02/19 at 1:50 p.m. and he/she acknowledged the above findings.
L0579      
27661 Based on surveyor observation and medical record review it was determined the hospice failed to ensure accepted standards of practice were followed to prevent the transmission of infections and communicable diseases including the use of standard precautions in two (2) of six (6) patients with wounds in the survey sample, patient #'s 4 and 12. Findings: Six (6) patient records in the survey sample contained orders for wound care. These records were reviewed in the agency on 09/30/19-10/2/19. Out of three (3) home visits conducted, one (1) home visit was conducted to a patient receiving wound care on 10/1/19. The findings are as follows: 1. The medical record for patient #12 with an election of hospice benefit date of 07/26/19 and a diagnosis of hemiparesis (paralysis affecting one side of the body) and cerebral vascular accident (stroke) contained a plan of care for the time period of 07/26/19-10/23/19 with wound care orders as follows: Perform wound care three times per week and prn (as needed) if soiled. Right and left buttock stage 2. Wound cleanser, pat dry, medihoney, optifoam dressing. During the home visit on 10/01/19 at approximately 11:05 AM, the nurse was observed performing hand hygiene with an alcohol wipe, donning clean gloves and partially removing the dressing from the patient's sacral area. The nurse pulled the soiled dressing away from the skin, exposing the wound. The nurse performed a visual assessment of the wound, measured the wound, and touched the wound with his/her gloved fingers. The nurse removed his/her gloves and donned new clean gloves without performing hand hygiene and replaced the used, soiled dressing back over the wound. 2. The medical record for patient #4 was reviewed on 10/01/19. The patient had a sacral wound with orders to clean with dermal wound cleanser, pat dry, us therahoney, cover with foam adhesive dressing. The nurse documented wound care on 7/16/19 and the reuse of the dressing that had already been on the wound per the caregivers request. The administrator reviewed the nursing note and acknowledged the deficient practice at the time of the record review. According to the Centers for Disease Control and Prevention (CDC), hand hygiene should be performed after contact with nonintact skin, after contact with wound dressings, and after removing gloves. (Guideline for Hand Hygiene in Health-Care Settings. Retrieved from https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf). The nurse placed the patient at risk for infection by not following standards of practice to prevent infection transmission and failing to perform hand hygiene at the required times. Additionally, the nurse did not follow the appropriate standard of practice by replacing the used, soiled dressing. Lippincott, Williams and Wilkins procedure for cleaning a wound and applying a dressing partially reads as follows, "11. Carefully remove the soiled dressings...12. After removing the dressing, note the presence, amount, type, color, and odor of any drainage on the dressings. Place soiled dressings in the appropriate waste receptacle." (Skill Checklist for Fundamentals of Nursing. The Art and Science of Nursing Care. 7th ed). These findings were discussed on 10/01/19 and 10/02/19 with staff member #1 who confirmed it is not the hospice's practice to reapply used dressings in order to measure wounds and again with staff members #1-3 during the exit conference on 10/03/2019. 36946
L0629      
36944 Based on review of clinical records and staff interview it was determined the agency failed to ensure that Hospice Aide supervisory visits were conducted by a Registered Nurse no less frequently than every 14 days to evaluate the services provided by the Hospice Aide for three (3) of five (5) clinical records reviewed of patient's receiving Hospice Aide services and for whom Hospice Aide supervisory visits were applicable (Clinical records: #2, #7 and #11). The findings: Clinical records were reviewed in the agency 09/30/19, 10/01/19 and 10/02/19 with staff members #1 and #2 as the navigators for the electronic medical records. 1. The clinical record of patient #2 with a documented election of hospice/start of care date of 04/26/18 was reviewed for the recertification time frame of 04/21/19 to 06/19/19. The plan of care contained physician orders for Hospice Aide services five (5) times a week for one (1) week, then five (5) times a week for eight (8) weeks. The clinical record contained documentation of Hospice Aide visits as per plan of care. The first documented Hospice Aide supervisory visit was on 05/03/19 with the next Hospice Aide supervisory visit on 06/07/19; 35 days in between visits. On 10/01/2019 at 12:30 p.m. staff member #2 acknowledged the past due Hospice Aide supervisory visit during the electronic medical record review for the above noted patient #2. 27661 2.The clinical record of patient #7 with a documented election of hospice/start of care date of 5/24/19 was reviewed for the recertification time frame of 8/22/19 to 11/19/19. The plan of care contained physician orders for Hospice Aide services one (1) time a week for one (1) week, then three (3) times a week for twelve (12) weeks. The nurse failed to document a supervisory visit the week of 9/23/19 when a supervisory visit was due. 3. The clinical record of patient #11 with a documented election of hospice/start of care date of 5/31/19 was reviewed for the recertification time frame of 8/29/19 to 11/26/19. The plan of care contained physician orders for Hospice Aide services one (1) time a week for one (1) week, then two (2) times a week for thirteen (13) weeks. The nurse failed to document the first supervisory visit until 9/20/19, twenty-three (23) days into the certification period.