QA Investigation Results

Pennsylvania Department of Health
EXCELA HEALTH HOME CARE & HOSPICE
Health Inspection Results
EXCELA HEALTH HOME CARE & HOSPICE
Health Inspection Results For:


There are  14 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced Medicare recertification and State relicensure survey completed on 9/21/2018, Excela Health Home Care & Hospice was found to be in compliance with the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care - Emergency Preparedness.





Plan of Correction:




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey conducted on 9/18/2018 through 9/21/2018, Excela Health Home Care & Hospice was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.







Plan of Correction:




418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT

Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:

(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.



Observations:


Based on review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to review all the patient's allergies and update the medication profile for one (1) of sixteen (16) MR reviewed (MR13).

Findings included:

A review of agency policy on 9/18/2018 at approximately 10:20 AM revealed:
Policy "TITLE: Initial Assessment/Reassessment...III. Guidelines...5. A comprehensive assessment will be performed. This assessment must include a review of all medications the patient/client is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, noncompliance with drug therapy, and drug therapy currently associated with laboratory monitoring. The assessment includes a review of all of the patient/client's drugs including all prescribed, over the counter medications, and herbal remedies and other alternative treatments that could affect drug therapy the patient/client is using. The physician is notified regarding any medication discrepancies, side effects, problems, or reactions..."

A review of MR13 on 9/21/2018 at approximately 1:05 PM revealed, start of care date of 6/20/2018 for a current certification period starting 6/20/2018 and ending 9/17/2018. The terminal diagnosis was respiratory failure. The hospital "Allergies" form (review electronic at 1:20 PM 9/21/2018) was compared to the hospice agency "Medication Profile" (print date 9/18/2018 4:23:23PM).

The allergies listed on the forms did not match, the following medications were listed under the "Allergies" section on the hospital document: "avelox, fentaNYL, flagyl, Neosporin, Niaspan ER, Plaquenil Sulfa, Prevacid, PriLOEC, Stadol." Listed under "Allergy" on the agency medication profile was: "PRILOSEC, FENTANYL, NEOSPORIN, AVELOX, Flagyl, Niaspan Extended-Release, Plaquenil, Prevacid." Stadol was not listed on the hospice medication profile or plan of care.

An exit interview was conducted on 9/21/2018 at approximately 3:45 PM with the executive director, hospice supervisor, nurse educator, hospice supervisor, director of finance, manager home health, manager education quality, manager hospice/palliative care, manager homecare & hospice and quality supervisor which confirmed the above information.










Plan of Correction:

L0530: 418.54(c)(6)- Content of Comprehensive Assessment:
Mandatory education will be provided to hospice nursing staff by the Hospice Supervisors. Education to include review of the medication profile including the reconciliation of medications and allergies. Education will be completed by October 31, 2018. During the months of November and December 2018 an audit of 100% of new admission patient charts will be conducted by the hospice supervisors or designee for ongoing compliance with the policy. A monthly written report on the findings will be provided to the executive director, the quality manager, and the hospice manager. Any non-compliance will be addressed immediately with the involved staff member and action taken as needed. After the two month audit concludes the hospice QAPI program will continue to monitor this measure to ensure continued compliance.


418.104(c) STANDARD
PROTECTION OF INFORMATION

Name - Component - 00
The clinical record, its contents and the information contained therein must be safeguarded against loss or unauthorized use. The hospice must be in compliance with the Department's rules regarding personal health information as set out at 45 CFR parts 160 and 164.



Observations:



Based on review of agency policy, observation, and staff (EMP) interview, the agency failed to ensure medical records (MR) were protected from loss and protected from unauthorized access in accordance with the agency policy for eight (8) of sixteen (16) MR review (MR1-MR8).


Findings included:

A review of agency policy on 9/18/2018 at approximately 10:20 AM which revealed, Policy "Clinical Record...III. Guidelines...9. Patient/client clinical records are routinely reviewed and protected according to the Agency's policy/procedure and applicable law and regulations..."

A review of agency policy on 9/18/2018 at approximately 10:20 AM which revealed, Policy "TITLE: Confidentiality...I. Objective 1. To protect the patient/client's right to privacy. 2. To protect the patient/Client's clinical record and its content against loss, defacement, tampering, and/or unauthorized disclosure or use...III. Guidelines...2. Patient/client clinical records will be maintained in the appropriate Hospice office file...3. The patient/client's clinical record is accessible to all Hospice staff directly involved with the provision of care/service...4. Hospice Office staff involved with the filing of patient/client forms and billing process of Hospice visits are authorized to access the patient/client's clinical record and the computer...8. Professional personnel/agencies not directly involved with the patient/client's care are not permitted access to the patient/client's clinical record without a completed and signed consent form for release of information..."

During an initial tour of the agency on 9/18/2018 at approximately 9:40 AM the surveyor asked EMP2 where the agency medical records were located. EMP2 showed the surveyor were the agency hospice patient medical records (MR) were located. The location of the (MR) filing cabinets was in a hallway next to the copying machine. The surveyor asked EMP2 where the keys were for the file cabinets that housed the (MR). EMP2 was unsure were the keys were kept. On 9/18/2018 at 1:00 PM The surveyor asked EMP1 about the filing cabinets that housed the agency (MR) active and inactive (beside the copier), and if the files could be locked. EMP1 referred the surveyor to EMP5. EMP1 also confirmed the cleaning staff were contracted and not agency employees. On 9/18/2018 at approximately 1:07 PM EMP5 confirmed the filing cabinets were inherited and there were no keys for the cabinets. On 9/18/2018 at approximately 2:12 PM EMP5 confirmed "the locksmith made keys for the cabinets and they are now locked." The agency failed to protect medical records from unauthorized access.

An exit interview was conducted on 9/21/2018 at approximately 3:45 PM with the executive director, hospice supervisor, nurse educator, hospice supervisor, director of finance, manager home health, manager education quality, manager hospice/palliative care, manager homecare & hospice and quality supervisor which confirmed the above information.











Plan of Correction:

L0680: 418.104(c)Protection of Information:
Review and revise hospice confidentiality policy to reflect security of file cabinets that contain patient records. New policy will include statement "Patient records are protected and maintained in secure file cabinets that will be locked at the close of business each day." Mandatory education will be provided to all staff related to updates to the hospice confidentiality policy. Education will be completed by November 16, 2018.

UPDATE: Hospice Manager will be responsible to monitor the continued implementation of the Plan of Correction.


418.106 STANDARD
DRUGS BIOLOGICALS MEDICAL SUPPLIES & DME

Name - Component - 00
Medical supplies and appliances, as described in 410.36 of this chapter; durable medical equipment, as described in 410.38 of this chapter; and drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, must be provided by the hospice while the patient is under hospice care.


Observations:



Based on review of agency policy, observation and staff (EMP) interviews, the agency failed to review all medical supplies and appliances related to the palliation and management of the terminal illness and related conditions for one (1) of three (3) observations (OBV1).

Findings included:

A review of agency policy on 9/18/2018 at approximately 10:20 AM which revealed:
Policy "TITLE: Bag Technique-hospice...I. Objective To implement the basic practice of infection control measures utilized for bag technique and car stock supplies. II. Guideline 1. All Hospice staff that visit multiple patients, provide direct patient/client care, and take equipment and supplies from patient/client should practice proper bag technique. 2. Staff members are responsible for checking the expiration dates of all bag supplies, and care supplies; supplies should be rotated on a regular basis..."

During observation #1 on 9/20/2018 at approximately 9:20 AM revealed,
(EMP6) was asked by the surveyor what agency disinfectant is provided to use to clean equipment and surfaces. EMP6 identified "Sani-Cloth GERMICIDAL DISPOSABLE WIPE " The surveyor ask for a sample, EMP6 provided a sample from the bag used while providing services. The expiration date was labeled "EXP 07/2018."

During a staff interview on 9/21/2018 at approximately 8:22 AM (EMP1) confirmed the above findings.









Plan of Correction:

L0687 418.108 Drugs Biologicals Medical Supplies & DME:
Mandatory education will be provided by the hospice supervisors to all hospice staff providing direct patient care. Education will include a review of the "Bag Technique-Hospice" policy. Education will be completed by November 16, 2018. Random bag/supply checks will be conducted for 20% of the hospice staff providing direct patient care per month over a two month period. 100% compliance to the policy is required. Any non-compliance will be addressed immediately with the involved staff member and action will be taken as needed. A monthly written report on the findings will be provided to the executive director, the quality manager, and the hospice manager for any necessary follow-up.


418.112(d) STANDARD
HOSPICE PLAN OF CARE

Name - Component - 00
In accordance with 418.56, a written hospice plan of care must be established and maintained in consultation with SNF/NF or ICF/MR representatives. All hospice care provided must be in accordance with this hospice plan of care.


Observations:


Based on review of agency policy, observation (OBV), and staff (EMP) interview, the agency failed to ensure a written hospice plan of care must be established and maintained in consultation with the skilled nursing facility (SNF) for one (1) of four (4) OBV's reviewed (OBV2).

Findings include
A review of agency policy and procedure was conducted on 4/23/2018 at approximately 9:10 AM revealed, Policy "TITLE: Plan of Care...I. Policy Statement All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any) the patient's representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. II. Guidelines...All members of the interdisciplinary group, volunteers, and contracted personnel have access to the patient's plan of care and are expected to provide care in accordance with it...10. For both hospice and non-hospice related concerns, interdisciplinary communication will be provided to ensure continuity of the plan of care...The hospice will ensure that for patients in facilities, that the facility staff are aware that the patient is receiving hospice services and that hose [sic] service ae [sic] in accordance with the patients Plan of Care."
During observation #2 at a skilled nursing facility on 9/20/2018 at approximately 11:30AM revealed, the surveyor reviewed the skilled nursing facility patient medical record and hospice binder. There was no plan of care available to review from either source. The surveyor observed both (EMP8) and (EMP9) RN's review both the patients' medical record and agency hospice binder. Neither employee was able to locate a copy of the patient's plan of care.

During a staff interview on 9/21/2018 at approximately 8:22 AM (EMP1) confirmed the above findings.










Plan of Correction:

L0773 418.112(d) Hospice Plan of Care:
Mandatory education will be provided by the hospice supervisors to all hospice nursing staff. This process will impact 100% of our hospice patients in facilities. Education will include an overview of the Plan of Care policy. Education will be completed by November 16, 2018. Random audits will be conducted on four patient records at facilities per month for three months. 100% compliance with the Plan of Care policy is required. If a record is found to be out of compliance, the hospice RN assigned to that facility will be re-educated on the Plan of Care policy. A monthly written report on the audit findings will be provided to the executive director, the quality manager, and the hospice manager to ensure compliance and to assist with any necessary follow-up.


Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 9/21/2018, Excela Health Home Care & Hospice was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.





Plan of Correction:




Initial Comments:



Based on the findings of an onsite unannounced Medicare recertification and State relicensure survey completed 9/21/2018, Excela Health Home Care & Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: