QA Investigation Results

Pennsylvania Department of Health
COMMUNITY NURSING SERVICES OF NORTH EAST
Health Inspection Results
COMMUNITY NURSING SERVICES OF NORTH EAST
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced recertification and relicensure survey completed on 11/30/18, Community Nursing Services Of North East 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 completed 11/30/18, Community Nursing Services Of North East was found not to be in compliance with the following requirement(s) of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.




Plan of Correction:




418.60(a) STANDARD
PREVENTION

Name - Component - 00
The hospice must follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions.


Observations:

Based on review of agency policy and procedure, observation during home visits and staff (EMP) interview, the agency failed to ensure skilled nursing staff followed agency policy and procedure to prevent the transmission of infections and communicable diseases for two (2) of two (2) staff observed during home visits (HV). (EMP3, EMP4)

Findings Included:

A review of agency policy and procedure, conducted on 11/30/18 at approximately 10:00 a.m. revealed "... PURPOSE: To prevent contamination of bag and equipment, avoid cross infection and establish a clean work area. ... CONSIDERATIONS: ... 7. The inside and contents of the bag are always considered "clean." ... 9. Keep bag closed when not in use. ... PROCEDURE: ... 2. Select a clean flat surface or a doorknob for the bag. Use discretion and consideration when placing bag on patient's furniture. Never place bag on patient's bed or on upholstered furniture. ... 3. Perform hand hygiene. 4. Remove needed items from bag and place on clean area or barrier. Close bag. ... 5. Perform hand hygiene prior to re-entering bag for any reason. 6. Following care: a. Clean, reusable items, e.g., blood pressure cuff, stethoscope and oximeter, that will be returned to the bag. ... ."

A home visit was conducted with EMP3 on 11/28/18 at approximately 10:30 a.m. Prior to the visit, this surveyor met EMP3 in the parking area and this surveyor observed the main pocket and side pocket of the nursing bag was unzipped and the items within those pockets were exposed and visible. The aforementioned unzipped pockets remained unzipped throughout the visit to include the end of the visit when this surveyor departed. Additionally, during the visit this surveyor witnessed EMP3 reach into the nursing bag to retrieve supplies three (3) times without first performing hand hygiene. Finally, EMP3 was observed returning a stethoscope to the main pocket of the bag after patient care without cleaning.

A home visit was conducted with EMP4 on 11/28/18 at approximately 12:00 p.m. Prior to the visit, this surveyor met EMP4 in the parking area and this surveyor observed the main compartment of the nursing bag unzipped and the items within those pockets were exposed and visible. The aforementioned unzipped pockets remained unzipped throughout the visit to include when this surveyor departed. Additionally, upon entering the patient's home, EMP4 placed the nursing bag on a carpeted floor without utilizing a barrier. Also, EMP4 was observed retrieving supplies from the nursing bag two (2) times without first performing hand hygiene.

An interview with the agency administrator (EMP2) on 10/29/18 at approximately 10:35 a.m. confirmed the above findings did not follow agency policy and procedure stating "I agree" and "It looks like we have some work to do, we usually have them [nursing staff] watch a video [bag technique] yearly but we may need to change that."




Plan of Correction:

All Hospice staff that use equipment/supply bag will attend a live inservice on bag technique presented by Executive Director. Inservices to be completed by 12/19/2018. Attendance verified by sign in sheets. The same staff will receive a copy of the agency policy Section 14:20 on bag technique, the portion of the survey relating to deficiency on bag technique and sign off sheet attesting to review of both. Review to be complete by 12/19/2018.
Compliance with policy will be monitored as follows:
Home visit to be made by either Executive Director, Clinical Services Manager or Quality Management Director with each hospice staff as identified above. The management staff will review each employee's bag technique at that visit. If the employee is not able to complete successfully, he/she will be tutored and another monitoring visit will be conducted within one week. All monitoring visits and successful demonstration (100%) will be accomplished by 12/31/2018.

Ongoing monitoring will be provided for a six month period (through June 5, 2019). Each hospice staff person identified above will be randomly selected for a revisit with the management member so that each will have at least one additional visit. All monitored visits will yield 100% compliant results for the monitoring period to successfully close.




418.112(e)(3) STANDARD
COORDINATION OF SERVICES

Name - Component - 00
The hospice must:]
(3) Provide the SNF/NF or ICF/MR with the following information:
(i) The most recent hospice plan of care specific to each patient;
(ii) Hospice election form and any advance directives specific to each patient;
(iii) Physician certification and recertification of the terminal illness specific to each patient;
(iv) Names and contact information for hospice personnel involved in hospice care of each patient;
(v) Instructions on how to access the hospice's 24-hour on-call system;
(vi) Hospice medication information specific to each patient; and
(vii) Hospice physician and attending physician (if any) orders specific to each patient.



Observations:

Based on review of agency policy and procedure, a review clinical records (CR) and staff (EMP) interview, the agency failed to follow agency policy and procedure and provide the SNF (skilled nursing facility) with the Hospice election form, and physician certification of the terminal illness for one (1) of one (1) clinical records reviewed during a home visit (HV) at a skilled nursing facility (CR1).

Findings Included:

A review of agency policy and procedure conducted on 11/30/18 at approximately 10:30 a.m. revealed: "... PROVISION OF CARE TO RESIDENTS OF SNF/NF OR ICF/MR Policy NO. 2-059.1 ... PROCEDURE ... 7. The organization will provide the SNF/NF ... with the following information specific to each patient: B. Hospice election form ... C. Physician certification of the terminal illness. ... ."

A home visit was conducted at a skilled nursing facility (SNF) for CR1 on 11/28/18 at approximately 10:30 with CR3. A review of the clinical record in the SNF did not contain the hospice election form and the physician certification of the terminal illness.

An interview at the SNF with EMP3 on 11/28/18 at approximately 10:45 a.m. confirmed the findings with EMP3 stating "I will have them faxed over".

An interview with the agency administrator on 11/29/18 at approximately 10:35 a.m. confirmed the above findings stating "I heard about it and faxed everything over [to the SNF]."





Plan of Correction:

Each hospice R.N. Case Manager will receive a copy of the policy 2-059.3 (section 7) that delineates the information document copies that are to be provided to the S.N.F. for incorporation into the S.N.F. medical record. Each R.N. Case Manager will receive a copy of the recent hospice survey statement of deficiencies that presents the subject. Each R.N. Case Manager receives a "Required Shared Document Checklist" developed by the Executive Director. Each R.N. Case Manager receives a signature sheet to indicate receipt and review of the documents listed above. Review of and signature receipts will be returned to Executive Director by 12/17/2018
Monitoring will occur in the following manner.
Immediate:
By 12/21/2018 each R.N. Case Manager will review the S.N.F. medical record of each hospice patient to assure 100% compliance with the required shared documents that will appear on checklist. The Case Manager will attest via signature that all documents are present and/or that he/she obtained and placed any that were missing. A checklist is developed by Executive Director that includes each of the items listed in the policy (2058.3 Section 7) 100% compliance will be attained by 12/31/2018

Longer Term Monitoring:
For a period three (3) months, a member of the management team (Executive Director, Clinical Services Manager or Quality Management RN) will make no less than one visit per hospice patient residing in a S.N.F. to conduct the same comparison and report back to the Q.A.P.I. committee. 100 % compliance will be noted within this three (3) month period.




Initial Comments:


Based on the findings of an onsite unannounced relicensure and recertification survey completed 11/30/18, Community Nursing Services Of North East 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 relicensure and recertification survey completed 11/30/18, Community Nursing Services Of North East was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: