QA Investigation Results

Pennsylvania Department of Health
COMPASSUS - GREATER PHILADELPHIA
Health Inspection Results
COMPASSUS - GREATER PHILADELPHIA
Health Inspection Results For:


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Initial Comments:

Based on the findings of an unannounced on-site Medicare complaint investigation survey conducted March 14, 2018, Compassus Hospice -Greater Philadelphia 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 unannounced on-site complaint investigation survey conducted on March 14, 2018, Compassus Hospice -Greater Philadelphia was not in compliance the requirements of 42CFR, Part 418, Subparts A, C and D: Conditions of Participation: Hospice Care







Plan of Correction:




418.52(c)(2) STANDARD
RIGHTS OF THE PATIENT

Name - Component - 00
[The patient has a right to the following:]
(2) Be involved in developing his or her hospice plan of care;


Observations:

Based on the review of clinical records and interview with the managing clinical directors, the agency failed to discuss the plan of care and had no documentation that family was involved in the plan of care on the day of admission to hospice including discontinuing medications for one (1) of one (1) clincal record with revocation of the hospice benefit. Clinical record # 1.
Findings:
Review of clinical record # 1 on March 14, 2018 at 1100 with certification period January 21, 2018 to April 20, 2018. No documentation that the plan of care including discontinuing medication was discussed with the family.
Interview with the managing clinical directors on March 14, 2018 at 1500 confirmed the above findings.








Plan of Correction:

The patient/guarantor will be involved in developing his or her hospice plan of care.

Education will be provided to the RN Case Managers, Social Work and Chaplain on including the patient/guarantor in the development of the plan of care.

The Director of Clinical Service or designee will review current patient records for documentation that patient/guarantor was involved in plan of care.

The Director of Clinical Services or Designee will audit 100% of charts until 100% compliant for 3 consecutive months and then 10% monthly for another 3 months.


418.54(c)(7) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT

Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(7) Bereavement. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.



Observations:

Based on review of clinical records, agency policy and procedure and an interview with the managing clinical directors, the hospice failed to provide initial bereavement assessments for the patient/caregiver/family members for two (2) of four (4) clinical records. Clinical Records # 1 and 4.

Findings

Review on policy on March 14, 2018 at 14:30 p.m., titled " Bereavement Services " states " Compassus provides bereavement support to patients and family members to assist in minimizing the stress and problems that arise from the terminal illness, related condition and the dying process. A comprehensive bereavement risk assessment is completed no later than 5 days after admission. Compassus will make bereavement services available to the family, and other individuals in the bereavement plan of care for at least one year following the death of the patient. "

Interview with the managing director at the branch location revealed she did not audit the bereavement services at the branch site because she thought it only applied to parent site.

Clinical record reviews revealed:

Review of clinical record # 1 on March 14, 2018 at1100 with certification period January 21, 2018 to April 20, 2018. Social worker documented on January 22, 2018 patient was with two daughters, the bereavement assessment included only the one daughter.

Review of clinical record # 4 on March 14, 2018 at 1300 with certification period January 14, 2018 to April 13,2018. The initial assessment completed by the social worker on January 21, 2018 identified a nephew and niece, no bereavement risk assessment documented for the nephew.

Interview with the managing clinical directors on March 14, 2018 at 1500 confirmed that the bereavement assessment and plan of care did not include the caregivers and families as identified in the above clinical records.











Plan of Correction:

A bereavement risk assessment will be completed for family members and other individuals identified as involved in the plan of care.

Current patients will be reviewed by the Bereavement Coordinator to ensure completion of initial bereavement risk assessment for all involved caregivers impacted. Any records missing bereavement assessments will be amended.


Education will be provided to all Social Workers on the proper completion of the bereavement risk assessment for all identified family members/caregivers/individuals involved in a patient's plan of care.



The Director of Clinical Services will audit 100% of charts until 100% compliant and then 25%, then 10% quarterly for one year with documentation of findings in QAPI minutes.



418.116 STANDARD
FEDERAL, STATE, LOCAL LAWS & REGULATIONS

Name - Component - 00
The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. If State or local law provides for licensing of hospices, the hospice must be licensed.


Observations:

Based on the review of admission packets for both sites, clinical records and interview with the managing clinical directors, the agency failed to provide the correct hotline number at the branch site for four (4) of four (4) clinical records. Clinical records # 1, 2, 3 and 4.
Findings:
Review of clinical records revealed:
Review of clinical record # 1 on March 14, 2018 at 1100 with certification period January 21, 2018 to April 20, 2018. Information on how to file a complaint by telephone using the hotline, the documented number was the incorrect phone number.
Review of clinical record # 2 on March 14, 2018 at 1400 with certification period November 28, 2017 to February 25, 2018. Information on how to file a complaint by telephone using the hotline, the documented number was the incorrect phone number.
Review of clinical record # 3 on March 14, 2018 at 1430 with certification period August 14, 2017 to October 12, 2017. Information on how to file a complaint by telephone using the hotline, the documented number was the incorrect phone number.
Review of clinical record # 4 on March 14, 2018 at 1300 with certification period January 14, 2018 to April 13,2018. Information on how to file a complaint by telephone using the hotline, the documented number was the incorrect phone number.
Interview with the managing clinical directors on March 14, 2018 at 1500 confirmed that the hotline number listed was incorrect for the branch location.












Plan of Correction:

All admission packets will be corrected to include the current hotline number.

The Executive Director will notify all current patients/guarantors of the correct hotline number. Notation of delivery will be made in the patients clinical record.

Education will be provided by the Executive Director to all current colleagues on the correct hotline number.

The Team Coordinator or designee will audit 100% of admission charts until 100% compliant for 3 consecutive months and then 10% monthly for another 3 months.


Initial Comments:

Based on the findings of an unannounced on-site state complaint investigation survey conducted on March 14, 2018, Compassus Hospice -Greater Philadelphia was found to be in compliance with the requirements of 28 Pa. Code, Part IV, Health Facilities, and Subpart A. Chapter 51.






Plan of Correction:




Initial Comments:

Based on the findings of an unannounced on-site complaint investigation survey conducted on March 14, 2018, Compassus Hospice -Greater Philadelphia was found to be in compliance with the requirements of 35 P.S. 448.809 (b).






Plan of Correction: