QA Investigation Results

Pennsylvania Department of Health
ASERACARE HOSPICE
Health Inspection Results
ASERACARE HOSPICE
Health Inspection Results For:


There are  8 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 state relicensure survey completed 8/23/18, Asera 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:




418.52(b)(1) STANDARD
EXERCISE OF RIGHTS/RESPECT FOR PROPRTY/PERSON

Name - Component - 00
(1) The patient has the right:
(i) To exercise his or her rights as a patient of the hospice;
(ii) To have his or her property and person treated with respect;
(iii) To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; and
(iv) To not be subjected to discrimination or reprisal for exercising his or her rights.



Observations:


Based on review of the agency admission packet and staff (EMP) interview, the agency failed to provide accurate information regarding the Department's complaint hotline number in order for the patient to voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice.

Findings Included:

A review of the agency admission packet on 8/20/18 at approximately 10:08 a.m. revealed, "Hospice Care Handbook Revised January 2018" The "Pennsylvania Department of Health" complaint hotline number, located on the lower left hand corner of the cover page, was listed as "800-222-0989" [incorrect number].

An interview with the agency administrator [EMP1] on 8/20/18 at approximately 10:25 a.m. confined the listed number is incorrect. During the interview the [incorrect] number was called and revealed it was a number for a vacation travel agency with EMP1 stating "we were not aware this was an incorrect number".




Plan of Correction:

418.52(b)(1) Education: Patient Rights. Exercise of rights and respect for property and person.
1. Education will be provided by the Director of Hospice Operations to all staff regarding 418.52(b)(1) and Organizational Policy: Hospice.SNF Required Medical Record Documentation -by 9/28/18.
2. Director of Hospice or designated staff will replace all Hospice Care Handbooks with corrected admission label showing the Pennsylvania Department of Health complaint hotline number. The DHO will call the number to verify that it is the correct phone number for the DOH compliance. The phone number will be verified by the Business office staff that is printing the labels. New labels were printed on August 23, 2018. -by 8/23/18
RESPONSIBLE PARTY: The Director of Hospice Operations is responsible for the implementation and outcome of this plan of correction.

MONITORING:
1. Agency audits will be completed by the DHO or designee on 100% of patient handbooks weekly x 2 months until 100% compliance is met. Once this goal has been attained, random audits will continue to ensure compliance.
2. The DHO will present PA DOH survey results to Staff and QAPI Committee. Further reporting of analysis, trending and results will be given to QAPI committee, quarterly, for oversite and further recommendations as needed.



418.54(c) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT

Name - Component - 00
The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process.




Observations:


Based on review of agency policy and procedure, clinical records (CRs) and staff (EMP) interview, the agency failed to ensure the comprehensive assessment identified the physical needs of the patient to promote the hospice patient's well-being and comfort for eleven (11) out of fourteen (14) records reviewed. (CR1-3, CR5-6, CR8-11, CR13-14).

Findings included:

A review of agency policy and procedure, conducted on 8/23/18 at approximately 11:45 a.m. revealed "... NURSING SERVICES ... PROCEDURES: 1. Nursing Services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient's comprehensive and updated assessments. 2. Nursing services are provided in accordance with accepted standards of practice and a copy of the State's Nurse Practice Act ... ."

Agency Policy "... ASSESSMENT OF THE PATIENT ... 5. Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient's plan of care. ... 7. The hospice's assessment and reassessment tools contain data elements that allow for the measurement of outcomes. 8. The interdisciplinary team treats and prevents symptoms of the patient's disease and/or comorbidity factors based on findings in the comprehensive assessment and reassessments.

A review of CR1 on 8/20/18 at approximately 12:15p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 10/18/2017 with a terminal diagnosis of Malignant neoplasm of the pancreas.
A review of CR1's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed that no vital signs were taken on 8/15/18.
Blood pressure and respirations were not taken on 8/18/18 as part of the clinical assessment documentation.

A review of CR2 on 8/20/18 at approximately 1:25 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/16/18 with a terminal diagnosis of Senile Dementia.
A review of CR2's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "PAIN FEVER".
A review of Skilled Nursing Visit Note Reports revealed that no vital signs were taken 8/17/18.
Blood pressure and temperature was not not taken on 8/18/18 and 8/19/18.

A review of CR3 on 8/21/18 at approximately 11:40 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 6/22/18 with a terminal diagnosis of Malignant neoplasm of the stomach.
A further review of CR3 revealed orders for an antibiotic for "PNX" [pneumonia] on 7/17/18 and was also placed on an antibiotic on 8/1/18 for "STOMACH MESH INFECTION" and orders on 6/22/18 for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed incomplete vital sign documentation on the following dates:
No temperature was documented on 6/26/18, 7/5/18, 7/19/18, 7/24/18, and 8/8/18
No temperature or pulse was documented on 6/29/18
No temperature or respirations was documented on 7/2/18, 7/11/18, and 8/10/18
No temperature, pulse or respirations was documented on 8/3/18
No vital signs were documented on 8/17/18


A review of CR5 on 8/23/18 at approximately 11:35 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/6/18 with a terminal diagnosis of Senile Dementia.
A review of Skilled Nursing Visit Note Reports revealed that only pulse and respirations were documented on 8/18/18, 8/19/18 and 8/20/18.

A review of CR6 on 8/23/18 at approximately 11:10 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/13/18 with a terminal diagnosis of Heart Failure.
A review of CR6's medication report revealed orders for Cardizem CD 120mg two times daily for "HTN" [high blood pressure], Metopropolol Tartrate Oral 50mg two times daily for "HTN", and Eliquis Oral 5mg two times daily for "AFIB" [irregular heart rate].
A review of Skilled Nursing Visit Note Reports revealed incomplete vital sign documentation on the following dates:
There was no documented vital signs on 8/13/18 (start of care), 8/14/18 and 8/17/18.
There was no documented blood pressure and respirations on 8/19/18

A review of CR8 on 8/20/18 at approximately 1:53 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 5/22/18 with a terminal diagnosis of Cirrhosis of Liver.
A review of CR8's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "MILD PAIN/FEVER".
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 5/22/18 [admission assessment] and 5/25/18.
Additionally, on 5/23/18 only a blood pressure and pulse was documented, on 5/24/18 only a pulse was documented and on 5/26/18 only a pulse and respirations were documented.

A review of CR9 on 8/21/18 at approximately 11:10 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/8/18 with a terminal diagnosis of Heart Failure.
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 8/1/18 and 8/14/18.

A review of CR10 on 8/23/18 at approximately 11:15 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 6/12/18 with a terminal diagnosis of Malignant Melanoma of Skin.
A review of CR10's medication report revealed orders for Lopressor Oral 50mg two times daily for "HTN", Ramipril Oral 10mg daily for "HTN" and Acetaminophen Rectal 650mg (milligram) every six hours as needed for "PAIN/FEVRR [sic]".
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 6/14/18, 6/18/18, 6/21/18, 6/216/18, 6/29/18, 7/5/18, 7/9/18, 7/12/18, 7/16/18, 7/18/18, 7/24/18, 7/26/18, 7/30/18, 8/3/18, 8/10/18, 8/14/18, and 8/16/18.
Additionally, a blood pressure and temperature was not documented on 7/21/18 and 7/22/18 and a temperature, pulse and respirations were not documented on 8/6/18.


A review of CR11 on 8/23/18 at approximately 10:50 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/9/18 with a terminal diagnosis of Malignant Neoplasm of Breast.
A review of CR11's medication report revealed orders for Tylenol Oral 325mg two tabls every 4 hours as needed for "ELEVATED TEMP OR FEVER".
A review of Skilled Nursing Visit Note Reports revealed a blood pressure and temperature was not documented on 8/10/18, 8/11/18 and 8/15/18.
Respirations were not documented on 8/13/19 and a temperature was not documented on 8/14/18.


A review of CR13 on 8/23/18 at approximately 12:47 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 10/3/17 with a terminal diagnosis of Chronic Airway Obstruction.
A review of CR13's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed a blood pressure and temperature was not documented on 7/30/18, 8/2/18, 8/6/18, 8/10/18, 8/13/18, and 8/16/18.


A review of CR14 on 8/23/18 at approximately 10:46 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 12/7/17 with a terminal diagnosis of Senile Dementia.
A review of CR14's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every four hours as needed for "TEMP 100 OR ABOVE".
A review of Skilled Nursing Visit Note Reports revealed no blood pressure and temperature was documented on 8/6/18 and 8/15/18 and no blood pressure was documented on 8/8/18.

An interview with EMP1, EMP2 and EMP5 on 8/23/18 at approximately 12:15 p.m. confirmed the above findings. EMP1 also confirmed that the were unable to find any agency policy and procedure related to checking vital signs as part of the comprehensive assessment and/or updates to the comprehensive assessment stating "it would probably revert to the accepted practice and standards".













































Plan of Correction:

418.54(c) Standard Content of Comprehensive Assessment and 418.56 (b) Standard Plan of Care:
1. Director of Hospice Operations will provide education to all staff regarding CoP 418.54 and 418.56(b) and organizational policy Assessment-Comprehensive Assessment of the Patient and Nursing Services, and Standards of Practice. -by 9/28/18
2. Director of Hospice Operations will provide education to all staff regarding the use of vital signs as part of the comprehensive assessment to ensure symptom management.
Responsible Party: Director of Hospice Operations is responsible for the implementation and outcome of this plan of correction.

Monitoring:
1. Agency audit will be completed by DHO or designee on 50% of all patient charts will using the Clinical Audit Tool weekly for appropriate Vital Signs.
2. Once 100% compliance is met for 3 consecutive months, 25% of charts will be audited for 3 consecutive months until 100% compliance is met. Once this goal has been attained, random audits will continue to ensure compliance as per policy as part of the Agency's Quality Assurance Performance Improvement Program.
The DHO will present PA DOH survey results to Staff and QAPI Committee. Further reporting of analysis, trending and results will be given to QAPI committee, quarterly, for oversite and further recommendations as needed.



418.56(b) STANDARD
PLAN OF CARE

Name - Component - 00
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 or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.



Observations:


Based on review of agency policy and procedure, clinical records (CRs) and staff (EMP) interview, the agency failed to follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician in accordance with the patient's needs for eleven (11) out of fourteen (14) CRs reviewed (CR1-3, CR5-6, CR8-11, CR13-14)

Findings included:

A review of agency policy and procedure, conducted on 8/23/18 at approximately 11:45 a.m. revealed "... NURSING SERVICES ... PROCEDURES: 1. Nursing Services are directed and staffed to assure that the nursing needs of all patients are met as identified in the patient's comprehensive and updated assessments. 2. Nursing services are provided in accordance with accepted standards of practice and a copy of the State's Nurse Practice Act ... ."

Agency Policy "... ASSESSMENT OF THE PATIENT ... 5. Discipline-specific assessment tools obtain accurate and timely information that guide decisions for the development of the patient's plan of care. ... 7. The hospice's assessment and reassessment tools contain data elements that allow for the measurement of outcomes. 8. The interdisciplinary team treats and prevents symptoms of the patient's disease and/or comorbidity factors based on findings in the comprehensive assessment and reassessments.

A review of CR1 on 8/20/18 at approximately 12:15p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 10/18/2017 with a terminal diagnosis of Malignant neoplasm of the pancreas.
A review of CR1's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed that no vital signs were taken on 8/15/18 and a blood pressure and respirations were not taken on 8/18/18 as part of the clinical assessment documentation.

A review of CR2 on 8/20/18 at approximately 1:25 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/16/18 with a terminal diagnosis of Senile Dementia.
A review of CR2's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "PAIN FEVER".
A review of Skilled Nursing Visit Note Reports revealed that no vital signs were taken 8/17/18 and a blood pressure and temperature was not not taken on 8/18/18 and 8/19/18.

A review of CR3 on 8/21/18 at approximately 11:40 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 6/22/18 with a terminal diagnosis of Malignant neoplasm of the stomach.
A further review of CR3 revealed orders for an antibiotic for "PNX" [pneumonia] on 7/17/18 and was also placed on an antibiotic on 8/1/18 for "STOMACH MESH INFECTION" and orders on 6/22/18 for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed incomplete vital sign documentation on the following dates:
No temperature was documented on 6/26/18, 7/5/18, 7/19/18, 7/24/18, and 8/8/18
No temperature or pulse was documented on 6/29/18
No temperature or respirations was documented on 7/2/18, 7/11/18, and 8/10/18
No temperature, pulse or respirations was documented on 8/3/18
No vital signs were documented on 8/17/18


A review of CR5 on 8/23/18 at approximately 11:35 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/6/18 with a terminal diagnosis of Senile Dementia.
A review of Skilled Nursing Visit Note Reports revealed that only pulse and respirations were documented on 8/18/18, 8/19/18 and 8/20/18.

A review of CR6 on 8/23/18 at approximately 11:10 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/13/18 with a terminal diagnosis of Heart Failure.
A review of CR6's medication report revealed orders for Cardizem CD 120mg two times daily for "HTN" [high blood pressure], Metopropolol Tartrate Oral 50mg two times daily for "HTN", and Eliquis Oral 5mg two times daily for "AFIB" [irregular heart rate].
A review of Skilled Nursing Visit Note Reports revealed incomplete vital sign documentation on the following dates:
There was no documented vital signs on 8/13/18 (start of care), 8/14/18 and 8/17/18.
There was no documented blood pressure and respirations on 8/19/18


A review of CR8 on 8/20/18 at approximately 1:53 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 5/22/18 with a terminal diagnosis of Cirrhosis of Liver.
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 5/22/18 [admission assessment] and 5/25/18.
Additionally, on 5/23/18 only a blood pressure and pulse was documented, on 5/24/18 only a pulse was documented and on 5/26/18 only a pulse and respirations were documented. A review of CR8's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "MILD PAIN/FEVER".

A review of CR9 on 8/21/18 at approximately 11:10 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/8/18 with a terminal diagnosis of Heart Failure.
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 8/1/18 and 8/14/18.

A review of CR10 on 8/23/18 at approximately 11:15 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 6/12/18 with a terminal diagnosis of Malignant Melanoma of Skin.
A review of CR10's medication report revealed orders for Lopressor Oral 50mg two times daily for "HTN", Ramipril Oral 10mg daily for "HTN" and Acetaminophen Rectal 650mg (milligram) every six hours as needed for "PAIN/FEVRR [sic]".
A review of Skilled Nursing Visit Note Reports revealed that there was no documented vital signs on 6/14/18, 6/18/18, 6/21/18, 6/216/18, 6/29/18, 7/5/18, 7/9/18, 7/12/18, 7/16/18, 7/18/18, 7/24/18, 7/26/18, 7/30/18, 8/3/18, 8/10/18, 8/14/18, and 8/16/18/ Additionally a blood pressure and temperature was not documented on 7/21/18 and 7/22/18 and a temperature, pulse and respirations were not documented on 8/6/18.

A review of CR11 on 8/23/18 at approximately 10:50 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 8/9/18 with a terminal diagnosis of Malignant Neoplasm of Breast.
A review of CR11's medication report revealed orders for Tylenol Oral 325mg two tabls every 4 hours as needed for "ELEVATED TEMP OR FEVER".
A review of Skilled Nursing Visit Note Reports revealed a blood pressure and temperature was not documented on 8/10/18, 8/11/18 and 8/15/18. Respirations were not documented on 8/13/19 and a temperature was not documented on 8/14/18.


A review of CR13 on 8/23/18 at approximately 12:47 p.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 10/3/17 with a terminal diagnosis of Chronic Airway Obstruction.
A review of CR13's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every six hours as needed for "FEVER".
A review of Skilled Nursing Visit Note Reports revealed a blood pressure and temperature was not documented on 7/30/18, 8/2/18, 8/6/18, 8/10/18, 8/13/18, and 8/16/18.


A review of CR14 on 8/23/18 at approximately 10:46 a.m. revealed a physician ordered plan of care with an election of the hospice benefit date of 12/7/17 with a terminal diagnosis of Senile Dementia.
A review of CR14's medication report revealed orders for Acetaminophen Rectal 650mg (milligram) every four hours as needed for "TEMP 100 OR ABOVE".
A review of Skilled Nursing Visit Note Reports revealed no blood pressure and temperature was documented on 8/6/18 and 8/15/18 and no blood pressure was documented on 8/8/18.



An interview with EMP1, EMP2 and EMP5 on 8/23/18 at approximately 12:15 p.m. confirmed the above findings. EMP1 also confirmed that the were unable to find any agency policy and procedure related to checking vital signs as part of the comprehensive assessment and/or updates to the comprehensive assessment stating "it would probably revert to the accepted practice and standards".







Plan of Correction:

418.54(c) Standard Content of Comprehensive Assessment and 418.56 (b) Standard Plan of Care:
1. Director of Hospice Operations will provide education to all staff regarding CoP 418.54 and 418.56(b) and organizational policy Assessment-Comprehensive Assessment of the Patient and Nursing Services, and Standards of Practice. -by 9/28/18
2. Director of Hospice Operations will provide education to all staff regarding the use of vital signs as part of the comprehensive assessment to ensure symptom management.
Responsible Party: Director of Hospice Operations is responsible for the implementation and outcome of this plan of correction.

Monitoring:
1. Agency audit will be completed by DHO or designee on 50% of all patient charts will using the Clinical Audit Tool weekly for appropriate Vital Signs.
2. Once 100% compliance is met for 3 consecutive months, 25% of charts will be audited for 3 consecutive months until 100% compliance is met. Once this goal has been attained, random audits will continue to ensure compliance as per policy as part of the Agency's Quality Assurance Performance Improvement Program.
The DHO will present PA DOH survey results to Staff and QAPI Committee. Further reporting of analysis, trending and results will be given to QAPI committee, quarterly, for oversite and further recommendations as needed.



418.78(e) STANDARD
LEVEL OF ACTIVITY

Name - Component - 00
Volunteers must provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff. The hospice must maintain records on the use of volunteers for patient care and administrative services, including the type of services and time worked.


Observations:

Based on review of agency policy and procedure, documentation, and staff (EMP) interview, the agency failed to provide day-to-day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract staff from June to August 2018.

Findings Included:

A review of agency policy and procedure on 8/23/18 at approximately 11:00 a.m. revealed "... VOLUNTEERS- SERVICES ... POLICY STATEMENT: The Volunteer Program is designed to meet Federal regulations for the provision of volunteer services to hospice pateints and their caregivers. ... 2. Recruitment efforts are sufficient to ensure that the hospice has enough volunteers to meet the ... requirements of Federal regulations. ... ."

A review of agency "Hospice Volunteer Requirement Report" for Year 2018 revealed that the total volunteer percentage hours went from 13.49% in May of 2018 to 4.82% in June of 2018 and 4.44% in July of 2018.

An interview with the Volunteer Coordinator (EMP4) on 8/21/18 at approximately 10:30 a.m. confirmed the above findings revealing that the agency had been using interns from the local university as hospice volunteers and the numbers dropped when the school year ended. When asked if the agency was taking any action as a result of the percentage drop, EMP3 stated "We were waiting until our office move was complete." [office move occurred on 8/22/18]








Plan of Correction:

418.78 (e) Standard: Level of Activity:
1. Director of Hospice Operations will provide education to all staff regarding CoP 418.78 (e) and Organizational Policy: Volunteers Services. -by 9/28/18
2. Director of Hospice Operations will meet with Volunteer Coordinator weekly to review recruitment activity of new volunteers so that a minimum of 5% of the total patient care hours is met.
-by 9/28/18
RESPONSIBLE PARTY: Director of Hospice Operations is responsible for the implementation and outcome of this plan of correction.
Monitoring:
1. The DHO will meet weekly with the Volunteer Coordinator weekly to review all recruitment activities using the Volunteer Recruitment Record, beginning the week of September 14, 2018.
2. DHO will audit 100% of volunteer recruitment activities and volunteer hours monthly and ongoing. Sustained compliance will be monitored monthly.
3. Volunteer Coordinator will attend monthly volunteer education mentor call.
4. 100% of volunteer recruitment and volunteer hours will be audited to determine compliance that hospice maintains volunteer staff sufficient to provide administrative and direct patient care in the amount that, at a minimum, equals 5 percent of the total patient hours of all paid hospice employees and contract staff.
5. Audit results will be reported to the agency QAPI committee quarterly for oversight and further recommendations.
The DHO will present PA DOH survey results to Staff and QAPI Committee. Further reporting of analysis, trending and results will be given to QAPI committee, quarterly, for oversite and further recommendations as needed.




418.112(f) STANDARD
ORIENTATION AND TRAINING OF STAFF

Name - Component - 00
Hospice staff must assure orientation of SNF/NF or ICF/MR staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.


Observations:



Based on review of clinical records (CRs), observations during home visits, agency contract with skilled nursing facility and staff interview, it was determined the hospice failed to provide hospice orientation to staff of the nursing care facility where a hospice patient resided for one (1) of one (1) CR that resided in a nursing care facility and received hospice services during observation on a home visit. (CR14)

Findings Included:

A review of CR1, conducted during a home visit at a skilled nursing facility on 8/22/18 at approximately 2:30 p.m. revealed CR1 elected the hospice benefit on 12/7/17 and resided in the skilled nursing facility while receiving hospice services from the agency.

A review of the agency contract with the skilled nursing facility on 8/23/18 at approximately 11:45 a.m. revealed the contract became effective on 2/20/18. A further review of agency documentation did not show that the skilled nursing facility staff were ever oriented to the hospice philosophy by agency hospice staff.

An interview with the agency administrator (EMP1) on 8/23/18 at 12:00 p.m. confirmed the findings stating "it is scheduled for today [approximately six months after the signed contract agreement], the facilities are not always eager to cooperate".






Plan of Correction:

418.112 (f) Standard: Orientation and Training of Staff:
1. Director of Hospice Operations will provide education to all staff regarding CoP 418.11 (f) and Organizational Policy: Hospice Care for NF Residents -by 9/28/18
2. DHO or designee will audit 100% of contracts for verification of completed education. If education is found to be missing, it will be scheduled as soon as possible with the facility and completed.
-by 9/28/18
RESPONSIBLE PARTY:
The DHO is responsible for the implementation and outcome for this plan of correction
Monitoring:
1. Agency audit will be completed by DHO or designee on 100% of all SNF contracts using the Clinical Audit Tool, weekly until compliance is met.
2. Once 100% compliance is met for 3 consecutive months, 25% of charts will be audited for 3 consecutive months until 100% compliance is met. Once this goal has been attained, random audits will continue to ensure compliance as per policy as part of the Agency's Quality Assurance Performance Improvement Program
The DHO will present PA DOH survey results to Staff and QAPI Committee. Further reporting of analysis, trending and results will be given to QAPI committee, quarterly, for oversite and further recommendations as needed.



418.114(d)(1) STANDARD
CRIMINAL BACKGROUND CHECKS

Name - Component - 00
The hospice must obtain a criminal background check on all hospice employees who have direct patient contact or access to patient records. Hospice contracts must require that all contracted entities obtain criminal background checks on contracted employees who have direct patient contact or access to patient records.



Observations:


Based on review of volunteer files (VF), and staff (EMP) interview, agency failed to obtain a criminal background check, before patient contact and/or access to patient information, for one (1) of six (6) volunteer files (VF) reviewed. (VF6).

Findings included:

Review of VF6 on 8/21/2018 at approximately 12:00 p.m. showed a hire date of 6/04/2017. VF6 revealed no documentation to show required criminal background check was obtained.

Interview with EMP1 on 8/23/2018 at approximately 1:00 p.m. confirmed findings "the request was never submitted".










Plan of Correction:

418.114(d)(1) Standard Criminal Background Checks:
1. Director of Hospice Operations will provide education to all staff regarding CoP 418.114(d)(1) and Organizational Policy: Pre-Employment Verifications and Volunteer Services -by 9/28/18
2. Director of Hospice Operations or designee will audit 100% volunteer personnel files for criminal background checks. If one is missing, the volunteer will not be permitted to visit patients until one is completed and placed in the file. -by 9/14/18
RESPONSIBLE PARTY: Director of Hospice Operations is responsible for the implementation and outcome for this plan of correction.
Monitoring:
1. 100% of Volunteer personnel files will be audited monthly until 100% compliance is met using the personnel audit tool. After 3 months of 100% compliance is maintained, volunteer personnel files will be audited quarterly to ensure sustained compliance, using the personnel audit tool.
2. Audit results will be reported to the agency QAPI Committee for oversight and further actions if compliance is not sustained.




Initial Comments:


Based on the findings of an onsite unannounced relicensure survey completed 8/23/18, Asera 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 relicensure survey completed 8/23/18, Asera Care Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: