Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted 3/24/2025 through 3/28/2025, Penn Hospice Inc. 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 3/24/2025 through 3/28/2025, Penn Hospice Inc. 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:
418.54(b) STANDARD
TIMEFRAME FOR COMPLETION OF ASSESSMENT
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The hospice interdisciplinary group, in consultation with the individual's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care in accordance with §418.24.
Observations:
Based on a review of agency policy, medical record (MR), and staff (EMP) interview the hospice failed to ensure that the plan of care was developed in consultation within five (5) days after the election of the hospice benefit for two (2) of nineteen (19) MR reviewed. (MR7 and MR15).
Findings Included:
Review of the policy and procedures was conducted on 4/1/2025 at approximately 9:00 AM which revealed, COMPREHENSIVE ASSESSMENTA comprehensive patient assessment will be performed by the interdisciplinary group no later that 5 calendar days after the election of hospice care in consultation with attending physician. PROCEDURE 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevantThe assessment should determinePatient goals related to the terminal illness D. Type of services, frequency, and duration needed to meet patient care needsof the policy and procedures was conducted on 4/1/2025 at approximately 9:00 PM which revealed, ONGOING COMPREHENSIVE ASSESSMENTSThe scope and intensity of ongoing hospice patient assessments will be determined by the patients prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse will assess each patient on each visit, forBased on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. 5. Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. 6. The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approvalreview of MR #7 was conducted on 3/25/2025 at approximately 12:12 PM, with a start of care of 1/23/2025, and hospice benefit election of 1/23/2025 to 4/22/2025. The facility did not provide documentation to confirm an assessment was completed by the chaplain or social worker within the first five (5) days of hospice benefit election. No documentation was available to confirm the patients or patients representatives declined Chaplain and/or social worker services.
A review of MR#15 was conducted on 3/27/2025 at approximately 3:42 PM, with a start of care of 3/19/2025, and hospice benefit election 3/19/2025 to 6/16/2025. The facility did not provide documentation to confirm an assessment was completed by the chaplain or social worker within the first five (5) days of hospice benefit election. No documentation was available to confirm the patients or patients representatives declined Chaplain and/or social worker services.
An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.
Plan of Correction:Penn Hospice Social Worker and Chaplain will ensure that the plan of care will be completed timely within five days after the election of hospice. A comprehensive assessment will include all baseline data and all relevant information needed to meet patient care needs. Assessment will include problem, needs, goals, outcomes type of service, frequency and duration needed to meet patient care. Physician will be notified to verify any changes that needed made and approved by physician. If any discipline is declined a note stating that will be entered into the chart.
1. Medical records MR 7 was corrected and MR 15 was not corrected due to patient ceased to breath.
2. A review of all active patients was conducted to ensure completed correctly.
3. Education provided to Social worker and Chaplain on completion of comprehensive assessment with baseline date and relevant information and timeliness.
4. Monitor all new admissions monthly for 3 months
418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT
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[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 a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking in order to identify and address potential adverse effects, drug reactions for three (3) of nineteen (19) MR's reviewed (MR3, MR4 and MR16).
Findings included:
Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, Reconciliation at admission and resumption of care: a. On accepting a patient referral, obtain the patients list of active/current medications from the referring facility or from the primary care provider. b. Call the patient/caregiver before making the visit to perform the initial comprehensive medication assessment. c. Ask patient/caregiver to collect all medications 1) Prescribed and over-the-counter meds 2) Vitamins and nutritional Supplements 3) Meds taken routinely or as needed 4) By any route, including inhaled, injected, applied to skin, eyes, etc. 2. During the visit, record all medicines the patient has collected on the Medication Profile (or Reconciliation Form). a. Include the name, dose, route, and how frequently the patient takes each oneCarefully compare the Medication List you have created from the drugs in the patients home to the medication list supplied by the discharging facility or by the primary care provider. a. Identify any discrepancies cannot be resolved by the nurse, report and resolve the discrepancies with the primary care provider within one day. c. Amend the Medication Profile as per the primary care providers ordersreview of (MR3 OBV1) was conducted on 3/31/2025 at approximately 2:00 PM with a start of care date of 2/19/2025 for a certification period starting 2/19/2025 and ending 5/19/2025. The primary diagnosis was other Alzheimers disease. The facility physicians orders was compared to the agency medication profile.
The following three (3) medications were not listed on the on the facility physicians order report compared to the agency medication profile:
7/26/2024 Carboxymethylcellulose 0.5% liquidlevocetirizine 5 mg oral tablettamsulosin 0.4 mg oral capsule
The following three (3) medications were not listed on the on the agency medication profile report compared to the facilities physicians orders:
Lubiprostone 24mcg CapsDate: 20-jan-2025CAP 100 MGDate 10-Oct-2024
Guaif-Codeine 100-10/5mLDate 31-Oct-2024review of (MR4 OBV3) was conducted on 3/31/2025 at approximately 2:15 PM with a start of care date of 3/8/2024 for a certification period starting 3/3/2025 and ending 5/1/2025. The primary diagnosis was heart failure unspecified. The facility active medication profile was compared to the agency medication profile. The following three (3) medications were not listed on the on the facility active medication profile compared to the agency medication profile:
3/8/2024 Daily vite/iron 1 dose tabletCalprotect 0.44%-20.6% topical ointmentRemedy phytoplex Z-Guard topical pastereview of MR16 on 3/25/2025 at approximately 1:07 PM with a start of care date of 12/4/2024 for a certification period starting 3/4/2025 and ending 6/1/2025. Review of the plan of care revealed under Safety MeasuresPrecautionTeach patient/caregiver regarding oxygen therapyThe primary diagnosis was Chronic obstructive pulmonary disease with acute exacerbation.
The following medication was not listed on the on the medication profile:
Oxygen
An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.
Plan of Correction:Penn Hospice Nursing staff will reconcile the medication list of the patient/facility within the 24 hours and amend as per the physicians orders and discrepancies will be corrected ensuring that the medical profile matches including oxygen.
1. MR 16 and MR 4 was not corrected due to being discharged from services. MR3, medical profile were reviewed and reconciled to ensure that the medication profiles are correct and matched the facility or home patient medication list.
2. All active patients medication profiles and facilities MARS and home patients discharge list matches and if they are on oxygen, it is on the MAR.
3. Education provided to the nurses on reconciling all medications that are ordered for the patients are on the medication profile including oxygen
4. Monitor all active patients and new patients monthly for 3 months
418.56(c) STANDARD
CONTENT OF PLAN OF CARE
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The hospice must develop an individualized written plan of care for each patient. The plan of care must reflect patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:
Observations:
Based on review of the agency policies/procedures, medical record (MR), and staff (EMP) interview the hospice failed to ensure that goals and interventions were documented on the plan of care relating to the management of the terminal illness and related conditions for four (4) of nineteen (19) MR reviewed (MR7, MR10, MR12, MR15).
Findings included:
Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, THE PLAN OF CARE, PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issuesOrders for the start of care will be verbally received by the Case Manager (or hospice registered nurse) from the attending physician (or other authorized independent practitioner) and documented on the plan of care/physician order form. 4. The plan of care will identify the patients needs and services to meet those needs including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. 6. The plan of care will be provided to both the attending physician and the hospice Medical Director for approval of verbal orders and certification of the terminal illness signaturesEach patient will be monitored for his/her response to care or services provided against established patient goals and patient outcomes to evaluate progress toward goalsThe written plan of care will contain, but will not be limited to, the followingStatement of treatment goalsMeasurable outcomes anticipated from implementing and coordinating the plan of care. 13. All appropriate hospice staff will have access to the plan of care. 14. Care provided to the patient will be in accordance with the plan of careof the policy and procedures was conducted on 4/1/2025 at approximately 9:00 PM which revealed, ONGOING COMPREHENSIVE ASSESSMENTSThe scope and intensity of ongoing hospice patient assessments will be determined by the patients prognosis, diagnoses, condition, desire for care, response to previous care, and the care setting. PROCEDURE 1. During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. 2. The nurse will assess each patient on each visit, forBased on the assessments, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and updated by the interdisciplinary group members responsible for the case. 5. Based upon the findings of the assessment, change/verbal orders will be generated and forwarded to the physician (or other authorized independent practitioner) as needed. 6. The physician will be notified to verify any changes in medications, including over-the-counter medications, and treatment/interventions that require physician approvalreview of MR7 was conducted on 3/26/2025 at approximately 2:15 PM with a start of care date of 1/23/2025 for a current certification period starting 1/23/2025 and ending 4/22/2025. The primary diagnosis is melanoma of right lower limb including hip. Review of the plain of care revealed Orders/Treatments: Discipline OrdersNursing; 1-2 wk 14wk 28 PRN1-2wk 14 wk; 12 PRNSocial Worker to Assess and EvaluateUnder the interventions section only intervention for aide was listed. No Goals were listed for any discipline on the plan of care.
A review of MR10 was conducted on 3/26/2025 at approximately 2:40 PM with a start of care date of 8/19/2024 for a current certification period starting 2/15/2025 and ending 4/15/2025. The primary diagnosis is Alzheimers disease unspecified. Review of the plan of care revealed Orders/Treatments: Discipline Orders4-5 wk 9 wk; 12 PRNUnder the interventions and goals section only intervention and goals for aide was listed. The orders were reviewed on 3/27/2025 at approximately 2:00 PM which revealed OrdersDate 2/15/2025 To Date 4/15/2025Social Worker; 1 m, 3m 1PRN1-2 m 3 m 3 PRNNursing 1-2 d 13 wk 30 PRNNo orders, interventions or Goals were listed for skilled nursing on the plan of care.
A review of MR12 was conducted on 3/25/2025 at approximately 12:38 PM with a start of care date of 2/13/2025, for a current certification period starting 2/13/205 and ending 5/13/2025. The primary diagnosis is end stage heart failure. Review of the plain of care revealed Orders/Treatments: Discipline OrdersNursing; 1-2 wk 14wk 15 PRN1-2wk 13 wk; 12 PRNto Assess and EvaluateSocial Worker to Assess and EvaluateUnder the interventions and goals section only intervention and goals for skilled nursing were listed. No interventions or goals were listed for disciplines: aide, Chaplain and social worker were on the plan of care.
A review of MR15 was conducted on 3/27/2025 at approximately 3:42 PM with a start of care date of 3/19/2025 for a current certification period starting 3/19/2025 and ending 6/16/2025. The primary diagnosis is heart failure unspecified. Review of the plain of care revealed Orders/Treatments: Discipline OrdersNursing; 1-2 wk 14wk 15 PRNUnder the interventions and goals section no interventions or goals were listed for any disciplines on the plan of care.
An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.
Plan of Correction:Penn Hospice staff will develop an individualized written plan of care for each patient. The plan will reflect needs, goals and interventions and outcomes based on the problems identified on the initial assessment. The plan of care will include all services necessary to manage the terminal illness and related conditions. Including hospice order to start care, pain and discomfort, symptom relief, scope and frequency of services. Needs, goals and outcomes, the physician will be notified of any needed changes.
1. MR 12, 10 and 15 plan of cares were not corrected due to MR 12 being discharged and MR 15 ceased to breath..
2. Review all active patients and new admissions to ensure they had individualized written plans of care including the Needs, goals, outcomes start of care order, pain symptom relief.
3. Education provided to all disciplines to ensure all details are included in plan of care.
4. Audit monthly for 3 months.
418.60(a) STANDARD
PREVENTION
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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 (OBV), and staff (EMP) interviews, the agency failed to ensure employees followed infection control policy and procedure during observations for one (1) of four (4) observations (OBV1).
Findings included:
Review of the policy and procedures was conducted on 3/28/2025 at approximately 2:00 PM which revealed, BAG TECHNIQUE, PURPOSE To describe the procedure for maintaining a clen nursing bag/computer bag and preventing cross-contamination. PROCEDURETechnique 1. The bag will be placed on a clean surface (i.e., a surface that can be easily disinfected) in the car and in the home(OBV1), during a visit to MR3 residence on 3/27/2025 at 9:02 AM revealed, EMP3 provided direct patient care. EMP3 placed the bag on clean towels located on a table. A strap from the nursing/supply bag and a cleaning towel connected to the nursing/supply bag was lying off the towels on the tablecloth.
An exit interview was conducted with the executive director and clinical director on 3/27/2025 at approximately 4:30 PM which confirmed the above findings.
Plan of Correction:Penn Hospice will follow accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions by following the procedure of the Bag Technique to prevent cross contamination.
Unable to fix the original action
1. Education provided to staff that carry a nursing bag and employee number 3 to ensure that when bag is placed on clean surface that the entire bag and strap and cleaning towel that is connected to the bag is all on the clean surface and not touching anything else.
2. Educate the staff that carry and use a bag on the bag technique and have return demonstrations
3. Return demonstrations once a month for 3 months
Initial Comments:Based on the findings of an onsite unannounced state relicense survey completed 3/28/2025, Penn Hospice Inc. 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 state relicense survey completed 3/28/2025, Penn Hospice Inc. was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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