QA Investigation Results

Pennsylvania Department of Health
GALLAGHER HOSPICE, LLC
Health Inspection Results
GALLAGHER HOSPICE, LLC
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification and state licensure survey conducted 4/23/2019 through 4/26/2019, Gallagher 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 licensure survey conducted 4/23/2019 through 4/26/2019, Gallagher Hospice 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:




418.114(d)(2) STANDARD
CRIMINAL BACKGROUND CHECKS

Name - Component - 00
Criminal background checks must be obtained in accordance with State requirements. In the absence of State requirements, criminal background checks must be obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.



Observations:

Based on review of Hospice policy, personnel files (PF) and staff interviews, the Hospice failed to conduct criminal background checks in accordance with Hospice policy for two (2) of ten (10) PF reviewed (PF2 & PF6).

Findings included:

A review of Hospice policy titled "SELECTION/HIRING OF PERSONNEL Policy No. 1-006.1" on 4/25/2019 at approximately 12:30 p.m. stated "A criminal background check...will be obtained for positions as required by law and regulations".

A review of PF was conducted on 4/25/2019 between 12:30 p.m. and 2:00 p.m.

Review of PF2 showed a hire date of 11/16/2018 and a PA State Police background check result dated 11/13/2018. There was also an acknowledgement letter from the PA Department Of Aging dated 11/30/2018 indicating that the results of an FBI background check had been sent to the applicant with instructions to provide the results to Human Resources. The result of the FBI background check was not in the PF.

Review of PF6 showed a hire date of 6/25/2018 and a PA State Police background check result dated 6/27/2018. There was also an acknowledgement letter from the PA Department of Aging dated 6/25/2018 indicating that the results of an FBI background check had been sent to the applicant with instructions to provide the results to Human Resources. The result of the FBI background check was not in the PF.

An interview with the Executive Director on 4/25/2019 at approximately 3:00 p.m. confirmed findings.













Plan of Correction:

1) On 4/26/19 Human Resources contacted area of aging to validate that EMP#2 and #6 letters have been sent to the employees, and requested a second delivery to be sent due to employee change of address. According to the area of aging, employees will receive letters in 7 days. As of May 8, 2019 both employees have received their respective letters and the letters have been placed in their Personnel Files.
2) Human Resources confirmed that both employees identified in the citation have been monitored with social security check and OIG exclusion check on a monthly basis since date of hire.
3) Compliance Monitor performed an audit of all hospice personnel files which was completed May 1, 2019. A summary of findings was submitted to Human Resources and Executive Director. This was also presented to the QAPI committee on May 9, 2019.
4) At our monthly staff meeting on 5/7/19, educated employees of the DOH survey results, review of personnel file audit results, and education of policies identified in the citation.
5) Performance Improvement Plan was developed by Compliance Monitor and implemented with the baseline data from step #3. Compliance Monitor will develop a tracking tool for personnel file with deficient items for clinical managers to monitor for completion.
6) Monthly QAPI meetings will monitor the tracking of the deficient items from personnel files. Additionally, all new hire personnel files will be reviewed and reported at this meeting.
7) The Executive Director will be responsible to submit a summary of findings to the Governing Board.



Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification and state licensure survey conducted 4/23/2019 through 4/26/2019, Gallagher 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 licensure survey conducted 4/23/2019 through 4/26/2019, Gallagher Hospice was found to be in compliance with the requirements of 35 P.S. 448.809 (b).




Plan of Correction: