Initial Comments:Based on the findings of an onsite unannounced complaint survey completed 11/3/2025, Family Hospice was found not to be in compliance with the following requirement of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.100(e) STANDARD
PROFESSIONAL MANAGEMENT RESPONSIBILITY
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A hospice that has a written agreement with another agency, individual, or organization to furnish any services under arrangement must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged services must be supported by written agreements that require that all services be--
(1) Authorized by the hospice;
(2) Furnished in a safe and effective manner by qualified personnel; and
(3) Delivered in accordance with the patient's plan of care.
Observations:
Based upon review of agency policy, medical records (MR) and staff (EMP) interviews the agency failed to have services provide by a contracted entity for one (1) of four (4) MR's reviewed (MR2).
Based upon review of agency policy, medical records (MR) and staff (EMP) interviews the agency failed to have services provide by a contracted entity for one (1) of four (4) MR's reviewed (MR2).
Findings included:
Focused review of the agency policy on 10/21/2025 at approximately 1:47 PM revealed, "HOSPICE MEDICATOIN POLICY #303 ...POLICY Hospice will provide, to the patient under hospice care, drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care. Hospice will assure the safe and effective administration of all medications in accordance with applicable State and Federal Laws ..."
Focused review of the agency policy on 11/3/2025 at approximately 3:00 PM revealed, "POLICY The hospice will organize, manage and administer hospice resources to provide hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. PROCEDURE Nursing, physician and drugs and biologicals are routinely available 24 hours a day, 7 days a week. Other services are available on 24-hour basis when reasonable and necessary to meet the needs of the patient and family ...Professional Management Responsibility Hospice retains administrative and fiscal management, and oversight to staff and services for all arranged services through written agreements with other agencies, individuals, or organizations, to ensure the provision of quality of care ..."
The following contract was reviewed on 11/3/2025 at approximately 1:30 PM which revealed, "AGREEMENTS (PROVIDER) to the Hospice Program ...(AGENCY) ...1. ROLES AND RESPONSIBILITIES A. Patient Admission Process 2. The PROVIDER shall: a) Verify, prior to delivering, that the equipment and/or supplies, for the terminal illness of a Hospice patient, has been authorized by the Hospice nurse ...b) Provide, deliver, pick up and remove the equipment and/or supplies authorized by the AGENCY, for the patient's terminal illness, to the home of the Hospice patients, or if requested, to other sites. (1) If specific equipment authorized by the AGENCY is unavailable, Provider will contact Hospice staff with the time delay the AGENCY patient can expect.(a) If Hospice staff believe that AGENCY patient cannot wait longer than 24 hours until (twenty four) hours until the equipment will be delivered, PROVIDER will find comparable, AGENCY approved substitute equipment and ensure delivery through one of their subcontract agents that meet all the terms and conditions of this Agreement ...E. Scheduling of Visits/Hours 1. The AGENCY shall: a) Maintain a 24-hours a day, seven days a week on-call system. 2. The PROVIDER shall: a) Maintain availability of services 24 hours a day, seven days a week for delivery, removal, consultation, and emergency maintenance, repair and /or replacement services ..."
"Case Communication Report ...Entered: 8/31/2025 5:19:55PM ...Subject: IV Infusion-morphine Call placed to (doctor) who recommended increasing the frequency to Q1 hour PRN for both the ativan and morphine. (Doctor) ordered a morphine infusion at 3mg/hr continuous with a 3mg PCA bolus Q30 minutes PRN. Orders and plan relayed to (RN) and (patients' family) Advised that the turn around time for the IV morphine to be stared is likely 6 hours ...
Page sent to (Provider) around 3:30pm to request a midline, per (doctors) order. Second page sent around 4:30pm. Return call received from (provider employee) with the (provider) around 4:45pm. Unfortunately, they are not available for line placement today. (Provider employee) will touch base with us tomorrow to determine if there is still a need for a midline.
Will plan to have RN place SQ line at the time of medication delivery and initiation ..."
An interview was the senior manager clinical operations and senior manager of quality was conducted on 11/3/2025 at approximately 11:10 AM and the above finding was reviewed.
Plan of Correction:
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1. The following plan of correction will be implemented in order to ensure care is delivered in accordance with the patient's plan of care. Ongoing monitoring will occur to ensure the deficient practice will not recur.
a. By November 17, 2025, appropriate policies and procedures will be reviewed and revised as necessary to ensure the understanding of the patient's plan of care.
b. By November 17, 2025, associated contracts with the vendor involved will be reviewed and revised as necessary.
c. Education will be developed in the form of a power point.
i. Education will instruct the nurses in the process of reviewing and supporting the patient's plan of care with the need to notify the ordering provider with any revisions needed in the plan of care.
ii. Nursing staff will receive education by December 19, 2025. Participation will be tracked to ensure that staff receive the education. Staff members will have the opportunity to ask questions and verify that they understand the information.
d. In order to continually monitor and to ensure the deficient practice will not recur, the following actions will take place:
i. Following the patient's plan of care will be audited as part of the quarterly clinical record review. The results will be presented at the quarterly QAPI meetings.
1. Any deficient practices will result in additional education for specific staff members.
Initial Comments:Based on the findings of an onsite unannounced complaint survey completed 11/3/2025, Family 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:
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