Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 12/18/2023, Conemaugh regional 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 relicensure survey completed 12/18/2023, Conemaugh Regional 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:
418.54(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 review of agency policy, medical records (MR) and staff (EMP) interviews, the agency failed to review all the patient's medications and update the medication profile and allergies for one (1) of nineteen (19) MR reviewed (CR8).
Findings included:
Review of the agency's policy was conducted on 12/18/2023 at approximately 9:43 AM which revealed, "Monitoring Medications...PROCEDURE...1. Compare medication list to actual medications patient is taking. If the patient resides in a facility, compare medication list to the facility's medication administration record (MAR) rather than reviewing actual medications. 2. Review over the counter (OTC) medications, vitamins, herbs and herbal products, and crems and topical ointments and medical marijuana (in states where legalized) to identify issues such as: a. potential adverse effects and drug reactions b. ineffective drug therapy c. significant side effects d. significant drug interactions e. duplicate drug therapy f. noncompliance with drug therapy g. dosage errors h. drug omissions...3. All nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care. Through a collaborative process the care team will: a. Compare medication information patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies..."
A review of CR8 on 12/15/2023 at approximately 1:14 PM with a start of care date of 11/10/2023 for a current certification period starting 11/23/2023 and ending 2/7/2024. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The hospital history and physical document was compared to the agency "Medication List " (printed 12/12/2023). The following allergies were listed on the hospital history and physical as followed: "ALLERGIES/HOME MEDICATIONS Allergies: Allergies Statins-HMG-CoA Reductase Inhibitor (Coded, 09/11/23), Sulfa (Sulfonamide Antibiotics) (Coded, DIARRHEA, 11/20/18), levofloxacin (Coded, 09/11/23), sulfamethoxazole (From BACTRIM) (Coded, 05/03/20), trimethoprim (From BACTRIM) (Coded, 05/03/20)." The agency medication list listed allergies as followed: Allergies: BACTRIM, STATINS, LEVOFLOXACIN..."
An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.
Plan of Correction:L0530
All Nurses were educated on 01/05/2024 regarding Hospice Policy #12.009 Medication Administration - which states; "The clinician will check all medications a patient is taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies, contraindicated medication(s), and known drug to drug interactions and shall report any problems to the physician". All Nurses were instructed on the requirement and process to assess for drug allergies and to document any findings in the patient electronic medical record. The RN will review any history and physical documentation with patient or caregiver, including a focus on any medication allergies. All allergies will be documented in the patient's electronic medical record. In the event that there are any discrepancies regarding the patients reported allergies and the allergies identified in the patient medical record, the RN will update the patient electronic medical record and will contact the patient's Attending Physician and/or the Medical Director if there is a need for further orders, such as medication adjustments. A sign in sheet was used to document attendance and understanding of information provided.
The Executive Director completed a 100% review of all active patients to ensure that any allergies listed in the patient's history and physical were recorded in the patient's electronic medical record. Any discrepancies were reviewed with patient or caregiver to verify that the allergy information in the history and physical documentation was accurate. The Hospice Nurse updated the allergy information in the electronic medical record and informed the Medical Director and Pharmacy provider.
To ensure ongoing compliance the Executive Director or designee will review all admissions to ensure that any allergies identified in the patient history and physical documentation are identified in the patient hospice electronic medical record, or a note is present identifying that the allergy information in the history and physical documentation is incorrect. The audit will occur for at least three months, or until 100% compliance is achieved for three consecutive months. Audit results will be reviewed monthly with Hospice leadership.
418.56(e)(4) STANDARD
COORDINATION OF SERVICES
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[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(4) Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.
Observations:
Based on review of agency policy and procedure, observation (OBV), and staff (EMP) interviews, the agency failed to ensure an ongoing sharing of information between all disciplines providing care and services in all settings related to patient care for one (1) of four (4) patient observations that were conducted (OBV4).
Findings included:
Review of the agency's policy was conducted on 12/18/2023 at approximately 9:43 AM which revealed, "Monitoring Medications...PURPOSE: To provide a process to ensure continuous monitoring of medications in patient's home POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all nurses will participate in medication review and reconciliation throughout the benefit period ...All nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care..."
(OBV4) MR4, patient home visit was conducted on 12/14/2023 at approximately 1:50 PM. Start of Care was 8/28/2022. Two folders were available with agency information in the home. The surveyor asked EMP8 to review the medication list and plan of care. The medication list and plan of care were both dated 8/11/2023. A current medication list and plan of care was not found within the agency information.
An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.
Plan of Correction:L0557
On 01/05/2024 Reviewed LHC Policy 12.008 Medication Management with all clinical staff which states: All nurses participating in the patient's care are responsible to assist in maintenance of accurate patient medication information throughout the tenure of care. Through a collaborative process the team will: Compare medication information patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. A signature sheet was used to document attendance. RN will audit 100% of current patients to ensure that a current medication list is present in patients' home. Executive Director or designee will randomly audit 4 patients per month to ensure compliance. Compliance will be achieved when 100% of patients audited are compliant for three consecutive months. Audit results will be reviewed monthly with Hospice leadership.
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 visits (OBV), and staff (EMP) interviews, the agency failed to ensure one (1) of four (4) staff followed infection control policy and procedure for bag technique (OBV1).
Findings included:
Review of the agency's training document was conducted on 12/18/2023 at approximately 9:25 AM which revealed, "Home Care Bag Protocol Job Aid...5...*One area of the bag shall be dedicated to clean, reusable items such as B/P cuff. * One area of the bag shall be dedicated to sterile, non-reusable items such as sterile dressings/items. Items removed from his section of the bag shall not be returned to this section...6. Personal items such as hand-held devices, cell phones, wallets and keys should not be carried in the clean section of the bag but may be carried in an outer pocket of the bag away from patient care supplies..."
Observations (OBV1), during a visit to MR1 residence on 12/13/2023 at 2:00 PM revealed, EMP5 provided direct patient care. EMP5 placed the bag on a clean chuck/barrier on the bed side table. Then placed reusable items from the nursing bag on the chuck/barrier the bag was sitting on. Thermometer, blood pressure cuff, computer, container of wipes, hand cleanser and cell phone.
An interview was conducted on 12/15/2023 at approximately 3:30 PM with the executive director, regional quality coordinator and regional vice president of operations which confirmed the above information.
Plan of Correction:L 0579
On 01/05/2024 100% of staff were educated on LHC Policy 10.011 Infection Control with specific focus Medical Equipment, Device and Supplies Cleaning Compliance and Hand Hygiene Compliance which states: The agency will prevent the transmission of infection through proper sanitation of medical equipment, devices, and supplies such as: stethoscopes, blood pressure cuffs, pulse oximeters and thermometers. A signature sheet was used to document attendance. Staff were reminded that only devices used to provide patient care should be placed on the barrier. The Executive Director or designee will perform audits of 4 visits per month to ensure proper bag protocol/infection control is being practiced in the patient's home. Compliance will be achieved when 100% of audits performed are compliant for three consecutive months. Audit results will be reviewed monthly with Hospice leadership.
Initial Comments:Based on the findings of an onsite unannounced State relicense survey completed 12/18/2023, Conemaugh Regional 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 State relicense survey completed 12/18/2023, Conemaugh Regional Hospice was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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