Initial Comments:Based on the findings of an onsite unannounced Medicare recertification survey completed 10/26/2023, Grane Hospice Care 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 completed 10/26/2023, Grane Hospice Care Inc. 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:
418.56(e)(4) STANDARD
COORDINATION OF SERVICES
Name - Component - 00
[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 a system of integration with all disciplines providing care and services in all settings related to patient plan of care for one (1) of four (4) patient observations that were conducted (OBV4).
Findings included:
Review of the policy and procedures was conducted on 10/24/2023 at approximately 2:00 PM which revealed, Policy "THE PLAN OF CARE...PURPOSE To ensure that an individualized plan of care is completed that complies with accepted standards of care and regulatory issues. POLICY A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care...PROCEDURE 1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed...11. As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with. 12. The written plan of care will contain, but will not be limited to, the following...S. Drugs and treatments (including allergies) ...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 care."
A patient's home visit, (OBV4) MR4, was conducted on 10/23/2023 at approximately 1:30 PM. Start of Care was 10/14/2023. A (agency) three ring binder was available. Upon review of the binder no plan of care (POC), medication list or POLST was available for review. The surveyor requested EMP1 review the binder. No POC, medication list or POLST was available per EMP1.
An exit interview was conducted with the administrator, vice president of operations, human resource manager, and senior director of compliance, via conference call, on 10/27/2023 at approximately 10:30 AM which confirmed the above findings.
Plan of Correction:- Case manager or admitting RN will complete the initial assessment and will initiate the development of the plan of care after the consent forms are signed. Policy No. 1-006.1
- Hospice care team will place a copy of patient's plan of care in the binder at the patient's residence (location).
- All staff, including new hires, will be reeducated on "Care /Service Coordination" Policy No. 1-006.1 by 11/27/2023.
- Team coordinators will be reeducated on providing a copy of the plan of care to receiving care team by 11/27/2023.
- Starting 12/1/2023, initiating audit 10 new admission patient binders, monthly, for 3 consecutive months or until 100% compliance is met for 3 consecutive months, then ongoing with quarterly QAPI for 1 year. If negative findings are found, re-education will be implemented and the initial audit plan will be restarted until compliance is achieved and maintained.
Responsible Party: Clinical Manager
418.60(a) STANDARD
PREVENTION
Name - Component - 00
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 two (2) of four (4) employees followed infection control policy and procedure during observations for bag technique conducted during (OBV1 and OBV3).
Findings included:
Review of the policy and procedures was conducted on 10/24/2023 at approximately 2:00 PM which revealed, " BAG TECHNIQUE POLICY No. 7-016.1 ...POLICY As part of the infection/exposure control plan, hospice personnel will consistently implement principles to maximize efficient use of the patient's care supply bag when used in caring for patients. PROCEDURE...Bag Technique 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...5. The bag will contain a designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.). 6. When the visit is complete, reusable equipment will be cleaned using alcohol, soap and water, on other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag..."
A visit was conducted to (OBV1) MR1 residence on 10/23/2023 at 8:35 AM revealed: EMP3 provided direct patient care. EMP3 removed items from open nursing/supply bag and placed the bag on a clean chuck/barrier another chuck/barrier was laid adjacent to the chuck/barrier the nursing/supply bag was located on. This area was being used for clean supplies. The following equipment was observed being used during treatment stethoscope and blood pressure monitor. After patient use EMP3 placed the stethoscope and blood pressure monitor back to the same location on the chuck/barrier prior to cleaning the equipment.
A visit was conducted to (OBV3) MR3 residence on 10/23/2023 at 8:35 AM revealed: EMP5 provided direct patient care. EMP5 removed items from open nursing/supply bag and placed the bag on a clean chuck/barrier. This area was being used for clean supplies. The following equipment was observed being used during treatment stethoscope, pulse oximeter, thermometer, blood pressure monitor. The reusable items were placed back onto the same chuck/barrier prior to cleaning the equipment.
An exit interview was conducted with the administrator, vice president of operations, human resource manager, and senior director of compliance, via conference call, on 10/27/2023 at approximately 10:30 AM which confirmed the above findings.
Plan of Correction:On 11/14/23, in-service will provide re-education to all IDG Staff on the following Agency Policy and Procedure: Bag Technique 7-016 by RN Administrator/ RN Clinical Supervisor Designee. By 11/27/22, re-competency of Bag technique of 100% of clinicians has been completed by RN Clinical Supervisor/ Designee. In-service records, Recompetencies, and Observations shall be submitted to Administrator and HR for tracking.
This policy sets forth:
BAG TECHNIQUE
Policy No. 7-016
"As part of the infection/exposure control plan, hospice personnel will consistently implement principles to maximize efficient use of the patient's care supply bag when used in caring for patients. The bag will be placed on a clean surface (i.e. a surface that can be easily disinfected) in the care and in the home. When the visit is complete, reusable equipment will be cleaned using alcohol, soap and water, on other appropriate solution, hands will be washed, and equipment and supplies will be returned to the bag. The bag will be cleaned as soon as feasible when it is grossly contaminated or dirty. Soap and water, alcohol, or another approved cleaning agent will be used." Staff were also educated to clean/disinfect the strap of the bag should it become contaminated prior to exit from the home. Education provided regarding "designated clean and dirty area. The clean area contains unused or cleaned supplies/equipment, and the dirty area is designated for contaminated materials (i.e., used equipment, etc.)."
RN Supervisor/preceptor designee will perform visit observations of 100% clinicians to assess compliance with standard precautions for infection control, including disinfection of all parts of the bag. Staff remediation to be noted on focus audit tracker and acknowledged by RN supervisor and staff member in writing with staff re-competency tool(s) completed and submitted to Human Resources. Observations will occur for 90 days and until full compliance is achieved by all nurses.
Threshold is 100% compliance with observed evidence of compliance with standard infection precautions. Once threshold met, 25% clinicians will be directly observed each quarter for one year to ensure ongoing compliance. Staff shall receive bag technique in-service with re-competency a minimum of twice annually as a measure to support these actions. If threshold not met, nursing observations shall continue at 100% every 90 days and Administrator/Designee will re-educate involved staff, progressively, involving human resources for discipline, if needed.
There must be 100% compliance for three consecutive audits prior to recommendation to removal of the audits from the Performance Improvement Audit schedule. The results of the audits will be reported quarterly to the QAPI Committee for discussion, revision, or completion determined by whether the threshold has been met as outlined and demonstrated with ongoing compliance.
The QAPI Committee will report the level of compliance to the Governing Body.
Initial Comments:Based on the findings of an onsite unannounced State relicensure survey completed 10/26/2023, Grane Hospice Care 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 relicensure survey completed 10/26/2023, Grane Hospice Care Inc. , was found to be in compliance with the following requirement(s) of 35 P.S. § 448.809 (b).
Plan of Correction:
|