Initial Comments:Based on the findings of an onsite unannounced state re-licensure and Medicare recertification survey conducted on January 22, 2024 through January 24, 2024, Angelic 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 state re-licensure and Medicare recertification survey conducted on January 22, 2024 through January 24, 2024, Angelic Hospice was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C, and D, Conditions of Participation: Hospice Care.
Plan of Correction:
418.56(e)(2) 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-]
(2) Ensure that the care and services are provided in accordance with the plan of care.
Observations:
Based on review of agency policy, clinical records (CR), and interview with the agency's administrator, the hospice failed to follow the Hospice Plan of Care and/or Physician orders for ten (10) of fourteen (14) clinical records (CR # 1, 2, 5, 6, 7, 8, 9, 10, 11 and 13).
Findings include:
A review of the agency policy and procedures was conducted on 1/24/24 at approximately 2:30PM and revealed the following:
Policy titled, "Documentation Requirements" reads in part, "members of the interdisciplinary group document the interventions provided to the patient/family, their response to care, services provided, and the goals or outcomes achieved. Procedures: 1. Documentation is completed by all Hospice staff and the volunteers whenever: a. Patient/family visits occur;"
Policy titled, "Clinical Records" reads in part, "a clinical record is established and maintained the for every patient receiving care and services from Angelic Hospice. The record is complete, promptly and accurately documented, readily accessible, and the systemically organized to facilitate retrieval.... Procedure: 6. Clinical records are safeguarded against the loss or destruction. 10. Clinical records are readily retrievable and readily accessible when requested by appropriate authorities."
Policy titled, "Coordination of Services" reads in part, "The IDG ensures that there is a coordinated and the effective ongoing sharing of information amongst and between all disciplines, with all contracted service providers end in all settings... Procedures: 6. Coordination of services and continuity of care is a facilitated by established formal and informal communication mechanisms between all disciplines providing care (whether directly or under contract)."
A review of clinical records (CR) was conducted on 1/22/24 from approximately 10:50 AM until 3:30 PM, 1/25/2023 from approximately 1:00 PM until 3:30PM, and 1/26/24 from approximately 10:00 AM until 1:00 PM revealed the following:
CR#1. Start of Care: 9/21/23. Discharge date: 11/5/23. Certification period reviewed: 9/30/23 to 12/28/23. File contained Hospice Aide orders for two (2) times weekly for thirteen (13) weeks. There is no evidence that HHA visits during certification period. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#2. Start of Care: 9/26/23. Certification period reviewed: 9/26/23 to 12/24/23. File contained Hospice Aide orders for two (2) times weekly for eleven (11) weeks. During the week of 10/8/23 - 10/14/23, only 1 visit was conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#5. Start of Care: 9/6/23. Certification period reviewed: 9/6/23 - 12/4/23. File contained Skilled Nurse orders for two (2) times weekly for twelve (12) weeks. During the week of 12/3/23 to 12/9/23 and 12/10/23 to 12/16/23, only 1 visit was conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#6. Start of Care: 12/14/23. Certification period reviewed: 12/14/23 - 3/12/24. File contained Hospice Aide orders for two (2) times weekly for twelve (12) weeks. During the week 12/17/23 to 12/23/23, 12/24/23 to 12/30/23 and 1/7/24 to 1/13/24, only 1 visit was conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#7. Start of Care: 6/28/23. Certification period reviewed: 11/25/23 - 1/23/24. File contained Hospice Aide orders for four (4) times weekly for eight (8) weeks. During the week of 11/26/23 to 12/2/23 and 12/17/23 to 12/23/23, only three (3) visits were conducted during each week. During the week of 12/24/23 to 12/30/23 and 12/31/23 to 1/6/24, only two (2) visits were conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#8. Start of Care: 5/20/23. Certification period reviewed: 11/16/23 - 1/14/24. File contained Skilled Nurse orders for two (2) times weekly for eight (8) weeks. During the week of 11/26/23 to 12/2/23 and 12/31/23 to 1/6/24, only one (1) visit was conducted. File contained Hospice Aide orders for five (5) times weekly for eight (8) weeks. During the week of 11/19/23 to 11/25/23 and 11/26/23 to 12/2/23, only two (2) visits were conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#9. Start of Care: 7/5/23. Certification period reviewed: 11/17/23 - 1/15/24. File contained Hospice Aide orders for five (5) times weekly for eight (8) weeks. During the week of 11/19/23 to 11/25/23, 11/26/23 to 12/2/23 and 12/31/23 to 1/6/24, only 4 visits were conducted during each week. During the week of 12/24/23 to 12/30/23, only two (2) visits were conducted. File contained Skilled Nurse orders for two (2) times weekly for eight (8) weeks. During the week of 11/26/23 to 12/2/23 and 12/17/23 to 12/23/23, only one (1) visit was conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#10. Start of Care: 11/9/23. Certification period reviewed: 11/8/23 - 2/5/24. File contained Hospice Aide orders for three (3) times weekly for eleven (11) weeks. During the week of 11/19/23 to 11/25/23, 11/26/23 to 12/2/24, 12/3/23 to 12/9/23 and 12/10/23 to 12/16/23, only two (2) visits were conducted during each week. File contained Skilled Nurse orders for two (2) times weekly for thirteen (13) weeks. During the week of 11/26/23 to 12/2/23, only one (1) visit was conducted. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#11. Start of Care: 5/7/23. Certification period reviewed: 11/13/23 - 1/11/24. File contained Hospice Aide orders for five (5) times weekly for eight (8) weeks. During the week of 11/19/23 to 11/25/23, 11/26/23 to 12/2/24 and 12/31/23 to 1/6/24, only four (4) visits were conducted. During the week of 12/24/23 to 12/30/23, only two (2) visits were conducted. File contained Skilled Nurse orders for two (2) times weekly for nine (9) weeks. During the week of 12/24/23 to 12/30/23, only one (1) visit was conducted. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
CR#13. Start of Care:1/3/23. Certification period reviewed: 10/30/23 - 12/28/23. File contained Hospice Aide orders for five (5) times weekly for eight (8) weeks. During the week of 11/19/23 to 11/25/23, only four (4) visits were conducted. File contained Skilled Nurse orders for two (2) times weekly for nine (9) weeks. During the week of12/10/23 to 12/16/23 and 12/17/23 to 12/23/23, only one (1) visit was conducted during each week. File did not contain missed visit documentation regarding above missed visits, there was no documentation that the IDG was notified about the above missed visits, and there was no verbal order to update or discontinue the order.
An interview with the agency's administrator on 1/24/24 at approximately 3:30 PM confirmed the above findings.
Plan of Correction:1. All PA RN, SW, SC, and HHA will be in-serviced on 2/12/2024 on writing, visit frequencies, and how to properly modify frequencies when ordered and how to accurately document a missed visit in our electronic Medical record. (completed 2/12/2024)
Plan of Correction: hospice requirements 42 CFR, Part 418.56 Subparts A, C, D, conditions of participation: Hospice Care:
CR#5: Start of care 11/15/2023 (Correction).
CR#8: Start of care 5/20/23 with certification period reviewed: 11/16/23-1/14/24: Chart review reveals skilled nursing visits are present at 2x/week for weeks 11/26-12/2 and 12/31-1/6. Visits are present in chart, without deficiency seen.
CR #9:Skilled nursing visits are present with chart containing missed visit documentation from 12/1 and 12/22. Deficiency with visit frequency deficiency not seen. Visit note submitted to surveyor.
CR#10:
Skilled nursing reveals a pre-existing missed visit documentation from 12/1/2023. No deficiency noted. Visit note sent to surveyor.
CR#11:
For skilled nursing: chart reveals visit frequency of 2X/week are present in clinical chart for dates 12/27 and 12/29. No deficiency noted. Visit notes sent to surveyor.
Plan of correction: All active patient charts will be audited immediately to ensure correct visit frequencies as per the plan of care. Completion Date 2/12/2024
All discrepancies will be reviewed and corrected (if applicable by 2/16/24 to ensure 100% compliance with 42CRF 418.56 (E)(2). Completion Date: 2/16/24
DON (Director of Nursing) will audit 25% of all active charts for compliancy for 2 consecutive months to ensure continued compliancy. Completion Date:3/24/2024
DON (Director of Nursing) will audit 10% of all active charts quarterly on-going to ensure continued compliance as part of Angelic Health's internal performance improvement project (PIP). PIP activated 2/12/2024 and will be ON-GOING for 2024 until 100% compliance is maintained and QAPI/Governing Body approve PIP completion.
418.116 STANDARD
FEDERAL, STATE, LOCAL LAWS & REGULATIONS
Name - Component - 00
The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. If State or local law provides for licensing of hospices, the hospice must be licensed.
Observations:
Based on a review of personnel files (PF), the Pennsylvania Adult Protective Services Act, and an interview with the agency's administrator, it was determined the agency failed to ensure personnel to have the required clearances per the Pennsylvania Adult Protective Services Act for eight (8) of eight (8) files reviewed (PF# 1, 2, 3, 4, 5, 6, 7 and 8)
Findings include:
Review of the Pennsylvania Adult Protective Services Act was conducted on 1/23/24 at approximately 2:00 PM. According to the Act 169 of 1996 as amended by Act 13 of 1997, "If the applicant/employee has been a resident of the Commonwealth of Pennsylvania for 2 or more years prior to application for employment, the applicant will need to obtain a clearance from the Pennsylvania State Police. This clearance is obtained by doing the following: Request for Criminal Record Check Form (SP4-164)." "When the applicant/employee has not been a resident of the Commonwealth of Pennsylvania for the entire two years (without interruption) immediately preceding the date of application for employment or currently lives out of state, in addition to the Pennsylvania State Police Criminal History Check, the applicant/employee will also need to obtain an FBI Criminal History Check. Facilities are defined by the act to include: Domiciliary Care Homes, Home Health Care Agency, Nursing Facility (licensed by the Department of Aging), Personal Care Home (licensed by the Department of Public Welfare). A Home Health Care Agency is further defined to include those agencies licensed by the Department of Health and any public or private organization which provides care to a care-dependent individual in their place of residence." "If entities run into special circumstances where they need to hire an employee before the results of their record checks are returned, there is a provision in CPSL that allows for a provisional hiring period. The period is to not exceed 30 days for in state residents and 90 for out of state residents."
A review of personnel files (PF) was conducted on 1/17/24 starting at 1:40 PM. The date of hire (DOH) is indicated below.
PF#1 DOH 8/26/23 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#2 DOH 10/12/21 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#3 DOH 11/27/21 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#4 DOH 10/3/23 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#5 DOH 5/31/22 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#6 DOH 7/18/23 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#7 DOH 7/12/22 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
PF#8 DOH 11/15/18 did not contain evidence of PATCH (Pennsylvania State Police Criminal Background Check) upon hire.
An interview conducted with the agency's administrator on 1/24/24 starting at 3:30 PM confirmed the above findings.
Plan of Correction:Tag L)798: All current active staff will receive PATCH background checks as soon as possible. All active staff has been submitted effective 1/31/2024. DOH will be notified of PATCH background checks when completed. 8/8 personnel files reviewed during survey have been entered/submitted for PATCH background review.
Angelic Health will ensure that 100% of all new hires receive a PATCH background check prior to on-boarding
Angelic Health will audit all personnel charts quarterly to ensure PATCH background checks are present and current to ensure 100% continued compliance
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure and Medicare recertification survey conducted on January 22, 2024 though January 24, 2024, Angelic Hospice was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced state re-licensure and Medicare recertification survey conducted on January 22, 2024 through January 24, 2024, Angelic Hospice was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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