The Pennsylvania Department of Health inspects hospices on site every twelve to twenty-four months. If they have a history of serious problems or complaints are received, they may be inspected more frequently.
Act 95 of 1998 requires that all hospices must have a license to operate in Pennsylvania. The Department of Health is in the process of promulgating regulations for hospices. Until regulations are finalized, the Department is utilizing the Federal regulations for hospices. Inspections of hospices are called surveys. The Department of Health surveys hospices to make sure they are following federal regulations (rules). The federal regulations apply when hospices choose to receive reimbursement for their patients' care from the Medicare and/or Medicaid programs.
During a hospice survey, areas of concern (non-compliance with regulations) are identified. The department staff, also known as surveyors, write an official report of their observations and record them on a form called the HCFA 2567. For every problem that is identified, the surveyors must decide how serious the problem is for the patients. The surveyors write a description of the problems, which is then called a "statement of deficiencies". A copy of the report is sent to the hospice requiring that a plan to fix the problems be submitted. The hospice must submit in writing their proposed solutions to the identified problems. This is called a "plan of correction". You can ask to see a copy of this report from any hospice, or you can view these reports on the Department of Health web site.
When you look at the HCFA 2567 please keep in mind that the report only tells you what was observed on the dates of the survey. It is simply a "snapshot" of the care the hospice was providing during the time frame of the survey. Since that date, conditions at the hospice could have changed. While reviewing survey results is a good beginning in determining the quality of a hospice, it should not be the only way you judge a facility.
When you select a survey to review from our county map you will notice several things. First, this is a slightly modified version of the HCFA version. The column identifies sections noting the regulation, observation, findings, and regulation number. The surveyors write these sections, and each contains information for the facility and public to understand how their conclusions were reached.
The heading regulation identifies the specific rule from the federal guidelines with which the facility was not complying. It may also include reference to other regulations that could be used in citing the particular area of non-compliance.
The section observation and findings describe the process by which a surveyor gathers information. Detailed documentation of observations of deficient practice assist the provider in identifying when and where the deficient practice was observed and, as appropriate the duration of each observation. Essentially, the statement of findings describes the specific results and consequences of the hospice's deficient practice for the individual cases reported in the findings.
Immediately following the section written by the surveyors, you will find a section entitled "Plan of Correction - To be completed: Date." This section is written by the hospice and tells you what steps they will take to correct the problems noted on the HCFA 2567 and the date they expect to have the problem corrected. Hospice Understanding Results