Initial Comments:
An offsite follow-up survey completed February 16, 2024 found that Chandler Hall Health Services, Inc. had corrected the deficiency cited under the requirements of 42 CFR, Part 418.113, Subpart D, Conditions of Participation: Hospice Care-Emergency Preparedness. The deficiency was cited as a result of a state re-licensure and federal recertification survey completed January 11, 2024.
Plan of Correction:
Initial Comments:
An offsite follow-up survey completed February 16, 2024 found that Chandler Hall Health Services, Inc. had not corrected the deficiencies cited under the requirements of 42 CFR, Part 418, Subparts A, C &; D, Conditions of Participation: Hospice Care. The deficiencies were cited as a result of a state re-licensure and federal recertification survey completed January 11, 2024.
Plan of Correction:
418.112(f) STANDARD
ORIENTATION AND TRAINING OF STAFF
Name - Component - 00
Hospice staff, in coordination with SNF/NF or ICF/IID facility staff, must assure orientation of such staff furnishing care to hospice patients in the hospice philosophy, including hospice policies and procedures regarding methods of comfort, pain control, symptom management, as well as principles about death and dying, individual responses to death, patient rights, appropriate forms, and record keeping requirements.
Observations:
Based on a review of the agency plan of correction and email correspondence with the agency Director, the agency failed to ensure the skilled nursing facility was provided orientation to the Hospice philosophy, as stated in their Plan of Correction, for one (1) of one (1) agency Plan of Correction documentation reviews (Documentation review #1).
Findings include:
Review of Agency Plan of Correction on 02/16/2024 at approximately 3:00 p.m., approved by the Department on 01/23/2024, revealed the following:
"1.) For SNF#1, a Hospice 101 Vendor Orientation was completed by RN Liaison#1 on 01/22/2024. This orientation included, but was not limited to, responsibility determination, hospice philosophy, mission and values, infection control, and 24hr availability of hospice services.
2.) The Operations Coordinator will complete a 100% audit of all facilities with which there is an existing contract to identify any other vendors affected by the deficiency. Any identified facilities will receive Hospice 101 Vendor Orientation by an RN Liaison or designee. The completed Hospice 101 Vendor Orientation will be placed in the corresponding section of the Facilities binder. "
Corrective action date: 02/12/2024.
Documentation review #1: No documentation provided of stated "Orientation included, but was not limited to, ....... hospice philosophy, ......." Documentation provided of a Hospice Vendor Orientation' checklist, dated 01/22/24, with the 'Name' section listing (skilled nursing facility representative) and with the 'Company' section listed as (Skilled Nursing Facility #1) which included (4) sections, 'General', 'Safety', 'Specifics' and 'Contractor'. Under the "General' section, Mission/Values/Vision was listed. Hospice Philosophy (to include all required regulatory elements) was not included on the checklist.
On 2/15/24 at approximately 12:54 p.m. agency was sent email requesting additional documentation to demonstrate that Skilled Nursing Facility #1 was oriented to the Hospice Philosophy, including all required regulatory elements. The agency Director replied "The hospice vendor orientation education comes primarily from the hospice welcome book. I do see on the vendor form that I did not specify "hospice philosophy" as I should have along with mission, values and vision. I have added the verbiage to the form. I have also included the page from the welcome book that includes it." A revised blank 'Hospice Vendor Orientation; checklist was sent. This revised blank checklist 'General' section included listed Mission/Values/Vision/Hospice Philosophy." A single page from the 'Welcome Book' with 'What is Hospice?' and 'Criteria for Hospice Care' sent with the revised blank 'Hospice Vendor Orientation' checklist.
No documentation provided of the agency assuring orientation of staff furnishing care to hospice patients in the hospice philosophy/coordinating the staff training with representative/s of the facility. The agency reviewed the 'Hospice Vendor Orientation' checklist with a representative from (Skilled Nursing Facility #1). Per forwarded email correspondence dated 02/16/24 between the agency Director and the agency 'Orientor' who signed the 'Hospice Vendor Orientation' checklist that was provided to (Skilled Nursing Facility #1), the 'Orientor' stated "I have only in-serviced one person (the person who signed) to pass on info to other staff."
Documentation was requested of the stated "100% audit of all facilities with which there is an existing contract". No documentation provided of the facilities listed on the agency audit form receiving orientation to 'Hospice Philosophy.'
Email correspondence on February 22, 2024 at approximately 12:58 p.m. with the agency Director confirmed the above findings.
Plan of Correction:1.) For SNF#1, The RN Liaison will coordinate with SNF #1 to meet with staff and provide a comprehensive hospice orientation. All facility staff providing care to agency patients will be in-serviced on hospice philosophy.
2.) The Operations Coordinator will complete a 100% audit of all facilities with which there is an existing contract to identify any other vendors affected by the deficiency. Any identified facilities will receive hospice philosophy in-service by an RN Liaison or designee.
3.) RN Liaison #1 was educated on the updated vendor form and the regulatory requirements. A standardized agenda for vendor orientation is in development to provide a structured way of relaying all required information when discussing with facilities. A lunch and learn sign in sheet has been developed to identify staff members who participated in the in-service.
5.) The above plans of correction will be completed by March 29, 2024.
Initial Comments:An offsite follow-up survey completed February 16, 2024 found that Chandler Hall Health Services, Inc. had corrected the deficiency cited under the requirements of 35 P.S. § 448.809 (b). The deficiency was cited as a result of a state re-licensure survey completed January 11, 2024.
Plan of Correction:
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