QA Investigation Results

Pennsylvania Department of Health
CHANDLER HALL HEALTH SERVICES, INC.
Health Inspection Results
CHANDLER HALL HEALTH SERVICES, INC.
Health Inspection Results For:


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Initial Comments:Based on the findings of an unannounced on-site hospice federal recertification survey completed on January 11, 2024, Chandler Hall Health Services, Inc. was found not 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:




418.113(a) STANDARD
Develop EP Plan, Review and Update Annually

Name - Component - 00
403.748(a), 416.54(a), 418.113(a), 441.184(a), 460.84(a), 482.15(a), 483.73(a), 483.475(a), 484.102(a), 485.68(a), 485.542(a), 485.625(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at 482.15 and CAHs at 485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at 483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at 494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

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Observations: Based on a request of agency policy/procedure, agency emergency plan review, and an interview with the agency Administrator, it was determined that the agency failed to review and update the agency emergency preparedness plan at least every 2 years, for one (1) of one (1) emergency preparedness plan (EP) reviewed (EP#1). Findings: Agency policy related to the agency emergency plan was requested on January 11, 2024 at approximately 11:00 a.m. no specific policy was provided. A review of the agency EP was completed on January 8, 2024 at approximately 2:00 p.m. EP#1: No documentation provided of the agency reviewing and updating the agency emergency preparedness plan at least every 2 years. Per the agency Administrator on 01/10/24 at approximately 11:15 a.m., the plan was reviewed this past summer (2023) but there is no documentation available. Documentation requested for the EP review/update for 2021. No documentation provided. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

Administrative Director, Patient Care Coordinator, Human Resources Director, and Operations Coordinator met on 01/11/2024 to discuss the Emergency Disaster Preparedness Plan.
Policy #: HCH 15-04 Title: Hospice Emergency Disaster Preparedness Plan was located and saved to a shared folder in the Emergency Management section of policies and procedures. The policy has been updated as of 01/22/2024 to include requirements of reviewing and updating the Emergency Preparedness Plan (EP) at least every 2 years. A policy and procedure review signature page has been added to the EP binder to ensure it has been reviewed. Signatures of Patient Care Coordinator, Administrative Director and Operations Coordinator are in the binder as of 01/22/2024. The EP will be reviewed quarterly for compliance at Safety Committee meetings beginning 01/25/2024. The POC will be incorporated into the QAPI program which meets quarterly to evaluate the effectiveness of planned interventions.



Initial Comments:

Based on the findings of an unannounced on-site hospice state re-licensure and federal recertification survey completed on January 11, 2024, Chandler Hall Health Services, Inc. was found not to be in compliance with the requirements of 42 CFR, Part 418, Subparts A, C &;; D, Conditions of Participation: Hospice Care.




Plan of Correction:




418.104(e)(2) STANDARD
DISCHARGE OR TRANSFER OF CARE

Name - Component - 00
(2) If a patient revokes the election of hospice care, or is discharged from hospice in accordance with 418.26, the hospice must forward to the patient's attending physician, a copy of-
(i) The hospice discharge summary; and
(ii) The patient's clinical record, if requested.



Observations: Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to forward to the patient's attending physician a copy of the hospice discharge summary for one (1) of two (2) live discharge clinical records (CR) reviewed (CR#19). Findings: Agency policy was reviewed on January 11, 2024 at approximately 11:00 a.m. Policy# HCH 24-10 'Discharge from Hospice Services' 'Procedure' section (9) states "A copy of the discharge summary will be sent to the physician ...." A review of CRs was completed on January 11, 2024 at approximately 11:00 a.m. CR#19 Start of Care 06/12/23: Patient revoked hospice care on 07/07/23. No documentation provided of the hospice completing a discharge summary. No documentation provided of the hospice forwarding to the patient's attending physician a copy of a hospice discharge summary. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

1.) For CR#19, a discharge summary was created on 01/22/2024 reflecting the patient's status at time of discharge and will be forwarded to the attending provider.
2.) A report will be pulled by the Operations Coordinator or designee for discharges from the EMR identifying patients for whom a discharge summary is required but was not compiled and sent to the attending physician to identify other individuals affected by the deficiency.
3.) A discharge checklist has been modified to include the requirement of compiling a discharge summary and sending it to the attending physician. Clinical staff were educated on Policy# HCH 24-10 'Discharge from Hospice Services' 'Procedure' and given the updated checklist at a team meeting on 01/17/2024.
4.) The Patient Care Coordinator or designee will audit 100% discharges bi-weekly until 100% compliance of standard and quarterly thereafter for adherence to Policy# HCH 24-10. The POC will be incorporated into the QAPI program which meets quarterly to evaluate the effectiveness of planned interventions.
5.) The above plans of correction will be completed by February 12, 2024.



418.104(e)(3) STANDARD
DISCHARGE OR TRANSFER OF CARE

Name - Component - 00
(3) The hospice discharge summary required by (e)(1) and (e)(2) of this section must include-
(i) A summary of the patient's stay including treatments, symptoms and pain management;
(ii) The patient's current plan of care;
(iii) The patient's latest physician orders; and
(iv) Any other documentation that will assist in post-discharge continuity of care or that is requested by the attending physician or receiving facility.


Observations: Based on a review of agency policy/procedure, clinical record review, and an interview with the agency Administrator, it was determined that the agency failed to ensure the discharge summary included all required elements for one (1) of two (2) live discharge clinical records (CR) reviewed (CR#18). Findings: Agency policy was reviewed on January 11, 2024 at approximately 11:00 a.m. Policy# HCH 24-10 'Discharge from Hospice Services' 'Procedure' section (10) states "At the time of discharge, other service providers who will provide care, treatment, or services to the resident/patient will be informed of the following: ...... A summary of care, treatment, or services that have been provided. ...." A review of CRs was completed on January 11, 2024 at approximately 11:00 a.m. CR#18 Start of Care 06/21/23: Patient transferred to another hospice agency on 06/30/23. The agency provided documentation of 'Administrative Communication' and 'DME Communication' notes and presented them as a discharge summary. The communication notes did not include a summary of the patient's stay including treatments, symptoms and pain management. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

1.) For CR#18, a discharge (agency transfer) summary was created on 01/22/2024 reflecting the patient's status at time of discharge and will be forwarded to the attending provider. Including A summary of care, medications, treatment, and services that were been provided.
2.) A report will be pulled by the Operations Coordinator or designee for discharges from the EMR identifying patients for whom a discharge summary is required but was not compiled and sent to the attending physician to identify other individuals affected by the deficiency.
3.) A discharge checklist has been modified to include the requirement of compiling a discharge summary and sending it to the attending physician. Clinical staff were educated on Policy# HCH 24-10 'Discharge from Hospice Services' 'Procedure' and given the updated checklist at a team meeting on 01/17/2024.
4.) The Patient Care Coordinator or designee will audit 100% discharges bi-weekly until 100% compliance of standard and quarterly thereafter for adherence to Policy# HCH 24-10. The POC will be incorporated into the QAPI program which meets quarterly to evaluate the effectiveness of planned interventions.
5.) The above plans of correction will be completed by February 12, 2024.



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 request/review of agency policy/procedure, a review of hospice services contracts, and an interview with the agency Administrator, agency failed to assure hospice philosophy orientation for skilled nursing facility staff for one (1) of one (1) skilled nursing facility contracts (SNFC) reviewed (SNFC#1). Findings include: Agency policy related to agency providing facility staff education of the hospice philosophy was requested on January 11, 2024 at approximately 11:00 a.m. No specific policy provided. Agency 'Hospice Services Agreement' signed by the hospice agency and the skilled nursing facility (SNF#1) on 10/02/23 section '1, Responsibilities of Hospice' (m) states "Upon execution of this agreement, hospice shall assure that facility staff furnishing care to residents who are under hospice's care are educated in the hospice philosophy, ....." SNFC #1: No documentation provided of the hospice agency orienting the skilled nursing facility (SNF#1) staff to the hospice philosophy. (Hospice patient Clinical Record #21 currently resides/resided at this facility). An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

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.
3.) A vendor/facilities checklist has been created to include the requirement of orienting contracted entities by utilizing the Hospice 101 Vendor Orientation form. On 01/12/2024 RN Liaisons #1 and #2 were reintroduced to and educated on the Hospice Services Agreement and the requirements of orientation for vendors and the vendor/facilities checklist.
4.) The Operations Coordinator or designee will audit 100% of contracts bi-weekly until 100% compliance of standard and quarterly thereafter for adherence to the Hospice Service Agreement and vendor/facilities checklist. The POC will be incorporated into the QAPI program which meets quarterly to evaluate the effectiveness of planned interventions.
5.) The above plans of correction will be completed by February 12, 2024.



418.114(d)(2) STANDARD
CRIMINAL BACKGROUND CHECKS

Name - Component - 00
Criminal background checks must be obtained in accordance with State requirements. In the absence of State requirements, criminal background checks must be obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years.



Observations: Based on a review of employee files, agency policy/procedure, and an interview with the agency Administrator, it was determined that the agency failed to ensure Pennsylvania State Police criminal background checks were conducted for one (1) of eight (8) employee files (EF) reviewed (EF#1). Findings: The Pennsylvania (Pa.) 'Health and Safety (Title 35)' 'Older Adults protective Services Act' Information relating to prospective facility personnel. (a) General rule, -- A facility shall require all applicants to submit with their applications, ............, who have or may have direct contact with a recipient to submit, there following information obtained within the preceding one-year period: (1) pursuant to 18 Pa. C.S. Ch. 91 (relating to criminal history record information), a report of criminal history record information from the state police or a statement from the State Police that their central repository contains no such information relating to that person". Agency policy was reviewed January 11, 2024 at approximately 11:00 am. Agency policy 'HRS 04-09, Criminal History Reports' 'Policy' (1) states "As part of the application process, utilizing the Conditional Employment form, the applicant will; (a) provide information necessary to obtain a criminal history background check. (c) affirm in writing if a resident in the State of PA for 2 or more years, which if less than two years would warrant a federal criminal record (FBI clearance). (2) New hires will be considered provisional hires for 30 calendar days for individuals who need a Pennsylvania State Police Background Check and 90 days for individuals who need the FBI Background check. A copy of the Background Check will be maintained in the personnel file. A review of EFs completed on January 11, 2024 at approximately 11:00 am. revealed the following: EF#1, date of hire 10/21/21: No documentation of the agency conducting a Pennsylvania State Police criminal background check. Documentation provided of a Federal Background Check dated 02/26/2019. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings

Plan of Correction:

1.) For EF#1, a Pennsylvania State Police Criminal Background Check was completed by HR on 01/23/2024 and added to the employee file.
2.) The Operations Coordinator will complete a 100% audit of personnel files to verify no other employee files have been affected by the deficiency.
3.) The employee files checklist has been relocated to the filing cabinet with the personnel files to facilitate adherence to Policy# HRS 04-09 Criminal History Reports. The Operations Coordinator was educated on the above policy including the difference between federal and state background check requirements.
4.) The Operations Coordinator or designee will audit 100% of personnel files monthly until 100% compliance of standard and quarterly thereafter for adherence to Policy# HRS 04-09 Criminal History Reports. This plan of corrections will be incorporated into the QAPI program which meets quarterly to evaluate the effectiveness of planned interventions.
5.) The above plans of correction will be completed by February 12, 2024.



Initial Comments:Based on the findings of an unannounced on-site hospice state re-licensure survey completed on January 11, 2024, Chandler Hall Health Services, Inc. was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart
Plan of Correction:




Initial Comments:Based on the findings of an unannounced on-site hospice state re-licensure survey completed on January 11, 2024, Chandler Hall Health Services, Inc. was found not to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:




35 P. S. 448.809b LICENSURE
Photo Id Reg

Name - Component - 00
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.



Observations: Based on observation of Identification badges (ID) and an interview with the agency Administrator, agency failed to format/issue ID badges per regulatory requirements for one (1) of one (1) observation (Observation #1). Findings include: Observation #1: Observation of employee Identification Badge (ID) on January 10, 2024 at approximately 11:00 a.m. revealed the current ID badge employee title (registered nurse) is abbreviated 'RN' and does not occupy the bottom 1/2" of the badge, as large as possible. An interview conducted with the agency Administrator on January 11, 2024, at approximately 11:45 a.m. confirmed the above findings.

Plan of Correction:

1.) For Observation #1, an updated badge with the title Registered Nurse occupying the bottom half inch of the badge was created.
2.) A message was sent to all clinicians requesting the format of their ID badges and notified that anyone with RN, LPN, or MD would need to bring their ID badges to get replaced.
3.) An email was sent to HR and the executive assistant with the regulatory requirements for photo IDs. The executive assistant is responsible for ensuring new ID badges follow regulations. The executive assistant will develop a checklist for badges being made to ensure new badges are not affected by the deficiency. All clinical staff have been informed of the regulation through a secure messaging system.
4.) The Patient Care Coordinator will audit 100% of existing employee ID badges and request new ones be made if they do not conform to the standards. The Patient Care Coordinator will audit 100% of new employee badges during new hire orientation to hospice to ensure compliance with regulatory requirements.
5.) The corrective action will be completed by February 12, 2024.