QA Investigation Results

Pennsylvania Department of Health
CENTRE CROSSINGS HOSPICE
Health Inspection Results
CENTRE CROSSINGS HOSPICE
Health Inspection Results For:


There are  17 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced, onsite hospice Medicare recertification survey conducted May 24, 2021 through May 27, 2021, Centre Crossings 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 unannounced, on-site Medicare recertification survey conducted May 24, 2021 through May 27, 2021, Centre Crossings 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:




418.54(c)(7) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT

Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(7) Bereavement. An initial bereavement assessment of the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care.



Observations:


Based on review of agency policies, clinical records (CRs) and interview with hospice Director (EMP #1), it was determined the agency failed to ensure an initial bereavement risk assessment was completed for seven (7) of seven (7) CRs reviewed. (CR #1-7).

Findings include:

Review of agency policy, 'Initial and Comprehensive Assessment of the Patient' conducted on May 27, 2021 at approximately 10:00 a.m., reads, "Comprehensive Assessment:... 4) Content of the assessment includes: ...initial bereavement assessment of patient's family or caregiver".

Clinical records review was conducted on May 26, 2021 between approximately 10:00 a.m and 3:30 p.m. and on May 27, 2021 between approximately 8:45 a.m. and 3:00 p.m. revealed the following:

CR 1, Start of Care (SOC) dated 12/24/19, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #2, SOC dated 4/14/21, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #3, SOC dated 3/2/21, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #4, SOC dated 5/18/2020, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #5, SOC dated 5/13/21, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #6, SOC dated 4/21/2020 the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

CR #7, SOC dated 3/3/21, the clinical record did not contain documentation that an initial bereavement risk assessment was performed.

Interview with the agency EMP #1 conducted May 27, 2021 at 3:30 p.m. confirmed the above findings.













Plan of Correction:

CR1 – 7 will have their initial Bereavement assessment completed by 6/11/2021 by the Medical Social Service employee.

All current hospice patients will be reviewed for a bereavement assessment. If assessment was not completed one will be completed by 6/11/2021.

Education to the social workers, on the policy and procedure for the "Initial and Comprehensive assessment of patient". Any new hires for the social worker position will be reviewed with the hospice director or designee. Review of policy will be conducted at the social service meeting on June 9th, 2021 and a follow up meeting to be held on June 16th, 2021.

Audit will occur by Hospice Director/Designee with each Start of Care, changes noted by the IDG team, and after death. Hospice admissions will be reviewed for completion of the pre-bereavement risk assessment upon admission until July 20th. Following this, random checks of 5 charts per month will be conducted by Hospice director/Designee for the for 3 months until 100% compliance. If compliance is not met further education to be provided, and will continue audits until 100% compliant.

This corrective action will be completed by July 20th, 2021.


418.56(b) STANDARD
PLAN OF CARE

Name - Component - 00
All hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire.



Observations:


Based on review of agency policies, clinical records (CRs) and interview with hospice Director (EMP #1), it was determined the hospice failed to ensure services were provided as identified in the plan of care (POC) for two (2) of seven (7) CRs reviewed. (CR# 1 and CR# 6)

Findings include:

Review of agency policy, 'Interdisciplinary Group-IDG' conducted on May 27, 2021 at approximately 10:10 a.m., reads, "B. Group responsibilities:...Provide care and or supervise services rendered by the Hospice Team...Ensures that care and services are provided in accordance with the plan of care."

Clinical records review was conducted on May 26, 2021 between approximately 10:00 a.m and 3:30 p.m. and on May 27, 2021 between approximately 8:45 a.m. and 3:00 p.m. revealed the following:

CR 1, Start of Care (SOC) dated 12/24/19. The certification period reviewed was dated: 4/17/21-6/15/21. The POC documented Skilled Nursing (SN) visits 1-3 times a week, Home Health Aides (HHAs) visit 1-3 times a week, Social Worker (MSW) 1-3 times a month and Chaplain (Chap) 1 time a month: all starting on 4/7/21. Review of the clinical record revealed there were no documented SN or HHA visits on 4/17/21- week 1 and no documented visits of an MSW or Chap between 4/16/21 and 5/25/21. No documentation provided of any visits being refused or reason for missing frequency visits.

CR #6, SOC dated 4/21/2020. The certification period reviewed was dated: 4/16/21-6/14/21. The POC documented HHAs visit 1-3 times a week. Review of clinical record revealed four (4) HHA visits from 4/25/21- 5/22/21 (weeks 3 to week 6). No documentation provided of a physician order to increase HHA frequency visits.

Interview with the agency EMP #1 conducted May 27, 2021 at 3:30 p.m. confirmed the above findings.












Plan of Correction:

CR1, and CR6 have been reviewed on 6/1/2021 and clarification orders created on 6/1/2021. The Hospice Director/Designee has updated care plan for compliance.

Hospice Director/Designee will review current Hospice Patients for accuracy of frequency for the ordered disciplines. This will be completed by June 25th, 2021. If clarification is needed the physician will be contacted for current orders and care plan to be updated.

Hospice Director/Designee will conduct staff Education for the policy of "Interdisciplinary Group –IDG" provided on June 11th, 2021. A follow up meeting will be conducted on June 25th with IDG. Any new employee that would be responsible for updating and initiating items on the plan of care will be educated through the orientation process.

Audit will occur by Hospice Director/Designee who will review 5 random active patients for accuracy of orders for all disciplines ordered beginning of June 7th to week ending June 25th. If found compliant for the next 4 weeks 3 charts will be randomly checked for accuracy ending the week of July 16th. If noncompliance noted, education will be completed as necessary. If compliance remains below 100% will continue to complete audits until 1 month of 100% compliance.

This will be completed by July 20th, 2021


418.100(g)(3) STANDARD
TRAINING

Name - Component - 00
(3) A hospice must assess the skills and competence of all individuals furnishing care, including volunteers furnishing services, and, as necessary, provide in-service training and education programs where required. The hospice must have written policies and procedures describing its method(s) of assessment of competency and maintain a written description of the in-service training provided during the previous 12 months.


Observations:


Based on review of agency policies, employee files (EFs) and interview with hospice Director (EMP #1), it was determined the agency failed to ensure hospice employees had competency evaluations with orientation specific to hospice duties for five (5) of seven (7) EFs reviewed(EF #1, 2, 3, 4 and 6); failed to ensure hospice employees had an initial hospice orientation for one (1) of seven (7) EFs reviewed, (EF# 1)

Findings include:

Review of agency policy, 'Skills and Competency Evaluations' conducted on May 26, 2021 at approximately 9:10 a.m., reads, "Procedure:...III. Prior to clinicians released from orientation, the skills/competency/evaluation check list for their discipline must be reviewed by the supervisor for completeness...."

Employee file review was conducted on May 26, 2021 between approximately 9:00 a.m and 10:00 a.m. revealed the following:

EF #1, Date of Hire (DOH), 1/24/2019: The file did not contain a completed initial hospice orientation and a completed and verified initial skills and competency evaluation.

EF #2, DOH, 10/6/2020: The file did not contain a completed and verified initial skills and competency evaluation.

EF #3, DOH, 7/20/2020: The file did not contain a completed and verified initial skills and competency evaluation.

EF #4, DOH, 10/29/2018: The file did not contain a completed and verified initial skills and competency evaluation.

EF #6, DOH, 5/13/2019: The file did not contain a completed and verified initial skills and competency evaluation.

Interview with the agency EMP #1 conducted May 27, 2021 at 3:30 p.m. confirmed the above findings.











Plan of Correction:

EF 1-7 will obtain accurate skills check list that shows the supervisor is signing for each skill listed on the check list that these employees are competent. EF 1 resigned, EF3 resigned, EF 2, EF 4, and EF 6 will be reviewed with the Hospice Director/Designee for verification of competency for hospice specific skills.

Currently employees hired in the last 3 years will be reviewed for accurate completion of the skills check list by the Hospice Director/Designee by June 18th.

The policy "Skills and competency Evaluations" to be updated to reflect the staff members to conduct visits/skills on only the items already signed off on by the preceptor with continuation of necessary skills. This will be completed on June 2nd, 2021 and approved by the Board of board of directors on June 2nd, 2021. New policy to be reviewed at nursing meeting on June 2nd, 3rd, and June 8th of 2021.

The Clerical team will review new hire paperwork for completion. The skill's check list will not be filed away until reviewed and signed off by the Hospice Director/VP. If further education is needed on a particular skill the policy will be reviewed, and a simulation will be conducted with the employee for training prior to completing the task independently.

This will be completed by July 20th 2021


Initial Comments:


Based on the findings of an unannounced, on-site state hospice re-licensure survey conducted May 24, 2021 through May 27, 2021, Centre Crossings 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 unannounced, on-site state hospice re-licensure survey conducted May 24, 2021 through May 27, 2021, Centre Crossings Hospice, was found to be in compliance with the requirements of 35 P.S. 448.809 (b).





Plan of Correction: