QA Investigation Results

Pennsylvania Department of Health
CONCORDIA HOSPICE OF WASHINGTON
Health Inspection Results
CONCORDIA HOSPICE OF WASHINGTON
Health Inspection Results For:


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Initial Comments:Based on the findings of an onsite unannounced Medicare recertification, state re-licensure, and complaint investigation survey conducted 5/14/24 - 5/20/24, Concordia Hospice of Washington 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 onsite state re-licensure, Medicare recertification survey, and complaint investigation conducted 5/14/24 through 5/20/24, Concordia Hospice of Washington was found not to be in compliance with the following requirements of 42 CFR, Part 418, Subparts A, C, D, Conditions of Participation: Hospice Care.






Plan of Correction:




418.54(c)(6) STANDARD
CONTENT OF COMPREHENSIVE ASSESSMENT

Name - Component - 00
[The comprehensive assessment must take into consideration the following factors:]
(6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes, but is not limited to, identification of the following:

(i) Effectiveness of drug therapy
(ii) Drug side effects
(iii) Actual or potential drug interactions
(iv) Duplicate drug therapy
(v) Drug therapy currently associated with laboratory monitoring.



Observations: Based on a review of clinical records (CR), observations during home visits, policy reviews and interviews with staff (EMP) and patients, the agency failed to complete medication reviews consistent with agency policy for one (1) of thirteen (13) CRs reviewed. (CR 7) Findings included: A review of agency policy titled Managing Drugs and Biologicals on 5/16/24 revealed: "Procedures...Medication Administration...4. A medication profile will be completed for each patient at the time of admission and will be updated as needed to include any changes or additions of new medications..." A review of agency procedure Medication Reconciliation revealed: "20. Compare the information gathered from the patient, family, or caregivers with the most recent medication lists found in the patient's record, pharmacy medication list, and pharmacy labels. Identify the differences and document them...24. Communicate all changes to the patient, family, and caregivers..." CR7: Start of Care (SOC) 6/30/23. Certification period reviewed 4/25/24 - 6/23/24. During a home visit conducted on 5/15/24 at approximately 10:00 am with the patient of CR7, two medications were identified as currently being taken by the patient but not listed on the CR7's current Medicine List [printed 5/14/2024]: 1. metoclopramide 10 milligram tablets to be administered every six hours as needed for nausea and 2. Miralax 17 grams to be taken with 8 ounces of water twice a day for three days. The finding was reviewed with EMP4 (Clinical Manager) and EMP7 (RN) on site. The finding was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.

Plan of Correction:

How will the agency will correct the deficiency?
- CR 2 was updated on 5/16/2024 to reflect all current ordered medications.

Measures or systems the Agency will alter to ensure the problem does not occur:

- All clinicians to be re-educated on the requirement that the comprehensive assessment must take into consideration the following factors: (6) Drug profile. A review of all of the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. This includes but is not limited to identifications of the following:(i) Effectiveness of drug therapy (ii) Actual or potential drug interactions (iv) Duplicate drug therapy (v) Drug therapy currently associated with laboratory monitoring.

- All clinicians to be re-educated on all components of complete medication reconciliation and medication review at every visit to ensure a complete and comprehensive medication record and the agency is meeting the patient's needs.
Plans to monitor the Agency's performance to ensure the problem does not occur:

- Weekly chart audits will be completed (5/week) to verify that the medical record that has a complete and comprehensive medication list that matches what is in the home until 100% compliance. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation

- Auditing will be completed by the Quality team and/or designee and will begin 6/24/2024.




418.56(c)(5) STANDARD
CONTENT OF PLAN OF CARE

Name - Component - 00
[The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including the following:]
(5) Medical supplies and appliances necessary to meet the needs of the patient.



Observations: Based on an observation during a home visit, employee interviews (EMP), and clinical record reviews (CR), the agency failed to develop a plan of care which included the medical supplies and appliances necessary to meet the needs of the patient for one (1) of thirteen (13) CRs reviewed. (CR7) Findings included: During a home visit conducted on 5/15/24 at approximately 10:00 am with the patient involved in CR7, a hospital bed was noted at the patient's residence. CR7 Start of Care (SOC) 6/30/23. CR7's plan of care for certification period 4/25/24 - 6/23/24 did not contain the bed within the durable medical equipment (DME) list. During an interview with EMP4 (Clinical Manager) conducted after the home visit, it was determined that the bed was supplied by the hospice but was not listed within the plan of care. EMP4 was unable to obtain an existing order for the equipment. The finding was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.

Plan of Correction:

How will the agency will correct the deficiency?

- CR 7 was updated on 5/16/2024 to reflect DME that is in the home and being utilized in the home.

Measures or systems the Agency will alter to ensure the problem does not occur:

- All clinicians to be re-educated on the requirement that all medical supplies and appliances necessary to meet the needs of the patient must be entered in the medical record and on the Plan of Care.
Plans to monitor the Agency's performance to ensure the problem does not occur:

- Weekly chart audits will be completed (5/week) to verify that the medical record and plans of care included all of the medical supplies and appliances necessary to meet the needs of the patient, until 100% compliance. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation.

- Auditing will be completed by the Quality team and/or designee and will begin 6/24/2024.




418.100(c)(1) STANDARD
SERVICES

Name - Component - 00
(1) A hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice:
(i) Nursing services.
(ii) Medical social services.
(iii) Physician services.
(iv) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling.
(v) Hospice aide, volunteer, and homemaker services.
(vi) Physical therapy, occupational therapy, and speech-language pathology services.
(vii) Short-term inpatient care.
(viii) Medical supplies (including drugs and biologicals) and medical appliances.


Observations: Based on a review of Clinical Records (CR), agency policy, and interviews with staff, the agency failed to document wound care services in a manner that was consistent with agency procedures or accepted standards of practice for two (2) of (13) CRs reviewed. (CRs 4 and 9) Findings included: A review of agency procedure for Pressure Injury and Wound Assessment on 5/16/24 revealed: "Documentation...Wound Assessment...Appearance of the wound...wound size (length, depth, and width) ... presence of tunneling...status of surrounding skin...amount of drainage...phase of healing...undermining, if present..." A review of pressure ulcer assessment and staging guidance published by Agency for Healthcare Research and Quality states, "Assessment and Staging...The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing...." Lyder CH, Ayello EA. Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 12. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2650/ A review of CR4 on 5/17/24 at approximately 11:35 am revealed: CR4: Start of Care (SOC): 10/2/23. CR 4 contained a hospice plan of care certification period 3/30/24 - 5/28/24 which contained an order for a single skilled nursing visit per week for 8 weeks and 6 as needed nursing visits to "...observe and assess the patient to identify changes..." Skilled Nurse Visit Notes for CR4 dated 5/1/24 -5/15/24 revealed: 5/1/24 narrative note identified a stage 2 pressure ulcer to coccyx. A wound assessment was not documented as per agency procedure or per standard of care. 5/8/24 narrative note identified skin "impaired" to coccyx, but a wound assessment was not documented as per agency procedure or per standard of care. 5/15/24 note identified "discoloration to coccyx." A wound assessment was not documented as per agency procedure or per standard of care. A review of CR9 on 5/16/24 at approximately 9:45 am revealed: CR9: SOC: 12/15/23. CR 9 contained a hospice plan of care with a certification period of 3/14/24 - 6/11/24 which contained orders for skilled nursing to "observe and assess the patient to identify changes..." Skilled Nurse Visit Notes for CR9 dated 3/18/24 - 3/28/24 revealed: 3/18/24 note contained an integumentary assessment note identifying an area of skin abnormality on the coccyx stating, "Abnormal Integumentary Assessment Findings...erythema [redness], pale, turgor...Indicate Location of Erythema...small spot on back/coccyx..." The area was not identified as "blanchable" to exclude pressure ulcer staging criteria. Therefore, a wound assessment was not documented as per agency procedure or per standard of care. 3/23/24 note identified a "Stage 2" [partial thickness skin loss] coccyx wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/24/24 note identified a "Stage 2" coccyx wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/25/24 note identified a "Stage 2 pressure ulcer." Wound assessment was not documented as per agency procedure or per standard of care. 3/26/24 note identified a "ST[age] 2 coccyx" wound. Wound assessment was not documented as per agency procedure or per standard of care. 3/27/24 note identified a"ST[age] 2 coccyx" wound. Wound assessment was not documented as per agency procedure or per standard of care. The finding of incomplete wound assessment documentation was reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.

Plan of Correction:

How will the agency will correct the deficiency?

- Re-education of nursing staff on the agency expectations and standards of care in regards to skin, wound assessment and documentation.

Measures or systems the Agency will alter to ensure the problem does not occur:

- Re-education of nursing staff on the agency expectations and standards of care in regards to skin, wound assessment and documentation.

Plans to monitor the Agency's performance to ensure the problem does not occur:

- Weekly chart audits will be completed (5/week) on patients with wounds to ensure appropriate assessment and documentation of wounds are being completed according to standards of practice, until 100% compliance. Then 10 charts per quarter will be audited to monitor continued compliance. Any chart reviewed that is inaccurate will have follow up with the clinicians for education review and or individual remediation.

- Auditing will be completed by the Quality team and/or designee and will begin 6/24/2024.



418.108(c)(5) STANDARD
INPATIENT CARE PROVIDED UNDER ARRANGEMENTS

Name - Component - 00
[If the hospice has an arrangement with a facility to provide for short-term inpatient care, the arrangement is described in a written agreement, coordinated by the hospice and at a minimum specifies-]
(5) That the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training is documented;



Observations: Based on a review of facility agreements (AG), policies, and staff interviews (EMP) the agency failed to maintain documentation verifying the training of staff within facilities contracted for inpatient care for two (2) of two (2) agreements reviewed. (AG 1 and 2) Findings included: A review of agency policy titled, Hospice in SNF/PCH on 5/15/24 revealed, "Procedures...6. Orientation and Training of Facility Staff...a. The hospice must assure orientation of facility staff furnishing care to hospice patients...b. The hospice is responsible for: Assessing the need for staff training...Coordinating staff training with facility representatives...Determine how frequently training needs to be offered..." A review of facility agreements was conducted on 5/15/24: AG1: Agreement date: 11/11/2018. Titled Facility Provider Agreement revealed: "2.3 Orientation and Education: Both parties agree to provide sufficient orientation and in-service education...Such in-servicing to personnel shall occur at least annually...Education will be documented including names of those giving and receiving education...C. Personnel and Training...Upon hospice's request, facility shall cause facility personnel who provide Facility services to Hospice patients under this agreement to 1) attend annual training..." No documentation of annual facility staff hospice training for 2023 or 2024 was available as per agency policy or signed agreement. AG2: Agreement date: 10/16/2018. Titled Facility Provider Agreement revealed: "2.3 Orientation and Education: Both parties agree to provide sufficient orientation and in-service education to personnel...Such in-servicing to personnel shall occur at least annually...Education will be documented including names of those giving and receiving education. C. Personnel and Training...Upon hospice's request, facility shall cause Facility personnel who provide Facility services to Hospice patients under this agreement to 1) attend annual training..." No documentation of annual facility staff hospice training for 2023 or 2024 was available as per agency policy or signed agreement. The findings were reviewed during an exit conference on 5/20/24 at approximately 11:30 am with EMP1, Administrator, EMP2, Clinical Supervisor, EMP3, Compliance and Education, EMP4, Clinical Manager, EMP5, Human Resources, and EMP6, Director of Compliance.

Plan of Correction:

How will the agency will correct the deficiency?

- Education to be completed with AG1 and AG2 facility staff by 7/1/2024.

Measures or systems the Agency will alter to ensure the problem does not occur:

- On an annual basis, the agency will provide the facilities in which there are agreements for, the required education and have appropriate documentation saved to ensure compliance.

Plans to monitor the Agency's performance to ensure the problem does not occur:

- On a quarterly basis, the agency will review all active facility contracts to ensure that the required training was completed and documentation of that training is saved to ensure compliance.
Auditing will be completed by the Quality team and/or designee and will begin 6/24/2024



Initial Comments:Based on the findings of an onsite state re-licensure, Medicare recertification survey, and complaint investigation completed 5/20/24, Concordia Hospice of Washington was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.



Plan of Correction:




Initial Comments:Based on the findings of an onsite state re-licensure, Medicare recertification survey, and complaint investigation completed 5/20/24, Concordia Hospice of Washington was found to be in compliance with the requirements of 35 P.S. 448.809 (b).


Plan of Correction: