Initial Comments:Based on the findings of an unannounced, onsite complaint investigation survey conducted on September 5, 2024, and completed off-site September 9, 2024, Amedysis Hospice of PA 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:
418.52(b)(1) STANDARD
EXERCISE OF RIGHTS/RESPECT FOR PROPRTY/PERSON
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(1) The patient has the right:
(i) To exercise his or her rights as a patient of the hospice;
(ii) To have his or her property and person treated with respect;
(iii) To voice grievances regarding treatment or care that is (or fails to be) furnished and the lack of respect for property by anyone who is furnishing services on behalf of the hospice; and
(iv) To not be subjected to discrimination or reprisal for exercising his or her rights.
Observations:
Based on review of clinical records (CR), hospice policies, and staff interviews, the hospice failed to follow internal policy for investigation and resolution of grievances and complaints for four (4) of four (4) CR reviewed (CR1-4).
Findings included:
Review of Hospice policy on 9/5/24 at approximately 10:30am revealed:
Policy: RI-006A... Patient Grievances and Complaints... Operational Guidelines: ...2. in the event of a complaint: HCHB system: The staff member receiving the complaint documents the complaint via the Point Care device directly into the HCHB console., a. The report is given to the DOO or designee., 3. The DOO or designee: a. Investigates and determines the nature of the complaint. In the event that the complaint regards allegations of abuse or neglect by an employee, the DOO will remove the employee of any bedside care or contact with patients until the complaint has been fully investigated., b. HCHB system: Documents findings and resolution via the PointCare device or directly into the HCHB console., c. Communicates the resolution to the patient and/or caregiver that initiated the complaint process verbally and follow up via the Service Recovery letter... 3. In the event the complaint is not resolved at the agency level, the patient or interested party contacts the Regional Office. The Area Vice President or designee: a. HCHB system: Documents the complaint via the PointCare device or directly into the HCHB console., b. investigates the complaint., c. HCHB system: Documents finings and resolution via the PointCare device or directly into the HCHB console., d. Submits the Customer Complaint Report and all supporting documentation regarding the complaint to the Agency.
Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed:
CR1, election of benefit date 3/4/24, dates reviewed 3/4/24-3/7/24. Complaint intake documented by agency director of operations on 3/11/24 to include reported concerns of failure of DME to be picked up from home, medications received in pill form versus expected liquid form, different nurse providing visit than admission, and oxygen humidification bottle not filled. Agency follow-up documentation included that complainant "did not want to speak to anyone at from the care center at Mon Valley. Wished for higher up to call her back..." Email written from Area Vice President of Clinical to agency director dated 3/11/24 includes summary of noted concerns, and additional concerns to include: defibrillator shut off, nurse not offering to put air mattress on patient bed, not receiving aide visits daily, morphine dose different than complainant thought it would be, aide not having supplies, catheter not removed post death before sending patient to funeral home, follow up on death certificate. No agency documentation, per policy, of additional concerns relayed to Area Vice President of Clinical. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver.
CR2, election of benefit date 12/31/23, dates reviewed 12/31/23-1/1/24. Complaint intake documented 1/1/24 to include reported concerns of failure of medications to be provided to manage patient pain for 2 days. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver.
CR3, election of benefit date 5/29/24, dates reviewed 5/29/24-6/6/24. Complaint intake documented 6/1/24 to include reported concerns of failure of nurse to provide information and support to family, and alleged nurse was rude. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver.
CR4, election of benefit date 2/9/24, dates reviewed 2/9/24-2/23/24. Complaint intake documented 2/10/24 to include reported concerns of failure of medications to be provided to manage patient pain. No documentation, per agency policy in electronic medical record system, of findings and resolution or communication of the resolution to the patient and/or caregiver.
Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.
Plan of Correction:1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and Area Vice President of Clinical implemented comprehensive and systematic changes to ensure ALL patients' Rights are upheld and the care center leadership follows the company's policy RI-006A Patient Grievances and Complaints.
a.Education/Training –
- On 9/10/2023 Comprehensive re-education and remediation for ALL staff on agency policies related to patient complaints and grievances.
CR-HSP-RI-006 Patient Grievances and Complaints
b.Identification/Implementation –
- Effective immediately all complaints will be documented via the Point Care device or directly into HCHB.
- The report will be provided to the agency Director or designee.
- The Director or designee will investigate the nature of the complaint and notify the appropriate agencies as needed.
- Investigation findings and resolution will be documented in HCHB.
- The Director or designee will communicate the resolution to the patient and/or caregiver that initiated the complaint and follow up via the Service Recovery letter.
- In the event the complaint is not resolved at the agency level, the Area Vice President of Operations and/or the Area Vice President of Clinical contact the patient or interested parties, enter the complaint into HCHB system, investigate the complaint, and submit the customer complaint and supporting documentation to the agency.
- The complaint/concern report is maintained electronically within the QI Events Reports section in the HCHB console and logged within the agency complaint binder.
c.Auditing and Monitoring –
- Effective immediately all complaints/concerns are to be reported to the Area Vice President of Operations and/or the Area Vice President of Clinical to ensure adherence to policy CR-HSP-RI-006 Patient Grievances and Complaints.
- The Director will audit 100% of all complaints/concerns via the QI Events Report to ensure the complaint/concern process was followed, resolution was reached, the Service Recovery letter was sent, and interventions were implemented and in place.
- Auditing will continue monthly for a period of 2 months or until 100% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be done as needed to assure compliance.
- Ongoing the Director will run the QI Event Summary and Detail Report quarterly per policy for QAPI reporting
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at minimum annually.
d.Ongoing adherence – The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e.Completion date 10/28/2024
418.52(c)(1) STANDARD
RIGHTS OF THE PATIENT
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§418.52(c) Standard: Rights of the patient
The patient has a right to the following:
§418.52(c)(1) Receive effective pain management and symptom control from the hospice for conditions related to the terminal illness;
Observations:
Based on review of clinical records (CR), hospice policies, complaint log/reports, on call coordination notes, and staff interviews, the hospice failed to ensure that the patient had the appropriate medications available to manage the patient's symptoms for two (2) of four (4) CR reviewed. (CR 2 &; 4).
Findings included:
Review of Hospice policy on 9/5/24 at approximately 10:50am revealed:
Policy: MM-001 PA... Medication Management Policy-Pennsylvania... Operational Guidelines: A. Provision of Medications: 1. Provision of medication to meet emergent needs of the patient will be made available twenty-four (24) hours, seven (7) days a week., 2. A pharmacist is available to all clinical staff twenty-four (24) hours, seven (7) days a week for consultation..."
Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed:
CR2, benefit election date 12/31/23, dates reviewed 12/31/23-1/1/24. Complaint Report documented complaint intake dated 1/1/24 at 6:52pm reporting concern that "patient has been home for 2 days now and still does not have pain medication. Patient is currently in pain and ...has nothing to give [patient] to help..." On call coordination notes include this call intake documented 2/10/24 at 6:47pm. At 6:59pm documentation reflects on call nurse "is at patient home and aware of medication need. AOC (administrator on call) has been made aware of need for pain medication at this time..." Narrative note dated 1/1/24 written by licensed nurse reads, "...No comfort kit medication administered as not yet delivered..."per available documentation patient/caregiver did not have the appropriate medications available to manage the patient's symptoms from election of benefits on 12/31/24 through patient death on 1/1/24.
CR4, benefit election date 2/9/24, dates reviewed 2/9/24-2/23//24. Admission note dated 2/9/24 included " continue all medications, add Ekit [emergency kit] meds..." Complaint Report documented complaint intake dated 2/10/24 at 9:54am reporting concern that "PT [patient] was discharged from hospital on hospice yesterday [2/9/24]. Medications were supposed to be delivered last night or early this morning. No medications and patient is in distress. Trying to climb out of bed, restless, O2 [oxygen] dropping ..." on call coordination notes include this call intake documented 2/10/24 at 8:06am. At 8:10am documentation reflects on call nurse "stated [he/she] put orders in last night and requested MD scripts..." 8:30am documentation "Call placed to back-up nurse...states will follow-up with pharmacy and family." Narrative note from nurse visit dated 2/11/24 states "Ekit meds present and narcotics counted." per available documentation patient/caregiver did not have the appropriate medications available to manage the patient's symptoms from election of benefits on 2/9/24 until 2/11/24.
Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.
Plan of Correction:1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and Area Vice President of Clinical implemented comprehensive and systematic changes to ensure ALL patients receive effective pain management and symptom control for conditions related to the terminal illness.
a.Education/Training -
- On 9/10/2023 Comprehensive re-education and remediation for ALL staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
MM-001 Pa Medication Management Policy
AA-005 Hospice Plan of Care
AA-003 Assessments
b.Identification/Implementation –
- Effective immediately a comprehensive auditing process of all new admissions will be completed to ensure proper assessment and establishment of an individualized plan of care is developed to meet the patients' needs and all medication orders are in place for symptom management.
- During each Interdisciplinary meeting all patients plan of care will be reviewed including review of all medications to ensure orders are in place and all medications are available to ensure the palliation and management of the terminal illness and related conditions.
- The Director and/or Clinical Manager will ensure all new medication orders have been processed and prescriptions sent to the pharmacy to ensure there is no delay in patients receiving medications.
- The registered nurse completing the assessment and obtaining medication orders will notify the Director/Clinical Manager of any delays in the patient receiving the medications timely.
- A 24-hour nursing visit will be scheduled for all patients that have had a change in condition and new medication orders received for symptom management to ensure medications are effective.
c.Auditing and Monitoring -
- Initiated immediately 100% of all medication profiles will be audited to ensure medications are in place and appropriate for symptom management of the terminal illness and related conditions.
- Auditing to continue monthly for a period of 2 months or until 90% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be done as needed to assure compliance
- Ongoing, an audit of 10% of all current patient's medication profiles will be completed to ensure medications are in place for symptom management.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at minimum annually.
d.Ongoing adherence – The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e.Completion date 10/28/2024
418.56(b) STANDARD
PLAN OF CARE
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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 clinical records (CR), and staff interviews, the hospice failed to provide services only as ordered by a physician for two (2) of four (4) CR reviewed (CR1 &; 2).
Findings included:
Review of CR conducted on 9/5/24, from approximately 1:50pm to 3:30pm and 9/9/24 from approximately 11:45am -12:45pm revealed:
CR1, benefit election date 3/4/24, dates reviewed 3/4/24-3/7/24. Plan of care (POC) and medication list included Oxygen to be administered at 3 liters via nasal cannula daily. Narrative note written by registered nurse dated 3/4/24 reads "...nasal flaring noted, oxygen in home from Medcare, O2 [oxygen] reading was 78%, placed on 5 L [liters], came up to 89%..." Narrative note written by registered nurse dated 3/5/24 reads, "...Patient currently on four liters nasal cannula and saturations were at eighty nine percent." Narrative note written by registered nurse dated 3/7/24 reads "...oxygen saturation was eighty percent on five liters and went to ninety two percent when adjusted to six liters..." No order to administer oxygen at any other saturation than 3 liters nasal cannula. Narrative note written by registered nurse dated 3/6/24 reads, "...16 FR (French) (foley catheter) 10ml balloon placed today..." Additional narrative note dated 3/6/34 written by registered nurse reads, "...Patient now has a catheter draining a clear straw color urine..." No evidence of order obtained or written for insertion of foley catheter.
CR2, benefit election date 12/31/23, dates reviewed 12/31/23-1/1/24. Plan of care (POC) and medication list included Oxygen to be administered at 3 liters via nasal cannula daily and PRN (as needed). Narrative note written by licensed nurse dated 1/1/24 reads, "...Terminal anxiety. Puling at bedsheets. Oxygen continuously 5 L..." No evidence of order to increase oxygen administration from 3L to 5L.
Exit interview with the Area Vice President (VP) of Operations, VP of Clinical, Area VP of Clinical, Director of Operations, VP Regulatory Affairs, VP Clinical Practice and Quality, and Director of Bereavement Services on 9/9/24, at approximately 3:00pm confirmed findings.
Plan of Correction:1.Upon notification of areas of deficiencies, the Administrator/Director of Operations with the assistance of the Area Vice President of Operations and Area Vice President of Clinical implemented comprehensive and systematic changes to ensure ALL current patients and future patients' plan of care is individualized to meet specific needs/goals, 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 patients' needs if any of them so desire. Plan of Care will include all medications and treatments necessary for the palliation and management of the terminal illness and related conditions and will be updated to reflect changes in patient condition.
a.Education/Training -
- On 9/10/2023 Comprehensive re-education and remediation for ALL staff on appropriate agency policies related to deficient areas. Review of Agency Policies and Procedures included the following policies:
AA-005 Hospice Plan of Care
AA-003 Assessments
MM-001 Pa Medication Management Policy
CR-PUL-001 Administration of Oxygen
b.Identification/Implementation -
- Initiated immediately all active patients plan of care will be reviewed at IDG to ensure plan of care reflects patients' needs/goals and includes all medications and treatments necessary for the palliation and management of the terminal illness and related conditions.
- With each IDG and order changes, the patient plan of care will be revised to ensure the plan of care reflected goals are based on the current patient assessment and current patient services that are necessary for the palliation and management of the terminal illness and related conditions.
c.Auditing and Monitoring -
- Initiated immediately, 100% of current patients' plan of care will be audited to ensure plan of care is individualized and reflects goals based on current patient assessment and current patient services necessary for the palliation and management of the terminal illness and related conditions.
Including measurable goal and outcomes in coordination/oversight of patients' physician (if any), Hospice Medical Director and Interdisciplinary team.
Appropriate delivery of care and interventions provided based on plan of care and patient's needs.
- Auditing to continue monthly for a period of 2 months or until 90% compliance is met. If compliance is not met after 2 months, the audits will continue for the next 2 months, and staff remediation will be done as needed to assure compliance.
- Ongoing, an audit of 10% of all current patients will be completed to ensure plan of care reflects goals based on current patient services necessary for the palliation and management of the terminal illness and related conditions.
- Audits will be added to QAPI plan.
- All findings will be reported at the quarterly QAPI committee meeting and Governing Body as appropriate, but at minimum annually.
d.Ongoing adherence – The Administrator/Director of Operations will ensure ongoing adherence and monitoring of all aspects of the plan of corrections for cited deficiencies.
e.Completion date 10/28/2024
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