Initial Comments:
Based on the findings of an unannounced, onsite complaint investigation survey conducted on Apil 7, 2025,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.\~
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Plan of Correction:
418.52(b)(1) STANDARD
EXERCISE OF RIGHTS/RESPECT FOR PROPRTY/PERSON
Name - Component - 00
(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, hospice complaint tracking, and staff interviews, the hospice failed to follow internal policy for investigation and resolution of grievances and complaints for one (1) of four (4) CR reviewed (CR1).
Findings included:
Review of Hospice policy on 4/7/25 at approximately 11:30am revealed:
Policy: RI-006A... Patient Grievances and Complaints... Purpose: To ensure appropriate action will be taken to address all patient/caregiver complaint... Policy: A grievance is a formal or informal written or verbal complaint that is made to any hospice employee, including volunteers and individuals furnishing hospice services under arrangement, by a patient or the patient's representative regarding the patient's care, abuse, neglect, or misappropriation of property...The Agency (hospice director0 will initiate an investigation immediately upon receipt of the complaint. The complaint investigation shall be completed within 5 working days of the agency's receipt of the complaint. All components of the investigation should be documented via the PointCare device or directly into HVHB console...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. 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... 4. 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.
Complaint intake record reviewed 4/7/25 at approximately 11:00am revealed complaint intake by agency director of operations on 1/3/24 documented the unsatisfactory survey returned by the complainant, as per the allegations reported. Action taken documented on 2/4/25 a service recovery letter was sent to complainant.
During Interview on 4/7/25 at approximately 11:20am, Director of Operations reported start of employment with agency was 1/27/25 and the noted survey was in the que of returned surveys and the preceptor instructed to follow up like a complaint. Director of Operations reports sending a service recovery letter and confirms no contact was made with complainant and that the complaint was not logged into the Homecare Homebase (HCHB system or PointCare.
Exit interview with the Area Vice President (AVP) of Operations, 2 AVP's of Clinical, 2 Directors of Operations, and Director of Bereavement Services on 4/7/25, 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 4/23/2025 Comprehensive re-education and remediation for ALL staff on agency policies related to patient complaints and grievances.
Ø 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 6/16/2025
418.56(e)(5) STANDARD
COORDINATION OF SERVICES
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[The hospice must develop and maintain a system of communication and integration, in accordance with the hospice's own policies and procedures, to-]
(5) Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
Observations:
Based on review of clinical records (CR), hospice policies, and staff interviews, the hospice failed to ensure coordination of care between hospice staff and facility staff for two (2) of three (3) CR reviewed (CR1 &; 3).
Findings included:
Review of Hospice policy on 4/7/25 at approximately 11:40am revealed:
"... Professional Management...POLICY: ...The hospice retains professional management responsibility for those services related to the terminal illness and ensures that they are furnished in a safe and effective manner by appropriately qualified persons, and in accordance with the patient's plan of care... OPERATIONAL GUIDLINES: ...2. When hospice services are provided to a patient who is a resident of a licensed nursing facility, licensed intermediate care home or licensed personal care home the services will be provided under arrangement., b. the hospice will designate an IDT that will be responsible for i. Providing overall coordination of hospice care of the patient with the designated facility representative(s)., ii. Communicating with the designated facility representative(s) and other health care providers participating in the provision of care for the terminal and related and other conditions to ensure quality of care for the patient/family., iii. Ensure that the hospice IDT communicates with the facility medica director, the patient's attending physician, and any other physicians participating in the provision of care to the patient as needed to coordinate the hospice care of the patient with the medical care provided by the other physicians., iv. Providing the facility with: the most recent hospice POC, the Hospice election of benefits, any advance directives, physician certifications and recertifications, names and contact information for hospice personnel involved in the patient's care, instructions on how to access the hospices 24 hour on call system, hospice medication information, physician orders..."
Review of CR1 conducted on 4/7/24, at approximately 12:20pm revealed an election of benefits dated 5/24/23. Dates reviewed were 5/24/23-9/16/24. CR revealed patient resided in a personal care facility. The CR included documentation dated 7/19/23, that the medication, Risperdal 2mg by mouth every morning, was changed to 1mg by mouth every morning. Skilled nursing note dated 7/19/23, documentation confirmed no medication reconciliation was conducted. No documentation in clinical note of coordination with the facility staff of the change in medication or symptoms to be aware of or education on the change. On 7/21/23, documentation that the medication, Risperdal 1mg by mouth every morning and Risperdal 1mg by mouth every night, was discontinued. Skilled nursing visit note dated 7/21/23, confirmed no medication reconciliation was conducted. No documentation in clinical note of coordination with the facility staff of the change in medication or education.
Review of CR3 conducted on 4/7/24, at approximately 2:00pm revealed an election of benefits dated 1/12/24. Dates reviewed were 1/12/24-10/8/24. CR revealed patient resided in a nursing facility. The CR included documentation that upon election of benefits/start of services, patient was taking the medication, Atorvastatin 40mg by mouth daily. Th CR contained an order to discontinue this medication 4/22/24 noting the reason to be due to ineffectiveness. Skilled nursing note documentation confirmed no medication reconciliation and no coordination of care with the facility regarding medication change.
Exit interview with the Area Vice President (AVP) of Operations, 2 AVP's of Clinical, 2 Directors of Operations, and Director of Bereavement Services on 4/7/25, 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 that coordination of services is occurring and provide for ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
a. Education/Training –
· On 4/23/2025 Comprehensive re-education and remediation for ALL staff on agency policies related to coordination of services.
Ø MM-001 Pa Medication Management Policy
Ø TX-005 Professional Management
Ø AA-005 Hospice Plan of Care
Ø AA-006 Interdisciplinary Team (IDT)
b. Identification/Implementation –
· Initiated on 4/23/2025 all active patients plan of care will be reviewed at the next IDG to ensure the plan of care and reflected goals based on current patient assessment are provided to ensure palliation and management of the terminal illness and related condition are addressed and completed in accordance to the established plan of care per IDG team and hospice medical director with appropriate interventions, coordination of care, and an individualized patient-specific plan of care.
· With each IDG and order changes the patient plan of care will have appropriate revision to the plan of care as reflected in the clinical documentation in accordance with the patient's current condition/needs and agency's policies and procedures in coordination with the patient's physician, Interdisciplinary Team; nursing facility (as applicable) and patient/patient caregiver to the extent possible.
· All medications will be reviewed at IDG policy and hospice nurses will conduct medication reconciliation at every visit to ensure the medication administration record at healthcare facilities, as applicable, match the hospice plan of care/medication record.
c. Auditing and Monitoring –
· Effective immediately 100% of charts will be audited to identify all patients residing in a healthcare facility and ensure coordination of care is included in the plan of care.
· Effective immediately 100% of all facility charts will be audited to ensure they contain most recent POC, Election of Benefits, Advanced Directives, Certification of Terminal Illness, Names and Contact Information for Hospice, Assigned Hospice IDG team members, How to access Hospice 24 hours, Current Medication List, and Physician Orders.
· 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.
· 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 6/16/2025
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